Lancet Editor in Chief Dr Richard Horton said: Politics ultimately determine our health
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The most hard-hitting message around World Tuberculosis Day 2018 for us
was on twitter
by Shirin Aliabadi, who tweeted that Dr Richard Horton (Editor in chief of
The Lancet) said, politics is, in many ways, the ultimate determinant of our
health. Decisions made by politicians determine our well-being in so many
ways.
Elected parliamentarians, especially in democracies, must be held to account,
as to why a tiny minority of rich people get richer and enjoy the highest
quality of life, whereas the majority of the populations are forced to live in
inhumane conditions that put them at increased risks of not just TB, but several
other infectious diseases, non-communicable diseases; as well as put them at
high risk of facing exploitation, abuse and violence at different levels.
Booker Prize winner and noted writer-activist Arundhati Roy had rightly said
that "There's really no such thing as the 'voiceless'. There are only
the deliberately silenced, or the preferably unheard."
Despite political decisions majorly determining our health and well-being, it
is indeed shocking that health and social security has slipped so far
out of the political radar.
TB gets on political radar but is it high up?
Even if late, TB is definitely moving up the ladder as a priority for not only
national TB programmes (NTPs), but also beyond NTPs within Ministries of
Health, and at times, further beyond for other ministries and stakeholders.
When we talk of pushing TB up on the political agenda, one of the most historic
meetings was the first-ever "WHO Global Ministerial Conference: Ending
TB in Sustainable Development Era" held in Moscow, Russia, in November
2017. Russian President Vladimir Putin endorsed the #endTB agenda in this
meeting of over 75 ministers of health as well as of other non-health
disciplines (especially from high-burden TB countries), and other stakeholders
and affected communities. These ministers endorsed the Moscow Declaration
and acknowledged that TB (including its drug resistant forms) causes more
deaths than any other infectious disease worldwide, and is a serious threat to
global health security. Earlier, over 190 governments had promised to
Sustainable Development Goals (SDGs) in UN General Assembly 2015, which
includes goals to achieve Universal Health Coverage (UHC) as well as to end TB
by 2030. Last month in Delhi, the Indian Prime Minister gave another thrust to
the promise of ending TB by 2025 in India.
One of the key leads in organizing the WHO Global Ministerial
Conference was Dr Mario Raviglione (then head of the WHO Global TB
Programme). Dr Raviglione is now the Director, Global Health Centre, University
of Milan, and was the key expert for World
TB Day 2018 Webinar, who reiterated the political (and public health)
significance of TB getting on the agenda of G20 meeting in Germany (2017), G7
meeting in Italy (2017), Asia Pacific Economic Cooperation (APEC) meeting in
Viet Nam (2017), among others.
But does this indicate that TB is high up enough on political agenda? Or for
that matter, is health security high up on political agenda? For instance, will
Prime Minister of India's commitment to end TB by 2025 give a thrust to TB
agenda in political decision making? Probably early next year India goes to
general elections and let us hope that public health takes centre-stage in
politics.
Progress made to stop TB but not enough to
#endTB
Dr Mario Raviglione who spearheaded the global fight against TB for several
years, said that efforts to prevent TB have been successful but not enough to
end the epidemic. Soft political and financial commitments have posed major
challenges.
Dr Mario Raviglione said that 53 million lives were saved from TB, and TB
deaths fell by 22% during 2000-2016. This is a commendable achievement where
the world, especially the high burden TB countries, built up a strong fight to
stop TB as per the Millennium Development Goals (MDGs) targets. But progress is
clearly way off track to end TB by 2030. As per the latest WHO Global
Tuberculosis Report, 1.7 million TB deaths occurred in a year, 5000 TB
deaths every day! Out of these, were 400,000 people living with HIV (PLHIV)
who died due to TB in the same year. MDR-TB is now at crisis level, with only 1
in 5 being able to access existing care services. Half a million women and
250,000 children died of TB in 2016. With the call to end TB reaching its
zenith, we have to ensure that TB rates decline faster enough so that we can
keep the promise to end TB, and also make better progress on other SDGs.
Accountability of each actor in multisectoral
partnership
Since TB was threatening to reverse gains made in other health 'silos',
partnerships had to be eventually forged between TB programmes and those
on HIV, diabetes, tobacco control, to name a few. These partnerships are at
different levels, but all are gearing towards not only improving TB programme
outcomes, but also of those addressing other specific health issues.
But delays in forging partnerships despite compelling and scientific evidence,
is not acceptable. Who is accountable for avoidable disease burden, as well as
for averting preventable untimely deaths? As per the latest WHO Global TB
Report, 400,000 TB deaths occurred in PLHIV. With scientific evidence, policies
and programmes being in place to prevent, diagnose, treat TB in PLHIV, each of
these 400,000 TB deaths could have been averted and both TB and HIV programmes
would have fared better, only if we could translate scientific evidence into
public health benefits with utmost diligence and urgency.
Unless we determine and monitor accountability of different actors who need to
do their part to end TB, multisectoral partnerships can seldom become very
efficient. But the good news is that, in the Moscow meet, governments and other
partners agreed to progress on multisectoral accountability framework, so
that the world gets on track to end TB by 2030 as per SDG targets.
The deadly mismatch
On one hand political leaders commit to end TB by 2030, but on another hand
they also promote questionable development policies that exacerbate
inequalities in society - one manifestation of which is increased risk for diseases
like TB.
Wardarina, Co-Chair of Asia Pacific Regional Civil Society Engagement
Mechanism (AP-RCEM), who has been a part of Asia Pacific Forum on Women, Law
and Development (APWLD) for past several years, rightly pointed out such
contradictions: "We have to look into SDGs critically, focussing on the
existing contradictions, and not just on their progress and implementation. For
us the contradictions are that along with the SDGs, we also have a lot of
unjust trade and investment agreements, massive land and resource grabbing,
patriarchy and fundamentalism, militarism and conflict, retaliatory governance.
All these need to be addressed, if we aim to achieve the sustainable
development goals."
If we truly want a world where no human being is forced to suffer inhuman
treatment, and end TB and other preventable/ avoidable causes of human
suffering, then it is critically important to ensure that the gap between
'haves' and have-nots' is reduced as much as possible.
But it is the political decisions that make us chase a 'development model'
which not only further widens this chasm between the rich and the poor, but
also puts the poorest of the poor at highest risk of undergoing even more
severe forms of suffering, including elevating TB risk. A report
released by Oxfam, around the time of recent World Economic Forum, showed
that in 2017, 1% of the world's richest owned 82% of the global wealth. This
report also showed that in India, 1% of its population owned 58% of the
nation's wealth in 2016, and in 2017 this inequality worsened with 1%
owning 73% of the wealth. How can we expect to have social equity if only a
miniscule percentage of our population enjoys the highest quality of
healthcare, education, lifestyles, while the vast majority
of the people are forced to live with appallingly poor quality of
healthcare, education, and are deprived of even the most basic amenities. Renowned
Indian socialist leader Dr Ram Manohar Lohia had advocated a ratio of not more
than 1:10 between the lowest and highest incomes. An unbridled income gap brews
inequality, exploitation, imbalance, injustice and unrest in society.
Dr Mario Raviglione also said in the webinar
that migrants, refugees, prisoners, and ethnic minorities face higher risk
for TB, and also face discrimination and barriers to accessing care.
"To prevent latent TB converting into active TB disease we need food security
and compulsorily have to address malnutrition" rightly said Dr
Raviglione, pointing out another area where NTPs need to partner effectively
with government programmes to end hunger (one of the SDGs is to end hunger by
2030). It is apparent that addressing all forms of inequality and injustices
will also have a positive ripple effect on TB programmes' performance too.
There is hope
Over
950 doctors and 150 junior doctors (who are pursuing post-graduation studies or
seeking advanced super speciality training) in Quebec province of Canada recently
declined to accept a salary hike, saying that they cannot, in "good
conscience", accept an increase in their salary when nurses and other
healthcare staff and patients are facing hardships due to cuts in health
budget. These doctors believe that only stronger public health systems can
deliver health security to all. When public health systems are reeling under
resource crunch, how can raising the salaries of doctors be justified? If
nurses and other healthcare staff are forced to work in stressful and
challenging conditions, and lifesaving healthcare services slip beyond the
reach of people, then how will the tall promises of health security and
universal health coverage be delivered? These doctors have appealed that
instead of raising their salaries, government should rather utilize these
resources in strengthening the public health system, so that nurses and other
healthcare staff can work in better and secure conditions, and healthcare
services are within the reach of all those in need, especially the most
deprived or terminally ill.
Public health systems are getting weakened, not strengthened with
aggressive privatisation and other chronic issues that ail the system. Oxfam tweeted
on 3rd April 2018 "Sorry state of India's #Healthcare. Nearly 2000
Primary Health Centres (PHC) in India do not have a single doctor, meanwhile
61% operate with just one doctor. Guidelines suggest 2 doctors minimum per
PHC." If we are to deliver on SDGs, ensuring health security for the 'last
person in the queue' is of utmost urgency. And delivering healthcare and other social
security and welfare benefits to the most marginalized cannot be privatized, so
do we believe.
Canadian doctors have indeed shown a silver lining for those who believe in
strong public health systems. Other doctors and people from all sectors
should emulate them, be inspired by their conscience and agree to share
resources equitably with all.
Low domestic funding to #endTB is bad
politics and economics
Evidence shows that 22 countries with the world's highest numbers of TB cases
(India shares biggest TB disease burden globally) could earn significantly
more than they spend on TB diagnosis and treatment if they fully fund and
effectively implement the WHO strategy to end TB. So not funding TB control is
a bad economic decision and bad politics, right?
Dr Mario Raviglione said in the webinar
that the global fight against TB faces a financial crunch of US$ 2.3 billion.
TB research funds are short of US$ 1.2 billion! Unless governments step up to
fully fund the fight to end TB and deliver on other SDGs, promises will remain
merely words, and fail to translate into action.
Another bad politics, and bad economic decision, is not to implement tobacco
control effectively. An important report
provides the vital evidence that the tobacco industry and the deadly impact
of its products cost the world's economies more than US$ 1 trillion annually
in healthcare expenditures and lost productivity. Tobacco kills more than 7
million people every year worldwide. More than 6 million of those deaths are
the result of direct tobacco use while around 890 000 are the result of
non-smokers being exposed to second-hand smoke. Who should be held to
account for not protecting people from tobacco (including secondhand smoke)
despite over 180 governments ratifying the global tobacco treaty (formally
called the WHO Framework Convention on Tobacco Control - FCTC)? It is not a
coincidence that around 80% of the world's 1.1 billion smokers live in low- and
middle-income countries, and major tobacco companies and industries are
headquartered in the richer nations. No prizes for guessing that it is
the low- and middle-income countries that are reeling under the severest impact
of non-communicable diseases (such as heart disease and stroke, cancers,
diabetes, chronic respiratory diseases, etc)!
Corporate interference in development policy?
Is it not bad politics to make funding decisions that do not serve the best of
interests of the majority of our population? Who is influencing these political
decisions that make the rich, richer, and deprive communities from accessing
basic services? While corporate interference in development policy making needs
to be further investigated, but there are no prizes for guessing who is
financially benefitting due to such policy decisions that only serve the
interest of the rich!
To end TB we need to deliver on all SDGs
One of the most important statements made by Dr Mario Raviglione in the World TB Day 2018 Webinar was
that "approach to ending TB cannot be different or other than the
approach for comprehensive development." Only by ensuring that sustainable
development becomes a reality for everyone, where "no one is left
behind" we can progress towards ending TB, as well as achieving all the
other SDG targets and goals.
World Health Day: Health security, SDGs
and politics?
Let us hope that on 2018 World Health Day, and before the governments meet for
World Health Assembly 2018 next month in July, health security and all SDGs
begin to take centre-stage in politics in every country. Amen!
Shobha
Shukla and Bobby
Ramakant, CNS (Citizen News Service)
(Shobha Shukla and Bobby Ramakant, both are part of editorial team of CNS (Citizen News Service). Be welcome to visit www.citizen-news.org)
- Shared under Creative Commons (CC) Attribution License
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