Natural disasters and infectious disease outbreaks can disproportionately affect communities in developing countries with vulnerable public health infrastructure and health systems. The Public Health Insight Team discusses the investment and innovation that may be required to successfully repurpose and scale-up efficient elements of existing public health systems in low-resource settings.
Share your thoughts with us at ThePublicHealthInsight@gmail.com.
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Natural disasters and infectious disease outbreaks can disproportionately affect communities in developing countries with vulnerable public health infrastructure and health systems. The Public Health Insight Team discusses the investment and innovation that may be required to successfully repurpose and scale-up efficient elements of existing public health systems in low-resource settings.
Share your thoughts with us at ThePublicHealthInsight@gmail.com.
Icon made by Freepik from www.flaticon.com
[00:00:00] Sully: Public health is a population-based field of science focused on preventing disease and promoting health. Every week, we will be engaging in interactive discussions and analyses of the latest public health issues affecting you, and your communities all around the world. This is the Public Health Insight podcast.
[00:00:24] My name is Sully, and I'm here with the usual public health panel, Ben, Leshawn, Gordon, and Will.
[00:00:31] Ben: Before we move on it's important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or are affiliated with.
[00:00:39] Sully: A fundamental goal of public health is to spend resources on preventative interventions that are naturally cost-effective in the long run to ensure its sustainability. In this episode, we will be discussing an opinion piece from The Hill titled: "Want to stop pandemics? Strengthen public health systems in poor countries". The [00:01:00] article discusses how developing countries are suffering the consequences of poor public health infrastructure and healthcare in general. India is the greatest example, as it is one of the lowest in terms of spending on healthcare per GDP, compared to other countries.
[00:01:16] Other developing countries simply do not have the GDP to support building strong public health systems. In light of the COVID-19 pandemic, India and the majority of developing countries are grossly ill-prepared to face such an issue, which may result in many deaths that could have been preventable in the first place.
[00:01:37] So isn't an opportune time for everyone to invest in effective public health systems that can truly prevent unnecessary deaths?
[00:01:46] Gordon: So, I'm not sure if it's an opportune time. I think there's a lot of challenges posed by COVID-19, you know, economies are suffering and global GDP is dipping as well. I believe in one of our previous [00:02:00] episodes, we mentioned it would be something like a 2 to 5% decline in global GDP.
[00:02:05] And we talked about how, many populations will descend below the poverty line. So given that less people are working and able to support economies, um, investment requires money. And I'm not sure that it will be available after COVID-19.
[00:02:20] Ben: Yeah, it's not an opportune time right now because of what Gordon explained, but.
[00:02:25] We were probably going to see the effects of investment within public health systems, probably 20 years from now. My question is, is that going to be enough time before the next pandemic hits?
[00:02:34] Sully: But then the other side of the coin is, what if these countries actually invested in strengthening their public health systems before the current pandemic hit and like, I'm sure that investment would have been like nothing compared to the losses they've been suffering currently, in terms of their economy.
[00:02:53] Ben: Oh, absolutely. Absolutely. And I think the issue with that is that we never been hit by something like COVID-19 before. Where [00:03:00] such emphasis has been put on strengthening public health systems. Cause before you had the occasional outbreak, usually isolated, but due to the nature of this virus and how transmissible it is through either community transmission or beyond borders, it's the first time where everyone's healthcare system is being universally challenged to the point where the leaks between different countries in terms of the strength of their healthcare systems is being put into the spotlight.
[00:03:24] Gordon: Before we continue, we should probably define what public health is and what healthcare is.
[00:03:29] So if we use COVID-19 as an example, the health care system deals with people who are already sick and need to be for example, hospitalized and put on, you know, admitted and put on ventilators. Public health measures include social distancing, uh, staying at home orders, and hand hygiene. So when we think of the two interrelated, but distinct systems, public health investments would require addressing the social determinants of health.
[00:03:55] So overcrowding is one of the big factors that goes [00:04:00] into the transmissibility of infectious diseases like tuberculosis and like COVID-19. So, when we're talking about public health investments, we're also talking about investments in the determinants of health, which will require small and large countries to improve things like housing quality and the abundance of housing.
[00:04:19] So I think, the public health investment is not minuscule because there's a lot of upfront investment that is required only to reap the benefits years down the line. So these nuances make it difficult for policy makers and decision makers to make this investment because unlike healthcare where someone was, life was spirit because they took Remdesivir, it's harder to say because we built a house for 'X', he did not get COVID-19 and die 20 years later.
[00:04:51] Will: One of my issues I have with this article, is just how much they emphasize the need to focus on developing countries. And, you know, like how can we [00:05:00] help them? Seems very much like a savior mentality. And if we use COVID 19 as an example, what countries have, one, reported the highest number of confirmed cases? And two, have recorded the highest number of confirmed deaths?
[00:05:13] Ben: Yeah.
[00:05:13] Will: Seven or eight out of the top 10 are what we would typically consider developed, over developed economies, right? So we look at this from that one observation, I find this article very problematic because it's kind of continues to perpetuate that idea, which we discussed in one of our early episodes.
[00:05:30] Of how, you know, the Western or European ideas of health, and healthcare, and health systems, it's the dominant discourse and information or voices from any other areas around the world is seen as inferior and needs help to be strengthened.
[00:05:44] Ben: Absolutely, Will, I mean, if you look at the WHO's guidelines of how to combat COVID-19 in terms of social distancing, a lot of the recommendations were given as a blanket for countries to kind of just generally enforce.
[00:05:56] So if you take it to a case, India. India was not [00:06:00] able to do some of these recommendations because of their infrastructure population. You have a huge part of the population that is homeless or living in slums. There is no means to social distance there. A lot of people are traveling on transportation like buses, there's people literally overflowing, how are they supposed to do social distancing or have the protection equipment necessary to stop COVID?
[00:06:21] Like these recommendations that are given from primarily, primarily Western perspective, do not take into account the nuances within countries. And I understand it's a very hard thing to do. However, I feel as though there should be more engagement within countries in the discussion of how can we best prepare?
[00:06:36] Leshawn: Right. It reminds me of that refugee episode that we did. And we talked about the nuances that go on within refugee camp and how they're not able to follow some of these guidelines.
[00:06:47] Sully: Yeah, definitely. So, given what we've been talking about, why do we need to invest in public health systems? And I'm not talking only about developing countries, that's for everyone.
[00:06:57] Gordon: Yeah. So as I've discussed [00:07:00] before, even though both systems are interrelated, so the healthcare system and public health system, there needs to be a clear distinction in funding going to each one of those, because when you dissolve public health systems to beef up healthcare systems, public health inevitably suffers.
[00:07:17] So we talk about funding. Part of the funding conversation needs to happen around what things are being funded, because I think the general public sees public health as part of healthcare, you know, public health, primary care, and healthcare work together a lot to prevent disease and improve treatment outcomes for people, but there's clear distinctions in terms of what they do.
[00:07:41] So public health systems in the case of COVID-19 would be responsible for testing and contact tracing. And are also in terms of the non-pharmaceutical interventions, such as staying home and physical distancing. So that is public health systems and that requires contact tracing. For example, [00:08:00] requires a lot of human resources because as we've learned, one person can then infect two or three other people.
[00:08:06] So if there's several generations of this, there's going to be 20, 30, 40 people who can be connected to back to one person. So you can imagine how much human resources you will need to address this issue, uh, in terms of the healthcare system, you need doctors, nurses, and medical equipment. So as we can see now, a lot of resources are being put into building more hospitals, you know, recruiting more retired nurses and doctors to help with the fight.
[00:08:33] But another fight is also happening at testing. Interesting thing about the flatten the curve and the, you know, all these interventions, in a lot of higher income countries, COVID-19 hasn't spiked to the point where I know if we take Italy and Spain out as examples, it hasn't spiked to the point where it's consistently overwhelmed the healthcare system for a prolonged period of time.
[00:08:56] But then if you notice, if you tune your ear, most [00:09:00] conversations that are happening are around the lack of availability of testing. And I'm sure health units all around Ontario, for example, test results are taking a week or even two weeks to come in, and this is a part of the public health system. So as we can see already the public health system and the lack of resources, uh, is making life more difficult for the healthcare system.
[00:09:21] Will: And I just want to add that the reason we invest in the public health system is so that the health care system isn't as burden, right? Because if we only focus on investment and providing resources for healthcare, and we don't actually focus on the prevention side, because our main job is in public health is to prevent and improve the overall health.
[00:09:40] If we only focus on the treatment side of things, and there isn't any upstream interventions being done, you're only going to be getting more and more people who need healthcare and then what's going to happen from that, we're going to need to invest more and more into the healthcare system. And it's an unwinnable war because the more you invest in healthcare, and if you don't [00:10:00] focus in public health, that that, that doesn't solve the problem at its root.
[00:10:03] And that's the importance of public health is to go back to that root cause and target it from there, so that everything that follows it, is comes out clean.
[00:10:12] Ben: Yeah. Well, and I think it's hard to buy into psychologically, in the sense of investment it's a public health. Cause as Gordon said, you're only going to get to see the effects years down the lane.
[00:10:22] Right. And I think what was the line that we learned is that, you know, public health is doing its job when nothing is wrong. So it often works in the background and it's very hard for people to buy into that. So my question is, yes, we have to invest in public health and increase that. But in the sake of talking about global communities, why are we pretending that we have to start from square one?
[00:10:44] Why can't we already use existing infrastructure? And other, uh, funding venues through NGOs to kind of help with the COVID 19 pandemic. For an example, the U.S. George W. Bush, they created the President's Emergency Plan for Aids Relief, PEPFAR, [00:11:00] since its conception, it's invested $90 billion and it's helped contain global HIV epidemics in Africa, and it's saved about 17 million lives. Many of the countries that are under the umbrella of PEPFAR, are also countries that are vulnerable to COVID-19. So you already have this channel, but people aren't seeing the repurposing of existing assets in order to use it for COVID-19. A lot of the conversations, be like, how can we start this?
[00:11:24] Well, we already have for other stuff, let's just repurpose and use it for something else.
[00:11:30] Will: Right. I think that's a very good point that you talked about repurposing existing systems. And let's just go with follow what the article was saying and focusing on these developing countries, typically a lot of the public health education and things like that is done through community health workers or at the community level.
[00:11:49] And even WHO emphasizes this as one of its pillars for targeting COVID 19 is community action, as well as government action. And so I think that in [00:12:00] order for public health systems to thrive in developing countries, we can't be focusing on them and developing them and strengthening them, um, the same way that we strengthened the public health system say in Canada, right?
[00:12:13] Where it's a lot of different levels of government passing down policies, passing down, um, education material, and things like that. Rather, we have to look at the systems that they have in place, like Ben said, and strengthen those systems because those are the ones that actually have been shown to work.
[00:12:30] Sully: We talked about why public health is important and like how investing in public health compares to investing into healthcare. But, that leads me to the question of how should we strengthen the public health systems? How should it be carried out? Especially given that developing countries have low resources in the first place?
[00:12:48] Gordon: Uh, one of the important things is to, in my opinion, is to include health in all policies. So social determinants is one of the biggest predictors for when, for populations getting a disease. [00:13:00] So some of the social determinants are housing, income, uh, food and nutrition, and lifestyle. Those have to be invested in on a fundamental level to prevent negative outcomes and disease. So I think reframing our narrative of what health and public health is to the very basic level of making sure everyone has their human rights fulfilled. So access to clean drinking water and housing are some essential things that can help prevent the spread, and whether someone else is diagnosed with a disease.
[00:13:32] Will: Another strategy would be partnering with the private sector. In many cases, funding is always an issue. And if you're the government, it's difficult to choose public health as a priority, because there are so many other things to focus on and it's hard to, to justify to the population that you're spending X amount of money bolstering public health.
[00:13:55] So in that case, I see it as a lot of working with the [00:14:00] private sector and other funding sources to find opportunities to strengthen the system in that way, rather than having to tap into your government treasury and sources like that.
[00:14:10] Gordon: And in terms of tangible ways to strengthen it, what's important to me is for example, in Canada, um, we have a universal healthcare system.
[00:14:20] So people in all the provinces and territories can seek medical care when they need it. Uh, however, absent from our healthcare system is PharmaCare. So this is where public health would be helpful in bridging the gap between healthcare and human health. Because if you're able to go and see a family doctor, or to a walk-in clinic to see a primary care physician, and then you're prescribed medication for diabetes, but you're not able to afford it, um, you're not going to take your diabetic medications.
[00:14:53] And we know from research that cost related medication, not adherence. So the percentage of people who don't [00:15:00] take medication, because they're not able to afford it is around 10%, 15%. So can have a strong health care system in place in the fact that, you know, doctors per a hundred thousand population and access to clinics.
[00:15:14] But then if you don't go that step further and ensure that people can afford the medications they need and afford to live in the environment that they need, so that they're not getting any more sick, then everything falls apart. So strengthening the health system requires that primary care, population health, public health, and healthcare system all work together to prevent disease.
[00:15:36] But as we know, there's certain diseases, you know, that are genetic that will occur anyway, despite public health measures. And this is where, um, the hospital and care settings will come into place, because no matter how effective public health measures are we'll still need a healthcare system to capture people who still get sick.
[00:15:54] Ben: I think a, another challenge with trying to strengthen the public health care system is that there's a lot of [00:16:00] context and in political situations, that one has to be aware of. So from, from one of my personal experiences, I worked for an NGO that tried to help incorporate concussion policy within a country in Africa.
[00:16:11] And we were originally recruited to help with sports related concussions, but they also wanted general concussion guidelines as well. So we did our research. We had obviously had a Western perspective, but we were in discourse with them, trying to understand what was happening within the country and how we can modify those guidelines to help out.
[00:16:31] And one of the interesting things that I found is that originally they wanted information and the primary source of concussions that we found was in soccer and boxing as a sport. And that's kind of what the narrative, the guidelines were going to be. But when we looked at a third party in the statistics of why these concussions were actually taking place, it was turned out to be, it was domestic violence, and that's a subject that a government doesn't want to really talk about.
[00:16:56] So it's difficult to kind of have these [00:17:00] strengthening of the public healthcare system, if both sides of the party don't agree to the same result based off the data.
[00:17:06] Gordon: Yeah. And something Sully and I always talk about is, uh, cost-effectiveness. So in order to strengthen public health systems, uh, some of the measures that you need, need to be, uh, affordable and you get the best bang for your buck, essentially.
[00:17:20] So if you are going to roll out, for example, testing to low and middle income countries, um, if the test costs a thousand dollars per test, that's not going to work very well. Right? So you need innovation in public health to make sure the price is manageable for these low and middle income countries. And NGOs can then help and support and subsidize any difference that may exist, but let's not kid ourselves cost is a very important factor in determining whether public health system can be successful or not.
[00:17:51] Ben: Yeah. On top of that, we also have to, there has to be agreement on the outcome. Like for example, if you're going to cost and you're talking about quality and you're framing the [00:18:00] discussion in terms of quality adjusted life years was basically, if I do this intervention, how many extra years of life am I going to get based out of it?
[00:18:07] And if they don't want to hear that, and they'd rather just say, let's just see how much money you were going to save. That's part of the discussions that we should have in terms of strengthening the system. It has to be very contextual.
[00:18:19] Gordon: So you're saying cost savings and savings in terms of premature years of life lost.
[00:18:24] Ben: Yes, exactly.
[00:18:25] Gordon: And Sully, willingness to pay, we were talking about how for certain drugs, you know, like the National Health Service in the UK has, has a threshold cutoff point where society essentially is comfortable paying $50,000 for every quality adjusted life year saved.
[00:18:43] Sully: Yeah. This whole conversation. It's about like, how the decision maker of what benefits does he or she see? And what does it mean to them? So you have like say all the different public health interventions that you want to invest in. Well, it doesn't matter, unless it's [00:19:00] actually meaningful to the decision maker. You know what I'm saying? So, okay.
[00:19:03] So in terms of qualities or cost savings, you have to know what benefits decision-maker values before you pitch an idea to them, or, you know, a program. So we talked about public health systems and how we should strengthen them and improve them and how it compares to healthcare systems and the necessity to actually differentiate between these two and gain the trust of the public.
[00:19:28] What, what are some takeaways from this?
[00:19:31] Gordon: Public health is a bit of an enigma because as Ben mentioned, Uh, public health works when nothing happens and it's hard to verify and justify something that is not easily justifiable, uh, and it is hard to make, as you mentioned, uh, make the case of decision-makers the importance of public health measures.
[00:19:51] So I think in general, public health needs to do a better job of educating the public on the importance of some of the common measures that are out [00:20:00] there such as, you know, sunscreen is a common public health measure. And the goal of it is to reduce the incidence of skin cancer from UV radiation. Uh, so things like that are very important to highlight the work of public health.
[00:20:13] Naturally public health likes to stay behind the scenes, but I think it's important to give visibility. You know, doctors and nurses are very visible in the important work that they do. And, uh, public health probably needs to put more of a face to it.
[00:20:26] Sully: So, as you've heard in this episode, we've explored why strengthening public health systems around the globe is important, and what obstacles are at play. Both developing and already developed countries should realize the benefits public health can offer so that we avoid the unnecessary loss of life. Thanks for listening.
[00:20:45] Remember public health is a field of inquiry and an arena for action to improve lives, one population at a time.
[00:20:52] This has been the Public Health Insight podcast. If you've enjoyed this episode, please drop us a like, and follow us on Spotify, Apple [00:21:00] podcast, Google podcast, or your podcast platform of choice. You can also send us your questions, comments, and suggestions for discussion topics at: thepublichealthinsight@gmail.com
[00:21:11] Thank you for listening and we'll see you in the next episode!