During the Western Regional International Health Conference I had the privilege of lunching with a group of inspirational and innovative undergraduate students from the University of Washington and University of British Columbia. At University of Washington students have created the Critical Development Forum (CDF), a think-tank creating Continue reading
Heads of State vow to “achieve social and health equity.” Students respectfully ask for more specifics.
Last week, Heads of State, Ministers, government representatives, and leaders of different sectors met in Rio de Janerio at the WHO World Conference on Social Determinants of Health. (Writing and discussions about social determinants of health can often get lost in very academic and sterile sounding language, so it is important to keep it as close to real life as possible.) What is important about the World Conference on Social Determinants of Health (WCSDH) in Rio is that 125 nations pledged their commitment to work to promote awareness, develop policies, and support programs to transform certain social factors that play a significant role in determining whether or not a person will be healthy. The U. S. Centers for Disease Control uses the following words in an attempt to define ‘Social Determinants of Health’, “…complex, integrated, and overlapping social structures, and economic systems that are responsible for…” As you can see, we are already getting off into language that feels far removed from the daily realities of global health disparities like lack of access to care. Of course, all this has to do more with economics, education, and politics than with the common understanding of health and healthcare. And that is exactly the point. The fact that many high level political decision makers were present in Rio gives us some hope that there is a growing realization that health ministers alone cannot address these issues.
The Rio Declaration referenced a similar conference in 1978 that produced The Declaration of Alma Ata, named for the Russian city –then in the USSR, where health was defined as “…a state of complete physical, mental, and social wellbeing, and not merely the absence of disease of infirmity… .” It went on to declare health as “a fundamental human right.” So we have known for a very long time that the goal of health for a nation and for the world is larger than healthcare, at least as we know it in the United States.
More than thirty years later, it is great to see the Spirit of Alma Ata is still alive. For, as economics, politics, and situational specifics change, it is imperative to remember that fundamental values and rights remain constant. It was right for Alma Ata to call for essential primary healthcare for all the world’s population back in 1978, and it is right for Rio to say today that just because we have not yet achieved the promise of Alma Ata does not mean that we should stop trying.
Progress is being made, but there is much more that can be done. That is why it is good to see the fresh eyes of students also present at the Rio conference. The International Federation of Medical Students (IFMSA) sent a delegation of ten medical students to Rio. Their take on the events of the WCSDH can be found on the IFMSA blog. While the IFMSA students don’t have the experience of some of the professionals who have been working at this for several decades, they do bring a fresh perspective and the ability to think more simply, with less jaded minds. In their critique, Renzo Guinto, the leader of the youth delegation, hits the nail on the head by saying: “The main problem of the Rio Declaration is that it failed to explicitly tell us how the unfair distribution of power, resources and wealth will be addressed, especially by Member States. The WHO Commission on Social Determinants of Health has been adamant about the need to tackle this lingering issue, as health inequities within and between countries are rooted in power relations and resource maldistribution. We understand that changing the current dynamics of power will not happen overnight. However, we believe that this Declaration could have been the watershed moment for leaders to make a strong commitment in making this world a fairer place.”
Students who participate in any of Child Family Health International’s (CFHI) Global Health Immersion Programs are, in fact, immersed into underserved communities around the world. They are mentored by local healthcare workers who face the challenges of few resources and many patients. Students say that they are deeply impacted as they see dramatic health disparities and the realities of the social determinats of health playing out right in front of their eyes. They become some of the most effective advocates for global health equity because they are eye witnesses to the consequences of inequity. And some of them are moved enough to have the experience directly impact their career plans, like Erin Newton who wrote about her experience on the Great Nonprofits Website. “Having never been exposed to the poverty, illness, and disease that I experienced in India, I learned so much about myself and found that I have a true passion for underserved and rural patient care. I learned that much of it can be prevented and I want to help treat these individuals and educate the rural communities as a future physician.”
Along with his challenges, Mr. Guinto also seems to speak for IFMSA in pledging to “…commit ourselves to continue engaging with all sectors involved in the work towards global health equity, spreading awareness of the social dimensions of health to our fellow young people, mobilizing them to take action in their respective communities and countries, doing our part, little by little, but with courage, constancy, and conviction.” We call on all CFHI alumni, whether they be part of IFMSA, AMSA (America), AMSA (Australia), ASDA, NSNA, SNMA, as well as many other groups, or just individual health science students, to read Mr. Guinto article and find the best way to engage in the great effort to achieve heath equity both at home and abroad.
With additional specific yet respectful challenges, Mr. Guinto offers an important contribution to the dialogues around social determinants of health that may require the veterans of this work to take a step back and refocus for a fresh look at what is taken for granted, or thought to be impossible. For it is only that kind of courage that will produce the bold steps needed to truly transform the status quo and bring about the promise of Alma Ata that is still waiting for us all.
Today is World Food Day. The United Nations Food and Agriculture Organization has issued a report that should be on the ‘must read’ list of anyone interested in global health. There is some good news but also some disturbing news that should act as a wakeup call for the world community. Staple food prices are at or near all time highs. One of the most alarming facts in the report entitled Food Prices From Crisis to Stability is that just since last year the increases in the cost of basic food has, “pushed nearly 70 million people into extreme poverty.”
Past Successes Have Not Kept Pace
The report points out that while the world’s population doubled between 1960 and 2000, there were significant advances in agriculture that allowed food production to “meet and even exceed demand in many countries.” Unfortunately, the investments in research that were made, by both rich and poor countries, to produce the much needed innovations have not been maintained in recent decades. There has been a 43% decrease in government spending on research and development in the area of agriculture in the last 30 years. Therefore while the population of the world continues to increase, food production has not kept pace.
The last time food prices were this high was in 2008, when the price of various staple foods shot up very quickly and there was rioting in over 20 countries as a result. Certainly the global
economic situation is in even less shape to deal with record high food prices today. What’s worse is that due to the inability of food production to keep pace, “The global market is tight, with supply struggling to keep pace with demand and stocks are at or near historical lows.”
Promising New Successes
While the report warns that food price volatility may become an unsettling fact of life for the foreseeable future, it also gives some success stories that offer great hope. If we can prioritize research and development and scaling of existing successes, we may be able to prevent some of the volatility that now seems inevitable. Some scientific advances in Africa and Asia are resulting in higher yields but much more needs to be done in this area. Some countries have made increasing their food production a priority by encouraging agricultural land use and supporting research. Other countries like Mexico have been proactive in targeting assistance to some of the 70 million globally who are the new poor. Through carefully monitored programs tied to the education system, the Mexican government has been able to provide assistance to one in four families who have been hardest hit by rising food process. Even in these difficult times, this effort has, “…been credited with improving the health of children and adults, and raising nutrition and school enrollment levels.”
As we advocate for improved basic healthcare, we must also advocate for smart basic development that learns from the past and is doing the necessary research to keep up with our current and future needs. For the cornerstones of global public health continue to be water, food, sanitation, and education.
Dr. Rajagopal Dispenses Needed Medicines and a Healthy Dose of Respect.
After a meeting with CFHI’s Founder, Dr. Evaleen Jones at Stanford University, Dr. Rajagopal (Dr. Raj), the Founder of Pallium India agreed to become one of CFHI’s newest partners in India. CFHI India Coordinator, Ms. Hema Pandey, and I had the privilege of spending three days with him in Trivandrum, Southern India as we work to develop a CFHI Global Health Immersion Program exploring Palliative Care.
As the monsoon season takes its time to come to a close, the beautiful, lush countryside around Trivandrum in Kerala –Southern India is as calming as the presence of Dr. Raj to his patients. We were given the great privilege of being allowed to shadow Dr. Raj during a day of home visits to various patients of Pallium India, the nonprofit he founded.
Who is Dr. Rajagopal
Dr. Raj is responsible for beginning the palliative care movement in India. He tells me that while the goal of palliative care might be the same in India as it is in England, where the modern hospice movement was started, the implementation is different. Dr. Raj feels that to simply pick up and transplant palliative care as it has been developed in the West can inadvertently have consequences that cause more suffering –when the main goal of palliative care is to reduce suffering. Dr, Raj is indeed a unique individual; he is both a visionary and a worker in the trenches. To follow him for a day doing home visits was inspiring. It was also a primer in how to do this kind of patient care.
Dr. Raj pointed out to me the four domains of patient care that were outlined by Cicely Saunders, the founder of the modern hospice movement. The four interlocking domains are Physical, Emotional, Social, and Spiritual. It is certainly a tall order for anyone to provide such comprehensive care, and to do it in low resource settings is even more challenging.
A Day in the Life– Implementing Palliative Care in India
As we drove into some of the poorest communities in Southern India, Dr. Raj and his team, a nurse, a social worker, and a driver went about their routine. Patient files are reviewed as we travel in the van. The size of the patient files is notable. After Dr. Raj read the file a bit, he begins to tell us the context of the family we are about to see. We get a succinct yet
thorough description of the family composition and history. The level of detail is impressive and we even had a few questions about the family that Dr. Raj answered from the record. I asked him when he last saw the family and he said that this was his first visit to them. There are three other teams conducting home visits and so the family has been seen by the other teams in the past. It is amazing to see the level of detail that is recorded from the home visit. From these notes, other services from nutrition, to physical therapy, to social work are provided –all driven initially from the teams’ weekly or fortnightly visits.
As we arrive, Dr. Raj gives warm and respectful greetings. He makes use of his reading of the chart right away to let the family know that he is up to speed on the situation even though this is his first time seeing them. Telling and retelling the story can be a help, at times, for a family but to have to do it with every healthcare worker that shows up, can become a burden.
In the home visit, Dr. Raj is totally in his element. Calm, positive, and respectful, he has a way of making the patient and the family feel that he has all the time in the world to spend with them –they have no idea that he has six more home visits to do. His careful touch, his undivided attention, his deep listening, his affirming comments are all the epitome of what a home visit should be. He listens and draws
out information to help him tweak the treatment plan based on what has happened since the previous home visit. As he leaves, he has given not only some medicines and ordered some more physical therapy but he has also given the family and the patient dignity, respect, and acknowledgment through his manner, his interactions, and his presence.
And, of course, as we make it back to the van, it’s time for Dr. Raj to write page after page of notes so the follow-up treatments can be done and so the next home visitor can pick up right where he left off.
We at Child Family Health International (CFHI) are deeply honored to be featured in the Everyday Ambassador blog post by Kate Otto. Kate’s own accomplishments in global citizenship and smart diplomacy are considerable for anyone, especially for someone at such an early point in her career. She is a great example for students today who are interested in global service.
CFHI is equally proud to be a member of the International Volunteer Programs Association (IVPA), also featured in the blog post.
Many CFHI alumni are already doing their part in the Global Health field. With over 6,000 alumni now, we have a wonderful, growing family of everyday ambassadors who advocate and educate through their everyday activities. Through their first-hand accounts of shadowing local healthcare workers in underserved and low-resourced settings, they can speak with conviction and in compelling stories about the similarities and the differences of healthcare systems, and about important global health issues. Whether they do it in a professional capacity as a lecturer or professor, or in the informal setting of a party or a dinner, they can be equally effective in telling the story and enlightening people about global realities, thereby each doing his or her own part to bring us all closer together as the human family and improve the health of the world community.
You don’t have to be abroad to be making a difference. Visit our Facebook and LinkedIn pages and join in the conversations that are happening with people all around the globe. Follow #GlobalHealth on Twitter and keep yourself current on issues and causes. Share all of this with your own social networks and you will be surprised how much influence you can have as an individual. Our world is, in so many ways, becoming a ‘smaller place’. Be a part of it; participate!
Happy World Health Day, April 7, 2011!
Each year on the anniversary of the founding of the World Health Organization, we celebrate World Health Day.
This year the WHO is using the observance of World Health Day to promote the understanding of a serious issue and to work together to combat it. The issue is the spread of anitmicrobial resistance. The World Health Organization’s website has a great deal of information including a WHO Six-Point Policy Package.
We also this this is a perfect opportunity to invite people to utilize and support the outstanding resources of the Hesperian Foundation. Our great friends at Hesperian have resources in many different languages focused on community health and primary care. They even have great resources to address antimicrobial resistance at the community health worker level that you can access by clicking on the image above.
Visit their website and find a wealth of information and resources for the venerable classic Where There Is No Doctor, to the most recent information on Disaster Response for Japan.
A Post From CFHI’s Medical Director:
I’m just returning from conducting a workshop at the NEGEA Regional Conference. NEGEA is the Northeast educator’s chapter of the AAMC – a gathering of the people who oversee medical student and resident education. Just like many in global health medical education, they are grappling with how to get their hands around the subject and figure out how to increase collaboration.
In October of 2009, fresh from a visit to South Africa, I wrote an entry to this Blog called The Roots in Grassroots –Ukwanda Rural Health Program. I was so impressed with the intentional efforts of the University of Stellenbosch to successfully bring primary health care to Avian Park, an underserved community in the rural areas well north of Cape Town. CFHI’s work has always intentionally been at the community level so this was the first time that we were helping to fund a project of a university. On paper, it looked like a serious effort to truly do the relationship building and ground work necessary to successfully establish the first primary healthcare facility for this poor but growing community. Our contacts on the ground were also very enthusiastic about this initiative and so CFHI chose to help support it.
What I saw in 2009 was an idea beginning to take form. What had looked so possible on paper, was proving to be a significant challenge to implement.
I saw a very run down set of metal freight containers being used as a makeshift TB clinic. I saw some initial linkages with the community but everything was still new and tenuous. CFHI’s commitment was funding that would be used to renovate the freight containers to make them fully functional. The project was already well beyond its targeted schedule and I could see during my visit that the freight containers were not in good enough condition to be renovated but would need to be replaced. Stellenbosch was able to get some additional funding as well as some in-kind help to make the new containers possible. Concerns about acquiring the land where the new clinic would be, the full support of the local political and community leaders, and other logistical details were still not resolved. Success felt illusive. Yet, in the face of the many challenges, the Ukwanda team from Stellenbosch chose to dig in deeper, engaging the community, dealing with their concerns and creatively finding the resources to deal with many unforeseen issues that arose.
At a stage like this, I am, quite frankly, used to seeing a big university either pull back its funding and sunset the project, or do an end run around the community and find a maneuver that would give them the legal security they need to move forward even if it does not lead to community support. Instead of using the university’s paid legal teams to get it out of a jam, the University of Stellenbosch chose to involve its School of Law and get faculty and students from this arm of the university to research creative solutions.
This week, I paid another visit to Avian Park and I met with Prof. Hoffie Conradie, also a medical doctor whose blood, sweat, and tears have flowed into this clinic for years now. What I saw this time was the brand new set of freight containers fully set up, painted, and functioning at about 80% of the planned use.
In addition to the original TB clinic, there is now an ARV clinic and a team of home-based care workers based out of the clinic. Weekly physician clinic hours by Dr. Conradie are well attended and welcomed by the community. Still to come will be family planning and other health education initiatives. While a water line has made it to the clinic, electricity is still lacking but this is in the works and seen only as a minor inconvenience. The clinic was bustling with activity and clearly has become a focal point of the community.
Even more impressive was that I just happened to arrive as a team from the University Of Stellenbosch School Of Sociology was just concluding an intensive study of Avian Park. A social anthropology professor and his students had made many visits and conducted house to house interviews. The students made use of volunteers from the community, mostly young people who assisted the students in navigating the unpaved maze of roads and any unfamiliar customs or local norms. The result is a significant body of primary research data that will now be analyzed and synthesized to produce a profile of the community that will not only help the Medical School in its work in the community but also all the other arms of the university; agriculture, theology, social work, as they also look to begin projects in Avian Park.
Meeting later with Project Coordinator, Lindsay Meyer, in Cape Town, she attributed the tremendous cross pollination of efforts from Stellenbosch at Avian Park to the leadership of the university. The Rector of the University of Stellenbosch has motivated and guided his faculty across all schools to develop strategic plans that have goals that are connected to the Millennium Development Goals of the United Nations. All schools and departments are also required to have initiatives that are benefiting the community in some way. With this kind of guidance, a university that often has so many disparate activities can instead become like an orchestra, each producing their own sound but from the same sheet of music.
And so it was in Avian Park. The sociology students and the medical students were each doing their own endeavors but in a way that appeared to the community and to this outsider as a coordinated effort that will build on each other. Universities can easily become a place of many silos of information growing ever higher and rarely moving horizontally in a way that combines data for richer analysis and in a way that can most effectively benefit communities. How refreshing it is to see what can happen when the full resources of a university are coordinated and focused to help a community.
Our hats are off to the University of Stellenbosch and its Ukwanda Rural Health Project and the Avian Park Rural Clinic for their dedication and commitment to community-based work done well!
Dr. Jessica Evert, the Medical Director of Child Family Health International, received the Christopher Krogh Award at the GHEC – INSP Conference today.
The award, honoring the memory of Dr. Krogh, a founding member of GHEC, who died in 1994 in a plane crash while traveling as a physician for the Indian Heath Service, is given to an individual who shows dedication to serving the undersered both domestically and internationally.
Dr. Evert has worked in various places around the world, and also works on a daily basis treating patients in several underserved communities in the San Francisco Bay Area. Prior to becoming the organization’s global Medical Director, she volunteered with CFHI for several years so we are well aware of her talents and her dedication. CFHI extends a hearty congratulations to our new Medical Director as she receives this distinguished honor!
This is my second report from the Global Health Conference happening in Cuernavaca, Mexico. The conference is the joint effort of the Global Health Education Consortium (GHEC), based in San Francisco, California, and the Instituto Nacional de Salud Publica (INSP), here in Curenavaca. I spoke with Lisa DeMaria, Investigadora en Ciencias Medicas of INSP and she told me about a perhaps lesser known part of the Global Health field. “There is a sophisticated network in Latin America of middle income countries with similar health issues that are working closely together to address common challenges.” “The face of Global Health is changing,” she told me as we discussed that there is much more happening today in Global Health than just the very wealthy countries attempting to help the very poor countries.
The conference this weekend is a good manifestation of this with at least 22 countries represented. It is also the First Latin American Caribbean Conference on Global Health and so the extensive regional network of health professionals is strongly represented. INSP and GHEC have championed the effort to establish this first of a kind conference without knowing for sure if there would be a second conference but the momentum that has been created here seems to be sufficient to ensure continuation with countries like Brazil, Chile, and others stepping up to carry on the tradition.
The 19th Annual GHEC Conference and the 1st Latin American and Caribbean Conference on Global Helath
Of course, the planning for a conference like this happens more than a year in advance so as we are gathered comfortably here in Curenavaca, Mexico, having important discussions and sharing of ideas, it is important to look back and see all that has happened along the way on the journey to Cuernavaca. Not long after the decision to have the conference, came the outbreak of H1N1 in 2009 and many questioned the wisdom of continuing with the conference plan especially with the fear that a repeat flu outbreak could happen in early 2010.
More fundamentally, the intention of this conference –different, I think, from other South-South conferences– is to have the South participants truly take the lead. “The idea from the beginning was that the North participants are the guests and are primarily coming to learn” said Karen Lam, the Global Health Education Consortium (GHEC) Program Manager. With its almost 20 year history and strong following, GHEC has been able to bring the numbers that frankly support the undertaking of a major conference like this and make it financially feasible. The back story is all the effort to truly make it a success. GHEC has partnered with the Instutio Nacional de Salud Publica (INSP) here in Cuernavaca. INSP is the conference venue and has been a great host for this event. Both INSP and GHEC are to be highly commended for all the hard work to bring this event to a reality and in such a successful way!
“The vast majority of the presentations are by and from the perspective of the South participants,” Lam pointed out. Sessions are covering everything from Ethics and Equity Issues, to Global Health Diplomacy, to Public Policy, and Social Determinants of Health.
It is encouraging to see so many Mexican, Caribbean, and South American students able to be a part of this conference and to see the work of the collaborations of their fellow students and teachers so prominently featured. So far the sharing and exchange of ideas is stimulating and leaves one hopeful for all the collaborations that will now have their beginnings here in Cuernavaca.
It is true that Child Family Health International does not have any programs in Haiti. It is also true that we are part of the world community and, in a situation like this, if there is a way for us to help, we will do all that we can do, as we did in the Asian Tsunami and have done in other events over the years. CFHI has actually worked in the past with our friends at VIDA and a Haitian partner, the Consortium for the Development of Haiti, to send medical supplies to a number of grassroots clinics and hospitals. It was a very successful endeavor. And so when news of the earthquake came, we tried to re-initiate our successful partnership and get disaster relief supplies to Haiti as quickly as possible. We sent out a message to CFHI supporters, who were already contacting us to find ways to help, and they responded generously.
Our great friends at VIDA (Volunteers for Inter-American Development Assistance) were also right on it, and within about 24 hours of the Tuesday quake, they had assembled over one million dollars in urgently needed first aid and disaster medical supplies. Being on the West Coast, we found ourselves at a disadvantage as the access to the airport and other avenues to get supplies in were quickly clogged. It was also only later, by late Friday and Saturday, that the impact of the earthquake on the functionality of the airport and the seaport were really known. Once it was obvious that all avenues to get supplies in would have to go through the military (directly or indirectly) and staging areas in Florida and other close points, we realized that there was no way to get a shipment directly to Haiti.
We found great support from another wonderful NGO, MedShare, which recently opened a warehouse on the West Coast. They were dealing with the same issues, and through their East Coast connections, were able to get shipments into the pipeline for Haiti. We are grateful for all this collaboration and happy to be in such good company. Our role is very small but, as we are seeing, if we all pitch in and do what we can, a big difference can be made.
On a personal note, having spent some time in Haiti in the early ’90s, when I worked for Food For The Poor, I was moved by the earthquake through the memories that I carry. My visits to Haiti gave me an experience that has stayed with me ever since. The overall work of Food For The Poor was refreshingly simple: provide for basic needs, and develop ways for people to pull themselves out of poverty. Expecting to find people beaten down by poverty, I was challenged to reevaluate my assumptions. Sure the poverty was there, and it was among the worst I have seen anywhere in the world, and some of the people were caught in its clutches in a way that made it hard for them to break free. But, as I have seen in other places, that wasn’t the whole story. By and large, I saw, in Haiti, people who did not let poverty define them or their happiness. These are the people that don’t make the news but carry on their lives as best they can. I gained deep respect for people who perhaps had a better sense of the important things in life than I did. It was a lesson I have tried never to forget and one that I am reminded of again as I see images that trigger forgotten memories of sadness and beauty, despair and hope all mixed and juxtaposed in a society so abused by history, and so full of potential. The people of Haiti re-taught me lessons of never making assumptions, of never writing anyone off, and of the richness that comes from allowing another person, another culture, to change the way I think. I carry these lessons to my work today, even as I carry the memories and, too, the hope that the resounding resilience of the Haitian people and their great joy in living will raise them up, once again, from being dealt a terrible blow.
During a program visit to South Africa, I continue to be amazed by the dedication, commitment, and resourcefulness of the healthcare workers. I find examples everywhere I go –this one, I wasn’t ready for:
With HIV rates among the highest in the world, you’d think there may be no higher priority in South African health services than addressing this disease and working to prevent it. Meet the new menace, “Tik.”
Dr. Adam has been head of G. F. Jooste Hospital for a little more than a year and in his short tenure, he has witnessed an explosion of drug use in the surrounding community that at times has crippled the functioning of this district hospital. These are the Cape Flats, just ten minutes from the beautiful city center of Cape Town, and there is a real fight here to stop this menace from spreading. The drug is crystal meth, and the impact is devastating. Dr. Adam has had a long and distinguished career as a practicing physician and in more recent years, adding a degree in public health, he has been the doctor/administrator at various facilities in South Africa but he has never seen anything quite like this. They thought they had a challenge seeing 40 or 50 patients per month in the ER who were out of control, high, and totally unpredictable, but now these patients number more than 180 per month, and this is in addition to all other patients seen in the facility. The psychiatric effects of tik (which gets its name from the noise made when the crystalline structure is heated) are severe, and Dr. Adam explains that the ER is not a psychiatric ward. Instead of adding medical equipment, they have been forced to add bullet-proof glass and a metal detector to the entrance area. Patients can arrive in a wild state, combative, and completely noncompliant. “The only choice we have is to sedate them until they calm down and we can begin to help them,” Dr. Adam says, noting that recently one female doctor had to be rescued from underneath a male patient who simply jumped on top of her. This 184-bed hospital is already stretched beyond capacity most every day, and sees 4,500 patients in its emergency room every month. But the evidence suggests things may get even worse. In today’s edition of the Cape Times newspaper, a story by Anso Thom reports that “Tik is the most commonly abused recreational drug in Cape Town…,” and that a new study shows one in ten pregnant women are using tik.
“Tik is holding us hostage in this hospital,” proclaims Dr. Adam. But he is not sitting still. He has formed strong alliances with neighborhood and community groups to help coordinate a positive response from within the community to reclaim its streets and build a network of neighborhood watch and support. He opens the hospital auditorium on Saturdays for community meetings and to provide a safe place for children to come for organized activities. He is most proud of getting approval and funding for an outpatient substance abuse program that will begin very soon. The relentless cycle of treating patients, releasing them, only to have them return in a worse state in only a few days can finally be stopped. Armed with a psychiatrist, an addiction recovery expert, and a local public health masters student to document the progress, Dr. Adam is putting together a team that will take a stand against the menace. Dr. Adam knows that the only way to really fight this new epidemic is to break the cycle of addiction. A holistic approach will aim to help strengthen the family unit as well as the patient. Strengthening the community by strengthening individual families is a plan for wellness in the face of an almost hopeless situation.
“We’ve got to start somewhere,” says Dr. Adam. Reflecting on the toll it has taken on his hospital, Dr. Adam says it would be tempting to say that the hospital is simply not equipped to treat these patients and send them elsewhere. But there is really nowhere else, and Dr. Adam is not the kind of person who could turn a blind eye to a problem like this. You can sense the conviction and commitment in his voice as he says, “Our core business is the health of the community.”
CFHI is proud to announce the donation of a Macbook computer to one of our partner sites in Oaxaca, Mexico– the teaching department of Hospital Civil. The donation to the subdireccion de ensenanza department came after the hospital requested this equipment from CFHI as a useful tool in improving operations there. The replacement for the manual typewriter, also in the picture, is a welcome addition to this very busy facility.
The computer will serve in many capacities including logging various activities occurring within the department and in managing the coordination of medical residents working at Hospital Civil. In the photo above from left to right: CFHI Oaxaca Medical Director Dr. Tenorio, Dr. Gabriel Augustin Velasco, the head of Hospital Civil’s teaching department, and CFHI Program Manager Nick Penco, alongside the new computer. CFHI would like to thank the participants of our Global health Education programs as well as support from our donors in making such contributions possible.
Hospital Civil is an outstanding facility with a dedicated staff. CFHI has enjoyed a long relationship with this excellent teaching hospital. This municipal facility is an anchor of the community and has seen everything from the increase of chronic diseases, to the fallout of civil unrest. And Oaxaca was one of the initial detection points of the Novel H1N1 Virus this past year. We commend them on their quick and professional response to what was an unknown crisis. The quality of their work has helped to blaze the trail for everyone working to treat and stop this pandemic.
Alliances for Global Health Education: Learning from South-South Collaboration, has been announced as the theme for an upcoming conference to be held April 9-11, 2010, in Cuernavaca, Mexico. The joint collaboration represents the 19th annual conference on Global Health Issues for the Global Health Education Consortium (GHEC), based in the United States and the 1st Latin American and Caribbean Conference on Global Health hosted by the Instituto Nacional de Salud Publica (INSP), based in Mexico.
A White Paper and call for abstracts can be found on the GHEC website here.
This promises to be an exciting conference addressing current issues and even leading edge ideas, research, and practice. The Call for Abstracts is through November 1, 2009. The website reports that all aspects of Global Health and Global Health Education are welcome for submission and there is a special request for “progressively-minded projects that take into consideration the ideals of global health that embrace: Social Justice, Ethical Practices, Community Ownership, Equity and Fairness, True Partnership, and Bilateral Exchange.”
Just prior to the opening of the United National General Assembly this year, I was fortunate enough to be at the UN to represent the small but powerful global family of Child Family Health International (CFHI). Recently CFHI was granted Special Consultative Status with the Economic and Social Council of the United Nations (ECOSOC). This is a great honor that speaks to our unique collection of dedicated professionals and students who truly work at the grassroots level to improve the health of the world community.
As the Executive Director of CFHI, it was indeed a high honor for me to represent our organization and I came prepared to explain our work and our efforts in Bolivia, Ecuador, India, Mexico, and South Africa. To my great surprise, I did not have to do any of that. I found the staff at the NGO Section of ECOSOC wonderfully welcoming and accommodating, and also found they had done their homework and already were quite aware of CFHI and our work. They had read the documents we had sent more than a year earlier in the process of being granted consultative status and they also brushed-up by reading our website prior to my arrival.
What with the UN being such a huge organization, I expected everything to be very bureaucratic and fairly impersonal. Sure it is a big place and with the leaders of the world, about to arrive, there was quite a bit of bustle all about, so it was a surprise to find such personalized service and attention. My meetings with the Deputy Chief of the NGO Section and the Program Officer were cordial and productive.
I learned that there are about 3,200 NGOs around the world that have been granted consultative status. Many are more associated with a cause while they see CFHI as a more “practical” organization. The grassroots nature of our work is appealing to them as well as the diversity of our global family along with the close, long term relationships with CFHI partners who are at the front lines of the delivery of healthcare in so many places. To a large extent, we have our finger on the pulse of global health at the grassroots level and so we have much to share, especially the CFHI model of empowering local communities. Of those more than 3,000 organizations, only about 800 are really active. Work is going on to improve the website of the NGO section and the hope is that there will be much more online functionality to allow for sharing and collaboration.
One official told me, “The international community has looked at your organization from top to bottom and the feeling is that it is a good organization and has a model that is important. We actually hope that it can be replicated in areas of health yes, but also in other areas.” So as we add the UN flag to the flags of nations comprising the CFHI Global Family, we do so with great honor and great pride, and with responsibility for the role that we have assumed through this honor.
As Dr. Calvin Wilson began his plenary presentation at the Sixth Annual Family Medicine Global Health Workshop in Denver earlier this month, he said to the audience of physicians, “Now class today we’re going to learn geometry.” As he began talking about the vertical approach, and the horizontal approach, Dr Wilson was joking but he was also making a point. As disparities related to health continue to be significant and much more is needed to be accomplished in order to achieve the Millennium Development Goals set by the United Nations, it is clear that a different approach is needed to address global health issues. Dr. Wilson, an associate professor of family medicine at the University of Colorado School of Medicine, and the director of the Center for Global Health of the Colorado School of Public Health, was attempting to deal with a controversial issue in global health today: the debate between vertical and horizontal funding of health initiatives. The vertical initiatives are programs that address a single area of focus, such as a disease like HIV/AIDS, or malaria. The horizontal initiatives are programs that attempt to improve aspects of the health care system in an area or a country. Dr. Wilson gave a careful and balanced approach to this issue and pointed out pluses and minuses to both sides. His presentation can be found through the website of the American Academy of Family Physicians.
Dr. Julio Frenk, the Dean of Harvard’s School of Public Health, and former Minister of Health for Mexico used examples from his home country to illustrate the importance of the diagonal approach when he was interviewed in the June issue of Global Pulse. Dr. Frenk sights, how work on HIV/AIDS in Mexico was designed to also enhance the healthcare system. “By starting with AIDS, we were able to build an entire insurance system that was then in place to start covering other diseases.” Dr. Frenk’s interview with Global Pulse can be found here
It is unfortunate that this debate has gone on for so long and that there is still no clear resolution to it. Perhaps two next steps are helpful in this process.
- Cease the Competition: It is sad that any debate has developed regarding this issue at all. Even more counterproductive is that at times there seems to be a competitive nature to the debate from one side or another. From the grassroots perspective, it is often obvious that these approaches are much more in concert with each other rather than in competition. Resources are needed for programs that implement specific treatments and for specific prevention methods but these programs are usually only as good as the infrastructure available to make things happen on the ground. The reality is that vertical strategies will, at some point, need to hit the ground and their implementation will involve: public health education, vaccination, or training to increase the competencies of treating healthcare workers. To utilize the existing infrastructure, no matter how lacking it might be, is preferable to starting from scratch or to creating parallel infrastructures. Building on the existing infrastructure allows the lessons of past implementation experiences to inform the future and, if done well, allows for culturally appropriate adaptations to be made for each setting that can improve the effectiveness of any implementation, while reducing the potential for inflicting unintended harm. In most resource-poor settings, when you bring in relatively small amounts of cash, you can make many things happen. Unfortunately when you pull out the cash, it often has the effect of inhibiting the local input.
- A workable Construct: While there has been a lot of talk about the need for a more balanced approach, there has not been a lot of action. It is hard to move forward without a method of implementation. Since we are talking about a very broad spectrum of health initiatives, it is unrealistic, and frankly not very helpful to propose anything that is too specific. One option has been proposed that appears very promising. 15 by 2015 is an initiative proposed by a partnership of the World Organization of Family Doctors (WONCA), Global Health through Education, Training and Service (GHETS), and the European Forum for Primary Care (EFPC). In an article published in the British Journal of General Practice in January, 2008, they make their proposal, “We propose that by 2015, 15% of the budgets of vertical disease-oriented programmes be invested in strengthening well-coordinated, integrated local primary healthcare systems and that this percentage would increase over time. 15 By 2015 is a very helpful construct. It raises the awareness of the need for both vertical and horizontal approaches that complement each other and creates a simple framework that allows customization as needed. The 15% threshold is not meant to be the highest possible for the horizontal component but it is a conservative number that can surely be an agreed upon minimum. In this way, new initiatives can build on the existing knowledge and experience, and leave the community with an incrementally improved infrastructure.
In his address to the Global Health Workshop in Denver, Dr. Wilson used some different language. Instead of consistently using “vertical” and “horizontal,” he used the terms disease focus approach and integrated systems approach. These are terms that seem to fit more logically to the conversation. Perhaps these terms can be seen to be more obviously collaborative than their geometric versions and help us bridge the gap by taking the shortest distance between these two points that should not be divergent at all.
Defining global health has been a challenge. This has been especially true in recent years with the increased interest in science, philanthropy, and politics related to global health. In the June 6, 2009 issue of The Lancet, a multidisciplinary and international panel brought together by the Consortium of Universities for Global Health (CUGH), and led by Jeffrey P. Koplan, MD, has taken a bold step in offering the world a definition.
The article entitled Towards a Common Definition of Global Health, represents an important step in bringing together the work, “and priorities for action between physicians, researchers, funders, the media, and the general public.” A thoughtful process is outlined considering the origins of global health in the areas of public health and international health.
The attempt is to be broad rather than limiting, and emphasizes multidisciplinary approaches and mutuality, as well as equity and collaboration.
We applaud CUGH for this effort and recommend this article to all CFHI students. We greatly appreciate that an effort has been made across continents and cultures to find common ground for the advancement of the study and the work of Global Health.
In recent years, at conference after conference, speakers have noted that there is no real agreement on just what is involved in Global Health. This long-awaited work is welcome, especially in its tone –it is not forceful or proprietary but open, inviting, and humble. We hope that it serves as a good starting point for people from all aspects of Global Health to find a workable construct that will be helpful to collaboration in our work and research.
Please go the The Lancet website and find the article.
WHO Director-General, Margaret Chan, called for greater equity in health to be considered as part of how we measure progress as a global community.
“Greater equity in the health status of populations, within and between countries, should be regarded as a key measure of how we, as a civilized society, are making progress,” Dr. Chan said speaking at UN Headquarters in New York.
At the very least, we should all recognize that Dr Chan has a perspective that almost no one else shares. In her role as Director-General, she has been very active in discovering and learning as much as she can from all corners of the world. So when she stands before the world’s ambassadors and says, “The world is in such a great big mess,” it is the considered opinion of the world’s doctor. Of course she was trying to speak in a way that cuts through ceremony and can be easily understood by all.
She went on to give more of her considered opinion, “Pandemic influenza, for example, will hit hardest in developing countries, which have large vulnerable populations. With their weak health systems, these struggling countries will take longer to recover. In many ways, developing countries facing the pandemic are virtually empty-handed,” said Dr Chan.
With calls for systemic change being a big part of recent United Nations discussions, Dr. Chan took the opportunity to advocate for health with the assembled global leadership, “We hear clear calls, from leaders around the world, to give the international systems a moral dimension,” said Dr Chan, “to redesign them to respond to social values and concerns… A focus on health as a worthy pursuit for its own sake is the surest route to the moral dimension, the surest route to a value system that puts the welfare of humanity at its heart. Greater equity in the health status of populations, within and between countries, should be regarded as key measure of how we, as a civilized society, are making progress.”
As noted with her remarks on the WHO website, “One method for achieving fairness, she suggested, would be for more countries to embrace primary health care. As she noted, a primary health care approach introduces greater fairness as well as efficiency, and allows health systems to reach their potential as cohesive, stabilizing social institutions.”
At the Global Health Council conference in Washington, DC, in June of 2008, on Primary Health Care, a discussion involving Dr. Chan at a public session included the notion of conducting a health systems impact study when any significant funding is allocated. Typically large amounts of funding from governments, world bodies or foundations focus on a particular disease or health issue. Too often, in the heroic attempt to eradicate a menacing problem, the impact on, or even the essential contribution of the existing health system and the health workforce are considered only tangentially or perhaps not at all.
The analogy was to an environmental impact report that is often required before any large-scale building or infrastructure projects are conducted. While environmental impact reports have their own problems, the notion of considering all aspects of the health system in a community or a country can be an important way to find the strengths and successes that will be critical to the success of new efforts. Building on the local strengths and knowledge of a community and allowing a new idea to be informed by the local cultural wisdom can go a long way to achieving greater equity, including Primary Health Care in the process, and ultimately more efficient progress.