Archive for the ‘Chronic Disease’ Category
BMI is far from a perfect measure of obesity and can be misleading – but you get the picture below (via Miscellanea). Also check out our previous obesity related posts:
A Massive Wave of Chronic Disease in China and India, link
The 88 Worst Fast Food Items, link
Scientific American on Food, Fat and Famine, link
The above two headlines on global health funding flows and allocation caught my attention. The original study was published in PLoS Medicine. The article has some great figures (some of which I have reproduced below). A few things immediately stick out – the amount concentrated on HIV/AIDS, TB and malaria is astounding. Second the US is providing 70% of the funding and on the surface one could argue that other countries really could be pitching in more. On that note, the Gates Foundation by itself is out funding the European Commission almost 4 to 1 – if that isn’t embarrassing I don’t know what is. Finally, the US Department of Defense is high on the list (surpassing USAID). Interesting stuff:
“HIV/AIDS, tuberculosis and malaria initiatives accounted for about 80% of the $2.5 billion that was spent on research and drug development for developing countries in 2007… However, pneumonia and diarrheal illness, which are two major causes of mortality in developing countries, received less than 6% of funding.”
Guest post by Khizer Husain, Owner of Shifa Consulting (see also previous post on healthcare in the Emirates)
Three Observations in Arab Healthcare Delivery
I attended the 34th annual Arab Health Congress in Dubai last week. This is the largest regional conference on healthcare. The event was massive: it drew more than 50,000 visitors and 2,300 exhibitors which span all facets of healthcare including care delivery, technology, consulting, staffing. According to the medical director in Abu Dhabi’s Sheikh Khalifa Medical City, ‘Our institution looks forward every year to Arab Health as a means of reviewing the latest technology; networking with suppliers and vendors and to update medical knowledge. The increased participation and attendance at Arab Health is of value to all of us in the healthcare field.’ Here are some observations on the delivery of healthcare in this part of the world:
Economic Downturn Putting Projects on Hold
The global financial meltdown has not spared the Middle East and the UAE in particular. There are many sites that are empty pits with cranes standing idle. Hospitals have put on ice new expansion plans. Overall, it is estimated that 8% of the labor force in Dubai has left the country in the last four months due to the worsening economic climate. I heard a couple of people talk about the thousands of cars that were left abandoned at the Dubai airport as people could not pay their loans and thought it best to flee the country. Up until last year, healthcare expenditures in the region were growing 16% per year and exceeding $74B.
The silver lining here is that global steel prices are down 75% and smaller construction projects at well-capitalized institutions can for the first time gain traction. A notable exception to the economic dip is Qatar. According to ArabianBusiness.com, Qatar’s economy (http://www.arabianbusiness.com/541046-qatar-economy-could-grow-by-10-in-2009) could grow 10% in 2009 as it expands exports of liquefied natural gas, making it the world’s fastest growing economy.
Thirst for World-class Standard of Healthcare
There is a strong desire in the Gulf to catch up to the healthcare levels of the industrialized world. Until just a few years ago, the only way to bridge the gap between what national populations desired and what was offered in their native countries, was to open the doors (wide open) to medical tourism. The UAE reportedly spent over $2B per year to ship its citizens to foreign countries for medical treatment. Not only were these expenditures unsustainable, but they put these countries at a competitive disadvantage for recruiting highly skilled expatriates. The only way to turn down the medical tourism spigot was to invest locally in building healthcare expertise. Due to poor perceived quality in local healthcare, stymied access to care, and perverse financial incentives to go abroad for care, medical tourism is still a powerful force.
Enter Multinational Healthcare Corporations
The landscape for international healthcare providers with business in the Middle East is becoming increasing crowded with the major players hailing from the US, Europe, and Canada. There seem to a few dominant models:
a. Market Destination Hospital: A number of institutions have outposts in the Middle East that they use to run clinics and make the necessary arrangements to funnel patients to the flagship entities. Mayo, Washington Hospital Center, University of Chicago follow this model. The Great Ormand Street Hospital in London sends in a rotational team of pediatric specialists to run clinics close to the patients.
b. Secure Management Contract: This is where the cash is. Running a tertiary hospital in the UAE can yield $6M per annum. The big players in this sector include Cleveland Clinic—which runs Sheikh Khalifa Medical City and will run the new Cleveland Clinic Abu Dhabi when it finishes in a few years. Johns Hopkins International has three affiliate hospitals in the UAE and a hospital in Beirut. UPMC runs the gamut of managing whole hospitals to managing individual departments like the emergency room. The Methodist has teamed up with property development company Emaar to create an outpatient clinic which they will manage—the Burj Medical Centre. Emaar has aggressive plans to expand clinics and hospitals throughout the Middle East and North Africa.
c. Joint Venture: South African Mediclinic obtained ownership share of Emirates Healthcare in 2007 for $53M. With two hospitals and three clinics in the pipeline, they are the largest private provider of healthcare in Dubai. Mediclinic derives nearly half of its profits from overseas ventures (in the Middle East and beyond).
While it is quite exciting to see all this development in healthcare, everyone agrees that the only way to have real, sustainable progress in region is to build an army of indigenous healthcare workers. Unfortunately, the curse of petrodollars is that it leaves little incentive for nationals to aspire to become nurses and doctors, let alone outstanding clinical managers. In the meantime, India and the Philippines serve as the golden geese.
As you may have heard by now, Obama might be seriously considering Sanjay Gupta of CNN to be the US Surgeon General. Two good friends had an initially negative reaction to this – “but he is just another TV anchor!”. Well Gupta is much more than that. In addition to his proflic duties as a medical correspondent for CNN where has done in-depth assignments on Iraq and Katrina, he practices surgery on a weekly basis, is the associate chief of neurosurgery at a major university, has traveled the country and the world witnessing first hand major health issues giving him a global sensibility. Also along with his government experience ( as a White House fellow), he knows how to reach mass audiences and will be a media savvy. Clearly he can handle high pressure situations and his celebrity is a huge plus (how many people can remember the name of the last or current surgeon general or know of any significant issues they have tackled?).
For better or worse we are already far down the path of celebrity endorsed causes (what impact this has, I really don’t know, but it certainly commands some attention in a world with lots of noise and information overload). We have Bono, Bill Gates, and Bill Clinton – all rockstars for global health. Even NextBillion is advocating for rockstars in public health, which I do agree with. Sanjay Gupta is extremely smart and talented and can be a celebrity for public health on a national scale. And actually much more than a rockstar, public health in this country and globally needs an ambassador, a champion and an activist. This pick is good for both domestic and global health, and the two have never been so intertwined (not just with the migration of infectious diseases across borders but also with the explosion in chronic disease (and see here Jan 2009) in developing countries and issues like brain drain). You would have someone who has appeal beyond the experts and policy wonks, he has strong credibility with the American public. As such, this is a great media strategy by the Obama team – they have found someone who is well known, a media professional (and as some criticize – a propaganda machine), and can deliver complex health policy messages.
As with any candidate there are drawbacks and deficiencies, with Gupta, these will all come out in due time. I understand that some in public health circles and others will consider this pick to be more style than substance, but my main point is that is time for us to think creatively beyond our traditional notions and perhaps take a risk with someone who doesn’t have a strong public health background, but who has the potential to have a major positive impact. Gupta is someone who can link both local and global health causes together and that is rare and signficant skill. The envirionmental movement over the last decade has made tremendous strides in melting the division and lines between local and global into something that can be grasped at all levels and into something where people understand the connection. Granted health is a very different animal, but as a community and movement we are light years behind the environmental folks – perhaps Gupta helps to push this in another way.
- Krugman on the Trouble with Sanjay Gupta, link
- See Abel and Jake over at Science Blogs on their differing views
– WSJ health blog on Gupta, link
– Read the comments over at Daily Kos, link
- Huff Post on Gupta, link
– Questions about Gupta at KevinMD, link
We previously mentioned the malaria ad sponsored by ExxonMobil during the Olympics. I have seen this several times now during coverage and said in the original post:
“with regard to ExxonMobil’s commercial on Malaria during prime time, when over 1 Billion people were watching, this might have been the largest audience ever for a global health ad.”
I realized after I said this that I probably made a major miscalculation. The NBC channel broadcast I have been watching is only produced for an American audience. The top estimates I have seen for viewership at a given time hit 66 million people. So while Exxon may have had their ad broadcast across countries and major national networks, it is likely that somewhere between tens and hundreds of millions of people saw their commercial – which is still an impressive number. Thanks to Responsible China I found the youtube version of this ad, which is below. In addition I have also seen GE’s portable re-designed low cost EKG machine advertised several times as well. Despite what you may think about these companies it is better than nothing to see MNC’s promoting social causes. We blogged about the EKG machine previously and the commercial is the first one below, followed by the malaria ad. For another check, definitely check out ResponsibleChina.
When most people think of global health they think of infectious diseases and all of the associated images this conjures up (and it is harder to capture provocative images of chronic diseases). However, as we have empahsized before, developing countries are facing a dual burden of both chronic and infectious diseases.
This past Tuesday I was privileged enough to attend the launch of the new Health Affairs issue on global health in China and India. I was joined by an esteemed panel of guests who gave great presentations about various issues facing these two nations. Unfortunately I don’t have time to summarize all of their talks but encourage you to read them in the latest issue. I want to focus on Dr. Somnath Chatterji’s paper because the projections of the aging of China and India are quite stunning and the associated social and economic implications will be profound.
Somnath Chatterji runs the WHO’s Study on Global Ageing and Adult Health (SAGE). Here are some highlights from his paper and quotes I picked up (these are based on my hand written notes, so please forgive any factual mistakes):
The pace of change is stunning – what took 100 years in France (the graying of the population) is going to take place in 30 years in China/India (I can’t remember which one he specified). “Aging has been on the backburner…but China and India are facing dramatic demographic shifts in very short periods of time”.
By 2030, 65.6 percent of the Chinese and 45.4 percent of the Indian health burden are projected to be borne by older adults.
By 2019 in China and 2042 in India, the proportion of people age sixty and older will exceed that of people ages 0–14.
Within the next 20 years there will be 42 million diabetics in China and 80 Million in India.
“In four decades 40% of the worlds elderly population will be in China and India…these countries are getting older before they get richer”.
“Traditionally, people think of chronic diseases as diseases of the of the rich, this is probably not going to be true for China and India…we really need longitudinal data to track this”.
There are dozens of issues that come to mind when hearing these projections, some of which include – access, who will get access to care? how will the delivery system be set up for this? where will the focus be (primary care?)? how will this be financed at both health system level and a household level – how much payment will be borne by the patient? can we use capacity developed for tackling infectious diseases for chronic diseases (a very different ballgame in some ways)? what will be the role of the private sector? if the private sector gets involved heavily to sell their drugs and devices in this new “market” – will that lead to better infrastructure for delivery and distribution of medical supplies? how will this impact the economic growth of these countries? There are many more pressing questions, but I will stop here.
Another one of the articles in this global health issue is on obesity in China. This paper is authored by one of world’s leading experts in nutrition (Barry Popkin). We covered some of this before in a recent issue of Scientific American and here is the link for the new paper. Kudos to Health Affairs for the issue and to Burness Communications for a well run launch.
A C.K. Prahalad speech was recently profiled by a Wharton newsletter, in that lecture he spoke about Indian farmers paying 13 cents a month for health insurance which allowed:
Narayana Hrudayalaya, a pediatric heart hospital in Bangalore, to operate upon 25,000 farmers and to offer free medical consultation to 85,000 more. “This year we have increased the monthly contribution by farmers to Rs 10 (25 cents) a month, but still, we hope to cover 13 million individuals using the world’s largest telemedicine network to deliver critical health services to rural areas…
This displays the power of pooled community based insurance. The first thing that came to my mind is that this has a shot of working because India is a place with massive volume, human resources and technological capacity. These are sweeping generalizations, but they are worthing thinking about when comparing India to other developing regions that do not have the same capacity on these three fronts. Never-the-less this is a great example and experiment that may hold powerful lessons.
‘The Poor Deserve World-Class Products and Services’
Published: January 24, 2008 in India Knowledge@Wharton
The “a Calorie Counter” site came up with this catchy and interesting analysis of the worst fast food joints as determined by the worst trans fat offenders (hat tip to Big Picture). As the post states – “The absolute worst ingredient your food could possibly contain is trans fat. Maybe you’ve heard of it? ” The top offenders, ranked by the numbers of times they appeared in the top 88, were:
- Jack in the Box: 24 times
- Burger King: 16 times
- White Castle: 16 times
- A&W: 10 times
- Dairy Queen: 8 times
For the exact listing of specific meals and fast food chains check out “a Calorie Counter” here.
Currently, everyone knows that the US is the leading fast food market in the world as you can see in the below graphic from WorldMapper (via Creative Class). The scary thing about this picture is that it is apparently sourced from a McDonald’s campaign absurdly and insultingly called “One World – One Taste“, which begs the question of whether some fast food chains are engaging in a type of food genocide. The fact that the US is the largest market, only means that so called emerging markets represent a largely untapped source of growth for various chains. The growth will be explosive, India alone is witnessing 40% growth in this area (via Siliconeer, search for “fast food” on this page).
We did a previous post on obesity in developing countries that you can see for more sources along with the WHO page on this issue… For additional fast food facts you can check out the Yale’s Rudd Center for Food Policy and Obesity, here are some select ones:
- Two-thirds of all cardiovascular deaths occur in developing countries.
- Approximately 20,000 new food and beverage products are introduced into the market each year.
- In some parts of Africa, overweight children outnumber malnourished children three to one.
- Of America’s 15 top-rated hospitals, 6 have fast food franchises in the lobby.
Poor air quality after California fires safer than indoor air from biomass-burning in low-income countries
A Berkeley school of public health prof recently posted to the SPH listserv a great NASA link to high altitude photos of the southern California fires. You can click through several days worth of pics and see what conditions were like prior to the fires as well as tell when the winds kicked up as they carried dust plumes in areas unaffected by fire (for instance Oct 22nd).
The point the prof made was that as bad as the air is there, the particulate matter density of 200-300 micrograms per cubic meter (10x greater than average figures for US cities) is still less than the levels typically seen in biomass-burning homes in the developing world.
More efficient, hotter burning charcoal stoves are one immediate solution to indoor particulate matter (i.e. soot) in low-income homes. In Uganda for instance, Kampala residents use a huge amount of charcoal (my own estimate…) every day. The city’s air, not to mention the air in individual homes, has a great deal of suspended soot – you can easily smell it across the city during the peak cooking hours. Venture Strategies for Health and Development in Berkeley, together with an innovative Kampala for-profit stove manufacturer, are marketing the hotter burning stoves through targeted subsidies financed in part with carbon credits.
Perhaps one silver lining to the devastation in southern California will be greater awareness of the importance of high air quality.
Its great to see a generally conservative business magazine discussing positive, successful global health efforts in Africa. Forbes has 3 very recent pieces that are worth skimming. Again, this is yet another indication of increasing convergence of the social and business sectors that we had previously profiled (trends in global health coverage by the business press).
The Rwanda Cure: Success Stories
Forbes Oct 29.2007, link
Western do-gooders are pouring billions of dollars into ontrolling malaria, AIDS and other killers ravaging the world’s poorest continent. Now comes the hard part…Some of what sub-Saharan Africa needs is new technology, like a malaria vaccine. But what’s needed most, particularly in Africa, is better logistics.
“The hardest truth for people to come to terms with is that the practical solutions are already out there, but they are not being applied…Donors always want to do something new. The simple things aren’t so glamorous.” Full story
In Pictures: Seven Ways To Fix Health Care In Africa
Follow this link
HealthStore to expand to Rwanda, link
How do you get basic care to the remotest villages in Africa? One clever idea is to borrow tactics from retail chains like McDonald’s and Subway–operate an easy-to-replicate, owner-operated franchise system focusing on health care.With a budget of under $1 million a year, HealthStore Foundation subsidizes nurses in rural areas to run 65 for-profit retail clinics in Kenya that provide basic treatments for malaria, respiratory infections and worms.
Nurses pay about $300 to buy a clinic, and sell medicines for a modest profit at a retail price of $1. The 65 clinics run under the name CFW Shops and treated 400,000 patients last year. Many are run by retired nurses lured back to work by the prospect of owning their own business.
Full story here.
Britain has decided to use very graphic pictures on cigarette packs, I am guessing this will work much better than written warnings. The below wording is part of press release which I find partly amusing because they say “words failed to stamp out smoking”. I find it hard to believe they thought words would actually deter smoking. If they did, all I can say is that is very very scary. Perhaps other countries and regions will follow suit, but that is not likely. Up to 160 million smokers in Asia could be dead by 2050 and 1 billion smoking related deaths by the end of the century, so this is a massive problem (see the following – here, here and here).
“This image is one of the graphic pictures to be place on packs of cigarettes to discourage smokers. Words failed to stamp out smoking, so Britain will require graphic pictures of diseased organs on cigarette packs next year, the government announced. The images include a diseased lung, a chest cut open for heart surgery, and a large tumor on a man’s neck. The new warnings will be required on cigarette packs in the second half of 2008, the department said.” Full story.
An account manager from Scientific American’s PR firm let me know about their latest issue on Obesity and Malnutrition (many thanks to Scott for the email) which you should check out. This special issue focuses on “Food, Fat and Famine” and has some of the world’s leading experts writing for the issue (Barry Popkin, world food prize laureate Per Pinstrup-Andersen, and others) along with a bonus article by Jeffery Sachs. I got a chance to quickly skim the introduction to the issue and this line struck me (paraphrased from memory): “For the first time in the world’s history the number of obese people has surpassed the undernourished” (roughly 1.3 billion vs 1 billion).
The shift to sedentary lifestyles (use of mopeds vs bikes) and drive to “Westernization” (fast food, sweetners, mass produced food, urbanization) is dramatically altering the landscape and will lead to a substantial rise in chronic diseases. As Barry Popkin says in his excellent article, The World is Fat, these changes have “paved the way for a public health catastrophe”. A couple of facts from Popkin’s article about the radical change that has taken place in Mexico in just 20 yeras:
-1989: Less than 10% of Mexicans were considered overweight
-2006: Over 66% of Mexican men and women are overweight or obese
-1990: Diabetes was almost non-existent in Mexico, not so today
The above rapid change maybe compounded in developing regions where evolution may have altered genetic makeup such that people in those regions have a greater ability to store fat due to the need to conserve in times of famine. Add in the lack of access to drugs, obesity leads to greater rates of diabetes and hypertension and in China for example, only 1/3 of hypertension patients receive medications. This issue is fascinating and I highly recommend perusing it. For a blog that posts on obesity in general as well as other issues, I would recommend the Med Journal Watch. Unfortunately the online links below only have free abstracts and not full articles, but you will get a decent sense of the article content:
The Global Paradox of Obesity and Malnutrition
A Question of Sustenance, abstract
Globalization ushered in a world in which more than a billion are overfed. Yet 800 million or so still suffer from hunger’s persistent scourge
The World Is Fat, abstract
How can the poorest countries fight obesity?
Still Hungry, abstract
One eighth of the world does not have enough to eat
Sowing a Gene Revolution, abstract
A new green revolution based on genetically modified crops could help reduce poverty and hunger, but only if formidable institutional challenges are met
Is Your Food Contaminated?, abstract
New approaches to protect the food supply
Sustainable Developments: Breaking the Poverty Trap by Jeffrey D. Sachs, abstract
Targeted investments can trump a region’s geographic disadvantages
An interesting commentary piece in yesterday’s Washington Post, excerpts below:
Health diplomacy: Rx for peace
Susan J. Blumenthal/ Elise Schlissel
The Washington Times
August 26, 2007
“A survey of Americans’ political and social values reveals that belief in the effectiveness of military power as a foreign policy tool has dropped to the lowest point in the last 20 years…This diminished confidence in military intervention as a cornerstone of international relations raises an obvious question: What other tools are available to advance U.S. interests in the world? Health diplomacy is an important and underutilized instrument in our nation’s foreign-policy toolbox.”
“More than 63 percent of the people infected with HIV live in Africa; 79 percent of the chronic disease burden is in the developing world. Whether “over there” is Africa, Southeast Asia or Latin America, inhabitants of the United States for far too long have seen little reason to worry. But Americans — and the world — have much to gain from increasing our focus on global health.”
“Health diplomacy is a means of self-preservation in an increasingly interconnected global community. SARS, H5N1 avian influenza, AIDS, TB — the list goes on and on — are only a jet plane away from America’s shores. Globalization facilitates the rapid response to health problems between rich and poor nations by quick mobilization of health professionals, medicines and supplies, and deployment of information technology for surveillance of diseases and sharing health information and best practices worldwide…”
“The United States spent $571.6 billion on defense last year alone, but spends only 0.14 percent of its gross national product on global health and development, the least of any major industrialized nation…”
“For example, the tsunami relief efforts in Indonesia: A poll found after the visit of two former U.S. presidents coupled with a commitment to invest significant funds toward rebuilding communities, support for the United States rose from 36 percent to 60 percent virtually overnight in the world’s largest Muslim country, while support for Osama bin Laden dropped from 58 percent to 28 percent.” Full commentary here.
Great article in the NY Times about China’s pollution, a country where cancer is now the leading cause of death. As the article mentions, China unlike any of the industrialized nations will be forced to deal with this extremely serious problem while they are still a poor country. The catch 22 is that this may curb China’s development and hence also its future. This NY Times feature article includes additional audio and visual material. Below are some highlights from the article:
As China Roars, Pollution Reaches Deadly Extremes, NY Times
No country in history has emerged as a major industrial power without creating a legacy of environmental damage that can take decades and big dollops of public wealth to undo…its pollution problem has shattered all precedents. Environmental degradation is now so severe, with such stark domestic and international repercussions,
Public health is reeling. Pollution has made cancer China’s leading cause of death, the Ministry of Health says. Ambient air pollution alone is blamed for hundreds of thousands of deaths each year. Nearly 500 million people lack access to safe drinking water…
Chinese cities often seem wrapped in a toxic gray shroud. Only 1 percent of the country’s 560 million city dwellers breathe air considered safe by the European Union…China is choking on its own success.
China’s problem has become the world’s problem. Sulfur dioxide and nitrogen oxides spewed by China’s coal-fired power plants fall as acid rain on Seoul, South Korea, and Tokyo. Much of the particulate pollution over Los Angeles originates in China, according to the Journal of Geophysical Research…
Other sources and perspectives:
In China, Global Environmental Injustice Kills Millions, It’s Getting Hot in Here
China is choking on growth, China Law Blog
As China Roars, Pollution Reaches Deadly Extremes, 8Asians
China’s Pollution Problem – Our Pollution Problem? Working Life (Labor Research Association)
Here is another story on the growth of medical technology consumption and production in emerging regions. A few days ago we had a related post (Trends in Global Pharmaceutical Manufacturing). According to the McKinsey report, the rural health services sector will provide significant growth in the demand for pharmaceuticals.
India’s fast-growing economy, expansion in health care insurance and infrastructure, to grow national drug sales to triple by 2015. The report said India will undergo a “significant transformation” to become one of the top 10 pharmaceutical markets in the next decade.
In addition, improvements in medical infrastructure – like rural hospitals and clinics – would contribute to 20 percent of the projected growth, while the strengthening of health insurance within the country would contribute to 15 percent of the growth, the report said. Full news release at CNN Money.
Pharma boom: Drug market to hit $20 bn by 2015, The Economic Times
Table: Global Insight, Link
KPMG Pharmaceutical Practice Report: The Indian Pharmaceutical Industry, (PDF)
India: The Next Pharma Superpower?, IPA Convention 2007, Trade Group
Pharma & Biotech in India Presentation, (PDF)
In place of unaffordable pap smears, 8 years ago researchers at Johns Hopkins validated a “simple method” for detecting cervical cancer: the use of vinegar. That study was conducted in over 10,000 women across 15 clinics in Zimbabwe (1999 BBC news story). Fast forward to this month and we have a re-validation of this method in 50,000 women in India. A new study was conducted from 2000-2006 (hat tip to Drug Wonks):
A cheap method to detect cervical cancer using vinegar, cotton gauze and a bright light could save millions of women in the developing world, experts reported Friday. The study, published in The Lancet medical journal, found a simple visual screening test to look for the early signs of cervical cancer reduced the numbers of cases by 25%. “This is a landmark study,” said Dr. Harshad Sanghvi, medical director at JHPIEGO…Experts think that the simple, inexpensive technique could be rolled out across the developing world relatively easily. Pilot projects are already under way in a handful of countries in Asia and Africa. Full story: Simple Method Detects Cervical Cancer.