5.B - top down and bottom up strategies

Question 1

key idea

Answer 1

• whether its better/easier/more effective to use top down or bottom up strategies for disease eradication

Question 2

what are top down strategies?

Answer 2

• government led campaigns to eradicate diseases using a combination of direct/indirect strategies often with people being told what to do

Question 3

what are bottom up strategies?

Answer 3

• where communities make their own strategies and they are consulted
• often this is with NGOs and relies more on indirect strategies such as sdeducation to tackle disease

Question 4

what role do TNCs play in disease eradication?

Answer 4

• e.g. GlaxoSmithKlein
• for diseases to be eradicated on whatever scale, you need a TNC with the wealth, expertise and resources to generate the drugs, the technology to administer the drugs and the ability to modify these if/when the disease mutates
• political will is also needed, as is money to pay. often comes from national govts/international agencies eg. WHO or large aid investors e.g. Bill and Melinda Gates

Question 5

why are top down sometimes unsuccessful?

Answer 5

• social/cultural reasons
• e.g. difficult to eradicate Polio in Pakistan as the Taliban, who control large areas of Pakistan, have not allowed the vaccines to be administered
• there have been enormous movements of people which have meant that it has been hard to keep track of who has/has not been vaccinated
• there was a distinct mistrust of the ‘outsiders’ coming in to vaccinate children

Question 6

where do bottom up strategies come into play?

Answer 6

• it is essential that the country/people in the country ‘buy in’ to the eradication strategy and this is where the conceptual approach of bottom up strategies come into play
• where local people and communities are trained/educated and then worked with collaboratively to tackle a disease
• often working with women in these communities is most important as in LIDCs women will do most of the household chores/raise the children.

Question 7

who are GSK

Answer 7

• GlaxoSmithKline
• Market capitalisation of £81 billion
• drugs and vaccines earned £21.3 billion in 2013

Question 8

why do GSK have a bad reputation in Africa?

Answer 8

• bad reputation in Africa for high cost of HIV drugs in the past
• they sold their drug 5000x more expensive than it is. reinvented an existing drug for a limited market.
• to reform, they have controversially partnered with Save the Children, aiming not to generate profit or loss by donating £15 bill in 2013

Question 9

what do GSK want?

Answer 9

• to tackle the root cause of disease
• help transform millions of lives
• working to get new treatments to everyone who needs it
• price their products at levels each country is able to pay
• they’ve reached 300,000 patients, 64 countries and 300 clinical trials so far

Question 10

GSK criminal trial

Answer 10

• pleased guilty to the promotion of drugs for unapproved uses and failure to report safety data
• “Advair” = asthma drug sold for uses that weren’t approved by FDA
• paid £1.9bn settlement
• largest healthcare fraud to date

Question 11

when have GSK faced criticism?

Answer 11

• in 2009 they said they would cut drug prices by 25% for 50 poorest nations
• criticised for not helping NEEs and excluding HIV from this

Question 12

how many countries do GSK work in?

Answer 12

operations are global with 84 manufacturing sites in 36 different countries

Question 13

what is their main turnover?

Answer 13

2/3 of their turnover is from pharmaceuticals, including medicines for a range of acute and chronic diseases

Question 14

how may vaccines where distributed in 2014 and where did most go?

Answer 14

• over 800 million doses of vaccines
• of which 80% went to countries in the developing world

Question 15

give 3 well known drugs that it distributes

Answer 15

• Amoxicillin to fight bacterial infections
• Zidovudine for HIV infection
• bendazole to combat parasitic infections
• the drugs are on WHO’s list of essential medicines

Question 16

outline GSK’s investment in research and development

Answer 16

• employs 13,000 people in R&D and spends more than £3 billion researching new medecines
• usually taken in partnership w/ other companies, unis and research charities

Question 17

how is GSK helping LIDCs?

Answer 17

• one of the few companies currently researching treatments for WHO’s 3 priority diseases (HIV/AIDs, malaria and TB)
• problem it faces is that demand for new drugs in LIDCs, whose economies are weak, is often too small to recoup development costs
• despite the problems, GSK devotes significant R&D resources to the needs of the developing world
• e.g its research centre in Spain focuses primarily on TB, malaria and other tropical diseases
• the company is close to launching the first effective vaccine against malaria
• its also developing a vaccine for the ebola virus.

Question 18

give 5 GSK ethical policies

Answer 18

1. a commitment to a small return (5%) on each product sold
2. providing 3 HIV/AIDs drugs to LIDCs at significant discount
3. granting licences for the manufacture of cheap generic versions of its patented drugs
4. capping the price of patented drugs for developing countries to 25% of the UK price
5. investing 20% of its profits from sales in each developing country into that country’s health infrastructure

Question 19

how sig are TNCs in reducing disease risk?

Answer 19

• money - a lot more than govts/NGOs
• most sig in developing countries

Question 20

should TNCs be this significant?

Answer 20

• unsettling that they determine price and therefore a country’s ability to protect its citizens

Question 21

what are top-down global strategies?

Answer 21

• include strategies such as vaccination campaigns, research and development of effective treatments and pharmaceutical drugs
• institutions such as the WHO coordinating health initiatives, surveillance and monitoring on a global scale such as flows of people, implementing awareness/education schemes on a global scale
• and providing financial aid to everyone in need

Question 22

example of top down global strategy?

Answer 22

• small pox eradication
• they used global topdown strategies such as universal childhood immunisation programmes, mass vaccination in other groups of people, surveillance and commitment strategies to track the spread
• this meant that by 1980 small pox was fully eradicated

Question 23

why was the small pox eradication successful? (top down global strategy)

Answer 23

• successfully eradicated smallpox across the globe
• this was so successful because it ensured that recurrent infectivity did not occur
• they did this by making sure that there was no animal reservoir that carried small pox, and that there was an effective stable vaccine available
• because this was done on a global scale it ensured that everywhere had the resources/infrastructure to be able to eradicate smallpox.

Question 24

what are the limitations of top down global strategies?

Answer 24

• often require significant financial resources, manpower and infrastructure to implement effectively
• this can strain the resources of both donor countries and international organisations
• the global campaign to eradicate smallpox, led by the WHO, cost around $400 mill USD
• without ongoing efforts there is a risk of resurgence, especially if surveillance systems are weakened or vaccine coverage declines. this requires long term commitment and investment
• top down strategies may not always address the underlying issues of equity and access to healthcare services
• marginalised communities or regions with limited resources may be left behind, perpetuating health inequalities

Question 25

how can political instability disrupt eradication efforts? (top down global strategy)

Answer 25

• political instability, conflicts or diplomatic tensions can disrupt eradication efforts
• cooperation between countries may be hindered by geopolitical factors, affecting the success of global strategies
• Polio is still in Afghanistan and Pakistan due to the fact that outsiders are not trusted by governments, so organisations can’t get to certain areas.
• countries relying heavily on external aid for disease eradication may struggle to sustain efforts once external funding diminishes/international priorities change.

Question 26

how does global mobility affect top down global strategies?

Answer 26

• global mobility is key in being able to implement topdown global strategies as it provides the ability to swiftly transport healthcare/services across the globe.
• global mobility is also providing a much faster spread of disease which means global organisations are having to react quicker than ever before
• e.g. COVID
• with new diseases/new areas of disease (most likely due to climate change) organisations are having to work increasingly closely to produce vaccines and get them worldwide

Question 27

what sort of places are top down global strategies appropriate for?

Answer 27

• most useful in places with strong government/authorities
• they allow for coordination of resources, the ability to enforce public health measures, implement vaccination programmes and allocate funds for disease eradication.
• can facilitate rapid deployment of interventions on a large scale
• best used in areas with well-established healthcare systems to leverage existing infrastructure tp maximise impact

Question 28

what sort of diseases are top down global strategies appropriate for?

Answer 28

• most useful for diseases that require large scale intervention e.g. vector borne diseases like Malaria
• as requires centralised planning/implementation by governments to address the root cause of disease and implement widespread controls
• was most useful for highly contagious diseases like Polio as ensures consistent strategies and resources were deployed worldwide.

Question 29

evaluation of top down global strategies

Answer 29

• if it works it is brilliant
• but sovereignty issues/migrant flows (refugees) make it very difficult to fully access a lot of people
• clear link to inequality - those that already live in inequality are most hard to access

Question 30

when did malaria become an epidemic in Mauritius? (top down national strategies)

Answer 30

• malaria became an epidemic in Mauritius in the mid 19thC
• in 1867 the pandemic had killed 1/8 of the island’s population

Question 31

how did the government use top down national strategies to tackle malaria in Mauritius?

Answer 31

• government backed elimination campaign launched between 1948-1951
• buildings and breeding sites sprayed with DDT reduced mortality rates from 6/1000 in 1943 to 0.6/1000 in 1951
• in 1973 WHO announced malaria had been eliminated from the island
• 1975 = Cyclone Gervaise - migrant workers employed in reconstruction reintroduced parasites to the islands/destruction caused by the event provided breeding opportunities
• 1982 = new epidemic forced govt to launch second vaccination campaign
• spraying resumed, predatory fish that feed on mosquito larvae were introduced and there was mass administration of anti-malarial drug
• since 1998 the govt has taken steps to prevent reintroduction:
  > rigorous passenger screening at international airport - 175,000 passengers/year are screened
  > spraying also continues with particular focus on breeding sites and migrant worker residences

Question 32

success of the top down national strategies in Mauritius?

Answer 32

• the original effort by the govt prior to cyclone Gervaise were highly successful with reduced mortality rates from malaria from 6/1000 by 1951 allowing WHO to announce that malaria had been eliminated from the island in 1973
• the second campaign to prevent reintroduction has proven highly effective as only 1 imported case of malaria has been seen since 1997

Question 33

what are the limitations of top down national strategies?

Answer 33

• the major limitation of top down national strategies is that they only limit or eradicate disease on a national scale so the disease can still be present on a global scale.
• only effective in a country with a stable government that has the resources needed in order to eradicate the given disease
• decisions reflect the wants and needs of governments and not necessarily the needs of the local people
• to maximise efficiency collaboration needs to occur with local communities
• only effective if govts are able to provide funding and resources to local communities and individuals
• resources may not be distributed evenly as some areas may require additional support which they haven’t been given
• top down strategies tend to encounter resistance from a local level and they also tend to exclude certain groups such as women and children

Question 34

what sort of places/diseases is top down national strategies appropriate for?

Answer 34

• top down strategies are often important for mobilising resources and coordinating efforts to help eradicate diseases therefore top down strategies often take a lot of resources and funding which can generally only be offered by AC/EDC governments. LIDCs may not have the spare funding to invest into full eradication of a disease
• aslo appropriate for communicate diseases like COVID where top down strategies implemented by government can often be more effective at combating the disease like lockdown in the UK
• another example was malaria in Mauritius when an epidemic killed 1/8th of the islands population
• a major government backed campaign was launched between 1948/51 which reduced the mortality rates from 6 per 1000 to 0.6 per 1000 people
• allowing WHO to announce that malaria has been eliminated in 1973

Question 35

evaluation of top down strategies

Answer 35

• political stability (synoptic link w/ P&B)
• easier in urban places = harder increasingly rural population - harder to access
• needs a solution that’s easy to implement
• most success stories from this approach

Question 36

what is guinea worm?

Answer 36

• when a person drinks contaminated water from ponds/shallow open wells the larvae are released and migrate through the intestinal wall
• after about a year of infection the worm emerges usually from the feet, releasing thousands of larva and thus repeating the life cycle

Question 37

what are grass roots strategies?

Answer 37

• an alternative approach to top-down strategies is a grassroots strategy which involves and empowers local communities
• they are most effective for eradicating communicable diseases that are present in LIDCs as they are cheap, easy to supply (e.g. education/changing behaviours) and effective even in countries with rubbish governments

Question 38

guinea worm eradication in Ghana (grass roots)

Answer 38

• in Ghana, the guinea worm eradication programme has partnered with the Ghana Red Cross women’s clubs to reduce the transmission of guinea worm
• this innovation programme involves teaching women volunteers how the guinea worm is transmitted and how transmission can be prevented. the volunteers then visit villages and educate local communities
• in the past this work was invested in male volunteers with limited success. this was because men frequently work outside villages and its mainly women who are responsible for sourcing water and its use for household consumption
• women were able to appreciate the value of filtering drinking water and avoiding contamination of water sources by people already infected with the parasite

Question 39

what were the responsibilities of women volunteers in Ghana? (grass roots)

Answer 39

• monitoring, identifying and reporting all new cases of guinea worm
• ensuring that those infected did not contaminate water sources
• distributing, checking and replacing water filters that remove water fleas (guinea worm vectors) from drinking water
• identifying water sources used by the community and requiring treatment with larvicides

Question 40

were grassroots strategies effective in Ghana?

Answer 40

• highly successful. guinea worm has been successfully eradicated from Ghana
• WHO reported that in 1989 there were more 179,000 cases. by 2010 the country reported its last indigenous case of the disease.
• the incidence of Guinea worm has been reduced by more than 99% to 14 provisional cases in 2023
• for the eradication campaign to continue successfully, enormous dedication and attention to detail is critical for all volunteers.

Question 41

limitations to grassroots strategies?

Answer 41

• a challenge is insecurity. part of some affected countries are inaccessible to the program because of internal conflict that makes these areas unsafe to enter or travel through
• guinea worm elimination cannot be confirmed until surveillance can be carried out in all areas
• there are no vaccines against guinea worm disease
• a few countries have recently had outbreaks linked to dogs infected with the worms which hadn’t been seen before
• that means extra efforts have been needed in recent years to prevent infections from dogs
• finally it has been difficult to eliminate guinea worm in countries with violence/conflict, where healthcare workers are less able to treat and prevent infections
• only works where education/behaviour change sufficient
• LIDCs better