Public health professionals condemn threats to health for Palestinians

By Cindy Sousa, International Health Section

The Palestine Health Justice Working Group, a committee of the American Public Health Association’s International Health (APHA-IH) Section, issued a statement last week focused on health justice for Palestinians. In it, they went beyond calling for a cease-fire to condemning ongoing settler-colonial violence and oppression by the Israeli government against Palestinians. The statement launched on Wednesday, May 19. Within 24 hours, they had 350 signatures from public health professionals across the globe (public health workers, social workers, physicians, nurses, medical students, and researchers, among others). By Saturday, May 22, this number had risen to 500 supporters.

To read the full text of their statement and to sign on: click here.

Pharmacy and Entrance to UNRWA Nuseirat Health Clinic, Gaza Strip, 2015. Photo by Ron J Smith.

Over the past month, Palestinians have seen spiraling violence at the hands of Israeli military forces, police, and private mobs. But the attacks of last week – following Palestinian resistance to the eviction of Palestinians in the neighborhood of Shiekh Jarrah by Israelis – were the worst in years. Between May 10 and May 21, the Israeli military killed at least 230 Palestinians in Gaza, including 66 children; injured almost 2,000; and temporarily displaced more than 77,000. In the West Bank, Israeli forces killed 27 Palestinians and injured 6,794 more. Israel destroyed or damaged six hospitals and nine healthcare centers in Gaza, including a clinic that housed its only coronavirus testing lab, and killed two of the most prominent physicians in Gaza: Dr Ayman Abu Auf, head of the internal medicine department and Coronavirus response at Gaza’s largest hospital al-Shifa and Dr. Mo’in Ahmad al-Aloul, one of the few neurologists in Gaza.

The violence has taken an extreme toll on Palestinians, a community already suffering from hostility, such that on April 27 of this year, Human Rights Watch released a report condemning Israeli authorities for “crimes of apartheid and persecution.” Israel has undermined Palestine’s public health system for decades, through blockades and direct attacks. These efforts have undermined efforts at containing COVID 19.   Vaccine access disparity reached such a critical point that many described it as institutionalized discrimination and as medical apartheid. These practices are especially damaging when viewed within the framework of ongoing occupation and deliberate gutting of the Palestinian health-sector under Israeli settler-colonial rule. On this point, Osama Tanous, a pediatrician and volunteer with the mobile clinic of Physicians for Human Rights-Israel in Gaza, described the larger context of the most recent attacks on Gaza, pointing out, “Healthcare infrastructure in Gaza was already heavily damaged by decades of Israeli de-development and siege. Now it has suffered additional, direct attacks on facilities and workforce.”

While the group was heartened last week by the news of cease-fire, their statement called for more, including independent investigations into the short- and long-term physical and mental health implications of the actions of the Israeli government. They are especially concerned about ongoing attacks on civilians, healthcare, and healthcare workers, which are in clear violation of international law and the ethics of public health. Palestine Health Justice Working Group also emphasizes that their statement – like their ongoing work – is not just about the most recent events, but about decades of violence and oppression against Palestinians. Group co-chair and global health scholar Yara Asi, asserted, “While our statement addressed the immediate need for a lasting ceasefire, this statement goes further, to situate the violence in its historical context. The public health community is very much seeing the need to act on our professional ethics to promote ongoing justice in Palestine and Israel – not just for this week, but for the long-term.”

Regarding the need to situate the violence of last week within a larger context, last week human rights experts from the United Nations called for an International Criminal Court investigation into not only the most recent Israeli attacks against civilians and healthcare facilities, but also wide-spread evictions and illegal transfer of Palestinians by Israelis, along with the ongoing constraints on Palestinian housing, education, and freedom of movement.

In support of the statement, Mads Gilbert, a Norwegian physician trained in emergency medicine who has been working with Palestinian doctors for four decades, said, “I’m a medical doctor. I’m trained to treat root causes of suffering, not just symptoms. The Israeli occupation, colonization of Palestine, and brutal apartheid that underlies the health crisis in Palestine must end.”

The majority of signatories are from the United States, with others signing from the UK, Egypt, Canada, Spain, Israel, and Palestine. Dr. Yasser Abu-Jamei, a psychiatrist in Palestine and head of the Gaza Community Mental Health Program, said, “This statement sends a positive message to all supporters of the Palestinian struggle. We see justice getting closer and closer. No matter how difficult life is for us now, our dignity and our rights to health and to freedom are increasingly recognized, in this case, as the statement demonstrates, by a growing public health community concerned with justice for Palestine.”

The statement by the APHA-IH working group joins with at least four other statements issued by health professionals aimed at addressing not only immediate fatalities, but also the health harms of the ongoing Israeli settler-colonial project in Palestine. Statements were also issued by People’s Health Movement; Jewish Voice for Peace (JVP) Health Advisory Council; Equal Health’s Campaign Against Racism; and a group of Canadian Health Workers. Other professional groups have issued calls, including a wide-ranging group of scholars; The National Women’s Studies Association (NWSA); Middle East Studies Association; the Middle East Section of the American Anthropological Association; and others.

Rachel Rubin, another co-chair of the Palestine Health Justice Working Group, who is also on the steering committee for the JVP Health Advisory Council, notes, “What we have seen this May is an increasingly urgent insistence that justice in Palestine is a compelling health issue, one that requires us to act on our ethical imperatives to promote freedom and oppose all forms of violence including settler-colonial control of Palestine.”

It was exactly this sentiment that led to the formation of APHA’s International Health Section Palestine Health Justice Working Group several years ago. The working group began as a network formed within the International Health Section to pass an APHA policy statement on the health harms of Israeli settler-colonial violence and oppression in Palestine. Serving as a forum for interaction, support, information exchange, and activism, the group works to raise consciousness about the issue among APHA members and other health professionals – through education at the APHA annual meeting and other venues, and through promoting the work and leadership of Palestinian health professionals.

As an organized body within APHA focused on health justice in Palestine, The Palestine Health Justice Working Group works not only externally, but also within APHA to pressure the organization to use our collective voice, as one of the leading global public health organizations, to voice opposition to Israel’s continual assaults on Palestinian health and freedom, as APHA has in contexts of Iran (#277718), Iraq (#200617), South Africa (#9122), Nicaragua (#8306), Yemen (LB19-13), and other locations.

The group’s statement aligns with several APHA resolutions, which have held that the prevention of genocide (#200030), the health effects of militarism (#8531), the health of refugees (#8531), law enforcement violence (#201811), attacks on healthcare workers (#201910), and health within armed conflict and war (#20095) are public health matters deserving of our attention and action. The statement also pushes APHA itself, as the Governing Council has–in four separate attempts (2008, 2009, 2012 and 2013)–failed to pass proposed resolutions expressing concern about how the Israeli occupation has undermined the health of Palestinians.

Site of the Wafa Rehabilitation Hospital, Gaza Strip. Destroyed in Israeli bombing raid July 23rd, 2014. Photo by Ron J Smith.

“People’s views are changing,” says Amy Hagopian, long-time section member and 2018 recipient of the section’s Victor Sidel and Barry Levy Award for Peace, who co-authored these resolutions, “APHA members are beginning to see through the rhetorical devices used to shut down debate on Palestine. This topic scares people because they think it’s too complicated, or they don’t want to be accused of being anti-Semitic, or the don’t see the connection to public health.  Maybe the meaningful conversation about Black Lives and police violence in the U.S. over the last year has helped people connect some dots. The widespread support for this statement – and others like it – demonstrate that APHA could have this conversation in a respectful way, and step up to advocate for health justice for Palestinians.”  

To get involved, people can join our Palestine Health Justice Working Group meetings at APHA’s annual meeting each year, or send a message to apha-palestine-health-justice-working-group@googlegroups.com. Please be sure to attend their invited session at APHA’s 2021 Annual Meeting: Sovereignty as a core determinant of health: The imperative for both social connection and independence, as well as other sessions that will be held on Palestinian health justice.

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;

Empowering Women to Take Control of their Sexual Health

Two weeks ago, I attended a powerful and motivating summit hosted by Florida International University (FIU) Robert Stempel College of Public Health and Social Work on empowering women to take control of their sexual health through knowledge of biomedical HIV prevention methods, connecting to community resources, and mobilizing key community stakeholders and providers.

What was most unique about this summit was the rawness of the various conversations. These conversations included voices of state congresswoman Frederica Wilson and Ileana Ros-Lehtinen, community women and activists, a panel of diverse physicians and nurse practitioners, researchers, and LGBT and minority women working across different sectors in the HIV prevention field. When it comes to empowering women surrounding their sexual health, pre-exposure prophylaxis (PrEP) is viewed as the driving vehicle. The problem is that there is a lack of awareness among women particularly LGBT and minority women, and providers about PrEP and post-exposure prophylaxis (PEP). During the engaging providers panel comprised of various physicians working in South Florida, a Haitian physician expressed that before the conference he decided to call several of his provider friends that practice within the local Haitian community and asked them if they have heard of PrEP. How many do you think said, “Of course, I know about PrEP”? The answer is…0. Not one single doctor whom was asked said they have heard of PrEP. We have a lot left to do. The work has not yet been done!

Miami’s HIV Epidemic

So maybe you are wondering…well why host this conference? The county of Miami-Dade continues to lead the nation in new HIV infections. Not too far away is the neighboring county of Broward which continues to compete with Miami when it comes to high prevalence rates as well.

Due to the rising rates of HIV in Miami-Dade County, city officials have responded to the epidemic with the development of a “Getting to Zero” task force comprised of city commissioners and individuals representing various public health agencies throughout Miami-Dade County as well as the state of Florida. The task force devised a multi-pronged action plan with priority goals for the next two years. The plans include to (1) reduce the rates of reported AIDS cases, (2) reduce the percentage of newly diagnosed HIV cases among residents aged 13-19 (3) increase the percentage of newly identified HIV-infected persons who are linked to care within 90 days of diagnosis and are receiving appropriate preventive care and treatment services in Miami-Dade County and (4) reduce the number of newly reported HIV cases in Miami-Dade County (http://www.miamidade.gov/releases/2016-09-29-mayor-getting-to-zero.asp).

Prep around the globe

PrEP has served as a vehicle for prevention and is being used worldwide. Countries such as the United States has large scale PrEP programs while others are still in the stages of development and some have not implemented as of yet. There has been many PrEP initiatives enacted. The US Agency for International Development (USAID) is currently supporting 5 Microbicide Product Introduction Initiative (MPii) projects in Kenya, South Africa, Zimbabwe, Malawi, and Uganda from 2015-2020 focused on gender-based violence, drug resistance, creating demand, introducing new products, and models for delivering services. Another program is the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative, a collaborative effort between US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare. DREAMS aims to reduce the incidence of HIV by 40% among adolescent girls and young women by 2020 in the highest HIV burden countries including Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of the 10 countries, 5 have included PrEP for adolescent girls and young women in their strategic plans to address HIV. Recent data from PEPFAR shows significant declines in new HIV diagnoses among adolescent girls and young women. In the 10 African countries implementing PEPFAR’s DREAMS partnership, the majority of the highest HIV-burden communities or districts achieved greater than a 25 percent–40 percent decline in new HIV diagnoses among young women (https://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/dreams). In other areas of the globe such as Latin America and the Caribbean, a combination of biomedical, structural, and behavioral interventions is greatly needed in order to reach target objectives and goals and ultimately increase HIV prevention efforts. I am excited to see the future of PrEP.

Women’s Perspectives

During the women’s perspectives breakout sessions, workshops were broken down into specific focus groups including African American, Latina and Haitian. Amongst the African American women breakout session, some key topics that were addressed included stigma, specifically communication between the medical provider and client such as clear language on how to ask questions during the appointment while also considering time constraints, policy, and the need for funding toward effective behavioral interventions for HIV negative black women in the community.

Sistas Organizing to Survive (SOS) is a grassroots mobilization of black women in the fight against HIV and AIDS. In Florida, one in 68 non-Hispanic black women are known to be living with HIV/AIDS and has been the leading cause of death among black women aged 25-44 years within the state. (http://www.floridahealth.gov/diseases-and-conditions/aids/administration/minority-initiatives.html)

Call to Action

Miami is the #1 city in the United States with new HIV infections. This is a huge public health issue. We have a call to action to advocate for ourselves and others when it comes to ending the epidemic. We have made significant strides, but the work has not yet been done. Sexual health including HIV prevention should be something that we freely discuss with our family, colleagues, peers, physicians, and anyone that we come in contact with that is willing to listen. It is these conversations that we can decrease stigma surrounding HIV. Women across the counties of Broward, Miami-Dade, and Palm Beach have answered the call to action by organizing and advocating for all women. We have accepted the call to action together that we can get Miami to Zero!

“A future where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

–Quote from the National HIV/AIDS Strategy Updated to 2020: Strategy Vision

For additional information, please visit http://www.who.int/hiv/topics/prep/en/ http://amp4health.org/ and http://getting2zeromiami.com/

Conference Reflections: Emergency Preparedness & International Health – Different Fields, Same Goals

Last week I was given the opportunity to attend the Preparedness Summit in Atlanta. This conference is the first and longest running national conference that discusses and revolves around the world of public health preparedness (think: natural disasters, medical countermeasures, flu, Zika and Ebola responses, biological threats and much more). There were many different opportunities to learn about preparedness activities including plenaries, small discussions, learning sessions and networking with local, state and federal partners. It was overwhelming, but in a good way!

As an epidemiologist, I have some experience and background in public health preparedness activities, but my main interests and time have always been spent with infectious diseases and global health initiatives. When I worked for the state health department, I actually was on a team that was half epidemiologists and half preparedness staff and we continually supported each other’s activities. Those experiences helped me with preparedness lingo and acronyms used during the conference so that things didn’t go completely over my head. However, I would not consider myself a preparedness expert by any means and soaked up as much as I could from the various sessions I attended.

One of the most exciting activities from the week was visiting the Emergency Operations Center (EOC) at the Centers for Disease Control and Prevention (CDC). This EOC is the center that gets activated in a public health emergency and where experts gather and get ready to respond. The main room of the EOC is spacious, with many computers, television screens and telephones set up and ready to be filled with points of contacts from different divisions and organizations. When there’s not an emergency response going on (like on our tour), it’s actually pretty quiet. However, staff are still on call working to monitor information and sift through potential threats. During a response, I’m sure the place is bustling with people, calls, information sharing and meetings. It was a neat experience to be in the center communication hub where past emergency responses like Hurricane Katrina in 2005 or the 2014 Ebola outbreaks took place.

I did some research after attending the summit and found that the EOC has become an integral part of meeting the goals of the “Global Health Security Agenda (GHSA)”. This agenda is focused on “accelerating progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Over 50 countries have joined in partnership with the U.S. to meet this objective and the CDC aims to activate the EOC and respond within 2 hours of any mandated public health emergency. There’s even a fellowship offered by the CDC called the “Public Health Emergency Management Fellowship” that provides an opportunity for public health workers to learn and train over a four-month course then go back to their respective countries and create their own local EOCs. Emergency management experts can also be sent to these countries and help guide and train responders in their own environment if needed.

This post-tour research made me start thinking about the importance of the EOC and preparedness in relation to international health. Public health threats (like pandemic flu, Zika, Ebola) of any degree can happen at any time at the local, state, national, or international level. Bill Gates recently spoke out about the necessity of being prepared for public health threats such as these at the Massachusetts Medical Society 2018. He stressed how unprepared we are for the next epidemic and the world’s need for a “global approach” with “better tools, an early detection system, and a global response system”. Gates’ is most likely alluding to the poor handling of the Ebola outbreaks in the recent past. These are a perfect example of why the field of preparedness is so important to global health. During Ebola, public health response was “too late” and there were too many “deaths that could have been prevented”. There were many disagreements among global health leaders over things like travel bans, how to handle public panic and how to best respond. The aftereffects of the outbreak point to the integral link between a strong preparedness field and international health that was lacking. Gates’ argues that we weren’t prepared to handle prior outbreaks, but we are capable and should spend time and money on planning and preparing for similar epidemics in the future.

Overall, these events – the conference, EOC tour and recent news and outbreaks – have helped hit home that these different public health fields, although working in slightly different capacities, are really aligned and influential on each other. Ultimately, preparedness and global health are working to reach the same goals of keeping our planet safe and healthy and we must first be prepared for any global threat in order to achieve these goals. Today, I feel refreshed in my perspective of the field and inspired and hopeful of future preparedness efforts. I no longer feel that preparedness and international health belong in the different boxes or divisions I’ve created in my mind, but as two parts to the same path.

I challenge other public health workers to also think about the important link between preparedness and global health and advocate for changes that strengthen this partnership. The Preparedness Summit conference is a great starting place and I encourage all fields of public health workers to look into it! I truly believe the more you learn, the more you see how everything is connected and the better you are able to achieve your public health goals … and maybe find some new teammates from other fields to help you along your journey, too.

 

A Highlight from National Public Health Week: North Dakota State University’s “New Perspective on Refugees Roundtable”

Every April, the public health community celebrates National Public Health Week.  National Public Health Week is a time in which we recognize the amazing contributions of public health professionals and highlight the pressing public health issues important to improving our nation’s health. This year’s National Public Health Week theme was Changing our Future Together.

IH Section Councilor Mark Strand organized a roundtable entitled A New Perspective on Refugees in the Community: Changing our Future Together at North Dakota State University where he is a professor. 40 attendees from 12 countries participated in this National Public Health Week event which was held on April 3rd. Attendees learned many things they didn’t know before:

(1) At least one member of the family is working within 6 months of arriving in the U.S.

(2) Over an adult’s first 20 years here, a refugee pays approximately $21,000 more in taxes than they receive in social service benefits.

(3) There is no evidence for increased crime rates among refugees.

(4) There are many positive impacts resettled refugees make on their new communities.

Visit their Facebook post for a look at some of the photos from their event:  https://www.facebook.com/ndsu.chp/posts/10160362153045694

Share your National Public Health Week highlights with us for a chance to be featured on our blog!