Category Archives: Publication

Engaging the public on global health

This post originally appeared here.

A simple Google AdWords search of Ebola keyword searches in the past twelve months in the U.S. shows a general disinterest in Ebola all through the summer when cases were raging in West Africa and a sudden spike to 24 million searches in October 2014 just when cases were coming to the U.S. Similarly, average search volumes of “Ebola in Africa” are around 8,100 per month, while “Ebola in the U.S.” gets about 74,000 searches per month. Clearly, something is not right.

Yet the problem may not be exactly what we think it is. It is certainly not the case that people simply don’t care about global health and only become concerned when a disease encroaches on their own borders. In a Kaiser Family Foundation survey from 2012, 52% of people said that the media pays too little attention to health issues in developing countries. 50% of people said they paid at least some attention to global health issues in the news, 18% said they paid a lot of attention, and only 6% said they paid no attention at all. Lest we think people are merely self-interested, when asked why the U.S. should spend money on global health, 51% of people said it was because “it is the right thing to do”. Charitable giving statistics lend a bit more meat to this argument. In 2013, individual donation to health organizations in the U.S. amounted to a total of $31.86 billion, up 6% from 2012. Naturally, many of these health organizations have domestic missions. However, it does show concern about health in particular.

From these surveys and statistics, it would be difficult to argue that the American public has absolutely no interest in global health and international development. But there does seem to be a barrier to getting more involved in these issues: the way the information is presented. But the American public seems interested in knowing more about global health outside of these crises.

At the same time, it will be important to provide some more perspective on what the most pressing global health issues truly are. The same Kaiser survey found that when given a list of health issues in developing countries and asked to rank priorities, the public had a difficult time choosing, and about 1/3 of people claimed that all 12 named issues should be “one of the top” priorities. This finding suggests that although people want to engage more with global health, they feel overwhelmed by the number of issues that plague developing countries and have no reliable regular source of information to help them understand it all.

Engaging people on a regular basis in global health news and issues, as well as offering some perspective on what drives health crises in developing countries, might go a long way in mobilizing a group of people who want to help in some way but don’t know how. But whose responsibility is it to provide this kind of engagement, and how should it be done? Some possibilities include encouraging the media to make use of health crises in developing countries, such as Ebola, to more thoroughly explore and report on the contexts in which these crises arise. In a similar manner, these journalists should be engaging more extensively with local communities, and, perhaps more importantly, with local journalists, whose voices are very often absent from our news sources.

One interesting example of a current concerted effort to engage the public in dialogue about global health is the Wellcome Collection. The Wellcome Collection opened in 2007 and is described as a “free visitor destination for the incurably curious”. The Collection offers a wide range of information and exhibits related to science and medicine in general, but since the Wellcome Trust is such a major funder of global health, the collection also provides the public with a great deal of information on global health issues such as malaria, epidemics, and infant mortality.

In addition, health care companies and major foundations such as the Gates Foundation could make a more concerted effort to engage the general public in global health issues, especially during times of crisis when they already have an audience. This kind of engagement should go beyond statistics about various diseases and requests for funding to really making people aware of the entire political, social, economic, and healthcare context in which these epidemics arise. Perhaps this kind of regular engagement in global health issues might prevent the kind of needless and sometimes dangerous hysteria we witnessed with the Ebola epidemic and also target people’s attention and concern to where it would be most helpful.

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Is Margaret Chan Really to Blame for the Delayed Ebola Response?

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January 6 article in the New York Times suggested that WHO Director-General Margaret Chan’s response to the Ebola crisis was woefully inadequate. The article notes that it took 1,000 Ebola deaths in Africa and the spread of the disease to Nigeria for the Chan to proclaim a global emergency. Citing criticisms of Chan’s response to the SARS epidemic as a public health administrator in Hong Kong, the article accuses the current WHO head of conceding too heavily to local governments. The article claims that she relied too heavily on African regional offices to manage the response when her agency should have stepped in more aggressively earlier. But the history of public responses to infectious disease announcements, as well as tragically underfunded global disease surveillance systems, suggest that, while Chan may not have done everything she could, the story is much more complex than it seems.

Image credit: star5112, Flickr

Sounding the alarm bell on an infectious disease threat and taking extreme measures such as quarantine and travel bans is not without risk. American history is littered with examples of harmful infectious disease panic. More often than not, American responses to infectious disease threats tend to tap into embedded racial tensions. We only need to look at vicious attacks on African boys at a Bronx, NY school in October, to the sounds of the nickname “Ebola,” to understand that these dynamics are still very much at play. Chan herself certainly knows the harms of acting perhaps too quickly in response to what seems like a global infectious disease crisis. In 2009, Chan was harshly criticized for supposedly “overreacting” to the H1N1 threat.

Image credit: Graeme Maclean, Flickr

Part of the problem is that our understanding of how regular people respond to risk is not entirely clear. Although we have a good theoretical understanding of the tenets of risk perception from the classic psychological work of scholars such as Paul Slovic, our understanding of how risk communication in contemporary health crises affects people’s decisions and emotions is not well-developed. People can react in surprising, emotional, and counterintuitive ways to images and information about diseases, and research has shown health risk communication can even have the opposite of the intended effect. So while Chan may have reacted too slowly and relied too heavily on over-burdened local governments, we must remember that if we want our public health officials to feel comfortable responding to infectious disease threats in situations involving limited information and unpredictable outbreak patterns, we must develop a much firmer understanding of what drives public hysteria surrounding infectious disease and how to quell the panic.

The Times article touches on one hugely important issue that gets overwhelmed in the article’s haste to place all the blame on Chan: the inadequacy of our current global public health surveillance systems. Surveillance systems in developed countries are often sufficiently robust, which is part of the reason why a case of Ebola in the U.S. is extremely different from a case of Ebola in Liberia. A case of Ebola in the U.S. will be rapidly identified and reported to authorities. Protocol will immediately kick in and complete isolation of the suspected case will begin almost instantaneously. In Liberia, a country with a poorly developed public health surveillance system, a case of Ebola may not be well-recorded, the information may not get to the appropriate authorities in a timely fashion, and advanced protocols might not exist to ensure the complete and rapid isolation of the sick individual.

Part of the problem here is a global culture that focuses on crisis and not prevention. Surveillance systems need to be built up in times of relative calm. Funding for surveillance systems, which can be significant, needs to appeal to people’s sense that they are preventing the next epidemic, not to their need to help a languishing, dying child in a moment of intense crisis. By the time the child is dying of Ebola, or flu, or malaria, or any other infectious disease, it is usually already too late, and the cost of helping the situation can be much more than investing in the proper public health infrastructure in times of relative calm.

As the Ebola crisis continues to fall out of the media spotlight, and even as the epidemic still rages in West Africa, we need to act immediately to maintain the momentum produced by this frightening epidemic not to point fingers at specific health officials but to figure out what went wrong on a more fundamental level. While Margaret Chan may in many ways be partly to blame, putting her at the center of the problem is not only misguided but also a waste of time and energy. We must recognize that if we are to improve the response to future epidemics, we have to do most of the work outside of times of crisis. Because once the index case of a major new epidemic is reported, it is already too late.

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When implementing universal health coverage, context matters

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As the WHO’s Millennium Development Goals reach their final phase, Sara Gorman reflects on what we have learned about how political, cultural and financial contexts impact the success of universal health coverage systems. 

Image Credit: Edith Soto, Flickr

In May of 2013, Margaret Chan affirmed the WHO’s commitment to achieving universal health coverage worldwide, proclaiming “universal health coverage is the single most powerful concept that public health has to offer”. For Chan, public health measures such as universal health coverage represent a key component of development work in the 21st century. As the Millennium Development Goals (MDGs) begin to wind down with their 2015 expiration date looming, the WHO has turned its attention toward the next set of goals for world health. With statistics revealing that more than 100 million are pushed into poverty each year due to excessive health care costs, it seems ever more urgent to advocate for universal health coverage, spreading the costs across entire populations.

Yet even as it is essential to embrace a global move toward universal health coverage, it is equally vital to continue asking whether there is enough evidence to show that universal health coverage really improves population health. If not, it will become important to search for ways to make universal health coverage more effective at achieving its underlying goal: improving health. Thus, questions must be asked not only about whether countries are implementing universal health coverage but also about whether this implementation seems to be working. What are the constraints to achieving better population health as a result of universal health coverage?

What is the evidence that universal health coverage improves population health?As Moreno-Serra and Smith have observed, much of the research on the relationship between healthcare financing and health outcomes has failed to take causality into account. A series of studies have demonstrated a correlation between greater pooling of health funds and increased life expectancy. Yet these correlations are not enough to suggest that this change in the structure of healthcare financing is causing an increase in life expectancy, especially in low- and middle-income countries facing a demographic transition.

More recent longitudinal studies have managed to show a causal relationship between universal health coverage and better healthRecent research in PLOS Medicine has noted the success of universal health coverage on women’s health in low- and middle-income countries, including Afghanistan, Mexico, Rwanda, and Thailand. However, the effects of universal health coverage can vary depending on the robustness of a given country’s governance. Countries with strong governance tend to benefit the most from increased health coverage, while countries with weak governance benefit much less. It therefore seems essential that health coverage expansion in countries with poor governance infrastructure be accompanied by improvements in public administration. Because the effects of universal health coverage seem prone to the influences of context, there is a need for more studies of ways in which particular small changes in local institutions and government and financial structures can affect the relationship between universal health coverage and improved population health.

Some low- and middle-income countries have faced serious setbacks in implementing universal health coverage. In Nigeria, for example, universal health coverage has largely faltered due to poor infrastructure and low-quality health services. Problems with implementing universal health coverage in Mexico are another example of poor infrastructure and efficiency before the implementation of the new plan carrying over into the new plan and reducing its potential effects on population health. A lack of health facilities in rural areas remains a major barrier for poor people who are now covered but have nowhere to go for healthcare. In addition, since the system is financed through central government allocations to states, the country has faced problems with lack of accountability and transparency regarding use of these state funds.

In theory, universal health coverage is among the most powerful tools public health has to improve population health. Yet in reality, implementing universal health coverage has to be accompanied by a wide range of other health systems strengthening approaches within a broader development framework. Attention to context is key. The structure of universal health coverage plans must be sensitive to the particulars of the government infrastructure and financial structures in place in the country in question. In addition, attending to issues of supply and quality is essential. Implementing a universal health coverage plan without insuring that there are enough quality doctors and hospitals means spending a lot of money with little chance of better health results, especially for the most disenfranchised portions of the population. Universal health coverage is no magic bullet, but it is a vital tool in improving population health in the post-MDG era.


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Does fear-based messaging help public health campaigns?

This post was originally published here.

A recent, well-publicized paper in Pediatrics cast considerable doubt on a tool public health practitioners value highly: informational messaging campaigns. The paper, based on a randomized-controlled trial, showed that neither information on the safety of vaccines nor details about the diseases being prevented by vaccination increased parental intent to vaccinate their children. In a surprising twist, graphic images of children suffering from vaccine-preventable childhood diseases, such as measles and pertussis, actually increased parental belief in an association between vaccines and autism and dramatic narratives about unvaccinated children who became ill increased parental belief in serious vaccine side effects.

The results of this study are decidedly disappointing to public health practitioners who strongly champion the utility of informational campaigns in producing better health outcomes and increasing rates of preventive behaviors. The study makes clear that much more research is needed on the particular effects of pro-vaccine messaging and that many public health campaign messages should be tested before being rolled out, not only to measure effectiveness but also to protect against any unforeseen negative effects. Testing for unintended consequences of health messaging is something that is often ignored in public health informational campaigns but may be just as important as testing for efficacy. Yet this study evokes an even wider question about public health campaign strategy: does fear-based messaging help or harm the cause? Does scaring people result in better health outcomes and increased uptake of preventive medical care or is it possible that this kind of messaging is actually associated with increased denial, psychological reactance, and increased distrust of the health and medical establishments?

Fear messaging in public health as well as in other related fields has a long history. In the past, public health authorities have tended to believe that fear messaging has the capacity to backfire. Yet recently, some health authorities such as the New York City Department of Health have begun to rely more heavily on fear appeals. For example, the city has launched a series of subway ads as well as television commercials featuring the terrifying consequences of lifetime smoking and graphic photos on the subway of amputated limbs due to diabetes from consuming too many sugary drinks. Widespread fear about an increasing tendency for parents to refrain from vaccinating their children and reports of several troubling measles and pertussis outbreaks in pockets of the country with low vaccination rates have led public health authorities to consider extending the fear appeal method to convince parents of the absolute necessity of vaccination. But is this the best way forward? If the method has a high likelihood of backfiring, as the evidence from the Pediatrics study seems to indicate, great care must be taken to vet and test all messages before they are disseminated to the public.

Several guidelines about constructing useful fear appeals do exist. In order to increase effectiveness, fear appeals must emphasize the severity of the threat as well as the intended population’s susceptibility. Without these factors, any fear-based campaign will inevitably be disregarded and fail. But these prerogatives do not justify simply flooding the public with gruesome images and messages about their inevitable susceptibility to the threat. Perhaps most importantly, fear-based messages should always be accompanied by strong efficacy messages. That is, the barriers that the intended population may face in preventing the dreaded health outcome must be carefully weighed and comprehensively addressed in any fear-based messaging campaign. Without reassuring people about their ability to prevent the feared outcome, strong fear appeals have a very high likelihood of backfiring. Public health practitioners must therefore walk the line between creating strong, efficacious messages about real, severe health threats and reassuring intended audiences that they do have the means and resources to prevent these threats. In addition, common counterproductive psychological responses, including denial and reactance, must always be taken into account when designing these types of messaging campaigns. The delicate balance between inventing efficacious fear-based messages and providing the public with hope for escaping these threatening outcomes is a large part of the reason why it is so important to test any fear-based messaging campaign before it is launched. Most importantly, if people are made aware of threatening health effects for which no practical solution seems accessible, fear-based messaging may result in precisely the reverse of the intended effect, including increased risk-taking behavior, denial, and hopelessness. It is the prerogative of public health officials to insure that messaging campaigns are not only effective but also, and perhaps even more importantly, not harmful.

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What do we really know about social resistance to vaccines?

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Last year, polio eradication efforts were severely compromised by a rash of killings by militants in Pakistan and Nigeria. Between December 2012 and January 2013, at least 16 polio workers were killed in Pakistan. In early February, more bad news arrived: 9 health workers were murdered in northern Nigeria while working on the polio eradication campaign.

Potential explanations and suggestions for future action poured out following the attacks. Some people thought the CIA’s actions years earlier in the Bin Laden assassination laid the groundwork for Pakistani suspicion of Western vaccination campaigns. By employing a Pakistani doctor to gain entry into what was thought to be the Bin Laden compound by feigning a vaccination program, the agency perhaps stirred local suspicion of the real motives behind Western-based vaccination campaigns. Of course, the resistance to polio vaccination is also largely political, especially in countries like Pakistan, where polio workers have been seen as “soft targets” for anti-Western terrorism. Some people believe that the murders are connected to beliefs that the vaccination campaign is really an effort to sterilize Muslim children. In response to these allegations, some are suggesting better education, outreach, and communications about the devastating effects of polio and the real benefits and risks involved in vaccination.

These killings should be stimulating an essential set of questions about our knowledge of vaccine resistance: what do we really know about social resistance to vaccines? How much do we know about the demographics of vaccine resistance, and how well do we truly understand fear of vaccines, a fear so overpowering that it has motivated murder? How much does social resistance to vaccination vary across cultures? In other words, are Muslim fears that foreign vaccination programs are designed to sterilize Muslim children that different from U.S. parents’ conviction that the government has been poisoning children with vaccines for decades and is intentionally covering it up?

A few, but not many, studies have been done to begin to understand the demographics, spread, and circumstances behind various anti-vaccination movements or instances of vaccine non-compliance. One study published inPLOS One in September 2012 examined fear and resistance to the polio eradication program in Aligarh, India in 2009. The study found that vaccine fear and resistance were borne from a kind of fatigue and suspicion that stemmed from confusion about changing vaccination strategies. When the polio eradication program shifted from a strategy of vaccinating a few times per year to a strategy of a more aggressive short-term vaccination campaign involving shots once per month, families were left confused and suspicious about the efficacy of the vaccine in the absence of explanation by officials. The result was what the authors call “vaccine fatigue,” suggesting that lack of proper explanation of all the details in a vaccine program, including the frequency of administration of shots, may contribute to suspicion and fear of vaccines. A 2007 study published inPLOS Medicine investigated the polio vaccine boycott situation in Nigeria. The author of this article insists that social resistance to vaccines be placed in the wider political and social context of health services in northern Nigeria. Controls on population growth in the region since the 1980s led to suspicion of vaccine programs in particular, which were believed to be a method of checking on the number of children in each family. Similarly, aggressive vaccination campaigns are particularly eyebrow-raising in a region where healthcare is generally difficult to attain. As the author notes, free door-to-door healthcare in northern Nigeria is as bizarre as a stranger going door to door handing out $100 bills in America. In the end, the study urges widespread public awareness campaigns about the benefits of vaccination and sensitivity to local politics to help avoid future boycotts.

A few similar studies following disease outbreaks in the absence of vaccination in pockets of the U.S. have revealed the general demographic of the anti-vaccine movement: middle-to-high-income whites who favor natural, organic foods and remedies. A few other studies have taken a close look at anti-vaccination websites to try and gain a better understanding of how anti-vaccination materials are formulated and how they spread.

The truth is, we have relatively little data about the demographics and nature of anti-vaccination thought and the mechanisms of its spread. But we do know that anti-vaccination sentiments have a very long history, at least in developed nations such as the U.S. and England. A common belief is that smallpox elimination in the U.S. represents a case of unique cooperation between a terrified public and an even-handed, responsible public administration. But resistance to smallpox vaccination was potent, probably much stronger than today’s American anti-vaccination movement. In fact, vaccination against smallpox in those days was often a risky business, with little government control over quality and safety. Compulsory vaccination was seen as potentially dangerous and certainly a threat to civil liberties. Antivaccination leagues in 1900performed very similar actions to antivaccination activists in 2013: they challenged compulsory vaccination laws and staged boycotts. They even rioted and hid sick children from vaccination authorities.

What can we learn from this long history of antivaccination sentiments and what do we still need to discover about today’s antivaccination movements, active all over the world? We can probably learn something from certain “golden ages” in vaccine history. When were people particularly cooperative, and what circumstances helped to produce this acceptance? Perhaps looking back to the types of messages and outreach that public health officials provided in times of low vaccine resistance might give us some ideas about how to offer a more effective PR message about vaccines today. Perhaps most importantly, we need to know more about how vaccine resistance movements operate. What exactly are the demographics behind these movements? What methods do they use to spread information? Are anti-vaccine believers clustered in certain geographical areas or social networks? How can we best distribute pro-vaccine messages to target the right people? These are all essential questions if we are to successfully encourage widespread uptake of this crucial public health tool. At present, the medical and public health communities often resort to pedantic educational campaigns and exhortation in the face of vaccine skepticism. But berating anti-vaccine adherents has not proven useful. Rather, we need to understand the roots and motivations of misguided health-related ideas in order to design effective counter efforts.

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Why infectious diseases still matter

Originally published here.

The headlines are everywhere. “Non-communicable diseases outsmart infectious diseases.” “Non-communicable diseases leading cause of deaths worldwide.”Non-communicable diseases take center stage.” Non-communicable diseases are certainly on the rise worldwide and represent a growing concern for global health systems. But are chronic diseases truly taking the place of infectious diseases? In a world of global health systems that tend to focus on one disease or one category of disease at a time, should we be shifting our focus from HIV, tuberculosis, and malaria to asthma, heart disease, and diabetes?

In a thought-provoking article, Alanna Shaikh, a global health professional and writer, convincingly argues “not so fast.” The old view of the epidemiological transition, whereby non-communicable diseases “replace” infectious diseases as the primary threats to health, is probably too simple. Instead, communicable and non-communicable diseases are combining in new ways to present new threats. Shaikh takes the intersection of diabetes and tuberculosis as one prominent example. People with diabetes have a risk for tuberculosis infection 2-3 times greater that among people without diabetes. Even worse, people with diabetes have a higher risk of dying during TB treatment or confronting treatment failure, largely due to the fact that people with diabetes have difficulty tolerating TB drugs. Of course, diseases such as TB and malaria are largely irrelevant in developed countries, but in developing countries, the rise of chronic disease could mean devastating setbacks in the control of infectious diseases.

The diabetes and tuberculosis duo is not the only example of the nasty confluence of communicable and non-communicable diseases. Non-communicable and communicable diseases often share the same risk factors. In fact, the same underlying social conditions, including poverty and unsanitary conditions, may cause both communicable and non-communicable diseases, and there are often significant overlaps in terms of causation and co-morbidity. Some infections cause non-communicable diseases, such as human papilloma virus and cervical cancer.  Treatment of communicable diseases may increase NCD risk, and NCDs and their risk factors may contribute to risk of developing certain infectious diseases.

In some cases, it is clear that communicable and non-communicable diseases function together to create larger health problems, such as maternal and child morbidity and mortality. We have long been aware that infections in pregnancy, such as malaria and HIV, represent major threats to maternal health and also contribute to prematurity and low birthweight. But it is also clear that adverse events in early life significantly increase risk of NCDs later in life. There is even a suggestion that metabolic disease in adult life may be prevented by malaria control in pregnancy. In a case such as maternal and child health programming, it is clear that joint interventions to control both infectious and non-communicable diseases are desperately needed and widespread recognition of the complex interactions between these two categories of diseases is vital.

Given current focus on the rise of non-communicable diseases, there is always a risk that excessively vertical health programs will be implemented. To avoid this, the constant interplay between infectious and non-communicable diseases needs to be recognized and acknowledged and greater integration and resource-sharing in health systems must be pursued. At the primary care level, maternal and child health programs could include interventions to improve nutrition and reduce tobacco use in pregnant and nursing women. Training a wide array of primary health providers to identify and manage hypertension and diabetes in pregnancywould also be essential in reducing risks of both NCDs and infectious diseases in both mothers and children. Reproductive and sexual health programs should include prevention of both sexually transmitted infections and certain kinds of cancer, including breast cancer and cervical cancer. Immunization programs should be expanded to include broad access to HPV vaccines to prevent cervical cancer and Hepatitis B vaccines to prevent liver cancer.

While it is true that devastating non-communicable diseases are on the rise and deserve our close attention, it is equally vital not to neglect infectious disease control in our efforts to prevent chronic illnesses. Not only are infectious disease threats still rife but non-communicable diseases and communicable diseases often fuel each other and require integrated prevention and treatment efforts. The future of health programming, particularly in developing countries, is not necessarily best guided by the epidemiological transition but more accurately by a holistic model that recognizes the key contributions of both communicable and non-communicable diseases to poor health outcomes.

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Why maternal mental health should be a priority

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As 2015 quickly approaches, the global health community has been made increasingly aware of our progress toward Millennium Development Goals (MDGs). Some remarkable progress has indeed been made. For example, the proportion of underweight children under the age of five in developing countries has declined from 28% to 17%between 1990 and 2011. Significant progress has also been made in reducing mortality among children under the age of five. In 1990, 12 million children under five died, compared with 6.9 million children in 2011. In 2011, 2.5 million people were newly infected with HIV, representing a 24% decrease from the 3.1 million people newly infected in 2001. However, one millennium development goal has shown particularly slow progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal morality by 75%. Sub-Saharan Africa is in the most dire position, with a regional maternal mortality rate of 640 maternal deaths out of 100,000 live births, and a decline rate of merely 0.1%. In the summer of 2012, the University of Cambridge hosted a conference on the topic of “New Approaches to Maternal Mortality,” recognizing the crucial need to address the question of what is going on with global maternal mortality rates and to begin to address potential solutions.

While numerous factors are still converging to produce this grim picture, one key element is often missing from the discussion: improving maternal mental health. Working toward solutions to mental health problems that plague new mothers in a wide variety of settings, including in developing countries, could go a long way in improving both maternal and child health. Integrating mental health programs with maternal health programs is not only as important in saving mothers’ lives as screening for malaria and treating HIV in pregnant women but it could also prove essential in achieving two distinct but interrelated Millennium Development Goals: improving maternal health and reducing the number of deaths in children under the age of 5.

A recent article in PLOS Medicine delineates some reasons why maternal mental health is not a high priority on maternal health agendas. For one thing, a number of myths prevail that make maternal mental health seem irrelevant or unimportant in comparison to other threats facing maternal health. One especially troubling myth is the notion that maternal mental health problems are rare in developing countries, where maternal deaths represent a more significant problem than in the developed world. The authors note that this perception is misguided and cite evidence that rates of perinatal depression in low- and middle-income countries are actually higher than in high-income countries, ranging from 18% to 25%. Another misperception involves the idea that maternal depression is only tangential to maternal health. There is a conception that obstetric complications and infectious diseases represent much more immediate threats to maternal health than mental health issues. Yet this notion turns out not to be entirely true. Maternal depression certainly contributes in a very direct and striking manner to poor outcomes in infants. Maternal depression has been associated with pre-term birth, low birthweight, undernutrition, and higher rates of diarrheal disease. Suicide is actually a leading contributor to maternal mortality worldwide, and suicidal thoughts and tendencies occur in up to 20% of mothers in low- and middle-income mothers, in comparison with 5 to 14% of mothers in high-income countries.

Part of the problem with treating maternal depression is that it can be difficult to detect, especially in resource-poor countries. Core symptoms of depression such as fatigue and poor sleep are also effects of motherhood and often go unnoticed in new mothers. Screening for depression should be an integral component of antenatal visits and health care professionals who do not specialize in mental health should be trained to recognize symptoms of depression in pregnant women and new mothers. Over the last decade, interventions by non-mental health specialists have produced promising results, and efforts are being expanded to low- and middle-income countries with encouraging outcomes. ThePerinatal Mental Health Project (PHMP), based at the Mowbray Maternity Hospital in South Africa, included screening by midwives of all women in antenatal care for mental health problems and referrals for counseling and psychiatric care if necessary. The intervention resulted in high coverage (90%) and uptake (95%) of PMHP screening, and staff responsible for the screening expressed relief, rather than a feeling of burden, about the integration of maternal and mental health systems in order to address a previously unmet need.

International donors and stakeholders should be made aware of the dire effects of maternal depression on maternal and child health and should be encouraged to provide funds and aid specifically for maternal mental health. In particular, the evidence for the effects of mental health on physical health should be emphasized in communication with international donors. In addition, donors should be made aware that integrating mental health services into existing treatment platforms could prove an important opportunity to leverage resources efficiently, a major current preoccupation of the global health community.

If the Millennium Development Goals are to be achieved, the international health community needs to stop viewing them in isolation from each other and recognize that many of them are intertwined and require integrated interventions. At the same time, holistic views of both health systems and individual health are vital. Strengthening across health systems, which includes strengthening local mental health services, will bring us closer to achieving the MDGs. In a similar manner, viewing individual health holistically, as the combined effect of the health of various systems, including not only the body but also the mind, will help ensure that we pay due attention to a wider variety of factors contributing to poor health worldwide.

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How can we improve global infectious disease surveillance and prevent the next outbreak?

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ABSTRACT Section: ChooseTop of pageABSTRACT <<The state of infectious d…Problems with global infe…Possible solutions to glo…References Next section


Despite a significant amount of progress in the past decade, global infectious disease surveillance still often falters, as in the case of the emerging novel coronavirus that has killed at least 17 people in Saudi Arabia. This article argues that we must continuously re-evaluate global infectious disease surveillance systems. It takes stock of problems in various countries’ infectious disease surveillance systems and offers recommendations for how to improve surveillance and ensure more rapid reporting. Chief among the recommendations are strategies for reducing fragmentation in global surveillance systems and methods for making these systems less disease-specific. Suggestions are also offered for ways to improve infectious disease surveillance strategies in resource-limited settings.

The state of infectious disease surveillance and reporting Section: ChooseTop of pageABSTRACTThe state of infectious d… <<Problems with global infe…Possible solutions to glo…References Previous sectionNext section

In light of recent panic over the detection of a novel influenza A virus (H7N9), an editorial in The New England Journal of Medicine warned that “we cannot rest our guard” [1]. The authors commended Chinese scientists for rapid identification and reporting of the new virus [1]. At the same time, by February 15, 2013, a novel coronavirus, occurring eerily exactly a decade after severe acute respiratory syndrome (SARS), had killed 6 of the 12 people infected to that point [2]. Yet 6 months after the first report of this novel coronavirus, not nearly enough is known about the illness. Scientists feel certain that there are more cases, some perhaps so mild that the infected individuals are not seeking care. Human-to-human transmission of the newly characterized coronavirus probably occurs, but little is known about the mechanism or efficiency of infection [3]. Part of the problem is that affected countries have not offered the appropriate amount of information for full epidemiological analyses to be conducted. Saudi Arabia has reported 9 novel coronavirus infections to the World Health Organization (WHO), but information is still missing about patient age, sex, residence, and circumstances surrounding infection [3]. Although SARS was ultimately largely contained, China’s initial reluctance to report the outbreak is another well-known example of resistance to reporting disease outbreak information [4]. China also did not report a 2003 case of H5N1 until 2006 [5].

‘Infectious disease surveillance’, an important component of any public health system, refers to a variety of strategies, including monitoring a disease over time and reporting of clinical cases or disease clusters. Some surveillance systems depend on clinical observation, some on laboratory tests, others on computer-based searches of public health records or individual patients, and still others on mathematical modeling and prediction [6]. A decade after the SARS epidemic, it seems apt to take stock of how much better prepared we are now to deal with emerging pathogens. The evidence is mixed. On the one hand, we have come very far. Infectious disease surveillance has improved, and scientific advances make it easier to sequence the genome of an emergent pathogen much more rapidly. The SARS experience also induced the introduction in 2005 of new international rules to report novel diseases [6]. Electronic and communication networks have expanded, and the WHO has even begun to provide information on emerging outbreaks in real time on their website. The WHO has also developed a wider network, the Global Outbreak Alert and Response Network (GOARN), aggregating information from a wider variety of sources, and has revised the International Health Regulations to include more infectious diseases [7]. At the same time, our experience with the novel coronavirus shows that there is still a ways to go in improving our global response to emerging infectious disease threats. Many countries still lack the infrastructure to detect and report a disease early on. After the first case of novel coronavirus in Saudi Arabia, it took 3 months for information about the illness to emerge in the global arena [3].

Problems with global infectious disease surveillance Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe… <<Possible solutions to glo…References Previous sectionNext section

What are some of the problems with the current operation of local and international infectious disease surveillance systems? One obvious problem is the reluctance of local governments to report diseases for fear of negative repercussions on tourism and trade and general feelings of embarrassment. On a more structural level, systems of disease reporting and surveillance are extremely fragmented, since surveillance systems tend to be reactive and disease-specific [5]. For example, in the USA, surveillance systems are decentralized, operating under local, state-controlled reporting regulations, with information then forwarded to the Centers for Disease Control and Prevention (CDC). Even in countries with centralized reporting procedures, there may not always be a straightforward link between centralized control and effectiveness of surveillance [5]. Reporting relationships between local entities and the capitals of these countries may often be lacking. For example, this was certainly the case in China during the SARS outbreak: although China has strong centralized political control, communication between localities and the capital were observed to be very weak during the SARS epidemic [5]. This lack of communication is not always the case, but it does show that centralized control does not always mean more effective surveillance.

Competition for public health resources can sometimes render funds for infectious disease control inadequate [5]. We also have a surprising dearth of knowledge when it comes to epidemiological mapping of infectious disease threats. It is difficult to gauge the seriousness of emerging disease threats if we do not have a full understanding of their geographical spread [8]. Surveillance systems that are too disease-specific can also miss the early warning signs of emergent infectious disease threats [9]. They are also often passive, picking up on new diseases in a haphazard manner, and developed according to the local organization of public health systems, making international recognition much more difficult [5].

Possible solutions to global infectious disease surveillance challenges Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe…Possible solutions to glo… <<References Previous sectionNext section

What can be done to improve surveillance systems and aid in the prevention of emerging epidemic threats? Evidence suggests that outbreaks in developing countries are being reported more swiftly, especially informally by individual citizens. As a result, some experts suggest that focusing on ways to improve infectious disease reporting via cell phones, whether through SMS or smart phones, could be an incredibly useful venture [10]. The development of more systems similar to HealthMap that aggregate and organize informal web-based modes of infectious disease reporting, such as online news sources and discussion sites, could also be incredibly useful [11]. These systems must be made more user-friendly to individuals living in developing countries in particular, where a significant infectious disease burden exists. Strategies may include developing interfaces in additional languages and implementing mobile phone alerts [11].

Coordinating global reporting systems to better aggregate and share data is essential, as is training individual citizens to recognize and report outbreaks [5]. Just as community health workers and clinicians have been trained to detect outbreaks, so should individual citizens be educated about the signs of emerging infections and the protocol for reporting. For example, community educators could teach village communities in developing countries about the warning signs of emerging infections or about symptoms of common infectious threats in the region. Village citizens would also be taught about how to report infectious disease threats to the appropriate authorities, always being encouraged to over-report rather than under-report. In more developed countries, where people have easy access to the internet and technologies such as iPads and iPhones, government agencies could even develop applications that function as checklists for infectious disease threats and facilitate the process of reporting. For example, the US CDC recently developed an iPad app called “Solve the Outbreak” that, although a game, allows people to function as infectious disease epidemiologists; it is also intended to teach people about the warning signs of emerging infectious disease threats and inform them about the steps to take to report these threats. Additionally, explaining to policymakers why disease surveillance should be a priority is vital [5]. Seizing upon the right timing is important in this process, for instance in the wake of an epidemic disease threat such as novel coronavirus, when the problem of infectious disease outbreaks is already on the minds of high-level decision-makers. Clarifying that proper surveillance efforts are cost-effective is also essential in convincing policymakers of the importance of strengthening these systems.

Directing disease surveillance efforts to the right locations is also crucial. At the moment, most disease surveillance efforts focus on more developed nations, but threats of emerging infectious diseases may be most significant in places such as Africa, Latin America, and Southeast Asia because of population growth and increased antibiotic use [12]. Encouraging more countries to adopt the same infectious disease surveillance systems, such as the ProMED-mail system, to complement their own strategies, and making subscriptions to such services easy and affordable, could help reduce fragmentation of global infectious disease surveillance techniques [13]. International veterinary agencies that monitor global animal safety and disease need to be better connected to agencies such as the WHO that focus on human disease in order to help control infectious diseases with animal reservoirs [14]. At the moment, the operations of these types of agencies are wholly separate from each other, demonstrating another key source of fragmentation in global infectious disease surveillance systems.

Quality infectious disease surveillance is lacking especially in developing countries, where the infectious disease threat is often greatest. One way to close the gap in infectious disease surveillance is to better disperse technological advancements such as rapid diagnostic tools [15]. There is evidence demonstrating that rapid, affordable, inexpensive diagnostic tools can greatly contribute to quicker and more effective infectious disease surveillance [6]. Diagnostic tests that differentiate between different strains and organisms and point-of-care diagnostic tests are also needed [16]. Steps should be taken to help more local clinics in developing countries connect to the internet and thereby have the opportunity to take part in an important form of emerging infectious disease reporting. Web-based forms to report diseases via cell phone should also be provided in developing countries, since cell phones are widely available even in low-income villages [5]. International aid and public health agencies need to create realistic funding plans to help improve healthcare infrastructure in developing countries, including distributing resources needed to develop and distribute rapid diagnostic tools and training local health workers to use them [6].

Much research on the effectiveness of certain kinds of surveillance still needs to be done. More reports about the timeliness of responses to infectious disease outbreaks should be implemented. The best way to measure timeliness is to calculate the median delay between the date of disease occurrence (as identified by disease onset date, diagnosis date, or laboratory result date) and the date the public health system was notified for particular infectious disease threats. Evaluations of surveillance systems should more regularly take timeliness of response into account as a key measure of further needed progress [17]. Similarly, comparative cost-effectiveness analyses need to be conducted on various surveillance systems to have a better understanding of which forms of surveillance and reporting are most financially efficient. Clear measures of effectiveness and cost-effectiveness of various, existing infectious disease surveillance methodologies are desperately needed [6]. One 2010 PLoS One study of the Integrated Disease Surveillance and Response (IDSR) system in Burkina Faso provides a good model of how to measure this [18]. The authors of this study collected epidemiological data on the number of meningococcal meningitis cases in Burkina Faso before and after the implementation of the IDSR. They found a significant decline in cases, and although they noted this decline could be the result of other factors, they hypothesized that the decreases were primarily the result of the novel surveillance system, largely because the authors did not find statistically significant evidence for the existence of other factors to explain the decrease, such as an increase in vaccine imports. They then estimated costs per case, costs per death, and costs per sequelae prevented and concluded that the implementation of the surveillance system was cost-effective. More studies such as this one could be conducted in other regions with other infectious diseases to measure cost-effectiveness.

Although infectious disease surveillance has been vastly improved in the decade since SARS, there is still plenty of room for further progress. Even as China is to be commended for the rapid response to H7N9, we cannot rest easy. We must still continuously re-evaluate global systems of infectious disease surveillance and continue to improve them.

Declaration of interest: No special funding has been received for this article. The author declares no conflicts of interest.

References Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe…Possible solutions to glo…References << Previous section
  1. Uyeki TMCox NJ. Global concerns regarding novel influenza A (H7N9) virus infections. N Engl J Med 2013; 368:1862–4.
  2. Kahn G. A novel coronavirus capable of lethal human infections: an emerging picture. Virol J 2013;10:66.
  3. Enserink M. New coronavirus reveals some of its secrets. Science 2013;340:17–8.
  4. Hipgrave D. Communicable disease control in China: from Mao to now. J Global Health 2011;1:224–38.
  5. Morse SS. Global infectious disease surveillance and health intelligence. Health Affairs 2007;26:1069–77.
  6. Hitchcock PChamberlain AVan Wagoner MInglesby TVO’Toole T. Challenges to global surveillance and response to infectious disease outbreaks of international importance. Biosecur Bioterror 2007;5:206–27.
  7. Enserink M. War stories. Science 2013;339:1264–8.
  8. Hay SIGeorge DBMoyes CLBrownstein JS. Big data opportunities for global infectious disease surveillance. PLoS Med 2013;10:e1001413.
  9. Mawudeku ARuben MLemay R. Global public health surveillance: the role of nontraditional surveillance tools. In: Lemon SMHamburg MASparling PFChoffnes ERMack A, editors. Institute of Medicine Forum on Microbial Threats. Global infectious disease surveillance and detection: assessing the challenges—finding solutions, workshop summary. Washington: National Academies Press; 2007.
  10. Chan EHBrewer TFMadoff LCPollack MPSonricker ALKeller M, et al. Global capacity for emerging infectious disease detection. Proc Natl Acad Sci U S A 2010; 107:21701–6.
  11. Brownstein JSFreifeld CCReis BYMandl KD. Surveillance sans frontières: internet-based emerging infectious disease intelligence and the HealthMap project. PLoS Med 2008; 5:e151.
  12. Jones KEPatel NGLevy MAStoreygard ABalk DGittleman JL, et al. Global trends in emerging infectious diseases. Nature 2008;451:990–3.
  13. Madoff LCWoodall JP. The internet and global monitoring of emerging diseases: lessons from the first 10 years of ProMED-mail. Arch Med Res 2005;36:724–30.
  14. Butler D. Disease surveillance needs a revolution. Nature 2006;440:6–7.
  15. Lipkin WI. The changing face of pathogen discovery and surveillance. Nature Reviews 2013;11:133–41.
  16. Heyman HLBrilliant L. Surveillance in eradication and elimination of infectious diseases: a progression through the years. Vaccine 2011;29S:D141–4.
  17. Jajosky RAGroseclose SL. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases. BMC Public Health 2004;4:29.
  18. Somda ZCPerry HNMessonnier NRDjingarey MHKi SOMeltzer MI. Modeling the cost-effectiveness of the Integrated Disease Surveillance and Response (IDSR) system: meningitis in Burkina Faso. PLoS One 2010;5: e13044.

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Is fear a useful measure in preventing outbreaks?

Post originally published here

In Los Angeles in 1924, after a series of mysterious deaths, Yersinia pestis, or bubonic plague, was swiftly identified as the culprit. Immediate quarantine of exposed people in selected areas helped to make the outbreak less than a devastating epidemic. But some public officials and newspaper reporters, in a desperate attempt to explain the origins of the illness, began equating the disease with people of Mexican descent. Panic quickly struck the city. Hotels and restaurants fired thousands of Latino workers. Health officials destroyed houses in low-income neighborhoods deemed “public health menaces” without offering compensation to the displaced. Fear of the disease rapidly attached itself to deep-seated fears of low-income individuals and foreigners and produced an unacceptable set of practices in the name of preventing an epidemic.

But is fear always detrimental in the face of potential epidemics? In other words, is fear ever, in fact, a useful preventative tool? Excessive, widespread panic may, of course, be counterproductive in the fight against emerging microbial threats. But small doses of fear, instilled carefully and systematically by epidemiologists and public health officials, may be vital in certain situations.

Complacency and lack of fear might have a role to play in the recent dramatic drops in vaccination rates in the U.S. and other developed countries. In states in which philosophical exemptions to vaccines are permitted, the rate of this voluntary opting out was 2.6% in 2009, up from 1% in 1991. A certain misplaced form of fear might in fact be driving this phenomenon in some cases: parents have latched onto the false belief that vaccines cause autism and overestimated risks associated with vaccination. But recent declines in vaccination rates may also be due to a lack of appropriate fear. Sixty years ago, the consequences of life without most modern vaccines were eminently visible: polio paralyzed 16,000 Americans every year; rubella caused birth defects in 20,000 babies; measles infected 4 million children and killed 3,000 annually. Today’s parents view infant mortality as a phenomenon of the past or a devastating problem relegated to developing countries. Parents in the second decade of the 21st century have probably never witnessed an infant suffering from pertussis or diphtheria. Newly trained pediatricians may not know what a Koplik spot is, let alone have seen one The threat of child mortality is not looming in developed countries, and many parents do not realize that, in the

absence of vaccines and proper herd immunity, these illnesses, as well as infant death, could once again become immediate threats. In the case of declining rates of infant vaccination, might not a small dose of fear help?  If parents were more frightened about the consequences of notvaccinating their children, whooping cough epidemics such as the one in Washington State this past year might be prevented.

When is it appropriate to sound the alarm bell and when should public health officials keep the public calm? Obviously, hysteria is never a useful response to any looming epidemic or public health threat. But in the case of emerging and not immediately apparent threats, such as the possibility of a pertussis outbreak or the growing rate of antibiotic resistance, it might be necessary to jolt people out of their complacency. Antimicrobial resistance is a complex problem, but there are a number of ways that we can reduce the damage. In many countries, there is no national regulation on antibiotics, healthy animals are given antibiotics for growth or to prevent disease, antibiotics can be purchased over the counter, and doctors prescribe antibiotics too readily. In this case, sounding the alarm bell loudly and repeatedly is absolutely necessary. On the other hand, in a case such as the 2003 outbreak of SARS, the amount of fear may have been out of proportion with the threat at hand, may have produced destructive mass hysteria, and may have resulted in a perhaps offensive avoidance of Asians and Asian countries.

Especially in cases of unknown, emerging microbial threats, health officials must help the public walk the line between healthy fear and detrimental widespread hysteria. Heightened fear of threats that are looming but not immediately in sight may sometimes be justified as a stimulus to preventative action. At the same time, fear of disease must be appropriately contained, in proportion with the crisis at hand, and must never become a proxy for irrational fears, such as xenophobia, that are all too easily stimulated in the face of complex health emergencies.

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Why Mental Illness-Focused Gun Control May Be More Harmful Than Helpful

This article was originally published here.

Dr. Sara Gorman examines the risks involved with mental illness-focused gun control.

In the aftermath of the mass shooting earlier this year in Newtown, Connecticut, debates have been raging in the U.S. about what steps to take to prevent such tragedies in the future. In particular, policy officials and the public alike have been pondering whether more stringent controls on potential gun buyers and gun owners with mental illness should be implemented and what these controls might look like. Shortly after the Newtown shootings, Senator elect Marco Rubio called for guns to be “kept out of the hands of the mentally ill.” In a more extreme statement, the National Rifle Association (NRA) suggested an “active national database of the mentally ill.” A recent study by researchers at the John Hopkins Bloomberg School of Public Health found striking similarities in the opinions of gun-owners and non-gun-owners when it came to restricting the ability of people with mental illness to own guns. 85% of all respondents to the survey supported requiring states to report people to national background-check systems who are prohibited from owning guns because of a history of being involuntarily committed or being declared mentally incompetent by a court. Most respondents, whether gun-owners or non-gun-owners, were resistant to allowing people with mental illness to own guns. Clearly, the provision of tight restrictions on potential gun owners with mental illness is an unusual arena in which gun-owners and non-gun-owners can agree.

There is no question that guns pose a potentially serious problem for people with mental illness. Some forms of mental illness can be associated with heightened potential for violence, but, more importantly, the risk for successful suicide among depressed persons with guns is much higher than the risk for those without guns. Nevertheless, are gun control efforts that require the names of people with mental illness to be kept in a national database such a good idea?

The truth is, we have to be much more careful about gun control efforts that have the potential to target people with mental illness. There are two main reasons to approach these kinds of laws with a healthy dose of caution: one reason is that gun control efforts focusing on mental illness have the potential to exacerbate public stigma about the potential violence associated with mental disorders; the second reason is that gun laws that in particular involve collecting the names of people with mental illness in national databases have the potential to deter people from seeking the care they may desperately need.

Ample evidence has suggested that stigma and discrimination against people with mental illness is often correlated with perceptions that people with mental illness are inherently violent. People who believe that mental illness is associated with violence are more likely to condone forced legal action and coerced treatment of people with mental illness and may feel that victimizing and bullying people with mental illness is in some way justified. The idea that mental illness and violence are closely related is quite common. A 2006 national survey found that 60% of Americans believed that people with schizophrenia were likely to act violently toward another individual. Even so, research has repeatedly established that psychiatric disorders do not make people more likely to act in a violent manner. Gun laws targeting people with mental illness are likely to worsen the perception that mental illness and violence go hand in hand, and, as a result, stigma and discrimination are likely to be exacerbated.

Gun laws targeting people with mental illness may in some instances save lives. Successful suicides, or even suicide attempts, might be avoided, for instance. On the other hand, in addition to perpetuating a stigmatizing belief that people with mental illness are dangerous, gun laws that focus on people with mental illness might involve measures that deter people from seeking psychiatric care. If people are afraid that the government and other parties will have access to their confidential mental health information, they may be much more reluctant to seek help in the first place. In the end, this kind of deterrence could cause more harm than good, not to mention that increased stigma and discrimination also often lead to a decrease in help-seeking behaviors.

It is true that the U.S. mental health system is in need of reform and that strategies to detect people in danger of hurting themselves or others earlier are desperately needed. Even so, it is difficult even for mental health professionals to predict the future violence potential of their patients. Furthermore, it is not only misguided but also potentially harmful to focus gun control efforts on people with psychiatric disorders. What’s more, these kinds of efforts will probably make very little difference in the homicide rate in the U.S. It would be more worth our while to focus gun control efforts not on mental illness per se but perhaps more importantly on alcohol abuse. The association between alcohol abuse and gun violence is convincing. As a result, in Pennsylvania, for example, people who have been convicted of more than three drunk driving offenses may not purchase a gun. Keeping guns out of bars and other drinking establishments is also probably a wise move. Doing background checks for domestic violence is also a useful measure in reducing gun violence in the home. As the U.S. reconsiders gun control legislation, it is important to recognize that some measures might do more harm than good. Paying closer attention to scientific evidence and remaining focused on the most effective strategies for targeting those most likely to commit violent acts must be the strategy going forward.

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