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.

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:
http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70365-1/fulltext

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!

Being Mindful of Global Health

By Usnish Majumdar

I have no fear of making changes, destroying the image, etc., because the painting has a life of its own.

- Jackson Pollock

When I try to imagine global health, I think of a vast and complicated network of people, institutions, and rhetoric. There are these huge hubs like the UN Refugee Agency, the World Health Organization, and Partners in Health, and there are the smaller hubs of academic medical centers and national advocacy groups, and then the tiny little pinpricks made up of student groups and incipient organizations. They all serve individuals in different ways and at different levels, adding to their perceived complexity. In my head, it all ends up looking a bit like the wiring of a brain. But it’s probably quite a bit more like a Jackson Pollock painting. 

This sort of hand-wavy network metaphor is one of many that exist in the rhetorical space of global health. In many cases, such networks are little more than words that pass with conversation, or transient constructs built for the sake of argument in a paper. In other cases, however, a network manifests as an institution (really, a hub) that often focuses on one particular interest or another. These institutions are serving an important goal: making the network more effective and efficient. We can see the benefits of bettering networks in many contexts – NGOs all over the world are solving similar problems but there is no easy way of exchanging relevant institutional knowledge. Even within a single city, it is sometimes difficult to figure out which entities (policy briefs tend to call them ‘stakeholders’) are impacting a problem in which ways. Many local networks contain redundant members or potential collaborators that are not aware of each other.

At UVA, ‘global health’ takes many forms. There are over a hundred different student groups devoted to a global health-related goal on grounds, and no real organizing principles. There are research groups across many different academic departments, not to mention multiple administrative centers that reach across multiple departments. Multiple national advocacy groups have student members on grounds. Occasionally you’ll come across a group’s educational or awareness campaign in one of numerous global-health related courses offered each semester. There are physicians and epidemiologists working as part of the hospital system that team up with students from multiple schools.

This glorious mess is part of why I love UVA, but the ‘network’ is plagued with many of the same inefficiencies that we see elsewhere. Even a cursory search reveals redundant student groups. Students that decide to engage with global health are faced with decisional overload – there are so many different ways of getting involved, some of which are far more visible than others. People working in a particular region will hear “through the grapevine” of other UVA projects in the same region, often after having done a lot of groundwork without knowing of potential collaborators. Research collaborations in global health are necessarily transient and spontaneous, but there are few structures that make this more likely at UVA. 

Over the past few months, the Student Advisory Board has been working to build an interactive, sortable network of all the Global Health entities around grounds. We hope to have it done by the end of the semester, but mapping everything out visually is only the first step. A network map is a tool, not an end. With some effort on all fronts, perhaps we can make a Jackson Pollock painting look a bit more like a brain.

To be continued...

Diabetes, Chili Beans, and A1C's: Project HOPE in Action

The A1C, or HbA1c, is a common test for diabetes that measures levels of glycated hemoglobin in an individual's blood stream.  When diabetes is not controlled, sugar buildup in up in blood is detected as sugars are glycated, or bound, with hemoglobin.

A chili cook-off in central Virginia might be the last place one would expect to find a group of medical students with handheld A1C machines.  But among the steaming pots of chili - where tasters wore camouflage coats and a guitarist covered hits of The Band and Bob Marley - citizens of Louisa, VA checked their blood sugar.

On Saturday November, 1st, patrons of the Earlyhouse 10th Annual Charity Chili cook-off also checked their blood pressure, discussed healthy food options with a dietician, and checked their kidney function.  It was overcast and windy, a perfect day for chili but also an ideal day for Project HOPE to do what it does best: interact with the local community and promote health through disease screening.

Ebola Panel: Action Now and in the Future

On her way out of the medical auditorium, Dr. Christiana Hena taught us the Liberian handshake. As you pull your hand away, you snap your finger against the other persons. But now in Liberia, people don’t shake hands like that anymore. They give each other a thumbs up. The reason: Ebola.

Today’s panel discussion allowed us a more intimate understanding of the effects the viral epidemic has inflicted upon West Africa over the course of a few short months, beyond the commonly cited numbers in the media. The loss of intimacy in everyday life cannot be as easily quantified as mortality statistics.

As Dr. Hena and the other panelists spoke (virologists, a WHO consultant and two anthropologists), they opened up how the epidemic is not merely an isolated outbreak. It has roots not only in the civil war that devastated the nation over a decade ago, destroying 242 of the 290 health centers, but also in the policies that have resulted in the inadequate restoration.

The problem has not been lack of international investment in health in Liberia, Sierra Leone and Guinea, explained anthropologist Dr. China Scherz. Rather, money poured into projects and vertical pharmaceuticals, instead of building basic infrastructure and education, has not lead to sustainable solutions.

In the region where Dr. Hena works, for example, there were only three physicians for 200,000 people at the time the epidemic began. In July, clinics were closed, and nurses took it upon themselves to care for patients. Thirteen without access to proper PPE equipment died.

Meanwhile, ex-patriots and NGOs fled. While no one could fault them as individuals, the gaps they left at all levels of basic service delivery show the problems in failing to train capable local individuals.

At the moment, resources must be aimed to contain the unimaginable disaster and develop therapies. Drs. Frederick Hayden and Judith White explored the current therapeutic and prophylactic options under development, explaining the molecular basis for the Zmapp, siRNAs and experimental vaccines under development.

The panel left me reflecting on the conditions that allowed the Ebola epidemic to develop. As Dr. Christina Hena said, the national and international organizations should have known this would happen in a country with fragile health infrastructure. In March, when the first cases were reported, nobody did anything. March went by. Then April, and nobody did anything, except Ebola songs (http://www.youtube.com/watch?v=1_WOR22-SnY ) started coming out and people danced to them. Because they didn’t know what Ebola was, so they danced to the music.

Given the delayed response, absence of health care and witnessing horrific consequences of the disease, it is hardly surprising that the public do not trust those who come in the “space suits” to provide them aid. Rather than blaming people for eating bush meat or their funeral practices, perhaps the better question is what public health practices have led people to not trust those who come to help at this late hour.

I cannot help to think what the implications will be even in the best-case scenario. The few hospitals there are empty, many health workers have died, schools are out and the social fabric made up of handshakes, hugs and family closeness have dissolved. Chronic health conditions and mental health sequela of the epidemic are unlikely to be resolved in the short-term. These all lead us to question how public health is carried out and how such enormous disasters may be prevented.

For now though, the escalating emergency calls for the investment of health care resources. During the session, the question was posed as to when UVA can return to West Africa. Pethreree Norman, a Liberian nurse and student here at UVA, had a response. UVA does not have to leave West Africa, but can participate in the efforts through fundraising. She has already collected 1705 dollars and 2000 units of medical supplies to send to Liberia. Your donation will help alleviate shipping costs to the organization Aid for Ebola Liberia.

You can contribute at: http://www.gofundme.com/dm8ybk Now is the time to stop this epidemic from devastating the lives of the thousands it continues to kill, 40% of which have died in the last 21 days.

But at the same time as we contribute in solidarity, the panelists urge us not forget about Liberia, Sierra Leone and Guinea once Ebola is out of the news. The solutions of empowerment and capacity building they offered are relevant in all of global health. If we do not want a next disaster, we need to fix the way we do public health.

Report and Reflection: The 2nd UVa Global Health Case Competition

“5:30am,” replied the bleary eyed student.

It was Saturday morning and I had just asked her what time she had gone to bed the previous night. No, she hadn’t been partying it up on the corner—she and her interdisciplinary team had been polishing up their presentation for the second UVA Global Health Case Competition. The first iteration of this event in 2013 had challenged participants to present proposals to control the menace of extremely-drug-resistant tuberculosis and other health concerns in the slums of Mumbai, India. This year’s case was equally challenging: prioritize the health needs of Syrian refugees and develop a pilot program to address these needs in Syria’s neighboring countries.

Case Competition Flyer (courtesy: Manya Cherabuddi)

The case, written by a group of students from across the University and including members of last year’s winning team, objectively described several problems and complicating factors that the United Nations High Commissioner for Refugees is currently facing. About six million Syrians are internally displaced and another 2.5 million have been scattered across the middle-east and Europe as a result of the crisis, which many believe to be the most serious humanitarian crisis since the Rwandan genocide of 1994-1995. Syria’s health infrastructure has been reduced to rubble by the conflict, leaving Syrians with no preventative health services. Consequently, the recurrence of polio was unsurprising, but horrifying for a global community that has invested some much to eradicate this disease.

The case also focused significantly on social and health issues plaguing the women among the Syrian refugees. Not only are there insufficient obstetric and gynaecological services available to Syrian women in the refugee camps, they are also forced into an oppressive social dynamic. For instance, young Syrian girls are coerced to marry older local males in hopes of establishing economic security for their families. The danger of rape and molestation is ever-present in the tumult of large refugee camps. The case cited the example of women in the Za’atari camp who actually dehydrate themselves during the day to minimize toilet use as they fear lurking rapists. The case challenged students to propose a realistic initiative with a maximum budget of $25 million to ameliorate one or more identified issues in Syrian refugee populations.

One of the finalists explaining their vision

The students were given the case on Monday and had until Saturday morning to formulate their proposals. Some of the teams were pre-made and others were randomly created with students who had applied to participate in the competitions individually. All in all, we had fourteen teams with representatives from at least three different disciplines. Within a week, they researched the situation, identified the issues they were going to tackle, and designed an innovative intervention. From my participation in the 2012 Emory Global Health Case Competition in Atlanta, I know the incredibly hard work required to produce a presentable solution. My team members and I easily spent more than 30 hours individually to develop an appropriate health intervention for Sri Lanka. I saw teams put in equally hectic hours for our internal competition this year.

The product of their labours was commensurately incredible. I really enjoyed the detailed and diverse proposals on display. The proposed interventions ranged from cash transfers and social entrepreneurship grants in Lebanon to enhancing the educational facilities in Jordan. The winning team, Healthy Hoo’s, had students from the Frank Batten School of Leadership and Public Policy, the Curry School of Education, and the College and Graduate school of arts and sciences. They were notable for the wonderful way in which they interwove their innovative proposals with the narratives of individual Syrian refugees, reminding us of the mass of humanity at the root of this situation. The runners up, Power Rangers, were a team of RAs, who were impressive in the focus and detail of their proposed GIS surveillance system.

Our wonderful judges

Obviously, I didn’t engage with the case with anything close to the intensity that the teams displayed. However, I think I learned an important lesson from our incredible case writing team and dedicated contestants. A common and powerful theme in all the presentations was the importance of providing normalcy to the refugees. Medical education instils a strong predilection for pragmatism into students like me. This leads us to focus on things like diarrhea, obstetric complications, and vaccinations. The importance and cost-efficacy of interventions like these are above questions, but are they enough?

Before medical school, I fancied myself to be a biologist and often had to consider whether an element in a given molecular process was necessary, sufficient, or both. In this case, I believe that our pragmatic medical priorities are necessary, but not sufficient. Refugees are not just broken bodies to be fixed and mouths to be fed. They include children who dream of becoming astronauts, teachers with a passion to inspire generations, and carpenters who take pride in things they construct with their hands. Often-times we forget this and, years after their formation, refugee camps continue functioning in an emergency-mode, putting bandages on wounds but not charting a path back to normal life.

At the 2014 UVa Global Health Case Competition I realized that working with (and I mean WITH) the refugees to construct channels back to a productive and vibrant life, in which they can heal from the scars of conflict, is as legitimate a priority as giving them clean water and food.