Reframing non-communicable diseases as socially transmitted conditions: it is not about naming, but framing

Allen and Feigl1 fail to emphasize that non-communicable diseases (NCD) were framed and not named in global health discourse. NCDs from a global health perspective are currently thought of as four diseases and four associated risk factors.2 This framing does not include many NCDs, such as genetic defects, mental health and injuries, which by definition are included in the categorization as they are not transmitted from person to person. Within the 4 prioritized NCDs there are conflicts with what Allen and Feigl1 and others propose3,4. Some cancers are caused by a virus and are curable. Type 1 diabetes is of unknown etiology compared to type 2 diabetes which is mainly driven by changes in the environment.

Allen and Feigl5 state that the “global health community does not spend much time on branding”. We agree with this statement, but highlight that three communicable diseases which receive significant funding, namely HIV/AIDS, tuberculosis and malaria did not rename themselves. Two stuck to the causative pathogens and the third with its original name linked to the notion that it was caused by “bad air”. Advocates reframed these health issues, beyond a purely health based discourse and the specialist and academic spheres, as wider concerns impacting global security, economies and development.6,7

The inclusion of NCDs in the Sustainable Development Goals (SDG) is a unique opportunity. We suggest linking NCDs with each SDG in order to highlight that development cannot succeed without the inclusion of NCDs.8 One could call this the COHESION approach in that the focus of our work on NCDs and NTDs are the tools that allow us to address the SDGs versus a disease centric approach. For example SDG 1 and NCDs as caused and causes of poverty; SDG 2 and malnutrition as a risk factor for NCDs and that the double burden of malnutrition needs to be addressed; SDG 3 and how NCDs need to be included in Universal Health Coverage; Gender issues (SDG 5) as NCDs impact women and men in different ways; SDG 11 and in making cities safe this needs to include NCDs with regards to road traffic accidents and providing safe spaces for exercise and access to healthy food; and SDG 17 that national and global partnerships across sectors will be necessary to solve this challenge.

“What’s in a name? That which we call a rose; By any other name would smell as sweet. As stated by Romeo and Juliet names do not have an impact and the rose remains a rose no matter what we call it. NCDs will not be solved purely by being renamed, they need to be reframed politically.

References
1. Allen LN, Feigl AB. Reframing non-communicable diseases as socially transmitted conditions. The Lancet Global health 2017; 5(7): e644-e6.
2. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization, 2013.
3. Lincoln P. Renaming non-communicable diseases. The Lancet Global Health 2017; 5(7): e654.
4. Rigby M. Renaming non-communicable diseases. The Lancet Global health 2017; 5(7): e653.
5. Allen LN, Feigl AB. What’s in a name? A call to reframe non-communicable diseases. The Lancet Global health 2017; 5(2): e129-e30.
6. Stabinski L, Pelley K, Jacob ST, Long JM, Leaning J. Reframing HIV and AIDS. BMJ 2003; 327(7423): 1101-3.
7. de Waal A. Reframing governance, security and conflict in the light of HIV/AIDS: a synthesis of findings from the AIDS, Security and Conflict Initiative. Soc Sci Med 2010; 70(1): 114-20.
8. Beran D, Chappuis F, Cattacin S, et al. The need to focus on primary health care for chronic diseases. The lancet Diabetes & endocrinology 2016; 4(9): 731-2.

Seminar in Peru: Health Policies and Systems Research

The CRONICAS Center of Excellence in Chronic Diseases is sharing knowledge, building capacity and mutual understanding of health Policy and Systems Research.

Given the growing emphasis on health systems research and the role of health policy in the health of populations, the Peruvian team of COHESION, CRONICAS recently held a seminar on the topic.

Here is an overview of what took place and what the main and most important messages were:

On July 03 2017, the Institute of National Health (INS) and CRONICAS Center of Excellence in Chronic Diseases with the support of The Alliance for Health Policy and System Research- WHO, held the seminar “Health Policies and Systems Research” at the headquarters of the INS.  The objective was to show and discuss a new area of research that can be used for the implementation of policies.

Dr. Hans Vasquez from the “General office of Research and Technology Transfer” opened the seminar and stressed the importance of moving forward from diagnostic research to doing research that can have a bigger impact on health. In countries like Peru there is little research on policies, health systems or implementation.

The first presentation was provided by Nhan Tran, manager of “The Alliance for Health Policy and Systems Research (AHPSR)”. He said that the current challenge is to ensure health interventions are effectively integrated into health systems and are designed to be scaled up in different contexts. He pointed out that one of the reasons why implementation is so difficult is because implementation is about change (asking organizations to behave differently, people to do things differently, etc.). That is why it is important to think implementation as a process of change. Finally, he emphasized three main important shifts on how to do implementation: 1) applying a more systems perspective, 2) thinking about research as part of the implementation research, and 3) having local investment in implementation.

(Left to right Dr. Hhan Tran and Dr. Hans Vásquez; picture from INS https://goo.gl/iwfkAt)

The next two presentations were from representatives of the public sector, Dr. Manuel Catacora Villasante from the “Institute of assessment in technologies in Health and Research” of the Social Security; and Bio Gisely Hijar Guerra from the “National Center of Public Health-INS”. They talked about the prioritized research subjects of their institutions, gave some examples of research being developed and pointed out some opportunities of funding.

The fourth presentation was given by Dr. Ludovic Reveiz from the Pan American Organization, where he explained how there is still too little information on how to do implementation research in policies. He showed the work the program iPIER is developing in Latin America and the Caribbean, which aims to facilitate improvements in program implementation through implementation research. An important part of this program is a workshop where the grant recipients receive a basic understanding of the research methodologies in implementation research.

The fifth presentation was from Dr. Fernando Llanos of the Universidad Peruana Cayetano Heredia. He talked about his research in health systems at primary care and universal coverage. He explained some conceptual frameworks, the methodology of the study and some final conclusions. He highlighted two important conclusions; first that before thinking in primary health care, there should be a clear definition of what is considered primary health care in Peru, and second, that talking about universal coverage meant to think of the system as a whole, because in the Peruvian context there are several subsystems.

Mg. Gerardo Seminario of “Salud sin Limites” gave the final presentation where he spoke about the process of making an agenda for public policies for the health of indigenous populations in Peru. He pointed out that a policy agenda is not necessarily a rational decision but derives from other factors like power roles, negotiations, institutional frames, etc. The making of an agenda consists on the concurrence of 4 factors: a problem, a possible solution, stakeholders and a window of opportunity. He concluded that the policies for the health of indigenous populations is still fragile, because the response for intercultural health is accepted but only on the surface, because the network of experts is not consolidated, because politicians change frequently as do their interests, because the vertical structure of the health system does not facilitate an intercultural health, and because the window of opportunities is narrowing.

(Picture from INS https://goo.gl/iwfkAt)

At the end of the seminar there were two panel discussions. One, about the priorities of research policies and health systems, included the participation of Dr. Maria del Carmen Calle Dávila (General Directorate of Strategic Interventions in Public Health) and Dr. Hans Vasquez (INS). The second panel was about funding opportunities for research in policies and health systems, and included Dr. Franco Romani (INS) and Dr. Alexander Tarev (General Directorate of Strategic Interventions in Public Health). The discussions brought to our attention the efforts of the public sector to do research, and though these efforts are few and recent, the road is being build. There is still the need that the research community meets the demands of the public sector. In that sense it is necessary that the public sector opens more opportunities where policy makers and researchers can encounter each other.

This seminar was a good opportunity for the dialog between the research community, policy makers and civil organizations. For the COHESION team, it was a good moment for engagement and to gain an update of the research being done in in health policies and systems.

CRONICAS and Health Systems Research:

At CRONICAS Center of Excellence in Chronic Diseases there have been past and ongoing research projects related to the assessment of health systems. Through 2012-2013 the project “Barriers” financed by the AHPSR, piloted for the first time in Peru a research implementation manual for the evaluation of healthcare systems’ responses to chronic non-communicable diseases. Currently the COHESION project has as objective to improving the health system response for attending the double burden of Noncommunicable and Neglected Tropical Diseases. Initiatives like these are in the path to look for solutions for the current health issues the health systems face.

Additional information:

Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

Summary: Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

On May 3, the COHESION project in Peru held a meeting with stakeholders, where stakeholders related to the health sector and the diseases related to the project (diabetes, hypertension and neurocysticercosis) were invited. The purpose of the meeting was to present the project, create links with different institutions and receive inputs or recommendations for the project.

The meeting was attended by members of the COHESION project in Peru, part of the COHESION team from Switzerland, public officials from both the Ministry of Health and the Superintendence of Health, as well as some civil society organizations such as the Diabetes Association of Peru and the Peruvian Federation of rare diseases.

The meeting began with the words of welcome from Jaime Miranda, Director of “CRONICAS center of excellence in chronic diseases”. During his welcoming he remarked the intention of the meeting to carry out a co-creation process between the COHESION project and the assistants, to think together ways of improving the health system, especially in the attention given in the primary health care.

Following, David Beran principal investigator of the COHESION project made a presentation of the project COHESION (in Spanish). He explained the linkage between the project with the Millennium Development Goals and the Sustainable development objectives. He also pointed out important qualities of the project like being a multidisciplinary and multi-country team. Finally he explained the different stages that the project has carried out and the stages to come in the next years.

Subsequently, the words were given by María Kathia Cárdenas, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. During her presentation she explained the COHESION project in the Peruvian scenario. She specified the project is being carried out in the region of Piura, in the health posts of Sicacate and Pingola, located in the districts of Montero and Ayabaca respectively. During this presentation it was also specified two of the studies that the project is carrying on, the evaluation of policies and the health system assessment. She explained details of each study and the different levels of analysis. Furthermore, she also explained the methodology that is being implemented based on the manual “How to investigate access to care for chronic noncommunicable diseases in low and middle income countries” (2012) from the WHO, and she also explained the activities that were already performed at the community level such as interviews with patients, health workers, head of facilities, among others.

Next, María de los Ángeles Lazo, researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases, detailed the steps that will follow the project in the next months to involve the stakeholders at the macro or national level. She explained to the participants the important need of their support and expressed the intention of the project to involve them actively in the process, as well as with other key stakeholders. It was also specified that in the short term the COHESION project will be contacting them to have personal interviews, to know their opinions on the health systems facilitators and barriers.

Finally the discussion was opened to the attendees so they could express their opinions, comment or question of the project. This final part was moderated by María Amalia Pesantes, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. Some of the most important arguments and recommendations are detailed below:

  • To include the perspective of caregivers. It is important the health system recognized their task, not only in a financial support, but also to be trained in the care of the patients and to consider the importance of psychological support for the caregivers, who were also called “acompañantes” (companions).
  • Developing engagement with key stakeholders such as public officials and political representatives is a long-term endeavor.
  • It is necessary to establish relations with the regional health directorate in Piura. This entity is the responsible of providing the health service, while the Ministry of Health is in charge of regulating and monitoring. It was also suggested to interview the head of the department of Planning and Budget and Human Resources, and to include the Regional Government, who has also responsibilities related to health, poverty, access to water and sanitation.
  • It was also highlighted the important role played by community agents in the health system.
  • It was acknowledged the low ability of the Ministry of Health to communicate strong messages. Furthermore, civil society lack of relevant information about diseases, especially the most neglected population.
  • Past experiences on training diabetes educators were shared and it was noticed that one of the main difficulties in the training of health workers was the high rotation to other health establishments, and this should be taken in to account for the project.

Participants:

COHESION Team (Switzerland):

  • David Beran
  • Sarah Lachat
  • Suzanne Suggs
  • Nathaly Aya Pastrana

COHESION Team (Peru):

  • Jaime Miranda
  • Maria Kathia Cardenas
  • Maria Amalia Pesantes
  • Maria de los Angeles Lazo
  • Charlotte Darwis
  • Rosa Salirosa
  • Silvana Perez Leon

Participants:

  • Jorge Calderón (President of the Diabetes Association in Peru)
  • Luciana Bellido Boza (Representative of Intendance of Research and Development – SUSALUD)
  • Jorge Ferrandiz (Executive Director of the Department of Prevention and Control of Noncommunicable, Rare and Orphaned Diseases)
  • Maria Lourdes Rodriguez (President of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)
  • Lilliam Lindley (Representative of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)

 

COHESION – a challenge to Frenk and Gómez-Dantés

In The Lancet, in February 2017 (http://dx.doi.org/10.1016/ S0140-6736(16)30181-7), two leading thinkers in global health, Julio Frenk and Octavio Gómez-Dantés, challenged the status quo of many of today’s public health and healthcare delivery processes through a detailed assessment of a variety of dichotomies that exist in global health. Frenk and Gómez-Dantés’ main message was the need for integration in global health across a wide range of challenges. This interesting piece led to a thought provoking discussion within the COHESION Team where we asked ourselves: are we operating within or beyond those scenarios of dichotomies?

The first dichotomy they describe is the prevention versus treatment debate. How does COHESION address this first dichotomy? For non-communicable diseases (NCD), even if all prevention measures are successful some people will still develop some of the conditions included in this overarching group. For Neglected Tropical Diseases (NTD) the “endgame” for many of these diseases is envisionable given the existence of medicines which provide a “magic bullet” to cure people and/or break the cycle of transmission. However, for both NCDs and NTDs people have already been exposed to some of the risk factors, have biological changes (e.g. high blood pressure; infected with Cysticercosis) and therefore require care. Yet, both NCDs and NTDs share fundamental root causes that determine its existence: poverty and exclusion. We cannot address treatment solely without the broader need for prevention.

The next “clash” described is the vertical versus horizontal debate. For NCDs and NTDs this debate is mute as the main driver of vertical programmes was funding. As was seen for HIV/AIDS funds were allocated to create complete vertical systems for distribution of medicines, training of health professionals, delivery of care, etc. For both groups of diseases that COHESION focuses on this funding is lacking thus vertical solutions are not implemented. That said NTDs are more at risk of becoming “verticalised” given the higher level of funding available in comparison to the burden, the “easier” solutions of mass drug administration (for some NTDs) and the defined populations that are impacted by some diseases. COHESION through its research and development of interventions will try to ensure a horizontal approach in order to benefit not only those with NCDs and NTDs, but any one requiring health care at primary level. We are allowing ourselves to redefine the interaction of an individual with the existing healthcare system where chronicity and continuity of care are fundamental.

Number three on Frenk and Octavio Gómez-Dantés’ list is primary versus specialized care. As mentioned above the main focus of COHESION is on primary health care. Given that our emphasis is on NCDs and NTDs which are both chronic in nature this will enable a strengthening of primary health care to guarantee continuity of care. Traditionally primary health care has been successful in maternal and child health, delivery of HIV/AIDS care (with significant funding) and acute care. However, with the burden of chronic disease a shift in the role of primary health care is needed. Through its formative research and interventions COHESION will focus its efforts on developing this level of the health system. We are not denying care, but aim integrate chronic care at primary health care as well as facilitate referral to specialized care when needed.

By design COHESION lays the fourth dichotomy to rest, the noncommunicable versus communicable disease prioritisaiton. By including NCDs and NTDs together within the core of its project COHESION wanted to focus on models of delivery of care versus mode of transmission. Leprosy and Type 2 diabetes from a delivery of care perspective share many similarities despite being communicable and noncommunicable. Need for proper diagnosis and initiation of treatment; patient education and empowerment; address issues of stigma; and prevention of complications.

Finally, the latest dichotomy posed the challenge between knowledge generation versus action. Again, COHESION is in a unique position thanks to the funding mechanism developed by the Swiss National Science Foundation and Swiss Agency for Development and Cooperation. The funding COHESION has received will not only enable the generation of new knowledge on NCDs and NTDs, at policy, health system and community level, but also to use this to co-create innovative interventions working closely with local partners through.

The title of Frenk and Octavio Gómez-Dantés’ comment includes the word “integrative”. COHESION in the design of its team and project has had this word as a guiding principle. Integration of different expertise from a variety of countries, institutions and individuals; different diseases and disease groups; different methodological approaches; local partners and stakeholders in the research and intervention development. As COHESION we would add another dichotomy to the list proposed by Frenk and Octavio Gómez-Dantés that is how solutions in global health are developed. Most solutions to date have had their roots in meetings at the World Health Organization, the minds of the best and brightest academics and in the offices of Ministries of Health. Our approach proposes a bottom up approach where interventions are informed by this, but designed by beneficiaries. To date although different normative documents exist on how to tackle the burden of NCDs and NTDs success is still far away. We hope through our innovative approach to find ways of addressing NCDs and NTDs as well as contributing to breaking down the dichotomies that Frenk and Octavio Gómez-Dantés highlight.

 

Written by David Beran and Jaime Miranda for COHESION

 

 

 

 

 

 

 

COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!

COHESION PI reflects on “Meu regresso a Moçambique”

Meu regresso a Moçambique – My return to Mozambique

Mozambique is a special place for me. It was the first country I visited in sub-Saharan Africa, my first project in looking at diabetes management in a low-income country and also a country where I was able to work for close to 7 years with the Ministry of Health and Diabetes Association. Besides the professional aspect, it was also a place where I made long lasting friendships with unique people who not only shared their passion for the work we were doing together, but also imparted me with the love of their beautiful country.

So the question I got from everyone after my recent trip to Mozambique for COHESION, how was it going back? AMAZING was my answer.

Going back to Mozambique was like seeing an old friend after a long time. The link, fondness and memories were there. Both Mozambique and I had moved on since my last visit. Economic development in Mozambique, but with current economic turmoil, more projects including the launch of COHESION and my move back to Geneva on my end.

My reunion with Mozambique was also positive in that the Mozambique COHESION Team had progressed with the research, been able to involve high-level individuals in the Advisory Boards as well as gain the support for our project in the two areas where our work will take place. I had a chance to visit Xipamanine and Moamba and speak to health professionals and local members of the community. In parallel Dr. Claire Somerville (Graduate Institute and COHESION Project Lead on the Policy Analysis component) and Sarah Lachat (University of Geneva, COHESION Project Manager) had the opportunity with our colleagues to work on and carry out some interviews regarding the Policy Analysis. We were also able to meet with the Swiss Cooperation Office in Maputo. The result of all of these discussions is that COHESION has a huge role to play in Mozambique to help improve the management of Noncommunicable (NCD) and Neglected Tropical Diseases (NTD).

Being back in Mozambique not only enabled me to see progress and continuing challenges based on my previous work, but mainly the importance of the current work of the COHESION Project. There are many challenges in Mozambique with a life expectancy of 53; high prevalence of HIV/AIDS and malaria; high maternal mortality, etc. NCDs and NTDs have been neglected by policy makers and donors. This results in a lack of capacity at the level of the health system to respond, leading to challenges for individuals and communities. The interventions that our project will develop will hopefully address these and help improve the conditions for people with NCDs and NTDs.

Até a proxima (until next time) Moçambique,

Dr. David H. Beran, Principal Investigator of COHESION

Swiss team goes to Mozambique

The COHESION team meets in Mozambique. Three members of the Swiss team (Dr. David Beran, Dr. Claire Somerville and Mrs. Sarah Lachat) join the Mozambique team this week at Eduardo Mondlane University.

Policy Analysis and gender are at the top of the agenda, but the team will not miss the opportunity to advance the community and health system assessments and reporting.

The team is grateful to be able to profit from face to face time in the country.

Household Survey in Nepal

For the first time, in the rural area, Baniyani VDC, Jhapa district, South-western Nepal, a major household survey on several health issues was conducted by the Nepalese COHESION team during the last week of November 2016. The aim of the survey was to collect baseline information needed to assess the level of NCDs and NTD prevalence and related health care in one of the two selected site for COHESION intervention in Nepal.

The Household survey was conducted in the framework of the Interdisciplinary “Community Diagnosis Program” organized by School of Public Health and Community Medicine which comprises of two weeks of residential posting in rural setting for 1st Year MBBS, BDS and B.Sc. Nursing students. More than 200 students took part to the survey, supervised by 30 postgraduates and teachers, to collect data of more than 1200 households.

The questionnaires used are an innovative mixture of closed and open-ended questions concerning the socio-demographic profile of the community, reported health problems, health seeking behaviour and access to health facility and services at PHC level from a consumer perspective.

An orientation program was first organized at the B. P. Koirala Institute of Health Sciences (BPKIHS) to deliver lectures for the students on the different methods to be used. A meeting with local authorities including VDC heads, health worker, leaders, school teachers, Female Community Health Volunteers and others was also organized the week before field work, to inform the community of Baniyani VDC about the program and its aim.

The total of 201 medical graduate and nursing students under the supervision of 26 supervisors, including MD/MPH/MSc. nursing students were grouped in nine groups in accordance with the total number of wards of Baniyani VDC and performed house to house visits during 7 full days and collected more than 1200 households using semi-structured questionnaires regarding the above mentioned issues.

All households of the VDC were visited. The local communities were very cooperative in general. However, some resisted for the interview which could be due to mistrust towards health institutions or business. Others could not be assessed because of locked houses, probably due to the harvesting season or migration for work. Some members of household questioned about benefits of the survey: the fact that we were holding a health camp in parallel (day program of on the spot consultations offered by the MDs/faculties from B. P. Koirala Institute) helped a lot in this regard. At the end of the data collection exercise preliminary findings were shared with the community representatives, which also fostered mobilization of the villagers.

A challenge of the survey was to visit the place of study from the place of residence with such a huge group of students. We had to travel for more than an hour by bus. We all were very busy during the data collection with regard to visiting different households by walking. In every evening, attendance of students and briefing of status of data collection was organized.

In general, this survey was a success. Not only data were collected, but because all students had the opportunity to gain a lot of valuable experience.

COHESION in the The Lancet Diabetes & Endocrinology

The Lancet Diabetes & Endocrinology has just published a commentary from the COHESION investigators on “The need to focus on primary health care for chronic diseases“.

DOI: http://dx.doi.org/10.1016/S2213-8587(16)30148-6

Beran, D., Chappuis, F., Cattacin, S., Damasceno, A., Jha, N., Somerville, C., Suggs, L.S., Miranda, J. J., for the COHESION Project (2016, July 15). The need to focus on primary health care for chronic diseases. The Lancet Diabetes & Endocrinology. http://doi.org/10.1016/S2213-8587(16)30148-6

Views from the World Cardiology Congress

COHESION at the heart of the matter: Views from the World Cardiology Congress
by COHESION Principal Investigator, Dr. David Beran

I was invited to give a talk at the World Cardiology Congress on lessons from diabetes and health systems that might be of use for cardiology. An interesting opportunity and when I found out that my co-Investigators Albertino Damasceno and Jaime Miranda would also be there I saw it as an added advantage to be able to see them and catch up on COHESION.

On my flight to Mexico, the Congress was in Mexico City, the person sitting next to me on the flight asked if I was going to Mexico on holiday and I said no that I was going to a Congress. They asked which Congress and I said a cardiology congress. “Ah so you are a cardiologist?”, my neighbour asked. “No” was my answer. “Then what kind of doctor are you?”, was his retort. “Actually, I am not a doctor, I work in public health and health systems”, I replied and started describing what I actually do. Luckily the bewilderment of my fellow rowmate was interrupted by the all too important question by the flight attendant͞, “Chicken or pasta?” At which point we wished each other a pleasant meal and that was the end of our interaction.

That brief contact with my fellow traveller highlighted many things. One, the view of health as that of a doctor’s domain. Secondly, that public health is a misunderstood concept and people outside the health arena do not really understand what it means. Another issue is that for many people when they hear a disease, e.g. cardiology, they see this as something that doctors and medicine can fix, versus a large societal health issue that requires multiple actors to address within and outside the health system. Finally, that I need to find a better way of explaining what I do…

These issues are essential to highlight based on this somewhat trivial interaction in that at the World Cardiology Congress many of the sessions were geared towards issues that could not have been further away from what my travel companion imagined what cardiology and a cardiology congress entailed. I attended interesting discussions on tobacco, alcohol, health systems and specificities of heart disease in different parts of the world, e.g. Africa versus Latin America. All of the presentations had one thing in common, that the COHESION project is well and truly at the heart of the matter.

To give you an example why I say that. The sessions discussing tobacco, alcohol or obesity or those discussing hypertension management highlighted that these phenomena once thought of as being only found in high-income countries have now become global issues impacting all strata of populations within and between countries. In parallel certain countries face this burden as well as the burden of cardiovascular disease linked to infectious agents such as Rheumatic Heart Disease. For an excellent review of the challenges of cardiovascular disease in poor populations see http://www.ncbi.nlm.nih.gov/pubmed/27297348 which Jaime Miranda contributed to. These examples highlight the double burden of disease as a challenge, but very few of the presentations or discussion highlighted what could be done. Many described possible avenue for improvement: strengthening health systems, better health promotion and prevention activities, the need for policy interventions, better training of health professionals, task shifting, use of “m” and “e” health, etc. None of the presentations I attended mentioned two of the cornerstones of the COHESION project namely Primary Health Care or the community.

This made me realise the importance of the COHESION project in not only addressing the specific NCDs and NTDs we are working on, but also wider health system issues. Also seeing my two co-Investigators discuss the work they do in parallel to COHESION highlighted the quality of the individuals we have and how they truly are at the forefront of their fields. Hopefully, in the future, the COHESION team will be able to present its results in such a forum highlighting lessons learnt from NCDs and NTDs in improving PHC for other conditions.

Cardiology congress_mexico 2016

Jaime Miranda, David Beran, Albertino Damasceno