The Forgotten Health Inequality: Languages and Medical Information

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

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

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

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

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

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

An “epidemic of poor quality”: New study finds that poor healthcare quality leads to millions of deaths globally

This is part 1 of a 4-part series on global healthcare quality.

The Sustainable Development Goals (SDGs), the global effort led by the United Nations to prioritize and standardize development goals in every country for the period 2015-2030, offer ambitious targets when it comes to the world’s health. SDG 3 is focused entirely on outcomes of health and well-being, such as reducing maternal mortality, ending diseases like AIDS and malaria, achieving universal health coverage (UHC), and ensuring universal access to reproductive health care. Other SDGs, such as Goal 2 which calls for zero hunger and Goal 6 that aims for universal and equitable access to safe drinking water as well as equal and adequate access to sanitation, have obvious implications for health. However, a recent Lancet Global Health Commission, chaired by Associate Professor of Global Health Dr. Margaret Kruk of the Harvard T.H. Chan School of Public Health, has come to some surprising conclusions about health systems in low- and middle-income countries (LMICs). Despite a push in humanitarian advocacy and research to focus on increasing healthcare access in LMIC, it is the quality of healthcare that is received by patients in these environments that may require more of our attention. The Commission estimates that as many as 5 million die each year because they are receiving poor-quality healthcare- more than a million more people than those who die due to no access to care at all (3.6 million). That means that annually, 8.6 million people living in LMIC are dying due to poor-quality healthcare systems. Poor quality care can be dangerous for patients, provides misleading data points about healthcare system improvements, and may support corrupt and fraudulent behavior by parties with power in the health sector. Is it possible to achieve the SDGs in this environment?

Health systems should be judged on “what they do for people- not how many doctors they train.”

Dr. Kruk describes quality healthcare systems as based on three factors: effective care, trust of the people, and a system that is able to adapt, both in cases of acute emergencies and with a longer-term vision. While many advancements in access can be supported by metrics, it is possible that we haven’t been measuring some of the factors that really matter. Dr. Kruk told NPR that health systems should be judged on “what they do for people- not how many doctors they train.” The Commission’s study, which was published by the Lancet earlier this month, found that the millions of deaths each year that can be attributed to poor health systems included many deaths due to factors the SDGs explicitly seek to reduce, such as neonatal conditions and traffic accidents. While one of the central tenets of SDG 3 is UHC, the Commission argues that the quality of care “is not yet sufficiently recognized in the global discourse on UHC” and that countries undertaking policies that bring them to UHC “must put better quality on par with expanded coverage” to improve health. The Commission identifies several individual initiatives in LMIC that are developing mechanisms for quality measurement and improvement. However, it is clear that improving the quality of care has not received the effort that expanding access to care has achieved, which will undoubtedly undermine efforts to achieve the SDGs, even if UHC is attained. While expanding access to care must remain a global priority, we cannot discount the need to ensure that care given is of high quality as well. Several studies from LMIC during the period of the Millennium Development Goals (2000-2015) suggested that in some instances, expanding access to care did not lead to more positive health outcomes because the quality of the care received was poor. However, we still do not even have highly rigorous and consistent tools with which to measure healthcare quality across global contexts in a way that would allow for standardized measures and generalizable conclusions.

Aside from the historical focus on access to care by humanitarian and governmental actors, there a few other reasons that quality of care has not received the appropriate amount of attention of donors and policymakers. Healthcare systems in LMIC are generally disintegrated, with pockets of government services, humanitarian agencies, and private facilities operating throughout the country. This complexity allows for the intrusion of many political and logistical barriers to providing high quality care consistently. In the public sector, corrupt bureaucrats may opt to control who is able to receive jobs at healthcare facilities rather than allow for a merit-based system where poorly qualified staff could be replaced by qualified employees, regardless of political factors. For-profit providers who have disparate financial interests may not properly follow treatment or diagnosis guidelines that are critical to quality care. However, entirely closing low quality facilities would leave some citizens with no access to care at all.

Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, published a response to the Lancet Commission, agreeing that “nothing less than a revolution” is needed to ensure that high quality care is delivered in every health system around the world, an essential component of SDG 3. He posits that poor data is one of the largest barriers to improving healthcare quality, arguing that we must “go beyond counting simply what services are delivered to measuring how they are delivered.” He calls for a “global learning laboratory for quality,” where local lessons based on the “messy realities of health services” are prioritized, but where these lessons are then disseminated and can be implemented, measured, and compared in contexts around the world. Policymakers and practitioners working in LMIC must consider these factors when designing and implementing health services or research studies. The Lancet Commission points to five distinct foundations where learning and improvement in the process of care leads to higher quality: the needs of the population, governance in the health and non-health sectors, platforms of care, the healthcare workforce, and the tools needed to provide quality care. To avoid the rising “epidemic of poor quality” that the Commission found and to put LMIC on a successful path to achieving the SDGs, we can no longer ignore the pressing need to address healthcare quality just as much as access.

United Nations High-Level Meeting on Tuberculosis: Importance of drug quality

At the end of next month, the inaugural United Nations (UN) High-Level meeting on Tuberculosis (TB) will take place in New York to discuss the future of the bout against the devastating yet elusive disease. As TB remains the largest infectious disease torturer in today’s society taking the lives of 4500 humans each day, the theme of this occurrence is “United to end Tuberculosis: an urgent global response to a global panic”. This unparalleled step undertaken by governments throughout the world along with those allies engaged in ending Tuberculosis will address an assortment of issues at this meeting. Although the exact agenda has yet to be revealed, the resolution to host this single day meeting mentioned the following items could be discussed:

  • Adequate funding for novel diagnostic testing, medications, and vaccinations
  • Multi-Drug Resistant Tuberculosis (MDR-TB)
  • Responsibility for multisectoral collaboration within nation states, regions, and the globe
  • Universal health care coverage and ensuring tuberculosis coverage is included

Each of these items – ranging from the use of prophylactic low dose isoniazid therapy to equal distribution of the recently designed TB diagnostic test Xpert MTB/RIF – are crucial in accomplishing the END TB strategy laid out by the World Health Organization. However, after looking over these action items for the meeting, Tuberculosis drug quality seems to absent.

As health care professionals across the globe continue to treat TB on a patient specific basis, certain untreated cases occur that puzzle even those who have treated the disease for years. The reasoning behind treatment failure? Adherence to medication or drug resistance are often the first assumed thoughts those sharing their patient’s fate may have. Yet, the actual medicine with its various active and inactive ingredients is often not called into question.

Towards the end of last year, the World Health Organization released an alarming figure concerning drug quality in low to middle income countries. In the report released to the public, WHO stated that approximately 10% of medications are counterfeit in these areas of the world – which happen to be the areas where Tuberculosis and other infectious diseases take their largest toll. In addition, WHO added that this percentage is most likely only a small part of the number of humans truly affected by counterfeit medications. To provide clarification, WHO considers counterfeit medications to be unapproved by regulators, unable to meet quality standards, or purposefully misrepresented active or inactive ingredients in the medication. In addition to this report by WHO, the National Institutes of Health (NIH) published a report outlining in 2015 that 9% to 41% of anti-tuberculosis and other infectious disease medications failed to meet the standards sought in specific studies.

It is vital for the global health community to obtain an effective vaccine to prevent pulmonary tuberculosis, to have a rapid yet specific TB diagnostic test, to create a strategy for various sectors of a nation state to work together in ending TB, and novel agents to treat the most severe cases of MDR-TB. Individuals in rural Kampot, Cambodia, inmates in the Russian prison system, or those residing in the slums of Bangalore, India often can be restored to health through the means that have been available for the last half a century. The RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) regime has proven its success in treating non-resistant tuberculosis – so long as each of the medications are of appropriate quality. However, The Lancet released a report in January 2017 that found that 8.9% of Indian rifampicin products were of inadequate quality in a country that is burdened with the highest prevalence of tuberculosis across the globe. Moreover, WHO revealed that 28.3% of rifampicin containing medications found in the Russian Federation in 2011 failed to meet predetermined specifications for proper quality – a country known to have one of the highest MDR-TB burdens in the world. With the aforementioned statistics released by the WHO, The Lancet, and NIH, a renewed emphasis needs to be placed on ensuring the quality of each and every tuberculosis medication that reaches a human being. The possibility of one in ten (or more) TB medications being counterfeit will continue to lead to failed treatment regimes, inappropriate use of resources, and spread of MDR-TB even if innovative technology is developed.

In order to combat counterfeit medications on a global level, the World Health Organization developed a reporting system for the interconnectedness of the medication market. The Global Surveillance and Reporting System (GSRS), that all WHO members are eligible to contribute to, aims at collecting data on falsified medications, vaccines and other medical equipment to address real-time situations and prevent further harm. With this reporting arrangement in place, the WHO has reacted and thwarted mortality and morbidity associated with counterfeit medications – including the contaminated cough medication supply that led to 60 deaths in Pakistan and a number of individuals treated with an antidote in Paraguay in 2013. On top of the GSRS, WHO has implemented Good Manufacturing Practices (GMP) that each manufacturer should achieve in order to be certified by WHO; thus, providing a reliable source of medications that nation states can purchase from. Although these initiatives have brought about encouraging results along with halting global medication emergencies, there are still barriers that accompany these programs. The technical training, technology, and adequate staffing to properly identify and report through the GSRS is often difficult to obtain in the developing world while GMPs are often misapplied and have inadequate supervision. The root cause is the long-term development of countries’ public health systems – of which continuing problems with counterfeit medications remains deficiently addressed. A county’s public health care system is the vital organ to ensuring quality medications through these mechanisms that WHO has created and employed. An underutilized and under resourced public health care system leads a budding yet unregulated private market – unable to ensure proper treatment for those seeking it.

Since the United Nations declared this a high-level meeting, meaning all heads of member states are encouraged to participate in the highest level possible, this venue provides the ideal opportunity to recommit to guaranteeing TB drug quality. The sustained empowerment of the public health care systems for those countries tirelessly battling tuberculosis will be a step forward into truly ending this devastating disease. Each health care professional spanning the globe has a responsibility to accompany these governments, colleagues, and fellow humans by investing their time, resources, and talents to develop procedures and systems to ensure effective drug quality.

Access to PrEP under NHS England: My trip to London

Pre-exposure prophylaxis (PrEP) is a way to prevent HIV infection for people who do not have HIV but who are at high risk of getting it by taking the pill everyday. When someone is exposed to HIV through sex or injection drug use, PrEP can work to keep the virus from establishing a permanent infection. Individuals who take 7 PrEP pills per week, have an estimated level of protection of 99%. It is a powerful prevention tool combined with condoms.

In the United States, PrEP became available in 2012 by the FDA and can be accessed in most clinics and hospitals and is free under most insurance plans. As of 2017, there are an estimated 136,000 people currently on the drug for HIV prevention. This is not the case in the United Kingdom. As a part of a research project for my MPH degree I traveled to London, England to meet with members from the LGBT community, advocates and public health professionals and to learn more about access to PrEP under the National Healthcare System (NHS) England. Currently, PrEP is not available under NHS England even though HIV continues to be a prevalent problem in England, namely among men who have sex with men (MSM) where approximately 54% of the total of MSM population were diagnosed in 2015. England is however enrolling 10,000 people over 3 years through the PrEP IMPACT trial.

Wales, Scotland, and Northern Ireland are also a component of the NHS. Wales has commenced their PrEPared Wales project, which provided information on where to access PrEP in the country. Scotland is currently the only country in the UK that offers a full PrEP provision through their NHS. Northern Ireland currently has no provision of PrEP.

The NHS is widely regarded as a remarkable system, allowing UK citizens to access certain free healthcare services. England has had some shortcomings however when it comes to preventing HIV and I was interested in learning more. I visited the Terrance Higgins Trust (THT), a British charity that campaigns on and provides services relating to HIV and sexual health. In particular, they aim to end the transmission of HIV in the UK, to support people living with HIV (PLWH), and decrease stigma around HIV. I met Greg Owen, the founder of iWantPrEPNow, a website that explains why it is important for HIV protection, who might consider PrEP, what you need to do before you start, where to buy it online, and how to take it. I also met with Will Nutland, who works alongside Greg and is the founder of Prepster, a guide and movement to safely buying PrEP. Both websites have experienced a lot of traffic since the IMPACT Trial began in October 2017. The trial seems like a step in the right direction when it comes to accessing PrEP, this is not the attitude for many and there continues to be a debate.  While there is significant evidence from other trials that demonstrates PrEP is an effective HIV prevention tool, many people believe that NHS will not endorse PrEP after the trial is complete.

I asked Liam Beattie, also a member of the THT team, why he believes NHS England did not endorse PrEP under its guidelines. He believed that it was because of 1. homophobia among the NHS and 2. the media. Liam was recently interviewed on BBC News. During the interview, PrEP was categorized as a “controversial drug,” which paints a negative light on the topic from the get-go.  While England is well-developed and progressive in so many ways, HIV is still known as the “middle-aged gay male virus.” THT and other organizations continue to develop new marketing tools and programs in order to target women, transgender persons, and people of color to visit a sexual health clinic and get tested. Taking PrEP is an advantage for not only the individuals health but the overall cost of healthcare. Many are hopeful that in the future, the NHS will work with organizations like THT to promote PrEP and other educational resources to prevent HIV.

The next big thing in global health innovation? A little less innovation, a little more implementation

A post like this should come with the qualification that I am no luddite when it comes to technology and innovation in global health. Quite the opposite actually. I have dedicated my entire career to championing ideas. Whether that was working in academic research evaluating new ways of helping people with chronic diseases live well or researching the technology and innovation pipeline to help healthcare organizations make decisions on what technologies and innovations to invest in; I have been and will continue to be a health technology and innovation advocate (and when I talk about innovation, I’m not just talking about clinical and biological technology or information and communication technology but more broadly about new programs, interventions, etc).

Five years ago I embarked on a new career path in global health which transformed the way I now think of innovation. One of my first projects was to help a local partner organization implement a logistics management information system to manage their post-rape care medication inventory. Since then, I have helped our partners through the process of implementing other technologies and in that short time, I learned the many pain points of implementing innovations.

When you have spent a good part of your career as I did working in controlled research environments where the protocol is often laid out months ahead of time with little room for deviance and with study participants who are often given incentives to participate, working on the last mile problem required a skill set refresh and a change in the way I viewed the innovation pathway. Whether it is learning how to integrate an innovation into a user’s workflow; getting users to trust you enough to tell you when something is just not working for them; finding out how to get innovations to stick; making mistakes and reiterating; using real-time data to enable feedback loops; understanding (and dealing with) organizational politics and leadership; mapping out relationships, etc. – graduate training in public health does very little to prepare you for the trial by error approach required for these undertakings. Researching and evaluating is very different from implementing. So many of us in this field spend much of our time working on research studies and programs based on the models and theories we’ve learned in school that we very rarely think closely about whether or not the studies or programs we work on are scalable, sustainable, or even ethical.

I recently attended a panel at Stanford consisting primarily of philanthropic organizations discussing how those of us working in the social sector and those of us supporting the work need to rethink innovation in terms of scale. One of the things that struck me during the discussion was that when it came to what metrics we use to define success we’re often talking about success on a small scale.  And too often they’re developed with the mindset of pleasing the donor or funder. When we think success metrics, we usually talk about some quantitative statistic that goes something like this: X% reduced morbidity or mortality in our sample size of N. At the end of the study or funding period, we leave the site, taking with us our intervention. We then go on to write a paper about it, submit it crossing our fingers it gets accepted in a high impact journal, we publish it, we present our ideas at conferences. We then call it a success and move onto our next grant.

While this is often the gold standard of success for academics and should still remain an important part of the innovation pathway, there are parts of this road to innovation success that are concerning, especially in the low-resource settings we work in. Firstly, is it ethical to put in an innovation into a site and then remove the intervention once the study period is over if we know it has helped them? Would the site be even able to afford the innovation once it passes the research phase? Secondly, is it enough to define the success of an innovation by saying the intervention did what we wanted it to do? After all, I’m pretty sure a company like Facebook didn’t call themselves a success after running a small study of 250 users that found that everyone liked the product and it changed their lives. They are successful because they have 1.94 billion daily active users worldwide (scale) and have been around for 14 years (sustainability) and they have changed the way we connect with others.

Dear global health colleagues, we have an enormous task at hand. One that requires us to roll up our sleeves and stop thinking small and start thinking big. Let’s end this epidemic of health technology pilotitis and start innovating in the implementation space. Let’s start thinking about ways of innovating outside of the academic space and in real-world settings with real-world obstacles. Implementing innovations demands collaboration so let’s also make sure that we influence those around us. We need to change the conversation on impact and start asking our colleagues and the organizations that support our work to start thinking about the long game. From there we need to make it easier to decide which technologies and innovations to adopt. Let’s also not forget about training our next generation of public health professionals to focus on creating true impact by teaching effective implementation in schools.

Implementation work is incredibly unsexy and a risky investment but needs to be the next big thing in global health as its value proposition is substantial. It is of notable importance when the future of funding for global health is becoming more uncertain. We need now more than ever to deliver long-lasting solutions, not just short-term fixes.

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A study looking at the proportion of children’s health grants funded by the US National Institutes of Health and the Bill and Melinda Gates Foundation found that 97% of grants were for developing new technologies and only 3% for improving delivery and use of existing technologies. Additionally, they found that new technologies would only reduce child mortality by 22% compared to 63% if existing technologies were fully utilized.

Although this study looked only at children’s health grants, the implementation gap can be found universally throughout global health. Learn more about how to bridge the “3/97” gap: