These are Exciting Times

Week 14 is over and we've come to the end of the semester and while I'm elated to be graduating, it seems a bit bittersweet, as I no longer have the safety net of school and must go out into the real world.
It's a also a very exciting time, as my colleagues are working on creating a project we hope will go on beyond our careers at USC.
We're starting a new venture called the Global Health Review
with a newsletter publication, website and multimedia components, similar to the law reviews put out by law students. Global Health Review's mission is to increase awareness of global health issues, needs, and opportunities, to promote education & initiative, and to facilitate change in global health.

The newsletter is most likely going to be on a monthly basis with email blasts to PH students at USC as well as other stakeholders and PH professionals around the globe (connections will be facilitated by our prof. Dr. G. Shahi), and the website will provide a channel for for people to sign up for publications, to find resources, to post media (i.e. documentaries, interviews, etc.), to mediate a forum, to create a blog and for networking. Eventually we will put out a journal once we've established the endeavor.
Stay Tuned for more on Global Health Review.
Yet another reason for the excitement is the publication of our book Emerging Trends in Global Health, which is a compilation put together by Dr. Shahi of our topical review papers from PM 565 and it's available for purchase and all proceeds go to the Global Health Review. So please purchase away!


P.S. When this class is over and I start my practicum in India at the end of May this blog will be transformed as a journal for my Indian adventures. I'm very excited about that as well.

Ethics in Global Health

During Week 13 we discussed Ethics and Global Health and the need for a universal code of conduct for Global Public Health professionals. In addition to increased empathy, I believe we must be educated in and have strict adherence to a set of values which are consistent with our desire to do good and conduct ourselves in an ethical and professional manner.

While there are international standards for conducting medical research on human subjects as established by the 1964 Declaration of Helsinki, there is currently no universal code of ethics for public health practice and no mechanisms in place for enforcement.

As a result, our own Dr. Shahi has proposed a code of conduct for life science professionals in Future of Biotechnology: Safeguarding the Opportunity, Dealing With the Risk”
at a 2004 Conference in Singapore. It serves as a guide for ethical behavior in global health.

Public-Private Partnerships in Global Health

During Week 12 we discussed Public-private partnerships (PPPs) , which have become prolific in Global Health in the past several years. While government has the ultimate responsibility of providing and improving the health of its population, there are limits to what the public sector can achieve on its own, as has been demonstrated again and again. Also, the private sector is now realizing that good health is a prerequisite to an effective workforce and fundamental fro economic growth and development and has increasingly become involved in global health solutions.
PPPs pool resources (financial and human capital) from the public and private sectors and have evolved as a response for the need to improve the quality of public service delivery. According to Thomas and Curtis, PPPs have emerged as a result of "an ideological shift which has created a facilitating environment for business, disillusionment with UN efficiency, a recognition that the global health agenda is too large for a single sector or organization to address on its own, a realization that the market alone cannot provide solutions, and a growing interest within the private sector to enhance its involvement in social issues."

Currently, PPPs in health provide preventative healthcare for Sexually Transmitted Disease and malaria, as well as developing and facilitating access to vaccines and drugs ( GAVI Alliance )and improving health service delivery.

The emergence of such cooperation between the public and private sectors is very exciting in global health because they 1. signal a fundamental shift in how things are done in Public Health 2. the adversarial relationship and distrust that has long existed between the sectors is now morphing into mutually beneficial partnerships and the global community will benefit as a result 3. The private sector will bring in efficiency and understanding of market mechanisms and the public sector will contribute with accountability and creation of markets 4. cooperative partnership will yield more favorable health outcomes, especially in developing countries where public health infrastructures are anemic.

However, in order for these partnerships to succeed they must be transparent, have accountability, a well-defined leadership and good governance.
It is an exciting time to be involved in Global Public Health, as technology and now public-private partnerships offer a viable solutions to global problems.

Heathcare Financing and Health Outcomes in the Global Context

During Week XI we discussed healthcare financing and health outcomes in the global context. I presented on performance based financing in health care based on the article Making Health Care Accountable: Why performance based funding of health services in developing countries is getting more attention by Hecht, Batson & Brenzel, published in 2004 in Finance & Development. The article discusses the increasing importance of performance based financing, which refers to efforts to link international aid money for health to concrete, measurable results on the ground. PB financing was pioneered by Global Alliance for Vaccine & Development GAVI, The Asian Development Bank, and USAID.

Governments in developing countries and their international partners are increasingly becoming more interested in performance-based health financing for three reasons: including Achieving the MDGs, increasing the effectiveness of aid resources, and increasing accountability.
Achieving the health MDG's: governments and donors are interested in funding programs that have measurable results toward health MDG’s & results are closely tracked for MDG achievement, for instance if immunization & fast treatment of pneumonia decreases # of child deaths (a health MDG) programs that combat respiratory disease are more likely to get funded.
Increasing Effectiveness of Aid Resources: Donor agencies want to increase effectiveness of aid money by allocating them to countries/programs that can demonstrate progress as measured by performance indicators
Accountability: If financing is dependent on performance results, providers are more likely to produce results.

Types of Performance-based financing in health include:
Performance-based contracts with NGO’s where governments in Low Income Countries fund NGO’s to deliver basic-health services on a performance basis. NGO's performance is measured against various indicators, i.e. immunization coverage, % of families using ORT and bonus structures are in place to reward NGO's for performance beyond the negotiated budget. Guatemala presents a success story in large scale contracting with 80 NGO's to provide basic health services to 3.7 million indigenous people, which resulted in a rise in immunization rates from 69% in 1997 to 87% in 2001.

Another type of PB Financing is accomplished when the central government makes per capita transfers of funds to local municipalities based on the municipality's performance in strengthening the health system.

The third type of PB financing is done through the mechanism of direct donor disbursements to national governments based on performance results. GAVI provides an excellent illustration of this type of PB financing. GAVI provides commodity assistance to countries in the form of new & underused vaccines and safe injection supplies. GAVI further allocates grant funds to countries that increase coverage rates for vaccinations. For instance, in 2004 GAVI gave $15 million each to 10 different countries for achievements in increasing immunizations particularly for DPT3 vaccine. The way this mechanism works is low income countries apply to GAVI, specifying current immunization coverage levels & at the end of the year countries receive $20 for each additional child immunized above the baseline level. GAVI verifies the country's performance based on externally audited data.

Performance based financing can help stimulate countries/providers to expand their coverage to reach poor people who lack access to health care and help enhance the quality of service delivery. PB financing is also helpful in focusing all parties on services produced, rather than inputs such as drugs, number of hospital beds etc.

There are a number of challenges that developing countries face in implementing PB financing, including difficulty of measuring performance quickly & accurately, quality & comprehensiveness of national monitoring systems to track health performance, and lack of Ministry of Health capacity to design, negotiate, and enforce performance contracts with NGO's.

Performance based financing, if designed and executed properly can result in accountability for international aid money and change in health status of people in developing countries and will become the standard in health care financing.

Monitoring, Surveillance and Rapid Response Capabilities

In Session X we discussed Global Monitoring, Surveillance and Rapid Response Capabilities and Disaster Management including epidemics and natural disasters.

The 1918 Spanish Flu epidemic is now believed to have been a strain of avian influenza, which mutated and spread from people to people. The epidemic killed an estimated 20-50 million people worldwide. The flu was fast acting and killed the post productive members of society, the working age population of 15-34, whereas during season flu the most vulnerable populations tend to be the elderly and young children.

The current Asian Avian flu strain H5N1 has thus far killed 62 people (122 cases per WHO), most of whom lived with or worked closely with domestic fowl, however it has not yet mutated to spread from person-to-person. The Spanish flu traveled at an unprecedented rate and killed millions within months. In today's fast globalized world it would take only a fraction of that time for such a virus to jump oceans. Therefore, our response systems must be equally fast if not faster to be able to contain the wildfire that could result.

The World Health Organization's Epidemic and Pandemic Alert and Response (EPR) is an integrated and internationally coordinated global alert and response system for epidemics and other public health emergencies.

Epidemic and Pandemic Alert and Response (EPR) has six core functions:
* Support Member States for the implementation of national capacities for epidemic preparedness and response in the context of the IHR(2005), including laboratory capacities and early warning alert and response systems;
* Support national and international training programmes for epidemic preparedness and response;
* Coordinate and support Member States for pandemic and seasonal influenza preparedness and response;
* Develop standardized approaches for readiness and response to major epidemic-prone diseases (e.g. meningitis, yellow fever, plague);
* Strengthen biosafety, biosecurity and readiness for outbreaks of dangerous and emerging pathogens outbreaks (e.g. SARS, viral haemorrhagic fevers);
* Maintain and further develop a global operational platform to support outbreak response and support regional offices in implementation at regional level.
[Source W.H.O. http://www.who.int/csr/en/]

I reminded of Larry Brilliant's INSTEDD, for International System for Total Early Disease Detection, an internet based early warning system that would be:
"transparent, with basic information freely available to everyone, preferably in their own language, and will be housed in a neutral country, independent of any single government, any single company, any single UN agency, but will offer its alerts, data, access to all."

INSTEDD would be based on the Canadian GPHIN, which detected and reported SARS before the W.H.O. and is now being utilized for Avian Flu. Established by Health Canada's Lab Centre for Disease Control, GPHIN stands for Global Public Health Intelligence Network and is an internet based system that continuously scans thousands of online sources, including local newspapers, the wires, blogs and health bulletins worldwide in seven languages, flagging news of infectious disease outbreaks, natural disasters and other public health calamities. The flagged data is then forwarded to public health experts for analysis including the W.H.O.

With Larry Brilliant's transparent technology and the W.H.O.'s capacity building, the framework is being established for rapid response capabilities. Technology and innovation will be the crucial components of any 21st century solutions to epidemic response.

Biometrics in Healthcare

Session IX centered around information technology innovation in healthcare. In discussing the Smartcard, which has been in use in Asia and Europe for several years but has yet to come to the U.S., Dr. Shahi mentioned Biometrics in healthcare, where fingerprint scans identify an individual's medical history and other confidential information, as an alternative to the Smartcard, which can be stolen, it can break and healthcare facilities may not be able to access the card if it's damaged. Whereas biometrics would be completely private, individualized, and HIPPA compliant.

Biometrics refers to the statistical analysis of biological characteristics, which is applied to provide identification and verification of human characteristics for security purposes. While fingerprint scanning is most prolific in the healthcare industry, the category of biometrics also includes handprints, retinal scans, facial geometry and voice recognition.

A well designed biometric IT solution allows healthcare organizations to protect patient confidentiality, eliminate passwords, lower IT support costs, reduce paper use and fraud and support HIPPA compliance.

Fingerprint biometrics are currently the most widely used form of the technology in healthcare. The fingerprint scanner works by analyzing the position of minutiae, the small unique marks on the finger where the two ridges on the fingertip meet. Fingerprint biometric technology is the least expensive form of the technology at initial cost and is capable of being very accurate and yielding low false acceptance if it is well maintained and personnel are well trained.

According to HealthcareItNews.com, the most extensive use of biometrics is in healthcare, in addition to the finance, military, and security sectors. There has been an impressive adoption rate of the technology in healthcare, driven partly by the push toward shifting to electronic medical records, HIPPA compliance and security issues in healthcare. Furthermore, the adoption of the technology by other sectors, including border patrol and national security has driven prices lower and made it more affordable for the healthcare industry.

Biometrics, if adopted industry wide has the potential for efficient security, patient identity protection and confidentiality, as well as possibly reducing costs and time associated with paper based medical records.

Technology in Healtcare: How HIT can reduce costs

During Session VIII, we made a shift in class from discussing all that ails the world to possible solutions to the problems the global community currently faces. Technology's role in revolutionizing many industries, including medicine and healthcare over the past several decades is undeniable. In fact, according to Dr. Shahi, none of the innovations in healthcare including the mapping of the human genome would have been possible without the tools that computer systems have provided to scientists.

Healthcare Information Technology (HIT) includes electronic medical records, Decision Support systems and Computerized Physician Order Entry for medication prescriptions. HIT systems provide access to patient information and if networked with other providers and hospitals can communicate patient health information to other providers making the patient's care at various providers integrative and efficient.

According to the Rand Corporation, there are three additional benefits in implementing HIT industry-wide, including efficiency savings, increased safety, and increased health benefits.

Efficiency savings refers to the care provided to patients using less resources, including reduced hospital stays because of increased safety and better coordination of care, reduced administrative time of nurses and more efficient drug utilization. Rand estimates a potential efficiency savings of $77 billion annually if HIT were implemented system-wide.

Increased safety would be obtained mainly during the prescription process through the Computerized Physician Order Entry system, which will generate alerts and warnings for any drug interactions and adverse effects. According to Rand's research, $1 billion dollars can be saved by eliminating annual 200,000 adverse drug events.

In terms of increased health benefits, HIT would be instrumental in chronic disease management by helping providers maintain constant communication with patients, by providing remote monitoring and transmission of patient's vital signs and by responding very quickly when the patient is in distress. Effective disease management can reduce the need and duration of hospitalization, which will reduce costs and maintain good health.

Currently, there are a number of hindrances in the marketplace and the healthcare industry to implementing HIT, including low numbers of providers/hospitals who have HIT systems, especially in rural and poorer facilities. Additionally, there is currently no market pressure for creating systems that can talk to each other and as a result HIT systems are currently fragmented and interconnectivity is limited.

Rand's policy recommendations center on government action, including continuing current efforts to implement HIT, accelerating market forces, and instituting subsidies to encourage adoption. These can further be accomplished by aggressively using federal purchasing power to overcome obstacles in the market.

System-wide implementation of HIT has the potential of improving health status and the healthcare system in the U.S. by improving efficiency of service delivery and reducing costs.

In his 2006 State of the Union speech, President Bush called for the widespread adoption of HIT, especially electronic medical records. Mr. Bush appointed David Brailer, M.D. to lead the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services. Mr. Brailer strongly supports organizational interconnectivity, which will encourage health care IT investments and facilitate health care reform. While some industry experts are excited by the renewed attention on HIT, the administration must focus continued efforts and attention on the promises made by the President.

Source: Rand Corporation. Research Brief. Health Information Technology. Available online at: http://www.rand.org/pubs/research_briefs/RB9136/index1.html

Water and Sanitation

Women carry water 5 kilometers to their homes in Azad and Jammu Kashmir, Pakistan. (Image by Prof. Jennifer Davis.)


Image from UNICEF New Zealand


During Week 7, Session VII of class, we discussed lack of access to clean water and sanitation in developing nations. Lack of clean water and sanitation services seems so foreign to us living in the abundant U.S., we never stop to think about how many people lack these basic rights to human life and dignity around the globe. Indeed, access to clean water and sanitation is at the heart of so many other global problems, including disease and conflict. Without access to clean water and sanitation the other Millennium Development Goals cannot possibly be accomplished and in fact they are prerequisites to all of the other goals.

The Gender Perspective on Water and Sanitation, of the United Nations Commission on Sustainable Development, is an empowering work, as it contends that giving women control of water and sanitation in developing nations goes a long way in improving water source management and living standards, because in most countries women are primarily responsible for the use and management of water and women have an inherent "environmental wisdom."

At present, women are solely responsible for fetching water from communal sources which may be several hours away from home. These women and girls spend several hours a day carrying heavy water jugs, which takes away from their ability to attain education and can lead to injuries and assault. Furthermore, lack of privacy in sanitary facilities in schools discourage girls from attending classes. Building separate bathrooms for boys and girls is essential for gender equality. For instance, in Bangladesh, construction of separate latrines for girls and boys resulted in an 11% increase in attendance of girls per year from 1992 to 1999.

According to the article, empowering women in communities like Kerala, India and Cameroon, where women have banded together to manage and build community water projects have proven to be more successful than when men were in charge of the maintenance, because men were absent during the day and lacked service orientation and financial management skills. Equitable access to water for household and agricultural use is imperative for women in developing nations as it is essential for gender equality, sustainable development, and poverty alleviation.

“The human right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses. It is essential that both women and men be involved in decision making processes regarding the provision, location and technology of water and sanitation facilities in the community and household.”

I Belong to an International Humanitarian Organization called CARE, this video comes from CARE and it shows the impact of empowering women to bring about change. Please watch this short video of an Ethiopian woman who is changing social norms in her community. ABAY

Mind, Behavior & Global Health

Image from: www.abc.net.au/foreign/images/russiabeerboys.jpg

“All that we are is the result of what we have thought. The secret of health for both mind and body is not to mourn for the past, worry about the future,or anticipate troubles, but to live in the present moment wisely and earnestly.” -- The Buddha



The most difficult thing to do, for me at least, is to be present in the moment, at all times. Analysis of the past, worries and concern for the future, planning etc. etc. seem to always take precedence over the present. Meditation and yoga have helped me tremendously in "being in the moment," but it has yet to become intuitive and continues to be and perhaps will always be a practice.

In session VI of class we discussed the mind, behavior, and global health. Our case study discussion as presented very effectively by Jennifer and Ivette focused on the premature death of Eastern European and Russian men due to binge drinking of vodka and other hard liquors in the post-Soviet era. While vodka has been a mainstay of Russian and Soviet society for a very long time, Russia is a very cold country after all, alcoholism has been increasing tremendously following the collapse of the Soviet Union.
This development is not surprising, considering the tremendous socio-economic changes that have taken place in Russia since the collapse. Alcohol has for thousands of years been produced and consumed by different cultures and used as a means of escape from and a way to cope with reality. Someone mentioned in class that it is in the best interest of the Russian government to have people in a drunken stupor and therefore incapable of challenges government policy. This statement rings true and is characteristic of previous Russian and Soviet government behavior.

Since the beginning of the 20th Century, starting with the Bolsheviks, and again in the 1950's, 1970's and again in the 1980's under Mikhail Gorbachev, Russia has "tried" to institute prohibition against vodka consumption, sales, and marketing, however, they might have learned a lesson from the United States in that prohibition does not work. Nevertheless, even if vodka or other spirits are not readily available in the marketplace, people will illegally distill their own homemade brews, which may in fact be more dangerous for their health and much more difficult to control and regulate.
So how can the Russians reduce the mortality and morbidity burden attributed to alcohol? It's a complicated task and requires social norms change regarding the acceptability of male binge drinking in the culture in addition the implementation of evidence-based alcohol treatment programs. However, the biggest reason why alcoholism has sky-rocketed in Russia after the collapse of the Soviet regime is because of the desperation and disenfranchisement that these men feel in the new economic reality, in which they can no longer depend on the state for economic well being. Therefore, unless Russia institutes major economic and social reforms to make more jobs and more social services available to all sectors of society, alcoholism will continue to plague the nation.

Educate Women to Make the World a Better Place

Image from UK Department for International Development

In session V, our strategic overview of Food Security, Rural and Agriculture Development as expressed in the Millennium Development Goals

touched upon the importance of the Education of Women, a topic very near and dear to my heart. The article, Agriculture, Food Security, Nutrition and the Millennium Development Goals by Joachim von Braun et. al discusses the importance of educating and empowering women to help achieve several of the MDGs, including enhancements in agricultural productivity and rural development in addition to improving maternal and child health, reducing child mortality and decreasing malnutrition among children. Of course, none of these occur in a vacuum, there are other factors involved in achieving these goals, including policy and social norms change, however, as Dr. Shahi mentioned in class, educating women goes a long way in reducing a lot of the problems that challenge the global community today.

I come from a male dominated culture, which places very little value on the education of women and emphasizes the role of women in the domestic arena. In addition to that I was born and spent the first 12 years of my life in the Soviet Union and while primary and secondary education was provided by the state, only the elite and wealthy had access and enough money and connections to bypass the corrupt college admissions process. I'm very fortunate to have had to opportunity to relocate to this country, where for the most part, women have as much access to education as men do. Despite prevailing chauvinist attitudes about the education of women in this country, including those of ex Harvard President Larry Summers (whether the comments were misconstrued and taken out of context is a separate discussion), even Harvard is taking steps to remedy the situation in naming their first female President since its founding in 1636.

The Population Council and the Rockefeller Foundation
list the benefits to society of educating women, including increased economic productivity, improvements in health, delayed age at marriage, lower fertility, increased political participation, and generally more effective investments in the next generation.
"While there are many other possible interventions to achieve these social goods, girls' education is the only one which impacts all of them simultaneously."

So while we are raking our brains looking for solutions and interventions to help solve some of the most difficult ills that plague our society, we must not overlook the most profound action we can take to advance society, eradicate hunger and poverty, and reduce child malnutrition etc.

Non-Communicable Disease: The Bane of Global Health

Child Obesity in China, you can thank KFC, finger-licking disgusting.

Week 4's class was rather interesting, because we often dismiss chronic disease as the affliction of old age. My grandfather died of lung cancer but he had a long life, full of struggle as he survived the Armenian Genocide, fought the Nazis as a partisan in Greece, but also happiness as he had lots of grandchildren. He was also a lifetimes smoker.
This article was an eye opener as it talked about people in their 30's in Russia and India dying of heart attacks. From what we've discussed in class, the videos and articles we've read so far, it's clear that in the last couple of decades, along with global trade and exchange of information and culture, we've also exported the American diet and lifestyle and with it our cardiovascular disease. Someone in class mentioned a KFC in every corner in China. We're robbing these people fo their culture and killing them at the same time. According to "Race Against Time: The Challenge of Cardiovascular Disease in Developing Countries"
Report

In lower and middle income countries, cardiovascular disease morbidity and mortality is occurring at an alarmingly younger age, often during the most productive years of an individual's life, not only wrenching them away from their families, leaving widows in poverty, but also taking young people of out of the economy, thereby threatening its expansion.

Non-Communicable Diseases result in more deaths and account for more years of healthy life lost than communicable disease, yet there's little aid available for prevention efforts. Cardiovascular disease (CVD,including heart disease, diabetes, and obesity) is the cause of 30 percent of all deaths globally and 27 percent of deaths in low income countries, compared to HIV/AIDS, tuberculosis and malaria, which account to 10% of all global deaths and 11% of death, yet there is little aid going to prevent and treat CVD globally.
Johns Hopkins

Prevention and treatment programs for CVD are relatively low cost-per-life saved and disability prevented. The risk factors associated with CVD, including high fat diets, lack of exercise, smoking, and obesity are preventable and modifiable and there is no reason why the global health community should not emphasize prevention efforts on CVD in addition to infectious disease.

Early Detection, Early Response

I had the privilege of taking PM 546 Bioterrorism with the esteemed Dr. Marc Strassburg last semester, who was a member of the WHO team that eradicated smallpox with door to door surveillance and containment of the virus through a circle of immunizations around each case in India and Africa. Larry Brilliant's concept of an early detection system "INSTEDD" (video at: http://tedblog.typepad.com/tedblog/files/larrybrilliant.html ) which consists of web crawlers in various different languages, which would detect illness much sooner than the WHO, is a demonstration of the contribution of modern technology to Public Health as well as numerous other disciplines.

In the age of instantaneous communication, international travel, and re/emergence of infectious disease, the ability to detect and respond to emerging infections and epidemics through real time global surveillance via the internet is the necessary next step in the evolution of Public Health. H5N1 or Avian Flu has the capacity to spread faster than ever before because of increased international travel and globalization, as SARS demonstrated in 2003. As public health professionals we must be ready to combat pandemic influenza through All-Hazards Preparation, effective risk communication, and early detection/response. Technology like INSTEDD will be an invaluable tool in combatting the pandemic. And while, noble men like Drs. Strassburg and Brilliant helped eradicate smallpox by tackling each and every case in remote parts of the globe, we cannot possibly hope to combat re-emerging infections and new infectious disease without the sophisticated real time results and capacity that modern technology facilitates.

First Impressions

I was thrilled when USC offered the Global Health Leadership and Management track for the MPH program and switched from Health Promotion and Education right away. I did so because I believe that the world is becoming a smaller community due to globalization and we must change and adapt in order to be relevant. I also appreciate the track and especially this class, Emerging Trends in Global Health, because I believe that it is current and dynamic and I have much to learn. I'm especially excited for the passion Dr. Shahi will bring to class given his experience in public health as well as the private sector.

As the demographic patterns continue to change, a great dichotomy emerges in the world, where we have disease from deprivation alongside disease from over-consumption. In order to achieve a balance we must work as a global community to bring about a change in the way we view health, because health is a capacity and it is the foundation for every human endeavor.

Millennium Development Goals
In order for the MDG to be achievable, a crucial prerequisite of meeting these goals for developing countries is the ability to build up their core public health functions. Policy and infrastructure must be in place and strengthened so that interventions will be managed efficiently with accountability and disseminated to those who need them most. Further, in order for these noble yet lofty goals to be achieved, governments, non-governnmental organizations, and the private sectors must work in synergy, because health and parity in health benefits everyone.