Community Gardens for Improved Community Health

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

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Source: Communitygardens.org

Community Gardens in Developed Regions

Community gardens are either individual plots or collectively cultivated gardens, and there is often some form of public ownership (Jermé & Wakefield, 2013). There are various levels of commitment from local citizens. For example, NeuLand, a community garden in Cologne, Germany is run by a charitable organization with five paid staff members, a managing committee, about 20-30 committed gardeners, and about 40 occasional gardeners (Follmann & Viehoff, 2014).

In the Western World, community gardens have become popular because they are often viewed as a way to advocate for sustainable social and ecological change through a bottom-up approach (Follmann & Viehoff, 2014). Thus, they have proven to have an important impact on the health of citizens in various regions.

Health Benefits

Community gardens have specifically increased access to healthy foods in marginalized regions, consequently, alleviating issues of food poverty (Jermé & Wakefield, 2013). In order to increase the consumption of fresh vegetables, the Victory Garden program was founded in the United States during World War II (Armstrong, 2000; Chan et al., 2015). This led to a 40 percent increase in the consumption of fresh vegetables (Armstrong, 2000). Today, community gardens are still used to ensure that everyone has equitable access to fresh produce. One study revealed that households who did not participate in community gardens consumed fruits and vegetables 3.3 times per day (Alaimo, Packnett, Miles, & Kruger, 2008). In comparison, households with an individual involved in community gardens had a daily consumption rate of 4.4 (Alaimo et al., 2008).   

When community gardens are properly implemented and utilized, they can be an important source of empowerment for local citizens (Follmann & Viehoff, 2014). They can provide a space for productive work, interaction with each other, intercultural engagement and knowledge exchange (Follmann & Viehoff, 2014; Armstrong, 2000; Chan et al., 2015). Thus, they become a symbol of unity and increase neighborhood pride (Armstrong, 2000). This social capital is important to increase psychological support (Chan et al., 2015). As a result, community gardens have been established as a component of health promotion (Armstrong, 2000).

Policy Development and Citizen Engagement

Overall, the focus on community gardens is to foster a greater quality of life and community rather than consumption and individualism (Follmann & Viehoff, 2014). In order to continue to foster sustainable community gardens, policy development processes must be examined (Jermé & Wakefield, 2013). Local citizens must be able to participate in the development of policies, and the policies must ensure that citizens have access to gardens that are fairly allocated (Jermé & Wakefield, 2013). Success also depends on a collaborative approach between the various government agencies involved (Jermé & Wakefield, 2013).

References:

Alaimo, K., Packnett, E., Miles, R. a., & Kruger, D. J. (2008). Fruit and Vegetable Intake among Urban Community Gardeners. Journal of Nutrition Education and Behavior, 40(2), 94–101. doi:10.1016/j.jneb.2006.12.003

Armstrong, D. (2000). A survey of community gardens in upstate New York: Implications for health promotion and community development. Health & Place, 6(4), 319–327. doi:10.1016/S1353-8292(00)00013-7

Chan, J., DuBois, B., & Tidball, K. G. (2015). Refuges of local resilience: Community gardens in post-Sandy New York City. Urban Forestry and Urban Greening, 14(3), 625–635. doi:10.1016/j.ufug.2015.06.005

Follmann, A., & Viehoff, V. (2014). A green garden on red clay: creating a new urban common as a form of political gardening in Cologne, Germany. Local Environment, 20(10), 1148–1174. doi:10.1080/13549839.2014.894966

Jermé, E. S., & Wakefield, S. (2013). Growing a just garden: environmental justice and the development of a community garden policy for Hamilton, Ontario. Planning Theory & Practice, 14(3), 295–314. doi:10.1080/14649357.2013.812743

HPV Vaccination in the Japanese MSM Community: A Call to Action

~Written by David Boedeker (Contact: dhboedeker@gmail.com; Twitter: @dhboedeker)

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Source: cancerfrontline.org

HPV vaccination has faced pushback from communities since its introduction in 2006. Perhaps the most shocking story comes from Japan. In 2010, the Japanese government began to give girls ages 12 to 16 the vaccine for free. The government recommended girls receive the vaccine[1], and vaccination rates climbed. However, all of that changed in 2013 when an anti-HPV vaccination movement successfully advocated that the government withdraw its recommendation. The aftermath has been dramatic: vaccination rates dropped from roughly 70% to 1%, leaving millions of adolescents unprotected from HPV-related cancers. Interestingly, this decision coincided with the United States moving to ramp up vaccination efforts. Moreover, the scientific data that prompted the Japanese government to withdraw its recommendation is based in theories that are not biologically possible, as one critic noted[2].

In response, many researchers and physicians are advocating for increased vaccination campaigns in Japan. Historically, these initiatives have focused on females since it has been established that HPV vaccination is important to prevent cervical cancer and other HPV-related cancers. However, it is increasingly recognized that HPV vaccination for males is also critical, especially to prevent throat cancers, which are expected to surpass cervical cancers as the most common HPV-related cancer by 2020.

HPV infection is not only related to throat and cervical cancers; it also increases the risk of developing mouth, tongue, and anal cancers. These are all cancers men can develop, and these are all cancers that Japanese men are currently at risk of developing because they are not vaccinated. Physicians, researchers, and government officials in Japan must expand vaccination efforts to include males, particularly the men who have sex with men (MSM).

MSMs are especially susceptible to anal cancer, a rare cancer, but one that disproportionately affects the LGBTQ+ community. Gay men are 20 times more likely to develop anal cancer compared to the general population, and HIV positive gay and bisexual men are 40 times more likely than the general population to develop this cancer[3].

Why must the Japanese government in particular take action? In Japan, same-sex behavior is stigmatized, which makes the LGBTQ+ community a hard-to-reach population [4] that may face challenges [5] when seeking healthcare services. These challenges may negatively impact the likelihood that they will receive the HPV vaccine. Also, the oncogenic (cancer-causing) HPV infection rate in the Japanese MSM community is 75.9%. Among MSMs who are HIV positive, the oncogenic HPV infection rate is 66% [6]. Most of these infections would have been preventable with administration of the HPV vaccine.

So, what can these government officials do? A driving force behind HPV vaccination is provider recommendation. Many patients state the reason they ultimately received the HPV vaccine is because their provider recommended it to them[7]. Some Japanese OB/GYNs are currently advocating that the government reinstate its HPV vaccination recommendation. A reinstatement might encourage more Japanese physicians to recommend the HPV vaccine, increasing the country’s vaccination rate and protecting its currently vulnerable population. However, it is important for these providers to advocate that the government not only recommend the vaccine to females, but to males as well. Moreover, this policy may benefit the MSM community by improving healthcare access and decreasing oncogenic HPV infection rates.

References:

[1] Hanley SJB, Yoshioka E, Ito Y, Kishi R. HPV vaccination crisis in Japan. The Lancet. 2015 June 27; 385(9987): 2571. DOI: http://dx.doi.org/10.1016/S0140-6736(15)61152-7

[2] The Public Hearing on Adverse Events following HPV vaccine in Japan [Internet]. Japan: Ministry of Health, Labour and Welfare; 2014 Feb [cited 2016 Sep 10]. Available from: http://www.mhlw.go.jp/stf/shingi/0000048229.html

[3] Margolies L, Goeren B. Anal cancer, HIV, and gay/bisexual men [Internet]. New York: Gay Men's Health Crisis; 2009 Sep [cited 2016 Sep 10]. Available from: http://www.gmhc.org/files/editor/file/ti_0909.pdf

[4] Nomura Y, Poudel KC, Jimba M. Hard-to-reach populations in Japan. Southeast Asian J Trop Med Public Health. 2007 Mar;38(2):325-7.

[5] Hidaka Y, Operario D, Tsuji H, et al. Prevalence of Sexual Victimization and Correlates of Forced Sex in Japanese Men Who Have Sex with Men. Stephenson R, ed. PLoS ONE. 2014;9(5):e95675. doi:10.1371/journal.pone.0095675.

[6] Nagata N, Watanabe K, Nishijima T, Tadokoro K, Watanabe K, Shimbo T, Niikura R, Sekine K, Akiyama J, Teruya K, Gatanaga H, Kikuchi Y, Uemura N, Oka S. Prevalence of Anal Human Papillomavirus Infection and Risk Factors among HIV-positive Patients in Tokyo, Japan. PLoS One. 2015;10(9):e0137434. doi: 10.1371/journal.pone.0137434. PMID: 26368294, PMCID: PMC4569050

[7] Hanley SJ, Yoshioka E, Ito Y, Konno R, Hayashi Y, et al. Acceptance of and attitudes towards human papillomavirus vaccination in Japanese mothers of adolescent girls. Vaccine. 2012 Aug 24;30(39):5740-7. PubMed PMID: 22796375.

Refugee Health in Europe: Who is Responsible?

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

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Tents below a motorway pass, Piraeus Port, Greece. Photo credit: Victoria Stanford

The number of refugees arriving in Europe continues to rise, despite the EU-Turkey deal struck in March 2016 aimed at halting the numbers of new arrivals. This deal represented one of the first consensual decisions made by the 28 member states of how to respond to the unprecedented refugee crisis in Europe seen over recent years. However, across Europe there remains an overwhelming lack of political effectiveness, or indeed will, to co-ordinate the care of those arriving on the continent. Supranational institutions, European governance bodies, NGOs and humanitarian partners have scrambled in varying degrees of commitment to offer their services to refugees and the impression for many is that they are not achieving enough, quickly enough. But how have the various actors responded to the health needs of the refugees, and who is held accountable for this most basic human necessity?

Arrival versus Settlement

There is a significant difference between the immediate and long-term healthcare needs seen among refugee populations. This protracted crisis must be able to respond to both the immediate and often-life saving measures needed on Greek islands where refugees are still arriving by boat, and the long-term needs of refugees who have settled in host countries, in many cases for months or even years. Understanding this transition between the emergency and post-emergency phase, is essential for planning an effective healthcare response. The needs of those new arrivals mostly consists of sanitation, nutrition, shelter and basic safety provision, whilst those further along the asylum process must be integrated into long-term health systems that provide them with more complex and comprehensive services such as chronic disease management.

 As it stands, the initial needs of refugees arriving to European shores are often provided by humanitarian agencies who are equipped to launch an emergency response, and gradually they hand over this responsibility to the local health care structures. An excellent example of this was seen in Bulgaria when Doctors without Borders provided medical care to over 1500 refugees, allowing the national authorities who have now taken over healthcare service provision in this area, to build capacity and prepare (1). In many places this handover scenario has not been achieved so clearly and in fact often it is best for organisations and local partners to share the healthcare responsibilities. For example in Piraeus port in Athens (now dissolved), NGOs such as Praxis and the Red Cross were stationed within the camp itself and acted as primary care providers to the population on the ground, referring patients who required more specialised care on to state-run and funded hospitals or clinics in Athens. A similar system is currently established between the residents of the Jungle camp in Calais and the PASS clinic (Permanence d'Accès aux Soins de Santé)-provided by the government for refugees and others without social security insurance in France. However the extent to which this collaborative effort is effective depends much on the nature of the healthcare needs required; patients with mental health issues requiring long-term psychological treatment or those with post-surgery rehabilitation needs are often prematurely discharged or simply not offered longstanding care. Logistical difficulties are also often neglected as many appointments and consultations are arranged in neighbouring cities and patients are required to arrange their own transport which for many is an impossibility.  Achieving adequate provision and access in healthcare for refugees is complex and is largely dependent on context, their status in the asylum process and capacities of local health organisations.

The ‘Unofficial’ Refugee

Much complexity has been added to this crisis by the lack of clarity in defining those who are arriving in Europe- undocumented migrants, labour migrants, refugees and asylum seekers are terms often confused and used interchangeably and this has an impact on how these people can interact with official services. As refugees and others spread across Europe, the way in which they settle varies dramatically-there are families living in air-conditioned containers in official UN-led refugee camps, whilst others squat in abandoned buildings in the suburbs of Athens. This undoubtedly leads to much heterogeneity in terms of both their access to and quality of healthcare. Much of the healthcare that refugees living in official camps receive is provided by large, international NGOs such as Doctors without Borders (MSF) or the Red Cross. These organisations provide high-standard medical and nursing care, including psychological support in many cases, and also organise public health services such as child immunisations. As priority for official camp accommodation is usually given to families with children or vulnerable people with either chronic diseases or disabilities, providing comprehensive healthcare services to these populations is even more imperative. What this means however, is that resources are stretched thin and those refugees who are either in transit or living in unofficial areas often receive a lower quality or even a complete lack of healthcare.

The legal status of a refugee can also be a barrier to seeking healthcare, particularly in the few chaotic months after arrival in Europe. Many do not fully understand their legal rights or how to access healthcare in host countries; this is particularly problematic for those who are not settled immediately into official camps, instead attempting to cross international borders or avoid registration for fear of the barriers this may pose to freedom of movement (2). This means many do not receive their healthcare entitlements and depend on the ad-hoc and inconsistent presence of healthcare-providing groups often from outside any official aid delivery process.

The ‘unofficial’ refugee population is in fact where the grassroots organisations have trumped more established humanitarian groups. Countless groups have been set up in recent years by concerned citizens across Europe and have provided the in-the-field manpower that many official partners have failed to do. Groups such as Drop in the Ocean, Care 4 Calais, Help Refugees and many others have integrated into the ‘official’ aid delivery system and have in many cases outpaced those organisations who are often restricted by mandates or internal bureaucracy.  These groups offer assistance that is not always recorded on health surveillance statistics or official reports but in fact they are in many cases acting as primary carers. As healthcare itself is not the only way of keeping refugees healthy, these groups who attend to other needs such as shelter and food provision, hygiene, childcare and education may actually be having a significant impact on the refugee population’s health (3).

What about the Supranationals?

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Red Cross Measles Vaccination Campaign, Scaramangas Camp, Athens. Photo credit: Victoria Stanford

Under the 1951 Refugee Convention, refugees should enjoy access to health services equivalent to the host population, and institutions such as the World Health Organisation (WHO) and the Office of the United Nations High Commissioner for Refugees (UNHCR) are tasked with upholding these rights under the UN Charter (4). It is increasingly clear that Europe is struggling to deal with the crisis and the UN has put pressure on European governance bodies to establish a comprehensive, mutually-agreed response plan to address the health needs of the refugee populations. This has achieved some success particularly in communicable disease control with large-scale vaccination programmes used in camps and non-camp settings alike (5) (see photo).

 However, the long-term nature of this crisis will require more of a focus on capacity-building of existing healthcare structures in host countries. For this reason, the WHO has performed a number of Assessment missions in countries receiving the most footfall of refugee movement including Cyprus, Greece, Italy and others, providing countries with context-specific information and guidance on responding to the health needs of refugees either temporarily or permanently settling in these countries (6). These analyses of the current preparedness of national health structures have helped to pinpoint where increased funding or skills are needed to boost local response; the European Commission have subsequently invested over 5 million euros on projects with the aim of “supporting member states under particular migratory pressure in their response to health-related challenges” (7). Crucially, these projects integrate NGOs with national structures, bridging the gap between short and long-term response, and focus on fostering comprehensive access to all aspects of the health system, not only emergency care. One of these projects also places a particular focus on the health needs of pregnant women, unaccompanied minors and young children, highlighting a concern for the most vulnerable populations in this crisis (7). However, whilst these projects are theoretical problem-solvers, there is a gap between plan and action. Many projects will take years to see results and whilst they do, countries such as Greece are reliant on existing health care systems, which have been struggling for years to cope with both the steady influx of refugees over many years and domestic austerity policies (8).

The bottom line is that funded and elected institutions such as the UN are mandated to protect the rights of refugees and these include access to healthcare. This situation sees the heavily bureaucratised system overloaded and rendered flimsy by the sheer volume of refugees depending on it, not only in Europe. This has meant that other humanitarian partners and grassroots movements have stepped in and provided invaluable assistance on the ground. The provision of healthcare to refugees in Europe largely depends on capacity and it is clear that there must be far-reaching plans made to build on both national and international health system structures. Whether these plans will materialise into effective action that both prevents ill health and treats disease remains to be seen as the crisis, without long-term solutions, inevitably continues. 

References:

(1)   MSF (2016) Bulgaria: providing healthcare to Syrian refugees [Online] Available at: http://www.msf.org.uk/article/bulgaria-providing-healthcare-syrian-refugees [Accessed August 2016)

(2)   Global Health Watch (2015) Migrants and asylum seekers; the healthcare sector, London, Page 63.

(3)   Kuepper, M (2016) Does Germany need to rethink its policies on refugees? Researchgate.net [Online] Available at: https://www.researchgate.net/blog/post/does-germany-need-to-rethink-its-policies-on-healthcare-for-refugees [Accessed August 2016]

(4)   UNHCR; Health (2016) [Online] Available at: http://www.unhcr.org/uk/health.html [Accessed August 2016]

(5)   UN News Centre (2015) UN seeks common European strategy on healthcare for refugee and migrant influx [Online] Available at: http://www.un.org/apps/news/story.asp?NewsID=52630#.V7DT6_krK01 [Accessed August 2016]

(6)   WHO (2015) Stepping up action on migrant and refugee health [Online] Available at: http://www.euro.who.int/en/countries/greece/news/news/2015/06/stepping-up-action-on-migrant-and-refugee-health [Accessed August 2016]

(7)   European Commission Health Programme (2015) Health projects to support member states, Geneva.

(8)   Chrisafis, A (2015) Greek debt crisis: of all the damage, healthcare has been hit the worst, The Guardian, 9 July 2015 [Online] Available at: https://www.theguardian.com/world/2015/jul/09/greek-debt-crisis-damage-healthcare-hospital-austerity [Accessed August 2016]

Why I Love the International AIDS Conference

~Written by Jessica Taaffe, PhD (Contact: Jessica.Taaffe@twigh.org; Twitter: @jessicataaffe)

Originally published on Global Health NOW

I remember my first International AIDS Conference well.  It was 2010, and I attended the conference in Vienna to present a poster on my PhD thesis work. Walking through the conference one day, I came upon a group of activists loudly protesting for better access to harm reduction services, like needle and syringe programs and opioid substitution therapy.

I thought, “WHAT kind of conference is this???”

I’m a biomedical scientist. I was trained that science is neutral, objective, dispassionate. So I was naturally shocked by the activism at the conference. My perspective on this has changed since then, and it’s why I now love the International AIDS Conference. At this conference, scientists ARE activists; they are part of the large and inclusive community of people working to end AIDS. And at this conference, all of those people–scientists, policy makers, activists, civil society, communities living with or affected by HIV—come together.

Science, policy and activist communities don’t often intersect. At conferences scientists usually focus on research advances and less on how to put them into policy and practice. Conversely, high-level policymakers attend meetings that set global agendas but few scientists are in the room.

At this conference, they do intersect—and interact.  Scientists have access to sessions hosted by organizations setting global HIV policy. They can give the context of their evidence and influence how it is used (or not).  Policymakers and program directors have access to the latest research advancing the field, helping inform their recommendations and program implementation.  

And those researchers and policymakers have an opportunity to directly interact with the communities affected by the HIV epidemic.  For example, I attended a pre-conference event next door to a session on transgender rights. The cheering and loud applause seeping through the walls warmed my heart.

Mutual access and dialogue between communities is critical. As a scientist, a better understanding of affected communities or populations leads to more targeted research or solutions.  For instance, research presented yesterday indicates that African women are more susceptible to HIV infection and pre-exposure prophylaxis (PrEP) isn’t as effective in some of them due to differing vaginal microbial strains.  Targeting treatments against the responsible bacteria may enhance current and future HIV prevention efforts.  

For activists, having access to the science allows them to make demands and personal decisions based on the evidence. Men who have sex with men have been enthusiastic and early adopters of PreP. When these communities interact, real change happens.  

I love the International AIDS Conference because it epitomizes the HIV movement–the coming together of an expansive and diverse community with the common goal of ending AIDS.

That is what I want to see in global health: I want scientists to see how their research directly improves the lives of people.  I want them to be informed of larger issues in the field that may shape their research or inspire new studies. I want scientists to be PASSIONATE about their science and use it to directly advocate for policy change.  I want policymakers to appreciate the complexity of the research process and use evidence appropriately.  I want them to see the impact of their decisions on the lives they affect.  

I want more communities living with a disease or at risk from the disease to be science-literate and empowered to advocate for what the health services they need.

As the 21st International AIDS Conference unfolds this week in Durban, South Africa, I hope the global health community is paying attention.  Colleagues, this is how you mobilize an equitable, science-driven, people centered, and effective health response.  We need much more of these events in global health.

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. 

Is Measles Eradication Possible when the World is Still Trying to Eradicate Polio?

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

Also published on Global Contagions

Humanity has only truly conquered one human infectious disease, smallpox. Smallpox was successfully eradicated in 1977 after causing between 100 and 300 million deaths in the 20th century. Strides are being made to make polio the second eradicated infectious disease. Polio eradication efforts have been ongoing for almost 30 years, costing nearly 11 billion dollars. The World Health Organization (WHO) set a goal for polio eradication by 2000 but, 16 years later, that goal has yet to be achieved for reasons such as oral polio vaccine (OPV) effectiveness, armed conflict, and myths about vaccine dangers. The global public health community has been “burned” by the polio eradication campaign and may not have the money or energy for another global eradication campaign, especially since the polio campaign is still ongoing. Even if the global health community is burnt out on polio eradication efforts, is it time to turn our attention toward measles eradication?

Measles, along with smallpox and polio, is one of the very few diseases that meets the criteria necessary for eradication. Measles cases can be easily diagnosed due to the characteristic rash, the vaccine is incredibly effective, and there is no animal host where the virus can hide. Perhaps most importantly, measles transmission has been eliminated in large geographic areas, demonstrating that eradication may be feasible.

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Number of reported measles cases from April 2015 to September 2015 (6 months); Photo Credit: World Health Organization

Measles is a deadly disease. In 2013, measles killed an estimated 145,000 people, mostly children in Africa, while leaving countless others deaf, blind, or otherwise disabled. To prevent measles individuals need to receive two vaccinations, which are 99% effective at preventing measles. While the number of children receiving measles vaccinations has risen over the past decade, there are still a handful of countries where children aren’t receiving vaccines (Democratic Republic of Congo, Ethiopia, Nigeria, India, Pakistan). Even places like the United States and some countries in Europe, which have eliminated measles locally, are seeing outbreaks due to imported cases. Until measles is eradicated, imported cases will continue to pop-up in countries without local transmission.

While measles meets the criteria for eradication efforts, there are still challenges to achieving that goal. One major challenge is that measles is incredibly contagious; infectious droplets can linger in the air for up to two hours, infecting unsuspecting people. To interrupt measles transmission, over 95% of the population needs to be vaccinated, compared to only 80% for smallpox and polio. The measles vaccine is also harder to deliver than the OPV, which is administered via a few drops in a child’s mouth. The measles vaccine must be given via injection, thus trained staff is necessary, and the vaccine has to be reconstituted in the field (liquid added to the powder vaccine to make the complete vaccine). Once reconstituted, the vaccine is only viable for six hours, which isn’t much of an issue for large vaccination campaigns but becomes problematic when only one or two children need to be vaccinated.

As with many global public health campaigns, governments and non-governmental organizations donate money to help high-risk countries control the spread of measles. In 2009, the global recession hit and measles eradication efforts lost significant funding. Mass vaccination campaigns were canceled or reduced and routine vaccination programs suffered. Following the reduction in vaccinations the number of measles cases exploded in southern African countries, going from 170,000 in 2008 to 200,000 in 2011. Added to these challenges is the perception of measles in high-income countries. Even though measles is a deadly disease, many in high income countries view measles as a minor illness with  a rash and fever; certainly not something worth spending billions of dollars on over the course of many years.

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Source: Butler D (2015). Measles by the numbers: A race to eradication. Nature 518 (7538): 148-149. doi: 10.1038/518148a.

Measles eradication is feasible. Measles meets the criteria necessary for eradication; it is easily diagnosed, it has an effective vaccine, and humans are the only host. It has been successfully eliminated in large areas of the world (for example, all 35 countries of the Americas eliminated measles in 2002), demonstrating that it is possible to at least end local transmission. However, significant challenges do exist. While the global health world may be hesitant to embark on another “eradication” campaign after the continued struggle with eradicating polio, perhaps it’s best to start eradicating measles without labeling it an “eradication” campaign. Avoiding the “eradication” label may help prevent critics who are hesitant about taking on another potentially long and expensive eradication campaign, especially as the polio eradication campaign is still ongoing. Regardless of the use of the word “eradication” in the efforts to rid the world of measles, without measles in the world, lives will be saved. Let’s ensure measles is added to the very short list of human diseases we’ve eradicated.

Vulnerability of Urban Populations to Ambient Air Pollution

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

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Dannenberg et al. 2011

Urban populations have always been exposed to ambient (outdoor) air pollution because urban regions have high-density industries and populations (Dannenberg et al., 2011). High levels of pollution result from the concentration of sources of combustion (Dannenberg et al., 2011). There are two types of pollutants: primary and secondary. Primary pollutants are those that are directly emitted (Dannenberg et al., 2011). These include sulfur dioxide, which is released from power plants, and carbon monoxide from fossil fuel combustion (Dannenberg et al., 2011). In contrast, secondary pollutants result from the physical and secondary conversion of other pollutants (Dannenberg et al., 2011). Tropospheric ozone is one example; it forms through the chemical reactions of anthropogenic and biogenic precursors (Dannenberg et al., 2011).

Both primary and secondary pollutants lead to negative health consequences, including eye irritation, fatigue, headaches and more severe effects such as bronchoconstriction, lung impairment and neurological damage (Dannenberg et al., 2011). Certain populations are particularly vulnerable to ambient air pollution. For example, as a result of physiological and psychological factors, children are more sensitive to ambient pollution (Vanos, 2015). Furthermore, those with less education and lower socio-economic status also face a greater risk of exposure to ambient air pollution; thus, highlighting pollution an issue of environmental justice as well (Dannenberg et al., 2011).

Since air pollution is multifaceted, it is not easy to determine a solution. More research is required, to determine the severity of ambient air pollutants in different regions and how different populations are impacted. Furthermore, it is important to develop and implement policies that will reduce the prevalence of ambient air pollutants and their health consequences. For example, in order to provide evidence-based advice on the impacts of air pollution on health, the WHO Regional Office for Europe developed two projects-the “Review of Evidence on Health Aspects of Air Pollution” (REVIHAAP) and the “Health Risks of Air Pollution in Europe” (HRAPIE), which were completed in 2013 (WHO, 2013). The findings from these projects guided changes in the EU air quality policies that were implemented that same year (WHO, 2013).

The built environment also plays an important role in mitigating air pollution. Regions should employ sustainable development practices to ensure energy-efficient land use and transportation systems to reduce emissions (Dora et al., 2015). Moreover, attention should be given to the proximity of homes and schools to sources of pollution (Dannenberg et al., 2011). Urban Structure Types (USTs) is one method that could be used, as it is a spatial indicator that describes urban regions through the assessment of land use, physical properties and environmental characteristics (Réquia Júnior et al., 2015). The UST method assesses the morphology of housing, green spaces and industrial buildings which can be compared, to assess the relationship with a health risk (Réquia Júnior et al., 2015).

Like other global health problems, air pollution is complex. It is not unique to one region because it reaches across borders. As a result, governments and organizations from various regions need to work together to mitigate this problem.

References:

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places:

Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-rohani, H., Alabaster, G., … Neira, M. (2015). Indicators linking health and sustainability in the post-2015. The Lancet, 385(9965), 380–391. doi:10.1016/S0140-6736(14)60605-X

Réquia Júnior, W. J., Roig, H. L., & Koutrakis, P. (2015). A novel land use approach for assessment of human health: The relationship between urban structure types and cardiorespiratory disease risk. Environment International, 85, 334–342. doi:10.1016/j.envint.2015.09.026

Vanos, J. K. (2015). Children’s health and vulnerability in outdoor microclimates: A comprehensive review. Environment International, 76, 1–15. doi:10.1016/j.envint.2014.11.016

World Health Organization. (2013). Health risks of air pollution in Europe-HRAPIE project

Part III-Your Work is Never Finished: Why Iterating after You Launch Should Be Part of Your Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

If you missed our last three blog posts in this series on human centered design, you can learn about what human centered design is here, read a case example of how we build empathy with health works in Nepal, and see how we’ve used prototyping to test a new monitoring and evaluation dashboard in Benin.

Our final post is going to explore the concept that your project is never complete; even after you launch, it’s important to continue to get feedback. In this post we’ll share an example of how we’ve iterated on our software based on feedback from health workers and ministry officials in Benin.

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A health worker sorts through paper records. Source: VaxTrac.com

The Problem
The World Health Organization (WHO) and the Benin Ministry of Health issue a country-wide immunization schedule that recommends when children should receive their immunizations, beginning from the moment they are born and lasting through the first year of life. Health workers in urban clinics manage hundreds of children’s schedules using paper records. Keeping track of which children are due for which vaccine during any given vaccination session is a time-consuming task.

Parents of these children lead busy lives and often live far from the clinic. It takes hours out of their day to bring their child to vaccination sessions. While parents value vaccines, health workers don’t always communicate clearly to parents about when to come back to the clinic for the child’s next vaccination. A direct consequence of this is that children often miss their appointments.


Our Solution: Callback List 1.0
Clinics that use VaxTrac to record childhood immunization data have an advantage: as long as children are registered in the VaxTrac system, the system can automatically generate a list of children that are due for upcoming appointments. This can save health workers from several hours of paperwork each week.

Our team of software engineers saw this as an opportunity and developed a basic callback list. The first version of the callback list pulled a list of children that were due for an upcoming appointment along with basic information, such as date of birth, village and contact information. But health workers weren’t using it. We wanted to know why.

Back to the Drawing Board: Stay Responsive to User Needs through Iteration
Technology is meant to change over time. VaxTrac’s software engineers like to remind our team that the software is never finished; it’s constantly evolving and adapting to user needs.

When we began developing our mobile (Android)-based system, we brought health workers together to get their feedback on what they wanted from a callback list feature. We used a number of human centered design methods to elicit feedback, such as prototyping [link to prototype blog], brainstorming lists of what they do during vaccination sessions, and breaking into groups to sketch out what they wanted the callback list to look like.

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Meredith leads a focus group with health workers. Source: VaxTrac

We asked them to create the callback list over again from scratch. We asked guided questions: Is any of the information available on the callback list useful? If so, what is it used for? What other information should it include? How would they like to see the callback list organized? What rules should the callback list follow? How long should a child stay on the list?

Having health workers sketch their answers to these questions helped all of us think through these abstract questions together.

We found key insights:

• Health workers were using the callback list, but not in the way that we had originally intended. Instead of using it to contact the parents of children who were due for upcoming vaccinations, they used it to track down children who had missed an appointment.
• Phone numbers change often so we needed to make it easier for them to update parents’ contact information.
• In order to be more useful, the callback list would need to be interactive, allowing health workers to sort the information in a variety of ways.

Hearing the health workers’ perspectives helped us rethink the purpose of the callback list and how to redesign it.

Build, Do, Learn, Repeat: VaxTrac’s Philosophy on Iteration
Build: Our software engineers took our learnings from the user feedback session and went to work on building a new and improved callback list. In addition to the callback list, we created a defaulter list, providing health workers with a list of patients that have missed their appointment. We also made both lists sortable by any category (village, date of birth, sex, date of appointment, etc.) And lastly, we made it easier to update contact information.

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Callback List. Source: VaxTract

Do: After our software engineers updated the callback and defaulter lists, we made sure health workers received adequate training on how to use it. Our Benin-based team visited clinics for additional training.

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VaxTrac staff training health workers. Source: VaxTrac

Learn: After a few months of using the new callback list, we held a focus group with health workers to learn more about what they thought of the different VaxTrac features, including the callback list. We learned that health workers would like to be able to sort by the mother’s name in addition to sorting by the other categories. We also learned that health workers would like a way for the callback list to help them contact parents of children who are due for upcoming vaccination sessions.

Repeat: Each time we add new features and users, we get new perspectives. All of the feedback that we’ve gotten from health workers have helped us make our callback list and defaulter list more user-friendly. But we’re not done yet! We are currently conducting a study to assess the possibility of incorporating an appointment reminder feature to the callback and defaults lists, so health workers can use the system to contact parents directly, possibly through SMS or Interactive Voice Response (IVR).

Once we learn everything we can, our cycle will repeat again.

The more we iterate, the stronger our product becomes because it’s based on feedback from the people who use our system. While it can be daunting to go back to the drawing board, adding iteration into your project plan from the beginning can save you time and resources down the line.

We’ve embraced the philosophy that our software is never finished. And we can’t wait to see how far it’ll take us.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources[link: http://www.designkit.org/resources/1.

Part II-Prototypes Bring Ideation to Life

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Welcome to the second installment of our blog series on human centered design. In our introductory post we broke down what human centered design means for designers and implementers of international development projects. Our most recent post gave a case example of how we’re building empathy with health workers in Nepal. This post will share a case example of how we’re prototyping different iterations of a monitoring and evaluation (M&E) dashboard for our staff in Benin.

Once you have worked with your project partners to determine what you want to design or test, the most effective way to get useful feedback from the people you’re designing for is to prototype what you want to test.

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Sam facilitating the feedback session on VaxTrac monitor

Prototyping allows you to get feedback on something concrete rather than abstract. It is the difference between asking someone to describe their perfect cup of coffee versus giving them three different cups of coffee to critique. They will have a better grasp of what you are trying to design, and you will get more specific and useful feedback.

Prototyping also gives you the flexibility to test a variety of unique ideas without spending the resources on a project that might not work the first time.

The Problem
Our team in Benin needed a new, more efficient way to monitor our project. As we trained new health workers to use VaxTrac and added an entirely new health zone to our scope of work, our field team had to process more data than ever before.

Each field supervisor had devised his own method of monitoring how health workers use the tablets, what bugs occur in the software, and how to compare tablet-based reporting to paper-based reporting. Meanwhile, back in DC, our Learn team stayed busy exporting data from CommCare reports and spending a lot of time converting data into a more useful format.

It quickly became clear that we needed a more efficient way of tracking data so that our field-based team could spend less time entering data into spreadsheets and more time responding to health worker needs, prioritizing resources and tracking progress over time.

Prototyping Solutions to Test the Best Ideas
To solve this problem, we have been working with our team to design a monitoring tool that will allow our field supervisors to monitor the project more easily. After a series of feedback sessions interspersed with a variety of paper monitoring tool prototypes, we decided the best solution would be to design a web-based data dashboard that can automatically populate with data from CommCare, such as when a form is submitted, the time it takes to complete a form, when a child is fully immunized, among other pieces of data. We are also working to incorporate additional pieces of data such as, data use, battery level of the tablet and the last time the tablet had an internet connection.

In order to get feedback from our team in Benin, we designed a live prototype of a monitoring and evaluation (M&E) dashboard:
 

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M&E Dashboard Prototype

Our DC staff brought the prototype to our Benin staff during a trip to Benin a couple weeks ago. We held a focus group and asked our team questions about the types of data they want to monitor on the dashboard, how data should be grouped, how data should be displayed and how they would use the dashboard.

By providing a concrete example of an M&E dashboard, we were able to elicit specific and useful feedback from our team in Benin. The designing of the dashboard is an ongoing project. We will continue to get feedback and iterate on our designs until we come up with a solution that meets everyone’s needs.

Check out the final post in our series about human centered design, where we’ll give examples of how we keep iterating on our projects even after we implement.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources.

Water Risk Perception and the Use of Water Bottles

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Source: http://cbwa.info/

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

It is important to examine how social, organizational and cultural factors of the environment interact to influence health (Laverack, 2014). This has become increasingly evident as water quality and quantity is assessed to determine its impacts on the health of a community. As water is vital to human health, access to clean tap water is important; however, bottled water is often seen as a better alternative to tap water; especially in less developed regions. Many people in low-resources countries, such as Lebanon and Jordan, believe that bottled water is better than their tap water (Massoud, et al., 2013). However, the bottled water is not always effectively monitored for safety, and many are still at risk for various waterborne diseases. Thus, citizens face economic strain to pay for water that is perceived to, but may not be cleaner (Massoud et al., 2013).

Even when bottled water is cleaner than the local tap water, the poor are often unable to afford it, which further increases the gap between the different social classes (Massoud et al., 2013). Citizens should not have to pay for something that is a human right (Parag & Roberts, 2009). Encouraging the use of tap water pushes NGOs and government agencies to improve infrastructure that would make water available to all regardless of social class (Massoud et al., 2013)..

Although tap water in developed regions such as Canada is clean and reliable, bottled water is still popular as it is often purchased for convenience (Mikhailovich & Fitzgerald, 2014). Although the socio-economic implication of using plastic water bottles may not be as severe in such settings, there are still negative environmental consequences (Parag & Roberts, 2009). Manufacturing, packaging, transporting and disposing plastic water bottles is an inefficient use of resources and creates a large amount of waste (Parag & Roberts, 2009). This can have a negative impact on the ecosystem, as this waste can influence plants, animals, minerals and water (Parag & Roberts, 2009). As these systems interact with humans they eventually have a negative impact on the health of a population (Parag & Roberts, 2009). Thus, encouraging the use of re-usable water bottles encourages environmental awareness.

Nevertheless, non-reusable plastic water bottles have been beneficial for emergencies when clean water is not easily available (Canadian Bottled Water Association). With the gradual discontinuation of these bottles, alternative methods need to be determined to ensure that clean water is distributed during emergencies.

Overall, clean water is vital for human health, and easy accessibility is crucial. Thus, clean tap water must be made available and plastic bottles should be phased out in order to allow for greater use of re-usable bottles. This would be a lower burden on the environment, and decrease wealth inequality, consequently, having a positive impact on the health of citizens. 

References:

Laverack, G. (2014). A-Z of health promotion. UK: Palgrave Macmillan.

Massoud, M. a., Maroun, R., Abdelnabi, H., Jamali, I. I., & El-Fadel, M. (2013). Public perception and economic implications of bottled water consumption in underprivileged urban areas. Environmental Monitoring and Assessment, 185, 3093–3102. doi:10.1007/s10661-012-2775-x

Mikhailovich, K., & Fitzgerald, R. (2014). Community responses to the removal of bottled water on a university campus. International Journal of Sustainability in Higher Education, 15(3), 330–342. doi:10.1108/IJSHE-08-2012-0076

Parag, Y., & Roberts, J. T. (2009). A Battle Against the Bottles: Building, Claiming, and Regaining Tap-Water Trustworthiness. Society & Natural Resources, 22(7), 625–636. doi:10.1080/08941920802017248