Lessons Learned from Ebola

~Written by Kelly Ann Hanzlik (Contact: kelly_hanzlik@hotmail.com)

According to the World Health Organization, 28,616 people contracted Ebola and 11,310 lives were lost during the Ebola epidemic. After so many lives lost and the hopeful, but understandably tentative countdown of Ebola free days continues once again in West Africa, it is imperative that we take a moment to consider what we learned from the devastating and tragic epidemic.

I spoke with Dr. Ali S. Khan, former senior administrator for the Centers for Disease Control and Prevention, former Assistant Surgeon General, and current Dean of the University Of Nebraska College Of Public Health. He noted initially, that there is always the risk of importation of cases; that is how it started he reminds us. He elaborated further that the epidemic “changed the response from the WHO and caused a change in political focus by the nations involved that will affect future outbreaks and ensure native capabilities, as well as link them to the global response.” He also noted that new medical counter measures, such as vaccines and related therapeutics, were also the result of the Ebola impact. When asked about what we learned, he did not hesitate. “The first thing was a new vaccine that permits a novel prevention strategy using ring vaccination to prevent spread and new cases. The second is the new monoclonals and antivirals for treatment.” He also noted the better understanding of the viral progression and clinical diseases that will influence options for acute treatment and follow up of convalescents.

Ebola has provided us with a virtual plethora of opportunities to learn about the disease, its treatment and control, as well as the control of other infectious illnesses through our attempts to prevent its spread as well as through our failures, and successes. We gained valuable treatment modalities and tactics that will likely be used in future outbreaks of Ebola, as well as many other infectious diseases.

Ebola taught us other things too. It has been some time since global health has taken center stage. Ebola changed that. During the epidemic, one could not watch the news or go through a day without hearing an update on the latest development in the Ebola crisis. Although other infectious diseases like Plague, Polio, AIDS, SARS, H1N1, Cholera, and now Zika have captured the world’s attention, few diseases have made such an intense impact, nor caused the uproar and fervor that Ebola elicited. Ebola reminded us that global health is public health and affects us all, and as such, deserves to be a priority for national and international focus and funding for everything from vaccine development and research, to capacity for response locally, nationally, and internationally. Global health has teetered on the edge of public awareness, and remained a quiet player in the competition of priorities in national budgets. Today, it is abundantly clear how vital this sector is to each nation’s, as well as the world’s health, safety, success and even its survival.

Another effect from the Ebola crisis was the opportunity to educate people about public health and the transmission of infectious disease. Through education, public health officials were able to promote behaviors that ensured the safety and health of the public. It is stunning that in this day and age, we persist in so many behaviors that put us and those we interact with at risk. The discrepancy in what we say we will do, and what we are actually willing to commit to and take action on, looms large. Persisting low vaccination rates and the prevalence of infectious diseases such as sexually transmitted diseases, measles, pertussis and influenza show this. Ebola offers yet another opportunity to demonstrate the connection between our behaviors and our risks and disease.

Ebola also showed us that many nations continue to lack sufficient financing, infrastructure, facilities, support and medical staff to treat their own populations. Endemic conditions like malaria, and neglected tropical diseases like Guinea worm disease, Yaws, Leishmaniasis, Filariasis, and Helminths, as well as other conditions continue to affect millions globally.  Maternal and childhood morbidity and mortality rates remain deplorable as well. And millions of children around the world continue to suffer and die of malnutrition and disease before they reach the age of five. This is unacceptable, especially because proper treatment and cures for these conditions exist. Ebola also highlighted the need for treatments for chronic non-infectious conditions as well.

Moreover, Ebola clearly demonstrated the enormous need that remains for sufficiently trained medical professionals and healthcare staff to provide adequate care for many populations throughout the world. The loss of so many extraordinary and heroic staff that dedicated their lives to helping others in need under the most daunting and challenging of circumstances was devastating to those whom they served, and must not be in vain.

Additionally, Ebola provided us with yet another chance to relearn lessons about the role of safety in giving aid to others in need. We learned that we cannot just rush in with aid, but must recall the basics that every first responder and medical student must learn:  Ensure scene safety before giving care, and first do no harm. Ebola showed us the necessity to strategize and prepare to give care by utilizing personal protective equipment. It also reminded us very quickly that we could indeed do harm, and worsen the epidemic when we acted without first assessing the situation and ensuring proper protection and preparation.

So, it remains to be seen just how much we will learn from Ebola. Will we learn from our mistakes? Will we take the global view in the future, or the narrow one? Will we truly live by the motto of the Three Musketeers and be "one for all and all for one", or persist in "it's all about me"? Only time will tell. 

Program Science: Improving Public Health Interventions

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com) 

Program science is a relatively new term being used to describe the application of scientific knowledge to improve the design, implementation, and evaluation of programs. Evidence-based interventions are becoming more mainstream in public health but there is still work to do to ensure that public health concepts work the way we hope they will. That’s where program science can help.

Program science extends beyond looking at the implementation of a program, which is the logistics of developing and implementing evidence-based interventions, and focuses on the bigger picture. Program science looks at entire programs, which may include more than one intervention, for a particular population in a specific context. For example, program science may look at efforts to decrease HIV rates in youth of color in a specific borough of NYC. There are probably many interventions working on this issue, targeting different populations of youth via different methods. Program science would look at how all of these interventions work together to achieve the overarching goal of decreasing HIV rates in youth of color in that specific borough of NYC.

Program science focuses on questions like, "Who should be targeted and for how long?," "What is the best combination of interventions to achieve our goal?." " How can we sustain the program?," and "What quality improvement processes exist?" Program science helps to bring together researchers, policy makers, program planners, frontline workers, and communities for an ongoing engagement to help the program succeed.

View fullsize

Source: Sevgi O. Aral, 2012. Program Science: A New Initiative; A New Approach to STD Prevention Programs. 2012 National STD Prevention Conference

Program science is popular in HIV/STI work right now because such work involves long-term complex population-level behavioral interventions. For HIV/STI work, program science can be especially useful in determining why some interventions aren’t as effective as they were in the past and why some disease incidence rates are leveling out (or increasing) instead of continuing to decrease.

The Centers for Disease Control and Prevention (CDC) focused on program science at their 2012 National STD Conference. In the US, HIV/STI program science can be used to strengthen public health initiatives in a time when public health funding is decreasing and funders want to see substantial impact. Program science can ensure that money is allocated to the most effective interventions that will have the greatest impact on the population.  HIV related program science can be useful on a global scale to ensure that we fully understand the epidemic, who is impacted, and to ensure that the “money follows the epidemic and the interventions follow the evidence”.  Because each HIV affected population of the world has different characteristics it is important to not just apply one intervention to everyone but to really understand how each population is affected and what interventions would work best for each population.  

Program science is a logical progression from a focus on developing evidence-based interventions and rolling them out to a target population, to a more comprehensive focus on how various interventions are impacting the target population. this progression into a "big picture" way of looking at things will hopefully create more effective and efficient programs that contain targeted interventions to increase health of the target population. As program science continues to gain traction in public health, I believe we will see a shift to "big picture" thinking for all sorts of public health activities currently operating without this broad focus.

Sustaining the Fight against Malaria

~ Written by Randall Kramer, PhD, M.E. (Professor of Environmental Economics and Global Health, Duke University) & Leonard Mboera, PhD, MSc (Chief Scientist, Tanzania National Institute for Medical Research)

*Also published on the Duke Global Health Institute Website 

On World Malaria Day, April 25, there’s much to celebrate and acknowledge when it comes to the fight against malaria. Over the past 15 years, we’ve seen a huge ramp-up of international funding, and the latest statistics show impressive progress—a 46% decrease in malaria infections among children in sub-Saharan Africa and an estimated 4.3 million deaths averted globally over time.

One of the most effective malaria control measures has been the free distribution of several hundred million insecticide-treated mosquito nets that protect people from mosquitoes while sleeping. In 2004, only 3% of at-risk people in sub-Saharan Africa had an insecticide-treated mosquito net available to them, compared to 49% in 2014 after an international campaign.

The U.S. government is among the major funders of malaria control, and it’s one of the few international assistance programs that has garnered bipartisan support through the Bush and Obama terms. But despite the upsurge in spending and the laudable success of these programs, malaria remains one of the leading causes of death in poorer and tropical parts of the world.

The need for continued support is critical; it’s estimated that eliminating malaria as a major global disease threat would require double the current $3 billion invested annually in malaria control. But in the face of so many other pressing needs, why should we continue to invest in malaria?

In the last year, nearly 200 million people suffered from malaria, and its death toll—more than 500,000—was 50 times greater than that of the widely publicized outbreak of Ebola in West Africa. And malaria takes a particularly devastating toll on the young. More than 80% of the deaths from malaria are in children under five, and those who manage to survive the illness often suffer lasting effects on development, school performance and lifetime earnings.

Because malaria is such a resilient killer, we can expect to see these malaria losses continue and potentially rise in the absence of continued financial support. In fact, with temperatures steadily increasing throughout the world as a result of global warming, malaria-transmitting mosquitoes have begun to take residence in new regions, raising the specter of malaria spreading far beyond its current boundaries.

In addition to the physical suffering malaria causes, the disease stunts national economic progress.

Studies by Columbia University economist Jeffrey Sachs suggest that, if not for malaria keeping children out of school and agricultural workers out of the fields, the rate of economic development in sub-Saharan Africa would have been much higher in the past few decades.

And lastly, we can’t underestimate the goodwill generated by our investments in mosquito nets and other malaria-defeating approaches in recipient countries. As one community member told our research team in rural Tanzania, “Mosquito nets have been a great help to us. The day when mosquito nets were distributed, people were very happy, because many people in our community could not afford to buy the mosquito nets.”

The malaria parasite, a resilient and opportunistic pest, has successfully co-inhabited with humans for thousands of years, and it continues to adapt and evolve, damaging populations and economies across the globe. We now have the knowledge, technology and health systems to significantly reduce its devastating human impacts. But putting these assets into action will require renewed political will and financial commitment from rich and poor countries around the globe—including the U.S.

Review of Unite for Site Global Health and Innovation Conference 2015

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

I attended the Unite for Site Global Health and Innovation Conference last weekend which brought together over 2,000 global health and international development professionals, social entrepreneurs and students to exchange ideas and leading practices. One of the best parts of the conference was meeting committed global health professionals with the bonus of connecting with other TWiGH team members and viewers. The conference was held at Yale and participants had the opportunity to enjoy the quaint city of New Haven as well as the snow that fell throughout Saturday. The conference was similar to many other global health conferences I’ve attended but had a unique feel due to its social innovation edge and opportunity to hear from social entrepreneurs competing for the J.M.K. Innovation Prize. The innovation prize was established by the J.M. Kaplan Fund to provide grants to emerging social sector innovations.  

The conference had some very engaging and high profile speakers. I thoroughly enjoyed listening to the key-note address by the Honorable Minister of Health of Rwanda, Agnes Binagwaho, MD. She is an energetic women who isn’t afraid to speak her mind, even on controversial topics. She spoke about how Rwanda has greatly decreased its AIDS deaths, which is the fastest decrease ever in the world. She stressed how imperative it is that women have the choice for family planning since “There is no woman crazy enough to say, I want a baby every year”. She spoke about the need to meet people where they are and to move where you are needed most (rather than nice areas with beaches or better amenities). When asked what she would do if she were the Health Minister of the United States, she said she would put parents who refused to vaccinate their children on trial! Lastly, she urged us to work together and unite since “We live in one world, not three.”

Another engaging speaker was Cal Bruns, CEO/Chief Creative Incubationist at Matchboxology who presented on “What Condom Manufacturers Could Learn from Car Designers.” He spoke about a fact that car manufacturers learned long ago, that people are more motivated to purchase a product with a benefit that they want, rather than a product to prevent something they don’t want. He proposed that the condom companies should work on creating condoms with advanced technology such as stimulating beads on the inside of the condom to increase pleasure. Then men would be motivated to use condoms for the increased sensation which would as a by-product help reduce STIs and unwanted pregnancy. It was a different look on condom promotion than I’d heard before, but totally made sense.

The Social Impact Labs, which was the catalysis feature of the conference, brought together social entrepreneurs to pitch presentations about new innovations in front of a panel of judges and the audience in competition for the innovation prize. The innovation pitches ranged from nascent ideas, grassroots projects, to initiatives already underway being backed by large public health NGOs, universities and/or private companies. We heard about innovations ranging from a sex education program in Kenya teaching farmers to spread HIV prevention messages, a movement to create greenhouses in inner-city Baltimore to bring fresh produce to areas lacking produce options, to a project that creates wells to provide safe drinking water at a low cost to prevent arsenic poisoning in Bangladesh. The winning innovation was presented by Lucy Topaloff with a company called Miraclefeet which provides high quality, low cost braces for patients with Clubfoot in India. Miraclefeet won $10,000 which will be used to help provide braces to 40+ children. 

Overall it was a motivating and encouraging weekend. It’s always great to meet other public health professionals passionate about improving health and opportunities for disadvantaged populations globally. Listening to all the enthusiastic and motivated young people during the social innovation pitches drove home the idea that: great ideas + passion + commitment = opportunities. These individuals, in collaboration with their networks and connections, are turning ideas into solutions to help the less advantaged. That is inspiring!

The Complexity of Health and Wellbeing

~Written by Karen Hicks - Senior Health Promotion Strategist, Auckland New Zealand (Contact: Karen_ahicks@hotmail.com)

Achieving health and wellbeing goes beyond the absence of disease as it is determined by a range of factors such as the environment, culture, gender, biology, and politics and is in fact complex and multi-dimensional.

As a health promoter I suggest that to address such a complex issue requires:

•  An understanding of what being healthy means to those with whom we are working
• An understanding of the social determinants of health
• A holistic approach to health

For practitioners wishing to improve health outcomes we need to explore what being healthy means to those individuals and communities with which we are working. Practitioners often have their own ideas of what healthy means and our contracted outcomes and outputs may also identify what this means but it may not be the reality of our communities. To achieve sustainable health outcomes we need to ensure that we are meeting the needs of our communities.

We also need to understand what affects people’s health and communicate this effectively to the communities with which we work and our colleagues both within and outside of the health sector. The Dahlgren and Whitehead diagram is a few years old but is effective in explaining the range of determinants that influence health both positively and negatively and the interconnectedness of each determinant. 

Another effective resource is the Robert Wood Johnson Foundation frame developed in 2010 to effectively talk about the social determinants of health which has involved translating determinants of health messages for lay audiences such as Health starts where we live, learn, work and play.  For detail on the research and process- http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/a-new-way-to-talk-about-the-social-determinants-of-health.html

As practitioners we need to stop working in silos and with topic or issues based approaches. A holistic approach to health is the most effective approach to achieving sustainable health outcomes. Within New Zealand there is a holistic health model named Te Whare Tapa Whā (Durie, M. 1998). A Māori health model that supports a holistic approach to health and identifies the four cornerstones (or sides) of Māori health. With its strong foundations and four equal sides, the symbol of a house illustrates the four dimensions of well-being which are physical, mental and emotional, social and spiritual well-being.  Should one of the four dimensions be missing or in some way damaged, a person may become unbalanced and unwell.

The approaches identified are ways in which to undertake effective health promotion that reflect its values and principles of empowerment, inclusiveness and respect based on evidence and effective health promotion competencies. The approaches above provide opportunities to communicate with communities and work with them to provide solutions to the complex and multi-dimensional health and wellbeing issues affecting us all locally, nationally and globally.

Reference:

Durie, M. 1998. Whaiora: Maori health development, Auckland: Oxford University Press

Challenges on the Frontlines of Ebola

~Written by Marilyn Perez Alemu (Contact: marilyn.perez@gmail.com) 

Healthcare workers on the frontlines of the Ebola crisis in West Africa are daily putting their lives at risk to save the lives of others. The current epidemic is the largest of its kind in history, exacerbated by a reported 70% case fatality rate. Yet Ebola is a disease that knows no mercy. Since the initial outbreak reported in March, more than 450 healthcare workers have been infected in Liberia, Sierra Leone, Guinea and Nigeria. More than 200 have died.

Despite being faced daily with this reality, as well as the looming stigmatization from their communities and families, healthcare workers continue to provide medical support to Ebola victims for the sake of those who will survive the disease. The initial international response was markedly slow and, as the outbreak intensifies, emerging challenges have severely impacted the ability of healthcare workers to respond to the growing need.

When executed properly, contact tracing is a key method for containing the outbreak spread. Ideally each contact, or person linked to a confirmed or probable case, would be identified by a healthcare worker and monitored for 21 days following exposure, allowing public health officials to track the movement of the outbreak. In theory, contact tracing is an effective method to ensure early detection of infections and immediate treatment, and stem the spread of the virus. Essentially, contact tracing has been called the key to “stop Ebola in its tracks”. And while the process seems simple enough, critical information gaps, limited databases, and an exponential increase in the number of Ebola cases have led to a breakdown in contact tracing in West Africa. With limited infrastructure and many living in remote villages, even finding patients is a challenge. Add that to the fact that people are often uncooperative with tracers, as the fear of going to a health center is something akin to a death sentence. Without the ability to do complete and proper contact tracing, rapid diagnosis and patient isolation is hindered and the outbreak will continue to spiral out of control.

While past outbreaks of Ebola were sporadic and contained within small rural areas, the current outbreak poses a serious challenge in that it has spread quickly to more crowded urban areas in West Africa. In rural areas, population density is lower, community ties are stronger, and transmission prevention measures are presumably easier to implement. Now, in vastly overpopulated urban areas, Ebola transmission has accelerated exponentially and the outbreak has gone beyond the ability to contain it. Control and prevention measures have thus intensified in both innovation and urgency, evidenced by accelerated efforts in vaccine development and experimental therapeutics.

While an Ebola outbreak is caused biologically, an Ebola epidemic is a crisis of poverty and fragile health systems. West Africa is faced with the repercussions of a weak health infrastructure, including scarcity of healthcare workers, limited resources, and poor management systems. It should be noted that these shortcomings preceded the Ebola outbreak, with just 51 doctors to serve Liberia’s 4.2 million people and 136 for Sierra Leone’s population of 6 million. To put this in context, this is fewer than many clinical units in a single hospital in the United States. Having worked its way through the cracks of a fragile health infrastructure, Ebola has effectively brought healthcare to a halt in Liberia, Sierra Leone and Guinea. An added complication is the shortage of resources, including personal protective equipment (PPE) and other control materials, and the lack of straightforward protocols and guidelines. Efforts must increase not only to ensure an ample supply of optimal PPE but also to effectively disseminate information on proper use of the equipment.

At the frontlines of the Ebola outbreak, healthcare workers face a daunting challenge. In Liberia, Emmanuel Boyah, a primary health manager with the International Rescue Committee, recounts the stress and fear of this work. Yet he and many others continue to dedicate themselves to the cause and risk their lives to care for those affected: “I feel that providing services to people during this time, when they’re in need of you, is my call.”