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

Neglected diseases or neglected people?

During Saturday’s UAEM workshop on neglected diseases, one speaker brought up the point that perhaps we should not be talking about neglected diseases, but rather diseases that affect neglected people. HIV was neglected when it was thought to affect only gay men in San Francisco and it was neglected again when Africans were dying in troves even as HAART was dramatically extending lives in developed countries. Today, it remains neglected among such populations as African-Americans in Washington DC, who account for ~80% of HIV/AIDS cases in the city. And so not only do dengue, leprosy, Buruli and all the terrible “iases” remain neglected because they affect the types of people whom our society seems not to value, so do ailments that we would not intuitively place within the “neglected” category: heart disease, cancer, diabetes, which are increasing at alarming rates in the developing world. Sure, at least there is a prospect of advances in biomedical science against the diseases that affect people in developed countries, but this also means that we are restricting our efforts to interventions that are designed for the developed world and may be inappropriate/unaffordable, in other settings. There is little to no market incentive to develop interventions that specifically target the needs and constraints of poor/powerless people.

I think that the terminology of “neglected people” rather than “neglected diseases” forces us to face the underlying reason why we invest in certain diseases over others–not because they are less common or less amenable to intervention, but simply because the people who suffer from them do not have the requisite economic or political power to motivate a response. It also forces us to recognize the full scope of the neglect: it is not just disease, but also nutrition, access to education, simple interventions like ORT, civil protections… When we neglect entire classes of people, we neglect their every need, their every right, their every aspiration to “a life worth living”.

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)

Grace under fire: Responding to global emergencies

More thoughts from the MS1 Global Health selective. Last Tuesday we welcomed Dr. Emilie Calvello, who talked about her work in emergency disaster relief following Haiti’s devastating earthquake and the evolving response to the rapidly spreading cholera epidemic. She shared some of the difficulties of working in conditions of such great and urgent need but limited resources and insufficient infrastructure and organization, and the ethical dilemmas that she faces when deciding to care for one patient over the many others who seek help. Yet in spite of the many difficulties and sometimes overwhelming situations that she described, what was most evident was her indomitable passion for the work that she does…

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I really enjoyed last week’s discussion with Dr. Emilie Calvello. It was truly a unique and amazing opportunity for us to get an real view of what actually happened in Haiti after the earthquake and the kinds of roles that physicians have had there at that time and now. There were so many problems that had to be dealt with, especially in a country like Haiti, which had a poor health care infrastructure to begin with. What I thought was most interesting was the idea of triage and how it was applied to the disaster areas. As physicians we’re trained to be empathetic and have connections with our patients, even in busy ER’s. But in a situation like Haiti, you are forced to move extremely fast and sometimes not give the adequate amount of care necessary. Dr. Calvello talked about feeling guilty on multiple occasions because she spent so much time with one patient. She knew that with that same amount of time, 10 patients could have been treated. At times I feel that it’s definitely necessary to focus on one patient and their complex problem. It’s easier said than done, and doesn’t seem too realistic. In these situations physicians are sometimes forced to see things in the big picture and loose importance of each individual life. There is a constant battle between numbers and resources and I feel that it is the biggest problem in disaster settings.

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I took away two main thoughts from Dr. toxoid talk on the humanitarian response to the Haiti earthquake and the assigned readings.  First, I left her talk thinking about the implications for the standard of care and the decisions that physicians must make when there are insufficient resources to meet the medical needs of patients.  Even as first year medical students, we have already internalized a standard of care dedicated to providing the maximal benefit for each individual patient, and it seems unimaginable to be put in a situation where we must decide which patients will receive medical care and resources and which will essentially be left to die.  In the face of an imbalance between medical needs and resources, it makes logical sense that physicians should allocate the relatively scarce resources “for the greater good” of the population, but it also seems antithetical to our moral responsibility to each of our individual patients.  I know that decisions about how to ration care are unavoidable in an emergency situation where resources are inadequate to meet the needs of patients (and where the worst possible decision is probably not making a decision at all), but I still do not know how I would personally cope with having to make those decisions as a physician.

Second, I was struck by the extent to which emergency situations exacerbate the baseline health problems of the affected population — for example, the prevalence of tetanus after the earthquake in Haiti because only 53% of the Haitian population had been vaccinated (along with the inability to store tetanus toxoid or immune globulin without a cold chain during the emergency response).  Similarly, the problems resulting from weak infrastructure of the Haitian health care system were clearly magnified in the context of the earthquake, making the provision of medical care even more difficult in those circumstances.  It underscored for me the importance of understanding the baseline problems of the population when planning for and implementing a humanitarian response to an emergency situation.

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For many, the 2010 earthquake that devastated Haiti is quickly fading into the past as we look forward into 2011. Nearly one year after the earthquake, I was shocked to see how little recovery has taken place. Buildings are still crumbled and destroyed, people are still displaced, and the people and continually being presented with new health challenges. The challenges seem insurmountable for a country that was facing so many problems even before the earthquake. I truly admire people like Dr. Calvello who have stayed with Haiti since the earthquake and are now looking into the future and trying to figure out the best way to proceed. She showed us the many sides of emergency relief. From a clinical standpoint, she reminded us to pay attention to the basic diagnostic techniques because in an emergency setting, most diagnoses have to be made solely from a physical exam. She illustrated the logistical challenges of delivering aid vividly through her example of tetanus infections. When patients came to her with tetanus, she was able to recognize it, but could not treat it because there was no established cold chain. Finally, she showed us the ethical challenges faced by doctors in an emergency relief setting. It is such a challenge to balance a utilitarian view of doing the most good for the most people with the compassion that each human life deserves.

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One of the challenges often mentioned in global health projects is the issue of keeping volunteers safe in foreign countries. While the “safety” of countries varies greatly (and is a controversial issue in itself), this issue is of particular concern after natural and man-made disasters, events that often go hand-in-hand with health crises.  In her presentation, Dr. Cavello showed several pictures of the American soldiers stationed around her clinic shortly after the earthquake, and mentioned the contribution of US Armed Forces towards maintaining security at her site. This got me wondering about what exactly would be the “best” way to handle security issues, both for small-scale projects and large-scale disaster response.

From my own experiences, the group I worked with in Central America hired former local police officers as security guards, and stationed us at a base surrounded by a barbed wire fence and armed guards. Given the political instability of the country, and it’s reasonably high rate of violence against foreigners, I thought this level of security actually worked pretty well: to my knowledge, none of the hundreds of volunteers for this organization ever had any violence directed against them in country. Using locals, and specifically former police officers, as guards also helped us interact with the local community, in that the guards often acted as translators, and helped control crowds. On a few occasions, having police officers with us also helped us bypass police and military checkpoints with relative ease. While this strategy worked well for our purposes, I can see a major problem though: police forces are often not as highly regarded and received by the community as they were in our case. I could certainly see how having police officers as guards could actually make global health groups a target in some countries.

As evidenced by Dr. Cavello’s presentation, disasters create and exacerbate security issues exponentially. At that scale, I highly doubt having just a few armed guards or officers would be enough to secure a large clinic or hospital: larger and better-equipped military or paramilitary forces are likely required. The effect of disasters on security certainly aren’t unique to third-world countries either: large numbers of national guard troops were sent to New Orleans following hurricane Katrina. As we discussed in class, there seem to be several main groups that have responded to international disasters: US Armed Forces, UN Peacekeepers/Security Forces, and the military forces of the country in question. Each of these have positives and negatives. US Armed Forces have a strong logistical network, and good training, but are often viewed as an extension of imperialism, and resented by locals. UN forces don’t seem as resented as US forces, since they’re linked to an international organization and not a single country, but can have their own problems (I’m going to avoid going into these specific problems, as I don’t really know enough to comment accurately, and don’t want to open up a can of worms). The effectiveness and local opposition to the armed forces of the country in question can also vary wildly. After looking at the options, I’m not really sure there is a “best” option for securing global health interests in large-scale disaster response. Maybe this problem deserves some dedicated public health research?

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I was intrigued by Dr. Calvello’s description of those doctors who showed up to the main hospital (“where the action was”) and graciously offered their services for a couple of hours. I find this interesting not for the easy shot it allows one to take at a moment of unintentional self-absorbtion, but, rather, for the way it reminds us that we are all human and our reasons for doing anything will always be tied up in the sense we have or ourselves, what we want, and what we want to be. This, of course, is not to say that altruism cannot exist. But it is never simple, and I think Dr. Calvello did a good job of addressing this, however tangentially.

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Similar to Dr. Bollinger from the week prior, Dr. Emilie Calvello shared a tremendous amount of information on the benefits and potential pitfalls of engaging in global health work overseas. But Dr. Calvello’s work in emergency situations and disasters, as opposed to the long-term developmental work that Dr. Bollinger spoke of, added a completely new perspective to the world of global health for me. Learning of Dr. Calvello’s work in Haiti has allowed me to realize that dedicating one’s career to global health emergencies can provide immediate relief to areas ravaged either by natural disasters or man-caused crises (i.e. war).  Finally, a common theme from both weeks was the importance of balancing the desire to help in a foreign nation with a realization that foreigners, especially from the United States, are not always welcome – a point that all who plan on working in other countries may want to keep in mind. All of this has helped me learn a great deal more about global health.

*****

The degree of destruction that is pervasive throughout Port Au Prince is shocking. It has been almost a year since the earthquake, over 1 million people are living in tents, and the recent flooding and cholera outbreak have introduced additional complicating factors. Dr. Calvello’s presentation highlighted the fact that disaster relief requires collaborative efforts between many different foreign organizations and the local community. One of the pervasive themes throughout the last two global health sessions is that the opinions of the local community cannot be ignored and that a consideration in any global health endeavor should be sustainability. Although it is true that the purpose of disaster relief is to address an acute situation, one of the impediments to an efficient response in Haiti is because there is little infrastructure. Even global health workers in disaster relief should devote efforts to developing local expertise and sustainable practices.

“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.

 

Ethical Issues In Medical Missions

(Another reflection from the FPH Global Health selective)

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Over the last week, a chain email about the ethics of medical missions has bounced back and forth over the med student list servs. The issues brought up by my fellow students, in addition to the discussion in our public health selective last week, have made me reflect on my own experiences in organizing, planning, and participating in medical mission trips over the past two years. I worked to help found a chapter of [group name removed] at my undergraduate university, and helped lead two trips to staff and supply rural Central American medical clinics. While I think we did a great deal to help the local population in terms of providing free medical care, the amount of money we fundraised (probably over $100,000 to treat around 3000 people) could have been spent much more efficiently by distributing it to our local partners, instead of importing a handful of American doctors and students for one week. On the other hand, without the trips, it would have been difficult, if not impossible, to raise that much money. As harsh as this sounds, our donors would not have just given money directly to help with the populations we served; they donated in order to send our group. There is a real paradox in this sort of medical missions, in that while they provide a significant benefit to the population (though even this is arguable), they are not done for entirely altruistic reasons. In our case in particular, this was evidenced in some of the student-volunteers we brought along: though most students appeared to be primarily interested in the service aspect of our trip, others valued the benefit to their medical school applications more. For my part, we tried to select only the students I thought to be mainly altruistic to go with us, but several slipped through that we later realized had very non-altruistic intentions. As brought up in class, international projects also vary  greatly in how well local partners are integrated. In our case, we incorporated local guides, doctors,  pharmacists, drives, and security personnel. Overall, about a quarter of our total personnel were natives to the country, employed by the larger organization we worked for (and paid out of the money we fundraised). While I think this is reasonably better than some missions that employ no locals, it still leaves significant room for improvement. In particular, I was personally displeased that the upper ranks of our organization (CEO, president/vice presidents, etc.) was entirely composed of Americans. So this is going a bit over the  one-paragraph assignment, and I think there’s a lot more to reflect on here. Given all of the above, I am still highly interested in working on medical service projects, both at home and abroad, but there are a lot more issues to consider than when I first dove into this field. Hopefully, the global health selective should help with that.

Think Local, Act Global: making domestic reform work for global health

I am no expert on domestic healthcare reform and am just beginning to understand better what it involves, but I was very interested in the Affordable Care Act’s efforts to shore up the National Health Service Corps (NHSC), which recruits and supports physicians and other health professionals to work in underserved areas, and expand residency spots in primary healthcare. If done right, the US’s efforts to increase its medical workforce in underserved areas could help to reduce its dependence on foreign medical professionals in these areas, many of whom come from developing countries where there are woefully few medical professionals.

Although the impact of “brain drain” (as opposed to training capacity, for example) is debatable, it is clear that there is a global and growing shortage of HCPs, which has incited enough concern for the WHO to adopt a Global Code of Practice for the international recruitment of health personnel during the last World Health Assembly in May. The code recognizes that international migration of HCPs has several benefits (e.g. professional development, increased income) for individuals and does not purport to halt such migration, but emphasizes that it should have a net positive balance on the health systems of developing countries such that they can retain a skilled health workforce. As we all know, it is veeeeery expensive to train a medical professional, and in most countries this burden falls on states rather than on individuals; thus, the departure of an HCP represents a significant economic loss for a poor country in addition to its effects on the attrition of the health workforce. With a fourth of its physician workforce coming from other countries, the US (as well as other major recruiters of medical personnel such as the UK and Australia), should take a leading role in adopting policies that respect the ideals of the WHO’s code.

There is already some push for the US to invest in workforce development abroad: Congresswoman Barbara Lee has sponsored a Global Health Act, which would support the training of HCPs in developing countries. A former Assistant Surgeon General has also suggested the creation of a Global Service Corps, which would function somewhat like the NHSC and send US medical professionals (including foreign-trained professionals) to developing countries to help facilitate workforce development and the strengthening of health systems. Of course, sending US HCPs abroad through the GSC means that the US will need more medical graduates to replace them. It seems only fair that the US should assume the burden of training the HCPs it will need to fulfill its commitments to domestic and global healthcare to ensure that, in its efforts to provide more equitable access to care, it does not accelerate the attrition of the medical workforce in developing countries. This of course depends not only on the government but also on professional and licensing organizations (e.g., AMA, AAMC) that can help promote domestic training capacity by licensing more medical schools and encouraging existing schools to admit more students.

It is a difficult balance to strike, but hopefully the current and future reform initiatives will allow the US to continue providing opportunities for foreign medical personnel via immigration while assuming its fair share of responsibility (and costs) for the training of its medical workforce.

Summer Issue of The Globe

The summer issue of The Globe, the magazine of the Department of International Health at Johns Hopkins Bloomberg School of Public Health, is now available online and in print.

See here: http://www.jhsph.edu/dept/ih/news/summer2010/

Check it out! The issue focuses on the Department’s work in Nepal and the Nepal Nutritional Intervention Project-Sarlahi (NNIPS)

Thanks to Dr. Maria Merritt for the tip!

Hopkins and global access to medicines

For those of you who could not make it to the meeting on Thursday, here are some of the salient points that we covered.

• The impact of unequal access

An estimated 10 million people died in 2005 due to lack of access to medicines for which treatment exists

• The role of universities in drug development

Universities are a major contributor to biomedical research and drug development (e.g., Univ. of Wisconsin and warfarin); UAEM believes that as publicly funded institution they have a social responsibility to ensure that the products of their discoveries go towards helping those who need them. Most universities do not have the means to complete the full process of drug development and marketing (i.e., clinical trials and such), so they typically license out the later stages of drug development to pharmaceutical companies. When a university researcher makes a patentable discovery, the Technology Transfer Office (TTO) has the choice to take over the patent and sell/license it to outside companies that can implement the later stages of development, or to let the researcher retain the rights, in which case the patent holder must independently find partners who can further develop and market the discovery.

• The pharma side of things

There is concern about decrease in innovation but revenue loss from generic access in developing countries would be minor as these markets represent ~3% of revenues.

• What students and universities can do

Examples of previous successful actions include Yale students and researchers negotiating a decrease in the price of the antiretroviral d4T; MIT is to put patents from NTD research in a patent pool. Thus far, nearly 2 dozen institutions (including NIH) have endorsed a Statement of Principles and Strategies for the Equitable Dissemination of Medical Technologies. Although this statement is non-binding, it is a first step in reaching a critical mass of institutions that support equitable access. The more institutions sign on, the less “risk” there is that those who sign on will lose out on licensing contracts from pharma companies that do not want to be subjected to global access requirements.

• What is Hopkins doing?

The Hopkins TTO argues that Hopkins does not need a global access licensing policy as few drug discoveries come out of JHU and so they could be dealt with on a case-by-case basis but UAEM thinks that we need to have a policy in place to ensure global access for any future discoveries. The TTO should also provide support for researchers who expressly seek global access for their discoveries, which it did not do in the case of Stuart Grossman, who developed a subcutaneous implant for the delivery of opioids. Current problems that researcher are facing is that some funders like the Gates Foundation require grantees to have a plan for global access to the products of their discoveries but there is very little guidance on how to develop such a plan.

To read more, see this article from the Hopkins Newsletter about a recent UAEM protest and the university’s response.

• What do you think?

Do you think that Hopkins should do more to ensure global access to the products of discoveries that are made here? What do you think that we can do realistically as students? How can we balance concerns for global access and maintain incentive for innovation, especially for “neglected diseases”? How do we even promote NTD research given that these diseases affect almost exclusively the poorest of the poor?

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.