2017 Zika Update: A Synopsis

In 2015, I put together a panel of diverse public health professionals in order to provide graduate students with guidance on how to best prepare for (and land) a relevant public health job. The majority of the seasoned professionals on the panel (all epidemiologists) mentioned the impact 9/11 had on them being able to get a job, as a result of new positions created with emergency preparedness funding. I graduated shortly after this presentation and was able to secure a High-Consequence Infectious Disease (HCID) position at a local health department in Texas. These surge capacity epidemiologist positions had been made available as a result of the Ebola outbreak. Some of my peers were able to land similar positions around the state of Texas during the same time (or shortly after).

Although these positions were created in response to the Ebola outbreak, the emerging Zika crisis in Brazil became the high-consequence infectious disease of focus for us. Within a few weeks of starting my position, the epidemiology office at my local health department began to receive requests from local media for more information about Zika virus and the risk it posed to community members. Additionally, we were receiving continual updates from the Department of State Health Services, Zoonosis Control Branch concerning laboratory testing, preventive measures, and risk assessments for pregnant women and their partners. I was in charge of consolidating and disseminating this guidance to our local health care providers and community partners. It was also during this time that I  created a short quiz to gauge knowledge of key aspects of the illness and provide answers from relevant sources such as the Centers for Disease Control and Prevention (CDC), the Pan American Health Organization (PAHO), and the World Health Organization (WHO). The survey was tested out in the LinkedIn Global Health group and then later included in a presentation I put together for local health department and county staff. The quiz answers and presentation were updated periodically, as we learned more about Zika virus through conference calls and webinars. By the time I started a new position a year later, the number of Zika virus cases being reported globally had started to decrease.

That’s just a little of my experience with Zika. Now, I will share a brief, global synopsis of Zika.

In 2016, the World Health Organization (WHO) declared Zika virus to be a Public Health Emergency of International Concern due to its association with congenital microcephaly in infants born to women who had been infected during their pregnancy. Additionally, neurological conditions such as Guillain-Barre syndrome (GBS) were also being reported in adults who had been infected with Zika virus. Zika virus is said to be transmitted through the bite of an infected Aedes aegypti mosquito. It is also spread through sexual and congenital transmission.

Since May 2015, more than 750,000 confirmed and suspect Zika virus cases have been reported globally. Cases have been spread throughout more than 60 countries and territories. From May 2015-Dec 2016, there were 707,133 suspect and laboratory confirmed Zika virus cases in the Americas due to local transmission. Twenty-five percent of these cases were laboratory-confirmed. By late 2016, Zika virus transmission had occurred in 48 countries and territories in the Region of the Americas. Peaks were observed at various points during this time period (some regions even experienced more than one):

-January 2016 (Central America)
-February 2016 (Southern Cone, Andean subregions, and non-Latin Carribean)
-June 2016 (Central America and non-Latin Carribean)
-January-July 2016 (Latin Carribean; also the region with the highest number of Zika virus cases)

Zika virus rates in North America were relatively low, with a small peak occurring in October 2016. According to the U.S. Zika Pregnancy Registry (USZPR), 10% of completed pregnancies with confirmed Zika virus infection reported birth defects. Microcephaly was reported in 84% of completed pregnancies with birth defects. Additionally, birth defects were higher during the first trimester of pregnancy. Compared to pre-Zika levels in 2013-2014, 30 times more fetuses/infants were reported to have birth defects in 2015-2016. A similar trend was seen in Brazil when comparing pre-Zika data to data collected from mid-2015 to Jan 30, 2016 (read limitations in both articles).

In November 2016, WHO re-classified Zika virus as a long-term public health challenge  (instead of a Public Health Disease of International Concern). Since December 2016, there has been a significant drop in the number of cases being reported, however, CDC is reminding the public to follow preventive measures as the mosquito season gets closer.

Global Health in Conflict: A Weightier Commitment

It is important for early-career professionals interested in pursuing a career in global health to be aware of the realities of working internationally. Although stories of setting up vaccination clinics or fighting Ebola may stir up feelings of excitement, being a part of the action may require additional education and training in conflict resolution and institution building. This is especially true when it comes to conflict-affected areas and fragile states that are the most in need of health care/public health services as a result of the local health system infrastructure being weakened. A different kind of public health professional, one that is willing to risk their life and invest in the indigenous health system, is required in our world today.

I currently work as an epidemiologist at a regional health department in Texas. We serve two main roles for the 30 counties we cover. One of our roles is to function as a local health department and deliver a diverse range of services to 23 counties. The other main role is to serve as an extension of the state health department and provide surveillance/investigation guidance for the reportable conditions that health care providers, schools, and community members are mandated to report. This relationship is seen especially when we work with the 7 counties in our region that have their own local health departments. Before beginning this job, I actually worked at one of these local health departments and was on the receiving end of the interaction described above.

For most of my life, I’ve been interested in pursuing a career in global health or humanitarian work. When I was younger, I thought the only way I could pursue this dream was by being a physician (especially if I wanted to be able to support myself financially). I also believed this to be a great way to help communities that were dying from preventable illnesses. My introduction to public health helped me see that there were many other ways to help achieve the goal of combating deaths due to preventable illnesses. I focused in on epidemiology as a way to combine my science/laboratory background with my desire to serve and entered into an MPH program after completing my B.S. in Biology. Most of my MPH program was spent working hard to obtain tangible experiences in public health practice and deciding which skills would be most necessary for me to have before entering into the workforce. While pursuing my MPH from 2014-2015, some of the hot topics in public health were Ebola, antimicrobial resistance, bioterrorism, anti-vaccination movements, hospital-acquired infections, opioid abuse, tuberculosis trends related to travel, maternal and child health gaps, and continued efforts to end polio and AIDS, to name a few. Towards the end of my program, I began to hear more about the dangers of humanitarian work and global health as stories involving health care and humanitarian workers being targeted in conflict-affected areas/fragile states were highlighted in various media outlets. I also knew of at least one faculty member at the university I attended whose global health team was attacked shortly after the individual returned to the US (after working in the field for a number of years).

When I entered into the public health workforce in 2016, Zika was just becoming a hot topic in public health circles in the U.S. But there were other things for me to learn at my local health department. I received an introduction to the Immunization team and programs such as Texas Vaccines for Children which enable young people in Texas to receive affordable immunization coverage (there is an adult vaccine program too). I also received an introduction to the statewide ImmTrac system that stores vaccine records and learned about some of its strengths and challenges. Ultimately, I was able to see the importance of public health collaborating with healthcare providers, schools, and community members to ensure that a community has adequate herd immunity or, in the case of outbreaks, can deliver effective interventions in response to infectious disease threats. Something else I learned about was the role of immunization clinics or point of dispensing units (PODS) during natural disasters, such as floods, and other public health emergencies.

I’ve shared some of my experience working at the local level because it gave me a tangible picture of how public health functions in stable environments or areas that are not weakened by natural disasters. In conflict-affected areas or fragile states, public health efforts may be fragmented at best. For example, in August 2015 Nigeria was removed from the World Health Organization’s list of countries with endemic Wild Polio Virus (WPV). This was the result of global efforts aimed at eradicating polio through targeted immunization campaigns. Nigeria went two years without WPV cases before, in August 2016, two cases were reported in Borno-a conflict-affected state. Two additional cases were reported in September 2016. The cases were from inaccessible areas of the state with limited security and indicated that prolonged transmission had gone undetected as a result of armed conflict. Although the number of areas held by insurgents, and therefore without access to vaccines, eventually decreased, the conflict in Borno prevented timely vaccination campaigns and posed a risk to Nigeria as a whole. Specifically, migration between Internally Displaced People (IDPs) camps and refugee communities resulted in a higher potential for WPV cases to be reported in states not directly tied to the conflict. A similar trend was noticed with the Ebola outbreak that occurred in West Africa from 2014-2015. The disease posed an increased risk in fragile states and areas affected by conflict. For example, prior civil wars in Liberia and Sierra Leone severely weakened the countries’ infrastructure in the 1990s. The conflicts also affected surrounding countries and resulted in millions of displaced people. In some of instances, countries had the resources needed to respond to public health emergencies caused by conflict. However, groups of people or areas deemed to be inaccessible as a result of conflict continued to undermine the effectiveness of immunization clinics and infectious disease response efforts.

A comparative analysis conducted by Bourdeaux et al. in 2015 assessed the effect of conflict on health systems in Haiti, Kosovo, Afghanistan and Libya.  Health systems were defined as, “the organized network of institutions, resources and people that deliver health care to populations” and was based on the World Health Organization’s (WHO) Framework for Action (2007). The framework highlights financing, leadership/governance, information, medical products/vaccines/technologies, health workforce, and service delivery as essential components of effective health systems. When this organized network is destroyed as a result of armed conflict, high levels of morbidity and mortality occur and can have negative effects that persist even after the conflict is over. The analysis found that the building blocks most affected by conflict and security forces were “governance, information systems and indigenous health delivery organizations.”  In order to address these gaps, a suggestion provided by the authors is to deploy Health Security Teams comprised of individuals with training in public health and institution building to conflict-affected areas and fragile states. The teams would support indigenous health systems instead of creating parallel or temporary systems, and not be involved in serving military interests. Additionally, these teams would know how to guide security forces as they engage with health systems in diverse political climates.

At this point in time in my career, most of my work is done in an office on a phone or computer. When I started my journey in public health, I pictured something different. I still have the long-term goal to work internationally (or financially support myself while volunteering internationally). However, I am sobered by the fact that if I want to serve those who are truly in need (especially as it relates to conflicted-affected areas and fragile states) I will have to be at peace with laying my life on the line. I will also have to be prepared to navigate the challenges presented above. This includes learning as much as I can about conflict resolution and negotiating to protect health systems. In general, I feel that public health has much to do in terms of educating and re-assuring those we serve (both domestically and internationally). As a result, part of my journey in public health will include developing skills as a connector of people and someone that can see both sides of an issue. I think that all public health professionals interested in working in a global health or humanitarian worker capacity should consider this. At the same time, immigrants or refugees that have left their homes due to conflict or in search of better opportunities can also develop the skills needed to resolve conflict and rebuild institutions. The success of the suggested Health Security Teams could depend on this.


Photo: Diane Budd, M.D.


Exploring the role of corruption and democratic accountability on HIV/AIDS aid effectiveness

Over the past two decades, the role of good governance in aid effectiveness has been a topic of debate. Both donor and recipient countries have questioned why investments of official development assistance (ODA) over many years have not resulted in stronger economic and health outcomes. This blog post focuses on health aid (in particular HIV/AIDS aid) and the impact control of corruption and democratic accountability may have on improving health outcomes.

More than 95% of HIV infections are in developing countries. As a result, global communities have invested billions of dollars in the fight against HIV/AIDS using funding from ODA and other substantial donors. Although AIDs-related deaths have decreased by 35% and HIV infections have decreased by 40% since 2000, the decrease has not been significant and millions of new HIV cases are still diagnosed each year. The World Bank’s 1998, “Assessing Aid,” report is part of a body of literature that proposes that good economic policies in recipient countries are associated with (and may be necessary for) successful outcomes like preventing disease  and building stronger  economies. Furthermore, control of corruption in government leadership can be a major factor for growth and poverty reduction, due to good fiscal and trade policies that seek to invest in growth-promoting activities.

According to findings stated in the Hwa-Young Lee et al. article titled, “Control of corruption, democratic accountability,  and effectiveness of HIV/AIDS official development assistance,” control of corruption contributes to aid effectiveness in healthcare delivery. HIV/AIDS is a strong example of this since large amounts of funding are needed to control the illness due to the stigma associated with it, the price of drugs, and the breadth of the epidemic. Corruption at any level can weaken health outcomes by raising the price of services or weakening the quality of treatment . This can, in turn ,  discourage further investment from donors. Consequently, HIV/AIDS policies have to involve broad, democratic consensus about how to invest resources in a way that ensures improved health outcomes.

Hwa-Young Lee et al. used data from 2001-2010 to measure the role control of corruption and democratic accountability on improving HIV/AIDS outcomes. General Methods of Moments estimation showed that control of corruption and democratic accountability had independent effects on the amount of HIV/AIDS aid and the incidence of HIV/AIDS. Furthermore, democratic accountability had a negative interaction with the amount of HIV/AIDS aid on new cases of the disease. The results indicate that more funding may not lead to better outcomes in countries that do not have strong democratic accountability. The authors also propose that HIV/AIDS aid is effective because it focuses on preventing new   cases.  Although prevalence of HIV/AIDS was explored,  an increase in prevalence can be attributed to better treatments and prolonged life. As a result, looking at the relationship between HIV/AIDS prevalence and corruption or democratic accountability may not paint an accurate picture of aid effectiveness.

The debate over the effectiveness of aid in developing countries will likely not be going away soon. Now more than ever, it is important for recipient countries to share their success stories and for donors to work with them to deliver effective economic and health outcomes. At the same time, donors should evaluate their roles in helping alleviate or exacerbate corruption and democratic accountability in developing countries.

According to the International Institute for Democracy and Electoral Assistance’s (IDEA’s) Democracy and Development programme, democratic accountability refers to: ways in which citizens, political parties, parliaments and other democratic actors can provide feedback to, reward or sanction officials in charge of setting and enacting public policy. Well functioning accountability mechanisms are believed to provide incentives for governments to work in the best interests of citizens…Read more in their discussion paper titled, “Democratic Accountability in Service Delivery: A Synthesis of Case Studies.”



An Overview: Exploring Development Aid and Migration

This blog post explores the relationship between the history of international development aid and migration.

My previous posts have focused on high-level meetings and policies used as guidelines to advocate for development effectiveness and cooperation in the international aid and development sector. At a time when the Sustainable Development Goals (SDGs) have been rolled out to countries to make sure “no country is left behind,” nations have a shared framework to guide them and make sure their development policies support activities that lead to outcomes such as poverty alleviation, job creation, and sustainable communities. Additionally, the aim of development effectiveness and cooperation is to provide accountability for donors and financing agencies as countries move forward with their national agendas.

The focus on how to best do development has me wondering why development is necessary in the first place and, furthermore, what role migration plays in this discussion. To start off, the United States Agency on International Development’s (USAID) mission  is to “partner to end extreme poverty and promote resilient, democratic societies while advancing [the United States’] security and prosperity.” When I personally consider the end goal of development, I think about countries across the globe being able to support themselves economically. I envision healthy communities and the elimination of poverty. This is what I envision. However, in order to have a better understanding of development today, its history has to be re-visited.

In the United States, the concept of economic or international development first became widely circulated during the Truman administration, a period where there was a strong belief that science and technology could solve human problems like disease and malnutrition. More specifically, President Truman proposed an international development assistance program in 1949 called the Four Point Program. This development program built on the 1947 Marshall Plan  that focused on rebuilding Europe after WWII and promoting an exchange of U.S goods with European countries. It was also established to prevent vulnerable countries from joining the Communist party. Overall, European countries showed that reconstruction and development were possible in areas of technological and social infrastructure, and such a blueprint could possibly work in developing countries. During the time period of 1952-1962, the plan transitioned into the: Mutual Security Act, Mutual Security Agency, Foreign Operations Administration, International Cooperation Administration, and the U.S Foreign Assistance Act (which led to the creation of USAID). There were a few overarching goals of aid assistance: 1) promote economic development and support democratic societies, and 2) actively apply Rostow’s Modernization Theory to help countries out of poverty and provide the end products of urbanization, technological advances, and durable consumer goods. Other theories, such as the Dependency Theory, proposed that disparities existed not because countries were undeveloped or not “modern enough,” but were underdeveloped as a result of exploitation of human capital and natural resources by Western countries. In conclusion, both theories, in a way, try to explain the cause of disparities between richer and poorer countries. Over time, foreign aid, education, and investments in infrastructure are inputs that have been used by countries to close economic gaps and try to achieve some version of sustainable development.

So, what role does migration have to play in all this? I initially thought that more development gave individuals and families an incentive to remain in their countries of origin due to increased economic opportunity. However, this is not actually the case. In its initial stages, development inspires emigration, especially for those who are more educated. While this benefits destination countries, and even migrants, it often leads to “brain drain” in countries that are initially struggling to produce or maintain an adequate level of economic growth, particularly those below $6,000–8,000 GDP per capita. About half of all countries fall under this threshold. Brain drain can lead to shortages of talent in sectors that are necessary for infrastructure such as engineering, health, and education. Ultimately, these shifts in the population contribute to and perpetuate inequality on a global level. According to the Center for Global Development, there are at least six reasons why development initially causes these disadvantages:

  1. Development is usually accompanied by a demographic transition that favors a corresponding mobility transition
  2. Development means that more people can afford to emigrate
  3. Development means that more people can access the information they need to emigrate
  4. Development tends to disrupt economic structures that keep people immobile
  5. Development shapes domestic inequality in ways that foster migration, and
  6. Development in country A means that people in country B are more likely to give visas to migrants from A.

Although emigration can become beneficial when origin countries are able to retain educated natives, both the development level of the country and probability of emigration have to be just right – not too low and not too high. Emigrants are more likely to return to their countries of origin in response to increased development efforts that are competitive. In light of such data, development assistance programs may not actually be able to bridge the gap between rich and poor countries. In fact, questions have been raised concerning the effectiveness of aid in countries that have been receiving money for years but still remain impoverished.  Another thing to consider about migration is that economic mobility is not the only reason why people migrate. Migration is fueled by what is going on in home countries compared to what is going on in destination countries- political instability and corruption, religious persecution, limited career paths, or lack of economic growth. Ultimately, a combination of push and pull factors that can be related to international development activities make emigration desirable. For example, the initial stages of international development aid in the United States simultaneous occurred during the decolonization of Asian and African countries, some of which are the main recipients of foreign aid. Additionally, wars have continued to contribute to economic and political instability throughout the world.

Despite push and pull factors and challenges with ensuring that foreign aid actually benefits those it’s supposed to help, education continues to empower individuals and communities to be leaders and brainstorm new ways to create healthy, sustainable communities. Furthermore, educational settings may prove to be an effective bridge to foster relationships between receiving countries and countries of origin that make it easier for emigrants to return and provide human capital that is needed to reach the SDGs.


Should private enterprise be guided by development effectiveness principles?

Overview of CAPE Conference – Conference Note 3 – Investing in Private Enterprises

Since the private sector has been highlighted as having a significant role to play in reaching the Sustainable Development Goals (SDGs), there have been growing efforts to integrate it into international development financing activities. In my last post, an overview of DE principles used to guide key players in official development assistance (ODA) was provided. This post will focus on development finance institutions (DFIs)  and similar entities that invest public funds into private enterprises.

Public international development agencies make up the majority of donors. Now that donors are able to contribute to DFIs through ODA routes, the claim can be made that DFIs should also be required to follow DE principles as they invest in private enterprises.  Although DFIs are able to operate similarly to ODA, the overall goals and methods of these streams of funding are not perfectly aligned. One reason for this is that DFIs are focused on creating jobs and receiving a return on investment, while ODA focuses on poverty-alleviation. Additionally, each DFI has individual operating guidelines and procedures. The chart below includes items that were discussed at the 2016 CAPE Conference as DE supporters considered whether DFIs should be required to adhere to DE principles:

oda-vs-dfiAs a result of this discussion, the recommendations below were compiled and will be presented at the Second High-level Meeting of the GPEDC on November 28th:

  • DFIs and other donor-backed investment vehicles should commit to supporting national development strategies. The GPEDC should track whether donors incorporate country preferences into their investment strategies. Attempts to achieve wider ownership of investment decisions would be impractical.
  • Countries and donors should commit to harmonising the relevant elements of country results frameworks with those used by DFIs and other donor-backed investment vehicles. No indicator is necessary.
  • Donors should commit to putting in place rigorous procedures for identifying groups at risk, consulting affected communities and handling grievances. Monitoring could be based on an independent rating of these.
  • Donors should commit to a process that will establish shared transparency requirements when investing public money in private enterprise (PPP). Indicators could include the percentage of PPPs that conform to Open Contracting Partnership data standards, and the percentage of investments where: full beneficial ownership information is available; the upfront investment case is public; some indication of the degree of concessionality is stated.
  • Partnership and accountability should apply when formulating investment strategies and monitoring their execution, and in ensuring that those making day-to day investments take full account of the consequences of their decisions on local communities.