Possible themes for South African Norwegian Health research

Possible themes for South African. Norwegian Health research collaboration Halvor Sommerfelt, MD, Ph. D University of Bergen, Currently: University of the Western Cape & Medical Research Council, Cape Town Prof. Mhlanga: A nation without (healthy) women and children is a nation doomed Bloom

Main messages • Cost-effective (mother & child) health promotion programs: Powerful instruments economic growth and poverty reduction, if: main disease burden contributors (diseases & risk factors) research to generate evidence-base for program-relevant interventions extensive coverage and equitable delivery (Research functional health system). • Experiences from other collaborations, e. g. Indo. Norwegian: RSA as node for health research and postgraduate education in SSA? • Suggested areas for collaborative research & postgraduate education in health • Suggested strategies for Bloom collaborative health research

Sources · · · Presentations by Prof. David E. Bloom and David Canning, School of Public Health, Harvard University and Prof. David Sanders, School of Public Health, University of Western Cape at the GAVI-funded seminar “Development and Deployment of Vaccines Against Poverty-Related Diseases”, Bergen, Norway, September 21, 2004 (http: //www. cih. uib. no/GAVI/seminar 2004/index. htm). David E. Bloom and David Canning. The health and wealth of nations, Science. 2000; 287: pp. 1207 -1209; David E. Bloom et al. Health, Wealth, and Welfare. Finance & Development. 2004: pp. 10 -15. WHO/UNICEF Demographic Health Surveys (DHS) PF Basch. Textbook of International Health. ISBN 0 -19 -504897 -0. Oxford University press, 1990; pp. 164 -183. · Kramer, S. Mausner & Bahn. Epidemiology. An introductory text. ISBN 07216 -6181 -5. W. B. Saunders, Philadelphia, 1985, pp. 239 -256. · · · World Development Report 1993. ISBN 0 -19 -520890 -0, Oxford University Press, 1993. Commission on Macroeconomics and Health Lancet series on child survival 1993 Bloom

Age-adjusted measles mortality per 1000 US 1900 -1973 Similar for other major infectious diseases, the interventions came “too late” Vaccines: diphteria, whooping cough Treatment: TB, pneumonia, diarrhea Vaccine

Measles incidence US 1912 -1982 Vaccine

Measles incidence US 1912 - 1982 if effective vaccine available from 1915 Vaccine

Age-adjusted measles mortality per 1000 US if vaccine available from 1915 Vaccine

Historically in industrialized countries: Close link between general std. of living and health, limited effect of specific health interventions • 20 th/21 st century transitions (i. e. in developing countries) are often propagated or even initiated by health interventions • Declines in mortality and then fertility are often sharper than seen in present day industrialized countries (immunizations, health education, early treatment. . . ) Bloom

Historical data on health and disease Countries where large differences in S-E status (e. g. India and South Africa): Different strata of the population are actually simultaneously at two different stages of the demographic and epidemiological transitions! Fight at two fronts: Cheap - to - prevent/treat communicable diseases (of children) vs. expensive - to - treat degenerative diseases of adults/elderly.

The good… • UN/UNICEF data show that the global child mortality rate has declined from 196 (deaths per 1000 live births) in 1960 to 93 in 1990 to 82 in 2002 • Between 1960 and 2002, the child mortality rate has fallen in every country in the world. • Immunization coverage increased from 5 -10% in 1974 to about 75% by 1990. Bloom Source: David Bloom and David Canning, Harvard University

The bad… • 10. 5 million children under the age of 5 (=U 5) died in 2002, accounting for nearly 20% of all global deaths (U 5 only 10% of world population). • 6 -7 million of those deaths could have been easily averted through immunization and early treatment (as they are due to malnutrition, acute respiratory infections, diarrhea, malaria, and measles). • One fourth of children worldwide have not been immunized with DTP. Bloom Source: David Bloom and David Canning, Harvard University

The ugly…. • 98% of child deaths occur in developing countries • The ratio of child mortality in developing countries to child mortality in industrial countries was – 5. 5 in 1960 – 10. 3 in 1990 – 13. 0 in 2002 • The child mortality rate increased in 15 countries from 1990 -2002, many of which in SSA Bloom Source: David Bloom and David Canning, Harvard University

The Lancet 2003: Child survival I South Africa: TB Bloom

Justifications for devoting resources to health • moral, ethical, humanitarian • basic human right • vital social goal Bloom Source: David Bloom and David Canning, Harvard University

Justifications for devoting resources to health • • moral, ethical, humanitarian basic human right vital social goal health is a crucial element in the development of strong economies Bloom Source: David Bloom and David Canning, Harvard University

About the links between health and wealth…. Bloom Source: David Bloom and David Canning, Harvard University

Income and Life expectancy in 2001 Bloom Source: David Bloom and David Canning, Harvard University

Impact of child health on economic growth developing countries Bloom Commission on Macroeconomics and Health

From income to health: one part of the story Income Health Bloom Source: David Bloom and David Canning, Harvard University

From income to health: one part of the story Income Health • Better nutrition • Better access to clean water • Better sanitation • Improved access to preventive & curative health services • Better psycho-social resources Bloom Source: David Bloom and David Canning, Harvard University

From health to income – the rest of the story Income Health Bloom Source: David Bloom and David Canning, Harvard University

From health to income – the rest of the story Income Health • Productivity • Education • Investment • Demographics Bloom Source: David Bloom and David Canning, Harvard University

Health to income Income Health A 10 year gain in life expectancy translates into nearly 1 additional percentage point of annual growth of income per capita. In addition to this health effect, demographic transition accounted for roughly one-third of the “East Asian miracle”: 2 percentage pts/year. Comparison: E-economy: 2 -3 percentage points/year. Bloom Source: David Bloom and David Canning, Harvard University

The bottom line…. The rate of return to investment in the GAVI immunization program is conservatively estimated at 12% in 2005, rising to 18% in 2020. Bloom Source: David Bloom and David Canning, Harvard University

By comparison…. These figures are comparable to average rates of return to investments in schooling (based on a survey of 98 country studies during 1960 -97): primary: 19% secondary: 13% higher: 11% Source: G. Psacharopoulos and H. Patrinos, “Returns to Investment in Education: A Further Update”, World Bank Policy Research Working Paper 2881, September 2002 (social rates of return from Table 1). Bloom Source: David Bloom and David Canning, Harvard University

Thus… Vaccination and other cost-effective child health promotion programs have a strong claim to be powerful instruments of economic growth, poverty reduction, and human betterment. But: A prerequisite is extensive coverage and equitable delivery and therefore a functional health system that can deliver. Bloom Source: David Bloom and David Canning, Harvard University

Main Take-Home Message: Immunization and other cost -effective child health promotion programs can be highly cost-beneficial tools for promoting both the health and wealth of nations Bloom Source: David Bloom and David Canning, Harvard University

Global Immunization 1980 -2002, DTP 3 coverage global coverage at 75% in 2002 Bloom Source: WHO/UNICEF estimates, 2003

WHO/UNICEF: Review of Immunization Coverage in South Africa 1980 -2003: DTP 3 DEMOGRAPHIC AND HEALTH SURVEY (DHS) REPORT FOR EASTERN CAPE 1998 Bloom

1990 s: progress reversed Inequitable globalisation, Health sector “reform”, and HIV/AIDS result in slow progress and reversals. Bloom Source: David Sanders, University of the Western Cape

U 5 MR in Sub-Saharan Africa Bloom State of the World’s Children 2003. UNICEF The

Research steps in the development and evaluation of public health interventions Describe the problem. Disease burden studies Test interventions Identify risk factors Explore the contextual factors Formulate public health interventions De Zoysa et al, Bull WHO 1998, 76: 127 -133 Bloom Assess efficacy of public health interventions Select possible interventions Assess effectiveness of public health interventions

The Lancet 2003: Child survival IV Bloom

The Lancet 2003: Child survival V Bloom

Indo-Nepali-Norwegian research consortium on childhood illnesses and nutrition • • Generate evidence-base for improving child health and nutrition in developing countries. Contribute to: Improve case management of children with diarrhea and pneumonia Reduce the incidence of severe diarrhea and pneumonia Promote adequate childhood nutrition Institutional strengthening linked to postgraduate education. India Nepal Bloom

Zinc syrup supplementation Nepal and India Funding: • EU-INCO • NUFU • NORAD Bloom

Zinc for treatment of diarrhea, Nepal (n=1792) • Zinc reduced the risk of persistent diarrhea by 40% • Zinc was equally effective when given by mother • Children receiving zinc experienced some more regurgitation and vomiting Bloom Strand, T. A. , R. K. Chandyo, R. Bahl, P. R. Sharma, R. K. Adhikari, N. Bhandari, R. Ulvik, K. Mølbak, M. K. Bhan, and H. Sommerfelt. Pediatrics. 2002; 109: 898 -903.

Routine zinc supplementation for prevention of diarrhea and pneumonia, India 2 RDA of zinc (10 or 20 mg) every day for four months (1250 children vs. 1250 controls): Reduced incidence of – Persistent diarrhea – pneumonia 31% (95%CI 2 -52%) 26% (95%CI 1 -44%) Bhandari, N. , R. Bahl, S. Taneja, T. A. Strand, K. Mølbak, R. J. Ulvik, H. Sommerfelt, and M. K. Bhan. 2002. Pediatrics. 109 (6): e 86. Bloom

South Africa: Among few countries which fortifies flour with zinc Bloom Community- and hospital-based intervention trials to measure the efficacy of zinc as adjuvant therapy for pneumonia • India-Nepal-Norway • NUFU: 0. 6 mill EURO • EU-INCO-DC: 0. 9 mill EURO

Lancet 2003 child survival II With sufficient [1] or limited [2] evidence for reducing childhood mortality from the major causes of under 5 deaths Bloom

PROMISE-EBF • Promoting infant health and nutrition in Sub-Saharan Africa: Safety and efficacy of exclusive breastfeeding promotion in the era of HIV • EU-INCO 1. 3 mill. EURO Bloom

Norway Sweden France Burkina Faso Uganda Zambia South Africa Bloom

Key health research areas to consider • Cause-specific burden of disease studies guide intervention-oriented research. Mother and child health, HIV/AIDS, TB • Studies of disease determinants (SA and SSA) with an equity lens • Clinical/field trials: – Efficacy trials – Program-relevant effectiveness trials • Studies (including trials) of comprehensive, community-based approaches • Health systems research, particularly on operational aspects and on evaluation Bloom

EDCTP aims to: • accelerate the development of new clinical interventions to fight HIV/AIDS, tuberculosis and malaria • build relevant capacities in developing countries for clinical trials-based evaluation of such interventions Budget: 200 ME+200 ME, of which 25% for capacity building , Cape Town selected as hosting institution of the African branch office of EDCTP Secretariat Bloom

Possible strategies for RSA-Norwegian health research • • Regional collaboration: SADC Other “South-South” collaboration, e. g. w. India Funding: EU/EDCTP: SA as a regional nodal point Research linked to postgraduate training and institutional strengthening in both (all) countries Management after 2009? : S&T/NRF and Research Council of Norway/Norwegian Centre for International Cooperation in Higher Education? Bloom

ENKOSI! NGIYA BONGA! DANKIE! THANK YOU! TAKK! Bloom

South Africa – Norway March 15 2005 Prof. R E Mhlanga, University of Kwazulu-Natal Bloom

Health collaboration • Priorities for the Country • Free Health Care for pregnant and lactating women and for children under 6 years of age • Notification of and Confidential Enquiry into Maternal Deaths • Micronutrient fortification of basic foods • Safe(r) Motherhood • Millennium Development Goals • PERINATAL HEALTH Bloom

Health collaboration 130 million babies are born every year • 4 million die within 4 weeks of having been born • 4 million are born dead • Majority are in Sub-Sahara • How can perinatal health be improved – National question • How are the initiatives contributing to the national solution - SUSTAINABILITY Bloom

Health collaboration PROPOSALS – NATIONAL Management of HIV and other infections Present projects – skills for midwives and advanced midwives Management and administrative skills for midwives Exchange programmes – under- and postgraduate students for health Intersectoral collaboration – what do partners bring to the table to ensure a healthy nation? Bloom