Susan, thanks for the feedback. DN Mod.]
Follow up to 'Into the next century...'
---------------------------------------
Dear Afro-Nets subscribers,
A few weeks ago I sent around a message asking for your views on what
the major public health topics would be for the year 2010, and promised
that I would put together a digest of the responses. Here is the prom-
ised digest!
Many of you responded directly to me so the list subscribers will not
have seen all of the interesting views which were expressed. On the as-
sumption that those of you who responded directly may not have wanted
the whole list to know your name I will keep names off the responses
for now.
I would have been happy to have more responses from Africans and if
anyone out there would like to respond on what the big public health
issues for 2010 from an African perspective I would be really pleased
to have them.
Anyway -- here is a summary of what people said. Issues which concern
people are lack of resources and rationing; globalisation and its im-
pact on e.g. pharmaceuticals; increasing tobacco use, especially among
women; health effects of conflict and war, and displacement of people
and of the use of weapons including nuclear weapons; genetics and gene
manipulation; and emerging infectious diseases. Writer no. 3 made some
interesting comments on what skills public health professionals will
need in 2010 as well. The writers elaborated on the topics above and if
you want to see the details of what they said, just keep reading!
The whole responses with minimal editing are below. Many, many thanks
to those of you who took the time to respond -- I hope it was as help-
ful for you as for me!
Best wishes,
Susie Foster
--
Response No. 1:
I've been here in country XXX for almost 10 years now, working clini-
cally in district and provincial hospitals, than as DMO and now for
more than 3 years as public health programme co-ordinator (co-operation
with Min. of Health)...
The country's problems (well, here they call them challenges and oppor-
tunities) have increased over the past ten years: AIDS, economic deto-
riation, inflation, declining political stability, increasing poverty,
etc. In other words, the gap of even a country like XXX (who carried
some hope in the past) and industrialised countries is getting wider
and wider.... However, if I look at the health services run by govt.:
the quality of problems hasn't changed much. Public health advice is
becoming more and more sophisticated, but the operational problems on
the ground are the same: drug supply problems, transport problems, DNO
gone for a workshop, no spares for equipment, etc... When I visited the
hospital I worked in 10 years ago, nothing has really changed there.
Ok, there is now more talk about decentralisation and improving quality
of service, but the practical experience shows that a patient going to
that hospital today is sort of in a similar situation like 10 years
ago. Just like yesterday. Probably a bit worse but somehow not that
much.
So I suppose in 2020 the MPH course will probably take 3 years and pub-
lic health consultants will all be linked up via internet and know eve-
rything about the problems of developing countries (including the fac-
tors that prevent change). However, I'm quite certain the operational
situation on the ground will be just the same. I see lot's of people
here working very hard to keep it the way it is. Then... hopefully by
the year 2020, the donor community has given up the illusion of
sustainability (oups, did I say something) and will appreciate budget
support and taking over running costs. And hopefully the public health
community will stop looking at the watch timing development processes.
Maybe it's not such a bad thing that 20 years in Africa is like 20 days
in Europe...what's the rush anyway....?
BTW: The only improvements of quality of service around here are taking
place in the private sector. We may not want to hear this, but it all
boils down to the buck I guess.
--
No. 2:
In South Africa we are currently busy with a Foresight Exercise, with
the aim to systematically identify those areas of research, science and
technology that are likely to yield the greatest economic and social
benefits for South Africa in the next 20 years.
The Health sector is one of the sectors under scrutiny. We are using
various methods to determine what will be the main concerns, con-
straints and likely problem areas within the health field 10 years from
now. The purpose is to identify research and technology topics on which
to spend our money for the next 5 to 10 years.
For the purpose of this exercise we commissioned a scan of interna-
tional as well as local trends, within the health field.
We will also develop a set of scenarios on possible futures in South
Africa, but with special reference to the health sector.
Once this information is generated, you will be most welcome to it.
(NOTE: I HAVE ASKED HER TO PUBLISH IT ON AFRO-NETS SO THAT YOU CAN ALL
SEE IT. -- SF)
--
No. 3:
One area that will impinge more and more on the consciousness of the
world community, public health workers in particular, is that of the
increasing number of people who are displaced by war (cf. Sudan,
Kosovo) or natural disaster (cf. China).
The provision of immediate relief is mainly a logistical and technical
problem, though the medical skills, both public health and clinical are
peculiar to the situation. These need to be taught. Even with an in-
creasing number of specialist agencies in the field, some would say too
many (cf. Goma), the pool of medical and paramedical staff available to
deal with the ever increasing number of crises is likely to become too
small. Health workers from the countries most prone to these disasters
need to be able to work effectively and to be able to take charge in
emergencies rather than having to rely on (expensive and often inexpe-
rienced) outsiders.
The long term health implications of these crises are less well publi-
cised than the immediate effects of the disaster. More and more will
public health, in its broadest sense, be dealing with large numbers of
people whose lives have been shattered. Some will remain displaced from
their homes for long periods of time (for ever), others will return to
their home place but be unable to carry on as usual through loss of the
means of livelihood, break-up of the family unit and disruption of com-
munity structures. Once they are off the news they are out of mind.
These people need health care in the form of pills, vaccinations, tra-
ditional environmental health etc. but in addition their psychological
and spiritual needs have to be attended to. These dispossessed people
without hope will provide a challenge to health workers who will be re-
quired to have developed a range of skills that goes beyond medicine,
or even traditional public health.
Genetics and genetic manipulation (whether of humans, other animals or
plants) will still be a hot topic. Public health workers are not lead-
ing the debate at the moment, they are merely reacting to the astound-
ing technical advances that are being made by industry. This needs to
change and can only do so if the issues (technical and ethical) are un-
derstood more widely amongst the public health community.
By 2020, many of the health gains of the 20th century being reversed
amongst an increasing number of have-nots in rich countries, and across
broad swathes of most continents, Africa in particular. By then the
present minority of public health workers who consider politics and po-
litical advocacy to be core functions will be turning into a majority.
To be able to engage in this debate, public health workers need a
greater understanding of economics, politics, sociology and philosophy.
These subjects will no doubt be replacing epidemiology and biostatis-
tics as essential elements of a MPH!
These and many more things that we are going to be talking about, and
hopefully doing something about, require public health workers to ex-
pand the boundaries of their thought even further beyond biomedicine
than they are already. People studying public health now and in the
near future are the public health leaders of the future and their expo-
sure to ideas today should prepare them for the challenges of 2020 and
beyond.
Don't know if any of this helps, but it was fun to write! Your question
deserves to be asked more widely!
--
No. 4:
We just had a really first class and fascinating presentation today on
Trafficking in Women.
...and yesterday an equally good one on the big cigarette companies
targeting women (now only 8% smokers) in developing countries as their
primary market for the 21st century.
so there are two.
--
No. 5:
As a pharmacist in Africa, I must put in my vote for the issue of "ra-
tioning" - we face an increasing penetration of developing markets by
products from the metaphorical North, which bring to the global stage
the issues of what to spend a finite health dollar on, while trying to
stretch it the furthest. A good example from the North is the drug
Viagra - with projections that it could consume 25% of the UK NHS drug
budget. The same drug will soon be registered in South Africa. While it
will probably be restricted to the private sector, that sector already
spends 30% of its annual spend on drugs! Where to next? For more exam-
ples, look no further than the HIV vertical transmission story, or
cryptococcal meningitis treatment. Increasingly we will have the means,
but will not be able to afford them.
As a second issue, how about role definition amongst health profession-
als - the US Pew Commission has done some interesting work on multi-
skilling health professionals. In South Africa, as in many developing
countries, we face major personnel shortages in rural areas. This is
usually addressed by turning to nurse clinicians. What will the impact
be on the professions which have, through scarcity or cost, made them-
selves inaccessible?
--
No. 6:
Apart from all the predictable causes of misery, mortality and morbid-
ity such as pregnancy related problems, diseases caused by poor nutri-
tion and sanitation, and other infectious diseases, I suspect in the
year 2020 we will be looking at a huge complex of "tobacco-related pa-
thology" in the developing world.
Looking back at the enormous investments made in the First World to
curb the abuse of tobacco in relation to the relatively modest health
gains, and expecting that economic progress will be only modest in most
developing countries, it seems clear to me that most countries will not
have the resources for extensive health education campaigns, nor is it
probable that legislature in those countries will prohibit the wide use
of tobacco as from now.
--
No. 7:
In next decade or so:
1) Environmental degradation/global warming/climatic shifts...
2) Newly emergent pathogens (antibiotic resistance, HIV, prophylaxis-
resistent malaria...)
3) Increasing "first world"-type health problems in the developing
world (lung cancer/tobacco, heart disease, obesity, diabetes...)
Beyond that (in addition to the preceding):
1) Population pressure on the world's resources.
AND the Big One (hopefully not in the near future, but it could happen
today or tomorrow, or 30 years from now, but sadly is probably more or
less inevitable): the Health effects of weapons of mass destruction --
either in the form of a country-to-country (e.g., South Asian?) war or,
more likely, terrorist attack involving nuclear, biological, and/or
chemical weapons which would have devastating, long-term health effects
on the local (and possibly even global) population. I think this is by
far the most neglected aspect of international health planning, re-
search, etc!
--
Susan Foster, PhD
Distance Learning Co-ordinator
London School of Hygiene & Tropical Medicine
Keppel Street London WC1E 7HT, UK
Tel: +44-171-927-2359
Fax: +44-171-637-5391
mailto:s.foster@lshtm.ac.uk
PLEASE NOTE:
I am moving to Boston University's Department of International Health
on October 1, 1998.
New address:
Department of International Health,
T4W, BUSPH 715 Albany St Boston MA 02118, USA
Tel: +1-617-638-5234
**NEW EMAIL ADDRESS** <sfoster@bu.edu>
--
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