FORESIGHT Global Health - Autumn 2021 by FORESIGHT Media Group

FORESIGHT — 03 Global Health

The tightening grip of climate change AT THE CRITICAL JUNCTURE OF HUMAN AND PLANETARY HEALTH

GLOBAL HEALTH POLICY

Managing diabetes in crisis settings

Air pollution a threat to heart health

SPECIAL REPORT

Towards equitable access to health insurance

HEALTH FINANCE

TECH & INNOVATION

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PAGE 18

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Building trust on social media

THE ENVIRONMENTAL CRISIS AND GLOBAL HEALTH

On the precipice of change FORESIGHT Global Health AUTUMN / WINTER 2021

PUBLISHER FORESIGHT Global Health

CIRCULATION 1500

EDITORS Suzanne Moll Angela Tufvesson

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For generations, we have not listened to the message and now the planet is fighting back with what seems to be a final warning. At last, the world is talking about climate change—and there are a multitude of reasons why healthcare professionals are encouraged to join the conversation. At the November 2021 COP26 summit in Glasgow, the link between climate change and global health was made clearer than ever, with a group of 51 countries committing to developing climate-resilient health systems. Some links between climate change, global health and non-communicable diseases (NCDs) are obvious. Others are less pronounced. While it is well known that air pollution is a main contributor to respiratory illnesses, it may be surprising to learn that air pollution is also a core determinant of poor cardiovascular health. We have dedicated our special report to exploring some of the lesser known effects of the climate crisis on our bodies as well as emerging solutions improving both human and planetary health. Generating momentum to integrate new ideas and more broadly transform health systems is a challenging task. It starts with creating a consensus on the magnitude and urgency of the problem in front of us. Here, we can learn a lot from the climate change movement. For years, climate action groups have generated unprecedented media attention about the dangers and opportunities facing the world. In our special report we also cover how these learnings can be applied to change the narrative of NCDs from a long-term agenda to an urgent matter. As 2021 comes to a close, so too does the centennial of the discovery of insulin and a year marked by the launch of several diabetes initiatives. Our global health policy section is dedicated to uncovering the implications of rising diabetes rates in regions and settings where diagnostics and treatment are far from available to everyone. The disease is a growing problem in many African countries, putting even more strain on pandemic-hit healthcare systems. We focus on the situation in Zambia, where diabetes cases are rising faster than the global average, and explore potential remedies in better-resourced South Africa. The diabetes health gap is also evident in humanitarian settings like conflict zones and regions affected by natural disasters. We need to look at innovative strategies to broaden healthcare offerings for displaced populations, including better diabetes management. As the impact of the climate crisis on human health intensifies, we call for urgent action to remove barriers to improved human and planetary health and the courage to amplify bold ideas and solutions for a healthier world.

Suzanne Moll EDITOR-IN-CHIEF

CONTENT

GLOBAL HEALTH POLICY ZAMBIA PUSHING THROUGH THE BARRIERS TO BETTER CARE

Diabetes is on the rise as the country looks to solutions at home and further afield PAGE 4

TAKING ACTION AGAINST DIABETES IN CRISIS SETTINGS

Better provision of care for displaced people is a key challenge for healthcare experts PAGE 10

SPECIAL REPORT

HEALTH FINANCE

TECH & INNOVATION

AT THE HEART OF AIR POLLUTION

SMALL-SCALE HEALTH INSURANCE FOR A MORE SECURE FUTURE

TAMING THE FIRES OF SOCIAL MEDIA MISINFORMATION

Microinsurance reduces out-ofpocket healthcare costs across Africa

Fake news continues to threaten health literacy, but powerful antidotes can be found

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OPINION: CAN BLOCKCHAIN UNBLOCK NCD FUNDING SOLUTIONS?

OPINION: CHECKING THE BOX FOR BETTER MATERNAL AND CHILD HEALTH

Organisations have an opportunity to better finance NCD prevention and care

Sharing a mother’s medical history on her child’s health card could enhance quality care

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Poor air quality can have a serious impact on cardiovascular disease and mortality PAGE 18

TREATING PATIENT EARTH

Lessons from the climate change movement help the healthcare sector raise the urgency of NCD prevention and care PAGE 24

THE UNEXPECTED IMPACT OF CLIMATE CHANGE ON HEALTH

A series of unexpected effects are having far-reaching consequences on human health PAGE 32

SMART SOLUTIONS FOR HUMAN AND ENVIRONMENTAL HEALTH

Three innovative startups across three continents share their sucesses PAGE 34

FORESIGHT

PHOTO PixelCatchers and Carlo Kaminski

Gazing towards better care With diabetes on the rise in Zambia, scaling up preventative measures and access to care becomes an urgent matter

FORESIGHT

DIABETES MANAGEMENT IN AFRICA

Zambia pushing through the barriers to better care In Africa, non-communicable diseases like diabetes will be a more serious threat to life than all other illnesses within 10 years. The situation in Zambia offers insights into the challenges and opportunities facing the continent in pursuit of improved prevention and treatment of diabetes By ZARINA GELOO in Zambia

FORESIGHT

GLOBAL HEALTH POLICY

s celebrations marking the 100th anniversary of the discovery of insulin come to an end, and with the achievement of significant successes in the political environment to accelerate prevention and treatment of diabetes—including the launch of the World Health Organization (WHO) Global Diabetes Compact—our attention must now shift to regions of the world where managing the condition remains a particularly significant challenge. An estimated 537 million adults worldwide have diabetes, and the majority live in low- and middle-income countries (LMICs). In Africa, non-communicable diseases (NCDs) like diabetes are projected to overtake all other causes of death by 2030. Health systems across the continent remain burdened and under-resourced, unable to provide the healthcare people need. The Ebola and other seasonal epidemics, as well as the covid-19 pandemic, add further strain to healthcare systems. In countries like Zambia, significant cost and resourcing barriers affect access to diabetes care. In comparison, in better-resourced countries like South Africa, stronger healthcare networks and a grassroots system of care increase the likelihood of better outcomes for people with diabetes. In both nations, the adoption of a sugar tax offers promise of healthier lifestyles and a reduced risk of diabetes.

ESTIMATING SIZE AND SCALE Zambia is a country still grappling with high rates of communicable diseases like HIV/AIDS and tuberculosis (TB), and together with NCDs like diabetes that require substantial medical resources, these conditions pose a serious economic burden for the already limping healthcare system. As diabetes isn’t managed in isolation from other NCDs, it’s difficult to estimate the size of the problem. According to diabetesatlas.org, an estimated 726,300 people in Zambia were living with diabetes in 2021 out of a population of approximately 18 million. There were an estimated 386,900 undiagnosed cases and 15,500 deaths attributed to the disease. The covid-19 pandemic has exacerbated the situation, with the former Minister of Health Chuilufya Chitalu stating that most patients dying of the virus in Zambia had underlying conditions like diabetes and high blood pressure. There is no data on exact figures, but a small local study of people who died from covid-19 in Lusaka, the capital city, found 13% had diabetes. Lifestyle habits are another important factor, with the troubling combination of sedentary lifestyles and unhealthy food choices contributing to al6

most one-quarter of Zambia’s adult population being classed as overweight or obese.

GAPS IN TREATMENT In 2017, the Zambian Ministry of Health undertook its first national survey of NCDs and associated risk factors. The results, which provided baseline information and a guide for policy and planning for NCDs in Zambia, showed that only 36.8% of adults who had been previously diagnosed with diabetes were currently undergoing treatment. There are several reasons for this. The survey notes that Zambians do not, as a matter of routine, get screened for blood sugar or cholesterol levels. And although health facilities deliver free primary healthcare services at a community level, there is little focus on the prevention and management of diabetes.

“How can we achieve anything when we provide services in an ad hoc manner?”

To compound matters is the cost of treatment. The cost of insulin and items like test strips and syringes vary widely from one place to another and are unaffordable for the majority of people not covered by private health insurance. In the private sector, insulin ranges between $25 and $100 per vial, yet around 64% of Zambians live on less than $2 a day. Resourcing is another issue. Rodgers Phiri, a healthcare worker in one of Lusaka’s primary care facilities, says patients are routinely referred to private facilities to get tested for diabetes because public health facilities rarely have the resources. “I hear politicians say Zambia is on course to reach NCD targets by 2030, but the reality says something else,” he says. “How can we achieve anything when we provide services in an ad hoc manner?”

SHORT ON FUNDS AND FACILITIES In the last three years, Zambian health sector funding has reduced from 9.5% in 2018 to 8.1% in 2021, but permanent secretary Kennedy Malama says an increase in the budgetary allocation for health in 2022 will “spur improvements in health service delivery including for diabetes”. To ease the burden on the Treasury and help reduce out-of-pocket health expenditure for individuals, FORESIGHT

GLOBAL HEALTH POLICY

Leading a fatal race Comparative prevalence of diabetes in Zambia, South Africa and worldwide

16% 14% 12% 10% 8%

SOURCE: International Diabetes Federation, 2021

6% 4% 2% 0% 2011

2021

ZAMBIA

a national health insurance scheme was introduced in 2019 where every citizen pays 1% of their basic monthly salary as a subscription to access care. However, the effects of this minimal payment have not yielded any results as government health facilities are still short on supplies, equipment and human resources. With an increase in diabetes in Zambia, there is the inevitable rise in chronic kidney disease and the demand for dialysis. In 2015, the government acquired 21 dialysis machines from Germany for three referral hospitals. However, veteran journalist Swithen Hangaala, a long-time kidney disease patient, says people are dying for lack of regular dialyses. He says the 12 renal centres across the country have always been unreliable, but now they have not been operational for the last few months. “The renal units do not have the consumables to operate the machines,” Hangaala says. “They have cut down the hours on dialysis from four to two and cut down the number of times one can have dialysis FORESIGHT

2030

SOUTH AFRICA

2045

GLOBAL

in a week. Patients like me usually need at least three sessions a week.” The only alternative is to go to the private sector where each dialyses session costs about $118—far beyond the means of the average Zambian.

SIMILAR CHALLENGES DOWN SOUTH In South Africa, the second-largest economy in Africa after Nigeria, similar challenges remain, but the country is making some inroads in diabetes care. Like Zambia, South Africa also suffers from the added disease burden of high HIV/AIDS and TB rates, as well as NCDs, of which the rates of diabetes are particularly high. And it shares similar challenges to Zambia in preventing, diagnosing and treating the condition. South Africa is beleaguered by historic economic and health inequalities that have led to a substandard health delivery system, with outcomes often the same, or worse, than those of its lower-income neighbours. According to diabetesatlas.org, about 4.2 million 7

GLOBAL HEALTH POLICY

Distinct spending differences

GLOBAL $1839

South Africans are living with diabetes in 2021 out of a population of approximately 60 million. An estimated 1.9 million of these cases were undiagnosed and 95,700 deaths were directly attributable to the disease. The reasons for these startling figures are not unlike in other LMICs: insufficient access to health facilities, lifestyle changes like an energy dense and calorie deficient diet, and little or no knowledge about diabetes.

COMMUNITY-LEVEL CARE In search of solutions to its growing diabetes problem, South Africa launched a Diabetes Prevention Programme (DPP) in 2019 with the aim of delivering treatments in a culturally relevant context through household screening questionnaires and group gatherings for at-risk individuals. The information was used to educate communities and healthcare practitioners about diabetes. But the programme ended abruptly, says Margot McCumisky, a national manager at Diabetes South Africa (DSA). “We were doing well, and we trained about 400 home-based carers. About two and a half 8

SOUTH AFRICA $1701

AFRICA $547

years into the programme, without giving us a reason, the [health] department stopped funding.” Since then, DSA has pursued other strategies to educate communities about diabetes and facilitate access to healthcare. In 2020, it set up a covid-19 helpline for diabetes patients. It also plans to resume community diabetes wellness groups—so far, it’s helped to establish 40 groups throughout South Africa—and hopes to expand this initiative if funding becomes available. Within these groups, communities have access to talks about diabetes management, food and nutrition, which help to debunk the idea that healthy food is expensive. “We promote indigenous fruit and vegetables and warn that the 2-litre Cokes and bunny chows [popular fast food] have empty calories,” McCumisky says. Because healthcare facilities can be difficult to access, she believes this grassroots-level approach is the most effective way for people to find the support and information they need to avoid the devastating complications that can arise from unmanaged diabetes. Community groups also help people navigate the health system—namely, that testing facilities are free FORESIGHT

ZAMBIA $334

SOURCE: International Diabetes Federation, 2021

Diabetes-related health expenditure per person in 2021

GLOBAL HEALTH POLICY

Sugar tax In South Africa, sugar taxes drive tension between economic growth and good health

at government facilities and also covered by health insurance. Unlike many countries in the region, South Africa provides free insulin in its facilities, and it is covered by insurance in private hospitals.

NOT SO SWEET Encouraging behaviour that reduces diabetes risk with financial incentives is another approach South Africa is exploring. In 2018, the country implemented a sugar tax of about 10%, known as the Health Promotion Levy (HPL). Zambia, too, introduced a $0.02 per litre tax on all non-alcoholic beverages except water in 2019. By charging more for sugary drinks and foods, the governments of the two countries hope to fight obesity and help people make healthier choices. So far, the tax has yielded some positive results in South Africa. A national study published this year found households in urban areas had reduced the volume of sugary beverages they bought by onethird, cutting their sugar intake by half. However, neither country plans to raise the tax to the WHO recommended rate of 20%. In Zambia, the government is at odds with itself as it has committed FORESIGHT

to growing the economy through the manufacturing sector, which includes the food and beverage sub-sector. There was concern that the introduction of such a tax may lead to job losses due to a reduction in the demand for sugar-based beverages. Zambia’s sugar industry contributes more than 3% to GDP, 6% to total national exports and is directly responsible for more than 11,000 jobs. The Zambian Ministry of Health is now encouraging schools to integrate physical activity as part of the curriculum, particularly in urban areas where leisure parks are not free to access, and roads are not safe for pedestrians. Another initiative provides physical activity counselling as part of routine primary healthcare services. In South Africa, McCumisky says the jury is still out on the impact of the sugar tax as there are so many products that are not covered by the tax and still contain large amounts of sugar. She is hopeful that manufacturers will be encouraged to take a closer look at the amount of sugar in their products and that the tax debate might encourage a diabetes education campaign. • 9

FORESIGHT

PHOTO Anas Alhajj and Thomas koch

Rising rates Diabetes and other NCDs are on the rise in regions where the number of people displaced by humanitarian crises is also increasing

DIABETES CARE IN HUMANITARIAN ENVIRONMENTS

Taking action against diabetes in crisis settings The number of people displaced by humanitarian crises is rising, and there is a pressing need to address non-communicable diseases like diabetes. Devising practical, scalable and cost-effective solutions, and allowing these solutions to be integrated with broader healthcare systems, is more important than ever By ANDREA CHIPMAN in the United Kingdom

FORESIGHT

GLOBAL HEALTH POLICY

s the past two years of the pandemic have confirmed, non-communicable diseases (NCDs) are both a long-neglected and under-funded health burden and a growing crisis globally, particularly for low- and middle-income countries (LMICs). While it’s difficult enough for people living with NCDs to access consistent treatment in these regions, such care has been largely an afterthought in humanitarian settings like conflict zones or regions that have recently suffered natural disasters. This health gap is especially significant because the number of people trapped in these situations or on the move globally has continued to increase, with more than 350 million people currently affected by such crises and nearly 80 million people displaced around the world as of 2019, according to the International Alliance for Diabetes Action (IADA). Around 85% of this population is being hosted in LMICs such as Uganda, Lebanon, and Pakistan, and more than 65% of these cases involve protracted refugee situations, according to the United Nations High Commissioner for Refugees (UNHCR). It’s a problem that threatens to explode as climate change affects natural resources and infrastructure, accelerating levels of migration. For aid organisations and governments contending with desperate populations who are often homeless and hungry, addressing chronic conditions may previously have seemed like a luxury. Yet, as the increasing number of people on the move puts more pressure on national healthcare systems and donor funding, there is a growing consensus that the failure to include NCDs as part of the broader healthcare offering for displaced populations is a false economy. Providing evidence of the value of addressing NCDs alongside other health issues in humanitarian contexts will be a key challenge for policymakers and health experts, especially as they look to attract much-needed donor funding.

SPOTLIGHT ON DIABETES As experts seek strategies to treat NCDs in crisis situations sustainably, some experts have focused on diabetes management to provide policymakers with evidence about the benefits of standardising care in a way that benefits both displaced people and the broader population. In 2019, a group of diabetes experts and non-profit organisations met at Harvard University to brainstorm ways to formalise the diagnosis and treatment of diabetes in humanitarian settings, culminating in a series of proposals known as the Boston Declaration. The Boston Declaration outlined four major tar12

gets to define the group’s work over the next few years: unified and strengthened advocacy; universal access to insulin, diagnostic equipment and hypertension medicines available as part of humanitarian responses; establishment of a unified set of clinical and operational guidelines for diabetes in humanitarian crises; and improved and coordinated data surveillance. Achieving these aims is likely to involve collaboration between health experts, NGOs and health ministries. “If you can manage diabetes well—one of the most complex NCDs—you can likely manage other NCDs well,” says Dr Sylvia Kehlenbrink, director of Global Endocrinology at Brigham and Women’s Hospital, co-author of the Boston Declaration and the director of the NCDs in Humanitarian Settings programme at the Harvard Humanitarian Initiative. “In essence, we convened a kind of coordinating body to help align everyone around a key issue and make sure there is no duplication.”

“If you can manage diabetes well—one of the most complex NCDs—you can likely manage other NCDs well”

Diabetes is one of the most prevalent NCDs globally and one of the most difficult to manage, especially in LMICs, where it’s growing rapidly. It’s a particularly challenging condition to address in unstable and poorly resourced humanitarian environments, characterised by short-termism in focus and funding. Establishing a platform to identify and provide care to diabetic patients in crisis settings can help shape evidence-based approaches to treating all patients living with metabolic syndrome and other NCDs in humanitarian environments, as well as improve the detection and management of the disease in the wider population. The importance of creating more integrated and universally accessible healthcare systems that identify and treat people at risk of NCDs has never been more important, as the covid-19 pandemic has illustrated. At the same time, it’s clear that such solutions need to include displaced people, which will require national health ministries to work with NGOs to build comprehensive care pathways that work seamlessly across populations and, where possible, across borders. FORESIGHT

GLOBAL HEALTH POLICY

The Gordian knot of healthcare delivery Key barriers to effective diabetes management in humanitarian crisis settings

$ $

INSUFFICIENT DRUG SUPPLY due to ACCESS ISSUES to prescribed medications, blockages of supply routes due to armed violence and sudden rises in patient loads

$ $ $

OUT-OF-POCKET COSTS to individuals including health services, certain drugs and transport to and from clinics

SOURCE: RSPH Public Health, 2021

COMPLEXITY OF THERAPY, including the high cost of syringes, needles, glucometers and lancets, and the need for COLD STORAGE

LOW PATIENT EDUCATION on the condition and treatment, including lifestyle change and dietary recommendations, often due to LANGUAGE BARRIERS

“Our approach is to see how we can help the national healthcare systems in a country, and we are also trying to strengthen the existing healthcare system more specifically where the crisis is,” says Jakob Sloth Madsen, a senior advisor at the World Diabetes Foundation (WDF). “The question is whether it makes sense to separate a protracted humanitarian response from a long-term health system strengthening effort; in our view, you need to integrate the two dynamics and build permanently viable solutions for the health system in those countries.”

ing NCDs in unstable situations and creating a robust framework that can provide greater consistency of care. The NGO Médecins sans Frontiéres (MSF) noted in a recent article that diagnosis rates for diabetes and other NCDs remain extremely low in people living in crisis environments. For those who have been diagnosed with diabetes already, insulin is often unavailable in remote or rural environments with limited access to resources, and it’s often dangerous to travel to healthcare centres to collect insulin or receive treatment. Storage of medication is also difficult in places where fridges are in short supply and daily temperatures can exceed the recommended storage range. And the expense of managing diabetes remains a ma-

OBSTACLES TO CONSISTENT CARE The complexity of treating diabetes is a case in point about the challenges involved in identifying and treatFORESIGHT

GLOBAL HEALTH POLICY

jor problem, with diagnostics often even more costly than medication, according to Kehlenbrink. Meanwhile, the lack of regular healthy food supplies, a chronic concern for low-resource populations or people who have been displaced from their homes, exacerbates the challenge of managing diabetes. Kehlenbrink says humanitarian food assistance programmes have historically focused on undernutrition and the food baskets provided in humanitarian settings are typically composed of goods that provide nutrition such as rice, sugar, oil and salt, which are incompatible with the needs of people living with diabetes. Delays in detecting and treating diabetes in these settings can lead to complications like kidney failure, heart disease and vision loss. MSF has recognised the fact that many of its patients present with existing and newly detected NCDs, including diabetes, as well as other health needs such as malaria and malnutrition. Consequently, it offers a range of preventative, primary and secondary health services—incorporat14

ing acute and chronic management of diabetes—as part of its treatment of Burundian refugees in the Nduta camp in northwest Tanzania. Plus, healthcare professionals working in crisis settings already have experience with another chronic illness, HIV, which offers lessons on how to ensure adherence to treatment in challenging circumstances. One 2014 study found that 87% to 99% of displaced people with HIV had achieved 95% adherence and positive treatment outcomes, and that with the appropriate support, HIV treatment outcomes for forced migrants could be similar to those in the host community. In addition, some NGOs in humanitarian environments issued modified or supplementary food baskets to the elderly or people living with HIV/AIDS or TB where nutrition was a priority, Kehlenbrink says, adding that NGOs could aim to make similar arrangements for people with type 1 diabetes or those who require insulin. The availability of alternative diets, FORESIGHT

Data shortage Keeping track of medical care in humanitarian settings is often a paper-based process

GLOBAL HEALTH POLICY

where possible, would also help aid agencies to manage the conditions of those living with type 2 diabetes and hypertension.

CONFOUNDING THE CONVENTIONAL WISDOM Lebanon has some of the most extensive experience with caring for refugee populations and provides an example of how more comprehensive systems could work. It’s host to two primary groups of Middle Eastern refugees, says Dr Mona Osman El Hage, an assistant professor of family medicine at the American University of Beirut (AUB). The country’s Palestinian refugees still largely live in camps in the south of the country, where their care is managed by the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA), while the more recently arrived population of Syrian refugees are housed in local communities, where their care is supported by NGOs along with the Ministry of Health through the country’s 245 primary healthcare centres (PHCs).

“Diabetes was not on the humanitarian radar 10 years ago; they were not screening for it, and they were not looking for it”

Because medicines and lab tests for chronic conditions are traditionally covered by private donors, not all PHCs offer them, Osman says. A programme for type 1 diabetes that AUB is running in conjunction with the WDF is helping to fill that gap for both the Lebanese and Syrian populations and could serve as a model for integrating care for displaced people living within the community with that for domestic populations. “This project is really timely for everyone, because it supports not only awareness and screening, but management of diabetes and hypertension, as well as coverage for needed blood tests, followed up in health centres,” Osman says. “This project will build the capacity of healthcare workers in providing a good service to diabetes patients and is helping to contain the brain drain [of physicians from Lebanon]. It is also building the capacity of diabetic patients for self-management.”

KEEPING TRACK OF PEOPLE IN NEED One of the key challenges facing policymakers looking to set guidelines and frameworks for treating NCDs in humanitarian settings is the absence of data FORESIGHT

on management and guidelines for chronic conditions in such settings. These difficulties are hampered by the lack of funding allocated explicitly for diabetes and other NCDs in humanitarian contexts. “If you look at humanitarian settings, data is scarce on mortality rates,” Madsen says. “We are working at helping healthcare services improve their health information systems so they can have a more solid registry of who they are treating.” Other approaches will be necessary, however, for some displaced populations. Traditionally, diabetes and other NCDs are managed via patient records held at clinics. While that is possible in cases treated within the community, for migrants in temporary settings different approaches will be necessary to ensure that patients receive follow-up care. In some cases, this means making sure that patients have simple hand-held records to carry with them, as well as appointment books and the use of reminder messaging or community health workers to trace patients. In Lebanon, the Sijilli project, named after the Arabic word for ‘my record’, is archiving the medical information of Syrian refugees electronically so their healthcare providers can access it anywhere in the world. A ‘Bootcamp’ on NCDs in humanitarian settings held in Copenhagen in 2018 harnessed the opinions of researchers and NGOs to develop six goals for policymakers. Among them was a recommendation that member states fund the World Health Organization (WHO) and partners to develop a “secure, personalised, mobile health data system for humanitarian settings, building on new technology”, as well as a direction to governments and aid organisations to plan for and resource NCD prevention before and during humanitarian crises. Bootcamp participants suggested that new technologies, such as Blockchain, could be used to ensure secure and reliable access to patient data. Any effort to develop comprehensive policies for dealing with diabetes and other NCDs in humanitarian situations will need to be tailored to a variety of different environments and stages of conflict, ranging from more spartan and flexible programmes for people who are not in fixed accommodation, to more traditional treatment and prevention pathways for those living in the community. Kehlenbrink says she is encouraged by the willingness of so many stakeholders to work together. “Diabetes was not on the humanitarian radar 10 years ago; they were not screening for it, and they were not looking for it,” she says. “I’ve been doing this for five plus years, and the amount of progress that has been made is unbelievable. It’s slow progress, but it’s progress.” • 15

SPECIAL REPORT

Our greatest global threat The November 2021 COP26 summit in Glasgow was yet another reminder of the impending environmental disaster facing the world. Targets are easy to set, but hard to achieve, and time to reduce the worst impacts of climate change and keep temperature rises to within 1.5°C is running out. For humans, the threat is existential. There is no doubt the damaging consequences of the climate crisis are having a harmful effect on global health outcomes. This special report explores how a changing planet is affecting its inhabitants, and how caring for our health and that of the planet are inextricably linked.

FORESIGHT

COUNTRIES COMMITTING TO FUTURE CLIMATE RESILIENT HEALTH SYSTEMS Governments that formally pledged to develop national health plans at COP26 to continue efficient and responsive healthcare amidst an unstable climate

FORESIGHT

IMPACT OF AIR POLLUTION ON HUMAN HEALTH Air pollution is an invisible threat to human health as well as the planet—and not only because of its connection with respiratory diseases. Research shows air pollution is associated with cardiovascular disease and causes a staggering one in five heart attacks. How can we clean up the air we breathe to save more lives?

At the heart of air pollution By JO WATERS in the United Kingdom

trations of PM2.5 and PM10 are especially hazardous, with PM2.5 capable of entering the bloodstream and affecting the cardiovascular and respiratory systems. The growth of urbanisation and more mega cities— with large amounts of traffic and industrial pollution alongside densely populated areas—is accelerating the problem of air pollution. India is home to 35 of the world’s most polluted cities with the highest levels of PM2.5, and the others are found in China, Bangladesh and Pakistan. “Air pollution is a threat to health in all countries but hits people in low- and middle-income countries (LMICs) the hardest,” says WHO Director-General, Dr Tedros Adhanom Ghebreyesus. Dr Sophie Gumy, team lead on ambient air pollution at the WHO, says air pollution is now considered the largest environmental threat to health—and a significant risk to heart health. “Air pollution from particulate matter affects almost every organ in the body, but mostly respiratory and cardiovascular systems.”

CAUSED BY AIR POLLUTION A recent World Heart Federation (WHF) report reveals that more than 20% of all cardiovascular disease (CVD) deaths worldwide are caused by air pollution. Of the seven million deaths worldwide from indoor FORESIGHT

Heartbreaking facts The air we breathe has a significant impact on heart health

ILLUSTRATION Luke Best PHOTO AerialPerspective Works

hen most of us think about the risk factors for a heart attack, it’s probably smoking, high blood pressure and being overweight that first spring to mind. But there’s another hidden and universal threat to our cardiovascular health: the polluted air that nine out of 10 people in the world are currently breathing. Air pollution is estimated to kill seven million people each year, affecting every organ of the body. The risk of respiratory diseases is well understood, but the connection between heart disease and exposure to air pollution has gained traction only recently even though it’s believed to cause 3.5 million deaths globally every year. Newly updated World Health Organization (WHO) Global Air Quality Guidelines published in September 2021 provide mounting evidence of the damage air pollution inflicts on human health and set ambitious new targets for reducing levels of key air pollutants like particulate matter (PM), ozone, nitrogen dioxide, sulphur dioxide and carbon monoxide. PM is of particular concern for heart health and is generated from fuel combustion from traffic, energy, households, industry and agriculture. Fine concen-

SPECIAL REPORT

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SPECIAL REPORT

Inhaling ill health Global deaths from NCDs attributable to air pollution, by disease

Number of deaths

3.5M

CARDIOVASCULAR DISEASES

3M 2.5M

1.5M CHRONIC RESPIRATORY DISEASES

1M 500k

NEOPLASMS DIABETES AND KIDNEY DISEASES

0 1990

1995

2000

2005

and outdoor air pollution, 34% are from ischaemic heart disease (heart problems caused by narrowed arteries that supply blood to the heart muscle) and 20% from stroke. The report says the evidence for impact on cardiovascular disease is most consistent for PM, particularly PM2.5 and PM10, although nitrogen dioxide is also believed to play a role. Yet the authors highlighted that there is “still limited understanding among specialist physicians and cardiologists of the importance of air pollution contributing to premature cardiovascular death.” Professor Michael Brauer, chair of the WHF Air Pollution Expert Group from the University of British Columbia in Canada and the Institute for Health Metrics and Evaluation in the US, and one of the report’s authors, says outdoor air pollution is responsible for eight per cent of all deaths globally. “While it’s quite well recognised that air pollution 20

2010

2015

causes lung disease, it’s not so well recognised that it also causes heart disease, even among many cardiologists,” says Professor Brauer. Dr David Carbalho, a cardiologist at University Hospital of Geneva and spokesperson for the European Society of Cardiology, agrees with the report’s authors: “Knowledge of the impact of air pollution on cardiovascular health, although scientifically established, remains certainly underestimated by a significant proportion of general and specialised physicians as well as by other healthcare professionals.” Brauer warns that if we’re to reduce cardiovascular disease deaths around the world, we need to consider pollution. If it’s ignored, many of the advances we’ve made in prevention and treatment of CVD are in danger of being eroded. “Unlike a lot of approaches to diseases—[as] we know how to solve this one—we’re not looking for a miracle cure. We have examples from many counFORESIGHT

SOURCE: Institute for Health Metrics and Evaluation, 2019

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Asia-Pacific overrepresented Top five countries for deaths attributable to air pollution in 2019

DPR KOREA 23.3%

76.7%

NEPAL 21.8%

78.2%

SOLOMON ISLANDS 21.2%

78.8%

SOURCE: Institute for Health Metrics and Evaluation, 2019

BANGLADESH 20.4%

79.6%

VANUATU 18.6%

81.4%

8.7%

91.3%

BENEFITTING FROM REDUCED POLLUTION

GLOBAL AVERAGE

Air pollution attributable deaths

Ozone also has an indirect effect on CVD. “[It’s] is a very powerful reactive pollutant and essentially it destroys lung tissue,” says Brauer. “If your lungs are compromised, you’re not able to move as much oxygen into the body, [which] puts a strain on the heart.” Plus, nitrogen dioxide is thought to affect the body’s immune responses to respiratory infection— which is particularly relevant to covid-19—and “can put a strain on the whole body including the heart”. Dr Mark Miller, a senior research scientist at the British Heart Foundation Centre of Cardiovascular Sciences at the University of Edinburgh, was a member of a team of scientists who discovered how inhaled particles pass from the lungs and into the bloodstream in a key 2017 breakthrough. “PM damages blood vessels, causes irregular heart rhythms and increases the risk of blood clots,” says Miller. “These actions would increase the chances of someone developing heart or circulatory disease. “Our team were the first to establish that tiny particles the size of diesel exhaust particles can be inhaled and cross over from the lungs into the bloodstream. The particles then build up in fatty plaques in the arteries, where they could possibly trigger a heart attack or stroke.”

All other deaths

“We’re not looking for a miracle cure. We have examples from many countries in the world now where air quality has been improved and mortality reduced” tries in the world now where air quality has been improved and mortality reduced,” says Brauer.

SPREADING TO THE HEART PM2.5 poses the biggest danger to the cardiovascular and circulatory system. “There are several mechanisms involved,” says Brauer. “One of those is that PM2.5 causes inflammation in the lungs and this spreads into the bloodstream causing systemic inflammation that affects the heart and arteries and other organs.” FORESIGHT

There is now an extensive evidence base to show that cutting air pollution results in reductions in mortality and a decrease in healthcare costs, says Professor Dean Schraufnagel, a professor of medicine and pathology at the University of Illinois in Chicago, who published a 2019 paper detailing the benefits. “Studies have shown important health improvements came after the Clean Air Act was passed in the United States in 1970,” he says. “The improved air quality tracked with decreases in several diseases and death rates. This occurred in conjunction with an economic growth of 259%, so it’s clear you can decrease air pollution and increase country wealth at the same time.” Professor Schraufnagel says these health improvements can come quickly too, especially for cardiovascular health. “When Ireland banned smoking in indoor public places, ischaemic heart disease was reduced by 26% within weeks.” Other success stories include a 1990 restriction on the sulphur content of fuel oil used for power plants and motor vehicles in Hong Kong, which led to a 45% drop in ambient sulphur dioxide concentrations. A study found this intervention led to a decline in the annual rates of all-cause mortality (2.1%), respiratory mortality (3.9%) and cardiovascular mortality (2.0%), improving life expectancy by 20 days for women and 41 days for men. 21

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The dramatic impact of covid-19 lockdowns on air pollution and the likely health benefits is another area of interest for future research. Highroad to change There is much that can be done at personal, national and global levels to combat air pollution

INDUSTRIALISATION VERSUS HEALTH GAINS However, Schraufnagel says improving air quality may be harder to achieve in low-income countries (LICs) where industrialisation is seen as key to alleviating poverty. But he says health gains will be even greater in countries with the highest levels of pollution. “The pollution problems of India are daunting, with urban population growth of 31.8% and overall population growth of 17.6% between 2001 and 2011,” he says. “But the national government, as well as several cities, have put into place a broad range of policies to halt pollution and expand green space.” Some of the interventions include developing and monitoring air pollution standards, emissions testing, travel restrictions, increased taxes on and removal of subsidies from polluting sources, increased use of clean energy, and restriction of burning biomass fuels. Brauer says Mexico City now has far cleaner air than in the 1980s and even China has turned the corner: “Although China still has high levels of pollution, levels have been going down since 2012-13 due to using less coal and using cleaner sources of energy, cleaning up the dirtier sources, more motor vehicle regulation, and banning the burning of coal in and around major cities.”

“The impact of air pollution on cardiovascular health remains underestimated by a significant proportion of healthcare professionals ”

Gumy from the WHO warns the global air pollution situation is grave, but says because the causes are multi-factorial there is no one-size-fits-all quick fix: “There is a need to adapt and change energy policies—towards renewable energies and targeted fossil fuel subsidies—transport policies, the way we envisage mobility, land-use policies, the way cities are built, waste management, agriculture practices and also the way we consume. “The overall message is [to reduce] fossil fuels combustion. Adopting air quality standards and enforcing them is indeed critical to successfully achieve better air quality.” FORESIGHT

The scale of the threat to heart health was acknowledged by the European Society of Cardiology in new guidelines in 2019 that ranked air pollution as the second biggest risk factor for a heart attack after smoking—more important than blood pressure, sedentary lifestyle or raised cholesterol. Professor Brauer says awareness of the connection between air pollution and heart health is an ongoing challenge. Indeed, very few people have air pollution written on their death certificate. “It’s very easy for a cardiologist to ask patients about their diet, exercise and smoking, and give advice accordingly, but not so easy to ask about air pollution exposure—that’s a really difficult question to answer,” says Brauer. But if health professionals and organisations like the WHF can get the message out, the benefits have the potential to be widespread and less dependent on individual lifestyle changes that are typically associated with a reduction in CVD risk. “A lot of preventative health measures such as smoking cessation are at an individual level, but if you improve air quality, everyone benefits without having to actually do anything except carry on breathing,” says Brauer.

FUTURE FOCUS Schraufnagel says there’s more to be done at the personal, national and global levels to combat air pollution. “For instance, there is a group of schoolrun mothers in London who have been running an anti-idling traffic campaign to encourage parents doing drop-offs and picks-ups to turn off their engines so children are not exposed to car exhaust emissions. What could be simpler than just turning off their ignitions?” Cooking with an open fire could be replaced with a non-polluting stove, he says. The Clean Cooking Alliance works with a global network of partners to promote clean cooking technologies in LMICs, with the goal of achieving universal access to clean cooking by 2030. Schraufnagel says exercising a few streets back from a main throughfare could significantly reduce exposure to PM, while mask wearing and air purifiers may also be beneficial. He also recommends national policy makers introduce polices such as air quality monitoring, low emission zones and pedestrianised areas. “The car industry is also switching to electric cars quite rapidly now and coal power plants are moving over to cleaner fuels such as natural gas,” says Schraufnagel. “Tackling air pollution and climate change really go hand in hand.” Above all, says Gumy from the WHO, “advocacy, science-based communication and multisectoral and coordinated action are key.” • 23

THE INEXTRICABLE LINK BETWEEN CLIMATE CHANGE AND NCDS With every day comes new evidence of the devastation caused by climate change, and paralleling this rise is the rapid escalation of the global burden of non-communicable diseases. Climate change and non-communicable diseases have an undeniable link—treat one and the other will follow

Treating patient Earth By BECKY MCCALL in the United Kingdom

ic, he says covid-19 has reinforced the link between planetary science and health. “There is a complete alignment between NCDs, climate change and, to an extent, covid-19.”

A FOREBODING SENSE OF URGENCY In 2018, the Intergovernmental Panel on Climate Change (IPCC) published its report detailing the impacts of global warming of 1.5°C above pre-industrial levels. Now, in 2021, we witness the Conference of Parties COP26 summit in Glasgow that aims to accelerate action towards the goals of the Paris Agreement and the UN Framework Convention on Climate Change. Likewise, with NCDs, the urgency is written in the epidemiological data, with these chronic conditions accounting for seven of the world’s top 10 causes of death globally. Rajesh Vedanthan is an associate professor and director in the Section for Global Health at NYU Grossman School of Medicine. He developed the concept FORESIGHT

Switch the narrative Inspired by the climate change movement, we must change the NCD narrative from longterm to urgent ILLUSTRATION Luke Best PHOTO Jan Grarup

he resounding message is loud and clear: act now to protect our climate and planet, because time is rapidly running out. But this call to arms is not the preserve of climate change alone. Similarly, messages and action around non-communicable disease (NCDs) need to adopt a heightened sense of urgency: act now to prevent future disease burden. In fact, there are multiple parallels between NCDs and climate change, with many of the measures used to prevent NCDs also mitigating the effects of climate change. For example, eating less meat and trans fats to prevent cardiovascular disease and cancers also reduces carbon emissions, while swapping car travel for cycling offers wide-ranging benefits for physical fitness and results in the burning of fewer fossil fuels. Professor Stefan Swartling Peterson, a professor of Global Transformations for Health at Karolinska Institutet in Sweden, has witnessed the alignment between climate change and human health unfold over the past 30 years. Reflecting on the current pandem-

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The yawning gap between policies and practice 2020 implementation status of NCD policies across 194 WHO member countries

National NCD targets National physical activity awareness campaigns National clinical NCD guidelines Provision of national cardiovascular therapies Policies to limit fat in foods

Alcohol advertising bans

FULL

Tobacco advertising bans

PARTIAL NONE

Tax increase on alcholic beverages

N/A

Tax increase on tobacco retail NUMBER OF COUNTRIES

of ‘proactive prevention’ aimed at targeting younger, healthier populations with interventions to prevent NCD risk factors and chronic diseases later in life. “The epidemiological transition is where we see countries with high levels of infectious diseases drop off, while NCDs creep in over time as lifestyles change,” says Dr Vedanthan. “Consequently, the burden of NCDs increases in these populations, most often in low- and middle-income countries (LMICs).” He also highlights that in some countries there remain populations that do not have a significant NCD problem now, but in decades to come will likely develop NCDs. Crucially, he says changing the narrative on NCDs to one of greater urgency involves disrupting this epidemiological transition. Since most NCDs are significantly associated with lifestyle (even if there is a genetic predisposition), in a similar way to climate change humans need to recognise the importance of the environment—that is, diet, exercise, air quality, stress levels and health checks to name a few. Importantly, we need to acknowledge that individual decisions and choices are constrained by the options that are available. 26

100

150

HARNESSING POLITICAL WILL ON PAPER Agendas, treaties and agreements on paper help cement good intentions and retain focus. Because climate change knows no borders, just like NCDs, a lot rests on international as well as national agreements and action. In 2015, the Paris Agreement required heads of governments to commit to lower greenhouse gas emissions and increase renewables such as wind and solar, with the aim of keeping the global temperature increase ideally below 1.5°C. Since Glasgow, however, this goal seems unlikely to be met. Similarly, efforts have been made by NGOs and international agencies to galvanise political will and commitment towards NCDs. In 2016, the United Nations Sustainable Development Goals (SDGs) set out a vision, with 169 targets to be met by 2030 that strive for a world free from poverty, hunger and disease. Health has a central place in SDG 3. It reads: “Ensure healthy lives and promote wellbeing for all at all ages”, while almost all of the other 16 SDGs are related to health in some way. Of note, the part of SDG 3.4 that relates most directly to NCDs recommends, “by 2030, reduce by one third premature mortality from FORESIGHT

SOURCE: The Lancet, 2021

Policies on marketing food to children

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NCDs through prevention and treatment and promote mental health and wellbeing.” In 2018, a UN high-level meeting on NCDs led to a political declaration to meet this target, introducing a ‘5 x 5’ framework used by the World Health Organization (WHO) that includes five sets of diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, cancers and the newly added mental health) caused by five behavioural risk factors (tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity and the newly added air pollution). For widescale and significant change to happen, political will, combined with effective strategic planning and policy change at international, national and local levels, is essential—whether it applies to strategy around chronic diseases or climate change, or ideally both.

DISRUPTING EARLY EPIDEMIOLOGICAL TRENDS Swartling Peterson, who also sits on the NCD Child’s Governance Council, says NCDs in childhood need to be addressed from multiple angles. “It is more than just treating the patient. We need to look at this from a risk factor and a life-course perspective, because risk factors during childhood and adolescence set the individual up for problems in later life.” The global food system is central to the planet’s climate issues. “The food industry says you have the choice, but someone’s choice is dependent on the environment, so we need to modify this so people make the right choices,” Swartling Peterson says.

“Changing the narrative on NCDs to one of greater urgency involves disrupting the epidemiological transition”

In fact, he notes that by around the age of six or seven a young child can recognise food brands that he or she will eat lifelong. Encouraging children to make healthy food choices during their early years can effectively programme good habits for the next 70 or 80 years of their health, which has flow-on effects for food systems and the health of the planet. Vedanthan from NYU Grossman School of Medicine also wants to see younger populations prioritised with proactive prevention strategies, especially in LMICs. “We need to disrupt this epidemiological transition with proactive prevention of what almost seems inevitable.” Proactive prevention includes reducing trans fats in processed foods, tobacco taxes, reconfiguring the built FORESIGHT

INSIGHTS

How brain biases affect our future focus

iven the widescale global devastation related to climate change, and likewise the mountain of evidence that NCDs are related to accepted risk factors such as poor diet and lack of physical activity, why do so many people find it hard to act now to protect the futures of themselves and those around them? The mechanism may not be as self-centred as it first seems. Our evolution has a large part to play. In the interests of human survival and reproduction, we had to rapidly filter lots of information and decide what needed immediate attention, like an imminent animal attack, and what could wait. So, we have evolved to focus on immediate threats such as those that are clearly defined in our minds and easy to remember, like a terrorist threat, whereas a long-term and complex problem like climate change is hard for us to mentally get to grips with. Conor Seyle, a political psychologist and director of research at One Earth Future Foundation, told BBC Future in 2019, “Too much information can confuse our brains, leading us to inaction or poor choices that can place us in harm’s way.”

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environment to encourage physical activity and altering food environments to consciously or sub-consciously increase preference for healthier options. “Ultimately, whichever intervention it is, we ask, does it have impact, does it make a difference and is it possible to do?” Vedanthan says.

SHARING THE LOAD The WHO has an ambitious strategic plan, known as the Triple Billion targets, that by 2023 aims to ensure one billion more people benefit from universal health coverage, are better protected from health emergencies and enjoy better health and wellbeing. The NCD agenda is relevant to all three strategic priorities. Progress towards universal health coverage will increase access to essential services to prevent and treat NCDs; protecting people from the devastating impact of humanitarian emergencies and ensuring the continuity of health services will benefit populations living with NCDs; and promoting health and preventing disease will require intensified action on the major risk factors and underlying social and commercial determinants of NCDs.

“I think NCD projects in, for example Rwanda, already demonstrate what countries can do with domestic resources” Adnan Hyder is a professor of global health at the George Washington University Milken Institute School of Public Health in Washington DC. He says we need to shift thinking from long-term to urgent, whether it is NCDs or climate change. He also believes LMICs can lead the agenda to tackle NCD burden rather than wait for large international agencies to come up with a plan. In a similar way to climate change, countries, communities and individuals need to take responsibility and enact change now, as they wait for high-level treaties and commitments. “We should not wait for leadership to come from Geneva and New York,” Hyder says. “It will be too late. I think NCD projects in, for example, Rwanda, Uganda and Ethiopia already demonstrate what [countries] can do with domestic resources. With more external resources they could do an even better job.

The road to school Children swimming to school in South Sudan through the contaminated water of the Nile that has flooded the land. PHOTO: Jan Grarup 28

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DRIVING CHANGE THROUGH FOOD Echoing Hyder, Swartling Peterson points out that the commercial pressures of health need more attention because they are central to driving the food systems transition happening across the globe with semi and hyper-processed foods. Similarly, the demands of global food systems contribute to the destruction of our planet and the systems that keep the climate in check. “The commercialisation of food products is unhealthy for us, particularly for children, and this is driving both the NCD pandemic and climate change,” says Swartling Peterson, who was global chief of 30

Government interest rises Proportion of countries referring to climate change, health or the intersection of both during UN General Debates

Proportion of countries (%) 100

0 1980

HEALTH

2000

CLIMATE CHANGE

health for UNICEF from 2016-20. “If we fix the food system then we will also make a large contribution to reducing further climate change.” To meet the challenge of human health and planetary health, Swartling Peterson emphasises that we need to join the dots between planetary health activism and human health activism. He is involved in launching a novel concept of sustainable health for people and planet, with the aim of harmonising the two. “Make the Anthropocene [the period of time during which human activities have had an environmental impact on the Earth] more anthropocentric, effectively, and place a different human narrative on climate change. This is where the connectedness between human health and climate change comes in.” • FORESIGHT

2020

INTERSECTION

SOURCE: The Lancet, 2021

“I would like to humbly challenge LMIC governments and say, ‘you have a problem, use whatever resources you have, make a start and show the world what you can do’. Some countries are doing this already; they provide the UN with evidence of success with inexpensively run, domestic programmes, and so they break the cycle of top-down leadership. That’s what we need in global health.” Ethiopia and Rwanda have taken some novel strides in this area. “Healthcare workers have been trained in doing palliative care for cancer patients, for example,” Hyder says. “Nobody would have thought that palliative care, that is normally hospital-based, could be conducted by healthcare workers.” Further to the WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) programme—a standardised method for collecting, analysing and disseminating data on key NCD risk factors in countries—he advocates for the benefits of more regular digital surveys. “In the past few years, we have developed rapid surveys on digital platforms that can be done in days or weeks, to complement household surveys that can only be done every five years or so. And we have shown, in countries like Uganda and Colombia, that these mobile phone surveys gather useful information on NCDs.” Hyder says it’s also important to remember the commercial or corporate determinants of health when taking on the global and LMIC challenges of NCDs. The tobacco industry is, after many years of hard work, much better controlled in terms of the influence it exerts. “Alcohol, however, has not really been addressed and is strategically exerting influence on governments (such as ministries of health, transport and finance), non-governmental organisations (by funding them) and even academia (by sponsoring research),” Hyder says. He cites recent data from a study in The Lancet showing that for every unit increase in ‘corporate permeation’, implementation of NCD interventions decreased by 5%.

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Treating patient Earth in the Caribbean islands

s an idyllic holiday destination, it’s easy to forget the low-lying islands of the Caribbean are extremely vulnerable to the impacts of both climate change and non-communicable diseases. “Climate change in the Caribbean means hotter, drier weather, with more category 4 or 5 storms,” says Trinidad-based Dr James Hospedales. “These lead to disruption of access to medicines and services for people with NCDs. If you are displaced after a hurricane, someone will likely give you somewhere to sleep and food, but not medicines.” For example, he says, “in Puerto Rico after Hurricane Maria, the official death toll was 64, but months after the authorities realised 3,000 additional persons died, mostly due to chronic diseases and lack of medicines or dialysis”, clearly illustrating the NCD-related vulnerability created by devastating climate events. Other struggles on the islands relate to escalating NCD risk factors. “With the exception of tobacco, the other three major risk factors are going in the opposite direction: people drink more alcohol, are less FORESIGHT

mobile and use cars, are more overweight due to poor diets, and in recent years there’s been a significant childhood obesity epidemic,” Hospedales says. As a result, Hospedales founded Earth Medic, an organisation that joins the dots between health and environmental concerns. He uses the term ‘patient Earth’ to describe how climate change is destroying the conditions for life. “It’s very connected to NCDs, and climate action as related to what we eat and how we get around will have huge benefits for NCDs. To do this we need to work together.” Now in the Eastern Caribbean there’s a project looking at identifying the most vulnerable people affected by NCDs and their needs before future storms hit. Together with a partner organisation, Hospedales also visited Chile to learn about the country’s food labelling system. “It was all about changing the health of future generations,” he says. “It was very powerful.” Looking to the future, Hospedales says gaining ground in this battle will require partnerships across conventional silos like governmental departments and research disciplines. “We have a bombardment of high sugar, high-calorie food advertising, and a weak regulatory regime that needs to warn people that particular packaged foods are high in sugar, salt, calories or fat,” he says. “It is as much a regulatory and consumer issue as a health issue.” • 31

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The unexpected impact of climate change on health

CO2 and CognitiveAbility

Extreme Weather and Children's Mental Health

As more CO2 is released into our atmosphere, we are predicted to experience a deterioration in cognitive ability. It is estimated that humans will experience an approximate 25% reduction in decision-making ability and a 50% reduction in complex strategic thinking by 2100 if atmospheric CO2 concentration continues to increase at the current rate

After an extreme weather event, trauma occurs in exposed populations at a rate of between 25% and 50%. Children on average have stronger responses; early child experiences of trauma can lead to long-term or permanent health effects, including impairment of ability to regulate emotions, learning or behavioural problems, and mental health problems later in life

Deforestation and Emerging Disease

Rising CO2 and Undernutrition

Land use change, especially deforestation, is a primary driver of infectious disease emergence. Diseases originating from forest-dwelling animals are more easily transmitted to humans as their habitats are destructed or as humans move into their habitat. Research shows 31% of emergent infectious diseases are casually linked to land use change

Nutritional declines in iron, zinc and vitamin B have been measured in staple foods as atmospheric CO2 levels rise. By 2050 in low- and middle-income countries, if CO2 levels continue to rise at current rates, an estimated 150 million people will be at risk of protein deficiency, 138 million at risk of zinc deficiency and 1.4 billion at risk of iron deficiency—a possible epidemic of anaemia

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SOURCE: EcoHealth Alliance (2019)GeoHealth (2020)Journal of Anxiety Disorders (2020) The Lancet (2021)Nature Climate Change (2018 & 2020) The Uninhabitable Earth (2019)

Surprising effects that challenge the way people will derive nutrition, promote mental health and manage illness in the future

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Extreme Heat and Maternal Health

Changing Climate and Vector-Borne Diseases

On the day of exposure, extreme heat causes an increase in births, and can shorten gestation periods by up to two weeks. In the US alone, an estimated 25,000 infants per year are born earlier as a result of heat exposure, and by the end of the century, it is predicted that 250,000 days of gestation will be lost among expecting mothers

Climate change will alter the distribution of ticks, mosquitoes and other vectors, both in seasonality and geography. Diseases like malaria, once endemic to only hotter regions of the world, will spread farther. It is estimated that by 2030, there will be around 3.6 billion cases of the disease, 100 million of which will be as a direct result of climate change

Soaring Temperatures and Antibiotic Resistance

Global Heating and Physical Activity

As temperatures increase globally, so too may antibiotic resistance to pathogens. An increase of 10°C in local temperature has been associated with an antibiotic resistance of 4.2% for the common pathogen E. coli. An increase in average temperature will likely render common medications less effective against pathogens

As temperatures rise, the potential number of hours of safe physical outdoor activity per person per day will reduce. Already in 2020, in low human development index (HDI) countries 3.7 hours of every day were above the recommended safe temperature—an increase of 1.2 hours since 1990. In high HDI countries, this rose from one hour in 1991 to 1.5 hours in 2020

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Q&A WITH THREE INNOVATIVE STARTUPS

Smart solutions for human and environmental health Simple, scalable initiatives that enhance day-to-day living offer huge potential benefits for human health and that of the planet. FORESIGHT Global Health asked the founders and CEOs of three innovative startups how their solutions build healthier and more resilient populations and reduce the effects of climate change—and why education is key to their success

ILLUSTRATION Luke Best

By ANGELA TUFVESSON in Hong Kong

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asking him to make them one. That is how Smart Air entered the market with a $30 air purifier. The essence of Smart Air is to democratise the air purifier industry to make these products available to everyone so they can be protected from the harms of air pollution in indoor environments. All that has changed seven years later is that we have made our air purifiers a little bit better looking. We also have larger air purifiers that have bigger fans and bigger filters, but they are still just a fan and a filter.

Q: Why does an air purifier manufacturer spend time on education and awareness initiatives?

Smart Air The clean air startup Paddy Robertson, CEO — China

A: We’re a social enterprise, and we do a lot of work educating people about how air purifiers work through our blog and workshops. There are a lot of bogus claims in the industry—right now the buzzwords are ‘bipolar ionisation’ and ‘UV purifiers’—and we work to debunk the idea that air purifiers need to have these fancy things to work well. In some ways, our ‘product’ is telling people the truth about air purifiers: that they are simply a fan and a HEPA filter. We also try to encourage behavioural change to help solve the problem of air pollution. We educate people about broader solutions to air pollution, like riding a bike to work instead of taking the car. We also strive to create environmentally friendly products and reduce packaging waste. For example, the packaging for one of our products is 99% plastic-free and recyclable.

Q: What is the inspiration behind Smart Air? A: Our founder, Thomas Talhelm, was a student living in Beijing in 2013 when the ‘airpocalypse’ [a period of particularly poor air quality] struck and he was looking for a way to protect himself. Like in many Chinese cities, air pollution is a big problem in Beijing, especially during winter, with implications for human and environmental health. Air purifiers cost around USD 1,000, which is a lot of money for a student and other people on low incomes, so Thomas set about finding a cheaper solution.

Q: How do your air purifiers work? A: Thomas did some research and discovered all that is needed to construct an air purifier is a fan and a HEPA filter. It is that simple. So, he made his own DIY air purifier for just USD 30, which an air quality monitor showed was just as effective as the more expensive air purifiers. He shared his findings in a blog post, and more and more people started approaching him 36

Q: What is next on your journey? A: So far, we have shipped over 70,000 air purifiers globally. We have partners in six Asian countries, where air pollution is a particularly serious problem, and we have engaged with distributors in the US, UK, Netherlands and several other countries. We are using a franchise model, which means we can scale much, much quicker. In the next few months, we will launch a new USD 30 air purifier, which will be accessible to many more people. But the biggest impact we can have will be in creating education and awareness about the problems of air pollution and our low-cost solution. We have conducted more than 500 air pollution workshops attended by 15,000 people. This is really how we can scale—by reaching the masses via the internet and raising awareness that a fan and a HEPA filter is all that’s needed for an effective air purifier. Then the knowledge will trickle down, and we just need to make sure people can access our air purifiers. FORESIGHT

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Ruby Cup The women’s health startup Julie Weigaard Kjær, CEO and co-founder — Spain

Q: How does period poverty affect women, especially in low- and middleincome countries (LMICs)? A: Menstruation can be inconvenient and difficult to manage, especially in LMICs. Together with my co-founders, Maxie and Veronica, I did a lot of research into what’s now called ‘period poverty’. After contacting organisations all over the world that work with women, we realised something that I had never thought about in my life as a menstruating woman: if you don’t have disposable income, or access to disposable income, to go to the shop and buy the products you need, menstruation is a huge challenge. It can become something that gets in the way of work, life and educational opportunities, and in many countries, there is a lot of shame and taboo related to menstruation.

of waste each year in the EU alone. Because they’re reusable and therefore cost effective, menstrual cups are a great solution for women who live in LMICs. We developed and designed a menstrual cup called Ruby Cup in 2011. We wanted it to be a business from the get-go and not a charity so we wouldn’t be relying on donations. That’s why we came up with the ‘buy one, give one’ model. We sell the Ruby Cup online commercially, then we donate one cup for every cup sold.

Q: How important is education to the adoption of the menstrual cups? A: When the business was launching, we moved to Kenya for three years. We really immersed ourselves in the field—we talked to girls and women to understand their problems. What we saw was a massive lack of knowledge about menstruation. So very quickly we adjusted our model to include education and support for women. We work with local organisations that have a presence and have built trust in the communities where they work. We have created a curriculum about menstruation, the female anatomy and how to use and look after a menstrual cup. Girls and women that receive our cups tell us they have this feeling of freedom, of independence, because now they do not have to ask for money to buy pads or they do not have to use rags or things that are shameful. They have a cup that is their own. We are never just sending the cups alone to our users, as we know that if you do not have the training, follow-ups and support in place, most of the cups will go to waste because the end user will be too scared to try it. When education programmes are carried out according to our recommendations, our cups have an adoption rate of 80-90% among end users.

Q: How have you scaled your distribution for greater impact? Q: How do menstrual cups promote better health and environmental outcomes? A: We were introduced to menstrual cups and became convinced that they’re the best period products for women. They are comfortable, and you will always have them on hand—you’ll never run out like you can with pads and tampons. Menstrual cups are also much more sustainable than pads and tampons because they require fewer raw materials to manufacture and contribute much less waste to landfills. Single-use menstrual products generate 590,000 tonnes FORESIGHT

A: So far, we have donated 114,000 cups to women in 16 countries across Africa and Asia, and we have also launched programmes in Europe because period poverty is an issue everywhere where women struggle with income or vulnerability. We now work with big NGOs like CARE International and PSI as well as smaller grassroots organisations. The scalability really depends on our partner portfolio. If we can find good partners that have the capacity to manage distribution, we can scale. The more cups we sell, the more cups we can donate, and the better the environmental and health impacts. 37

SPECIAL REPORT

Rapid Gas The clean cooking startup Kennedy Afia, founder — Nigeria

Q: What sorts of problems do Nigerian households encounter with common cooking methods? A: Indoor air pollution caused by burning solid fuels like charcoal and firewood for cooking is associated with serious health problems and even death, especially among women and children, as well as serious environmental impacts. In rural areas of Nigeria, many people are still using these methods of cooking. And for households that have gas, they are often caught out when the gas in their cylinder finishes unexpectedly, such as while cooking a meal. I came up with the idea for Rapid Gas when my mum was cooking on a Sunday morning and ran out of gas before the meal was finished cooking.

Q: How does your solution help when households run out of gas? A: We have developed a gas cylinder smart metre that tracks and monitors the fuel level of gas cylinders remotely. It will sit on top of the gas cylinder and connect to a kitchen interface, wirelessly sending data from the cylinder to the kitchen interface so the user knows how much gas is left in the cylinder. Before a customer runs out of gas, they are notified that the level of gas is running low and invited to place an order for a refill. The initial cost of switching 38

to gas can be very high, so we offer smaller 3kg and 6kg cylinders. To cater to rural communities without good internet, we are using Bluetooth technology. Our main target group is low- and middle-income people living in rural and semi-rural parts of Nigeria who are accustomed to cooking with charcoal and firewood. We hope that our product will help them switch to gas, which is a cleaner and safer cooking method. From my research, I have not seen a similar solution that is trying to solve this issue in Nigeria.

Q: What are some of the challenges in delivering your product to consumers? A: Not everyone is familiar with gas cooking. What we are trying to do is encourage a ‘transition in energy mix’, where we teach people about clean cooking and the benefits for the natural environment. As a result of our campaign, a lot of homes have switched from charcoal and firewood-based methods of cooking to gas. First, we needed to help them see the need for cooking gas as many of them did not understand the benefits.

Q: Do you plan to expand outside Nigeria? A: Our gas cylinders are already on the market, and we have about 500 users in Nigeria that are buying cooking gas as a service from us. It has been a big achievement to see local communities in rural areas embrace cooking gas. We plan to launch our tracking technology [smart metre] in the first quarter of next year. Later in 2022 we hope to expand in Nigeria, and in the future, we are hoping to be the leading brand in the industry in Nigeria and across Africa. • FORESIGHT

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PROMISES AND PITFALLS OF MICROINSURANCE High out-of-pocket healthcare costs in African countrie send many low-income people into significant debt. Microinsurance has the potential to complement national health insurance schemes and offer affordable healthcare but several obstacles continues to challenge scale-up of the insurance model

Small-scale health insurance for a more secure future By PAUL ADEPOJU in Nigeria

hen Bimpe Ibidun (not her real name) was diagnosed with early-stage squamous cell carcinoma—a type of skin cancer—in early 2021, her doctor recommended an urgent surgery to prevent spread of the cancer to other parts of the body that same week. But it took nearly seven months for the 50-year-old Nigerian mother of four to raise the $590 she needed to pay for the surgery. When she returned to the hospital, new tests showed the cancer had spread and now required both surgery and radiotherapy that could cost at least five times more than the initial estimate. “I did not have the money the doctors asked me to pay so I had to beg family and friends,” she says.

THE HEALTH PROTECTION PARADOX Stories like this are common in Nigeria and other African countries where most healthcare is funded out-of-pocket by private citizens. In sub-Saharan Africa, 33% of health expenditure was financed out-of-pocket in 2018, compared to 18% globally. The situation is even worse in Nigeria, Africa’s most populous country, where about 77% of health expenditure came from out-of-pocket payments in 2018—up from 60.2% in 2000. The trouble with out-of-pocket healthcare costs is they are difficult to budget for, especially in sub-Saharan Africa, where more than 40% of the population lives on just $1.90 a day. Saving for known and unknown future health needs and FORESIGHT

Out-of-pocket healthcare In sub-Saharan Africa, 33% of health expenditure was financed outof-pocket in 2018, compared to 18% globally

HEALTH FINANCE

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HEALTH FINANCE

emergencies is unrealistic, so when health needs arise, it’s extremely difficult to foot the bill without compromises and sacrifices ranging from food rationing and indebtedness, to suspension of schooling for children, loss of jobs and housing. Sometimes these strategies aren’t enough, and a patient could stay for months in the hospital until relatives are able to raise the funds. With over 100 million people becoming impoverished annually due to very high health expenditures, particularly in Africa’s low and middle-income countries (LMICs), developing viable long-term solutions is increasingly important. According to finance experts, micro health insurance is touted as an important potential solution. It operates in much the same way as conventional insurance except it’s targeted at low-income people with few or no financial reserves. Premiums and coverage limits are usually low and paid in irregular instalments to account for fluctuating incomes. For people across Africa who can access urgent health services for diabetes, hypertension, cancer and other non-communicable diseases (NCDs) without the financial burden of high out-of-pocket costs, microinsurance can be life changing.

models including social insurance models that encompass both national health insurance services and microinsurance.

NOT QUITE UNIVERSAL Even though most countries in Africa now have national health insurance services, the inability to ensure every person has access to all (or most) of their healthcare needs without needing to make out-of-pocket payments has made these services unattractive. Research examining inequality in health insurance coverage in 36 countries in sub-Saharan Africa led by Edwine Barasa, director of the Nairobi Programme of the KEMRI-Wellcome Trust Research Programme, reported that only four countries—Rwanda, Ghana, Gabon and Burundi—had coverage levels with any type of health insurance, national health insurance or microinsurance, above 20%. They found health insurance coverage was low and largely favoured wealthier people in the populations. Access to information on health insurance, socioeconomic status and level of education were the leading contributing factors associated with access to insurance coverage in the countries studied.

RETHINKING HEALTHCARE FINANCING The foundations for microinsurance can be traced back to 2001, when Africa’s health ministers gathered in Abuja, Nigeria’s capital city, and committed to allocating 15% of their annual national budgets to improving their healthcare systems. The commitment, referred to as the Abuja Declaration, soon became a rallying call to mobilise more resources from government coffers for the health sector. However, it has become a commitment that most African countries could not keep. According to the South African Institute of International Affairs (SAIIA), the 16 members of the Southern African Development Community (SADC) have found that meeting the 15% target is a continuing struggle. “Indeed, the push towards the more sustainable allocation of resources to healthcare requires that governments in the SADC region, as in the rest of Africa, increase investment in all facets of the healthcare system…[But] the latest data from the World Bank’s World Development Indicators shows that countries in the SADC region are failing to spend enough on public health,” SAIIA says. African governments have realised that improving healthcare services in their respective countries is a costly venture. They have also come to terms with their limited fiscal space. Realising they cannot solely rely on budgetary allocations for health financing, African countries are now exploring other funding 42

“The latest data from the World Bank’s World Development Indicators shows that countries in the SADC region are failing to spend enough on public health”

In Ghana, the National Health Insurance Scheme (NHIS) has been credited with removing some socioeconomic barriers in accessing healthcare services in the country by providing free coverage for elderly people, children and pregnant women. It also improved health service-seeking practice among insured Ghanaians. But the Ghanaian scheme doesn’t equate to universal healthcare, as premium payment is required before many citizens can access healthcare services and it’s comparatively more expensive in some parts of the country. Experts believe this may discourage more people from enrolling. According to a World Bank study, the proportion of the Ghanaian population covered by the scheme is about 40%. “We have a situation where you will say you have health insurance coverage, but you will have to pay some money to get treated,” says public health expert John Appiah, who’s based in Accra, the Ghanaian capFORESIGHT

HEALTH FINANCE

A ripe market yet to be harvested Estimated market potential of microinsurance in Africa

SOURCE: Microinsurance Network, 2021

17-37

5.0

MILLION

BILLION

Number of people reached by microinsurance

Estimated value of the microinsurance market in target countries (USD)

4-9%

11 %

Share of the target population covered

Proportion of the estimated microinsurance market value captured

BASED ON 13 COUNTRIES (Côte d’Ivoire, Egypt, Ghana, Kenya, Morocco, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Uganda, Zambia, Zimbabwe)

ital. “We know of countries like the United Kingdom where you will not be asked to pay anything, but this is rarely the case here. Because even when they know you have insurance, there will always be one or more additional payments to be made.” For many people across the continent, private health insurance provided by employers fills in the gaps, or perhaps serves as a substitute for national health insurance services. Nigerian quality assurance officer Philip Towo says he’s never paid any money for health coverage, with the private insurance company contracted by his employer covering all his immediate family’s healthcare needs. “My wife delivered our baby and I got treated following a motor accident without paying anything. I also enjoy routine medical check-ups for me and my family. I know this is not the experience everyone has, but if it’s possible for some of us, they should be able to find a way to extend it to other citizens,” says Towo.

A CAUTIOUSLY BURGEONING MARKETPLACE Some African countries are adopting a new approach, rolling out multiple health insurance offerings to proFORESIGHT

vide coverage to as many people as possible. The largest are the national health insurance schemes, and there are also packages managed by state and local authorities. Plus, there’s now a plethora of offerings from the private sector, ranging from all-inclusive health coverage deals signed by major companies with health management organisations, to tiered premium offerings that individuals and families can sign up for. But a major shortcoming of these approaches is their consistent exclusion of people who aren’t earning enough to be able to afford coverage through traditional insurance companies. Microinsurance can help to fill the gap by delivering low-cost, affordable health insurance—and several approaches have already been deployed on the continent. In 2014, the International Finance Corporation unveiled an agreement to expand micro health insurance to low-income and informally employed people in Senegal. The pilot aimed to provide low-cost health microinsurance products to 108,000 people. In Tanzania, Jamii Africa targets the low-income population through their mobile phones. The startup, launched in 2015, performs all the administration ac43

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Massive African market on hold In Nigeria, microinsurance providers still struggle to find the right business model

tivities of an insurer and allows users to access cheap insurance starting at $1 per month. Jamii Africa says it now has more than 20,000 active users, about 400 registered hospitals and has raised over $1 million. In Kenya, microinsurance is often bundled with other services. One example is MicroEnsure’s Fearless Health product that offers on-demand loans for primary healthcare at outpatient clinics, medical advice by phone and insurance for inpatient care. By bundling financial products in this way, the company says customers can enjoy the benefits of insurance without making costly separate insurance premium payments. But a major cog in the wheel of these and other microinsurance products in several African countries is the end-users’ desire for more coverage and the low-cost solutions’ inability to generate large enough revenues to justify and finance the inclusion of more services. This is one of the reasons why microinsurance remains a small player in the continent’s health insurance sector.

“Some microinsurance schemes only cover vaginal delivery, so how do you convince the woman that she has to pay if the baby was delivered via caesarean section?”

Nigerian physician Dr Victoria Feyikemi says healthcare professionals often struggle to help patients with microinsurance coverage understand they have access to a limited range of services. Patients sometimes believe they’re being cheated by the healthcare workers or the coverage provider, or both. “[For example], some [microinsurance schemes] only cover vaginal delivery, so how do you convince the woman that she has to pay if the baby was delivered via caesarean section?” she says. “Or when there are complications, [patients] may start a serious argument when asked to pay more.”

A MATTER OF TRUST It is therefore not surprising that startups that set out to provide access to health insurance coverage in several African countries have stopped operations, leaving health management organisations as the only major players in the private sector. In Nigeria, even though the country has a large population and a potentially large market for health insurance, the top health startups making a difference in the country FORESIGHT

are not health insurance startups. Instead, they cover areas like telemedicine and health data collection. Dr Ifeanyi Nsofor, CEO at EpiAFRIC, an African health consultancy, argues the way to better position microinsurance and health insurance services more generally on the African continent is to find a way to convince people to channel high out-of-pocket expenditure into health insurance. He says the dominance of out-of-pocket payment for health services in most African countries, where being able to quickly make payments could decide who lives or dies, shows there is still an unmet need for health insurance services. But only a proportion of the population has enough money to set aside for future unforeseen health emergencies. Nsofor says the way out is to go back to basics and improve the level of trust among Africans for health insurance, by explaining to the general public how insurance—traditional insurance as well as microinsurance—works. “We need to improve knowledge by drawing parallels between other operating expenses and health insurance. For instance, what people spend monthly treating themselves can get them a health insurance cover for a year. Health management organisations and community health workers must step up in this regard,” he says. With new microinsurance services and packages regularly emerging and re-emerging in the various markets, the ecosystem will favour players who are willing to be in the market for the long term—long enough to gain trust and do the hard work of educating users about the different health insurance plans and what they cover. Nsofor says helping consumers understand that microinsurance isn’t a complete and perfect substitute for traditional health insurance is at the core of ensuring its success in Africa. “It helps to manage expectations when those with health insurance go to hospitals to access care,” he says. He also advocates for measures to ensure transparency and enable consumers to safeguard trust through easily identifying fraudulent, scrupulous and controversial service providers. As the microinsurance space continues to attract more startups, new market entrants, international organisations and partnerships between existing health insurers and telecommunications firms, more innovative solutions will increasingly become available to Africa’s low-income groups. Indeed, Bimpe Ibidun in Nigeria was able to secure a microinsurance-type loan to help cover the cost of some of her treatment. Eventually, microinsurance providers will be able to balance profitability with attractive product pricing. This is an equilibrium that is yet to be found, but a firm foundation is being laid. • 45

HEALTH FINANCE — OPINION

Can blockchain unblock NCD funding solutions? Dr Andrea Feigl is the founder and CEO of Health Finance Institute

revolutionising the way donations are made and outcomes are measured. These developments have exciting implications for the achievement of the UN Sustainable Development Goals (SDGs), including Good Health and Wellbeing, which at times has been slow due to misaligned incentives and lack of accountability. Blockchain innovations may hold some of the solutions.

BLOCKCHAIN DEMYSTIFIED Blockchain is a distributed ledger technology that facilitates the recording of transactions and the tracking of assets in a network of users. While bitcoin was the first digital currency to gain popularity, there are now more than 10,000 publicly traded cryptocurrencies, including Ethereum, Cardano and Tether. Also within the world of blockchain exist non-fungible tokens (NFTs), which are one-of-a-kind assets stored on the blockchain ledger. NFTs have created the concept of scarcity in a digital world typically defined by replicability. Some cryptocurrencies, like bitcoin, FORESIGHT

have yet to gain significant traction as payment mediums and instead are bought and held for speculative purposes, which has led to wild swings in the currency’s value. Further, the immutability of crypto transactions, while often touted as an advantage, can present problems for payers who wish to reverse or amend transaction mistakes. Finally, crypto’s regulatory landscape is largely still taking shape and its ultimate form may dilute some of the technology’s benefits seen today. For example, it has been used in nefarious ways, though cryptocurrency defenders are quick to highlight the scale of issues like fraud are much higher for traditional currencies than crypto.

LIVING UP TO ITS POTENTIAL Despite the challenges, these technologies have already begun to make their mark on philanthropy, impact investing and progress towards the UN SDGs. Cryptocurrencies have already started reducing transaction costs associated with charitable giving, improving transparency avail-

ILLUSTRATION Sine Jensen

he non-communicable disease (NCD) community is no stranger to innovation and evolution, from new pharmaceuticals and devices to increased access and empowerment of people living with NCDs. However, the financing deficit from traditional public and philanthropic funders has persisted. Even though non-communicable diseases—including cancer, diabetes, cardiovascular disease, chronic respiratory conditions and mental health conditions— are responsible for 71% of annual deaths worldwide and 85% of premature deaths in low- and middle-income countries (LMICs), NCDs have received just 1-2% of total global health financing since 2000. This misalignment between global health needs and financial allocations prompted the Health Finance Institute (HFI) to host a panel of blockchain experts during the 76th session of the UN General Assembly to better understand how the technology can be applied to impact investing and development finance. We noticed recent developments in blockchain and cryptocurrency that are

EXPLORING NEW APPLICATIONS

“Cryptocurrencies have already started reducing transaction costs associated with charitable giving, improving transparency available to donors and better enabling peer-to-peer giving”

able to donors and better enabling peerto-peer giving. These developments are particularly encouraging combined with the strong adoption rate of mobile devices and cryptocurrencies in emerging economies, which are among the highest in the world. Blockchain platforms facilitating the lowcost transfer and acceptance of funds bring banking to many developing regions for the first time. New fundraising methods have also arisen, including digital auctions of NFTs held by philanthropic and non-profit or-

ganisations. Several such auctions have successfully taken place to date, including UNICEF’s digital auction of ‘land’ in Sandbox’s metascape. In October, HFI and Sandclock, a crypto investment company, launched an NFT digital artwork auction to raise funds for type 1 and 2 diabetes programmes in Mexico and Armenia. Similarly, a wave of new charitable organisations, including the Pineapple Fund and BitGive, are making donations to causes directly in cryptocurrency. This could catalyse a new trend towards more health funding from crypto or NFT sources. FORESIGHT

In addition to traditional philanthropy, revolutionary new models within the “crypto-economy” are emerging that support development goals. For example, in Axie Infinity, a mobile blockchain game, players can earn tokens through battles or adventures that have real-world value. Axie Infinity was a source of income that allowed people in developing nations to put food on the table for their families during the pandemic. Alongside ‘gamification’ are models like that of Steemit, which enables users to earn crypto tokens for publishing or editing social media content. These concepts could open the door to gamification or rewarding of NCD prevention behaviours or disease management. Blockchain holds promising applications outside of just cryptocurrency, including data security and accountability in contracts. Data security applications are exemplified by Prescrypto, a Mexican company with a secure blockchain network enabling the sharing of sensitive health information between healthcare providers. As for accountability, some cryptocurrencies can be used for ‘smart contracts’, in which payments are only released if certain contract terms, like the delivery of goods or services, are met. Applications in the health space are growing and we are hopeful that more technologies that support people living with NCDs and equitable access are created and scaled in the years to come.

FUNDING OF THE FUTURE This could be a ‘Kodak moment’ when it comes to blockchain—much as film companies were when digital photography emerged. While uncertainties remain, organisations across the public and private sectors have the opportunity to embrace these new technologies to better fund and serve NCD prevention and people living with NCDs. We hope the transparency, decentralisation and data-driven characteristics of blockchain will unblock new funding to address the outsized burden of NCDs and save lives. • 47

THE BATTLEFIELD OF INFODEMICS AND HEALTHCARE EDUCATION Social media is a perfect vehicle for health education but it is being diverted by fake and damaging content, disrupting preventative health measures and proper treatment. Evidencebased information delivered by trusted organisations and public figures, along with structural changes to social media platforms, are powerful potential antidotes

Taming the fires of social media misinformation By DANNY BUCKLAND in the United Kingdom & TEBBY OTIENO in Kenya

Polluted social media messaging has been raging throughout the pandemic with wild claims about drinking bleach or ethanol and, in July 2021, US President Joe Biden warned that the spread of covid-19 misinformation on social media was “killing people”.

DESTRUCTIVE CONTENT Social media has long been a malign influence in non-communicable diseases (NCDs), giving platforms to damaging information in sensitive areas such as diet, obesity and mental health. Several societal and cultural factors can dilute or derail health communication allowing a social media torrent of good, bad and downright destructive content to cascade. The covid-19 pandemic has crystallised the issue with misinformation (ill-guided repetition of myths and half-truths) radiating around the world and disinformation (the insidious manipulation of data and science) causing confusion and steering people away from life-saving vaccination programmes. FORESIGHT

PHOTO Shutterstock

ocial media is a digital wildfire with the ability to move public opinion and behaviour, but its directionless form is having scorching impact on healthcare. Off-beat treatments, folklore remedies, family traditions and half-truths that defy scientific scrutiny are part of the health landscape, but the internet lets them take flight and spread at a bewildering pace. In a social media minute, there are 4.2 million Google searches, 510,000 comments posted on Facebook, 350,000 tweets on Twitter, 4,100 clicks on sponsored Instagram posts, 694,000 videos viewed on TikTok and 3.47 million videos watched on YouTube. This is the arena where healthcare messaging and misinformation compete. Factual information, from symptoms through to lifestyle guidance, is a vital component of the quest to improve outcomes across all health conditions but it is at risk in hard-to-reach communities where there is less trust in official sources.

22.6 million followers One tweet from pop star Nicki Minaj with misinformation sparked reluctance towards covid-19 vaccines

Not everyone is internet savvy or has the time or capabilities to fact-check everything they see. Some communities are distrustful of authority and official sources, while others are easily influenced by unfiltered internet content. To tackle the spread of disinformation on their platforms, social media companies have signed up to the European Commission’s Code of Practice on Disinformation and have been required to submit reports on their efforts. Rick Evans, social strategy director at UK healthcare communications agency 90ten, says the biggest challenge lies with the algorithms that tune content to a user’s browsing history. “If you are a young girl who has been looking at fad diets [popular diets that promise health benefits like weight loss but often lack scientific evidence] then you are more likely to receive dodgy diet advice and dubious information. It’s very much the quality of the information that drives the algorithm.” FORESIGHT

PREJUDICES AND UNTRUTHS “The more you engage with disreputable sources, the more the channels will serve you up this type of information,” Evans says. “People who seek out or who maybe are more disposed to looking at information that is not scientifically or medically accurate are more likely to be exposed to more of the same that confirms prejudices and untruths. The problem is that positive, accurate information gets drowned out and that is particularly worrying around mental health and diet and obesity.” Indeed, social media’s malign influence on covid-19 behaviour patterns should not be regarded as a hot streak that will cool and fade post-pandemic as recent research has indicated that exposure to pandemic misinformation is associated with a higher susceptibility to wider misinformation across other conditions. This is a significant and lasting threat to healthcare literacy and behaviour. A 2020 study published in 49

TECH & INNOVATION

Royal Society Open Science demonstrated a clear link between susceptibility to misinformation and vaccine hesitancy and a reduced likelihood of complying with public health guidance.

COMBATTING MISINFORMATION Health misinformation is far from a recent phenomenon as false and fake statements have been raging across the entire NCD landscape for years. “It has been out there for a long time with anti-vaccination movements and conspiracy theories existing way before the pandemic,” says Aleksandra Kuzmanovic from the World Health Organization’s (WHO) social media team, which is deploying a range of tactics to combat misinformation and leverage communication channels to spread accurate information. “Just because there is a focus on covid-19 doesn’t mean that other areas, such as NCDs, are not being impacted. But it always spikes with a new virus and anything that turns people away from treatment or towards the wrong treatment can be devastating.” The issue was made hugely evident when singer Nicki Minaj broadcast to her 22.6 million Twitter followers (the main WHO Twitter account has 10 million followers) that her cousin in Trinidad allegedly said he would not be vaccinated against covid-19 because “a friend got it and became impotent. His testicles became swollen. His friend was weeks away from getting married, now the girl called off the wedding”. There was no scientific basis to the claim but the tweet gained 100,000 likes and sparked an internet backlash against the vaccine. Fears about the side effects are the main driver of public reticence to get vaccinated and the Africa Infodemic Response Alliance, which tracks dangerous content, has debunked more than 1,300 misleading reports through the pandemic. “Social media has played a key role in spreading anxiety about the covid-19 outbreak, fake treatments, the rising number of deaths, and up until now covid vaccines. This has really made a number of people be hesitant on getting the vaccines,” Makinia Sylvia, a senior researcher at Africa Check, the independent fact checking agency. The deluge of covid-19 misinformation is merely the latest in a procession of anti-vaccine campaigns. In 2003, a polio vaccination campaign was disrupted in northern Nigeria by a string of spurious claims that the vaccine was possibly being contaminated with anti-fertility agents. A 15-month boycott of the vaccine ensued and the country’s polio immunisation campaign was dealt a heavy blow. This boycott meant that by 2008 Nigeria alone accounted for 86% of all polio cases in Africa, and since the boycott the country has struggled to be declared polio free. 50

EVIDENCE-BASED SOURCES A recent systematic review published in the Journal of Medical Internet Research confirmed the wide-reaching influence of misinformation on NCDs. It found that although the greatest concentration of false claims fell on vaccines, NCDs, drugs and smoking were also targeted. According to WHO, the pandemic has been a springboard for wider health misinformation, and it has stated: “The amount of misinformation surrounding NCDs has increased substantially during the covid-19 pandemic.” Dr Nino Berdzuli, director of the Division of Country Health Programmes at the WHO Regional Office for Europe, adds: “False and inaccurate information related to the risk factors for NCDs is a huge challenge.

“Exposure to pandemic misinformation is associated with a higher susceptibility to wider misinformation across other conditions”

“And with people seeking dietary advice, lifestyle counselling and even treatment online, this can lead to serious consequences. It reveals the importance of having trustworthy, evidence-based sources for information on health which the public can trust and that will allow informed and sound decisions.” The challenge is to ensure that accurate information is delivered across geographies and cultures by people, or organisations, that are trusted and relevant. WHO’s social media pandemic response has cleverly invoked popular children’s cartoon characters such as Peppa Pig, Baby Shark and Akilia on hand washing campaigns as well as rolling out heavy-hitting artists and political and sports figures. The double Olympic marathon champion and world record holder, Kenyan Eliud Kipchoge, used his profile in September to urge youngsters to come forward for the jab, stating on television: “Please let us get vaccinated because you are our future. If you do not get vaccinated then you are ruining our future, we rely on you.”

BREAKING THE MISINFORMATION CHAIN WHO’s Kuzmanovic adds: “We have a broad approach, partnering with social media platforms, who are endeavouring to minimise misinformation, amFORESIGHT

TECH & INNOVATION

IN ONE SOCIAL MEDIA MINUTE ...

350,000 TWEETS on Twitter

SOURCE: LOCALiQ, 2021

510,000 COMMENTS posted on Facebook

4.2 MILLION Google searches

694,000 VIDEOS viewed on TikTok

4,100 CLICKS on sponsored Instagram posts

3.47 MILLION VIDEOS watched on YouTube FORESIGHT

TECH & INNOVATION

bassadors, sports stars and celebrites and have partnered with Disney and cartoon characters that are popular in different countries. “We are operating in a challenging environment, but we are making progress. It has been successful, given the levels of misinformation that are out there. We can always do more, but we are committed to giving people the information they need and help people stop the chain of misinformation transmission.” The Journal of Medical Internet Research review also warned that false or misleading health information may spread more easily than scientific knowledge through social media. It called for more research to understand how misinformation infects health decision making and behaviours. The big social media platforms are responding by collaborating with health organisations in different countries, and Google, Facebook, Twitter, TikTok and Microsoft follow the European Commission’s Code of Practice on Disinformation. 52

POSITIVE POWER The power of positivity and alternative routes of communication should not be neglected as crucial to prevention and control of NCDs. Indeed, the power of positivity was given centre stage when model Lila Moss, who is a type 1 diabetic, wore her insulin pump while walking down a fashion catwalk in a bikini. She shared the photo with her 200,000 Instagram followers, generating more than 60,000 likes and more than 1,600 positive comments. Innovative ways of reaching groups who do not engage with social media is also a key weapon and success has been scored by holding events in neighbourhood settings and on public transport. In Kenya, a door-to-door information programme to tackle vaccine hesitancy was launched and pop-up events in schools, churches and community centres have also been used. The country’s chief administrative secretary, Dr Mercy Mwangangi, comments: “We are now using what is known as a hybrid approach. FORESIGHT

TECH & INNOVATION

“There is no cure for the malady of misinformation and disinformation, but the antidote will need a new approach to social media and relentless efforts and co-ordination across health communities”

Trusted source Innovative ways of reaching groups who do not engage with traditional media is a key antidote

We are going to the people, we are having outreaches, we are partnering with churches and different institutions to ensure that the vaccine is closer to Kenyans.” Several healthcare systems in Europe partnered with Imams to make sure accurate messaging got through to hard-to-reach Muslim communities during the pandemic. 90ten’s Evans adds: “I have worked in the HIV sector and in many sub-Saharan programmes, SMS text messages have been very effective. Less people have internet access, but they do have phones and outreach workers have had good success with SMS. “It is also important to partner with respectable voices, such as faith leaders, and it’s about using the right language that people can identify with and showing respect to the people you are trying to reach.” A graphic example came when Portuguese superstar footballer Cristiano Ronaldo removed two Coca-Cola bottles placed in front of him at a European FORESIGHT

Championship press conference in June and replaced them with a bottle of water, an action seen by millions around the world. The fight against misinformation will continue long after the pandemic has passed, and campaigners will need to evolve techniques and strategies to keep pace with a fast-changing technology. Evans advocates greater resources being put into education, even adding digital literacy to the school curriculum, to equip future generations with the skills and awareness to navigate away from misinformation and disinformation. The actions of the internet giants and how willing they are to sacrifice profit and tame algorithms so harmful content is eradicated or marginalised will have a huge impact on health outcomes. There is no cure for the malady of misinformation and disinformation, but the antidote will need a new approach to social media and relentless efforts and co-ordination across health communities. • 53

TECH & INNOVATION — OPINION

Checking the box for better maternal and child health Dr Anil Kapur is chairman of the World Diabetes Foundation

stetric care and high rates of maternal and neonatal mortality and morbidity. There are two key challenges to effectively improve pregnancy outcomes, particularly in LMICs. The first is the ability of the health system to screen women for common medical conditions causing pregnancy complications early enough to identify those requiring treatment and preventive care. This critical area is a major focus of the World Diabetes Foundation (WDF) and many of our partners, and deserves its own discussion. In this article, I would like to focus on the second challenge, which does not receive nearly as much attention as the first. It is the ability of the health system to follow up with women after an NCD-related pregnancy complication, and to engage and empower the mother and child to mitigate long-term risk by adopting a healthy lifestyle. A simple check box on a child’s health card indicating the mother experienced a pregnancy complication is an effecFORESIGHT

tive strategy that can be implemented in health clinics globally.

WINDOW OF OPPORTUNITY When a health system successfully diagnoses and manages a pregnant woman with gestational diabetes, pregnancy hypertension or pre-eclampsia, what happens next? What is done to ensure her future good health? Today, this window of opportunity is all too often missed. The literature offers some insights into why. A review of relevant studies reveals screening for diabetes following a gestational diabetes pregnancy is, in general, low. A Canadian study that investigated why women with a history of gestational diabetes didn’t complete routine screening found the most common reason by far was time pressure. A qualitative study of women attending a high-risk obstetric clinical practice in the United States found multiple barriers to postpartum care, namely tending to their babies’ health issues and adjusting to the new baby (both

ILLUSTRATION Sine Jensen

illions of women each year are diagnosed with pregnancy complications like gestational diabetes and pregnancy hypertension (a precursor to pre-eclampsia, which is characterised by signs of damage to another organ system). Research shows women who experience these conditions during one pregnancy are at very high risk of the same and additional problems in subsequent pregnancies, as well as type 2 diabetes, hypertension and cardiovascular disease later in life, especially if they experience difficulties with post-pregnancy weight loss. These pregnancy complications, like other non-communicable diseases (NCDs), hit low- and middle-income countries (LMICs) the hardest. Studies from South India and China have found gestational diabetes prevalence rates of around 18%, significantly higher than the global rates of 12-14%. High-risk pregnancies also add to the burden on healthcare systems in LMICs already struggling with lack of access to ob-

risk of potentially life-threatening conditions like type 2 diabetes and cardiovascular disease later in life.

PROPOSING A SOLUTION

“A simple check box on a child’s health card indicating the mother experienced a pregnancy complication is an effective strategy that can be implemented in health clinics globally”

of which take time they might have spent on themselves), feeling healthy and not in need of care, and being worried about receiving bad news. Very few studies are available from LMICs, but in decades of work with the World Diabetes Foundation I have witnessed many of the same barriers as those reported in high-income countries. Many women feel healthy and do not see the need for follow-up treatment, while others lack the time or money to prioritise their health. What’s more, women who have experienced pregnancy complications are often

told to adopt healthier lifestyles during and after pregnancy, but with little or no practical guidance on how to do so, and no explanation of why it’s important. New mothers in LMICs face similar barriers, as well as some additional challenges. Changing family diet and lifestyle, for example, is especially difficult when healthy food is expensive or unavailable, or such changes are not supported by the extended family or community. As a result, all too many women who have had one pregnancy affected by a complication like gestational diabetes go on to have another, which increases the FORESIGHT

I believe a simple check box on a child’s health card indicating that the mother experienced a pregnancy complication could interlink maternal health, child health and NCD prevention—and end this vicious cycle. Most new mothers—in high-income countries and LMICs—visit health services for vaccinations, baby check-ups and other services, and are likely to do so at regular intervals for at least five years. Why not use this opportunity to provide women with postpartum services and education that can transform their lives? Why not connect the mother’s pregnancy complication status to the child’s health card for the benefit of both? This box, when checked, would trigger an extra five to 10 minutes during health clinic visits to discuss the mother’s lifestyle and check her weight, blood pressure and blood sugar. These services can continue for three to five years post pregnancy, until the child ages out of the childhood vaccination programme. The result: the mother’s health improves before the next pregnancy, and her risk for serious long-term health conditions is reduced. And there’s an important bonus. A healthier lifestyle for the mother has flow-on benefits for her children, as children born to women who experience pregnancy complications are also at elevated risk of conditions like type 2 diabetes and cardiovascular disease. When I advocate for this change, people nod with agreement. But for it to work, health systems must be integrated, and silos broken down. An intervention that helps women who have had one high-risk pregnancy avoid future complications— especially if that approach leverages existing health structures and services—is worth pursuing. Healthcare providers, healthcare planners, public health professionals and policy makers can work together to add a simple check box to children’s health cards, without forgetting to involve the women at risk. • 55

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