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

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 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!

Tools of the Trade: GPS Assisting in Exploring the Challenging Environments by Mary Louise Tatum

The expansions of peri-urban environments are occurring without any strategic development or management which places its inhabitants at risk for environmental hazards.  In 2013 I was fortunate to develop a partnership between Kent State University (Geography Department) and The University of Zambia (Public Health Department) (please look for my next blog discussing in further detail creating international opportunities). As a result, I was able to observe various environments in Lusaka in close detail. This included illegally settled peri-urban areas on the outskirts of Lusaka, Zambia.

Zambia is a landlocked country with a population of approximately 13.1 million located in southern Africa. The capital of Lusaka has a population of 2,191,225 and has seen disproportionately higher growth compared with the national average: Lusaka has an annual population growth rate of 4.6% compared with 2.8% nationally (Central Statistical Office Ministry of Health; 2013 Zambia Demographic and Health Survey). As a result, there has been rapid growth in illegal settlements. Due to rural urban drift many people have settled in unoccupied land in the peri-urban areas. “Six-Mile” is one such peri-urban community in the outskirts of Lusaka.  As residents of an unofficial settlement, residents lack municipal support and basic needs conceivably leading to increased disparities in environmental health related diseases.

Assessing and documenting public health risks have proven to be a challenge in such environments.  Minimal information is currently available regarding Lusaka’s peri-urban environments. Fortunately, advanced technologies, such as, Google Earth and cameras equipped with a Global Positioning System (GPS) can be used to capture, analyze, manipulate, and understand patterns and relationships between people and their environment. Geography and public health unite to utilize geospatial techniques to explore the construct of a specific peri-urban environment. Utilizing a vector-based system, a real world (Local Map) map will be created demonstrating the “real” environment for analysis. This is important as currently there is no paper map documenting this settlement. Data was collected using cameras equipped with a GPS during walks and drives through the area in August 2013 and July 2014.

Preliminary data collection demonstrates Six Mile residents may be at risk for exposure to malaria, cholera, and other bacteria, as a result of the pools of stagnant water and piles of waste observed during the walks and drives through the area. The one closet-size toilet, shared by a community of approximately seventy-five people, is a tiny areas surrounded by discarded plastic pieces that rest on wooden posts of various dimensions. The toilet, which also doubles as a bathing area, is in close proximity to the source of water collection for drinking and household use. During the walk-through and drive-through it was noted that children played in the stagnant pools of water and piles of trash without interruption.

Our partnership is planning to continue data collection this year and to add to our evolving map. Our goal is to develop a visual tool that may be used by agencies to educate residents in healthier practices and for improved development practices that will mitigate environmental hazards that lead to infectious disease.

With advanced technological tools, such as GPS, Google Earth, and other mapping systems we can capture real-time information to analyze how the environment impacts residents and vice versa. As noted during this field study there are numerous hazards which may be mitigated with government and/or nonprofit environmental organization involvement. Promoting behavior change is one aspect of addressing this issue, but the stark lack of adequate water, sanitation, and hygiene facilities is a major public health threat that needs simultaneous attention for risks to be alleviated.

The expansions of peri-urban environments are occurring without any strategic development or management which places its inhabitants at risk for environmental hazards.  In 2013 I was fortunate to develop a partnership between Kent State University (Geography Department) and The University of Zambia (Public Health Department) (please look for my next blog discussing in further detail creating international opportunities). As a result, I was able to observe various environments in Lusaka in close detail. This included illegally settled peri-urban areas on the outskirts of Lusaka, Zambia.

Zambia is a landlocked country with a population of approximately 13.1 million located in southern Africa. The capital of Lusaka has a population of 2,191,225 and has seen disproportionately higher growth compared with the national average: Lusaka has an annual population growth rate of 4.6% compared with 2.8% nationally (Central Statistical Office Ministry of Health; 2013 Zambia Demographic and Health Survey). As a result, there has been rapid growth in illegal settlements. Due to rural urban drift many people have settled in unoccupied land in the peri-urban areas. “Six-Mile” is one such peri-urban community in the outskirts of Lusaka.  As residents of an unofficial settlement, residents lack municipal support and basic needs conceivably leading to increased disparities in environmental health related diseases.

Assessing and documenting public health risks have proven to be a challenge in such environments.  Minimal information is currently available regarding Lusaka’s peri-urban environments. Fortunately, advanced technologies, such as, Google Earth and cameras equipped with a Global Positioning System (GPS) can be used to capture, analyze, manipulate, and understand patterns and relationships between people and their environment. Geography and public health unite to utilize geospatial techniques to explore the construct of a specific peri-urban environment. Utilizing a vector-based system, a real world (Local Map) map will be created demonstrating the “real” environment for analysis. This is important as currently there is no paper map documenting this settlement. Data was collected using cameras equipped with a GPS during walks and drives through the area in August 2013 and July 2014.

Preliminary data collection demonstrates Six Mile residents may be at risk for exposure to malaria, cholera, and other bacteria, as a result of the pools of stagnant water and piles of waste observed during the walks and drives through the area. The one closet-size toilet, shared by a community of approximately seventy-five people, is a tiny areas surrounded by discarded plastic pieces that rest on wooden posts of various dimensions. The toilet, which also doubles as a bathing area, is in close proximity to the source of water collection for drinking and household use. During the walk-through and drive-through it was noted that children played in the stagnant pools of water and piles of trash without interruption.

Our partnership is planning to continue data collection this year and to add to our evolving map. Our goal is to develop a visual tool that may be used by agencies to educate residents in healthier practices and for improved development practices that will mitigate environmental hazards that lead to infectious disease.

With advanced technological tools, such as GPS, Google Earth, and other mapping systems we can capture real-time information to analyze how the environment impacts residents and vice versa. As noted during this field study there are numerous hazards which may be mitigated with government and/or nonprofit environmental organization involvement. Promoting behavior change is one aspect of addressing this issue, but the stark lack of adequate water, sanitation, and hygiene facilities is a major public health threat that needs simultaneous attention for risks to be alleviated.

Tips for students and young professionals embarking on their first international health experience

Guest blogger: Geoffrey Horning

As members of the APHA and specifically as students in the International Health section, none of my colleagues find the thought of living and working overseas all that strange. In fact, they quite often find the thought exciting, intriguing and something they aspire to do. Many of us, myself included, already have work experiences outside of American borders. In this two part posting, I thought I would share a little of the perspective that I have developed as a “westerner” currently working in the Middle East and North Africa.

On November 11th 2011, I boarded the first of three flights from St. Louis Missouri that would ultimately land me in Riyadh, Kingdom of Saudi Arabia. News media, YouTube and the rest of the internet do not do Saudi Arabia justice, but I thought I had some idea of what to expect from my previous travels…I was wrong. Here are some of the things I’ve learned about living in another culture, and especially one completely different from your own.

First Things First: Know your surroundings and be aware of your situation at all times. The last thing I want to do is scare you or encourage you to stay inside. Neither of those things is necessary, and in fact they are both counterproductive. However, it is important for your safety that you remain alert. Failure to do so can make you the target of groups looking to exploit your naivety, whether it be for a simple street hustle, unlicensed taxi ride that keeps getting more expensive, bribes or more nefarious robbery and kidnapping. Always make sure someone knows where you’re going and when you will be back, register with your embassy in the countries you’ll be visiting, and always keep an eye on a possible exit.

Roll with the punches: Nothing is what it seems, you are a foreigner, a stranger in a strange land, and you learn daily. If you crave the stability of familiar things, this is going to be rough. Every time you think you’ve figured something out, it changes, or more likely, you realize you were just wrong about your previous assumptions. When you laugh things off, or regroup and try a different approach, when you finally realize the “punches” aren’t directed at you and in fact are simply cultural differences — then you’ve made it.

Know the Law-BEFORE you arrive: Two of the “silliest” things I see here are people who have no knowledge of the laws, and worse, people who flagrantly violate the laws and then expect a United States Passport to get them out of trouble. This doesn’t work; it understandably annoys the State Department, and reflects poorly on all of us from your home country. Please follow the law of the land.

Know your health status-and respect it: Consider any medical conditions that you have that require specialized treatments and or medication. Do a quick internet search and see what you have to do in order to get those treatments or those prescriptions filled in the host country. Never, stop taking a medication without a doctor’s advice. Items of specific concern are analgesics/painkillers which may be considered illegal narcotics where you’re headed and psychotropic medications that may just not be available. If you have a history of cardiac problems, it would behoove you to look into the state of cardiac care in the country and region you’re going to.

Learn the language: A vast majority of people in Saudi Arabia are already bi or tri-lingual. English, French, and of course Arabic are commonly known. My Arabic is probably best described as “atrocious”, and the Saudi dialect of Arabic can be quite a bit different from Modern Standard Arabic, which is what you’ll usually get from a language program. That being said, I know enough to get around, and it helps. Start working with it from day one. Your supervisors, co-workers, cashiers, waiters, driver and hotel bellman all speak two or three languages; you might want to go ahead and try to catch up. It’s appreciated.

Check your privilege at the customs counter: The idea of “privilege” is a contentious topic in modern day America. However you feel about it, I assure you that it exists. You’ll see it up close as you process through customs and immigration the first time, and you will probably realize that you have more travelling money in your wallet than some of the people in that line make in a month. If a customs officer recognizes that you’re American/Canadian/British (i.e. “Westerner”), he might pull you out of line and take you to the front, bypassing the 100 people in front of you. Don’t argue with this man – but don’t act like you deserve it. If you’ve been recruited as I was for your abilities in a specific area, then prove it through your performance, but do not act as though you deserve it just because your first moments of life were in a Western hospital. As you learn, as time goes on, you’ll figure it out. Keep the great aspects of your home country and culture, leave the rest: Remember, you just became an unofficial ambassador!

Hurry up and wait: Life in the United States and other Western nations is often a little more: go! go! go! than it is elsewhere in the world. Whether you call it the “rat race” or “climbing the corporate ladder” or what have you, many parts of the world don’t do this. Time is more fluid here, and as an example, work starts at 8 for me which, means I arrive between 7:30 and 8:30. For the first year, I was vigilant about being on time. Now I make sure I’m within reason, which is what my co-workers do. This is what makes me part of the group, rather than an outsider. Learn to interpret signals, take things as they come, and just relax. You might find that you really enjoy the more relaxed pace.

Watch what you say, watch what you write: You should be culturally sensitive anyway, but sometimes it takes a little bit to figure out what’s culture and what’s not. I actively wrote a blog the first 18 months I was here; I really enjoy going back and reading it now, as I can see my development and change over the months and year. There’s nothing wrong with doing this, and I actually encourage it. The reason I gave it up was the time commitments of work and school, not fear of Saudi government intervention. That said, it is always a good idea to be aware of what you say. Not every country in the world, including some western ones, recognizes your “right” to say whatever happens to pop into your head today. Insulting a nation’s government or royal family may be illegal, insulting the culture is poorly regarded, and insulting the state religion and/or proselytizing is treated as blasphemy and can be punished severely. If you make it public, anyone can read it.

These are some tips to get you started in your planning process, In my next post, I’ll talk a little bit about the steps to cultural adjustment that you’ll be taking, as well as give some real life examples of people who’ve been both successful and failed miserably in their transitions.

GHorning

Geoffrey Horning is an Emergency Medical Services (EMS) Training Consultant at the Al-Ghad International Colleges for Applied Health Sciences in Riyadh, Kingdom of Saudi Arabia. His expertise is in EMS/Fire and EMS/Fire Training with specialization in HazMat and Disasters. Geoff’s objective within the Department of Academic and Educational Affairs is to improve and assure the quality of the educational processes and thereby provide the best possible learning environment for students and faculty alike. A veteran of the United States Marine Corps, Geoff is simultaneously working on his MPH at the George Washington University which he will be complete in August 2015.