As the world reviews progress on the Millennium Development Goals (MDGs), Dr Jai P. Narain, Director, Communicable Diseases, World Health Organization, Regional Office for South East Asia, shares that the South East Asian region is "on track" towards achieving MDG 6, that focuses on HIV/AIDS, Malaria and Tuberculosis (TB).
Q: Do you agree with the view that the MDGs are a one-umbrella approach to addressing the world's development and health concerns?
A: The MDGs process, endorsed by 189 countries in 2000, is the most ambitious mission ever undertaken to address poverty and human suffering. The MDGs represent a shared commitment by all countries to work together to tackle hunger, ill-health, illiteracy, gender inequality and improve access by the poor to safe water and sanitation and to health services. These are based on the over-riding principle of equity and social justice, keeping the most vulnerable populations in mind. The progress the world makes on the MDGs would indicate its commitment to these issues.
Q: MDG 6 focuses on HIV/AIDS, Malaria and TB. These diseases remain a major source of concern in the South East Asia region. Any progress?
A: The region, I believe, is on track in terms of achieving MDG 6. Of course, given the diversity between and within countries, the progress could be considered uneven. Overall, though, it has been good. For example, in the case of TB, all the countries have expanded DOTS and have achieved nationwide coverage. As a result, we see a reduction in the risk of infection and TB-related mortality. India, Indonesia, Myanmar, Nepal and Bangladesh are spearheading this progress. Clearly, global success in TB control is being driven by progress here. With regard to HIV, prevalence is declining in many countries. On malaria, while there has been some progress, we need to do a lot more in ensuring accelerated scale up of bed net distribution and adopting new and effective treatments that not only treat malaria but limit its spread.
Q: Some population groups have reportedly developed resistance to TB drugs. What should be done?
A: Drug resistance is a major concern. In the context of TB, it renders treatment more difficult, more expensive, and oftentimes it poses a challenge to cure. Of course, drug resistance is a global phenomenon. It can occur naturally, but more often it is caused by the irrational use of medicines. Strategies to combat drug resistance include the rational prescribing of medicines by doctors and health-care workers and the appropriate use of drugs by the patients themselves, which can be reinforced through public education. Regulation also has an important role to play.
Q: When we refer to "infectious diseases", especially vis-a-vis HIV and TB, people surmise that they are "other people's problems". Perhaps, as a result, they even report late for possible treatment.
A: This is a problem. Early diagnosis and early treatment is very important because they help in many contexts, such as in TB, in breaking the chain of transmission. Once you diagnose early and treat it, you can render an infectious case, non-infectious. Partly, the problem also has to do with the treatment-seeking behaviour of patients. There are some that normally seek treatment late - like the poor, particularly women. It is important to address this missing link. There is a need for creating awareness across all groups that TB is curable and treatment is free. Private medical practitioners, too, have a very crucial role to play in partnering with the government and in ensuring that patients complete the full course of treatment.
Q: How well are we doing in addressing the issue of migrants and people crossing international boundaries, who may be carrying infections like HIV and TB?
A: Population movement is a growing phenomenon and people are increasingly crossing international borders for a variety of reasons. When people cross borders, along with them disease agents also cross borders; they do not require passports! The cross-border spread of infection is a rather complex and politically sensitive issue, requiring inter-country collaboration - especially between the two countries directly involved - and a coherent approach to disease prevention and control. We have to also understand that the border districts are outside the mainstream and generally neglected, and where health service infrastructure is relatively inadequate. Health delivery, therefore, must be improved not only for the people living there but for those crossing the borders.
Q: Most psycho-social health studies indicate that although a sizeable number, especially the young, has a relatively high awareness of the problem, they don't necessarily change their behaviour.
A: True.While creating awareness is important, it is not enough in order to bring about a sustained change in behaviour. Getting information or being aware is only the first step. People have to internalise or personalise the information. Then they have to be concerned about their behaviour, and become motivated to change it. Then they will have to adapt to a healthy/health-seeking behaviour. Finally, behavioural changes have to be sustained; become a part of the person. In the context of HIV, behavioural change also requires an enabling environment, one that is free from stigma and discrimination and where health services are available. Here, local organisations can play a greater role in bringing about behavioural change because they are integral to a given community and are able to provide information and support in a more sustained manner.
Q: Child and maternal mortality - MDG 4 and MDG 5 - remain a huge concern.
A: While there has been progress on both over the past few years, it is neither substantial nor fast enough, especially on MDG 5. There are also great social disparities to contend with - most of the deaths among children below five occur in the poorest populations. It is tragic that in spite of simple and cost-effective interventions available today, more than 1.3 million children below five die in this region of pneumonia and diarrhoea. There are many factors responsible for this, including poverty, under-nutrition, poor sanitation and personal hygiene, and, of course, lack of access to health services, information, and safe water. Clearly, this is a multi-factorial problem that needs a comprehensive inter-sectoral approach. So, it is critical that we prioritize MDG 4 and MDG 5 and ensure adequate progress in these two areas.
Q: Related to this is the record on sanitation, which seems very mixed.
A: Sanitation is another area the region is lagging behind in. Today, there are 2.6 billion people globally who lack adequate sanitation, 50 per cent of whom live in China and India. If we accelerate the rate of progress, it can be done. Take the example of Myanmar. It was able to increase its sanitation coverage from 21 per cent in 1990 to 81 per cent by 2008 because sanitation was identified as a high priority and more effort was put to improve the situation. Myanmar's success needs to be replicated if we are to make progress towards achieving the target of 75 per cent sanitation coverage by 2015.
Q: What are the principles to keep in mind while addressing communicable diseases in the region?
A: A few things are important, in my opinion: First, a complete understanding of the disease and its determinants. Without good understanding of the disease distribution and associated risk factors, we can neither plan properly, nor set realistic targets that can be monitored systematically. What gets assessed gets done. Second, partnerships and collaborations are essential. Health is not the responsibility only of health ministries, it has to become the responsibility of everybody. Third, we need to improve health system capacity to be able to deliver services focusing on health promotion and disease prevention. Finally, we need to ensure equity and provide good quality and affordable health services, particularly to those who need it the most - the poor and the vulnerable.
By arrangement with WFS