VIEW POINT
MALAWIMEDJ. 2003;15(l )l 8-l9
Vaccinesor Latrines? Debatingspendingon health. Msolomba B, PathiranaL, Purcell B, Bowie C. Tbe final sessionof the lst year Environmental Ilealth module took the form of a class debate. increasing "This class believes that the r€cent trend of investment in health care in low income countries at the expenseof environmental health measureswill be detrimental to health outcomes overall." A few days prior to the debate, esch student Y)ssLsked to prepsre s short paper arguing either for or against the motion. Students could not choose which side of the debate to argue on for, but voting was free choice. We took s vote at the slafi the motion. Three people ftom each side of the debste present' ed their case before the dehate was opened up to the Jloor A spokes-percon from each side summed up, then there h'as a second vote otr the motion. Interestingly, most of the class agreed rtith the ti e of the debste st the outsel But those srguing fot the relative merits of health cure spending, particularly in relation to redacing mortqliy in un(kr-rtve's, htd managed to convince more skep' tics b1tthe end of the morninS' Two of the best papers arc given here' Bridget Msolomba: Arguing in favour of the motion. Low-income countrieshave always faced infectious diseaseeptdemics. Rather than focusing on prevention,the trend has been to react to crises as they arise, such as the cholera outbreak in Malawi 2001. In this way resourcesare spenton treatingthe condition in an emergencyrahereaccessto affectedareasis often difficult due to poor transport and roads. In my oplnlon governments should not focus narrowly on cure after the event, but should broadentheir policies to include mass prevention through environmentalhealth measures,which will prove more cost effective in the long run. Most developing countries are caught in a dilemma over how best to invest in health. Worldwide, amually 400 million people are infected with malaria, 200 million with bilharzia and 9 million with TB. Deaths from these diseasesare not only a burden to the families and communitiesbut have socioeconomiceffects as well. One estimate suggestedthat AIDS deaths by the year 2000 would cost Asian countries$50 billion in lost productivity aloner.Methods of prevention and treatmentfor many of these diseasesare known. However, growing pressureof budget cuts and population growth overwhelmsgovemments'ability to control thesediseases.Also there hasbeen a vast disparity in provision of preventive measures between the rich and the poor, for example water supply typically is to urban landownersleaving out the rural majority. Sixteenpercent of the world's population (- 1.1 billion people) has no accessto a safe water supply and 40% are living without adequatesanitation.Eighty percent of all diseasesin the developing world are associatedwith a lack of clean water, accounthg lor 24 million deaths each year' Several studies however have shown that by simply providing piped water to homes,diseaseoccurrencecan drop by as much as 25%o.Furthermore,the quantity ofwater available appearsto be a more important determinant of diseasereduction than quality, with sanitation and hygiene also playing a role'. l8
In the early 80's, govemments aimed to provide water pumps and boreholesto their populations,but maintaining theseproved expensive and difficult. More recently there has been a shift in emphasisto treatment,for examplepromoting Oral Rehydration therapy. Earlier interventions were focusing on governments' being the sole provider, but increasinglythe private sectoris the provider under monitored surveillanceby govemment officials' i agreewith this ideologl in which gor emmentsmerelyprovide incentives and a fiaction of financial support for projects whilst encouraging communities to raise funds, provide labour and comnittees. In Malawi where there is a high demand for new boreholeswith only I5,000 boreholesfor a rural population of9 million', this policy will ensue that demand is met without excessivegovemment sPending. In conclusion,I believe that whilst short-tem investmentshould be directed at epidemicsthere should be equal investmentnow in environmentalhealth. Regardlessof the effort spent on treatment, if lhe root of the problemlike cleanwaler supply is not solved in the long run the problem will keep on recurring and resources will continue to be poured into the same problem insteadof locusingon development Rel-ercnces l.Chukwuma, S. 1996 New sludy on infectious diseasein developing countries.MMLYM -OPISK 2.Vaz, L. Jta, P Commissjon on macroeconomicsand health CMH working paper series.PaperWG5: 23. Note on the health impact ofwater and sanitation ;ervices.httpr/ww3.who-in/whosis/cmh./cmhiaper/e/pdfl wg5laper 3. Mpanje, L. Milanzi, L.1997 water and saoitation for all: parhrershipsand innovation of community management of rural water supply'
On the other hand... Lakdini Pathirana argues against This paper aims to highlight some of the reasonswhy lnvestment in health care is a good use of tesoulces in low-income countriesrelative to environmentalhealth measures' Low-income countdes have high mortality rates in general' Considering the mortality in under-fives for instance,in 1995, 10 million of the 10.5 million deathsamong children under the ageoffive were in developingcountries.Worldwide, the African regions have the highest under-five mortality rates of 150/1000 live births followed by S.E. Asia with 88/1000'.Although child mortality rat€s in low-income countries have been declining since 1950, the decline has not been constant and the level of child mortality is still extremely high in some countries ln Malawi, more than one in five children die before they reach the age of five, and many of those who do survive are unable to
grow and develop to their fulI potential. Most childhood deaths are attributable to infectious diseases, chiefly acute respiratory hact infections, diarrhoea,malaria and measles. Hence, improving child mortality rates necessrtates tackling these diseases. Improving environmental health will help to lower the occurence of these diseases' Meanwhile acciss to oral rehydration therapy, antibiotics, anti malaria drugs and vaccines is needed.Such int€rventions don't require hightech inputs and ar€ not unduly costly. Malnutdtion contdbutesto about halfof all childhood deaths'lt is causednot only by the lack ofaccess to food but also by poor feeding practices(such as inadequatebreastfeeding,offering the wrong ioods and giving food in insufficient quantities) and infection, or a combination ofthe two. Improving breastfeeding can help prevent diseasessuch as pneumonia and diarrhea and WHO has estimatedthat improved feeding practicescould save 800 000 lives per yeat'. Micronutrient supplementationis also an important means to improve health outcomes Supplements of vitamin A ior example have been found to reduce the Malawi Medical Journal / vaccines or Larines?
VIEW POINT severity ol both measles and diarrhoea. Trials in developing countries have shown that vitamin A supplementscal reduce death from theseand other infectious diseasesby almost 25olor. Socioeconomiciactors such as low occupational status of the headof the householdand low family incomeare crucialdeterminants ofchild mortality. The level of educationofthe mother is also important. If the mother is uneducated,she is less able to prqvide the best possible care for her child. Child mortality is alsb affectedby the availabilityofpre and post-natalcare,iack of which carr lead to low birth weight. Therefore, investment in health carein general,as well as the wider socioeconomicdeterminants of health is neededto control child mortality and provide a better health outcome overall Environmental health progammes may bring benefits in the long term but action is required in the short term to deal with the present high ratesof mortaliry Invesftnentsin health care,deal with the immediateproblem as well as ensuringlong-term effects. Therefore,govemmentsneed to invest in health care as a prioriqr if we are to control child mortality; and such investnents even at the expenseof environmental health measuresshould improvehealthoutcomesoverall. References 1.Commission onMadoeconomics andHealth.CMHWorkingpaperSedes. PaperNo. WG5:9. Theevidence basefor interventions to reduce underfive mortalityin low andmiddle-income countries. H. Gelband, S.Stansfield. 2. Health,NutritionandPopulation Series, HumanDevelopment Network, WorldBankHealthExpenditures, Services andOutcomes in Afiica:BasjcData andCross-National Comparisons, 1980-1996. D.H.peters, K. Kandola. A.E. Elmendorfand G. Chellamj.http://www.worldbank.org/afilindex,&eaexp.htm 3. Reducingmortalityftom majorkillersofchildren.FactsheetNo.l?8. WHO Information. Revised.SeDtember 1998.
TPONG)A SUPEFIMAFIKETS! A INTEFINATIONAL TFIANSPGIFITEFTSi
a
PO Box 2519,Blantyre.- Tol:01 633883/01 636936- Fax: 01 624 136/01 634715. ' Email:[email protected]
Malawi Medical Joumal / Vaccinesor Latnnes?
MALAWIMEDJ. 2003;15(l )l 8-l9
Vaccinesor Latrines? Debatingspendingon health. Msolomba B, PathiranaL, Purcell B, Bowie C. Tbe final sessionof the lst year Environmental Ilealth module took the form of a class debate. increasing "This class believes that the r€cent trend of investment in health care in low income countries at the expenseof environmental health measureswill be detrimental to health outcomes overall." A few days prior to the debate, esch student Y)ssLsked to prepsre s short paper arguing either for or against the motion. Students could not choose which side of the debate to argue on for, but voting was free choice. We took s vote at the slafi the motion. Three people ftom each side of the debste present' ed their case before the dehate was opened up to the Jloor A spokes-percon from each side summed up, then there h'as a second vote otr the motion. Interestingly, most of the class agreed rtith the ti e of the debste st the outsel But those srguing fot the relative merits of health cure spending, particularly in relation to redacing mortqliy in un(kr-rtve's, htd managed to convince more skep' tics b1tthe end of the morninS' Two of the best papers arc given here' Bridget Msolomba: Arguing in favour of the motion. Low-income countrieshave always faced infectious diseaseeptdemics. Rather than focusing on prevention,the trend has been to react to crises as they arise, such as the cholera outbreak in Malawi 2001. In this way resourcesare spenton treatingthe condition in an emergencyrahereaccessto affectedareasis often difficult due to poor transport and roads. In my oplnlon governments should not focus narrowly on cure after the event, but should broadentheir policies to include mass prevention through environmentalhealth measures,which will prove more cost effective in the long run. Most developing countries are caught in a dilemma over how best to invest in health. Worldwide, amually 400 million people are infected with malaria, 200 million with bilharzia and 9 million with TB. Deaths from these diseasesare not only a burden to the families and communitiesbut have socioeconomiceffects as well. One estimate suggestedthat AIDS deaths by the year 2000 would cost Asian countries$50 billion in lost productivity aloner.Methods of prevention and treatmentfor many of these diseasesare known. However, growing pressureof budget cuts and population growth overwhelmsgovemments'ability to control thesediseases.Also there hasbeen a vast disparity in provision of preventive measures between the rich and the poor, for example water supply typically is to urban landownersleaving out the rural majority. Sixteenpercent of the world's population (- 1.1 billion people) has no accessto a safe water supply and 40% are living without adequatesanitation.Eighty percent of all diseasesin the developing world are associatedwith a lack of clean water, accounthg lor 24 million deaths each year' Several studies however have shown that by simply providing piped water to homes,diseaseoccurrencecan drop by as much as 25%o.Furthermore,the quantity ofwater available appearsto be a more important determinant of diseasereduction than quality, with sanitation and hygiene also playing a role'. l8
In the early 80's, govemments aimed to provide water pumps and boreholesto their populations,but maintaining theseproved expensive and difficult. More recently there has been a shift in emphasisto treatment,for examplepromoting Oral Rehydration therapy. Earlier interventions were focusing on governments' being the sole provider, but increasinglythe private sectoris the provider under monitored surveillanceby govemment officials' i agreewith this ideologl in which gor emmentsmerelyprovide incentives and a fiaction of financial support for projects whilst encouraging communities to raise funds, provide labour and comnittees. In Malawi where there is a high demand for new boreholeswith only I5,000 boreholesfor a rural population of9 million', this policy will ensue that demand is met without excessivegovemment sPending. In conclusion,I believe that whilst short-tem investmentshould be directed at epidemicsthere should be equal investmentnow in environmentalhealth. Regardlessof the effort spent on treatment, if lhe root of the problemlike cleanwaler supply is not solved in the long run the problem will keep on recurring and resources will continue to be poured into the same problem insteadof locusingon development Rel-ercnces l.Chukwuma, S. 1996 New sludy on infectious diseasein developing countries.MMLYM -OPISK 2.Vaz, L. Jta, P Commissjon on macroeconomicsand health CMH working paper series.PaperWG5: 23. Note on the health impact ofwater and sanitation ;ervices.httpr/ww3.who-in/whosis/cmh./cmhiaper/e/pdfl wg5laper 3. Mpanje, L. Milanzi, L.1997 water and saoitation for all: parhrershipsand innovation of community management of rural water supply'
On the other hand... Lakdini Pathirana argues against This paper aims to highlight some of the reasonswhy lnvestment in health care is a good use of tesoulces in low-income countriesrelative to environmentalhealth measures' Low-income countdes have high mortality rates in general' Considering the mortality in under-fives for instance,in 1995, 10 million of the 10.5 million deathsamong children under the ageoffive were in developingcountries.Worldwide, the African regions have the highest under-five mortality rates of 150/1000 live births followed by S.E. Asia with 88/1000'.Although child mortality rat€s in low-income countries have been declining since 1950, the decline has not been constant and the level of child mortality is still extremely high in some countries ln Malawi, more than one in five children die before they reach the age of five, and many of those who do survive are unable to
grow and develop to their fulI potential. Most childhood deaths are attributable to infectious diseases, chiefly acute respiratory hact infections, diarrhoea,malaria and measles. Hence, improving child mortality rates necessrtates tackling these diseases. Improving environmental health will help to lower the occurence of these diseases' Meanwhile acciss to oral rehydration therapy, antibiotics, anti malaria drugs and vaccines is needed.Such int€rventions don't require hightech inputs and ar€ not unduly costly. Malnutdtion contdbutesto about halfof all childhood deaths'lt is causednot only by the lack ofaccess to food but also by poor feeding practices(such as inadequatebreastfeeding,offering the wrong ioods and giving food in insufficient quantities) and infection, or a combination ofthe two. Improving breastfeeding can help prevent diseasessuch as pneumonia and diarrhea and WHO has estimatedthat improved feeding practicescould save 800 000 lives per yeat'. Micronutrient supplementationis also an important means to improve health outcomes Supplements of vitamin A ior example have been found to reduce the Malawi Medical Journal / vaccines or Larines?
VIEW POINT severity ol both measles and diarrhoea. Trials in developing countries have shown that vitamin A supplementscal reduce death from theseand other infectious diseasesby almost 25olor. Socioeconomiciactors such as low occupational status of the headof the householdand low family incomeare crucialdeterminants ofchild mortality. The level of educationofthe mother is also important. If the mother is uneducated,she is less able to prqvide the best possible care for her child. Child mortality is alsb affectedby the availabilityofpre and post-natalcare,iack of which carr lead to low birth weight. Therefore, investment in health carein general,as well as the wider socioeconomicdeterminants of health is neededto control child mortality and provide a better health outcome overall Environmental health progammes may bring benefits in the long term but action is required in the short term to deal with the present high ratesof mortaliry Invesftnentsin health care,deal with the immediateproblem as well as ensuringlong-term effects. Therefore,govemmentsneed to invest in health care as a prioriqr if we are to control child mortality; and such investnents even at the expenseof environmental health measuresshould improvehealthoutcomesoverall. References 1.Commission onMadoeconomics andHealth.CMHWorkingpaperSedes. PaperNo. WG5:9. Theevidence basefor interventions to reduce underfive mortalityin low andmiddle-income countries. H. Gelband, S.Stansfield. 2. Health,NutritionandPopulation Series, HumanDevelopment Network, WorldBankHealthExpenditures, Services andOutcomes in Afiica:BasjcData andCross-National Comparisons, 1980-1996. D.H.peters, K. Kandola. A.E. Elmendorfand G. Chellamj.http://www.worldbank.org/afilindex,&eaexp.htm 3. Reducingmortalityftom majorkillersofchildren.FactsheetNo.l?8. WHO Information. Revised.SeDtember 1998.
TPONG)A SUPEFIMAFIKETS! A INTEFINATIONAL TFIANSPGIFITEFTSi
a
PO Box 2519,Blantyre.- Tol:01 633883/01 636936- Fax: 01 624 136/01 634715. ' Email:[email protected]
Malawi Medical Joumal / Vaccinesor Latnnes?
