@WHO Video: Reforming its emergency response

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

Last week, the WHO posted a five-minute video to YouTube outlining the intended reforms to its emergency response protocols. The video opens with some fairly dramatic clips of an explosion or two and then mainly consists of clips of primary and emergency medical care being administered to a wide variety of harrowed-looking disaster refugees mixed in with people waiting in line for food and shots of damage caused by a mishmash of catastrophes. The voiceover, which sounds like somebody reading from a technical report, explains that “[g]uided by an advisory group of global emergency experts, WHO is instituting change to make the organization more adaptable, predictable, dependable, capable, and accountable in its work in outbreaks and emergencies. It is adopting game-changing measures across all levels of the organization.” The rather verbose narration contrasts oddly with the quietly urgent soundtrack.

The accompanying description reads:

WHO launched in 2015 a wide-ranging reform of the Organization’s work in outbreaks and emergencies with health and humanitarian consequences. The outputs of the reform will include creating a unified programme for WHO’s work in outbreaks and emergencies, featuring a platform for rapid response to outbreaks and emergencies, a global health emergency workforce and a Contingency Fund for Emergencies. Guiding this reform process is the objective of strengthening Organizational capacities, particularly in-country, to better prevent and prepare for, respond to and recover from outbreaks and emergencies.

I certainly do not disagree that the WHO needs reforms, but they might consider sending their social media guy to a class on how to make engaging videos (or maybe just connect him with MSF’s guy).

The WHO has actually been doing quite a bit this year in the way of assessing its response protocols and drawing up a roadmap (PDF) for improvements. They even have a newsletter! Unfortunately, none of this information is mentioned in the video or linked to in the description.

@MSF Video for World #AIDS Day: People with #HIV still face major hurdles

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

Another year and another December mark the passage of another World AIDS Day. This has been an exciting year for HIV research and policy, with the WHO updating guidelines to recommend that anyone diagnosed with HIV get on ARVs, PrEP gaining traction in the US (even in my own Lone Star State!) and approval in France, new optimism in the effort to development a vaccine, and talk of ending AIDS by 2030. Aw, yeah.

Alas, we are not there yet – and World AIDS Day is an important day to remember that. While many countries have turned the tide of their HIV epidemics, it is getting worse in several others and, in South Korea’s case, presents the potential for a fast-approaching crisis. MSF is always a good resource for bringing optimists back to reality. In this video, they remind us that in order to keep up the progress we have made against AIDS by treating HIV, we need to make sure that those who are infected stay in care – which will take sustained efforts in treatment, policy, and funding.

Urban Jungle by M. L. Tatum

I returned to Northeast Ohio for a brief visit and was feeling a bit nostalgic; however, I did not stroll through my childhood neighborhood with the same ease of once upon a time ago. I felt a bit apprehensive. With an expressionless face, I kept my head up, looking straight ahead, and making no eye contact, this just did not feel right; it felt so wrong being on guard. What happened?  I am missing the past when neighbors use to watch out for each other. It was okay for strangers to wave and even engage in verbal interactions. What has happened to this once—thriving, working class community? It’s difficult to imagine the beauty of manicured lawns, various flower shrubs, and fruit trees, or the streets filled with vibrant life, as children played ball or hide and seek.

The term “urban jungle” adequately describes the unaesthetic appearance of dilapidated homes, storefronts, and gas stations in need of repair. Not to mention, the abandoned buildings with exposed frames (I assume this is from random people ripping off the siding for quick cash), missing window frames and doors, allowing access to anyone wishing to enter, the yards with overgrown grass and shrubs. It’s a bright beautiful day, but these streets appear dim with an overcast of gloominess.

Urban decay is a public health nightmare. Moreover, the number of related health issues that need to be addressed are overwhelming, including, but not limited to: teen pregnancy, substance abuse, inadequate nutrition, food deserts, gun violence, obesity, lead poison, HIV cases, high school drop- out, unemployment, single parent homes, crime, and the list goes on. In this particular urban community, the land area is 3.09 square miles with 5,782 persons per square mile, in contrast to 282 persons per square mile in the state of Ohio (U.S. Census Bureau, 2015).  According to the most recent US Census Bureau report, the median household income in 2009-2013 for this community was $20,577. Forty two percent of the population lived below the poverty level during this time, with only 33% of the residents owning their home.

Sadly, this is one of many “urban jungles” within the United States that is in need not of destruction, but support. Those who empathize and have the skills should offer assistance to community leaders who are struggling to make a difference.

Potential can, and does, exist anywhere and everywhere. Even in this urban blight, I can see a few community gardens trying to produce edible foods in between abandoned buildings, an adolescent engaging with an elderly man, and a woman picking up trash along the street. These are the stakeholders who would benefit the most from support in such communities.  As humanitarians, it would behoove us to engage, inspire, and assist those who desire positive change, for these communities to thrive once again.  It would not only benefit the immediate community, but us as a nation, overall.urban blight

At least one Congressman is being reasonable about Syrian refugees

In response to an online petition, Dr. Amy Hagopian, our Section’s Nominations Committee Chair, received the below thoughtful reply from her Congressman, Adam Smith (D-WA). The petition asked that U.S. welcome refugees from Syria, despite opposition from xenophobic governors around the country. Here’s a link to a petition YOU can sign!

Dear Amy,

Thank you for contacting me with your concerns regarding the situation in Syria. I appreciate hearing your thoughts on this important issue.

The civil war in Syria is a highly complex struggle between Bashar al-Assad’s authoritarian regime and the fragmented groups that oppose it. As the conflict in Syria has become more violent and protracted, radical elements that directly and seriously threaten our and our allies’ security have become more powerful. It has also become an enormous humanitarian catastrophe. Since the unrest and violence began in 2011, the number of Syrians seeking refuge in neighboring countries or Europe has increased above 4 million. The United Nations Refugee Agency reports that 12.2 million people inside Syria have been affected by the conflict, with nearly 7.6 million displaced internally.

The tragic terrorist attacks in Paris have complicated the situation even further. Our number one priority must be protecting the United States and the American people from terrorist attacks. In the strongest possible terms, I condemn the cowardly attacks in Paris and send my deepest sympathies to the victims. I also welcome the French government’s increased efforts to combat terrorists in Syria. It is important that as we fight terrorism, we must stay true to the values enshrined in our Constitution, remember that we are a nation of immigrants, and not let terrorist groups define or change who we are.

Amidst the conflict, radical groups – like Jabhat al Nusra and the Islamic State of Iraq and Syria (ISIS) – have established safe havens and where, they have attracted substantial financial resources. The strongest and most violent group, ISIS, has continued a campaign of terror and has launched violent and deadly attacks in Northern and Western Iraq. ISIS victories over the Iraqi armed forces have made them a real and dangerous threat to the government in Baghdad and the region. Additionally, the civil war in Syria has attracted a large number of foreign fighters, including from Europe, many of whom are fighting with forces affiliated with ISIS or al Qaeda. As we have seen, these foreign fighters may eventually return to their home countries or go to others where their new combat skills and increased radicalization can be used to subvert other governments.

The civil war in Syria has devolved into a protracted conflict that is dangerously destabilizing. The increasing flows of refugees to neighboring countries place a real strain on already over-burdened public services. Sectarian tensions are on the rise and can lead to further displacement of refugees as host communities become increasingly frustrated with the length of their stay. The humanitarian crisis is quickly shifting from being a consequence of the Syrian conflict to being a potential driver of conflict itself, threatening regional stability. Additionally, the increased activity of Hezbollah, the Iranian-allied militia within Lebanon, and its involvement in the Syrian conflict has escalated tensions between Lebanon and Israel, presenting a great security risk.

The United States has not turned a blind eye to the hurt and suffering of the Syrian people and has been the largest contributor of humanitarian assistance to the crisis, providing over $4.1 billion between Fiscal Years 2012 and 2015. These funds have been used to provide critical, lifesaving services for internally displaced populations within Syria and refugees in neighboring countries, including Jordan, Iraq, Lebanon, Turkey, and Egypt. Channeled through United Nations (UN) agencies and non-governmental organizations, U.S. emergency assistance provides Syrian families with food, medical care and supplies, shelter, and funding for water, sanitation, and hygiene projects.

Due to the worsening refugee situation and immediate need for increased assistance, on July 31, 2015, the U.S. Agency of International Development (USAID) announced an additional $65 million in emergency food assistance. These funds are for the UN World Food Program (WFP), which serves approximately 4 million people inside Syria and 1.6 million refugees in neighboring countries every month.

To help address the refugee crisis, I have taken a number of steps. I supported increased funding for refugee-related program in Fiscal Year 2016 so that resettlement agencies have the resources necessary to help these refugees. I believe that helping our partners in the region and European allies cope with this stressful and destabilizing situation is in our national interest and ultimately helps keep this crisis from devolving into further chaos. I also joined a letter to Secretary of State John Kerry and Secretary of Homeland Security Johnson asking them to increase the number of people eligible to apply for refugee status. I have also called for the Department of State and Homeland Security (DHS) to improve coordination of the lengthy security check process for those applying for asylum, as well as informing families when some but not all of their members have been cleared. Finally, I have joined other members in advocating for the U.S. to increase the number of refugees we are admitting through our resettlement program from 70,000 to 85,000 per year.

To date, of the millions of law-abiding Syrian refugees, less than 1,800 have been resettled in the United States. Applicants for refugee status are held to the highest level of security screening through which we evaluate travelers or immigrants to the United States. If as a result of the security process, U.S. security agencies cannot verify details of a potential refugee’s story to that agency’s satisfaction, that individual cannot enter the United States. I will continue to pursue ways to make sure our vetting process is effective, without unduly burdening bona fide refugees fleeing the terrible situation in Syria and Iraq.

To be very clear, the United States thoroughly vets all refugees. Refugees are subjected to an in-depth interagency vetting process that includes health checks, verifications of biometric information to confirm identity, and multiple layers of biographical and background checks. Moreover, applicants get interviewed in-person. Members of the interagency team includes the FBI’s Terrorist Screening Center, the State Department, DHS, the National Counterterrorism Center, and the Department of Defense. The background check process takes between 18-24 months, happens before an application is approved; and occurs long before a refugee would be able to enter the United States.

The American SAFE Act of 2015, H.R. 4038, which was brought to the House floor for a vote by House Republicans on November 19, 2015, would effectively shut down resettlement of refugees from the Syria and Iraq region. It is wrong to deny asylum to refugees on the basis of inaccurate assumptions, fear, and prejudice, and that is why I voted against it. We must continue to stand strong as an international community and remember that refugees are fleeing terrible conditions and persecution. As we move forward, let us unite to use the tools at our disposal – diplomatic, military, intelligence, and development – to defeat extremism and the terrorism it breeds.

I have also heard several concerns regarding U.S. military involvement in Syria. I am acutely aware of the great cost we incur in both blood and treasure when we ask our men and women in uniform to secure our interests abroad. I share your concerns about becoming militarily involved in another costly conflict in the Middle East. Any consideration of the use of U.S. military force is not one to be taken lightly – especially considering our experiences in Iraq and Afghanistan and the limited ability to affect certain outcomes in those countries. Ultimately, this is a fight between the Syrian people about who will control the future of their country.

The best way to protect ourselves and our allies in the region from the chaos in Syria is by building the Syrian moderate opposition’s capacity so they can stand their ground and fight this war. There is no easy way to identify those elements in the opposition that we can work with, although we have some developed some local allies, such as the Iraqi and Syrian Kurds and some local Sunni allies and are working to identify additional such forces that we can support. By helping those who are fighting ISIL, the U.S. can ensure moderate elements have a chance at playing a role in the creation of an inclusive transitional government, if a peace deal were to be reached in the future.

Due to the extremely concerning developments in Syria and Iraq, the President has taken a number of actions. First, the United States has conducted literally thousands of airstrikes intended to degrade ISIS in Syria and Iraq, reduce their ability to raise money, and to support the local allies we have identified. We are also currently retraining and equipping a number of brigades in the Iraqi Army and Congress has provided over $1 billion for this process. The President also decided that training and equipping moderate elements of the opposition was necessary in Syria. On June 26, 2014, he requested $500 million as part of a supplement to the budget request known as “overseas contingency operations.” These funds would be used to train and equip vetted elements of the Syrian armed opposition to help then fight against the Assad regime. As you may know, this training program did not meet expectations nor objectives and the training portion has been suspended. Since that time, however, the approach has transitioned to equipping moderate elements in hopes of empowering them in this fluid situation, and the President has announced that fewer than 50 U.S. Special Forces will be deployed to Syria to help accomplish this goal. I will continue to monitor developments in the region, understanding that there are always risks involved in conflict and I do not take them lightly.

Moreover, I support the Obama Administration’s diplomatic efforts to find a political solution to the situation in Syria that respects the rights of people. While those efforts have not yet produced any sort of agreement that would lead to an end of the war in Syria, I believe that it is helpful to have the major international countries that are involved in the conflict in Syria discussing possible ways to bring about a political transition and end to the civil war. Hopefully, such a course forward would also address the underlying causes of the refugee crisis. Until a solution can be found, we must continue to help those seeking refuge. We cannot let what happened in Paris cloud our judgement, drive policy or destroy the fabric of what America stands for. We need to be strong and smart to fight terrorism. If we turn our backs on refugees, then we risk making ISIS stronger.

Again, thank you for contacting me with your concerns regarding these important issues.. Rest assured that I will closely follow the continuing developments as they arise. Should you have any additional questions or concerns, please do not hesitate to contact me again.


Adam Smith
Member of Congress

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.