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?

This post originally appeared here.

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

This post originally appeared here.

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?

Post originally published here

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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Legal and medical bases for granting asylum in the USA to women with female genital mutilation: a systematic review

Originally published here

Background

A precedent exists for granting asylum based on fear of persecution in the form of female genital mutilation (FGM), but it does not apply to women who have already undergone FGM on the logic that they have no grounds to fear further persecution. I assessed the published work about whether women who have already undergone FGM should be granted asylum to the USA on the basis of the medical consequences of the procedure.

Methods

I searched legal and medical databases (HeinOnline and PubMed) for the terms: “asylum and female genital mutilation”, “health consequences of female genital mutilation”, “mental health consequences of female genital mutilation”, and “PTSD and female genital mutilation”. All articles published since 1994 were screened. In the legal database, only documents fitting the description “articles”, rather than “notes” or “commentaries”, were screened. I excluded: articles about asylum or FGM but not about both, articles that did not discuss asylum for women who have already undergone FGM, articles that relayed anecdotes about treatment or clinical advice for patients who have undergone FGM, articles about countries other than the USA, and articles analysing women’s and health-care providers’ attitudes toward FGM. Articles had to be about FGM in particular and not about other forms of violence against women.

Findings

The database searches yielded 1007 articles. Most articles (n=881) were from the legal database. The final analysis included 35 articles. The medical—especially obstetric—complications associated with FGM can be severe but might be reduced by deinfibulation, which is done in the USA. Women who are forced to return to their native countries might be subject to a repeat FGM procedure. Furthermore, return to the scene of FGM engenders substantial risk of worsening trauma-related psychiatric illness.

Interpretation

Women who have already undergone FGM should have the right to be granted asylum in the USA on the basis of significant threats to their physical and mental health if returned to their native countries.

Funding

None.

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