As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

1. Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent’s development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverage and is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

2. Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW’s.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW’s numbers have been reduced as a result of war, poor political will and Ebola.

3. Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW’s have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett’s latest article:

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

4. Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW’s.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc…

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

5. Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.


A question posed by Jessica Taaffe on twitter, who is a TWIGH panelist, is my inspiration for this weeks blog. The question posed was: If you were to list three major research gaps for access to medicines what would they be? I posted 2 comments to that statement, the 140 characters per tweet, was not enough to fully weigh into the matter, so I am using this weeks post as a soapbox to expand further.

Firstly you might be asking what does this have to do with global health? In a nutshell, it has a huge impact, access to medicines, is dependent on the research that underpins it, it is the foundation on which medicine that we use stands. How firmly it stands depends on the strength of the research. If the road travelled to arrive at the end product is not evidence based (we will discuss the vagaries of this shortly), we then run the risk of having a flawed product, or even in some cases a product that never sees the light of day, (see my blog on Politics and Medicine).

The two comments I posted to twitter stated that evidence based medicine must be driven by independent clinicians, scientists and medical policy makers. Furthermore I stated that Levels of Evidence A (LOE – A) must be the benchmark. We cannot just be led by the large multinationals (Pharma and Medical Device Industries), they can most certainly push money into research, but the parameters of that research must be in the hands of independent clinicians, shared decision making can and must play a key role. This is a huge challenge but must be addressed, we need to claim back the labs and work alongside the drug and medical device industries

So what is evidence based medicine , why is it important and why do I say the we need to adhere to LOE -A?

Evidence based medicine grew out of critical appraisal, when Gordon Guyatt took over as the director of the internal medicine registry programme at McMaster University. He wanted to change the program so that physicians managed patients based not on what authorities told them to do but on what the evidence showed worked. It then appeared in an article in “The Rational Clinical Examination” series in Journal of the American Medical Association (JAMA) in 1992.

The strength of evidence is assessed by a specific grading system which, in fact, is quite simple. It combines a description of the existence and types of studies supporting a certain recommendation.

-Level of evidence A: recommendation based on evidence from multiple randomized trials or meta-analyses

-Level of evidence B: recommendation based on evidence from a single randomized trial or non-randomized studies

-Level of evidence C: recommendation based on expert opinion, case studies, or standards of care.

So the highest standard to attain is LOE – A, is this always the case? In 2009, a very interesting paper was published in JAMA, assessing the strength of evidence underlying the American College of Cardiology (ACC) and the American Heart Association (AHA) practice guidelines. They were reviewing recommendations to see if they were based on strong levels of evidence (LOE – A) and how much is based on “expert” opinion.

In only 11% of the guidelines published was LOE – A the benchmark, and most of the current guidelines included more than 50% of LOE – C as the standard! The authors correctly concluded that “expert opinion remains a dominant driver of clinical practice, particularly in certain topic areas, highlighting the need for clinical research in these fields”. I am sure if we had to review other areas of medical research we will be in a similar ballpark.

I can cite numerous examples from my own area of speciality where we have used certain drugs for years, with no studies definitely stating that they were beneficial to the patient, but there use was continued because of expert opinion, what drove that expert opinion is open to debate.

The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of “unfiltered” data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.

This is where the Cochrane Review stands the test of time, as it enable the practice of evidence-based health care, where health care decisions can be made based on the best available research, which is systematically assessed and summarised in a Cochrane Review. Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.

In closing then, to come back to the original question; what three major research gaps for access to medicines:

  1. Research must be evidence based with LOE-A as the gold standard

  2. Research must be driven by independent clinicians, scientists and medical policy makers

  3. Research needs to be taken back to the labs and institutions who will research what is needed globally.

We would need large NGO’s such as the WHO and the European Research Council (amongst others) to monitor and guide where research needs to be focussed. We need to thank all scientists, inventors, and researchers who are motivated by the need to know, the thrill of discovery,and the desire to make a positive contribution to mankind as a whole and acknowledge the right of people to the common ownership of medicines/vaccines etc. which are basic to their common and individual well being, as to life itself.

As the cognitive linguist George Lakoff puts it, “Empathy is at the heart of real rationality, because it goes to the heart of our values, which are the basis of our sense of justice. Empathy is the reason we have the principles of freedom and fairness, which are necessary components of justice.”