Rwanda: Transforming Eye Care

 The charity ‘Vision for a Nation’ has transformed eye care in Rwanda and now the Government of Rwanda has assumed responsibility for the management and financing of primary eye care services as from January 2018.

“In just five years we have built a sustainable nationwide eye care service that is accessible to all 11.8 million Rwandans.

In the first truly nationwide programme of its kind, we have worked with the Government of Rwanda to:

  • Establish local eye care services across Rwanda
  • Develop an eye health course for the rapid training of general nurses
  • Train general nurses for deployment at all of the nation’s 502 health centres
  • Build a nationwide supply chain for eye medication and glasses from Asia to all of the health centres
  • Mobilise the public to access the new service at their local health centre
  • Extend the service to each of the nation’s 15,000 local villages”



Diarrhoea kills half a million children globally

“Globally, in 2015, we estimate that diarrhoea was a leading cause of death among all ages (1·31 million deaths, 95% uncertainty interval [95% UI] 1·23 million to 1·39 million), as well as a leading cause of DALYs because of its disproportionate impact on young children (71·59 million DALYs, 66·44 million to 77·21 million). Diarrhoea was a common cause of death among children under 5 years old (499 000 deaths, 95% UI 447 000–558 000). The number of deaths due to diarrhoea decreased by an estimated 20·8% (95% UI 15·4–26·1) from 2005 to 2015. Rotavirus was the leading cause of diarrhoea deaths (199 000, 95% UI 165 000–241 000), followed by Shigella spp (164 300, 85 000–278 700) and Salmonella spp (90 300, 95% UI 34 100–183 100). Among children under 5 years old, the three aetiologies responsible for the most deaths were rotavirus, Cryptosporidium spp, and Shigella spp. Improvements in safe water and sanitation have decreased diarrhoeal DALYs by 13·4%, and reductions in childhood undernutrition have decreased diarrhoeal DALYs by 10·0% between 2005 and 2015.” Study published in the Lancet




Precision global health: beyond prevention and control

“As we step into 2017 and look back at the past year, Zika undoubtedly stands out. 2016 saw the rise and fall of the epidemic in the Americas and worldwide spread of cases, until WHO declared on Nov 18 that the virus and associated consequences no longer constituted a Public Health Emergency of International Concern, but represented a “significant enduring public health challenge requiring intense action”. As such, Zika joined other “enduring public health challenges” to which “intense action” has been directed for a long time, particularly other communicable and vector-borne diseases, on the list of health priorities. With Zika we are almost in uncharted territory: the heterogeneity in the natural history of the disease and transmission pathways still blur the picture of what is likely to be a long-term global health issue. Yet with some other diseases, a wealth of knowledge and seemingly defined course of action have not enabled us to close the chapter.

Much has been achieved on malaria, for example, but progress is fragile and we are still scrambling in areas where the burden persists despite decades of interventions. One major concern is resistance to pyrethroids used in long-lasting insecticidal nets (LLIN), a cornerstone of malaria control. During the 65th American Society for Tropical Medicine and Hygiene (ASTMH) meeting in Atlanta in November, WHO released the results of a study that shows that LLINs provide protection against malaria even in areas with resistance. However, in this issue of The Lancet Global Health, Laura Steinhardt and colleagues report contrasting results of a case control study in Haiti that raises doubts on the usefulness of nets in a low transmission setting, hinting that their mass distribution is not a panacea everywhere. In fact, a session at ASTMH explored key knowledge gaps in malaria interventions and raised thought-provoking questions on what is needed to finally get rid of the disease, given issues of resistance, uncertainties about newer strategies such as seasonal malaria chemoprevention or intermittent preventive treatment for pregnant women, and potential impact of the RTS,S vaccine. As highlighted during the session, there is no silver bullet, and success may only be found by putting multiple axes of pressure on the vector through combinations of interventions. The trick is figuring out what combination works in what setting, and that seems to be the next big question around malaria elimination: how do we develop decision tools to tailor interventions to a set of biological and social determinants—in other words, how do we move on to a more customised approach, through what could be called “precision global health”?

The idea of a “precision” approach to global health is not limited to malaria. Prevention strategies against soil-transmitted helminths (STH) for example have included water, sanitation, and hygiene interventions and mass drug administration, another imperfect and controversial intervention as highlighted in an Article by Vivian Welch and colleagues and two Comments in this issue. In their network meta-analysis, Welch and colleagues found little to no effect of mass deworming on children’s growth, cognition, and school attendance. Eliminating the last pockets of STH incidence and prevalence will therefore require another precision approach, maybe one that combines controlling the parasites with working on more distal determinants of infection such as poverty.

A tailored approach will also help in reaching broader global health targets. The decrease in child mortality during the Millennium Development Goals era has been real but insufficient, and unequal. In some areas progress could be accelerated with more refined targeting of causes of death. Knowing where to target interventions to reduce mortality, by analysing the variability in the distribution of health outcomes for different causes would optimise efforts to reduce child mortality. A study by Marshall Burke and colleagues published in the last issue provides such valuable input, by identifying subnational mortality hotspots across sub-Saharan Africa in which the mortality decline is not on target to reach the Sustainable Development Goals (SDG) by 2030, as well as potential drivers for the difference in mortality. Spatial analyses of this kind provide crucial granular information—in line with a precision approach to global health—that could contribute to the progress towards the SDGs.

So beyond the essential steps of event surveillance and case management, on which the prevention and control of diseases are based, if we are to truly advance health and eliminate diseases, a case can be made for a tailored approach and the advent of precision-style global health.” Lancet – Global Health – Jan 2017


Heart Disease and Strokes top the 10 most common causes of death

Of the 56.4 million deaths worldwide in 2015, more than half (54%) were due to the top 10 causes. Ischaemic heart disease and stroke are the world’s biggest killers, accounting for a combined 15 million deaths in 2015. These diseases have remained the leading causes of death globally in the last 15 years.

Chronic obstructive pulmonary disease claimed 3.2 million lives in 2015, while lung cancer (along with trachea and bronchus cancers) caused 1.7 million deaths. Diabetes killed 1.6 million people in 2015, up from less than 1 million in 2000. Deaths due to dementias more than doubled between 2000 and 2015, making it the 7th leading cause of global deaths in 2015.

Lower respiratory infections remained the most deadly communicable disease, causing 3.2 million deaths worldwide in 2015. The death rate from diarrhoeal diseases almost halved between 2000 and 2015, but still caused 1.4 million deaths in 2015. Similarly, tuberculosis killed fewer people during the same period, but is still among the top 10 causes with a death toll of 1.4 million. HIV/AIDS is no longer among the world’s top 10 causes of death, having killed 1.1 million people in 2015 compared with 1.5 million in 2000.

Road injuries killed 1.3 million people in 2015, about three-quarters (76%) of whom were men and boys.

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