Public Health and Migration

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.  

 

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Moving in the right direction: India court legalizes gay sex in landmark ruling

There currently are no official demographics for the LGBT population in India. However according to unofficial estimates submitted by the government of India to the Supreme Court, there were about 2.5 million gay people in 2012. Lesbian, gay, bisexual, transgender (LGBT) people in India face many difficulties, both social and legal. Reports of killings, attacks, torture, and beatings are not uncommon. LGBT people in India also face discrimination in the community and rejection from their families. Continue reading “Moving in the right direction: India court legalizes gay sex in landmark ruling”

United Nations High-Level Meeting on Tuberculosis: Importance of drug quality

At the end of next month, the inaugural United Nations (UN) High-Level meeting on Tuberculosis (TB) will take place in New York to discuss the future of the bout against the devastating yet elusive disease. As TB remains the largest infectious disease torturer in today’s society taking the lives of 4500 humans each day, the theme of this occurrence is “United to end Tuberculosis: an urgent global response to a global panic”. This unparalleled step undertaken by governments throughout the world along with those allies engaged in ending Tuberculosis will address an assortment of issues at this meeting. Although the exact agenda has yet to be revealed, the resolution to host this single day meeting mentioned the following items could be discussed:

  • Adequate funding for novel diagnostic testing, medications, and vaccinations
  • Multi-Drug Resistant Tuberculosis (MDR-TB)
  • Responsibility for multisectoral collaboration within nation states, regions, and the globe
  • Universal health care coverage and ensuring tuberculosis coverage is included

Each of these items – ranging from the use of prophylactic low dose isoniazid therapy to equal distribution of the recently designed TB diagnostic test Xpert MTB/RIF – are crucial in accomplishing the END TB strategy laid out by the World Health Organization. However, after looking over these action items for the meeting, Tuberculosis drug quality seems to absent.

As health care professionals across the globe continue to treat TB on a patient specific basis, certain untreated cases occur that puzzle even those who have treated the disease for years. The reasoning behind treatment failure? Adherence to medication or drug resistance are often the first assumed thoughts those sharing their patient’s fate may have. Yet, the actual medicine with its various active and inactive ingredients is often not called into question.

Towards the end of last year, the World Health Organization released an alarming figure concerning drug quality in low to middle income countries. In the report released to the public, WHO stated that approximately 10% of medications are counterfeit in these areas of the world – which happen to be the areas where Tuberculosis and other infectious diseases take their largest toll. In addition, WHO added that this percentage is most likely only a small part of the number of humans truly affected by counterfeit medications. To provide clarification, WHO considers counterfeit medications to be unapproved by regulators, unable to meet quality standards, or purposefully misrepresented active or inactive ingredients in the medication. In addition to this report by WHO, the National Institutes of Health (NIH) published a report outlining in 2015 that 9% to 41% of anti-tuberculosis and other infectious disease medications failed to meet the standards sought in specific studies.

It is vital for the global health community to obtain an effective vaccine to prevent pulmonary tuberculosis, to have a rapid yet specific TB diagnostic test, to create a strategy for various sectors of a nation state to work together in ending TB, and novel agents to treat the most severe cases of MDR-TB. Individuals in rural Kampot, Cambodia, inmates in the Russian prison system, or those residing in the slums of Bangalore, India often can be restored to health through the means that have been available for the last half a century. The RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) regime has proven its success in treating non-resistant tuberculosis – so long as each of the medications are of appropriate quality. However, The Lancet released a report in January 2017 that found that 8.9% of Indian rifampicin products were of inadequate quality in a country that is burdened with the highest prevalence of tuberculosis across the globe. Moreover, WHO revealed that 28.3% of rifampicin containing medications found in the Russian Federation in 2011 failed to meet predetermined specifications for proper quality – a country known to have one of the highest MDR-TB burdens in the world. With the aforementioned statistics released by the WHO, The Lancet, and NIH, a renewed emphasis needs to be placed on ensuring the quality of each and every tuberculosis medication that reaches a human being. The possibility of one in ten (or more) TB medications being counterfeit will continue to lead to failed treatment regimes, inappropriate use of resources, and spread of MDR-TB even if innovative technology is developed.

In order to combat counterfeit medications on a global level, the World Health Organization developed a reporting system for the interconnectedness of the medication market. The Global Surveillance and Reporting System (GSRS), that all WHO members are eligible to contribute to, aims at collecting data on falsified medications, vaccines and other medical equipment to address real-time situations and prevent further harm. With this reporting arrangement in place, the WHO has reacted and thwarted mortality and morbidity associated with counterfeit medications – including the contaminated cough medication supply that led to 60 deaths in Pakistan and a number of individuals treated with an antidote in Paraguay in 2013. On top of the GSRS, WHO has implemented Good Manufacturing Practices (GMP) that each manufacturer should achieve in order to be certified by WHO; thus, providing a reliable source of medications that nation states can purchase from. Although these initiatives have brought about encouraging results along with halting global medication emergencies, there are still barriers that accompany these programs. The technical training, technology, and adequate staffing to properly identify and report through the GSRS is often difficult to obtain in the developing world while GMPs are often misapplied and have inadequate supervision. The root cause is the long-term development of countries’ public health systems – of which continuing problems with counterfeit medications remains deficiently addressed. A county’s public health care system is the vital organ to ensuring quality medications through these mechanisms that WHO has created and employed. An underutilized and under resourced public health care system leads a budding yet unregulated private market – unable to ensure proper treatment for those seeking it.

Since the United Nations declared this a high-level meeting, meaning all heads of member states are encouraged to participate in the highest level possible, this venue provides the ideal opportunity to recommit to guaranteeing TB drug quality. The sustained empowerment of the public health care systems for those countries tirelessly battling tuberculosis will be a step forward into truly ending this devastating disease. Each health care professional spanning the globe has a responsibility to accompany these governments, colleagues, and fellow humans by investing their time, resources, and talents to develop procedures and systems to ensure effective drug quality.

Global News Round Up

Politics & Policies

Technological innovation, expansion of the use of frontline personnel such as community health workers, and rapid increases in health care financing are likely to be instrumental to achieving universal health care (UHC) in countries around the world, according to a new analysis led by Harvard T.H. Chan School of Public Health.

UW Provost Mark Richards joined Sen. Patty Murray and seven global health security experts in Kane Hall on Monday morning to discuss the future of global health in a violent world.  The event was hosted by the Center for Strategic and International Studies (CSIS) Commission on Strengthening America’s Health Security.

On August 3, Representatives Chris Smith (R-NJ) and Barbara Lee (D-CA), with Ed Royce (R-CA), Eliot Engel (D-NY), Ileana Ros-Lehtinen (R-FL), and Karen Bass (D-CA) as additional cosponsors, introduced the PEPFAR Extension Act of 2018 (H.R. 6651). The bill reauthorizes the President’s Emergency Plan for AIDS Relief (PEPFAR) through 2023 and upholds the United States’ commitment to address the HIV/AIDS epidemic.

Perhaps no other prominent African personality of international clout, apart from late Nelson Mandela, has attracted so much accolade, sympathy, empathy and condolence like the seventh Secretary-General of the United Nations Kofi Atta Annan, who died in Bern, Switzerland, on August 18, 2018.

Programs, Grants & Awards

The Duke Global Health Institute (DGHI) has selected three new Doris Duke International Research Fellows for the 2018-19 academic year.  The fellows—one medical student from Indiana University and two from Duke University—will conduct clinical global health research throughout the upcoming academic year.

Research

Researchers explored the link between cardiovascular health level (defined using the 7-item tool from the American Heart Association [AHA]) and risk of dementia and cognitive decline in older persons. They observed that increased numbers of optimal cardiovascular health metrics and a higher cardiovascular health score were related to a lower risk of dementia and lower rates of cognitive decline.

The financial fallout from breast cancer can last years after diagnosis, particularly for those with lymphedema, a common side effect from treatment, causing cumulative and cascading economic consequences for survivors, their families, and society, a study led by Johns Hopkins Bloomberg School of Public Health researchers suggests.

Despite increased attention to opioid abuse, prescriptions have remained relatively unchanged for many US patients, new research finds.

Diseases & Disasters

It’s been years since the tobacco industry promised to stop luring young people to smoke cigarettes.  Phillip Morris International says it is “designing a smoke-free future.” British American Tobacco, likewise, claims to be “transforming tobacco” into a safer product.

In a shocking revelation, a recent study has found that alcohol is associated with nearly one in 10 deaths in people aged 15-49 years old.  Overall, according to the research that estimates levels of alcohol use and health effects in 195 countries between 1990 to 2016, 2.8 million deaths occur each year worldwide.

Listeria monocytogenes as the main causative agent of human listeriosis is an intracellular bacterium that has the capability to infect a wide range of cell types. Human listeriosis is a sporatic foodborne disease, which is epidemiologically linked with consumption of contaminated food products.  Listeriosis may range from mild and self-limiting diseases in healthy people to severe systemic infections in susceptible populations.

Approximately one-third of the earth’s population – that’s 2.4 billion people – drinks alcohol, and 2.8 million deaths a year are caused by alcohol-related problems, according to a massive study estimating alcohol use and health effects in 195 countries.

Salt may not be as damaging to health as is usually claimed, according to a controversial new study which suggests campaigns to persuade people to cut down may only be worthwhile in countries with very high sodium consumption, such as China.  The World Health Organization recommends cutting sodium intake to no more than 2g a day – the equivalent of 5g of salt – because of the link to increased blood pressure, which is in turn implicated in stroke.

Those who fail to vaccinate are bound to suffer the diseases of the past.  Measles, which once killed an estimated 2.6 million people a year, is still killing almost 90,000 people a year according to the World Health Organization (WHO), and may be endemic again in the Americas, according to the latest data from the Pan American Health Organization.

The Democratic Republic of the Congo started using an experimental vaccine against the deadly Ebola virus yesterday after identifying it as the virulent Zaire strain. The latest outbreak has spread to a conflict region and is suspected of killing at least 36 people during its first week.

Aardman Animations, creator of the popular “Wallace and Gromit” claymation films, and actor Hugh Laurie teamed up for a 2-minute video on the history of his disease, which claims 450,000 lives a year.  It’s called “Malaria Must Die, So Millions Can Live.” And it stars “Mozzie the Mosquito.”

Technology

A new report from researchers at the Centers for Disease Control and Prevention (CDC) details the investigational use of a drug to treat Chagas disease now available commercially in the United States.

A rotavirus vaccine introduced in rural Malawi has reduced deaths from infant diarrhea morale by more than a third, proving for the first time that a major intervention in a low-income country can be highly effective.

Environmental Health

Exposure to a prevalent type of air pollution—particulate matter called PM2.5—takes one year off the average global lifespan, according to research published Wednesday (Aug. 22) in the journal Environmental Science & Technology Letters. But that air pollution is never evenly distributed; for people living in the most-polluted areas of Asia and Africa, the situation is worse—life expectancy for them drops between one year and two months to one year and 11 months.

Equity & Disparities

Women’s Equality Day commemorates the ratification of the 19th Amendment and the resilient women who work to promote the American value of equality.  Today, Peace Corps recognizes the contributions that volunteers have made to help advance equality across the globe and back home in the United States. Currently, women make up 63 percent of all Peace Corps volunteers.

Women, Maternal, Neonatal & Children’s Health

An estimated 6.5 million abortions take place across Latin America each year.  Three-quarters of these procedures are unlawful, often performed in unsafe illegal clinics or at home.

Interventions and Strategies for Addressing Global Intimate Partner Violence

This is the fourth part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Written by: Ewinka Romulus MPH and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate Partner Violence (IPV) continues to be a serious global public health concern affecting millions of women (and in some cases, men). IPV refers to any harmful behavior within an intimate relationship that includes physical, psychological or sexual harm. Existing research suggests that different types of violence often coexist. For instance, we tend to see physical IPV often accompanied by sexual IPV and emotional abuse. While the extent of IPV varies across regions, higher prevalence exists amongst poorer countries and within communities of a lower socioeconomic level. The World Health Organization (WHO) reports a higher prevalence of IPV among African, Eastern Mediterranean, and South-East Asia Regions (approximately 37%). Whereas, lower rates of IPV are found among women in European and Western Pacific regions.

To date, different theories and models have been used to explain IPV behavior within communities. The most widely used model for understanding intimate partner violence is the Social-Ecological Model which considers the complex interaction between the individual, relationship, community and societal factors that may influence IPV. The societal level identifies broad societal factors including social and cultural norms, health, economic, educational, and social policies, which may create an environment where IPV is either encouraged or inhibited. Researchers are continuously examining the factors associated with IPV at these different levels and factors.

Relying on this conceptual framework interventions and strategies to address IPV globally require a multi-level approach. Accordingly, the World Health Organization’s Global Plan of Action to Address IPV 2016, calls for a multi-sectoral approach in which strategies for addressing IPV occur on all levels of the Social-Ecological Framework (e.g. individual, relationship, community, etc.). The goal of this plan is to strengthen the role of the health system in all settings and within a national multisectoral response to develop and implement policies and programmes, and provide services that promote and protect the health and well-being of everyone, and in particular, of women, girls and children who are subjected to, affected by or at risk of interpersonal violence. The plan calls for several actions that respond to and prevent gender-based violence against women and girls (VAWG). These include “creating an enabling legal and health policy environment that promotes gender equality and human rights, and empowers women and girls; provision of comprehensive and quality health-care services, particularly for sexual and reproductive health; evidence-informed prevention programmes promoting egalitarian and non-violent gender norms and relationships; improving evidence through collection of data on the many forms of VAWG and harmful practices that are often invisible in regular surveillance, health and crime statistics.”

Several countries, such as Uganda, India, and Nigeria have integrated multiple approaches encompassing the key principles mentioned above. For instance, in Uganda, an organization called Raising Voices works to prevent violence against both women and children. Raising Voices focuses on transforming attitudes and behaviors to promote gender equity in communities through a tool called SASA!. SASA! is a well-known intervention that has been adapted and implemented across regions, namely, the Caribbean, the Middle East, and Southeast Asia. The SASA! intervention includes four steps: Start, Awareness, Support, and Action which focus on educating communities through a series of activities that address the importance of power and awareness in relationships. A recent evaluation of SASA! in Uganda demonstrated a significant reduction in the reported level of physical partner violence against women. In Haiti the MDG Achievement Fund  partnered with local women’s organization to establish health clinics and provide counsel and care for victims of violence. Local leaders are trained to educate and spread awareness about domestic violence within communities and to report a witnessed crime to local authorities. The MDG Achievement Fund partners with UN Women to create educational and socio-economic opportunities for vulnerable women to increase economic independence and autonomy. There has also been an increase in the number of One-Stop Crisis centers worldwide to help recent victims of violence.

Contextual factors shape the etiology and manifestation of IPV and thus effective interventions differ within communities and across countries. Programs that employ models that are specific to cultural norms while including community members have been found to be effective in addressing IPV. In addition, structural and systematic intervention strategies (economic, social, political, and physical) to reduce IPV or its impact may also be essential to reduce IPV’s global burden (Bourey C, 2015). An example, of an issue embedded in underlying structural and systemic inequities is that may be potentially modified to improve IPV is that of literacy.  Regions with lower literacy levels show a higher prevalence of IPV among women. One study conducted in Ethiopia (Deyessa, 2010) found illiterate women were more likely to justify the reasons for a man beating his wife, compared to literate women. The study also found that literate women with a literate spouse were least likely to have experienced physical violence compared to literate women with an illiterate spouse. Similar findings were reported in a study in India (Ackerson, 2008) in which women residing in neighborhoods with high literacy rates were were less likely to experience IPV. Literacy can also have an important impact on other indicators of well-being entwined with outcomes for IPV such as contraceptive knowledge and use. In our recent work we found that literacy was significantly associated with the utilization of modern contraceptives (adjusted odds ratio (AOR) = 1.166, 95% CI = 1.015, 1.340). Thus, interventions that seek to modify systemic and structural components that influence literacy may have important implications for IPV.

Intimate partner violence is a common problem worldwide that needs to be addressed incorporating contextual needs. The World Health Organization calls for a collaborative, coordinated and integrated response for addressing this significant public health issue. It is evident that interventions should be multi-sectoral and a comprehensive approach should aim to address IPV implications on individual, relationship, community and societal levels.

Screen Shot 2018-08-17 at 11.00.41 AM.pngEwinka Minerva Romulus, MPH is a recent graduate from Arcadia University’s MPH program. Her master’s thesis focused on the influence of literacy on contraceptive knowledge and use among women in Swaziland. Prior to her graduate career, she studied Bio-behavioral Health at the Pennsylvania State University where she gained an understanding of the interactions among biological, behavioral, psychological, sociocultural, and environmental variables that influence health. Ewinka gained interest in global health after observing the existing issues around poverty, health, and inequality in her own country – Haiti.  She is planning on continuing her studies at Drexel University in the fall of 2018 to obtain a certificate in Epidemiology and Biostatistics. Her current interests are in women’s health, global health, and nutrition. Her global health experience includes traveling to Guatemala with Mayanza Organization to provide health education and health screenings to school-children. She is also involved in organizations in Haiti with a mission of eradicating many communicable diseases. During her free time, Ewinka enjoys reading, traveling, and learning to play the guitar.

McClintock.PictureDr. Heather F. de Vries 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.