Global Health Unit Newsletter June 2018 FINAL

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Jun 1, 2018 - in the upcoming 71st World Health Assembly in May followed by 3rd UN ..... activity for at least 30 minutess each day for at least 5 days a week'.
Year 4

Issue 1

June 2018

Editorial Translational Research for tackling Non Communicable Diseases: need of the hour insufficient physical activity increase the risk of NCDs.

Dr. Pranil Man Singh Pradhan MD Chief Editor Assistant Professor, Department of Community Medicine and Public Health Global Health Alumni Non communicable diseases (NCDs) pose significant burden on the health of the people worldwide. NCDs account for 40 million deaths each year out of which 15 million die prematurely between the ages of 30-69 years. Almost 80% of such premature deaths are caused by four major diseases namely cardiovascular disease, cancer, respiratory diseases and diabetes. (1)The factors driving these diseases globally include unhealthy lifestyles, population ageing, unhealthy diet and lack of physical activity. A number of modifiable risk factors like tobacco consumption, excess salt intake, alcohol use and In this Issue Editorial - Translational Research for tackling Non Communicable Diseases: need of the hour

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Message from Prof. MandiraShahi, Executive Director, National Center for Health Professions Education

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Diabetes a leading problem in Nepal: How should we tackle it?

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Obesity a rising problem in Nepal

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Cholesterol: Facts, fads and changing concepts

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"Pill not for Every Ill":Behavioural and psychological interventions for Mental Health and Non Communicable Diseases (NCDs)

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My voice: Time for action to combat mental illness

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Universal Health Coverage and NCDs in Federal Nepal

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Improving data quality in Nepal

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Are Electronic Nicotine Delivery Systems (ENDS) really a safer alternative to cigarette smoking?

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Experiences of attending 11th European Breast Cancer Conference

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Journey of Global Health Course leading to endless possibilities

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As part of the 2030 Agenda for Sustainable Development, Heads of State Government have committed to reduce the premature mortality from NCDs by one-third though prevention and treatment (SDG target 3.4).(1)NCD is one of the agendas in the upcoming 71st World Health Assembly in May followed by 3rd UN High-Level Meeting on NCDs in September 2018. Nepal has also adopted the ten targets related to prevention and control of NCDs in line with the sentiments of South East Asia Regional NCD targets. (2) Considering the future burden of NCDs on the existing health system of countries like Nepal, the strategies like surveillance, health promotion and primary prevention and management need to be prioritized.(3) WHO recommends three steps for screening of NCDs which are estimating the population need through assessing the current risk profile, formulate and adopt NCD policy and identify policy implementation steps.(3)Regarding step one,NCD Risk Factors: STEPS Survey was conducted in 2012/13, which found high prevalence of NCD risk factors among Nepalese population (smoking 18.5%, current drinking 17.4%, overweight 17.7%, hypertension 23.4%, raised total cholesterol 22.7%).Following the High Level Political Declaration at the UN General Assembly, Nepal achieved a significant step towards adoption of NCD policy by drafting the multi-sectoral action plan for prevention and control of NCDs in 2014. The current efforts should be directed towards identifying the effective steps in implementation of research findings and policy implication towards prevention and control of NCDs. Research findings have been used to guide and formulate health policies worldwide. Despite large number of global, regional and national policies and interventions, there remains a significant gap in translation of these policies into practice as a result of which, the health problems continue to exist. For example, Nepal formulated the tobacco product control and regulatory directives in 2014, being a signatory to Framework Convention on Tobacco Control (FCTC). But even after four years, the provisions of the directives seem to be partially implemented. Reducing this “evidence-into-implementation” or “know-do” gap is associated with significant reduction in

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morbidity, mortality and healthcare costs.(4)Translational or implementation research has been defined as the scientific study of the processes used to implement policies and interventions and the contextual factors that affect these processes.(5) It helps to identify which components of a policy or intervention are needed to obtain intended outcome, thereby help reduce the know-do gap. (4) Cardiovascular disease (CVD) is one of NCDs given high priority for prevention and control. Strategies like reduction of dietary salt intake, screening, replacing trans-fat in foods with polyunsaturated fat, multidrug therapy for those at risk of myocardial infarction and stroke are considered to be the best buys or affordable strategies to address CVDs. (6)However adequate evidence on how to implement these strategies to achieve maximum effectiveness at the local level has been lacking. Number of studies from low resource settings including Nepal, have already shown that mobilizing community level health workers is an effective in management of hypertension and reducing the risk of CVD using through lifestyle interventions.(7,8)Current need is to further build up on such evidences through translational research and identify sustainable, affordable, and reproducible ways to implement these strategies across different settings to tackle the NCDs. References WHO. Noncommunicable diseases Fact sheet [Internet]. 2017 [cited 2018 Apr 19]. Available from: http://www.who.int/ mediacentre/factsheets/fs355/en/ 2. Government of Nepal, WHO. Multisectoral Action Plan for the Prevention and Control of Non Communicable Diseases ( 2014-2020 ). 2014; Available from: http://www.searo.who.int/nepal/mediacentre/ncd_multisectoral_action_plan.pdf 3. Habib S, Saha S. Burden of non-communicable disease: Global overview. Global Health Newsletter Team, 2018 Diabetes Metab Syndr Clin Res Rev [Internet]. 2010;4(1):41–7. Available from: Editorial Advisors https://www.sciencedirect.com/science/article/abs/pii/S1871402108000489 Prof. Dr. Jagdish Prasad Agrawal 4. World Health Organization. A guide to implementation research in the Dean, Institute of Medicine, Nepal prevention and control of noncommunicable diseases [Internet]. 2016. [email protected] Available from: http://www.who.int/ncds/governance/policies/NCD_MSA_ plans/en/ Prof. Mandira Shahi 5. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Executive Director, NCHPE, IOM Guide [Internet]. Alliance for Health Policy and Systems Research, World Prof. Dr. Archana Amatya Health Organization. 2013. Available from: http://r4d.dfid.gov.uk/ Coordinator, Global Health Unit, NCHPE, IOM Output/195409/Default.aspx [email protected] 6. Peprah E, Lopez-Class M, Shero S, John_Sowah J, Engelgau M. A Global Assoc. Prof. Dr. Pradeep Gyawali Perspective on Using Implementation Research to Address HypertensionAssociated Target Organ Damage. Ethn Dis [Internet]. 2016;26(3):395–8. Global Health Unit, NCHPE, IOM Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948807/ Chief Editor 7. Abdel-All M, Putica B, Praveen D, Abimbola S, Joshi R. Effectiveness Dr. Pranil Man Singh Pradhan of community health worker training programmes for cardiovascular disease [email protected] management in low-income and middle-income countries: a systematic Editors review. BMJ Open [Internet]. 2016;7(11). Available from: http://bmjopen.bmj. Asst. Prof. Prem Basel com/content/7/11/e015529 [email protected] 8. Neupane D, McLachlan CS, Mishra SR, Olsen MH, Perry HB, Karki A, et al. Administrative Support Effectiveness of a lifestyle intervention led by female community health Sunil Pokhrel volunteers versus usual care in blood pressure reduction (COBIN): an [email protected] label, cluster-randomised trial. Lancet Glob Heal [Internet]. 2018;6(1):e66–73. 1.

Message from Prof. Mandira Shahi Executive Director, National Center for Health Professions Education Nepal has now embarked into a phase of a triple burden of diseases. Deaths due to non-communicable diseases (NCDs) and injuries at the population level have soared high. Almost two thirds of the deaths are due to NCDs and injuries. With this epidemiological transition of diseases, it is high time that we revisit our health care delivery system, financing and appropriate human resources for health to address the issues adequately. The Government of Nepal has put forward the Multi-sectoral Action Plan on the Prevention and Control of NCD in Nepal (20142020) to reduce preventable morbidity, avoidable disability and premature mortality due to NCDs. Realizing these facts, Global Health Unit, National Centre for Health Professions Education

(NCHPE), Institute of Medicine (IoM) is conducting a 4th National Course in Global Health on the theme of “Non Communicable Diseases (NCDs)” in August 2018. I would like to acknowledge the continuous support received from the Finnish Medical Society Duodecim, Finland and University of Tampere and Institute of Medicine in conducting the Global Health Course which has no boundaries in imparting global health education, training and research and in publishing the Global Health Newsletter. I would like to congratulate the team of Global Health Unit and particularly Dr. Pranil Man Singh Pradhan, in bringing out the next issue of Global Health Newsletter. I wish the global health course a grand success.

Diabetes a leading problem in Nepal: How should we tackle it? Dr. Prajjwal Pyakurel (MD) School of Public Health and Community Medicine B.P.Koirala Institute of Health Sciences, Dharan, Nepal Diabetes is the fifth leading cause of death in most highincome countries and there is substantial evidence that it is epidemic in many low- and middle-income countries.(1) Complications from diabetes, such as coronary artery disease, peripheral vascular disease, stroke, diabetic neuropathy,

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amputations, renal failure and blindness result in disability, reduced life expectancy and enormous health costs.(2) It also brings about substantive economic loss to people with diabetes, their families, health system and the national economies through direct medical cost, loss of work and wages.(3) In Nepal, there is lack of reliable and representative data on the prevalence of type 2 diabetes. Various small studies from

different parts of the country have shown prevalence rates ranging from 6.3% to 8.5%.(4) The burden of diabetes in terms of disability adjusted life years has increased almost 100% from 1990 to 2010. (5) Diabetes has become a severe public health problem in Nepal. The Nepalese health system is struggling to deliver comprehensive, quality treatment and services for diabetes at all levels of health care.(6) It is time that the Ministry of Health takes concrete actions in combating this deadly epidemic. Easy accessibility to basic diagnostics such as blood glucose testing should be made available in all primary health care setting. Established systems for referral and back-referral should be prioritized as patients will need periodic specialist assessment or treatment for complications. Holistic approach and multisectoral collaborative approach should be considered from government in trade, agriculture, finance, transport, education and urban planning. Policy and programmatic intervention are needed to improve equitable access for essential medicine critical to gaining control over diabetes.(3) The public responsibility for their health should be of utmost priority. Four dietary changes can have a big impact on the risk of type 2 diabetes: choosing whole grains and whole grain products over highly processed carbohydrates, skipping the sugary drinks, and choose water, coffee, or tea instead, choosing good fats instead of bad fats and limiting red meat, avoiding processed meat; choosing nuts, whole grains, poultry, or fish instead.(7) The clinicians, nurses and public health practitioners working in the subject area should conceptualize effective counseling and health education for risk factors and preventions.(8) Self- help group for patients with type 2 diabetes should be established at the community level. This will be beneficial especially to elderly patients with longer duration of diabetes who are isolated from health professionals and have difficulty changing their care behaviors.(9) The international global health bodies (International Diabetes Federation and World Health Organization) should collaborate and work with Ministry of

Health, Government of Nepal to strengthen the health system for diabetes prevention. Together we all can combat diabetes! References: 1. 2. 3. 4. 5.

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Global Status report on Non-Communicable diseases2014. Switzerland: WHO press; 2014.176p.Report No. ISBN 9789241564854 Diabetes Atlas.Belgium.International Diabetes Federation; 2003.Report No. ISBN 2-930229-27-6 World Health Organization. Global Report on Diabetes. 2016;88. Available from: http://apps.who.int/iris/ bitstream/10665/204871/1/9789241565257_eng.pdf Gyawali et al. Prevalence of type 2 diabetes in Nepal: a systematic review and meta-analysis from 2000 to 2014. Global Health Action.2015 November 15,8(1):4-13 Institute for Health Metrics and Evaluation.GBD Profile: Nepal [Internet].Seattle, USA. [Cited 2018 May 10]. Available from: https://www.healthdata.org/sites/default/ files/files/country_profiles/GBD/ihme_gbd_country_ report_nepal.pdf Gyawalietal.Challenges in diabetes mellitus type 2 management in Nepal: a literature review. Global Health Action.2016 0ctober 18,9(1):1-12 Harvard T.H.CHAN School of Public Health. The Nutrition Source [Internet].Boston, USA[Cited 2018 May 10]. Available from: https://www.hsph.harvard.edu/ nutritionsource/disease-prevention/diabetes-prevention/ preventing-diabetes-full-story/ Alkhatib et al.Functional Foods and Lifestyle Approaches for Diabetes Prevention and Management.Nutrients.2017 December 1,9(12):1-18 Kotani and Sakane. Effects of a self-help group for diabetes care in long-term patients with type 2 diabetes mellitus: an experience in a Japanese rural community.Aust J Rural Health.2004 December,12(6):251-2

Obesity a rising problem in Nepal Dr. Shankar Raj Lamichhane MS General Surgery, First Year Resident Global Health Alumni Overweight and obesity is the abnormal or excessive fat accumulation in the body. It is one of the major public health problems and root cause of non-communicable diseases. Overweight and obesity, once a major problem of developed nations is now rising in middle and low economic countries like Nepal. For adults, WHO defines overweight as BMI greater than or equal to 25 and obesity as BMI greater than or equal to 30. In 2016, more than 1.9 billion adults, 18 years and older were overweight. Of these over 650 million were obese in global perspective. According to CIA factsheet, the obesity in adults was 1.5% in 2008 that increased to 3% in 2014 and 4 % in 2016. The same source has stated that US has 36% of adults with obesity. India, Bangladesh, Japan share the same data, however Vietnam has the lowest prevalence of 2%. It is to be known that obesity is completely preventable and the public health programs need to be directed towards decreasing obesity rate. A study done by Smith C assessed the prevalence of obesity among Sherpa women and factors most predictive of it. BMI, energy consumption, and expenditures and physical activity pattern were compared to non-pregnant, premenopausal woman living in urban low altitude. The prevalence of obesity correlated with reduced energy expenditure, not to an increase in consumed calories. Reduced energy expenditures were related to shifts in occupation, access to motorized transportation, and increased affluence, which allowed Sherpas to hire servants to do manual

labor.(1)A cross-sectional survey among government employees in five urban Nepalese districts linked lifestyle to obesity and one third of the employees were overweight or obese. (2) Increased age, marital status, higher education, greater job responsibilities, increased alcohol consumption, and motorized transport were associated significantly with obesity. Taken together, these studies suggest that urbanization is the major driving force behind obesity in Nepal.(3) Changing dietary habits can shift a society’s disease pattern from infectious, communicable diseases towards a double-disease burden with increasing prevalence of obesity and non-communicable diseases (NCDs). Cardiovascular diseases mainly heart diseases and stroke, diabetes, musculoskeletal disorder and cancers ofendometrium, breast, ovary, prostrate, liver, gallbladder, kidney and colon are found to be related to obesity.Obesity can be controlled at the individual level by limiting intake of energy from fats and sugars, increase the consumption of fruits and vegetables, legumes whole grains and nuts; engage in regular physical activity of 60 minutes for children and 150 minutes spread through the week for adults.(4) Government of Nepal and food industries should regulate the fat, salt and sugar content of processed food and restrict such food in children. They must ensure that healthy and nutritious food choices are available and affordable, and support regular physical activity in workplace.(4) References: 1.

Smith C. Prevalence of obesity and contributing factors among Sherpa women in urban and rural Nepal. American Journal of Human Biology: The Official Journal of the Human Biology Association. 1998;10(4):519-28.

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Simkhada P, Poobalan A, Simkhada PP, Amalraj R, Aucott L. Knowledge, attitude, and prevalence of overweight and obesity among civil servants in Nepal. Asia Pacific Journal of Public Health. 2011;23(4):507-17. Vaidya A, Shakya S, Krettek A. Obesity prevalence in Nepal: public health challenges in a low-income nation

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during an alarming worldwide trend. International Journal of Environmental Research and Public Health. 2010;7(6):2726-44. World Health Organization. Obesity and overweight 2017 [cited 2018 30 April]. Available from: http://www.who.int/ en/news-room/fact-sheets/detail/obesity-and-overweight.

Cholesterol: Facts, fads and changing concepts Dr. Shreya Shrivastav Assistant Professor, Department of Pathology Global Health Alumni Nepal is among the developing countries that faces dual burden of disease, i.e. infectious diseases and increasing number of non-communicable diseases. Common noncommunicable diseases include hypertension, diabetes and related complications. Among the modifiable risk factors for these diseases, diet plays a central role. In particular, the role of cholesterol has been much discussed and in spite of decades of extensive research, there are evolving concepts and changing viewpoints. In the late 1940s and early 1950s several studies like the Framingham Heart study concluded cholesterol as a major risk factor for atherosclerosis and coronary artery disease. (1-2) However, there was a strong denial and disbelief in the medical community about the importance of cholesterol with many eminent scientists reporting the futility of dietary cholesterol regulation and raising doubts and accusations on studies that supported the lipid hypothesis even as far as the 1980s.(3) In spite of these, today, the role of raised cholesterol and LDL as a causative agent in atherosclerosis is undeniable and the use of lipid lowering drugs, predominantly, but not limited to statins, is standard practice, although treatment guidelines are numerous and frequently change.(4) Until recently, most guidelines recommended limiting dietary cholesterol to 200 or 300 mg per day. (5) However, in 2015 the dietary guidelines advisory committeestated that it would not bring forward this recommendation.(6) Still, it continued to warn against the consumption of saturated fat. This led to a flurry of news about how cholesterol was no longer a nutrient of concern and therefore not bad. The basis for these findings stems from the following few points. Firstly, dietary cholesterol or “exogenous” cholesterol accounts for approximately one-third of the pooled body cholesterol, and the remaining 70% is synthesized in the body (endogenous cholesterol) so dietary cholesterol is only a part of the reason for its increase. (7) Next, increased dietary cholesterol may result in increased serum cholesterol in some individuals, while others do not respond to dietary cholesterol. The distinction between them has a genetic basis, dependent on polymorphisms in the cholesterol transporters ABCG5/8 and NPC1L1, among others. (8) Griffin and Lichtenstein analyzed numerous studies over the past 10-15 years addressing dietary cholesterol and found that its effect on plasma lipids concentrations is modest and appears to be limited to some population subgroups, for example diabetics and obese patients with insulin resistance and in them, restrictions in dietary cholesterol intake are likely warranted. (9) It is worth remembering that many sources of cholesterol, such as butter, cheese and red meat are also rich sources of saturated fats, which again is bad, even by the new guidelines. Also of interest is the very popular ketogenic diet for weight loss in obese and overweight individuals. The diet constitutes a drastically low amount of carbohydrate (30g), normal or slightly high protein (1g/Kg body weight) and high fat (20% saturated fat, 80% polyunsaturated and monounsaturated fat). In addition to weight loss, it shows additional benefits such as a significant decrease in the level of triglycerides, total cholesterol, LDL cholesterol and glucose, and a significant increase in HDL

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cholesterol. (10)The rationale behind the diet is change in the body’s fuel from carbohydrate to fat. Incomplete oxidation of fatty acids by the liver results in the accumulation of ketone bodies- a state of ketosis. There are, however, a few concerns regarding patients with impaired renal function because of buildup of ketone bodies in the blood and high level of nitrogen excretion at the time of gluconeogenesis. (11) To conclude, there is a wealth of research out there regarding lipids, obesity and atherosclerosis and although big strides have been taken, the incidence of obesity and coronary artery disease continue to rise. The battle is nowhere near ending and we have to take all changes in concepts in stride. References 1.

2.

3. 4. 5.

6.

7.

8. 9. 10. 11.

Edelin YH, Kinsell LW, Michaels GD.Splitter SD: Relation between dietary fat and fatty acid composition of "endogenous" and "exogenous" very low density lipoprotein triglycerides (D--1.006). Metabolism. 1968Jun;17(6):544-54. McNamara DJ, Kolb R, Parker TS, Batwin H, Samuel P, Brown CD, et al. Heterogeneity of cholesterol homeostasis in man. Response to changes in dietary fat quality and cholesterol quantity. Journal of Clinical Investigation. 1987;79(6):1729-39. Oliver MF. Serum-cholesterol the knave of hearts and the joker. Lancet 1981 Nov 14;2(8255):1090-5. Nayor M, Vasan RS. Recent Update to the US Cholesterol Treatment Guidelines: A Comparison with International Guidelines. Circulation. 2016;133(18):1795-1806. Institute Of Medicine of National Academy of Sciences[Internet] Washington, DC: 2005. Dietary reference intakes. Energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids; p. 482.[cited 2018 Apr 30] Available from: https://www.nal.usda.gov/ sites/default/files/fnic_uploads/energy_full_report.pdf U.S. Department of Agriculture and U.S. Department of Health and Human Services[Internet] Scientific Report of the 2015 Dietary Guidelines Advisory Committee, 2015. [cited 2018 Apr 30] Availale from: :https://health. gov/dietaryguidelines/2015-scientific-report/06-chapter-1/ d1-2.asp Kapourchali FR, Surendiran G, Goulet A, Moghadasian MH. The Role of Dietary Cholesterol in Lipoprotein Metabolism and Related Metabolic Abnormalities: A Minireview, Critical Reviews in Food Science and Nutrition, 2016 Oct 25;56(14):2408-15 Rudkowska I, Jones PJH. Polymorphisms in ABCG5/G8 transporters linked to hypercholesterolemia and gallstone disease. Nutrition Reviews. 2008;66:343–48. Griffin JD, Lichtenstein AH. Dietary Cholesterol and Plasma Lipoprotein Profiles: Randomized-Controlled Trials. Current nutrition reports. 2013;2(4):274-82. Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Experimental & Clinical Cardiology. 2004;9(3):200-205. Paoli A. Ketogenic Diet for Obesity: Friend or Foe? International Journal of Environmental Research and Public Health. 2014;11(2):2092-107.

"Pill not for Every Ill":Behavioural and psychological interventions for Mental Health and Non Communicable Diseases (NCDs) Dr. Kedar Marahatta and Dr. Reuben Samuel WHO Country Office for Nepal NCDs and Mental Disorders are health threats that also adversely impact individual dignity, human rights and societal development. (1) Realizing this fact, the basic minimum interventions to prevent and treat priority mental health (MH) Disorders and NCDs are being proposed as a component of the Basic Health Service (BHS) package to be available for free to all as mandated by the constitution of Nepal. In addition to the interventions proposed in the BHS package, the government of Nepal is undertaking other more comprehensive programs for Mental Health and NCDs including the mental health gap (mhGAP) (2) based Community Mental Health Care Package (CMHCP) and the WHO Package of Essential Non-communicable Disease Interventions (WHO PEN) (3) respectively. These programs consist of a prioritized set of costeffective interventions that can be delivered at an acceptable quality of care, even in resource-poor settings. Both the PEN and the CMHCP strongly emphasize nonpharmacological interventions such as psychological and behavioural interventions for health promotion, reducing risk factors, and for treatment. Interventions to reduce alcohol use, to quit smoking, to help people remain physical active and to adopt healthy eating habits are recommended by the PEN (3) while psychological interventions to reduce stress and strengthen social support, motivational interviewing for alcohol use, behavioural action for depression are recommended by the CMHCP. These low technology interventions, if effectively delivered, can reap future savings in terms of reduced medical costs, improved quality of life and productivity. However, there are substantive gaps in the implementation of many of these interventions. This can be due to many factors: primary care providers are more bio-medically oriented; service seekers demand medications rather than the talk therapy; behavioural modification interventions are time consuming, they often require multiple sessions before results are visible and these interventions are often difficult as they demand significant changes in the social and the personal lives of the affected people. The current approach to train the existing cadre of primary care providers with additional skills does not seem to work very well as evident from the field experience of rolling out both the PEN and the CMHCP. The PEN training on behavioural interventions are limited to providing information and advice to individuals such as ‘you should quit smoking’, ‘you should eat 5 servings

of fruits and vegetables’ or ‘you should have moderate physical activity for at least 30 minutess each day for at least 5 days a week’. But these “simple advices" cannot adequately deal with complex issues such as smoking cessation or reducing harmful use of alcohol or changing eating or physical activity habits. The CMHCP on the other hand recommends more comprehensive psychological interventions which require skill based training for about 10 - 27 days for effective delivery. The implementation research on MH integration into Primary Health Care Centers (PHCCS) has shown that a new cadre of psychosocial workers – at a level similar to paramedical health workers - will be required at PHCCs to deliver these interventions effectively. (4) With the similar sets of skills required for psychological and behavioural interventions for both the PEN and the MH, it is rational to designate a health worker to be delivering these services in an integrated manner. There is potential to integrate these interventions to address other health issues requiring long term adherence, follow up and behaviour modification such as for HIV, Tuberculosis, childhood malnutrition, sexual and reproductive health or family planning. Given the central role of psychological/behavioural interventions in the prevention and treatment of chronic diseases, it is appropriate to create and employ a new cadre of health workers - the psychosocial workers - to deliver these interventions. This implies the establishment of a new accredited academic program to develop entry level psychosocial workers. Though, this demands significant resource investment, given the massive adverse impact that NCDs and MH disorders pose to health and development, it will result in good return. References: 1.

2. 3.

4.

Geneau R, Stuckler D, Stachenko S, McKee M, Ebrahim S, Basu S, et al. Raising the priority of preventing chronic diseases: a political process. Lancet Lond Engl. 2010 Nov 13;376(9753):1689–98. WHO | mhGAP Mental Health Gap Action Programme [Internet]. [cited 2018 May 9]. Available from: http://www. who.int/mental_health/evidence/mhGAP/en/ WHO | Package of essential NCD interventions for primary health care: cancer, diabetes, heart disease and stroke, chronic respiratory disease [Internet]. [cited 2018 May 9]. Available from: http://www.who.int/cardiovascular_ diseases/publications/pen2010/en/ Publications | Programme For Improving Mental Health Care [Internet]. [cited 2018 May 9]. Available from: http:// www.prime.uct.ac.za/prime-publications

My voice: Time for action to combat mental illness Shijan Acharya BPH, Institute of Medicine Global Health Alumni “It is difficult for me to study though I try hard. I always liked dancing but I am restricted to do that. My mother never loved me because I am a girl. Due to persistent pressure from family to study I feel stressed and I developed fainting tendency whenever I tried studying. People call it ‘hysteria’. In my family, I am not treated equal to my brother. When I have periods, I am not given food. I have to stay out of my room. I take medicines to halt my monthly period. I have taken medicine regularly for 4 months now. My own brother tried to harass me sexually. After that I attempted suicide, however I failed. If I had a friend or sister with whom I could share my feelings, I wouldn’t have to go through all of these by myself.” -A 15-year old girl

I met the girl when I visited a school of Kailali district a year back for mental health related study. It was really shocking to know what she had been through. Cases related to mental health issues are on the rise, due to many factors such as psychological illness, substance abuse, financial hardship, gender discrimination and rape.(1,2) Sharing of feelings to others or an expert would help prevent most of the cases like above, but mental illnesses are not discussed openly because of fear of stigmatization and social rejection. (3) The stigma of mental illness is an important constriction to access health care and to induce negative feelings such as hate, shame, disgrace or fear.(3) Such feelings lead to secrecy, reluctance to seek help from experts, isolation and social exclusion.(4) For those who go through such crisis, suicide may seem like the only available option. Data proves that suicidal rates are alarming. Suicide is the second leading cause of death among 15-29 age groups worldwide. Besides these there are many more attempted suicides.(1) In Nepal, suicidal rate have increased in past three years with majority being depression and

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mental illness.(5) The alarming increase in suicidal rate worldwide is now being recognized. The theme of World Health Day 2017 was “Depression: Let's talk.” However, in Nepal, hardly any programs are set forward to combat mental health issues.The health policy of Nepal 2014 emphasized on increasing investment in health services for mentally ill. Whereas in reality, only 2.85% of total budget has been given for health in 2075/76 (it was 7.4% in 2067/68), which is not enough even to provide basic health care.(6) So, there is dire need to address mental health issues in order to prevent many young people from being depressed and ultimately being the victim of suicidal deaths in future.

2. 3. 4. 5. 6.

References 1.

WHO.[updated 30th April,2018]. Available from: http://www.who.int/mental_health/prevention/suicide/

suicideprevent/en/. Patel V. Mental health in low-and middle-income countries. British Medical Bulletin. 2007;81(1):81-96. Regmi S, Pokharel A, Ojha S, Pradhan S, Chapagain G. Nepal mental health country profile. International Review of Psychiatry. 2004;16(1-2):142-9. Benbow A. Mental illness, stigma, and the media. The Journal of clinical psychiatry. 2007;68:31-5. Dhakal S. Sucides increasing at alarming rate, says report. The Himalayan Times. 2017 11th September, 2017. Neupane A. [Article]. Kathmandu: Swasthya Khabar Patrika, Help Publication Pvt. Ltd.; 2018 [cited 2018 May 11]. Available from: http://swasthyakhabar.com/newsdetails/23630/2018-04-06.

Universal Health Coverage and NCDs in Federal Nepal AmbikaThapa MPH, Institute of Medicine Countries which were able to control infectious diseases are now facing the problems of anti-microbial resistance and non-communicable diseases.. With the trend of health care transforming into health care industry, people of lower and middle income countries (LMICS) are in the trap of financial hardship with observed gap in health status. NCDs which were once taken as the disease of the rich are now knocking doors of poor harder and these are evident because of increasing premature deaths in LMICS (1). The commonly depicted picture of the cube lying within a cube in three dimension advocates for universal health coverage (UHC) and we are in a rush to see who, what and how much is covered with health care without financial hardship. (2). The health, economic and political benefits of UHC demands political vision and courage as many families are burdened with expenses in health care industry. The need of long term medication and expensive medical interventions with NCDs not only impoverish the families but also declines the productivity of person suffering from NCDs. Under the new constitution, Nepal is visioning its integrated health infrastructure development project and revising its basic health care service package. At this time, UHC approach can be used as the window of opportunity to tackle NCDs. The buying in of the easy and non-expensive interventions like

primary health care facilities based screening of NCDs (like regular monitoring of blood pressure) connected as part of UHC becomes vital to prevent deaths from stroke and cardiac arrest. UHC tuned up with programs on raising awareness and advocating the people on what they have been doing as part of the customary tradition of working in the farms and growing food for themselves have been the best possible prevention of the NCDs. With federalism, authority and accountability lies on the local government. Their lead in awareness raising programs about non-expensive interventions can ensure the availability and access of health care among the community people. Context based health care planning can help drastically decrease the community spending on health and focus on other investments that will help progress the health. The mechanism inbuilt to reduce development of major risk factors in NCDs, need to be included as part of UHC- an example of it being the move towards Framework Convention for Tobacco Control. The dimension of UHC should move with people’s perspective and contextualize what people want rather than one size fit all approach. 1. 2.

Nugent R. Benefits and Costs of the Non communicable Disease Targets for the Post-2015 Development Agenda. Copenhagen Consensus Center. Perspective Paper. 2015. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization. 2013 Aug;91(8):602-11.

Improving data quality in Nepal Dr. Nitesh Shrestha Global Health Alumni It is good news that evidence-based decision making is gaining wider acceptance in Nepal. In this light, we now need to ensure better quality of our data. In particular, we need to focus on proper recording and reporting because they form the basis of generation of required data. In this article, I will briefly outline current issues regarding recording and reporting in Nepal and possible ways to address them with emphasis on NCDs. I thought it would be highly relevant to talk about this problem in relation to NCDs because I feel concerned about the data we have regarding NCDs. We are missing out on a lot of data related to NCDs and this might be one of the reasons why the figures representing burden of NCDs in Nepal appear to be unexpectedly low in documents such as Annual Report

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published by the Department of Health Services (DoHS). Certain factors need to be considered for this situation. First, in my experience there is a tendency to underrecord encounters with patients of NCDs. For example, health professionals may measure the blood pressure or provide some service to a hypertensive patient but they do not record it. One of the possible reasons could be that they consider the service too meagre to be recorded. However, event that is not recorded is equivalent to the case being non-existent and the service never being provided in the eyes of the health system. Our health professionals need to be made aware about this. Secondly, recording a case of NCD is a bit tricky especially for ones not used to it. Patients of communicable diseases usually get cured in a single visit and the recording becomes relatively simpler whereas in case of NCDs, the same patient has several follow-up visits and if these are not recorded properly, it will lead to under reporting. This problem may be addressed by conducting trainings about Health Management Information

System (HMIS) and encouraging health professionals to discuss amongst themselves within each institution to ensure proper recording. Lastly, there are no extensive national programmes and hence no separate section in current HMIS forms for NCDs yet. Updating HMIS forms to incorporate NCD data will be helpful. We are also missing out on the data from the private sector from where large numbers of patients get services. However, getting

data from the private sector has not been a priority. Mostly, it is left to individual private institutions to maintain and report their data. This might lead to a large amount of data never getting into the national system. So, innovative measures to ensure recording and reporting from the private sector such as involving them in annual reviews may be fruitful.We need to further strengthen the HMIS so that it depicts the current health scenario, including burden of NCDs, more robustly.

Are Electronic Nicotine Delivery Systems (ENDS) really a safer alternative to cigarette smoking? Dr. Pranil Man Singh Pradhan MD Global Health Alumini Electronic Nicotine Delivery Systems (ENDS), also called e-cigarettes, e-cigars, personal vaporizers, vape pens, e-hookah or vaporing devices, operate by heating a solution to generate aerosol. These devices do not burn tobacco leaves but vaporize a solution which is inhaled by the user. Main constituents of the solution are nicotine, propylene glycol with or without glycerol and flavoring agents like fruits, candy, coffee, peppermint, bubble gum and chocolate. ENDS can resemble traditional cigarettes, cigars, pipes and nowadays these are manufactured as gadgets charged through USB ports and use nicotine cartridges or ‘pods’ with various flavors. (1,2) The aerosol generated from ENDS produces glycols, aldehydes, volatile organic compounds, polycyclic aromatic hydrocarbons (PAHs), tobacco-specific nitrosamines (TSNAs), dicarbonyls and hydroxycarbonyls, many of which are known to cause ill health effects. Higher concentration of nicotine in ENDS is likely to be more addictive. In addition, nicotine has adverse effects on fetus during pregnancy and may function as a tumor promotor. Long term use of ENDS is expected to increase the risk of chronic obstructive pulmonary disease and cardiovascular diseases. Flavoring agents in ENDS have been known to cause airway irritation. Second hand aerosol exposure from ENDS can be damaging to bystanders due to respiratory pre-conditions. (1) Evidence on ENDS as a suitable alternative for smoking cessation is scant therefore not suitable to generate credible inferences. Reviews have also suggested that ENDS could reduce the chances of quitting smoking; however the evidence was of low quality. Longitudinal studies indicate that ENDS use by minors, who have never smoked, doubles their chance of smoking in

the future. Use of ENDS by the youth has drastically increased in the United States, exceeding the combustible tobacco use. (3) In such scenario, there is considerable debate regarding whether the ENDS use among youth is a precursor to smoking or it promotes dual use of ENDS and smoking.(1) In context to Nepal, there is scant published literature on the use of ENDS. Tobacco Product Control and Regulatory Directive 2014 has strict provisions against electronic cigarettes and prohibits its manufacture, import, sale and distribution in public places and public transportations. The directive has also prohibited the promotion and advertisement of electronic cigarettes through media. However, these products are easily available in online stores for purchase. As we celebrate World No Tobacco Day 2018 focusing on tobacco and heart diseases, more effort is needed to explore ENDS use in Nepal and associated health effects before we can reach a conclusion on ENDS as a safe alternate to cigarette smoking. References 1.

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WHO FCTC. Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ ENNDS) Report by WHO. In: Conference of the Parties to the WHO Framework Convention on Tobacco Control [Internet]. 2016. Available from: http://www.who.int/fctc/ cop/cop7/FCTC_COP_7_11_EN.pdf?ua=1 American Academy of Pediatrics. Electronic Nicotine Delivery Systems [Internet]. [cited 2018 May 30]. Available from: https://www.aap.org/en-us/advocacy-and-policy/ aap-health-initiatives/Richmond-Center/Pages/ElectronicNicotine-Delivery-Systems.aspx Willett JG, Bennett M, Hair EC, Xiao H, Greenberg MS, Harvey E, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob Control. 2018 Apr 7;

Experiences of attending 11th European Breast Cancer Conference Abha Sharma MSc Nursing, Global Health Alumni Personal Experience 11TH European Breast Cancer Conference (EBCC) was held in Barcelona, Spain from 21-23 March, 2018 with the aim to provide a unique multidisciplinary setting for all professionals with a common interest in breast cancer to discuss debate, inform and educate about breast cancer’s evolving landscape. This conference highlighted the importance of teamwork and interactions between all professionals and specialties involved in breast cancer. I got an opportunity to present my research entitled “Depression and its predictors among breast cancer patients in Nepal” as a poster in the conference. The central attraction of the conference was the manifesto- Call to action for policy makers, health professionals and advocates in all European countries on the topic “Genetic risk prediction testing in breast cancer.” The manifesto stated “Information about a person’s genetic make-up is providing crucial clinical information about risk, prevention and treatment in breast cancer

and other diseases, and is a rapidly evolving field. Genetic tests that predict someone’s risk of getting breast cancer are now widely available not only in national health systems but also commercially, including on the internet, for low cost and frequently unregulated for quality and guidance. The results of such tests can be complex and misinterpreted if people do not have access to high-quality explanation and counseling, and can lead to pressure on health systems if testing increases (such as with the ‘Angelina Jolie’ effect in the US and elsewhere). (1) It is important that genetic risk prediction in breast cancer is available to people and their doctors and the EBCC recognizes that people have freedom to obtain the latest genetic tests if they are unavailable through national health systems. But tests must be of high quality and information must be interpreted by appropriate healthcare professionals to give people an accurate understanding; to inform evidence-based interventions; and to avoid possible harm, both physical and psychological, through unnecessary interventions and anxiety.” (1)

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Similarly, the Chair of the conference, Professor Robert Mansel has called for men to be included in trials to find better treatments for breast cancer. He also added “We need trials to start including men, so that we can discover whether or not they respond in the same way to targeted treatment as women. They may not as the hormones involved in the cancer are different, but until this is investigated in trials.”

work is an essence to provide quality of life to cancer patients, survivors and families. The conference gave equal importance to screening, treatment and psychological rehabilitation of patients as well as families for positive outcome.For developing countries, these conferences give a clear overview of the breast cancer treatment horizon which we have to thrive for.

The conference included teaching lectures, round table, plenaries, manifesto session, debate and clinical science symposiums to communicate data, information, advancement, clinical trials and success stories as evidence that multidisciplinary team

European Cancer Organization.Manifesto-Genetic risk prediction testing in breast cancer. 2018. https://www.ecco-org. eu/Events/EBCC11/Manifesto (accessed 11 May 2018)

Reference

Journey of Global Health Course leading to endless possibilities

Dr Alisha Manandhar,MBBS Global Health Alumni Personal experience Health has always been a fascinating field to me-one of the foremost reason I chose to study Medicine. It is so diverse that I find countless ways to help those in need. Health care has endless possibilities and room to grow to help improve people’s lives. I grew up wanting to help people and by being able to finally work in this field I realized how much opportunity there is to do so in countless ways. I am genuinely interested in the field of Global health focusing on community and public health concerns where I believe I can create changes in innumerable ways coming across day to day hindrances people are facing regarding health and its standards. It is a matter of great sorrow that major communicable diseases have long been eradicated from developed countries but is still a big concern in developing countries like ours.

long years of rigorous medical school training and one year of work with cardiac patients. One day I came across the Global Health Course that was going to be organized in IOM. My happiness and ecstasy knew no bounds. Without a second thought, I quickly went through the post in the website and applied then and there for the course. It was the most appropriate time for me to work in the field of health and education which would allow me to challenge myself through critical thinking, creativity and innovative ideas since it fits my educational background, my continuous willingness to learn new skills and a perfect chance to improve upon them. Luckily, I was chosen for the interview. Interview session went quite well but I was still bewildered whether I would be chosen or not as there were equally competitive applicants. But to my happiness, after few days I received a mail with the invitation to join the course.

In the current era of globalization, the world is more interdependent than any other time. It has allowed more people and products to travel around the world at a faster pace. Meanwhile it also opens the airway to transcontinental movement of infectious disease vectors. Globalization has increased the spread of infectious diseases from South to North, but also the risk of non-communicable diseases by transmission of culture and behavior from North to South.

As I aspire to work in the same field in future, I believe that this course will be valuable in helping me develop a deeper understanding of complex dynamics that drive the health care delivery. I strongly believe this opportunity will help me collaborate with allied health professionals in developing educational programs to raise awareness about early diagnosis, better disease management and improved patient prognosis. These experiences will certainly foster strong skills which will translate both in a hospital and community level. Furthermore I am eager to apply lessons that I have learnt in the course to improve clinical quality and patient prognosis in healthcare delivery system.

I had recently resigned from my job after one year of continuous full time duty as a House Officer in Manmohan Cardiovascular Thoracic and Transplant Center in IOM and was making plans to leap towards yet another journey of preparation for postgraduate studies. I was enthusiastically looking forward to something innovative I could do with the skills I possessed through five

I possess a strong determination that can be a great addition to a team of healthcare activists serving my nation. The combination of my academic and practical experiences will provide me the interpersonal and analytical skills which will enable me to make significant contribution to support services and patient centered care in future.

About Global Health Newsletter Global Health Newsletter is an initiative of the Global Health Unit, NCHPE, IOM to sensitize health professionals about global health issues, engage its alumni and other interested in writing articles on pertinent issues of global health and to inform people about the activities of Global Health Unit. Thus, this newsletter is an advocacy tool for promotion of global health. This newsletter is the first issue and we will continue to bring out further issues. We welcome research report, view points, commentaries, short communication, and interesting facts on global health in our future issues. You can email us at [email protected]

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Mailing address Global Health Unit National Center for Health Professions Education Institute of Medicine, Tribhuvan University Mohego Building, Maharajgunj, Kathmandu, Nepal Email: [email protected] Post Box No: 2533 Website : www.ghciom.com