Trade, Health, and Access to the COVID Vaccines

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!

My global health journey: a reflection on my time in the field and advice for students and young professionals

By: Kiran Kamble, M.B.B.S., AFIH, MPH, PhD Candidate

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.

Global Health Resources

https://www.fic.nih.gov/Global/Pages/NGOs.aspx, https://www.albany.edu/globalhealth/organizations-working-global-health, https://sph.umich.edu/global/non-governmental-orgs.html; https://ocs.fas.harvard.edu/explore-careers/global-health; https://www.who.int/emergencies/partners/non-governmental-organizations; https://www.tephinet.org/global-health-and-international-nonprofit-organization-websites; http://www.imva.org/Pages/orgfrm.htm;

Creative Writing and Mental Health

By Sarah Edmonds and Dr. Heather F. McClintock PhD MSPH MSW 

This is the sixth part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

Part VI – Special Topic: Creative Writing and Mental Health 

Standard treatments approaches (counseling and/or medication) for addressing mental health issues are important, yet alternative approaches and strategies are growing in popularity. One alternative approach is Creative Art Therapy (CAT) which encompasses the use of many creative mediums (e.g. visual art, music, dance, and writing). The literature base indicates that CAT may be low-risk and high benefit for persons with severe mental illness. However, further methodologically rigorous studies are needed to substantiate the effectiveness of these approaches. 

Writing is one medium that has been widely used and studied in application as a tool for enhancing mental health through different forms aimed at self-improvement such as journaling, diaries, and dream logs. In contrast, the usage of writing as a craft through the creative process is an approach that has received relatively little attention. This approach involves persons writing for an outside audience at the point of creation rather than solely for the writer’s own benefit or reflection. Writing as a craft gives the writer the ability to form life and order out of thoughts and chaotic experiences. Some work has shown that a creative approach can help patients build their sense of “self” potentially helping them cope with difficult experiences. Improved confidence is a key mechanism through which creative writing may influence mental health. Research has shown that creative writing can help in building a sense of confidence, community, and connection among marginalized groups.

As a creative writer (SE), the statement “We create as a means of understanding the world around us and our place in it” is often used to describe why our creative process works in helping us deal with social issues or the emotional turmoil we feel in our own lives. As a woman with a minor physical disability, my fiction writing deals frequently with characters thriving despite sexism and ableism. The creative process whether applied through writing or other art forms aids us in coping and understanding our experiences enhancing our mental health. My friend, an eco-artist by profession, uses biodegradable materials and often inoculates her work with mushroom mycelia so that it grows and decays as is the process of all living things.

Other writers and artists that I know also say that “it’s always been easier for me to express emotions or come to terms with different things that have happened in my life through the written word,” “it’s something like meditation. I’m able to block out everything else and focus solely on what I’m creating. It’s like nothing else matters or exists,” and that “I feel like I would probably be in a worse spot mentally if I wasn’t creating.”

Based on my (SE) experiences as well as recent research, creative writing as a craft may have the potential to be a powerful tool for individuals to improve and maintain their mental health and wellness. As seen in a study conducted across the UK, creative writing workshops open to both residents and refugees allowed deeper connections between refugees and those whose community they were trying to become a part of. Also, it has been suggested that, in cases such as cultivating the mental health of people in protracted conflict areas such as the West Bank, creative expression and communication is a better stress-management tool than the current foreign aid systems that may not consider cultural biases in their methodology. The benefits of creative arts, in general, can also be seen through the work of organizations such as Colors of Connection’s project Courage in Congo that uses community-based art programs to provide therapeutically—as well as economically—beneficial skills to adolescents who are at risk or are victims of sexual and gender-based violence (SGBV). By making the program community-based, it also works towards fighting the social biases the community has against women and young girls.

Whether someone had a rough day at school, is struggling with a severe mental illness, or lives in a community that is unsafe or unwelcoming, the ability to craft narrative and shape events through words that are solely their own gives people a much-needed sense of strength and autonomy. Creative writing gives us the power to find a sense of self, the power to create a safe space in an unforgiving world, and the power to take control over who we are and how we connect to everything and everyone around us.

About the Authors:

Sarah Edmonds

Sarah Edmonds is a Dual Master of Arts in English and Master of Fine Arts in Creative Writing student at Arcadia University. She has won awards for her work in film at festivals such as the BareBones International Film and Music Festival. Her creative work focuses on giving voice to underrepresented groups; she is currently working on a short documentary about biracial women’s identity struggles in the United States. While working with the Carroll County Media Center, she produced local news and interview segments about substance abuse and mental health awareness. Her main goal in her professional and creative work is to open dialogues about topics that normally carry social stigma so that no one ever has to be afraid to get help or to be who they truly are.

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 examine health literacy and 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.


Integrated Mental Health Care

This is the fifth part of an IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

In the context of a pandemic, access to and the quality of mental health care is paramount. Effective and feasible delivery models for mental health care service provision are critical for meeting growing demands for care. Many new and innovative models have been proposed and integrated approaches have been identified as potentially effective strategies to address this growing need. The goal of integrated mental health care is to enhance accessible, affordable, cost-effective mental health services for individuals. There are a range of different integrated care models including collaborative care, hub-based systems, and patient-centered medical homes. Collaborative care, for example, is an integrated care program that combines behavioral health care management and consultations with mental health specialists in the primary care setting. 

Mental health care provision in the context of primary care settings is important because primary care is the first point of contact for patients in the healthcare system. The Declaration of Alma-Ata, adopted at the 1978 International Conference on Primary Health Care organized by UNICEF and WHO, identified primary health care as a central function of health systems and the key to attaining the goal of ‘Health for All.’ Forty years later, at the Global Conference on Primary Health Care, primary care was re-emphasized as the most effective way to sustainably solve today’s health challenges, partly through the provision of integrated services. The promotion, maintenance and improvement of mental health is explicitly included in the 2018 Declaration as a service that primary health care should provide to patients. 

Mental illness is frequently comorbid with a long list of chronic illnesses and disorders. Depression is common among people who have cancer, coronary heart disease, diabetes, multiple sclerosis, HIV/AIDS, and rheumatoid arthritis, among other chronic illnesses. Some disorders increase the risk of depression. At the early stages of Parkinson’s disease dopamine decreases which can cause depression. Chronic stress, whether it be illness-related or social stress, can trigger anxiety and depression. Researchers have found high levels of the stress hormone, cortisol, to disrupt neuroplasticity in brain structures that are functionally abnormal in depression, such as the hippocampus. Medication used to treat certain chronic disorders can lead to depressive symptoms. Nifedipine, used in the treatment of cardiovascular conditions, has been linked with the induction of depression. Even drugs used to treat and prevent asthma have been found to have psychiatric side effects. Bronchodilators mimic adrenaline and trigger the body’s sympathetic “fight or flight” nervous system response. This response causes one to feel anxious and panicky. Montelukast is another asthma medication that has neuropsychiatric side-effects in children and has recently elicited the FDA to require a stronger box warning of the side-effect. 

Conversely, adults with serious mental illnesses are at greater risk for chronic physical illnesses and other medical conditions, such as stroke and cardiovascular disease, than the general population. One explanation for this association is that individuals with mental illness can have a harder time caring for themselves, seeking care, eating well, exercising and taking medication as prescribed. Scientists have found that depression increases inflammation, reduces heart rate variability, and disturbs the metabolic system

Ethiopia, India, Nepal, Nigeria, South Africa and Uganda have strengthened integrated mental health care through the World Health Organization’s mhGAP program. Through the mhGAP program, primary care providers are trained to identify and manage mental disorders, prescribe psychotropic medication, and provide evidence-based psychosocial interventions. For integrated mental health care to fully flourish, change needs to come from within the medical sector, as well as outside of it, in the policy sector. The Netherlands, since the early 2000s, has worked to integrate mental health care into a number of health care settings, including hospitals and community health centers. They also introduced an innovative bundled payment system in 2007 to promote and incentivize integrated care. 

There are many challenges inherent in implementing integrated care models. Countries face resource constraints including workforce shortages. Primary care providers can be trained to provide mental health care, but they must be supported by secondary mental health professionals who are the experts in their field. Finally, to ensure optimal success and sustainability, countries must enact legislation that fosters the development of infrastructure that supports integrated mental health care. 

About the Authors:

Screen Shot 2020-03-31 at 7.52.50 PMElena 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.

McClintock.PictureDr. 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.

 

 

 

 

Global Mental Health Agenda and Pandemic Preparedness

This is the fourth part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

Part IV – Global Mental Health Agenda and Pandemic Preparedness

The COVID-19 pandemic has exposed a need to improve preparedness for mental health care services provision in the context of pandemics. The mental health burden associated with COVID-19 and prior pandemics is pervasive, highlighting a critical need for preparedness plans to incorporate a mental health response. As discussed in our previous blog, there are initiatives related to global mental health and COVID-19 that are being implemented, but a fully adaptive and comprehensive approach is needed to mitigate mental health consequences.

The agenda and priority setting of international governing bodies provides the foundation for establishing and implementing comprehensive preparedness plans and approaches. For the first time in 2015, the United Nations (UN) established mental health as a priority by including substance abuse and mental health in the 2030 Agenda for Sustainable Development. A total of 17 Sustainable Development Goals (SDGs) were created and adopted by all UN Member States. Mental health is specifically a part of SDG 3: “Ensure healthy lives and promote well-being for all at all ages.” Within Goal 3, two targets are directly related to mental health. Target 3.4 states: “by 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.” Target 3.5 focuses on drug addiction, proposing that countries: “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.” 

In 2013, the World Health Assembly published a Comprehensive Mental Health Action Plan for 2013-2020 in response to the growing burden of mental illness. In the action plan’s foreword, Director-General Dr. Margaret Chan stated that mental health is a fundamental part of WHO’s definition of health. The action plan was extended to 2030 at the 72nd World Health Assembly to align with the UN’s 2030 Agenda for Sustainable Development. The plan’s framework is intended to be adapted at the regional level in order to address regional priorities and circumstances. 

With this action plan, all WHO Member States committed to contributing efforts to meet the global targets around improving mental health. The plan includes four objectives around effective leadership and governance, service provision in community-based settings, promotion and prevention, and strengthening research. Each objective is broken down into specific, measurable targets and their respective indicators. This structure allows countries to monitor progress and impact and report these data back to WHO to monitor progress and impact. The full action plan, published in 2013, can be read here.  This article by the Lancet, also published in 2013, summarizes the plan. 

WHO has created practical tools that national authorities can use to improve mental health service resilience during and after public health emergencies such as the WHO Recovery Toolkit. These resources can help national authorities develop or update national pandemic preparedness plans. Even though there has been increased prioritization of global mental health by the UN and WHO, there is significant work to be done on integrating mental health into emergency preparedness and pandemic planning. 

Given the current global agenda, the revision and implementation of preparedness planning that supports care for mental health is critical. With revised multisector pandemic preparedness plans that incorporate new and emerging evidence, we could lessen the lingering mental health effects of future pandemics. A recently published JAMA article highlights the need for prevention and early intervention to proactively prepare for an increase in mental health conditions from the COVID-19 pandemic. The authors mention the necessity of having mechanisms in place for surveillance, reporting and intervention, as well as bolstering mental health systems in preparation for increased service demands.

About the Authors:

Screen Shot 2020-03-31 at 7.52.50 PMElena 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.

McClintock.PictureDr. 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.