People are now living longer in sub-Saharan Africa than they did two decades ago. This is an achievement, given that life expectancy in the region went down the drain from the 1990s to the mid-2000s as it choked under the devastating effects of the HIV epidemic.

The question to ask is whether the additional years are spent in good or poor health. This question matters because how long people live affects the population’s state of health and leading causes of disability. Longevity means that these change over time which in turn has implications for policy, planning and provision of services.

We used information from the Global Burden of Disease study to calculate healthy life expectancy in sub-Saharan Africa. Healthy life expectancy refers to the average number of years that a person at a given age can expect to live in good health, taking into account mortality and loss of functional health.

The data suggest that people are living many years in poor health in the region. And our paper shows that there are large inequalities in healthy life expectancy and disease burden between – and within countries – in sub-Saharan Africa.

This points to the fact that much more effort is needed to increase healthy life expectancy in the region.

Discrepancies

We found that the increase in healthy life expectancy in sub-Saharan Africa was smaller than the increase in overall life expectancy. This indicates that many years are lived in poor health in the region. In 2017, life expectancy at birth in sub-Saharan Africa was 63.9 years, but healthy life expectancy was only 55.2 years. This means that 13.6% of years of life in the region is spent in poor health.

Life expectancy in 2017 varied by sub region, ranging from 62.4 years in Central Africa to 65 years in Southern Africa. However, in Central Africa 14.4% and in Southern Africa 13.8% of these years are estimated to be spent in poor health, respectively.

The proportion of years of life spent in poor health varied between countries, ranging from 11.9% in Djibouti to 14.8% in Botswana.

While women live longer than men, many of these extra years are lived in poor health. The life expectancy at birth for women in sub-Saharan Africa in 2017 was 66.2 years, but healthy life expectancy was only 56.8 years. Thus, women spend 14.2% of their years in poor health. For men, life expectancy was 61.7 years and healthy life expectancy was 53.7 years. Thus, men in sub-Saharan African spend 13% of their lives in poor health.

Healthy life expectancy

The average healthy life expectancy at birth in sub-Saharan Africa increased by 9.1 years, from 46.1 years in 1990 to 55.2 years in 2017. The increase in health life expectancy at birth varied from 0.9 years in Southern Africa to 12.4 years in Eastern Africa.

Even larger variations in healthy life expectancy than these were observed between countries, ranging from a decrease of 4.9 years in Lesotho (51.9 years in 1990 to 47 years in 2017) to an increase of 23.7 years in Eritrea (30.7 years in 1990 to 54.4 years in 2017).

In most countries, the increase in healthy life expectancy was smaller than the increase in overall life expectancy, indicating more years lived in poor health.

Causes of premature mortality and disability

We calculated a measure known as disability-adjusted life-years, which captures both early death and ill health. In 2017, the leading causes of disability-adjusted life-years in sub-Saharan Africa for all ages and both sexes combined were neonatal disorders, pneumonia, HIV/AIDS, malaria, and diarrhoea.

However, we observed various dramatic changes in causes of early death and disability between 1990 and 2017. Measles decreased from a ranking of 5th to 20th, heart attacks increased from 16th to 11th, stroke from 12th to 10th, and diabetes from 27th to 14th. We are thus witnessing gradual shift from communicable to non-communicable causes of disease burden.

There was wide variation between countries in the causes of early death and disability.

In Eritrea, the top causes of early death and disability were neonatal disorders, diarrhoea, tuberculosis, pneumonia, and congenital defects. The most dramatic changes were with conflict and terror (1st in 1990 to 14th in 2017), measles (7th to 74th), tetanus (9th to 82nd), heart attacks (17th to 11th), stroke (12th to 10th), and diabetes (22nd to 15th).

In the Central African Republic, the top causes of early death and disability were diarrhoea, neonatal disorders, pneumonia, HIV/AIDS, and tuberculosis. The main changes were with conflict and terror (164th to 9th), measles (7th to 20th), heart attacks (14th to 11th), and diabetes (21st to 16th).

In South Africa, the top causes of early death and disability were HIV/AIDS, neonatal disorders, pneumonia, interpersonal violence, and diabetes. The most dramatic changes occurred with HIV/AIDS (53rd to first), measles (12th to 55th), diarrhoea (2nd to 8th), and diabetes (from 13th to 5th).

In the Gambia, the top causes of early death and disability were neonatal disorders, pneumonia, HIV/AIDS, diarrhoea, and sickle cell disease. There were substantial changes in rankings for HIV/AIDS (61st in 1990 to 3rd in 2017), malaria (4th to 25th), measles (9th to 70th), heart attacks (13th to 6th), stroke (14th to 9th), and diabetes (28th to 18th).

Extraordinary progress, but . .

Since 1990, we have seen exceptional progress in sub-Saharan Africa in reducing the burden of communicable diseases, especially measles, tetanus and other vaccine-preventable diseases. However, early death and disability due to these causes remain unnecessarily high in many countries. Immunisation efforts have been helpful, but progress in coverage has slowed in the past decade. Close to 20 million children worldwide, most of them in sub-Saharan Africa, didn’t receive vaccines against these deadly diseases in 2017. Conflict, inadequate investment in national immunisation programmes, and vaccine stock outs were among the reasons for the stalled progress in immunisation coverage.

Our report shows that there is an unfinished agenda of controlling communicable diseases – compounded by an increase in non-communicable diseases – in sub-Saharan Africa. The continued burden of disabling conditions has serious implications for health systems and health-related expenditures in the region.

Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Maternal mortality remains high around the world, with more than 303,000 women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa.

A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About 15% of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.

One potentially devastating complication in childbirth is obstetric fistula. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated 50 000 to 100 000 women in sub-Saharan Africa develop fistula every year.

If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.

While conducting research in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.

In my more recent research I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost.

Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.

Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings.

What we found

Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region.

We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system.

We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.

We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51.

What is needed

Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries.

But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas.

Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula.

While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high as 99%. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes.

All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.

Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.

Tobacco remains the biggest public health threat, killing more than seven million people globally every year. The World Health Organisation (WHO) has recognised progress in Nigeria, but concerns remain about effective implementation.

Nigeria is a key tobacco industry market in Africa because of its population size and access to other markets in the region. One of the largest publicly traded tobacco companies in the world, British American Tobacco, built a state-of-the-art manufacturing plant in the country in 2003 to service West African countries. In 2016, BAT opened its new West Africa Head Office in Lagos.

A Global Adult Tobacco Survey done six years ago estimated that 4.5 million Nigerian adults smoked. The country has an estimated population of 198 million. Nearly a third of the adult population was exposed to secondhand smoke.

Nigeria started trying to regulate tobacco smoking in the 1970s. But it only enacted its first tobacco smoking control decree in 1990. This made Nigeria one of the first African countries to regulate tobacco. But the decree became less and less relevant because the government didn’t raise public awareness or prioritise implementation.

In 2005, Nigeria signed the WHO Framework Convention on Tobacco Control. But it took until 2015 to pass a law, the National Tobacco Control Act to implement the framework.

Nigeria’s 2015 National Tobacco Control Act was an improvement on the 1990 Act because, among other things, it:

• regulated the interaction of government and industry,

• regulated e-cigarettes, and other tobacco products,

• established the National Tobacco Control Committee (a multisectorial coordinating mechanism) and a Tobacco Control Fund, and

• stipulated more stringent measures for violating the law.

But the law had lots of loopholes. And three years later it still hasn’t been implemented.

Why implementation is moving so slowly

The non-implementation of the 2015 tobacco law is due to problematic clauses slipped in late in the process of passing it.

In particular, the act includes the unprecedented requirement that regulations prepared by the federal ministry of health must be approved by the National Assembly. This additional step slows down the process. It also provides another opportunity for the tobacco industry to block progress.

The regulations have not yet been submitted to the National Assembly.

The law also requires the Standards Organisation of Nigeria, a body that regulates products, to issue guidelines for regulating tobacco products.

A major problem with the organisation is that the tobacco industry dominates its processes. For example, tobacco industry representatives outnumber those from other agencies on the committee that writes the guidelines.

The Standards Organisation has defended this situation by saying it is mandated by law to include the industry. But having the tobacco industry on the committee is a serious impediment to developing effective regulations.

Another problem with these guidelines is that they only cover cigarettes at present, not all tobacco products. This leaves snuff, hookah, pipe, and e-cigarettes without any regulatory guidelines.

The tobacco industry in Nigeria is aware of every move the government makes even before new measures are introduced. This is because it has representatives on the regulatory committee as well as through membership of the National Tobacco Control Committee. This means that the industry is in a position to mobilise against any new regulations.

These situations represent clear conflicts of interest and violate Article 5.3 of the WHO’s framework which commits parties to insulate public health policy making process from the tobacco industry’s interference.

Moving Forward

Fresh efforts have been made to close the loopholes in the 2015 law by getting an updated law through the Senate. This includes ensuring that there is zero industry interference

Because of its size, Nigeria has the potential to boost the global anti-tobacco movement. But this requires it to have comprehensive laws in place that are compliant with the Framework Convention on Tobacco Control. And that are properly implemented and evaluated.

Advocates and policymakers in other African and low and middle income countries should learn from Nigeria’s experience and focus on making laws that are strong from the outset.

And since the tobacco industry is a major threat to comprehensive and effective tobacco control policies, countries should ensure strict compliance with the framework to ensure non-interference – direct or indirect.

The other step the Nigerian government needs to address is the fact that tobacco control is massively underfunded. Tobacco control is mostly funded by international donor agencies rather than the government. It’s time the government took responsibility for the lives of its people and adequately fund tobacco control activities.

Catherine O. Egbe, PhD currently works for the South African Medical Research Council, Alcohol, Tobacco and Other Drug Research Unit, Pretoria, South Africa.

Stanton Glantz receives funding from the National Institutes of Health and the Truth Initiative.

Stella A. Bialous receives funding from research funding from California’s Tobacco Related Diseases Research Program, NCI, ISNCC. She is a board member of Americans for Nonsmokers Rights, international Society of nurses in cancer Care, sacred heart cathedral preparatory.

At any given time, there are around 4300 people waiting for organ donations in South Africa. These patients usually need new livers, kidneys, lungs or hearts. But organ donors are in very short supply.

This isn’t unique to South Africa. Many countries around the world are unable to meet the demand for donor organs. There are a few exceptions, though. One example is Norway, where a surplus of deceased donor livers has been reported.

So what explains South Africa’s organ donor shortage?

Religious and cultural beliefs play a role, because they influence the decisions people make about the remains of their loved ones. Sometimes families prefer that a relative’s body remain whole and intact; in other cases it’s considered important to bury a person within a certain time frame. But attributing the shortages to these factors alone grossly oversimplifies the issue, as research has shown.

There are many complex elements that keep donor numbers low. These permeate the social fabric from a population and legislation level down to the practice of health care workers in hospitals.

It’s important to tackle each of these elements to ease the country’s organ donor shortage.

Public perception

At a societal level, religious and socio-cultural practices do play a role in the shortage of donor organs. But in my extensive research into the factors influencing low donor numbers, other issues have come to the fore.

These include a suspicion of the biomedical system in South Africa. Sometimes there are perceptions that doctors and hospitals can’t be trusted, or that some aspects of practice are unethical.

Some of these opinions are justified; the so-called kidneygate saga of 2001 is one example of poor medical ethics. This scandal saw “donors” from poor families in Brazil flown to South Africa and paid a nominal sum for a kidney, which was implanted in most cases into wealthy Israeli recipients. The sale of human organs is illegal in South Africa, as it is in most other parts of the world.

The issue is also influenced by a negative and often sensationalist portrayal of organ donation in the media, and reports of unethical research on the continent.

Suspicion breeds distrust. People question what will happen to their loved ones’ organs should they suspect that doctors and hospitals profit from donations. In the face of these questions, many families find it easier to refuse organ donation, especially in light of the mixed messages which are often communicated to the public.

Legislation

South Africa’s organ transplant legislation is vague. The National Health Act admirably addresses the serious issue of organ trafficking and perverse incentives. It also specifically stipulates that consent to deceased organ donation can be written or oral, and can be given by a mentally competent person in the presence of two witnesses prior to that person’s death.

Technically, this means that a next-of-kin consent to organ donation isn’t actually required where the person stated a preference to donate during his or her lifetime. But the Act doesn’t go any further in adequately addressing the procurement of donor organs from people who are deceased. For example, the law doesn’t make it mandatory to offer all eligible families the option of donating a relative’s organs after brain-stem death, and the conflicts with common law norms are not resolved.

This has left a vacuum. Questions about the legal rights of a person to decide what is done with their remains after they have died need to be weighed against the family’s decision making rights. Families have some common law rights to determine the fate of the remains of their next-of-kin.

As a result, written family consent for organ donation is required in South Africa, though it is not a legal necessity.

Donors are lost at this point. A number of people who would willingly donate may fail to inform their families of their decision. People think that signing up as a donor is enough to guarantee that their organs will be considered for donation upon their death. But telling one’s family is in fact the most important thing. Even if a person has signed up as an organ donor during their lifetime, the family can still reverse this decision under the current system. They may be more likely to do so if the decision has not been communicated in advance.

Another challenge is that health care workers sometimes face difficult situations, for example, around concepts like brain-stem death. This is an essential step in the organ donation process, because only people who are legally certified as deceased can be deceased organ donors. In South Africa, brain-stem death is a legally accepted definition of death. This can be difficult to understand, especially when the patient is maintained on a mechanical ventilator, still looks pink and feels warm. When such a patient has been declared brain-stem dead they are unequivocally deceased. But it can be hard to believe.

In our research, we found that this was especially true for nursing staff, for whom the saving and maintenance of life is an imperative goal. There was a sense that the person was being “killed” even though the donor is already dead.

Finding solutions

It’s clear, then, that no single factor is keeping organ donor numbers low in South Africa. Policymakers, health care professionals, civil society advocacy groups and academics must work collaboratively to address these issues if the situation is to be improved.

There are a number of countries that have increased their donor numbers by introducing more robust policy. The most notable is Spain, where they have adopted an “opt-out” system under which it’s assumed that a person consents to organ donation when they die, unless they have issued a clear, written statement to the contrary.

Harriet Etheredge does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Some people suffer from repeated attacks of malaria. These can occur weeks to months or longer after contracting the disease. The phenomenon is only too familiar to those who were bitten by mosquitoes carrying the type of malaria-causing organism known as Plasmodium vivax. Whereas the malaria agent in Africa is primarily Plasmodium falciparum, P. vivax is the most widespread of the more than half a dozen malaria parasite species that infect humans globally.

An unresolved issue is why people experience recurrences of P. vivax malaria despite having received treatment for the disease. There’s also still not absolute clarity about where – in which organs and tissues – the parasites that are responsible for persisting infections hide. Because we don’t know this, we can’t determine how to kill them. Without filling in these blanks, we won’t be able to achieve the goal of eradicating malaria parasites everywhere in the world.

For the past four decades, I have intermittently been giving consideration to what makes malaria recur long after people have become infected by P. vivax, and have made some significant conceptual breakthroughs. These, combined with subsequent research by other scientists, have greatly enhanced our understanding of why malaria recurs.

The most recent advance has been the ultimate acceptance of the theory I first propounded seven years ago. Namely, that the parasite multiplies – undetected – in more organs and tissues in the body than only the liver and bloodstream (which is conventional dogma).

One of the outcomes of this new conclusion is the increasing realisation that drugs might not eliminate malaria parasites with equal efficacy in all of the parts of the body that they inhabit. This is a possible explanation (there are others too) for why malaria can recur despite treatment.

We still don’t have all the answers. But significant new insights are emerging which have important implications for the treatment of malaria, and eventually its eradication.

The journey of discovery

For some time now, it has been assumed that there’s only one source of malarial relapse, namely, a dormant liver stage of the P. vivax parasite called the “hypnozoite”. This term, which I coined 41 years ago, is derived from the Greek words hypnos (sleep) and zoon (animal). Thus, a “sleeping animal”.

When a hypnozoite wakes up, it multiplies in the liver cell in which it’s living, resulting in the formation of a large number of progeny, called merozoites. After emerging from the liver cell, they invade red blood cells and reproduce inside them. When these cells burst, they release merozoites which then enter other red blood cells, in which the cycle is repeated.

It’s the ongoing proliferation of merozoite stage parasites in the bloodstream that leads to a recurrent bout of symptomatic illness.

Until now, liver cells – and especially blood vessels – have generally been considered to be the only habitats in humans where malaria parasites live and multiply.

But biomedical knowledge has changed. It’s now becoming clearer that recurrences are caused by not only merozoites inside blood vessels, but in fact by merozoites outside blood vessels too.

Seven years ago, I pointed out for the first time (on the basis of some complicated initial evidence) that P. vivax recurrences can also be explained if there is a reservoir of merozoites outside the bloodstream.

The concept is simply that the non-bloodstream origin of P. vivax malarial recurrences can be both merozoites that occur outside blood vessels and hypnozoites in the liver (not hypnozoites only).

More recently, I figured out at the University of the Witwatersrand that bone marrow probably serves as a merozoite reservoir for the P. vivax parasite. Other researchers had already suggested the possibility.

Additionally, I have repeatedly rationalised that the same thing might apply to the spleen, and perhaps other sites too. This was concluded by joining the dots (in other words, theoretically), partly through analysis of published literature, some of it relatively obscure.

A paradigm shift

This improved understanding is an important development and has implications for both the treatment of malaria and elimination of malaria parasites in human populations. This is because there are indications that a drug that kills merozoites in one site in the body will not necessarily kill all merozoites that occur elsewhere.

So not only might the patient not be cured, but parasites may periodically enter the circulating bloodstream and be sucked up by mosquitoes when they feed. This can result in further transmission of malaria when the infected mosquitoes bite other people.

But scientific dogma is often firmly entrenched. It took until last year for the idea that there is a dual origin of non-bloodstream parasites in P. vivax recurrences (both merozoites outside the bloodstream and hypnozoites) to gain acceptance.

Disbelief – as well as some demonisation in knee-jerk reactions to my unconventional views – is progressively metamorphosing into agreement. This is happening mainly because of new research at Harvard University, the University of Glasgow, and elsewhere. Studies have yielded results which can be adduced as additional support for my seven-year-old concept.

Consequently, a dramatic – and welcome – shift in attitude is taking place. Malariologists are beginning to reiterate my concept and repeat supporting evidence for it that I had unearthed and included in bits and pieces in my publications in recent years, as well as presented at international conferences.

What’s next

More research is being carried out to gain an even deeper understanding of the process of malarial recurrence. It involves studying parasites in cell culture, laboratory mice, and non-human primates, using sophisticated imaging and other cutting edge techniques. In association with this work, drug-related investigations are being undertaken in order to find out how best to treat patients who have P. vivax malaria.

Miles B. Markus received relevant funding from the Bill & Melinda Gates Foundation; the British Council; the Royal Society (U.K.); the Wellcome Trust; and the South African Medical Research Council. A relevant conference travel grant was awarded by the National Research Foundation of South Africa.

Tuberculosis (TB) is one of the leading causes of death from infectious diseases. Globally, it accounts for around 1.3 million deaths and 10.4 million people develop the disease every year.

The standard first-line treatment regimen used for newly diagnosed TB patients involves taking four different drugs over a period of six months. Some patients experience varying degrees of adverse reactions as a result. These factors have led to patients defaulting on their treatment. This, in turn, has led to a rise in drug resistance.

TB drug resistance – when the bacteria become resistant to at least one anti-TB drug – is a growing problem across the world. Current treatments that include more than one drug known as combination therapy have become inadequate because the bacteria have devised ways to survive even when antibiotics are used. An estimated 3.5% of new cases and 18% of previously treated cases of TB are drug resistant. There is therefore still a need to identify alternative drugs. But the drug discovery process is fairly lengthy (10 to 15 years). This timeline can be shortened with the aid of computers.

In an effort to find new ways of overcoming the problem, my colleagues and I at the South African National Bioinformatics Institute and school of pharmacy at the University of the Western Cape used a number of computer strategies to identify alternative drugs. The results were published recently in the Plos One Journal.

Our research presents a cost effective alternative way to tackle drug resistance by identifying drugs that prevent the bacteria from overcoming drug pressure. Using computer modelling, we were able to identify new drugs by building a reliable replica of the bacterial protein and then working out what the best orientation is for the drug to fit in the bacterial protein.

Ongoing studies using a combination of drugs will examine the effect of the drugs on stopping the growth of the bacterium. This, in turn, could lead to a new drug being included in the treatment regimen to beat drug-resistant TB.

Finding a solution

One way the bacteria is able to survive drug pressure, is by making proteins which mitigate the effect of the drug such as pumping the drugs out of the cell. Because some antibiotics are only effective when they are inside the bacterial cell, they become ineffective treatments.

The protein’s that play this role are called efflux pumps. They’re very important targets in the drug discovery process. But it has been a struggle to identify drugs that can withstand the effect of the efflux pumps, with a number being dismissed as either too toxic or simply ineffective.

Using computer modelling we aimed to identify a drug that binds to the efflux pump protein.

Previously, the gold standard for identification of drugs with activity against the bacterium has been the use of wet-lab screening – growing the bug in a petri dish and adding drugs to it and measuring the loss of colony forming units. This is a high throughput method whereby large number of drugs can be added to different wells on a plate containing the growing bug. This approach is only feasible to specialised laboratories that not only fulfils biosafety standards but have large funding.

The approach has another drawback: many of the active drugs identified may bind to human drug targets that in turn could be harmful to the human host.

This is where the use of computers is proving useful. They can develop drugs that specifically target efflux pumps and reduce the harm to people. These computer-based methods have been used in the past to develop various drugs against several diseases like HIV, bacterial infections and Alzheimer’s disease.

Computers can simulate the work in a laboratory by performing complex calculations. This is powerful when working with thousands of small drug molecules that must be evaluated as a possible treatment option.

The first step in our research involved building a three dimensional shape of the protein using computer programmes. The next step was to fit the drugs into the protein shape and to find the best fit. This elimination process can take anything from a few weeks – if only a small number of computers are used – to a few days if a cluster of high-performance computers is used.

We used 24 computers which made the process faster and more efficient.

Cost benefit

Using a large number of computers for screening drugs reduces the cost and time spent testing drug candidates in laboratories. Another benefit is that it can eliminate drugs that are very likely to fail later in clinical trials.

The drugs identified by computer methods are very likely to lead to new and better treatments for drug-resistant TB, and will help to restore the action of some drugs being used in first-line treatment, such as Rifampicin, to which resistance has developed.

Ruben Cloete does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

When pregnancy or childbirth go wrong, access to Caesarean section – usually known as C-section – can be the difference between life and death for both the woman and her baby.

Because they can save women’s and infants’ lives, C-sections should be universally accessible. But they aren’t. This is clear from the fact that there’s a huge disparity in C-section rates between countries, and even within countries. These patterns are highlighted in a recent Lancet series “Optimising Caesarean section use”.

The reports show that the number of children born by C-section worldwide was 29.7 million (21.1% of all births) in 2015 – nearly double the number in 2000. Wealthier women and private healthcare facilities are major contributors to the global increase of non-medical (those that aren’t absolutely necessary for medical reasons) C-sections.

The numbers have also gone up in developing countries, but not by nearly as much. And when it comes to access there are huge disparities between developed and developing countries as well as within low- and middle-income countries.

The Lancet reports show that access to C-sections remains a challenge in many low-income countries, particularly for poor women. This is especially true in sub-Saharan Africa. This means that poorer women – and their babies – are at a higher risk of dying during childbirth if there are complications.

Countries reporting low use have inadequate health facilities and are not equipped to provide emergency C-sections, especially in rural areas and urban informal settlements. Wealthier women generally have better access to not only the procedure but quality healthcare post-birth.

The Lancet reports highlight how much work still needs to be done to ensure that, on the one hand, poor women who need the service get it, and on the other, that it’s not overused and abused.

Understanding the factors that drive these trends is key if the problems are going to be solved.

Disparities

The rise in C-sections – most of which is happening in developed countries – isn’t viewed as a universally good thing. While more women can now access life-saving surgery, there’s also evidence that C-sections are being used when they’re not needed. For example, wealthier women opt to have a C-section for non-medical reasons such as to avoid the pain of childbirth.

This has led to overuse and is a cause for concern in many of the world’s regions because a C-section remains a major surgery with potential short and long-term complications for the mother and the newborn.

But the picture is very different for women at the other end of the access spectrum. A number of factors drive the fact that there is lower C-section use in less developed countries. These range from higher fertility, lower levels of female education and fewer physicians. There is also a class divide: rural women as well as the poorest women have much lower use of C-sections than urban and better-off women.

Even in countries with generally low access to C-section, such as Kenya, wealthier women on average reported higher use than poor women. Women in the wealthiest quintile in developing countries, on average, reported 2.4 times greater use of C-section than women in the poorest quintile.

This shows that even within one country, wealthy women can access better health facilities than poor women.

Drivers

In countries with low access to C-section – classified as less than 10% of births – the main drivers appear to be total fertility rates, female enrolment in secondary education, and the ratio of doctors to patients.

On the other hand, socioeconomic development and urbanisation seem to play a significant role. Possible reasons for the discrepancy between C-section rates among wealthy and poor women in the same country could be a low overall capacity to provide C-sections, particularly in rural settings, financial barriers, and the role of the private sector in providing C-section to wealthier women in mostly urban areas.

Ethiopia is a good example of big discrepancies between rural and urban areas. The national C-section rate in the country was 2%, but the capital Addis Ababa reported 21.4%.

The countries with the highest C-section rates were Bangladesh, Brazil and US. All reported a quarter of their births were C-sections.

In Asia, China and India reported large in-country differences with provincial differences in China ranging from 4% to 62% and inter-state differences in India from 7% to 45%.

When comparing the rates in public and private healthcare facilities, the rate was 1.6 times higher in private facilities according to data from 69 low- and middle-income countries. More than 50% of births within private facilities were by C-section in 12 countries.

What next

There are two challenges when it comes to C-sections – the first is to ensure that all women – no matter what their economic circumstances – should have access to surgery if they land up in difficulty during child birth.

The second challenge is that overuse of C-sections needs to be managed. This will require making sure that financial motives aren’t the biggest driving force behind decisions to do a C-section, and that the hospitals are sufficiently resourced so they don’t go for the “cheaper” option of an elected, pre-planned operation.

And the growing barrage of misinformation fed to women about childbirth needs to be stopped. Women need to be helped in their efforts to claim the right to decide on the way they want to deliver their baby.

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

An estimated 180,000 people die every year worldwide as a result of burns and survivors often suffer terribly. Burn injuries are particularly common in low- and middle-income countries.

It’s estimated that burns are the cause of 20% of all trauma seen at Kenyatta National Hospital, one of two national referral hospitals in Kenya. We did a study on patients admitted with burns to the hospital to determine the demographic pattern and risk factors for the injuries.

Our findings confirm other research which shows that in sub-Saharan Africa injuries from burns occur mainly in homes and children are most affected.

We found that burns were most common among children under five years. And the main causes of burn injuries in adults were; fire or flames, contact with hot objects, high voltage electricity and chemicals.

Based on our findings we identified areas of intervention for burn injury prevention strategies. In our recommendations we suggest that a number of risk factors should be addressed in burn injury prevention programmes for Kenya. The main factors we identified were low levels of education, use of kerosene for cooking and lack of knowledge of burn injury prevention and fire safety.

People with lower levels of education end up in jobs with less pay and are therefore more likely to live in informal settlements. Use of kerosene for cooking or lighting sometimes results in stove or lamp explosions if adulterated fuel is used, or appliances are handled poorly. Lack of knowledge of fire safety and burn injury prevention can also result in burn injuries.

What we found

Many children sustain hot fluid spillage or emersion burns at home mainly as a result of poor housing, overcrowding and inadequate supervision by caregivers. Some sustain injuries after touching electricity wires while playing on balconies of buildings constructed in close proximity to high voltage electricity lines.

Burn injuries in adults occur in homes, mostly after clothes catch fire or when a flammable substance spills and catches fire or results in an explosion. These happen in homes during cooking, lighting or extinguishing fires, during functions after spirit or gel burners catch fire or when houses catch fire. People have also sustained bad burn injuries or died in schools, factories and motor vehicle fires.

Slum or shack fires have been reported frequently and have resulted in many injuries and fatalities. In these cases the cause of the tragedies is usually carelessness, lack of knowledge, overcrowding and poverty.

Explosions related to fuel tankers, leaking oil pipelines or petrol stations have also been a cause of many burn deaths and burn injuries in Ghana, Kenya and Nigeria. In 2016, about 40 people died and scores were injured after a lorry carrying petroleum products rammed into a line of motor vehicles near Naivasha in Kenya.

Prevention

Burn injuries are a global public health problem. Fortunately, they are preventable. This has been demonstrated by the considerable progress made by high income countries in their burn injury prevention strategies. There are documented burn injury prevention success stories from several countries such as Australia, Canada, New Zealand and United Kingdom.

Low- and middle-income countries tend to focus on treatment with little or no funding allocated to injury prevention and research. But treating burn injuries is expensive which is why policies and legislation need to be developed to reduce them.

Our study shows that prevention strategies should include concerted public health campaigns. These must comprise of driving awareness, through the media, of the need for burn injury prevention. The American Burn Association has an annual burns awareness week and in South Africa, fire safety campaigns are often reported on in the media.

In addition, policies and laws targeting specific risk factors should be developed and enforced. For example, building and electrical codes in the US have resulted in fewer electrical burn injuries in homes. Kenya should make it illegal for buildings to be constructed close to high voltage electricity lines.

Joseph Kimani Wanjeri does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

All organisms are unique. Each having a set of genetic instructions for their build-up and maintenance. This set of genetic instructions is contained in genes that makeup a genome.

The World Health Organisation defines genomics as the study of genes and their complex interplay in influencing the growth and development of an organism. Through genomics, gene sequences can be manipulated to prevent – or manage – certain diseases and hence prolong life and improve public health.

More and more research is showing that a better understanding of the genomics of pathogens can play a crucial role in preventing and treating infectious diseases. Identifying genetic risk factors for diseases can ensure timely interventions. It can also help curtail the spread of emerging infections and drug resistance.

Because of this, genomic research has huge potential in helping African countries address public health issues. The problem is that Africa lags behind other regions. This is true in terms of research, resources as well as policy.

Burden of disease

Africa faces a heavy disease burden of both communicable and non-communicable diseases. In the last two decades, the continent has succeeded in decreasing some communicable diseases such as cholera and polio. But others such as malaria and HIV remain quite high.

This disease burden has been aggravated with the emergence of drug-resistant strains.

In addition, non-communicable diseases such as cardiovascular diseases, cancer, diabetes and chronic respiratory diseases are also on the rise. The number of deaths from these is projected to increase over the next decade.

This high disease burden can be significantly reduced. But it needs a proactive approach. This should include a combination of public health strategies as well as the use of genomics to help identify genetic risk factors.

Why genomics matters

Some examples of how genomic research has been used to address public health issues include:

• The identification of a new antimalarial drug;

• The development of new vaccines; and

• In the investigation of causes of infectious disease outbreaks, including the Ebola virus.

Genomic analysis has also provided important prognostic indicators for breast cancer patients. This has helped identify the drugs that individuals could best respond to. It opened the door to the new era of personalised medicine that aims to tailor therapy according to each person’s genetic makeup.

A good example was the use of genome sequencing that pointed to a new treatment regimen for Nicholas Volker who had a gastrointestinal disorder that was cured with a bone marrow transplant.

To date, the US Food and Drug Administration has approved 45 human genetic tests, and more than 100 nucleic acid-based tests for microbial pathogens. Most of this research is being carried out in the developed world.

But scientists in Africa have also been attempting large-scale genome research studies focused on specific diseases. For example, the international HapMap project and other previous studies have shown that people who live on the continent have the greatest genetic variation. Therefore understanding the genetic basis of both communicable and non-communicable diseases may provide useful insights into devising effective strategies to combat diseases that have had a large impact on the continent.

Challenges

Africa still lags behind the rest of the world in the field of genomic research. This is largely attributed to the following challenges:

• The cost of research remains prohibitive for African research centres. This is mainly due to lack of enough government funding and support;

• There’s a shortage of African scientists with genomic research and computational expertise who can translate genomic information into clinical medicine;

• A lack of biomedical research infrastructure to undertake genomic research;

• Lack of collaborative research among African scientists;

• A climate of fear about the potential for misuse and misinterpretation of genomic information among the public and health professionals in Africa;

• Poor engagement with national and regional agencies in the uptake of genomic research as novel methodologies to help tackle health problems; and

• No proper policies and clear guidelines to inform medical and public health professionals about the level of confidence and use of genomic information.

What to do

African Union member states have set a target of 1% of GDP to be invested on research and development. But most member states don’t meet this target. Only South Africa, Kenya and Senegal are close – at around 0.8%.

It’s crucial that genomic research is given higher priority on the continent. The research should be supported by establishing the infrastructure for genomic studies, capacity building and improving collaborations with credible international partners.

African genomic scientists should also build networks and collaborations that enable the exchange of new ideas and the transfer of knowledge. This could indirectly influence policy makers to support investments in genomic research.

There are programmes that are supporting initiatives like this. These include the Alliance for Accelerating Excellence in Africa, created by the African Academy of Sciences and the Human Heredity and Health in Africa. These programmes support studies led by African scientists by providing research funds that foster genomics research, capacity building, as well as specific scientific goals.

But there’s scope for considerable expansion.

Overall, policymakers need to be involved from the beginning in all discussions and debates involving genomics research. They should be engaging with communities, academics and public health professionals to help develop research questions. They should also be involved in preparing to set up legal regulatory frameworks. This would go a long way towards ensuring the translation of genomic research findings into public health benefits.

Lamech Mwapagha does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Public health research suggests that concerns about alcohol advertising and accessibility warrant strong regulatory action.

Alcohol is a major contributor to the global burden of disease. It’s also a key risk factor for preventable illness and death in Africa. For example, alcohol consumption during pregnancy is associated with many adverse effects on children. These include childhood behavioural and developmental disorders such as foetal alcohol spectrum disorders.

Easy access to alcohol is a critical risk factor in problem drinking. This is particularly true among adolescents. The problem has been exacerbated on the continent by the fact that alcohol companies have targeted young women in their marketing efforts.

Global evidence also suggests that alcohol advertisements increase adolescents’ favourable attitudes toward drinking. These adverts are also associated with higher consumption, as well as earlier initiation and higher intensity of drinking. And recent research indicates associations between exposure to alcohol advertisements and alcohol consumption among adolescents in South Africa.

We conducted a study on the impact of access to alcohol and exposure to alcohol advertisements on women of childbearing age in rural and urban areas of South Africa. We conducted interviews with 1,018 women in one of the country’s largest cities, Tshwane, as well as in rural areas in the Western Cape.

Our paper found that in both urban and rural sites easy access to alcohol – as well as exposure to alcohol advertisements – were associated with significant negative social and health impacts.

What we found

In urban Tshwane, easy access to alcohol was related to a number of problems. These included binge drinking (defined as six or more drinks per occasion) among partners and problem drinking in the community. Complications during pregnancy were another issue. And exposure to alcohol advertisements was related to hazardous drinking in the community and inter-partner violence.

In rural Western Cape, easy access to alcohol was related to problem drinking among community members. It was also inversely related to families’ ability to pay for health care. For its part, exposure to alcohol advertisements was related to a number of negative outcomes. These included hazardous drinking among women and community drinking. Inter-partner violence was also a problem.

The slight differences between patterns in urban and rural communities were likely because of varied social and economic contexts.

Our findings confirm what has been found elsewhere: alcohol advertising is not a harmless brand-promoting activity. It is associated with harmful health and social outcomes. Similarly, easy access to alcohol is associated with multiple adverse health and social impacts.

These effects might be ameliorated by stronger laws and regulations. That’s why amendments have been proposed to the country’s National Liquor Act. Our findings support these efforts to limit access to alcohol and alcohol advertisements.

But South Africa has a mixed record when it comes to legislating against alcohol use.

Strong industry lobby

The alcohol industry has used intense lobbying to hold back efforts to limit the availability of alcohol and alcohol advertisements.

For example, national legislation to ban advertising in South Africa has been stalled. Provincial legislation in the Western Cape has been weakened by the liquor, sporting and advertising industries.

The alcohol industry promotes self-regulation. But this leaves adolescents vulnerable to the harmful effects of alcohol advertisements.

The alcohol industry claims that it plays an indispensable role in South Africa’s economy. But public health researchers estimated that alcohol consumption cost the country approximately 10%-12% of its gross domestic product in 2009.

Limiting alcohol advertisements and regulating the availability of alcohol are critical to ensuring the well-being of women and children in South Africa. This is particularly true because the country has the highest rates of foetal alcohol syndrome in the world. These rates emerged, in part, from a system adopted in the colonial period of farmers paying workers with alcohol. The practice continued in some Western Cape farms well into the post-apartheid period even though it was illegal.

Leslie London receives funding from the South African Medical Research Council, the UK Medical Research Council, the International Development Research Centre and the US Centres for Diseases Control. He is a member of the non profit advocacy organisation, the People health Movement and has consulted to the Southern African Alcohol Policy Alliance.

Neo Morojele receives funding from the South African Medical Research Council, UK Medical Research Council and the International Development Research Centre and is affiliated to the Southern African Alcohol Policy Alliance.

Hanna Amanuel does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

What is medicine? We recognise it in all societies past and present. But the nature of medicine differs so greatly from place to place and time to time that it’s difficult to offer a single answer. So what is it that we see in common between a traditional healer’s throwing of bones and the cardiologist’s incisions?

One of the answers that often seems to be implicit in what we say and think about medicine is a curative thesis: medicine’s goal is to cure the sick. Curing the sick is the core medical competence, whose exercise is medicine’s core business.

But if the curative thesis is true, then most medicine throughout history – as well as much contemporary medicine – isn’t medicine at all. Much medicine was and is ineffective, or at best partially effective. The curative thesis leads to a dismissive attitude towards the past efforts upon which any current medicine is built, as well as failing to promote profitable collaboration between traditions.

A second idea is an inquiry thesis about medicine: although the goal of medicine is to cure, its core business is something quite different. It’s this thesis I explore in my latest article.

That “something” has to do with inquiring into the nature and causes of health and disease. The idea is that we don’t necessarily expect someone to be able to cure us. We will accept that they are a medical expert if they can show an understanding of our ailment, often by issuing an accurate prognosis. Perhaps they won’t have a complete understanding, but they should somehow be engaged with the larger project of inquiry into the nature and causes of health and disease.

The inquiry thesis offers a way to understand the history of medicine that makes it more than a tale of quackery and gullibility. It also provides a way to understand medical traditions that practised outside the West, or in the West in defiance of the mainstream. They may offer or at least engage with a project of obtaining; a kind of understanding that Western medicine cannot.

The inquiry model of medicine lays the ground for fruitful and respectful discussions between medical traditions that doesn’t descend into an untenable relativism about what works.

Towards understanding

The curative thesis faces a difficulty that I believe it cannot overcome.

We do not define an activity by its goal alone, unless it has at least some success in that respect. A blacksmith cannot be defined as one who makes horseshoes if he simply throws lumps of hot metal onto his anvil and hammers them randomly – occasionally producing something horseshoe-like, but more often producing a mess.

Yet, taking a historical perspective, something of this kind has been true of medicine for much of its history, before it developed a serious curative arsenal. Historian of medicine Roy Porter has remarked that

the prominence of medicine has lain only in small measure in its ability to make the sick well. This was always true, and remains so today.

What, then, could be the business of medicine – the thing in which we recognise expertise, even when we accept that there is no cure to be had?

This is where the inquiry model enters the picture. I propose that the business of medicine is understanding the nature and causes of health and disease, for the purpose of cure.

The core of the argument is simple: what could medical persons be good at doing, that relates to the goal of cure without achieving it? The most likely candidate is understanding. Understanding is something that we can gain without corresponding curative success.

Tackling objections

As with the curative thesis, there are several objections to the inquiry model. First, it is obvious that many doctors either don’t (fully) understand what they treat or, if they do, don’t (successfully) communicate this understanding to the patient. Who, then, understands? In what sense is the doctor’s competence understanding?

The answer is that understanding isn’t a binary. You can partially understand something. You can be one the road to understanding it better, by inquiring into it. Hence the inquiry model of medicine. The idea is not that medicine is a sack full of answers, but rather that it is an ongoing effort to find answers.

Another objection is that so-called understanding is often bogus, and that medicine is as unsuccessful in this regard as in cure. This fails to account for the historical record, which – at least for Western medicine –- is precisely a case of understanding without curative success.

And, just as false scientific theories have contributed to developing scientific understanding, so false medical theories have provided a foundation for what we now accept.

Medicine is an ancient and complex social phenomenon, variously seen as art, science and witchcraft. These visions share the goal of curing disease. But it is too crude to think medicine as only the business of curing, since in that case, few doctors would be in business.

The distinctive feature of medicine is that it tries to cure by obtaining some understanding of the nature and causes of health and disease: by inquiry, in short. This understanding of medicine permits a much healthier dialogue between proponents of different traditions, and enables a non-defensive perspective on areas where we remain sadly lacking in curative ability.

This is an edited, shortened version of an article that first appeared in the Canadian Medical Association Journal, ‘The inquiry model of medicine’, accompanied by a podcast available on the article’s page and also here.

Alex Broadbent receives funding from the National Research Foundation of South Africa.

A new study shows that 130 million women have undergone female genital mutilation (FGM) in 29 of the highest prevalence countries, many of which are in Africa. And 30 million more girls in Africa under the age of 15 will be at risk in the coming decade.

FGM types I-III comprise all procedures that involve partial or total removal of the external female genitalia for non-medical reasons.

The practice is concentrated in Africa, the Middle East and Asia and is carried out mainly for cultural and economic reasons. “Cut” girls are seen to be sexually pure, necessary for marriage, to protect the family’s honour and to get a good bride-price. But FGM carries signifcant health implications from severe pain and bleeding to numerous infections and even death as a result.

The pressure is on to understand what works to reverse this practice and see it at an end.

In my research I investigated what anti-FGM programmes were being run in Sudan. FGM isn’t uniformly present in Sudan but, on average, there’s a national prevalence of 66% with 84% in Northern states to 46% in West Darfur.

Anti-FGM interventions target areas with the highest prevalence, and there are many different organisations working towards this end. This has produced a highly complex web of policies and interventions with each organisation focused on implementing its own activities which range from public health campaigns to community advocacy work.

Because these interventions are mostly designed by global and national agencies and governments, they risk ignoring, and even sidestepping, important change agents – like youth and youth organisations – who are already challenging FGM from within. Young people are having conversations with their families and peers and challenge their support of the practice.

Efforts to end FGM should be directed at finding and encouraging these emerging networks that no longer want to be part of a community or family that practice it.

Medicalisation

One approach to ending FGM, that’s getting a lot of attention from international donors, is “medicalisation” – when the practice is performed by a medically trained practitioner, like a doctor, rather than a traditional “cutter”.

Because much of the campaigning in countries, like Sudan and Egypt, has emphasised the harmful impact of the practice, it’s led to an increase in medical professionals doing the procedures. In Sudan, 67% of all cut women have undergone the practice by a medial practitioner – the highest medicalisation rate in the world. In Egypt, the second highest, rates are at 42%.

Some medical professionals argue that medicalisation is positive as it reduces the risk of infection and long-term complications. But it masks a lack of progress in de-normalising the practice and putting an end to it.

Another worry on the impact of current interventions, is a shift between the three different types of FGM rather than an end altogether. By emphasising the long-term damage of the most extreme type, health messaging and human rights campaigns have unintentionally shifted the focus from the most extreme to a less severe version.

Youth perceptions

The purpose of my research is to try and understand what the most effective triggers are in changing the minds of families that support FGM. I found that local activists’ viewpoints are being squeezed by a focus on top-down change –when, to effectively address FGM, the process should be bottom up as it’s a cultural issue.

For instance, one of the main barriers to ending FGM is its culturally strong link to marriage, specifically the view that a girl must be cut in order to preserve sexual purity and family dignity.

Shifts in youth perception are already happening that challenge this. Young men increasingly declare that they do not want to marry cut girls. Saying that they prefer uncut girls because they are healthier and stronger. Young women are also challenging FGM, arguing that it violates their sexual identity and expression.

But these views are often hidden by an aggressively conservative discourse propounded by politicians and religious leaders that rises in backlash to suggestions that FGM must end.

Moving forward

Efforts must support these youth groups and bring them together.

It’s also critical that support is increased for girls who continue to be cut. The stigma associated with FGM is beginning to work both ways. Cut girls feel stigmatised by the human rights discourse that describes them as un-whole while uncut girls still feel the pressure to hide their status in case it brings shame on their family.

While my findings highlights how complex the issue of ending FGM is, they also show that activists against FGM are beginning to see more clearly how resources and efforts should be targeted.

Tamsin Bradley receives funding from UK Department for International Development. I am part of the evaluation team for UK Aid's Free Sudan from FGC intervention programme

There is increasing concern about the amount of time children and adolescents are spending in recreational screen time. There’s also increasing controversy over whether or not screen time is actually harmful.

Since 2016, we (researchers who’ve contributed to the development of the 24-hour movement guidelines for children and adolescents) have led a number of wide-ranging reviews of the scientific evidence on the impact of screen time from infancy to early adulthood. We examined whether or not the amount of recreational (spare time, non-educational) digital screen use influences health. These included risks such as obesity, reduced sleep, low physical fitness, anxiety and depression. We also looked at the impact of recreational screen time on social and emotional as well as cognitive and language development, well-being and educational attainment.

These reviews demonstrated that high levels of screen time, now typical among children, are associated with potential harm. And they showed clearly that less recreational screen time is better for avoiding obesity, and for promoting sleep, physical fitness, and cognitive, social and emotional development.

Over the past three years the evidence reviews generated authoritative guidelines nationally in Australia, Canada, South Africa, the UK and internationally.

We were all involved in the development of global guidelines for zero to four year-olds for the World Health Organisation (WHO). These guidelines all recommended that recreational screen time should be limited in infancy, childhood and adolescence.

limiting screen time

Guidelines from Canada, Australia, and South Africa recommend that recreational screen time should be avoided in the under two’s, limited to one hour per day in two to four year-olds, and to two hours per day in five to 17 year-olds.

Based on our collective experience in developing these guidelines it’s clear that these limits on recreational screen time are needed for a number of reasons.

First, the evidence suggests strongly that limits are required. The recommendations to limit screen time were based on a rigorous, widely-accepted, and evidence-based approach. This included systematic reviews, critical appraisals of the evidence, national and international consultation and review, and transparent reporting.

Second, less recreational screen time is clearly better. There is evidence in support of the specific time limits recommended and our wide consultation with stakeholder individuals and organisations – including parents and families – suggests that they find time limits helpful.

Third, our recommendations that recreational screen time should be limited are consistent with other recent and thorough reviews of the evidence conducted by authoritative bodies such as the WHO and the World Cancer Research Fund. These reviews highlighted the important role of recreational screen time in the development of obesity, many cancers and myopia.

Our specific recommendations are also consistent with those made by the American Academy of Pediatrics and the Canadian Paediatric Society.

Taking a laissez-faire approach to screen time would be to ignore the wider context. This is that modern childhoods are characterised by low physical activity, excessive sitting and time indoors. Children and adolescents also suffer from poor motor skills, high levels of myopia, increased risk of type 2 diabetes and hypertension.

And as new forms of screen time emerge, a precautionary approach is required – some limits on recreational screen time would be prudent until it is clear that there are negligible harms.

Still time to act

Some argue that the “genie is out of the bottle” in relation to screen time. But this is defeatist. The same arguments could have been made in relation to control of tobacco and alcohol and sugar. But it is now accepted that unlimited exposure to these substances isn’t compatible with public health. And constraints are accepted as essential.

In addition, in many parts of the world the genie may not yet be out of the bottle. In many low- and middle-income countries exposure to recreational screen time may still be relatively low among children.

There is also scope to prevent excessive screen time in babies and young children, acting before adverse, or at least sub-optimal, lifestyle habits become established later in childhood or adolescence.

Screen time harms can be indirect as well as direct – recreational screen time increases with age and as it does it displaces more beneficial forms of sedentary behaviours such as reading. Screen time also displaces physically active play, and sleep.

Recreational screen time may seem to be an inevitable part of modern life. But even from infancy and early childhood, we should all be concerned about the potential for harms – at least until new, robust evidence demonstrates no harm. The most prudent approach would be cautious, attempting to follow recent evidence-based guidance that recreational screen time should be restricted.

John receives funding from The Scottish Government Chief Scientist Office, WHO, Hannah Foundation, Cunningham Trust, and Inspiring Scotland.

Anthony (Tony) Okely receives funding from the Australian Government Department of Health, National Health & Medical Research Council of Australia, and NSW Department of Health

Catherine Draper receives funding from the British Academy for the Humanities and Social Sciences. She has an honorary affiliation with the Division of Exercise Science at the University of Cape Town

Mark S. Tremblay receives funding from the Public Health Agency of Canada, the Canadian Institutes of Health Research, the Conference Board of Canada, the University of Alberta, the Canadian Society for Exercise Physiology and in kind from ParticipACTION.

The release of a final report about the state of competition in South Africa’s private health sector has been delayed again. It was compiled by an inquiry panel made up of medical, legal and economic experts. The panel heard submissions from a range of stakeholders including members of the public, civil society organisations as well as private hospital groups.

The inquiry was set up under the auspices of the country’s competition authority in 2013. It’s remit was to investigate characteristics of the private health sector that may prevent, distort or restrict competition. Its preliminary report, released in July 2018, concluded, among other things that the sector was highly concentrated in the hands of a few major players. The final leg of work was to get inputs from various players on the initial findings before concluding the inquiry. The inquiry has cost tax payers R197 million so far.

Another delay of the report – which should have been released in March 2019 –is therefore bad news. The sooner South African authorities deal with the issues of anti-competitive behaviour in the private sector, the more likely access to quality health care will improve.

South Africa has a two-tiered health care system. The public sector is under-resourced and stretched while the private sector is highly sophisticated and expensive. Even though only 16% of the country’s population uses private health care, it nevertheless gets a large portion of the government’s health expenditure in subsidies.

At the same time, private health costs continue to balloon and fewer people can afford it.

Read more: Explainer: how competitive is South Africa's private health care sector

The inquiry’s preliminary recommendations offered a clear agenda for how the private sector can become an integral part of the current national health system. There must be no more delays: if South Africa is to reach its lofty goal of universal health coverage, the report must be released and those recommendations adopted.

Key findings and recommendations

The inquiry examined three aspects of the private sector.

• Medical schemes through which people pay for private health services and the administrators who run them.

• Private facilities, such as hospitals and clinics.

• Medical doctors and specialists in the private sector.

The key preliminary findings and recommendations were:

• Medical schemes provide multiple plan options for cover without providing adequate information to understand what they cover, how the plans compare and what value the patients receive. As a result, consumers aren’t able to compare what schemes offer or choose plan options on the basis of value for money.

• There is a lack of transparency on the pricing of health care goods and services, standardised reporting of health outcomes and implementation of evidence-based guidelines and treatment protocols.

• Medical practitioners and specialists are concentrated in the private sector. As a consequence, there is time to over-service and inefficient use of expertise and time.

In light of these and other findings, the inquiry made a number of recommendations to remedy the situation.

These included putting measures in place to enable the Council for Medical Schemes, which regulates medical aids, to exercise more effective oversight.

In addition, to ensure that people who belong to medical aids get more comprehensive cover, the inquiry proposed that all medical schemes also offer a standalone standardised obligatory basic benefit option. The basic option would include a standard basket of goods and services and be comparable among schemes. This option would include cover for the prescribed minimum benefits, make provision for the treatment of these prescribed minimum benefits outside of hospital settings and add primary and preventive care.

And the inquiry recommended tighter regulation of the sector through the establishment of a dedicated health care regulatory authority. This would govern the number and distribution of doctors and hospitals to meet current and future needs. And it would ensure the development of clinical protocols as well as shape the structure of payment systems.

The inquiry also recommended that a centralised national licensing framework be introduced. This would accredit all health facilities including clinics, hospitals and GPs’ rooms. Another recommendation was to establish a price-setting mechanism.

Important

The recommendations are innovative and would go a long way toward making health care in the country more equitable. But South Africans will have to keep waiting to see if they actually bear fruit.

The latest development is that, due to a lack of funds, all the inquiry’s work has been suspended until the end of the financial year in March after which a new date for the release of the final report will be published in the Government Gazette.

It’s important that the inquiry is allowed to complete its task sooner rather than later. This is because its findings could have a bearing on a piece of legislation currently making its way through parliament – the Medical Schemes Amendment Bill. The bill proposes changes to medical scheme governance and benefit options. Reports suggested that the department of health wanted to wait for the outcome of the inquiry before finalising the bill.

The inquiry could also affect the National Health Insurance Bill which is meant to herald in universal health care. But the bill is mired in controversy. The most recent version was recently rejected by the country’s cabinet which instructed the national department of health department to review what’s been proposed.

Until the final report is released, South Africans must contend with a fragmented, poorly regulated and expensive health care delivery system.

Wezile Chitha currently heads an oncology service funded through a tender from the KwaZulu Natal Department of Health. He is an ANC member, member of South African Committee of Medical Deans.

Economic growth, accompanied by a fall in infectious diseases over the past two decades, has changed the profile of the biggest threats to the health of people living in low and middle-income countries.

At the turn of the century, the greatest threats were posed by infectious diseases like diarrhoea, pneumonia, tuberculosis, and HIV. Today, the biggest threats are posed by so-called “diseases of lifestyle”. These include diabetes (high blood sugar), hypertension (high blood pressure), and hypercholesterolaemia (high cholesterol), which have been slowly and quietly rising around the world.

While diabetes, hypertension and hypercholesterolaemia often don’t cause symptoms, they have debilitating and deathly consequences which can include heart attacks, angina, heart failure, amputation, stroke, kidney disease, and blindness. These are now the most common causes of death and disability in many low and middle-income countries. But unlike many infectious diseases, there’s no course of antibiotics to treat them.

Obesity and lack of activity contribute to the rise of diabetes, hypertension, and hypercholesterolaemia. These are driven, in turn, by lifestyle changes, often biased towards foods that are convenient (sugary and fatty) and jobs that require less physical activity.

Strong policies are desperately needed to alter the environment to promote physical activity and prevent obesity. But there’s also a need to treat people who already have diabetes, hypertension, and hypercholesterolaemia– which are largely without symptoms – to try to prevent their consequences.

Unfortunately, access to care for people with these conditions is poor in many low and middle-income countries. South Africa is no exception. In our research we set out to establish who suffers from these conditions, who has access to care and what the consequences would be if the access to care didn’t change. We also wanted to establish what the cost savings would be for the South African government if access to care improved.

After analysing our findings in relation to these questions, we concluded that South Africa should invest in care for treating diabetes, hypertension, and hypercholesterolaemia. This will, in the long run, save the country a lot of money.

Managing risks versus treating the diseases

As far as deathly and debilitating consequences are concerned, we found that poorer black men were at high risk and they had the worst access to care.

Overall, only 50.4% of people in the study community with hypertension were treated to acceptable levels. Just under 9% were treated adequately for diabetes and less than 1% for high cholesterol.

We estimated that if access to care continued at current levels, premature deaths due to cardiovascular conditions would be around 40 per 1000 people annually. Although HIV still causes the greatest percentage of premature deaths in South Africa, diabetes, stroke, and heart attacks are all in the top 10 causes, with diabetes rapidly rising through the ranks. More of these deaths would occur among those who are poor, black and male. There is also substantial risk for blindness and kidney disease.

We further estimated that the cost of treating all of these deathly and disabling consequences of diabetes, hypertension, and hypercholesterolaemia would be $34.2 billion a year. That’s roughly 10% of South Africa’s GDP in 2017.

We also found that if access to care for diabetes, hypertension, and hypercholesterolaemia was improved to levels seen in the UK or Germany, deaths and disability would be reduced. The benefits would also be seen among people who currently lack access to care, such as poor, black men.

If people are sceptical of South Africa’s ability to achieve access to care at the same level as the UK or Germany, it may be reassuring to note that Cuba has managed to achieve these levels of access to care.

In addition to determining the costs of treating consequences of diabetes, hypertension, and hypercholesterolaemia, we calculated what it would cost to treat these conditions by improving access to care and implementing locally appropriate guidelines. We used two guidelines for our estimates: the World Health Organisation’s (WHO) Package of Non-Communicable Disease Interventions, and the locally developed South Africa Primary Care 101 Guidelines.

We found that it was cheaper to improve access to – and treat these conditions – using either guideline than to stick with current levels of access and care and suffer the consequent diseases. In fact, implementing the WHO guidelines would save around US$125,000 per 1000 people and US$185,000 with South Africa’s guidelines. The local guidelines are more cost effective. They are also more equitable, with better improvements in treatment and reduction of risk in black people, men, and those who are poorer.

What needs to be done

Even though we have shown that rolling out the guidelines would save costs in the longer term, there still needs to be substantial investment in building programmes for treatment in the short term. And there needs to be monitoring and evaluation to ensure the guidelines are correctly implemented.

The balance is tipped in favour of widescale implementation of the guidelines because they are likely to lead to the well-being of individual patients. This would include reductions in death and disability, and improved equity, quality of life and accompanying cost savings.

Justine Ina Davies receives funding from The Wellcome Trust.

Ryan G Wagner does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

The World Health Organisation (WHO) has emphasised that an experimental vaccine is playing a major role in controlling the spread of Ebola in the ongoing outbreak in the Democratic Republic of Congo (DRC). Without the vaccine, the outbreak has the potential to spiral out of control, considering the country’s social and political landscape as well as the sheer ability of the virus to spread.

It’s clear that having a vaccine in use early in an epidemic is a significant breakthrough in the fight against this deadly disease. And yet, six months after the first case was diagnosed, the outbreak is still not contained and cases are being reported almost daily and occasionally spreading outwards.

By the end of January, a total of 759 people had been infected with the death toll rising to 468. This makes it the second worst outbreak in recorded history.

Normally the DRC is well prepared and has substantive experience in dealing with Ebola. But a number of factors have hampered the current situation and made it hard to contain the outbreak – even for experienced frontier medical teams.

Read more: Why Ebola is proving hard to beat in the DRC

The epicentre of the outbreak was in North Kivu province. This lies in an active conflict zone and has very little infrastructure making it very difficult to administer enough of the vaccine to ensure immunity. In addition, health workers have been confronted with widespread violent unrest due to political instability in the country. A number of units had to be pulled out following attacks. Response rates were also slowed down following protests at the time of elections in December.

The vaccine rollout

The rVSV-ZEBOV vaccine is being tested in the DRC. It was first rolled out towards the end of the West Africa epidemic in Guinea in 2015. This was part of a phase III trial to evaluate the efficacy of the vaccine to prevent Ebola spreading among people.

Initial investigative data came from comparing a group of at-risk people who were vaccinated immediately after diagnosis of an Ebola virus case in their surrounding with a similar group of people who received the vaccine after a delay of 21 days.

The “immediate” group didn’t contract Ebola while some individuals in the delayed group contracted the disease. This evidence gave the WHO hope that the vaccine could be 100% effective.

But that point hasn’t yet been reached. More data and investigation are required before the vaccine is licensed for general use.

The rollout of rVSV-ZEBOV in the DRC has been done using a conventional strategy common in other vaccine trials. Called “ring vaccination”, it involves vaccinating the first and second degree contacts of an infected individual. The aim is to form an immunised “ring” around every infection and prevent it from being transmitted further.

Since August 2018 nearly 66,000 doses of this experimental rVSV-ZEBOV vaccine have been administered in the DRC.

The WHO’s confidence in the vaccine has been boosted by the fact that the cases of Ebola haven’t increased at the same rates as was the case in 2014 in West Africa before the vaccine was introduced.

But vaccine effectiveness isn’t always straightforward to gauge. Detailed data from the current outbreak will help make a more confident assessment and predict the future of its licensing and application.

The vaccine landscape

Currently, the WHO and the international community are in favour of the Merck rVSV-ZEBOV vaccine, as it has already been used and a number of studies prove that it’s a promising candidate for licensing in the near future. In the current scenario, it’s a ray of hope in addressing the current outbreak and preparing for future ones. Merck has recently promised to roll out another 120,000 doses of the vaccine to the DRC.

Further academic research on this vaccine have shown a sustained antibody response across two years, with little or no adverse effects to health in a large multicentre study.

In addition to rVSV-ZEBOV, other potential vaccines are also being investigated. Two of them are being developed by Johnson & Johnson and GlaxoSmithKline. The former has tested a prime-boost vaccine, which is administered in two stages at different times; while the latter has introduced a single dose variant, administered as a one-time injection.

Two other candidates come from China and Russia. The one from China was licensed by the country without a trial or human efficacy data, and the one from Russia is also pending clinical trials. Hence, little is known about their safety and efficacy yet, and have not been employed during these outbreaks.

Vaccine development for challenging diseases like Ebola and Marburg viruses remains a very difficult task. The pace at which the rVSV-ZEBOV vaccine has been developed and implemented, in addition to the effectiveness of the ring vaccination strategy, has paved a way for dealing with future outbreaks.

The challenge, however, is to reach adequate numbers of vaccinated people in unfavourable sociopolitical and underdeveloped infrastructure situations, such as those in many of the countries that are hot spots of viral outbreaks.

The viral disease burden in Africa is largely underestimated and the rVSV-ZEBOV vaccine is hopefully the first of many to be fast-tracked and invested in, to address what is fast becoming a global health challenge. It’s certainly a much needed vaccine in the fight against Ebola.

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Teen pregnancies are a pervasive phenomenon in Kenya. Based on the most recent national figures, one in five girls in Kenya between 15 and 19 years has begun childbearing, and half of these pregnancies are unwanted.

Media attention focuses on the consequences of unplanned teenage pregnancy, such as school dropouts or unsafe abortions. Indeed, these are important parts of the problem that often generate repercussions into adulthood. But look a bit deeper and additional problems emerge. Teen mothers frequently suffer in silence from social stigma, facing rejection from their families and communities. The feeling of not fitting in among friends forces many to opt out of school even though they are legally entitled to remain.

This constant rejection may lead to a vicious cycle of mental stress, depression and suicidal thoughts. This impact can be worse in the urban slums where girls are also exposed to abject poverty.

We started the Sasa Mama Teen Project in 2018 with the aim of understanding the daily experiences of teenage mothers in Kenya. We wanted to know what they go through, their fears as well as hopes for the future, and what can be done to ensure that they remain strong and determined during pregnancy.

The girls we worked with expressed overwhelming feelings of stigma, fear, shame, pity, confusion and rejection from the parents and community members. As one teenage girl from Korogocho, a slum northeast of Nairobi, put it:

I never told my mother about the pregnancy, but when she learnt about it from people, she insulted me, telling me to go away from her house. I never went anywhere and ignored her insults until I was used to them. I dropped out of school after getting pregnant. I was in secondary school form 3. Some gossiped and laughed at me, but some advised me.

Another teenager from Kawangware, a bustling settlement southwest of Nairobi said:

When I discovered I was pregnant, I felt stupid at first. No one wanted to be associated with me, so I used to lock myself in the house. When I get stressed I walk together with my baby to somewhere cool then come back in the evening…

The Sasa Mama Teen project approach

The project, currently being piloted with 150 teenage mothers in four Nairobi informal settlements, has three phases. The first phase, conducted between August and November 2018, consisted of facilitated meetings with the teenage mothers to create an inventory of different types and sources of stress in their daily lives. We used participatory methodologies such as PhotoVoice to collect information. PhotoVoice is particularly attractive among adolescents as it allows them to express problems and challenges in their lives through photos taken themselves.

The second phase of the project which started this January is dedicated to developing solutions to shield teenage mothers against the risk of mental stress during pregnancy and early motherhood. We are developing a structured youth-friendly toolkit containing health information and activities for problem-solving, stress management and confidence building.

We will validate how useful and effective the tool kit in the last phase of the project with a field experiment via girls’ chats in safe spaces at community-level and peer-group support discussions on WhatsApp.

The next steps

Mental health is not a part of routine care in the health facilities of Nairobi’s informal settlements. Health workers often lack the resources to manage patients holistically - they lack even the basic equipment to provide quality maternal and child health information and services. In the facilities, perinatal mental health is usually not prioritised due to other competing health challenges that require urgent attention.

This means that the mental health and well-being of the teenage mothers living in the informal settlements is constantly under threat. The tool kit developed through the Sasa Mama Teen project would be a potential aid for mental health promotion at community level. Plans are underway to test the tool kit on a larger scale in the country in the coming year.

We also plan to engage policymakers and various stakeholders at local and national levels on options to address the current mental health needs of teenage mothers.

Caroline Wainaina, research officer at African Population and Health Research Center, Nairobi (Kenya) and Icoquih Badillo-Amberg, MSc in Public Health candidate at McGill University in Montreal (Canada) contributed to this article_

Estelle Monique Sidze does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Vaccines are recognised as one of the most powerful tools in controlling and preventing infectious diseases. This despite strong anti-vaccination movements around the globe.

It was with vaccine in hand that one of the most dreaded diseases of the last two centuries, smallpox, was eradicated. Likewise, the eradication of vaccine preventable diseases such as poliomyelitis and measles remain global goals. And vaccines have lessened the burden of many other diseases around the world.

Ebola outbreaks have been sporadically reported since 1976. Before 2014, these outbreaks occurred mostly in countries located in the equatorial belt of Africa. Often outbreaks occurred in remote locations, affecting very isolated communities. They could be controlled by identifying sick people and isolating them, tracing contacts of the sick, monitoring them and in turn isolating them if they developed illness. This essentially allowed for the chain of transmission of the virus to be interrupted and, eventually, the containment of the outbreak.

This approach was more effective in earlier Ebola outbreaks because they happened in areas that were fairly isolated geographically.

But this changed dramatically during the course of the West Africa Ebola outbreak from 2014 to 2016. Communities were more mobile. They crossed borders more easily, spreading the disease across three countries – Guinea, Liberia and Sierra Leone – in a matter of months. This rendered the conventional containment approach problematic, and led to the outbreak spreading rapidly and widely. This resulted in the largest Ebola outbreak recorded to date.

It took a massive multinational effort to bring the outbreak under control. The scale of response efforts were historic.

The fear of Ebola spreading across a region have once again surfaced during the current outbreak in the Democratic Republic of Congo (DRC). Extensive efforts are again being undertaken to prevent this from happening.

Controlling the outbreak

The outbreak in the DRC has been raging on for six months. A total of 759 people had been infected and 468 deaths reported by the end of January 2019. This makes it the second worst outbreak in recorded history, after the outbreak in West Africa.

But the World Health Organisation recently announced that an experimental vaccine that has been rolled out in the affected area of the DRC that has been highly effective. Although the vaccine, known as rVSV-ZEBOV, is yet to be licensed, evidence to date indicates that it protects against the strain of the Ebola virus behind the current outbreak.

The vaccine underwent limited testing during the West Africa outbreak and the outbreak in the DRC between May and July 2018. More than 60,000 doses of the vaccine have been used in the current outbreak. It was primarily provided to front-line health workers and other at-risk contacts. Health workers in Uganda, South Sudan and Rwanda have also been vaccinated to help prevent the disease from spreading across borders.

The ability to vaccinate and protect proactively may largely remove the proverbial sting from Ebola.

Ebola is a feared disease, not only for the communities directly affected by an outbreak, but for countries around the world nervous that it can spread closer to home. The direct and indirect effects of the West Africa outbreak are well appreciated and demonstrated how these fears play into economies, travel and trade beyond the affected countries.

Much of this was driven by a disease that seemed to be an unstoppable killer. This may no longer be the case.

The Ebola vaccine – like others – should have the obvious advantage of protecting the outbreak-affected communities. But there are other advantages to having a vaccine in use in the ongoing outbreak. These include:

• Vaccinating and protecting health care and other front-line workers during an outbreak supports improved care for patients, and containment efforts due to a lower or removed risk of infection for workers who come into contact with sick individuals;

• Vaccinating and protecting contacts and possible contacts of people known to be infected with the virus allows health workers to create a barrier of immunity (called “herd immunity”) that prevents the virus from proliferating and spreading. This aids with the interruption of an outbreak;

• The psychological impact of having prophylaxis – a tangible tool to address the problem, allowing fears to be allayed and approached in a way that was not possible before.

It’s with great anticipation that the world awaits the final outcome of the efficacy testing of this vaccine. This would allow for licensing and pave the way for its availability in the future.

Time will also tell how the unprecedented approach to accelerating the testing and rollout of an Ebola vaccine will affect the development of vaccines for other infectious diseases.

It also remains to be seen if a successful Ebola vaccine could aid in restoring public faith and interest in vaccinations, and support longstanding efforts to eradicate disease such as polio and measles.

Jacqueline Weyer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

There’s been a recent increase globally in outbreaks of vaccine-preventable diseases. This can be seen in recent measles outbreaks in parts of the world where it was thought to have been eradicated.

This has prompted the World Health Organisation to list “vaccine hesitancy” (the reluctance or refusal to vaccinate despite the availability of vaccines) as one of 10 global health threats in 2019.

While there are many complex reasons why people choose not to vaccinate, changes in the way that information is accessed may provide one explanation for the rise in vaccine hesitancy.

We are involved in projects at the South African Research Chair in Science Communication at Stellenbosch University which explores vaccine communication. In a world where people are increasingly encountering science information online, particularly on social media, it’s important to understand why people are vulnerable to anti-vaccination messages and why this kind of information spreads so easily.

Effective communication strategies will be crucial if scientists want to counter the worrying trend of increases in vaccine hesitancy.

New media change the way people process science

In recently completed research, author Francois shed some light on how the anti-vaccination movement uses social media to amplify doubt and fuel hesitancy. The research found that “anti-vaxxers” select and share scientific information from open access journal articles on social media to escalate uncertainty in the broader population.

Anybody, including activists with specific agendas, can produce and share information online. This is heightened on social media, where people are connected in real time on a global scale.

Most online media don’t benefit from the quality control of journalists and editors that shapes the content of traditional mass media. Consequently, content is generated by experts and quacks alike, and opinion and facts become blurred. This makes it hard to judge if information is credible or not.

To complicate matters, people are able to create virtual communities of like-minded individuals who seek out information sources that they feel comfortable with. So people get more information they already agree with and few (if any) alternative views in online “echo chambers”. This results in anti- and pro-vaccine messages being shared and replicated in isolated groups, which polarises the contesting views even further.

So how can false information about vaccines shared on social media be countered? Scientists may think that sharing peer-reviewed, factual evidence about the safety of vaccines could change people’s views. Sadly, this is not the case.

Facts alone are not enough

One-way, top-down communication simply does not work. This is especially true when communicating about a controversial topic rooted in science.

That’s because a lack of information is not the problem. The issue is the way people process that information. Sometimes, people simply “refuse to know” what scientists are trying to tell them. This is what may cause vaccine opponents to reject years of research proving that vaccines don’t increase the risk of autism, even in vulnerable children.

Facts may even backfire. Research shows that bombarding vaccine-hesitant parents with evidence about the safety of vaccines may make them more vaccine-resistant. These studies confirm that it’s particularly difficult to dislodge incorrect information from someone’s memory. And it’s possibly even harder to change a person’s mind if they hold strong beliefs about a contested issue.

People’s views about contested issues in science are polarised by “cognitive bias” and “motivated reasoning” that result from their personal beliefs and values. If they are inclined to like new scientific information, they will view it more positively. But if new information dispels preexisting views, they won’t be receptive.

The so-called “negativity effect” also comes into play. People are more likely to share stories and images about harm and tragedy, than neutral or positive content. This explains why messages about the alleged dangers of vaccines, often accompanied by emotive images of sick children, are amplified more powerfully via social media compared with pro-vaccine messages.

New research

To address these issues, two new research projects are underway at the South African Research Chair in Science Communication at Stellenbosch University.

The first focuses on two public pages on Facebook that are specifically aimed at South African audiences. One is opposed to vaccines; the other is in favour.

The objective is to understand the nature and origins of anti- and pro-vaccination claims and images, as well as to explore the evidence provided in support of these claims. It’s hoped that a better understanding of claims made by these opposing groups via social media may provide a starting point for constructive dialogue between these groups.

A second study will examine how scientific information about vaccines and other contested issues is fed into online social networks by ideologically-motivated social movements to advance their cause. A better understanding of how scientific information flows from the formal science communication system to online communication networks will provide important insights about how to protect scientific information from strategic abuse.

The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Imagine bringing the best of all academic disciplines, artistic creations, activist experience and health care knowledge to bear on understanding and addressing current health care concerns. Rather than silos of people working in their specific areas of interest, imagine collaborations committed to listening and learning from all participants.

This is the vision of Medical and Health Humanities in Africa. It’s a field that grew out of the medical humanities in the US and UK. It brings together academics, researchers, practitioners, creative artists, health care seekers and providers.

Essentially, it straddles disciplines and practices in an effort to address health concerns. Artists compose music to open up understandings of health care and specific conditions, such as delirium. Some academics open up new conversations about existing health concerns like AIDS or use everything from yoga to photography to observation and drawing to help educate health sciences students. Others pair academics and artists to help young people talk about sex and sexuality or tuberculosis.

At its core, Medical and Health Humanities is about conversations and collaborations between people who are interested in health. This encourages new understanding, practice and knowledge. It also seeks to provide “translators” who can make often complex ideas in science and humanities accessible. They can also use creative arts to change perceptions, frame new questions and direct new discussions that result in more nuanced answers to health issues.

While still a relatively new field on the African continent, it is growing and gaining momentum. The latest milestone is the first English-language special issue of the globally respected BMJ Medical Humanities Journal to deal exclusively with work on and about medical and health humanities in Africa.

The special issue came out in December 2018. It showcases work from various countries in Africa, among them Nigeria, Malawi, Kenya, Tanzania and South Africa.

The projects profiled in this special issue, and others elsewhere on the continent, reveal the vital role Medical and Health Humanities can play across Africa in bridging the gaps between disciplines to improve people’s experiences of health care.

Beyond disciplinary boundaries

One of the Medical and Health Humanities projects highlighted in the BMJ’s special edition deals with digital storytelling and antiretroviral adherence in KwaZulu-Natal, South Africa. Another article shows how opium, thalidomide and contraceptives contributed to the making of modern South Africa.

The projects and articles themselves are, of course, important. But another critical element that must not be overlooked is how the field exemplifies inter-, trans- and multidisciplinary research and practice. It removes people from their disciplinary silos.

This is becoming increasingly important across academia. In the worlds of medicine and health, people often work on similar concerns in familiar ways; in doing so, they miss out on new perspectives. Working across disciplines and practices is a way to learn from each other and reflect on how things could be changed for the better.

And, crucially, it creates conversations about how we might improve our collective understanding of health and wellness.

Different forms

On the African continent, the Medical and Health Humanities community is also trying to do things differently when it comes to how research is conducted and presented.

If a field is genuinely committed to collaboration, collective engagement, building networks and relationships, it must do more than work quickly to “produce measurable outcomes” limited to academic articles. It must spend time building connections that extend beyond one event or “outcome”.

We attempted to do this during the writing of the special issue of the BMJ Medical Humanities journal. We were among a group of practitioners in South Africa who pooled resources from two universities to bring as many people who were working on the special issue together as possible. We wanted to ensure that experienced and emerging writers from multiple disciplines and practices had a chance to benefit from each other’s knowledge and experiences.

A workshop was held in 2017 at the Wits Institute for Social and Economic Research (WiSER). Participants came from Zimbabwe, Kenya, Nigeria, Tanzania, Malawi, Swaziland, South Africa, the UK and Canada and presented and discussed their work.

From this, people put together a range of material for the journal and the blog linked to the special edition. Some of this material took the form of academic articles; there are also podcasts, photographs, pieces of music, images and poetry.

This allowed us to present creative and academic work in a format that was more accessible to those with digital access and moved beyond academic journals. After all, part of what the field is concerned with is maintaining critical, intellectual rigour while making information available to people in a number of ways. In doing this the field tries to break down some of the barriers that prevent people from sharing work or ideas.

New networks

There is more to come for the Medical and Health Humanities field in Africa. A group called the Medical and Health Humanities Africa network has been established. CODESRIA, the Council for the Development of Social Science Research in Africa, among others, has been drawn into discussions about growing the field’s networks on the continent. The second conference organised by the Malawi Medical Humanities Network will be held in Zomba, Malawi in August and a workshop in Johannesburg in March called State of Dis-ease will continue these exciting new conversations.

Carla Tsampiras has received funding from the National Research Foundation.

The WellSexuality project was funded by a Wellcome Trust Seed Award no 208082/Z/17/Z