New American Public Health Association policy statements address gun suicides, tuberculosis prevention, global food security and more

Summaries of 2018 APHA policy statements adopted by the Governing Council in San Diego

San Diego, Nov. 13, 2018 – The American Public Health Association Governing Council adopted 12 new policy statements at its 2018 Annual Meeting and Expo in San Diego today, covering topics from gun suicides to tuberculosis prevention, global food security and more.

The following are brief descriptions of the 12 policy statements adopted by the Governing Council at the Annual Meeting. One of the new policy statements is a latebreaker, meaning it was not open to the same review as the other 2018 policy statements and will serve as an interim policy statement until reviewed by the Governing Council at its regular 2019 meeting. For more information on any of these policy statements, email policy@apha.org.

These brief descriptions are not comprehensive and do not include every point, statement or conclusion presented in the policy statements. For the full policy statements, which will be posted in early 2019, visit www.apha.org.

20181 Reducing global child mortality rates — Noting that one child younger than 5 worldwide dies of diarrhea every minute and that oral rehydration salts and zinc treatment can prevent many such deaths, calls on federal officials to appoint a U.S. global “Children’s Champion” charged with coordinating U.S. activities to reduce diarrhea-related mortality and serving as a global voice for children’s health. Encourages U.S. global health programs to fund investments to improve the supply of oral rehydration salts and zinc, fund innovations in home-based diarrhea treatment, and train local health providers in treatment guidelines, among other measures. Urges public health professionals and organizations to support efforts to reduce diarrhea-related deaths in young children and work toward increasing public-private partnerships that scale up oral rehydration salts and zinc treatment by at least 30 percent within three years.

20182 Addressing potential health impacts of fracking — Because unconventional oil and gas extraction — often known as fracking — poses a range of known and unknown risks to public health and the environment, including risks to drinking water, air quality and worker health, recommends that unconventional oil and gas development cease and that a strategic phase-out of existing development be encouraged where possible. Calls for policies that explicitly compare the economic and public health trade-offs of fracking, that require environmental impact assessments and that minimize greenhouse gas emissions. Encourages federal, state and local agencies to adopt a precautionary approach to unconventional oil and gas activities, including discouraging the use of chemicals with unknown health risks. Also calls for the elimination of unconventional oil and gas exemptions from federal worker safety rules and encourages federal health officials to establish an industry-wide worker health registry.

20183 Ensuring a healthy energy future — As communities move toward to non-fossil fuel and alternative energy sources, calls on stakeholders across sectors to monitor, evaluate and support effective strategies to transition to healthier, more efficient energy supplies. Regarding coal, calls on the Mine Safety and Health Administration to vigorously enforce worker health and safety standards. Also calls on officials to suspend new coal-fired power plants and cancel plans for future plants. Urges Congress to set fuel economy and emissions standards for vehicles, and urges car manufacturers to begin a complete phase-out of fossil fuel-dependent vehicles. Encourages federal officials to develop effective energy efficiency standards for homes and commercial buildings, and calls on people, families, businesses and governments to expand the adoption of alternative energies, such as wind and solar.

20184 Reducing gun-related suicides — With U.S. suicide rates increasing by nearly one-third over the last 20 years and considering that guns are involved in more than half of U.S. suicide deaths, calls on advocates and professional associations to adopt and promote guidelines for mental health providers on screening for guns in the home and to equip them with information on local offsite gun storage options. Urges state public health agencies to collaborate with public safety and mental health agencies to advocate for increasing the availability of temporary gun storage outside the home. Calls on public health agencies to partner with gun owners and suicide prevention professionals to advocate for increased funding for gun-related suicide research, including research on developing effective marketing campaigns on gun-related suicide prevention.

20185 Understanding, treating violence as a public health issue — With national data showing an increase in violent deaths, such as gun-related homicides and suicides, as well as research finding long-term health effects from childhood exposures to violence, calls on health departments to collect, analyze and report data on violence, including details on how violence impacts historically marginalized communities. Encourages community health programs to start programs that detect and interrupt the transmission of violence using professionally trained workers. Also encourages health providers to screen patients for domestic violence, past exposure to violence and behavioral problems that can lead to violence, all while using a trauma-informed and culturally competent approach. Calls on federal, state and local governments to invest in public health approaches to violence prevention, and recommends that federal agencies help establish an active surveillance system for monitoring violence in communities.

20186 Regulating electronic nicotine delivery products — With the use of electronic nicotine delivery systems increasing among all U.S. demographic groups and little known about their long-term safety or efficacy in helping people quit cigarettes, calls on the Consumer Product Safety Commission to add nicotine to its list of substances covered by regulations and to require special packaging and warning labels for such products. Also calls on Congress to amend the Prevent All Cigarette Trafficking Act to include electronic nicotine delivery systems. Encourages federal agencies and health organizations to fund research on the short- and long-term health effects of such products on both users and those subject to secondhand exposures. Calls on state and local officials to enact laws prohibiting the use of electronic nicotine delivery systems in enclosed public spaces and places of employment.

20187 Preventing tuberculosis among health workers — With tuberculosis causing nearly 2 million deaths worldwide in 2016 and with health care workers at higher risk of infection than the general population, urges national and state governments to develop and implement policies that strengthen workplace health and safety programs that focus on prevention and education. Calls for workers’ compensation programs that provide adequate tuberculosis treatment and counseling, paid leave and death benefits. Recommends workplace programs that have rigorous respiratory protection components, improve exposure control efforts inside hospitals, promote new diagnostic strategies, and provide counseling to help workers cope with the side effects of tuberculosis treatment. Calls on the Centers for Disease Control and Prevention to increase funding for tuberculosis research, including more support for research efforts focused on developing a vaccine for the disease.

20188 Advancing the health of refugees — With global instability contributing to historic levels of displaced people and knowing that refugees face significant health challenges, calls on the U.S. government to fully invest in and cooperate with the international community in efforts to prevent conflict and to reaffirm the New York Declaration for Refugees and Migrants and its goal of coordinating a multi-sector response to the refugee crisis. Encourages U.S. officials to work with state and local partners to coordinate housing, educational and health needs among refugees. Urges health care systems and providers to tailor their services to meet the needs of refugees, including the use of trauma-informed, culturally competent care. Calls on the U.S. government to work cooperatively to ensure safe passage for refugees, and urges the international community to adopt legal protections for displaced people.

20189 Achieving health equity in the U.S. — With research documenting clear disparities in morbidity and mortality, particularly among racial and ethnic minority groups, calls on federal officials and members of Congress to fully fund the Affordable Care Act, the National Prevention Strategy and Implementation Plan, and the National Partnership for Action to End Health Disparities. Calls on federal public health agencies, as well as public health organizations, to develop and implement evidence-based toolkits that communities can use to reach vulnerable populations. Calls on state and local officials to support social policies to improve education, income, housing, jobs and transportation, and urges state and local government to work with urban planners and health professionals to integrate health considerations into planning, policy and decision-making. Encourages people and communities to advocate for the enforcement of civil rights and disability laws.

201810 Supporting global food security — With hunger still a daily challenge for more than 815 million people worldwide, calls on U.S. leaders to ensure adequate funding for U.S. Agency for International Development programs that improve food security and encourages leaders to fund efforts focused on preventing and mitigating the effects of climate change on world food production. Encourages U.S. leaders to sign or ratify relevant United Nations conventions that support food security, such as the Convention on the Rights of the Child, the UN Resolution to Support Breastfeeding, and the Convention on the Elimination of All Forms of Discrimination Against Women. Urges the U.S. government, foundations and other donors to mobilize funding and resources to increase the scale, scope and impact of food security efforts. Calls on U.S. officials to support the creation of a system to collect and interpret global dietary data.

201811 Addressing police violence as a public health issue — With law enforcement violence — including death, injury, trauma and stress — often disproportionately affecting marginalized populations, calls on federal agencies, localities and states to add death and injury by legal intervention to their list of reportable conditions. Calls on Congress to fund the National Institute of Justice and the Centers for Disease Control and Prevention to conduct research on the health consequences of law enforcement violence, with a particular focus on disproportionate burdens among people of color, people with disabilities or mental illness, people living in poverty, people experiencing homelessness, immigrant populations, and lesbian, gay, bisexual and transgender populations. Urges governments and law enforcement agencies to review policies that can lead to disproportionate violence against specific populations. Calls on governments to allocate funding from law enforcement agencies to community-based programs that address violence and harm without criminalizing communities, including restorative justice programs.

LB-18-12 Opposing family-child separations at the U.S. border — With the separation of immigrant children and families at the U.S.-Mexico border a public health crisis with the potential for long-lasting negative health impacts, calls on federal officials to permanently halt such separations unless there is an imminent, ongoing threat to the child’s safety in a respective parent’s care. Urges the federal government to collect relevant data to ensure that children and parents can be located if separated. Calls on federal officials and agencies, as well as contractual partners, to offer culturally competent resources and support to reunite separated families. Urges public and private funding agencies to support additional research to understand the mental, physical, spiritual and cultural consequences of separating families, including the separation of lactating mothers and their babies. Recommends that such research examines the roles and history of racism, xenophobia and inequality in the creation of family separation policies.

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The Man-Made Health Crisis in Yemen Cannot Wait for the End of the War: What Can Humanitarian Actors Do?

In 2017, only a few years into a brutal civil war, Yemen reported a cholera outbreak of one million cases, more than half of which were children, making it the worst outbreak in history. At the time, Yemen was already in the midst of what was considered a dire humanitarian crisis, with more than 20 million citizens affected. A year later, the situation has become even more critical, with the United Nations warning of “the worst famine in 100 years” within the next few months if the war continues. Many more Yemenis have died from lack of access to basic needs, such as clean water, food, medical care, and sanitation, than fighting.

Yemen was already considered one of the poorest countries in the world before the war, with low rankings on all indicators of human development. However, the war has completely devastated the nation and the health of its citizens. Multiple outbreaks of infectious disease such as cholera and malaria, high rates of food insecurity and malnutrition, tens of thousands of trauma-related injuries, and widespread mental distress have exhausted the healthcare system. Almost 80% of Yemeni children reported symptoms of post-traumatic stress disorder, an exceedingly high rate even when compared to other conflict-affected nations. Healthcare workers, many of whom have been unpaid for months or years, have been kidnapped, harassed, and killed, while hospitals have been directly attacked and bombed. Medical facilities are left with barely functional equipment, empty supply shelves, and sometimes no medical staff at all. One article detailed how the grandmothers of an infant born four months premature brought him to a hospital where they found no physicians, who had all walked out in protest the previous day after one of them was beaten up by one of the hospital guards. The grandmothers attempted to place the infant into an incubator themselves, but both machines were broken.

In April 2018, as long-term wars in Syria, Iraq, Afghanistan, and South Sudan rage on, as a probable Rohingya genocide in Myanmar goes into its second year, and as natural disasters strike with increasing frequency and strength around the world, United Nations Secretary-General António Guterres called Yemen the world’s worst humanitarian crisis. The International Rescue Committee reports that 16 million people (almost three quarters of the country’s population) cannot access basic medical care, with more than half of the country’s already limited health facilities destroyed. What is left of the health system is Yemen is almost entirely sustained by contributions of medicines, supplies, and money by international donors. An estimated 9.5 million people were provided some form of medical intervention by the WHO and their partners in 2017 alone. However, the politics of the conflict have rendered even this emergency care inconsistent and unreliable. Médecins Sans Frontières (MSF) has occasionally had to cease providing services in some parts of the country due to sustained attacks on their facilities and staff by both Houthi fighters and Saudi warplanes. An intermittent Saudi blockade on Yemen’s ports has prevented humanitarian agencies from bringing in food, medicines, and fuel, and even when supplies can enter the country, distribution networks are insecure due to airstrikes and combatants. Like many of the world’s worst humanitarian crises, the devastating circumstances are almost entirely man-made. It is not lack of money or resources that has brought Yemen to this point- the entirety of the budget that the Yemen Ministry of Health proposed for 2018 amounts to just three days of what Saudi Arabia alone spends on the war campaign.

Yemen would not be the first country to see the health and well-being of its citizens used as a bargaining chip in an intractable conflict. Alex de Waal, a professor at Tufts University and the Executive Director of the World Peace Foundation, called these types of man-made famines and humanitarian emergencies “economic war,” which is much more difficult to classify under international humanitarian law than a violent bombing campaign or overt starvation tactics. “The coalition air strikes are not killing civilians in large numbers but they might be destroying the market and that kills many, many more people,” he told The New Yorker. Couple destroyed markets with ruined medical facilities and it is clear that the quality of life of human civilians will be devastated for the long term. This is by no means a new wartime strategy. Perpetrators try to bring their enemy -combatants and civilians who are in any way affiliated with them- to the brink of humanitarian desperation to force concessions.

What is needed is immediate and meaningful action on the part of the actors involved in the war as well as the international community that is both providing the weapons and aid that sustain the conflict. Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, outlined three requests to ease the humanitarian burden in the country. First, he called for guaranteed safe access throughout all of Yemen so that aid agencies can provide goods and services. Second, he demanded an end to all attacks on health workers and facilities. Lastly, he insisted that civilian health workers who remain in Yemen must be paid for their vital services. Similarly, a report by the International Peace Institute recommends that the international community, especially the UN Security Council, enforce compliance to international humanitarian laws and norms. Humanitarian actors must also work to coordinate their responses by sharing data, involving local stakeholders, and collectively pushing against blockade efforts. While meeting immediate needs is the clear priority, prevention and long-term health capacity building must also be pursued to both avert widespread catastrophe and prepare for the Yemen that will remain after the war ends. None of these actions must wait for a political end to the war, which is the only way to truly protect civilian life and ensure basic access to the human rights of food, water, sanitation, and health. However, these actions can push back against efforts by all sides of the conflict to use the health and well-being of Yemen’s citizens as pawns in the achievement of their aims.

 

Three Observations from UN High Level Health Meetings

During the United Nations (UN) General Assembly, two historical High-Level meetings in the realm of health were held addressing ailments that afflict individuals from every corner of this fragile planet. The first UN High-Level meeting on Tuberculosis (TB), focusing on preventing and treating this elusive disease, was held on Wednesday, September 26th which finally put TB in a global spotlight. Additionally, the third UN High-Level Meeting on Non-Communicable Diseases (NCDs), under the theme “Scaling up multi‑stakeholder and multisectoral responses for the prevention and control of non‑communicable diseases in the context of the 2030 Agenda for Sustainable Development,” took place on Thursday, September 27th. World leaders and their ministers, non-government organizations (NGOs), and other stakeholders partook in these crucial meetings to curtail the suffering these various diseases cause. For each of these meetings, governments approved drafts of political declarations that commit countries to follow through with health policy, funding, and a multisector approach to these disorders. The following summarizes key points and commitments from each of the high-level meetings:

UN High-Level Meeting on Tuberculosis

  • A commitment to mobilize $13 billion for universal access to quality prevention, diagnosis and treatment
  • $2 billion for research and development of new drugs, diagnostics, vaccines, and other tools.
  • Commit to provide diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022 (including 3.5 million children, and 1.5 million people with drug-resistant tuberculosis including 115,000 children with drug-resistant tuberculosis)
  • Pledge of 30 million people (including 4 million children under five years of age, 20 million other household contacts of people affected by tuberculosis, and 6 million people living with HIV and AIDS) to receive preventive TB treatment by 2022
  • Promise to overcome the global public health crisis of multidrug-resistant tuberculosis through actions for prevention, diagnosis, treatment and care, including compliance with stewardship programs to address the development of drug resistance
  • Oblige to consider how digital technologies could be integrated into existing health systems infrastructures and regulation for effective tuberculosis prevention, treatment and care
  • Commit to provide special attention to the poor, those who are vulnerable, including infants, young children and adolescents, as well as the elderly and communities especially at risk of and affected by tuberculosis.

UN High-Level Meeting on NCDs

  • Commitments to reduce NCD mortality by one third by 2030, and to scale-up funding and multi-stakeholder responses to treat and prevent NCDs
  • Health systems should be strengthened — and reoriented — towards the achievement of universal health coverage and improvement of health outcomes
  • Greater access to affordable, safe, effective and quality medicines and diagnostics
  • A commitment to ambitious multisectoral national responses, integrating action on prevention and control with promotion of mental health and well‑being
  • Increasing energies to reduce tobacco use, harmful alcohol use, unhealthy diets and physical inactivity through cost‑effective, evidence‑based interventions to halt obesity
  • To develop a national investment plan in order to raise awareness about the national public health burden caused by non‑communicable diseases and health inequities

While these are not all-inclusive of the commitments between nation states at these two meetings, they highlight the prominent concerns leaders in both the political and health dominion share. However, special attention should be brought to the dialogue held before and after the duration of the meetings. These discussions reveal the true apprehensions that world leaders fear affects their citizen’s health and well-being. The following are three observations from these two UN high-level meetings that may provide some significance in the future battle with TB and NCDs.

1. Is health trending towards being a right rather than a commodity among world leaders?

Before the UN high-level meeting on TB came to fruition, there was a highly controversial commitment in the declaration that concerned high-income countries like the United States. The commitment was centered around access to affordable medications, in particular, generic medications. The concerned countries had expressed reservations about language supporting UN member states’ rights to interpret and implement intellectual property rights in a way that defends public health and encourages access to medicines. Global health advocates believed this point as being essential to equitable access to medications across the world – treating health as a right rather than a product. In the end, health as a right was included into the declaration, through the leadership of South Africa and Médecins Sans Frontières (MSF), despite upsetting these powerful nation states. In addition, at the high-level meeting on NCDs, language was included that stated a similar commitment – to affirm the rights of UN member states to use intellectual property flexibilities to safeguard public health. Although the fight against these two devastating classes of diseases is certainly at the forefront of leaders’ minds, the seemingly endless interchange of health as a right and health as a commodity seems to be finally leaning towards the betterment for humanity – health as a right.

2. Technology and Policy – Finally Uniting to fight TB & NCDs

Throughout the UN General Assembly last week, several reports, policies and studies were released or highlighted that may prove to shape the future treatment of TB & NCDs. The following list are just a few of the major contributions that various sources released:

Health care professionals throughout the world realize that diseases need to be undertaken in a biosocial manner – utilizing both technology and policy. The outcomes that resulted from last week’s reports reaffirm that political leaders realize that the true way to overcome these burdens is to address them through this manner.

3. Multi-Sectoral Approaches – How should they be conducted?

One of the biggest initiatives in global health is the necessity to bring together all stakeholders in disease management in order to properly address the situation. With a vast array of input and ideas, different perspectives, and an atmosphere of collaboration, global health is trending rapidly in this manner – with a significant portion of the world partaking in multi-sectoral approaches already. However, the manner in which these are conducted can vary within countries and between NGOs and governments. Although these remarks may not apply to every country, the following statements made by world leaders may provide some insight into how a country could carry out these approaches:

  • A representative from the Netherlands state that including all stakeholders into the approach may cause conflict of interests – “The days are gone when the tobacco industry has a seat at the table” while also stating “multi-sectoral approaches are good, but governments should be in the lead” in reference to NCDs.
  • An NCD Alliance representative mentioned “it is for governments to determine their own priorities” and “civil society is ready to support, but governments must lead the way.” while simultaneously reaffirming her support for multi-sectoral approaches.
  • Finally, Gerda Verburg, coordinator of Scaling-Up Nutrition Movement explained that “Bigger companies are part of the problem, but we won’t succeed unless we make them part of the solution,” while also adding that she realizes that this is often difficult for civil society, and that “too often, they stand with their backs to the table where we need a critical dialogue with the private sector.” In addition, she supports the priority to “strengthen national systems.”

In a global society where the healthcare landscape is in constant motion, the ability to gather world leaders to commit to significant leaps of change is promising to all those who inhabit this planet. However, these commitments need to be followed up with action, funding, and the political will to properly solve the world’s number one killer and the deadliest infectious disease. The global health community should inspire and encourage their governments while correspondingly holding them accountable to adorn these commitments and continue to battle these overwhelming diseases.

 

World Rabies Day: Rabies Prevention Around the World

September 28th is World Rabies Day! This day of observance was created by the Global Alliance for Rabies Control (GARC) to spread awareness about the disease and educate others on how to prevent it. This year’s theme is Rabies “Share the message. Save a life.” 

Rabies is a preventable viral disease that affects only mammals and is transmitted through the saliva, cerebral spinal fluid or brain tissue of an infected host. If untreated, rabies is fatal. Most commonly, the disease is transmitted through a bite, but can also be transmitted if the infectious material gets directly into the eyes, nose, mouth or an open wound.  Rabies infects the central nervous system and causes a “disease of the brain.” Early symptoms of rabies can include fever, headache and fatigue – symptoms that are similar to many other illnesses such as the flu or common cold. However, as the disease develops, symptoms specific to rabies begin to appear: insomnia, paralysis, hallucinations, agitation, hypersalivation, difficulty swallowing and hydrophobia. The disease typically results in death within a few days after the onset of these rabies-specific symptoms.  

In the United States, reported rabies cases have shifted from mainly domestic animals to predominantly wildlife animal reports. Specifically, more than 90% of all rabies cases today are from wild animals. In addition, the number of rabies-related deaths in humans has decreased dramatically from 100 cases per year in the 1900’s to 1-2 per year. Our efforts to encourage prophylaxis after an exposure and the effectiveness of the vaccine have proven successful in decreasing rates of rabies in the United States.

However, rabies is found on every continent other than Antarctica and some continents struggle with the burden of rabies more than others. The overall death rate for rabies around the world is estimated at a staggering 59,000 people a year. Countries in Africa and Asia are affected by rabies disproportionately than the other continents and almost half of the victims of rabies in these countries are children younger than 15 years.

A main reason that such a young population affected is due to uncontrolled canine rabies in these countries. Canine rabies – which spreads from dog to dog – is actually the cause of 98% of human deaths globally. In the United States it has been eliminated because many people keep their animals vaccinated to prevent this type of rabies from re-entering our environment.  However, in many other countries, stray dogs roam around neighborhoods freely and when they contract rabies, they likely spread it to many people (primarily children) they come in contact with. Scientists predict that if 70% of dogs are vaccinated for rabies in an area, rabies can be controlled and human deaths will decrease.

Haiti has the highest number of human deaths by rabies – around 2 deaths per week. CDC and the Government of Haiti have started an animal rabies surveillance program (2013) to detect and have situational awareness of which regions of the country are greatly affected by rabies. In 2015, CDC also evaluated how many dogs were vaccinated in the country and found that only 45% of dogs received their shots. In addition, the total amount of dogs in the country was actually double the number they initially predicted. After these studies were done, the CDC helped train animal health workers to conduct large dog vaccination campaigns and continue rabies prevention efforts.  Many children started bringing their puppies to the events and were proud of their certificates ensuring their dogs had been vaccinated. It is CDC’s (along with the Government of Haiti) hope to reach a 70% vaccination rate among their dog population and sustain it for five years – long enough to create a ripple of effect among human deaths due to rabies.

CDC has helped establish similar campaigns in other countries. For example, they have trained animal control officers in Ethiopia to capture, vaccinate and release stray dogs as well as monitor human exposure cases and keep track of post-exposure prophylaxis (PEP) treatments.  In Vietnam, while there is not a high human death rate for rabies – 91 per year, the government spends an extraordinary amount of money on expensive PEP. It is much more feasible to vaccinate dogs than provide the costly post exposure treatment – $1.32 dollars vs one course of PEP at $153 dollars.  The CDC has helped support Vietnam in improving their rabies surveillance and coming up with new approaches to vaccinate their dogs and achieve the 70% canine vaccination goal.

The World Health Organization has been having meetings to discuss ways to eliminate rabies in Africa too. This past month, representatives from 24 countries in Africa met in Johannesburg to share information from a study they conducted regarding rabies.  The representatives pitched ideas for implementing the new recommendations for human rabies vaccines and how to improve surveillance dog vaccination campaigns. These meetings are exciting as they provide new insight for the global plan to achieve zero deaths from rabies.

Single countries like the Philippines, have proved to be great examples for national campaigns organized against rabies. The Philippines holds a nationwide World Rabies Day celebration as part of its educational outreach campaigns each year. The celebration has continued to grow yearly as more and more events are added to the agenda. It’s success emphasizes the importance of a program that is led and supported by their own national government and how the topic of rabies elimination is valued by the country’s leaders.

Overall, targeting the countries where rabies poses a significant risk and coming up with goals, campaigns and new tactics to eliminate rabies are substantial goals for the globe and many lives will be impacted by the CDC, the WHO and its many public health partners. But what can YOU do on a personal level that can also impact many lives? Here’s a quick checklist to follow:

  1. To start, you should always take your pet to the vet to get vaccinated for rabies regularly.
  2. Spaying or neutering your pet can also help with decreasing the amount of stray and potentially dangerous animals into your pet’s environment.  
  3. Always supervise your pet when they are outdoors. Wild high risk animals for rabies such as raccoons, coyotes or opossums can be in your backyard.
  4. Lastly, avoid contact with wild or unfamiliar animals (including dead animals). As tempting as it is to pet a stray cute kitten or dog, it is in your best interest to not feed or handle them.
  5. Continue sharing the message and saving lives!  Happy World Rabies Day!

An “epidemic of poor quality”: New study finds that poor healthcare quality leads to millions of deaths globally

This is part 1 of a 4-part series on global healthcare quality.

The Sustainable Development Goals (SDGs), the global effort led by the United Nations to prioritize and standardize development goals in every country for the period 2015-2030, offer ambitious targets when it comes to the world’s health. SDG 3 is focused entirely on outcomes of health and well-being, such as reducing maternal mortality, ending diseases like AIDS and malaria, achieving universal health coverage (UHC), and ensuring universal access to reproductive health care. Other SDGs, such as Goal 2 which calls for zero hunger and Goal 6 that aims for universal and equitable access to safe drinking water as well as equal and adequate access to sanitation, have obvious implications for health. However, a recent Lancet Global Health Commission, chaired by Associate Professor of Global Health Dr. Margaret Kruk of the Harvard T.H. Chan School of Public Health, has come to some surprising conclusions about health systems in low- and middle-income countries (LMICs). Despite a push in humanitarian advocacy and research to focus on increasing healthcare access in LMIC, it is the quality of healthcare that is received by patients in these environments that may require more of our attention. The Commission estimates that as many as 5 million die each year because they are receiving poor-quality healthcare- more than a million more people than those who die due to no access to care at all (3.6 million). That means that annually, 8.6 million people living in LMIC are dying due to poor-quality healthcare systems. Poor quality care can be dangerous for patients, provides misleading data points about healthcare system improvements, and may support corrupt and fraudulent behavior by parties with power in the health sector. Is it possible to achieve the SDGs in this environment?

Health systems should be judged on “what they do for people- not how many doctors they train.”

Dr. Kruk describes quality healthcare systems as based on three factors: effective care, trust of the people, and a system that is able to adapt, both in cases of acute emergencies and with a longer-term vision. While many advancements in access can be supported by metrics, it is possible that we haven’t been measuring some of the factors that really matter. Dr. Kruk told NPR that health systems should be judged on “what they do for people- not how many doctors they train.” The Commission’s study, which was published by the Lancet earlier this month, found that the millions of deaths each year that can be attributed to poor health systems included many deaths due to factors the SDGs explicitly seek to reduce, such as neonatal conditions and traffic accidents. While one of the central tenets of SDG 3 is UHC, the Commission argues that the quality of care “is not yet sufficiently recognized in the global discourse on UHC” and that countries undertaking policies that bring them to UHC “must put better quality on par with expanded coverage” to improve health. The Commission identifies several individual initiatives in LMIC that are developing mechanisms for quality measurement and improvement. However, it is clear that improving the quality of care has not received the effort that expanding access to care has achieved, which will undoubtedly undermine efforts to achieve the SDGs, even if UHC is attained. While expanding access to care must remain a global priority, we cannot discount the need to ensure that care given is of high quality as well. Several studies from LMIC during the period of the Millennium Development Goals (2000-2015) suggested that in some instances, expanding access to care did not lead to more positive health outcomes because the quality of the care received was poor. However, we still do not even have highly rigorous and consistent tools with which to measure healthcare quality across global contexts in a way that would allow for standardized measures and generalizable conclusions.

Aside from the historical focus on access to care by humanitarian and governmental actors, there a few other reasons that quality of care has not received the appropriate amount of attention of donors and policymakers. Healthcare systems in LMIC are generally disintegrated, with pockets of government services, humanitarian agencies, and private facilities operating throughout the country. This complexity allows for the intrusion of many political and logistical barriers to providing high quality care consistently. In the public sector, corrupt bureaucrats may opt to control who is able to receive jobs at healthcare facilities rather than allow for a merit-based system where poorly qualified staff could be replaced by qualified employees, regardless of political factors. For-profit providers who have disparate financial interests may not properly follow treatment or diagnosis guidelines that are critical to quality care. However, entirely closing low quality facilities would leave some citizens with no access to care at all.

Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, published a response to the Lancet Commission, agreeing that “nothing less than a revolution” is needed to ensure that high quality care is delivered in every health system around the world, an essential component of SDG 3. He posits that poor data is one of the largest barriers to improving healthcare quality, arguing that we must “go beyond counting simply what services are delivered to measuring how they are delivered.” He calls for a “global learning laboratory for quality,” where local lessons based on the “messy realities of health services” are prioritized, but where these lessons are then disseminated and can be implemented, measured, and compared in contexts around the world. Policymakers and practitioners working in LMIC must consider these factors when designing and implementing health services or research studies. The Lancet Commission points to five distinct foundations where learning and improvement in the process of care leads to higher quality: the needs of the population, governance in the health and non-health sectors, platforms of care, the healthcare workforce, and the tools needed to provide quality care. To avoid the rising “epidemic of poor quality” that the Commission found and to put LMIC on a successful path to achieving the SDGs, we can no longer ignore the pressing need to address healthcare quality just as much as access.