Impact of Syrian Crisis on Public Health

Turn on any news channel or open any paper and you will find stories of war-torn Syria. For most of these stories, the focus is on the political uproar and civil unrest among the people. Most of these stories overlook the public health impact from the months and months of fighting. In the future, research will unravel the long-term health impacts from the war. However, the health of the Syrian people is at risk as we speak.

Currently, over 1.5 million Syrians refugees are camped in the countries surrounding Syria including Lebanon, Turkey, Jordan, Iraq and Egypt. Though these camps are a safe haven from the violence of Syria, the healthcare can be a threat to the safety of these people. The World Health Organization has created health targets for each of these countries serving Syrian refugees because of the high risk for communicable disease outbreak and lack of quality services. These countries have requested millions of dollars of aid from WHO. WHO has been able to provide a very large portion of the funding but there is still a gap between what was requested and what has been received. Without adequate funding, the natives of each country and Syrian refugees will not receive adequate care.

Many of the WHO activities and achievements within these countries focus on immunization and prevention. Vaccinating the at risk population, children, is crucial to stopping the spread of disease such as measles and rubella. This will also cut down on the health services needed and the health problems that can occur following infection. Implementing stronger surveillance systems has been vital to preventing epidemics. For instance, in Lebanon, Syrian refugees account for over 20% of the total population. If Lebanon did not upgrade and expand the surveillance system to include the refugee population, disease would spread among refugees and the Lebanese population without knowledge of the source and how to stop it. Though risk within the countries providing aid for refugees is high, it is not the primary concern. Within Syria, the entire population is in danger both in terms of violence and health. 

While many people have fled to “safer” areas, this displacement has caused overcrowding and unsanitary conditions. These conditions have caused endless problems in terms of disease transmission. Lack of access to clean water has resulted in a 172% increase in acute watery diarrhea between January and May of 2013. 35% of the public hospitals are closed and 70% of trained healthcare workers have fled the country. This has resulted in a significant drop in vaccination rates- from 95% in 2010 to 45% in 2013. As these people flee to neighboring countries, they bring with them measles, TB and many other diseases prevented through vaccination. Also, without healthcare workers, Syrians do not have access to medicines or care.

                 
 The World Health Organization has cited areas of focus including safe drinking water and sanitation, early warning systems for detection of disease, distribution of bed nets and mass vaccination campaigns. However, it becomes more and more difficult to reach this country and these people with the war raging on. The impact of war can be deadly for the health of the affected population. If disease takes over your body before any weapon can cause harm, then public health needs to become the priority rather than an after-thought.   

Sources:

http://www.emro.who.int/press-releases/2013/disease-epidemics-syria.html

http://www.who.int/hac/emro_region_dashboard_6june2013_final_small.pdf

Publication Bias

Publication Bias

Something really struck me this past week after reading the article by Fewtrell et al. (2005) which analyzed different health interventions with use of meta-analysis: the mention of possible publication bias and the possibility that health interventions that produced negative or non-significant results weren’t submitted or published.

 When a researcher is conducting research or writing an article that involves analysis of data, or testing effectiveness of interventions, we are usually looking for significant evidence to support our alternative hypothesis, or for a positive outcome resulting from the intervention. Not only do we want to be correct in our assumptions, but we know that the likelihood of our research being published, or received well at a conference, is highly dependent on the significant/nonsignificant findings. This isn’t an irrational fear. It has been demonstrated by numerous studies that the likelihood of being published is higher with statistically significant results (Dirnagl & Lauritzen 2010; Hopewell et al. 2009; Dwan et al. 2008; Rothstein et al. 2005; Weber et al. 1998). Further, for clinical trials, negative results take longer to get published (8-9 years) as opposed to positive results (4-5 years) (Hopewell et al. 2009).

 Not only is this an issue for the studies conducting meta-analysis of interventions on a certain topic, such as the one we read in class last week (citation), but what about the important information that could be passed on to other researchers about null, or even negative, results? Altman and Bland (1995) stated “Absence of evidence is not evidence of absence”, and I think that is absolutely true.

 I came across an article that was specifically addressing the shortcomings, theoretical and specific reasons for the failure of a performance based contract pilot study implemented in in Uganda (Ssengooba et al. 2012). Why do we not see more articles like this? In the discussion section of the article, the author addresses the amount of successful case studies on PBC (performance-based contracting) that is found in the literature, but the lack of the popularity of this Uganda case. The author mentions how long it took to be considered for publication, and also attributes the lack of popularity in this unsuccessful case to the differing results from other countries, such as Rwanda and Cambodia, who showed successful results from PBC (Ssengooba et al. 2012).

How can we contribute to real progress in academic fields if negative results are deemed unworthy (or less worthy) of publication? This not only discourages researchers and scientists from trying to publish finished studies that showed non-significance or an ineffective intervention, but it also doesn’t present information to fellow researchers that could inform them about possible different outcomes. I think this is especially important to international/global health researchers, as we have learned that different countries face different structural and cultural issues that may cause an intervention to be ineffective.

Failures or varying levels of success in health interventions should be known and taken into account when creating an intervention, but that is nearly impossible when we aren’t able to access that information. I believe there should be an effort made on not only the editors and reviewers of journals’ parts, but also authors and researchers, to reconsider the value of mixed or negative findings, and find the courage to submit and publish that work anyway.

What do you guys think?

 

References

Altman D, Bland M. 1995. “Absence of evidence is not evidence of absence.” Br Med J 311:485.

Dirnagl U,  Lauritzen M. 2010. “Fighting publication bias: introducing the Negative Results section” Journal of Cerebral Blood Flow & Metabolism 30: 1263–1264.

Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, Decullier E, Easterbrook PJ, Von Elm E, Gamble C, Ghersi D, Ioannidis JP, Simes J, Williamson PR. 2008. “Systematic review of the empirical evidence of study publication bias and outcome reporting bias.” PLoS One 3:e3081

Fewtrell L, Kaufmann R, Kay D, Enanoria W, Haller L, Colford Jr, J. 2005. “Water, Sanitation, and Hygiene interventions to reduce Diarrhoea in less developed countries: a systematic review and meta-analysis.” Lancet Infect Dis 5:42-52.

Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K. 2009. “Publication bias in clinical trials due to statistical significance or direction of trial results”. Cochrane Database of Systematic Reviews 2009, Issue 1.

Rothstein H.R., A.J. Sutton, M. Borenstein (Eds.).2005.” Publication bias in meta-analysis: Prevention, assessment and adjustments” Wiley, Chichester, England .

Ssengooba, Freddie, Barbara McPake, and Natashe Primer. 2012. “Why Performance –based contracting failed in Uganda- An “open-box” evaluation of a complex health system intervention.” Social Science & Medicine 75: 377-383.

Weber EJ, Callaham ML, Wears RL, Barton C, Young G. 1998. “Unpublished research from a medical specialty meeting: why investigators fail to publish”. JAMA 280:257–9.

Sex Workers and Safety

Making Prostitution Safer?

After reading and listening to last week’s case study about the 100% Condom Program in Thailand sex workers, I began to think about an article I read recently in the news. Prostitution is legal in Switzerland and has been since 1942; however, it was not until recently that the city officials in Zurich, Switzerland have taken action in an attempt to make prostitution safer.  The city has now forbidden women to solicit in the streets and expects them to use newly constructed facilities known as “sex boxes”. 

Zurich’s hope is that these sex boxes will make prostitution not only safer for the women but also for their clients. The facility is located in the suburbs of Zurich and is surrounded by security gates manned by guards. Men (clients) will be able to drive around in their cars, select a woman and continue business in that woman’s designated drive-in sex box. In each box there is an alarm button and an emergency escape, as well as safe sex reminders (such as condom use to prevent STIs and HIV). Also onsite are social workers, full bathrooms and a kitchen for the women to use and get assistance if necessary. Regulations also require all prostitutes to buy a daily sex workers license and have health insurance. The project was paid for using tax dollars and was approved by citizens who wanted the prostitution off their streets and out of the main city.

Although the main goal of this initiative is not HIV/AIDS prevention, I can’t help but wonder if it will not only successfully make prostitution safer but also lower rates of STIs and HIV/AIDS? This may be hard to determine, since Switzerland already has a low prevalence rate (0.4%) of HIV/AIDS. However statistics show that men ages 15-24 and women ages 20-24 have the highest risk for sexual transmission, so perhaps if this is the population predominantly using the sex boxes, it very well could lower the incidence of HIV/AIDS in these age groups. 

I realize a program similar to this is not feasible for many other countries, especially if prostitution was not legal and the citizens were not willing to have their tax dollars pay for such a program. However, I think it will be interesting to see the outcomes of this project in Zurich and to look for anything that can be learned and applied elsewhere.

I drew comparisons between the case study from last week and this article for several reasons. First both countries are trying to make prostitution safer, although it is legal in Switzerland and not in Thailand; both initiatives addressed a marginalized group of people (prostitutes). Second, although the initiatives had different objectives, the overarching goal was to make prostitution safer for both the women and their clients (and therefore the general population). Thailand was successful and the verdict is still out for Switzerland. Is it time that other countries began to address issues that are typically overlooked and frowned upon in order to improve the health of many? Switzerland did it in the past by battling drug addiction and unsafe usage in the streets with needle exchanges, injection rooms and even prescriptions for the drugs with success. If Switzerland and Thailand can do it, can other countries?

References:

http://www.bbc.co.uk/news/world-europe-23839358

http://www.unaids.org/en/regionscountries/countries/switzerland/

Culture, Spiritual belief, and Marginalized Populations

What is culture? I still remember clearly this was the first question I encountered when I came to the field of health. Basically a group of people tends to think, believe, and behave in a shared way and pattern, which is distinct with other group. This integrated system of behavior patterns is culture (Hoebel, 1966). Culture controls, oppresses and forms traditional ways of knowing and meaning making, being an important impact on human health status, hope and expectation. In the world of health, I think, culture is like a seed, which provides individuals, a group, a population original power of living, developing, and achieving goals. At the same time, the environment and context around it bring sunshine or storm, illuminating or restricting health behaviors. Also, culture is like embrace of a mother, emotionally and cognitively upholding patients.

As we approach more knowledge about culture from the global perspective, it is interesting to find out that a normal phenomenon in one culture may be considered as unusual thing. There are different even opposite cultures everywhere in the world. Dutta-Bergman (2004) implied in the paper “Poverty, Structural Barriers, and Health” that the Ojha, a spiritual healer, played a strong role in the Santali people’s health. Why people there believed in a spiritual healer. I was impressed by the point that the Ojha was trusted by the Santal, because he understood the pain of the patients, as a member of the community. In addition, it was associated with the poverty of the Santali people. They had no access to food and health care. How can they survive? Who knows their struggles? The Ojha was here to help them. I think spiritual concern is an alternative way of knowing that requires notice. Patients who have spiritual beliefs tend to contribute healing to God or spiritual power’s will. Spiritual values create power for them to resist the violence. Various ways of healing and knowing bring complication to health professionals’ work. What can we do? Without doubt we need to obtain deeper understand of people’s religious beliefs and cultural beliefs. Then, how to be more sensitive to the spiritual beliefs? I think we should learn appropriate ways to be perceptive of patients’ cues; learn how to identify patients’ agenda and underlying motivation and expectation.

When Dutta-Bergman (2004) came to the issue of “marginalized”, I was thinking there may be a wall between the “central populations” and the “marginalized populations”. The central populations enjoy most of the basic resources, such as food, money, and materials, but in the meantime, marginalized populations endure pain of inadequacy of resources. Why? It is because they are in the other side of the thick wall, no one sees their situation, and no one hears their voices as well. The wall is built by the structure, the culture, and these lead to inequality in race, gender, and socio-economic status. It seems like a vicious circle. Culture is a constructor of meanings, values, and roles within which the community exists, and it also can become a barrier of the existence of the community. The web of violence that is knitted by the structure is covering over the head of the “marginalized populations”. They are suffering, struggling, striving, and hovering. They need support and direction, and their nature of suffering requires to be understood. As mentioned earlier, there is a circle. Cultural difference is a start of meaning making process, and one of the causes of inequality. To jump out of the circle, we need to put culture in the center, recognize the differences the structure leads to, identify potential methodology for resistance the structural violence and make efforts to achieve social change.

Reference:

Dutta-Bergman, MJ. (2004). Poverty, structural barriers, and health: a Santali narrative of health communication. Qual Health Res, 14(8), 1107-22.

Hoebel, Adamson (1966). Anthropology: Study of Man.

The Idea of Empowerment

I found this week’s reading very insightful regarding the topic of empowerment and how culture affects this concept. There is currently a huge emphasis in the healthcare community on transitioning from handing health information down a professional chain to the layman to the practice of “empowering the patient” and facilitating “self-management.” Increasing patient engagement in their care and protecting their autonomy is lauded as a top priority. The following quote from the article is a very accurate expression of what I’ve been taught so far in my nursing education: “It is assumed that improved knowledge and a change in attitude are the twin engines that generate expected outcomes in behavior” (Airhihenbuwa, 1999). This idea has gone virtually unchallenged, but Airhihenbuwa provides an differing perspective. He brings to light the underlying basis of the western push for empowerment as (perhaps misguidedly) an effort of the highly educated to change the behavior of the “disenfranchised” on an individual level. He contends that effective empowerment must rely on manipulating environmental, cultural and political contexts rather than just personal choices within those infrastructures.  

This is a welcome perspective in my mind as I have witnessed firsthand the frustration of trying to instill change in people and feeling as though you’re talking to a brick wall. Even if you can get as far as helping people actually understand their health (not to mention the all-important task of figuring out what will make them want to change), if they lack resources or community support or financial stability, it will not come to fruition. Even in accomplishing the first two points, we are slowly realizing that imparting knowledge is not enough to incentivize behavior change (hence the focus on giving patients a collaborative role in their healthcare).  However perhaps what we are not realizing is that improving outcomes may have less to do with personal motivation and education and more to do with home environment, cultural values access to outside support, etc.

Culture indeed has a significant role to play. Although culture is talked about much more today than in years past, differing cultures are often presented as a factor to be aware of and acknowledged, but not necessarily to be embraced and integrated into care. One tends gets a sense of how various cultures clash with our western methods and how our “normal” care must be altered. Rarely do we see specific aspects of cultures exemplified as beneficial and helpful. 

What do you think? Do you see culture as an important factor in healthcare? What about the most important factor? Do you there is a place for individual patient empowerment or should our focus really be on collective empowerment of populations?

HIV/AIDS Prevention Programs

The case study discussed last night focused on preventing HIV/AIDS and STI’s in Thailand. HIV/AIDS cases in Thailand increased dramatically in the late 1980’s among injecting drug users and sex workers. The young military population was also seeing an increase in cases. When investigated further, a connection between young military men and the frequent use of sex establishments was found. The intervention was first pioneered in the province of Ratchaburi and then expanded throughout the entire country. After watching the TEDX event featuring Mr. Condom, I questioned how effective this program could be if used in other countries.

Mechai Viravaidya, also know as Mr. Condom, has been the leader of the family planning movement in Thailand since the 1970’s. He founded the Population and Community Development Association, aimed at slowing Thailand’s rapid population growth. As a public health advocate, Viravaidya did not just plan interventions strictly by the books, theory and research. Humor was one of the most essential parts of his effort.  In one interview, Viravaidya said “You cannot win people with embarrassment and shame.” Viravaidya has reached the Thai population through school campaigns, restaurants, markets and other popular public arenas. The Thai people do not need to search for condoms or information related to HIV, STI’s and family planning. Instead, they can simply walk out their doors and down the street to the local market or restaurant to find condoms.

My first reaction to this public health campaign was astonishment. In America, where sex is talked about or alluded to on almost every single television station, we are still very “conservative” in our sex education. During my practicum this past summer, I worked in the STD clinic of a health department. After many, many years of fighting to get into the school system, the health department’s STD staff had finally been able to break through the school board and will begin a sexual education course this fall. After watching the TEDX video, I had wondered how many setbacks Viravaidya had to endure during the implementation of this campaign. My search online did not come back with much information on the setbacks, only on the successes.

I question how many other countries would be able to adopt a program such as this one? With many countries deeply rooted in spirituality and/or religion, it would seem nearly impossible for the government and gatekeepers to allow such open discussion about sex and condom use. It is evident the Thailand campaign was extremely successful, as seen by the 90% reduction in new HIV/AIDS cases. However, this may not be enough evidence for other countries to accept.

I believe one of the next steps in this war against HIV/AIDS in Thailand would be the implementation of a surveillance system. The pioneer program briefly mentioned the use of contact tracing, by identifying the partners of infected men and women. From what I learned during my practicum, this is an essential part in breaking the chain. The case study mentioned the lack of focus on noncommercial sex. Implementing a surveillance system and hiring Disease Intervention Specialists to interview and track down partners, especially those taking part in noncommercial sex would be extremely beneficial.

Privilege or Right?

Is healthcare a right or a privilege? What should healthcare be? Can healthcare truly be one or the other?

These questions keep coming up in my classes, and although I have been pondering on them for some time, I cannot come to a clear conclusion. Obviously, healthcare in some countries is more of a right than in other countries and vice versa, but is healthcare ever truly a right OR a privilege? For example, in the countries that offer universal care, almost everyone may be able to receive care at low costs, but is it always the care they need, when they need it? Or do the people get put onto waiting lists and receive the minimal amount of care needed for the time being? If so, is this what is considered a right? Even in countries that offer universal care, access to healthcare may still be a huge problem. The healthcare may be available but if the people cannot access it, then what good is it? If you can only use the universal healthcare if you have access, then wouldn’t it be considered more of a privilege?

In countries such as the United States that do not offer universal healthcare, almost everyone can still get care if they can get to an emergency room.  Granted this may not be the best care and may be expensive, but  they can still receive care (although access could still be a problem).  So in a way, could healthcare in this situation also be considered a right?  Also in countries such as the U.S., if you have insurance then you can receive excellent care, albeit expensive, whenever and wherever you need it. So although this may seem like a privilege to many, do Americans view it as a right to have the choice to purchase or not to purchase healthcare and insurance?

In this way, I believe whether healthcare is considered a right or privilege is influenced by cultural, historical, social and even personal factors.  A country may state that they offer universal healthcare and that they believe healthcare is a right, which I believe to be a wonderful goal, but will it ever be truly attainable? There will probably always be a portion of the population for which healthcare is more of a privilege than a right. And even in countries that have great universal healthcare, people can still purchase supplemental health insurance which gives them a wider range of options when it comes to healthcare. So within a system that healthcare is viewed as a right, there are still people with healthcare privileges.

I guess what I am trying to get at is that it seems no healthcare system is perfect and can treat everyone within the system as complete equals. I think this is a great goal to work towards, and some countries have come closer to achieving it than others, but there is still progress to be made in all countries. I know there is a lot of debate surrounding this issue occurring right now in the United States, and as long as this issue is being discussed I believe there is hope for change.

“Most of us spend too much time on what is urgent and not enough time on what is important.” Stephen R. Covey

 

Sometimes Global Health spends too much time on solving the health issues superficially instead of looking at the root of the health problem. For years organizations such as WHO and Bill Gates Foundation have spent billions of dollars to solve malaria's problem in African countries. Scientists have not yet developed any vaccine or proper treatment for malaria. They have spent too much time on treatment of malaria's symptoms, but not enough time on how to solve the origin of this disease. When a problem still exists after spending time, and efforts, and resources, we better look at the problem deeper. Solving malaria problem is like a patient who has herniated disc and is dealing with pain, and goes to a doctor and the doctor prescribes pain killers for the patient, but the patient keeps coming back because still has pain. The doctor tries to solve the symptoms instead of solving the root of the problem. The best way to find a solution for any problem is to recognize why problem has happened and where the origin of the problem is and then set priorities to determine which strategy have long term effects. According to studies, Anopheles mosquitoes complete their cycle in the stagnant water and grow rapidly in warm weather and if you look at the situation of African countries dealing with malaria  through media you can find out why malaria problem is still unsolved. The Government of these countries should pay more attention on roads holes, pedestrians holes, and  buildings which are perfect places for malaria fast growth and production.

In my view WHO and philanthropists should provide resources and founds  combined with appropriate monitoring for African countries which are dealing with malaria in order to help them  for their infrastructure projects and ask the government and people of such nations to work together to build their countries. Global Health then might have greater chances to succeed in these countries not only on malaria eradication but also it could stimulate their economic growth.

 

 

Lack of communication may be to blame for unethical practices

Marmot’s definition of poverty has been resonating in my mind:  poverty is more than lack of money; it is also a lack of opportunity, empowerment, security, and dignity.  This definition of poverty is just as complicated as the one with which we tried to come up for health in our first meeting and is very closely tied to human rights.  Oppenheimer et. al wrote in 2002, “it is not just the kind of deprivation that raises human rights concerns that affects life prospects, but hierarchy itself, no matter how subtle the steps of differentiation.”  They add “one of the most enduring contributions of the human rights perspective on public health has been its illumination of the ways in which stigmatization and discrimination have been pathogenic forces.”  First of all, one’s financial status dictates many aspects of life – the amount of money you have or make limits or enables where one lives, one’s purchases and activities, and sometimes one’s social circle.  Second, I was surprised that Oppenheimer called stigmatization and discrimination pathogens, as my scientific mind automatically thinks of a disease-causing bacterium or virus.  There are no vaccines or medicines for to treat stigmatization and/or discrimination!  So the challenge now becomes to address those issues.  The Nuremberg code, the Declaration of Helsinki, and the Belmont were written to ensure social value, scientific validity, fair subject selection, acceptable risk to benefit ratio, required informed consent of subjects, and respect to subjects (Skolnik, Ch. 4).  The Tuskegee experiment contributed scientifically but was unethical.  Without it, the progression of syphilis would not have been determined in humans, not to say that the stages of the disease could not have been determined in another model system (i.e. mice or rabbits), but there may have been different results.  The unethical aspect of the study was that the researchers were not honest about their intentions as the subjects never knew their true diagnosis and did not receive appropriate medical treatment despite the knowledge of penicillin as a cure. 

I am not sure if the researchers did not want to explain in laymen’s terms what the study entailed; I can empathize when "non-science people" asked what I did for research and all I could really say was “I’m working on bacteria in hopes to find a protein to target with antibiotics.”  I also wanted to bring up the Henrietta Lacks story here.  In short, Henrietta’s cells were biopsied at Johns Hopkins while she received radiation treatment for cervical cancer.  Her cells were the first cells to successfully be cultured in a laboratory environment (HeLa cells), even though she had never given consent for research to be performed on her tumor. News of a human cancer cell line that could be used in vitro (outside the body) spread like wildfire.  While researchers benefited from their findings using HeLa cells academically and financially, the Lacks family struggled financially and health-wise as Rebecca Skloot’s book chronicles Henrietta’s story through interviews with her children.  Henrietta’s daughter thought her mother was still alive (despite having attended her mother’s funeral as a young girl) and she even thought her mother was sent to space when only a vial of cells was placed in a rocket.  I found that the most difficult part in explaining research is the jargon (vocabulary), similar to learning a new language where sometimes, the right word just does not exist in one language.  Going back to the poverty and equity question, I don’t think experts (scientists/doctors/researchers) mean to be unethical.  They, especially those who don’t have people skills, may think that their time is better spent on scientific problems/curing the next patient, which lead to skipping over crucial details and therefore unethical practices.  What do you guys think?

Migration of Healthcare Workers

Part of this week’s readings discussed the problem of “brain drain,” or more specifically the migration of skilled healthcare workers from resource-poor countries to developed ones. In my studies thus far this topic has barely been addressed, so much of this information was new. Some of the statistics mentioned by Garrett in “The Challenge of Global Health” were staggering (only 50 of 600 Zambian-trained doctors remain in country?) and show just how deep the issue of “access to healthcare” goes. Many examples have been given of failed interventions due to of the lack of infrastructure. A huge piece of that infrastructure is a sufficient quantity of adequately trained health workers to deliver basic health care. 

Many factors come into play when healthcare workers choose to migrate, both personal and systemic. From the perspective of global health, the context of different countries’ policies and regulations, economy and medical educational systems is crucial. A primary reason for trained healthcare workers to leave their home country is because of the opportunity to earn significantly higher income. For example, the average salary of an R.N. in Botswana is approximately $17,700 compared to nearly $66,000 in the United States. It seems a hopeless problem as countries with severely limited funds and/or resources cannot afford to simply start paying their nurses and doctors higher salaries. 

There are other ways of attacking the problem, however. As Onias mentioned in class, many Zimbabwean physicians leave the country to work in the U.K. because their training and credentials are accepted there. Changing accreditation and licensing between countries would affect the ability of healthcare workers to move about and could be a tool used to retain human resources. Or perhaps in countries where the government subsidizes the cost of education, medical professionals would be required to work for a certain number of years in their local community. This would enable the government to gain from their investment.

I was also highly surprised to learn about how actively some developed countries recruit skilled workers from resource-poor areas. My gut reaction was to view these actions as incredibly careless and unjust. Previously I had not thought deeply about the implications of foreign physicians and healthcare professionals working in other countries, or had simply viewed it as a personal choice of that individual. As attractive as opportunities abroad may seem, the impact it leaves on home countries is shown to be devastating. The other side of the coin is that even developed countries such as the U.S. and the U.K. are predicting major shortages of healthcare workers as well. The root cause of this problem is not a scarcity of qualified trainees, but rather not enough educators available to train. It is fascinating to me that, in a sense, opening more nursing schools in the U.S. and retaining those nurses could indirectly improve healthcare issues in a different country.

complexities and approaches to global health

As we have discussed several times, I would like to think of what ‘being healthy’ is. Now, I guess many students in our class would know that being healthy does not mean ‘without disease’. (From my perspective, being healthy should refer to basic human right and it is necessary for people worldwide in order to live their own lives in a direction that they wish to have). While I read several articles, I realized there are many challenges to deal with global health issues. What I mean by this is we have to time to think of its complexities and realities.

First, NCBI (National Center for Biotechnology Information) reported at early 2002 there are over 36 million people were living with HIV (human immunodeficiency virus) including more than 1.9 million children. Antiretroviral therapy, therefore, aimed to prevent for mother-to-child transmission of HIV infection. Many resource-poor or low-income countries got aid from multiple international organizations and distributed ARV drugs to HIV-positive mothers. However, the government in each country could not take care of maternal and infant health. There are any other health programs to fundamentally support gynecological care. I DO NOT mean that the program is unsuccessful at all since 45% of HIV-positive women (628,000) received treatment in low-income countries at 2008, which increase of 10% over the previous year (United Nations, 2010).

I think ‘being without HIV’ does not mean ‘being healthy’. Of course, it should be the first step to pursuing global health. As mentioned in class, The Millennium Development Goals (DMG) Project will be end at upcoming 2015. As students and future researchers, what we have to think of is that what should be the next?

Second, One of the goals in DMG project is reducing Malaria. Multiple international funds have made health-poor countries improve access to insecticide-treated mosquito nets (ITNs). DMG projects showed in their report, 39% of children were sleeping under ITNs in sub-Saharan Africa at 2010, which portion has grown from 2 % in 2000. However, One newspaper, The Daily Nation, reported at 2009 that many people in the nations were using mosquito nets for other purposes such as making clothing, shoes or fishing rather than covering their beds.
Dr Juma, head of malaria control under the Ministry of Public Health and Sanitation, mentioned in the newspaper: “This is wrong and totally unacceptable. Bed-nets are supposed to play a noble role of preventing deaths that would be caused by malaria. I think there is need for further sensitization and education for the entire public to understand the importance of sleeping under insecticide treated mosquito nets,” (http://www.nation.co.ke/magazines/artandculture/-/1222/562818/-/85l4eez/-/index.html)

Is the outcome reported by DMG project reliable? The program may have been seen as a success. What is your opinion? My answer is neither No nor Yes. I think we need to have more accurate approaches to the outcome. Since global health is ongoing project and will be existing issues in the future, organizations need to set up precise evaluation metrics and efficient supply chains. Today, we are going to talk about people who run for global health and global health care system. I expect many complexities and realities will come from our topic. See you in the class all!

Culture and global health – a melting pot

Culture has such a great impact on global health. As someone who has lived on two continents, I have learned about the impact (both positive and negative) of  culture on global health. As a native and a former health worker of Southern Africa, I was oblivious of some of my cultural beliefs that stood in the way of attaining global health initiatives.

When I talk about culture, I refer to both overt and covert cultural tenets. There are those cultural values that everyone is aware of and feel free to talk about. These are not much of a challenge to address when they come in conflict with global health initiatives. Through education and open discussion, there can be a positive change. The hidden cultural tenets are the ones that pose a great challenge when they cross paths with global health initiatives.Hidden cultural tenets result in "passive aggression" from the natives.  They do not oppose the health initiatives but at the same time they do not support them.

Having worked in Southern Africa from 1995 to 1998 on HIV/AIDS prevention programs where I was born, I experienced challenges faced by  health workers as they deal with issues that go against "cultural grain." I struggled with presenting sex education lessons. I was uncomfortable and my audience was uncomfortable too. In Southern Africa, the subject of sex is not openly discussed among people of opposite sex and different age groups. Since most values are passed down through oral tradition, this makes it difficult to provide sex education to children. The word “sex” is regarded as dirty and can never be used in a family or formal setting. Sex organs are never referred by names because it is a taboo.Children do not discuss sex education with their parents.  In school, sex is barely talked about in biology during a lesson on reproductive system.

Such cultural beliefs/tenets make it difficult for a health worker to engage the community in sex education to avoid contracting HIV/AIDS. For most people, HIV/AIDS does not exist.  For some, it does but it is just like flu or Malaria. One year, the then president of South Africa, Thabo Mbeki made headlines when he said HIV/AIDS does not exist. This is an example when culture and global health are at odds.

Most groups of people have certain cultural values that go contrary to global health initiatives. This is more prevalent in developing countries. It may be an issue of women's rights in  Middle Eastern countries or women circumcision in Africa. The challenge is how global health workers address those subjects that are “no go areas.” Failure to handle these topics in a culturally sensitive may may result in poor global health outcomes. It is imperative for global health workers to be cognizant of host country cultural tenets that may be hot spots and deal with them with respect and candor.

The Challenges of a Shifting Global Health System

For the average American, one who only listens to news headlines and glimpses at the front cover pictures on magazines and newspapers, it would seem like we are doing a decent job helping the world's sick and poor. We see stories about the Bill and Melinda Gates Foundation giving millions of dollars to this program or see pictures of Angelina Jolie in Africa feeding hungry children. However, buried beneath those headlines and pictures are major problems with our global health system that money and celebrity faces will not be able to fix. 

According to an editorial piece in the Lancet "Who run global health," the last 2 decades of global health has seen a shift from primarily government influence to donor-driven influence. On the surface, it seems as though these private foundations are providing billions of dollars, so we should all feel satisfied. Unfortunately, beneath the surface, there are many concerns about the future of global health due to the shifting influence. There is increasing inequality in services, reduced domestic spending, misalignment of health needs and the list goes on. In many cases, efforts are so focused on specific diseases that the population's general well-being is being overlooked. We are also fighting an aging society within developed countries, which is resulting in a shortage of health care workers.

Even though it seems like there is a huge flow of money between donor organizations and health programs, the burden of disease is much larger. For instance, it is estimated that over $300 million dollars were spent in 1999 on HIV/AIDS. That $300 million fell quite short of the $5 billion lost annually in medical care and productivity among African countries (Garrett, 2007). More money will not be the solution. Funding to poor countries comes with stipulations about how every dollar should be spent. So, countries walk away from it. Many times, the money gets stuck in banks or bureaucracies. Investing more would just mean a larger amount is stuck or misappropriated.   

As I read and learn about the challenges facing global health, I cannot help but think about America's current status. As the highest spender per person for healthcare in the world, we are achieving even higher scores in terms of patient dissatisfaction, reduced quality and uncoordinated care. In response to our unraveling healthcare system, the triple aim is focusing on changes such as improving care, lowering cost and improving overall health for Americans. But with such a hand in global matters, should America really be involved in fixing the face of global health when we cannot fix ourselves?

With each of these global challenges comes a slew of possible solutions- focus on reducing waste by coordinating key players, mobilize adequate and stable resources and implement exit strategies for health programs. Just as I have read about all of the possible solutions to helping America's healthcare system, it seems like everyone has their own ideas and agendas about what is best. It makes me question, how can we tackle a problem that is so vast and large? How do we bring together so many key players and agree on changes? How do we divert foundations away from their agendas and try to create just one?