Global Health in Conflict: A Weightier Commitment

by scanyatonwu, posted in APHA IH Section, Careers, Community-Based Primary Health Care, Conflict and Health, Disaster Response, Health Systems, Infectious Disease

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

Global Health Photography Feature Opportunity

by ihsection, posted in APHA IH Section, Section Announcements

We are inviting International Health section members to submit their global health photos to share their global health experiences with other section members. Accepted submissions will be featured on the APHA IH blog or the Section Connection newsletter and may be used in APHA IH materials. This opportunity is ongoing and submissions are accepted at anytime, subject to the approval of the APHA IH Communications Committee.

Who can participate?

American Public Health Association International Health section members are encouraged to participate. All photographs submitted must be taken by the person submitting them.

What photos are you looking for?

We encourage members to send different types of global health photos whether that highlights their global health work or brings awareness to an important global health issue. As such, subject matter can vary between landscapes, photos of healthcare facilities, people, global health events, etc.

How do I submit my photo for consideration?

Each section member can submit up to two high-resolution photographs in a JPG file format. Please use the following naming convention for each photograph file: lastname_firstname_number (e.g. Smith_Jane_1).

In your submission, please include the following information in a MS Word Document:

  • Your Name:
  • For each photograph:
    • Title:
    • Brief description of photo as it relates to your global health work or bringing awareness on an important global health issue (250 word maximum):
    • Location of Photograph:
    • For photos with faces, confirmation that you received, at the minimum, verbal consent: Yes/No

Submissions should be sent to ihsection.communications@gmail.com.

Ethical Considerations

If you are submitting photographs of people, please make sure you have taken into consideration the following:

  • Did you obtain verbal consent from the person or people you photographed?
  • If the photos are of children, did you obtain verbal consent from their parents or guardians?
  • For photos of people from vulnerable populations (e.g. persons living with HIV, refugees, etc), ensure the utmost respect for their privacy and that you have followed any applicable rules or customs (e.g. hospital or clinic photography rules).

For more information on ethical considerations in global health photography, please visit the Unite for Sight website.

Conditions of Submission

Submissions are reviewed by the APHA IH Communications Committee and will be accepted on a rolling basis. If accepted, a participant’s photo and story may be shared via the APHA IH Section Connection newsletter or the APHA IH blog. Additionally, participants agree to the unlimited, royalty-free license to use their photos for APHA IH section materials including but not limited to IH section informational flyers and brochures, social media, the APHA IH Connect website, and the APHA IH Section Connection newsletter. This agreement will remain in place until canceled in writing by the submitter or the IH Communications Committee.

For more information, please contact Jean Armas at ihsection.communications@gmail.com.

Global News Round Up

by abbhirami, posted in APHA IH Section, News

Politics & Policies

William “Bill” Steiger, a global health official under former President George W. Bush who crossed swords with many scientists, is now advising President Donald Trump.

After the Trump’s administration submitted a budget to cut foreign aid, the world’s wealthiest man and co-founder of Microsoft Bill Gates met with President Donald Trump to discuss progress in programs for global health and development as well as domestic education.

In President Trump’s proposed budget, there’s a $54 billion bump in military spending. U.S. foreign aid would be cut by 28 percent. Global health spending beyond AIDS, malaria and vaccines will suffer.

The American Society of Clinical Oncology (ASCO) today issued a clinical practice guideline on human papillomavirus (HPV) vaccination for the prevention of cervical cancer. This is the first guideline in primary prevention of cervical cancer that is tailored to multiple regions of the world with different levels of socio-economic and structural resource settings, offering evidence-based guidance to healthcare providers worldwide.

Programs, Grants & Awards

March 21 was World Down Syndrome Day.  The need to receive proper education, to get a job, to live with independence, to catch up with friends, to play sport, to fully exercise our rights as equal citizens are important aspects of life for each of us and needs that no one would dream of defining as “special”. Yet for people with Down syndrome, the label of “special needs” is often used to describe them and their needs.

The Golisano Foundation and Special Olympics, the largest public health organization for people with intellectual disabilities (ID), honored the Beijing Tongren Eye Hospital, Capital Medical University in Beijing, China for coordinating medical professionals throughout China and ensuring sustainable eye health and treatment access are available to Special Olympics athletes.

Research

Assess the prevalance of metabolic syndrome (MetS) among patients in rural Lesotho who are taking first-line anti-retroviral therapy (ART) containing either zidovudine or tenofovir disoproxil.

In this analysis, we examine the effect of wages on obesity by constructing pseudo-panels to conduct a dynamic estimation of Grossman’s human capital model. The results indicate that wages have an increasing effect on obesity status.

To examine county-level geographic variation in treatment admissions among opioid treatment programs (OTPs) that accept Medicaid in the continental United States.

We analyze the evolution of mortality-based health indicators in 27 European countries before and after the start of the Great Recession. We find that in the countries where the crisis has been particularly severe, mortality reductions in 2007–2010 were considerably bigger than in 2004–2007.

Over the next 20 years, there will be 49 million new cases of HIV, a mathematical model has indicated.  This number, however, could be drastically reduced if current interventions are acted upon and a vaccine is introduced in the next four years.

Diseases & Disasters

A small but growing number of pain doctors and addiction specialists are overseeing the use of marijuana as a substitute for more potent and dangerous drugs. Dr. Mark Wallace, chairman of the division of pain medicine in the department of anesthesia at the University of California, San Diego, said over the last five years he has used marijuana to help several hundred patients transition off opiates.

People who wake at night with an urge to go to the bathroom may need to cut back on salt in their diets, doctors from Japan are suggesting.

Technology

The National University of Singapore (NUS) and Holmusk, a digital health and data analytics company, signed a Memorandum of Understanding (MOU) recently to explore collaborations for improving healthcare delivery in the region.

A new diagnostic tool to test for up to 7 micronutrients using a single serum sample has been developed by Quansys in collaboration with PATH. This multiplex tool can help gather national data on micronutrient status and use these data to implement appropriate interventions.

Environmental Health

Hydraulic fracturing, more commonly known as fracking, has the potential to affect drinking water resources in the U.S., the Environmental Protection Agency announced in December.

Equity & Disparities

Health and health care disparities, which are differences between groups in their health status and their ability to obtain care, remain a persistent issue in the United States. This brief describes health and healthcare disparities today, highlights recent advancements in reducing disparities under the Affordable Care Act (ACA), and discusses how the American Health Care Act (AHCA) and proposed reductions in discretionary funding may affect ongoing efforts to address disparities.

Niger’s population is set to double in about 17 years and high birth rates have contributed to this population growth. Already 80% of Nigeriens live in poverty and there is growing concern that such population expansions could lead to famines, political instability and violence in this landlocked nation.

The UN has warned that due to climate change about one in four children will be living in areas with extremely limited water resources by 2040.

Hundreds of thousands of people in India could be left without essential government services and benefits – including free school meals and uniforms, food subsidies and pensions – under new rules that make access to more than three dozen state-funded schemes conditional on showing identification.

Maternal, Neonatal & Children’s Health

China has achieved a substantial reduction in maternal mortality over the past three decades, from 88.8 deaths per 100 000 live births in 1990 to 21.7 deaths per 100 000 live births in 2014, down by 75.6%. The Article by Yanqiu Gao and colleagues in The Lancet Global Health is a valuable and welcome opportunity to present progress and discuss how maternal health can be improved in developing countries.

An UNFPA representative has urged Nigeria to invest more in maternal health since it has the potential to save Nigeria nearly $1.5 billion annually.

What happens when both mothers and newborns weigh significantly more than they did just several decades ago? The question occupies one of the most active areas of obesity research.

Future of Conflict Minerals murky under Trump administration

by Kendall Penndorf, posted in APHA IH Section, Human Rights, Policy and Advocacy, Trade and Health

You’ve likely heard the term “blood diamonds.”  Also known as “conflict diamonds,” these precious stones have helped fund civil wars and contributed to some 3.7 million deaths in Angola, Sierra Leone, and the Democratic Republic of Congo (DRC) according to an Amnesty International report.

The term “conflict minerals” doesn’t have quite the same ring, nor a titular film starring Leonardo DiCaprio, but they are at the center of a recently leaked memo from the White House.  The memo seeks to dismantle the Conflict Minerals Rule in the 2010 Dodd-Frank Wall Street Reform and Protection Act.  Under Dodd-Frank, companies had to disclose whether or not their products contain minerals mined in the Democratic Republic of Congo or a neighboring country.  The reason to withdraw this clause that valued human life over electronics?  Perceived job loss and costs to American companies, estimated at $3-4 billion in upfront compliance costs and $200 million annually thereafter.

What is life like for the miners of conflict minerals – tin, tantalum, tungsten, and gold ore – in the Democratic Republic of Congo and neighboring countries?  The Guardian reports a systematic web of sexual violence, kidnapping, child labor, and modern-day slavery.

An overwhelming abundance of human suffering all so we can play Bejeweled on an almost dizzying array of devices.  Tech giants, Apple and Intel, have spoken out against the repeal of the Conflict Minerals Rule, but fear that enforcement will be difficult without written law.  Human rights groups representing some 100 organizations in and around DRC have also spoken out against repeal of the Rule:

Thanks to the Dodd-Frank Act, Eastern DRC has to date more than 220 certified green mining sites, more than 300 mining police officers trained and deployed to secure mining sites,an independent audit mechanism, and a regional certification system. These advances undoubtedly contribute to reducing the rate of crime and human rights violations, including rape of women and exploitation of children in mining areas. All these efforts and progress will be destroyed if the US Government decides to contradict itself by repealing the Dodd-Frank Act.

It isn’t just Big Business that has taken a hit under the Conflict Minerals Rule.  A healthy dose of criticism cites that the Rule has actually made miners and their families in DRC poorer.  In many ways, the implementation of the Rule slowed down, or stopped, mining due to implementation issues of the government and business variety.  Millions, out of work, were left between the proverbial rock and the hard place: either face starvation or join the militias that the very Rule were designed to protect them against.  Closing of mines is felt throughout communities:

With less money flowing in, shops in Luntukulu have closed. Many people struggle to feed their families through farming. “If Obama’s law wasn’t signed, the ban would not have existed,” said Waso Mutiki, 41, president of the miners’ co-operative in Luntukulu. “It destroyed everything.”

Others who contest the Rule say that the it does not acknowledge or alleviate deeply systemic issues afflicting the region, such as in this open letter signed by academics, politicians, and civil society professionals:

First, while the minerals help perpetuate the conflict, they are not its cause. National and regional political struggles over power and influence as well as issues such as access to land and questions of citizenship and identity are just some of the more structural drivers of conflict. The ability to exploit and profit from minerals is often a means to finance military operations to address these issues, rather than an end in itself.

The authors of the open letter above offer some alternative strategies which seek to buoy the economy by incentivising better practice and fair competition for international and Congolese businesses. Dollar for dollar, the Democratic Republic of the Congo is one of the richest countries in the world when it comes to untapped mineral resources.  The people who seek to own that wealth and exploit its potential are many, and unfortunately, Congolese citizens and their communities are not among those to first reap those benefits.

So, what is the bottom line?   Some might say the Conflict Minerals Rule sees the forest but not the trees, doing significant damage to local economies and livelihoods despite the progress made by eliminating a driver of local conflict.  It serves as yet another example of the need for policies to be developed and refined with community feedback. A globally engaged U.S. administration might attempt to build on the successes of the Rule with foreign and trade policy that takes such feedback into account. But the current administration seems to have different priorities. Rather than approaching policymaking in a way that benefits the communities most heavily impacted, or even that takes into account the expectations of American consumers, President Trump fights for the common man…the average, American CEO:

Government and community collaboration are key in achieving meaningful reform. Whether or not the U.S. Administration will take part in that exchange remains to be seen.

Call for Papers: AJPH Special Edition on Climate Change and Health

by ihsection, posted in APHA IH Section, Section Announcements

This announcement is posted on behalf of Rose Schneider, the IH Section’s Climate Change and Health Working Group Chair.

The American Journal of Public Health (AJPH) intends to publish a supplement issue on the topic of Climate Change and Health: Research, Translation, Policy, and Practice. Climate change is widely considered the greatest challenge to the public’s health. This issue will showcase scientific research that evaluates the degree to which climate change is a present-day and future threat to population health and health equity and highlight emerging and innovative evidence, strategies, solutions, and policies to address the health and equity consequences of climate change. Original research articles, briefs, systematic reviews, commentaries, editorials, as well as analytic, photographic, and historic essays on the health and equity impacts of climate change are invited. Papers that highlight translational practices as well as evaluation or policies that demonstrate advancement of health and equity are encouraged. Topics of interest include, but are not limited to, best-practice models, co-impacts of climate change and other policies, economic evaluation, climate literacy and communication, and gaps in research, policy, and practice implications related to climate change adaptation, community resilience, and mitigation.

Potential authors should visit the AJPH website (www.ajph.org) to review the Instructions for Authors and specific guidelines for the various types of manuscripts. All manuscripts will undergo standard peer review by the AJPH editors and peer referees as defined by AJPH policy. Manuscripts must be submitted April 1, 2017, via the online submission system at http://editorialmanager.com/ajph.