Nicholas Banatvala

Improving responsiveness of health systems to non-communicable diseases

In almost all countries, development of health systems that are responsive to the challenge of prevention and treatment of non-communicable diseases (NCDs) is a priority. NCDs consist of a vast group of conditions, but in terms of premature mortality, emphasis has been on cardiovascular disease, cancer, diabetes, and chronic respiratory diseases—diseases that were also the focus of the UN high-level meeting on NCDs, held in 2011. In 1990, there were 26·6 million deaths worldwide from NCDs (57·2% of 46·5 million total deaths), increasing in 2010 to 34·5 million (65·5% of 52·8 million deaths) as the leading cause of death in all regions apart from sub-Saharan Africa and south Asia. Similarly, the global burden of NCDs has increased from 43% (1·08 billion of the total 2·50 billion) in 1990, to 54% (1·34 billion of 2·49 billion) of the total number of disability-adjusted life-years in 2010. The global economic burden of NCDs is large, estimated at US

Helicobacter pylori Infection in Dentists - a Case-control Study

6·3 trillion in 2010, rising to

Migration and Helicobacter pylori seroprevalence: Bangladeshi migrants in the U.K.

13 trillion in 2030. A 10% rise in NCDs leads to a 0·5% decrease in gross domestic product. The projected cumulative global loss of economic output due to NCDs for 2011–30 is estimated at

Tuberculosis in Russia

46·7 trillion, with around

Sugar, tobacco, and alcohol taxes to achieve the SDGs

21·3 trillion (46%) in low-income and middle-income countries. The growing burden of NCDs in low-income and middle-income countries will compound the poverty and economic hardship created by communicable diseases and hold back development. Yet, few such countries have the fi scal strength to meet the future health, economic, and social burden that NCDs will impose, which raises concerns of economic instability, arrested development, and government fragility—with implications for global security as well as foreign policy. An ageing society, alongside improving health care, means that health systems have to manage not only diseases such as heart disease, stroke, and cancer, but also individuals with multiple chronic disorders. Multimorbidity disproportionately aff ects those who are poorest. Furthermore, around 9 million people in lowincome and middle-income countries now benefi t from antiretroviral treatment (ART), with remarkably im proved survival, but with new comorbidities such as diabetes or cardiovascular disease. Health systems also have to manage patients with new comorbid disease patterns, in which infectious diseases combine with NCDs. Management of people with NCDs and multimor bidity will be particularly challenging in low-income and middle-income countries with weak health systems characterised by fragmented health-care services, which are still designed to respond to single episodes of care, or the long-term prevention and control of infectious diseases such as HIV, tuberculosis, and neglected tropical diseases. These health systems are ill prepared to manage changing disease patterns with a growing burden of NCDs and multimorbidity. To achieve the World Health Assembly target of 25% reduction in preventable deaths from NCDs by 2025, health systems need to be transformed to provide person-centred care with improved outreach and selfmanagement to eff ectively manage risk factors, illness episodes, and multimorbidity over many years. Along with outreach and community-based services, health facilities in low-income and middle-income countries need to be strengthened to develop reliable individual records that enable assessment and management of risks of individuals under their care. Yet, in many such countries, long-term care and risk management that includes follow-up at clinic and repeat prescriptions are a new idea for many patients and health staff . However, existing service delivery platforms can be used to address chronicity, the emerging NCD epidemic, and multi morbidity. Resource constrains imposed by the worldwide economic crisis means that sustaining increases in global health fi nancing will be a challenge. There is an imperative to fi nd solutions that create synergies among investments in low-income and middle-income coun tries for diff erent diseases, especially HIV and tuber culosis, which have substantially benefi ted from international fi nancing and have clear links with NCDs. In this paper we provide examples of how HIV and tuberculosis investments have been used to strengthen health systems and opportunities to integrate NCD prevention and control with HIV and other programmes. We describe the importance of building health services that profi le the risks of NCDs and multimorbidity in their population. Finally, we propose a stepwise approach to scale up health systems by building on existing programmes to tackle NCDs and multimorbidity.

Securing support for eye health policy in low- and middle-income countries: Identifying stakeholders through a multi-level analysis

To test the null hypothesis that frequent and multiple salivary exposure is not a risk factor for developing H. pylori infection, serum anti-H. pylori IgG from 179 dentists and dental students and 179 age-, sex- and socioeconomic-matched controls were assayed using an ELISA. Seroprevalence in dentists was 16% (11/70); clinical dental students 6% (3/47); and pre-clinical dental students 10% (6/62). There were no differences in H. pylori seropositivity between cases and controls. There was an increase in H. pylori seropositivity with age (chi (trend)2 9.04, p = 0.003). These data provide evidence that adults are not at high risk of developing H. pylori infection as a result of exposures to saliva from multiple sources.

Helicobacter pylori in dental plaque.

Helicobacter pylori, an infectious agent of worldwide public health importance, has higher seroprevalence in developing countries than in developed countries. We investigated whether Bangladeshi women, born in Bangladesh, have a greater H. pylori seroprevalence than Bangladeshi women born in the U.K. and, in addition, whether there is an association between H. pylori seropositivity and age of migration to the U.K. amongst Bangladeshi women. Women attending antenatal clinics at the Royal London Hospital were screened using ELISA for anti-H. pylori IgG. In Bangladeshi individuals born in the U.K., 13/16 (81%, 95% confidence interval (CI) 54%-96%) and, in Bangladeshi individuals born in Bangladesh 91/137 (66%, 95% CI 59%-74%) had antibodies to H. pylori. No significant association was found between H. pylori seropositivity and country of birth, or age at migration to the U.K. Public health strategies concerning H. pylori should consider migrant populations with high seroprevalence of H. pylori.

Use of the Polymerase Chain Reaction to Detect Helicobacter Pylori in the Dental Plaque of Healthy and Symptomatic Individuals

The Sixth All-Union Congress of Tuberculosis was held in Moscow from June 9 to 16. It was attended by more than a thousand specialists from the U.S.S.R. and by about sixty foreign physicians from more than twenty countries, including four from the United Kingdom. Simultaneous translation was provided into English and French, and we were given English summaries of the main papers. We were able to supplement what we learnt about Soviet methods in the conference proper by visits to institutions and private discussions with our Russian colleagues.

Comparison of urease gene primer sequences for PCR-based amplification assays in identifying the gastric pathogen Helicobacter pylori

More than a decade after the adoption of the WHO Framework Convention on Tobacco Control, there is compelling evidence that raising tobacco prices substantially through taxation is the single most effective way to reduce tobacco use and save lives. Similarly, alcohol taxation is a cost-effective way to reduce alcohol consumption and harm. With growing evidence, sugar taxes are another fiscal tool to promote health and nutrition. Mexico’s sugar tax reduced sugarsweetened beverage sales by 5% in the first year, with an almost 10% further reduction in the second year. Tobacco taxes in South Africa contributed to tobacco consumption decreases of about 40% between 1993 and 2003. When Finland reduced taxes on alcohol in 2003, alcohol-related mortality increased by 16% among men and by 31% among women. As part of a broader public health approach to promote a life-course approach to prevention and to address commercial determinants of health, it is now time for governments to adopt sugar, tobacco, and alcohol taxes (STAX). Despite their potential, taxes on sugar, tobacco, and alcohol are underused by policy makers. The 2017 WHO Report on the Global Tobacco Epidemic showed that only 10% of the world’s population is covered by sufficiently high levels of tobacco taxation. According to this report, the tobacco industry undermines taxation efforts by lobbying policy makers and exaggerating their industry’s economic value and the risk of illicit trade. The alcohol and food industries are now deploying similar tactics—one example is successful efforts to erase language on alcohol and sugar taxes in the Montevideo Roadmap on non-communicable diseases (NCDs). Despite industry efforts, taxation is gaining more attention from policy makers as a win–win–win policy measure for public health, domestic resource mobilisation, and equity. Taxes on sugar, tobacco, and alcohol have been, or are now being, introduced in diverse contexts, including Botswana, Chile, Ecuador, India, Mexico, Nigeria, Peru, Saudi Arabia, South Africa, the United Arab Emirates, and the UK. Tobacco and alcohol taxes are recognised by WHO as “Best Buys” to prevent and control NCDs; taxes more broadly are a focus of the Bloomberg Task Force on Fiscal Policy for Health in advance of this year’s UN High-Level Meeting (HLM) on NCDs. NCDs are estimated to account for 72% of all deaths globally and this proportion is growing. Worldwide, tobacco is estimated to kill more than 7 million people and alcohol more than 3 million people each year. The global number of young people aged 5–19 years who are overweight and/or obese has increased from 11 million in 1975 to 124 million in 2016. Sugar consumption is a major contributor. High body-mass index is estimated to claim at least 4 million lives each year. The consumption of tobacco, alcohol, and sugar are risk factors for health and NCDs that disproportionately affect people with low socioeconomic status and low-income countries, which are the least prepared. STAX could help mitigate these risk factors. Yet existing efforts are inconsistently applied. Scaled-up country support is needed to accelerate and implement STAX as a cost-effective fiscal policy to contribute to the Sustainable Development Goals (SDGs). STAX not only contribute to improving health and saving lives, but they can also raise resources. For example, Thailand’s Health Promotion Act of 2001 established a tax on tobacco and alcohol, which now contributes about US

Chronic diseases in developing countries

120 million annually for domestic health promotion efforts. In 2012, the Philippines raised taxes on tobacco and alcohol and are using the revenues to supplement efforts towards universal health coverage (UHC). After 3 years of implementation