Thursday, November 19, 2015

The Future of mHealth

by Mary Heekin          

          This Wednesday, November 11th marks the final day of the 2015 mHealth Summit.  This annual conference explores the latest innovations in mobile, connected and telehealth, as well as their impact on healthcare delivery, patient engagement and clinical outcomes.  The growing role of technology in healthcare management and delivery and the diversity of platforms currently employed for health promotion are revolutionizing the healthcare industry.  Within the last two decades, these technologies have moved beyond electronic medical records to include tools such as smartphones, mobile applications, video calling and fitness trackers.  Individuals utilize “a variety of mobile tools including: app-enabled patient portals, telehealth services and text communications” (2015 HIMMS Mobile Technology Survey). These innovations are giving care providers a more optimistic outlook on the future of public health by integrating health more fully into patients’ everyday lives.

            Mobile health technologies offer many advantages in increasing patient knowledge and access to personal health data, individualizing care and encouraging patient engagement.  As a result of the availability of more tangible health indicators, such as blood glucose levels, daily steps and blood pressure measurements, individuals are provided with some of the necessary information to assist them in making informed health decisions.  Patients are empowered to engage in consistent self-management, and studies reveal that people who use mobile health technology are more inclined to follow physicians’ advice and be proactive in their care (Health Information and Management Systems Society, 2015).  In an NIH-sponsored study conducted on the uses and benefits of mobile devices and applications for health care professionals (HCP), many care providers responded positively to the advantages of health technology.  HCPs associate mobile health with greater efficiency when accessing patient data, accuracy in documentation, improved productivity with an average increase in electronic prescriptions and enhanced clinical decision-making. Check out article here.

               Despite widespread support for the use of technology in improving patient outcomes, long-term benefits from mobile health remain in question.  There is no significant data which might reveal the effect of mhealth on societal burdens, like chronic disease, due largely to the recent application of health information systems.  Will those patients who currently use mobile health technology continue to do so in 5 years, or will these applications face a fate similar to that of many fitness trackers like FitBit: user apathy.  In the midst of these uncertainties, continuous technological advancements are one constant.  Responding to the growing emphasis on outpatient care, mobile, connected and telehealth may be the future of healthcare. 

Additional articles:

Dr. Christiana Hena: A Physician to Many & A Front-Line Provider in the Ebola Crisis

by Callie Jacobs

Jet-black, slicked hair neatly piled into a tight bun reveals a warm, kind face. Wide brown eyes, a rich chocolate color, look out into the audience in front of her. Standing tall, poised in her vibrant floral shawl, she is a woman whose grace and composure is noticeable at first glance. This is Dr. Christiana Hena, a Liberian physician who is visiting the United States to share her perspective as an Ebola front-line care provider.

Dr. Hena was born in Liberia and later attended medical school in Russia. Afterwards, she practiced medicine all over the world; for instance, she lived in Kazakhstan for several years treating patients who were affected by nuclear testing. Meanwhile, in her home country, Liberia was facing a civil war, at the end of which 200,000 people had died—a staggering number, given the fact that the country has a population of about 4.2 million.

In the face of this situation, Dr. Hena felt called to return home to Liberia. Always finding a way to serve the people around her, Dr. Hena began a clinic in her front yard. The clinic, while simple and constructed mostly of hanging shower curtains, served a tremendous role in the surrounding communities. Dr. Hena was one of only 51 doctors in the country, and the dentist who worked at the clinic was the only one for the 200,000 people in the area. Together, they saw about 50 patients a day for hours on end, with patients still waiting in lengthy lines at the end of the day. Meanwhile, 22 community health workers ventured daily into the surrounding 36 communities, treating patients and referring more serious cases to the clinic. The clinic bridged the gap between the community and other services, too. Dr. Hena has now instituted an After School Program in her yard, and she also teaches young men and women various life skills like sewing and collecting data. The clinic has been so successful that Dr. Hena, in partnership with the Building Goodness Foundation, is now building a larger, more permanent structure that will open its doors in the summer of 2016.

When the Ebola outbreak began in Liberia, Dr. Hena’s clinic provided her a unique firsthand perspective of the problems on the ground. Firstly, because many of the doctors currently practicing in Liberia at the time of the outbreak were foreign, they were required to leave Liberia once Ebola took hold of the country. This left Liberia, a country that already had a shortage of physicians, with about 30 doctors. Furthermore, as Dr. Hena explained to us, one of the most difficult aspects of the situation was the incompatibility between cultural practices and the necessary actions to end the crisis. For example, all corpses, whether the cause of death was Ebola or not, had to be cremated, despite that cremation was not the traditional burial practice. Moreover, people could not shake hands or hug one another—a difficult restriction in such a tight-knit community.

Fortunately, the community eventually realized the gravity of the situation. As Dr. Hena told us, “once the community came together, we immediately saw the decline of Ebola.” According to Dr. Hena, the most significant intervention was the implementation of buckets full of chlorine for washing hands in each community. As a result, Ebola slowly stopped spreading, and the crisis came to an end.

Now, it is time to look to the years ahead. For Dr. Hena, the main goal should be “to use limited resources more carefully.”  For the short-term future, she suggests that the country should turn to doctors from abroad. These doctors will be able to respond to the extremely high demand for primary care physicians that Liberia currently has. However, in the meantime, these doctors should also focus on training locals in Liberia in order to have a stable supply of physicians in the long run.

While there is much work to be done, I am excited to see what comes of calls to action like these from Dr. Hena. This discussion of next steps is not only crucial for Liberia but for all of us as avid participants in the exciting world of global health.  

Scrutinizing the Sustainable Development Goals

by Maddie Shiff 

At the turn of the millennium, leaders from around the world convened to commit their intentions to solving what they deemed as the world’s most pressing, transnational problems. The resulting set of objectives, known as the Millennium Development Goals, is set to expire at the end of 2015. While progress was made towards many of these goals, not nearly all of them were achieved. These goals have now have been replaced by a brand new list of aims, labeled “Sustainable Development Goals.”

A link to the Sustainable Development Goals can be found here:

The 17 SDGs include:
  •         End poverty in all its forms everywhere
  •         End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
  •         Ensure healthy lives and promote wellbeing for all at all ages
  •         Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
  •       Achieve gender equality and empower all women and girls
  •        Ensure availability and sustainable management of water and sanitation for all
  •        Ensure access to affordable, reliable, sustainable and modern energy for all
  •        Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for all
  •         Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation
  •       Reduce inequality within and among countries
  •        Make cities and human settlements inclusive, safe, resilient and sustainable
  •       Ensure sustainable consumption and production patterns
  •       Take urgent action to combat climate change and its impacts (taking note of agreements made by the UNFCCC forum)
  •       Conserve and sustainably use the oceans, seas and marine resources for sustainable development
  •       Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation, and halt biodiversity loss
  •       Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels
  •         Strengthen the means of implementation and revitalize the global partnership for sustainable development

These goals were created to “follow and expand on the millennium development goals” (The Guardian). What makes these goals more sustainable than the previous set of goals? How can they be more effective?

First of all, these goals were created by an open working group rather than a group of leaders at the Headquarters of the United Nations. The SDGs were born from the UN’s “largest consultation program in its history” to gather “opinion[s] on what the SDGs should include” (The Guardian). Additionally, these goals incorporate first world countries in a much more comprehensive manner than the MDGs by making rich countries “sites of development themselves” (The Guardian). These goals apply to all countries rather than just acting as “targets for poor countries to achieve” (The Guardian). The creators of the SDGs also recognized that, although the MDGs” provided a focal point for governments,” they “were too narrow” (The Guardian). Further, these goals do appear more detailed than the Millennium Development Goals, for they each incorporate specific targets under each main heading, adding up to 169 targets overall.

Major aspects of the SDGs remain up for debate, however, including sources of funding and measurement indicators. Both these goals and the international collaboration that it took to create them are promising, but only time will tell if they are truly sustainable and successful.   

Thursday, October 22, 2015

Co-Creation, Consciousness, and Community

by Sasheenie Moodley 

Co-authorship and co-ownership are becoming more and more relevant in conversations surrounding sustainable involvement in developing areas. The idea of authoring or owning intellectual and experiential information with another individual can be described in a single term: co-creation. Co-creation is imperative, as more and more countries move toward globalization, in an effort to preserve the uniqueness of self-identities within a ‘community,’ as described by Nana Anyidoho in ‘Communities of Practice:’ prospects for theory and action in participatory development. Recognizing self-identity is particularly significant as identity pertains to the ideology of a ‘good life,’ and how we define ourselves, and our relationships in society. The idea of co-creating something, an idea, research or narrative, strives to ensure that both contributors assume roles in a
sharing process, evident in Richa Nagar’s Storytelling and Co-authorship in Feminist Alliance Work. While co-creation allows the original author to claim agency and participate in shaping a narrative that will be shared outside the author’s realm of consciousness, subaltern narratives are likely framed subjectively due to individual self-identities, and unique experiences. Therefore, we should read all narratives with awareness in order to disprove generalized misconceptions, and guard against subaltern’s subjective opinions.

Central to research, co-creation aims to restore (some) power to the original author of a narrative or experience. Co-creation attempts to correct the cycle that has existed for many generations: a researcher from the more-developed country 1) listens to someone’s narrative, 2) writes an article retelling the narrative that inevitably transfers ownership and/or power to the researcher, and 3) inherently detaches power from the original author of the narrative. Without co-creation researchers not only assume ownership subconsciously or consciously, but they also risk painting one group of people with the same brush: “the individual is not correctly perceived as a dynamic being with multiple and shifting self-identities and social positions over space and time…differences between
individuals within the assumed community are obscured” (Anyidoho 2010:5). Thus, co-creation allows individuals in the same “community” to showcase their self-identities, and unique personalities. Anyidoho emphasizes the reality that individuals in the same area do not necessarily share the same opinions, values, beliefs or aspirations. Individuals around the world are in fact “dynamic beings” who have certain social and cultural obligations in their respective networks. Through co-creation, individuals have a space in which their self-identities can be recognized, actualized, and respected.

As we realize that individuals in other parts of the world have autonomy and unique personalities, we must also question our preconceived notions, and misconceptions. Nagar emphasizes this in her account of two Indian sex workers, Roopa and Seema. While Roopa offers a “fake story” of “victimhood,” Seema shares her personal experiences, and how she embraced the “terms and conditions of her profession” as a sex worker (Nagar 2012:2). Herein lies the complexity of each narrative, as each woman presents her narrative laced with subjectivity, and self-identity. Additionally, we should consider how applicable each narrative is to the larger sex worker population. While Roopa’s “fake” narrative may be indicative of another women’s experiences in the sex worker industry, her violation of the truth deems her narrative untrustworthy. If other researchers relate to all individuals in the community based on this fact Roopa’s dishonesty could endanger the validity of similar narratives in the future. While Seema’s honest account of the challenges, and jubilations in her life may be indicative of Seema’s experiences, other women who are her colleagues may not share her opinions. Researchers who relate to all individuals in the community based on Seema’s narrative could perceive the sex worker population as content, and untroubled in their situations. In this way, we see that neither account can completely describe all women in the population. The fact that we often risk generalizing a small population based on lone narratives highlights our prejudice, and inherent bias. We need to have awareness of such misconceptions, and “interrogate (our) own assumptions about marginality, oppression, liberation, and charity” (Nagar 2012:2).

Self-identity, situational factors, and self-expression are no doubt exhibited within existing social realms long before researchers arrive on the scene. In this way, while co-creation may grow ownership and agency, there remains some uncertainty regarding the type of information gathered in a collaborative process, because of inevitable subjectivity expressed by subalterns. In other words, co-creation tackles the ‘how’ of research such as the methods and dynamics of research, but the ‘what’ remains unclear as it pertains to the kind of information presented by the subaltern due to his/her unique experiences or personality. The ‘what’ is influenced by the way subalterns perceive various situations, and how they interact with researchers outside their usual networks, as well as how they interact with individuals within their everyday communities. For example, when we talk to our peers and friends at UVA about our summers abroad, or our field experiences we consciously decide what kinds of information we wish to share based on how we perceive those peers and friends. We carefully craft the way we convey our narratives based on who we are talking to, and their past experiences. We “frame” our narratives hoping that the listener can empathize with, and understand our experiences the way we express them (Nagar 2012:4). Similarly, subalterns consciously craft the narratives they share with researchers, as evidenced by Seema and Roopa’s stories: “altogether, the two responses highlight the complexities of subaltern agency and the ways in which the formulations of radical desire might be unruly, ill-tempered, incomplete, conformist, and/or seemingly contradictory” (Nagar 2012:2). Nagar nicely describes the process of carefully crafting a narrative using “complexities of subalterns,” as she conveys that most individuals offer subjective narratives. It is an archaic assumption that individuals in an area or network all share a common narrative simply because they belong to the same geographic region, or “community” (Anyidoho 2010:5). Thus, individuals in one region offer the kinds of stories that are not homogenous or standardized, because the individuals in that single region are not homogenous or standardized.

In conclusion, Seema and Roopa highlight the important reality that original authors do not always offer true, or expected versions of narratives. In Nagar’s article, both women consciously shaped their personal narratives according to the message they aimed to convey. This message was crafted because of how each woman wanted Nagar to perceive her, and how each woman wanted Nagar to perceive the people in the community. Such preferences likely developed from each woman’s comfort level with Nagar, perception of Nagar’s work and purpose, the types of questions and prompt that Nagar offered, life experiences, and relationships with Nagar given the social context of the interactions.

Thus, there are many external factors that affect narratives, in addition to careful crafting by the original author. By introducing co-creation to correct basic power dynamics, we must realize that we are not ensuring fair narratives. There are many others factors as play in ethnographic research. In fact, reducing the effects of power in research has uncovered other controversial issues such as the idea of a ‘community’ and conflicting narratives within it, and transparency of the interviewer (researcher) and interviewee (subaltern). It is important to remember, therefore, that writing with a balanced perspective through co-creation alone is not enough to correctly construct research. Additionally we, as readers, must be conscious of who is being represented in the research that we read. The articles we read are narratives offered by a few individuals, and often do not represent the narrative of an entire ethnicity or nation. Ultimately, the responsibility is two-fold: authors must consciously co-create narratives with balanced perspectives and minimal subjectivity, and readers must consciously read narratives with awareness of self-identities to challenge misconceptions.

What’s in a Name? Disease Naming Guidelines set by W.H.O

The mission of many global health organizations is to promote health, cure diseases, build health system infrastructure, and implement pro-health equity policies. Recently, an article in the New York Times that caught my eye, “W.H.O Urges More Care in Naming Diseases.”  The World Health
Organization recently made an announcement that “disease names may not include geographic locations, people’s names, species of animal or food, references to culture, population, industry or occupation, and ‘terms that incite undue fear’”. Making changes and implementing policy on the process of disease naming may seem insignificant at first when compared to the necessity of medicine and healthcare poverty-stricken areas desperately need, however W.H.O offered substantial arguments for why the name of a disease can have harmful effects and should render greater significance.

Disease names that include place, name, or any other signifier previously mentioned, can have the harmful effects of stigmatizing not only a disease, but the geographic location, culture, population or industry itself. Furthermore, it can lead to false conceptions of a disease that could lead people to think they are not subject to contract a disease due to a name that may be geographically confining such as is with the case of Middle East respiratory syndrome (MERS), which originated in the Middle East but has spread around the world. WHO is not suggesting to change the names of known diseases, rather, it effectively set guidelines for naming diseases hereafter that will “help counter stigmatization and faulty assumptions made by the public and decision makers when addressing emerging infectious diseases” (Dr. Jewel Mullen, Public Health commissioner).

This notion of disease naming brings attention to the idea of health as a component of ‘being’. It’s not just about disease treating. The name of the disease and the standing associations bound to the disease among people and society effectively influences how one not only perceives, but experiences the disease.

Contributed by Sedona Hoppe-Brosse

Tuesday, September 29, 2015

Reflecting on Global Health Week

by Eliza Campbell

A little over a week ago, the Center for Global Health hosted their second annual Global Health
Week. Global Health Week seeks to engage students in the study of global health as well
as encourage them to connect with health issues locally and globally through service,
research, and advocacy. We had an exciting schedule of speakers, discussions, and other
events and the week was a huge success! I attended a number of the events and thought
that they all provided an interesting perspective on global health but I particularly
enjoyed the discussion led by Professor Edmunds of the Global Development Studies
program about the role of technology in community collaborations.

Professor Edmunds is currently working on a research project where he is using
Skype and other technologies to connect women in Charlottesville public housing with
women in Cape Town, South Africa. The women connect over Skype to share their views
on community health as well as exchange ideas of what they do to live healthier
lifestyles. Their dialogue spans from tips for how to grow herbs to domestic violence and
it seems that Professor Edmunds has already gathered a wealth of information.

I was particularly interested by Professor Edmund’s research because I thought
that the idea of collective learning and exchange was a fascinating approach to
development as well as empowering for the women involved. I feel that often times there
is a perception of development as being a process of imparting our exclusive knowledge
onto others but Professor Edmund’s research demonstrates that development goes both
ways: we have as much to learn from the people we are working with as they do from us.
I think that it is important for us to understand that we can learn a great deal from the
communities we work with and that development is more effective and valuable for both
communities involved if it is a two-way dialogue. I applaud Professor Edmund’s research
not only for its focus on community collaboration but also because it empowers the
women of Charlottesville and Cape Town to be the bearers and leaders of public health in
their communities.

While this research project is still in its early stages, I am excited to see what
comes of it and how this compelling dialogue will transform the communities and
individuals it engages while also challenging common perceptions of the direction and
nature of development work.

Wednesday, September 23, 2015

Surgery in Global Health: Not an Open-and-Closed Case

Imagine a scene in which ‘global health’ is occurring. What do we see? Perhaps a physician is down on bended knee, delivering vaccines to small black children, set against a blurred backdrop of village. Or we see looming figures in blue Hazmat suits hanging an IV bag to rehydrate an Ebola patient. Maybe a community health worker sits cross-legged among a group of women discussing pregnancy and distributing prenatal vitamins in sealed pink pouches. We don’t initially think of surgery. Increasingly, however, the scene of ‘global health’ will be set in a windowless sterile room, its providers will wear green masks and gowns, and its patients will receive life-saving laparotomies, open fracture treatments, and caesarean sections. Surgical services are greatly needed across low- and-middle income countries, and could reduce the global burden of disease by an estimated 77.2 million disability-adjusted life-years annually (Lancet Commission 2015). However there are numerous challenges facing this growing field including difficulty of health system scaling, scarcity of training sites, difficulty obtaining equipment, and lack of inclusion under the traditional umbrella of global health.

Surgery is an atypical topic in global health. Global surgery has historically been overshadowed by
movements to eradicate certain communicable diseases and bolster community health - movements which focus on preventative measures, not surgery. Indeed, while the UN Millennium Development Goals and its 2015 revision focus extensively on combatting HIV/AIDs and reducing infant/mother mortality, neither document includes any mention of surgery (link here: That surgical interventions are absent from these goals is perplexing: increased access to caesarean delivery is demonstrated to reduce neonatal mortality by between 30-70% (Molina, Esquival ,Uribe-Leitz et al 2015). Considering that among the Millennium Development are reduce child mortality and improve maternal health, perhaps our picture of global health should include a surgeon?

Many voices are now calling attention the absence of surgery as a global health priority. Among these: Paul Farmer, Atul Gawande, and the Word Health Organization. Perhaps the most prominent voice is the landmark Lancet Commission on Global Surgery (2015). The Commission states that an estimated 16.9 million lives are lost each year from conditions that can be treated surgically (by comparison HIV/AIDS and tuberculosis claim 1.46 million and 1.17 million lives respectively). At the same time there is a vast inequality in the delivery of surgical services worldwide: 90% of global injury deaths occur in low-and middle-income countries (LMICs), while the poorest third of the world receives only 3% of its surgeries (Lancet 2015). These figures identify both a clear need and a vast inequality in surgical infrastructure globally. But is it necessary – or possible – to build infrastructure where needed?

To the first question, “is global surgery necessary?” To some observers, surgery seems an unnecessary byproduct of Western medicine: it is invasive, highly technical, and involves little patient autonomy (besides signing “X” on a consent form). Unnecessary surgery occurs frequently in the Western world where it is readily available, and the surgeons may become wealthy by gaming a fee-for-service system. So why should we impose this product of Western medical excess upon the non-Western world? The answer: because surgery, when used as a life-saving measure, is never unnecessary. In cases of trauma, appendicitis, and births requiring a cesarean section, surgery is truly needed to save a life. Surgery, whenever is the only treatment option, is by definition “necessary.”

To the second question “is global surgery possible?” Frankly, the cost associated with scaling up health systems infrastructure in LMICs to parity with US systems would be astronomical. While surgery itself is a very cost-effective intervention - which will come as a surprise to many - the investment in system strengthening for safe surgery would be expensive.  It would occur through academic partnerships with Western institutions. Presently, a number of US medical colleges have sustaining commitments to health systems in LMICs (i.e. UVA surgeons spend time in Rwanda training residents and developing surgery programs). This brings us to our final question, the million (or multi-billion) dollar question: who pays?

We all do, either by shouldering the global burden of disease, or paying for the health system
strengthening necessary to address this burden. This kind scale-up through sustaining partnerships is a pressing problem global health today. In sum, while a global need for surgical services is present, there remains an equal need for funding through sustainable partnerships. It is uncertain at this time whether or not these partnerships are attainable under present models of global health. Importantly, for global surgery to become viable, it should be prioritized by UN Development Goals. There are numerous conceptions that may prevent surgery from falling under the aegis of ‘global health,’ not the least of which holds surgery to be a luxury item misused by the Western healthcare system.  Our picture of global health may not include a gown or scalpel, but if we are serious about delivering necessary care to all people, we ought to consider sketching in a surgeon or two (or about 20,000 by the year 2030).

- Michael R. Novack