The Forgotten Health Inequality: Languages and Medical Information

Health inequalities and disparities have plagued this fragile earth since the beginning of unprecedented medical advances, the wealth divide, and the transition from agricultural economies to industrialized states. These health inequalities can range from lack of access to diagnosing technology, unaffordable medications that treat ubiquitous ailments, and distribution barriers that cause a shortage of preventive tools and drugs. Each one of these entities cause an immense amount of suffering for both health care providers, who are required to overcome the barriers, and, for those who are directly afflicted – patients and their families. In addition to these aforementioned health inequalities, the distribution of medical information is directly affected by another concealed yet detrimental form of disparity: the lack of diversity within the languages it is presented in.

Those who inherently speak English won’t face the same barriers as a rural Brazilian physician being unable to fully comprehend English specific instructions for a novel diagnosing tool for the Zika Virus. Nor will those inhabiting anglophone countries endure the same struggle of a Burmese pharmacist who isn’t able to utilize the pharmacokinetic data from a recently approved medication for colon cancer. The fact that information in English related to lifestyle changes for coronary heart disease might not be clear to some community health workers may not be realized from those hailing from the developed world where English is commonly spoken. Treatment guidelines, publications in prominent internationally renowned journals, medication inserts, and countless other resources are typically exclusively published in the English language – creating an insurmountable barrier for those having little access to an English medical education. While having a universal language like English as a connecting tool for the international health community has several benefits, this encompasses a little more than a billion fluent/semi-fluent English-speaking individuals on this earth: leaving about 6 billion humans with little or without access to this rich collection of health information. This language barrier for the majority of humanity amplifies the problems with the quality of care a health care provider is able to administer when also considering other health disparities like lack of access to technology and medications.

This disparity infects and disrupts many facets of the global health communities desire to truly empower local health care professionals and create sustainable public health care institutions. Although the leading global health entity, the World Health Organization (WHO), has attempted to tackle this disparity and expand its impact through diversifying its official languages, it still leaves half of the world population without access in their native tongue. The official languages of the WHO include Arabic (242 million native speakers), Chinese (1197 million), English (335 million), French (76 million), Russian (16 million), and Spanish (399 million) which totals to be only approximately 2.4 billion people. Furthermore, even with these six official languages, only WHO official documents are translated into the six languages while technical reports, guidelines and even the majority of the website is strictly in the English language. Besides WHO and as previously mentioned, the venues novel information is presented in like journals/guidelines is inaccessible to the great majority of health care professionals attempting to provide evidence-based care for their patients. A study published in Deutsches Ärzteblatt International in 2008 revealed that the amount of English-only journals in Medline has risen to 89% with roughly 9/10 new journals with Medline are in the English language. In addition, of 103 journals that are ranked and listed based on frequency of being cited, only 13 are not written (entirely or primarily) in English. This remote information can lead to situations where proper treatment guidelines are not followed causing morbidity or mortality, a lack of awareness of a necessary change within a hospital system, and other negative events that prevents local health leaders from taking charge of their community’s health and creating maintainable interventions.

Although making this medical information accessible to a superior majority of humanity is a difficult task due to lack of awareness, cultural aspects in languages, funding, and human resources, several programs have been recently developed throughout the world to begin addressing this health inequality with the assistance of WHO and political will:

    • In 2009, King Saud bin Abdulaziz University of Health Sciences in Saudi Arabia conducted a study that revealed that just over 4% of all Arabic health information websites met international quality standards. With this data being brought forth, the WHO’s Global Arabic Program was established to disseminate the work of WHO through Arabic publications, make reliable and current health information and research outcomes available in Arabic, and establish networks and knowledge communities in Arabic translation, terminology and publishing. In addition to this WHO program, an establishment of an Arabic health information foundation was created to govern and accredit Arabic health websites and an Arabic health encyclopedia
    • In 2012, WHO established a program, called the WHO Moscow documentation centre, which was funded by the Russian government to increase the number of technical WHO publications in Russian, such as clinical guidelines, and to establish a mechanism for consulting Russian-speaking public health experts on which publications they needed most. In order to ensure proper translation and clinical effectiveness, Russian experts are also invited to review the Russian publications before being revealed. This has directly empowered local health care providers and has provided a sustainable foundation for future Russian health dissemination success.  
  • In 2005, WHO established the ePORTUGUESe program to increase access to health information in Portuguese as part of a collaboration with Angola, Brazil, Cabo Verde, Guinea Bissau, Mozambique, Portugal, Sao Tome & Principe and Timor-Leste. This has allowed each country to develop their own specific health information library to meet specific needs for their populations. This platform can be accessed by anyone with an internet connection, giving health care providers a venue to improve patient care.

These are promising starts to addressing the language barriers that affect health care providers each day while caring for their patients. However, a continued devotion for assisting Khmer-speaking midwives in rural Cambodia utilizing a new birth spacing method, Creole-speaking pharmacists in Haiti checking for drug interactions between coumadin and levofloxacin, and Portuguese-speaking pediatricians in Mozambique deciding what dose of a powerful antibiotic to give needs to be followed through with to honor the global health’s community commitment to each other. While these examples serve as templates for success, an increase in awareness must be brought to the attention of heads of states and health leaders to ensure this health inequality is properly addressed. International health journals have the obligation to better structure their publications in order to make the information more language accessible; while local journals need to promote publications in the residential language to improve the provided health care in the area. The empowerment of public and private health care professionals is vital to the success of their country’s health, and overcoming the medical language barrier is the first step to achieving this.

Global News Round Up

Politics & Policies

As the United States offers crucial humanitarian aid to Venezuelan migrants, it is doubling down on its opposition to Venezuela’s president.

The Global Health Technologies Coalition (GHTC) applauds yesterday’s Senate passage of the Global Health Innovation Act, a bipartisan bill to support efforts by the US Agency for International Development (USAID) to develop affordable, appropriate technologies to advance the health of people in the world’s poorest places.

According to the UN health agency, “countries are spending more on health, but people are still paying too much out of their own pockets.”  The agency’s new report on global health expenditure launched on Wednesday reveals that “spending on health is outpacing the rest of the global economy, accounting for 10 percent of global gross domestic product (GDP).

The 2019 spending bill passed by the House and Senate Thursday that the President has announced he will sign, reflects a meaningful commitment to moving our country forward and to continued U.S. leadership of the fight against the world’s most devastating infectious disease killers.

The United Nations says North Korea’s government has asked for help from international humanitarian groups to combat food shortages.

Programs, Grants & Awards

Speakers at a conference organized by students at Harvard T.H. Chan School of Public Health questioned the ways that global health is taught and practiced from the scholars studied in classes to the agendas set by mega-funders like Bill Gates. They urged the packed audience of students and researchers to consider the ways that unequal power relationships between the global north and south affect the health of formerly colonized people, and to work toward a “decolonized” global health field.

With only 10 years left to reach Sustainable Development Goal 7 (SDG7), which calls for ensuring “access to affordable, reliable, sustainable and modern energy for all”, including universal access to clean cooking, an estimated 2 billion people are in danger of being left behind.

The first International Global Health Security Conference will he held in Sydney, Australia on June 18-20, 2019.

UCSF will host one segment of the first ever “Pan Global” live streamed World TB Day Symposium, with London, San Francisco, and Hanoi participating in a 24-hour baton passing effort to raise awareness about and share research on TB.  The UCSF World TB Day will be held on Friday, March 22 in the Oberndorf Auditorium at Mission Bay.

In Liberia, GHSA supports a multi-sector coordination mechanism for smoking and testing animals; builds capacity of animal health professionals for risk-based epidemiology and response; and implements behavior change communications to influence risky behaviors.

Research

In the 21st century, increases in immunization coverage and decreases in under-5 mortality have substantially reduced the global burden of measles mortality. However, the assessment of measles mortality burden is highly dependent on estimates of case-fatality ratios for measles, which can vary according to geography, health systems infrastructure, prevalence of underlying risk factors, and measles endemicity.

The 2019 edition of the Bloomberg Healthiest Country Index ranks 169 economies according to factors that contribute to overall health.  The index grades nations based on variables including life expectancy while imposing penalties on risk such as tobacco use and obesity. It also takes into consideration environmental factors including access to clean water and sanitation.

Diseases & Disasters

In September, public health officials in South Africa finally declared victory over the world’s worst-ever outbreak of listeriosis, a foodborne illness that had sickened more than 1,000 people and killed more than 200 there since January 2017.

Experts have warned of an epidemic of diseases such as malaria and dengue on an unprecedented scale in Latin America following the collapse of the healthcare system in Venezuela.

The World Health Organization says that an epidemic of measles in Madagascar has caused more than 900 deaths.

Technology

The GHIT Fund is pleased to endorse the Khartoum Call for Action, announced in Khartoum at the Sixth International Conference on Mycetoma. The Call for Action urges the global community to work together with multilateral agencies, partners, research institutions and pharmaceutical companies to address the devastating consequences of this disease.

Environmental Health

Plastic pollution is a “threat to human life and human rights” and, in order to stem this problem, we have to overhaul how we produce, use and dispose of it, according to an international report released today.

The filling and draining of meltwater lakes has been found to cause a floating Antarctic ice shelf to flex, potentially threatening its stability.

The idyllic Micronesian island of Kiribati, next door to French Polynesia (Tahiti) and boasting one of the largest marine sanctuaries in the world, is a tropical paradise. It’s hard to believe that it’s people are expected to become some of the world’s first climate change refugees.

Equity & Disparities

Between the 24-hour news cycle, the internet, and the smartphone the world has never been so saturated with information. Yet a new report by CARE International finds that humanitarian crises affecting millions of people around the world snagged relatively few headlines last year.

Women, Maternal, Neonatal & Children’s Health

Cohn and colleagues showed recently that pre-puberty exposures to DDT may have increased the breast cancer risk for women through their early postmenopausal years.

Death rates for asthma in 10 to 24-year-olds was highest in the UK among all 14 European nations included in an analysis of 19 high-income countries.  The UK also had the highest obesity rates for 15 to 19-year-olds among the European nations.

An obstetrician experience and knowledge on how women are treated in labor and delivery in the United States and internationally leads to a pursuit of a global health PhD.

Postdoctoral Fellowship Position Available with National Institute of Environmental Health Sciences, Social and Environmental Determinants of Health Equity Group

Position Description:

The Social and Environmental Determinants of Health Equity group, led by Dr. Chandra Jackson, is seeking an experienced and well-qualified post-doctoral fellow. The group is part of the Epidemiology Branch in the Division of Intramural Research at NIEHS, NIH. The group investigates how physical and social environmental determinants of health influence racial, ethnic, and socioeconomic disparities in cardiometabolic health. In addition to identifying the biological mechanisms by which factors in the social and physical environments affect health and contribute to health inequities, this group is also interested in the translation of epidemiologic findings into interventions that address structural, macrolevel as well as individual-level barriers to achieving and maintaining optimal health. Ongoing research addresses how physical and social attributes of neighborhood/housing and work environments affect, for example, insufficient sleep duration and inadequate sleep quality as well as subsequent cardiometabolic disease risk.

Post-doctoral fellows in this group will have access to data from the National Health Interview Survey and cohorts such as the Multi-Ethnic Study of Atherosclerosis, Jackson Heart Study, Sister Study, Study of Environment, Lifestyle, and Fibroids, and the Agricultural Health Study. Using existing resources, fellows can develop their own research initiatives within the mission of the research group. Postdoctoral fellows within the Epidemiology Branch are encouraged to build on existing resources to develop new projects that become the basis for transition to independent awards. Initial appointments are two years with additional years possible depending on productivity and availability of funds.

Fellows will be encouraged to take advantage of the rich and varied training and career development opportunities offered at NIEHS. The training environment is enhanced by proximity to the University of North Carolina Gillings School of Global Public Health where many of the Epidemiology Branch investigators have adjunct appointments.

Qualifications: Candidates with an earned doctoral degree in epidemiology or a closely related field or those with a medical degree and advanced graduate training in epidemiology, population health, or biostatistics within the past five years are invited to apply. Applicants must have extensive experience with epidemiologic or statistical data analysis. Preference will be given to candidates with demonstrated research interests in areas currently under investigation (e.g. health disparities; social determinants of health; sleep) in the research group and branch as well as to candidates with superior analytic and communication skills.

To Apply: Applicants should submit the following materials to epifellowships@niehs.nih.gov:
• Letter describing areas of research interest
• Curriculum vitae with bibliography
• Copies of 1-2 recent publications
• Contact information for 3 individuals serving as references
Application Deadline Date: Until filled. Position available immediately.

Learn more about the Social and Environmental Determinants of Health Equity group here:
https://www.niehs.nih.gov/research/atniehs/labs/epi/pi/sedhe/index.cfm

The Future of HIV: Novel Treatment Options & A Possible Cure

As the medical community and those it serves welcomed in a new year, it brought with it the hope of scientific advancements that will alter the course of certain disease states. These advancements include the use of stem cells to treat to treat macular degeneration, novel microscopic techniques to capture images of the brain, the continued observed effectiveness of the experimental Ebola vaccine, and countless other interventions aimed at creating a healthier global society. Included in these optimisms for 2019 is the possibility for novel treatment options and a possible cure for one of the world’s leading causes of death, HIV. The stories of Timothy Brown – the only individual ever to be cured of HIV, the Mississippi baby and Clark Hawley – both having an extended period of time with undetectable HIV viral load with an interruption of Antiretroviral Therapy (ART), and the Boston patients/Mayo Clinic patient – all three having undetectable HIV viral loads for an extended period of time after a stem cell transplant, have brought much sanguinity to health care professionals and patients alike. However, these exciting results have been unable to be replicated in the majority of the population suffering from HIV and remain unique in their respective occurrences. Although ART has been vital to the HIV community in terms of longevity and quality life, there are still certain populations that are seeking other mechanisms to treat this infectious disease – and, of course, always coveting the idea of a cure. The following is a brief glimpse at the vast pipeline that awaits 2019 and the anticipations of the global healthcare community.  

Combination Approaches

  1. The AIDS Clinical Trial Group (ACTG) is currently exploring the option of combining vorinostat, a HDAC inhibitor along with tamoxifen, which is an FDA approved medication the treatment of breast cancer for postmenopausal women. Utilizing this approach is thought to prevent the reactivation of HIV in CD4+ cells that are latent in addition to increasing the latency-reversal effect of vorinostat through tamoxifen.
  2. Researchers from the USA, France, Germany, Italy, Spain, Switzerland, and the UK are collaborating for a trial testing the combination of two HIV vaccine candidates alongside a monoclonal antibody called vedolizumab. This method of treatment is thought to target a certain protein in the body, α4β7 integrin, that plays a role in transmission of HIV into CD4+ cells. In a macaque model, this combination has shown the control of SIV (HIV but in simians) after discontinuing ART.
  3. At the University of Minnesota, researchers are testing infusions of natural killer (NK) cells with the administration of cytokine interleukin-2 (IL-2). The researchers are hoping to add to the evidence of NK cells being able to exhaust HIV reservoirs and to control virus replication.
  4. In a version of the “kick & kill” method of curing HIV, researchers in Oxford and Barcelona are using a medication to active the latent HIV reservoir while boosting the immune response 1000 times stronger than the usual to rid the body of the virus. Preliminary results showed that 5/15 patients had undetectable viral loads for seven months without ART.

Immunotherapy Approaches

  1. Immunocore, a company founded in Oxford with heavy investment by Bill Gates, has designed T cell receptors that seek out and bind with the HIV virus. These receptors then instruct immune T cells to eliminate any HIV-infected cells, even when the levels happen to be extremely low. Since levels can be rather low in the reservoir of HIV virus that exists in an infected individual, this is a promising lead to completely remove this retrovirus from the body. This immunotherapy has shown to be effective in human tissue samples, but no results being tested in humans have been released.
  2. In France, a company known as InnaVirVax has established a vaccine, VAC-3S, that allows the body to stimulate a production of antibodies against the HIV protein 3S. This, in turn, causes T cells to attack the virus. This is considered a novel approach because it encourages the immune system to recover while equipping it with the tools to continue fighting off the virus. VAC-3S has completed Phase 2a trials, and is partnered with a DNA-based vaccine from FIT Biotech, a Finnish company, that both parties believe can lead to a functional cure.  
  3. In a recently initiated trial, IMPAACT 2008, held in the USA, Botswana, Brazil, and Zimbabwe, a broadly neutralizing antibody termed VRC01 is being investigated for its effectiveness in infants with HIV who are also started on ART within 12 weeks of birth. Although the study aims at establishing the safety profile for VRC01, it is also observing the difference in the HIV reservoir compared with only ART.

Novel Antiretroviral Agents

  1. The manufacturer, ABIVAX, believes it has developed a compound that may help the immune system recognize cells infected with HIV by allowing an increased presentation of HIV antigens on the cell’s service. This would lead to an augmented immune response to abolish these infected cells. This compound has been labelled ABX464 and targets the HIV protein Rev, which is responsible for the transcription of HIV RNA. Reductions of measured HIV DNA have been reported from 25% to 50% in eight of the fifteen patients participating in the study; however, no delay in viral load rebound was found when compared with placebo.
  2. Gilead has created a novel mechanism of targeting the HIV virus through the capsid inhibitors class. Capsids are involved in protecting HIV RNA and related proteins, and capsids also breaks down to release the viral contents into CD4 cells which enable reverse transcription to take place. The novel agent by Gilead, GS-CA1, blocks both the assembly and disassembly of capsids that create non-infectious and defective viruses.

Gene Therapy

  1. Chimeric antigen receptor (CAR) T therapy has been re-initiated in the first cure related clinical trial of this approach in people living with HIV who are on ART. CAR T cell therapy involves the modification of an individual’s T cells that can target antigens of interest. The specific cells modified by the initiative in China, called VC-CAR-T cells, have been modified to target HIV gp120. These modified cells were able to induce the destruction of HIV-infected cells, including latently infected cells exposed to latency-reversing agents, in the laboratory setting.  
  2. With the knowledge of knowing that about 1% of the world’s population is immune to HIV due to a genetic mutation on the gene that encodes for CCR5, US-based Sangamo has begun to edit DNA to introduce the aforementioned mutation. The CCR5 protein is attached to the surface of CD4 cells that allows HIV to enter and infect the cell; with the mutation, it would be impossible for HIV to enter cells. This company extracts patient’s CD4 cells in order to use zinc finger nucleases to edit patient’s DNA to make them resistant to HIV.
  3. Although a highly controversial topic amid the recent publication of the use of CRISPER in twin daughters in China, scientists believe that this tool can lead to a cure for HIV as it is believed to be a much easier, faster, and effective approach than other gene-editing methods. However, the majority of the global health community is in agreement that years of laboratory research and ethical standards need to be established before human trials are properly started.

With the HIV virus adapting and mutating to evade treatments almost as rapidly as the world is producing novel approaches to treating this infectious disease, the drive for continued research and testing should be relentless. These aforementioned examples of novel treatments and possible cures display the creative and diverse thought processes the medical community has put forth to tackle one of the most stigmatized diseases on this earth. However, the ethics behind these trials need to be sound and forthcoming for all of humanity. The trials that occur need to ensure an assortment of demographics including individuals from both developed and developing nations – a subtle form of medical colonialism has no place in the global health community. In addition, trials that enroll patients who willingly accept the benefits and risks associated with the experimental therapy have the moral obligation to supply lifetime treatment if it happens to be effective. The researchers and medical professionals who monitor these participants need to take extreme caution in ART interruptions/discontinuations and certify that the patients realize what complications could transpire due to them. Finally, and most importantly, the interventions that show promise of novel ways to approach HIV or even a cure have to be accessible, affordable, and available to all humans who suffer from HIV. The health inequalities that plague this fragile planet have already been clearly highlighted in this ailment throughout history; the global health community is in debt to humanity for a cure for all when discovered.  

With the global health community’s commitment, the future of the HIV virus continues to transition from infectious disease to chronic disease. While the step that will advance the chronic disease to a cure is still thought to be unknown, the excitement behind the aforementioned gene editing therapy is substantial. The ability to safely, effectively and ethically modify human cells to prevent the entry of the virus into the immune system is certainly the most promising option recently and possibly from this disease’s initial appearance; although, health care professionals haven’t quite figured out how to combine these aspects yet. A cure or even functional cure may be years away, but the global health community needs to continue to accompany those inflicted by this chronic infectious disease to meet the hopes and expectations of alleviating the burdens of HIV.

2019 World Cancer Day – “I Am and I Will”

Every year on February 4th, World Cancer Day is celebrated by bringing awareness and providing education about the disease. Many of the efforts focus on making the reduction of preventable cancer a global health priority.

In 2018, it was estimated that there were 26,000 deaths that occurred due to cancer across the globe every single day. This rate is only predicted to increase with time due to a variety of factors. To name a few: the age of the world population is increasing, there is a general lack of education about ways to prevent cancer in developing countries, and early detection methods and treatment are scarce in these same developing countries. By 2030, the rate of cancer deaths per year is expected to hit 21.6 million – this is 8.4 million more than the 2010 rate. To put this into perspective with infectious diseases, in 2015 alone, the deaths per year due to malaria was 72,000 while cancer rates met 8.9 million – with the majority of the deaths coming from developing countries.

The largest gaps in rates of cancer survival can be noticed in cancers that are more responsive to early screening and treatment (for example: breast and colorectal cancers). These rates vary greatly between developing and developed nations as well as in different racial groups in the same country.  In the United States and Australia, the 5 year survival rate for breast cancer (2010-2014) was up to 90% compared to only 65% in Malaysia for the same time frame. In the U.S. between 2004 and 2009, there was a difference in the 5 year survival for cervical cancer between whites and blacks, 64% and 56% respectively. These differences in rates can be attributed to differences in prevention and treatment programs. For example, in many developing countries, cancer patients do not have access to radiotherapy facilities near their homes. There are 60 countries across the globe with cancer patients that do not have one radiotherapy facility in the entire country. On the screening side, many developing nations do not have the health care infrastructure or funds to provide regular cancer screenings.  The same gaps in access to care and resources can be said about different areas of socioeconomic status in the United States.

Current efforts to develop prevention and treatment programs across the globe are focused on the WHO’s recommended 4 main approaches or areas of: prevention, early detection, diagnosis and treatment and palliative care… and there have been successful feats! An example of a successful cancer prevention program is in Sudan. Their program focuses on promoting public awareness of breast cancer and early detection through in-home breast exams done by trained female volunteers. Another positive program was implemented in India in 2013. This program increased breast cancer awareness in the study urban area, and a subsequent increase in early stage diagnosed breast cancer increased from 74% to 81% in 3 years (2013-2016). Most cancer prevention and reduction programs in developing nations focus on the initial stages of increasing awareness and education about cancer as they are cost efficient and effective.

To fight these discrepancies in cancer death rates, many use this day to spread social media messages about cancer prevention and early screening, attending festivals or walks that raise awareness or support and encouraging public government officials to make cancer issues a priority in their own countries through policies and research. In general, the day brings people together with a common cause and mission: getting rid of preventable cancer. This map is a great resource to find and join activities anywhere on the globe related to World Cancer Day.

In addition, 2019 introduces the start of a 3-year campaign called, “I Am and I Will”, and focuses on the personal commitments required to help decrease the global burden of cancer as a whole. The American Cancer Society highlights a few ways people can personally decrease the effects of cancer as well as support others in their circles by:

  • Making healthy life choices such as saying no to tobacco products, limiting alcohol, being conscientious about time spent in the sun and eating an overall healthy and wholesome diet
  • Knowing the signs and symptoms of cancer and seeking early treatment when identified
  • Sharing cancer experiences with decision makers in government and advocating for change and funding to go into cancer research
  • Encouraging schools and businesses to adopt healthy practices such as nutrition, physical activity and no tobacco policies to support their students and workers

Visit www.worldcancerday.org before February 4th to learn more about this day and how you can get involved in your own personal way.  Every little action makes a difference in shining a light on the importance of defeating cancer on many different scales. #IAmAndIWill