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:
http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf) 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

DELAYED POST: CGH Journal Club Recap: Hepatitis C Drug Affordability

The Global Health on Grounds committee had our first journal club meeting this
past week. An excerpt from the article from the Lancet that was discussed:
“The new generation of highly effective medicines to treat hepatitis C offers new hope
for those affected, but the high prices of these drugs block countries from integrating
them into their treatment programmes.”

A link to the article can be found here:

This article prompted a lively discussion on equitable access to healthcare, what
the fair payoff for research and development for pharmaceutical companies is, the role of
insurance companies in funding this treatment, and government regulation of
pharmaceutical companies.

The group ended up being pretty divided. Some argued that pharmaceutical
companies need to have high economic incentives to invest in research and development,
otherwise life saving drugs would never be made in the first place. While currently many
people cannot afford the drug, if it wasn’t profitable then no drug would have been
developed in the first place and no one would have access to it. In addition, the price of
the drug not only makes up for the cost of developing that one drug, but the many drugs
before it that were ultimately not successful.  Hepatitis C, when left untreated can lead to
liver cancer and ultimately rack up extremely high medical costs in the future. Because of
the efficacy of the drug and its ability to prevent higher medical costs in the future, some
people in the group argued that the price, ($85,000-$110,000 in the US and -$900 in
some developing countries) was actually fair.

On the other hand, many believed that people should have equitable access to a
life saving drug and one cannot quantify the cost of a human life.  In addition, a lot of
research funding that ultimately leads to the development of pharmaceutical drugs is
funded by governmental agencies such as the NIH. Pharmaceutical companies also spend
more money on marketing their products than they do on research and development.
While this is necessary to get their product out, in the special case of the Hepatitis C
drug, the companies do not need to market the drug due to its high efficacy and need.
Therefore, there should be more regulation on how these pharmaceutical companies to
lower the price.

Whether you agree, disagree, or feel we missed out on some points that are
essential to the discussion, we’d love to hear from you! Feel free to email
ejj3xb@virginia.edu with opinions on this past book club or topics and articles you
would like us to feature next! Our next meeting will be this Thursday March 19th, 7pm at
the Center for Global Health and we will be discussing Global Health and Climate
change. As always, we will provide dinner and a lively discussion!