Public Health Progress, In a Perilous Time
Travel to India, Bangladesh, Ethiopia, and Nigeria highlights the challenges — and great promise — of community-led public health
Covid mortality is ebbing, the toll of the climate crisis is growing, war in Ukraine is grinding on, and the global economy is sputtering. In many countries, security is increasingly compromised, media is becoming less free, and intolerance and social stress are increasing.
Global health must navigate in this rocky context, but progress is possible — even during a pandemic. I saw this firsthand during recent travel to India, Bangladesh, Ethiopia and Nigeria to meet stakeholders, partners, and staff of Resolve to Save Lives, the organization I lead.
Heart health and epidemic preparedness are two of the most important yet most neglected public health interventions. Controlling hypertension, eliminating trans fat from the food supply, and reducing sodium in our diets can save 100 million lives from heart attack and stroke. Quickly finding and stopping infectious disease outbreaks before they become epidemics can make all of us much safer.
We’re all connected, and progress anywhere improving health and saving lives is progress we can all celebrate.
The power of community
I first traveled to India to work on tuberculosis control in 1995, and I had the honor and pleasure of living and working in India, on secondment from the U.S. CDC to the World Health Organization, from 1996–2002. I’ve traveled back for work just about every year — until the pandemic — so it was great to be back.
India has been a global leader in passing regulations to ban trans fat; trans fat is a dangerous chemical added to food. The country’s India Hypertension Control Initiative is the world’s largest public health approach to treatment of hypertension. Patients with diabetes are also treated in the program, and the population covered will soon reach 300 million. More patients are being treated, and being treated more effectively, than ever.
“She’s better than the doctors in town! Because of her, we’re able to get the medicine we need!” one patient told me, his eyes beaming with pride.
Perhaps the most promising health development in my 27 years working with colleagues and communities in India is the country’s expansion of Health and Wellness Centres. These community-based health facilities, staffed by nurses and other health professionals with advanced training, are able to care for the most common needs of patients.
In Varanasi, a district in the enormous state of Uttar Pradesh (state population: 230 million, larger than all but three countries in the world) our team visited a Health and Wellness Centre where we met a nurse who has helped nearly all of her 78 patients with hypertension get their blood pressure under control. It was remarkable how much the patients I met respected and appreciated her. “She’s better than the doctors in town! Because of her, we’re able to get the medicine we need!” one patient — the man to the right of my in the photograph below — told me, his eyes beaming with pride.
The Health and Wellness Centres in India have been crucially important for progress in hypertension control. A recent scientific publication by the Indian leaders who have spearheaded the program shows that patients treated in these local centers are far more likely to be effectively treated and have their blood pressure controlled than patients treated in outpatient clinics of hospitals. If this model is extended nationally, this could represent about an additional 10 million patients whose hypertension is controlled every year!
In Nigeria, I was deeply moved by the impact of community-based treatment, with assistance from PEPFAR, on progress treating patients living with HIV. With community health workers going door to door in the pandemic, the country was able to increase the number of people treated for HIV infection by more than 1 million! More than 95% of all people estimated to be living with HIV are now on treatment, and 96% of those have their viral load suppressed. This is enormous progress in less than three years, and during the Covid pandemic. This is so impressive, with many lessons for better management of hypertension and other conditions.
A little can go a long way, but more support is needed
In Bangladesh, Ethiopia, and Nigeria, far too little funding and attention goes toward saving lives from heart disease and stroke. Unfortunately, these and many other countries don’t have the budget to pay for even basic medications. Medicines to treat hypertension need not cost more than $5–10 per patient per year, and yet this is more than many country health budgets can cover.
Imagine how many more lives could be saved if countries were able to fully fund their efforts to prevent heart disease and invest in public health systems.
With terrific support from our local partner, the National Heart Foundation (NHF) of Bangladesh, Bangladesh was able to start their 100,000th patient on hypertension treatment. By coincidence, this happened while I was in the country — something it was possible to know because they have adopted the Simple app, which Resolve to Save Lives created, so they have accurate, real-time information on treatment. I was honored and delighted to meet the NHF’s 93-year-old visionary founder, Professor Abdul Malik. Dr. Malik spoke at a conference on heart disease and addressed the problem that some efforts focus on education without providing life-saving treatment. He commented, “Dead people don’t listen”! Clear thinking: Education is important, but doesn’t replace treatment.
Bangladesh has made an encouraging start, including purchasing high-quality blood pressure monitors for their hospitals and health clinics. They could do so much more with additional funding and support from the global community.
In Ethiopia, insecurity and economic hardship are slowing the country’s health progress. Although more staff and training are necessary, clinics are defying the odds and helping hypertension patients get the care they need.
In Nigeria, not only are costs for medications higher than necessary, but treatment is inconvenient to patients, resulting in high rates of treatment discontinuation.
Local health centers such as Health and Wellness Centres in India, Community Clinics in Bangladesh, health posts staffed by Community Health Extension Workers in Ethiopia, and community-based treatment of HIV in Nigeria show the best and most affordable way forward: Expand treatment by allied health care workers in patients’ own communities.
Imagine how many more lives could be saved if countries such as Bangladesh and Ethiopia were able to fully fund their efforts to prevent heart disease and invest in public health systems.
Preparedness is key
It costs far less — in dollars and lives — to rapidly detect and effectively stop a disease threat BEFORE it spreads widely than to respond after it becomes an epidemic. The Covid pandemic, which has cost the world millions of lives and trillions of dollars, is a searing example.
New disease threats emerge frequently, and we have to be ready to deal with them. Our team at Resolve to Save Lives has proposed a global goal of 7–1–7: Every new health threat detected within 7 days, reported to public health authorities within 1 day, and response fully in place within 7 days.
In the five years since Resolve to Save Lives launched, we have seen enormous progress at the Africa Centres for Disease Control and Prevention, the Ethiopian Public Health Institute, and the Nigeria Centre for Disease Control. All three entities are much stronger than they were years ago, all have performed well throughout the Covid pandemic, and we are honored to partner with them on many projects and to provide staff to work shoulder-to-shoulder with staff of the organizations.
The next level of improvement will be at the sub-national level, particularly in large countries such as Nigeria and Ethiopia. Like states in the U.S., there’s a great deal of variability in the resources and capacity of different states/provinces in many countries. Strengthening the national level is essential, but so is strengthening sub-national and local levels.
Primary care is where it’s at
Details matter. Policies may make headlines, but small, focused investments can make a huge difference. One example is accurate blood pressure monitors. Mercury-based monitors work well for skilled health care workers in quiet offices with plenty of time. But we’re phasing out mercury — for good reason. Digital monitors are the way to go — as this 1-minute video we produced shows. But even the best monitor won’t be accurate unless it’s used correctly. Daniel Burka, our Director of Design and driving force behind the Simple app, made this clear poster with a checklist to measure BP correctly. That poster is now in use in tens of thousands of health facilities in countries all over the world.
The stronger our primary health care systems are, the more people will be treated effectively for high blood pressure.
Not all digital monitors work well. Some are not validated, some are made for home use rather than the more frequent use in health care facilities, and some break often. This is an area Resolve to Save Lives has worked on for years, and we’ve learned a few lessons. For the busiest health facilities, an “arm-in” monitor, widely used in Thailand and elsewhere, can be a good choice. For rural health posts without regular electrical supply, a semi-automated monitor, which requires the health care worker to pump the bulb to inflate the cuff so that the rechargeable battery can last at least a few days between charges, is most practical.
Four years ago, we began providing a starter set of monitors to partners in Bangladesh and elsewhere. As I watched patients having their blood pressure taken with this arm-in monitor and receiving a printout of the result, I calculated that this one monitor has measured the blood pressure of 1 million patients at this busy hospital. The Government of Bangladesh, impressed by the performance of the monitor, used its own budgetary resources to order 219 more of them — one for every busy hospital, covering more than a quarter of the country — the next phase of expansion for the Bangladesh Hypertension Control Initiative. In the coming years, these monitors, along with the poster checklist, will provide hundreds of millions of accurate blood pressure readings. This will save lives, not only from hypertension, but also from eclampsia, a potentially deadly complication of pregnancy.
Partnering with countries, learning from and with them, and catalyzing sustainable progress — that’s what we do when we’re at our best at Resolve to Save Lives.
Heart health and epidemic preparedness meet at primary health care. The stronger our primary health care systems are, the more people will be treated effectively for high blood pressure. The stronger our primary health care systems are, the sooner outbreaks will be detected and can be stopped. The stronger our primary health care systems are, the better we will deliver life-saving vaccines every day and in emergencies.
Despite the many problems of the world, despite new viruses, despite economic and financial woes, there is rational reason for optimism. All over the world, patients are being cared for, life-threatening conditions detected and treated, and bonds of trust being strengthened. One patient at a time. One health center at a time. One community at a time. One country at a time. One world at a time. Please join us in our Resolve to Save Lives.
