Progress toward #polio eradication is a much-needed reminder that global health is still winning

I always love spotlighting polio eradication. Along with Guinea worm, it is one of the few candidates to follow smallpox to the eternal (or so we all hope) halls of eradicated diseases. While the eradication effort has suffered its setbacks in recent years, public health workers have persisted, steadily marching onward. And frankly, there has been so much hand-wringing in global health in recent weeks that it is important to occasionally remember that there are still wins we can, and should, celebrate.

What makes this success possible in addition to trackable is the global network of polio surveillance systems, which was featured in CDC’s MMWR at the beginning of April:

The primary means of detecting poliovirus transmission is surveillance for acute flaccid paralysis (AFP) among children aged [less than] 15 years, combined with collection and testing of stool specimens from persons with AFP for detection of WPV and vaccine-derived polioviruses (VDPVs)…in WHO-accredited laboratories within the Global Polio Laboratory Network. AFP surveillance is supplemented by environmental surveillance for polioviruses in sewage from selected locations. Genomic sequencing of the VP1-coding region of isolated polioviruses enables mapping transmission by time and place, assessment of potential gaps in surveillance, and identification of the emergence of VDPVs. For public health nerds like me, all of MMWR’s polio reports can be found here.

Basically, a combination of syndromic and environmental surveillance allows public health systems to track polio where it pops up, and genetic sequencing helps to trace how the virus got to where it did to shed light on transmission patterns and find gaps in surveillance.

The WHO followed with two YouTube videos featuring the global polio surveillance system and polio vaccination, which is what will make eradication possible:



This is all pretty straightforward stuff – we all know generally that surveillance systems do, in fact, work when their infrastructure is properly supported and that children should be vaccinated against polio. But it’s important to not lose focus on our successes and global health progress, even when it is simple, straightforward, and sometimes slow.

Global Health in Conflict: A Weightier Commitment

It is important for early-career professionals interested in pursuing a career in global health to be aware of the realities of working internationally. Although stories of setting up vaccination clinics or fighting Ebola may stir up feelings of excitement, being a part of the action may require additional education and training in conflict resolution and institution building. This is especially true when it comes to conflict-affected areas and fragile states that are the most in need of health care/public health services as a result of the local health system infrastructure being weakened. A different kind of public health professional, one that is willing to risk their life and invest in the indigenous health system, is required in our world today.

I currently work as an epidemiologist at a regional health department in Texas. We serve two main roles for the 30 counties we cover. One of our roles is to function as a local health department and deliver a diverse range of services to 23 counties. The other main role is to serve as an extension of the state health department and provide surveillance/investigation guidance for the reportable conditions that health care providers, schools, and community members are mandated to report. This relationship is seen especially when we work with the 7 counties in our region that have their own local health departments. Before beginning this job, I actually worked at one of these local health departments and was on the receiving end of the interaction described above.

For most of my life, I’ve been interested in pursuing a career in global health or humanitarian work. When I was younger, I thought the only way I could pursue this dream was by being a physician (especially if I wanted to be able to support myself financially). I also believed this to be a great way to help communities that were dying from preventable illnesses. My introduction to public health helped me see that there were many other ways to help achieve the goal of combating deaths due to preventable illnesses. I focused in on epidemiology as a way to combine my science/laboratory background with my desire to serve and entered into an MPH program after completing my B.S. in Biology. Most of my MPH program was spent working hard to obtain tangible experiences in public health practice and deciding which skills would be most necessary for me to have before entering into the workforce. While pursuing my MPH from 2014-2015, some of the hot topics in public health were Ebola, antimicrobial resistance, bioterrorism, anti-vaccination movements, hospital-acquired infections, opioid abuse, tuberculosis trends related to travel, maternal and child health gaps, and continued efforts to end polio and AIDS, to name a few. Towards the end of my program, I began to hear more about the dangers of humanitarian work and global health as stories involving health care and humanitarian workers being targeted in conflict-affected areas/fragile states were highlighted in various media outlets. I also knew of at least one faculty member at the university I attended whose global health team was attacked shortly after the individual returned to the US (after working in the field for a number of years).

When I entered into the public health workforce in 2016, Zika was just becoming a hot topic in public health circles in the U.S. But there were other things for me to learn at my local health department. I received an introduction to the Immunization team and programs such as Texas Vaccines for Children which enable young people in Texas to receive affordable immunization coverage (there is an adult vaccine program too). I also received an introduction to the statewide ImmTrac system that stores vaccine records and learned about some of its strengths and challenges. Ultimately, I was able to see the importance of public health collaborating with healthcare providers, schools, and community members to ensure that a community has adequate herd immunity or, in the case of outbreaks, can deliver effective interventions in response to infectious disease threats. Something else I learned about was the role of immunization clinics or point of dispensing units (PODS) during natural disasters, such as floods, and other public health emergencies.

I’ve shared some of my experience working at the local level because it gave me a tangible picture of how public health functions in stable environments or areas that are not weakened by natural disasters. In conflict-affected areas or fragile states, public health efforts may be fragmented at best. For example, in August 2015 Nigeria was removed from the World Health Organization’s list of countries with endemic Wild Polio Virus (WPV). This was the result of global efforts aimed at eradicating polio through targeted immunization campaigns. Nigeria went two years without WPV cases before, in August 2016, two cases were reported in Borno-a conflict-affected state. Two additional cases were reported in September 2016. The cases were from inaccessible areas of the state with limited security and indicated that prolonged transmission had gone undetected as a result of armed conflict. Although the number of areas held by insurgents, and therefore without access to vaccines, eventually decreased, the conflict in Borno prevented timely vaccination campaigns and posed a risk to Nigeria as a whole. Specifically, migration between Internally Displaced People (IDPs) camps and refugee communities resulted in a higher potential for WPV cases to be reported in states not directly tied to the conflict. A similar trend was noticed with the Ebola outbreak that occurred in West Africa from 2014-2015. The disease posed an increased risk in fragile states and areas affected by conflict. For example, prior civil wars in Liberia and Sierra Leone severely weakened the countries’ infrastructure in the 1990s. The conflicts also affected surrounding countries and resulted in millions of displaced people. In some of instances, countries had the resources needed to respond to public health emergencies caused by conflict. However, groups of people or areas deemed to be inaccessible as a result of conflict continued to undermine the effectiveness of immunization clinics and infectious disease response efforts.

A comparative analysis conducted by Bourdeaux et al. in 2015 assessed the effect of conflict on health systems in Haiti, Kosovo, Afghanistan and Libya.  Health systems were defined as, “the organized network of institutions, resources and people that deliver health care to populations” and was based on the World Health Organization’s (WHO) Framework for Action (2007). The framework highlights financing, leadership/governance, information, medical products/vaccines/technologies, health workforce, and service delivery as essential components of effective health systems. When this organized network is destroyed as a result of armed conflict, high levels of morbidity and mortality occur and can have negative effects that persist even after the conflict is over. The analysis found that the building blocks most affected by conflict and security forces were “governance, information systems and indigenous health delivery organizations.”  In order to address these gaps, a suggestion provided by the authors is to deploy Health Security Teams comprised of individuals with training in public health and institution building to conflict-affected areas and fragile states. The teams would support indigenous health systems instead of creating parallel or temporary systems, and not be involved in serving military interests. Additionally, these teams would know how to guide security forces as they engage with health systems in diverse political climates.

At this point in time in my career, most of my work is done in an office on a phone or computer. When I started my journey in public health, I pictured something different. I still have the long-term goal to work internationally (or financially support myself while volunteering internationally). However, I am sobered by the fact that if I want to serve those who are truly in need (especially as it relates to conflicted-affected areas and fragile states) I will have to be at peace with laying my life on the line. I will also have to be prepared to navigate the challenges presented above. This includes learning as much as I can about conflict resolution and negotiating to protect health systems. In general, I feel that public health has much to do in terms of educating and re-assuring those we serve (both domestically and internationally). As a result, part of my journey in public health will include developing skills as a connector of people and someone that can see both sides of an issue. I think that all public health professionals interested in working in a global health or humanitarian worker capacity should consider this. At the same time, immigrants or refugees that have left their homes due to conflict or in search of better opportunities can also develop the skills needed to resolve conflict and rebuild institutions. The success of the suggested Health Security Teams could depend on this.

 

Photo: Diane Budd, M.D.

conflict

Growth and challenges of health research in the WHO Africa Region: new analysis in the BMJ

This was cross-posted to my own blog.


I have always been devoted to the principle of evidence-based policy and decision making in public health, but I have taken a keen interest in the finer points of research and methodology since taking my current position as an epidemiologist (and contemplating the pursuit of a doctorate more seriously). Earlier this month, I spotted an article from BMJ examining the output of health research in the WHO Africa region from 2000 to 2014 (h/t to Dr. Ron LaPorte, professor of epidemiology at the WHO Collaborating Center at the University of Pittsburgh and co-founder of the Supercourse project). The article, entitled “Increasing the value of health research in the WHO African Region beyond 2015,” is a bibliometric analysis of the health research publications from the WHO Africa region indexed on PubMed; it analyzes the influence of various factors, including GDP, population, and health spending on the number and growth of published papers by country over the time period. The abstract reads:

Objective To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium.

Design Bibliometric analysis.

Data collection and synthesis In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications.

Results We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47).

Conclusions There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).

In the discussion, there is some fascinating commentary on the challenges facing researchers in the research and the barriers to publication, as well as to making those publications available to other researchers in the field. Some of them are familiar and strike me as a common symptom of the complicated relationship between politics and (especially evidence-based) policy making:

Although there is clearly a need for improving the performance of health researchers on the continent, African health decision makers should use the available research evidence to guide policy, strengthen practice and maximise the use of resources in order to improve the welfare of their citizens. However, there appears to be a failure to apply available research evidence to improve the health of populations on the continent. This unfortunate situation may be related to the lack of sharing of research evidence for translation into policy and practice, a non-alignment of research conducted in African countries to national research policies and/or the non-existence of national health research policies with clearly defined priorities.

However, others are somewhat unique to Africa. Not of them are economic (though funding plays a major role), and the paper goes so far as to describe some of the challenges as “intractable”:

The difficulties in research, publication, editorial bias and information access facing Africa are profound and seem almost intractable. Another difficulty facing African researchers is dissemination of findings to other parts of the world. Most of the information published in African journals is largely not included in major databases. Access to technological tools, information access and other equipment and supplies to ease research work is not always possible.

I hope this will influence the wider debate on the future of aid and health spending in Africa. The call for a shift in funding and emphasis from technologically-focused solutions to health-systems strengthening and sustainability has gained momentum, and research and academic exchange is a crucial part of the latter.

Opportunities Lost — Could Ebola Have Been Better Contained?

This blog post, by IH Section member Mary Anne Mercer, originally appeared on Huffington Post. It was co-authored by Scott Barnhart and Amy Hagopian.


In a desperate attempt to contain the highly contagious Ebola virus in Liberia, 50,000 people were recently quarantined in a slum neighborhood of Monrovia, whether they were sick or not. Imagine being trapped in an open-air prison without any sense of when you would be released. And if you get sick inside that slum, there is no organized system to take care of you.

Quarantining 50,000 poor slum dwellers is far different from quarantining a household, a plane, a bus or a boat. Why would Liberia feel driven to take such a drastic move when only a few of the residents in the area had Ebola? Such is the desperation of a country with a health system so weak that it has no other way to cope with an epidemic of any serious threat, let alone one this virulent.

Francis Omaswa, who led Uganda’s successful effort to control an Ebola epidemic in 2000, said last week, “Controlling the epidemic is about early detection, isolation, treatment of new infections, contact tracing, and safe handling of body fluids and the remains of those who die.” These routine infection-control procedures are not hard to implement, but doing so requires basic public health infrastructure. When a country has no capacity to perform these functions, desperate measures such as quarantining a whole slum can seem reasonable.

How did Africa’s health systems come to be so weak? Didn’t the United States and other major donors just spend billions of dollars on global health in Africa? In the process of providing all that care for diagnosing and treating HIV, preventing malaria and distributing vaccines, didn’t we build clinics and laboratories and train health workers and create medical records systems? Well, not exactly.

Recent major global health initiatives have been aimed almost exclusively at specific diseases such as HIV, TB and malaria, while strengthening the health system is typically an afterthought. Funding generally favors the private sector, particularly faith-based non-governmental organizations, and views with skepticism the role of public institutions such as ministries of health. The private health organizations proliferating across Africa lure health workers away from their jobs in public clinics and hospitals, usually offering higher salaries than governments can pay. Yet the over-riding responsibility to care for an entire population, including the poorest, resides with governments, which remain under-resourced and struggle to keep up with the needs of their citizens.

When the choice was made to invest in single-disease programs that were walled off from government health systems, we missed an opportunity. We could have developed the capacity to address other emerging health problems by building infrastructure: facilities, information systems, the work force, logistics and supply chains. Some donors hoped their disease-specific initiatives would “spill over” in a way that would strengthen the health system. Unfortunately, recent research shows this did not occur.

When the funds stop flowing to private organizations that implement these single-disease programs, the work stops. Weak health systems limp along until the next emergency, when another cycle of global health programs sweeps through.

Meanwhile, the routine burden of illness from malaria, pneumonia, diarrhea, TB, malnutrition and, increasingly, diabetes and other chronic diseases, continues to shorten life expectancy in Africa. Weak systems can’t effectively keep up with those problems, let alone the sudden shocks imposed by emerging diseases like Ebola.

What will help? For one thing, we must stop focusing on disease-specific initiatives implemented primarily through the private sector. Donor funding should go through ministries of health whenever possible, and flow from there to health facilities and staff. Health workers funded by external donors must be paid at the same salary scale as the public sector.

Finally, as Ebola has shown, feeble ministry of health surveillance systems must be bolstered. Better surveillance is a large part of why wealthier countries are at much lower risk of major epidemics than are nations with scant public health resources. Ebola would not be the crisis it is today if it had been recognized earlier, with contacts traced, quarantined and cases treated. But for that to happen, the essential elements of functioning health systems in the affected countries would have to be in place. When we hear stories of nurses dying because they didn’t have the simple protective equipment needed to care for Ebola patients, the gaps in those health systems become clear.

The expanding Ebola epidemic underscores the urgency of making investments in the health systems of African governments. Global health initiatives of the last decade largely missed an opportunity to strengthen health care capacity in Africa. Will we have another chance with the next epidemic? Let’s make Ebola the last one to trample across the continent because there are no health systems to contain it.

Mary Anne Mercer began life in rural Montana and recently returned to her Montana roots, where she is rehabilitating a small ranch near Red Lodge. She holds a doctoral degree in public health and is on the faculty of the University of Washington in Seattle, where she teaches global health. She has worked or studied in 15 developing countries, lived in rural Nepal and Thailand, and currently supports maternal and newborn care projects in East Timor for a nonprofit organization, Health Alliance International. In addition to academic publications, Mary Anne co-edited a book on the health effects of globalization, “Sickness and Wealth: the Corporate Assault on Global Health.” She was a silver Solas Award winner for Travelers’ Tales in 2012. During the academic year she also sings and studies writing in Seattle.

Scott Barnhart, MD, MPH, is Professor of Medicine and Global Health at the University of Washington. He has worked on health system strengthening in Haiti, Southeast Asia, and several countries in Africa.

Amy Hagopian, PhD, is Associate Professor of Public Health at the University of Washington. She has studied the migration of doctors and nurses from poor countries to rich ones, including Uganda, Nigeria, and the Philippines.