Eradicating infectious diseases involves more than science and medicine — community-level understanding and social change are crucial.
When panic erupted in South Africa’s Parliament in 2014 over an Ebola crisis occurring thousands of kilometres away, Health Minister Aaron Motsoaledi tried to be the voice of reason.
There was another disease that was a much bigger threat to South Africans, he told legislators — one that had killed more people than HIV/AIDS, malaria, cholera, Ebola, pneumonic plague, influenza, and polio, put together. It was tuberculosis, a disease that has also left deep scars in Canada.
“Despite all my explanations they were not satisfied,” Motsoaledi told an audience of researchers, students, politicians and delegates attending a side event at the Global Fund’s Fifth Replenishment conference this month in Montreal. He was forced to close South Africa’s borders to ward against Ebola. “I told them, if you want to be scared, be scared about TB.”
What’s more, the public cried foul, saying talk of TB was a diversion, a trick! A year later, nobody in his country had died of Ebola, but a staggering 40,000 South Africans had died of TB.
“Any one of us can stand up on a top of a mountain and say they will not become HIV positive,” he said. “But none of us can ever stand up and say we’ll never get TB. Anyone who breathes is vulnerable to TB.”
How to end epidemics of the world’s communicable diseases, including preventable ones such as TB, is a component of the UN’s Sustainable Development Goals. Canada adopted the goals with other world leaders last year as part of the 2030 Agenda for Sustainable Development.
This month’s Global Fund conference raised $12.9 billion toward the fight. This conference took place just as the federal government is in the midst of an international policy review. The government’s approach to meeting the health targets of the UN agenda will play a key role in that review.
Last year more than 2 million people were infected by AIDS, and over 1 million died from it. There were also 214 million cases of malaria, and almost half a million deaths. Tuberculosis infects a third of the world’s population, and kills 1.5 million a year.
Mark Dybul, executive director of the Global Fund, suggested that the focus should be on localized action, addressing one micro-epidemic at a time.
“If I hear one more time about a silver bullet I’m literally going to slit my wrists. The fact is there’s no global epidemic. There are micro-epidemics all over and in each country,” he said.
Canada is facing several HIV micro-epidemics in Saskatchewan on First Nation reserves. Rates of infection there are 11 times higher than the national rate, with 63.6 cases per 100,000, compared with the Canada-wide 5.9 cases per 100,000. Earlier in September, Saskatchewan doctors called for a state of emergency to tackle the problem, asking for increased funding and resources.
Moving from global talk to community action
On the Ahtahkakoop First Nation reserve, Chief Larry Ahenakew got funding for increased HIV testing, a needle-exchange program and developing Canada’s first on-reserve methadone clinic. This is the kind of community-focused approach Dybul is advocating for in international assistance.
To get a good grasp of each of these outbreaks, Dybul said, aid teams must first assess who is infected, then get an understanding of who else in a community might be at risk. Next, they must look at evidence from other similar outbreaks to see how it was tackled in the past, and decide what the response should be. Any action should take into consideration community norms and culture; for example, talking to community leaders and working with local health centres.
Next, he advises there be an in-depth follow-up to ensure continued progress. He said that throughout the process, aid workers need to figure out how to work with the community to get new medical technologies to people who need them. No single approach works; every micro-epidemic needs to be assessed separately.
Alex Dodoo, the director of the African Collaborating Centre for Pharmacovigilance at the University of Ghana, agrees that there must be a community-based approach to eradicating these diseases.
“There is still much superstition; when it comes to HIV/AIDS, people still believe in witchcraft,” Dodoo said after an event with Medicines for Malaria Venture.
“We know that some people smoke antivirals [Efavirenz] to get high instead of taking them for infection. We see people taking Rifampicin [which is supposed to be used to treat TB] to try to get rid of sexually transmittable diseases. It turns the urine red, so they believe it gets rid of sexual infections.”
He said women and children are the hardest hit, as they are most vulnerable, and doctors are still embarrassed to talk about women’s health issues. He recalls a situation where a woman brought back her oral dose of antifungal medication saying she could not swallow it – the pill was too big. The doctor neglected to explain it needed to be inserted vaginally, not swallowed.
Dodoo advocates getting the right technology and medicines to communities through connections with faith-based organizations, saying they are a good source of funding and a good avenue for education.
“Few Africans change their church, their mosque, their football club. Since we can’t access them through the football club, the churches are potentially the most transformative,” he said.
Canada is not immune
Part of what makes the UN’s Sustainable Development Goals so groundbreaking (and challenging) is their core principle of universality. All participating countries, including the developed ones, must make changes domestically to meet the targets.
Canada’s Health Minister Jane Philpott notes that there are 50 new HIV infections every week in Canada, and the number hasn’t come down in two decades. Philpott, who worked for a decade at a rural hospital in Niger for Doctors without Borders, said that equity, access to care and human rights are crucial in fighting communicable diseases everywhere, not just in the developing world.
To illustrate, the stigma attached to HIV means many people are scared to be tested for fear of being ostracized by their community. Even when they are tested, some vulnerable populations (such as those in rural areas) don’t always have access to quality care, and they often lack family and community support.
“Men who have sex with other men and other LGBTQ individuals are still the largest part of the vulnerable populations. Indigenous Canadians are vastly disproportionately affected,” said Philpott during a panel discussion at McGill University as part of the Global Fund conference. She said sex workers, people in prison, and people that use drugs are most at risk.
While malaria only affects Canadians who travel abroad, TB continues to be a problem at home in 2014 there were 1,568 reported cases. Rates of infection among Indigenous Canadians are 33 times higher than they are among non-Indigenous Canadians, and in Inuit populations they are 275 times higher.
While she didn’t detail any specific policy initiatives, Philpott said, “Individually we can make progress. But it’s only collectively and collaboratively that we can contemplate the end of these epidemics.”
Peter Singer, CEO of Grand Challenges Canada, a Canadian platform for development innovation in maternal, newborn and child health, spoke about innovations that could be a solution for Indigenous communities. He said that while medical innovation and research may have a 10- to15-year timeline due to clinical trials, business innovations such as better diagnostic or communications tools can be rolled out in two or three years.
“Indigenous people are going to solve the problems themselves by innovating,” he said. With the exception of the work being done at CIHR’s Institute of Aboriginal People’s Health, Singer says there is not enough support for Indigenous innovation.
“I often lie in bed at night thinking, if Canada could do for its own Aboriginal people what it did for innovators in low- and middle-income countries, for example, the $200 million investment in Grand Challenges Canada, that would be transformational,” he said.
Photo: Ryan Remiorz/The Canadian Press
This article is part of the International Assistance special feature.
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