Way back in April 2018, the World Health Organization issued its Thirteenth General Programme of Work, which attracted a certain amount of notice at the time, but was certainly not treated as front-page news. The GPW 13, as WHO called it, was centered on three ambitious targets – worthy, but in the view of many, perhaps just a trifle unrealistic. Here’s how the WHO characterized their targets:
WHO dubbed their plan “a set of interconnected strategic priorities and goals to ensure healthy lives and promote well-being for all at all ages.” This is WHO’s statement of purpose:
“The ‘triple billion’ goal is a joint effort of Member States, WHO and other partners. WHO has a catalytic role to play in reaching the goals in GPW 13. No single actor operating alone can achieve these goals. Contributions are required from many partners – principally Member States themselves, but also non-State actors and the WHO Secretariat. Consequently, there is a need for both collective action and accountability, as well as for demonstrating the contribution made to outcomes and impact. In setting these three “1 billion goals”, WHO is signaling its ambition and extending an invitation to members of the global health community to work with the Organization in order to optimize and implement these SDG-based goals.”
Having stated these worthy and ambitious goals, WHO turned its attention to the threats that would have to be overcome, or at least seriously addressed, to ensure healthy lives and promote well-being for all at all ages. As you will see, several of these global threats cover a number of separate individual areas.
WHO obviously ranked the threats according to the size of the population that would be affected by each threat. Thus, the report starts out with a threat (actually, two linked threats) that affect almost every person on the planet.
Air pollution and climate change
“In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing 7 million people prematurely every year from diseases such as cancer, stroke, heart and lung disease. Around 90% of these deaths are in low- and middle-income countries, with high volumes of emissions from industry, transport and agriculture, as well as dirty cookstoves and fuels in homes.”
WHO then goes on to link air pollution with climate change, the common factor being the burning of fossil fuels. According to WHO, climate change is expected to cause as many as 250,000 deaths per year beginning about 2030.
That link is obvious, but somewhat unpersuasive from the point of view of action. Air pollution is a result of many factors that have little or nothing to do with climate change. There are many pollutants in the air that are not the result of fossil fuels, and some of these are more dangerous than the smoke emitted from the smokestacks of a coal-burning steel mill or electric generating plant, e.g., asbestos.
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For example, many people in less-developed parts of the world cook over small, primitive stoves that essentially sit on the floor in poorly-ventilated huts or houses. This means that the air that these people are breathing is heavily polluted, not only with the smoke that these stoves (or sometimes open fires) generate, but by the vapors that are released from the foods that they are cooking. Currently, one of the efforts being made to lessen exposure to such pollutants is the distribution of small, efficient stoves with venting mechanisms that can be adapted to many uses.
It is possible to remove the solid particles that cause disease from the emissions from fossil fuel ignition. Removing the carbon dioxide that causes climate change is another matter altogether. A planet with minimal air pollution but undiminished carbon dioxide emissions is entirely possible. The diseases caused by air pollution would sharply drop in frequency, while the increase in global temperatures would continue.
And, on the other hand, it is also possible to imagine a planet in which carbon dioxide in the atmosphere is maintained at a constant level such that there is no increase in global temperature, but where the air is so polluted that all kinds of diseases thrive – perhaps something like Manchester, England, in the 19th century.
In short, actions to lessen air pollution will not necessarily address climate change, nor will actions to address climate change necessarily reduce air pollution.
“Noncommunicable diseases, such as diabetes, cancer and heart disease, are collectively responsible for over 70% of all deaths worldwide, or 41 million people. This includes 15 million people dying prematurely, aged between 30 and 69.
“Over 85% of these premature deaths are in low- and middle-income countries. The rise of these diseases has been driven by five major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets and air pollution. These risk factors also exacerbate mental health issues, that may originate from an early age: half of all mental illness begins by the age of 14, but most cases go undetected and untreated – suicide is the second leading cause of death among 15-19 year-olds.”
The statistic that catches the attention of Doc Gumshoe in this case is the 15 million people dying prematurely, defined as between the ages of 30 and 69. The other 26 million, ages 70 and higher, might be said to have lived relatively normal life-spans – the Biblical three-score years and ten. But if those major risk factors were effectively addressed, normal life-spans could well increase, perhaps to four-score years and ten. Then, would the deaths of persons between the ages of 30 and 89 then be defined as “premature”?
However, no matter how a normal life-span is defined, there will always be an immense number of people succumbing to those noncommunicable diseases. Or, if not to the trio mentioned by WHO – diabetes, cancer, and heart disease – to the next killer that comes along, immortality not having been achieved by the human species, at least as of now. I am not sure whether the deaths of people who have attained a normal life-span and beyond should be considered as a global health threat.
To return to the issue of premature death, the specific risk factors mentioned by WHO certainly require action at the most comprehensive as well as individual level. Among other plans, WHO has an initiative to work with governments around the world to reduce physical inactivity by 15% by the year 2030.
I am dubious whether addressing WHO’s five major risk factors would have much effect in terms of reducing or managing mental illness. In some parts of the world it is neither treated nor even recognized. It’s estimated (don’t ask me how the estimators arrive at these figures) that in China alone there are about 173 million mentally ill persons, a huge majority of whom are entirely untreated. This is in part due to the stigma that accompanies mental illness. Family members of a mentally-ill person are more likely to attempt to shield that person’s signs of mental illness from observation than they are to seek any kind of treatment. A child or a relative with what would be seen in other nations as clear signs of mental illness is viewed as a source of shame and hidden from observation. Much the same situation exists in other Asian nations and in Africa, with the result that treatment for mental illness is rare.
Global influenza pandemic
“The world will face another influenza pandemic – the only thing we don’t know is when it will hit and how severe it will be. Global defenses are only as effective as the weakest link in any country’s health emergency preparedness and response system.
“WHO is constantly monitoring the circulation of influenza viruses to detect potential pandemic strains: 153 institutions in 114 countries are involved in global surveillance and response.”
Whether or not there is a global influenza pandemic depends on the proportion of people who have received an influenza vaccine. Of course, at present the flu vaccine is only as effective as the best guess as to which strains of the influenza virus will be the most menacing in the coming season, and, as we know, those best guesses can be considerably wide of the mark.
However, as reported in the previous Doc Gumshoe epistle, “Short Bits for a Short Month,” a universal flu vaccine is in the works. The maker, a UK biotech called hVivo, has just posted very positive Phase 2b results which strongly suggested that their vaccine, for now called FLU-v, would confer resistance to any strain of flu that had any one of four conserved immunoreactive regions. Since these regions are conserved regardless of whether the virus mutates, the vaccine would continue to be effective for much longer that the duration of effectiveness of the current generation of vaccines.
But even if a universal flu vaccine should become available, “available” means different things in different parts of the world. In the highly-developed world we inhabit, I would venture that a majority of the populace would be vaccinated – a larger proportion of the populace than is now vaccinated with the seasonal vaccine. But that proportion would diminish steeply in the less-developed parts of the planet.
WHO’s emphasis with regard to the probability of another global influenza pandemic seems to be on response rather than prevention. That is certainly reasonable given the effectiveness of the current flu vaccines. In our part of the world, many of us get the current flu vaccine. Moreover, we’re confident that if, perchance, we nevertheless contracted influenza, we have excellent doctors and hospitals standing by to restore us to health. That is not the case in many parts of the world, and WHO is rightly attempting to focus attention on that issue.
Fragile and vulnerable settings
“More than 1.6 billion people (22% of the global population) live in places where protracted crises (through a combination of challenges such as drought, famine, conflict, and population displacement) and weak health services leave them without access to basic care.
“Fragile settings exist in almost all regions of the world, and these are where half of the key targets in the sustainable development goals, including on child and maternal health, remains unmet.
“WHO will continue to work in these countries to strengthen health systems so that they are better prepared to detect and respond to outbreaks, as well as able to deliver high quality health services, including immunization.”
WHO lists drought, famine, conflict, and population displacement as “challenges” without mentioning another issue which is strongly linked to those four challenges. That issue is population growth, which is poorly controlled in those same parts of the world, and certainly contributes to conflict and population displacement, and likely also to famine. I can certainly understand any reluctance on the part of the World Health Organization to point to population growth as an underlying cause of some of those issues, since they would then be vulnerable to the charge that they are “blaming the victim.” Yet several of the “challenges” they cite will be difficult or impossible to meet without some form of population control.
“The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy.
“Resistance to tuberculosis drugs is a formidable obstacle to fighting a disease that causes around 10 million people to fall ill, and 1.6 million to die, every year. In 2017, around 600 000 cases of tuberculosis were resistant to rifampicin – the most effective first-line drug – and 82% of these people had multidrug-resistant tuberculosis.
“Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment. WHO is working with these sectors to implement a global action plan to tackle antimicrobial resistance by increasing awareness and knowledge, reducing infection, and encouraging prudent use of antimicrobials.”
The emergence of pathogens that are resistant to antimicrobials is not a mystery. Those nasty little microbes are simply behaving according to the principles of evolution. Like all living creatures, microbes – whether pathogenic or not – mutate as they reproduce, meaning that the offspring are not absolutely identical to the parents. Microorganisms reproduce by dividing, and making copies of the parental DNA. But those copies are not always perfectly accurate. Sometimes the errors in transcription mean that the offspring are defective, and when that happens, the offspring do not survive. But sometimes the errors in transcription give those offspring a survival advantage. That’s what sometimes happens when the microbes are exposed to an antimicrobial. Some of the pathogenic microbes may develop a characteristic that enables them to fight off the antimicrobial. When that happens, those mutated microbes have a clear survival advantage. As succeeding generations of microbes are exposed to the antimicrobial, the microbes without that mutation get killed off, while the mutated microbes live and reproduce. Those mutated microbes may then spread to other hosts, and eventually, a new breed of microbes that are resistant to a particular antimicrobial or to a group of antimicrobials becomes a threat to the community.
There are many ways that resistance to antimicrobials occurs. It should be noted that because antimicrobial resistance is, in a certain sense, completely normal, it will continue to occur, no matter how careful we are in the employment of antimicrobials. However, there are certain actions that especially favor the creation of resistant pathogens, and those should be avoided.
One is failing to complete the full course of a prescription. When little Timmy develops a cold and is taken to the pediatrician, the pediatrician may prescribe an antimicrobial for Timmy, to be taken for a certain number of days. But then, when Timmy feels just fine after just one day on the drug, his mother doesn’t give him any more pills and puts the container back into the medicine cabinet. Chances are Timmy now harbors some resistant pathogens. If Timmy had continued taking his medicine, it’s possible or even likely that the resistant pathogens would also have been wiped out, because resistance is not an absolute. Sometimes it works to hit them again. However, when Timmy’s mother stops the drug, the resistant little bugs live on in Timmy, perhaps doing him little or no harm. But then, in a few weeks, Timmy’s grandmother comes to visit, and Timmy passes on his resistant pathogen to that enfeebled elderly lady…
Another is the indiscriminate use of a drug for prophylaxis in a large population. For example, newborns in India are routinely treated with antimicrobials, and sometimes these antimicrobials are the latest, most effective antimicrobials available, which are already being manufactured generically shortly after their introduction. In this case, the widespread use of these drugs is compensation for the inadequate sanitation that prevails, but it’s hard to imagine a practice that more effectively fosters resistance to antimicrobials.
And another is the use of antimicrobials in animals, not to counter any particular disease that may affect the animals, but simply as a prophylactic measure, to keep them growing nicely for human consumption. Those antimicrobials may wind up in the food we eat and also in the water supply.
Antimicrobial resistance also threatens the development of new drugs, in a roundabout way. When a new antimicrobial is introduced, prudent medical practice may suggest that the new agent be held in reserve, as the backup drug in case the older, more widely-used drugs prove to be ineffective. Thus, a pharmaceutical company spends billions to launch a new antimicrobial only to find that it doesn’t get used as a first-line drug. That discourages further development. And it doesn’t help when the new antimicrobial is quickly copied elsewhere and used indiscriminately.
Ebola and other high-threat pathogens
“In 2018, the Democratic Republic of the Congo saw two separate Ebola outbreaks, both of which spread to cities of more than 1 million people. One of the affected provinces is also in an active conflict zone.
“This shows that the context in which an epidemic of a high-threat pathogen like Ebola erupts is critical – what happened in rural outbreaks in the past doesn’t always apply to densely populated urban areas or conflict-affected areas.
“At a conference on Preparedness for Public Health Emergencies held last December, participants from the public health, animal health, transport and tourism sectors focused on the growing challenges of tackling outbreaks and health emergencies in urban areas. They called for WHO and partners to designate 2019 as a “Year of action on preparedness for health emergencies”.
“WHO’s R&D Blueprint identifies diseases and pathogens that have potential to cause a public health emergency but lack effective treatments and vaccines. This watch list for priority research and development includes Ebola, several other haemorrhagic fevers, Zika, Nipah, Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS) and disease X, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic.”
WHO is correct when it states that the context in which these disease outbreaks occur is critical. The Ebola outbreak currently taking place in the Democratic Republic of Congo, which had resulted in 907 cases and 568 deaths by the beginning of March, has become far more difficult to treat than it otherwise could be because of the attitude of the populace in which the outbreak is happening. The outbreak is taking place is in the war-torn north-eastern part of the country, bordering Rwanda, South Sudan, and Uganda. The people in the area do not entirely understand the way Ebola is transmitted, and in particular they are unaware of the extreme danger associated with the bodies of persons who have died of the disease. They have burial customs meant to honor the spirit of the victim, and they deeply resent the interference of authorities in their carrying out of burial customs. The authorities, on their part, have little sympathy for these customs, and have developed a reputation for riding rough-shod over the locals as they impose strict sanitary rules on all matters Ebola-related, especially contact with the sick and the corpses of victims.
Thus, the aid teams are regarded as enemies by the local people, and the efforts of the aid team to curb the disease by whatever means are frustrated by the very people whom these measures are intended to help. Dr Joanne Liu, president of Doctors Without Borders, was recently quoted as saying “Ebola responders are increasingly seen as the enemy. In the last month alone, there were more than 30 different incidents and attacks against elements of the response. The existing atmosphere can only be described as toxic.”
The Ebola vaccine has helped to some degree. More than 80,000 people have been vaccinated, but aid workers have been criticized as to why some persons have been vaccinated, while others seeking vaccines have been turned away.
Aid teams may also be confused with semi-military groups that have nothing to do with fighting the Ebola outbreak. For example, in two areas of Congo, residents were barred from voting in the election, supposedly because of concerns about the spread of Ebola. However, residents of those areas concluded that being barred from voting had nothing to do with Ebola and everything to do with influencing the outcome of the election.
A similar situation obtains in Nigeria with regard to polio vaccines. I’ll describe it in detail below, when we discuss Vaccine Hesitancy, as WHO politely calls it. However, the situation in the Congo underscores the reality that combating disease is vastly different in different areas of the world, and it requires skill and understanding in many spheres besides health care.
Weak primary health care
“Primary health care is usually the first point of contact people have with their health care system, and ideally should provide comprehensive, affordable, community-based care throughout life.
“Primary health care can meet the majority of a person’s health needs of the course of their life. Health systems with strong primary health care are needed to achieve universal health coverage.
“Yet many countries do not have adequate primary health care facilities. This neglect may be a lack of resources in low- or middle-income countries, but possibly also a focus in the past few decades on single disease programmes. In October 2018, WHO co-hosted a major global conference in Astana, Kazakhstan at which all countries committed to renew the commitment to primary health care made in the Alma-Ata declaration in 1978.
“In 2019, WHO will work with partners to revitalize and strengthen primary health care in countries, and follow up on specific commitments made by in the Astana Declaration.”
On this subject, Doc Gumshoe presents the seal of approval to the World Health Organization. Primary care is indeed primary when it comes to meeting the health needs of individuals anywhere in the world. A Doc Gumshoe diatribe, entitled “Looking Out for Your Own Well-Being,” which posted on April 20 of 2018 was dedicated to the importance of primary care. An important source for that posting was the work of an advocate for primary care named Barbara Starfield. Here’s a small quote from that piece:
“The Starfield paper reviews a colossal amount of evidence about the effects of primary care on health. The more than six hundred references provide three types of evidence on those interrelations.
- Studies that demonstrate that health is better in areas with more PCPs.
- Studies that demonstrate that individuals who receive health care from PCPs are in better health.
- Studies that demonstrate that the specific characteristics of primary care, as defined above, are associated with better health.”
Starfield also refers to the surprising improvements in the health of the Cuban population since the nation began emphasizing community health workers. Regardless of the many seriously negative results of the Castro regime, the Cuban health system has been a remarkable success, such that both infant mortality and life expectancy in Cuba are now superior to those health indices in most of the rest of Latin America, and nearly on a par with those in the US.
“Vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved.
“Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence.
“The reasons why people choose not to vaccinate are complex; a vaccines advisory group to WHO identified complacency, inconvenience in accessing vaccines, and lack of confidence are key reasons underlying hesitancy. Health workers, especially those in communities, remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines.
“In 2019, WHO will ramp up work to eliminate cervical cancer worldwide by increasing coverage of the HPV vaccine, among other interventions. 2019 may also be the year when transmission of wild poliovirus is stopped in Afghanistan and Pakistan. Last year, less than 30 cases were reported in both countries. WHO and partners are committed to supporting these countries to vaccinate every last child to eradicate this crippling disease for good.”
WHO is pussy-footing here. Yes, it might be politically unwise to label the people who refuse to their kids vaccinated with a less flattering term, like “vaccine deniers,” or “anti-vaxers,” but that’s what they are. These folks will cite their reasons, such as the myth that vaccinations cause autism. I am not going to go into detail on that subject other than to state that the myth is founded upon a deliberate outright lie by Andrew Wakefield, a former doctor who has since lost his license for falsifying that data. Lancet, the journal in which that falsehood was published, also retracted the article in which Wakefield made that phony claim.
But vaccine deniers have a range of reasons for refusing vaccination. Some are hard to argue with, like religious objections, although as far as I know none of the major religious groups has a stated objection to vaccinations. A more general objection is that vaccines aren’t 100% reliable, so why bother with a vaccine? Many of these illnesses that vaccines supposedly protect you from are no big deal, they say. Measles and mumps? An excuse to stay home from school. Besides, hardly anyone gets measles any more, say the deniers.
Up to a point, those vaccine deniers are right. Hardly anyone – in developed parts of the world – gets measles and mumps any more. Just like no one gets small pox or polio. But that isn’t because the disease-causing pathogens have vanished. It’s because of a phenomenon that doesn’t get much attention – a phenomenon called “herd immunity.” Stated simply, the fact that so many people have been vaccinated against certain diseases means that those nasty pathogens haven’t found hosts. Herd immunity will protect one unvaccinated child in a classroom of vaccinated kids, and will even compensate for the incomplete effectiveness of a vaccine .
But if the percentage of the unvaccinated start to grow, that presents a risk, to the unvaccinated and the vaccinated alike. An instance of that risk has occurred in Rockland County, New York, where (as I write this) there are 156 cases of measles, in an area where measles had been eradicated. Authorities think that the origin of this outbreak was immigrants from Israel. Although there is no specific doctrinal injunction against vaccination in Orthodox Judaism, some of the adherents have an objection to vaccination and claim exemption on religious grounds. As they put it, “if God wants you to get the measles, who are we to interfere?”
In an effort to contain the spread of this measles outbreak, Rockland County has issued a ban on unvaccinated children in all public places. This ban has been decried as being anti-Semitic. And it will certainly be difficult to enforce.
However we look at it, the measles outbreak in Rockland County underlines the difficulty facing WHO in overcoming “vaccine hesitancy.”
Not to forget w