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. 

The Journey of Health Promotion: From an Education Focus to a Multi-Disciplinary and Contemporary Approach that can Improve Health and Reduce Health Inequities

~Written by Karen Hicks, MA, MPH (Contact: karen_ahicks@hotmail.com)

As a concept, health promotion is not new as aspects of its approach can be traced back to ancient Greece. Since then it has continued to develop into an effective approach to address global health challenges.

Developments within health promotion date back to the beginning of the nineteenth century when there was an increased awareness of health promotion principles and an increased recognition that health was influenced by poverty and living conditions. The 1940s then observed the term health promotion being defined and the approach being used by the medical historian Henry E. Sigeres, who identified four related health promotion tasks within the field of medicine, namely the promotion of health, prevention of illness, restoration of the sick, and rehabilitation (Kumar & Preetha, 2012).

During the 1970s there was increased recognition that merely concentrating on increasing the capacity of health and medical services was not effective. Such recognition was significant for the health promotion field as this was the first acknowledgment that medical services alone could not improve health. Such challenges were recognized by Marc Lalonde, the Canadian Minister of Health, which resulted in the 1974 publication of “A New Perspective on the Health of Canadians” later known as the Lalonde Report (Lalonde, 1974). The report’s findings were momentous for health promotion as it emphasized that social structures influenced health and suggested that health care was not the most important determinant of health.

With increased recognition of the link between health and social determinants of health a conference was held by the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) during 1978 in Alma Ata, Russia. An outcome of the conference was a declaration signed by 134 world health ministers with a goal of Health for All by the year 2000 that would be achieved through the provision of universal primary health care. This became known as the Alma Ata Declaration, and was the primary international policy initiative for WHO (Godlee, 1994) that is considered by some as the founding framework for health promotion. Such acclaims are a response to the significant statements positioned within the report, namely a comprehensive definition of health, recognition of health as a human right, and the unacceptability of inequalities in health. The report also identified that primary health care was key to improving health and reducing health status inequalities alongside providing a clear political understanding of health (WHO, 1978). Such statements have resulted in Alma Ata being identified as ‘the foundation for the evolution of modern health promotion’ (Kickbusch, 2003).  Alma Ata was followed by a number of international WHO conferences during the 1980s when declarations were written and WHO Europe undertook a programme of work that identified health promotion concepts and principles (WHO, 2005). The result was health promotion emerged as a broader concept and an approach that recognized that identifying individuals as responsible for their poor health without acknowledging the structural determinants of health resulted in victim blaming (Tones, 1986). This new health promotion approach increasingly acknowledged that people’s health seeking behaviour was influenced by societal norms and socioeconomic position (Goodman et al., 1996).

Such ideology influenced and informed the first international health promotion conference in Ottawa, Canada from which the Ottawa Charter was produced (WHO, 1986). The Ottawa Charter defined health promotion and is a framework for health promotion that identifies prerequisites for health alongside key actions and approaches for health promotion practice. Through the charter’s strategies of action, namely the building of healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services (WHO, 1986), it aimed to operationalise the Alma Ata principles. As a result the Ottawa Charter contributed to the birth of the ‘new public health’ and identified a role for health promotion, placing it alongside disease prevention and health protection (Sparks, 2013) and by defining health promotion, it has augmented both its recognition and progression to an academic subject. The result of which is increased tertiary education opportunities, research, and texts with a theoretical basis that informs effective practice (Murphy, 2005).

Health promotion was later strengthened by the Commission on the Social Determinants of Health 2008 report “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health” (WHO, 2008) which provided further evidence on the requisites for health equity and the necessity to address the structural factors affecting health and well-being (Crouch & Fagan, 2014). Since the Ottawa Charter there have been a number of international treaties, declarations, and frameworks that continue health promotion developments. Alongside a series of conferences on health promotion continue to develop health promotion globally, such as the Adelaide Conference on Healthy Public Policy (1988), Sundsvall Statement on Supportive Environments (1991), Jakarta Declaration on Leading Health Promotion into the 21st Century (1997), Mexico Ministerial Statement for the Promotion of Health: From Ideas to Action (2000), The Bangkok Charter for Health Promotion in a Globalized World (2005), Nairobi Call to Action (2009) and Helsinki Health in All Policies (2013) (WHO, 2015).

Such developments have resulted in the transformation of health promotion as an approach that uses a range of models, strategies and approaches to improve health and wellbeing. It has moved it from a behaviour change focus to a comprehensive socio-environmental model (Harris & McPhail-Bell, 2007) resulting in a contemporary approach with a knowledge base and practices that reflect a paradigm shift in our understanding of health resulting in health promotion developing into a field of study in its own right (Davies, 2013).

This contemporary health promotion has been identified as ‘one of the most ambitious health-related enterprises of the 20th century’ (Carlisle, 2000). It has also been identified as a visionary approach due to its global concern for equity, justice, the environment and its multi-faceted approach of working in partnership across sectors and disciplines (WHO, 1997) extending the role of health promoters to one that is increasingly broad and diverse requiring an increased body of skills to address global, public health issues. Such diverse knowledge and skills are increasingly recognised and informing international development related to competencies and regulation of the health promotion workforce (Barry, 2009), escalating the recognition of health promotion within the wider public health workforce.

It is timely for us to celebrate the journey undertaken by health promotion and recognise its role in reducing inequities and addressing the global health challenges that we face. Well done health promoters!

References:

Barry, M. M. (2009). The Galway Consensus Conference: international collaboration on the development of core competencies for health promotion and health education. Global Health Promotion. Vol 16. 2: 05-11.

Carlisle, S. 2000. Health promotion, advocacy and health inequalities: a conceptual framework. Health Promotion International. Vol. 15. 4: 369-376.

Crouch, A., & Fagan, P. (2014). Are insights from Indigenous health shaping a paradigm shift in health promotion praxis in Australia? Australian Journal of Primary Health;, 20, 323-326.

Davies, J. K. (2013). Health promotion: a unique discipline. Health Promotion Forum of New Zealand.Godlee, F. (1994). WHO in retreat: is it losing its influence? British Medical Journal. 309:1491.

Goodman, R.M., Wandersman, A., Chinman, M. Imm P. and Morrissey E. (1996).An ecological assessment of community-based interventions for prevention and health promotion: approaches to measuring community coalitions. American Journal Community Psychology. American Journal of Community Psychology. Feb: 24 (1): 33-36.

Harris, N., & McPhail-Bell, K. (2007). Evolving directions in health promotion workforce development. Health Promotion in the Pacific, 14(2), 63-65.

Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health. March 93 (3) 383-388.

Kumar, S, & Preetha G.S. (2012). Health promotion: An effective tool for global health. Indian Journal of Community Medicine. International Institute of Health Management Research.

Lalonde, M. (1974). A new perspective on the health of Canadians a working document. Government of Canada.

Murphy, J. (2005). Health promotion. Economic roundup. (Winter ed.) The Treasury, Australian Government.Sparks, M. (2013). The importance of context in the evolution of health promotion. Global Health Promotion, 20(2), 74-78.

Tones, B.K. (1986). Health education and the ideology of health promotion: A review of alternative approaches. Health Education Research. 1:3-12.

WHO. (1986). The Ottawa Charter for Health Promotion. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

WHO. (2005). Milestones in health promotion: Statements from global conferences. http://www.who.int/healthpromotion/milestones_yellowdocument.pdf.

WHO. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization.WHO. (2015). Global conferences on health promotion. Retrieved from http://www.who.int/healthpromotion/conferences/en

WHO. 1997. Jakarta Declaration on Leading Health Promotion into the 21st Century. http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/

Karen Hicks, RGN, BSc, Cert Ed, MA, MPH is Senior Health Promotion Strategist at the Health Promotion Forum of New Zealand and Lecturer at Unitec College of Technology