By: Mary Anne Mercer, IH Section representative in the Trade and Health Forum
The International Health Section is part of the Trade and Health Forum, an intersectional group that aims to inform and activate members on how various aspects of trade affects health, both at home and in the rest of the world. That topic is a bit of a mystery to most of us. But as globalization becomes ever more evident, the relevance of its effects on health is more obvious.
Take the COVID-19 pandemic, for example. If there is one key lesson to be learned from this past year, it’s that we will only be able to crush the pandemic here when it can be done everywhere. And an important strategy to making that happen is to step up access to the new vaccines as quickly and as widely as possible. “Herd immunity” can only be reached safely by massive levels of immunizations.
Right now the 84% of the world’s population that lives in low and middle-income countries is at a huge disadvantage because of rules of the World Trade Organization (WTO) constraining the development of generic drugs and vaccines. Those of us who were involved in the early response to AIDS in Africa see eerie parallels with that time. The first drugs to treat AIDS were too costly for low-income countries to adopt. I worked with a health program in Mozambique in the late 1990’s, and it was only after an Indian pharmaceutical company, CIPLA, began producing generic versions of the triple-drug therapy in 2001 that we were able to support drug treatment for people living with HIV and AIDS. As a result of that delay of more than a dozen years—during which HIV spread unchecked in countries unable to afford drug treatment—some 15 million Africans died of AIDS.
Right now global access to the vaccine is an important issue that is central to concerns of the Trade and Health group. The WTO patent regulations in question are documented as Trade-Related Intellectual Property right section (TRIPS). The WTO can temporarily waive the patents on COVID vaccines to allow generics to be developed—which would allow a massive scale-up of the immunization effort. The proposal to issue an emergency TRIPS waiver for the period of the pandemic has wide support in low and middle income countries but, so far, is opposed by the currently US administration as well as several other of the rich countries.
The essence of the patent waiver controversy is, of course, the bottom line. Pharmaceutical profits tend to be substantial; it’s estimated that the profit margin for the Pfizer vaccine, for example, will be four billion dollars by the time the pandemic ends. The US could be a leader in supporting the proposed TRIPS waiver, but so far has not indicated it’s willing to take that stand.
For more information about this issue, please check out my recent Medium article or any number of concerned groups such as Global Trade Watch and HealthGap. And take action!
After graduating with a medical degree, I started my professional career as a primary care physician in Mumbai, India, where I partnered with Government of India’s Revised National Tuberculosis Control Program (RNTCP) providing free diagnostic and treatment services to my patients suffering from tuberculosis (TB). In many cases, the financial savings these services created for the low-income families made them avoid bankruptcy. This challenging yet tremendously satisfying experience showed me the complementary nature of clinical medicine and public health. Later, when I took up a job at the World Health Organization supporting India’s RNTCP implementation through public private partnerships (PPP), I got to experience the tremendously influential role of the civil society in public health. Working with the not-for-profit and for-profit health and non-health organizations, I experienced first-hand the importance of socio-economic determinants in health policies and programs.
Later, as a consultant, I got the opportunity to work on diverse projects such as developing the bottom-up (from a village level) action plan for India’s national health sector reform initiative, mapping HIV/AIDS high-risk groups to develop focused behavioral interventions for these groups, operationalizing protocols for emergency first responders, evaluating India’s financial voucher scheme for reducing maternal mortality, and conducting a feasibility study to establish super specialty diagnostic centers through PPPs in underserved areas. I learned the crucial role a public health practitioner can play in shaping public health policy and implementation to improve lives.
My first foray into global public health (global health) was as a member of an international team tasked with revising health policies for the Government of Abu Dhabi. I was amazed with the complexity of developing a health policy, let alone implementing it. Stakeholder mapping, understanding, and accommodating demands of different groups, and balancing and prioritizing conflicting needs is as difficult as performing a heart transplant. I also understood how important it is for a public health practitioner to have basic knowledge of certain quantitative and qualitative skills. On learning those tools through an MPH from Harvard University, I got the opportunity to expand my experience in global health by providing consultancies to The Global Fund, various United Nations (UN) organizations, European Union (EU), United States Agency for International Development (USAID), and other global health organizations across 30 countries and counting. Working in fragile nations such as Afghanistan, Central African Republic (CAR), Haiti, Iraq, South Sudan, and Yemen as well as developed countries like Japan and South Korea, gave me insights into different health systems.
My global health experience keeps me grounded when I think of all those ordinary people doing extraordinary tasks that I had the opportunity to learn from. From the Auxiliary Nurse Midwife in a small tribal village in India, who despite being physically assaulted, continued her work of vaccinating children for decades traveling on foot across forests; the Catholic nurses and Ramakrishna Mission priests in Jharkhand, India, who tirelessly provided care to TB and leprosy patients; the community health workers in Iraq and Yemen who risked their lives to ensure availability of HIV, TB, and malaria medicines to hard-to-reach areas; the orthopedic surgeon manning a primary health care center in Afghanistan, working on a meagre salary of $120 per month yet providing free care to the poor; the medical doctor in Guyana who spent after work hours educating people about HIV prevention in his community; the warehouse stock keeper in Haiti who acquired a supply chain management diploma to contribute to strengthening medicine supply in his country; the woman NGO owner in Somali, Ethiopia, who without any technical knowledge or experience, conceptualized a revolving fund system using funds from The Global Fund grant to help people living with HIV establish their own small-scale businesses; the Director of TB Control in Solomon Islands who spent his own funds to travel across the islands to monitor the program; the District Administrator in Oyam, Uganda, who underwent training for malaria control and attended as many village-level camps as he could to motivate his staff; and the Peace Corps volunteers from the United States who get out of their comfort zone to live and work on social projects in the most remote parts in the developing world. There are so many such stories that may never be told but will always inspire me. Besides, COVID-19 has shown us how unavoidably interconnected we are and how important the global health approach is.
So, some of you who want to make a career in global health but wonder how to go about it? Here are my two cents. Most important, in my opinion, is having a passion for public health and acknowledging that it is more than a job. I chose the path of consultancies against a full-time job as I wanted to explore different program areas and it suited my personality better. It is, however, not easy to immediately take a plunge into the world of consultancy. One would need to establish some work experience and build their network. I will give network building a higher level of importance and it should start right from when you are as a student. Try and identify your interest area and reach out to the experts in your field – seeking knowledge of the field and advice on how to maneuver your career path. It is easier said than done but you would be surprised how many would respond to you, provided that you do not put them on the spot by asking for a job recommendation. Use your school faculty and alumni to make such connections and actively use professional networking platforms. Learn what specific skill sets organizations are looking for in your field of interest. Get to know the keywords they look for and try and get those skill sets into your curriculum vitae through the academic route first. At the end I have listed a few resources, apart from your very own APHA membership, that will help you explore global health organizations and jobs.
From my understanding, one of the core requirements in global health, in addition to domain knowledge, is the readiness to travel internationally and relocate, at least initially. The rewards are tremendous personally, academically, professionally, and financially too. Global health will make your friend circle and professional network grow exponentially. And please do not forget the pleasure and honor of interacting with different cultures and learning from them! After having explored a few different career paths myself, medical practice, pharmaceutical manufacturing and retail, and occupational health consulting, I can unequivocally state that there are few other fields like global health that give such breadth and depth of knowledge, exhilaration, soul-satisfaction, and adrenaline rush. Of course, as any other profession, there are risks and stressors, but the benefits certainly outweigh the risks.
A few photos from my global health journey:
Photo Captions Top Left: Director of National Malaria Program directing his driver through a flooded street in Dushanbe, Tajikistan. Bottom Left: Hotel constructed from shipping containers in Juba, South Sudan. Middle: This may just be the world’s smallest pharmacy – in Port-au-Prince, Haiti. Right: The smallest plane (6-seater) I have ever traveled in. The pilot asked me to plug a piece of paper in this aperture to keep it open so that air pressure inside the cabin was maintained– Solomon Islands.
Who is affected by FGM? As the name suggests, this issue is one that plagues individuals assigned female at birth —primarily African and Middle Eastern women. Some cultures view FGM as a rite of passage girls undergo before transitioning into womanhood while others believe it suppresses a woman’s sexual desire, allowing her virginity to stay intact when the time for marriage comes. The latter has fostered an environment where FGM became the norm as mothers are expected to ensure the next generation kept the traditions alive. Certain communities also believe it enhances the sexual pleasure for their husbands.
Where is FGM most likely practiced? There are about 200 million women and girls who are currently living with the consequences. Somalia is believed to have the highest prevalence with a whopping 98%, followed by Guinea at 97%, Djibouti with 93%, etc. Although the practice is a concern in European, Asian, and South American countries alike, cases in African countries continue to soar. Preventative measures are being taken to combat FGM through educating women on the complications, advocating for fathers and men to speak against the practice, and compelling religious leaders to denounce it. The key factor is educating mothers, as the cultural expectations are deeply ingrained into their upbringing. Young girls are more likely to follow along if their mothers are uneducated about the health issues brought on by the practice.
While International Day of Zero Tolerance for Female Genital Mutilation falls annually on February 6th as a joint effort to combat FGM on a global level, the COVID-19 pandemic has set back the goal of stamping out the practice completely by the end of 2030. The global lockdown has brought forth high rates of domestic violence incidents, has made many educational programs wholly unable to function, and families have had easier access participating in the procedure without being cornered. Despite the unforeseeable circumstances brought by the pandemic, the fight to dismantle FGM practices continues to rage on.
This is the seventh part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.
Out of over 7 billion people on Earth, more than 80% identify with a religious group. The Pew-Templeton Global Religious Future Project reports that Christianity is the world’s largest religion, with approximately 2.4 billion individuals affiliating as Christian. The project estimates that 1.9 billion individuals affiliate as Islamic, 1.2 billion with Hinduism, 507 million with Buddhism and 15 million with Judaism. In most countries, a majority claim that God plays an important role in their daily lives.
As mentioned in the first part of this IH Blog Series, over one in three people will experience a mental health problem in their lifetime. Out of the total number of people who experience a mental health problem, 76-85% of people do not receive the treatment they need. With religion playing such a significant role in people’s lives and with mental illness being a global crisis, understanding the interplay between religion and mental health care seeking is of crucial importance.
Religion divides but it also unites us. All religions offer explanations for the meaning of life, purpose of life and rationalize human suffering. With religion being a source of individual growth, community strength, solidarity and resilience, it is clear that a person’s faith and spirituality has implications on their mental health. For example, in Hinduism, there is a broad view of life summed up in four aims (Purushartha): Dharma, Kama, Artha and Moksha. Each highlights harmony in different dimensions of life. Religious and spiritual beliefs and activities are commonly used to cope with stressful life events. Whether an individual lives in a high, middle or low-income country, people look to religious leaders and advisors for guidance in place of or before seeking out mental health treatment. In addition to poor access, stigma, a lack of understanding and religious insensitivity by mental healthcare professionals are just a few of the barriers religious people face in seeking out formal mental health services. We are discovering more about the role religion and spirituality play in mental health care seeking globally, but there are a number of gaps in our current knowledge on the subject. Most studies on religion and mental health treatment seeking have been done in the U.S. and Europe with religiosity garnering more attention than spirituality.
Elena: I first became interested in the relationship between religion and mental health when I interned at the National Alliance on Mental Illness’s (NAMI) national office in Arlington, Virginia five years ago. I remember exploring the NAMI website and discovering a page on faith and spirituality with a link to NAMI’s interfaith resource network, NAMI FaithNet. As a spiritual Jewish atheist, I found this perspective to mental health eye-opening. In the summer of 2019, at the start of my Master of Public Health program at Arcadia University, I began developing my capstone research project on the topic of Black clergy and their role in the mental health of their congregants. The aim of this research was to explore Black Protestant Philadelphia clergy’s perceived self-efficacy in the mental health gatekeeper role. From my background research, I discovered that Blacks are more likely to report serious psychological distress compared to Whites, but are less likely to utilize formal mental health services. Instead of utilizing these services, many Christian Blacks seek guidance from clergy, who are increasingly being called mental health gatekeepers. Philadelphia is a large, historical center of the Black Protestant community, but through a detailed literature review, I discovered that qualitative research was lacking on this topic within this population.
After conducting six semi-structured interviews with Philadelphia Black clergy, several themes emerged. The clergy I interviewed had differing mental health gatekeeper identities, with some considering themselves mental health gatekeepers and others not identifying with the title at all. Self-efficacy was high for clergy’s ability to recognize what was and was not within their scope of expertise, but self-efficacy varied for other skills, such as recognition of mental illness. Clergy acknowledged similar challenges in assisting congregants in need of mental health treatment and all admitted a need and desire to improve access to mental health resources. All respondents discussed interest in developing collaborations that may help them provide mental health assistance and connect congregants to mental health professionals in Philadelphia. Intervention and policy initiatives aimed at collaborating with Black Philadelphia Protestant clergy to address the perceived mental health needs of their congregations could strengthen their self-efficacy in the mental health gatekeeper role.
The role of religion in mental health and well-being is substantial. In a time when mental health outcomes globally are declining, exploring and understanding the mechanisms that shape our mental health is critical. This provides the foundation for developing effective strategies to prevent mental health issues as well as manage and treat these conditions. Further research is needed to fully elucidate the relationship between mental health and religion/spirituality in a range of populations and settings to inform intervention development and dissemination.
About the Authors:
Elena Schatell MPH (c) MMS (c)
Elena Schatell is a current student at Arcadia University enrolled in the Dual Master of Public Health/Master of Medical Science in Physician Assistant Program. She aims to promote public health in underserved communities as a future physician assistant. Her current public health interests include access to mental health services, stigma surrounding mental illness, and the relationship between faith and mental health. She has interned at the National Alliance for Mental Illness (NAMI) national office in Arlington, Virginia, working closely with the Advocacy and Public Policy team on conducting research on service barriers and state mental health policy. During her time at NAMI, she also authored articles for the Advocate magazine and blog.
Dr. 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 Study and Integrating Management for Depression and Type 2 Diabetes Mellitus Study.