Ebola after the fact: a news round-up

The Milken School at GWU sent out an interesting e-mail earlier this week with a collection of media stories (basically, a news round-up) about the Ebola outbreak in West Africa. I get quite a few messages from PR departments because I manage the IH Blog, but MPH@GW usually puts good information together, so I do not have any qualms sharing it here:

The recent outbreak of Ebola in West Africa has claimed thousands of lives, and although fewer infections are reported each day, the fight to stamp out the virus continues, and the ripple effects of Ebola will be felt for years to come. Many in the public health community blame the media for inciting hysteria about the risk of contracting Ebola in the United States and contributing to vast misinformation about the outbreak. Despite fear mongering headlines and news features, progress against the crisis is being made, and technological advances are being discovered that will improve the next response to an outbreak of this magnitude. MPH@GW is featuring coverage of the crisis that focused on the real story, and not sensationalist headlines, and highlighted truth, heroism, and new advances.

The hysteria surrounding Ebola in this country was indeed frustrating to just about every public health professional I work with, and it led to some really disappointing political pandering and discrimination. The round-up itself is pretty good, too – I recommend checking it out.

The trouble with models

Note: This was cross-posted to my own blog.

As a research epidemiologist, I love all things data. I will totally nerd out with a book on best practices for designing and maintaining disease surveillance systems all over the world (which I may have done this summer by reading this book by my apartment complex pool). My husband joked once that “you are one of probably five people who read MMWR in the entire country…ten, tops.” I spent a significant portion of my time at APHA in Chicago scoping out doctoral programs, so research is kind of my thing. Nonetheless, I found myself agreeing with an editorial in Lancet Global Health two issues ago which discussed the value and limitations of theoretical/mathematical epidemiological models. I had intended to write about it, but things have an unfortunate tendency to slip off my radar during busy days…and then, unexpectedly, another editorial in the current Lancet Global Health issue, this time on a malaria vaccine trial, jogged my memory.

The October editorial lauded a research paper in the same issue which plugged ten years worth of HIV surveillance data in South Africa into ten different models used to predict HIV prevalence in 2012, and then compared those predictions to actual 2012 data collected in that year’s household survey. (Note to self: read this paper.) The editorialists praised the paper authors for their courage (which, although actually testing the validity of models should not be a terribly scary thing, I suppose researchers do not enjoy proving themselves wrong any more than anybody else) and raised some very good points about the utility of models.

Overall, the models got many of the details correct, such as a shift in HIV burden from younger to older age groups, but got the big picture wrong—predicting stable or declining overall prevalence, whereas prevalence actually increased…Only one model predicted a noticeable increase in HIV prevalence towards the level measured in the survey, and the best estimates of only two of the ten models were within the 95% CIs of the 2012 household survey data. This finding raises the sobering question: if we can get model predictions so wrong in the data-rich setting of South Africa, where there are ten leading HIV epidemiological modelling groups focusing their attention, where can we get it right with confidence?

One possible answer is to redefine what is meant by getting it right. Three of the ten models included in this study incorporated uncertainties…For most indicators for these three models, the empirical data did fall within the uncertainty bounds of the models. If all models provide wide limits of possible epidemic projections based on all plausible trajectories, which ultimately include what does occur in future findings, then they could be regarded as right, but they would not be very helpful.

It is also possible that models can correctly predict what would have been expected to occur, had unforeseen [political, financial, programmatic, or behavioural] changes in underlying conditions not affected the epidemic…In such circumstances, the models project a counterfactual that can be compared with the actual outcome to assess the effect of the changes in conditions, but in themselves might not be able to be validated.

These raise some very interesting questions about the real-world value of mathematical models. While they can provide a framework for understanding epidemiological patterns, or using them for resource planning, their predictive power strikes me as not terribly reliable. What good are predictive models with massive error margins? There is also, of course, the inability of models to account for political chaos change, social unrest, or natural disasters (which underscores the importance of disaster planning). Of course, no model is perfect or able to account for all contingencies, but it is important to acknowledge that their inability to do so inherently limits their everyday usefulness in public health planning.

I was a bit surprised, then, to see an editorial in this month calling for swift action on widespread malaria vaccination citing model predictions as the evidence base for its recommendation.

The [WHO Strategic Advisory Group of Experts on Immunization (SAGE) and the Malaria Policy Advisory Committee (MPAC)] advised that, despite the vaccine having shown partial efficacy in a large phase 3 trial published in The Lancet in April, further real-world demonstration studies should be done before wider roll-out. This small bombshell was doubtless on many minds at ASTMH as four sets of malaria modelling groups presented the results of a major collaborative project on the potential public health impact and cost-effectiveness of the vaccine.

The models used empirical data on vaccine efficacy from the phase 3 trial and historical data relating clinical and severe incidence to mortality. Over a 15-year follow-up period, with 72% coverage of four doses, and at a parasite prevalence in 2–10 year olds (ie, transmission intensity) of 10–65%, the models predicted that the vaccine could prevent a median of 116 480 clinical cases (range across models 31 450–160 410) and 484 deaths (189–859) per 100 000 fully vaccinated children.

When the inevitable question from the floor about the SAGE/MPAC advice came, WHO’s Vasee Moorthy was quick to stress that the organisation had not yet stated its formal position on the matter. Peter Smith, chair of one of the technical expert groups reporting into MPAC, added that the modelling study had shaped the group’s thinking, but that uncertainties remained regarding implementation practicality and safety (the phase 3 trial showed a higher number of cases of meningitis and cerebral malaria in the vaccine group).

I am by no means a modeler, and there may be distinct differences in the reliability of models for HIV versus malaria transmission – particularly considering that HIV transmission is heavily influenced by behavior, while the vector-borne nature of malaria may make predictions more accurate. But I think that mathematical models would have similar limitations with predicting the efficacy of vaccination campaigns, since those are also affected by a whole host of political and economic factors that are difficult to account for. The authors of the malaria editorial also cited research modeling the efficacy of antimalarial drugs at controlling the disease spread, and I would imagine that access to, and distribution of, pharmaceuticals are impacted by factors that models simply are not able to capture.

In the end, though, I suppose models are one of the few robust tools that scientists have to guide policymakers in resource and programmatic planning for public health. As the authors in the first editorial point out, “[Models] are instruments for assessment of the available data, often attempting to reconcile several sources of data together, to provide implications, inferences, and further insights with more rigorous predictions from the knowledge base than could be achieved otherwise through simple extrapolation of past trends or speculation.” Nonetheless, I think it is important to use caution when arguing for “bold action” on the basis of theoretical models. WHO may be right in considering additional studies before a mass vaccination campaign, particularly, when injury rates are high.

#APHA2015 Governing Council Report

The following summary of the Governing Council session at this year’s Annual Meeting in Chicago was compiled by Carol Dabbs, the Section’s Whip for this year. We look forward to next year’s summary by Governing Counselor and 2016 Whip Caroline Kingori.

Seven members of the IH Section represent us on the APHA Governing Council (GC); the number of representatives is based on the number of primary members in the section. State affiliates and the other sections also are represented on the GC. Each year, we meet on Saturday afternoon and again all day on Tuesday. Many items are introduced during the Saturday session, with votes being taken on Tuesday. This provides an opportunity for GC members share the status of the agenda and options to be decided with the rest of the section during the Sunday afternoon and Monday morning IH Section meetings.

GC conducts the basic business of the Association, including setting bylaws; electing the President, Executive Board members, and Nominating Committee members; and approving APHA Policies. Because of the importance of these matters to the Association, serving as a GC member is rewarding for those who have patience with large meetings following strict parliamentary procedure. We also receive reports from the Executive Director, the Executive Board, and many APHA-wide Committees.

This year’s agenda was fairly typical. The following decisions were taken by the GC this year:

  • As discussed on our conference call in June, we approved revisions to the SPIG policy, which allow new SPIGS to have sufficient time to identify those who would join the SPIG if formed, and also a new policy regarding sections which details the process for a SPIG to become a section.
  • The Program Emphasis for the 2017 Annual Meeting will be Climate Change. Further refinement of the exact wording will be done in a smaller body. (Wordsmithing in a group of over 200 is not considered a good use of time!)
  • The proposed dues increase of 10% for each category, rounded to the nearest $5 was approved by a majority of 68%.
  • Bylaws changes to increase student representation on GC, and to improve wording concerning the editor of the AJPH and women’s issues were approved.
  • Proposals for archiving of older policies were approved, except for those relating to civil rights, which were instead approved to be reviewed for updating during the next year. Such updated policy proposals would be considered at the 2016 Annual Meeting.
  • Fifteen policy proposals were approved as part of a consent agenda recommended by the Joint Policy Committee. Two proposals were removed from the consent agenda at the request of GC members, for discussion during this meeting along with the two late breaking proposals. These were as follow:
    • B8: Cancer Prevention. The Joint Policy Committee (JPC) advised against passage of this policy for several reasons; it failed by a wide margin.
    • D4: Role of Health Educators. Amendments were offered and passed regarding the definition of Clinical Social Workers (CHW) and the relationships between Health Educators and CHW. The policy passed as amended.
    • LB1: Leveraging Community Development Investments to Improve Health. This passed with 96% of the vote.
    • LB2: Negative HIV Test as a Condition of Employment for Foreign Nationals. This proposed policy, developed by our own Jessica Keralis, passed with 95% of the vote. As with all approved late breaking policy statements, it will be considered (possibly in amended or refined form) for approval as a permanent policy at next year’s Annual Meeting.
  • The president-elect is Thomas Quade.
  • Elena Ong, Benjamin Hernandez, and Marc Guest were elected to Executive Board. The new chair will be Lynn Bethune.

@Lancet editorial: Iran and Global Health Diplomacy

Note: This was cross-posted to my own blog.

Global health diplomacy is an emerging field that has been gaining traction and attention recently. There was a session on it at this year’s APHA Annual Meeting (which I unfortunately had to miss), as well as a pre-conference workshop for the bargain price of $30 – certainly a steal compared to the $100 pricetag on the Global Health Fellows Program’s Saturday session. Interestingly, Lancet Global Health ran an editorial on global health diplomacy in its new issue that was released this week, focused specifically on Iran. The piece is open access and short enough to be worth copying here in full.

In their Correspondence, Kamiar Alaei and colleagues (September, 2015) suggest that the Iran–USA relationship could be normalised through academic educational and research collaborations, which has been defined as global health diplomacy. Diplomacy no longer only concerns power, security, and economics, but global challenges such as health. Foreign policies (eg, economic sanctions) can endanger health as well as promote it.

The lifting of economic sanctions could stabilise, steadily driving up all prices including food to some extent, and address the limited availability of high quality drugs and medical devices. Sanctions have not only led to material shortages, but have also endangered mental health because of continuous threats. People exposed to stressful life events have higher mortality and morbidity. Moreover, research including medical research in Iran has suffered greatly during the international economic sanctions. One of the bibliometric indicators of a country’s scientific performance is the number of publications. According to Web of Science, the number of publications by Iranian authors in medical and health sciences has decreased from 23 409 in 2012 to 22 918 in 2013, whereas this number had been steadily increasing in the years before the economic and banking sanctions.

In conclusion, the Iran nuclear deal is an opportunity to strengthen the academic and scientific relationship between Iran and the USA and to promote medical research activity and public health especially in Iran. Since Iranian citizens compose the sixth largest group of international practising physicians in the USA, and in view of the academic positions that Iranian-Americans hold, their role in a scientific relationship could be prominent.

#APHA15, Day Four: Wednesday is for Breakfast, Presentations, Moderating, and Final Thoughts

The final day of the conference is normally a pretty relaxed. Section members have typically eaten a good meal (and had a good laugh) at the Awards Dinner and social, the Governing Council has convened to pass policies and elect APHA presidential and executive board candidates, and they have had plenty of time to scope out the expo for the best SWAG. For me, however, this was not the case: the highlight of my Annual Meeting experience was presenting my very first abstract on Mandatory HIV Testing in the Republic of Korea at the International Health and Human Rights session.

Global Health Leaders Breakfast
My last day began early with the Global Health Leaders Breakfast hosted by APHA and coordinated by Vina HuLamm, our Global Health Manager on APHA staff. This year’s featured speaker was Dr. Sir Michael Marmot, arguably one of the most well-known and respected epidemiological researchers in the world. Unfortunately, I could not stay long enough at the breakfast to hear him speak, as my presentation was the first one of the session and began at 8:35 sharp, but I did have enough time to snap a picture of him with some of our Section leaders.


Alas, one drawback of being the Section’s Communications Chair is that I am usually behind the camera. Maybe I can hire a Co-chair in time to be in the picture next year.

I also got a chance to hear Dr. Jim Chauvin, a Canadian public health professional and former president of the World Federation of Public Health Associations, introduce Dr. Marmot and share his excitement about the election of new prime minister Justin Trudeau, which he hoped would bring a revival of public health and its prioritization. It is too soon to tell whether Trudeau will usher in a public health renaissance, but videos like this one lend some optimism to the prospect:

Presenting on International Health and Human Rights
After Dr. Chauvin finished his remarks, I dashed off to the International Human Rights session to present my abstract on Korea’s discriminatory policy of mandatory HIV tests for foreign English teachers and EPS workers. I was the first presentation of the session and was followed by two presentations on Palestinian human rights violations by the IDF in the last Gaza war, a talk on women’s rights with the Beijing Declaration as a framework, and an overview of USAID’s efforts to promote gender equality within its development projects (e.g., an indoor residual spraying program). Palestinian human rights is obviously a hot topic, and our Section in particular is active on the issue (and even has a Palestinian Health Justice working group), so most of the discussion with the audience focused on those talks. However, I did get one question from the audience that allowed me to discuss the difficulty in overturning HIV-related travel restrictions in national immigration policies.

Moderating M&E
I volunteered to moderate our Section’s session on Monitoring, Evaluation, and Quality Improvement, which is of particular interest to me as an epidemiologist and a research specialist. This session was a bit shorter, featuring three presentations on different monitoring and evaluation programs, including a health and microfinance intervention in Tanzania, adapting an existing system to monitor the WHO’s efforts to mitigate the Ebola outbreak in West Africa, and an effort to improve data usage by reducing the number of indicators used in data collection to only those which are absolutely essential (always a win in my book!).

Final Thoughts
APHA 2015 marked the fourth Annual Meeting that I have attended, and the second that I attended as a member of the Section leadership. This one was one of the most successful for me personally: I had an abstract accepted and authored a late-breaker that was adopted (and will hopefully pave the way for a permanent policy position on the issue for APHA to adopt at next year’s meeting). I met lots of interesting and engaging people, made connections with emerging Section leaders, and even planned a global health jobs analysis as a joint effort between the Communications and Global Health Connections Committees (stay tuned for more details; we will be seeking volunteers soon!).

The Section leadership’s next hurdle is to make sure that interested members get plugged into the Section’s activities that interest them. There are always ways to get involved, put yourself out there, and gain valuable experience in global health advocacy, research, fundraising, and networking. Please contact any member of the leadership for more information on how to get more involved!

#APHA15, Day Three: Tuesday is for Science, Policy Victories (with T-shirts), and Awards

Ever since my first meeting in 2009, my favorite aspect of the Annual Meeting has been the scientific sessions. It is a really great opportunity to keep track of emerging research and developments in your area of interest, meet other public health scientists and advocates (and potential collaborators), and get exposures to new ideas and approaches to public health issues.

HIV Prevention with an emphasis on PrEP
My first session of the day was International Issues in HIV Prevention, which featured presentations on PrEP and PEP access in Japan, elevated HIV risk among MSM in China, conception and family planning among HIV-positive women in South Africa, and the intersection of conflict, substance abuse, and HIV risk. (Basically, it had just about everything that interests me – HIV, human rights, refugee issues, and East Asia.) I was particularly pleased to have the chance to chat with the speaker who presented his work on PrEP and PEP in Japan, as I imagine that many of the same sociopolitical and cultural barriers to effective HIV prevention programs in Korea also affect Japan. I am hoping that his work will help to inform mine, and he took great interest in my work once he figured out that I was the person behind the late-breaker that his section had endorsed and was following very closely (he is a Governing Councilor for the HIV/AIDS Section).

After that, I dashed over to Chinatown to replace my phone at the T-Mobile store after the screen on my faithful Galaxy S3 bit the dust when I dropped my phone at a Spanish tapas bar last night, and to grab lunch. When you are the Communications Committee Chair, being without a phone (and unable to access social media and a phone camera at a moment’s notice) simply will not fly…and if the nearest T-Mobile store is in Chinatown, it seems only logical to get lunch in the neighborhood.

I made my way to the second PrEP session of the conference with my new phone in hand and had a chance to listen to presentations on provider perspective and challenges in prescribing PrEP and helping their clients get access to it, as well as studies on awareness and attitudes toward PrEP among high-risk groups, particularly MSM. PrEP is obviously a hot topic in HIV prevention and has unique implications public health in the US vs. globally (as approaches to approval, coverage, and provision will differ by country and depend how well a given health care system functions), and these presentations will be informative to my day job.

Policy Victories do Ninjas Make, so I Bought a T-shirt
After meeting a very nice red panda, whom I noticed on Twitter earlier in the day and who happened to be in the PrEP session at the same time, I had another shift at the IH Booth. It was there that, to my delight, one of our Governing Councilors e-mailed me to let me know that our late-breaker opposing mandatory HIV tests for foreign nationals passed with overwhelming support. Naturally I was thrilled, but unfortunately I was only halfway through my shift at the booth, so I resisted the urge to do my victory dance in the Expo (and potentially scare off interested members). After finishing my shift, however, I decided that getting a late-breaker resolution passed qualified me as a Public Health Ninja, so I treated myself to a t-shirt identifying me as exactly that.


Afterwards, I headed to International Perspectives on Healthcare Administration, mainly to listen to the two presentations on research done on South Korea’s healthcare system.

Section Awards Dinner: Putting Faces to Names
The highlight of the day, of course, was the IH Section Awards Dinner and Social. This was a nice chance for me to unwind a bit, chat with other Section members (including some, like the chairs of the Global Health Connections and Student Committees, whom I had only spoken to by phone until now), and enjoy Gopal Sankaran’s great emcee skills and Paul Freeman’s delightfully Australian sense of humor. We had fantastic turnout even despite having the same time slot as the social for the Global Health Fellows Program.

My own Annual Meeting magnus opus is yet to come, however. Tomorrow morning I present my abstract on Mandatory HIV Testing for Foreign Nationals in the Republic of Korea: Human Rights Violations and Bad Public Health Policy. Stay tuned!

#APHA15, Day Two: Monday is for Networking (and @ninjasforhealth)

After dashing hither and thither on the first day of the conference to ensure that our HIV testing late-breaker was ready, I woke up early on Monday morning to be ready for the real meat of the professional conference experience: networking.

International Health Section: Second Business Meeting 
The second IH business meeting – always held delightfully early at 7 a.m. – traditionally focuses on reports and updates of Section activities, both at the Annual Meeting and throughout the year. Most of the activity involves the elected leadership and committee/working group chairs. This year we had several observers, both regular members and students, which I thought was great, as it allows members to see the meat of what the Section does. GC Whip Carol Dabbs presented policies of interest that will go before the Governing Council today (including one on climate change), and Governing Counselor Caroline Kingori gave an overview of the candidates for APHA President-Elect and Executive Board. Program co-chairs Mini Murthy and Vamsi Vasireddy then discussed successes and reflections of the Program Committee in reviewing abstracts and putting the Section’s program together for the AM, which includes both scientific and invited sessions. (This committee is a great way to gain experience reviewing abstracts and always needs help – students, take note!) Finally, Global Health Connections Committee Chair Theresa Majeski engaged section members and leadership on how to better engage students and new members, including some strategies for improving how our Section communicates its activities (I guess that’s me). I personally plan to take those suggestions to heart, so readers will hopefully see some changes to this blog in the coming weeks, once the AM irons cool and we all recover from traveling.

Students Want Jobs: IHSC’s Career Roundtable
My next stop was the Career Roundtable session, where the Student Committee asked me to lead a discussion table as a freelancer and still-aspiring global health professional. My personal goal was to show that landing that “perfect job” in global health can sometimes take more time and persistence than originally anticipated, but there are different paths a professional can take to get there (including working in domestic public health to gain experience). I also wanted to provide a “Millenial” perspective on breaking into the field, as paths of entry now look very different than they did for Gen X. I also feel like my publications and freelance history in global health work speak for themselves, but I get that not everyone is interested in doing freelance work.

This was a very interesting experience for me. As predicted, students were hungry for tips on how to get an edge in the application process, how to get applicable volunteer experience (like participating in IH section activities), what types of short-term experience abroad are valuable for a resume, how to frame their domestic public health experience when applying for global health positions later (if they chose to go that route), and – always the key question – how to make themselves stand out from the (massive and ever-growing) pile of applications for the highly-coveted global health full-time jobs. There were questions about the Peace Corps (whose recent re-vamp of the way volunteers are recruited is much improved, thank God), how to secure valuable internships (and what those look like), the value of short-term missions trips, and where to find post-graduate fellowships that provide the initial year or two of experience required of most permanent positions. I also strove to keep the discussion candid, which gave me a chance to glimpse both the zeal and frustration of aspiring professionals of my generation. Stories of applying to dozens of jobs with a steady stream of rejections, worry over servicing student loans post-graduation, and outrage over the abundance of unpaid internships were common. I strove to emphasize that experience in state and local health departments and domestic non-profits can go a long way in building skills required by global health jobs, and that volunteer experience with global health and development organizations (like working with the IH Section!) is just as valuable as paid work. One student even asked me if I put my work with the IH Section on my resume, and I was proud to say that I do – and I usually put it first.

Public Health Expo: Staffing the Section Booth, Scoping out Schools, and Networking with Ninjas
The expo is one of my favorite parts of the AM. I love the bigness and busy-ness of it, and I have a hard time resisting the SWAG (though I was mostly successful this time since I am flying with Spirit). I started out by staffing the IH Section’s booth (many thanks to members who volunteered to do this, btw), engaging members and attendees interested in Section membership and promoting our Section activities at the during the meeting.

Section leaders at our booth in the Expo.

Section leaders at our booth in the Expo.

After my shift, I spent some time collecting information on doctoral programs from schools of public health, as I expect to be in the market for a Ph.D. or DrPH program in the next year or two. I got some great information on how to seek out funding and even got to practice my (rusty) French with the outreach coordinator of the London School of Hygiene and Tropical Medicine.

Unfortunately, I can never resist the LSHTM mugs, so I will have to find space for it in my oh-so-professional Hello Kitty bag.

I also chatted with several global health employers and programs, including PHI’s Global Health Fellows Program with USAID, Abt Associates, and the Public Health Institute. But my favorite booth by far was Ninjas for Health. This duo focuses on bringing emerging tech and development talent into public health and impressed me by calling for improvement and a wider variety of talent to the APHA Codeathon, which debuted this year (I think). These guys speak my language, and I highly encourage any members interested in technology, ICT4D, programming, and social media to check them out.

Note to self: Go back to this booth and buy a ninja t-shirt.

Next up: Tuesday is for Science!