Harvard College Global Health Review Winter 2011: Global E-Health by Rajarshi Banerjee

Global E-Health

6 Mapping the World’s Diseases 8 10 12 14 16 18

Table of Contents

36 Re-structuring Urban Healthcare Beyond the Cultural Model for Immigrants’ Healthcare Disparities Big Players, Small Players Sarah McCuskee Innovations in Mobile Health 38 The Silent Killer Charlotte Lee The Effort Toward Global Elimination of Telemedicine in Developing Countries Maternal and Neonatal Tetanus Challenges and Successes Frederic Hua Nora Eccles 40 From the Floodwaters Flow Applying Technology to Global Mental Health Issues The Impact of Water in Bangladesh Beneficial or Detrimental? Michelle Lee Leeann Saw 42 Global Health in Japan The Impact of Social Media on Medicine A Moral and Economic Dilemma Expanding the Scope of Treatment Corinne Maguire Megan Parsons 44 Neglected MoTeCH and m2m Raising Funds for the “Best Buy” in Using Mobile Technology to Improve Maternal Health Global Public Health Homan Mohammadi Sheba Mathew Global Health Informatics GIS and Spatial Analyses for Global Health Shalini Pammal

The Impact of the Internet on Peru’s Healthcare System Allie Pace

20 Global Health 2.0

What Does the Future Hold? Tarina Quraishi

Student Initiatives

22 Current Student Global Health Initiatives

Interviews

26 An Interview with Dr. Peter Piot 29 An Interview with Dr. Elizabeth Bradley

Panorama

32 Altruism and Profit The Changing Role of Pharmaceutical Companies in Global Health Hannah Semigran 34 Engulfed in a Toxic Cloud The Effects of Coal Mining On Human Health Rachel Sapire

The Expert Perspective 46 Integration of Health Services: Theory and Practice

Jacqueline Sherris, PhD & Jeffrey Bernson, MPH, MPA

50 Availability of Essential Medications for Non-communicable and Chronic Diseases in Low and Middle Income Countries

A Persistent and Growing Violation of Human Rights and Potential Solutions Rajesh Balkrishnan, PhD & Sofia D. Merajver, MD, PhD

Student Submissions

53 The Issue With Quinoa and Nutrition in Bolivia Carlos de Mestral 54 Notes from the Field: A Summer in Salone

Nigel Deen 56 Caring for Kakuma Alex Palmer

HARVARD COLLEGE GLOBAL HEALTH REVIEW, WINTER 2011 EDITORIAL BOARD

GRADUATE BOARD OF ADVISERS Section Editors

Editors-in-Chief

Shalini Pammal ‘13

Alison Kraemer ‘12

(Student Submissions)

Lavinia Mitroi ‘12

Judy Park ‘13

Managing Editors

(Features)

Daniel Wilson ‘14

Justin Banerdt ‘13

(Panorama)

Annemarie Ryu ‘13

Pratyusha Yalamanchi ‘13 (Experts and Interviews)

STAFF Writers

Vishal Arora ‘14 Shaira Bhanji ‘14 Nora Eccles ‘14 Frederic Hua ‘14 Adam Joseph ‘15 Cameron Johnstone ‘13 Elizabeth Kinsella ‘13 Young Kwon ‘15 Andrew Lea ‘14 Charlotte Lee ‘14 Michelle Lee ‘15

Corinne Maguire ‘15 Sheba Mathew ‘13 Sarah McCuskee ‘13 Joy Ming ‘15 Homan Mohammadi ‘14 Dylan Neel ‘15 Alexandra Pace ‘14 Samuel Parker ‘14 Megan Parsons ‘15 Tarina Quraishi ‘14 Rachel Sapire ‘15

Riad Abdelkarim Adriana Benedict Aparna Chandrasekhar Vivek Datta Geethika Fernando Ana Luíza Gibertoni Cruz Alexander Hawkins Hoffman Moka Lantum Natalia Linos Mathieu Maheu-Giroux Melissa Neuman

Leeann Saw ‘13 Carlos Schmidt ‘15 Hannah Semigran ‘14 Audrey Zhang ‘15

Interviewers

Ava Carter ‘13 Sheila Ojeaburu ‘15

Tej Nuthulaganti Daniel Oh Sophia Qiu Minal Rahimtoola Katherine Record Danae Roumis Alex Ryu Jose Sarmiento Sonya Soni Amy VanderZanden Jennifer Ward

DESIGN BOARD Samuel Mendez ‘14 (Chair) Herbert Castillo ‘14 Justine Hasson ‘14 Katherine Kelley ‘14 Ketsia Saint-Armand ‘14 Melissa Sanchez ‘14

BOARD OF EXPERT AND FACULTY ADVISERS Prerna Banati, PhD, MPH

Takemi Fellow, Department of Global Health and Population, Harvard School of Public Health

David Bloom, PhD

Chair, Department of Global Health and Population, Harvard School of Public Health

Allan Brandt, PhD

Dean of the Graduate School of Arts and Sciences; Professor of the History of Science at Harvard University

Arachu Castro, PhD, MPH

Assistant Professor of Social Medicine, Department of Global Health and Social Medicine, Harvard Medical School

Paul Farmer, MD, PhD

Kolokotrones University Professor, Department of Global Health and Social Medicine, Harvard Medical School

Jeremy Greene, MD, PhD

Allison Linden, MD

Cecil Haverkamp

Michael Murphy

Joel Lamstein

Conrad Muzoora, MD, MMed

Ana Langer, MD

Jonathan Quick, MD, MPH

Assistant Professor of the History of Science at Harvard University; Associate Physician at Brigham & Women’s Hospital Former Coordinator of Strategic Partnerships and Global Health Practice, Harvard School of Public Health CEO, President, and Co-Founder of John Snow, Inc.; Co-Founder of Management Sciences for Health Professor, and Coordinator of the Dean’s Special Initiative on Women and Health, Department of Global Health and Population, Harvard School of Public Health

Paul Farmer Global Surgery Research Fellow, Children’s Hospital Boston; Surgical Research Fellow, Harvard Humanitarian Initiative Co-Founder and Executive Director of MASS Design Group

Global Health Scholar, Harvard Global Health Institute; Lecturer, Mbarara University of Science and Technology, Uganda CEO and President of Management Sciences for Health; Former Director of Essential Drugs and Medicines Policy at the World Health Organization

The Harvard name is a trademark of the President and Fellows of Harvard College. It is used with the permission of Harvard University. Opinions, views, and statistics printed in this journal are those presented by the contributors and not necessarily a reflection of the views of the editors. No part of this publication may be reproduced, sold, or transmitted without written permission of the editors-in-chief of the HCGHR.

Dear Reader,

From the Editors

As society rapidly zooms forward into the modern technological age, the meaning of “global” in “global health” becomes ever more palpable. It increasingly appears as though human actions and innovations that are daily changing our world are capable of impacting every aspect of our lives, including our health. At the same time, the swelling interconnectedness of our globalized world is permitting technologies developed in the global North to reach populations in the global South. Among all the brilliant technologies in existence, we insist that emerging social media tools and communications technologies, in particular, are proving to be remarkable vessels for change in the movement to improve health outcomes. Cell phones, wireless Internet, and Facebook, to name a few, are not only enhancing our everyday lives but also opening innumerable doors for the fields of medicine and global health like never before. This issue of the HCGHR assumes a forward-looking perspective by exploring these very advancements. Within the pages of our Features section, we aim to shed light on the realms where social media, technology, and global health unite. By taking a defined look at a relevant and exhilarating trend, we hope to invite spirited dialogue and debate, especially within our comment reels and blog on our fantastic website (www.hcs.harvard.edu/hghr). Our Features articles tackle this great undertaking by demonstrating the benefits being derived from the use of various technologies and asking what limitations exist in their implementation. Our writers investigate the role of the Internet in transforming the patient-doctor relationship in Peru, the application of technological advancements in mental healthcare, and the ways in which Geographic Information Studies (GIS) are improving information sharing in global health. Other pieces survey the multiple ways social media outlets, telemedicine, and mobile health (mHealth) are impacting healthcare delivery. Our final Features article presents challenges and predictions for the future of global health given our perseverance towards technological progress. To fulfill our promise of a well-rounded glimpse onto the global health stage today, our Panorama section offers an array of intriguing topics that, roughly speaking, “take the temperature” of the global health field today. The articles take a critical glance at water in Bangladesh, big pharma and generic drug manufacturers, neglected tropical diseases, public health issues resulting from coal mining, barriers to

immigrant healthcare, efforts to eliminate maternal and neonatal tetanus, and the manner in which nations other than the U.S. are devoted to the case of global health, with an eye to Japan. Also included within this issue is an exclusive interview with Dr. Peter Piot, the founding Executive Director of UNAIDS and former Under Secretary-General of the United Nations. In addition, we are excited to present to you a new section of the HCGHR: the Student Initiatives Section, where you will find submissions about student-initiated projects and on-campus campaigns in global health. This Fall, the HCGHR has experienced many other exciting developments. We have proudly expanded our staff to include not only print writers but also online columnists. The online columns accomplish what we cannot always do in print, which is to provide frequent up-to-date commentary on current events in global health. We launched two sets of our first exclusive online columns on the HCGHR website this semester, and we encourage you to take a look. We have also begun to cross-post our articles to the Global Health Hub (www.globalhealthhub.org), share copies of the Review at global health conferences, and launch partnerships to make the Review available as a teaching tool at local high schools. These activities and many more are part of our strategy moving forward as a burgeoning publication. For aiding us in this journey, we graciously thank our greatly expanded and enriched Advisory Boards and our financial supporters, particularly the Harvard Global Health Institute. We hope you will continue to follow the Review as we join the ranks of publications following the trend to build dynamic online information platforms. Indeed, as the field of global health reacts to developments in social media and communications technology, we plan to follow suit. Hopefully, then, the HCGHR will be part of the collection of innovations that will revolutionize global health in ways that are truly exciting to envision. Sincerely, Alison Kraemer and Lavinia Mitroi Editors-in-Chief “By opening up a critical self-reflection on our world and ourselves, we can prevent ourselves and others from becoming worse people under the pressure of changing conditions...and keep our moral practices in line with our sense of what is right.” Arthur Kleinman, What Really Matters

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Mapping the World’s Diseases GIS and Spatial Analyses for Global Health

By Shalini Pammal

he increasing complexities of current global health issues demand multifaceted solutions that integrate advancing technology with knowledge. A successful example of this is the 1993 Long Island Breast Cancer Study Project (LIBCSP), which was developed to determine risk factors for the unusually high breast cancer rates in this region. The LI-Geographic Information Studies (GIS) project uses topographic, demographic, health outcome, and environmental data along with satellite imagery to add a spatial component of information that has been absent from traditional breast cancer studies. This study allows for identification of high risk areas on a finer scale, so it can be known where within this region the problem exists. Given these findings, further investigation can examine these characteristics and most importantly, spatially target interventions that increase public health impact. The LI GIS effort to expose geographic trends in disease occurrence illustrates the advantages of utilizing GIS technology and spatial analysis in public health research and programming. GIS technology has proven to be an extremely valuable tool for offering a more holistic, spatially conscious context for addressing global health problems. “We are used to thinking about questions or research problems in an

analytical way, but what is often missing is the spatial dimension,” said Dr. Patrick Vinck, a research scientist at the Harvard School of Public Health and associate faculty with the Harvard Humanitarian Initiative, to the HCGHR. “Geospatial analysis tools promote the ability to think spatially about problems and to build complex models in order to look at connections, networks and proximity.”

were mapped across different countries in order to predict potential infectious disease outbreaks like the yellow fever epidemic and the subsequent cholera outbreak of 1854 in London, England. Since then, increasing complexity, functionality, and sophistication of such technology has helped researchers more deeply understand the etiology of disease and undertake geographic correlation studies.

The instant visual appeal and widespread availability of GIS mapping technologies will promote future use toward generating awareness and developing solutions for some of the most pressing global health concerns. The increasing ease and accessibility of GIS software has made spatial statistics and geostatistical analyses powerful methods for ordering and analyzing geographically indexed health data which incorporates demographic, environmental, and socioeconomic information among other risk factors. Focusing on the geographical distribution of disease dates back to public health analyses in the 19th century where disease rates

Senior GIS specialist at the Center for Geographic Analysis, Jeff Blossom, has been involved in spearheading the Surgical Safety Map as part of a collaborative between the Harvard School of Public Health and the World Health Organization “Safe Surgery Saves Lives” challenge. The project aims to improve the safety of surgical practice around the world in WHO member countries, through adherence to a tested checklist

FEATURES that minimizes complications and improves patient outcomes. The Surgical Safety Web Map uses mapping to overlay hospital registrants and active users of the checklists with additional information on pilot sites, endorsing organizations and national implementation. Blossom cites proximity analyses and a sort of “geographic mash-up capability” as an example of how “this technology has enabled real-time surveillance that was previously not possible.” This case is one successful example of the ways in which GIS can present a large information supply to a global audience in an extremely clear visual manner. “I do see a need though to find more creative ways to take mountains of data and enable people to see the big picture in just a few minutes. More work can be done to streamline these processes and make it easier to achieve,” said Blossom to the HCGHR. Similarly, Vinck commented on the necessity for greater ease and accessibility of this technology from the highly specialized researcher to an individual who does not necessarily have advanced training with this software. “The complex nature of this software has been improving and there is a wider range of software which is open-source or easy to use online, but it is still challenging for an organization that lacks the advanced skills and knowledge in this technology to produce a map.” Challenges extend beyond the need for technical expertise into larger issues concerning both data integrity and security. Data quality is constantly called into question, as anyone can learn the software and contribute to the online geographic information pool without fully understanding the geospatial statistics being calculated. Unclear methods of collection and the unreliability of data cast a particular amount of uncertainty upon the viability of such information in spatial epidemiological studies. It is also quite difficult to carry out validation studies on large spatial data

This map depicts school locations in Boston with 1,000 foot buffers, and tobacco retailer locations. GIS was used to determine how many tobacco retailer locations were within 1,000 feet of each school in a teen smoking prevention public health study. (Courtesy of the Center for Geographic Analysis Project Resume)

sets, which may result in widespread inaccuracies. Moreover, it is imperative that adequate security measures are instituted to safeguard usage of an information store that includes individual addresses and other sensitive personal information. For example, data regarding HIV or sex-offender status raises a larger question of how individuals and this information are protected. The availability of more intricate geocoded data raises new concerns about novel methods for guarding classified public health records and geographic information. Despite challenges on the horizon, GIS technology poses an exciting avenue for enhanced understanding of the environmental, socio-economic and political among other relationships to health and increased information availability related

to disease mapping. “The future is one that will see a wider sharing of data and a greater ability to connect between institutions and data centers. While data already exists, the influx of information from various sources will increase tenfold and change the understanding of geospatial analyses,” said Vinck. The instant visual appeal and widespread availability of GIS mapping technologies will promote future use toward generating awareness and developing solutions for some of the most pressing global health concerns. It is an important tool for illuminating connections between the environment and health that will engage public health researchers across the world and universalize information flow between the public, academic institutions, and research centers. q

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Big Players, Small Players Innovations in Mobile Health By Charlotte Lee

urrently, over 70 percent of the five billion wireless subscribers in the world live in low or middle-income countries. As usage expands, so does the potential for the application of mobile phones in improving healthcare. In a recent WHO report, 22 low-income countries and 29 high-income countries reported having at least one initiative in mobile health (mHealth). mHealth empowers patients and health workers to better manage health with varied applications spanning diagnostics, text-message reminders, and electronic training manuals. The diverse group that has come together around mHealth initiatives includes “big players,” such as

government systems and large humanitarian organizations with the manpower to restructure a country’s healthcare system, and “small players,” which are innovative individuals and teams that tend to focus on creating smaller-scale solutions to specific problems. Increased future collaboration between these groups is crucial to resolving larger economic, social, and health issues. D-Tree International is a large mHealth provider that works on maternal and child health issues in Tanzania. One of D-Tree’s current projects deals with the electronic conversion of Integrated Management of Childhood Illness (IMCI) protocols. Instead of using confusing paper protocols while

under high-stress situations, health workers with the eIMCI can pull up step-by-step instructions on smartphones to correctly diagnose common diseases like pneumonia and measles. In an interview with the HCGHR, President of D-Tree International Dr. Marc Mitchell explained that these electronic protocols allow health workers to ask more questions and perform essential procedures that might not otherwise have been conducted. The protocol accuracy is promising: the eIMCI made the correct diagnosis 64 percent of the time for severe pneumonia and 91 percent of the time for severe diarrhea, whereas the rates were 22 percent and 67 percent, respectively, for paper

A man uses the simple EyeNETRA clip-on apparatus to take an optical test. (Courtesy of EyeNETRA)

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A healthcare worker using the eIMCI protocol to treat patients in Tanzania. (Courtesy of Dr. Marc Mitchell)

protocols. Dr. Mitchell stated that the accurate diagnosis of patients would lead to an increased confidence in the reliability of the healthcare system: “What is important is that we consistently correctly treat patients so that people build trust in the system and not only use it when they are sick, but believe the messages they are given about preventive care and disease medicine.” Interestingly, Dr. Mitchell views the difference between D-Tree and other mHealth organizations as a systemic one. “Many organizations working in mHealth are basically technology organizations that are looking for ways to apply their technology to a health problem. We are a health organization that looks at how to use technology more generally to solve systemic problems. We are focused on using mHealth to transform the way healthcare is delivered, rather than simply adding a new tool to an existing system,” he declared. In the future, Dr. Mitchell foresees that many of the point-of-care diagnostic tools will be integrated into the healthcare system. He also agreed that isolated mHealth projects are significant but

ultimately asserted that there is a greater need to improve the system. “Health systems in most poor countries don’t work very well, and [although] we can use texting to get people on TB drugs to take their drugs, if half the people with TB are misdiagnosed, it doesn’t really solve all the problems…we must fundamentally make the whole system better,” he argued. Instead of focusing on the entire flow of healthcare in a country, smaller players can concentrate on bringing high-impact technology and health services closer to people. As a simple eye exam clip-on to a smartphone, the MIT Media Lab’s award-winning NETRA (Near-Eye Tool for Refractive Assessment), led by Professor Ramesh Raskar, shows the impact that smaller projects can have on local healthcare accessibility. Professor Raskar called NETRA the “thermometer for the eye” because of its ability to inexpensively characterize refraction errors that health workers can subsequently act upon to detect preventable blindness earlier. Commenting on its portable nature, Professor Raskar stated that “many

times, [health care workers] had to pay 300 or 400 dollars for custom duties just to carry [bulky equipment] across borders” and that the mobile phone “makes it extremely good for them to travel with the solution.” The NETRA lab has implemented its technology in India, Brazil, and Kenya and successfully overcome unanticipated challenges, such as language barriers and local “discomfort with technology,” through establishing a collaborative relationship with local workers. Furthermore, Professor Raskar and his team are hoping to target children through the use of game applications. With a simple shooting game, researchers can identify defects such as near-sightedness or astigmatism by observing the sequence of keys that a child types while playing. In general, larger mHealth organizations have been actively encouraging entrepreneurs and scientists to come up with inventive projects. NETRA itself was a winner of the Vodafone Americas Foundation Wireless Innovation Project in 2011, hosted by Vodafone and the mHealth Alliance. Such increased interaction can enhance global healthcare access by scaling up creative solutions for local problems, allowing for increased awareness of new mHealth tools, and creating possible opportunities for collaboration between groups. Dr. Mitchell noted the existence of an active mHealth community in Tanzania that is coordinated by the government and two NGOs—one of which is D-Tree—and meets quarterly to discuss both different mHealth initiatives and new chances for partnership. The mHealth movement is just beginning to revolutionize healthcare management, and can be further propelled by increasing discourse between big and small players. Like Dr. Mitchell and Professor Raskar, it is imperative for us going forward to consider how we, too, can translate our passions to induce positive healthcare change.q

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Telemedicine in Developing Countries Challenges and Successes

By Nora Eccles

n rural or impoverished pockets of the world, where disease is prevalent, doctors are scarce, and health care infrastructure is inadequate, telemedicine is an innovative solution that connects the developing world to the resources of the developed world. Telemedicine, defined by the WHO as “the use of information and communications technology (ICT) to deliver health care particularly in settings where access to medical services is insufficient,” holds promise in expanding health care access worldwide. Certain aspects of telemedicine, however, are often difficult to implement in underdeveloped settings and should be addressed to capitalize on the potential these new tools offer. Telemedicine can employ a multitude of modern technologies, transmitting information via text, audio, video, or still images to a range of specialists. It is relevant to a variety of disciplines

Courtesy of Glenn Edwards

including dermatology, radiology, and cardiology. With a simple Internet connection, patients can videoconference with a health care professional half-way around the world or email MRI scans for medical analysis. More remarkably, without any face-to-face interaction, doctors can distantly monitor the blood pressure or glucose levels of a clinic’s patients through a computer screen. For regions without adequate healthcare infrastructure, the possibilities of telemedicine are tremendous, as it enables effective medical care despite understaffed clinics and undertrained practitioners. Basic telemedicine initiatives can be established with low startup costs. As Kathleen Fiamma, a Senior Remote Consultation Coordinator at the Center for Connected Health, said in an interview with the HCGHR, “As long as you have a computer, Internet access, and a camera, you can do telemedicine.”

The Center for Connected Health is a Boston non-profit that runs Operation Village Health, a project that provides health services in two Cambodian villages using a few cameras and a handful of donated x-ray, ultrasound, and EKG machines. Doctors at Massachusetts General Hospital and Brigham and Women’s Hospital provide remote consultations for these patients at no charge. In general, telemedicine potentially eliminates a number of other costs, including travel expenses for specialists and patient transfers. In a resource-constrained setting, this can have a substantial impact on health care access. Moreover, by utilizing these technologies, local doctors are able to learn from more experienced physicians across the globe. For Operation Village Health, nurses provide a diagnosis and outline treatment strategies before e-mailing patient data to Boston doctors, who then revise these proposals as they see

FEATURES fit. With practice, local nurses are better able to recognize particular diseases and devise treatment options. Kathleen Fiamma observed, “A lot of the problems that we had seen an abundance of in the beginning we do not see any longer, and I think that is just because [the local nurses] know how to manage them so well that it is second nature to them.” At first, language barriers and unfamiliarity with technology often inhibit communication between professionals, but these issues are usually solved with time, as both parties grow accustomed to working with one another. Although telemedicine may reduce physical barriers to care, it also can generate a new series of concerns that need to be addressed in order to produce successful outcomes. The Opportune Breast Cancer Screening and Diagnosis Program (OBCSDP), a pilot program initiated in rural Mexico to send mammograms to radiologists in cities via the Internet, recognized equipment breakdowns and impossibly slow Internet connections as major impediments.

Adrian Pacheco, director of the Centro Nacional de Excelencia Tecnológia en Salud, explained to the HCGHR, “The biggest challenge is [Internet] connectivity. The diagnostic centers are ready and available to do more than 150 screenings every day and they do not reach even 50.” While OBCSDP is working to acquire more reliable technologies, doctors instead place the image scans on CDs and use ground transportation to deliver them; this serves as a good interim solution but results can take up to three weeks, substantially delaying the diagnostic process. The lack of an international framework to enable health care professionals to deliver medical services outside of their licensed jurisdiction presents another barrier. Furthermore, transmitting patient files via the Internet threatens patient privacy. To address this concern, non-profits such as the Center for Connected Health are working toward solutions like making Skype, a videoconferencing tool, compliant with medical codes so that doctors can communicate

over the Internet without the liability of breaching doctor-patient confidentiality. Finally, despite their successes, telemedicine programs are still working to achieve the results needed to propel this new mode of health care forward. A survey by the Pan-Asian Networking Project, which studies the effects of telemedicine in India, emphasizes the importance of documenting the costbenefits of telemedicine programs in order to rationalize initial ICT expenses to potential investors. In a world where income level, ethnic origin, and geographical location serve as primary determinants of people’s access to health care, telemedicine constitutes a possible approach to overcoming many of the existing barriers to care. While there are still many concerns that lie in the way, Dr. Joseph Kvedar, Director of the Center for Connected Health, asserted to the HCGHR that telemedicine is exceptionally promising due to “the great value that can be brought… by the possibility of time and place independence in health care.” q

Local nurses can perform telemedicine by using a simple digital camera to document a patient’s ailment and sending it to a specialist doctor for consultation. (Courtesy of Glenn Edwards)

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Applying Technology to Global Mental Health Issues Beneficial or Detrimental? By Leeann Saw

n the technology-inundated societies of the West, popular health media often bemoans the negative impact that laptops, iPods, and smartphones have on mental wellbeing. As Dr. Frederick Muench of Columbia University puts it, the media warns us that surrounding ourselves with technology can transform us from healthy individuals engaging with society into “socially avoidant impulsive sexters.” However, in countries like the United States and the United Kingdom, healthcare providers are beginning to utilize technology to improve mental health outcomes. New and innovative practices are bringing together the fields of technology and mental health in a productive way, and it is useful to explore how these recent Western practices might or might not be applied in the developing world. E-monitoring and telepsychiatry are two widely used new techniques that are bringing technology into mental health treatments. E-monitoring is the use of online tools and smartphone applications to track patient progress and symptoms. In 2008, the BBC highlighted a new e-monitoring system pioneered by Oxford University in which patients receive a text message from their clinician each day and respond with a letter indicating their mood on a scale from

A to E. The medical team then analyzes the data to plot mood swings, monitor medication-effectiveness, and decide when the patient needs his/her next faceto-face appointment. Telepsychiatry, or the use of videoconferencing systems to deliver care, is also gaining popularity in the U.S. and Europe. According to a New York Times article entitled “When Your Therapist Is Only a Click Away,” Skype and thirdparty online therapy sites, are making “online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.” Therapists can contact patients who live far away and can treat patients for whom leaving the comfort of home exacerbates symptoms. However, the article also discusses some of the disadvantages of the method, including camera-position on computers (which makes gazes off-kilter), lighting issues, and a reduced feeling of intimacy between doctor and patient. These innovative uses of technology are becoming increasingly accepted as a part of Western mental health, but the export of any Western psychiatric treatment to the developing world is highly controversial. Some contend that there is a moral imperative to provide U. S.

and Europe-based treatments to other nations. In its August 2006 issue, the American Journal of Psychiatry ran an editorial on the “moral case for international mental health,” which stressed the treatability of mental disorders in developing countries while highlighting human rights violations perpetrated against mentally ill individuals in these nations. The authors hold up the global battle against HIV/AIDS as a case in which treatment has been successful in combatting both disease and social stigma. Conversely, other mental health professionals insist that Western mental health diagnoses do not map onto understandings in other countries, rendering Western solutions useless or even detrimental to foreign patients. In an article published in BMJ in May 2008, Dr. Derek Summerfield of the King’s College Institute of Psychiatry asserted that because the psychiatric categories used in the West are essentially descriptive syndromes, they are not universally valid. In fact, in the developing world, symptoms that might in the West be considered “satisfying criteria for a mental disorder,” might actually be a “normal reaction to harsh living conditions.” This larger debate raises important questions about the potential effectiveness of recent technological applications

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Many Western mental health professionals are now using texting to monitor patient progress between face-to-face appointments. (Courtesy of Alton, Wikimedia Commons)

outside the U.S. and Europe. In an interview with the HCGHR, Holly Prigerson, an Associate Professor of Psychiatry at Harvard Medical School, discussed her work on an online intervention for Prolonged Grief Disorder (PGD) in this context. The intervention, called Healing Emotions After Loss (HEAL), is currently being used to treat the grieving family members of deceased patients at the Dana-Farber Cancer Institute. The advantages of the system have become clear in testing. In Dr. Prigerson’s words, “HEAL is anonymous, can be accessed at any time of day, and is a cost-effective, low-intensity way of getting to people who are at risk for years and years of not feeling happy.” Though her international research has indicated that PGD is a largely generalizable diagnosis, Dr. Prigerson emphasized that “more data is needed about the universality of grief and grief treatments before [she] would universally recommend any kind of broad online version of HEAL.” Dr. David C. Henderson, an Associate Professor of Psychiatry at Harvard Medical School and Director

of the Division of Global Psychiatry at Massachusetts General Hospital, also stressed the importance of conducting thorough research before attempting to apply new technology-based treatments abroad. “People are rushing to do treatment over the internet,” he said in an interview with the HCGHR, “but if you don’t understand the population, you’re going to miss things.” Before making new treatments available in the developing world, Dr. Henderson suggested that healthcare providers should “build partners with people who understand the population and the population’s cultural

idioms” and tailor the treatments to the needs of specific groups. Innovative technology-based psychiatric treatments are becoming increasingly common in the U.S. and Europe. But the application of these solutions abroad is, like the field of global mental health in general, highly controversial. However, what is clear is that these technological treatments cannot be applied wholesale in foreign environments. Instead, their universality must first be confirmed through thorough research into the culture of the target population. q

VISIT THE HCGHR ONLINE FOR MORE GLOBAL HEALTH COVERAGE http://www.hcs.harvard.edu/hghr/

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The Impact of Social Media on Medicine Expanding the Scope of Treatment By Megan Parsons

he confluence of social media and medicine has many benefits. In fact, the medical community has been able to take advantage of the power of the diverse and cohesive online community that has formed around social media websites like Facebook, Twitter, and YouTube to propel medical interests forward. These medical communities include an array of doctors, relief workers, patients, and advocates who would otherwise be inaccessible if the success of social networking websites had been more limited. The reciprocal impact of social media on medicine is a new phenomenon with far-reaching implications for disaster relief efforts, disease advocacy, and epidemiology. The devastating magnitude 7.0 earthquake that struck Haiti in 2010 left the country in ruins: collapsed buildings, separated families, and unsanitary conditions remained in the wake of the disaster, posing significant challenges to survivors and aid workers. In the race to provide relief, organizations mobilized to provide food, shelter, water, and medical supplies to families in need. Foreign aid immediately poured into Haiti to provide necessities, and there was a sustained effort to help rebuild infrastructure. The world received its first glimpse of the destruction not through

traditional media outlets, but through social media sites. Images of the devastation, taken by camera phones and uploaded to the Internet, reached millions of viewers and focused attention on the victims of the quake. Instead of relying primarily on news organizations for the latest information, people logged onto websites where they were able to see the effects of the earthquake through first-hand accounts.

Over the past few decades, social media has considerably extended the scope of medicine for better disaster relief and medical treatment in the global community. Eight days after the earthquake, Oxfam International managed to raise $110,000 through Facebook in its hugely successful “Help Earthquake Survivors in Haiti Cause.” Oxfam also

used Twitter to spread awareness and raise funds for emergency relief efforts. These successful fundraisers took advantage of the extensive following on Facebook and the ability to “re-tweet” information on Twitter. Management Sciences for Health (MSH), a nonprofit international health organization, benefitted from the use of social media tools during the earthquake as well. “During the Haiti earthquake, MSH also utilized Twitter and Facebook to try and communicate with and locate missing staff members. Luckily all staff were eventually accounted for,” said Dr. Jonathan Quick, President and CEO of MSH, to the HCGHR. “MSH relies on social media to educate – in real-time – evidence-informed health practices to a wide audience. We tweet about field reports, new tools and about innovative ideas discussed at conferences or symposiums that we attend. ‘Go to the people’ is a core value of our mission – since many of the world’s people are active in social media and get information via mobile phones, social media is another element of going to and reaching people where they are. By using social media, MSH increases its global health impact,” said Quick. Social networking can also help bring resources to impoverished areas. Tom Vanderwell, in his blog for the Mayo Clinic Center for Social Media,

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shared a story of how Facebook brought an orphanage in Haiti in need of a particular medicine to the attention of the Chief Medical Officer for a regional health center. The need was noticed by a friend-of-a-friend and the situation was remedied; the children of the orphanage were able to receive proper medical care. Accordingly, social media is an effective and efficient way to bridge the gap between the needs of impoverished areas and the resources of professionals around the globe. Vanderwell believes that “lives will be saved because of Facebook.” In addition to assisting with disaster relief and resource scarcity, social networking can prove useful for combating chronic diseases. According to the National Institutes of Aging, there are as many as 5.1 million Americans with Alzheimer’s disease. Experts say that it’s likely that we will see an increase in prevalence of the disease over the next few decades as advancements in medical technology extend average life expectancies. In order to tackle this global issue, the public must be made aware of the

devastating impact Alzheimer’s disease has on individuals and their families, the increasing prevalence of the disease, and the hope that exists because of the ability of the community to effect change collectively. When a loved one is diagnosed with Alzheimer’s disease, a supportive community can help someone understand the progression of the disease and ways to handle it. The Alzheimer’s Society educates a wide audience through its YouTube channel with videos like “Living with Dementia” and “Caring for a Person with Dementia.” In addition to education, another vital component of tackling this disease is advocacy. On the Alzheimer’s Association website, for instance, it is recommended that people use Facebook applications such as “Fundraise with Facebook” to raise money for care and research. Members can also exchange personal experiences through Facebook’s “Share Your Story” feature. Not only can social media provide caring communities, but it can also assist epidemiologists in studying

disease trends. One such instance of this is the tracking of dengue fever in Brazil by scientists at the Brazilian National Institutes of Science and Technology using information posted by the nation’s Twitter users. The project’s software identifies key words in tweets, such as “dengue” and symptoms like “bone pain” and “eye pain,” and subsequently matches the origins of these key words to specific locations. It was tested on 2447 tweets between January and May 2009, showing a strong correlation with data from the Brazilian Ministry of Health. Such valuable information can be used to conduct a real-time surveillance of outbreaks and potentially launch preemptive public health measures to prevent their spread. Over the past few decades, social media has considerably extended the scope of medicine for better disaster relief and medical treatment in the global community. As our technological capabilities expand, there is no doubt that it will become a potent tool for healthcare in the decades to come. q

Facebook allows its users to create pages like “Help Earthquake Survivors in Haiti” to spread awareness and fundraise for the cause. (Courtesy of Megan Parsons)

MoTeCH and m2m FEATURES

Using Mobile Technology to Improve Maternal Health By Homan Mohammadi

aternal health has been a key priority in the global health agenda for decades, as its issues, despite their persistence, are largely preventable. Despite efforts, however, death during childbirth remains one of the leading causes of mortality among women worldwide; according to a 2008 study published in The Lancet, 342,900 women die annually during pregnancy or childbirth. The vast majority of maternal deaths in the developing world, however, are avoidable with timely prenatal and postnatal care. Recently, there has been a surge in the use of mobile devices to improve healthcare in the developing world â&#x20AC;&#x201C; a practice referred to as mobile health or mHealth. Since mobile phones are abundant in developing nations, governments and leading NGOs have enthusiastically supported their application to maternal health issues. Two global health programs, mothers2mothers (m2m) and Mobile Technology for Community Health (MoTeCH), have employed mobile health technologies to improve the provision of maternal healthcare. The successful integration of mobile phones in these programs has expanded their opportunities for conducting health interventions and improving access to care. Yet, these organizations face the key challenge of reducing the barriers that prevent mothers and health professionals from fully utilizing these

potentially beneficial resources. m2m, which has over 700 sites in nine African countries, has integrated maternal health services in communities to prevent mother-to-child transmission of HIV. They hire and train Mentor Mothers living with HIV to work in health facilities alongside doctors and nurses. The Mentor Mothers offer psychosocial support and health advice to pregnant mothers who are also HIV-positive. m2m recently began using cell phones to provide information to pregnant mothers, as well as to receive their feedback. Mentor Mothers and site coordinators have been communicating with mothers through cell phones

to collect and share health information. m2m is currently collaborating with Johnson&Johnson on the Mobile Alliance for Maternal Action (MAMA), a new partnership that leverages mobile technology to help prevent death during childbirth. Dr. Mitch Besser, founder and medical director of m2m, stated in an interview with HCGHR, â&#x20AC;&#x153;[m2m] is currently considering the role of incentives to have mothers return to clinics, and is thinking about using a grant from Vodafone to give mothers cell phone airtime. This could serve as an incentive.â&#x20AC;? m2m expands upon currently existing mHealth initiatives like the MoTeCH program. Launched in Ghana

mothers2mothers mentors provide psychosocial support to new HIV-positive mothers . (Courtesy of m2m)

FEATURES

Cecilia Adda, a nurse at the Wuru Community Health Compound, Ghana, reviewing the immunization records of a newborn. (Courtesy of the Grameen Foundation)

in 2010, MoTeCH is comprised of two integrated services: the Mobile Midwife Application and the Nurses’ Application. The Mobile Midwife Application focuses on providing weekly, timespecific updates and reminders for pregnancy-related concerns, including required vaccinations and awareness of transportation costs to nearby health facilities. The Nurses’ Application is utilized by community health workers at rural health facilities to log information about patient visits into mobile phones. Thus far, MoTeCH has only had the time to gather preliminary results from qualitative interviews to evaluate the efficacy of these programs. Initial feedback for the Mobile Midwife Application has been very positive. Feedback for the Nurses’ Application, on the other hand, has been mixed, with some nurses complaining about the length of time involved in entering data. Ms. Allison Stone, the Project Manager of MoTeCH, stated in an interview with the HCGHR, “To our knowledge, there are very few mHealth projects that encompass all that is included

in MoTeCH: data capture by health workers, data feedback to health workers, information services for clients, and data reporting for supervisors, managers, and policy-makers.” Despite its comprehensive approach, MoTeCH has faced difficulties such as incomplete data entry by nurses and lack of access to text messaging amongst mothers. With regard to the last concern, Stone indicated that MoTeCH is considering various new tactics. “We expect that solutions might include loaning phones to women during pregnancy and their child’s infancy, providing extra training for women in the use of phones so that they will be able to confidently access their messages, or making the procedure for accessing MoTeCH messages simpler,” said Stone. The inventive solutions considered by MoTeCH to improve access to messaging underscore the importance of innovation within mHealth. Recently, users on Open IDEO, a website for devising new solutions to social problems, submitted numerous ideas about how mobile technologies can improve

maternal health globally. One winning idea was a program that, unlike m2m’s hiring and training model, allows pregnant mothers to choose a mentor via text from a list of qualified, experienced mothers who are volunteering their time in the community. Rather than serving in health facilities, mentor mothers can meet with their mentee in a public location such as a local market and share their personal experiences in an informal setting. Such creative approaches hold much promise for the future of maternal health. Initiatives that encourage the establishment of personal connections in the community may transcend the simple utility of the mobile phone itself. Regular updates from phones would not be needed to sustain these projects; instead, mobile technology can simply act as a social trigger that sparks new connections and ultimately improves health outcomes. In this manner, mHealth can reach beyond simple delivery and feedback technologies, allowing for sustainable solutions that are in tune with social and cultural contexts.q

FEATURES

Global Health Informatics The Impact of the Internet on Peru’s Healthcare System

By Allie Pace

nformation transfer through the Internet has rapidly transformed the doctor-patient relationship. Particularly in places like the U.S., almost everyone owns a computer and has easy access to a wide range of often valuable but conflicting health information with a simple mouse-click. Specifically, the state of Peru’s health informatics system provides a lens into the transformation of the doctorpatient relationship that is resulting from Internet expansion in developing nations, and exposes a pressing need for educational training in the medical profession concerning the impactful use of these online resources. Peru has one of the highest numbers of Internet users in public areas, totaling over 10 million users in 2006. “[In Peru,] Internet access has been promoted by Internet cafes. The poorest areas can now access the Internet, so [it] has become a potentially very important tool to empower people and give them access to information,” explained Dr. Walter Curioso, a professor at the Universidad Peruana Cayetano Heredia (UPCH) in Lima and at the Biomedical

and Health Informatics department at the University of Washington School of Medicine. The Internet is serving as a new medium for Peru’s health systems to improve and expedite data acquisition, information transfer, and patient awareness. In a survey conducted in 2007, a staggering 93 percent of patients living with HIV/AIDS in Peru reported an interest in obtaining their lab results via the Internet. As a result, the Peruvian National Institute of Health developed NETLab, a pioneer online system providing test results to patients. By 2008, over 900 patients living with HIV/AIDS were registered. Due to its success with patients, NETLab is now expanding to report patients’ lab results for other

conditions. Dr. Wafaie Fawzi, Chair of the Department of Global Health and Population at the Harvard School of Public Health, addressed the potential impact of these online resources. “The Internet allows patients to be proactive in the management of their own conditions,” said Fawzi in an interview with the HCGHR. Online tools like NETLab empower patients to access their own diagnostic information, resulting in more efficient clinical rounds. As Curioso noted, “[Patients] want health information, but sometimes the health professionals do not have the time to provide it.” As for physician use of these online resources, a cross sectional survey of nearly 300 physicians in Peru revealed

The internet allows patients to be proactive in the management of their own conditions.

FEATURES that 84.2 percent have used the Internet to seek medical information. In fact, several virtual libraries and online journals have recently gained popularity due to their provision of quick, relevant information to physicians, health care workers, and patients alike. The Health InterNetwork Access to Research Initiative (HINARI), managed by the World Health Organization, is one of the main initiatives present on the online healthcare scene to provide free or low-cost online access to over 8,000 international science journals. Unfortunately, the presence of these helpful programs does not guarantee their regular use. In fact, physicians obtain most of their information by first consulting textbooks (69.1 percent), colleagues (50 percent), and then finally the Internet (32.9 percent). Renzo Bustamante, a medical student at UPCH in Lima, commented in Curioso’s eHealth case study on Peru about the lack of training that students receive in this area. “The majority of

students do not know how to search for the medical information they are looking for, and they do not even know how to access to specific journals,” Bustamante reported. “Most of my peers do not know how to perform a systematic search...most of them use Google, because [it] is easy and less complex.” Accordingly, the major factors that hinder the effectiveness of training programs need to be addressed. Fawzi noted

that the developing world faces obstacles such as the limited availability of adequately trained health workers, an inequitable distribution of workers, and a disparity between knowledge that is needed and knowledge that is available. He recommended a potential solution in which training in Internet utilization can be integrated into both preservice and in-service training for medical professionals.q

VISIT THE HCGHR ONLINE FOR MORE GLOBAL HEALTH COVERAGE http://www.hcs.harvard.edu/hghr/

A typical Internet Cafe found in Peru. (Courtesy of Nicolas Nova, Flickr)

FEATURES

Global Health 2.0 What Does the Future Hold?

Courtesy of Grant Miller

magine a world in which all people are well-informed about HIV/AIDS, travel with their medical history on a mobile phone, and have instant access to the world’s best physicians via telemedicine. These are only a few of the advances that experts have envisioned as part of the future of global health. Today’s technology is driving unprecedented changes that will shape tomorrow’s health care policy and delivery. In order to understand what lies ahead in the health care field, we must adopt a multidimensional perspective of the major challenges that global health will experience in the immediate future and beyond.

CHALLENGES FOR THE FUTURE

The field of global health is undergoing a technological revolution. Emerging subfields such as mobile health (mHealth) and telemedicine are poised to define the future of health care delivery. Jay Bernhardt, Director of the Center for Digital Health and Wellness at the University of Florida, said in an interview with the HCGHR, “Hundreds of exciting mHealth pilot

By Tarina Quraishi programs are underway throughout the developing world, but many of them have not yet been evaluated.” He added that both mobile health and telemedicine require access to data services like 3G, which are currently unavailable in rural regions of countries such as India and China. Indeed, the widespread and effective use of these technologies has yet to be realized. In an interview with the HCGHR, Grant Miller, an assistant professor of medicine at the Stanford Center for Health Policy, remarked, “Adoption and use are often low even when these technologies and services are provided at low or no cost.” For example, if HIV vaccine information is distributed over mobile phones to rural African villages, but a single phone is shared among a community, not everyone will have equal access to the information. “Economics and other social sciences have large contributions to make in shedding insight into these behavioral obstacles and helping to formulate strategies to circumvent them,” said Miller. Building understanding through comprehensive research of cultural norms in specific

communities and their connection to health is a critical strategy for the advancement of health care in the 21st century. Climate change is another significant factor that may shape future global health issues. “In recent years, there has been an increase in occurrences of drought and reduced rainfall in parts of China and northern and western Africa due to climate change,” said Dr. Jennifer Leaning, Director of the Francois-Xavier Bagnoud Center for Health and Human Rights at Harvard University. Climate change causes agrarian crises such as a decline in the nutrient value of crops, leading to malnutrition and economic plight. “These events have a long term impact on population health and disease,” said Leaning. Moreover, in populous developing countries such as China, drought and famine lead to increased migration to cities whose populations are already extremely large. “This contributes to the proliferation of infectious disease and introduces new environmental health issues, such as upper respiratory problems caused by air pollution,” said John Spengler, Professor of Environmental

FEATURES Health and Human Habitation at the Harvard School of Public Health.

TOMORROW’S GLOBAL HEALTH

In the next decade, information technology will drive health innovation, especially in developed regions such as the United States and Europe. Data integration has the potential to move health care forward. “As more data from government and other sources become available, and we gain the ability to mine long-term data from Twitter and other sources, a lot of exciting discoveries can be made around health,” said Bernhardt. For example, compiling and analyzing all Tweets that reference Type 2 diabetes could help researchers find predictive patterns of Type 2 diabetes patients’ most common medical concerns and health care choices, allowing physicians to better inform patients’ decisions. Geo-location technology in mobile

phones will also contribute to the development of digital health. Bernhardt cites the example of how GPS could prove invaluable to a diet-tracking mobile phone application: “If you are trying to manage your diet, we can track which foods you eat in which place. If lunchtime at work is when you’re eating unhealthy food, we can send you reminders an hour before lunch to eat a healthy lunch, or even nag you when you get to a fast food restaurant.” In this manner, geo-location and mobile technology can be utilized to compile an individual’s data and send them customtailored information to promote health awareness. Major innovations in health technology may also arise in developing countries, where rapid growth of population, economy, and infrastructure will lead to unique new challenges in health care. Miller illustrated the scenario of a country such as India, which

has both a large, rising middle class and a substantial low-income population, so that health care providers might need to address malnutrition and obesity simultaneously in one region. In order to address these new health needs, we must rethink the role of international organizations as partners rather than leaders in developing nations, with a focus on empowering local institutions and individuals to develop new health care delivery strategies. “People who know local settings best are the ones with the greatest potential for new insights into how to address challenges to the implementation of health improvement measures,” explained Miller. In the end, as Leaning asserts, “challenges to health are challenges to society.” As the world becomes more urban and interconnected, diverse perspectives must merge in order to prudently shape the future of global health.q

In rapidly developing countries like India, issues like malnutrition and obesity can often co-exist in one region, causing a double burden. (Left to right: Courtesy of Christian Bachellier, Flickr; Courtesy of Sandra Cohen-Rose and Colin Rose, Flickr)

Student Initiatives Remindavax is an mHealth project leveraging text-message reminders to improve health care delivery in rural southern India. Students Annie Ryu (College ’13), Alex Ryu (HMS ’15), and Brandon Liu (College ’14) founded Remindavax in 2010 with advising from Professor S.V. Subramanian at HSPH and funding from the Harvard Global Health Institute, the South Asia Initiative, University of Pennsylvania’s Center for the Advanced Study of India, and Microsoft’s Imagine Cup.

Teammates Brandon Liu, Alex Ryu, and Annie Ryu and Microsoft Evangelist Edwin Guarin smile for a photo after Remindavax placed fourth in Microsoft Imagine Cup’s U.S. Finals.

Alex and Annie had the idea for Remindavax in summer 2010, when Alex was interning with the NGO Karuna Trust in India, and Annie was working to improve maternal and child health in Nicaragua. The two deduced that a text-message-based intervention could have a significant impact on improving use of antenatal checkups and infant vaccinations in India, given the tremendous market penetration of mobile phones in rural India. Alex briefly piloted a basic text-message reminder program while in India and gained Karuna Trust’s enthusiastic support for the intervention. Over the course of the next year, Alex and Annie partnered with Brandon Liu, Remindavax’s initial lead developer, to design the software. By summer 2011, Remindavax had evolved into a patient management and electronic medical records system, operating through a web application and sending text-message reminders to patients and providers.

Annie and Alex implemented Remindavax in six primary health centers in rural Karnataka, India, in summer 2011, and the program is currently serving over 2,200 mothers and pregnant women. With the help of our Director of Field Operations, we are expanding to serve several other primary health centers managed by Karuna Trust and are forging collaborations with other healthcare organizations in developing countries. Our aim is to realize the potential benefits of textmessage reminders in healthcare: to improve treatment adherence, appointment attendance, and, moreover, health outcomes for the people we serve. Students interested in working with Remindavax should contact Annie or Alex through info@remindavax.org. We are looking for a Director of Field Operations to lead project development from India for summer 2012. We welcome ideas and proposals from students, who can then lead in developing these projects if they wish.

STUDENT INITIATIVES

Harvard Tobacco-Free Initiative Top Row (left to right): Bran Shim, Helen Yang, Mackenzie Lowry, Annie Ryu, Yun Jee Kang; bottom row (left to right): Bridget Gosis, Audrey Zhang

In the 2011-2012 school year, the Harvard Undergraduate Global Health Forum (HUGH Forum), as part of the University-wide initiative Harvard Tobacco-Free Initiative, is working to increase student awareness of tobacco-cessation resources and make Harvard Yard smoke-free by the end of this school year. This initiative, led by Mackenzie Lowry ’11, has already garnered the support of many stakeholders, from the IOP Tobacco Control Policy Group and Harvard DAPA, to professors and administrators. In light of recent successful transitions to smoke-free campuses near the Longwood Medical Area and at many colleges around the country, support for this initiative is bold and ever growing, and its adoption would make our university the first Ivy League school to go smoke-free. This fall, members of the IOP Tobacco Control Policy Group, which is advised by Lowry (now a freshman proctor in Wigglesworth), assembled a policy brief entitled “Eliminating the Smoke-Screen: Steps to a Smoke-Free Harvard 2012” outlining the steps to take towards reaching the goal of making Harvard Yard smoke-free by the end of this school year. In March 2011, HUGH Forum sponsored a panel on the WHO’s Framework Convention on Tobacco Control (FCTC) in an effort to increase students’ awareness of the challenges of tobacco control policies. The FCTC treaty has been signed and ratified by more than 160 countries, with the United States notably absent. Moderated by Lowry, the panel featured Dean Allan Brandt, HSPH Professor Greg Connolly, and Corporate Accountability International representative Gigi Kellett, all of whom emphasized the urgency for students to become involved in this cause. In the following weeks, HUGH Forum acquired many students’ support for Corporate Accountability International’s petition to President Obama to ratify the FCTC. Although we have made significant strides toward our goal of making Harvard Yard smoke-free, there is still much to be done. Ours is a multi-faceted approach, including polling and assessing student views on tobacco, holding discussion forums, reaching out for support from faculty and administration, researching effective models of cessation and tobacco-free practice at other universities, and ultimately presenting our research and recommendations to the University Provost and President. There are many ways to be involved in this campaign through HUGH Forum, and we ask that any and all interested persons please contact Helen Yang ’12 at global@hcs.harvard.edu for more information. Smoking is one of the leading causes of preventable death worldwide, and with your support, Harvard can lead the Ivy League and the country in ensuring that campuses become smoke-free.

Say Yes to (AIDS) Drugs

Participants in Harvard’s “Say Yes To Drugs” campaign held this “Pool Party” demonstration at Merck’s laboratories on October 21, 2011.

The “Say Yes To (AIDS) Drugs” campaign urges pharmaceutical companies to join the Medicines Patent Pool, an innovative model in which pharma, universities, and research institutes voluntarily share their patents and allow generic production of lifesaving AIDS medicines. This semester, we are specifically working with Merck, a pharmaceutical company that holds the patents for vital antiretroviral medications that could save millions of lives. Merck, which coincidentally has research labs adjacent to Harvard Medical School and strong ties to Harvard, has refused to negotiate with the Patent Pool. We will be working to show Merck the importance of the generic access provided through the Pool and will be meeting with professors, community groups, and, we hope, representatives from Merck to discuss the Patent Pool. With new studies showing that treatment is prevention, the Patent Pool represents an important opportunity and innovative way to move our generation toward the eradication of HIV.

Come join the fight! Check out our website sayyestodrugs2.org or email hcghac@gmail.com for more information and to get involved!

Initiative to End Childhood Malnutrition

Global Hunger Initiative Presidents Chris Goldstein and Katherine Lim weigh a severely malnourished child at Karoli Lwanga Nyakibale Hospital in August 2010.

The Initiative to End Childhood Malnutrition (IECM) was created in 2009 as a collaboration between the Harvard College Global Hunger Initiative (GHI), Massachusetts General Hospital (MGH) Division of Global Health & Human Rights, Department of Emergency Medicine, and Karoli Lwanga Nyakibale Hospital in Uganda. This collaboration was founded to establish locally sustainable, effective, and reproducible malnutrition programs within developing areas. Currently, IECM is targeting Rukungiri district, Uganda, which has a high incidence of severe acute malnutrition amongst children under five. Dr. Keri Cohn, an MGH Global Health Fellow, has been the incountry director under the leadership of Dr. Thomas Burke and Dr. Roy Ahn of the MGH Division of Global Health & Human Rights. Harvard students Sarah Nam, Gordon Liao, and Katherine Lim led the student portion of the inaugural January-term trip in 2011.

STUDENT INITIATIVES

Sustainable Point-Of-Use Treatment and Storage (SPOUTS) of Water was founded in January 2010 by Kathy Ku ’13 to combat the high incidence of water-borne illnesses in Uganda. Along with other founding members Suvai Gunasekaran ’13, Ryan Heffrin ’13, and Esther Chung ’14, Ku established SPOUTS of Water as a Massachusetts non-profit organization and worked to produce a new ceramic filter design through the combined efforts of Boston professional engineers and Harvard students. SPOUTS of Water aims to build a ceramic water filter factory in Uganda. Many of the non-governmental and other aid organizations currently working to improve water quality in Uganda import their water filters from outside the country. SPOUTS of Water wants to help bring this market into Uganda by producing affordable ceramic filters in-country using local materials and labor. In addition, SPOUTS hopes to eventually become self-sustainable by using the income generated by the factory to fund the project. SPOUTS engineers have also created a cost-effective ceramic water filter design to help bring down the costs of production even more. Finally, SPOUTS of Water’s partnership with Kampala University in Uganda aims to increase local collaboration and education initiatives though the ceramic filter factory and business. Currently, SPOUTS members are working with Kampala University to find the land and local resources necessary to set up a factory. Members are also exploring other local partnerships that could help turn this idea into a viable business. SPOUTS of Water plans on having an assessment trip in January and hopes to implement the project in the summer of 2012. To become involved, students can visit spoutsofwater.org or contact us at spoutsofwater@gmail.com. Weekly general meetings are held from 8:30 to 9:30 in the Lamont Forum Room.

The MGH Division of Global Health & Human Rights, Nyakibale Hospital, and the Harvard College GHI have since supported the program and continued to send students and doctors to assist with the implementation of this project. Since its inception, the program has: 1) established a locally sustainable Inpatient Therapeutic Care component that has decreased malnutrition-associated morbidity and mortality, 2) implemented a local microenterprise initiative to ensure financial sustainability, 3) developed community gardens to provide nutritional education, and 4) established an Outpatient Therapeutic Care Program to target malnourished children who cannot be treated on an inpatient basis. Along with these accomplishments, GHI/IECM has hopes to replicate the program in another Ugandan Hospital in a comparable rural setting, integrate the malnutrition protocol into the Nyakibale Nursing School, create a Village Health Team education component, and evaluate efficaciousness of nutritional education. The Harvard College GHI is directed by Chris Goldstein and Katherine Lim and is open to all Harvard undergraduates. Students interested in participating in the program are encouraged to attend GHI meetings, which are held Sundays at 4 PM in the Lamont Forum Room. If you have any questions please e-mail Chris Goldstein at cgoldstein13@gmail.com. This work is funded by The John and Katie Hansen Family Foundation, Harvard International Relations Council, Ujenzi Charitable Trust, and IZUMI Foundation.

INTERVIEWS

An Interview with: Dr. Peter Piot

Interviewed by Ava Carter

Courtesy of Pieter Morlion, Wikipedia

HCGHR: In light of the global recession and the recent problems in the U.S. budget and economy, what problems in the funding of global health do you forsee in the immediate future? Specifically, how do you see a downturn in funding affecting the number of people newly infected with HIV or in need of treatment? Dr. Piot: First of all, it is not a U.S.-specific phenomenon. Last year, for the first time, UNAIDS reported AIDS funding went down. I mean, there’s been a historic increase since 2001, when the UN general assembly on AIDS said that was a tipping point, and now last year for the first time there’s been a decrease. And the U.S. at this time last year continued to increase, but now nearly all the countries are reducing their AIDS budgets in general as a result of the economic downturn and financial crisis in the West. And the emerging economies like China and India have not come in and have not replaced the western countries that are declining in this kind of funding. And so the first point is that it’s quite a general phenomenon. Secondly, you know, I am

concerned that this is going to get worse but the problem is that it is hard to predict anything and it will depend on how the economy is going to evolve and emerge, and I would say there is a bit of a paradoxical effect in the sense that there are real achievements in terms of AIDS. There are less people dying and less people becoming infected and so some people say, ‘Okay, it’s done,’ but AIDS is not over. Thirdly, we know that when funding is going to go down, less people will have access to treatment and more people will become infected and we’re seeing that the achievements in AIDS are both a result of increased funding and increased programs and political commitment. So it’s not such an optimistic picture, but on the other hand I think that we need to do two things. One is to do better with the money that we have at the moment. We can save costs, we can be more strategic with what we’re doing and we can be more efficient. And two is to lobby and continue to show that this is still a crisis by any standard. HCGHR: As the new director of the London School of Hygiene and

Tropical Medicine, you have taken on the task of teaching and inspiring the next generation of students interested in making a difference in the field of global health. What changes do you expect and would you like to see in global health education and training both at LSHTM and worldwide? Dr. Piot: Yes, first of all, I think that one of the drivers of this global health movement are young people and the incredible interest of the Facebook generation and [that] people feel so connected... So that is something that I think is so positive but it’s not something that has always been reflected in the teaching and training programs. And for me there are two quests: global health should not only be taught and should not only be a concern for students in health sciences, in medicine, or in public health. It is something that affects all disciplines so there could be contributions across the university. I personally think that it should also be part of the undergraduate package and collecting that with practical experience in the U.S. or overseas. But for me I think it is important to make it part of the core curriculum. And lastly, I

INTERVIEWS

Global health should not only be taught and should not only be a concern for students in health sciences, in medicine, or in public health. would say what I mentioned before. To go beyond the health sciences. I mean the business schools and engineers, etc. I think we tend to think of it too much in our box of medical science. HCGHR: During your time at UNAIDS, you focused a lot on spreading information about how to impact the HIV/AIDS epidemic through social media, such as YouTube and television, to reach youths. How do you think the use of YouTube, Facebook, Twitter, text messaging, and other forms of social media have impacted the prevention and treatment of the disease? Dr. Piot: I do not know because I do not have the facts or data, but I think it’s playing a major role in the sense of the global interconnectedness that I see. And spreading information has been a major element in the powerful AIDS activism movement globally and this has been key in terms of being effective and impacting the official agenda. I think that it can go either way. It’s wonderful to spread very fast information but it can also be a way of concentrating or spending time on trivial issues that are not going to be changing the world. HCGHR: The London School of Hygiene and Tropical Medicine in 2010 launched its 10:10 campaign, a campaign to reduce its CO2 emissions, and continues to be committed to combatting global climate change. What do you see as the largest problems that global climate change will

cause or exacerbate in global health, both in long-term health and in acute natural disasters? Dr. Piot: This is a very important question and it’s not well studied. In terms of climate change, it’s studied very well, but in terms of the impact on health it is not so clear and straightforward. While there might be direct impacts such as vector-borne diseases that were limited to tropical regions that now have an effect in countries that traditionally didn’t have these kinds of mosquitoes. For example, in Italy, a few years ago they had quite an epidemic of Chikungunya fever which had never occurred there before. We may see more reimportation of malaria so that’s one thing. Also extreme climate events, like heat waves are killing people, especially older people. But another thing, I think, it’s a combination of climate change, of further urbanization, of droughts, extreme climate events, [that] could lead to major population pressure. So what we haven’t really looked at carefully. And I think we need to look at it the other way around. I mean how improving health could maybe contribute to alleviating climate change. For example, we have an epidemic of noncommunicable diseases. There was a study a few weeks ago in The New Yorker in the U.S. drawing attention to it. What they call an obesogenic environment. We eat all this beef and we are not moving and that contributes to CO2 emissions. And if we were to adopt a healthier lifestyle both in terms

of healthier foods and moving, using public transportation and cycling on a massive scale that could also contribute to reducing climate change. But there is an enormous need for serious studies and that’s only starting now. We have a new group at the school and two years ago we published this paper but this was based on observation not empirical research which is what we need. HCGHR: As you know, there are many aspects and necessary steps to combatting the global HIV/AIDS epidemic. The UNAIDS website lists its strategy goals to be reached by 2015, including ending vertical transmission, reducing sexual transmission, preventing HIV among drug users, providing treatment, avoiding TB deaths due to co-infection, supporting women and girls, stopping violence, ending punitive laws, lifting travel restrictions, and protecting the vulnerable. As these goals are complicated and broad, what kinds of organizations do you think are making the strongest effort toward these goals, and how can a small global health program be successful in addressing all of these adequately? Dr. Piot: First of all, I think that there will never be enough global health programs. You should not say, ‘Oh there are big ones, I cannot contribute.’ So you need to identify a niche. You need to say what are you good at and what can you make a difference in very specifically, and contribute. Global health is not the work of one person or organization. Some people make it all the time to the limelight but it’s

INTERVIEWS

28 the hard and daily work of hundreds of thousands of people and it’s very important to think through what exactly can you achieve. And I think what you are doing is extremely important because it is spreading the message and providing the communication for young people at Harvard and that is going to have a multiplier effect. But I think don’t be overwhelmed by the enormity of the agenda, which is reality, but just go for where you can make a difference. I don’t think that it is that much of a problem in a sense. HCGHR: As the first director of UNAIDS, from 1995 to 2008, you succeeded in building the organization from its inception. What was the greatest challenge that you faced and what was your greatest success?

Dr. Piot: I think that the greatest challenge was resistance. Not resistance from virus but resistance from institutions and experts in the early days. You know there were people who did not want to accept that AIDS was a problem, who were concerned, for example, with treatment access. It is hard to imagine ten years later but in 2001 there was a majority of donors who were against any mention of ARV treatment access in the declaration of commitment of the UN. It’s hard to imagine today. The U.S. was against it, the U.K., Japan, even African countries. It was very much influenced by public health specialists and development specialists who said, ‘Oh there are all these obstacles and it is not possible to provide treatment because of how the systems are working.’

All true. But we didn’t accept it. And that was the biggest challenge. And then of course mobilizing the money. And achievements, I would say putting AIDS on the world’s top agenda, in various countries, globally, regionally, and I think also having negotiated lower prices for ARVs which was essential to make this life-saving treatment available. In 2000 there were less than 200,000 people on ARV in the developing world, and that was mostly in Brazil because that was the country that was offering it free of charge. And today it’s gone to 7 million. I’m not saying it’s all because of me, but it’s a big achievement and we played a large role.q

Biosketch Peter Piot, MD, PhD is the Director of the London School of Hygiene & Tropical Medicine and Professor of Global Health. In 2009-2010 he was the Director of the Institute for Global Health at Imperial College, London. He was the founding Executive Director of UNAIDS and Under SecretaryGeneral of the United Nations from 1995 until 2008, and was an Associate Director of the Global Programme on AIDS of the World Health Organization. Dr. Piot co-discovered the Ebola virus in Zaire in 1976, and led research on AIDS, women’s health, and public health in Africa. He was a professor of microbiology at the Institute of Tropical Medicine, Antwerp, the Free University of Brussels, and the University of Nairobi, was a Senior Fellow at the University of Washington, a Scholar in Residence at the Ford Foundation, and a Senior Fellow at the Bill and Melinda Gates Foundation. He held the 2009 chair “Knowledge against Poverty” at the College de France in Paris. He is a member of the Institute of Medicine of the US National Academy of Sciences, of the Académie Nationale de Médicine of France, and of the Royal Academy of Medicine of his native Belgium, and a fellow of the Royal College of Physicians. He is the President of the King Baudouin Foundation, was knighted as a Baron in 1995, and has published over 500 scientific articles and 16 books.

INTERVIEWS

An Interview with:

Dr. Elizabeth H. Bradley Interviewed by Sheila Ojeaburu

Courtesy of Dr. Bradley

HCGHR: You have done research on a wide range of topics, from hospitals’ proficiency in treating cardiovascular disease, to how race affects black physicians. What criteria do you use to determine on which topics to conduct research? Dr. Bradley: Would we have a large impact on the society or population? That’s the biggest thing. What kind of ultimate impact would we have by answering the question? Secondly, if we look deep into the literature, can we find the answer? If the answer’s there, then no, I wouldn’t touch that question. I would try to find something novel that we really needed to know about. The third criteria that I would use is whether this is truly feasible because there are an awful lot of good ideas out there, but a good idea without any implementation is nothing but a daydream. So, I try to take on projects that I think are feasible and could be marked improvement. HCGHR: You have received the Teacher of the Year award by the Department of Epidemiology and Public Health at Yale three times. What do you find most rewarding about teaching?

Dr. Bradley: When you, as the teacher, have some wisdom about something, start to talk and lecture about it, and then suddenly see the light bulb go off in the heads of students, who don’t stop there, but then embellish and add something to the idea, you realize that you are forever changed because you’ve really learned something. You’ve learned as much as you’ve taught. I don’t get that high every class, but I will get it several times a semester, and it’s a really special realization that I’ve seen some part of the world that I’ve never seen before because we spent that couple of hours together. I also get a huge charge out of seeing what students I’ve taught and colleagues I’ve worked with, are doing now. Because I’ve been teaching since 1994, to see what some of the graduates do is pretty inspirational, especially if they keep in touch. You just feel a little bit more connected to the real world. You trained a number of the people who are now out making policy. HCGHR: Have a lot of your students gone on to public health? Dr. Bradley: Yes, I would say many have gone on to public health. If we think of public health broadly, which

would include governmental agencies, and all kinds of private sector, delivery systems, and practices. If we add that all together, I would say most of my students, one way or another, have done something in public health. HCGHR: What do you think an ideal health care system looks like? Dr. Bradley: Well, you can never answer that quickly, but I would hope that the system promoted equity in health, and was integrated with social care and social services. So, we would look at the health of the population as determined not just by their medical care, but also by their social and behavioral [status], like what kind of occupation people have, how much money they have, what kind of education they are able to attain, and what kind of nutrition they have. So, an ideal health care system would recognize that there is a connection between the medical care system and the rest of our social contacts, and direct itself that way. I think that means that the medical care system and health care spending would be of sizes relative to the extent of social services. We have a pretty large medial care system now. So, I guess

INTERVIEWS

30 recognizing that health is determined by multiple determinants, and promoting equity would be critical. The last principle I would look for in a system is that the system was responsive to community voices and community needs. HCGHR: What role do you think the government should or should not play in ensuring that every individual has access to proper health care? Dr. Bradley: I think that what role the government should play is debatable, but that they should play a role, no question in my mind. I just don’t think you can expect any private sector alone to insure people for whom it is not really in the interest of private investors to insure. I just don’t think you can do that through a private model alone. I do believe you can fund Medicaid and Medicare programs through delegated private insurance companies, but the financing and regulation should still have to come from a selective voice of the government. HCGHR: You have helped to develop and implement strategies to improve health care in other parts of the world. How is dealing with issues of public health in the U.S. different than in other countries, like Ethiopia or the United Kingdom? Dr. Bradley: Well, I think that in the United States, it is close to invisible sometimes, but less and less so because we now understand more about social marketing, obesity, smoking, and the environment (these things would fall into public health). The medical care system is so huge here. We have technology and sophisticated drugs. People can get into a hospital easily, and hospitals are highly invested in. And of course, in Ethiopia, the balance between medicine and public health is quite different. There are only 120 hospitals for 80 million people in

Ethiopia; there are 6000 for 300 million, here. There is such a tiny number of hospitals in Ethiopia, so the medical care system is very underdeveloped. The public health system--that’s kind of all they have in many ways, and it’s all government run. So, I would say the relative side of medicine and public health is very different in low income settings. In such settings, major issues are infectious diseases and malnutrition, maternal

implementation. I have a unique interest, not just in policy, where you decide how to pay and regulate. Primary for me is the actual implementation. How do we actually get hospitals to perform in a certain way? How do we get communities to perform in a certain way? How do we get nurses and physicians to work together? That implementation was of interest throughout my managerial training, which is kind of ironic because

I think one thing the next generation can do is ensure that they travel the world, and that they engage, not just on the Internet, but with diverse communities, and really work at understanding and bridging what is sometimes an ‘us’/ ‘them’ view of health... mortality, and very basic health needs. Whereas in Europe, of course there are infectious diseases, etc., but they have an awful lot more resources to treat cardiovascular and chronic diseases. Needless to say, nearly everything is government run, so that’s different from the United States as well. HCGHR: You have an MBA from the University of Chicago, in addition to a BA from Harvard, and a PhD in health economics and health policy from Yale. How does a business mindset shape your perspective on health care policy? Dr. Bradley: Well, I do have an MBA, although my focus was organizational behavior, not accounting. In organizational behavior, you’re really thinking about how organizations are able to organize to produce the most effective and equitable outcome. So, I was really influenced to understand

although I agree that most MBAs go into business, I got a health administration degree. I learned an awful lot about how hospitals work and how health care interacts. So, that’s really how it’s influenced me. I guess it’s a little unusual for most MBAs. HCGHR: How has public view on health care changed during the time you have been working in the field? Dr. Bradley: In the ‘80s, when I began, there was just a very hospital based system. I think we were still in expansionary mode, and still trying to enact our health care system. Then, in my early career and certainly in the ‘90s, we were trying to contract the health care system. Then, questions about medical errors increased. When I began, there was no such thing as thinking about medical errors. It was before quality improvement in health care, before the medical error report.

INTERVIEWS Mostly, people had a much stronger sense that physicians were doing everything right and the health care system worked really well, and we needed to expand it. Now, I think we’re in a different situation where the physicians are not viewed at the same level of legitimacy that they were in the ‘70s. There was a fall from power. People ended up questioning whether hospitals have done the right thing, and whether doctors have done the right thing. There are all types of medical errors people are now documenting. There’s much more qualm about the medical care system and I think there is also much more attention on how the environment and our health behaviors influence outcomes, which was almost non-existent when I began. People just did not think a whole lot about that. So, I think we’re becoming more enlightened, actually.

HCGHR: The Harvard College Global Health Review is geared towards young people aspiring to become involved in the field of global health. What do you think the next generation can do to improve health care policy? Dr. Bradley: I think one thing the next generation can do is ensure that they travel the world, and that they engage, not just on the Internet, but with diverse communities, and really work at understanding and bridging what is sometimes an ‘us’/ ‘them’ view of health. We’re in the same world and our outcomes are determined in part by outcomes in low income settings. So, I think you get that insight by spending time in other countries and cultures, and really engaging with an open heart and

an open mind. I honestly think that’s the number one thing. I also think that the next generation can promote health policy by elevating health to become part of national policy. In other words, getting good at the language of economics and law, the language of lobbying, and the language of politics. I think in the old days, people who wanted to be doctors or hospital administrators went into a technical field and had to learn accounting for Medicare cost reports, etc. It adds to the technical knowledge of health, but I think the best thing the next generation can do for health policy is really get a good idea of how to use cost effectiveness analysis. They have to understand finance, politics, and lobbying, and use those tools in a sophisticated way to promote health and a peaceful society. q

Biosketch Elizabeth H. Bradley, MBA, PhD is faculty director for the Global Health Initiative and the Global Health Leadership Institute at Yale, professor of public health and director of Global Health Initiatives at the Yale University School of Public Health. As a recipient of the Bill & Melinda Gates Foundation Grant, Dr. Bradley is leading the development of an operational framework of diffusion, dissemination, and widespread take up of family health innovations. She also works with the Centers for Disease Control and Prevention and the Clinton Health Access Initiative on the Ethiopian Hospital Management Initiative. Dr. Bradley has also been involved with several projects regarding health system strengthening in other international settings as well, including China, Liberia, South Africa, and the United Kingdom. She is a member of the World Economic Forum, Network of Global Agenda Councils, and, in 2010, she was selected as facilitator for the strategic planning retreat for the Board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Dr. Bradley has a BA from Harvard, an MBA from the University of Chicago, and a PhD from Yale University in health economics and health policy.

32 PANORAMA

Altruism and Profit

The Changing Role of Pharmaceutical Companies in Global Health By Hannah Semigran

ig pharmaceutical companies have long played a role in the field of global health—from both hindering the dissemination of fairly priced drugs in developing countries and, more recently, working with generic manufacturers to drive down the aforementioned prices of these drugs. As a result of a novel combination of moral and financial incentives through social activism and generic manufacturing, however, pharmaceutical companies have been motivated to refocus their efforts when working in the developing world. Within the past 20 years, the price of antiretroviral drugs (ARVs) has fallen significantly. The decrease is dramatic: from an original price of $10,000 to $15,000 per year, the drugs now cost around $300 annually. This sharp decrease followed a decision by Cipla Limited, a generic pharmaceutical company in India, to produce generic ARVs that were identical to the high-priced ARVs distributed. This decision caused an uproar in the pharmaceutical community, as the expensive treatments sold by these firms reached only 2 percent of people living in developing countries. Five years after the treatment was introduced, companies faced pressure from activist groups, foundations, and governments to lower their prices. As a result, prices of firstline ARVs in low- and middle-income countries fell 30-68 percent between 2004 and 2008. More recently, pharmaceutical

companies have come under scrutiny once again for the price of life-saving vaccines distributed in the developing world. In May 2011, UNICEF publicly announced for the first time the prices of the vaccines that it pays for and distributes from GAVI, the Global Alliance for Vaccines and Immunization, astounding donors with the huge disparities across manufacturers. Organizations hope that the public will react well to this information. Daniel Berman, Deputy Director of Doctors Without Borders noted, “As soon as the donors see the differentials, they’re going to insist that UNICEF and GAVI get better prices.” For example, the compound that prevents diphtheria, tetanus, whooping cough, Hepatitis B, and haemophilus influenzae type B costs $2.25 per dose when produced by the generic producer Serum Institute of India but $3.20 per dose when produced by Crucell, a company recently purchased by Johnson & Johnson. Pharmaceutical companies demonstrated their concern with intellectual property in their swift response to UNICEF. For example, Glaxo-Smith Kline announced a price cut of twothirds in its rotavirus vaccine just two days after the announcement. To Anne Pollock, an assistant professor of science, technology, and culture at Georgia Tech, this reaction by drug companies displays the changing role of these organizations in global health. In an interview with the

HCGHR, Professor Pollock said, “The convergence of philanthropic and pharmaceutical interests adds a new layer. Political pressure does have an impact, and the pharmaceutical industry has taken into account the political price [in lowering] the price.” Professor Pollock, however, also pointed out the underlying interests of movements, saying, “Philanthropy, itself, is also very interested in intellectual property. It makes sense, for example, that Bill Gates is supporting the pharmaceuticalization of the global South with protection of intellectual property.” On the Harvard campus, social activism groups are also participating in movements to pressure big pharmaceutical companies to rethink their strategies in the developing world. For instance, The Harvard Global Health and Aids Coalition (GHAC) has spent the fall semester promoting the Medicines Patent Pool, in which pharmaceutical companies willingly share their patents with the Pool in order to allow generic manufacturers to create medicines of the same caliber and at a lower price. In addition, the GHAC is involved with pressuring Merck, the patent holder of two essential HIV/ AIDS drugs, to join the Pool, as the company has thus far been reluctant to do so. Currently, the National Institute of Health (NIH) and Gilead are members of the Pool. The GHAC has requested that Merck begin negotiations to enter the

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Members of the Harvard community and the Global Health and AIDS Coalition gathered outside of Merck Laboratories in October for a “Pool Party” in order to convince Merck to begin talks to join the Medicine Patents Pool. (Courtesy of Lauren Onofrey)

patent pool by 2012, allowing generic manufacturers access to their patents for these expensive ARVs. On October 21, 2011, the GHAC organized a “Pool Party” outside of the Merck laboratories in Boston, MA in order to deliver a petition requesting their entrance into the Pool. Nathan Georgette ’13 said, “Companies won’t make more of a profit from joining the Pool, but they will not really lose that much profit either. Our primary message is the moral imperative of having a resource that can alleviate suffering; refusing to make that accessible to those suffering runs counter to fundamental human morality.” On the other hand, credit cannot be entirely attributed to activist groups in the demand for the creation

of generic drugs for use in developing countries. According to Dr. Stefan Ecks, a medical anthropologist at the University of Edinburgh, it is the producers of generic drugs that have encouraged this trend. In an interview with the HCGHR, Dr. Ecks said, “I don’t want to suggest that there is anything wrong with activism, but it is more of a nuanced picture. What is usually completely overlooked is the role of the generic producers and their relationship with big brand manufacturers.” Commenting on generic manufacturers’ interests, Dr. Ecks added, “Often, the companies just have a product that is cheaper than their competitors, which makes them more attractive to humanitarian organizations.

They are, however, just selling their own products. There are, for example, a few manufacturers in India that present a kind of nonprofit alternative to the generic “brand,” but they also need to make sure that their own profits are in order and would drop any product or drug if it doesn’t turn a good profit for them as well.” While interventions by pharmaceutical companies in global health have long been criticized and debated, it is clear that big companies, generic manufacturers, and activists alike share a similar goal: maximal dissemination of lifesaving drugs. It is, therefore, from this standpoint where collaboration must occur to improve the equity of delivering these drugs to those in need around the world. q

PANORAMA

Engulfed in a Toxic Cloud

The Effects of Coal Mining On Human Health By Rachel Sapire

he continued growth of coal mining has left communities with pervasive and irreparable damage. Until recently, however, the effects of coal on human health have been largely ignored and mining has continued without many appeals for improvement. In both the United States and China, industrial achievements have created a legacy of pollution that is taking a major toll on human health. Despite relatively modest concentrations of hazardous air pollutants and the sophisticated pollution control systems employed in the United States, recent studies have proven that the resulting health effects of mining can be devastating. Such facts have largely

been ignored, especially in Appalachia, an important American coal region. Dr. Michael Hendryx, a researcher at West Virginia University, began uncovering alarming ailments resulting from coal production. Hendryx told the HCGHR, “When I first started talking to my colleagues about it, their immediate reaction was somewhat skeptical. They assumed that if there were significant health problems that those problems were the result of poverty or some other socioeconomic disadvantage.” Hendryx explained, “Their own assumptions got the better of them.” As a result of their proximity to coal mines, members of these mining communities are plagued by higher chronic heart, respiratory, and kidney

X-Ray near coal-fired plant in China. (Courtesy of Greenpeace)

disease mortality. Hendryx also discovered that the rates of birth defects are significantly worse in Appalachia, with defects ranging from circulatory and respiratory issues to central nervous system problems. In addition to the adverse health effects in mining communities, negative social impacts have also arisen as a result of the establishment of mines. Coal mining has taken place in Appalachia since the 1700s, but practices have changed within the last 30 years. “The mechanization of mining has become so advanced, that there are not that many human jobs that are required anymore to run a coal mine,” Hendryx explained. As a result, communities are left with fewer job opportunities as well as greater adverse health effects. Coal has been the cause of major health issues in China as well. With a denser population and more widespread usage of the resource, coal mining has caused significant air pollution. As the result of major reforms, economic development in China has reached spectacular heights. The economic boom has been matched with an increase in energy production and in turn, a rise in negative health effects. In fact, pollution has made cancer China’s leading cause of death and has left a grey cloud over the nation. China now produces three billion tons of coal every year. China’s rapid economic growth has led to the deteriorating health of the Chinese population. Economic growth has not necessarily meant technological advances in coal mines. Dr. Sun Qingwei,

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a coal campaigner for Greenpeace China, stated in an interview with the HCGHR, “Traditional coal mining is labor intensive. The reason is that the technology is underdeveloped.” China is plagued by a continually increasing level of dependence on coal for domestic and energy uses. Paradoxically, China’s greatest achievement has evolved into its most burden-

The Chinese Academy for Environmental Planning predicts that the government will allocate about $454 billion for environmental protection, which is more than double the previous cycle’s allocation. some problem. Similar health concerns to those in Appalachia have been found in mining communities in China. Qingwei reports, “There is a widespread problem with children and birth defects near coal mines, especially in the Shangxi province, which has been the largest coal producer in China.” Despite these reports, research on Chinese coal production is lacking, and most data is inconclusive. Domestic uses of coal for heating and cooking can be especially harmful because the coal is generally mined locally, with minor regard to their

Coal ash disposal site in China. (Courtesy of Greenpeace)

chemical composition. Poor ventilation in homes further exposes residents to the dangerous emissions. In fact, more than 75 percent of China’s primary energy needs are supplied by residential coal use. Will improved policy even be effective? Hendryx is skeptical that coal can ever become “clean.” The US federal government intends to put a lot of money into carbon capture and sequestration from coal fired power plants, but these plans only address how coal is burned, not the practices of extraction, processing, or transporting prior to burning. “It’s an exceedingly dirty product from start to finish,” Hendryx says. He noted the extraordinary resources required to extract coal – heavy equipment, chemicals to treat the coal, and vast amounts of water – and remarked, “Even the cleanest coal burning power plants still produce more greenhouse gases, more mercury, and more pollutants than any other form of energy that we have.” Researchers in China share this sentiment. In light of these recent findings, China is taking strides to alleviate their

growing coal problem. The Chinese Academy for Environmental Planning predicts that the government will allocate about $454 billion for environmental protection, which is more than double the previous cycle’s allocation. However, the rate of economic growth in China is hard to keep up with. “Greenpeace thinks that China should switch to renewable energy, like wind-power and solar energy,” Sun says, “China is now the biggest producer of solar energy, so we think that China has been doing well, but its not, because China’s economic growth is so rapid that the government should be doing more to produce its share of renewable energy.” Therefore, the alternative to “cleaning” coal requires serious economic diversification programs and a complete rearrangement of current energy sources. In mining communities, coal has become the most serious public health issue, and only some of the adverse health effects have been uncovered. In order to curb the growing problems, China and the United States must diversify their energy sources and eliminate the lingering pollutants.q

36 PANORAMA

Re-structuring Urban Healthcare Beyond the Cultural Model for Immigrants’ Healthcare Disparities By Sarah McCuskee

mmigrant populations, including the Boston Haitian community, face staggering disparities in health. Structural issues are largely at fault—but more ambiguous “cultural” factors are often blamed as well. These factors—things like language and “health beliefs”—may be important: in 1970, Philip Tumulty wrote “what the scalpel is to the surgeon, words are to the clinician…the conversation between doctor and patient is the heart of the practice of medicine.”1 But the role of culture in immigrants’ health disparities is frequently ill-defined and overestimated, and “cultural” effects are seen as immutable by policy. When policymakers address healthcare disparities for Haitian minorities in several major cities in the US, dividing culture and structure allows them to treat the associated barriers differently.

The role of culture in immigrants’ health disparities is frequently ill-defined and overestimated. Immigrants’ “cultural” differences are seen as relatively immutable by policymakers, who argue that “cultural”

barriers to health will only disappear with a process of acculturation.2 Indeed, one study equates recent immigration with lack of acculturation and resulting poor language skills in order to explain differential patterns of cancer screening for ethnic minorities, including Haitians in U.S. cities.3 Acculturation is necessary, the conclusion goes, but it happens at different rates for different groups and individuals; policy can do little to affect this process. Structural factors--education, insurance/ability to pay for care, transportation, availability of childcare, leave from work--are the focus of policy, and they certainly merit examination and intervention. But there is growing evidence that this distinction between culture and structure is artificial and possibly even harmful. Pushing “culture” outside of policymakers’ responsibility may divert attention from solvable problems in healthcare, so examining the role that “culture” plays—and does not play—in immigrant communities’ health is necessary. For this purpose, healthcare can be divided into three necessary sequential components: access to care, willingness to seek treatment, and finally, communication between provider and patient.2 What role does “culture” play in each step? A vague but prominent “cultural” factor, “health beliefs”4 are viewed as only mutable through acculturation; inversely, acculturation often means

changing health beliefs.3 But the link between culture and willingness to seek treatment is rarely examined. In the Boston Haitian community, commonly-cited “cultural factors” such as modesty may play a role in women’s willingness to seek screening for cervical cancer,5 but for breast cancer especially, a patient’s access to a primary care provider is the largest determinant of screening prevalence.6 This is hardly “cultural.” As Michele David, Co-Director of the Haitian Health Institute at Boston Medical Center, told the HCGHR, “If [women] had a

A PACT community health worker helps bridge linguistic and administrative gaps between physicians and patients. (Courtesy of Partners in Health)

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primary care provider, they had all the appropriate health screenings. If they didn’t have the health provider, that made a huge difference.”5 Systematic factors may also masquerade as “health beliefs” and become general barriers to immigrants’ willingness to seek healthcare, especially preventive care. As Samuel Slavin, Coordinator of Training and Technical Assistance for Partners in Health’s Prevention and

it a lot harder to keep medical appointments.”7 Gendered differences in careseeking behavior may therefore be due to structural factors like childcare and sick leave, rather than vague “cultural” factors. An important caveat to this argument, however, is mental health care, which David argues is “under-addressed” in the Boston Haitian community.5 Language, an element of culture, is criti-

Pushing “culture” outside of policymakers’ responsibility may divert attention from solvable problems in healthcare. Access to Care and Treatment (PACT) Project in Boston, told the HCGHR, “people coming from Haiti or from other countries are…coming from a totally different healthcare system or the absence of a healthcare system in most parts of Haiti.”7 This leads to underutilization of preventive, as opposed to acute, care; these preventive services are sparse in Haiti. Ignorance, misinformation, or cultural prejudices against prevention3,4 are less important than familiarity with healthcare structures. Slavin summed this up: “It’s not so much about Haitian culture per se as coming from a really different [healthcare] system.”7 It may also be worth reconsidering the specificity of medical condition and type of medicine which guides much thought about disparities. For many patients in the Boston Haitian community, insurance, time off work, and childcare are the primary factors which influence their access to all healthcare. Rather than influencing patients’ likelihood to seek care for specific health concerns and not for others, these factors limit access to all non-urgent care. As Slavin told the HCGHR, “having children makes

cal here. Access to mental health services is limited because, as David points out, Boston has “a dearth of Creole-speaking mental health providers.”5 Coupled with the prevalence of post-traumatic stress disorder symptoms after Haiti’s 2010 earthquake, this issue is worsening. Willingness to seek treatment can be affected by cultural beliefs too; Slavin and David say that mental healthcare is “stigmatized”7 and “taboo,”5 respectively, in Haitian culture. But fears of mistranslation or inadequate privacy may be just as important, especially

because non-professional translators are frequently used.7,8 This also makes communication between provider and patient problematic. David puts this plainly: “something gets lost in translation when you have…an interface between the mental health provider and the patient.”5 Even Haitian-born providers may not have received medical training in a Haitian context7— and while providers may speak Creole, administrative services which do not include options for Creole speakers limit patients’ access to providers.7 Attributing disparities to “culture” tends to divert attention away from access barriers and toward problems in patients’ willingness to seek care and clinical communication. This can negatively affect immigrants’ health: first, it minimizes policymakers’ responsibility to eliminate barriers to care instead of waiting for acculturation to occur, and second, it delegitimizes practices, experiences, and models of understanding which affect patients’ roles in their own healthcare. Health education and access to interpretive services and bilingual providers are crucial; but underestimating the structural elements of “culture” risks ignoring opportunities to eliminate health disparities among immigrant populations. q

Tumulty, Philip. “What is a Clinician and What Does He Do?” New England Journal of Medicine 283 (1970): 20-24. 2 Page, J. Bryan. “The Concept of Culture: A Core Issue in Health Disparities.” Journal of Urban Health 82 (2005): iii35-iii43. 3 Brown, William, et al. “Time Spent in the United States and Breast Cancer Screening Behaviors among Ethnically Diverse Immigrant Women: Evidence for Acculturation?” Journal of Immigrant Health 8 (2006): 347–358. 4 Consedine, Nathan, et al. “Breast Cancer Knowledge and Beliefs in Subpopulations of African American and Caribbean Women.” American Journal of Health Behaviors 28 (2004): 260-271. 5 David, Michele. Personal INTERVIEW. 17 October 2011. 6 David, Michele. “Mammography Use.” Journal of the National Medical Association 97 (2005): 253-261. 7 Slavin, Samuel. Personal INTERVIEW. 28 October 2011. 8 Woloshin, Steven, et al. “Language Barriers in Medicine in the United States.” Journal of the American Medical Association 273 (1995): 724-728. 1

38 PANORAMA

The Silent Killer

The Effort Toward Global Elimination of Maternal and Neonatal Tetanus By Frederic Hua

lostridium tetani, the bacterium responsible for tetanus, is ubiquitous, yet its effects are found to be most devastating in developing countries. The World Health Organization (WHO) estimated in 2008 that 59,000 newborns die from tetanus every year. Termed â&#x20AC;&#x153;maternal and neonatal tetanusâ&#x20AC;? (MNT), the condition is generally caused by lack of proper vaccination in conjunction with unhygienic delivery practices. In neonates, this is particularly precarious as the detachment of the umbilical cord provides a readily available breach for C. tetani infiltration. In the developed world, tetanus has been eliminated almost exclusively via well-established post-natal care services. However, achieving elimination in such a manner has proven to be more difficult in the developing world. As a result, recent efforts for worldwide elimination are driven firstly by extensive administration of the tetanus toxoid (TT) vaccine, followed by establishment of health programs promoting clean delivery practices. Tetanus presents itself uniquely worthy of attention as an issue in which significant progress has been made despite being incapable of true eradication. The first system towards global elimination of MNT was developed during the 1989 World Health Assembly. Elimination was characterized as 1 case of tetanus per 1000 live births, with a deadline in 1995. Districts at risk were identified and strategies for combating MNT were

drafted with governmental collaboration. For countries with moderately developed health services, achieving MNT elimination was relatively simpleâ&#x20AC;&#x201D;women who became pregnant were administered TT and taught clean delivery practices. However, the highest burden of MNT was found to be in hard-to-reach rural areas, where there is underdeveloped health infrastructure and a prevalence of unhygienic postdelivery practices.

vaccinated with three doses of TT. Campaigns are followed with educational programs designed specific to the communities, emphasizing proper cord-care and clean delivery along with the establishment of routine perinatal services. Without substantial external funding however, 1995 came to pass with global elimination unrealized. The effort was launched again in 2000 by the WHO, UNFPA, and UNICEF, targeting the 58 countries

Infant suffering from neonatal tetanus. (Courtesy of Martha H. Roper)

This prompted the development of the supplementary high-risk approach. With this continuing approach, a series of campaigns are conducted into selected high-risk areas, and all women of childbearing age (15-45 years) are

in which MNT still existed as a public health issue and with a goal set at elimination by 2005. The estimated cost was $1.20 for each woman, including vaccines, operational costs, and promotion of clean deliveries. Despite the apparent

PANORAMA This brings up the concept of maintenance, which is of equal if not greater importance than elimination. Dr. Orenstein states: “To the extent we can deliver all of these doses, it would be great, but it’s something that has to be done day in and day out—which means investment on the part of the countries themselves in building and maintaining these systems.” It is essential that there is proper coordination with agencies in all levels of state for effective management and continuance Vaccination protects women of child-bearing age from tetanus and provides passive of health programs. “You really need to have good surveillance. Surveillance immunity to their children. (Courtesy of Martha H. Roper) has to be done with national or district cost effectiveness, the total expenditure including Proctor & Gamble, JICA, the level government. WHO and UNICEF provide technical guidance and conover the intended 5 years was expected Gates Foundation, and Kiwanis. to amount to $130 million. Dr. Walter Orenstein, assistant sultative support, but they do it under Also in 2000, The GAVI Alliance professor at the Emory University government authority.” More recently, Uganda announced was established in order to provide School of Medicine, director of the proper funding and vaccines for eli- Emory Program for Vaccine Policy and successful elimination of MNT, with gible countries, with support from Development, and former director of several countries awaiting their own the International Finance Facility for the National Immunization Program validations. The current status of the Immunisation (IFFIm). In order to at the CDC, explains the exhaustive elimination is unclear because elimiensure commitment to health pro- efforts needed to tackle tetanus: “The nation can only be declared after a grams, countries must also contribute problem is with elimination and not latency period. Since the first big financially to the initiatives. Although eradication. What you have is a res- launch in 1989 towards MNT elimithe 5 year goal was unable to be ervoir in the environment, and hence nation, however, neonatal deaths due reached, significant accomplishments you can never stop immunizing. This is to tetanus have dropped remarkably; were able to be made. By 2007, more different than smallpox, different than from nearly 800,000 a year to a few tens than 70 million additional women were what we’re hoping for polio, and dif- of thousands. Nevertheless, a continuadministered vaccines, and 10 coun- ferent than measles. You can’t eradicate ing effort on parts of both government tries had declared the elimination of tetanus. You always have to be aware and organizations alike is necessary for MNT. The effort is still firmly active, and you have to keep immunization completing the elimination project and maintaining it for future generations. q with several organizations now onboard coverage up.”

I’d go to the remotest of remote areas in very poor countries and ask older medical staff and TBAs when was the last NT case they’d seen. Without exception, they’d laugh and say ‘Oh, we used to see a lot but not since we started giving the vaccine.’ They’d occasionally report the odd case, but for them, the situation was like night and day. The numbers I’d been writing about for some years never had the same impact on me. -Martha H. Roper

40 PANORAMA

From the Floodwaters Flow The Impact of Water in Bangladesh By Michelle Lee

ituated at the confluence of the Ganges, the Brahmaputra, and the Meghna Rivers, Bangladesh has a tumultuous relationship with water, a problem present in both excess and scarcity. Though the country has many water sources and receives abundant rainfall, clean water is limited and often polluted. Flooding during the monsoon season leaves thousands without homes every year. Despite repeated efforts, a number of interplaying social, economic, and cultural factors contribute to the current stagnation in water quality improvement. Bangladesh’s story has been a difficult one, but not one without hope. Though the country is limited in economic means, with per capita GDP

of only $673, it is still one of the few developing countries on target to meet many of the Millennium Development Goals. Government led initiatives, such as the community-led Total Sanitation Campaign, have increased ground water tube wells, hand pumps, and latrines in remote areas where water access is especially limited. Since the 2005 discovery of arsenic pollution in groundwater sources, however, Bangladesh’s water efforts have reached a major stumbling block. Deemed the “largest poisoning of a population in history” by the WHO, the arsenic exposure has affected up to 70 million people since its discovery. Studies have linked high exposure to cancer as well as various skin, lung, and cardiovascular diseases.

Boy bathes at a public tap in Pallebi, Bangladesh. (Courtesy of Water.org)

Since 97 percent of the rural population in Bangladesh uses groundwater tube wells as a drinking source, arsenic poisoning has greatly limited water sources. Experts say that for some communities, the only alternative water source is surface water, which is often wrought with disease carrying bacteria and chemical fertilizers. Treating the water chemically or digging deeper aquifers are two solutions, but are often too costly for rural communities. Other alternative sources such as rainwater harvesting have been explored, but are currently unreliable as a result of mosquitoes, bird feces, and unreliable weather. Diarrheal diseases such as cholera are prevalent especially in rural areas, where sewage treatment is rare

PANORAMA

Young man bathes from a community hand pump in Pallebi, Bangladesh. (Courtesy of Water.org)

and limited. Dr. Ed Ryan, a leading cholera researcher at Massachusetts General Hospital, commented on the devastating impacts of diarrheal diseases to the HCGHR: “With recurrent episodes of diarrhea, kids get tropical enteropathy, where intestinal surfaces are inflamed and eroded. This leads to a lot of secondary effects, such as the ability to absorb nutrients, which plays into a vicious cycle with malnutrition. Diarrhea and malnutrition combined kill around 2.2 million globally each year, superseded only by respiratory infections.” Diarrheal diseases have also been linked to poor drug and vaccination absorption, as well as cognitive stunting, with studies showing that children with recurring diarrhea had lowered IQ of nearly 10 points. With a population that has doubled in the past 30 years, Bangladesh is one of the most densely populated countries in the world. As a result, urban slums dot the landscape, and these communities lack sewage treatment systems. As Dr. Ryan explained to the HCGHR: “For most slums, there are regional centers with a communal latrine, which is an open pit or a squat pit. People may not use it, and many slums are not in the sewage grid. Sewer systems also run over due to the flood. It’s hard to keep good hygiene when

you’re living on three feet of water.” Often, poor city dwellers have to buy water over the black market, often paying up to 15 times the original price. There is much to be done. Community education should be a priority in order to sustainably address issues of hygiene and sanitation. Education initiatives, experts stress, must go hand in hand with cultural sensitivity and awareness. As Dr. Richard Cash of the Harvard School of Public Health states, “Water from other sources could give people better quality water bacteriologically, but it may not look as good, taste as good, smell as

good, so people need to be convinced to use it.” Innovation to increase clean water access is also necessary. Dr. Ryan and other experts have found that even for those close to the municipal water supply, water may not be safe: “It may leave the facility perfectly fine, but people have done illegal tap ins, or the power has gone out, or there is a crack in the pipe in the street, so you can’t trust it coming out of your faucet.” Because of this, point-of-access treatment is now encouraged for both rural and urban areas. Different options such as filtering by ceramic, sand, ultraviolet light, and halogen chemicals should be chosen specific to the community’s needs. Water plays an integral role not just as a drinking source; it is also an important part of the Bangladeshi culture and influences various industries in the country’s economy, such as agriculture, energy, and fishing. In this way, water plays a role not just in health, but also in the social and economic livelihood of the people. This, in turn, influences the overall standard of living of the population, which ultimately influences the population’s health. Because of these various interconnected factors, water usage must be dealt with wisely in order for it to be sustainable for the future. q

Boy with water pots in Pallebi, Bangladesh. (Courtesy of Water.org)

42 PANORAMA

Global Health in Japan

A Moral and Economic Dilemma By Corinne Maguire

World leaders at the G8 Summit held in Tokyo, Japan (2008). At the summit, global health was identified by the Japanese Government as a major agenda item. (Courtesy of Eric Draper)

fter the Great East Japan Earthquake disrupted the lives of thousands of Japanese citizens in March 2011, it was expected that Japan’s foreign assistance would be significantly diminished in favor of domestic aid. Yet, Japan has continued to be involved in global health despite the tragedy. Japan’s commitment to global health illuminates how global health is seen by Japan as a critical moral and economic issue. As an island with limited resources, Japan’s economy is heavily dependent on trade and globalization. Because of this, Japan’s foreign

assistance—including global health aid—is often viewed through an economic lens. By providing global health aid, Japan is able to cement key relationships with its trade partners. Japan’s perception of global health can be seen in its distribution of foreign aid. For example, in recent years, regions in the Middle East and Africa have been receiving the largest proportion of Japanese assistance: 26.2 percent and 22.5 percent of Japan’s Official Development Assistance (ODA), respectively. Central to this shift is the goal to not only improve health in these

regions, but also to form potential economic relationships. These countries are resource-abundant, and aid enhances economic development and Japanese access to those resources. Specifically, there has been a sharp increase in global health assistance to Ethiopia, a country long associated with poverty. The strategic significance of assistance towards Ethiopia is outlined in Japan’s ODA proposal, which states that Ethiopia is economically important due to it accounting for 8 percent of Africa’s population and its “abundant potential for development.” Dr. Kiyoshi Kurowaka, an advisor

PANORAMA on global health to the Japanese government, provided his perspective on the economics of Japanese global health aid in a recent article. He explained that with global health support from Japan, developing countries become healthier. These improvements will in turn enhance developing countries’ economies, and they will “recall how their donor country helped them.” Because Japan is heavily dependent on emerging countries’ economies, forming strong relationships with countries is essential to the survival of Japan. Retaining and improving close relationships with countries is also a top priority. In previous years, Japan has concentrated a great deal of its global health aid to countries it already has economic ties to, specifically East and Southeast Asian countries, thus insuring a continuation of trade partnerships. Indonesia serves as an instructive example: from 2005 to 2009, it received approximately 19.5 billion U.S. dollars in aid from Japan. Indonesia is a key recipient of global health aid due to its interdependent relationship with Japan in trade and investing. Specifically, Japan is dependent on Indonesia for natural resources, like oil, and as a market and manufacturing base. Economic development in East and Southeast Asia is viewed as essential to the peace and prosperity of Japan. Since Japan’s economy is inseparable from East and Southeast Asia’s economies, economic development in these countries is directly related to Japan’s economic success. The economic approach to global health is not unique to Japan. Many other countries have also approached global health as more than just a moral issue. One such example is the United States, which often addresses global health aid through a political, security and economic lens. Various consequences arise because Japan’s global health aid is often influenced by economic concerns. One issue is that countries that are considered less

Women wait in line for vaccinations given out by UNICEF in the Ethiopian village of Ereguda (2005). The Government of Japan has announced a nearly $16 million donation to UNICEF to improve global health in African countries such as Ethiopia. (Courtesy of The Gates Foundation)

economically important are sometimes overlooked. In terms of income group countries, only 16 percent of Japan’s ODA went to Less Developed Countries in recent years. The majority of Japan’s ODA went to Lower Middle Income Countries, due to a higher potential for developments in such countries. Even further examination reveals that the actual percentage of ODA devoted towards improving health is very low. According to an article written recently in the Lancet, “Japan’s health ODA is set at only two percent of its total ODA, which is substantially lower than the average for OECD countries at 15 percent.” Despite the low percentage devoted to global health aid, most Japanese feel it should be given top priority. In an interview with the HCGHR, Dr. Keizo Takemi, the former Vice Minister of Health in the Japanese government, stated that more than 70 percent who responded to a recent opinion poll for Japanese ODA believed health issues should be the highest priority for ODA. Takemi further explained that most

Japanese feel that it is their responsibility to improve global health care because of their own success with domestic health. In Japan, the average life expectancy is 86 for women and 78 for men-- a very high number as compared to the world average of 67. Because of this success, Takemi claims, it is Japan’s responsibility to share their “experiences on how to achieve a healthy society at low cost with equity.” This attitude of responsibility is reflected in Japan’s recent improvements in global health aid. From 1990 to 2005, Japan has increased its developmental assistance in global health from US $2.5 billion to US $14 billion. And recently, at the 2008 G8 Summit hosted by Japan, global health was identified as one of the nation’s top priorities and deserving of more attention. Whether Japan’s involvement has been spurred by moral, economic or even security reasons, Japan has started to take on a strong leadership role in the global health community. With Japan’s help, real and sustainable gains will be made in global health.q

44 PANORAMA

Neglected

Raising Funds for the “Best Buy” in Global Public Health

By Sheba Mathew

eglected disease campaigns, like any other, demand money, but they do it to save lives. $25 to save a life with an HIV test. $20 to save a life with six months of tuberculosis medications. $10 to save a family with a malaria net. What about fifty cents a year to save a life by treating neglected tropical diseases? This question drives the “Just 50 Cents” Campaign, an effort of the Global Network for Neglected Tropical Diseases. The campaign illustrates the cost-effectiveness of treating neglected tropical diseases (NTDs), which are now recognized to have a global burden of disease exceeding that of TB or malaria. Yet current funds for NTD control programs, while generous, represent just a fraction of those available for AIDS, TB, and malaria programs. According to Dr. Peter Hotez, one of the founders of the Global Network and current President of the Sabin Vaccine Institute, the U.S. government funds “upwards of 100 million dollars to treat people in developing countries with rapid-impact packages [of

drugs] for neglected tropical diseases… which still pales in comparison to the roughly eight billion dollars annually for PEPFAR.” On average, NTD control programs receive just 16% of the amount of Official Development Assistance for health given to malaria or TB annually. As a result, experts assert that funds for NTDs are not only insufficient but also inequitable. This inequitable funding persists largely because the metrics emphasized for priority setting in health have undervalued the global burden of NTDs, though investment has been increasing significantly over the past few years. NTDs share two primary characteristics that have made them historically neglected. In Hotez’s words NTDs “generally occur among the poor, the really forgotten people,” and puts them in a stranglehold of poverty. This salient factor, says Hotez, coupled with the tendency of NTDs to be “long-standing, chronic, and debilitating conditions with high morbidity and low mortality,” suggests why NTDs, until recently, have been undervalued in the global

health agenda. The metric of Disability-Adjusted Life Years, or DALYs, has been the primary tool for global health priority setting since its inception. Two seemingly minor calculation flaws, however, resulted in a significant underestimation of the global burden of disease caused by NTDs. The first was an emphasis on acute morbidity. The chronic burden of NTDs meant that the most longterm complications of NTDs, including cognitive impairment, growth stunting and other negative outcomes such as impaired economic productivity and food security, were overlooked in the calculation of their DALYs. The second crucial flaw was a

What about fifty cents a year to save a life by treating neglected tropical diseases?

PANORAMA failure to incorporate co-morbidities into the original DALY calculations. This masked the critical role NTDs play in increasing the incidence rate of “the big three”—malaria, TB, and AIDS. Hotez claims that schistosomoiasis, which causes ulcers in women’s cervix, uterus, and genital tract, is “now probably the most important co-factor in Africa’s AIDS epidemic that no one has ever heard of.” Yet the DALY system’s disaggregation of these diseases from the big three reinforces the status quo, making NTDs appear unimportant and an expected part of life in poverty despite the ease with which they can be treated. Since their installment in 1990, the DALY calculations have evolved to more accurately depict reality. Although this undervaluation has historically undermined efforts to acquire equitable funds for NTD control, research, and development, treatment programs formed in the past decade alone have been notably effective. Director of the Schistomiasis Control Initiative Dr. Alan Fenwick praised the “unbelievable and unprecedented success” of such programs and cited lymphatic filariasis control programs, which now treat 600 million people annually, as one example. These programs do not simply treat; they in

fact produce some of the highest rates of economic return of any public health program. This success can be largely attributed to the integrated delivery of safe and highly affordable medicines, some that are donated and others that cost as little as one US cent per treatment. According to Hotez, trained healthcare providers aren’t even necessary to distribute the medicines, which “can be given by community health workers or even schoolteachers because of their excellent safety profile.” The high impact of NTD control programs has been paired with a recent increase in philanthropic and public funding. The U.S. Global Health Initiative alone has increased its NTD funding by a factor of five in the past three years. Yet funding remains insufficient and inequitable. The U.S. and the U.K. are the only nations that currently finance NTD programs, and Hotez is calling on the BRIC countries, particularly Brazil, India, and China, “to really step up and invest in neglected tropical diseases, both for mass-drug administration and innovation,” which would double the impact of U.S. commitment. Fenwick adds that “we could eliminate severe morbidities [caused by the

Courtesy of the Global Network for Neglected Tropical Diseases

Experts assert that funds for NTDs are not only insufficient but also inequitable, reflecting the very mechanisms of thought that have made NTDs neglected. seven most common NTDs] in Africa if we had a billion dollars spread out over the next seven to ten years.” The need to rally political will around funding for NTDs is dire, and their financially neglected status compared to their sister diseases of AIDS, TB, and malaria underscores the highly beneficial effects of integrating NTD control with programs for the big three. Yet NTDs have never before been more clearly presented as the “best buy” in global public health. Perhaps now, more countries will start buying in. q

EXPERTS

Integration of health services: Theory and Practice

Jacqueline Sherris, PhD and Jeffrey Bernson, MPH, MPA

n Seattle we often are fortunate enough to have access to a good health clinic or physician, where we can go for regular check-ups and screening tests, get necessary immunizations, address our reproductive health needs, get assessed and treated for many illnesses or injuries, and obtain referrals when we need care that the clinic does not provide. This kind of accessible, integrated care, with its focus on prevention, standard treatment for common health problems, and monitoring of chronic conditions is good for individuals, families, and communities. Yet many people around the world face a much different health care picture. In developing countries particularly, access to health care is limited and services often are provided through vertically-organized programs. Immunizations are offered separately from reproductive health care, which in turn often is not integrated with HIV/ AIDS care. Malaria control programs often do not have the resources or capacity to address other very common infectious diseases that strike their target groups, for instance pneumonia, diarrhea, or even seasonal flu. And as populations in the developing world age and cancer, diabetes, and other non-communicable diseases become common, men and women living in developing countries have few opportunities to obtain

necessary screening tests or receive information and services to help them combat these illnesses (WHO 2011). To address these challenges, the global health community is increasingly focusing on how to provide clientcentered integrated services to meet the health needs of men, women, and children, including in the lowest-resource settings (WHO 2008). While great successes have been achieved through vertical programming -- notably in childhood immunizations, HIV/AIDS programming, and malaria control, -- it is recognized that integration of health services can derive greater overall impact from health resources and systems. Global health advocates, funders, and implementers see integration— including the use of a single encounter with a client to address multiple health or social concerns—as an important tool to better meet the needs of individuals and health systems. Over the past year or two, PATH – an international non-profit organization headquartered in Seattle – has been considering how to design and evaluate integrated programs for greater impact, recognizing that integration can occur within communities, health organizations, broader health systems, and across sectors. We have implemented integrated health projects in a number of countries, including combined HIV/AIDS

and tuberculosis diagnosis and care in Tanzania, integrated care for HIV/AIDS and maternal and child health in Kenya, integrated interventions for diarrheal disease and child health in Vietnam, and a project linking agriculture and nutritional health in Kenya. This article describes our approach to health services integration and outlines the critical elements we consider when developing integrated programming.

Defining Integration PATH defines health services integration as the organization, management, and delivery of a continuum of preventive and curative health services. We do this in accordance with patient and family needs over time and across different levels of the health system. Our definition builds on existing literature – including technical guidance from the World Health Organization - that describes integration as an approach rather than an end in itself. (WHO 2008) PATH carefully weighs opportunities for integration in the places we work, knowing that integration is not always the best approach. We pose four questions as a starting point to assess whether integration is possible or desirable: • What type of service integration, if

EXPERT PERSPECTIVE any, is needed? Answering this question addresses the appropriateness of integration in a particular context, including challenges and benefits. • To what extent should services be integrated? Answering this question requires and understanding of the specific services to integrate, and the timing, scope, and strategy for integrating them. • What steps are needed to establish and sustain high-quality integrated services? Answering this question involves understanding the necessary operational steps at the community, provider, facility, and health-system levels to support a program’s integration goals and objectives. • What information is needed to

measure success and inform improvement, replication, or scale-up? Answering this question requires analysis of which indicators should be used to determine if integration is working to improve health services and outcomes.

A Conceptual Framework for Integration Our conceptual framework for integration encompasses four levels of a country’s health structure— client-centered services at the community level, health operations planning at the organization or agency level, health system coordination at the national level, and intersectoral initiatives across development sectors. (PATH 2011)

Figure 1. PATH’s Approach to Integrated Health Services

• Client-centered services at the facility and community levels: Integrated programming must fit the needs of clients, including individuals and families, as well as the broader community. It may involve expanded clinic hours, more efficient referral systems, increased use of preventive and lifesaving technologies, and improved access to treatment services, drugs, or innovative interventions to enhance care. • Operational elements at the health organization or agency levels: Integrating services often requires changes in how services are delivered by ministries of health, nongovernmental or local organizations, and privatesector agencies. Existing or new health system inputs (such as resources, time, money, or expertise) may need to be allocated differently to support planning, management, staffing, interpersonal communication, or the measurement of integrated services. • Broader governance and capacity issues at the health system level: New levels of coordination or joint planning of the policies, processes, and infrastructure that make up a health system may be needed to deliver integrated services. Integration at this level often requires significant involvement and support from stakeholders, including donors, ministries of health, politicians, advocacy groups, the private sector, and nongovernmental organizations. • Intersectoral coordination: Crosssector integration may occur when, for example, a health system intersects

EXPERTS

Attributes of integrated health services

Regardless of the level at which integration occurs, the PATH believes that the following nine attributes should be considered in planning for successful integrated services.

Planning and budgeting

Planning for integration must be informed by data on the availability, strength, and organization of existing services and by staff perspectives on activities and areas to be coordinated. Budgeting efforts should use available financial resources and policies to help facilities or communities implement integrated services in a coordinated way.

Organization of health services

Training

Training is essential to ensure that staff are prepared and can competently perform new functions and improve their skills. Especially when programs are transitioning to integrated health services, training activities must provide information and skill-building to frontline health and community workers, supporting their efforts to deliver multiple services and minimizing their chance of becoming overwhelmed by increased client volumes or different work flows.

Community outreach

Creating demand for services and educating communities and individuals about the benefits of integrated services require effective communication and education. These activities can include community outreach as well as efforts to improve providersâ&#x20AC;&#x2122; ability to communicate directly with clients about available options.

Referral services

Effective referral mechanisms ensure that clients receive the recommended Integrated programming may require or requested services and are tracked reallocating resources or staff and Supervision through a reliable health information examining pay scales or other forms of Supervisors play an important role in compensation so the internal organiza- supporting change, particularly by help- system, rather than being lost to followtional structure supports the intended ing staff adopt new behaviors. Mentor- up. Ideally, referral systems provide clients with information on the location of coordination of services. Organization ing, joint problem-solving, and strong referred services, their hours and fees, of services may also need to address is- communication between supervisor sues of patient volume, human capacity, and employees are important aspects of and contact information. In addition, information such as the anticipated duwork flow, and facility infrastructure. promoting and supporting change. ration of the visit and the waiting time for results or services can be helpful.

Staffing

Logistics

Staff numbers, roles, and responsibilities must be clarified or codified to reflect new responsibilities and interventions that will be incorporated into a position. To determine the appropriate number of qualified staff needed to deliver integrated programming, health providers at the facility and community levels must have a solid understanding of how the staff will work together to achieve health outcomes.

Delivering integrated services often requires that health programs consider how they supply critical products and commodities. Integration of these logistics helps reduce redundancies that may occur in vertical supply chains while still meeting product and customer requirements. Program managers must pay attention to how various logistics systems can be reconciled so that coordinated acquisition, distribution, and inventoryrecording processes ensure reliable supplies.

with an educational system to administer vaccines through schools or with an agriculture program to address nutritional deficiencies. Integration across sectors requires engagement and commitment at multiple levels of the agencies involved. Figure 1 provides a graphic illustration of this conceptual framework.

integrate maternal and child health services with HIV/AIDS care and treatment. Previous to the integration effort, nearly all mothers in government hospital-based antenatal care programs were being tested for HIV, but only one quarter of those identified were being successfully enrolled in follow-up care and treatment offered though separate comprehensive care centers for HIV. PATH focused was on developing more client centered services, and adjusting health operations to support integration of services (the central two elements of the conceptual framework

Integrated Care in Kenya and Beyond Working with partners in Kenyaâ&#x20AC;&#x2122;s Western Province, PATH is helping

Monitoring, evaluation, and research

Accurate and actionable data are critical to improving the performance of integrated services and measuring their effectiveness. In government health systems, altering information management systems and procedures can be a complex process requiring the use of special research studies or operations research to measure the effectiveness of integrated interventions. illustrated in Figure 1). Maternal and child health clinics were used as the point of entry for a range of health services for both mothers and babies; HIV care and treatment were added to the existing services. The shift to integrated services was associated with more HIV-positive mothers and babies being treated for their HIV disease, better compliance with drug treatment, early diagnosis and enhanced care for newborns, and improved opportunities for testing and treating spouses and other family members.

EXPERT PERSPECTIVE For instance, Western Province, officials report an 80-100 percent increase in the number of HIV-positive mothers enrolling in follow-up care and enhanced access to family planning services among these women. Some of the key attributes that were considered during the shift to a more integrated approach included: building on shorter waiting times and improved quality of care in MCH clinics (health service organization), developing ongoing training and mentoring programs to link MCH and HIV providers (training, supervision), providing and tracking antiretroviral and other drugs through both MCH and HIV care centered (logistics), reaching out to men to build their support for their wives’ care (community outreach), and linking families with HIV/AIDS comprehensive care centers as they “graduate” from MCH care (referrals).

While much remains to be done to expand integrated care in Kenya – particularly in developing stronger tracking and monitoring tools to evaluate the impact of integration on health outcomes (an issue for many integrated health programs [Butta et al 2011]) – the results described here have been met with enthusiasm at the national level, and the MCH-HIV/AIDS integration model is being rolled out at a number of other locations country-wide. Integrating services present challenges – and opportunities - on many levels. Consider the increasing burden of noncommunicable disease in lowresource settings, and the heath needs, for example, of poor, older women in developing countries. These women likely have survived various infectious diseases, as well as the threats of pregnancy and childbirth, and often have a key role in the social and economic

health of their communities. Yet they are at risk of cancer – particularly cervical and breast cancer. They have increasing incidence of diabetes and other risk factors for cardiovascular diseases. And they have a range of other health needs, including gynecological problems related to frequent childbearing. The health systems that serve them must tackle the dual challenges of meeting ongoing infectious disease and maternal health challenges, and the noncommunicable disease threats needs of older women and men. As outlined in this article, considering how to achieve integration at various levels of the health structure, as well as how to manage specific changes in the organization of services, staffing, community outreach, logistics, etc., to support integration will be key to meeting these challenges.q

About the Authors Jacqueline Sherris, PhD Vice President of Global Programs at PATH (Program for Appropriate Technology in Health); Affiliate Assistant Professor in Global Health at the University of Washington School of Public Health Dr. Sherris has more than 20 years of experience in public health. From 2002 to 2007, she served as PATH’s program leader for the Reproductive Health Strategic Program, through which she led and expanded PATH’s cervical cancer prevention work, including efforts to increase access to human papillomavirus vaccines in developing countries. Other areas of reproductive health work that grew under her leadership include contraceptive supply security, pharmacists and reproductive health, technologies and interventions for women dealing with the consequences of unprotected sex, and integration of family planning and HIV and AIDS services. Prior to taking on the reproductive health program leader responsibilities, she led various reproductive health projects and programs at PATH. Before joining PATH in 1987, Dr. Sherris coordinated the University of Washington’s Academic Programs for Teachers and was a staff associate with the Population Information Program at The Johns Hopkins University, where she authored several issues of Population Reports. (Biographical information courtesy of www.path.org and www.urgentafrica.org)

Jeffrey Bernson, MPH, MPA Advisory Board, Urgent Africa

Having obtained an educational background from the University of Washington in International Health, Public Administration and International Development Policy and Management, Mr. Bernson has focused much of his work experience on international relief and devoted two years to serving as a Peace Corps Volunteer in Honduras where he acted as a coordinator for the construction of gravity water systems. As an intern for PATH (Program for Appropriate Technology in Health), Mr. Bernson spent four weeks in the Philippines where he established an evaluation framework for a project integrating population health and coastal resource management. He has also worked as a Consultant in Participatory Strategies in Relief and Disaster Settings for Health Alliance International. Mr. Bernson has a solid background in planning and management as he held the position of Associate Director of Structural Trades for Facilities Resource Management where he oversaw the structural trades staff as well as the annual budget.

EXPERTS

Availability of essential medications for noncommunicable and chronic diseases in low and middle income countries: A persistent and growing violation of human rights and potential solutions Rajesh Balkrishnan, PhD and Sofia D. Merajver, MD, PhD

on-communicable and chronic diseases (NCDs) are on the rise throughout the world, but they pose an especially great challenge in low and middle income countries (LMIC). With limited resources for healthcare and prevention, these regions, still affected by a high burden of infectious diseases, are now facing a double epidemic. Many of the chronic diseases such as diabetes, chronic respiratory disease, cardiovascular disease, and cancer, require medications to prevent, treat, and alleviate their painful and persistent symptoms. The availability of reliable and efficacious medications for those populations that most need them is a constant and growing challenge. A significant proportion of the 35 million chronic disease related deaths can be prevented if medications are made accessible and affordable. This challenge can and should be met. Here, we briefly summarize why and how.

Medicines Exist in LMIC, They Are Being Sold, but Few Can Get Them

Policies of Access to “Free Medicines” are Often neither Free nor Accessible

In most LMIC, the availability of medicines in the public sector is much lower than in the private sector. This is a reflection of ineffectual or lack of coordination between government, the regulatory body, and pharmaceutical providers and industries. This status quo is not bad for everyone, as profits are being made, but it violates a basic human right to health: up to 90 percent of the population in developing countries would need to pay out-of-pocket for medicines, which can then be priced at many times their retail price. This unregulated system impoverishes those who can afford even some of the medicines and further marginalizes and violates the rights of those who could never afford any of them.

Policies of access to “free medicines” are often neither free nor accessible. Although there are policies and systems stating that many medicines are provided free of cost by the public sector, they are not consistently available and must, in reality, be purchased from private outlets. These medicines then cost more due to add-on costs in the supply chain or due to retail mark-ups. Therefore, public distribution facilities are a primary “access” option for the poor and the revenue gained from them can be used to subsidize other parts of the government, not at all the intended end. This is inherently inequitable and denies these essential medications to the patients that most need them. Many families in LMIC are being plunged into poverty by unaffordable life-saving medicines.

EXPERT PERSPECTIVE

Proposed Solutions The solutions to this crucial challenge in global public health and human rights, are not very complicated. According to a recent report by the NCD alliance, a majority of the medications needed to treat NCDs are present and potentially available in LMIC regions in generic versions for very nominal prices (some diabetes medications for as low as 10 cents per month and asthma inhalers for 3-4 dollars per month). However, many of these medications are not yet available to the people in the poorest regions of the world. Governments impose duties, taxes, and levies greatly increasing the costs of these medications by the time they might reach the public. Therefore, health care systems need to be developed cooperatively in LMIC settings that will enhance widespread access to a list of low-cost generic medicines tailored and optimized to ameliorate the regional burden of disease. Policies and infrastructure that can be implemented towards this end include: 1) eliminating taxes/duties by governments and regulating mark-ups; 2) registration procedures that preferentially promote the use of generics; 3) regulate, monitor, and ensure the quality of generic products; 4) encourage competition in the private sector to provide inexpensive medicines. Price negotiations/buyer co-payment, local production (which can be very costly in small quantities), compulsory licenses and government use orders with adequate compensation, and pooled procurement (countries with small purchasing volumes pool their purchases) of essential medications for NCDs are other suggested strategies to increase access to essential NCD medications. The treatment of patients with NCDs is different from the treatment

of acute infectious diseases. Patients with NCDs generally need care over extended periods of time, sometimes life-long, and should have a continuum of care provided to them by trained health care workers or health professionals.

Appropriate diagnosis, treatment and longitudinal monitoring of patients with NCDs is crucial for good outcomes, as in many of these conditions, there is no cure available. It is a basic human right to have access to essential controller and reliever medications and to provide low cost monitoring strategies to help adherence to suggested medication regimens. Appropriate diagnosis, treatment and longitudinal monitoring of patients with NCDs is crucial for good outcomes, as in many of these conditions, there is no cure available. Patient education thus becomes a cornerstone of successful management of NCDs, and this education should include discussions about the appropriate medication use behaviors that are needed to improve patient outcomes in these conditions.

Strategies for Potentially Effective Solutions What can we do about this challenge from a global perspective? We need to work more closely with NGOs in

LMIC in monitoring, pricing, availability, and affordability of NCD medicines and identifying and promoting successful interventions to improve access to these medications, while strongly advocating for the elimination of added costs. We need to mobilize additional resources and develop strategies to increase not only access to essential NCD medications, but also conduct more evidence-based policy analyses that will help remove some of the financial barriers in access to these medicines. The development and maintenance of cost-effective evidence-based guidelines regarding NCD treatment in LMIC as well as the development of insurance/payment systems that will target and pay for low cost generic medications, are going to be key interim metrics for improving outcomes related to NCDs . To quote the former director general of the WHO, Dr. Brundtland: â&#x20AC;&#x153;Access to essential medicines is a prerequisite for the progressive realization of this fundamental human right, and, as such, is an issue of great consequence to the health and well-being of individuals throughout the worldâ&#x20AC;?.

...it becomes paramount that we all recognize that we all need to be willing to share critical assets... Thus it becomes paramount that we all recognize that we all need to be willing to share critical assets, resources, skills and capabilities to facilitate the alleviation of the burden of NCDs in LMIC by working with governments to develop health care systems that can provide patients with NCDs access to the most essential medications. q

EXPERTS

For further reading... Dr. Balkrishnan is a member of the Essential Medicines Working Group of the NCD alliance. This alliance has recently put out a detailed working paper with detailed references on the issue of “Access to Essential Medicines and Technologies for NCDs” which can be found at: http://www.ncdalliance.org/

About the Authors Rajesh Balkrishnan, PhD Associate Director for Research and Education, University of Michigan Center for Global Health; Director, Center for Medication Use, Policy and Economics; Associate Professor, Health Management and Policy Dr. Balkrishnan’s research at the University of Michigan is composed of two focus areas. The first area is the intersection of health informatics and applied statistical methodology in pharmaceutical health services research. For the past 15 years, Dr. Balkrishnan has designed and analyzed large population-based databases to understand chronic medication use behaviors longitudinally. The second, and emerging area of research for Dr. Balkrishnan is the design and analysis of studies of medication use and preventive health services occurring globally, and expanding database capabilities for working with large, population-based studies in the developing world. Because of this aspect, Dr. Balkrishnan is now an integral part of the activities of the University of Michigan Center for Global Health. He is working to refocus his research efforts more towards evaluative studies of comparative and non-comparative health systems in a global context. Dr. Balkrishnan has published over 200 research articles in many journals including Medical Care, Health Service Research, Health Affairs, Lancet, and Journal of the American Academy of Dermatology. He co-authored what is considered by many in the field as the definitive text on health services research evaluation, published by AcademyHealth/Health Administration Press. Dr. Balkrishnan also serves on the editorial boards of two journals: Clinical Therapeutics and The American Journal of Managed Care. He serves on several national and international research review groups, and chairs the Behavioral Sciences and Epidemiology study section of the American Heart Association. (Biographical information courtesy of www.umich.edu)

Sofia D. Merajver, MD, PhD Director, University of Michigan Center for Global Health; Professor, Epidemiology, Department of Internal Medicine; Director, Breast and Ovarian Cancer Risk and Evaluation Program

Dr. Merajver is a physician scientist with a translational focus of integrating the molecular genetics of breast cancer with clinical, social, and environmental determinants of outcomes in the global stage for women at high risk for breast cancer and women affected with aggressive breast cancer phenotypes. As Director of the Breast and Ovarian Cancer Risk Evaluation Program, which she founded at the University of Michigan in 1995, and as a scientific leader of the Breast Oncology Program, she is engaged with clinical translational research that tests prevention and therapeutic interventions as well as educational tools to improve cancer outcomes globally. Dr. Merajver’s global health research has encompassed comparative studies on expression of metastasis associated genes in inflammatory breast cancer in the US and Africa, perceived risk, dynamics of social interactions in the family of patients at high risk, fear of insurance and employment discrimination as a major decision making determinant, and acceptance and barriers to utilization of chemoprevention in breast cancer. Future directions in her role as Director of the University of Michigan Center for Global Health include collaborations with multidisciplinary teams in the medical, epidemiological, engineering, and social sciences to train translational scientists and to best deliver cancer risk management interventions around the globe and rigorously evaluate their impact in ameliorating inequities in health.

STUDENT SUBMISSIONS

The Issue With Quinoa and Nutrition in Bolivia By Carlos de Mestral

hile I was having lunch in Quincy dining hall last week with my friend Helen, we both commented that our quinoa meal tasted delicious. I mentioned how happy it made me that such a nutritional meal actually was so pleasing to the palate. Upon agreeing with me, Helen told me something that really struck me. She told me how while spending a semester studying abroad in Bolivia, she witnessed the changing habits in people’s diets in the country. Simply put, fewer and fewer Bolivians consume quinoa every day. Bolivians have been harvesting and consuming quinoa for hundreds of years. Today, the decline in quinoa consumption is linked to the increasing global market for quinoa. Developed countries have just recently discovered the unique nutritional value that quinoa affords, which includes a complete set of amino acids, dietary fiber, phosphorous, magnesium and iron. The seeds have become a high commodity in the diet of high-income countries, as exemplified by our own Harvard dining hall menu, which now offers quinoa at least once a week. Quinoa’s success in the international market has come with a high cost, unfortunately, as local prices have skyrocketed in Bolivia, and an increasing number of Bolivians can no longer afford the nutritional seed. Quinoa is being replaced with processed foods

Carlos de Mestral Carlos, a proud resident of Quincy House, majored in Human Evolutionary Biology while at Harvard. He also fulfilled the pre-med requirements and is planning to enroll in medical school for the Fall of 2013 to pursue a joint MD/MPH. Until then he is spending a few months interning at the UN in Geneva, followed by one year of volunteer work in the Philippines and more traveling to still unknown destinations.

such as rice and noodles, which do not compare to quinoa’s nutritional value. This is a serious problem, especially since Bolivia is the poorest country in South America and has struggled for years to feed its population. Although malnutrition rates have declined over the past decades, in recent years there has already been an increase in chronic malnutrition among children in quinoa-growing areas. And prices continue to rise, which will cause even fewer

Bolivians to be able to afford quinoa. Many argue that the export of quinoa to developed countries is promoting the economic growth of quinoa growing areas, and that in the long run this growth has the potential to decrease rates of malnutrition. However, transitioning from a quinoa based diet to one based on highly processed foods might cause more nutritional problems than expected, such as overweight and obesity, which will exacerbate the double burden of disease. Therefore, something ought to be done to stop this decrease in local quinoa consumption. The government of Bolivia should set a limit to local prices and offer subsidies, as well as tax breaks to farmers who choose to sell domestically. In addition, higher export taxes can be established. Furthermore, the government should promote awareness of the highly nutritional value of quinoa, and the potential risks of a diet based on highly processed foods. q Written for SLS19: Nutrition and Global Health, Spring 2011 Semester.

For centuries, Bolivians have harvested the highly nutritional seed, which includes a complete set of amino acids, dietary fiber, phosphorous, magnesium and iron. (Courtesy of Jacqueline, Flickr)

STUDENT SUBMISSIONS

Notes from the Field: A Summer in Salone By Nigel Deen

n April 2010, the government of Sierra Leone declared that all healthcare services for pregnant and lactating women, and young children be free of charge, in response to the high maternal and infant mortality rate. The government of Sierra Leone launched the Health Sector Strategic Plan 2010-2015 to ensure successful implementation of the Basic Package of Essential Health Services (BPEHS) to improve service delivery. According to the government, this package ensures the provision of minimal essential quality of care for all and includes services

that have the greatest impact on major health problems (especially that of maternal and child health) . Last summer, I traveled to Sierra Leone to assess the success of the Health Sector Strategic Plan with respect to maternal health. My research focused on two key issues that prove especially important in reducing maternal mortality rates. The first goal was to evaluate the availability of maternal health resources. In order to assess the quality of the maternal healthcare, I travelled to maternal facilities in Sierra Leone and evaluated the medicines, staff,

I managed to travel around Sierra Leone quite a bit. Visiting Sussex beach during the rainy season, I found that the beaches become flooded making it hard to walk in but providing beautiful scenery. (Courtesy of Nigel Deen)

equipment, and utilities available at each of the facilities. Additionally, I interviewed pregnant and post-partum women at these facilities to find out more about their experience with maternal care. The second goal was to conduct interviews with healthcare officials and health workers to determine the challenges that exist in providing health services to pregnant and post natal women. I went to Sierra Leone with the intention of interviewing at least 100 women and by the end of the first week I was successfully able to interview 30. I was accompanied by another Harvard undergraduate and a family relative, Mohammed; having their support was invaluable and allowed us to cover ground more quickly. When visiting these hospitals I was amazed at the level of care expected despite the scarcity of resources. Medicines for the women are few and far between, and women often have to wait hours in the heat for antenatal checkups that rarely go on for more than ten minutes. Additionally, the pay for hospital staff is mediocre, further de-incentivizing professionals to remain in the industry. After reviewing interviews with these women, it is clear that pregnant women in Sierra Leone must overcome many barriers in order to receive basic maternal care. These barriers can be classified into physical access barriers, community barriers, and resource barriers. Alone, each obstacle did not exclusively affect a womanâ&#x20AC;&#x2122;s chance

STUDENT SUBMISSIONS

of survival; rather, they each played an integral role in triggering the series of events which determined healthcare quality for pregnant women in Sierra Leone. Many women did not go to school and almost all live in abject poverty, depicting the immense impact social determinants have on health outcomes for women. Most women didn’t own a flushing toilet and didn’t know that they shouldn’t cook outside in the vicinity of a pit latrine. While healthcare officials and health workers are passionate about the work they do, they are discouraged due to a lack of adequate support. They often go without electricity for many hours a day; many doctors fear that they will have to deliver babies by candle light. Without air conditioning pharmacists believe that the drugs will denature and be rendered useless. A lack of space in most of hospitals means that the few neonatal wards must be converted into delivery rooms while also serving as storage rooms for medication. Amidst all the shortcomings, there does seem to be a glimmer of hope. Based on my findings, the free maternal healthcare policy is effectively convincing women who would normally give birth at home to give birth at a clinic or hospital. The challenge however remains twofold: (1) to regain the trust of those who continue to visit Traditional Birth Attendants (TBAs) despite having access to free care, and (2) to help support the hospitals so that they are able to provide for the increase in patients without compromising service quality. These objectives require money that Sierra Leone does not have, or has not allocated for this purpose. While it is true that the policy has effectively increased the number of women who are now delivering at hospitals despite these barriers, it

Nigel Deen Nigel, a senior in Quincy House, is concentrating in Neurobiology with a secondary in Global Health and Health Policy. Working for the Center for Health Decision Science, Nigel spent a year researching the causes and socioeconomic determinants of maternal mortality in Sierra Leone, with a specific focus on post-partum hemorrhage and possible packaging interventions to reduce maternal mortality and morbidity in rural regions. As a David Roux Global Health Traveling Fellow, he spent the summer of 2011 researching the effectiveness of the free maternal healthcare policy in Sierra Leone. After graduation he plans to attain a Masters in Public Health and continue working in Sierra Leone. remains to be seen as to whether or not this policy is sustainable for the hospitals. The increase in pregnant women attending hospitals, without an increase in the number of facilities and improvement of conditions, has placed a tremendous amount of strain on doctors, nurses, and hospital staff. The Sierra Leonean government cannot

afford to lose the gains it has made in maternal health and must stage a second effort to bolster the healthcare resources in the country. Whether or not this means accepting outside aid, or incurring debt, it is an investment that must be made in order to positively influence the health outcomes of the Sierra Leonean women and children. q

The West Africa Fistula Foundation in Bo, Sierra Leone. A women’s health program dedicated to reducing maternal mortality caused by obstetric fistula through providing access to education and medical remedies. (Courtesy of Nigel Deen)

STUDENT SUBMISSIONS

Caring for Kakuma By Alex Palmer Courtesy of Alex Palmer

very day, I would carry Zablon across the schoolyard to the kitchen, pour water on the infected cut on his foot, and clean it with surface cleaner—the only disinfectant available. Zablon was a Congolese refugee and a student in my class, and while I would clean his cut, he liked to tell me about his life and especially his plan to play soccer for Arsenal one day. After checking in with Zablon, I would make my way across the dusty yard to the preschool classroom, where the teachers wanted me to make sure that another student’s skin infection was not worsening. I did not go to Kakuma Refugee Camp in Kenya expecting to become a makeshift health worker—but then again, I wasn’t sure what to expect. I traveled to Kakuma intending to work as a volunteer teacher and amateur documentary photographer, but during my time there I learned lessons that resonated far outside the classroom. Time and again, I saw that issues of education, health, culture, governance, and development are critically intertwined for refugee populations. Any attempt to address the health-related issues—from high levels of HIV/AIDS infection to malnutrition and simple infections— that plague places like Kakuma will have to take account of these interwoven threads to find solutions that are both locally feasible and community-driven. As in many parts of rural Africa, perhaps the most serious health problem confronting Kakuma is the rate of HIV/AIDS infection. Though reliable

statistics are not available, a number of factors indicate that the rate of infection among the local population is high: although premarital and extramarital sex occur, condoms are rarely used and false rumors about potential side effects abound; commercial sex workers thrive in both the refugee camp and the surrounding community; and some of the groups residing in the camp, particularly Somalis, swear by false and harmful methods of infection prevention, like having sex with a virgin or drinking camel urine. Given that rates of HIV/AIDS infection are already high throughout Kenya, these local circumstances point to an especially acute problem. Other less extreme but nonetheless deadly health issues include malnutrition, drought, and inability to successfully treat infection. Ironically, the extreme heat and dryness that protect Kakuma from mosquitoes carrying malaria also expose the entire region to extreme shortages of food and water on an almost annual basis. Food aid continues to pour in from the developed world through the local United Nations sub-office and the World Food Programme compound, thereby removing much of the impetus for long-term local solutions. Addressing health issues will require an approach that works within local restraints and finds a way to appeal to the individuals of various nationalities that call Kakuma home. Childhood educational programs that focus on hygiene, disease prevention, and sexual health

education have shown positive results, though sensitivity to cultural issues is always a necessity. At the same time, local NGOs and international organizations must do a better job of connecting with influential community members, both to ensure better governance inside the camp and to create partners who can help bring national communities around to the idea that they must be the ones to spark change. For better or worse, Kakuma Refugee Camp will likely be around for a long time to come, and it will have to be local residents, not international aid workers or volunteers, who find the solutions that the community so desperately needs. After all, even when my time in Kakuma had come to an end, Zablon’s infection had not improved. In the end, it is up to the people of Kakuma to care for and heal their community. q

Alex Palmer

Alex, a senior in Quincy House, is a Social Studies concentrator with a focus field in Ethics, Security Studies, and Humanitarianism and a language citation in Spanish. As a Michael Christian Traveling Fellow, he spent the summer of 2010 volunteering as a teacher and documentary photographer at Kakuma Refugee Camp in Kakuma, Kenya. After his experience in Kakuma, he founded an NGO that works to provide educational opportunities for refugee children. He returned to Kakuma for follow-up research in January 2011 under the sponsorship of the Harvard Humanitarian Initiative’s Cogan Family Research Fund.

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