IH Section Webinar 8/20: Insights from Managing a Health Systems Development Program (HSDP) Grant

Dr. Iyabo Obsanjo, the Co-Director for African Development at the College of William and Mary will discuss her involvement with a World Bank-funded Health System Development Project in Ogun State, Nigeria. She’ll share what worked and what didn’t from her perspective as the Commissioner for Health, in addition to describing areas where Health System development funding is lacking.

Date: Tuesday, August 20, 2019
Time: 11 AM – 12 PM ET

Register to attend here

This webinar is hosted by the APHA IH Section’s Health Systems Strengthening Group. The objective of the working group is to provide a venue for interested global health professionals to learn about systems sciences, collaborate around research and practice activities, and advocate for increased consideration of system sciences in education, practice, policy and evaluation for strengthening health systems. We welcome interested members (APHA membership is not a prerequisite) with expertise and/or interests in applying systems thinking approaches and methods to strengthen health systems, in both developing and developed countries. 

Find out more about the Health Systems Strengthening Group  

Happy World Breastfeeding Week!

Happy World Breastfeeding Week (8/1-8/7)! This year’s theme, “Empower parents, enable breastfeeding” is a particularly poignant reminder of how the U.S. government is doing neither for parents and infants entering at the southern border. It is critical to consider the effects of involuntary separation of breastfeeding mothers and their children.

There are short- and long-term physical, emotional, and economic consequences of abrupt discontinuation of lactation. Lactating individuals need to express milk to relieve the pain and fullness in their breasts to avoid plugged ducts and mastitis, a breast infection requiring medical attention. If there is no provision of time, space, and privacy for regularly expressing milk, those individuals will gradually lose their milk supply. Shortened, suboptimal lactation increases risks for breast and ovarian cancers, and metabolic and other diseases and costs $302 billion globally [1].

Infants who no longer receive human milk need a substitute, which will be inherently nutritionally inferior to human milk and cannot provide them the immunologic protection they received from their mothers’ milk [2]. Those infants will need to learn how to feed from a bottle, which may cause distress, can introduce bacteria, and may teach them to ignore satiety cues [3], increasing their risk for overeating as they get older.

Emotionally, the parent–infant bond is severed with involuntary separation. Breastfeeding is not just a feeding method, but also provides an infant with temperature regulation and comfort. We have witnessed maternal distress from this inhumane practice [4]; it is likely that an infant’s distress would be extreme.

On top of the life changing health effects of abrupt discontinuation of breastfeeding, the most egregious offense may be the negation of these individuals’ rights to breastfeed. They were feeding their children optimally until a poor substitute was imposed upon them for political reasons. Now those children have higher risks of infections and chronic disease, from the moment they were taken from their parents and for the rest of their lives.

There have been many discussions about the traumatic effects of parent-child separation but we have not seen or heard a discussion of effects due to abrupt cessation of lactation and breastfeeding. Those effects provide more compelling reasons to end this inhumane practice immediately.

Guest Blog Written By: Jennifer Yourkavitch, MPH, PhD, IBCLC – International Health Section Breastfeeding Forum Liaison, APHA and Research Scientist, University of North Carolina, Greensboro; Whitney P. Witt, PhD, MPH – Chair, Maternal and Child Health Section, APHA and Inaugural Dean and Professor, College of Health, Lehigh University; Briana Jegier, PhD – Chair, Breastfeeding Forum, APHA and Associate Professor, Health Services Administration, D’Youville College


1.      Lancet. (2016). Series on Breastfeeding. http://thelancet.com/series/breastfeeding. Accessed July 31, 2018.

2.      Mannel R., Martens P., & Walker M. (eds.). Core Curriculum for Lactation Consultant Practice. Burlington, MA: Jones & Bartlett Learning, LLC, 2013.

3.      Li R., Fein S.B. & Grummer-Strawn LM. (2010). Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics125(6).

4.      CNN. June 14, 2018, https://www.cnn.com/2018/06/12/us/immigration-separated-children-southern-border/index.html. Accessed July 29, 2018.

Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

By Samantha Dulak BS and Heather F. McClintock PhD MSPH MSW

This is the second part of a IH Blog series featured this summer, Sexually Transmitted Infections in sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part II: Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

Sexually transmitted infections (STIs) are a significant public health burden globally and are a leading cause of mortality in lower middle income countries (LMICs). In 2016, there were 988,000 women infected with syphilis worldwide, resulting in 350,000 deaths and delivery complications (Korenromp, Rowley, Alonso, et al., 2019). Human papillomavirus (HPV), an incurable STI, leads to over half a million new cases of cervical cancer every year (Bray, Ferlay, Soerjomataram, et al., 2018). Cervical cancer can be the result of other factors, however, in 90% of all cervical cancer cases that resulted in death, the cancer was caused by HPV (WHO, 2018). Of the 1.8 million newly diagnosed HIV infections each year, 940,000 individuals died globally from AIDS related factors (UNAIDS, 2019a). Unfortunately, a third of those deaths (302,700) are among females aged 15-49 living in sub-Saharan Africa (UNAIDS, 2019b). Higher rates of complications are found in sub-Saharan Africa because of inadequate clinician training, delayed diagnosis, and limited care seeking behaviors (Mayaud & Mabey, 2004). STI surveillance systems are absent or poorly functioning in Africa causing unreliable data on the prevalence of these infections.

STIs are common in low resource settings and their impact can be catastrophic on the lives of individuals. The list of potential complications is extensive. Untreated gonorrhea and chlamydia are associated with the development of arthritis, hepatitis B with liver cancer, and syphilis with central nervous system disorders (Aral, Over, Manhart, & Holmes, 2006). While all individuals are at risk, women and children are disproportionately affected by a greater burden of disability, as assessed by disability adjusted life years. Women suffering without treatment can experience chronic pelvic and abdominal inflammation leading to infertility, spontaneous abortions, and many adverse pregnancy outcomes (Chesson, Mayaud, & Aral, 2017). 

International attention on STI outcomes is imperative to reducing the incidence of STIs not only in sub-Saharan Africa, but globally. Most attention has focused on HIV due to the public health crisis we are experiencing now. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that Africa has the highest burden of STIs compared to all other continents (Lewis, 2011). The UNAIDS 2018 report on the global AIDS epidemic found that there are 37.9 million people living with AIDS in the world and 20.6 million of them live in eastern and southern Africa (UNAIDS, 2019a). 

Prevention strategies in sub-Saharan Africa place a heavy emphasis on sexual health education. A meta analysis of 51 papers reported that while school-based sexual health education significantly increased condom usage, there was no significant effect on the incidence of STIs (Sani, Abraham, Denford, & Ball, 2016). This information is promising, though. School aged children are experiencing positive behavior changes through the use of physical protection methods. Some studies even report a change of attitude towards persons living with HIV/AIDS (Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008). However, a focus on at-risk groups is missing. Sex workers, men who have sex with men, and intravenous drug users all have high susceptability to contracting an STI and greater attention needs to be directed towards prevention in these populations to reduce the incidence of STIs. 

To address the vast number of cases of cervical cancer caused by HPV, many sub-Saharan countries now qualify for assistance from the Global Alliance for Vaccines and Immunization. As of 2018, eight countries have HPV vaccine programs for school aged children, with pilot programs implemented in nearly 16 additional countries (Black and Richmond, 2018). Data for all 8 countries is not public as of now, but of the five countries with available data, the success rate for at least one dose of the vaccine is 83% (Black and Richmond, 2018). Rwanda was the only country to successfully complete three doses, covering 98.7% of girls (Black and Richmond, 2018).

From a global perspective, Sustainable Development Goals (SDGs) aim to ensure access to sexual and reproductive care and end the AIDS epidemic by 2030 (UN General Assembly, 2015). Primary prevention strategies have become popular among many countries to promote these goals. In 2018, the WHO reported on global STI surveillance, indicating that 44% of countries have HPV vaccines in their immunization programs (WHO, 2018). To reach those who are not benefiting from immunization initiatives, the 2016 Global STI Strategy, along with strategies for HIV and viral hepatitis, fight to meet the SDG 2030 agenda (WHO, 2018). The Global STI Strategy focuses on creating affordable interventions for at-risk individuals and adolescents in all countries. These plans are financed and delivered by promoting universal health care coverage to keep costs low (WHO, 2018). Additionally, the Gonococcal Antimicrobial Surveillance Programme (GASP) has improved national monitoring of antimicrobial resistance to gonorrhea in order to provide stronger data for new treatment research (Wi et al., 2017).

Samantha Dulak BS

Ms. Dulak was a biology major and global public health minor at Arcadia University. She has a strong interest in nutrition as well as maternal and child health. She now hopes to attend graduate school for public health and pediatrics.

Heather F. McClintock PhD MSPH MSW 

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.


Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Black, E., Richmond, R. (2018) Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination. Vaccines, 6(3), 61. doi: https://doi.org/10.3390/vaccines6030061

Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A., Ahmedin, J. (2018). Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68: 394–424.

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Korenromp, E.L., Rowley, J., Alonso, M., Mello, M.B., Wijesooriya, N.S., et al. (2019) Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012. PLOS One, 14(2): e0211720.

Lewis, D.A. (2011). HIV/sexually transmitted infection epidemiology, management and control in the IUSTI Africa region: focus on sub-Saharan Africa Sexually Transmitted Infections. BMJ, 87(2), ii10-ii13. doi: 10.1136/sextrans-2011-050178

Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health, 8(4). doi: 10.1186/1471-2458-8-4

Sani, A.S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health, 16, 1069. doi: 10.1186/s12889-016-3715-4

UN General Assembly. (2015). Transforming our world : the 2030 Agenda for Sustainable Development. Retrieved 16 July 20219 from https://www.un.org/sustainabledevelopment/health/

UNAIDS. (2019a). Global HIV & AIDS statistics — 2019 fact sheet. Retrieved 16 July 2019 from https://www.unaids.org/en/resources/fact-sheet

UNAIDS. (2019b). In sub-Saharan Africa, three in five new HIV infections among 15–19-year-olds are among girls. Retrieved 15 July 2019 from https://www.unaids.org/en/resources/infographics/women_girls_hiv_sub_saharan_africa

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

The World Health Organization [WHO]. (2018). Report on global sexually transmitted infection surveillance. Retrieved 15 July 2019 from https://apps.who.int/iris/bitstream/handle/10665/277258/9789241565691-eng.pdf?ua=1.

Malaria SBC Evidence Discussion Webinar: Prescriber and Patient Interventions, 8/6

How can research findings inform and improve social and behavior change (SBC) programs? What questions can SBC practitioners keep in mind to help sift through research, interpret publications, and apply lessons learned? Join Breakthrough ACTION for the third in a series of online guided discussions following a journal club format about malaria SBC evidence on August 6, 2019, from 9:30 a.m. to 10:30 a.m. (EDT). More information about the article and how you can prepare for and participate in the online discussion is found below.

Featured presenter

Dr. Clare Chandler, Co-director of the London School of Hygiene and Tropical Medicine Antimicrobial Resistance Centre

About the article

In the article Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial, the impact of a health worker training and health worker patient-oriented training were compared with the standard government training on rapid diagnostic tests. This facility-based cluster randomized trial demonstrated that a combination of prescriber and patient behavioral interventions can reduce prescription of antimalarials to patients without malaria to near zero. Small group training with SMS messaging was associated with a significant and sustained improvement in prescriber adherence to rapid diagnostic test results.

Preparing for the discussion

Download and read the article.
Download and use the Discussion Guide, which has questions to consider as you read and to help you follow along during the webinar discussion.

Register to Attend

Global News Round Up

Politics & Policies

President Trump’s nominee to be the U.S. Representative to the United Nations Office in Geneva sparred with the top Democrat on the Senate Foreign Relations Committee on Thursday over whether rape victims should be allowed to have abortions.

Programs, Grants & Awards

Cancer is a truly global epidemic, with rates rising dramatically in low- and middle-income countries and continuing to increase in wealthier countries. Across Fred Hutch, our cancer and infectious disease researchers are making discoveries and testing new diagnostics and therapies that can have potentially worldwide impact.

Each May, the World Health Assembly brings a whirlwind of global health debate and discussion to the UN’s Palais des Nations in Geneva.


Researchers in the United States and the Netherlands propose a new theory: global warming may have played a key role in the spread of Candida auris, a new and highly drug-resistant yeast, and suggest that this may be the first example of a new fungal disease emerging from climate change, according to a study published in mBio, a journal of the American Society of Microbiology.

Despite substantial progress, only three African nations expected to meet global breastfeeding goals. Guinea-Bissau, Rwanda, and São Tomé and Príncipe, are singled out in a new study from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine.

Weizmann Institute of Science researchers have developed an algorithm that may predict the onset of such diseases as tuberculosis. The findings of this research were recently published in Nature Communications.

Diseases & Disasters

In epidemic preparedness, we dive deep into the core components of outbreak detection and response like laboratory strengthening and response planning. But when an outbreak occurs, it’s the strength of the system working as a whole—not the individual pieces in isolation—that determines whether it will be contained quickly or spiral out of control.


China passed a law on Saturday tightening the supervision and management of how vaccines enter the market, requiring stricter management of their production, research and distribution, after a series of safety scandals.

The Salzburg Statement on Vaccination Acceptance lays down several recommendations to combat the global fall in vaccination rates fuelled by a powerful worldwide ‘anti-vax’ movement.

Public mistrust of vaccines means the world is taking a step backwards in the fight against deadly yet preventable infectious diseases, warn experts.

Four years ago, antibiotics developer Tetraphase Pharmaceuticals Inc. had a market value of almost $2 billion. Now its shares trade for about 70 cents as investors flee the market for new drugs that kill bacterial infections.

Environmental Health

The prime minister called on the G20 countries to set targets for net zero greenhouse gas emissions.  Instead, 19 pledged to meet their targets set in the 2015 Paris agreement. The US did not sign up.

The world’s wood products — all the paper, lumber, furniture and more — offset just 1 percent of annual global carbon emissions by locking away carbon in woody forms, according to new research.

An Oakland-based environmental health group is threatening to sue the manufacturers and retailers behind two bottled water brands for failing to warn consumers about allegedly high levels of arsenic in their products. 

Equity & Disparities

Too often toxic coal ash, a byproduct of coal-fired power, ends up in poor, minority communities. U.S. civil rights officials are launching a deeper look at federal environmental policy to find out why.

In countries such as Zambia, Senegal and Tunisia, everyday drugs like paracetamol can cost up to 30 times more than in the UK and USA.

President Trump became the first sitting U.S. president to cross from South Korea into North Korea (in a demilitarized zone dividing the two countries). The goal was to meet with North Korean leader Kim Jong Un in a diplomatic effort to discuss the denuclearization of North Korea. But the country poses much more of a global deadly force and significant security concern than just nuclear weapons.

Women, Maternal, Neonatal & Children’s Health

Luciana Angueira, a social worker in Villa Fiorito, a poor neighborhood outside of central Buenos Aires, Argentina, says many of the women she sees are looking to end their pregnancies, but don’t want their husbands to know.

For 10 years, Honduran women like Emilia have been unable to legally and easily buy the morning-after pill (also referred to as the day-after pill), a form of contraception that the World Health Organization (WHO) considers a human right.

Approximately 1 million treatment courses of new tuberculosis medicines designed for easy administration in children have been ordered by 93 countries since they were first introduced in 2016, according to the nonprofit organization TB Alliance.

The report, “Adolescent Girls in Crisis: Voices from Beirut,” reveals that girls between the ages of 10-19 living in refugee communities in this region face gender-based violence and rising child marriage — which parents are supporting less for cultural reasons, but in a bid to protect their daughters.