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A Challenge Called Public Health

Submitted by on September 26, 2012 – 6:01 PM

Life on earth is becoming harsher despite the development in civilization due to emergence of new type of diseases and infections. Global tourism, global trade of animal and animal products, change in feeding habits, increase in risk seeking behavior in people, invasion into new territory due to population expansion and increased interaction with pets are some of the reasons for emergence and re-emergence of diseases and infections. Increasing prevalence of Chlamydia infections and STDs in Europe reflects widespread changes in risk behavior among the general adult population. Finally, rapid transportation of crowds of people all over the globe has helped facilitate the spread of the new H1N1 influenza virus, leading to the first pandemic of the 21st century.

Increased incidence of air and water borne diseases, ecchinococcosis, tuberculosis, malaria, Japanese encephalitis, dengue, rabies, avian influenza, swine flu, salmonellosis, yersiniosis and leptospirosis are major threat to human beings as well as animals. Not only these, sex abuse, cholera, obesity, smoking, alcoholism and drug abuse are other challenges to public health. Developing and least developing countries are at more risk. Public health challenges are no longer just local, national or regional but global. They are no longer just within the domain of public health specialists and have crossed the limit of control. They are major hindrance to the human welfare. They are not only political and economical but also cross-sectoral. They are intimately linked to environment, civilization and development. Some of the causes of poor health conditions in under developed countries are Insecurity and conflict, lack of human resources (high vacancy rates in rural locations), lack of supplies and equipment at rural facilities, lack of sufficient infrastructure inputs, mismanagement of ‘poor funds’ and subsidies, mistrust and fear of government services, poor perceived quality of care and provider behavior, supply and demand centralized and inaccessibility.

 South Asia’s low life expectancy and high rates of malnutrition, infant mortality, and incidence of TB and HIV/AIDS are second only to those of sub-Saharan Africa. This region faces problems like poor sanitation, poor maternal health, poor access to healthcare services, widespread malaria and an emerging chronic disease epidemic. The rural areas of these regions do worse than urban areas in life expectancy, immunization rates, maternal health, malaria incidence, and access to almost all health services. The HIV/AIDS epidemic has contributed to a resurgence of tuberculosis (TB) morbidity and mortality. TB co infection is the region’s leading killer of HIV-positive people. From 2000 to 2007, all five countries saw progress in life expectancy, infant survival, and childhood immunization. Of the 27 million unimmunized children in the world, however, approximately 10 million live in India alone. Diarrhea, acute respiratory infections, and diseases preventable by vaccines make childhood mortality a continuing public health challenge, particularly in Pakistan, where 90 of every 1,000 children will die by age five. Lack of basic health systems throughout the region has had disturbing ramifications for maternal health as well. In South Asia, shortfalls in health services, complicated by systemic poverty and malnutrition, result in one of the highest maternal mortality rates in the world (Hate and Gannon, 2010).

The problem is not distributed evenly. Sri Lanka bears 58 maternal deaths for every 100,000 births and Nepal bears 830. Approximately 185,000 women in the South Asian region die during childbirth every year. With a population that exceeds 1.1 billion people, India accounts for 136,000 of those deaths, even though skilled professionals attend nearly 50 percent of births. Nepal and Pakistan have skilled professionals at only 19 percent and 29 percent of births, respectively. Unattended home delivery is both a cultural tradition and a current necessity in many rural parts of Bangladesh, India, Nepal, and Pakistan (Hate and Gannon, 2010). The ten leading causes of death in low income countries are Lower respiratory infections, Coronary heart disease, Diarrheal diseases, HIV/AIDS, Stroke and other cerebrovascular diseases, Chronic obstructive pulmonary disease, Tuberculosis, Neonatal infections, Malaria and prematurity and low birth weight (WHO, 2008). Diarrheal diseases are the second leading cause of childhood mortality globally despite the availability of an effective vaccine for rotavirus, the major cause of enteric infections.

The overuse of antibiotics has led to the emergence of antibiotic-resistant strains of common organisms and lack of vaccines for many dangerous microorganisms poses problems to humankind. Some progress is made in control of many tropical diseases, but malaria, tuberculosis and other infectious diseases remain enormous global problems. Most of the tropical diseases are associated with poverty and unsanitary. Despite great progress in leprosy, filariasis and onchocerciasis control, approximately one billion people are affected by neglected tropical diseases (NTD) which includes Burgle ulcer, Chagas disease, cholera/epidemic diarrheal diseases, dengue/dengue hemorrhagic fever, dracunculiasis (guinea-worm), endemic treponematosis (yaws, pinta, endemic syphilis), human African trypanosomiasis (sleeping sickness), leishmaniasis, leprosy, lymphatic filariasis, onchocerciasis, schistosomiasis, helminth infections (roundworm, hookworm and whipworm), and trachoma. Co-infection with certain tropical diseases and HIV is even more worrisome and often proves lethal. As an example, Sudan and Ethiopia are currently facing a surge in leishmania/HIV co-infection. WHO reports that HIV infection increases the risk of developing visceral leishmaniasis by a factor of 100-1000 in endemic area.

Higher standards of living and urbanization, especially in high and middle-income countries, have led to a demographic transition from high to low birth rates and short to long life spans. The burden of illness has shifted from acute childhood infections to chronic non-communicable diseases (Felding, 2010). New and emerging infectious diseases have brought important new challenges to public health globally (Schlipköter and Flahault, 2010). At the beginning of the 21st century, a wide variety of animal species, both domesticated and wild, have acted as reservoirs for these pathogens which include viruses, bacteria and parasites. Considering the wide range of animal species involved and the usually complex natural history of the pathogens concerned, effective surveillance, prevention and control of zoonotic diseases pose a real challenge to public health (WHO, 2010). The newly emerged zoonoses such as bovine spongiform encephalopathy (BSE), other food borne diseases and a number of viral infectious agents (e.g., Nipah, Ebola, Hendra, Avian H5N1 influenza virus, Monkeypox virus) have had serious direct and indirect impacts on public health (WHO, 2010). As our environment continues to change, more such occurrences can be expected in the future. Although vaccines and antibiotics brought a sense of widespread optimism to public health, the desired level of expectations could not be achieved. In Afghanistan, control of endemic polio is affected by the war conditions. Higher standards of living and urbanization, especially in high and middle-income countries, have led to a demographic transition from high to low birth rates and short to long life spans. The burden of illness has shifted from acute childhood infections to chronic non-communicable diseases. Nevertheless, the epidemiologic transition is not complete, unfolding at different rates around the globe. New and emerging infectious diseases have brought important new challenges to public health globally. The emerging and re-emerging diseases such as the “big three” (HIV/AIDS, malaria and tuberculosis) are accompanied by new problems such as bioterrorism threats, increase of hospital-acquired infections and pandemic outbreaks, to name a few. Half of the world’s population is at risk of malaria. There are over 250 million cases of malaria each year causing nearly one million deaths, 90 percent of which occur in Africa mainly among preschool-aged children.

More than two billion people are infected with the tubercle bacillus (TB) and one in every 10 of those people will become sick with tuberculosis during their lifetime. In 2008, there were 9.4 million new cases and a total of 1.1 million – 1.7 million deaths from TB among HIV-negative people and an additional 0.45 million – 0.62 million among HIV-positive people. Concurrent infection with both TB and HIV is a lethal combination and TB is the leading killer of people who are HIV-positive. Multidrug resistant TB and Extensive drug resistant TB are challenges to health workers. Outbreaks of Methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections (HCI) threaten numerous settings in developed countries. Wars and natural disasters also create environments where pathogens can thrive. Recently, Hanta viral outbreak occurred in USA that has threatened the life of the travelers in those areas. The virus showed for the first time in 1993 in Mexico. More and more newer diseases are on the queue to happen.

In conclusion, the challenges of population growth, urbanization, deforestation, pollution, global climate change and global movement of populations have been associated with a shift in geographical distribution and accelerated diffusion of old and new pathogens resulting in an increased number of outbreaks. Global anticipation of the most recent influenza epidemic has required international, national and local health authorities to undertake extensive preparation. Much effort is still needed to better understand the biological mechanisms of pathogen transmission and diffusion as well as people’s behaviors/attitudes in the face of risk before we can hope to better combat tomorrow’s outbreaks.

About the author: Laxman Ghimire is a student of B.V.Sc. & A.H. (10th semester or Intern) at Institute of Agriculture and Animal Science, Rampur, Nepal and has keen interest in zoonosis and public health. He has submitted a review paper on “Use of RBGh in Dairy industry” to Altech Young Scientist programme. Laxman is also  a founder member and technical consultant of Madhuban Agriculture and Multipurpose Co-operatives Pvt. Ltd.

The author can be reached at [email protected]

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This article is competing for the JPMS International Medical Writing Contest 2012 .

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