Journal Club Recap: Violence in Bahrain Against Health Care Workers

In our first Journal Club of the school year for the Global Health Interest Group (GHIG), we discussed a recent JAMA article by M.J. Friedrich on the human rights crisis in Bahrain in which health care workers were abducted and interrogated following an anti-government protest. With the Johns Hopkins School of Medicine class of 2015 joining the GHIG discussion for the first time, there was general consensus that this incident was a clear governmental breach of medical neutrality and human rights. From this point, much of the conversation was over the role of physicians abroad, and how future physicians should view their responsibility in the global arena. A debate formed over whether physicians should report human rights violations when they see them or remain neutral and provide only medical care. An example of the latter was the Red Cross, which is able to work in several countries with restricted access because of its adherence to disaster relief  and medical care without political involvement. However, many felt that the dual role of being a physician and a global citizen motivated them to report human rights violations. A similar situation was presented from the United States in which physicians must straddle the dual role of treating a patient while being a social advocate when a situation like child abuse is observed. All in all, it was a lively discussion that began a dialogue among participants about what their own role as medical students would be in global health when faced with situations such as that in Bahrain.

Learning from the past (or not?)

Another round of comments from the FPH Global Health Selective, this time on the history of global health and how it arose from what was once more commonly known as “international health”. A rose by any other name…?

I was highly intrigued by Dr. Packard’s presentation on the history of global health, mainly because I hadn’t realized the amount of influence that politics, specifically those of the cold war, exerted on the progress of global health initiatives. I was also interested by how many global health projects had focused more on “technological” solutions to health problems, such as vaccines and pest control, then “social” solutions, such as improving health care education and infrastructure. As Dr. Packard pointed out, this trend seems to have continued to the present, with multi-billion dollar campaigns focused on researching cures or vaccines for diseases such as HIV or TB, but little money going towards developing desperately needed medical infrastructure in third world countries. Perhaps we have been harmed by our own success in eliminating smallpox through a vaccination-based technological approach, in that we now devote too much of our limited resources towards technological instead of social solutions? Certainly, we are much better off now that smallpox has been eliminated, but the malaria eradication campaign around the same time period turned out to be an utter failure. Maybe we need to look more into treatment and control of global diseases, rather then spending all our resources on researching cures that may be many years down the line?

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Dr. Packard’s talk inspired me to meditate on what the future of global health might look like. Although the term “global health” brings up images of rural villages and people living on the margins of society, I feel like this scene will become less common in the future. In a few decades a greater percentage of the world’s population will shift from living in rural areas to urban centers. As this trend towards urban demographics continues to rise, the way we respond to public health crises must change. Theoretically, technology will continue to advance and keep up with the increasingly urbanized world.

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Dr. Packard’s presentation on the history of international health highlighted two paradigms for the delivery of global health services. One involves focused campaigns to eradicate a particular disease (i.e. HIV or malaria) or target health care towards a particular subpopulation (i.e. women or children). Another involves the development of comprehensive health care infrastructure that considers the social determinants of health. Historical trends and strategies have vacillated between these two paradigms, and there are advantages and disadvantages to each. Comprehensive strategies are more sustainable, tend to address the root causes of health care disparities, and build capacity for future development. Targeted approaches have more tangible goals and may be easier to implement successfully. One factor that should be shared between the two strategies, however, is that global health interventions must involve substantive collaboration between foreign partners and community members. The contributions and perspectives of local community experts must not be underestimated

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)

“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.

 

Rethinking “Global Health”

The FPH Global Health selective was off to a great start last week, with a presentation by Dr. Bob Bollinger that brought up lots of (sometimes uncomfortable) questions about the purpose of global health and the challenges involved in global heath work. One of the key questions that we pondered was, well, what is “global health”? Is it strictly international? What relationship does it imply between “developed” and “developing” countries? How do we perceive our role in whatever we think global health is? Nick and Caleb’s post has gotten the train rolling with some great online food for thought.  Here are some more thoughts from other Med’14ers. Enjoy, and respond!

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What is my role in global health? This question, seemingly harmless at first glance, has become harder and  harder for me to answer the more that I think about it. As a student interested in global health, I have grand  aspirations of traveling to developing countries, working with the local people, and really making a difference. However, as we talked about the upcoming possibility of traveling abroad for the summer and doing research, I  realized that my contributions would be rather limited. Upon further reflection, I realized that the primary  beneficiary of a summer trip abroad would be me. The experience would teach me about research, the culture of another country, and would open my eyes to new possibilities. What started as a selfless urge to help others;  now seems rather selfish. Hopefully, this initial investment in myself will translate into the ability to contribute  in a sustainable way in the future.

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I came into this first session not knowing much about the intimate details of doing work in global health. I believe Dr. Bollinger’s lecture helped me gain a great deal of information on not only the benefits and rewards of dedicating oneself to global health, but also the difficulties that must be overcome. Dr. Bollinger’s key rule that the first response to any idea will usually be negative opened my eyes to the fact that foreign governments will not always be receptive of outsiders with new ideas, even if they are well-intentioned. Finally, I found Dr.  Bollinger’s anecdote on the Indian government official who attempted to bribe him to be both fascinating and thought-provoking. The story sheds light on some of the ethical dilemmas that we could face as future global
health practitioners. Would it ever be acceptable or reasonable to go along with a bribe if doing so could save thousands of lives? That is a question we may all have to grapple with at some point in our careers.

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I’m not quite sure what I expected from this selective. I’ve always been interested in global health, but I don’t know much about it. Bob was very enthusiastic about his work, and you could get a real sense of how he genuinely wanted his efforts to go towards making the world a better place. I can’t imagine all the difficulties he and others in his field of work had to go through. It sounds almost impossible, yet people devote their lives to it, and do make it work. I hope that I can find something that I am just as passionate about, because when you’ve found it, you can accomplish so much through perseverant work. To me, it’s not worth it just to do a job that will get you by, but not help others. Research sounds dreary to me though; I hope that I can find clinical opportunities that will fit my personality. I have no idea what those would look like or where to find them, but this selective will hopefully be a good place to start!

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Dr. Bollinger’s talk was certainly eye opening to the problems that we face when doing Global Health research. In addition to difficulties we also talked about his work specifically in Pune, India. It was amazing to see the degree of progress at the BJ medical school in Pune over the last 10 years. Starting from the upgrading of technology and resources to the organization and better training of members and the development of a more efficient research system. It was interesting to note the amount of time it takes to initiate such a project, keep it running and eventually get results. Global Health initiatives are a long-term commitment from both sides and it certainly is reflected in Dr. Bollinger’s work in India. I really liked our discussion on the problems we face while doing global health work; whether it be in research or giving out medical services to certain areas. There’s always this problematic idea that we are doing more harm than good, taking advantage of a population for research purposes or helping a group for only a small period of time. Personally, I think all of this really comes down to the length of a project and keeping connections to that area once a project has been completed. This is definitely being emphasized in many global health initiatives and I think it’s a way to combat this problem. Our continual connection to a community will really help in its progression and development.

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Global health involves promoting population health and decreasing health disparities in the global arena. The world’s most vulnerable populations should be targeted, and the issues that affect them most should be prioritized. These populations (women, children, elderly, refugees, etc.) and issues (infectious disease, infrastructure development, etc.) will inevitably vary from one region of the world to another, and a strategy that is successful in one may not be suitable in another. As a result, “successful global health workers” must be integrated in the target community and have a comprehensive understanding of the cultural, socioeconomic, and political environment. Providing training to local community members and sustainability should be a primary focus for all global health initiatives. A component of global health may also involve training or raising awareness in students. Although students may be enthusiastic and well-intentioned, they may not have the skill set needed to contribute effectively to global health projects, particularly on a short-term basis. This should not preclude interested students from exploring global health. However, they should have a realistic perspective on how much they can contribute with limited skills and/or time and embrace the experience as a learning opportunity. As a side note, this week’s episode of The Office touched on some of the conflicts and issues that surround global health. A group of young adults in a church group went to Mexico for 3 months to build a school. The leader of the group had a savior complex. She encouraged the group to think of the earth as a burning building and its people as family members who needed to be saved. She did not speak the language fluently, and she believed that at the end of 3 months, the group would be practically Mexican. One of the group members was forced by his parents to go on the trip, and he abandoned the group when given the opportunity. The group also allowed Michael and Andy to join them on their trip to Mexico, even though they knew nothing about the project. This episode highlighted some of the issues that can cause global health trips/projects to be limited in their success.

Bureaucracy

A while ago, I was sitting in the office of a major clinician and researcher at one of the largest and most well-regarded hospitals in Mumbai, India. The room was expansive, cool, comfortable. Just outside the door, however, patients sprawled on benches and the floor, sweltering in the heavy heat of the monsoon season.

It wasn’t this radical contrast, however, that troubled me most. I had come to the meeting filled with enthusiasm and ideas. My study, already approved through several institutional IRBs and deemed non-human subjects research, attempted to observe physician practices and standard-of-care in the treatment of previously rare, but increasingly common, leprosy/HIV coinfections. But none of this mattered. I was foreign (I’m Indian-American, but nevertheless…), a woman, and (gasp) attempting to talk about medicine with a male professor. This, apparently, rounded out the trifecta. He barely made eye contact, almost refused to shake my hand, and sneered at the idea that I could do research.

And then came the red tape. He cited organizations I had never heard of — an alphabet soup of acronyms: approval boards, governmental regulatory groups, watchdog associations. He suggested I send applications to three different agencies. When asked how long approval would take, he merely shrugged. I told him that I had never heard of these agencies, nor had other scientists mentioned them. Again, a shrug. In a final effort, I asked if he wanted to look over my study protocol (since it would then become apparent that it required no further approval). This time, a point-blank “No.” I left, frustrated.

This anecdote does not do justice to the many wonderful scientists I’ve met and worked with in India — it merely highlights an issue that might be as troubling as corruption in the developing world, the point Alex raised a while ago. The useless bureaucracy and entangled red tape that go hand in hand with said corruption are just as problematic and obstructive.

Live from Hopkins: Secretary Clinton on the US Global Health Initiative

For those of you who are in Baltimore, Secretary of State Hillary Clinton will be paying you a visit on Monday to discuss the Obama administration’s Global Health Initiative. That the Secretary of State is giving this talk underlines the important role of aid in the US’s foreign policy and diplomacy strategy in the developing world. Recently we have seen how various groups are competing for “the hearts and mind” of the populations devastated by the floods in Pakistan by offering the desperately needed aid that, many complain, the government is incapable or unwilling to provide.

But of course, the union of aid and diplomacy is a double-edged sword. The diplomatic fringe benefits can motivate the governments of developed nations to invest more in aid, and to shift this aid towards health and education efforts that have a more direct impact on communities (as opposed to say, massive infrastructure projects that tend to create the perfect opportunity for corrupt officials and businesspeople–not that global health efforts are immune from corruption!), but if diplomacy is the primary motivation, there is a significant risk that most decisions will be based not on the best interest of the communities in need, but rather on the political interests of those in power.

Unfortunately only SAIS students and staff will be allowed to attend the event in person, but there will be a live webcast accessible at http://www.sais-jhu.edu/.

Blurb from the Center for Global Health:

Hillary Rodham Clinton, U.S. Secretary of State, will speak at the Johns Hopkins University Paul H. Nitze School of Advanced International Studies (SAIS) on Monday, August 16 at 11:30 a.m.

Secretary Clinton will speak about “The Global Health Initiative: The Next Phase of American Leadership in Health Around the World.” The Global Health Initiative is a centerpiece of the Obama Administration’s foreign policy and an expression of U.S. values and leadership in the world. Secretary Clinton will describe the Global Health Initiative’s core principles, and call on governments, organizations and individuals to join the United States in pursuing a sustainable approach for delivering essential health services to more people in more places.

In Memoriam: Carl Taylor

The key to the whole program is the empowerment of women in the greatest need. Helping those women to take leadership: defining their own problems, and actually doing something about them” – Carl Taylor, 2008

Carl Taylor

He helped to establish international health as an academic discipline in the U.S. He authored a study–the first of its kind– connecting malnutrition to infectious disease. He conducted research in more than 70 countries, and outlined some of the foundational tenets of public health research. Dr. Halfdan Mahler, former WHO Director General, called him “the greatest public health expert I have come across.” When Carl Taylor passed away in February 2010, he left an incredible impact on the world — both a rigorous researcher and humanitarian, he is missed not only here at Hopkins (his academic home for almost fifty years), but across the global community.

In honor of today’s  Carl Taylor memorial lecture (cf. Mariam’s announcement), I wanted to share this video, Professor Taylor’s final interview with Global Health TV.