The what, why and how of health and development

UK teen pregnancy success story threatened by cuts

With the rate of teenage pregnancy in England halving since the government’s ambitious Teenager Pregnancy Strategy was launched in 1998, the programme is widely viewed as a public health success story.

It should rightly be celebrated. Any drop in the number of teenagers falling pregnant, who if they went on to have children would be less likely to take up further education and employment opportunities, is a good thing.

A look at the figures shows that as the numbers have fallen, however, the stark differences in the rate of conception between poorer and richer areas of England have persisted. In 2004, the most deprived 20 percent of local authorities in England saw, on average, 56 conceptions per 1,000 girls aged 15–17. This compared to 25 in the 20 percent least deprived. Another way of looking at it, for every single girl pregnant in the richer areas, 2.24 would conceive in the poorer areas.

Using more up-to-date data, this ratio gap grows slightly. Taking the latest government data on the 20 percent most and least deprived local authorities – available up to 2014 – and comparing it to 2015 data on pregnancy among 15-17-year-old girls, we can see that for every pregnant girl aged between 15 and 17 in the areas with least deprivation, there are now 2.54 girls getting pregnant in the most deprived areas.

This correlation between deprivation and teenager conception is no new thing. Research carried out by the Office for National Statistics has long examined this correlation, and also shown a link between high unemployment rates and child poverty with under 18 conception rates.

Why is there a link between deprivation and teen pregnancy?

One reason for this is the perception of motherhood held by young women. A study carried out back in 2004 by the Joseph Rowntree Foundation concluded that ‘young women who perceived their lives as insecure were more likely to view motherhood as something that might “change their life” in a positive way. Those who were certain that their future life would develop through education and employment were more likely to opt for abortion.’

Other reasons include personal factors such as low self-esteem, lower educational and occupational aspirations, less knowledge of contraception and sexual health services and higher gender power differentials’, according to one ONS report from 2002.

“Easy access to sexual health services is also likely to have a role,” explains Senior Policy and Public Affairs Officer Laura Russell at the sexual health charity Family Planning Association. “There is a correlation between good contraception services and lowering rates of teenage conceptions.”

The impact of local authority budget cuts

Since the 2012 government reforms, improvements in health – including contraceptive services – have largely fallen under the remit of local authorities, paid for by a ring-fenced budget. Following the announcement from the Treasury earlier this year that public health budgets for councils are to be cut by 7 percent – or 200 million – some medical organisations have been concerned about the wider impact this will have on conception and healthcare in general.

Plus with councils of less well-off areas less able to raise significant funds through council tax, as suggested by the Treasury, people living in these authorities might be disproportionally affected.

The Advisory Group on Contraception (AFG), an expert group of clinicians and advocacy group, argue that cuts to contraceptive care in primary care settings means there will be “tighter restrictions on who can access the service and what contraceptive methods are available”.

Using figures provided by the Department for Health, they point out that there is an £11 saving for every £1 spent on contraception, arguing it is “a false economy” to cut funding to this area.

However, a survey carried out by AFG in 2014 found that around a third of local authorities reported having no plan in place to reduce the rate of unintended pregnancies, leading to concerns it is not being prioritised. A spokesperson for the group also confirmed that an update to this survey is due to be published later this year.

The British Medical Journal has also carried out investigations into the impact of public health cuts on sexual health services. For those with access to BMJ articles (not me!), you can find more details here.


Sexual and reproductive healthcare is a basic human right – for undocumented migrants too

Despite the right to sexual and reproductive health being well established in EU international human rights instruments, they are – along with many others – frequently denied to undocumented migrants.

I’ve previously written about the problems undocumented migrants have trying to access healthcare here. While researching that piece, it became clear there is a gulf between rights enshrined in international law and policies implemented at a national level. Often care for undocumented migrants depends on the extent of engagement from local government and healthcare groups, who often are best placed to recognise the significant cost savings that can be made by providing preventative care.

Of this group, women in need of sexual and reproductive healthcare are – along with children – arguably the most vulnerable. According to the Platform for International Cooperation on Undocumented Migrants (PICUM), they are disproportionately affected by high rates of maternal and infant mortality, limited access to contraception and pregnancy termination, and heightened levels of discrimination and gender-based violence, including at the border, in transit and in detention.

PICUM say deficiencies of policy and practice on sexual and reproductive health in the EU have been thrown into sharp relief by the recent arrival of millions of refugees and migrants to the continent.

“The desperate trip across borders brings an untold number of new dangers for vulnerable women and girls – violence, rape, sexually transmitted infections, unintended pregnancies, unsafe abortionn,” said Caroline Hickson, Regional Director, International Planned Parenthood Federation (IPPF) Europe. “Access to essential sexual and reproductive health services can be the difference between life and death. Yet it is still shamefully neglected in response strategies. If we value women’s lives, it must move from afterthought to priority.”

An undocumented woman from the Philippines, living in Denmark, shared her experience: “Throughout the course of my pregnancy in Denmark, I did not visit a doctor. I was afraid, because I was in the country without permission. So I continued my work as a cleaner. I went to the hospital only when the pain was unbearable.  The labour was already advanced. There was so much blood. I had a caesarean section, but the baby did not survive. She died in an incubator. But I did see my daughter, I have a photograph of her.  I named her Claire*. She is buried in Copenhagen.” 

A few weeks after giving birth, the woman was deported from Denmark after she was reported by hospital staff to immigration officials.

PICUM’s are now calling for countries to reform legislation and policies that deny or limit access to sexual and reproductive health services on the basis of residence status.

It also urges governments to establish a ‘firewall’ to delink the provision of basic services, including sexual and reproductive health services, from immigration control. In practice, this requires limiting the sharing of personal data between health care providers and immigration enforcement authorities to ensure that patients can access care without fear of being denounced or deported.

To read PICUM’s latest report on the topic, click here.


World AIDS Day: The worst messages sent to HIV positive guys on dating apps

It’s December 1st, which means…it’s World AIDS Day. This year I wanted to share this funny and revealing video from the gay men’s health charity GMFA. They got a bunch of guys to read out messages sent over a dating messaging app to HIV+ men. The results suggest even though education about HIV has come along way, stigma and misinformation is still a problem faced by many.


Bringing morphine to millions

The following article was originally published on Think Africa Press in December 2012. The site has since closed down but since this topic is a very important one and continues to be close to my heart,  I wanted to republish it again here:

Bringing morphine to millions

Credit: Treat the Pain

Credit: Treat the Pain

For people with difficult health conditions which cause them unrelenting pain, only the strongest form of relief can allow them to live an anywhere near comfortable life. For many in the West, the cheap and plentiful opioid morphine provides this respite. But for millions elsewhere, this essential relief is yet another denied right.

Frank, a 49-year-old Ugandan man, had been living alone with an open tumour on his neck, abandoned by his family because of the stench caused by his illness. He had not slept or eaten in weeks because of the pain.

Frank was fortunate enough to be found by a community volunteer worker from Hospice Africa Uganda (HAU). He was referred to the hospice team, who treated his would, and he was shown how to use oral morphine. Soon after, his family returned to continue his care.

“He was able to eat a little, sleep a little more, and settle his affairs before he died in peace, with his family and pain-free three weeks later”, Zena Bernacca, CEO of the hospice, tells Think Africa Press. “Having pain relief makes a real difference; otherwise one’s whole existence is narrowed down to suffering unimaginable pain, obliterating everything else.”

Relief from pain also allows for time to address other social and emotional needs, such as future childcare or religious wishes. For Frank, the palliative care and morphine provided by HAU meant that he could be with his family.

“I have slept for the first time in many weeks”, he told hospice care workers shortly before his death. “This wound is clean and no longer smells. I have my family back and I have food to share. I am blessed.”

Essentially lacking

Considered essential by the World Health Organisation (WHO), morphine costs relatively little to provide. But 80% of the world’s population lacks access to this treatment. In fact, where demand is highest, access to pain relief is at its lowest. Low- and middle-income countries, which account for 70% of cancer deaths and 99% of HIV-related deaths, consume just 6% of the world’s medicinal opioids.

“Pain relief is a central component to palliative care”, says Dr Emmanuel Luyirika, Executive Director of the African Palliative Care Association. “Without the immediate release of oral morphine, it’s impossible to manage moderate to severe pain.”

According to a 2010 survey conducted by the International Narcotics Control Board, the major reasons given by governments for the low availability of opioids include fears of addiction, a reluctance to prescribe, and insufficient training for professionals.

“There’s an issue of strict regulations in countries based on unfounded fear of abuse, but also limited understanding of palliative care at most levels of policy, service provision and community within those countries”, explains Luyirika.

Setting a trend

However, a number of models of pain treatment in Africa have allowed palliative care on the continent to grow, providing opportunities for governments and organisations to collaborate and learn.

Hospice Africa Uganda offered the earliest model designed for the African setting. Founded by Dr Anne Merriman in 1993, HAU has long provided oral morphine for a growing numbers of patients. Two years ago it broadened the reach of this drug significantly when Uganda ran out of stock. Encouraged by The Global Action for Pain Relief Initiative (GAPRI), an NGO working to spread awareness of palliative care methods, the hospice tendered for the contract and has since been selling stocks to the Ugandan government for national distribution.

Uganda also overcame another obstacle by becoming the first country to train nurses to prescribe morphine. Previously only doctors could prescribe the drug, making it impossible to meet demand. Routine meetings and training allow the hospice to alleviate any staff worries about misuse, and staff can in turn placate any fears from patients and families.

“Out of ignorance, so many are concerned about potential addiction”, explains Bernacca. “However, once there is an understanding of how morphine works as a painkiller, and that when used appropriately it does not cause addiction, the patient is relieved. And the majority of carers are also relieved of the distress of witnessing such pain.”

Along with programmes in Tanzania, Kenya and Zimbabwe, this public/private partnership is now a model of morphine production, and other countries are following suit. Research into palliative care and pain relief on the continent is still lacking, but these programmes are building understanding of how such care can be incorporated alongside other African health policies.

“These palliative care programmes are helpful because they show us what is possible”, says Dr Meg O’Brien, Director of GAPRI. “They provide models that can be adapted to other programmes, and they give us evidence about the cost and impact of services that we can use to help leaders in other African countries make more informed decisions about what kind of care is achievable.”

Obstacles on the road

Indeed, the complexities of supplying morphine mean that in many African countries political will is not enough. GAPRI has consistently found governments to be keen to provide pain relief services, but hampered by technical and bureaucratic barriers.

Pain treatment does not sit easily in one area of healthcare, and this can cause questions about department responsibility. Moreover, an effective programme requires cooperation among disparate groups that include policymakers, training institutions, hospital administrators, drug procurement bodies, financing offices, clinical guidelines committees and drug regulators.

“Sorting out the necessary collaborations is time-consuming, and many governments simply lack the capacity to push changes through quickly”, says O’Brien. GAPRI addresses this by helping ministries of health with research, chasing paperwork, consultations and consolidating data. Founded only two and a half years ago, the organisation is young and still small, but its rapid development reflects a growing interest in pain treatment.

As calls increase for non-communicable diseases (NCDs) to be included in any post-2015 sustainability goals, palliative care and pain relief programmes could offer an initial achievable step in this direction. Uganda has only one radiotherapy machine, which is held together with sticky tape. Scaling up resources to combat the increasing incidence of NCDs requires a long-term strategy and significant funding. Pain relief programmes offer opportunities to expand into this area and start bridging the false divide between communicable and non-communicable diseases.

“Rather than distract ministries, I think an initial focus on palliative care actually focuses efforts”, suggests O’Brien.

“Provision of modern pain relief and palliative care is a ‘low-hanging fruit’. It can be done using existing funds and resources and will have an immediate benefit for cancer patients and others who suffer pain. I see it as an ideal starting point for ministries to expand care for NCDs while the international NCD community works on expanding funding and staff.”

 


Reblogged from The Wire: India Must Resist US Pressure on Generic Drugs, African Leaders to Tell Modi

This explainer from journalist MK Venu writing for the Indian magazine The Wire talks us through the pressures on the Indian government from US pharma and African governments, representing both sides of the generic medicine debate:

In his ‘Mann ki baat‘ radio show on Sunday, Prime Minister Narendra Modi proudly spoke about how India will host 54 heads of state from Africa for the first time to reinforce “our nation’s historical and cultural links’ with African countries.

However, invoking this very spirit, the visiting African leaders will place before the Prime Minister an issue of life and death for their peoples in which India can play a critical role – the export of cheap and affordable generic medicines for the cure of AIDS and other deadly diseases. The African heads of state will urge Modi to resist growing pressure from the United States government and Western drug multinationals on India to stop exporting cheap generics to Africa.

Continue reading at The Wire.


UK ranked top for palliative care by Quality of Death Index

The UK continues to deliver the best palliative care in the world according to the latest revision of the Quality of Death Index.

The report commissioned by a Singapore philanthropic organisation the Lien Foundation and released by the Economist Intelligence Unit compares palliative care services in eighty countries using interviews with more than 120 experts.

As in previous reports, the UK was followed by Australia, New Zealand, Ireland and Belgium as the best countries in terms of structures supporting palliative care, although the report did not look at the effect these services had on patients and families.

Funding is a key factor in determining the quality of these structures, although examples of resource-poor countries that have made gains in this area include Panama – which has integrated palliative care into primary care and Mongolia – where education and the enthusiasm of individuals has also helped to develop services.

Click here to read the full report


Malaria control “great public health success story” but drug resistance concerns persist

The number of people dying from malaria has dropped 60 percent since 2000, according to a UN report declaring the goal of halting the spread of the disease has been “convincingly” met.

The report released today from the World Health Organisation and UNICEF says that 6.2 million lives have been saved in that time and new malaria cases have also dropped by 37 percent.

Wikipedia/Alvesgaspar

Wikipedia/Alvesgaspar

According the report, the latest data shows that the malaria Millennium Development Goal, which aimed to halt and begin the reverse the incidence of malaria by 2015, has been met.

The vast majority of people saved were young children, the UN organisations said.

Director General of WHO Dr. Margaret Chan described global malaria control as “one of the great public health success stories of the past 15 years”.

She added: “It is a sign that our strategies are on target, and that we can beat this ancient killer, which still claims hundreds of thousands of lives, mostly children, each year.”

The report claimed it was a surge in funding since 2000 that helped to tackle the onslaught of the disease, with approximately one billion insecticide-treated bednets (ITNs) being distributed in Africa, thought to account for an estimated 68 percent of malaria cases prevented since 2000.

The increasing use of rapid diagnostic tests, and effective treatment using Artemisinin-based combination therapies (ACTs) are also factors contributing to the drop in the number of people dying from malaria.

The number of deaths due to malaria are still extremely high, however, with an estimated 438,000 dying in 2015 alone from the preventable and treatable disease, the majority in Sub-Saharan African countries.

The report also emphasised that 1 in 4 children in sub-Saharan Africa still lives in a household with no ITN and no protection provided by indoor residual spraying.

Recent research has also pointed to the growing resistance of some malaria parasites to treatment.

Researchers at the London School of Hygiene & Tropical Medicine, writing in the journal Antimicrobial Agents and Chemotherapy, confirmed in April this year early indicators of the malaria parasite in Africa developing resistance to the most effective drug available.

Mutating the malaria parasite in a laboratory to mimic mutations seen in Kenya, they found the parasite required 32 percent more of the anti-malaria drug artemisinin to be killed.

Separate research published in the New England Journal of Medicine in July 2014 also found that resistance to artemisinin is now present in Eastern Myanmar, Thailand and Southern Vietnam, as well as Western Cambodia.


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