Category: Guest Blog

And The Band Played On: Politics, People and the AIDS Epidemic (Book Review)

by ihsection, posted in Guest Blog

Guest blogger: Barbara Waldorf, RN
For everyone concerned about public health, HIV-AIDS, MSM and human rights are key issues. Homosexuality is illegal in 80 countries worldwide. A major battle is brewing in Uganda, with a virulent anti-homosexuality bill in parliament and donors like Sweden threatening to cut all aid if it is passed. There are implications for all public health projects. Randy Shilts wrote eloquently about these issues at the beginning of the AIDS epidemic. Despite the extraordinary progress that has occurred over the last 30 years, what he explored is as relevant today as it was when it was written.

Marginalized groups of people die while the world does nothing, despite key players being able to stop the slaughter. Randy Shilts states he wrote this book, so “…it will never happen again, to any people, anywhere.” “Never again” was said after the holocaust in Europe. The AIDS epidemic can be seen as another holocaust. The overarching issues this book reveals are universal. It forces us to contemplate: What would I do? What is the impact of our prejudices? How do we treat the “other”? And how do we care for those that society has disenfranchised – whether they were Jews in Europe in the 1930s, American gay men in the 1980s or undocumented aliens today?

And the Band Played On is a compelling account of the first five years of the AIDS epidemic. Shilts takes us on a journey, starting with an unknown disease in Africa, to the first CDC case report of unusual pneumonia appearing in young gay men, to the growing awareness of the disease by the mainstream society. The breadth of research is staggering, covering the growing controversy within the gay community; the scientists researching a cause while competing for fame; the politicians more worried about popularity than people dying; and the impact of the conservative fiscal policies of Ronald Reagan that cut funding for the CDC and government health facilities, just when they needed to engage the biggest pubic health threat of the century. Shilts delineates the complex response to the emergence of AIDS that was impacted by prejudice against gays and other marginalized people. He was a journalist, and wrote this book to catalogue the lack of response, that caused a huge number of deaths and allowed the virus to spread virtually unchecked for years.

His premise was that because the virus emerged in groups the mainstream culture wanted to ignore, scientists, doctors and politicians were blinded and failed to halt the spread of AIDS. Shilts forces us to question the social and political milieu this medical crisis arose within, which prevented any unified response. It always takes enormous energy and commitment to see our own blind spots. For anyone interested in public health, the important questions that arise are: Who is the “other” now? Do I have the vision and courage to respond to the next crisis, no matter where it arises? Given these questions, this book becomes a contemporary cautionary tale. Shilts warns us to chronicle the ways that AIDS was ignored so that we can have the humility not to repeat history with the next disease that appears among the disenfranchised. He makes the point that despite apparent differences, we are all human beings, intimately connected. He leaves us to contemplate how to create a world where there is no “other.”

Barbara Waldorf is an RN and working on her MPH at Boston University School of Public Health with a concentration in International Health. Having lived and worked in Asia, Europe and Australia, her current interest is in the emerging field of Global Health nursing and learning from other nurses who are active in this field.

Cuban Disaster Preparedness: Lessons Learned

by ihsection, posted in Disaster Response, Guest Blog

Guest blogger: Joe Vargas

The California Disaster Medical Services Association, in conjunction with the Medical Education Cooperation with Cuba (MEDICC), provided an opportunity for 17 health care professionals to be part of an exciting research team to examine Cuba’s acclaimed public health system, including its renowned disaster preparedness and medical response systems. The research group traveled to Havana, Cuba in December 2010 for nine full days of lectures, educational presentations and interchange with Cuban medical professionals and public health response teams. Although the United States has not had diplomatic relations with Cuba and travel is restricted, the group was allowed permission under the US treasury’s general license for professional research that includes full-time health and emergency response professionals doing research in Cuba.

During the visit, the group examined Cuba’s elaborate yet unsophisticated system for population protection during disasters. Given their limited physical, technical and transportation resources, the Cuban people, including school children, are taught at an early age about their role and responsibility in a disaster. Education is compulsory up to the 12th grade. Cuba’s hurricane-prone geographical location has necessitated an efficient and coordinated approach with an emphasis on accurate, early and frequent communication information. These internationally recognized measures include prioritized evacuation procedures for vulnerable populations that include high-risk seniors, pregnant women, disabled and individuals living in remote areas where flooding occurs. Transportation is prearranged using city buses to evacuate large communities to safer ground until the storm diminishes. Other preparatory efforts include frequent meteorological reports, monitoring and the shutdown of power and utilities days before the storm arrives. Cuba is one of the few countries that offer early advisories and information phases as preludes to the hurricane watch. Historically, very few deaths and injuries have occurred as a result of the many powerful hurricanes (Charlie, Wilma, Ivan) that have struck Cuba using this preparation approach.

The group also toured several medical facilities including Havana’s polyclinics (neighborhood clinics). At these facilities, the research team was able to view Cuba’s robust primary prevention-focused medical system and understand its critical ties to civil defense teams and meteorological and information sharing systems. Highlights included meeting with grassroots organizations in disaster preparation, response and recovery, including neighborhood organizations and the neighborhood-based physician medical team. The Ministry of Public Health directs all health sectors to support a comprehensive system of healthcare specifically oriented to prevention activities and primary care. Family physicians work in residential neighborhoods where they are provided a home and a functional clinic. Working alongside a nurse, they are responsible for approximately 80-130 families in their community. This closeness allows healthcare professionals to provide immediate emergency and personal care to their neighbors. Physicians develop an overall understanding of all their community needs, which contributes to their overall wellness and whose population health indicators are comparable to developed countries like the US and Canada.

Team members will be sharing their experiences throughout the country at conferences and workshops. To schedule a presentation or for further information you may contact Joe Vargas at jvargas [at] ochca [dot] com.

Cancer: the Next Challenge for Global Health

by ihsection, posted in Chronic Disease, Guest Blog

Guest blogger: Dr. Isobel Hoskins

We think of cancer as a disease of affluent countries. That may have been true in the 1970s, but since then, cancer levels in developing countries have risen alarmingly. This massive rise in cancer is one reason why a UN summit in June is addressing chronic diseases, including cancer, with the aim of kickstarting the fight against these illnesses.

Some figures: 5.5 million of the nearly 8 million deaths from cancer in 2008 happened in the developing world. Back in 1970 only 15% of cancers were found in the developing world. However, by 2008, according to the World Cancer Report, more than half of cases were in developing countries. These numbers hide a burden of misery – cancers in developing countries are often detected at a late stage – too late for many treatments. These patients often don’t even have access to pain medications.

What drove this increase? The WHO Director General, in a recent address to the IAEA, cited ageing, urbanization and the globalisation of unhealthy lifestyles. Population growth has also driven the numbers up. Isn’t it ironic that improved life expectancy leads to increased cancer burdens?

Many papers can be found indicating the enormous problem that cancer is for developing countries. Given the expense of treatment is there anything that can be done to reduce the cancer burden? Fortunately there is – I read a paper in the Lancet that gives a ray of hope…

Farmer et al. say that we shouldn’t accept that cancers in developing countries will remain untreated. Instead, we should make cancer prevention and treatment broadly available as rapidly as possible. We should consider the example of HIV and TB a decade ago: critics asserted that HIV and TB treatments were too complex and long term for weak health systems. These arguments proved unfounded. Farmer et al. point out examples of successful treatment and prevention of cancer in low resource settings that we can build on.

The approach should concentrate on curable and preventable cancers. Farmer et al. have come up with a list. These cancers can be prevented by reducing risk factors such as tobacco use or infection, or they can be cured by early detection and surgery methods or specific low cost systemic drugs. It includes some very common cancers: lung cancer, breast cancer, cervical cancer and liver cancer.

Many problems posed by cancer care, including cost of drugs and lack of infrastructure and specialists, was a big obstacle for HIV, too. The solutions could be similar: Farmer et al. suggest reducing drug cost by drug purchasing and production negotiations, as well as the use of primary and secondary caregivers to deliver services. The paper cites an example of cancer care in Malawi that uses such workers with remote support from specialists.

And if there is no suitable treatment, pain control is low cost, and the paper asserts that all should have access to that as a human right.

Farmer and co-authors have formed the Global Taskforce on Expanded Access to Cancer Care and Control in Developing Countries to address cancer care worldwide. I for one hope this taskforce prospers!

Dr Isobel Hoskins is Co-Editor of the bibliographic database Global Health which covers public health research worldwide. Global Health is produced by CABI, an international not-for-profit information provider. She’s usually found blogging on the Global Health Knowledge Base and on Twitter here: @CABI_Health.

Reflections on Community Based Participatory Research

by ihsection, posted in Guest Blog, Research

Guest Blogger: Xeno Acharya

As an MPH student at University of Washington, Seattle, I have often wondered if Community Based Participatory Research (CBPR) is a philosopher’s stone in the academics’ head. Having worked in Ethiopia and Sudan (as the researcher) and having been born and raised in Nepal (as the researched), I have come face to face with both sides of this idealistic myth.

In short, CBPR is a research method that has three core elements: participation, research, and action. It emphasizes “authentic partnership” between the researcher and the community, in which perspectives, knowledge, resources, and skills of both are combined.

It is important to remember that most of the time it is the researcher that initiates the research, no matter how participatory. For purposes of convenience, let’s call the researcher M and the researched N. M brings in research funding, manpower, technology, and white man’s knowledge. N (hopefully) brings in local experience, networks, subjects, manpower, and consensus to have been intervened/researched. When I was in Sudan and Ethiopia, I was a Caucasian-looking male who was struggling with the language and cultural nuances, but who was also clearly better paid than most staff working in the same company although I neither had the educational background or the experience the local staff members did. My positionality affected the way my colleagues spoke to me about their work and about themselves, and no amount of CBPR could overcome that.

In Nepal, too, the same power dynamics played out. Although I am a native there and speak the language, I look “white,” and the clothes I wear and the way I walk scream the fact that I have clearly not been around in Nepal for a while. I work for a small non-profit based in Portland, Oregon, that runs a school for untouchable refugee children in Kathmandu. When I visit the school every couple of years, I get the attention (I like) from kids and parents alike, not just because I am the founder but also because of the same power dynamics that comes back to bite at me again and again. So I have settled for the fact that the imbalance is always going to be there no matter what. To me, CBPR is a theory that can never fully come to fruition. Like communism, the idea itself is good and is meant to do well, but a hundred percent CBPR is only a goal to strive for, never a reality.

That said, I think CBPR is still an idea to strive for. There are things I (as a researcher) can change to reduce the imbalance of power between myself and the researched/intervened, and they are still important to do. Reflecting on my own positionality and being aware of this power dynamics is something that I can constantly incorporate in my work; so can you!

Xeno Acharya, originally from Kathmandu, Nepal, is an MPH candidate at the University of Washington. In Nepal, he has worked with local NGOs on awareness campaigns on disability among children, taught in mobile schools for displaced populations, and currently runs a school for children of victims of the civil war (1996-2008) through Namaste Kathmandu; he has also worked on short-term projects in Ethiopia and Sudan. He is currently a research assistant in the Health Systems Strengthening division of a Seattle-based non-profit called International Teaching & Education Center for Health (I-TECH) and is interested in infectious disease prevention, refugee populations, and health systems strengthening.

Politicizing our National Health Security

by ihsection, posted in Guest Blog, Health Systems, Policy and Advocacy

By Dr. Samir N. Banoob

In 1994, after the Republicans paralyzed the Clinton health reform proposal, I published an article in the Florida Journal of Public Health titled “Reforming health care in the US and Europe: Why we fail and they succeed.” It explained why health reforms succeed in other Western countries with policies of universal access and user-friendly systems. In our case, the Republicans sacrificed health security of all citizens to play the political game of “Repeal the Obama Affordable Health Care Act,” responding to lobbyists and funding from interest groups. Members of Congress who voted to repeal the law come from the same category of irresponsible politicians who represent special interests that opposed Social Security, Medicare and Medicaid for short political gains.

To review where we are, the American health care non-system:

  • is the only system that does not provide health security to its citizens. The uninsured population reached 46.3 million in 2008 (compared to 36 million in 1993) and is steadily increasing. If the status quo continues by repealing Obamacare, it is expected to reach 75 million in 2019.
  • is the most expensive system in the world. American healthcare expenditures made up 16.2% of our gross national income in 2008, compared to an average of 9% in Europe. Without the recently passed reforms, it will soon reach 25%, which is almost double the cost in any country of comparable national income. The cost per individual reached $7,681 in 2008.
  • has one of the lowest provider-to-population ratios and the highest administrator-to-provider ratios (8 administrators per 10 health providers) among Western nations. The administrative portion of private health insurance agency expenditures is 30%, compared to 2-4% in Medicare and governmental agencies.
  • has one of the lowest proportions of hospital beds for the population, the lowest hospital admission rate and the shortest length of hospital stay among Western nations. While European citizens use an average of 7-8 outpatient doctor visits per year, Americans use 3.8 visits per year.

These are just few features of our system that some falsely call “the best system in the world.” By technical and scientific standards, this system is ranked 37th among the 190 countries in the world. Life expectancy at birth, 78 years in the US, is among the lowest of industrial countries. Seven out of 1,000 American children die before their first birthday, a figure similar to that of Thailand and Lithuania. While many are proud of our rate of high-tech surgical procedures, research has demonstrated that about 20% of these procedures are unnecessary and are financially driven or performed to avoid litigation. The scientific measures of quality of care indicate that the American system is, at best, comparable to most Western countries.

Many opponents of the reforms cite concerns such as mandating insurance coverage or government involvement. However, health insurance is compulsory in most developed nations to avoid the costs incurred by individuals who do not pay for coverage and go to emergency rooms for care, shifting the cost to the insured. Also, the notion that the public option will increase government’s involvement in health care is false: about 45% of Americans’ health care costs are covered by governmental programs, including Medicare, Medicaid, Veterans health services, and state and local government services. Another allegation is the cost and the deficit, but this does not take into account the savings for individuals and families from reducing out-of pocket costs, as well as the cost to employers, who will either pay more or will lower health benefits or shift the cost to the employees. Others intentionally confuse the debate by bringing in political ideology or simply targeting the President and the Democratic party. This irresponsible act will hurt all Americans in the future.

It is essential at this time to focus the debate on the health system. To those fighting for repeal, please come with the alternatives first. What will happen to the escalating number of citizens who are uninsured, and those who have preexisting conditions, and the skyrocketing health care cost?

Let us play politics away from the nation’s health security.

More Information
WHO World Health Statistic 2009 Report (PDF)
OECD Health Data 2009

Samir Banoob, M.D., D.M., D.P.H., Ph.D., is the president of International Health Management, consulting firm in Florida that leads international health projects and trains scholars from more than 70 countries. He has taught as a professor of international health policy and management and has worked as a consultant to WHO, World Bank, and other international agencies on projects in 76 countries. He served as the Chair of the International Health Section from 1992 to 1994, and again from 2006 to 2008.