Category: APHA IH Section

“Tejas means friend” and other lies we tell ourselves.

by hanstewart, posted in APHA IH Section, mental health

If you hear me speak more than a few sentences, you’ll hear the unmistakable accent. And as soon as I can find a natural way to fit it into the conversation, I’ll tell you flat out: I’m from Texas.

As a Texan, I was required to take one year of Texas history in the seventh grade, a statewide tradition since 1946. In Texas history, you’ll undoubtedly learn a few facts that every one of us 29-million Texans has engraved in our hearts.

1.     You don’t pick bluebonnets. They’re a sacred part of our state’s landscape.

2.     Texas was a sovereign nation once: the Republic of Texas. 

3.     California may have more people, but we’re bigger in size.

4.     “Tejas means friend”.

I’ve always found the root of the state’s name to be fascinating, because it has evolved with the land itself and represents the story of Texas. The word traces back to the Caddo word for “friend”, taysha. That word would be misspelled and mispronounced to be Tejas and eventually, Texas. For those of us whose hearts are deeply intertwined with the “Lone Star State”, the root of the word feels right. It embodies our roots, who we were, and the Southern hospitality on which we grew up. The origin of Texas’ name does NOT embody who we are today.

Texas has become the frontline of continued inhumane policy experimentation by the Trump administration. To deter undocumented entry to the United States and tamp down the number of asylum claims made at ports of entry, Trump and his nominated officials began separating children from their caregivers. 2,654 children were taken from their parents, guardians, and chaperones during the peak of this policy’s enforcement, and most of those children were detained in Texas.

The science around this matter is still developing, but one thing is certainly clear: this is bad news for the cognitive development and mental health outcomes of these children. In fact, the picture is becoming clearer that family separation policies produce rates of toxic stress and trauma that are as detrimental to the child psyche at the violence as the violence and insecurity they are fleeing. Researchers, and even the United Nations, cite evidence that separating children from their caregivers creates the type of emotional disturbance and dysregulation seen in survivors of torture.

We aren’t talking about acute emotional disturbance that will recede after reunification. The child’s brain has evolved to be incredibly respondent to its environment. Continued exposures to “fight, flight, or freeze” (especially in the absence of a trusted attachment figure) train the brain to bypass emotional inhibition and complex, rational thought to depend on more primitive survival mechanisms. This means permanent alteration of the brain, shrinking the prefrontal cortex and hippocampus (the parts of the brain that largely control decision making, working memory, and personality expression).  Their brains, and often their relationships with the parents, may never recover. 

“Here we have taken away what science has said is the most potent protector of children in the face of any adversity—the stability of the parent-child relationship”

– Jack Shonkoff

It’s not just theoretical damage happening in research studies void of a human face. Children inside these Texas detention centers have reported high rates of insomnia, decreased ability to concentrate, diminished literacy (even in their native languages), severe mood swings, and feeling constant states of panic and fear. And when they leave, their medical records (including any psychiatric care they’ve needed or received) are often incomplete. Many of these children will receive asylum in the United States, and we will have to face the mental health epidemic we created with a mental health system that is underfunded and culturally inadequate.

Sweeping separation of families and detainment of children was theoretically stopped, but the Human Rights Watch has found that nearly 200 children have been subject to the continuation of this policy since last year. There is no law on the books in the US that requires the separation of families at the border. This was a policy decision that can be rescinded as quickly as it was haphazardly implemented.

These children have often experienced trauma before they ever arrive at our border. They have left the familiarity and comfort of home. They are often physically vulnerable at the end of their migration journey. And they are welcomed with something that, for most of them, is even more traumatic: facing the hostility of a foreign country all alone.

This isn’t exclusively a Texan issue. ICE detention centers now exist in all 50 states. And it isn’t uniquely American, as 100 other countries have policies that allow children to be detained as part of standing immigration policy. But Texas has become ground zero for what the inhumane treatment of children looks like. Texas is no longer a land of Southern hospitality. It certainly isn’t embodying the state motto of “friendship”. And no one should be angrier about what’s happening in our home state than Texans ourselves. 

This article was written in memory of the children who needlessly died in Texas as a result of inhumane immigration policy. These faces represent the failure of all of us.

From top left to bottom right:

Mariee Juarez, aged 2, died after leaving a detention center in Dilley, TX

Carlos Hernandez Va’squez, age 16, died in US custody in Brownsville, TX

Jakelin Caal Maquin, age 7, died in US custody in El Paso, TX

Juan de Leo’n Gutie’rrez, age 16, died in US custody in Brownsville, TX

Malaria SBC Evidence Discussion Webinar: Prescriber and Patient Interventions, 8/6

by ihsection, posted in APHA IH Section, Events and Webinars

How can research findings inform and improve social and behavior change (SBC) programs? What questions can SBC practitioners keep in mind to help sift through research, interpret publications, and apply lessons learned? Join Breakthrough ACTION for the third in a series of online guided discussions following a journal club format about malaria SBC evidence on August 6, 2019, from 9:30 a.m. to 10:30 a.m. (EDT). More information about the article and how you can prepare for and participate in the online discussion is found below.

Featured presenter

Dr. Clare Chandler, Co-director of the London School of Hygiene and Tropical Medicine Antimicrobial Resistance Centre

About the article

In the article Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial, the impact of a health worker training and health worker patient-oriented training were compared with the standard government training on rapid diagnostic tests. This facility-based cluster randomized trial demonstrated that a combination of prescriber and patient behavioral interventions can reduce prescription of antimalarials to patients without malaria to near zero. Small group training with SMS messaging was associated with a significant and sustained improvement in prescriber adherence to rapid diagnostic test results.

Preparing for the discussion

Download and read the article.
Download and use the Discussion Guide, which has questions to consider as you read and to help you follow along during the webinar discussion.

Register to Attend

Building Global Health Funding Opportunities

by awpain, posted in APHA IH Section

By Amanda Pain

Sustainable funding in global health is often a rallying cry among practitioners. A consistent funding stream can make or break the effectiveness of a global health program, but this funding can be hard to come by. The need for additional funding for global health, especially in regards to achieving Sustainable Development Goal (SDG) 3, is great. In fact, researchers estimate an additional $371 million per year is needed to achieve SDG 3 by 2030 in Low and Middle Income Countries (LMICs). Overall funding for global health has plateaued since 2010, and changing political landscapes and priorities can make government funding ephemeral. With the current Trump administration’s proposed cuts to global health funding, organizations need to look for new funding streams.

Historically, the private sector has always played a role in funding global health initiatives. Private sector funding can not only offer more consistent funding for a program, but can also be more flexible in adapting programs to meet community specific needs in LMICs. Corporations also know that giving back to communities, and developing philanthropic endeavors, is good for business. While there are several private sector funders, many corporations are looking for non-profits and non-governmental organizations (NGOs) that have missions that align with company culture; and at times competition for these funding sources can be fierce. Therefore, looking beyond existing corporate funders to growing companies with nascent, or undeveloped philanthropy programs, presents global health organizations with a opportunity to secure sustainable funding, and assist in creating a corporate philanthropy program from scratch.

How can organizations find these successful growing companies?

Companies today have been waiting longer to announce an I.P.O. (initial public offering), sometimes waiting for Series F or G rounds of funding before going public. However, once a company receives Series C funding from venture capitalists and investors it is considered to be growing successfully, as well as making a profit. Additionally, after eBay set aside funds for charitable giving in 1998 before going public this became a growing trend in the tech industry. This means global health organizations do not necessarily have to wait until a company goes public before reaching out to partner on potential philanthropy initiatives. One example of a tech company partnering with global health organizations is the Tableau Foundation, which aims to make the world a better place with data. 

Of course organizations want to seek out companies where a potential partnership can be mutually beneficial, therefore identifying growing companies and understanding the business platform will be necessary before pitching ideas for philanthropic endeavors. Crunchbase.com is a platform that analyzes start-ups to help investors identify successful companies. Another resource is Gartner annual vendor ratings that showcase company strengths. Global health organizations can use these resources to identify viable companies as potential sustainable funders.  

While investigating growing companies will require staff time and resources the potential for a sustainable partnership with the private sector is worth the effort. Helping design a company’s philanthropic programs is an opportunity for global health organizations to build funding opportunities that are flexible and consistent, rather than trying to morph organizational mission and goals into the prescribed priorities of current funders. 

The Rise of Global Mental Health

by hanstewart, posted in APHA IH Section

The constitution of the World Health Organization (WHO) opens with a definition of health that underscores the importance of “mental…well-being.” Even still, mental health has struggled to achieve parity in global health. For much of its history, the field of mental health developed parallel to public health. Mental health, and the lack of it, was nebulous and eluded the gold standards of clinical measurement like bioassays and microscopy. As a result, psychology and psychiatry (components of the larger field of mental health) were shunned by other disciplines for a perceived lack of scientific basis and over-emphasis of sociological factors. Those with mental disorders, cognitive and developmental impairments were thusly cared for largely by religious institutions and, eventually, asylums rampant with inhumane treatment and neglect. 

Psychiatric patients in Bucharest sleep two to bed with feet bound;
Image Credit: Bernard Bisson

By the 1970’s the United States was moving toward deinstitutionalization and curiosity about how to effectively study and treat mental illness in the context of culture. Mental health research worldwide began engaging with patients as active participants with “lived experience.” The sharing of epidemiological data around mental health indicators became more fluid. The push for data-driven and evidence based decision making in global mental health produced big payoffs. The 1990’s saw both the WHO’s first World Mental Health Report and the first iteration of The Global Burden of Disease study. 

These publications highlighted the sheer burden of poor mental health. Of the ten leading causes of disability, five were mental illnesses, including the leading cause of disability in the world: unipolar major depression. Self-inflicted injury was among the top ten leading causes of premature death in developed countries. While the psychiatric epidemiological data continued to underscore the need for new interventions and novel funding mechanisms for global mental health, not much has changed. Last year, the Lancet Commision on global mental health and sustainable development released a 45-page report outlining a global health crisis that is severely underfunded relative to its burden on society. Even in developed countries, only 20% of individuals living with depression will receive adequate treatment. In developing countries, the number is a dismal 4%. But only 1% of global health development funds are allocated to mental health programs. That comes out to just $0.85 per year of healthy life lost to mental illness, compared to $144 for HIV/AIDS programming and $48 for malaria and tuberculosis. 

Even if the funding existed, global health education has yet to produce a reliable pipeline of mental health professionals with the skills necessary to address the crisis. Educators at schools of public health in the United States have identified that mental health is still not adequately integrated into public health curriculum. Johns Hopkins remains the only school of public health in the country with a dedicated mental health department. While the majority of other public health programs offer coursework that have mental health as a component of its curriculum, few programs offer tracks or courses that have mental health as its primary focus, leaving students interested in the field to piecemeal their education together through independent study and practicum/thesis work. 

(Read the study on mental health in schools of public health here)

The evidence is clear that global mental health should be recognized as a global health and global development priority. Despite the lack of full acceptance by the global health donor community and larger public health community, the field of global mental health has continued to grow. Organizations like the Movement for Global Mental Health serve as collaboration spaces for mental health researchers and advocates. The Lancet Commission on Global Mental Health continues to produce calls for action that elicit drastic, even if short-lived, spikes in mental health earmarked development assistance. And just this year, the field’s superstar, the Peter Piot or Paul Farmer of global mental health, Dr. Vikram Patel was awarded the prestigious John Dirks Canada Gairdner Global Health Award. 

“...All countries can be thought of as developing countries in the context of mental health“

Patel et al.

We are living in the age of a changing climate, protracted humanitarian crises, and a global population that is increasingly forcibly displaced from their homes. The burden of mental health problems will continue to pose a threat to health that will require the unique skill set of the field of global mental health. Leaders like Dr. Patel continue to advance the global mental health agenda in an effort to realize the complete definition of health that lies at the core of global health. For those of us for whom global mental health is our calling and passion, we must continue to push for our place at the table when the global health agenda is being set. 

Note: One of the photographs used in this blog appears elsewhere on the internet in an unredacted form. However, to protect the privacy and dignity of those who appear in the photograph, I’ve elected to hide their faces.

Global Mental Health: How Are We Doing? (WHO)

Perspectives on Global Health from Pharmacists Around the World

by pragmaticsolidarity, posted in APHA IH Section, Health Systems, Pharmaceuticals

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, these roles accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. This initial segment focuses on medication access in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Throughout both developed and developing healthcare systems, access to medications is consistently a top priority for pharmacists and health care systems. As this health care profession attempts to provide services that meet the needs of their communities, access deficiencies habitually impede the ability to follow through with individualized and compassionate care. The lack of access to life altering chemical entities can affect anyone anywhere, from an affluent metropolitan city like Washington D.C. to a small rural Cambodian village in the province of Kampot. Despite the differences in these locations, each of these instances cause significant harm, breed mistrust in healthcare professionals, and create despair among those that seek healing. These frustrating situations are due to intensify because of the increased strain on medical resources who take a “do-what-has-always-been-done” approach. These following four pharmacists, all from various corners of this vast planet, will describe the barriers they consistently face regarding medication access and initiatives that are being undergone to ensure that a novel approach is commenced to address this looming medical tragedy.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Before discussing medication access in the United Arab Emirates, I would like to give a brief introduction about the United Arab Emirates (UAE). It is a middle eastern country with a population of 9.68 million. The country is comprised of seven emirates and healthcare in UAE is regulated both federally & at the Emirate level. 

Now, starting with the topic on hand about medication access in UAE, there are several factors that have an impact on it and I will touch on them individually and in detail. 

First and foremost, I think the most important factor is the number of medications available in UAE. The majority of medications available in UAE are imported drugs. UAE imports pharmaceutical products from 72 different countries. Of those, 10 countries constitute approximately 80% of the entire country’s supply. The domestic sector is rather small; however the UAE Ministry of Health (MOH) plans to increase the number of pharmaceutical manufacturing facilities to 30 by 2020 up from 16 in 2017. Availability of different medication combinations or different strengths are difficult to find due to the limited number of industries in UAE. One such example is oral prednisolone, which in UAE is available in strengths of 1mg, 5mg, 10mg & 20mg. In the USA, there are more strengths available including 1mg, 2.5mg, 5mg, 10mg, 20mg and 50mg. Tourists or expats coming from overseas that need a particular medicine or medicine combination or a particular strength may not find it available.

The second hindrance to medication access is the cost of medications. There are many reasons for the high cost medication. The aforementioned fact that about 80% of medications in UAE are being imported rather than locally manufactured is one reason. Another reason is an insignificant availability of generic medicines as the majority of medicines available are brand name. The final reason is the national health insurance model. Because all national citizens do not have to pay for their own medications, there is no incentive to keep the medicine prices low. As a result, individuals who are not insured under the public national insurance system, for example expats and tourists, face a huge barrier to obtaining medicines. 

With these barriers in mind, initiatives have started to take place in UAE to find a solution. The government reduced 24% of the prices for 8732 medicines over the course of 6 years. Another initiative which took place is increasing the number of generic medicines while also advising physicians and pharmacists to dispense the generic rather than the branded medicines. Through this initiative, generic medicines now account for 30% of the overall pharmaceutical market which has increased from 12% of the market two years ago. If the UAE can bump these numbers up to 70-80% of the overall market in UAE, the UAE will be seen in better position in terms of generic medicines. 

I am glad to be a part of a region where these issues are actively tackled, not just by the government but by private sectors as well. We are also seeing that pharmacists are playing a larger role, providing information on availability of cheaper alternatives on medicines. Pharmacists are the most accessible healthcare professional and it should be part of their responsibility to help make medicines as accessible as possible to their clients.

 Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

Although there are a host of issues surrounding access to medications, I will be focusing on oncology medications as oncology is my current specialty as a medical science liaison in the USA. 

To begin, I would like to highlight encouraging statistics that show the accessibility of oncology medications in the USA. A recent 2019 study found that 96% of new cancer medications were available within the United States, the next highest nation was at 71%. Furthermore, the average delay in the availability of cancer medications within the United States was 3 months, with the next closest nation being at 9 months.

In terms of novel and innovative treatment options, oncology drugs have been increasingly approved by the Food and Drug Administration (FDA) throughout the last few years. The FDA has enacted policy changes to attempt to increase the efficiency of drug reviews. The results have been significant – in 2017 alone, 46 new oncology drugs were approved. Moreover, from 1991 to 2016 there was a 27% decrease in cancer related deaths in large part to the expanded and more targeted-based therapy. The chance that a patient will live for 5 or more years has increased by 41% since 1975.

Outside of regular treatment options of those living with cancer, patients have the ability to participate in a clinical trial. Currently, there are 24,351 clinical trials listed as active (defined as not yet recruiting, recruiting, enrolling by invitation, or active) – 11,813 of those trials are active in the United States. However, even with the surplus of ongoing clinical trials, it still seems there is a lack of patient enrollment. It is estimated that roughly 70% of patients are interested in clinical trials, and yet <5% of patients actually enroll in clinical trials. Some of these barriers to enrollment include: lack of availability at a specific clinic, lack of a specific trial available, patient ineligibility, physician is unaware of trials/not offering them to patients, and a patient deciding not to enroll in a clinical trial (perhaps due to a fear of receiving the placebo).

An aforementioned barrier to cancer treatment that needs to be emphasized is the locations of specialized cancer clinics. Studies have shown that patients who are diagnosed with advanced staged cancer are likely required to drive an hour or more to the nearest cancer clinic for the appropriate care they need. Additionally, travel distance may affect treatment decisions. A patient may select a slightly less efficacious therapy if that means they have to travel less often. 

Two initiatives have recently been instituted to further increase the accessibility of medications. First, in an effort to go towards value-based contracting, some companies are beginning to only charge patients if their medications are effective. While this is a rarity, it will be interesting to follow the impacts of this on other more costly treatments and to determine the impact on patients. Secondly, in 2018, the right to try act was passed. This essentially gives terminally ill patients who are unable to enroll in a clinical trial and have no other remaining FDA approved options, access to other treatments. While this is a relatively new policy and there are some restrictions, hopefully it will give patients hope and additional treatment options. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In rural Cambodia, access to medication is especially limited when compared to urban areas. Access is limited by two main factors in these communities. Firstly, many people living in rural areas have low incomes which means it is difficult for poor rural individuals to buy medicines for serious illnesses. Secondly, community drug outlets and public health facilities are generally concentrated in the provincial capitals/cities, making it difficult for people from rural, remote areas to get access to those places. 

Usually, medicines imported from other Asian countries such as India, China, Vietnam, Thailand, or Malaysia are cheaper and therefore, more accessible. These cheaper medications, however, tend to be held toward a lower quality standard which can lead to disease state progression, antibiotic resistance, and other situations that can inflict harm onto patients. However, western brand medicines, which are usually held to a higher standard of quality, are less accessible because their prices are higher. Locally, they are generally considered “medicines for the rich.”

The lack of access due to  these aforementioned barriers makes diseases difficult or impossible to treat in cases where medication is necessary to cure it. Patients may see their disease aggravated and could die of it.

In order to address these medication access complications, a specialized team should be created that assists patients or their relatives to get medication which is far from their home and provide a specific loan with very low or no interest rate for villagers who cannot afford to buy medicines. This approach has been initiated in Cambodia through the increased access of health equity funds (HEF). These funds, allocated to individuals unable to afford the out-of-pocket expenses for public services, are pooled from a variety of sources like the national health budget and various donors. These patients are then given a specialized card to receive these funds when public services are used. The HEF focuses on addressing low medication access through the initial financing as aforementioned, community support, quality assurance, and finally policy dialogue. The results of this project have been promising – there was a 28% increase of patients utilizing public services with HEF than before without the HEF. In addition, the patients were not perceived to be more stigmatized within their communities.  

Veda Peddisetti, B. Pharm.

Clinical Pharmacist – Satya Sree Clinic & Diagnostics 

Hyderabad, India 

India is the largest country in South Asia and the second most populous country (1.35 billion) in the world. In addition, India is said to be in the third stage of demographic transition with birth rates declining and death rates decreasing. In the past few decades, India has experienced monumental population growth. This has led to many problems in healthcare management throughout the country, in particular, medication access. The direct cause seems to be the over-demand of medications. However, various indirect causes include poverty, varying per-capita incomes, unemployment, and out of pocket expenditures (India doesn’t have an established federal healthcare insurance system like Medicare in the USA, National Health Service in the United Kingdom, etc.).

In addition to the aforementioned causes, the literacy level in villages and rural areas are quite low. Many of the farmers and laborers from rural India are uneducated. As a result, many don’t know how medication can help them get better and how important it is to take medication every day to keep chronic conditions like hypertension and diabetes in control. In urban areas, all income classes are more educated and are given awareness more frequently about healthcare when compared to individuals in rural areas. So, they tend to use medication and other healthcare facilities more frequently. Accessibility is not a huge issue in cities but this creates competition among providers and results in high costs which turns into a problem for low and average income communities of the urban population.

Usually, regular medications like anti-diabetics, anti-hypertensives, common antibiotics, analgesics, vitamins are available throughout the country except in some deeply located tribal areas. Medications which are used for some cancer chemotherapies, auto-immune diseases, and some orphan drugs are not widely available. People have to go to highly rated hospitals in developed metropolitan cities to get these medications, and I believe this scenario is the same anywhere in the world. This kind of accessibility shouldn’t affect any patient or healthcare provider unless there is any medical emergency. And thanks to the continuous efforts of the Government of India, India is improving the accessibility of medication. Recently, various health benefit schemes were implemented like free supply of in-patient medications in civil hospitals and sale of reasonably priced generic medications in rural and urban communities.

It is a well-established fact that India is a potential supplier of medications to many countries in the world. India is a manufacturing and research hub for many reputed pharmaceutical companies. However, this often leads to pharmaceutical companies who are exporting their products in large quantities rather than supplying them domestically. These medications range from certain medications for chronic diseases like diabetes drugs to life saving medical devices like the Epi-Pen. These pharmaceutical companies more interested in profit are preventing the Indian population from getting the best medications.

With the lack of proper medications, healthcare professionals cannot take the proper steps in patient care that they could actually do if they had adequate access to medications. So, it is vital to educate people of India, especially the rural population, while simultaneously framing and implementing some regulations and limits on the export of medications by pharmaceutical companies in order to improve healthcare in India.