Towards a better world

“Many cities are neither healthy, sustainable nor environmentally friendly. However, if we can succeed in improving just one of these areas, we will also positively impact on the others. In this, we as researchers can engage in cross-disciplinary collaboration and together contribute to finding smart solutions,” says Tobias Alfvén.

Another unifying strategy proposed by Tobias Alfvén is to consider how we can make life as good as possible for our children, from the womb, through birth and on to adulthood.

“A reasonable environment in which to grow up in good health – I think we can all reach some kind of agreement on what that looks like. If we succeed in that, then we will have a society that works for almost everyone,” he says.

Tobias Alfvén and his colleagues recently published an article analysing how the health of children can benefit from improvements to a number of sectors of society in addition to medicine; for example, education, commerce, agriculture, social security and transport.

Conversely, children are among those who suffer most in poorly performing societies. One SDG target on child health states a mortality rate for children under five years of age globally of less than 25 deaths per 1,000 live births.

“This figure, which I consider to be perhaps the most important indicator of health globally, is currently 43. That means that we need to almost halve that figure, which is very ambitious.”

Reduction in child mortality

However, Tobias Alfvén thinks that this is a reasonable target. He points out that the world has already succeeded in halving child mortality once, during the period 1990-2015 when working towards the Millennium Development Goals.

“The enormous reduction in child mortality over the past 25 years is an entirely unprecedented improvement,” he says.

Major positive social transformations, such as the reduction in extreme poverty and increased access to clean water and education, combined with targeted measures such as vaccinations, fluid replacement in cases of acute diarrhoea and improved malaria prophylaxis and treatment, were crucial in reducing child mortality.

However, even in societies where basic human needs are met, children will be born prematurely, meaning that a good healthcare system is also essential. This is difficult to achieve rapidly in countries that lack the necessary preconditions. According to Tobias Alfvén however, it is important to ensure that minor changes to existing systems can lead to major changes to the efficiency of healthcare.

He and his colleagues have just completed a study in Ethiopia to reassess how children with fever should be treated. Fever may be the result of a relatively innocuous infection or a symptom of malaria, pneumonia or diarrhoea – the three most common causes of death in children under five years of age. Local village health centres may identify these diseases, although sometimes their cause is not immediately apparent.

In the researchers’ study, half of these children were instructed to return after three days in accordance with World Health Organization guidelines. The other half were advised not to return unless the fever persisted or became worse.

“It became apparent that this made no difference whatsoever to the outcome for the children. We hope that this will influence the global advice on how these children are dealt with,” says Tobias Alfvén.

The purpose is to free resources for those in real need.

“Global guidelines affect millions of healthcare visits each year but they are far from always evidence-based. Unnecessary healthcare visits can result in a deterioration in health as resources are taken from elsewhere, both from healthcare services and from families who could have worked instead of travelling long distances to hospitals,” he says.

Another project is refining rapid testing to more easily differentiate between bacterial and viral pneumonia.

Oxygen deprivation during birth

A further research project is aimed at the second most common cause of death during the first month of life, oxygen deprivation during birth. The current standard treatment is to assist breathing using a bag valve mask. Correctly administered this is an effective method but it requires experience. If the child’s neck is held at the wrong angle, no air will be admitted.

As an alternative, the larynx mask has therefore been trialled in a randomised study conducted in Uganda. The larynx mask is easier to use for those with limited experience. The question that remains to be answered is whether this will lead to more children being saved.

To facilitate the evaluation of SDG goals and targets, the UN has agreed on 232 measurable indicators. Of these, 50 deal with health. The Global Burden of Disease Study (GBD) international research collaboration monitors the global health situation and has analysed 37 of these indicators for 188 countries during the period 1990-2016.

According to GBD, Singapore, Iceland and Sweden are the countries that best meet the development goals, while Afghanistan, the Central African Republic and Somalia have furthest to go.

However, Emilie Agardh, Associate Professor in epidemiology at Karolinska Institutet’s Department of Public Health Sciences and a driving force behind Swedish cooperation with GBD since 2012, points out that there are major inequalities even within countries. Sweden is no exception and even here there is much left to do.

“Even if Sweden’s healthcare system has been ranked as one of the best in the world, as in many other high-income countries, there are significant variations in health between different regional health authorities, as well as between social groups. The underlying causes of these variations are not entirely clear and we still lack a good, comparable overall picture,” she says, and believes that GBD has the potential to offer just that.

A cornerstone of Agenda 2030 is that SDGs apply to all segments of the population. No one may be left behind. In order to make this possible, many countries are currently attempting to make visible their internal health inequalities. Emilie Agardh contributes by working to ensure that future analyses within the framework of GBD contain more detailed information about Sweden, based on the various health authorities and socioeconomic groups.

“Information is required for future measures to reduce inequalities in health, as well as to facilitate evaluation of UN Sustainable Development Goals at a subnational level in Sweden and to compare ourselves with other countries at a more local level,” she says.

According to Emilie Agardh, Sweden, as one of the countries that best fulfils the SDGs, can also contribute knowledge of how and why progress is or is not being made, by highlighting successful initiatives and disseminating this information both nationally and internationally.

Noncommunicable diseases

The primary causes of the burden of disease globally are noncommunicable diseases such as cardiovascular disease, cancer, mental illness/addiction, musculoskeletal diseases and diabetes. These are linked to physical activity, diet and other lifestyle factors that differ between social groups and countries.

According to SDG targets, premature mortality from non-communicable diseases should be reduced by one third by 2030. However, type 2 diabetes is a growing problem in many societies.