Two countries, opposite approaches: HIV on the rise in Russia and the Philippines

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


Two different articles on rising HIV rates in two different countries crossed my social media news feeds today; I though I would juxtapose them here because they embody very different approaches to a problem (embedded within two very different sociopolitical environments, of course).

The first piece from the BBC focuses on an alarming rise in HIV rates in Russia:

For years Russia has remained remarkably silent on the challenge it faces from HIV and Aids. Now that silence has been broken by an epidemiologist who has been working in the field for more than two decades – and he calls the situation “a national catastrophe”.

Vadim Pokrovsky, the softly spoken head of the Federal Aids Centre in Moscow, has watched as the figures have climbed remorselessly upwards.

There are about one million people living with HIV today in Russia and year on year the rate of infection is rising, unlike sub-Saharan Africa where the rate of increase is slowing. This is according to Russia’s official figures, which almost everyone agrees are a substantial underestimate of the true position.

The epidemic in Russia, argues Mr. Pokrovsky, has been driven by ideological (rather than evidence-based) policies on sex education and injection drug therapy that have been pushed by the Russian Orthodox Church and a conservative government. Education officials argue that comprehensive sex education will encourage kids to have sex (despite plenty of evidence to the contrary), while the use of methadone replacement as a harm reduction strategy for injection drug users is ridiculed and banned (despite the method’s success in reducing HIV transmission through injection drug use in Europe and Australia). HIV infections have predominantly been driven by injection drug use in the past, but sexual transmission is on the rise. Apparently Russia is not on the evidence-based health policy bandwagon.

According to Al Jazeera, meanwhile, the picture of rising HIV rates in the Philippines looks quite different:

In the last five years, HIV cases have gone up 277 percent in the Philippines. While the total number is less than one percent of the 100 million population, it continues to rise. From one reported case every three days in 2000, there are now 21 new cases recorded every day, according to the latest government report.

A separate UN study ranks the Philippines as among the seven countries with over 25 percent or more increase in HIV cases annually from 2001 to 2009, even as the worldwide trend continues to fall.

“Unlike in other parts of the world, the AIDS Epidemic in the Philippines has been growing rapidly,” the Philippine National AIDS Council said.

Danton Remoto, university professor and gay rights activist, however, said that the real number could be 10 to 20 times higher. And he attributed the underreporting to the stigma associated with the disease, particularly among the gay community, the section of the Philippine society worst hit by the disease.

In the case of the Philippines, it has largely been government inaction (rather than counterproductive policies) and social stigma surrounding homosexuality and safer sex practices in the overwhelmingly Catholic country that have driven the epidemic. There is a silver lining here, however, as governments have begun to move (albeit slowly):

Cortes said that only a handful of the 1,634 cities and towns in the country, have programmes related to HIV prevention. She also said that a “very low condom use and low overall knowledge” about reproductive health has contributed to Filipinos engaging in risky sexual behaviours.

It was only in 2014, when the country’s reproductive health law was given a greenlight by the Supreme Court, after it was challenged by the Catholic Church as unconstitutional. The law mandates sex education and access to artificial birth control methods, including condom use.

It also includes provisions on HIV-AIDS awareness and treatment.

What is sustainability?

By Abbhirami Rajagopal, PhD MPH
This was cross-posted to my own bog

Sustainability is the ability of a system or a process to endure. And for a process to endure, we have to build it in such that it remains flexible and adaptable in many contexts.

The health program that comes to mind when you think about sustainability is the eradication of smallpox. The smallpox eradication effort was continually adapted to fit the changing needs and goals of the disease eradication program. Over time, with decreasing number of smallpox cases, the emphasis shifted from routine vaccination to surveillance.

Far too often, public health policies and programs are implemented on small scales and with limited funds and risks being discontinued when funding runs out – even if it was successful. There is a mismatch between the expectation of long-lasting effects of large-scale interventions and reality. Trying to scale up health innovations or even continuing a program when the funding runs out or political landscape changes is challenging.

In the last decade, there has been a big push toward creating programs and interventions that are sustainable. More and more donors are recognizing the importance of the sustainability of evidence-based health interventions and favor programmatic approaches that include long-term maintenance. All of this recognition has culminated in the adoption of Sustainable Development Goals (SDGs) by the United Nations earlier this year.

The SDGs differ from the Millennium Development Goals (MDGs) by virtue of being much more comprehensive with 12 goals and 17 focus areas. The SDGs set zero-oriented goals: getting to zero cases of hunger, child and maternal deaths and poverty. This lofty goal cannot be achieved by relying solely on the ever-shrinking development assistance from rich donors, as was the case with the MDGs. This is why the SDGs put sustainable, economic development right at the core of the strategy. The goals have been developed through consultation with nearly 100 member states and millions of citizens—probably the largest and most inclusive and participatory process we have ever seen. This allows for adaptable goal setting by countries that would then allow them to assess their own strengths and leverage their assets to meet the targets. To me, some of the most significant changes that we see in the SDGs are the emphasis on accountability, the separation of the issues of poverty from issues of food and nutrition security and the stronger goals with respect to women’s empowerment.

To strategically include sustainability in health programs and policies requires a “clear understanding of the concepts of sustainability and operational indicators to monitor sustainability” (1). The first step in designing sustainable health programs is to define the program elements that need to be sustained. It is also essential to build and effectively leverage partnerships for a program to be sustainable. This would imply that if you are planning a large scale program or intervention, you need to start early by planning, engaging the partners, using appropriate frameworks that conceptualize sustainability and incorporating outcome/success measures for your sustainability approach.

To go from theoretical frameworks to successful sustainability, there has to be more research with regards to how sustainable existing programs are, especially the ones that have incorporated “sustainability” into their programmatic approach. We need to know what works and what does not. We need to know what are the stumbling blocks that prevent programs from becoming sustainable. In doing so, in the future, we can design better plans for sustainable health programs, especially in settings where resources are becoming more and more limited.

Sustainability has been a huge challenge in programs designed to address micronutrient (vitamin and mineral) deficiencies. Micronutrient deficiencies impact a large number of children under-5 years of age worldwide. Many of these deficiencies co-occur with infections can exacerbate other infections that may be present (2-4).

One such micronutrient is Vitamin A; globally, nearly one-third of children under the age of 5 are deficient. We know vitamin A supplementation (VAS) works; a meta-analysis of 43 studies published in 2011 showed that VAS in children at risk for deficiency reduces mortality by about 24% (5). Despite large-scale efforts for VAS in children since the 1990s, as of 2013, the coverage rate is anywhere between 10-90% (6).

Nutrition interventions often rely on aid dollars and fortified foods or supplements from wealthy countries or private donors (for e.g. Vitamin A products for supplementation are obtained from the Micronutrient Initiative which is supported by Canadian International Development Agency). Both lack of support from the local Ministries of Health (since these programs may not align with their top priorities) and lack of policy initiatives to address micronutrient deficiencies contribute to the problems that dietary interventions encounter. The issues mentioned above point to one major theme— SUSTAINABILITY—that we as public health practitioners have to take into account when planning programs both at local and global levels.

References:

1) Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998 Mar;13(1):87-108. Review.

2) de Gier B, Campos Ponce M, van de Bor M, Doak CM, Polman K. Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis. Am J Clin Nutr. 2014 Jun;99(6):1499-509. doi: 10.3945/ajcn.113.069955.

3) Amare B, Moges B, Mulu A, Yifru S, Kassu A. Quadruple burden of HIV/AIDS, tuberculosis, chronic intestinal parasitoses, and multiple micronutrient deficiency in ethiopia: a summary of available findings. Biomed Res Int. 2015;2015:598605. doi: 10.1155/2015/598605. Epub 2015 Feb 12.

4) Bhutta ZA. Effect of infections and environmental factors on growth and nutritional status in developing countries. J Pediatr Gastroenterol Nutr. 2006 Dec;43 Suppl 3:S13-21.

5) Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD008524. DOI: 10.1002/14651858.CD008524.pub2.

6) Vitamin A supplementation coverage rate (% of children ages 6-59 months). Available at http://data.worldbank.org/indicator/SN.ITK.VITA.ZS

Abbhirami Rajagopal, PhD MPH: I am currently a postdoc at Baylor College of Medicine transitioning to a career public health. My graduate work involved identifying genes involved in heme homeostasis and for my postdoctoral work, I have worked on phosphate homeostasis and understanding pathogenesis skeletal dysplasias. During my postdoc, my drive for large-scale sustainable impact led me to an MPH degree from Johns Hopkins School of Public Health. I am interested in health equity, environmental issues, sustainable food, nutrition security and social justice. I love to write and I love to volunteer! Find me on Twitter @abbhi_515 LinkedIn and Facebook

Growth and challenges of health research in the WHO Africa Region: new analysis in the BMJ

This was cross-posted to my own blog.


I have always been devoted to the principle of evidence-based policy and decision making in public health, but I have taken a keen interest in the finer points of research and methodology since taking my current position as an epidemiologist (and contemplating the pursuit of a doctorate more seriously). Earlier this month, I spotted an article from BMJ examining the output of health research in the WHO Africa region from 2000 to 2014 (h/t to Dr. Ron LaPorte, professor of epidemiology at the WHO Collaborating Center at the University of Pittsburgh and co-founder of the Supercourse project). The article, entitled “Increasing the value of health research in the WHO African Region beyond 2015,” is a bibliometric analysis of the health research publications from the WHO Africa region indexed on PubMed; it analyzes the influence of various factors, including GDP, population, and health spending on the number and growth of published papers by country over the time period. The abstract reads:

Objective To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium.

Design Bibliometric analysis.

Data collection and synthesis In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications.

Results We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47).

Conclusions There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).

In the discussion, there is some fascinating commentary on the challenges facing researchers in the research and the barriers to publication, as well as to making those publications available to other researchers in the field. Some of them are familiar and strike me as a common symptom of the complicated relationship between politics and (especially evidence-based) policy making:

Although there is clearly a need for improving the performance of health researchers on the continent, African health decision makers should use the available research evidence to guide policy, strengthen practice and maximise the use of resources in order to improve the welfare of their citizens. However, there appears to be a failure to apply available research evidence to improve the health of populations on the continent. This unfortunate situation may be related to the lack of sharing of research evidence for translation into policy and practice, a non-alignment of research conducted in African countries to national research policies and/or the non-existence of national health research policies with clearly defined priorities.

However, others are somewhat unique to Africa. Not of them are economic (though funding plays a major role), and the paper goes so far as to describe some of the challenges as “intractable”:

The difficulties in research, publication, editorial bias and information access facing Africa are profound and seem almost intractable. Another difficulty facing African researchers is dissemination of findings to other parts of the world. Most of the information published in African journals is largely not included in major databases. Access to technological tools, information access and other equipment and supplies to ease research work is not always possible.

I hope this will influence the wider debate on the future of aid and health spending in Africa. The call for a shift in funding and emphasis from technologically-focused solutions to health-systems strengthening and sustainability has gained momentum, and research and academic exchange is a crucial part of the latter.

White House Takes a Stand on Climate Change and Public Health

“Climate change is making an impact on our public health.”
-President Obama

We know that climate change threatens our air, food, water, and homes but earlier this month at a round table discussion, President Obama spoke about the effects of climate change on public health. In this video he says the temperature of the planet is rising and that not only comes with adverse weather and environmental consequences, but also a “whole host of public health impacts.”

Accompanied by Surgeon General Dr. Vivek Murthy, President Obama put a spotlight on increased heat-related deaths, severe asthma, extended allergy seasons, and the spread of tropical or insect-borne diseases as some possible consequences of climate change. He also spoke about the need to focus on prevention and action and the costs associated with inaction.

This is the beginning of a big push from the White House to better understand and deal with the health effects of climate change and this statement outlines their plan to do so. This is such a great step in the right direction and a big win for the public health field. Here’s to hoping it all leads to a long-term commitment with the necessary funding and policies to make significant changes!

HUMANITY OF GENDER EQUALITY BY MARY LOUISE TATUM

“Girls must be told at an early age that they have the potential to become influential leaders before they fall victim to their own self-doubt”. These are the insightful words of Malala Yousafzaia, a Pakistani activist for female education and the youngest Nobel Prize laureate.

These words continue to ring true regardless of one’s geographical location. Girls and women from around the world continue to be marginalized.  For example, more high-income countries face challenges, such as, equal pay, maternity leave policies that allow women enough time to nurture their infants, and job security to continue in their careers.

It is reprehensible that females around the world are forced into marriage at ages as young as nine,  punished for “immodest behavior or dress”, not allowed to drive, denied an education,  excluded from politics, gang raped with no retribution, coerced into female genital mutilation (look out for  my June blog), and the list goes on.

Females are approximately half of the world’s population (http://data.worldbank.org).  Thus, women have to be allowed equal rights for human survival. Not to mention, we all have the basic human right to choose our own destiny.

However, supporters of female rights must be empathetic and meet those who desire or need support where they are. As public health professionals, we cannot force values and beliefs because we think they are superior or imagine a clear path to their implementation. We have to be empathetic, willing to learn, and understand the values of the community we are involved. We can provide education on evidence-based health practices and provide availability to health care, education, financial training, etc. These changes will come from within the community, so we have to develop partnerships within the community and provide the necessary tools that will build capacity and self-reliance. Let’s encourage the enhancement of inherent positive cultural attributes, increase self-esteem and self-awareness with financial resources and training to optimize the quality of life.

All persons have the right for their basic needs to be met and to feel confident and empowered. All persons deserve the opportunity to realize their potential.  Education and opportunity is the key for making the world better. The survival of humanity depends on the synergy of women and men.

How Peace Corps Volunteers in Senegal address gaps in health delivery systems

This post does not reflect the opinions of the US Government, the US Peace Corps or Peace Corps Senegal.


There is usually a general misunderstanding of what Peace Corps volunteers do or are capable of doing in field. This misunderstanding comes from families and friends of volunteers back home, the communities the volunteers serve, and sometimes, in the earlier stages of service, the volunteers themselves. How much impact can a volunteer make? How can the most impact be made during such a short service? What are the limits of a volunteer and how is their work truly sustainable?

While I can not speak on behalf of the entire Peace Corps (PC) community, I believe I can shed a light on how Peace Corps Senegal Health volunteers work to provide basic trainings and services to improve the health status of the communities they serve.

Currently PC Senegal health volunteers work in the areas of Malaria, Maternal and Child Health and Water, Sanitation and Hygiene. Our development approach ensures that initiatives are sustainable, that they exhibit long term vision, that they are from the bottom-up and that they are participatory and inclusive. Along with guidance from PC leadership, volunteers use these guidelines to creatively impact their communities.

The PC Senegal health sector works to address 3 delays in health care:

  1. Delay in the decision to seek care
  2. Delay in reaching care
  3. Delay in receiving adequate available health care and correct diagnosis.

The first delay is addressed at the household level. When signs and symptoms of disease begin to manifest themselves, we ensure that people have the knowledge they need to seek the care that is required. The delay in reaching care is addressed through several initiatives that range from planting gardens, training more community health workers, working in supply chain to ensure the health structure has the medicine and equipment it should have, rallying up the community to contribute towards an ambulance, or building a health structure. The last delay can be addressed through a series of trainings for community health workers, working side by side with health processionals to ensure that tests are being administered and being administered correctly, and empowering the patient to ask questions about disease stages treatment and medication.

Baseline assessments, barrier analyses and volunteer reporting tools are beginning to show us where exactly the needs are and where the obstacles to the behavior change exist. A lot of work is focused on strengthening the capacity of community health workers, clinical staff and health structures as a whole. We come in with fresh eyes to identify ways health care can be done better and in many cases, solve complex with simple solutions. I like to think that we help people think outside of the box to identify their problems and solve them with as little help from the outside as possible.

But the work is not easy. In a process that begins with intensive language, cultural and technical training, PC Senegal Volunteers must learn how to integrate into their communities and develop meaningful relationships with potential work partners before their own projects may actual begin. Volunteers spend a good amount of time learning the lay of the land in their communities. What development groups have worked here in the past? What have they done? Who exactly did they help? Where did they succeed or fail? Was there a former volunteer at this site? What did they do? What relationships did they build? Who did they work with and who did the intentionally avoid? Then the research and programming questions begin. What does the community know about these heath issues? What does this community need?  What can I do to address the need? How I can do it with the least possible resources? How will I monitor it? How will it be sustainable? So when we finally figure out-with the help of community members- what project we want to implement, we design it, we justify to our community leaders and to our PC leaders. When necessary, we write grants, we rally the community behind the project, we implement, we monitor and we evaluate.

So what is it exactly that volunteers do? Well, we do not claim to change the world. This is not why we’re here. We will not eradicate malaria nor will we completely bring an end to the deaths of children under 5. But if we can reduce those incidences, if we can provide much needed trainings, if we can build a health structure that otherwise would not have existed, if we can get just 20 more moms to wash their hands when they’re supposed to, if we can improve sanitation practices, if we can get that many more mosquito nets out there, if we can prevent malnutrition in a handful of infants and children, if we can keep addressing these gaps that cripple health systems, then, we would have contributed to a much a larger picture of global health and we would have served.


taiwo adesinaTaiwo Adesina is a MPH candidate at Loma Linda University in southern California. She is also a Masters International student, completing the final part of her Masters in Global Health with Peace Corps Senegal. In Senegal, Taiwo works in the areas of Malaria, WASH, maternal and child health and nutrition-helping health structures and groups better address these issues through the use of community health workers. Her interests also include project design and management, grant writing, and M&E. She has working/living experience in Nigeria, Honduras, the Philippines, the Bahamas and Senegal. She blogs at travelgiveworklove.

HOW TO DEVELOP YOUR NETWORK AND CREATE GLOBAL HEALTH OPPORTUNITIES

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Making that transition from student to employee or entrepreneur is a daunting task for most of us. And it’s even a bit more challenging when trying to make your way overseas. Nevertheless, we have what it takes to become involved in our dream career wherever it is, perhaps not immediately in the capacity that we desire, but overtime your dream can be attained: First, have an open mind. Second, be creative. Third, be tenacious.

Being a social butterfly can be helpful when trying to identify opportunities. I say talk to anyone and everyone; it’s surprising how much information is available from just talking with your colleagues. Also, don’t forget your professors and your school’s Career Services Department.  For instance, I was in the College of Public Health, but was fortunate to hear about a professor in the Geography Department who was working with Geographical Information Systems. I introduced myself and am now working on an ongoing project in Zambia (see my previous blog, click here.

Furthermore, this is your opportunity to take advantage of early career professional discounts offered by most organizations, such as the American Public Health Association. However, don’t just pay dues; reap the maximum benefits of all that knowledge and available resources.  Attend the annual conference and participate on general or section committees. Moreover, submit an abstract for a poster or oral presentation. This offers you an opportunity to demonstrate your talents to a plethora of professionals in positions of hiring or making recommendations for your future career. At the very minimal you may receive guidance or improving your Curriculum Vitae (CV), interviewing skills, or direction on untapped venues for opportunity.

It is very important to not discount volunteer experience, as there are many rewards from volunteering. For example, helping underserved communities, placing into practice classroom theory, and collaboration. Thus, these experiences should be placed on your CV as if it were a paid position, under “Research Experience” or “Program Experience” or other appropriate categories. Of course, most of us would prefer to be paid for our services. Fortunately, there are numerous organizations that offer opportunity to work in numerous settings, and some even offer stipends, housing, and/or food at no cost for your commitment.  I have provided links to a few options, but there are many more available.

Global Health Fellows Program II:  https://www.ghfp.net/internships/apply-for-an-internship/

Catholic Relief Services: www.crs.org

World Wide Opportunities on Organic Farms – WWOOF: www.wwoof.net/

International Cultural Youth Exchange – ICYE: www.icye.org/
Peace Corps: http://www.peacecorps.gov/

Just changing your environment can place you in a land of opportunity. I have been fortunate to develop friendships with individuals from many geographical locations, and when I travel to visit them opportunities arise. In 2013 my fellow classmate invited me to Kenya. While on a safari I met a teacher from Taiwan who asked if I would help her with providing sex education for youth who reside in Deep Sea Slum (Nairobi, Kenya). With that collaboration, I returned the following May 2014, and with the support of Victoria Sports Association, a local humanitarian organization, I developed and implemented a program focused on self-awareness, hygienic care, and health promotion. It is nice to have big “power” names on your CV, but you have a lot more freedom and opportunity to use your talent with smaller groups, as I learned with this experience.

In conclusion, any opportunity, paid or voluntary is worth the valuable space on your CV. Keep your CV current with all experiences. Employees and potential collaborators are seeking those who want to develop and utilize skills to make a difference in improving health globally. As you grow and expand your networks and comfort space, opportunities begin to emerge. Go after them!