Thank you. So I'm going to follow up on the theme of work in progress.
We didn't actually know what we were going to be talking about,
but I'm also going to be talking a little bit about some of my more reflective thoughts.
I will, so I will race through a bit of rationale.
I get a sense of who's in the room, who just help, who is who is self-identify as working in the health sector, says.
OK, so I'm going to race through that and it's a bit different.
So I'm going to talk a little bit about just pre-empt where I want to get to talking a little bit about the Avengers where we left off.
Yeah, I'm and the the ways in which the nature of the migration that is ongoing is influencing disease trends.
I consciously used that these trends, not health trends, because we often conflate them.
I will talk a little bit about our health system, health care system responses to some of those changes.
And then I'll spend most of my time talking more around my reflexive thoughts around bolder thinking for bolder action.
I'm going to give you a little bit of what kind of work that we've been doing
in the last few years as the Research Initiative for Cities Health Equity,
which I still lead. That's based in University of Cape Town.
So this is the racing through it. So this is what we know about the urbanisation, right?
This is not this is not new to, I'm sure everyone in this room.
The world is overnight waiting about 10 years ago.
For some more people live in urban and rural, the rate of urbanisation in Africa particularly more phenomenal than almost anywhere else.
Importantly, it's not just urbanised, and I liked the slide you into the image of what we what we think of when we think about
organising what the reality is often urbanised and pushed by high levels of inequity.
Largely, what we see is a huge growing informality,
and two thirds about two thirds of urban dwellers on the continent reside in the conditions of informality.
So we know that this is rapidly changing. We know it's complex. And yet sometimes we try to think simply, OK, so how is this?
What are the kinds of ways that this is impacting health?
All we see in terms of the built environment is that we see these dense, informal settlements increasing.
So making it easy for a disease to to transmit, but also importantly,
increasing the risk of not non-communicable diseases through the food environment that we have
access to through the ability to embrace active living that we see increases in obesity,
the increase in diabetes, hypertension, etc. and these diseases coexist and without in multimorbidity,
we see that we're pushing south to push the boundaries of human settlements that we see
re-emergence of old quote-unquote infectious diseases and zoonotic disease outbreaks,
which are then hottest control because they're in dense urban settings.
We see an inadequate urban infrastructure, unable to cope with some of those demands and resulting in the persistence of
infectious diseases in spite of what might be a slight of apparent development.
So, so as you mentioned, I lived in Cape Town for for about 11 years,
and I recently just moved back last year and I was I remember doing my public health,
very strong training and a lot is improving in South Africa, and I remember thinking that was in the middle of the country.
Why do we have a term like diarrhoeal season that makes the old start real, seasonal like this is this is this should not be just shouldn't be.
We see increasing exposure of young people to these unhealthy conditions.
So we see a lot of multimorbidity and multiple diseases happening at young ages and we way that we actually have.
OK, so the second point, so that was the first point to second point, these trends in health, what we see.
So this is looking at morbidity as measured by disability, adjusted life and so the years of life, not just instead of looking at mortality,
because not all diseases, particularly chronic disease, don't lend themselves to understanding the burden of disease looking at death.
So we. Look at years of life lost due to disability or years of life lost due to early 70s.
So looking at the changes between 1990 and 2010 for South Africa.
So anything above the line is up. Anything below the line is down, red is infectious, blue is non-communicable.
Green is enduring violence. So without having to read any of the text, a lot of blue going up.
Obviously, the spike of HIV aids because it's it's cost over the peak of the epidemic.
Some increase and decreases in diarrhoea and respiratory infections, but overwhelming what we see in public morbidity across the board is abysmal.
So that's the first point. The second point is speaking to the way in which the urbanisation has consequences on
health is there are multiple villages that we did a study a few years ago looking at.
So at the time, I was working in the primary care setting and doing HIV TB research,
and there was a lot there's a lot of work to be done in integrating HIV,
TB and I was looking at it all day and I was also doing some service provision in the HIV clinics.
And when I realised that actually what I was doing in terms of what I was looking at, it just seemed to to be one aspect of the reality, right?
So I started noticing that even though it was focussed on making your viral load and your adherence and looking at whether you had symptoms,
signs of TB and integrating those what what, what it wasn't doing was taking your BMI and taking your blood pressure and seeing my body.
And so I started seeing this anecdotally based on some of the symptoms patients I was seeing.
I thought, I wonder, based on people who are already in in in care what, how much overlap they exist between them.
So we just did a study looking at.
Fourteen thousand, a number of of episodes over a nine month period in the clinic and looked at just so this is just the tip of the iceberg,
is just amongst people who are receiving treatment for one of HIV, TB, diabetes, hypertension whilst they are all 70.
At the time they were separate, they had the same problem so that we could look at the clinic folder.
You can have a unique patient identifier, we can look at the prescriptions and look at Wolf.
What do we see? So if I said anything else, but if I said, if I said HIV,
given what you know about the way this disease is co-occur, what would what's the most common comorbidity?
Well, I think TB is hypertension. Why?
Because the presence of the patient health tension is just high in the population.
HIV doesn't protect you from it. So if I to see some some indicators when it goes the other way around.
So we saw that well, firstly, one in five had another one of those conditions already diagnosed.
Remembering that at least we know from other studies that at least half of people with high blood pressure are undiagnosed.
So, you know, just amongst people diagnosed, but interest in civil societies.
We also had some indicators that this was happening at a young age.
So if you look at compared the people on antiretrovirals, so this is the caveat is that HIV negative is not necessarily negative, but not on your own.
But it was in the setting where screening was very high and that spectroscopy is completely ruled out for several years.
What we saw that in particular in the 1835 already we saw is a huge difference in prevalence of treated diabetes,
hypertension in HIV infected on average about that.
But this is not so. It's just things happening at ages where we're not anticipating that.
OK, so think about health system stress,
maybe because then we have to do something right because these people are coming in to the clinics and seeing them regularly.
We all this is familiar to a lot of people.
Yes, this is a W.H.O. health system building block.
So we think about health system spending in this.
I think that Fraser came up a lot of pressure during the Ebola outbreaks and need to strengthen the health systems, right?
So the W.H.O., the health system, building blocks, so so the liveried, the health workforce, the information systems,
access to medicines financing, leadership and governance as a core foundation for what any health system needs.
So when you're thinking about responsive health systems,
where there's improved health and social financial risk protection and efficiency, that's what we think of.
OK, take a step back. Theoretical situation as rising as it may be, because let me explain it was it surprised me.
They might say a theoretical scenario.
You have a certain area of knowledge of people living in conditions of normality in Cape Town, working in an administrator in government.
So it's quite a base, isn't it?
Well, overweight or obese non-smoker had 15 year history of HIV on Second Life,
but really very well controlled, competitive loads of breath undetectable for over 10 years.
So one of the early events that emerged in the emergency department visits the symptoms of a neighbour of mine,
Michael Horseback, and further investigation shows undiagnosed severe heads into this less severe weather.
And off it was. She was undiagnosed diabetes.
Not sure. So in the scenario, it was complicated and resulted in mortality.
When you look into the health system response, what are the kind of things you want to ask yourself?
That's not rhetorical. And thinking about how to avoid this kind of warning system.
Right, so what are the ways that we could pick this up, right?
Sorry. Offering health checks, right? Would that would that have made a difference?
Right. So questions like, well, first we because because you came in with the condition and she died, right?
So could we have treated that better so that she received what was the what were the bad ones that were followed when they delivered in a timely way?
Of right? Why was someone we see regularly who is very well controlled for the the disease that we thought would be the most important poisoned place?
Why was her risk of cardiovascular disease not picked up?
In what ways can we organise the health care delivery service delivery method, like you say, which is to be, we think health checks.
We think not just about disease, but about different ways of bringing them together to integrate care.
You know, thinking about the building blocks, how do make sure that we screen people all are is our health workforce?
I would say with the criteria for diagnosis, et cetera, going through this building health.
Reasonable. Yeah. OK. But I recognise this ball.
That the real point. Everything. Do we react?
It is in the entirety of our response to improving population health reactive.
Then what's next? She was 39. Was it inevitable that she would be obese and have a high blood pressure?
That was inevitable? And then all we can do is just pick it up because that's how that's how we think those are important.
And I think we all agree that that was that those steps were vital.
But is that all is that all? Is that this other case to say, OK, we've done that.
That's all we need to do. The other thing is that we can't afford to do that at a population scale.
We can't afford to just wait. I showed about I showed concepts of weaponization.
So the context of the exposures that people live and work and socialise with and try and
kind of thrive in a changing in ways that are not necessarily conducive for health.
So the the need for health care is increasing.
There was a recently published paper by some colleagues of couple months ago that looked at the cost of implementing primary care one to one,
which is a kind of a basic package of primary care guidelines for cardiovascular disease in South Africa,
and implementing it at 70 percent of what it should be would essentially bankrupt the health budget.
Now I'm trying to get it. So do we just say that all we're doing is chasing the best we can?
We need people chasing. They get me wrong. We need you because there's less burden as a burden of disease and those risk now.
But if we all chasing who's thinking about how we can do things differently now.
So, yeah, so so I'm thinking about why we don't.
One thing I like about public health is that it's really quite obvious, right?
All you need to do is fairly obvious like, you know, the when you take a step back.
But then when you go into, well, why aren't we doing it? That's when it's wonderfully complex.
So I started thinking about one of my frustrations because I started off in infectious diseases.
And one of the things one of the big differences I've noticed about infectious diseases this is non-communicable disease
is the kind of rage and anger that you can muster and kind of rally for infectious diseases that you just cannot for not.
This is just you just can't get anyone just annoyed about the trends and people.
The deli's people, you know, say, lets you do that.
And it's not asking, Well, why is that and what is it about that?
And and what would it look like if it was?
What would a different scenario look like?
And that reminded me of the notion of a counterfactual which I was exposed to in, you know, from epidemiology perspective, right?
But I suspect that is not, you know, when you when you when it's your people, I guess it never really goes out.
And I got to Netflix. So the psychological test is a sociological is not is not you.
And I'm usually so I sort of reading around the counterfactual and just kind of exploring not just from the public health methodology perspective,
but just sociologically and from the psychology perspective.
What the what is it about thinking about things in the counterfactual that can help to change things?
Help stop them, so when they of the counterfactual, obviously it's a difficult position of the reality.
It can be a driver of change. It can result in space because it's just like, what if?
What if, what if, what if we can't do anything but it can by exploring other options drive change, sometimes without the counterfactual.
We're not inclined to take because it's just like, this is just the way it is.
What can we do about the way things are now?
So what happens if you don't like the way things are now? Talk, say some more of my readings of unexploded files.
A couple of ideas around or thinking around the spot that are needed to set a counterfactual thinking.
So I don't even think we there. I think we we accept.
The first move necessary is that the current situation has to be something perceived as negative or out of the ordinary.
Well, it is what it has always been this way. It's not this is not absolutely me, this is just how things are.
So not exploring, not not going into that counterfactual is one of the things that I see.
Oh, I recognise as potentially being the bonuses. The second is a direct link between cause and effect, side by side and public health.
This is something that, of course, at the macro level loves me.
But what if those links are diffuse and distant and you haven't reached the worst of it yet?
What if you can't quite pinpoint this is what caused it?
Because it's just a myriad of things. That's another we'd rather not think about.
It also it's also helpful to be able to say how you or someone like you or
somebody in a particular position can play an important role to make that change.
And if you can't see that, then it's not. It's difficult to see a way through.
Well, how do we deal with that in the context of a city where we have this complex adaptive systems?
How do you do that in the context of health and mental health when the roles are not so obvious,
where we see what we see is the tip of the iceberg and we don't see the determinants of health that drive it.
So we see how they'll health manifest, but we don't see the run up to it, which largely happens outside of the health care sector.
Some added complexities, I think. Then I kind of overlay that with additional considerations in the context of of rapidly going to snap again.
So thinking about so a lot of the work I do at the moment is looking at the ways
that the activity and food environments in cities can be harnessed for health.
Right. So not just the individual level, you must do this.
You must do that. When you know, I know you walk out the door and you are able to follow that advice in any way.
Be able to do that. It's a very typical access who's building and sitting in the comfort of the impulses in the moment.
Right?
Huge youth population with very little in terms of a disaggregated data on exposure and outcomes across different settings, and they're not together.
There is insufficient, in my opinion, regional sharing and exchange.
So we all starting from scratch every time because we think about something we don't know.
If someone tried this before in the similar context that it worked, why didn't they work?
What was left to take on? I think this is an important city sensitive to that because it's a lot of different things.
But I think it's is in the broader African context, the historical context of systematic exclusion,
whether that was spatial because the cities are not there for the majority, whether it's social, whether it's cultural, whether that's political.
We see that playing out in inequities in terms of how we see the circular migration, we see this unpredictable demand in services such as an influx.
So I thought, well, in what ways can the conceptual thoughts kind of sports onto this?
Well, perhaps those are Typekit glasses make it difficult to see, well, who's who's got a central side.
Perhaps the lack of is that big data data that you can put together makes it difficult to see what is causing the effect side by side,
even if they take a while to happen. If we have the data,
perhaps you could see it's a little bit better than perhaps the perception that it's something you'd need to get out of the ordinary.
If it's just kind of always been this way, this is what we have to kind of hustle through.
OK, so that's basically my last couple of minutes of the way in which we can rethink a health service in the confines of the city.
What does that mean? So it's not here.
I mean, this is not a retreat, but it's just to share with you the handle's network in the health care and health aspects of health services, right?
In terms of the exposure. We think about the, you know, the dimensions of access, what is available, accommodating.
And I thought about that actually when you were talking about energy, you know, thinking about access,
not just geographical and alive, but all these different dimensions in the intermediate outcomes.
It's the way that you conceive of chronic disease control your episodic collection of health care towards improving place.
Well, what if we thought about health services a bit differently?
What have we thought about health care as being one part of health of the health service where
you have the other sectors and access that play an important role but which are not visible?
Thinking about this counterfactual spots thinking about your habitation.
The planning or design of your place may be thinking about the kinds of exposures linking those,
the kinds of exposures that have a downside and actually result in you increased risk of cardiovascular disease.
Who who are the things to go to there? Whoever is responsible for the planning of the city when they've diagnosed with hypertension?
Right, so lovable. But what what is the what is the exposure and how is that impacting 74?
I mean, this is not exhaustive, but thinking about some of the this is just my things I'm interested in.
OK. This is another way of putting it to say that again, when you think about health care,
often we we interact with health care, health care at the top and bottom end of our lives and when things go wrong.
But actually the rest of the time, this is our exposures.
This is where we spend our time, if we lucky be healthy and the huge determinants of health outcomes.
But yet we don't connect them in a way that in thinking about patient health, we need to.
And we don't think about the systems for health that require reading together.
The health care system with those are the systems that are important roles in control so that some
of the thinking I think last night that I was informed of the my some of the work that I do.
So this is some of the conceptual thoughts kind of linking my background.
And so the research we've got ongoing at the moment looks to foster partnerships with a typical XS and XS who
co-created some into the interdisciplinary research to build capacity for this kind of work and foster exchange.
So we do do some health systems work of still doing some work looking at health system responses to HIV,
NCD integration thinking in the context of adolescents at the moment,
but also moving to the dark side to speak because they're looking at systems for health things.
So we've got a couple of studies in a study in a couple of cities looking at health and housing policy and the ways in which governance.
I really resonated with how the governance for health is out of whack, as I say,
and looking at opportunities for integrating health objectives into housing policy.
We're doing some work now average and with colleagues in also in Cape Town.
And there's a kind of living in Kenya and in Jamaica looking at a little bit more
around the diet and activity environment and the policies that govern them.
Adolescents form a huge target group,
important because I just don't think we can ignore them in the context of Africa and not just as a vulnerable group,
but actually as agents to make that change.
So, for example, one of the studies that we're looking at is exploring them as citizen scientists to actually work
with them in the collecting data and the analysis and in the co-creation of these therapies.
This is my last night. I put this here.
This is your my test audience because I've only been met with his hands because this gives me a little bit of humility,
because often we think about science, public health research.
Yeah. He's a better health.
But I think the reality is that we do it through other means and then if we if we if we do that, if we look at will the implementing acts.
So that's in the public sector, the people themselves and in the private sector, there's kind of actually have the force to an implementing power.
But if all the different levels and all with different complexities and all engaging with themselves in different ways,
and I find it helpful to think about well in terms of thinking about public health and why we said, where does that sit?
Where am I most comfortable? Where am I somewhat uncomfortable?
I'm actually not doing a lot of work in and but when I look at it and when I think about it ideologically, I should be.
So I'm trying to use that to drive the next and the follow on direction of of work.
But his plans to ensure that kind of going back to say, Well, am I just kind of sitting in my sweet spot looking at the strong links?
Or am I actually pushing a little bit and looking at where the evidence is weak and where we don't really play sufficiently?
So that's where I'm at. Thank you.