Welcome to Atlas and Axis 2011-2012!

Welcome to a new year of Atlas and Axis, your online global health resource from the Global Health Interest Group (GHIG) at the Johns Hopkins School of Medicine. We’re very excited to welcome the Class of 2015 to the Hopkins Med family, and we look forward to growing our global health community at Hopkins.

For those returning to this site, you’ll notice that we’ve refreshed the design. We will continue to make changes to make the site even better to use in the coming weeks, so please bear with us during this time. Look out in the coming weeks for updates about summer projects from the Class of 2014. Also, check out our Travel Map to see where various students have been traveling this summer. As always, feel free to contact us with questions and continue to check back for updates about upcoming events!

Infecting with Sugar

By now, many people have read the popular (and controversial) New York Times article “Is Sugar Toxic?” or have seen the lecture by Dr. Robert Lustig on “Sugar: The Bitter Truth” on YouTube (see below). Without doing either source much justice, the essential argument is that fructose has no nutritional value whatsoever and that it is the key cause of the obesity epidemic in America. Furthermore, it may be a primary contributor to insulin resistance, metabolic syndrome, diabetes, and even cancer. Thus, Dr. Lustig, a persuasive speaker, argues that we should go to such lengths as to even “card” children and teenagers when they try to purchase sodas with the goal of removing all fructose from the American diet.

If we are to accept Dr. Lustig’s proposition, then another issue arises. There is ample evidence that developing nations are increasingly adopting the so-called western (or American) diet while noncommunicable chronic diseases (NCDs) are rapidly on the rise. There is no doubt that there is significant interaction between the two. Then, by exporting our culture and diet, are we infecting other nations with the same chronic diseases that pervade our modern society? What sort of moral or ethical obligation do we have to take our understanding of fructose and help shape global food policy? Many U.S. organizations are now pouring funds into fighting infectious diseases in the developing world (on a related note, Happy World Malaria Day! - 4/25/2011). At the same time, however, food and beverage companies are flooding the up-and-coming nations with advertising and products full of the sugary foods that we enjoy in America. As such, we may be removing the threat of infectious diseases and simply replacing them with the chronic illnesses we bear today.

This “epidemiological transition” is nothing new, but we must stay alert to an issue that can be often ignored in global health. In order to address this growing transition more effectively, we need to understand who and what to target. If fructose, indeed, is the sweet but insidious killer, how we act on this knowledge will determine whether or not countries around the world become mired in the life-threatening, resource-draining quicksand of chronic diseases.

Best of Both Worlds?

This past week, Dr. Randall Packard presented the history of global health as a swinging pendulum between two forms of healthcare—a horizontal perspective of improving health systems for better primary care, and a vertical view of tackling large-scale disease-specific campaigns. However, the question arises: can we have the best of both worlds? Would it be unrealistic to pursue both horizontal and vertical forms of global health concurrently—in a hybrid “diagonal” model? Are we living in a world of limited resources in which we can only pursue one or the other?

The Global Fund to Fight AIDS, Tuberculosis, and Malaria began to tackle this idea in 2007 when the program’s original “horizontal” financing was reorganized to stimulate development of comprehensive country health programs rather than “vertical” campaigns against a single disease (or three, in this case). Such an endeavor could take advantage of the various established benefits of the Global Fund such as international sustainability and circumvention of IMF spending restrictions, but other donor sources were determined to be necessary in order to avoid collapsing both horizontal and vertical efforts (Ooms et al, 2008). As Dr. Packard alluded, money and politics will always be impediments to achieving the Alma-Ata ideals of “Health for All.” Nevertheless, the idea of “diagonal” global health financing is an intriguing approach that could potentially utilize the massive donor support and momentum of vertical campaigns to promote the goal of horizontally strengthening health systems in the developing world. This will require the collaboration of major players in various sectors—from governments to the World Health Organization to large organizations like the Gates Foundation to small and local NGOs.

On a separate but related note, it is enlightening to take a look at the Declaration of Alma-Ata and see how closely the language of primary health care in 1978 resembles the language of global health today, words we have been using throughout this blog in recent weeks. Why is such language and vision rehashed time and again? Are we simply just spinning our wheels?

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. (Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, September 6-12 1978)

Peacekeeping Gone Awry

Source: CNN.com

In her talk, Dr, Emilie Calvello expressed consternation about the multiple NGOs that flooded Haiti in the wake of the earthquake and the lack of partnership and cooperation with the local Haitian healthcare providers. She particularly emphasized that the willingness to help was not enough—we must help in the right way. This includes understanding the cultural perspectives of the Haitians as well as engaging their abilities to improve the crisis at hand.

This week, we saw how even in a disaster situation, we must view those we aid as “co-producers” of health, no matter how strong the impulse is to see them as helpless and suffering. In the aftermath of the earthquake in Haiti and the resulting destruction of public infrastructure, an epidemic of cholera has swept the nation with an equally dangerous wave of chaos. Now, reports have emerged that Haitians are violently protesting against UN peacekeepers. At first glance, this seems ludicrous. How can people protest against the malicious spread of bacteria? What good could come from fighting the “peacekeepers” that are there to help?

With a critical eye, however, it is clear that this cholera epidemic has only served to open the floodgates for the tension and mistrust that had festered between the Haitian population and the foreign occupiers. The situation is complex. The spread of cholera is a public health crisis, but we must realize that all diseases are socially, culturally, and politically grounded. Many Haitians from the slums, mistakenly but understandably, view the cholera treatment centers as hotspots for spreading the disease. Upcoming elections in Haiti are suspected to be the motivations for the cholera-related riots. It is almost overwhelming to comprehend and assess it all. Nevertheless, it is a necessary exercise, as disaster response has spiraled into a nationwide epidemic and now to political unrest. From this compounding crisis, we see the increasing urgency of appropriate international interventions, lest we face the unintended consequences of our supposed altruism.

“Co-producing” Health

Ever since the United States boldly asserted its influence over the international arena in the post-World War II era, the topic of its role in the development and progress of foreign countries has long been debated. This question reaches the U.S. medical profession today as we seek to better understand our role as healthcare providers in a time of growing global interconnectedness. One way of assessing our own international involvement is to evaluate our characterization of the presumed “target population.” Our view of the needs and responsibilities of those we treat abroad dictates our approach to global health.

We often preoccupy ourselves with the logistics of our own medical resources—how many doctors and supplies can we allocate, and how many clinics can we build? Moreover, we too easily view the population at hand as a model of a single disease or condition. We simply declare that we are going to “help HIV patients in Africa” and that becomes our singular goal. Yet this ignores the very social capital and means that are possessed by the persons we seek to help. We overlook the fact that health is not an isolated state of being, but that it is regulated by a series of social, cultural, and even political levers. As such, we should understand people as integral participants in their personal health maintenance and as key components of a larger social network. Earlier this year, Dr. Julio Frenk, Dean of the Harvard School of Public Health as well as the former Minister of Health of Mexico, wrote about expanding our view of global health systems through understanding a person in five different roles: patient, consumer, taxpayer/financier, political citizens, and co-producers of individual and societal health (Frenk, PLoS, 2010). If we do not see global health populations in these contexts, we not only provide an inadequate service but we miss the opportunity to build sustainability and self-sufficiency within the developing society. Such a sentiment is reflected in recent calls to action to develop an “International Health Service Corps” in which health care workers would engage in medical service and capacity-building partnerships abroad as an act of diplomacy (Kerry et al, NEJM, 2010).

Global health involvement of the U.S. is not a question of whether or not we should be involved. In a globalized age, international communication and exchanges are inevitable and necessary. The question is about the particular way in which we are going to partner with the local communities to implement the most effective health interventions and systems possible.  Global health is about how we can make something better overseas than if we had not been involved at all. More importantly, however, it is about how the people abroad can make something better than if they had not been involved at all.