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]

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. 

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.

Defeating Tuberculosis: A Possibility?

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

Disease has always played a part in reforming community and geographical distribution of people through the ages. The bubonic plague, the Spanish flu, cholera and tuberculosis (TB), are some of the illnesses that have altered human history. Interestingly, TB has been glorified in literature more than others. The characters, Mimi in La boheme, Fantine in Les Miserables and Satine in Moulin Rouge all met with a similar fate at the hands of this disease.

According to the Global Tuberculosis Report 2015, the year 2015 is considered a turning point for TB as the global community progressed from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). TB mortality has decreased by 47% since 1990. Between 1990 and 2014, as a result of correct and timely diagnosis, 43 million lives were saved. We have made progress by moving from the “Stop TB Strategy” to the “End TB Strategy”. According to the latter, the targets for 2030 are to reduce the number of TB deaths by 90% and incidence by 80% (1).

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Source: TBAlert.org

These statistics give us hope for a world without TB. But, having worked in a tertiary hospital in a low middle-income country, I have my doubts. Although the statistics reported by the World Health Organization (WHO) are the best available at the moment, these are estimates with very wide confidence intervals and may not provide a precise idea of the current situation in low and low middle income countries (LIC and LMICs).

In the surgical ward where I worked, one-third of the abdominal procedures were for perforation due to abdominal TB. To my knowledge, patient records were maintained through an electronic health system on the hospital server. Hard copies of the records were kept in nurses’ offices or junior doctors; duty rooms. These were put in storage, usually available for 4 to 5 years. The conditions of the storage area were extremely shabby and damp, where paper records could hardly survive. Electronic records, however, were said to be available in perpetuity. No one knew if these records were ever shared with the WHO to help with estimates. Popular opinion was that if the world knew the actual incidence and prevalence of diseases like TB in countries like ours it would be an embarrassment. Regardless, it is essential to have as accurate as possible estimates to converge efforts towards a TB free world.

Despite the best intentions and apparently achievable goals, the situation remains grim. According to the WHO, TB still imposes a great burden on the world. In 2014, 9.6 million new cases of TB were diagnosed while 1.5 million people died as a result of TB (2). Despite the history of this disease, research for newer TB drugs has been limited (3). In 2012, a new drug for multidrug resistant TB was introduced after a drought of 50 years (4). In addition, though BCG vaccines are part of immunization programs in countries where the disease is endemic, the current vaccine was developed in 1921 and is not entirely effective (5). A systemic review and meta-analysis that included articles from 1950 to 2013 reported 19% efficacy against TB in vaccinated children compared to non-vaccinated children (6). Although current research is encouraging there are questions of affordability of newer drugs for low resource countries where TB is more prevalent. Furthermore, five percent of the global burden of TB is due to multidrug resistant strains (7). The research required for averting these cases poses additional problems of affordability, availability and accessibility in LICs and LMICs.

Children present another area of grave concern. It is estimated that 550,000 children are infected with TB each year. The condition is frequently overlooked in children, often due to delayed and inefficient diagnosis (8). Adoption of the latest recommended diagnostic tools by the WHO is a challenge in itself because accessibility, affordability and availability again come into play in LICs and LMICs. Since TB flourishes in poor living conditions, the current global refugee and migrant situation has increased concerns about TB exposure, infection and transmission (9).

It is time that LICs and LMICs focus on establishing the true burden of major diseases like TB, and work towards adopting recommended diagnostic tools and treatment for all forms of TB. Unless the state actors and international community work together, the policies and aid provided will continue to fall short and the target to end TB will remain out of reach.

References:

1. World Health Organization. Global Tuberculosis Report 2015. 2015.

2. World Health Organization. Research for Tuberculosis Elimination. 2014.

3. Frick M. 2014. Report on Tuberculosis Research Funding Trends, 2005-2013. [Internet]. Treatment Action Group. 2015. Available from: http://www.treatmentactiongroup.org/sites/tagone.drupalgardens.com/files/tbrd2012 final.pdf

4. Médecins Sans Frontières, International Union Against Tuberculosis and Lung Disease. DR-TB Drugs Under the Microscope. Sources and prices for drug-resistant tuberculosis medicines. 2nd edition. 2013.

5. World Health Organization. Tuberculosis vaccine development [Internet]. World Health Organization; 2015 [cited 2016 Mar 19]. Available from: http://www.who.int/immunization/research/development/tuberculosis/en/

6. A Roy et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systemic review and meta-analysis.  BMJ 2014; 349:g4643

7. World Health Organization. Multidrug Resistant Tuberculosis (MDR-TB). 2015.

8. World Health Organization. Combating Tuberculosis in Children. 2015.

9. World Health Organization. Tuberculosis prevention and care for migrants. 2014.

Battling Cancer across Different Income Settings

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

David Bowie, Alan Rickman and Rene Angelil, are a few of the well-known people that the world lost to cancer in the year 2015. My familiarity with cancer comes not just from losing my favourite celebrities to cancer, or dealing with patients in a tertiary care hospital in Lahore, but also from losing a few people very dear to me in my family. Every case of cancer is a battle for the person, their families, friends and doctors, as well as the healthcare system.

Cancer forms a major proportion of non-communicable diseases today. There were an estimated 14.1 million new diagnosed cases of cancer with an estimated 8.2 million deaths in 2012 (1). The most common sites of cancer have been recognized to be lung, colon, breast, liver, stomach and the cervix while the majority of cancer-related deaths are due to lung, stomach and esophageal cancer (2). Previously, cancer remained a low priority for low income (LICs) and low middle income countries (LMICs), as well as for donors (3). In 2008 72% of deaths due to cancer occurred in LICs and LMICs (4).  This may be a consequence of not only longer life spans and the majority of the world’s population being in the LIC and LMIC countries but also a lack of accessible and affordable treatment in these parts of the world.

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Estimated global numbers of new cases and deaths with proportaions by major world  regions, for all malignant cancers (excluding non-melanoma skin cancer) in both sexes combined, 2012. Source: The Cancer Atlas

While higher income countries have progressed from chemotherapy and radiotherapy to gene therapy, LMICs continue to focus on finding ways for uneducated or less educated to identify cancerous conditions in order to seek medical help before it is too late, for instance promoting breast self-examination. The increasing prevalence of cancer in LMICs exasperates the health sector with an already increasing burden of infectious diseases like tuberculosis, malaria and diarrhea. In these contexts cancer contributes to altering the epidemiology of these countries adding to the burden of non-communicable diseases which in turn worsens the double burden of disease. This creates considerable strain on the healthcare system due to increasing needs of diagnostic and treatment modalities besides the already unmet needs concerning infectious diseases.

There is an immense need for healthcare systems in resource poor settings to focus more on prevention rather than cure. Health professionals working in LMICs need to place greater emphasis on informing and educating people about warning signs of cancer as many resource poor settings have technology constraints and limited means of gaining health information. There are no quick fixes and circumstances are never as simple as they seem. Campaigns against smoking to prevent lung cancer have been addressed by discussions advocating for the rights of the poor who own tobacco farms as their only source of income (5). Modification of social behaviours for instance, requires extensive out-reach programmes by medical professionals but also bring into question the financial constraints of the country in order to pay for the services of these local healthcare workers.

In summary, LICs and LMICs have a longer way to go to provide sufficient healthcare for cancer patients. While high income countries are more likely to make medical advances for cancer treatment, resource poor countries can make strides through preventive measures like vaccination, behaviour modification and self-examination.

References :

1. Cancer. WHO Media Centre. World Health Organization; 2016 [cited 2016 Feb 14]. Available from: http://www.who.int/mediacentre/factsheets/fs297/en
2. World Cancer Report published by the International Agency for Cancer Research, WHO
3. Scaling up cancer diagnosis and treatment in developing countries: what can we learn from the HIV/AIDS epidemic? Can Treat International. Ann Oncol [Internet]. 2010;21(4):680–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20338877
4. Cancer in Developing Countries International Network for Cancer Treatment and Research. INCTR. 2016 [cited 2016 Feb 14]. Available from: http://www.inctr.org/about-inctr/cancer-in-developing-countries/
5. Tobacco Company Strategies to Undermine Tobacco Control Activities at the World Health Organization. Committee of Experts on Tobacco Industry Documents. World Health Organization. 2000.
   
6. International Women ’ s Day 2014 : women ’ s health equity is progress for all. Ginsburg O. 2014.

Technology is Changing the Way Infectious Diseases are Tracked

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

Technology is progressively becoming a bigger part of our lives. This holds true in high-income countries and in low- and middle-income countries. By 2012, three quarters of the world’s population had gained access to mobile phones, pushing mobile communications to a new level. Of the over 6 billion mobile subscriptions in use worldwide in 2012, 5 billion of them were in developing countries. The Pew Research Center’s Spring 2014 Global Attitudes survey indicated that 84% of people owned a mobile phone in the 32 emerging and developing nations polled. Internet access is also increasing in low- and middle-income countries. The 2014 Pew Research Center survey indicated that the Internet was at least occasionally used by a median of 44% of people living in the polled countries.

The increase in Internet and mobile phone access has significant implications for how infectious diseases can be better tracked around the world. Although robust and validated traditional methods of data collection rely on established sources like governments, hospitals, environmental, or census data and thus suffer from limitations such as latency, high cost and financial barriers to care. An example of a traditional infectious disease data collection method is the US Centers for Disease Control and Prevention’s (CDC) influenza-like illness (ILI) surveillance system. This system has been the primary method of measuring national influenza activity for decades but suffers from limitations such as differences in laboratory practices, and patient populations seen by different providers, making straightforward comparisons between regions challenging. On an international scale, the WHO receives infectious disease reports from its technical institutions and organizations. However, these data are limited to areas within the WHO’s reach and may not capture outbreaks until they reach a large enough scale.

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Figure 1. CDC Flu View Interactive dashboard: http://gis.cdc.gov/grasp/fluview/fluportaldashboard.html

Compared to traditional global infectious diseases data collection methods, crowdsourcing data allows researchers to gather data in near real-time, as individuals are diagnosed or even before diagnosis in some instances. Furthermore, getting individuals involved in infectious disease reporting helps people become more aware of and involved in their own health. Crowdsourcing infectious disease data provides previously hard to gather information about disease dynamics such as contact patterns and the impact of the social environment. Crowd-sourced data does have some limitations, including data validation and low specificity.

Internet-based applications have resulted in new crowd-sourced infectious disease tracking websites. One example is HealthMap. HealthMap is a freely available website (and mobile app) developed by Boston Children’s Hospital which brings together informal online sources of infectious disease monitoring and surveillance. HealthMap crowd-sources data from libraries, governments, international travelers, online news aggregators, eyewitness reports, expert-curated discussions, and validated official reports to generate a comprehensive worldwide view of global infectious diseases. With HealthMap you can get a worldwide view of what is happening and also sort by twelve disease categories to see what is happening within your local area. 

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Figure 2. HealthMap. http://www.healthmap.org/en/

Another crowd-sourced infectious disease tracking platform was Google’s Flu Trends, and also their Dengue Trends. Google was using search pattern data to estimate incidence of influenza and dengue in various parts of the world. Google’s Flu Trends was designed to be a syndromic influenza surveillance system acting complementary to established methods, such as CDC’s surveillance. Google shut down Flu Trends after 2014 due to various concerns about the validity of the data. As an initial venture into using big data to predict infectious diseases, Flu (and Dengue) Trends have provided information that researchers can use to improve future big data efforts. 

With the increase of mobile phone access around the world, organizations have started using short message service (SMS), also known as text messaging, as a method of infectious disease reporting and surveillance. Text messaging can be used for infectious disease reporting and surveillance in emergency situations where regular communication channels may have been disrupted. After a 2009 earthquake in Sichuan province, China, regular public health communication channels were damaged. The Chinese Center for Disease Control and Prevention distributed solar powered mobile phones to local health-care agencies in affected areas. The phones were pre-loaded with necessary software and one week after delivery, the number of reports being filed returned to pre-earthquake levels. Mobile phone reporting accounted for as much as 52.9% of total cases reported in the affected areas during about a two-month time period after the earthquake. 

Text message infectious disease reporting and surveillance is also useful in non-emergency settings. In many malaria-endemic areas of Africa, health system infrastructure is poor which results in a communication gap between health services managers, health care workers, and patients. With the rapid expansion and affordability of mobile phone services, using text-messaging systems can improve malaria control. Text messages containing surveillance information, supply tracking information and information on patients’ proper use of antimalarial medications can be sent from malaria control managers out in the field to health system managers. Text messaging can also be sent by health workers to patients to remind them of medication adherence and for post-treatment review. Many text message based interventions exist, but there is a current lack of peer-reviewed studies to determine the true efficacy of text message based intervention programs.

Increasing global access to the Internet and mobile phones is changing the way infectious diseases are reported and how surveillance is conducted. Moving towards crowd-sourced infectious disease reporting allows for a wider geographical reach to underserved populations that may encounter outbreaks, which go undetected for a delayed period. While crowdsourcing such data does have limitations, more companies than ever are working on using big data and crowd-sourced data in a reliable way to inform the world about the presence of infectious diseases.

Data, Evidence and Strengthening Humanitarian Response

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

World Humanitarian Day on August 19th marks an opportunity to reflect on the current status of the global humanitarian system. Its workforce, resources and budgets have been pushed further than ever before in the face of increasingly complex and protracted crises. Health partners are currently responding to sustained crises in 32 countries, with the total number of people targeted to receive assistance reaching 74.9 million as of March 2015 (WHO, 2015 (i)). The scope of humanitarian response is therefore obligated to expand and adapt in response to its high-volume demand. Increasingly this means agencies need to include not only emergency relief, but also long-term capacity building and development support into their mandates (SOHS,2015). The nature of humanitarian response is in transition; it is no longer a “stop-gap” between crisis and recovery, but now also forms a significant part of crisis prevention and resistance in disaster-prone settings (OCHA,2015). The system now also involves a multitude of actors, including NGOs-international, local and regional, supranational agencies and even private sector partners. Unsurprisingly, this means the humanitarian system today requires more meaningful collaboration between its various partners which will depend on defining leadership, identifying accountability and ensuring quality.

An evidence-based culture

One of the ways in which these necessary improvements to the system could be achieved is to address its information-base. Information, evidence and data both used by and reported from the humanitarian system should be assessed for its gaps and inadequacies, enabling the system actors to understand the breadth and nature of the crisis they are responding to (Thieren, 2005). Evidence seems an ambiguous and uninspiring concept, one which does not comfortably fit with the misleadingly gung-ho image of the humanitarian sector and its workforce. Despite this, there seems to be an encouraging shift in mind-set within the system; there is a growing appetite for more academically-driven crisis responses which rely on a culture of evidence (Bantavala, 2000). Instead of ad-hoc policies based on individual NGO mandates and values, there is the desire to see a more co-ordinated approach to, particularly, health assistance which relies on useful information collected in a scientific manner, as for any field of study (Robertson, 2002). The effect of not providing good-quality, robust and accurate data is that aid policies, interventions and practices are left unevaluated. The danger here is that this leads to poor representation (often with underestimation) of the extent and nature of population need, and therefore uncertainty about how to provide assistance (Toole, 2001). Even more worrying is that “poor information on a problem is often interpreted to mean that a problem is unimportant” (Murray, 1996). Lacking credible evidence therefore creates a vulnerability for the humanitarian system when it needs to advocate on behalf of in-need populations for support from often unwilling or budget-bound governments and supranational agencies.

Introducing evidence into the humanitarian system

The concept of building an information-base of evidence procured by programme and intervention evaluation is not novel to the humanitarian system. The Joint Evaluation of Emergency Assistance to Rwanda (JEEAR) established in the aftermath of the 1994 genocide was the first system-wide, multinational, multi-donor evaluation, setting a precedent for recognising accountability in humanitarian assistance, largely by incorporating better information management and dissemination (Eriksson, 1996). In much the same way, the SPHERE Guidelines were also developed in answer to the failure of the humanitarian system to adequately respond to this same crisis (Buchanan-Smith, 2003). These guidelines were used to set out key concepts of quality control and ‘core humanitarian standards’ to reign in non-uniformity which leads to discrepancies in intervention performance and effectiveness. However this uniform “best practice” approach has been fiercely criticised by leading agencies such as Doctors without Borders (MSF) who lambasted the SPHERE protocols for discouraging contextualisation, creativity and flexibility (Orbinski,1998). Other initiatives such as ReliefWeb have also attempted to contribute to a growing information-base by creating a publically-available database system which allows individual agencies to report their programmes and outcomes. This and similar efforts however have been limited by a lack of responsible participation and resistance of academics to report findings before submitting for journal publication (Mills,2005). Nevertheless, certain systems exist which have been widely used that aim to provide data and evidence in emergency and crisis settings which should be acknowledged here, furthering the argument that an information-base is critical to the strengthening of the humanitarian response.

The information-base: EWARN and Health Information Systems

EWARN

The EWARN is a surveillance system which collects information on epidemic-prone diseases, using data analysis and statistics to initiate prompt public health responses. The subsequent statistical picture is disseminated to appropriate agencies to set about prioritising and planning interventions (WHO 2015 (ii)).  The EWARN has shown promise in South Sudan where the multi-partner style of data collection and management (using the WHO as a lead agency) means reporting to a central system creates a more timely and efficient response. In 2002 this was used during a suspected viral haemorrhagic fever outbreak and successfully side-stepped disaster (WHO, 2002). Also in countries such as Iraq, the EWARN functions well where the leading agency work closely with the domestic Ministry of Health to optimise the existing surveillance systems and incorporate them into the larger, more co-ordinated picture. This however means that i) an agency has to have the will and necessary legitimacy to take on leadership responsibilities and ii) the crisis in itself needs to be recognised internationally in order to attract actors with sufficient skills and resources to respond to the collected evidence. Further obstacles occur in particularly complex crises such as in Syria, where domestic surveillance systems are disrupted and the reach and physical capabilities of humanitarian agencies in the field is limited (Mala, 2014). Yet along with its various implementations issues, the EWARN in itself lacks the breadth that may be required of an evidence-collecting system within complex emergencies or long-term crisis support, where epidemic control is not the main, or even primary objective.

Health Information Systems (HIS)

Many large humanitarian agencies have created internal methods of building an evidence-base to guide planning which collect health data in a more integrated manner than the emergency-specific EWARN. The Health Information System (HIS) as a concept is not specific to the humanitarian system. An HIS aims to provide good quality data and its subsequent analysis and dissemination about the health sector, allowing evidence to directly underpin decision-making (WHO, 2008). The UNHCR is a particularly prudent example of an aid agency which has adopted and adapted the HIS for the crisis setting-with relative success. The UNHCR HIS operates on a large scale, collecting data from over 90 camps in over 20 countries (personal research of the UNHCR HIS Twine Application) and providing monthly reports on the status of various essential health indicators. Figure 1 shows the June 2013 report from Gasorwe refugee camp in Burundi. As is shown, the health indicators are compared between camp and national populations which is an essential comparison to make as it allows population-specific intervention. This disaggregation in populations is even more necessary given that protracted crises often see emergency-phase camps become long-term settlements where the health needs of the refugee and host populations overlap (Feldman, 2007)

The UNHCR HIS however has a number of failures, most notably that it only exists within post-emergency camps which by definition are stable and therefore health status is generally better than newer camps. Also, only those who are registered with the UNHCR are included in statistics and therefore the most vulnerable groups of refugees, particularly internally displaced persons (IDPs) are not included in statistics, leading to misrepresentation of the scale of the problem and increases the likelihood of ignoring a significant amount of human need. In essence, the HIS can provide an excellent framework for the health indicator-based, disaggregated information-base that humanitarian agencies should attempt to create on a system-wide basis. Yet, creative collaboration is required to ensure that high quality data and evidence can be collected from all contexts, in a standardised way that allows inter-agency data exchange and collective responses.

To put it simply, the EWARN and HIS are used here to illustrate that the humanitarian system has already acknowledged the need to use evidence to monitor population need and thus plan response, although efforts are currently inadequate. What is now required is a system-wide, scientific evaluation of the use of evidence as a guide for action in crisis and disaster settings, in order to legitimise humanitarian work on a global scale and safeguard it from opposing forces.

Concluding thoughts: deciding on outcomes

Optimising and prioritising evidence with the aim to strengthen the humanitarian system may force us to reflect on what should be considered as end-points. The outlook that governs public health initiatives can arguably be too consequentialist; they are based on success rates, outcomes and units of ‘effect’ (Robertson, 2002). It could be argued that humanitarianism by its very definition should adhere to a more human-rights based approach that focuses on duty and responsibility. With the increasing burden of human need, the humanitarian system must decide how it will approach new contexts, persisting barriers and emerging challenges such as climate change and the urbanisation of displacement with appropriate credibility and inter-agency consistency that can deliver powerful, effective humanitarian action.

References:

Banatavala,N and Zwi,A (2000) Conflict and health Public health and humanitarian interventions: developing the evidence base, BMJ, 321:101–5.

Buchanan-Smith, M. (2003). How the Sphere Project Came into Being: A case study of policy-making in the humanitarian aid sector and the relative influence of research. Overseas Development Institute.

Eriksson J (1996) The International Response to Conflict and Genocide; Lessons from Rwanda, Synthesis Report; Joint Evaluation of Emergency Assistance to Rwanda.

Feldman S (2007) Development assisted integration: a viable alternative to long-term residence in refugee camps? The Fletcher Journal of Human Security, Vol 22:49-68.

Mala P and Ghada M et al (2014) Establishment of the EWARN system for the Syrian crisis: experience and challenges, 16th International Congress on Infectious Diseases: Infectious Disease Surveillance Abstract No.53042; Cape Town, South Africa.

Mills J (2005) Sharing evidence on humanitarian relief, BMJ, 331:1485.

Murray,C and Lopez,A et al (1996) Evidence-based health policy-lessons from the Global Burden of Disease study, Science, 274(5288), p.740.

OCHA (UN Office for the Co-ordination of Humanitarian Affairs) (2015) OCHA in 2014 &2015 Plan and Budget [Online] Available at: https://docs.unocha.org/sites/dms/Documents/OCHA%20in%202014-15%20vF%2072%20dpi%20single%20WEB.pdf[Accessed 6 August 2015]

Orbinski J (1998) On the meaning of Sphere standards to states and other humanitarian actors, Lecture delivered December 3 1998; London.

Robertson D, Bedell R et al (2002) What kind of evidence do we need to justify humanitarian aid? The Lancet, 360:330-33.

SOHS (State of the Humanitarian System), State of the Humanitarian System, ALNAP, Progress Report 2015, April 2014 [Online] Available at: http://www.alnap.org/resource/20489.aspx [Accessed 6 August 2015]

Toole MJ, Waldman RJ & Zwi AB (2001) Complex humanitarian emergencies. In:International PublicHealth, Aspen Publishers, Gaithersburg, pp. 439±500.

Thieren, M. (2005). Health information systems in humanitarian emergencies.Bulletin of the World Health Organization, 83(8), 584-589.

WHO (2002) Weekly Epidemiological Record; Early warning response and surveillance network (EWARN):Southern Sudan, 25 January 2002.

WHO (2008) Health Informaiton Systems; WHO Toolkit.

WHO (2015) (I) WHO Humanitarian Response: Summary of health priorities and WHO projects in interagency strategic response plans for humanitarian assistance to protracted emergencies, April 2015 [Online] Available at: http://reliefweb.int/report/world/2015-who-humanitarian-response-summary-health-priorities-and-who-projects-interagency [Accessed 4 August 2015]

WHO (2015) (II) Early warning systems; emergencies preparedness and response [Online] Available at: http://www.who.int/csr/labepidemiology/projects/ewarn/en/ [Accessed 10 August 2015]

Life after Polio: Towards Improving the Situation of Polio Survivors

~Written by Hussain Zandam (Contact: huzandam@gmail.com, twitter: @zandamatique)

A woman paralyzed by polio, Rotary International (2010)

here is a surge of excitement among international development communities and global health partners as the World Health Organization announced that the battle against polio is gradually coming to an end (WHO, 2013). The Global Polio Eradication Initiative (GPEI) has set out a new strategy (Eradication and Endgame Strategic Plan), which hopefully will be the final onslaught that will result in a global certificate eradication of the disease by 2018 (GPEI, 2013). The eradication will be a significant victory for the global population, as future generations will also be saved from polio's devastating toll of death, morbidity, and disability.

Map of the world comparing countries with polio cases in 1988 and 2014. Centers for Disease Control and Prevention, CDC (2014).

While a vast amount of resources has been disbursed to prevent polio since 1952, inadequate attention has been devoted to understanding the devastations left behind in the lives and households of polio survivors. The damage is more severe in those permanently disabled by the disease and those recently identified with post-polio syndrome (PPS). Post-polio syndrome is characterized by a renewal or new experience of polio symptoms including disability and functional deterioration after years of recovery and functional stability. PPS usually occurs 30-40 years after original infection and affects about 40% of polio survivors including those who developed permanent disability and those who recover from initial affectation with no or few symptoms (Lin and Lim, 2005). 

Although the situation of polio survivors in high-income countries is relatively well documented, there is a dearth of information in low and middle-income countries. This has profound political, economic and social implications for local, national and international policy-making. While the number of individuals disabled by polio will begin to disappear in the next few decades in the developed world, those in the developing world will continue to be a major concern for at least another generation (Gonzalez et al., 2010). And as the population of younger polio survivors reaches middle and old age, a new wave of individuals with PPS will begin to make additional demands on developing countries’ health systems.

Generally, individuals disabled through polio confront not only a range of physical disabilities but also significant social, financial and human rights barriers hindering integration and participation in families and communities. These barriers in turn, lead to chronic ill-health, social marginalization, limited access to education and employment, and high rates of poverty (Groce et al, 2011). Women are impacted disproportionately, as are individuals from poorer households, minority communities and from rural and urban slum areas (WHO/World Bank, 2011). 

To design effective programs and policies that improve life course outcomes for polio survivors, more research is essential. To begin, more accurate estimates of regional prevalence of polio survivors and the degree of residual disability sustained will be useful for efficient planning and appropriate resource allocation. In particular, addressing the stigma and prejudice encountered by persons disabled by polio must be part of long-term strategies to address the needs of people living with PPS and must be linked to broader efforts to confront disability and stigma faced by all people with disabilities. Ratification by countries of the Convention on the Rights of Persons with Disabilities (CRPD) and progressive national legislation are not enough - inclusion of polio survivors in community awareness campaigns and increased support by DPOs is also needed. And given the disproportionate impact of polio on women, DPOs must pay particular attention to gender sensitive research.

References:

Global Polio Eradication Initiative, 2013. Polio Eradication and Endgame Strategic Plan: 2013e2018.

Groce, N., Kett, M., Lang, R., Trani, J.F., 2011. Disability and poverty: the need for a more nuanced understanding of implications for development policy and practice. Third World Quarterly 32 (8), 1493e1513.

Gonzalez, H., Olsson, T., Borg, K., 2010. Management of postpolio syndrome. The Lancet Neurology 9 (6), 634e642.

Lin, K.H., Lim, Y.W., 2005. Post-poliomyelitis syndrome: case report and review of the literature. Annals-academy of MEDICINE SINGAPORE 34 (7), 447

WHO, 2013. Poliomyelitis. Fact Sheet No. 114. WHO, Geneva. http://www.who.int/ mediacentre/factsheets/fs114/en/index.html (accessed 11.08.15.).

WHO/World Bank, 2011. World Report on Disability. WHO, Geneva. http://www. who.int/disabilities/world_report/2011/en/index.html (accessed 12.08.15.).

Lessons, Impact, and the 'Fearonomics' of the Ebola Outbreak in Nigeria

~Written by Sulzhan Bali, PhD (Contact: sulzhan.bali@twigh.org) 

Also published on the DGHI Diaries From the Field Blog

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Passport Sticker with Ebola Symptoms and National Helpline. Photo Credit: Sulzhan Bali, PhD

24th of July.

The day Macchu Picchu was discovered in 1911.

The day Apollo XI returned to the Earth after the first successful mission of taking humans to the moon in 1969. 

Yet, in Nigeria, that day in 2014 will always be marked as the day Patrick Sawyer—the index patient of Ebola—died and set an outbreak in motion in one of the most populated cities in Africa. Patrick Sawyer was a Liberian-American citizen and a diplomat who violated his Ebola quarantine to travel to Nigeria for an ECOWAS convention. His collapse at the airport, coupled with an ongoing strike by Nigerian doctors in public hospitals, landed him at a private hospital in Obalende, where he infected eight other people. 

Patrick Sawyer’s death marked the beginning of an Ebola epidemic in Lagos, a city of 21 million. Lagos is a major economic hub in Africa and one of its biggest cities. An uncontrolled Ebola epidemic would have a far-reaching economic impact beyond the borders of the city, its country, and even its continent.

A recent study has shown that Ebola virus remains active in a dead body for more than a week. Add to this that the body is most infectious in the hours before death, and it is a "virus bomb" waiting to happen if handled incorrectly. West Africa, especially Nigeria, has a strong funeral culture. This Ebola-infected Liberian diplomat’s body was transported and incinerated in accordance with the WHO and CDC protocol. This feat was achieved despite immense political and diplomatic pressure to return the body for funeral rites. It represents one of the many cases of collaboration and "clinical system governance" that are at the heart of the successful containment of Ebola in Nigeria. It is one of the many stories that I'm hoping to highlight in my research on the role of the private sector in Nigeria’s successful Ebola containment.

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One of Many Ebola Information Posters Around Lagos. Photo Credit: Sulzhan Bali, PhD

As part of my research, I am looking at 10 different economic sectors to understand how the Ebola outbreak impacted the private sector and how the private sector dealt with the challenges that the Ebola outbreak posed. My hope is that this research will lead to lessons for the private sector on how, in times of an epidemic, they can help the government to mitigate the disease’s economic impact. I also hope that the resulting report will help governments engage with the private sector more effectively in times of emergencies.

With many outbreaks, especially of highly fatal diseases such as Ebola, fear is the biggest demon. This fear has led to the crippling of economies of Ebola-affected countries. This fear has cost Sierra Leone, Guinea, and Liberia 12 % of their GDP in foregone income and unraveled the years of progress made by these countries. However, this fear is not just a phenomenon limited to West Africa. I had a very personal encounter with this fear recently, when I was quarantined for a few hours in the United States (despite Nigeria being declared Ebola free since October 2014). 

It has been a humbling experience so far, as I try to understand how this fear and the hysteria around Ebola can lead to significant behavioral changes—some of them necessary but some extreme. Everyone I speak to has a story to share. Some people tell of how they bought more than two bus tickets to prevent sitting next to other people. Others tell of hospitals resembling "ghost buildings" as people avoided hospitals and doctors like the plague. Many tell of the "Ebola elbow-shake" that replaced the usual handshake or hug. The reality is that although the Ebola outbreak infected 21 people in Nigeria, it actually affected the lives of 21 million people in Lagos alone, in one way or another. I have come to realize that there is a thin line between precaution and hysteria. Maintaining the equilibrium between the two is the key to controlling the disease and mitigating its economic impact.

As I wrap up my interviews, a few questions resonate with me time and time again from these sessions.

“Are we prepared for the next time?” 

“Ebola is back in Liberia. What can we do to prevent Ebola from coming back to Nigeria?” 

 For the doctors who died in Nigeria’s fight against Ebola:

“Can we truly say our country is a safer place after their sacrifice?” 

And for myself:

“How will your report help Nigeria?”

These are the questions that keep me going. Although my report may not be able to answer all of the aforementioned questions, I do hope it will at least get policy makers, students, and advocacy groups talking about how countries can be better prepared for the next big outbreak and how public-private collaboration can lead a country out of an epidemic and on a path of recovery.

To end on a positive note, 24th July, 2015 also marked one year since the last polio case in Nigeria—an achievement that clearly shows what collaboration in global health can achieve.

(To learn more about my research or to contribute/collaborate in my study, please contact me.)

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.

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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.