Environment – Health Relationship and Access to Health Services

#### **Chapter 1**

## Impact of Poverty on Health

*Ahmad Alqassim and Maged El-Setouhy*

#### **Abstract**

Poverty is not merely the absence of money but the absence of resources to get the necessities of life. Poverty and health are always in a reciprocal relationship. This relation came to light in 1948 when the WHO defined health as complete physical, mental and social well-being. In 1987, the Alma Ata Declaration opened the discussion on health inequity. This opened the door for thousands of projects, proposals, and publications on this relation. Although the relationship between poverty and infectious diseases was clear, there was inequity in funding. The Global Fund invests US\$ 4 billion annually for AIDS, tuberculosis, and Malaria, while other diseases lack funds. That is why they were considered neglected tropical diseases. However, the relationship between health and poverty is not limited to infectious diseases but includes noninfectious problems like malnutrition and injuries. In this chapter, we will assess the association between poverty as a predictor and health as an outcome.

**Keywords:** poverty, infectious diseases, malnutrition, developing countries, public health

#### **1. Introduction**

There are several definitions of poverty as a concept based on the context of the topic in which it is placed. During the World Summit on Social Development in Copenhagen in 1995, 117 countries adopted two concepts for poverty absolute and overall [1]. An ambitious global plan was proposed to eliminate absolute poverty and reduce overall poverty. Absolute poverty was defined as "a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education, and information. It depends not only on income but also on access to services." On the other hand, overall poverty is a "lack of income and productive resources to ensure sustainable livelihoods; hunger and malnutrition; ill health; limited or lack of access to education and other basic services; increased morbidity and mortality from illness; homelessness and inadequate housing; unsafe environments and social discrimination and exclusion. It is also characterized by a lack of participation in decision-making and civil, social, and cultural life. It occurs in all countries: as mass poverty in many developing countries, pockets of poverty amid wealth in developed countries, loss of livelihoods as a result of economic recession, sudden poverty as a result of disaster or conflict, the poverty of low-wage workers, and the utter lack of people who fall outside family support systems, social institutions and safety nets.".

Every country has its concept of poverty. However, the world bank defined poverty as "Poverty is a pronounced deprivation in well-being." [2].

Traditional poverty is a lack of essential resources for basic needs such as hygienic food, water, clothing, and shelter. However, access to healthcare, education, and transportation might also be included as indicators of poverty in the modern world. In general, Poverty is a state in which a community or person lacks the Necessary needs for minimal standard of living in that place.

#### **2. Global poverty lines**

Each country has its own definition of poverty. The poverty line is substantially lower in poorer countries than in richer ones [3]. This means that if we were to only depend on national poverty criteria for a global measure of poverty, the outcome would be a measuring framework in which a person**'**s place of residence would decide whether or not they were poor. Setting global poverty lines based on national definitions and applying them globally is one solution to this issue. The global Poverty Line was determined in this manner by the United Nations. The global poverty line must be frequently adjusted to account for changes in worldwide price disparities. The new global poverty line was updated to \$2.15 starting in the fall of 2022 [4]. Therefore, it is considered extreme poverty for someone to make less than \$2.15 daily.

#### **3. Poverty facts**

More than 689 million people rely on less than \$1.9 per day, while 250 million are under the global poverty line [5]. Two-thirds of the world**'**s poor people are children and young, while women predominate in most areas [6]. Sub-Saharan Africa sees an increase in the concentration of extreme poverty, and about A little over 40% of the local population makes less than \$1.90 each day [7]. Between 2015 and 2018, the Middle East and North Africa experienced a nearly doubling of the extreme poverty rate, from 3.8 to 7.2%, primarily due to the political conflicts in the area [8]. Between 2015 and 2018, the Middle East and North Africa experienced a nearly doubling of the extreme poverty rate, from 3.8 to 7.2%, primarily due to the political conflicts in the area [9]. Around 67% of the world**'**s poor people are predicted to live in unstable regions by 2030 [9]. In extreme poverty, 70% of adults over 15 either have no formal or minimal education. Around 1.3 billion people reside in 107 developing nations and experience poverty [10].

#### **4. Poverty and health**

Globally, poverty and poor health are deeply associated [11]. Disparities in politics, society, and the economy are the underlying causes of poor health among millions worldwide. Poverty is both a cause and a consequence of poor health [12]. Infectious and neglected tropical diseases affect millions of the world's poorest and most vulnerable individuals annually [13]. Poverty is a crucial contributor to poor health and a barrier to receiving necessary medical care [14]. Financial restrictions prevent poor people from acquiring the necessities for optimal health, such as enough quantity of high-quality food and medical care. However, the relationship is also

#### *Impact of Poverty on Health DOI: http://dx.doi.org/10.5772/intechopen.108704*

linked to other aspects of poverty, such as a lack of knowledge about the best ways to promote health or a lack of a voice to ensure that social services are effective for them. Because they lack the knowledge, resources, or access to healthcare that would enable them to prevent and treat disease, marginalized groups and vulnerable individuals frequently suffer the most. Indigenous communities and other marginalized groups may have severe health repercussions due to reduced healthcare use due to cultural and social barriers, which maintain their extreme poverty levels [15]. Robust health systems protect populations from the potentially disastrous effects of out-of-pocket healthcare costs and enhance the entire population's health status, especially the poor, who are more likely to experience poor health and limited access to healthcare [16]. In general, the poor are disproportionately more likely to have bad health [17].

#### **5. Ending poverty's current challenges**

Globally, the number of people suffering from extreme poverty, poor people living on less than \$1.90 a day, decreased from 36% in 1990 to only 10% in 2015 [12]. For nearly 25 years, the number of poor people living on less than \$1.90 a day has been steadily declining [18]. Unfortunately, this gradual improvement was halted in 2020 by the effects of the COVID-19 pandemic [19]. The COVID-19 pandemic has swept back decades of progress in the fight against poverty. According to the World Bank, the COVID-19 pandemic pushed between 143 and 163 million people in 2021 into extreme poverty [20]. Some countries have been affected more than others. We find that countries in South Asia and Sub-Saharan Africa have suffered from new waves of high extreme poverty rates, more than previously reported [21]. These large numbers of these "new poor" will be in addition to the already 1.3 billion poor people living in extreme poverty and experiencing exacerbated life difficulties in light of the COVID-19 pandemic [22]. Poverty rates are alarmingly high, especially in developing countries that are the most vulnerable to economic risks since the onset of the COVID-19 pandemic [23]. These devastating effects on developing countries are not just due to health crises but also because of the pandemic's impact as a devastating social and economic crisis for the foreseeable future [24]. According to the United Nations Development Program, income losses are expected to exceed \$220 billion in developing countries [12]. The world's population without access to social protection is expected to reach an estimated 5% of people [25]. All this will lead to the repercussions of these losses affecting education, human rights, basic food security, and global nutrition. There is a light at the end of the tunnel due to the beginning of the recovery phase from the pandemic starting in 2022 [26]. This might contribute to returning to the right track in achieving sustainable development goals in many countries where poverty rates have risen to record numbers [12]. These record numbers caused mistrust of these countries in the current global sustainable development plans. The need has become urgent and intense to start taking actual steps by developed countries to reduce poverty rates by opening economic cooperation and transferring sufficient expertise to improve the economic environment for these countries.

#### **6. Diseases related to poverty**

As described above, poverty and ill health are mutually related as each affects the other. Infectious diseases are mostly related to poverty, so we will only consider them in this chapter. Aiming to integrate health with the plans to eradicate poverty, the World Health Organization developed the International Poverty and Health network in 1997. This network of people and organizations from business, health, governmental and non-governmental organizations worked on developing policies to improve the health of the poor populations worldwide [27].

Three years later, with the support of the Group of eight (G8) (Group of eight, namely the United States, Canada, the United Kingdom, France, Germany, Japan, Italy, and Russia), the global fund was declared to cover three diseases that appear as unstopped in different countries. The Global Fund invests US\$ 4 billion annually for AIDS, Tuberculosis, and Malaria, while many other diseases lack funds for eradication or elimination.

That is why they were called neglected tropical diseases, mainly prevalent in the tropical and subtropical regions of Africa, Asia, and the Americas. However, they included a group of infectious diseases that are highly prevalent in these developing countries. These three events and declarations defined the diseases concerning poverty. But unfortunately, the first three Malaria, Tuberculosis, and HIV/AIDS were lucky to get the global fund, while others were neglected as defined.

To make it easy, we divided poverty-related diseases into two main groups those covered by the Global Fund and those considered neglected tropical diseases.

#### **6.1 Diseases covered by the global fund**

Replace the entirety of this text with the main body of your chapter. The body is where the author explains experiments, presents and interprets data of one's research. Authors are free to decide how the main body will be structured. However, you are required to have at least one heading. Please ensure that either British or American English is used consistently in your chapter.

#### *6.1.1 HIV/AIDS*

After the death of the first known case of HIV/AIDS in Kinshasa (Belonging to Congo nowadays) in Africa in 1959, the disease spread to many other countries in the world as a global blood-born and sexually transmitted disease pandemic (**Figures 1** and **2**) (**Table 1**) [28]. The estimated number of globally infected people now is around 38 million [29]. The virus attacks the immune system with different manifestations of the disease ranging from the carrier state with no manifestations to severe immune-depression states and death. No standard curative treatment is known for the disease [30–33]. That is why the patients' early diagnosis, symptomatic treatment, and care help them to live longer. However, primary prevention is considered the cornerstone in preventing the spread of the disease [34–36].

This would describe the much higher prevalence of deaths from HIV/AIDS in developing countries compared to developed countries and even the higher deaths in the developed countries among poor people who have limited access to healthcare facilities [37–42]. This fact is evident in maps 1 and 2 quoted from the WHO website 2017, especially compared to the extreme poverty presented earlier (**Figure 3**), where Africa carries the primary disease burden and deaths from the disease [43].

That is why the global health sector strategies (GHSSs) focus on HIV, viral hepatitis, and sexually transmitted infections for 2022–2030. The GHSSs guide the health sector in implementing strategically focused responses to end AIDS,

#### *Impact of Poverty on Health DOI: http://dx.doi.org/10.5772/intechopen.108704*

#### **Figure 1.**

*The global estimated number of people living with HIV, 2016. Source: WHO/UNAIDS/UNICEF©.*

#### **Figure 2.**

*The global prevalence of HIV among adults aged 15 to 49, 2016. Source: WHO/UNAIDS/UNICEF©.*

#### **Table 1.**

*The global burden of the HIV epidemic, 2021. Source: WHO©.*

#### **Figure 3.**

*Poverty proportion at \$1.90 a day, 2018. Source: World Bank©, Poverty Global Practice, and Development Economics Division. Data are based on household survey data obtained from different government statistical agencies and the World Bank country departments.*

#### **Figure 4.**

*The global endemic locations for malaria worldwide, 2020. Source: Global Health, Division of Parasitic Diseases and Malaria, CDC©.*

viral hepatitis B and C, and sexually transmitted infections by 2030. This would be achieved through the synergistic work of different health sectors with the Primary Health Care (PHC) [44].

#### *6.1.2 Malaria*

Malaria is a vector-borne parasitic disease transmitted by anopheline mosquitos [45, 46]. The disease is caused mainly by four kinds of malaria parasites that can affect man. They are called Plasmodium (P) falciparum, P. vivax, P. oval, and P. malariae [47]. The estimated number of Malaria cases in 2020 was 241 million in 85 endemic countries. The global Malaria map (**Figure 4**) is nearly the same as the poverty map presented earlier. Malaria is mainly prevalent in poor countries [48]. Most Malaria cases (around 95%) are present in Africa [49]. Although most developed countries eliminated the disease, developing countries did not [50, 51].

The World Health Organization (WHO) launched the first Global Malaria Eradication Program (GMEP) in 1955 [52]. The program targeted The Americas, Europe, and Asia through spraying DDT and the use of chloroquine [53, 54]. However, most African countries were excluded due to logistical difficulties at that time (most of them were occupied by European countries) [55, 56]. However, in 1969, the WHO suspended this program after developing resistance to the treatment and the insecticides [57]. Malaria re-emerged in Europe in the 1990s, and the WHO launched the Roll Back Malaria program in 1998 using insecticides that impregnated bed nets and new cheap drugs [52, 58–60]. In 1987 Mosquirix vaccine was created against P. falciparum malaria and hepatitis B after great efforts and funds. The vaccine is now available in Europe for children aged 6 weeks to 17 months, but not yet for poor African children, although Africa carried all the burden of the vaccine's clinical trials [61–63]. Although malaria is eradicated in

**Figure 5.**

*The global estimated TB incidence rates, 2020. Source: Global Tuberculosis Report 2021, WHO©.*

the United States and most of the European countries, it is still highly prevalent in the poor countries of Africa [52].

#### *6.1.3 Tuberculosis*

Tuberculosis (TB) is one of the oldest diseases caused by tubercle bacilli. It is a disease in poor people and countries. It is highly prevalent in developing countries, as shown in the map compared with the poverty map [64–67]. Despite all efforts to eradicate tuberculosis (TB), it remains a threat to global health (**Figure 5**). In the early 1920s, the BCG vaccine against tuberculosis was available. However, no universal global vaccination program has been adopted, and still, tuberculosis is responsible for millions of deaths [68]. Different lines of treatment were developed to eliminate the disease, as drug resistance developed for some medications used to treat the disease [69, 70]. However, Directly Observed Therapy (DOT) is still effective in many areas but in poor areas where direct observation of the therapy is impossible [71–73]. The concurrent infection with HIV in poor areas was a decisive factor hindering the disease treatment [74]. Poverty with overcrowding, inadequate housing, poor ventilation, and famines were all contributing factors to the disease's continued among poor populations.

#### **6.2 Neglected tropical diseases related to poverty**

Neglected tropical diseases (NTDs) are affecting more than 1 billion propel. They are mainly diseases of poor populations in the tropical and subtropical areas [75, 76]. They are a group of 20 diseases as mentioned down:


*Impact of Poverty on Health DOI: http://dx.doi.org/10.5772/intechopen.108704*


The NTDs are mainly diseases in developing countries, as shown in the maps of some of the NTDs down if compared to the map of poverty shown earlier in the chapter (**Figure 6**) [77–84]. However, due to a lack of funding, the WHO published a 2021 booklet as a road to end the NTDs by 2030 by integrating their prevention and control (**Figure 7**) [76].

As described above and with comparing the maps of the diseases described it is obvious that fighting poverty should be considered in preventing these diseases (**Figure 8**). Whatever we would do to prevent these diseases, they will continue affecting poor people till poverty is controlled (**Figure 9**).

#### **7. Conclusion**

Poverty is the economic condition in which the individual lacks sufficient income to obtain the minimum levels of food, clothing, healthcare, education, and all the

#### **Figure 6.**

#### **Figure 7.**

*The global endemic locations for Taenia solium, 2022. Source: WHO©.*

#### **Figure 8.**

*The global endemic locations for onchocerciasis and the status of its preventive chemotherapy, 2019. Source: WHO©.*

#### **Figure 9.**

*The global endemic locations for lymphatic filariasis and the status of its preventive chemotherapy, 2016. Source: WHO©.*

needs necessary to secure a decent standard of life. The phenomenon of poverty in all countries of the world is considered an intractable problem. However, in developing countries, the significant increase in poverty rates is the problem. In addition, the COVID-19 pandemic has dramatically affected the increase in poverty rates, especially in developing countries.

Poverty affects health significantly in several directions. Malnutrition is when the poor suffer from the lack of food, and it may not be healthy if available. They also suffer from malnutrition, which makes children starve to death. The inability to access healthcare, as the poor cannot afford the healthcare expenses or buy the medications they need, is a considerable obstacle. Poverty is associated with a higher risk of diseases, epidemics, and early deaths. The relationship between poverty with health remains a deep-rooted relationship, no matter how researchers differ in determining who affects the other. Therefore, developed countries must increase the rates of economic cooperation and support the development of developing countries.

#### **Acknowledgements**

We would like to extend our sincere thanks to international and local organizations such as the United Nations, World Bank, and CDC for making valuable data and information available to researchers and supporting developing countries**'** development process.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Ahmad Alqassim\* and Maged El-Setouhy Faculty of Medicine, Family and Community Medicine Department, Jazan University, Jazan, Saudi Arabia

\*Address all correspondence to: ahmadalqassim1407@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 2**

## Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health

*Aaron Briggs*

#### **Abstract**

The present era is defined by a confluence of crises and a degree of global interconnectedness without historic precedent. A Toxic Triumvirate of climate change, conflict, and contagion have synergistically functioned to cast our collective, global public health into extreme jeopardy. The COVID-19 pandemic, War in Ukraine, and advancing climactic catastrophe have devastated our world: destabilizing nations, severing vital supply lines, and fracturing indispensable health infrastructure. All the while, *the threat of nuclear war* and the risk of devastating pandemic from emerging infectious disease (EID) grow in the unchecked wounds of low- and middle-income countries (LMIC). Nations of the Global South have been rendered super-vulnerable to the Toxic Triumvirate's effects through historic global inequity and chronically anemic international support. These "developing" nations are subject to unsustainable extremes of risk secondary to a compounding of hazard. This amplified risk is transmitted through our world *via* vibrant arteries of commerce that intimately connect us. Our world's collective health is in a state of jeopardy demanding a vigorous, equitable, and cooperative international response. To chart a course toward a safe future for our children, we must rectify the profound inequities that present our world's shared Achilles' heel and invest in the sustainable development of LMIC.

**Keywords:** public health, climate change, vaccine inequality, pandemic, infectious disease, climate change, inequality, transfer of hazard

#### **1. Introduction**

*The world is entering a new danger zone, one that is more prone to shocks that can quickly knock countries off course. After navigating extraordinary challenges over the past two-and-a-half years, further extraordinary challenges lie before us…the path ahead is likely to be just as tough, if not tougher [we must] begin with a more proactive, precautionary mindset to build resilience in a more shock-prone world.*

*International Monetary Fund (IMF) Director Kristalina Georgieva, 2022.*

*We are at an inflection point in history. The COVID-19 pandemic has served as a wake-up call and with the climate crisis now looming, the world is experiencing its biggest shared test since the Second World War.*

#### *The United Nations (UN) Common Agenda Report, 2022.*

The needle ticks 100 seconds to Midnight. The atomic scientist's hands shake as she advanced the 2020-2022 Doomsday Clock closer to Armageddon than it had ever been. The Bulletin of Atomic Scientists, established in 1945 by Albert Einstein and Manhattan Project scientists, have watched in horror as crises have grown to become confluent, mounting a compounded risk to our collective global health that is without historical precedent.

Our international body, intimately, and vibrantly connected through coursing arteries of trade and travel, has become terminally ill. A poison of inequity taints our shared bloodstream, crippling the vital international and national organ systems it touches. Disease, violence, and climatic cataclysm have battered and deluged our world with unprecedented suffering. Beneath the bullets and bombs, the temperature and water level continue to rise, and the risk of lethal pandemic brews within the unchecked wounds of the Global South.

The upper extremities in the Global North, finding themselves circumstantially above a rising water level, have attempted to further secure themselves against catastrophe. Low**-** and middle-income countries (LMIC), who very literally find themselves underwater, are left to struggle for survival without sustainable and effective international support. Vital organ systems of infrastructure, indispensable to curtail our ever-advancing risk, have wasted from chronically anemic funding streams, now lying unable to maintain global homeostasis. As organs fail, our shared arterial supply lines lose pressure, and the vulnerable tissues of the Global South, deprived of support and oxygen, begin to necrose. Below the water line, impoverished and traumatized communities become a gangrenous point of entry for fatal superinfection capable of disseminating through our world's circulatory system like wildfire.

At our body's beating heart, nations stand united to treat these life-threatening wounds and protect our collective health. However, their work has been stymied and paralyzed by the reluctance of wealthy, non-LMIC nations of the Global North to invest in the sustainable development and protection of the Global South. In our increasingly interconnected world, the Global North's historic strategy of self-protection and investment at the expense of LMIC has become a fool's errand [1–4].

#### **1.1 An existential and ethical crisis**

*I begin by describing the role of justice in social cooperation…[presenting] the main idea of justice as fairness, a theory of justice that generalizes and carries to a higher level…the traditional conception of the social contract.*

*John Rawls, A Theory of Justice, 1971 (1921-2002).*

*If the misery of the poor be caused not by the laws of nature, but by our institutions, great is our sin.*

*Charles Darwin (1809-1882), Voyage of the Beagle.*

#### *Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

The triumvirate specters of climate change, conflict and contagion haphazardly sway about our heads like Damocles' Blades. Bound in strengthened communion by morally decayed sinews of inequity, these Toxic Triumvirate have grown to present the human species with the greatest existential dilemma of its relatively brief history.

Climate change is advancing at a rapid pace and its effects have become of cataclysmic severity. Climactic upheaval ranging from sweeping fires across Europe to catastrophic floods in Africa and Southeast Asia have devastated and destabilized nations across the globe. Amidst catastrophe and resource limitation, old fault lines of conflict are becoming active, and new flashpoints are opening across the world at a dangerous and intensifying pace. The War in Ukraine has paralyzed international trade and economic growth in a world still attempting to recover from an ongoing SARS-CoV-2 (COVID-19) pandemic. Humanitarian catastrophes cripple the Global South amidst a maelstrom of conflict and climatic cataclysm. Within these concentrations of human suffering and misery, the specter of zoonotic pandemic from emerging infectious disease (EID) gathers strength. In our interconnected world, a single spark struck in a war-torn, impoverished, and destabilized corner of the globe has the potential to start an international blaze. United Nations (UN) Secretary General (SG) Antonio Guterres opened the 2022 77th Session of the United Nations General Assembly (UNGA) noting, "We are meeting during a time of great peril." The theme of the assembly was designated: A Watershed Moment: Transformative Solutions to Interlocking Challenges. The meeting was a call for international cooperation in facing the uniquely interrelated crises of climate change, war, and COVID-19, as well as the catastrophic humanitarian crises emerging in their midst.

The field of public health is entering an era of challenge and demand that is without historical precedent. The triune wraiths of contagion, climate change, and conflict, each representing an existential threat in their own right, present a confluent crisis demanding an urgent and vigorous international response.

In this chapter, I will advocate for an approach to improving and preserving global health security that leverages the power of international solidarity and sustainable development to decrease our shared risk and to help ensure a safe and habitable world for our children. The vice of inequity has shifted from being a neglected ethical responsibility to an existential imperative. The present era demands that humanity reconcile the disparities that have so marred our past, or risk succumbing to the bitter fruit of our pride & prejudice [5–9].

#### **2. Inequality: a lethal intoxicant**

*All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.*

*Universal Declaration of Human Rights, (UNDR) Article 1, 1948.*

*There is no food. There is no medicine. The floodwaters have reached the village. Our children are sick, starving, and dying and there is nothing we can do….\*weeping\**

*S Sudanese Woman Interview Transcription, Al Jazeera (AJ), Oct 22, 2022.*

On December 10, 1948, the UNGA signed the United Declaration of Human Rights (UDHR) into inception, representing an important, global ethical advance. However, while nations proclaim support for the UDHR, basic rights remain unprotected across the world.

We live in an interconnected era where health and risk have become socialized and globally shared. The hazardous conditions presented by inequality anywhere reduce the safety of people everywhere. This is exemplified by the inequitable response to the COVID-19 pandemic, where critical under vaccination within the Global South has facilitated the development and circulation of COVID-19 variants that have wreaked havoc across wealthy and impoverished nations alike.

Inequity is fundamental to the persistence of COVID-19 and represents an increasingly exposed Achilles' heel for the continued recurrence of internationally paralytic pandemics. The international inequity and impoverishment that cripples nations of the Global South is not a natural phenomenon. Current global inequality has been created and maintained by specific national and international interventions, and it can be undone just the same. We enter an era where the reconciliation of international inequities must be expediently and sustainably accomplished if we are to meaningfully reduce our historic level of international risk [10–12].

#### **2.1 One health and one risk**

*Vaccine inequity is the world's biggest obstacle to ending this pandemic and recovering from COVID-19.*

*Dr. Tedros Ghebreyesus, World Health Organization (WHO) Director-General.*

*Complex risks result from multiple [catastrophic] hazards occurring concurrently, and from multiple risks interacting, compounding overall risk and resulting in risk transmitting through interconnected systems and across regions.*

*Intergovernmental Panel on Climate Change (IPCC) 6th Assessment Report, 2021-2022.*

The concept of One Health emerged as a solemn acknowledgment of the complexity of human health and the myriad of critical socioeconomic and environmental factors that influence it.

In 2021, the World Health Organization (WHO) formed the One Health High-Level Expert Panel (OHHLEP) to advise a multidisciplinary approach to address climate change as well as disparities in global infrastructure, agriculture, and environmental resilience.

These critical inequities pose a threat to global health with their combined effect noted to increase conditions favorable for pandemic pathogen introduction and dissemination, hereby referred to as *pathopermissive*. Because of how interconnected our global community is, the health and risk to one population is shared by all constituents of our international body [9, 13, 14].

#### **2.2 The challenge before us**

*Contemporary global inequalities are close to early 20th-century levels, at the peak of Western imperialism.*

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

*International Monetary Fund (IMF) World Inequality Report (WIR), 2022.*

*After centuries of [colonial] unreality, after having wallowed in the most outlandish phantoms… the youth of a colonized country [are forced to grow] up in an atmosphere of shot and fire…*

*Frantz Fanon, MD (1925-1961). Wretched of the Earth.*

In this age of unprecedented and complex risk to global health, the safety of our international community will rest upon cooperative, responsive, and effective international leadership. This is an area of urgent and utmost need. Global voices including Antonio Guterres and Pope Francis have sharply criticized the failure of current national and international leadership amidst COVID-19, the War in Ukraine, and climate change.

The COVID-19 pandemic has demonstrated that one of the largest contributors of international impotence is a lack of intergovernmental coordination and a poverty of financial commitment by wealthy nations. Our current lack of intact and effective health systems in the Global South will result in critical delay of pandemic detection. The risk wrought by this disparity in health infrastructure is compounded by critical inequities in other fundamental domains including: financial resources, education, food security, essential water/sanitation/hygiene, and energy infrastructure.

The extreme concentrations of hazard and risk present in LMIC of the Global South is transmitted and disemminated among our global community through a common international circulatory system. If we are to safely navigate this perilous era, we will need to repair the wounds of the past and equip nations of the Global South with the critical infrastructure they will require to reduce the currently unsustainable levels of global risk [9, 15, 16].

#### **2.3 Vital organs: five fundamental equalities**

*Imperialism leaves behind germs of rot which we must clinically detect and remove from our land [and] from our minds as well.*

*Frantz Fanon, MD (1925-1961). Wretched of the Earth.*

*We stress at the outset that addressing the challenges of the twenty first century is not feasible without significant redistribution of income and wealth inequalities.*

*International Monetary Fund (IMF) World Inequality Report (WIR), 2022.*

The benefit of even a perfect medicine is precluded in the absence of vital organs. Likewise, sustained development can only take root in the setting of functional, essential national infrastructure. Below I will review five essential equalities that are prerequisite to the sustainable and empowered global development that must be expeditiously accomplished if we are to mitigate our present level of risk [9, 15, 16].

#### *2.3.1 Global wealth equality*

*…the rules of the [international financial] game…are completely against the interests of developing countries…with debt problems, with liquidity problems, with inflation*  *problems, with instability, necessarily posed by this profound injustice in international financial and economic relations.*

*UNSG Antonio Guterres, High-Level Meeting on the Sahel, UNGA 77th Session, September 2022.*

*What matters [ultimately], the issue which blocks the horizon, is the need for a redistribution of wealth. Humanity will have to address this question.*

*Frantz Fanon, MD (1925-1961). Wretched of the Earth.*

Global wealth inequality has not changed in over a century. Wealth and finance, essential for the development of any nation, are home to some of our world's most egregious disparities. The Internal Monetary Fund (IMF) published its 2022 World Inequality Report (WIR) decrying severe disparities that developmentally stymie the Global South. The report indicated that approximately 10% of the world's population is responsible for 76% of global wealth, 52% of global income, and 48% of global carbon emissions. The poorest half of our global community was found to earn only 8.5% of world wealth. Despite our stated international commitment to reconciling fundamental disparities in wealth, the inequities that cripple the Global South remain as stark as observed in 1920.

October 10, 2022: The IMF and World Bank Group (WBG) began their annual meeting in Washington, D.C. to discuss the urgent issues of global economic downturn, poverty eradication, and economic development. The summative conclusions reported as the meeting progressed are grim. The twin crises of COVID-19 and the War in Ukraine have devastated the global economy resulting in skyrocketing inflation. In the wake of systemic, economic incapacitation, national GDP has been in free-fall affecting nations of the Global South disproportionately. Nations of the Global North have also been severely impacted, with the IMF forecasting diminishing national growth and possible, global recession into 2023 [15, 17].

#### *2.3.2 Universal energy infrastructure*

*If we use our fuel to get our power, we are living on our capital and exhausting it rapidly. This method is barbarous and wantonly wasteful and will have to be stopped in the interest of coming generations.*

*Nikola Tesla, The Wonder World To Be Created By Electricity: Manufacturer Record, 1915.*

Energy has been essential for human survival from time immemorable, but it comes at a price. Western European countries have experienced significant rises in energy and cost of living as international energy infrastructure has been critically disrupted by the conflict in Ukraine.

The Global South pays a different price. Inhaled air pollutants like combustion byproducts represent a leading cause of global morbidity and mortality estimated to be responsible for more than 10 million excess deaths each year. This suffering is disproportionately concentrated in LMIC whose infrastructural development and energy transition have been curtailed by international intervention and negligence.

#### *Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

The 1970s brought an American-led end to the Post-WWII Breton Woods International Economic System that had previously constrained the corporate flow of capital. In its place, a neoliberal, political-economic policy permitting ruthless corporate expansion and exploitation further deepened our global inequities. The Global North, having stumbled through the perils of industrial revolution at catastrophic cost to domestic labor workforce and the international poor, begin to power a transition to improved forms of energy by exporting upscaled, dangerous, and crude manufacturing processes to LMIC. The pressure to exploit LMIC as regions of manufacture due to lax labor and environmental regulation led to a critical *shift of environmental hazard* from the Global North to South.

Currently, approximately 50% of the world's population lack access to improved energy infrastructure and are dependent on solid fuels, which result in substantial increases in exposure to combustion's mediators of disease.

When energy infrastructure fails, cataclysm can become a catastrophe. Climate change and conflict have taken devastating tolls on the infrastructural integrity of nations across the world. Ukraine, following Russian shelling in early October, had lost 40% of its energy infrastructure resulting in sweeping outages and their pathologic sequela such as loss of access to clean drinking water and failure of sanitation resources [9, 18, 19].

#### *2.3.3 Universal food security*

*The water is dirty and the trip to get it is dangerous. I have to leave my children and by the time I arrive home it is dark. Today I do not know what my children will eat. Everyone has been affected by the drought. Our rains have failed, our children are not eating and going to sleep hungry. We need help we are hungry and cannot survive like this.*

*Kenyan Woman, Interviewed AJ Oct 2022, Translated into English and Transcribed.*

*Conflict, COVID, the climate crisis and rising costs have combined in 2022 to create jeopardy for up to 828 million hungry people across the world…. While needs are sky-high, resources have hit rock bottom.*

*World Food Programme (WFP).*

We have lost progress in the fight against global hunger. In 2022 the World Food Programme (WFP) declared a global food crisis, noting this to be a year of unprecedented food insecurity. The UN/WHO 2022 State of Food Security and Nutrition in the World Report described a deepening inequity in access to food that is heavily impacting the Global South. As of the late 2022 writing of this chapter, the African Horn and Eastern Africa are experiencing drought-induced famine with affected nations demonstrating concerning rises in child malnutrition. Last year in floodstricken Nigeria, the WFP announced that it would have to reduce food support by 50% due to funding limitations. At a time when international need has peaked, the anemic support from the Global North that has become the historic norm must change. Across the world, malnutrition is acting to weaken immune systems in the regions where outbreak risk is the highest. To leave nations to succumb beneath conflict, climactic catastrophe, and hunger represents both a reckless jeopardization of our collective health and an absysmal ethical failure [20, 21].

*2.3.4 Universal water, sanitation, and hygiene (WASH) infrastructure*

*Half of healthcare facilities globally lack basic hygiene services. 1 in 3 people globally do not have access to clean drinking water.*

*WHO, United Nations International Children's Emergency Fund (UNICEF) Report and Press Release: 2019, 2022.*

*Countries must double their efforts on sanitation or we will not reach universal access by 2030. If countries fail to step up efforts on sanitation, safe water and hygiene, we will continue to live with diseases that should have been long ago consigned to the history books:*

*Dr. Maria Neira, WHO Director, Department of Public Health, Environmental and Social Determinants of Health.*

The WHO and United Nations International Children's Fund (UNICEF) Joint Monitoring Program (JMP) has been monitoring global access to water, sanitation, and hygiene (WASH) infrastructure since its inception in 1990. Currently, 2.1 billion people lack access to safe drinking water and 4.5 billion people lack sanitation. Approximately 800 children die from preventable diarrheal illness every day because of this. Nearly all of the nations still requiring WASH infrastructure are located on the African continent. The lack of WASH infrastructure affects much more than health. Clean water and sanitation are essential for the development of children, economies, and nations. As such, this inequity represents a key barrier to the sustainable global development we will need to improve our collective safety. The UNICEF 2016-2030 WASH framework is designed to rectify this inequity with the goal of achieving universal and equitable access to safe water, sanitation, and hygiene by 2030. However, as with many efforts toward equity, the UNICEF WASH initiative has been critically frustrated by chronically anemic financial support from wealthy nations of the Global North [22, 23].

#### *2.3.5 Universal national health infrastructure*

*In Africa, most people are born, live, and die without leaving a trace in the official record.*

*Don de Savigny, Tanzania Essential Health Interventions Project.*

*It has long been recognized that a malarious community is an impoverished community.*

*T. H. Weller, Nobel Laureate in Medicine, 1958.*

*On Saturday night the doctor called me said my daughter is critical. All her organs are damaged, her brain, her heart and her eyes. On Sunday morning she had heart failure and died in my lap. The government needs to investigate this and come up with solutions. I do not want any mother to feel what I felt. I've lost my baby.*

*Indonesian woman, Interviewed AJ Oct 22, 2022, Translated into English and transcribed.*

#### *Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

In early October 2022, 70 children passed from acute kidney failure in the Gambia. The culprit was found to be tainted cough syrup shipped from an Indian pharmaceutical company. In the late 2022 final drafting of this chapter, more than 130 children were reported to have passed from acute kidney illness secondary to cough syrup in Indonesia and the case count is rising.

Vulnerable children are said to be "an infection away from catastrophe" and not even their medicine is safe. Global inequity in health infrastructure takes an immeasurable toll on LMIC. Preventable diseases of poverty shackle the economies of the Global South, while waves of outbreak from Ebola to COVID batter nations like storm surges.

Global equality in health infrastructure is the cornerstone of our defense against pandemic. In order for deadly pathogen to be effectively identified and contained within the region of introduction, there must be essential national health infrastructure in place. In its absence, such as in the 2014 Ebola Epidemic, outbreaks are able to spread unmitigated and undetected like wildfire. Functional national health infrastructure is also imperative to the control of the preventable diseases of poverty that disproportionately take their toll on the youngest generations—crippling the capacity of affected nations to develop.

Recent research on the health infrastructure of LMIC has articulated three consistent features found in health systems of the Global South: insufficient resources, weak state effective capacity, and high burden of disease. As their internal capability for development has been critically impaired, nations of the Global South will require significant and expedient international investment to kick-start the establishment of functional and sustainable civil infrastructure and healthcare systems. Universal health infrastructure will be fundamental to our global safety as effective, local pandemic preparedness and disaster response will require organized and decisive national action in order to control fires at their source [24–28].

#### **2.4 A road to sustainable development**

*Evidence of observed impacts, projected risks, levels and trends in vulnerability, and adaptation limits demonstrate that worldwide [catastrophically] resilient development action is more urgent than previously assessed.*

#### *IPCC 6th Assessment, 2022.*

The reviewed dilemmas of inequality represent recognized global emergencies to which the UN, WHO, and other international actors have responded. In the year 2000, the Millennium Development Goals (MDG) were designated by the UN. These eight goals represented key global disparities to be addressed through an internationally cooperative response.

The Sustainable Development Goals (SDG) were designated in 2015, immediately in succession of the MDG. The SDG represent an enhanced set of aims incorporating lessons learned from the prior MDG and distinguish themselves in their focus on sustainability. Chronic inequity has rendered nations of the Global South uniquely disempowered to affect their own development with many prior interventions in the Global South having been reactive, superficial, and unsustainable. Nations of the Global South must be released from poverty, debt, disease and violence, and empowered to develop and build the capacity necessary to weather the storms to come. In our present world, the health of our global community depends on the health of its

constituents. The watershed of development proposed in the SDG will likely generate a positive feedback cycle as more and more citizens of the world are released from inequity's shackles and empowered to contribute to the building of a cooperative, safe, and more resilient tomorrow [1, 3, 9, 29, 30].

#### **3. Climate change: the crisis to define an era**

*I have just returned from Pakistan, where I looked through a window into the future. A future of permanent and ubiquitous climate chaos on an unimaginable scale: Devastating loss of life, enormous human suffering, and massive damage to infrastructure and livelihoods. It is simply heartbreaking.*

*No picture can convey the scope of this catastrophe…. What is happening in Pakistan demonstrates the sheer inadequacy of the global response to the climate crisis, and the betrayal and injustice at the heart of it.*

*UNSG Antonio Guterres, 77th UNGA, Opening Press Conference. September 2022.*

October 2022: Approximately one-third of Pakistan is flooded, about 1.6 million children face malnutrition, and UNICEF has received only 30% of the funds necessary to mount the required response. Amidst the stagnant waters and rubble, reports indicate that waterborne and respiratory diseases are spreading.

Climate change has become the defining issue of our time. Such was the consensus among international leaders at the 77th UNGA High-Level Meeting on Climate Change. During the meeting, LMIC leaders noted concern at the faltering pace of climate adaptation and mitigation, calling for increased investment and accountability from the wealthy nations largely responsible the climate crisis.

The Intergovernmental Panel on Climate Change (IPCC) is the UN organization charged with empirically assessing climate change on Earth. The IPCC includes experts from around the world and is recognized as the foremost international scientific authority on climate change. In 2022, the body published its sixth assessment, emphasizing the existential severity of the crisis we are facing and decrying the lack of commitment from the Global North in rectifying the present catastrophe and preventing terminal escalation of cascading climatic processes.

Thus far, the Earth has warmed approximately 1.09°C above the pre-industrial temperatures noted prior to the turn of the twentieth century. The IPCC designated a critical threshold of 1.5°C increase above pre-industrial temperatures as being associated with significant increases in multiple climactic hazards with substantial projected loss of life and infrastructure. The Paris Agreement, the global rallying point for cooperative climate action, recognizes this threshold. However, our efforts have not been sufficient to curtail our advance—this is largely due to a lack of financial commitment from wealthy nations. The IPCC predicts a 50% chance of the Earth warming to 1.5°C within the next 20 years if the current trajectory is continued. As climate change and its aftershocks wreak havoc on international trade and agriculture, erode national economies, and devastate infrastructure, people suffer.

In the Global North, rising housing prices and anger over climate inaction motivates tens of thousands to march through their streets. For their counterparts in the Global South, the impact of climate change is measured in blood [3, 8, 9, 31].

#### **3.1 The impacts of climate change**

*Climate change is a threat to human well-being and planetary health….increases in frequency and intensity of extremes have reduced food and water security hindering efforts to meet Sustainable Development Goals.*

*IPCC 6th Assessment, 2022.*

*Diseases have attacked us because we are all still standing in the water…*

*Pakistani man, Interviewed AJ Oct 22, 2022, Translated into English and transcribed.*

Drought has suffocated the African Sahel and Horn leading to a vicious cycle of hunger conflict, and destabilization. Amidst the compounded suffering and concentrated misery, African leaders ask for their continent not to be forgotten.

Climate change is an active force of destabilization in our world that has wreaked havoc on the most vulnerable and its effects are accelerating. Unprecedented and devastating extremes of weather have been observed across the globe at increasing rates. Amplified monsoon seasons bring devastating flooding to Pakistan, and high-powered hurricanes batter the Caribbean and Central America. With floodwater and torrential wind come chaos, loss, trauma, destruction of livelihood, and the disruption of essential national infrastructure. In this way, climate change functions not only to injure humanity in its own right, but also functions to create conditions pathopermissive to violence and disease [3, 8, 9, 32].

#### **3.2 Climate change risks**

*Climate change impact and risk are becoming increasingly complex and difficult to manage. Multiple climate hazards will occur simultaneously, and multiple climactic and non-climactic risks will interact, resulting in compounding overall risk…*

*IPCC 6th Assessment Report, 2022.*

Climate change distinguishes itself from its Triumvirate counterparts in that it is a significant amplifier of risk. War-torn nations and refugee populations have always represented extreme vulnerability. Climate change adds to this risk in a globally pervasive and devastating manner that is without historical precedent.

Climate change's ability to exacerbate the inequities that multiply its catastrophic impact among LMIC is why it must be designated a priority threat to global health and safety. Numerous LMIC, rendered historically vulnerable to climactic upheaval by years of inequity, lie devastated and left to recover with insufficient resources. Beneath climactic calamity and fog of war, malnourished immune-compromised refugee populations journey through stagnant, mosquito-laced waters to huddle together in unsanitary, makeshift refugee camps. The specter of disease closely accompanies them, gaining strength amidst the chaos and trauma that riddle the Global South.

To allow historically maimed LMIC nations to struggle for survival in the midst of devastating cataclysm and conflict is to permit the compounding, superaddition of risk factors that will existentially threaten the health of our international community.

Climate change has tilled through the Global South uprooting populations and fracturing infrastructure—all the while providing increasingly fertile ground for conflict and deadly disease [3, 8, 9, 33].

#### **3.3 Climate resilient development**

*Any further delay in concerted anticipatory global action on adaptation and mitigation will miss a brief and rapidly closing window of opportunity to secure a livable and sustainable future for all.*

*IPCC 6th Assessment Report, 2022*

December 12, 2015: The Paris Climate Agreement was signed into inception and adopted by 196 nations. The agreement provided succession to the Kyoto Climate Protocol signed in 1997 and officially entering into force on November 4, 2016. The Paris Agreement is legally binding and represents the current international effort to address climate change. The two main pillars of its response are adaptation and mitigation.

Adaptation involves the active protection of vulnerable communities now increasing current resilience against catastrophe. Mitigation works to provide sustained protection in the future *via* the reversal of the vicious cycles that are driving the process. The Paris Agreement noted a goal of curbing global pre-industrial temperature increase below 1.5°C in recognition of the significantly increased hazard predicted by the IPCC beyond this threshold.

While the Paris Treaty provided a rejuvenating burst to climate change response, the battle against climate change has since stalled amidst a trend of waning investment from wealthy nations. While significant contributions have occurred, most funds have been dedicated to mitigation with little investment directed toward providing immediate, adaptive support for the LMIC nations who are being deluged and drowned beneath reiterant climatic catastrophes. Nations of the Global South must be expediently released from the shackles of poverty and hunger that constrain their national growth and must be assisted in the construction of resilient, essential infrastructure that will be fundamental to the empowered and sustained development of LMIC nations. With the five inequities reviewed addressed at minimum, adaptive measures can be more effectively and sustainably implemented, and nations of the Global South can be given freedom to undertake necessary, self-guided development [3, 8, 9, 34].

#### **4. Geopolitical tension and state conflict**

*We came very, very close [to nuclear war,] closer than we knew at the time.*

*Robert McNamara, late US Secretary of Defense*

*This was not only the most dangerous moment of the Cold War. It was the most dangerous moment in human history.*

*Arthur M. Schlesinger Jr., late advisor to President John F Kennedy*

October 27, 1962: Cuban Missile Crisis. A Soviet Foxtrot Class B59 submarine carrying a nuclear payload slipped through the Caribbean off the coast of Cuba.

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

Onboard was one Vasily Arkhipov (1926–1998), a then officer in the Soviet navy hailing from a humble background. An American destroyer had identified the vessel on sonar and began dropping depth charges. In response, the submarine was forced to dive to a depth from which Soviet radio communication could not be received. Amidst the subaquatic explosions, leaking water, and rising carbon dioxide levels, the ship's captain and political officers noted that a war had likely started, and the submarine should fire its nuclear payload. Vasily Arkhipov, then known and admired for prior demonstrations of courage, denied the order. He is widely recognized for his decisive, maverick action that saved the world from thermonuclear war. Until now, this has been regarded as the closest humanity has been to annihilation.

Six decades have passed and we continue to live beneath an ever-growing shadow of nuclear war. Thermonuclear Armageddon has been averted by the chance, heroic action of a single individual. This is no model for sustainability and the odds say that if we continue to roll the dice as we have, we will run up against our number. For all intents and purposes, in 1962, we already had [35–37].

#### **4.1 100 seconds to midnight**

*We can hear once again the rattling of nuclear sabres…The idea that any country could fight and win a nuclear war is deranged. Any use of a nuclear weapon would incite a humanitarian Armageddon. We need to step back.*

*UN General Assembly 2022 UNSG Antonio Guterres on Nuclear Disarmament*

*I know not with what weapons world war III will be fought. But world war IV will be fought with sticks and stones.*

#### *Albert Einstein*

We live in an unstable world precariously balanced on a razor's edge between peace and catastrophic war. The introduction of weapons of mass destruction (WMD) with the nuclear bomb in 1945 marked a pivotal turning point in human history. We had advanced technologically to a degree where we now held keys to our own destruction. The Bulletin of Atomic Scientists was established by Albert Einstein in solemn recognition of this. The risk and reach of conflict had critically extended from regionally limited devastation to now represent an existential, global threat. There are no winners in a nuclear conflict, it will be universally catastrophic.

From 1945 onward, the world has lived in the shadow of nuclear annihilation, and the Bulletin has closely watched. The Doomsday Clock was wound into motion in 1947 with the newly nuclear armed world set at 7 minutes to apocalyptic midnight. The Cold War Period brought the world to the brink of nuclear annihilation multiple times and advanced the clock to 2 minutes to midnight. This would be the closest humanity would dance with annihilation until 2018 when the mounting hazards of climate change and conflict returned the world to a Cold War level of risk. The progression of these crises and the introduction of a devastating, global pandemic prompted the Bulletin to advance the Clock to 100 seconds to midnight in 2020. This is closest humanity has come to existential catastrophe and the clock has remained fixed "on doom's doorstep" ever since [4, 38].

#### **4.2 Global arms control**

*Nuclear weapons are the most destructive power ever created. They offer no security just carnage and chaos. Their elimination would be the greatest gift we could bestow on future generations.*

*UNGA 77th Session 2022: UNSG Antonio Guterres on Nuclear Weapons.*

*The world is currently at a height of nuclear Armageddon risk not seen in 60 years.*

*Joseph Biden, 46th President of the United States.*

June 2001: A working group with the John's Hopkins Center for Health Security convene in Washington, D.C. for an exercise amidst growing concerns of WMD mass casualty events. The operation was called *Dark Winter*, and it was a modeled simulation of a bioterror attack on the United States. In the scenario, a smallpox outbreak was unable to be contained and spread through the continental United States like wildfire. The operation noted a concerning lack of surge capacity and preparation within the American health, pharmaceutical, and vaccine systems. *Dark Winter's* conclusion predicted massive civilian casualties, a breakdown in essential institutions, loss of confidence in the government, and extreme civil unrest. This noted vulnerability began a series of regular pandemic exercises that have continued to 2019. In June of this year, President Vladamir Putin of Russia and Alex Lukashenjo of Belarus agree to the deployment of Russian short-range nuclear-capable missiles in Belarus. As geopolitical tensions rise and exacerbating risk factors wreak havoc across the world, now more than ever, effective global arms control is needed if we are to safeguard our international community.

Four of the fundamental global arms treaties are the: Non-Proliferation Treaty (NPT), the New START treaty, The Chemical Weapons Convention (CWC), and The Biological Weapons Convention (BWC). Each of these international agreements found their inception in the latter half of the twentieth century when concern for terminal catastrophe from WMD had reached a crescendo. However, despite these efforts, nuclear arsenal stockpiles remain high, and a number of nations have raised concerns regarding active engagement in biologic and chemical warfare research. The frustrated progress of global arms control has been grossly contributed to by a lack of: funding, member state cooperation, and verification/enforcement capacity.

In response to the persistent and extreme hazard from WMD, the United Nations adopted and ratified the Treaty on the Prohibition of Nuclear Weapons (TPNW) in 2020. The treaty became active January of 2021. However, reminiscent of past stumbling blocks, 69 nations abstained from becoming party; pertinently: all nucleararmed world powers and nearly all NATO member states. The new arms control treaty provides comprehensive restrictions to nuclear weapon: development, testing, stockpile, transfer, stationing, and use. The ultimate goal of the TPNW is to achieve total nuclear arms elimination.

Superpower reluctance to ratify and commit to the TPNW renders the NPT the only binding treaty signed by the world's nuclear armed states. In the fall of 2022, UNSG Antonio Guterres convened a meeting of United Nations member states to review and re-commit to the NPT. However, after 4 weeks of intense negotiation, a consensus was unable to be reached—chiefly because of unilateral and discordant action taken by nuclear powers.

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

A review of major arms treaties demonstrates a concerning trend of waning international commitment to a sustainable and peaceful future. The United States, China, and Russia have been undertaking nuclear modernization and expansion efforts, while new arms races have started regarding emerging hypersonic and anti-satellite missile technology. However, some positive progress has been made and can be celebrated.

The American and Russian Federation New START arms reduction treaty's extension in 2021 marked a small but important step in movement toward a goal of disarmament. Since their inception, nuclear weapons have represented a ticking time bomb that have pushed humanity to the brink of annihilation on more than one occasion. We may not get another chance [4, 39–44].

#### **4.3 The War in Ukraine**

*The idea of nuclear conflict, once unthinkable, has become a subject of debate. The vulnerable are suffering most. There is only one way to end the suffering in Ukraine and that is by ending the war.*

*UN General Assembly 2022: UNSG Antonio Guterres: UN Security Council High-Level Debate on Ukraine.*

As of the final drafting of this chapter, 40% of Ukrainian energy infrastructure has been damaged by targeted Russian missile strikes and the entire country is being affected by rolling blackouts. Amidst a coming winter, Ukrainians are being directed to stockpile clean water and warm clothes.

The War in Ukraine is testament to how intimately interconnected our world is. Russia's invasion of Ukraine has reaped devastating tolls on Ukraine's population and infrastructure. Europe and the world continue to live beneath the shadow of nuclear catastrophe as tensions mount between world powers and Ukraine's Zaporizhzhia Nuclear Power Plant sustains collateral damage from the conflict.

However, thus far, some of the most devastating global effects from the conflict in Ukraine originated not from bullets or bombs, but from a critical snare of the global supply chain. The conflict has thus far pushed millions into extremes of poverty, significantly exacerbated the risk of famine, and reversed years of developmental progress.

SG Guterres and the UN quickly noted an emergency as Ukraine's grain exports plummeted following Russia's invasion. The War in Ukraine resulted in a critical disruption of global food supply that casts many impoverished regions into deeper risk of famine. The Black Sea Grain Initiative, brokered by Turkiye and the United Nations, provides an example of a successful, expeditious, and relatively equitable international response to emergency.

The disruption of the international energy supply chain prompted a global energy crisis. Nations in the Global North and South have endured significant collateral damage including: economic downturn, escalating inflation, rising costs of energy and food, internal destabilization, and escalating geopolitical tension. The impacts of war are unevenly distributed with impoverished nations rendered super-vulnerable to destabilizing collateral forces spinning off from regional and international conflicts [45, 46].

#### **4.4 Global trends in conflict**

*Insecurity and political instability in the Sahel continue to make an already catastrophic humanitarian situation even worse. In some regions, States have totally lost*  *access to their populations. Non-State armed groups are tightening their deadly grip over the region…Indiscriminate violence continues to kill and injure thousands of innocent civilians, while forcing millions of others to flee their homes.*

*UN General Assembly 2022: UNSG Antonio Guterres: High Level Meeting on the Sahel.*

*The tribal fighting has killed at least 200, and more than 200 others have been injured. In the first assessment there are 2004 families with children in 4 schools. The displacement has been massive and these displaced are now in schools in large groups. These habitats are not fit to be camps and lack the needed medical supplies. There are a lot of complications and we cannot handle the situation. The flow of displaced is growing and we are calling on aid organizations and friendly countries to send the necessary aid.*

*Sudanese Minister of Social Welfare, Interviewed AJ Oct 2022, Translated into English and transcribed.*

October 2022: An attach on a Somali hotel by Al Shebab kills nine innocents and wounts more while interstate violence in Sudan's Blue Nile State has filled hospitals past capacity with wounded. The fighting has resulted in significant displacement that has forced fleeing refugees into crowded, unsanitary conditions. This represents a trend of irregular/asymmetric violence that has torn apart nations of the Global South for decades.

Conflict is grossly divided into two major types: interstate conflict and intrastate conflict. Wars between nations have decreased in frequency since the end of World War II. However, intrastate conflicts have increased in frequency at an accelerating rate, particularly with the Global South. Since 2010, there has been a noted threefold increase in major civil war frequency, a sixfold increase in conflict mortality, and an approximately 60% rate of conflict recurrence.

This internal, irregular violence has been tearing nations of the Global South apart taking an especially heavy toll on the African continent. At the 2022 General Assembly, SG Guterres held a High-Level Meeting on the Sahel. During the meeting, SG Guterres expressed significant concern over the progressing risk and complexity of the Sahel's geopolitical situation as climate disruption, energy crisis, famine, and crippling impoverishment destabilize nations and spark intrastate violence. The increasingly recalcitrant and intractable nature of conflict is amplified by this noted uptick in complexity with many intrastate conflicts now proving less responsive to traditional political and diplomatic measures of resolution [33, 47, 48].

#### **4.5 The impacts of conflict**

*Armed conflict not only directly interferes with [Sustainable Development Goal]16, it negatively affects key targets of the entire UN sustainable development agenda…. Going well beyond direct death and physical destruction…consequences [of conflict] involve devastating long-term damage to social networks, human capital and trust in institutions that reinforce each other in powerful ways through perpetuation of violence and out-migration.*

*Cederman et al, 2018.*

#### *Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

Conflict takes a heavy toll. The acute human morbidity and mortality are the most immediate and readily seen impacts of conflict. However, the aftershocks of suffering that ripple through shattered national infrastructure prove equally devastating.

The ongoing Yemeni Civil War can prove instructive regarding the compounded risk levied on populations of the Global South. The devastation of Yemen's water and sanitation infrastructure by conflict produced widespread, unsanitary, and biologically hazardous conditions. The addition of unseasonal and significant rainfall and flooding to this caustic mixture resulted in the exposure of a chronically malnournished war-torn population to a compounded infectious disease risk. This interaction of complex biologic risk with extremes of vulnerability facilitated what would become the worst cholera epidemic in modern history.

In the case of the ongoing Civil War in Syria, more than half of the nation's population has been displaced and catastrophic damage has been done to over half of essential Syrian medical, educational, and energy infrastructure. This disruption in essential infrastructure has rendered the nation's chronically war-torn resident population especially vulnerable to climatic and contagious risk resulting in excess morbidity and mortality and a decline in Syrian life expectancy by 5 years. Population displacement from concurrent crises has caused significant increased in migrant populations resulting in a strain and fracture of critically underpowered international and national refugee support networks. This ultimately exposes exceptionally vulnerable, migrant populations to extremes of risk resulting in tragic loss of life. Standing as grim testament to this, the Mediterranean Sea has slowly become a graveyard to many migrants fleeing conflict and catastrophe.

In 2022, global inflation rose to 8.8%. The IMF cites the War in Ukraine and the COVID-19 pandemic as key contributors to the global financial crisis. While both Global North and South have experienced economic impact, LMIC have borne the brunt of the injury. In their annual meeting last year, the IMF and World Bank Group expressed concern double-digit rates of inflation which have impacted 40% of countries in sub-Saharan Africa—critically impairing essential national development and providing fertile soil for seeds of conflict and disease to take root [1, 15, 33, 49].

#### **4.6 A road to peace**

*Peace is the most important economic policy tool right now.*

*Nadia Calvino, IMF Chair and Spanish Vice President.*

*Without eliminating nuclear weapons, there can be no peace. There can be no trust. And there can be no sustainable future.*

*UNSG Guterres.*

An overabundance of military spending and a lack of investment in sustainable, global development are actively contributing to global risk. Sustainable, global peace will require a significant shift in national priority and finance away from defense spending. Weapons must be exchanged for plowshares and soldiering must bow to solidarity. The volatile, root causes of conflict will need to be tilled up from the soil of LMIC in the Global South to make way for the sustainable development that will need to occur if we are to effectively safeguard our collective, global health security. The mechanisms to affect this development have been defined and set into motion, the

lacking component has been fuel and international investment. In this dilemma, military budget reduction may provide a parsimonious and elegant way to power peace through disarmament. In addition to a treaty representing a new global commitment to disarmament, the United Nations brought *Our Common Agenda* into inception in 2020 at the 75th General Assembly. *Our Common Agenda* outlines and underscores the goals we must work to achieve in order to provide our younger generation with a safer tomorrow. The Human species has held fire in our hands for more than half a century, if we continue along this path, it is a matter of time until we are burned [2, 4, 50].

#### **5. Contagion: the curse of inequality**

*For there can now no longer be any doubt that such an epidemic dissemination of typhus had only been possible under the wretched conditions of life that poverty…had created.*

*Dr. Rudolf Virchow, 'Father of Modern Pathology.' 1848.*

Infectious disease has long been an intimate enemy of humanity. The flea vectorborne Bubonic Plague, H1N1 Influenza pandemic of 1918, and ongoing AIDS and COVID-19 pandemics offer humbling testament to human society's unique vulnerability to this curse. Contagion distinguishes itself among the Toxic Triumvirate in its long understood and inextricable relationship with conditions of poverty and inequity.

In the mid-nineteenth century, a young Dr. Rudolf Virchow was dispatched from the Prussian Ministry of Health to investigate a typhus epidemic that had been reported in the city of Upper Silesia. The dawn of the Industrial Revolution in the Global North resulted in a trend of urbanization that quickly exceeded the infrastructural carrying capacity of early cities. Crowded living conditions, poor air quality, and lack of sanitation provided conditions ideal for the spread of early urban diseases such as cholera and epidemic typhus.

Dr. Virchow was struck by the abysmal conditions of impoverishment and misery he observed among the urban poor of Upper Silesia. In his *Report on the Typhus Epidemic in Upper Silesia*, Dr. Virchow inferred that it was precisely these "adverse climactic conditions which contributed to the failure of [Upper Silesia's] crops and to the sickness of its bodies." Six years before an English anesthesiologist would begin a famous investigation of cholera in London, Dr. Virchow concluded his seminal report relating poverty and disease noting:

*If these conditions [of poverty] were removed, I am sure that epidemic typhus would not recur. Whosoever wishes to learn from history will find many examples.*

In nineteenth century Prussia and throughout human history, contagious outbreaks have demonstrated themselves to be exquisitely socially and environmentally. The impoverished, unsanitary, and environmentally unstable conditions that plague the LMIC represent a dangerous compounding of biologic hazard. Within the growing urban-slums of the Global South, vulnerable populations are exposed to extremes of infectious disease risk that are transmitted and shared across our international community through international trade and travel. In our increasingly interconnected world, the risk endured by one population is shared by all [51–54].

#### **5.1 Diseases of poverty: the poor man's burden**

*Poverty has been inextricably linked with infectious diseases since antiquity. Poverty, acting through non-genetic heritable principles, has transformed infectious diseases into "inheritable" conditions.*

*Hansen and Paintsil, 2016*

*Over the last 2 years, the multiple and overlapping crises that have rocked the world have…knocked back the global response to the AIDS pandemic. The new data revealed in this report are frightening: progress has been faltering, resources have been shrinking, and inequalities have been widening. Insufficient investment and action are putting all of us in danger: we face millions of AIDS-related deaths and millions of new HIV infections if we continue on our current trajectory. We can end AIDS by 2030. But the curve will not bend itself. We have to pull it down.*

*UNAIDS Global AIDS Update, 2022.*

Every 2 minutes a child dies of malaria. Infectious Diseases of Poverty (IDoP) are estimated to take 14 million lives annually with children disproportionately impacted. In this way, the young generations of the Global South who will be faced with unprecedented challenge are crippled at the outstart by preventable/treatable IDoP. The infections that unnecessarily curse the world's most vulnerable are myriad, but malaria, tuberculosis (TB), and HIV have proven exceptionally devastating. This apty named, "Unholy Trinity," acting in concert with diarrheal illness and Neglected Tropical Disease (NTD), have plagued Global South for decades—devastating populations, crippling economies, and paralyzing critical development.

Malaria is a preventable illness that has been successfully eradicated from many regions of the globe. In 2020, the WHO estimated there to be 241 million cases of malaria worldwide with 627,000 total deaths. The African continent is home to 95% of malaria cases and 96% of malaria deaths—80% of which are children under 5 years old. The WHO global malaria strategy is designed to achieve 90% reduction in cases and deaths by 2030, but progress has slowed. While COVID-19 caused significant disruption to health systems and medical care across the world, some significant advances in malaria control have been achieved and retained. These include the recent introduction of a vaccine for malaria and the historic reduction in annual childhood malaria mortality from 900,000 deaths in 2000, to approximately 650,000 in 2019. Insecticide-treated bed nets were credited with being responsible for approximately 68% of the cases averted. Malaria is a treatable and eradicable disease that has been successfully banished from many nations of the Global North. It is time the Global South is released from this burden as well.

In 2021, one child died of AIDS-related causes every minute. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported 38 million people living with HIV and 650,000 AIDS-related deaths in 2021. The majority of deaths occur in children who comprise 4% of people living with HIV but 15% of age-related deaths. In 2021, an estimated 53% children living with HIV lacked access to HIV treatment. UNAIDS reports that the lion's share of HIV incidence, morbidity, mortality, and lack of treatment access is concentrated among key vulnerable global populations. Disruptions in health infrastructure by COVID-19 caused a significant loss of global progress in the battle to control AIDS with many countries experiencing increasing

incidence rates. Inequity in treatment has grown as international AIDS support has fallen by 57% over the past decade with UNAIDS calling for renewed vigor and attention to be given to reducing disparities in global HIV/AIDS treatment and outcome.

Tuberculosis (TB) is a curable and preventable disease, and the second leading infectious cause of death worldwide. It exists in a viciously synergistic relationship with HIV's immunosuppression and is led only by COVID-19 in global infectious disease (ID) mortality. LMIC account for 98% of reported TB cases with countries such as India, Indonesia, Pakistan, Nigeria, and Bangladesh claiming some of the highest TB prevalence worldwide. As with the global AIDS response, international funding has been declining over time, falling 8.7% between 2019 and 2020. The UN has committed to ending the TB epidemic by 2030; however, if we are to reach this goal, channels of support must be bolstered significantly [55–59].

#### **5.2 COVID-19: a grim teacher**

*The COVID-19 pandemic rightly has absorbed the world's attention, given its demonstrated ability to sicken and kill millions…And yet, what the world has experienced during this pandemic is nowhere close to a worst-case scenario.*

*Bulletin of Atomic Scientists, 2022 Doomsday Clock Statements.*

Even a perfect medicine will be rendered inert when given in solution with inequity. This has been a public health lesson expressed ad nauseam by the cyclic, zoonotic pandemics that have become an unnecessary part of our reality. AIDS, MERS, SARS, Ebola, and now COVID-19 outbreaks/pandemics reiterantly wreaked havoc across the globe, becoming increasingly economically and sociopolitically devastating over time.

Over the past 2 years, COVID-19 has infected 767 million and killed 6.9 million, with the highest rates of excess death observed in LMIC [60]. COVID-19 crippled the global economy acting in tandem with the War in Ukraine to cause skyrocketing inflation and declining rates of national economic growth that have paralyzed or reversed developmental progress.

Both COVID-19 and non-COVID-19 zoonotic pandemics continue to represent an extreme global risk. Currently, the UN and WHO estimate that only 34% of lowincome country populations have been vaccinated against COVID-19. The pandemic's persistence is owed in part to COVID-19's consistent exploitation of the vulnerabilities inherent to undervaccinated populations. One manifestation of this can be found in the mutated viral variants that develop in the shadows of vaccination. These mutant strains have continued to fuel the pandemic's slow-burn course toward global and regional endemicity [4, 53, 54, 61–63].

#### **5.3 Emerging diseases and pandemic risk**

*The world has [long] witnessed how global travel, trade, urbanization, and environmental degradation can fuel the emergence and spread of infectious disease threats.*

*Nuclear Threat Initiative, 2021.*

October 2022: Pakistan remains devastated from atypical monsoon flooding, which inundated one-third of the country. Reports from the ground describe

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

increasing rates of waterborne illness and respiratory infection with maternal and fetal mortality rising significantly.

Emerging infectious diseases (EID) are infectious diseases to which we are naïve either because we have not met them, or because the disease we used to know has changed character physically, spatially, or biologically.

EID are comprised mostly of zoonotic pathogen such as coronaviruses, hemorrhagic fever viruses, and avian/porcine-derived influenza viruses, and represent an ever-growing threat to global public health. Over the past three decades, outbreaks of EID have been noted to increase in frequency—this disproportionately occurring within impoverished nations of the Global South. The increasing rate of emergence has been contributed to by a myriad of factors including: global warming, environmental change, dangerous animal husbandry practices and growing antimicrobial resistance. Underregulated microbiologic gain-of-function research represents a significant and growing hazard overall contributing to a historically unprecedented level of pandemic risk.

Avian influenza viruses, such as H5N1, naturally circulate among waterfowl in which they evoke a limited, mild upper respiratory inflammatory response upon initial infection. These viruses have the potential to be transmitted to chickens, pigs, and humans in whom they can elicit a much more severe and lethal inflammatory response. Of particular concern are recently detected, highly virulent avian viruses such as H5N9, which have caused numerous, limited outbreaks since identification in 2003 associated with a case-fatality rate of 50%. These viruses pose an ever-present risk as they may be only a mutation away from acquiring the enhanced human-human transmission needed to be pandemic-eligible, hereby very grossly defined as pathogen with Basic Reproductive Number (R0) > 1.

Porcine (swine) influenza viruses, such as H1N1, regularly circulate among pigs, resulting in ongoing outbreaks. Pigs may develop a mild respiratory disease upon infection, but the inflammatory response is usually limited and not associated with high mortality. Concerningly, pigs are also susceptible to infection from avian and human-borne influenza viruses. This leads to one of the greatest risks of influenza: mutation. Viruses mutate and produce variants—this has been clearly demonstrated by COVID-19. Influenza viruses are particularly prone to significant genetic mutation and alteration with risk rising substantially when animals are co-infected with several different strains. For this reason, mass animal husbandry practices such as Concentrated Animal Feeding Operations (CAFO) present a high outbreak risk by providing an ideal environment for the mixture and mutation of porcine and avian influenza viruses as well as an immediate interface for human acquisition.

Earth currently has about 8 billion inhabitants with projections estimating population growth to 9 billion by 2045. The majority of this population increase is projected occur within urban centers and has already resulted in the development of "megacities" across the globe. The United Nations defines a "megacity" as an urban center having a population in excess of 10 million. There are approximately 30–40 megacities worldwide and this number is expected to rapidly increase with most development occurring in LMIC. The inherent risk to current trends in urbanization presents an enormous public health hazard when superadded to the volatile mixture of malnutrition, fractured infrastructure, and conflict that inundate nations of the Global South. UN-Habitat estimates that approximately one-third of LMIC populations live in urban "slum" settings characterized by pathopermissive conditions of poverty, lack of sanitation, and population growth in excess of infrastructural carrying capacity. It is theorized that the Ebola virus outbreak sparked in West Africa was fanned into flame

by a combination of deforestation and pathopermissive urban conditions of impoverishment. In modern day LMIC nations, as in 1848 Upper Silesia, pathopermissive urban-slum conditions introduce significant levels of biologic risk and provide fertile ground for the introduction and dissemination of contagious pathogen [53, 54, 64–68].

#### **5.4 Outbreak's golden hour: insight from sepsis care**

*The theory [of sepsis] with the strongest support is that of a toxin causing [circulatory collapse via] increased capillary permeability and escape of plasma into tissue.*

*Dr. Walter B. Cannon, 1923. Early description of sepsis.*

Sepsis is a dangerous physiologic phenomenon and one of clinical medicine's oldest and most lethal enemies. It can occur when an infection or toxin has spread from its source point into the bloodstream. The pathogen's systemic dissemination sets off a lethal cascade of events that drop blood pressure, starving the organs of oxygen. In its advanced state, sepsis leads to multisystem organ failure and death.

The importance of early action in the treatment of sepsis is paramount. Ideally, an infection is immediately treated at its point source before dissemination occurs. Once a pathogen has entered the bloodstream and initiated a septic cascade, antibiotics must be administered within 1 hour. A moribund history has taught us that after this point mortality increases significantly. These principles of medicine can theoretically be extrapolated and applied to the management of infections within our international body. As in clinical medicine, prevention of infection is the first priority. When this fails, and an infection develops, it is critical to contain the outbreak at its source before it can disseminate through our shared arteries of trade and travel. Just as in septic care, rapid, decisive, and effective action must be taken within a critical window of time to avoid bad outcomes. The "Golden Hour" of sepsis provides an example of a systems approach to ensuring critical action be taken in appropriate time. There has not been a directly analogous golden window of action that has been defined for source containment of outbreaks. The variation in pathogenicity characteristics between pathogen naturally confounds the ability to establish broad, universally applicable protocols. However, in the sections that follow, I will attempt to utilize recent modeling studies and prior zoonotic pandemic patterns to clarify a possible action window for source containment of pandemic-eligible pathogen that could be used as a starting point to help inform a standardized, systematic approach to international outbreak response [69, 70].

#### **5.5 Insight from exercise and disease modeling**

*Outbreak science adapts to the emergency situation in a rapid assessment approach where evidence-making and decision-making emerge simultaneously…In the presence of uncertainty, mathematical models offer a bridge to 'knowing' by generating scenarios to enable rapid policy decisions. Projections thus afford biosecurity through calculus, by anticipating unknowns, and 'disease', into a governable present.*

*Rhodes et al, 2020.*

Beginning with the American *Dark Winter* bioterror exercise in 2001, modeled outbreak scenarios have been undertaken regularly. It is important to note that models are artificial and unable to fully account for the complex and multifactorial nature of

#### *Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

disease outbreaks. Mathematical models are well understood to have significant limitations and inherent uncertainty; however, they offer a unique and critical benefit in rapid pandemic response and policy making as decisions must often be made before all needed information is known. A working group of infectious disease experts and disease modeling specialists predicted that following initial index case infection, an airborne respiratory virus would be capable of spreading to infect 700,000 within the first month with complete international dissemination being possible 2 months later.

In March 2021, the Nuclear Threat Initiative and the Munich Security Conference collaborated to stage a high-level, tabletop-modeled pandemic scenario using current global infrastructure and response protocol. The scenario chosen was conservative, pre-supposing international cooperation and functional national health infrastructure. The exercise involved an unusual outbreak of monkeypox in a fictional nation with intact infrastructure. The fictional inoculation and introduction occurred during a national holiday on May 15, 2022. In June, the nation's national health department identifies and reports a novel, mutated strain of monkeypox virus to have infected 1400 citizens with four deaths reported to that date. There is no immediate evidence of international spread. An internationally supported containment response is then undertaken in an effort to establish disease source control.

The next scenario timepoint occurs 6 months later. In the interim, the international public health response had been unable to establish source control fast enough and the virus had internationally disseminated. As of January 10, 2023, the virus had spread to 83 countries with 70 million reported cases and 1.3 million fatalities. Critical trade and supply lines lay disrupted, and the global economy had come to a standstill [53, 54, 64, 71–75].

#### **5.6 Lessons from history**

*Those who cannot remember the past are condemned to repeat it.*

*George Santayana, 1863-1952.*

SARS, Ebola, and COVID-19 all-share devastating similarities and can prove historically instructive. SARS was first detected by Chinese health authorities in Guandong province on November 18, 2002. In February 2003, SARS had broken from its point of origin and was detected in Vietnam, Canada, and Hong Kong. The WHO was only officially notified of the outbreak in February with a global alert issued in March, by which time the virus had spread further to Singapore and Taiwan. In this instance, the lack of Chinese international cooperation precluded any ability to control international dissemination. The SARS coronavirus was confirmed present in more than three additional countries 4 months following initial detection.

In the case of Ebola in 2014, West African nations proved internationally cooperative but lacked the essential infrastructure necessary to achieve source control. Researchers believe that the index outbreak inoculation occurred in December 2013 in Guinea. The infection spread undetected for months until March 2014 when health officials announced an outbreak of a mysterious hemorrhagic fever virus that "strikes like lightning." That same month, Liberia reported similar cases. Medicines Sans Frontières (MSF) immediately responded but international aid was otherwise slow to follow. By April, the virus had spread to Mali followed by Sierra Leone in May. In August 2014, the disease reached the doorstep of the Global North. The United States, Spain, and the United Kingdom had active Ebolavirus cases in hospital. In the 2014

Ebola outbreak, the virus was provided an opportunity to emerge, propagate, and disseminate within a period of 4 months, largely due to pathopermissive conditions created by a resource-strapped public health system and confluent environmental risk factors. In the absence of effective national health infrastructure, source control was critically stymied, and the golden window for containment passed quickly.

COVID-19 represents the latest zoonotic pandemic. Its timeline is strikingly similar to that of SARS, but its impact has been orders of magnitude worse. COVID-19 was likely circulating in Wuhan in November of 2019. Its source of introduction remains unknown though the animal-to-human interface at wet markets and the resident institute of virology each pose known and significant infectious disease risk.

Two possible COVID-19 index cases had been identified on Nov 17 and Dec 1. The outbreak became noted by Chinese health authorities in December, but an international warning was not given. In January, China acknowledged an outbreak of acute pneumonia associated with a respiratory virus. However, conflicting reports were provided about transmissibility which proved critically misleading. By mid-January, COVID-19 had been reported in Chinese major urban centers, Thailand, Singapore, Hong Kong, Japan, France, and the United States. The WHO declared an international emergency on January 30, 2020, with the declaration of an international pandemic delayed into March. With international hands tied by disinformation and lack of cooperation, COVID-19 was able to rapidly disseminate from its point of origin and become internationally systemic within a period of 3 months.

An examination of modeling scenarios and pandemic trends in aggregate reveal a disturbingly common theme: We are consistently too late. By the time international support has been mustered and action has been taken, the horses are well out of the barn. SARS, Ebola, COVID-19, and pathogen modeling studies demonstrate a consistent ability for pandemic-eligible pathogen to internationally disseminate within approximately 3 months if source control is not achieved. This gross, roughly estimated 2–3 month "Golden Window" of outbreak response may be decisive in determining whether or not a pandemic-eligible pathogen will be able to be contained within its region of introduction. The above-proposed window is only a rough sketch generated from relatively scant data. Further, rigorous clarification of a pandemic response timeline may prove very beneficial in systematically orienting and organizing decisive and timely international response to outbreak containment [53, 54, 76–78].

#### **5.7 One health, one risk, one future**

*It is the microbes that have the last word.*

*Louis Pasteur.*

*Due to our shared elements of vulnerability, there is an urgent need for international cooperative endeavors to promote and preserve health since [Emerging Infectious Disease] no know geographic or economic borders.*

*M. J. Tosam et al. 2019*

Humanity stands at an ethical and existential crossroads and time is of the essence. Every minute a Somali child is admitted for severe malnutrition. The next, another has perished from malaria. At the end of the day, at least 800 more have been lost to preventable, diarrheal illness.

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

The development and integrity of LMIC nations of the Global South are actively being undermined by preventable disease, intrastate conflict, and climatic catastrophe. Our shared world continues to be repeatedly challenged by preventable pandemics that are proving increasingly devastating over time. COVID-19, the latest pandemic iteration, has not been controlled and is now moving toward global endemicity. All the while, the risk of another internationally paralytic pandemic from EID remains at a historic high and the stumbling blocks that stymied our prior containment responses to SARS, Ebola, and COVID remain present.

We live in an era of unprecedented risk that is shared by all members of our international body. The crises jeopardizing our global health security are interrelated and complex, but the solutions that have been defined are relatively elegant in principle: We must expediently invest in the empowering, sustainable development of our neighbors in the Global South. The health security of our international body will require all member nations to be developmentally healed and infrastructurally functional. Central organ systems critical to global homeostasis must also be operational and properly funded. It will be only through solidarity that we can hope to effectively and sustainably safeguard the health of our international community [9, 53, 54, 79].

#### **Acknowledgements**

I am a new author and a trainee in the field of preventive medicine and public health. In helping to usher this call to action, I stand on the shoulders of giants in the field who have clarified the present threats and defined potential solutions. This chapter was able to be completed only with the support of a village of mentors and colleagues. I would first like to sincerely thank IntechOpen for their dedication to Open Access publishing and information equity; and for the privilege and opportunity to contribute to a discussion and topic that is my passion. I would also like to thank the faculty of the University of California San Diego (UCSD) Preventive Medicine Residency Program and San Diego State University (SDSU) School of Public Health (SPH) for the phenomenal education I have been provided and for the faculty support I've received throughout this process. I'd like especially to thank SDSU SPH Divisions of Epidemiology & Biostatistics and Environmental Health for providing me invaluable preparation for the writing of this chapter.

I deeply thank my colleagues who have critically aided me in writing, including but certainly not limited to: Chief Editor Mr. Isaiah Briggs of Harvard Divinity School, Lead Editors: Mr. Joshua Kapusinski author of The Awakening (2022), and Ms. Maria Alexandra Hernandez and Mr. Haider Ghiasuddin of Geisel School of Medicine at Dartmouth for their invaluable assistance.

I would like to thank Mr. Antonio Guterres and Mr. Volodymyr Zelenskyy for their outstanding and truly inspirational international and national leadership during this time of extraordinary crisis. I would also like to thank MIT Emeritus Professor of Linguistics Noam Chomsky, as well as the late Yale Professor of Law, Arthur Allen Leff (1935–1981), for the pivotal role they have played in my (and many others) intellectual and academic development. I thank Al Jazeera for their excellent and equitable coverage of global news, and for making a point to uplift the voices of those seldom heard. I deeply admire and thank Medicines Sans Frontiers (MSF) for their critical and relentless work aiding migrants and refugees, and for MSF's consistent, strong advocacy for the world's underserved. Finally, I would like to thank and acknowledge Mr. Nikola Tesla (1856–1943) for his inspiringly genuine and wonderful approach to

nature and science, and most importantly, for his revolutionary development of the Alternating Current that powers our world and for which he is seldom recognized.

This chapter is written for, and dedicated to, my brothers and sisters in the Global South, who have endured unfathomable, preventable suffering for centuries without reason. I am an incredibly insufficient author in advocating for the prompt and sustainable development of LMIC; however, I do hope that this chapter can direct attention and action toward this goal as it is critical to the preservation of global health security. I pray the human species will find the moral courage required to heal our neighbors and ensure a safe tomorrow for our children. This chapter represents an independent work generously supported through the IntechOpen expanded sponsorship opportunity program.

### **Conflict of interest**

The author declares no conflict of interest.

#### **Notes/thanks/other declarations**

In closing, I would like to thank my Mom and Dad, who have worked hard to provide my little brother and I with opportunities that were not available for them.

### **Author details**

Aaron Briggs PGY2 UCSD Preventive Medicine Residency Program, University of California San Diego, San Diego, CA, USA

\*Address all correspondence to: ambriggs@health.ucsd.edu

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Climate Change, Conflict, and Contagion: Emerging Threats to Global Public Health DOI: http://dx.doi.org/10.5772/intechopen.108920*

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Section 2

## Access to Health Services for Important Health Problems

#### **Chapter 3**

## Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast and Cervical Cancer

*Michael Mncedisi Willie,Thulisile Noutchang, Maninie Molatseli and Sipho Kabane*

#### **Abstract**

Breast and cervical cancers are among the top five worldwide. The mortality rate for breast cancer is over 50%, when compared to cervical cancer, which is nearly 90%. Early breast and cervical cancer screening can reduce mortality risk. This study examined breast and cervical cancer rates among South African medical scheme members. The study's secondary goal was to analyse how medical schemes funded these two cancers, including patient and/or out-of-pocket payments, to identify funding gaps. The study was a cross-sectional retrospective review of medical scheme claims data for oncology benefits, especially for breast and cervical cancers. The study used a multivariate logistic regression model to assess cancer rates. The results showed that the relative proportion of beneficiaries with breast cancer was higher in open schemes than restricted, in large schemes than medium and small schemes, in comprehensive plans, efficiency discount options (EDOs), hospital plans than in partial cover plans, in age groups older than 55, in an out-of-hospital setting than in in-hospital setting. The paper advises examining the funding mechanism of oncology benefits to reduce out-of-pocket payments (OOPs) for cancer patients, revising network arrangements, and using designated service provider (DSP) as a barrier to access against uneven oncology provider distribution.

**Keywords:** breast cancer, cervical cancer, prescribed minimum benefits, diagnostic treatment pairs benefits paid, mental healthcare access

#### **1. Introduction**

Cervical and breast cancers threaten the lives of many women, accounting for two million newly diagnosed cases and 800,000 cancer-related deaths annually [1]. The incidence rate of cervical and breast cancer is much greater in low- and middleincome countries (LMICs) than in industrialised nations, where screening facilities and other preventive treatments are readily available [2–6]. Compared to low-income countries, high-income countries have significantly raised screening rates [7, 8]. In the World Health Organization Regional Office for Africa WHO (AFRO) African area, screening rates are still relatively low [7, 8]. In addition, 90% of cervical cancer deaths occur in women residing in low- and middle-income countries (LMICs), with sub-Saharan Africa bearing the heaviest burden [6, 9]. In South Africa, cervical and breast screening uptake disparities are caused by a lack of education and access to information. A study in Korea also showed that breast and cervical cancer screening rates varied widely among women with higher household incomes and education levels [1]. Other variables, such as limited access to health care facilities, lack of knowledge and health promotion, and inadequate support and awareness programmes for women, which are more prevalent in less affluent rural areas, influence early detection, diagnosis, and screening uptake [10, 11]. Recent research has shown that metropolitan location remains a significant factor related to greater awareness of cervical cancer risk factors, resulting in lower screening rates in rural regions [11–13]. In addition, lack of access to facilities in rural locations adds to inadequate screening services, a barrier to an admission that results in delayed seeking behaviour. Studies have demonstrated that early screening helps in detecting cervical cancer early [14]. The availability and accessibility of early screening and treatment services contribute to the notable disparities in cervical and breast cancer incidence. Early detection through screening and surveillance should be linked to available resources for treatment, such as access to providers and facilities [15, 16]. The author further warns that careful consideration must be paid to ensure that all aspects of cancer control programmes are balanced to limit unintended harm [15].

Other factors linked to health systems are human resources challenges, the scarcity of specialist services, and the uneven distribution of specialists by sector. Studies have shown that most specialists for oncology-related services are concentrated in the private sector rather than in the public sector [17]. In South Africa, nearly 80% of oncology specialists (radiation oncologists) practice in the private sector, are mainly remunerated through the funding model of medical schemes (health insurance providers), and cater for 16% of the population [18, 19]. The remaining 20% of the specialists cater to 84% of the population. **Figure 1** further illustrates inequities in the distribution of oncology service providers and how they have evolved over the last 3 years, showing a consistent trend toward an increasing share in the private sector.

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

#### **2. Breast cancer**

Breast cancer is the most common cancer among women and the top cause of death in more than 100 countries worldwide [20–22]. Over 2 million new breast cancer cases have been detected worldwide, representing a quarter of all cancer cases in women [20, 23, 24]. The incidence of breast cancer in the WHO's African region (AFRO) accounts for 27.7 percent of all cancer cases, and there are 29,593 breast cancer patients in South Africa [20, 22, 25]. The high incidence rates in affluent and developing nations are driven by non-genetic risk factors associated with menstruation, reproduction, exogenous hormone replacement, alcohol consumption, and weight gain [20, 26–28]. Age and gender are risk factors associated with breast cancer; the incidence of breast cancer increases and is more prevalent in women aged 50 or older than in men. Madeira et al. [29] stated that men account for 1% of all breast cancer cases [30, 31]. The average age of a breast cancer diagnosis varies according to gender. In a systematic analysis of 1,201 male breast cancer patients from 27 African nations, Ndom et al. [32] showed that the average age for men was 54.6 years, and for women, it was 47.7 years. Baudouin Kongolo Kakudji et al. [33] created an epidemiological, clinical, and diagnostic profile of breast cancer patients treated at the regional hospital in Potchefstroom, South Africa. The study's majority of patients (98.6 percent) were female, with a mean age of 56.2 years (standard deviation: 14.4) (95 percent confidence interval: (54.6–59.7) [33]. The average cost of breast cancer therapy varies by location or geographic area; sector, setting (in and out of hospital), treatment modality and level of care, disease severity, and disease stage [34]. The expected cost of chemotherapy in the South African public sector is R15,740 [34]. The average cost of medical treatment for breast cancer in each episode in South Africa is imprecise, and the available data contain methodological flaws. Finestone et al. [27] demonstrate that the average cost of breast cancer in the private sector was more than three times that of the public sector. During the first year after a breast cancer diagnosis, Discovery Health Medical Scheme (DHMS) estimated the average cost to treat breast cancer to be in the region of R207 561 [35]. Finestone et al. [27] estimate that the cost varies with stage, with the estimated cost for stage 1 in the private sector being R352 495 and the


*Source: Adapted from 1Life [36]: data excludes additional and aftercare: ongoing follow-up doctors' visits and health checks and tests*

#### **Table 1.**

*Estimated cost of medical treatment of breast cancer (Diagnosis and Treatment).*

projected cost for stage 4 being significantly higher at R522 553. Indicating a variation between health plans or benefit options, the author confirmed that the cost was considerably lower for low-cost benefit alternatives [27]. The costs vary based on diagnosis and therapy, as shown in **Table 1**.

#### **3. Cervical cancer**

In 2020, cervical cancer was the fourth most prevalent cancer in women worldwide, with a projected incidence of more than 600,000 cases and over 350,000 deaths [21, 22]. Cervical cancer incidence and mortality rates are the greatest in Africa, notably in Southern, Eastern, and Western Africa [25]. Cervical cancer is the most common in many sub-Saharan African countries (22 percent of all cancers), and its prevalence in poor developing countries is potentially 15 times higher. After breast cancer, cervical cancer accounts for 18.7 percent of all cancer incidences in South Africa's female population [22, 27]. The incidence of cervical cancer increases with age, with the average age of diagnosis ranging from 35 to 44. The average age of cervical cancer diagnosis in South Africa is 45 [37]. Due to the greater prevalence of cervical cancer in women with HIV, which is more prevalent in younger women, it is suggested that younger women get cervical cancer screening at an early age. Cervical cancer is diagnosed at an average age of 50 to 53 years [38]. A study conducted in South Africa revealed a significantly lower average age of 40.8 years (SD 18.6, range 15–95 years); nevertheless, the analysis concentrated on 5,903 females (15–49 years) [39]. Similarly to breast cancer, the average cost of medical therapy for cervical cancer varies by sector, setting (in and out of hospital), treatment modality, level of care, disease severity, and disease stage [37, 39]. In the private sector, the average cost of cervical cancer was 9 times greater for stage 1 and 13 times greater for stage 4 [27]. The limitations of the study by Finestone et al. [27] were that it contrasted one medical scheme to the public sector, excluding closed schemes like the Government Employees Medical Scheme (GEMS), which primarily serves public sector personnel; other medical schemes were also excluded in the analysis. Similarly, nonincluded plans may have a specific risk and age profile.

#### **4. Legislative requirements**

The level of care for breast and cervical (oncology) services (**Table 2**) is outlined in the Council of Medical Schemes Act's Prescribed Minimum Benefit (PMB) list [40]. PMBs are defined benefits designed to ensure that all members of medical plans have access to some fundamental health care, regardless of the benefit option selected. The PMB list consists of 25 Chronic Disease List (CDL) diseases and an additional 271 Diagnosis and Treatment Pair (DTP) conditions. Regarding breast and cervical cancer services, medical schemes must cover the diagnosis, treatment, and care for these disorders. However, medical schemes are not required to pay for diagnostic tests to determine that a patient does not have a PMB illness. Cervical cancer screening is a PMB level of service under DTP Code 960M. The treatment component of breast cancer screening includes PMB-level periodic breast examinations. However, members are entitled to specific screening intervals, instruments, and HPV versus cervical screening. **Table 2** demonstrates the optimal amount of care recommended by the regulator [40].

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*


#### **Table 2.**

*Level of care for breast and cervical (oncology) services.*

#### **5. Funding models (benefit design)**

Most oncology treatments are provided in-hospital and subject to network hospitals and designated service providers (DSPs), with some entry-level plans using the state as a DSP. Entry-level coverage plans typically cover oncology care at the PMB level. Oncology coverage includes PMBs in their entirety. Schemes provide different cancer treatment limits and extended benefits for more complete benefit options. However, after the annual maximum is reached, patients may be required to pay co-payments for treatment exceeding PMB level care (which costs more than the scheme rate). The oncology benefit does not cover hospital admissions; these are paid by the hospital benefit of the benefit choice the patient is enrolled in. After this hospital benefit has been exhausted, patients may be required to continue treatment at an entry-level network institution or a state facility. Most medical schemes include cancer benefits, annual limits for oncology treatment, and entry-level benefit alternatives for PMB-level care. Comparatively, comprehensive plans cover R400,000 or more [41–43]. ICON Oncology is the major designated service provider with regard to out-of-hospital benefits [19]. Nonetheless, in-hospital benefits are accessible through the state as a DSP (for some entry-level alternatives) and private institutions (subject to annual hospital limits).

#### **6. Objectives**

This study's primary purpose was to investigate the rates of breast and cervical cancer among South African medical scheme beneficiaries. The secondary purpose of the study was to analyse the funding model of these two types of diagnoses by medical schemes, including measuring the level of pocket payments made by these patients to identify funding gaps, and lastly, to execute a logistic regression model to identify the factors that contribute to the greater exposure rates of the two types of cancer.

### **7. Methods**

The study design was a retrospective cross-sectional investigation of medical schemes' claims data associated with oncology benefits, primarily breast and cervical cancer. The review period was 2019, and the secondary data came from the annual submissions of aggregated CMS statutory returns data. During the evaluation period, the analysis comprised claims data from 59 medical schemes with comprehensive expenditure data. There were 15 open schemes and 44 closed schemes. Breast cancer and cervical cancer were represented in the study by 47 886 and 4 116 participants,


**Table 3.** *Description of variables of interest.* *Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

respectively. 97% more women than men had breast cancer. Based on study and calculation, 46,571 female beneficiaries older than 20 were diagnosed with breast cancer. We counted and proportioned categorical variables. Unadjusted comparisons were statistically significant at p value <0.05. The study used a multivariate logistic regression model to examine cancer risk variables. **Table 3** shows model dependent and independent variables. The analyses were done in STATA and SAS 9.4.

#### **8. Results**

The average age of female beneficiaries with breast cancer was 59 years, whereas the age profile of female industry beneficiaries was substantially younger at 34 years. The breast cancer rate was, therefore, 14 per 1000 female beneficiaries. In the age range of 20 to 24 years, the rates were fewer than 1 per 1000 female beneficiaries, which was significantly lower than those for older age groups. In age groups 65–69, 70–74, 75–79, and 80–84, the breast cancer incidence rate was greater than 30 per 1000 female beneficiaries (**Figure 2**).

In addition, the analysed schemes accounted for 4,103 female beneficiaries diagnosed with cervical cancer who were 20 or older. Thus, the rate of breast cancer was 1.25 per 1,000 female beneficiaries. The average age of female beneficiaries diagnosed with breast cancer was 50 years, whereas the age profile of female industry beneficiaries was substantially younger at 34 years. Less than one per thousand female beneficiaries were between 20 and 24 years of age. The cervical's cancer rate was significantly greater in women aged 45 to 49, exceeding 3.3% per 1000 female beneficiaries (**Figure 3**).

**Figure 4** shows the distribution of beneficiaries diagnosed with breast cancer and cancer of the cervix. The analysis shows that there were more beneficiaries with breast cancer than cervical cancer in Gauteng (41% vs 33%) and Western Cape (21% vs 9%). There were more beneficiaries with cancer of the cervix than those with cancer of the breast, 17% and 12%, respectively. However, in other provinces, such as KwaZulu Natal, a more notable difference was in Limpopo province (13% vs 5%) and Mpumalanga (8% vs 4%) (**Table 4**).

**Figure 2.** *Number of female beneficiaries vs cancer of breast – treatable beneficiaries.*

#### **Figure 3.**

*Number of female beneficiaries vs cancer of breast – treatable beneficiaries.*

#### **Figure 4.**

*Distribution of beneficiaries diagnosed with breast cancer and cancer of the cervix.*



*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*


#### **Table 4.**

*Demographic characteristics, number of beneficiaries (%).*

#### **8.1 Distribution of oncology specialists**

Independent practice specialists' radio oncology services are available in all provinces. **Figures 5** and **6** show the distribution of oncology specialists by region. The results depict that many oncology specialists are concentrated in urban and more

**Figure 5.** *Distribution of oncology specialists by province.*

#### **Figure 6.**

*Distribution of independent practice specialist radiation oncology providers by province- adjusted for utilising beneficiaries.*

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

affluent areas such as Gauteng and KwaZulu Natal, as the proportion of providers was higher than that of beneficiaries within the province. Medical oncology services are based mainly in Gauteng province, which accounts for 92% of medical oncology services. At the same time, there are no medical oncology services in two regions, Western Cape and KwaZulu Natal, where each accounted for 4%. When adjusting for beneficiaries, there are significantly more independent practice specialists in radiation oncology than beneficiaries in Gauteng province. Slightly more beneficiaries than providers in KwaZulu Natal, Western Cape and the Free State province. There is a high scarcity of independent practice specialists in radiation oncology in Limpopo province, where the relative ratios were 1% vs 5%.

#### **8.2 Benefits paid by setting**

**Table 5** shows benefits paid per beneficiary by setting. The average amount paid differed by setting. The average amount spent per beneficiary was nearly twice that in-hospital setting compared to the out-of-hospital setting, R53 680 vs R30 984 for breast cancer, respectively. Similarly, the average amount spent on cervical cancer was R54 760 vs R31 044 for in-hospital and out-of-hospital settings, respectively. On average, cervical cancer was more expensive (nearly R10 000 more) to treat than breast cancer, R46 905 vs R38 114. The maximum amount paid per beneficiary with cervical cancer was R523 695 and R962 103 out-of-hospital and in-hospital settings,


**Table 5.**

*Benefits paid per beneficiary by cancer type and setting.*

**Figure 7.** *Distribution of benefits paid per beneficiary (Cancer of the cervix and the breast).*

respectively, as shown in **Figure 7**. The maximum amount paid per beneficiary for breast cancer was much higher for the in-hospital setting than for cancer of the cervix at R682 364. In contrast, the amount paid for breast cancer in the in-hospital setting was R 910 431.

#### **8.3 Level of OOP by setting**

**Table 6** shows the levels of OOP by setting; the data indicate that the in hospital setting was twice that and out-of-hospital setting at 2 and 4% for breast cancer, respectively. The same phenomenon was notable in cervix cancer, where the OOP was 2% and 4% for out-of-hospital and in-hospital settings, respectively.

#### **8.4 Benefits paid and OOP benefit design**

The analysis of comprehensive and hospital plans attracted higher expenditure levels on cancer of the cervix at R57 205 and R53 037, respectively. However, for breast cancer, benefits paid per beneficiary were higher for EDOs and hospital plans at R42 740 and R41 797, respectively. Benefit design groupings further stratified the analysis. When adjusting for the funding of cancer of the breast, the data show higher levels of OOP in EDOs (5.3% OOP levels) and hospital plans (5.9% OOP levels) compared to comprehensive (3.3 % OOP levels) and partial cover type of plans (3.4% OOP level). A slightly different phenomenon emerges when adjusting for cancer of the cervix, where, hospital plans (4.9% of OOP levels), EDOs (3.8% of OOP levels) and partial cover plans (3.6% of OOP levels) accounted for higher levels of OOP compared to comprehensive plans (2.6% of OOP levels) (**Figure 8**).


#### **Table 6.**

*Levels of OOP by setting.*

#### **Figure 8.**

*Average amount paid per beneficiary and OOP levels by benefit design.*

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

#### **8.5 Scheme type: Sector**

**Table 7** shows that open scheme beneficiaries were exposed to slightly higher copayment levels than those in restricted schemes. This was prevalent in both beneficiaries with cancer of the breast and those with cancer of the cervix. Similarly, with the average benefit paid on average, open schemes paid R41 797 for breast cancer compared to restricted schemes that paid R30 127. Again, open schemes paid even more for cervix cancer than restricted schemes, at R52 108 vs R43 160, respectively. Despite being less than 5%, OOP for open schemes was twice that of restricted schemes for cancer of the cervix beneficiaries, at 4% and 2%, respectively.

#### **8.6 Scheme size**

There were no significant differences in breast cancer funding by scheme size. The average expenditure per beneficiary for cervix cancer was higher for medium schemes at R57 911, followed by large schemes at R46 566 and small schemes at R42 176. However, large schemes paid slightly higher than medium and small schemes at R37 801, R35 713 and R30 733 per beneficiary for breast cancer, respectively (**Table 8**).


#### **Table 7.**

*Proportion of oncology benefits incurred by members by sector.*


#### **Table 8.**

*Proportion of oncology benefits incurred by members by scheme size.*

#### **8.7 Multivariate regression analysis**

**Table 9** shows the results of the multivariate regression analysis; the results showed higher cervical cancer rates were significantly associated with the hospital setting, geographic distribution of beneficiaries, sector, and benefit design. At the same time, breast cancer was significantly associated with the geographical distribution of beneficiaries, sector, and scheme type. The odds ratio is 1.24, which indicates that the odds that the cervix's cancer rate was 1.24 times higher in an in hospital setting than in out-of-hospital. The odds ratio is 6.482, which suggests that the odds of higher rates of cancer of breast cancer are seven times higher in Gauteng than in Limpopo. The odd ratio of 8.521 indicated that the odds of higher rates were 9 times


#### **Table 9.**

*Multivariate logistic model assessing the association between demographic, scheme characteristics and setting variables as predictors of cancer proportion.*

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

higher in Gauteng than in the Northern Cape. The cancer of the cervix was also significantly associated with scheme types. The odds ratio of 1.494 indicated that the odds of higher rates were nearly twice higher in open schemes than in restricted schemes. The results show the odds ratio of 1.165 for breast cancer, which indicated that the odds were nearly twice higher in open schemes than in restricted schemes. Similarly, North West, where the odds are 1.476, shows breast cancer rates are two times higher in Western Cape than in the Northern Cape province. Our study also found the effect of benefit design on the cervix's cancer rates, where the odds of 1.594 indicated that higher rates were in comprehensive plans than in hospital plans. The multivariate analysis results for breast cancer revealed that higher rates were significantly associated with the geographical distribution of beneficiaries in the Northern Cape and Gauteng provinces. The odds ratio of 1.587 indicated that Gauteng province had the odds of nearly twice higher rates than the Northern Cape province. The effect of the sector was also prevalent as this was statistically significant in both models. Benefit design and hospital setting did not affect the higher breast cancer rates.

#### **9. Conclusion**

This study finds a higher number of beneficiaries diagnosed with breast cancer, nearly ten times more than those diagnosed with cervix cancer. These findings are consistent with the literature, where breast cancer is the most common cancer in women [20–22, 27]. The study also found that 97% of breast cancer was diagnosed in females than in males, who accounted for 3 % of breast cancer, slightly higher than another study conducted in the public sector the study found the rate of 1.4% [33]. The findings, however, were still within range when compared to international norms ranging between 1–3% [29–31, 46]. The weighted average of women diagnosed with breast cancer was much older at 59 years; however, it was within the range of systematic review and meta-analysis, which showed the average age of female breast cancer in Africa ranged between 30.6 to 60.8 years [47]. There is evidence of a much younger mean age of beneficiaries diagnosed with cervical cancer. The findings of this study were consistent with a study conducted in the public sector in South Africa, which found a mean age of 56.2 years [33]. However, this study shows the early stage of diagnosis in medical schemes in the age band of 20–24 years, thus denoting risk exposure in much younger age profiles. The study found that cervix cancer was diagnosed ten years earlier than breast cancer, and the weighted average age of cervical cancer beneficiaries was 50 years. This is consistent with global trends reporting the average age range (50–53 years). Condition-specific findings show that the proportion of beneficiaries with breast and cervical cancer was higher in Gauteng (41% vs 33%). Though much lower, the Western Cape had a similar phenomenon where the proportion of breast cancer beneficiaries was more than twice that of cervical cancer beneficiaries (21% vs 9%). Other provinces showed a higher proportion of cervical cancer than breast cancer. The study discovered significant differences in the distribution of oncology specialists relative to covered lives in affluent urban provinces like Gauteng and Western Cape and rural provinces like the Eastern Cape and Limpopo. These disparities were more pronounced in KwaZulu Natal and Limpopo (17% vs 12% and 15% vs 5%), respectively. The Gauteng, Western Cape, and KwaZulu Natal provinces accounted for 85% of independent practice specialist oncologists, while the other provinces accounted for only 15%, with other provinces

showing less than ten specialists. The distribution of oncologists was less represented in other provinces than Gauteng, which accounted for 93% of the claiming medical oncologists. The two other provinces (Western Cape and KwaZulu Natal) accounted for the balance, with only one medical oncology service provider each. In rural provinces, there was no claiming medical oncologist. These findings further describe higher inequalities geographically, which are also prevalent in the private sector. The study also found a higher proportion of covered lives relative to the balance of independent practice specialist radiation oncologists in Limpopo (Rural) at 1% vs 5%, depicting an urgent need to develop and attract specialists in the province. This finding conforms to previous studies (e.g., [7, 48]) in those urban residences increase the access and uptake of cancer screening. A study by van Eeden et al. [49] further confirmed challenges with oncology services for lung cancer, mainly radiotherapy units primarily located in larger cities, limiting access to rural-based areas. The implication of practical recommendations for medical schemes is a scarcity of medical service providers as they relate to designated service providers and specialist network contracting. The significant shortfall of oncology specialists in poorer provinces directly leads to long treatment delays. High patient volumes in this province affect optimal treatment care irrespective of the sector, as this study shows [50]. The findings revealed a relatively higher proportion of beneficiaries with breast cancer compared to cervical cancer beneficiaries in open schemes than in restricted schemes; in large schemes than in medium and small schemes; in comprehensive plans, EDOs, and hospital plans than in partial cover plans; and in age bands older than 55; in provinces such as the Gauteng, Limpopo, and North West and Western Cape provinces; and in out-of-hospital setting than in an in-hospital setting. The multivariate analysis further supported these findings, which found that higher cancer rates of cervical cancer were significantly associated with the hospital setting, geographic distribution of beneficiaries, sector, and benefit design. Furthermore, this study provides critical insights for the National Health Insurance as they address human resources and relative socioeconomic challenges. The regression model's findings for breast cancer revealed that higher rates were significantly associated with the geographical distribution sector. The industry also affected the higher levels of cancer in the breast proportion. The odds ratio of 1.165 indicated that the odds were nearly twice as high in open schemes than in restricted schemes. Benefit design and hospital setting did not affect the higher breast cancer rates. The average expenditure for the two types of cancers differed by scheme type and was much higher in open schemes than in closed schemes, thus indicating the effect of setting. Cervical cancer was +/-R 10,000 more expensive than breast cancer per beneficiary. Partial cover plans paid around R25 000 for breast cancer compared to other benefit options, which paid around R40 000 per beneficiary region. EDOs and partial cover plans paid just under R40 000 for cervical cancer per beneficiary, while comprehensive and hospital plans paid just over R50 000. Finestone et al. [27] found that low-cost or less comprehensive benefit options paid much less for breast and cervical cancer treatments [27]. The authors found that the average cost for cervical cancer in the public sector ranged between R28 666 and R33 021 for stages 1–4.

The level of OOP for the two cancers was insignificant in the region of 2–4%; however, it still presents a financial burden to beneficiaries and could be detrimental for those rural-based provinces where the barrier to accessing specialist oncology services is even higher. The study recommends support programs (family support, government, medical service providers, private sector and government)

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

for cancer patients and integrated into managed care services. Due to inequalities between and within the two-tiered health system in South Africa, the study proposes a multidisciplinary approach to address the scarcity of resources. Public-private partnerships on cancer treatment and support programs should be the critical feature to help move South Africa closer to Sustainable Development Goal (SDG) 3.4

To reduce, by one-third, premature mortality from NCDs+ through prevention and treatment and promote mental health and well-being by 2030 [51, 52].

#### **10. Limitations**

This study has the following methodological limitation:


The analysis of the aggregated transaction data restricted the study because it did not consider patient or provider perspectives and experience; future studies should consider qualitative aspects such as patient experience. Future studies should include drivers of co-payment in PMB level of care conditions and an effort to develop approaches and interventions to minimise these.

#### **Acknowledgements**

The authors are grateful to Mr Phakamile Nkomo, Mr Martin Moabelo and Mr Sibusiso Ziqubu for their support in concluding this research work.

#### **Conflict of interest**

The authors declare that no financial or personal relationships may have influenced them inappropriately in writing this article.

#### **Ethical considerations**

The data were assessed and only reported at the consolidated level for privacy and confidentiality. No clinical or patient-specific information was accessed nor reported while conducting this research.

### **Author details**

Michael Mncedisi Willie\*, Thulisile Noutchang, Maninie Molatseli and Sipho Kabane Council for Medical Schemes, Policy Research and Monitoring, Pretoria, South Africa

\*Address all correspondence to: m.willie@medicalschemes.co.za

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast… DOI: http://dx.doi.org/10.5772/intechopen.107418*

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[43] Discovery Health Medical Scheme. Oncology program. [Internet]. 2022. Available from: https://www.discovery. co.za/wcm/discoverycoza/assets/ medical-aid/benefit-information/2021/ oncology-programme-2021.pdf

[44] Council for Medical Schemes Annual Report 2020/2021. Pretoria South Africa [Internet]. 2021. Available from: https:// www.medicalschemes.co.za/annualre port2020/

[45] Nkomo PWF, Koch SF, Tshela EMM, Willie MM. Optimising beneficiary choices: Standardisation of medical scheme benefit options. South African Health Review. 2019;**2019**:90-104. Available from: https://www.hst.org.za/ publications/Pages/SAHR2019.aspx. ISBN 978-1-928479-01-7

[46] Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. Cancer Journal for Clinicians. 2020;**70**(1): 7-30

[47] Adeloye D, Sowunmi OY, Jacobs W, et al. Estimating the incidence of breast cancer in Africa: A systematic review and meta-analysis. Journal of Global Health. 2018;**8**(1):010419

[48] Peltzer K, Phaswana-Mafuya N. Breast and cervical cancer screening and associated factors among older adult women in South Africa. Asian Pacific Journal of Cancer Prevention. 2014; **15**(6):2473-2476

[49] van Eeden R et al. Lung cancer in South Africa. Journal of Thoracic Oncology. 2020;**15**(1):22-28

[50] Sartorius K, Sartorius B, Govender PS, Sharma V, Sheriff A. The future cost of cancer in South Africa: An interdisciplinary cost management strategy. SAMJ: South African Medical Journal. 2016;**106**(10):949-950

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[52] Kroll C, Warchold A, Pradhan P. Sustainable Development Goals (SDGs): Are we successful in turning trade-offs into synergies? Palgrave Communications. 2019;**5**:140

#### **Chapter 4**

## Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward

*Malik Olatunde Oduoye, Aymar Akilimali, Umulkhairah Arama, Mohammed Fathelrahman Adam, Uwezo Biamba Chrispin and Bonk Muhoza Gasambi*

#### **Abstract**

This chapter is based on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behaviors. We noticed that physical challenge has a substantial long-term adverse effect on one's ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services. The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has and the importance it connects to the quality of life of its citizens. We advocate and recommend swift actions and disability inclusiveness to accommodate persons with physical disabilities in Africa for them to have a good perception of life.

**Keywords:** physically challenged, persons, Africa, healthcare, services, way forward

#### **1. Introduction**

Disability is the interaction between the person with a medical condition (e.g., cerebral palsy, down syndrome, or depression) and personal and environmental factors (e.g., negative attitudes, inaccessible transportation and public buildings, and social support limit) [1]. Physical challenge has a substantial long-term adverse effect on one's ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion

reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services.

The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has and the importance it connects to the quality of life of its citizens. We also note that disability upsets the visions and habits of individuals because it is the pure manifestation of difference from a certain normality erected by social representations. We must allow those whom the chance of birth or life has placed in a situation of handicap, to be recognized as subjects and to fully play their role in society.

#### **2. Concept of disability**

#### **2.1 Conceptual review**

This concept is based on previous studies, articles, research, and paper reviews on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behavior. We come to a realization that since the year 2001, the World Health Organization (WHO) has shown a wider, contemporary view of the concepts of "health" and "disability" through the recognition that every human being may encounter or have some degree of physical disability in their life span either through a change in health or environment. As you may know, physical disability is a global human experience, which is sometimes permanent and sometimes temporary. It is not something limited to a small part of the general population in the world [2]. Research shows that the number of people with disabilities has grown greatly over the last 2 decades. And it is estimated that there are over 1 billion disabled persons worldwide, with about 200 million of them experiencing very significant difficulties. This growth has been impacted both by the increasing life expectancy and by exposure to factors such as road traffic accidents, physical or mental stress, drug abuse, and infections. Thus, due to these factors mentioned, it is estimated that an individual born in a country where the mean life expectancy is 70 years of age is likely to spend, on average, 11 years of his/her life with some form of physical disability or challenge [1].

By definition, physical disability is a situation when there is a restriction in one's physiological functionality as well as anatomical activities, in other words, a person's day-to-day performances, movement, and flexibility (web.archive.org., 2003). This could be temporary, for a short period or long period, or may go into a lessening of the manifestations of the problems. Disability could be congenital or acquired. That is, a person could be born with physical disability from birth or after been born. The congenital disability could be due to some kind of genetic problems or chromosomal abnormalities. While the acquired form could be through external factors such as infections, harsh weather conditions, trauma, for example, road motor accidents. In a wide range, physical disability could exist. This could be from surgical removal of a limb (amputation), injury to the spinal cord, inflammation of the joints, progressive muscular weakness due to muscular dystrophy or from cerebral palsy, that is, a group of on-progressive, non-contagious conditions, caused by brain damage before birth or during infancy. Other conditions such as multiple sclerosis and Gullein–Barre syndrome have also been implicated.

#### *Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward DOI: http://dx.doi.org/10.5772/intechopen.108126*

Persons with physical disabilities are also human beings who form a proportionate size of population of the world in which they cannot be written off or neglected. According to research done by James et al., there are over 25 million individuals who have difficulty in moving around. This was made known by the National Coordinator of the Association of Indigenous People with Disabilities (AIPD), Dr. Josephy Ify Chikunie, a physically challenged lecturer at the University of Lagos (UNILAG), Akoka, Nigeria. Physically challenges have been seen to restrict the ability of an individual to perform excellently like other "abled" people as may be required. This is obvious to people through the ability to move or inability to move of the individual and thus can affect his or her ability to carry out habitual activities. In another way round, a physically challenged person is one who has a limitation with his body and, due to that, is unable to perform rudiment things that other people do easily. These rudiment things include but not limited to washing clothes, eating food, drinking water, sweeping, cycling, running, etc.

#### *2.1.1 Prevalence of disability*

We realized that the definition of disability, the quality and methods of data collection, rigor of sources, and varying disclosure rates are factors influencing the prevalence of disability. We also note that poor service provision and stigma may result in lower disclosure. On this note, we realized that national statistics can be misleading, incomparable, and inaccurate. And thus, these limitations may result in a higher prevalence of disability in developed countries being reported compared to developing countries. As a matter of fact, poor service provision, stigma, and predominantly collecting data through census result in lower-income countries recording lower disability prevalence rates compared to higher-income countries. Despite these potential influences, the data that do exist indicate that low- and middle-income countries in reality do have higher disability prevalence compared to high-income countries.

The prevalence of physical disability could also be enhanced by different factors many countries, most especially in sub-Saharan African countries. Certain features in health conditions, physical environmental factors, and other inconstant occurrences such as motor accidents, natural disasters, like earthquakes and volcanoes, a clash or disagreement, diet, and drug abuse, for example, cocaine, alcohol, has been identified. For example, an estimated 20 to 50 million people are injured by road motor accidents every year. And the number of people injured due to these accidents is not well documented, although road traffic injuries are estimated to account for about 1.7% of those living with physical disability. Also, individuals who have low source of livelihood, jobless, or have low educational background and stratification have been shown to have a higher risk of physical disability as compared with other children and those from poorer households, especially in the rural settlements, and have a significant higher burden of physical disability [3].

#### *2.1.2 Global perspective*

According to the WHO global disability action plan 2014–2021 [2]; globally, there is an estimate of over 1000 million people living with physical disability; this corresponds to 15% of the world's population or one in seven people. Among this population, between 110 million and 190 million adults experience significant difficulties in carrying out their normal physiological functions. A paper reviewed also showed an estimate of about 93 million children, and an equivalent of 1 in 20 of those below the age of 15 years, are living with a moderate or severe form of physical disability [4]. The number of people who experience physical challenges or disabilities will keep increasing as populations age, in a geometric form. Similarly, with the global increase in chronic health conditions, national patterns of disability are affected by certain trending features in health conditions and physical and social-environmental and other factors, such as road traffic injuries, falls, violence, emergencies including natural disasters, like earthquakes, volcanoes, and disagreements, unhealthy food and drinks and drug abuse [2].

#### *2.1.3 Disability in Africa*

According to the WHO, about 75% of people with disabilities are living in the developing countries. In Nigeria, for instance, WHO estimates put the number of people with disability at 19 million or approximately 20% of the country's population. Let us give a practical example. One of the authors of this chapter was discriminated by some of his lecturers in medical school in Nigeria, due to his impaired left arm. The author has untreated post-polio syndrome at the age 2 years, but was fortunate to study human medicine in the university. He was asked to change his medical course as a result of his impairment toward the end of his medical training. This made him frustrated and wanted to give up on his dream as a medical doctor.

Another scenario in the Eastern part of Nigeria, where a female medical doctor, named Dr. Judith Etim from the University of Nigeria, Nsukka (UNN), was discriminated due to her lower limb paralysis. Aside these sad stories and events, there are many untold stories of people in Africa with physical disabilities who have been discriminated and left to suffer. These people rather commit suicides if no one comes to their aid, or rather became beggar to sustain themselves. The question now is WHY? From the above stories, we realized that despite the expertise in therapeutic exercises and the available evidence of effectiveness, many people continue to live with physical disabilities across the globe, especially in Africa [5]. In Africa as in the world, people with physical disabilities face exclusion, discrimination, and difficulties in enjoying their rights, such as their rights to education, job, inheritance rights and property ownership, and social rights.

#### **2.2 Information needs of the physically challenged persons in Africa**

As we have highlighted earlier, persons with physical disabilities are also human beings like any other person; therefore, there are certain needs they long for. According to [6], these needs include the information for educational development and growth, the information needed for social and personal development, and the information needed for recreational or social purposes [3]. It must be emphasized that in trying to meet the above needs of persons living with physical challenges, in the library for instance, they are likely to need more assistance than the "abled" users.

We come to realize that it is also important that the information needs of the persons living with physical disabilities are quite numerous. Some of this information is available in the school libraries, music collections, spoken words collections, picture books, books in enlarged print, and high-interest/low-vocabulary materials. It is quite unfortunate that, in many countries in the world today, persons with physical disabilities still struggle to be educated/literate irrespective of their medical condition [3]. We realized that some of these people that are focused often perform better than their colleagues that are not suffering from any form of disabilities. For example, the

*Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward DOI: http://dx.doi.org/10.5772/intechopen.108126*

case of one of the authors and Dr. Judith Etim. And after their education, the next thing they think of is how to get a befitting paid job [3].

#### **3. Disability and accessing healthcare in Africa**

According to the United Nations (UN) standard rules for equal opportunities (United Nations 1993), it is stated that having access to health and rehabilitation services is a vital condition to equal opportunities, and an important component of being a respected and productive member of the society [5]. Statically speaking, globally, about 15% of people with disabilities have difficulty accessing healthcare. These problems are particularly common among person with physically disability in Africa and most developing countries, and widen the access gap between them and their counterparts in the developed world. These challenges are compounded in low- and middle-income countries (LMICs) where factors such as poverty, poverty-related diseases, inefficient healthcare systems, training and equipment, inaccessible transportation systems, corruption, political instability, and negative attitudes toward disability occur. The combination of high needs and low capacity to pay for healthcare is a major policy concern and a serious global challenge for providing available, accessible, and affordable healthcare for person with physical disability. For each patient, access to care is a fundamental right. And for people with disabilities, the pathologies are more numerous.

People with a specific type of disability such as mental illness and intellectual or psychosocial disabilities often face high social exclusion. They consult later, present more frequent emergency situations and more complex problems, and are more difficult to reach by prevention campaigns. A study in Ghana reported that inaccessible healthcare facilities and equipment, specifically the absence of ramps and elevators, narrow corridors, the absence of toilets, and lack of sidewalks, were among the biggest barriers to access healthcare services. Each individual with disability should obtain appropriate healthcare services in situations of perceived need for care.

A study conducted among South Africans with disabilities shows that these healthcare challenges aggravate the existing health conditions in them. There exist many layers of injustice, unfairness, and bias, as a result of the era of policy of racial separation/segregation and discrimination, which further worsens the challenges of the persons with disabilities face every day. This study further revealed that despite the adoption of democracy in 1994, many African people with physical disabilities remain less privileged in many ways, with African physically challenged females facing more discrimination based on their ethnicity, tribe, gender, and physical disability. Also, this study made it clear that the challenges facing persons with disabilities living in rural communities are even worse due to the lack of healthcare services, medical experts, long distant travels, poor motorable roads, as well as high rate of stigmatization related to physical disability.

Furthermore, we realized that during times of hardship like times of disaster, and other unforeseen occurrences, many individuals with physical disabilities are further alienated and opted out. These individuals witness an inability to access basic healthcare services especially from the primary healthcare centers and secondary health facilities. They are faced with difficulties to obtain information in an accessible way and receive good medical evaluations and interventions. Also, with regard to the era of COVID-19 pandemic, more factors such as preexisting comorbidities, as well as public living spaces like the home or educational facilities, further make the individuals with physical challenge vulnerable to contract the COVID-19 virus [3]. Many have

also experienced struggle and direct discrimination in accessing life-saving treatment such as critical care admission, ICU, and oxygen support. We believed that some of these issues have made persons with physical challenges more susceptible to a higher risk of contracting the COVID-19 virus during the present pandemic era.

Overall, persons with physical challenges have problems to have the possibility to identify healthcare needs, to seek healthcare services, to reach the healthcare resources, to obtain or use healthcare services, and to actually be offered services appropriate to the needs for care. They could not conceptualize five dimensions of accessibility of service, such as approachability, acceptability, availability and accommodation, affordability, and appropriateness.

#### **3.1 Problems to means of transportation for healthcare services**

Generally speaking, Africans have problems in accessing good transportation. These problems are compounded with people living with disabilities, most especially in seeking for healthcare. In Nigeria, for example, most of the roads are dilapidated. Most "abled" individuals are even finding it difficult to drive on these bad roads not to talk of the physically challenged people. As a result of this, most people living with disabilities in Africa and other developing countries find it difficult to go to the nearest hospitals for help. Thus, imposing their problems simultaneously and consequently, they develop more complications either from road accident or the disease itself. Similarly, most railway networks in many African countries are not accessible to wheelchair users. Unfortunately, there are limited or no assistance or support given to assist passengers with physical challenge in accessing and using trains. This makes these passengers more vulnerable because of safety concerns and measures.

In addition, several studies have shown that many African countries do not have telecoil (TTY) facilities available for passengers using hearing aids, and many airport stations have bad signage and faulty audio speaker devices. Persons with physical disabilities in many African countries experience many challenges, including lack of assistance getting into and out of a taxi. Most of these people are required to lift and carry their own wheelchairs on board, being charged an extra fare for their wheelchairs and concerns surrounding safety. In South Africa, for example, during national COVID-19 pandemic lockdown Level 1 and Level 2, public transport was significantly reduced in order to assist in containing the spread of the COVID-19 virus. Public train transportation was suspended, a limited number of busses were permitted, and small bus taxis were allowed to operate at limited capacity for limited hours. Transport was allowed for health professionals and other workers employed in essential work space and services, and individuals that require basic life amenities such as food, clothing, and shelter.

In recent times, it is quite unfortunate and sad in many African countries that travel time limits were too confined for many persons with physical challenges as a result of their disabilities and dependence on assistance and or support from others, requiring a longer time to finish up their morning hygiene routine, travel to buy food and medical provisions, and return home. It is of this note that the limited public transportation intensely affected the ability of caregivers to travel to assist the persons living with physical disabilities [7].

#### **3.2 Problem for means of personal assistance and caregivers**

It has been shown that persons with physical disabilities as well as their relatives carried an inner and incessant fear that their caregivers may be susceptible to *Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward DOI: http://dx.doi.org/10.5772/intechopen.108126*

sickness and/or need to be isolated [4]. Unlike high-income African countries such as Rwanda, Ghana, Nigeria, and South Africa where caregivers are paid for or procured *via* government structures and agencies [2], South Africans with disabilities are obligated to pay for caregivers in reserved way or use their R1890 state disability grant for this means. Also, we realized that in most cases, caregivers travel on public transport and interact with others at home, socially and while shopping when not on duty. Loneliness and social isolation from caregivers have also been shown to affect some persons with physical challenges and could have a long-term detrimental impact on their psychomotive well-being. It has been reported that isolation from caregivers who assist with drugs, together with reduced accessibility to mental health services, could lead to relapse of the disease [4, 7].

#### **3.3 Problems with communication systems**

Many African countries have poor communication systems. These are worse with persons with physical disabilities. The people living with hearing difficulties have limited accessible to hearing aids and interpretations. Studies show that African healthcare policy dictates that patients living with disabilities may not be followed by their friends or family when accessing healthcare, as these could impose more communication barriers and challenges to these people [7]. It is obvious that many deaf persons use sign language as their primary methods of communication and are unable to communicate with healthcare workers without interpretation. Also, for individuals who rely on lip reading, understanding healthcare workers wearing medical masks is not possible. Furthermore, we realized that the provision of a patient with disability history or having to sign consent may pose an obstacle, at times not possible for an individual with severe mental or psychosocial disabilities, or on the autistic symptoms [8].

#### **3.4 Problems for means of curative management, restoration, and medications**

Generally speaking, many countries face restorative solutions to disability problems especially chronic forms of disabilities and those that are related to nervous system. These problems are more rampant in most African tertiary healthcare facilities. Most of these facilities do not have a sophisticated physical therapy facilities to restore physical disabilities as well as well-trained experts in that aspect of medicine. Thus, many people with physical disabilities in Africa would rather have a sequela of their disabilities or die like that in their disabled form. Although African countries such as Nigeria, Ghana, South Africa, Rwanda, and Egypt have tried to establish neurophysiotherapy and functional recovery centers to correct some physical disabilities due to stroke, cerebral palsy, poliomyelitis, etc., only a few successes have been recorded. We realized that most of these centers end up referring their patients with such debilitating and physical impairment to the Western countries for possible curative and restoration, such as limb lengthening, nerve grafting, tendon transfer surgeries, and prosthetic insertions.

#### **3.5 Problems in accessing intensive care and emergency management and triage**

Several studies on emergencies and disasters show that when availability of resources is restricted, healthcare workers may be forced to make decisions as to who qualifies to receive life-saving healthcare. In emergency situations, such as the World Trade Centre attack (2001), and natural disasters such as earthquakes and hurricanes, the significance of having triage policies in place and what challenges that can occur if they are not established in emergency situations arises. For example, most hospitals, nowadays, adopt the Advanced Trauma Life Support (ATLS) system in managing multiple injured patients as well as mass casualties [9].

Triage policies are important in normalizing the allocation of resources and care, as well as guiding healthcare workers in emergency practice. There are different methods of triage systems utilized across the globe and are different within countries that have dual healthcare systems; for example, the scoop and run system is mostly practiced in many African healthcare systems, for example, in Ahmadu Bello University Teaching Hospital (ABUTH), Shika, Kaduna state, Nigeria, the University of Ilorin Teaching Hospital (UITH), Ilorin, Kwara state, Nigeria, and the University College Hospital (UCH), Ibadan, Oyo state, Nigeria. Unfortunately, even though this is been practiced, there are no special arrangements and inclusiveness to accommodate persons living with disabilities.

While triage policies are fundamental to effective emergency healthcare services, it is important to ensure that they do not discriminate against any specific population group especially with persons living with physical disabilities. We realized that such discrimination is currently in practiced in London, UK (United Kingdom), where, during the COVID-19 pandemic, persons with physical disabilities and the less privileged persons have reportedly been denied the rights to be admitted into health centers or receive life-saving emergency treatment if they become sick [7].

#### **4. Challenges of physically challenged persons in Africa**

We realized that disability affects virtually everybody but more rampant among the women, children, older people, and poor people in different proportions. African children from poorer homes, indigenous populations, and those in ethnic minority groups are significantly higher risk of experiencing disability. Women and girls with disability are likely to experience what is called double discrimination. Double discrimination as a concept includes gender-based violence, abuse, marginalization, and stereotyping. As a result, women with disabilities are likely to face more disadvantages when compared to men with physical challenges and women without physical challenges. A country man, internally displaced, or stateless persons, refugees, migrants, and prisoners with physical challenge also face peculiar problems [10].

#### **4.1 Challenges in the health sector**

The relationship between poor health and disability is not fully understood. However, persons with disabilities are commonly poorer, and suffer from stigmatization and discrimination in education, employment and access to different services [1]. We noticed that the challenges faced by disabled persons in accessing healthcare are not new and are numerous. Physically disabled persons have always been faced with challenges in healthcare services, political or leadership positions, and education. According to MacLachlan and Mannan [1], access to healthcare, even in wealthy countries, is often difficult for persons with disabilities, but in poorer countries the challenges are exacerbated, combining physical, financial, and attitudinal components. Many policies

#### *Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward DOI: http://dx.doi.org/10.5772/intechopen.108126*

have been put in place to improve these people's access to healthcare, but until now, physically disabled people show worse health outcomes than others. In addition to poor health system infrastructure and poor healthcare services in African countries, the access to healthcare services by persons with disabilities remain an unsolved challenge [2]; for example, in South Africa, persons with disabilities were found to have a higher un approached health needs compared to persons without disabilities [5].

There are many factors that serve as barriers to access healthcare services for persons with disabilities in Africa which include (1) stigmatization, (2) negative attitudes toward physically disabled persons, (3) cost of access to healthcare services and insufficient resources as a result of unemployment and poverty, (4) inadequate policy implementations by health and political authority, (5) physical inaccessibility to healthcare services, (6) long distance of health facilities and lack of transportation, (7) insecurity, (8) hilly terrains and flooding of rivers during the rainy season, (9) challenges as a result of inadequately trained healthcare providers to deal with disabled persons including poor communication and poor attitude, and (10) genderbased challenges in which women were the most affected group [3, 5, 7].

Those challenges commonly increased along with disability severity, being female in gender and declined with increasing education level, type of household, and age [2, 5]. Furthermore, in Africa, many physically challenged people are neglected because many of them are in the lower class in society, and many are left with no one to cater to them. They are often only catered to by their family members and sometimes neglected by the government. It is no doubt that many African countries are low-income countries, and healthcare systems are less developed compared with other countries in the world. A study conducted by Vergunst et al. [2] in rural Madwaleni, South Africa, showed that physically disabled persons faced barriers in accessing healthcare services, and the widely faced barrier was transportation; meanwhile, a higher level of education and socioeconomic status often reduced those barriers [11]. Another challenge is the sentiments and stereotypes toward people with disabilities. Some people view disabilities as punishments and abnormalities. A study conducted by Haruna [5] in Tamale Metropolis, Ghana, showed that some of the barriers faced by physically disabled people include the following: (1) sociocultural factors that consist of variables such as education, ignorance, stigmatization, and belief systems that exist within households and the communities, (2) service factors that relate to conditions prevailing at the health facility are the attitude of providers, service cost, waiting times, insurance, and distance, and (3) economic factors relating to income, occupation, and transport cost determine the physically disabled person's ability to access health services. Consequently, the falling standard of healthcare systems and migration of healthcare workers from African countries have worsened access to healthcare for physically disabled people. The lack of infrastructures like roads and standard hospitals, and lack of adequate policies that improve the welfare and inclusion of physically disabled people have increased the inaccessibility of physically disabled people to healthcare [10].

#### **5. Recommendations and way forward**

To address this issue, in which we believe stigma and the autonomy of people with disabilities are heavily implicated, we recommend to the African and international communities to think carefully about the psychological and social repercussions

suffered by disabled people who have difficulty accessing care, and to integrate into humanitarian aid programs a space reserved for supporting both financially and in terms of education for the independence of people with disabilities. This includes: (1)—To encourage initiatives, among others: investments, candidacies,… by people with disabilities in all sectors of activity. (2)—The establishment of specific organizations to support people with disabilities in terms of health and easy access to care [2]. To African governments to subsidize health insurance for all persons physically unable to work, (3)—to set up specialized structures at each medical training course for easy and unlimited access to care for any disabled person [2]. To sensitize the African population in the fight against discrimination or all other forms of stigmatization and to call on them to work together in perfect cohabitation… [5]. To nursing staff—to administer equal and satisfactory treatment to everyone. Taking for instance, the case of South-African government policy [5].

In a nutshell, we are recommending disability inclusiveness for persons with disabilities and anti-discrimination policies from the all-African government. We believed that this policy would provide an important backdrop to the development of more inclusive health services for persons with disabilities in Africa. As this would also reflect a greater understanding and awareness of the experience of individuals with disabilities in their health-seeking behaviors and of the impact of disabling barriers on their independence, and strengthening their autonomy, health and well-being, as a result, health service providers in African countries would be able to address the issues of medical consultation with and participation of persons with disability in planning and quality healthcare service delivery [12].

#### **6. Conclusion**

Persons with physical challenges in African countries experience significant challenges especially in having quality healthcare services and support. Most of these people are denied their rights to seek good and affordable healthcare and restorative services. They are often left to suffer in pain, frustrations, and regrets. Injustice, marginalization, and inequality have made them to have bad perceptions about a good quality of life. Thus, we are advocating for full inclusion of persons with disabilities. Anti-discrimination has provided an important backdrop to the development of more inclusive health services for persons with disabilities.

#### **Acknowledgements**

We give thanks to the Almighty God for giving us the abilities to put this piece of writing together. Special thanks to the main author of this book, Mr. Malik Olatunde Oduoye, who corroborated with us from different parts of Africa. We are indeed grateful. We also acknowledged our parents, siblings, teachers, friends, and colleagues for their support in helping us with ideas, and moral and financial supports. We say a big thank you to all of you.

Funding is by all authors that contributed to this book.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward DOI: http://dx.doi.org/10.5772/intechopen.108126*

#### **Dedications**

We dedicate this chapter to all persons living with physical challenges and disabilities in Africa.

#### **Notes/thanks/other declarations**

We declare that this chapter is for people who have interest in disabilities and willing to help and support people living with disabilities in the world, especially in Africa. Thank you all and God bless you! Amen!

#### **Acronyms and abbreviations**


### **Author details**

Malik Olatunde Oduoye1 \*, Aymar Akilimali2 , Umulkhairah Arama1 , Mohammed Fathelrahman Adam3 , Uwezo Biamba Chrispin4 and Bonk Muhoza Gasambi2

1 Ahmadu Bello University, Zaria, Kaduna State, Nigeria

2 Faculty of Medicine, Official University of Bukavu, Bukavu, Democratic Republic of Congo

3 University of Science and Technology, Omdurman, Sudan

4 Universite de Goma, Goma, Democratic Republic of Congo

\*Address all correspondence to: malikolatunde36@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[8] Vankova D, Mancheva P. Quality of life of individuals with disabilities. Scripta Scientifica Salutis Publicae 2015;**1**(1):21-28

[9] Love B A Short Practice Textbook of Surgery. 26th ed. 2015:1-1000

[10] Bright TKHA. Systematic review of access to general healthcare services for people with disabilities in low- and middle-income countries. International Journal of Environmental Research and Public Health. 2018. pp. 1-15

[11] Vergunst R, Swartz L, Hem KG, Eide AH, Mannan H, MacLachlan M, et al. Access to health care for persons with disabilities in rural South Africa. BMC Health Services Research. 2017;**17**:1-8

[12] United Nations-Division for social Policy Development (DSPD D of E and SA (DESA). Inclusive Health Services for Persons with Disabilities. Washington DC: United States of America (USA); 2012. pp. 1-37

#### **Chapter 5**

## The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive Issues in the Communities of South Africa

*Mxolisi Welcome Ngwenya and Gsakani Olivia Sumbane*

#### **Abstract**

South Africa yet again faces an upsurge of a national crisis. Approximately 13,774 deaths were reported in 2019 as a result of suicide. In total, 10,861 of the deaths were men. It has been said men usually take time to seek healthcare services. Most regard their problems to be solved over a few bottles of alcohol. Most of the suicides are linked to mental health issues. This poses an inquiry on the current services offered to address men's mental health issues. Therefore, this shows the significant urgency to access modified men-centered mental health services to address men's sensitive issues in the communities of South Africa (SA). However, this chapter seeks to review the prevalence of suicides, health-seeking behavior among men, and factors to poor utilization of mental health services in men. In addition, it discusses the proposed strategies to improve access to men-centered mental healthcare services.

**Keywords:** access, men-centered, mental healthcare, suicide, coping mechanisms

#### **1. Introduction**

Mental health is the state of which one is aware of self, able cope with normal stress situations, and work productively. However, some studies define mental health as a state of which there is absence of mental illness [1, 2]. South Africa yet faces an upsurge of national crisis of men's death in relation to mental health problems. Approximately 13,774 deaths were reported in 2019 because of mental-health-related problems. In total, 10,861 of the deaths were men. It has been said men usually take time to seek mental healthcare services. Most men regard problems to be solved over few bottles of alcohol. Studies showed that men have been found to seek psychological help at a lower rate compared to women [3, 4].

Men are more at risk of dying of suicide than women in South Africa. When compared with 10 years ago, more men are found to be depressed and are being admitted to psychiatric hospitals due to burnout and depression [5]. The Depression and Anxiety Group affirmed that men do not seek help until later when it is more serious, and although depression is ranked high on the list of chronic diseases, most men are not on treatment. The risk factors for mental health illness in men in South Africa are alcohol, substance use, unsafe sexual practice, diet, lack of physical exercises, violence, and other stressful life events [5].

Based on the recent statistics on suicide rates, it seems as if men's mental health is being neglected. It is against this background for the urgency of access of mencentered mental healthcare services to address men's sensitive issues in the communities of South Africa. Therefore, it requires redirection of resources to achieve a 100% sustainable mental health for all through access to men-oriented mental healthcare services to address sensitive issues among men.

#### **2. Prevalence of suicides associated with mental health issues among men**

Mental health is of significance to the well-being of individuals. However, individuals go through events in life that cause stress altering the mental health, consequently, resulting into suicides. Suicide is a major health problem worldwide contributing to 1.4% of the mortalities. The majority of the suicides are associated with mental health problems [6]. Over the years, gradual increase in acknowledgement of the role mental health in individual lives has been noted. Despite this progress and the transformed health system, men die every day as a result of mental health issues. Suicide is one of the leading causes. Furthermore, nearly 40% of countries have greater than 15 suicide deaths per 100,000 men [3, 7], with Lesotho, Guyana, Eswatini, South Korea, and Russia being the highest. Over 3000 Australians died of suicide every year. Some studies affirmed that majority of the suicides are linked mental illness such as depression, psychosis, and substance use [3].

Suicide is the twelfth leading cause of death in the United States, approximately 45,979 Americans died in 2020 as a result of suicide, and 1.2 million suicide attempts were reported. Correspondingly majority of the suicides were men accounting for 69.68%. Furthermore, in 2020, mortalities of men who died of suicide were 3.88 times than women [8]. The suicide rates have been gradually increasing over the years [9]. Similarly, in Shanghai, China, a rise in deaths due to suicide was noted, and most of the deaths were men with a rate of 6.38 per 100,000. Moreover, 22.54% of the suicide deaths were due to depression [10]. However, there are other factors associated with suicides; this includes sociodemographic, physical, lifestyle, stressful life events, and mental health factors (**Figure 1**) [11].

South Korea is the fourth highest country with higher suicides at a suicide rate of 28.6 per 100,000 [3]. Majority of the suicides were men with a suicide rate of 35.5

**Figure 1.** *Shows the rates of suicide in the United States over the years [9].* *The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive… DOI: http://dx.doi.org/10.5772/intechopen.108493*

#### **Figure 2.**

*Shows number of suicide deaths in South Korea by gender per 100,000 [14].*

per 100,000 deaths being the third highest suicide rate globally. It was revealed that some of the suicides were due to social factors, religious activities, and higher social isolation [3, 12]. However, the state of health reported that the reasons for committing suicides among Koreans were mental illness, which accounted for the 28% of the men, and financial problems as well as physical illness [13]. Therefore, this shows the significant urgent need of mental health services for men (**Figure 2**).

Suicidal behavior is a major public health concern global and in Africa. Studies in Africa revealed that suicide rates in Africa are three times higher in men than women [15, 16]. In South Africa, the suicide rates are approximately five times in men than women. As of 2012, suicides rates ranged from 11.5 per 100,000 to as high as 23.5 per 100,000 in 2019, rendering South Africa being number tenth of the countries with highest suicide rates [3, 17]. An exploratory study on how group of young South African men think and talk about suicide revealed that they perceived suicide as goaldirected behavior that provides a means of recuperating control, asserting power, communicating and rendering oneself being noticeable [18].

#### **3. Major mental health conditions associated with suicide in men**

A number of studies have specified that there is silent crisis in men's health, which is mental health. Over the years, the number of suicides linked to mental health conditions has been gradually increasing. Most studies affirmed that the most common mental health conditions among men subsequently resulting in suicide were depression, anxiety disorders, and substance abuse [6, 19]. Here below only depression is discussed as it is the major ignored one among men.

#### **3.1 Depression**

Over the years, depression has been positioned as a mental health disorder dominant in women. However, changes have been observed over the years where more

males are affected by depression; it been said some of the causes include financial problems, family problems, and overwhelming family responsibilities [20, 21]. Depression is regarded as an illness in which it affects the cognitive behavior of individuals. It affects how one thinks, feels, and acts [21]. Approximately 6 million men are affected by depression in the United States. Most of the men suffering from depression often remain undiagnosed or untreated, consequently resulting into suicide. Men's mental health has persisted undertheorized. One of the reasons includes social norms and masculinity such as statements like "Boys don't cry and men don't shed a tear." [22–24]. Furthermore, various masculinities identities and roles are implicated by men's depression; for instance, men's depression can be of result of divorce whereby the men are disrupted of from provider and protector roles. Moreover, also unemployment can exacerbate or trigger depression [25]. However, signs and symptoms of depression do not differ between males and females. Most depressed individuals exhibit different signs and symptoms, this includes [26]:


### **4. Factors contributing to poor access to mental healthcare in men**

#### **4.1 Role of culture**

The role of culture in mental health is not well understood in spite of the fact that the cultural conception of the self has a powerful influence on the manner in which the disorder is expressed and understood. The majority of men's understanding of mental disorder is informed by an indigenous cultural perspective. Men make sense of their illness from both cultural perspective and social context in which they found themselves. Some men's understanding of mental disorder is in terms of issues such as witchcraft [27].

#### **4.2 Socialization into traditional masculine gender roles**

Men are thought to be deterred from engaging in mental health services due to socialization into traditional masculine gender roles. The social and cultural expectations make men think of themselves as risk-takers, thus leading to the probability of

#### *The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive… DOI: http://dx.doi.org/10.5772/intechopen.108493*

engaging more in risky behaviors that could lead to injury and death. Environmental pressures have been proposed to be one of the major causes of men's premature death and have predisposed them to engage in unhealthy behaviors (e.g., risky sexual behavior, alcohol use and abuse, high-risk sports, reckless driving) detrimental to their mental health. The chances that men will seek mental health when they feel discomfort are reduced because of their socialization experiences.

Men are often socialized through role-playing in such a way that they undermine help-seeking behavior, and if at all they intend to seek help, the individual is faced with cognitive dissonance, which is a consequence of contradictory beliefs of what they believe they are and what action they intend to take. Traits associated with traditional masculinity include stereotypes of stoicism, invulnerability, and self-reliance, which are frequently discussed as they do not fit comfortably with psychological help-seeking. For instance, negative emotions are perceived as a sign of weakness, discouraging men from reaching out to friends. This negatively impacts men's overall help-seeking behaviors and their choice of treatment type. Failure to adhere to these masculine stereotypes can result in the internalization of discriminative views held by the wider public. These self-stigmatizing beliefs further discourage men from seeking help [28, 29].

#### **4.3 The problem of stigma – Social rejection and labelling**

Stigma is described as a painful and distressing experience and a significant barrier to the inclusion of persons living with mental disorders in community activities, healthcare service, workplaces, and accessing education [27].

#### **4.4 Differences in coping strategies**

Men cope with mental health difficulties differently compared to women, demonstrating an increased tendency to self-medicate with alcohol and drugs to alleviate emotional distress.

#### **4.5 Poor mental health**

Literacy is reported to be associated with lower use of mental health services. Men are regarded as having poorer mental health literacy compared to women as they are worse at identifying mental health disorders [27].

#### **4.6 Lack of appropriate diagnostic instruments and clinician biases**

Men express symptoms of depression that do not always conform to the Diagnostic and Statistical Manual of Mental Disorders [30]. For example, they may express more externalizing behaviors such as alcohol consumption, irritability, and aggressive behaviors while underreporting other symptoms. These factors may mask men's difficulties, leading to inaccurate diagnoses and inappropriate treatment.

#### **4.7 Clinicians may suffer from their own biases with the expectation that men should fulfill particular masculine stereotypes**

For example, when men do not conform to these traditional masculine stereotypes by expressing themselves emotionally or by taking responsibility for their health, they may be regarded as deviant and/or feminine. These biases influence the quality and

type of care provided and leave men less likely to receive a diagnosis despite presenting with similar or identical symptoms to women [29].

### **5. Adverse coping strategies used by men to deal with mental health-sensitive issues**

#### **5.1 Substance abuse**

Substance use and mental health issues have substantial impact on individuals, families, communities, and societies [31]. Substance abuse is often linked to a number of triggering factors and to deal with such factors, men often resort to substance use; some other scholars concurred that the common causes of substance abuse among men include the following:

#### i.*Masculinity and self-medication*

Men are taught from early that men should take risks and do not display any signs of weakness. As a result of such gender-related expectations, men involve themselves in dangerous activities to prove their masculinity. This includes the use of drugs and substances. Furthermore, masculinity impacts the heath-seeking behavior of men for treatment of mental healthcare services as it may be regarded as a sign of being a coward and will put stain in their expectant masculinity [32, 33]. Masculine norms internalize help-seeking behavior [34]. Therefore, as a result, they self-medicate with drugs and substances. Most individuals with substance abuse exhibit signs and symptoms such as mood changes, anger, and sadness [26].

#### ii.*Pressure from life circumstances*

Stressful life events play a major role in substance abuse among men. A study conducted among American African men revealed that unintentional drug use and substance abuse inflicted mental illness. Social issues such as struggling to succeed at work and lack of support family members, and financial struggles were a trigger to substance use and abuse [35].

#### iii.*Grief and loss of a loved one*

Complicated grief is prolonged bereavement-specific disorder with substantial psychological and physical consequences. Individuals deal with complicated grief differently. More complicated grief represents a greater risk of substance misuse and abuse [36]. Substance abuse has become a coping method to avoid dealing painful experiences such as grief and significant loss among men. Loss of a loved one is tied to emotions strains and poses suicidal ideation among individuals [37].

#### iv.*Trauma and negative childhood experiences*

Substance abuse and posttraumatic stress disorders are comorbid. Due to exposure of the traumatic events, individuals self-medicate with drugs and alcohol to deal with anxiety, subsequently leading to substance abuse [38].

*The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive… DOI: http://dx.doi.org/10.5772/intechopen.108493*

#### **5.2 Domestic violence as a coping mechanism**

Domestic violence has been gradually increasing worldwide; it is associated with the gender role inequalities such as abusing women as an exertion of power and assuming the traditional masculine role [39, 40]. However, despite the gender role inequalities as an expression of masculinities, domestic violence could be a result of substance abuse by perpetrators and could also be associated as a mechanism to deal with internal conflicts and mental health problems among men. The World Health Organization affirmed that as a result of societal expectations and traditional masculinities discouraging men from seeking help, instead they lash out and abuse their families as a coping mechanism to deal with the mental health problems. Although there is limited literature pertinent to domestic violence as a coping mechanism, majority of studies focus on the impact of abuse on the mental health of both men and women. Therefore, this requires further studies looking more into association of domestic abuse by men and their mental health status during the abuse toward their families.

#### **5.3 Informal support**

Dealing with mental health-sensitive issues among men is a difficult issue due to poor health-seeking behavior. Men often seek informal support from non-health professionals, and this includes family and friends; sometimes, they do not seek any support at all. They rather deal with such issues alone [40].

#### **6. Cultural norms as a major barrier to seeking mental health services**

Men are more disinclined to seek help with regard to health problems than women; this has mostly been associated with traditional ideas of masculinity [34]. Men are burdened by what is expected of them, and the masculinity roles are expected to assume in their lives. As a result, many young men are soldiering on nonetheless and swallow their own feelings, and this comes to a point the men reach a stage to take own life. While men are trying to accomplish the societal respects as a consequence of higher expectations from them, their stress levels increase and their mental health mostly remains unchecked (**Figure 3**) [28].

**Figure 3.** *Masculinity norms of what men are expected to be [41].*

#### **6.1 Theories of masculinity and its effects on men's mental health**

Masculinity includes cultural and social norms, behaviors, and practices. The concept of toxic masculinity aims at underlining how certain socially constructed definition of masculinity can be detrimental to a society, men, and women [42]. The numerous reasons behind toxic masculinity include biological and social dimensions. The social dimensions include the family and friend's environment, educational system, workplace, and religion [43]. Examples of toxic masculinity include overtly aggression of a man to a female to show power and dominance and also never showing emotions as they are viewed as feminine trait because it shows weakness. Toxic masculinity affects and harms the one's mental health [44]. This may be one of the reasons why men commit suicide. A study conducted on social media, behavior, toxic masculinity, and depression revealed that toxic masculinity is associated with depression [45].

#### **7. Strategies to improve access to men-centered mental healthcare services**

#### **7.1 Teamwork**

One of the key aspects of this approach is the recognition that professionals should work as a team and that high-quality healthcare involves improving relationships between staff and between patients and their families [46].

#### **7.2 An intervention aiming to reduce self-stigma associated with mental health problems**

Reducing stigma associated with healthcare, ill-health, and health-seeking behaviors by addressing internalized stigma with men. Reducing healthcare worker stigma associated with healthcare, ill-health, and health-seeking behaviors by providing sensitization training for healthcare workers [5]. A male-sensitive brochure to address help-seeking in depressed men, an intervention aiming to reduce self-stigma associated with mental health problems [29].

#### **7.3 Key processes that improved help-seeking attitudes, intentions, or behaviors for men**

The use of role models to convey information, psychoeducational material to improve mental health knowledge, assistance with recognizing and managing symptoms, active problem-solving tasks, motivating behavior change, signposting services, and finally, content that built on positive male traits were important processes that improved help-seeking attitudes, intentions, or behaviors for men.

#### **7.4 Public awareness campaigns and interventions designed to improve men's psychological help-seeking**

These include campaign focusing on educating the public about depression in men. This awareness can be motivated through advertisements and campaigns such as the Real men Real Depression campaign with emphasis on targeting at-risk subgroups first and then the general community [28].

*The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive… DOI: http://dx.doi.org/10.5772/intechopen.108493*

#### **7.5 Psychological referral**

When men seek help from mental health experts, men-centered therapy that emphasizes enhancing the client's capacity for accepting their circumstances is of important. A concise structured therapeutic plan that is clear and straightforward will be more effective and encourage client trust in both the therapist and the course of treatment [28].

#### **7.6 Bias reduction**

Every step of the therapy process should take the client's uniqueness and culture into account. In other words, prejudice reduction should be prioritized at all client contact levels. The client's belief that men cannot experience mental health issues could be a barrier to treatment acceptance and compromise the therapy's efficacy. Thus, taking into account this cultural idea will aid in neutralizing any potential therapeutic bias. According to the client's needs, it is suggested that the therapist take into account the numerous types of biases, including therapist, cultural, and individual [28].

#### **7.7 Demand**

A range of social and behavior change communication (SBCC) interventions are needed, including mass media communication, community outreach, and peer education. Such SBCC approaches need to provide clear, factual, and unbiased information, to increase men's knowledge and self-efficacy; promote communication among men, among peers, and within families; and encourage men to seek care and use services [5].

#### **8. Policy considerations to men's mental health**

#### **8.1 Platform for men's mental health**

Although there are mental health services available in South Africa, attention should be mostly directed toward creating more platforms to address sensitive issues affecting men, consequently leading to suicide. The extensive platforms should be of nonjudgmental and focused on self-determination as well as building the mental well-being of men. Studies revealed that men die of depression and substance abuse disorders; and these are mostly liked due to financial stress, pressure from society and family as well as cultural and social norms. Furthermore, to curve suicide mortalities globally, it is recommended that men's mental health should be given more attention and more research should be done in exploring strategies and procedures to address men's sensitive issues with the aim to reduce mortalities due to suicide among men. Therefore, health practitioners should be trained to have an effective role in asking men about their sensitive mental health issues to determine the root of the mental health problems [40]. Online support forums should be made available where men can vent their stories, experiences, and receive support [2]. In addition to addressing men's mental health issues, peer-led men-only groups may improve the self-esteem and confidence of men in disclosing weaknesses [34].

#### **8.2 Mental health before cultural norms**

Despite our pride toward our culture and religions, some of the cultural norms put an extensive pressure in men, leading them to most likely resort into depression and substance abuse, subsequently leading to suicide attempts. Traditional masculinities and cultural expectations for men's behaviors discourage men to recognize and seek mental healthcare services; consequently, these mental health problems remain hidden or manifest in disastrous ways such as domestic violence, substance abuse, and sometimes suicide [2]. Therefore, it is recommended that human lives should be a priority before our cultural norms. Putting the mental health needs of men before our cultural norms is most likely to save the lives of men worldwide. Moreover, healthcare professionals should be trained on the impact of masculine norms on the mental health [34].

#### **9. Conclusion**

Changes should be made on the existing social and cultural norms as they suppress the mental health being of men. To reduce the statistics of suicides mortalities due to mental distress, interventions should be implemented from early childhood stages to address gender variations. Despite the masculine advantages, men should not be raised different from women. This could reduce the implications of societal expectations and cultural norms in the mental being of men. Programs addressing the mental well-being of men should be vigorously implemented and inform men that there is no shame in seeking mental healthcare services and there is no shame in crying. This could possibly reduce completed suicides and suicide ideation among men as well as substance abuse and domestic violence.

#### **Author details**

Mxolisi Welcome Ngwenya and Gsakani Olivia Sumbane\* University of Limpopo, Polokwane, South Africa

\*Address all correspondence to: gsakani.sumbane@ul.ac.za

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men's Sensitive… DOI: http://dx.doi.org/10.5772/intechopen.108493*

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### **Chapter 6**

The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff Instead Experts Facing the New Threats, and New Approaches Can Reduce Mortality – Experience in Guatemala

*Luis Augusto Moya-Barquín, Diana Leticia Coronel-Martínez and Robert Conrad Sierra Morales*

### **Abstract**

Pediatric advanced life support courses provide widespread education on recognizing and treating cardiac arrest in children. Their main goal is to teach the cardiopulmonary resuscitation (CPR) sequence and improve early recognition and treatment of leading causes for better survival rates. Initially, there were four "H" and four "T" conditions, but now 12 are recognized. The 12 reversible conditions, categorized as "H's" and "T's," consist of seven starting with "H" and five starting with "T." The "H's" include hypovolemia, hypoxia, hydrogen ion excess (acidosis), hypoglycemia, hypokalemia, hyperkalemia, and hypothermia. The "T's" include tension pneumothorax, tamponade—cardiac, toxins, thrombosis (pulmonary embolus), and thrombosis (myocardial infarction). Finding specific training for these conditions in structured courses can be challenging. However, understanding their physiological basis enables healthcare providers to detect and treat them early, leading to improved outcomes and reduced mortality rates in Guatemala. In response to the COVID-19 outbreak, a regular course on managing these conditions was initiated for pediatric intensivists, pediatricians, and healthcare staff. In 2022, the Continuing Medical Education program at Universidad de San Carlos de Guatemala extended coverage to 134 physicians in rural areas and 50 pediatric intensivists from the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP).

**Keywords:** cardiopulmonary resuscitation, 4H & 4T, cardiac arrest, cardiopulmonary resuscitation education, cardiac arrest causes, reversible causes cardiac arrest

#### **1. Introduction**

The widespread education and goals of the pediatric advanced life support (PALS) have been demonstrated as an important competence that implies skills and attitudes related to decision-making and teamwork in the healthcare personnel. In high-income countries, when personnel is hired, this becomes a requirement for the startup and it is expected, as a hospital requirement, to keep and update certification [1–5].

PALS guidelines published by the American Heart Association (AHA) are designed for resuscitation in a broad range of scenarios and environments. In general, the main goal of several life support courses is to learn the sequence for cardiopulmonary resuscitation; the related algorithm for cardiac arrest evaluation always goes back to the recognition of its leading causes that need rapid assessment and treatment to increase survival. These conditions were initially described as 4 "H" and 4 "T" (H and T are related to the first letter of each of the conditions). Currently, several centers and healthcare providers recognize 12. The 12 H's and T's are reversible conditions, of these seven start with H and five start with T. These conditions are:


It is not easy to find specific training for H & T's conditions in structured courses. Understanding the physiological basis of these conditions can give the healthcare provider the opportunity of an early detection and treatment of these life-threatening conditions.

The required competencies, the understanding, and the metacognition of these conditions need more expertise than "getting the pass score" in the PALS course.

In developing countries, the main barrier to taking the PALS courses is the copyright and the merchandise; this course has been registered as intellectual property implying a payment for using the license. Currently in developing countries, the deployment of basic biological and educational science in the training and performance of the residents is still the focus. The quality assurance knowledge and the adherence to guidelines, protocols, and procedures still require a cultural change and the development of the teamwork concept; this is not only about technology [4].

Even knowing that the basic life support and the advanced life support courses are designed for the early recognition and treatment of the imminent cardiac arrest, the availability in low- and middle-income countries is very limited due to the market implications and subsequent cost, without any consideration about the design or quality of the training during the course. The AHA (American Heart Association) courses are more extended with all the implications already described [1–5].

Since the 1990s, the cardiopulmonary resuscitation courses in collaboration with colleagues from the USA begun; it was yearly and primarily directed to people who can speak English. Some years, the course was discontinued, and during other years, it was taken by the exact same group due to the English language barrier and consequence never disseminated among others, losing a lot of good opportunities for distributing knowledge to healthcare professionals only due to language barrier that could be easily solved.

#### *The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff… DOI: http://dx.doi.org/10.5772/intechopen.112164*

In 2003, at the Pediatric Intensive Care Unit in Hospital General San Juan de Dios, we started endorsing and implementing standard guidelines for pediatric traumatic brain injury and goal-directed therapy, using validated protocols, guidelines, and quality assurance in the formation of human resources and for clinical management. Between 1995 and 2003, a very high mortality rate in 12-bed wards in the national reference hospital in Guatemala was reported; the mean Pediatric Risk of Mortality score—PRISM III was 6–9 points in deceased patients.

In 2009, the RIBEPCI (Red Iberoamericana para el Estudio de la Parada Cardiorrespiratoria en la Infancia) started working with us in Guatemala; this group endorsed the Grupo Guatemalteco de Reanimación Avanzada Pediátrica (GRAP) GUATEMALA, who can keep in a local manner a regular structure and education of the Health Care Staff Spanish and with nonprofit purposes. This course gives the possibility to the healthcare providers of delivering these courses to their own staff once they are certified. The RIBEPCI courses are based on and endorsed by the European Resuscitation Council (ERC).

In 2009, the Postgraduate course of Pediatric Intensivists began with the endorsement of the Universidad de San Carlos de Guatemala.

The RIBEPCI experience and GRAP GUATEMALA experience in the Hospital General San Juan de Dios were combined and led to the creation of SOYUTZ Pediatric Emergencies Simulation Center in 2014. The word soyutz, it is a mixed word from Russian Soyuz that means "union" and Utz in quiche Mayan language that means "good" and the word soyutz means good union, this is representing teamwork).

There is an important need of retaining trained staff and of maintaining them updated, this will allow an integrated flow in the scope of an attention model based on decision-making process sharing for optimizing the time-sensitive interventions. The fragmentation of healthcare in several specialized medicine fields results very frequently in an orphan patients; these "orphan" patients are in the middle of several medical specialties and even with an overlapping attention, the decision-making is not shared and could become a great conflict. The artificially separated attention of patients who need noninterventional attention and the patients that could require a surgical intervention becomes a problem in facilities of developing countries; in this kind of setting, we can find a primary care physician able to solve several conditions; and the level of the University hospitals would be very important that surgery, orthopedics, trauma anesthesia, pediatrics, emergency, and pediatric intensive care residents share the algorithms for recognition and treatment, no matter if these belong to the pediatric field or to the primary care field [6].

The classical approach for diagnosing sepsis, trauma, burns, surgical conditions, pneumonia, dengue, hypovolemic shock caused by diarrhea, diabetic ketoacidosis, and even COVID-19, among others, using the construction of a concept adding signs and symptoms with some grade of sensibility and specificity, could lead to diagnostic criteria with a high level of uncertainty; this also generates important delays for patient stabilization in emergency departments and hospitalization wards. This situation plus, the decision-making about referring a patient to a healthcare facility without solving access barriers like distance and quality of the roads, constitute a model of delays avoiding a fast-track process of recognition–stabilization, increasing the negative impact of hypoxia, ischemia, and reperfusion injury [7–9].

Patients with trauma or requiring surgery, could also have a congenital condition or an oncologic diagnosis; these adaptative conditions related to the disease, their related treatment, and potential complications should be considered before the surgery due to their very high possible relationship with deterioration and cardiac

arrest when these are underestimated. In the perioperative environment, most of the arrests are witnessed, the patients are being monitored at the time of arrest, and the reason for the arrest may be related to the intervention or treatment. In this chapter, the perioperative period is defined as the period in which the patient is cared for by the anesthesia team and focuses on events that occur in the operating room, procedural areas, and diagnostic imaging areas from the moment that the patient is seen for the first time by the anesthesia team until the patient is transferred to another service or is discharged to home or to another facility. Cardiac arrest is defined as a "no-flow" state requiring chest compressions (open or closed chest) or failure to wean from cardiopulmonary bypass.

The cardiac arrest is categorized as out-of-hospital cardiac arrest (OOHCA) or in-hospital cardiac arrest (IHCA), both requiring a structured attention, using good quality cardiopulmonary resuscitation; the issue with this is that both conditions imply a pulseless event or a life-threatening condition. The cardiac arrest has three phases, and these phases have important implications for therapeutic actions. The cardiopulmonary resuscitation utilizes a rhythm-based approach, and the problem is that this action only considers the time elapsed after the onset of cardiac arrest. The cardiac arrest is addressed using the three-phase time-dependent model. This model is clearly time-dependent considering for clinical evaluation "0 min" as the startup [10].

The three phases in this model are:


It is very important to understand that the underlying processes of cardiac arrest and the related physiological conditions could start several minutes before [10].

The overall goal of all perioperative resuscitative efforts or stabilization like the golden hour in medical conditions is to minimize this no-flow period and to maximize the chance of spontaneous circulation return. Whereas the indications for resuscitation outside of the operating room may be simple (loss of consciousness, loss of pulse, etc.), the indications in the perioperative period may be more complex. They may include inadequate heart rate or blood pressure based on age, inadequate minute ventilation, cyanosis, failure of noninvasive blood pressure monitoring or pulse oximetry, loss of arterial waveform, or a sudden change in the end-tidal carbon dioxide (ETCO2) waveform or value.

For understanding the physiological instability, it is necessary to understand how the body's dynamic balance is related to a predetermined range of values in healthy conditions, and the most common for age and gender (e.g., perfusion, level of consciousness, blood pressure, work of breathing, and metabolic state) with or without clinical intervention.

The approach to organ dysfunction or failure cannot be done when one or more vital organ dysfunction or failure is due to chronic adaptation, with or without severe impairment, dysfunction, or external support. In fact, the main cause of an imminent

#### *The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff… DOI: http://dx.doi.org/10.5772/intechopen.112164*

life-threatening condition is the unrecognized process of deterioration due to treatment failure and deficient monitoring with the addition of poor knowledge of any chronic adaption of the patient. High accuracy and low opportunity (HALO) are required for improving any time-sensitive intervention. The HALO applicability will require at the same time healthcare workers with enough skills and with strong commitment and knowledge for decision-making and execution of any needed action in all patients, requiring or not an intervention [11–15]. The early approach is based on the probability and uncertain odds of potential reversibility. The recognition is time-sensitive, and this could help a situation may be reversible with defined goals and objectives of directed management. Sometimes, the organ dysfunction may persist and develop to adaptative physiology in case leading to a condition that could be technologydependence or chronic. Is there when Sir William Osler's quote describes the everyday practice of medicine "A science of uncertainty and an art of probability" [16].

There is a need for developing acute care in any place; the recognition and evaluation of the acute patient have common bases and could be done in any location outside the emergency department (ED) or the pediatric intensive care unit (PICU); sometimes could be related with surgical process (before operating room and recovery room). For making possible acute care independent of the location, teamwork has the most important role in recognizing, approaching, treating, and monitoring any pediatric patient.

It is important to recognize that the location sometimes is not designed and equipped with the optimal resources. The attention of the patient will be resourceavailability independent. In the developing countries' settings, attention is based on the equipment and facilities that are more focused on diagnostic or laboratory resources with a lot of delays, omissions, and pitfalls in attention [17–19].

The education process from basic concepts and its evolution is needed for allowing the growth of the healthcare worker in autonomy and responsibility. This process is a shared pathway that needs the supervision of a mentor; at some point, new mentors will be formed, able to train and able to work and educate as peers. In this moment, the student reaches the finest level of competence: the leadership. In the everyday teamworking process, the importance of the followership is growing; this very important and special skill is based in the capability of putting aside ego, seniority, and hierarchy for promoting the empowerment from the rest of the team. The


#### **Table 1.**

*Education matrix for learning process.*

competence model based on the Dunning–Kruger effect promotes self-confidence by using the capability to respond with responsibility. Based on Miller's Pyramid, Bloom's Taxonomy, and the International Pediatric Simulation Society, we can build an education matrix for learning process presented in **Table 1**.

#### **2. Academic content**

#### **2.1 Dominion level**

It is necessary to understand, in the education settings for medical students, nurses, and residents, how to have more operative performance to deploy anywhere the capabilities and response. The impact of the trained freshmen physicians is based on the opportunity to do appropriate and opportune interventions, the use of the resources, the proportionality of care, and the monitoring and treatment interventions.

It is different to define the sailing course and the destination of navigation, in this part, it is important to define routes and could be important to understand the steps and the sequence and the consequences of each step in order to teach the approach. The SODOTO methodology (See One, Do One, Teach One) for teaching and learning skills not necessarily is accurate when we review the cumulative sum analysis of the learning curve, based on patient safety. The cumulative supervised task requires enough amount for receiving the feedback and promoting the feedforward for making with reduced error any procedure or decision-making process. The experience of the 10,000 hours to reach mastery and the assessment using risk matrices is focused on the practice time using the most frequent scenarios in daily practice and the evaluation of the consequences of different decisions and their impact.

In PICU setting, is very important to know, to teach, to audit, to improve, and to learn step by step any process. A sequence of steps using mandatory commands (written process with sequences in programming imperative commands START, IF THEN, YES, NO, AND, OR FINISH) instead of flowcharts that could be confusing, the addition of the critical path method to distribute tasks and the crew resource management methodology for distributing the workload are the rules. All these allow the staff to track all the processes. The importance of having the algorithms using commands and tracked standard operative procedures (SOPs) is a blueprint for educative and performance purposes [20–22].

Nowadays is very frequent to find in our ward complex patients or technology dependent, medical education is based on diagnosis, syndromes, and diseases but not on ongoing processes and the tag to define one of those is not clear in the adaptative balance of the patient in these conditions.

It is very important to speed the early recognition of the signs of deterioration instead of being worried about the speed of the appearance of the signs of deterioration; this is the reason why monitoring is the basic recognition tool of a patient in a deteriorating process, with an apparent acute or sudden onset of illness in the settings of the compensated or decompensated shock, respiratory arrest, and cardiopulmonary arrest. Patients with chronic conditions who develop acute critical illness/ deterioration needs more close monitoring. This may include patients with chronic conditions (e.g., cerebral palsy, chronic renal disease, etc.) who develop acute critical illness when the basic start is not necessarily healthy.

Potential reversibility is a very common attribute of critical illness in pediatric patients with suspected, probable, or at risk of critical illness; they may have one or more abnormal physiological parameters or vital signs compared to healthy children.

#### *The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff… DOI: http://dx.doi.org/10.5772/intechopen.112164*

The evaluation of the deteriorating process instead of the cut-point of failure, or the diagnosis itself of disease is more important. In pediatric patients, trying to define the persistence of a condition for more than 60 min (1 h) based on the physiological parameters or vital signs, that are references from previous healthy children like >95th or < 5th percentile, or > 2 or < 2 SD for age and gender, could be risky when the monitoring and the consecutive evaluations are hourly. The changes of the trends of the vital signs are very important for recognizing the acute deterioration and could be necessary to have reevaluations at least every 15 min.

Qualitative and clinical physiological parameters or vital signs may include the pediatric assessment triangle and/or any pediatric early warning score or scale to promote early recognition and subsequent interventions. The used signs are mentioned in the following findings:

Central nervous system: Level of consciousness and response to external stimulus (awake, verbal response, pain response, or unresponsiveness) AVPU/Glasgow Coma Scale, pupils' size/reactivity-fixed, asymmetry.

Respiratory: Clinically, the breathing needs to be wide (lung expansion), correct (inflate in inspiration, deflate in expiration), and depth (enough volume and flow to expand the thorax). Signs of airway obstruction and respiratory distress, respiratory rate and effort, and the work of breath related to the respiratory pattern or mental status. Oxygen saturation is a measure to move the subjective evaluation of cyanosis.

Cardiovascular: Heart rate, systolic blood pressure, shock index (heart rate/ systolic blood pressure; normal value considered <1), capillary refill time, quality of central/ peripheral pulses, skin (temperature/color/perfusion), urine output, etc.

Nutritional problems could affect the clinical interpretation as in the case of core temperature, hepatomegaly, and signs of dehydration (e.g., sunken eyes, tears, dry mucosa), several studies report the bias in the accurate interpretation and pitfalls in the treatment of malnourished patients.

In terms of education, it is very important to share the decision-making process. The training should go from basic knowledge concepts to metacognition in explicit knowledge.

Human-dependent assessment can include but is not limited to vital signs, and the human-dependent monitoring/assessment needs an educational approach. The experience of COVID-19 in campaign hospitals demonstrated the urgency of competent staff instead of some experts.

The workload of the human-dependent assessment and monitoring of acute, critical, chronic, technology-dependent patients, requires a great number of hours/ shift but the pathway to reach and expert level is not always possible due to the high demands.

The approach of a suspected versus a confirmed diagnosis is quite different, in this case, the cut-point or the sum of the criteria sometimes could delay the treatment; other times, the syndromic approach could be useful for the recognition of patterns; this kind of pattern recognition is the base used for algorithms development, including artificial intelligence.

In statistics, likelihood is not the same as probability; we are performing for taking decisions in high uncertain, dynamic, and complex clinical scenarios with the addition of the technology and the devices that sustain a chronic patient. At this point, we need to teach critical thinking and the pattern recognition first and in a second step, make sure to teach also the adaptative physiology related to the medical device plus the function and programming of the medical device itself, including noninvasive or invasive mechanical ventilation. This technology is also related to

resources for follow-up monitoring like X-rays, arterial blood gases, oximetry, endtidal CO2, and others.

Pediatric patients with suspected, probable, deteriorating, or with critical illness may need frequent clinical evaluation and decision-making about the different trends or changes in patients' patterns. It is more important time-sensitive hands-on interventions instead of repetitive obtention of laboratory or diagnostic test. Those activities could be directed to the therapeutic interventions not only mobilization, suctioning, review of the tube's fixations, mouth care, repositioning, tracheostomy care, cold sponge bathing for fever, cleaning and dressing wounds/burns, or close follow,up of the fluids balance.

There is also a special group of patients who are in deterioration or at high risk related to traumatic or surgical conditions.

The priority in recognition is focused on pediatric patients with suspected, probable, or high risk for deterioration and evidence of critical illness; they may need time-sensitive life-supporting intervention, based on objectives and goals.

#### **3. Children with comorbidities or preexisting conditions**

The survival of patients from the Neonatal Intensive Care Unit (NICU), with congenital surgical or medical conditions is improving in developing countries. For this, recognition of co-morbidities and high-risk conditions is crucial.

In the PICU, the recognition of the risk of deterioration and/or exacerbation of any condition, or changes in the adaptative physiology is very important. Added malnutrition, obesity or overweight, congenital heart disease, oncologic diseases, primary immunosuppression or acquired immunosuppression like HIV/AIDS, transplant patients among others could increase the mortality rate in these patients.

Another important factors are the chronic pathologies with neurological disability, like cerebral palsy or neural tube defects and the use or dependence of invasive devices like shunt. These conditions imply adaptation of the patient's physiology. In these cases, the information given by the caregiver is fundamental for understanding the real changes of the mental status and behavior of the patient.

#### **4. Essential and optimal resources for educational competencies and performance**

Many times, the governance bodies believe that the growth in infrastructure and the recruitment of freshmen doctors are the solutions to the healthcare system; it is very common to think that hierarchy will give a person "magically," the required competencies, experience, and level of responsibility.

The definition of "Medical Attention Quality" will imply structure, process, and outcome. Any improvement of technology needs to be based on the comprehensive understanding of any tool as a resource (drug, device, laboratory test, X-ray, CT scan, among others) and is mandatory to understand any connected point as a chain of decision and iterative evaluations.

The physiology is the same in developing and developed countries, but to be effective, efficient, and explicit it is mandatory to be familiar with the local resources not only in the context of the access to some drugs (i.e., Amiodarone in several countries is substituted by Lidocaine, but Aminophylline is also widespread in some countries

#### *The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff… DOI: http://dx.doi.org/10.5772/intechopen.112164*

instead intravenous salbutamol and phenytoin used instead phosphenytoin). This is why we need to understand the reality of the environment where the educational process is being developed; in a first-level setting with fewer available resources, it could be more relevant to teach early noninvasive ventilation and bag-mask oxygenation instead of endotracheal intubation.

The essential resources that are known to be required in the health facilities besides the knowledge to solve medical problems and interventions including monitoring are enlisted but not reduced in the list below:

Central nervous system: Rewarming/cooling (targeting normothermia or therapeutic hypothermia), antidotes (naloxone and in the rural places consider acute or subacute organophosphates poisoning), first- and second-line antiepileptics, hyperosmolar therapy (mannitol/hypertonic saline), cerebrospinal fluid drainage or shunt for raised intracranial cerebral pressure (ICP), decompressive surgery, etc.

Respiratory: Continuous nebulizers, noninvasive/invasive ventilatory support from the high-flow nasal cannula (HFNC), bilevel positive airway pressure (BI-PAP), continuous positive airway pressure (CPAP) to the intubation drugs and supplies and mechanical ventilation as minimum, and thoracostomy tube.

Cardiovascular: Vascular access, intraosseous access, crystalloids, colloids, inotropes, vasopressors, vasodilators, cardiopulmonary resuscitation, pericardiocentesis, and blood products.

Metabolic: Feeding tubes, dextrose, bicarbonate, sodium, potassium, calcium, phosphorus, magnesium, and insulin.

Additional thrombolytics, heparin, and the supplies to make invasive procedures, and personal protective equipment for the health personnel.

#### **5. Conclusions**

Since 2003, the implemented educational process at the PICU in the Hospital San Juan de Dios in Guatemala showed a clear improvement in the medical attention and very clear impact on the mortality rate reduction. It is important to highlight that, during these years (from 2003 until now), we kept experiencing several economic constraints. Even with some improvements in equipment and resources, the major reason for the improvement has been the educational activities directed to the human resources at PICU.

On 2003, with a 12-bed PICU facility, 620 admissions per year were registered with 165 deaths; on 2022, with a 49-bed PICU, 99 deaths were reported. Currently, even the patients with the worst prognostic (average PRISM III score of 27 in 2022 compared to the average score of 9 in 2003) have better chances of survival. The 2019 COVID-19 pandemic gave us the opportunity of improving the on-site training and the virtual education using videos, simulation, remote training, and other resources.

Another important aspect during the pandemic was to increase the empathy for attending family and parents' needs. Situations like restricted access and the curfew among other conditions related to the pandemic were faced using different strategies like "phone access" and special support in cases of withholding and withdrawing treatment when parents were away and not easy to reach (i.e., living in remote areas).

After the COVID-19 pandemic in 2020, we started a regular course for teaching the management of H & T's for the pediatric intensivists, the pediatricians and the physicians, or health staff who need to be aware about the recognition and treatment of H & T's. In 2022, 134 physicians located in rural healthcare facilities were enrolled, the specialties of these physicians are anesthesiology, surgery, orthopedics, emergency care, and pediatrics, nurses were included. At the level of the Latino American Society of Pediatric Critical Care (Sociedad Latinoamericana de Cuidado Intensivo Pediátrico, SLACIP), 50 pediatric intensive care physicians were trained. This training now has the endorsement of the Continued Medical Education Department of the Universidad de San Carlos de Guatemala.

We believe that, worldwide, it is not only about improving the infrastructure, and the equipment, or purchasing new technology, or hiring more personnel; all these for sure are very valuable strategies; but also without education, none of this will work.

We need well-trained healthcare personnel; the key to this always will be education; we need to educate for improving the performance and the decision-making process; we need to track the improvement of the team. Negotiation, decision-making process, and teamwork are fundamental skills under the concept of command incidents system, knowing this, we could add another H and another T: Humanization and Teamwork.

### **Acknowledgements**

We are thankful for the contribution of Jesús López-Herce MD, MSc, Raffo Escalante-Kanashiro MD, MSc, Hugo Loayza MD Msc, Carlos Román-Ramos MD, MSc and Manuel Correa, MD Msc. in the development of this approach and diffusion of the related knowledge.

### **Author details**

Luis Augusto Moya-Barquín1 \*, Diana Leticia Coronel-Martínez<sup>2</sup> and Robert Conrad Sierra Morales1

1 Pediatric Intensive Care Unit, Hospital General San Juan de Dios, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala

2 Grupo de Reanimación Avanzada, Pediátrica—GRAP México, México City, México

\*Address all correspondence to: sistemaluismoya@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff… DOI: http://dx.doi.org/10.5772/intechopen.112164*

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### Section 3
