Yasuhide Nakamura

Human security approach for global health

The concept of security has shifted over the past 15 years, and has moved beyond a focus solely on the security of nations to include a focus on the security of individuals and communities. However, it was not until the 1990s that the concept of human security began to take clearer shape after it was reappraised within the UN. In particular, the UN Development Programme’s (UNDP) Human Development Report, 1994 fi rst made the connection between human security and the dual freedoms from fear and want, which were originally outlined in the US Secretary of State’s report on the 1945 San Francisco Conference. The UNDP report is also said to be the fi rst document to provide a comprehensive defi nition of human security, covering economic, food, health, environmental, personal, community, and political security. In practice, the need for an expanded conceptualisation of security was triggered by a series of tragedies around the world. The genocides in Rwanda (1994) and Bosnia and Herzegovina (1995) starkly illustrated to the world that the traditional concept of security as the protection of national borders was not suffi cient to save lives in the face of civil confl ict. In both cases, national security failed to protect individuals and communities within their own national boundaries, which thus provided justifi cation for expanding the object of security. To urge the international community in the new millennium to take action on the needs of individuals and communities around the world—in other words, to ensure human security for all—a second infl uential report was published in 2003 by the Commission on Human Security, co-chaired by Sadako Ogata and Amartya Sen. The refi ned defi nition of human security in this report advocated “protecting individuals’ and communities’ freedom from fear, freedom from want, and freedom to live in dignity.” The report also highlighted ten immediate areas requiring concerted action by the international community, with access to basic health services identifi ed as one priority. In parallel with the UN’s growing interest in human security, Japan has been one of the strongest proponents of the concept. As the generation of Japanese whose pacifi sm is based on the devastation they experienced fi rst-hand during World War II is nearly gone, Japan needs to develop a new motivation for pacifi sm. At the same time, Japan is trying to secure its position in an ever-changing world and fi nding that human security off ers a framework for a future-oriented pragmatic pacifi sm. The evolution of human security into a pillar of Japanese foreign policy thus refl ects the country’s quest to solidify its position as a global civilian power. This focus is prompting Japan to expand the pool of actors who are involved in policy making, as is happening around the world. First we saw the common framework transition from bilateral to multilateral diplomacy, and now the framework is being further expanded to include non-governmental organisations and other civil-society networks. This framework allows us to view the community not only as the endpoint of top-down policy making, but also as the starting point for a bottom-up approach to decision making. 1 London AJ, Kimmelman J. Justice in translation: from bench to bedside in the developing world. Lancet 2008; 371: 82–85. 2 Council for International Organizations of Medical Sciences. 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June 15–17, 2006. http://www.cohred.org/main/ Assests/PDF/communique-accra.pdf (accessed May 21, 2008). 7 Deen JL, Clemens JD. Issues in the design and implementation of vaccine trials in less developed countries. Nat Rev Drug Discov 2006; 5: 932–40. 8 WHO/UNAIDS/IAVI International Expert Group. Executive summary and recommendations from the WHO/UNAIDS/IAVI expert group consultation on ‘Phase IIB-TOC trials as a novel strategy for evaluation of preventive HIV vaccines’. AIDS 2007; 21: 539–46. 9 Participants in the 2001 Conference on Ethical Aspects of Research in Developing Countries. Moral standards for research in developing countries: from “reasonable availability” to “fair benefi ts.” Hastings Cent Rep 2004; 34: 17–27. 10 COHRED. Priority setting in health research: a management process for countries. http://www.cohred.org/main/prioritysetting.php (accessed May 21, 2008). 11 Jamison DT, Breman JG, Measham AR, et al. Priorities in health. Washington, DC: World Bank, 2006.

Influence of Women's Knowledge on Maternal Health Care Utilization in Southern Laos:

This study aims to clarify womens knowledge on obstetric care and to analyse the situation of maternal health care (MHC) utilization in southern Laos. Face to face structured questionnaire and focus group discussions were carried out for 205 mothers aged 29.6 ± 6.7 who had children under the age of five. Three measurements of MHC utilization comprised: 1) antenatal care (ANC), 2) tetanus toxoid (TT) inoculation, and 3) attendance delivery by health professional. Womens knowledge on obstetric care was scored. Womens knowledge was positively correlated with ANC and TT inoculation. It was found that the women with strong superstitious belief were less likely to utilize all three types of MHC than the others. Accessibility to health care facilities strongly affected ANC and attendance delivery. Enhancing womens knowledge on obstetric care and reducing barriers related with sociocultural beliefs are essential to improving maternal health in southern Laos. Asia Pac J Public Health 2001;13(1):13-19

Relationship between Transmission Intensity and Incidence of Dengue Hemorrhagic Fever in Thailand

Background Dengue is the most prevalent mosquito-borne virus, and potentially fatal dengue hemorrhagic fever (DHF) occurs mainly in secondary infections. It recently was hypothesized that, due to the presence of cross-immunity, the relationship between the incidence of DHF and transmission intensity may be negative at areas of intense transmission. We tested this hypothesis empirically, using vector abundance as a surrogate of transmission intensity. Methodology/Principal Findings House Index (HI), which is defined as the percentage of households infested with vector larvae/pupae, was obtained from surveys conducted on one million houses in Thailand, between 2002 and 2004. First, the utility of HI as a surrogate of transmission intensity was confirmed because HI was correlated negatively with mean age of DHF in the population. Next, the relationship between DHF incidence and HI was investigated. DHF incidence increased only up to an HI of about 30, but declined thereafter. Reduction of HI from the currently maximal level to 30 would increase the incidence by more than 40%. Simulations, which implemented a recently proposed model for cross-immunity, generated results that resembled actual epidemiological data. It was predicted that cross-immunity generates a wide variation in incidence, thereby obscuring the relationship between incidence and transmission intensity. The relationship would become obvious only if data collected over a long duration (e.g., >10 years) was averaged. Conclusion The negative relationship between DHF incidence and dengue transmission intensity implies that in regions of intense transmission, insufficient reduction of vector abundance may increase long-term DHF incidence. Further studies of a duration much longer than the present study, are warranted.

Child abuse and neglect in Japan

In this paper, the recent trends of child abuse and neglect in Japan is summarized to make a preliminary statement in the International Symposium of Child Abuse – For Survival, Development and Protection of All the Children in the New Century, sponsored by Japanese Society for Prevention of Child Abuse and Neglect (JaSPCAN) and International Society for Prevention of Child Abuse and Neglect. Three epoch-making events have occurred recently. Firstly, the Child Abuse Prevention Law was enacted in November 2000. Secondly, the number of reported cases of child abuse and neglect has increased dramatically from 1999. Consequently, community awareness to child abuse and neglect has been strengthened.

The Maternal and Child Health (MCH) Handbook in Mongolia: A Cluster-Randomized, Controlled Trial

Objective To assess the effectiveness of the Maternal and Child Health (MCH) handbook in Mongolia to increase antenatal clinic attendance, and to enhance health-seeking behaviors and other health outcomes. Methods A cluster randomized trial was conducted using the translated MCH handbook in Bulgan, Mongolia to assess its effectiveness in promoting antenatal care attendance. Pregnant women were recruited from 18 randomly allocated districts using shuffled, sealed envelopes. The handbook was implemented immediately for women at their first antenatal visit in the intervention group, and nine months later in the control group. The primary outcome was the number of antenatal care visits of all women residing in the selected districts. Cluster effects were adjusted for using generalized estimation equation. Masking was not possible among care providers, pregnant women and assessors. Findings Nine districts were allocated to the intervention group and the remainder to the control group. The intervention group (253 women) attended antenatal clinics on average 6•9 times, while the control group (248 women) attended 6•2 times. Socioeconomic status affected the frequency of clinic attendance: women of higher socioeconomic status visited antenatal clinics more often. Pregnancy complications were more likely to be detected among women using the handbook. Conclusion The MCH handbook promotes continuous care and showed an increase in antenatal visits among the intervention group. The intervention will help to identify maternal morbidities during pregnancy and promote health-seeking behaviors. Trial Registration UMIN Clinical Trial Registry UMIN000001748

Effect of a maternal and child health handbook on maternal knowledge and behaviour: a community-based controlled trial in rural Cambodia

Maternal and child health (MCH) handbooks are comprehensive home-based booklets designed to integrate MCH records. Although empirical evidence suggests the handbooks are more effective than current card-type records, this has not been scientifically demonstrated. The objectives of this study were to evaluate the impact of the MCH handbook on maternal knowledge and behaviour as measured by antenatal care (ANC) attendance, delivery with skilled birth attendants (SBAs) and delivery at a health facility. The Cambodian version of the MCH handbook was developed and introduced in two health centres, and two other health centres served as controls. Pre-intervention and post-intervention surveys were conducted with 320 women from the intervention areas and 320 women from the control areas who had given birth within 1 year before the survey. We evaluated the impact of the handbook by using difference-in-differences (DID) analysis and calculated adjusted odds ratios for pre–post changes in key indicators by using logistic regression. In addition, we interviewed multiparous women, health staff and health volunteers to assess the acceptance and cultural appropriateness of the handbook. Content analysis was performed with the English-translated transcriptions. The DID analyses revealed that all key indicators increased in the intervention group against counterfactual assumptions. The intervention also increased maternal knowledge of all topics addressed except for the risk of severe bleeding after delivery; this may be attributable to the influence of cultural belief. Logistic regression showed that the intervention increased ANC attendance, delivery with SBAs and delivery at a health facility, even after adjusting for maternal age, education and economic conditions. The qualitative data indicated that the handbook was well received and culturally appropriate. Thus, the MCH handbook is a reasonable and superior alternative to current card-type maternal records.

Relation between increased numbers of safe playing areas and decreased vehicle related child mortality rates in Japan from 1970 to 1985: a trend analysis

Objectives: To examine vehicle related mortality trends of children in Japan; and to investigate how environmental modifications such as the installation of public parks and pavements are associated with these trends. Design: Poisson regression was used for trend analysis, and multiple regression modelling was used to investigate the associations between trends in environmental modifications and trends in motor vehicle related child mortality rates. Setting: Mortality data of Japan from 1970 to 1994, defined as E-code 810–23 from 1970 to 1978 and E810–25 from 1979 to 1994, were obtained from vital statistics. Multiple regression modelling was confined to the 1970–1985 data. Data concerning public parks and other facilities were obtained from the Ministry of Land, Infrastructure, and Transport. Subjects: Children aged 0–14 years old were examined in this study and divided into two groups: 0–4 and 5–14 years. Main results: An increased number of public parks was associated with decreased vehicle related mortality rates among children aged 0–4 years, but not among children aged 5–14. In contrast, there was no association between trends in pavements and mortality rates. Conclusions: An increased number of public parks might reduce vehicle related preschooler deaths, in particular those involving pedestrians. Safe play areas in residential areas might reduce the risk of vehicle related child death by lessening the journey both to and from such areas as well as reducing the number of children playing on the street. However, such measures might not be effective in reducing the vehicle related mortalities of school age children who have an expanded range of activities and walk longer distances.

Re-invigorating Japan's commitment to global health: challenges and opportunities

Over the past 50 years, Japan has successfully developed and maintained an increasingly equitable system of universal health coverage in addition to achieving the worlds highest life expectancy and one of the lowest infant mortality rates. Against this backdrop, Japan is potentially in a position to become a leading advocate for and supporter of global health. Nevertheless, Japans engagement with global health has not been outstanding relative to its substantial potential, in part because of government fragmentation, a weak civil society, and lack of transparency and assessment. Japans development assistance for health, from both governmental and non-governmental sectors, has remained low and Japanese global health leadership has been weak. New challenges arising from changes in governance and global and domestic health needs, including the recent Great East Japan Earthquake, now provide Japan with an opportunity to review past approaches to health policy and develop a new strategy for addressing global and national health. The fragmented functioning of the government with regards to global health policy needs to be reconfigured and should be accompanied by further financial commitment to global health priorities, innovative non-governmental sector initiatives, increased research capacity, and investments in good leadership development as witnessed at the G8 Hokkaido Toyako Summit. Should this strategy development and commitment be achieved, Japan has the potential to make substantial contributions to the health of the world as many countries move toward universal coverage and as Japan itself faces the challenge of maintaining its own health system.

Infection surveillance after a natural disaster: lessons learnt from the Great East Japan Earthquake of 2011

PROBLEM On 11 March 2011, the Great East Japan Earthquake produced a catastrophic tsunami that devastated the city of Rikuzen-Takata and left it without an effective health infrastructure and at increased risk of outbreaks of disease. APPROACH On 2 May 2011, a disease-surveillance team was formed of volunteers who were clinicians or members of Rikuzen-Takatas municipal government. The teams main goal was to detect the early signs of disease outbreaks. LOCAL SETTING Seven weeks after the tsunami, 16 support teams were providing primary health care in Rikuzen-Takata but the chain of command between them was poor and 70% of the citys surviving citizens remained in evacuation centres. The communication tools that were available were generally inadequate. RELEVANT CHANGES The surveillance team collected data from the citys clinics by using a simple reporting form that could be completed without adding greatly to the workloads of clinicians. The summary findings were reported daily to clinics. The team also collaborated with public health nurses in rebuilding communication networks. Public health nurses alerted evacuation centres to epidemics of communicable disease. LESSONS LEARNT Modern health-care systems are highly vulnerable to the loss of advanced technological tools. The initiation--or re-establishment--of disease surveillance following a natural disaster can therefore prove challenging even in a developed country. Surveillance should be promptly initiated after a disaster by (i) developing a surveillance system that is tailored to the local setting, (ii) establishing a support team network, and (iii) integrating the resources that remain--or soon become--locally available.

Can Japan Contribute to the Post Millennium Development Goals? Making Human Security Mainstream through the TICAD Process

In 2013, the fifth Tokyo International Conference on African Development (TICAD V) will be hosted by the Japanese government. TICAD, which has been held every five years, has played a catalytic role in African policy dialogue and a leading role in promoting the human security approach (HSA). We review the development of the HSA in the TICAD dialogue on health agendas and recommend TICAD’s role in the integration of the HSA beyond the 2015 agenda. While health was not the main agenda in TICAD I and II, the importance of primary health care, and the development of regional health systems was noted in TICAD III. In 2008, when Japan hosted both the G8 summit and TICAD IV, the Takemi Working Group developed strong momentum for health in Africa. Their policy dialogues on global health in Sub-Saharan Africa incubated several recommendations highlighting HSA and health system strengthening (HSS). HSA is relevant to HSS because it focuses on individuals and communities. It has two mutually reinforcing strategies, a top-down approach by central or local governments (protection) and a bottom-up approach by individuals and communities (empowerment). The “Yokohama Action Plan,” which promotes HSA was welcomed by the TICAD IV member countries. Universal health coverage (UHC) is a major candidate for the post-2015 agenda recommended by the World Health Organization. We expect UHC to provide a more balanced approach between specific disease focus and system-based solutions. Japan’s global health policy is coherent with HSA because human security can be the basis of UHC-compatible HSS.