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. 

Health in All Policies: A Review of the 2015 American Public Health Association (APHA) Annual Meeting

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

The 143rd American Public Health Association (APHA) annual meeting was held in Chicago, IL from October 31 to November 4, 2015. The theme for this year’s annual meeting, “Health in All Policies”, focused on the impact of where someone lives, works, learns and plays on their ability to live a healthy life. Focusing on creating policies to address community issues ensures a long-lasting implementation of community improvements. There were a wide variety of sessions; some directly related to the theme and others which were less clearly aligned. In the following paragraphs, I provide some of my impressions of the meeting and highlight a few sessions I attended which really got me thinking about global health.

On Saturday Oct. 30, I attended the APHA Global Health Learning Institute. This half-day session focused solely on how students and young professionals can break into the global health field. The institute was run by representatives from Chemonics International and the Global Health Fellows Program (GHFP) II within the Public Health Institute. One highlight was the results of a survey, done by GHFP II, of global health employers to determine what they perceive as areas where applicants are lacking in skills. Most (85%) of the employers surveyed felt that academia could do a better job preparing students for the real-world by providing more non-clinical skill building in the areas of program management, strategy and project management, communication with stakeholders, and collaboration and teamwork. Employers perceived gaps in understanding the context and reality of global health work, flexibility and adaptability of applicants, cultural sensitivity, cross-cultural communication, and knowledge of how the key players and systems work in a global health capacity. What I took away from this session was the importance of adjusting one’s resume to demonstrate skills in the areas that global health employers think most applicants are lacking.

On Sunday I attended the Opening Session where the US Surgeon General Dr. Vivek Murthy spoke about three elements that are central to our work as public health leaders: information, inspiration, and equality. With these three elements Dr. Murthy believes that we can achieve our public health goals. Actor Ed Begely spoke briefly about the importance of climate change and how if everyone does small feasible things each day it can have a large collective impact. The keynote speaker of the opening session was Dr. Freeman Hrabowski from the University of Maryland – Baltimore County. Dr. Hrabowski spoke animatedly about public health and the importance of education. In the last few minutes of his talk, he stated that we should all watch our thoughts, for our thoughts become our words; watch our words because they become our actions; watch our actions because they become our habits; watch our habits because they become our character, andwatch our character because it becomes our destiny, dreams and values.

I attended many International Health section-sponsored sessions while at APHA. Several presentations really made me think about how we can and must do better in global health. Many groups around the world are making a significant impact in global health including the implementation of a mobile app to help maternal and child health community health workers in India, promoting communities to take greater control of their healthcare service delivery, determining the true prevalence of malaria versus other febrile illnesses which are often mistaken for malaria, and having a greater respect for established traditions in communities that require assistance from global health workers such as in the West African Ebola response. Attending international health sessions as APHA always inspires me to continue to learn about the vast field of global health and to continue to remain aware of all of the great work going on around the world.

That is my challenge to you, do not remain complacent in your job or life; continue to learn and grow, personally and professionally, as the field of global health continues to learn and grow.

How to Kickstart Your Career in Global Health with Mentorship

~Written by Suvi Ristolainen, RN, MPH

In our interconnected world, online communication and globalization offer increasing opportunities to meet new acquaintances from different corners of the Globe, yet the right channels to finding a dream job and like-minded colleagues is not always simple.

The global health field is constantly evolving and for many, this offers fascinating opportunities to move from one creative intervention to another interesting project. For others it is an ocean where navigation feels overwhelming, especially when there is uncertainty about one’s strengths and interests.

So then, what is the trick to sailing smoothly to the harbor of your dream job when beginning your career? The problem is that there is no perfect straight route. In addition to career advisors, YouTube videos, and job articles for young professionals, one influential compass could be a mentor. Mentors can play an essential role at the beginning of one’s career, especially one who is willing to give back to the global health community and is eager to hear fresh ideas from young minds.

In the Global Health Mentorships (GHMe) program, we are a group of global health-minded professionals with a vision to connect students and young professionals (SYPs) with the experts in their field. The aim of the GHMe program is to provide career guidance and boost leadership and networking skills in global health for small groups with similar interests.

We asked one of our initiators Camila Gonzales Beiras, PhD (from Global Health Next Generation Network) to reflect on the newly launched GHMe programme on why mentorship is important:

“Everyone needs a role model or mentor in all aspects of our life, but when it comes to our professional life, having someone to guide us at the start can make all the difference. In the world where global health is extremely multi-disciplinary and we are the first generation of ‘global health professionals’ with specialized degrees on this subject, yet there is no such thing as [a] ‘global health job’. This is the most multi-disciplinary area: every background can be redirected to health which means there is no defined or a [sic] written way to do things, which is why having a mentor in this field is so important for the new generation of global health professionals.”

When asked what is unique in this new mentorship project, she elaborated:

“Certainly the unique aspect is the new approach of ‘mentor groups’ instead of the traditional one-on-one mentor-student relationship. As global health professionals, we have to be ready to work in multidisciplinary groups to solve complex health issues. Learning how to work with professionals from completely different backgrounds is the key to creating long-lasting solutions in global health.”

Already on the first pilot program, which was launched in August 2015, GHMe has participants from 5 continents and across more than 22 countries. Each of our 28 mentors forms a group with 3-4 of our 83 SYPs. The GHMe program is run through the Global Health Next Generation Network (GHNGN) and the Swedish Network in International Health (SNIH). In GHMe, the mentoring groups have monthly gatherings with different themes and activities, such as global health career building and communication skills. The program uses different platforms for online communication between members, such as our own website, Twitter, and LinkedIn.

If you wish to join our next mentorship cycle (2016) and get updates, please sign up for our newsletter online at our website and follow us on Twitter @GHMentorships.

Review of Unite for Site Global Health and Innovation Conference 2015

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

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

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

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

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

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

Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.

References:

http://www.cdc.gov/polio/updates/

https://news.vice.com/article/afghanistan-confirms-new-polio-cases-as-pakistans-outbreak-reaches-grim-milestone

http://www.theguardian.com/society/2014/sep/07/us-nearly-600-measles-cases-this-year-cdc

http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/

http://www.polioeradication.org/

http://www.washingtonpost.com/blogs/worldviews/wp/2012/10/17/taliban-polio-vaccines/

http://www.bbc.com/news/world-asia-26121732

http://www.npr.org/blogs/goatsandsoda/2014/07/28/330767266/taliban-in-pakistan-derails-world-polio-eradication

Capacity Building to Address Global Health Challenges

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

Increasingly the world is challenged with complex health problems. Developing a competent health promotion workforce is essential to addressing the related inequities and global health challenges.

Global health issues provide both a challenge and an opportunity for a competent health promotion workforce to work across cultures and settings with an international perspective.  An approach requiring an understanding of the determinants of health and the vital role health promotion has in achieving sustainable health gains.

At times health promotion has been challenged by the belief that anyone can undertake health promotion. This is partly the result of its strategy to promote its principles across the community making it everyone’s business. However health promotion is increasingly acknowledged as a discipline with specific knowledge, skills and distinct approaches that challenges such beliefs. 

Health promotion competencies have been developed as a capacity building tool that has successfully defined the knowledge and practice for effective health promotion, ensuring that health promotion principles, values and philosophy are reflected.

There are a number of international health promotion competencies frameworks that can be used to:

• Guide planning, implementation and evaluation of initiatives
• Provide the base for accountable practice and quality improvement
• Inform education, training and qualification frameworks
• Clarify health promotion roles and develop relevant job descriptions
• Improve recognition and validation of health promotion
•   Further reading and examples of some health promotion competency frameworks:

References:

http://www.iuhpe.org/images/PROJECTS/ACCREDITATION/CompHP_Project_Handbooks.pdf

http://www.hauora.co.nz/assets/files/Health%20Promotion%20Competencies%20%20Final.pdf

http://www.healthpromotion.org.au/images/stories/pdf/core%20competencies%20for%20hp%20practitioners.pdf

http://www.healthpromotercanada.com/competencies-development/

Empowerment is Key to Improving Health Infrastructure in Developing Countries

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Providing greater health access and more efficient health care delivery, especially for vulnerable populations, are priorities for anyone involved in public health. Poor health systems in developing countries mean a shortage of trained health care workers, inconsistent inventory of medical supplies, and inadequate surveillance systems. This list is not exhaustive, but we can start here. Building a better health infrastructure, like many public health priorities, requires multi-level coordination. Empowerment has to spread out from the government to the community and to the individual.

We can address the problem first by tackling the shortage of health care workers. Doctors in developing countries are in critically short supply. In 2006, the World Health Organization compiled data on the impact of HIV/AIDS on the health workforce in developing countries. Results showed that while European and North American countries have doctors at a ratio of 160 to 560 per 100,000 people, African countries only have two to sixty doctors for every 100,000. In Malawi, for example, there is one doctor for every 50,000 people. The global shortage of trained hospital and health care staff currently exceeds four million. Training more staff and volunteers is one solution for improving health systems in developing countries. Training other previously unqualified individuals could ameliorate these shortages. Providing incentives for already trained workers to stay in a vulnerable state or country could help build a struggling health system. Having a foundation of trained workers and preventing them from migrating to wealthier countries is an important first step. Empowerment and opportunities to grow and help are at the heart of this strategy.

The second hurdle is maintaining a constant inventory of equipment, medicines, and other health supplies. War, along with political and social unrest, in certain regions further dampens the efforts to provide a steady supply chain. There has to be cooperation between donors and the government to work with the private sector to ensure receipt of necessary health supplies. Partnering with emerging pharmacy chains increases the availability of medicines and drives down the cost for the patients. In the Philippines, Generics Pharmacy has thousands of small storefronts that are widely used by both the rich and poor. Convenience and ease of access are often of paramount interest to every person, regardless of income. The issue of payment is another facet of the supply and demand problem. Corruption that trickles to the local governments, and even the health care workers themselves, leads to some patients having to pay for medicine or services that should have been free. Reforming payment systems to ensure that patients have the medicines delivered before payment is processed directly to the provider will empower the patients and promote compliance. 

Compounding the shortage problems, both of trained workers and supplies, are the inadequate surveillance systems in place. This is the third issue that needs to be addressed, and it is arguably the most crucial. Surveillance is necessary to monitor not only the needs within health facilities, but also within the community and surrounding areas. Without real-time tracking of disease and medical supplies, logisticians, doctors and community health workers are unable to properly estimate need and completely evaluate the effectiveness of their clinic’s efforts. This is where data comes into play. The Novartis Malaria Initiative, under the Roll Back Malaria Partnership, has led SMS for Life, which harnesses mobile phones, internet, and electronic mapping technology to track stock levels for health facilities. Sending SMS messages between health facilities and the district medical officers ensures treatment availability. Stock-outs have been reduced in Tanzania during a six-month pilot program from 79% to 26% in three districts. Not only are these stock-outs reduced, but when they occur, they are also resolved much quicker due to the ease of communication. In areas where internet is unavailable or running inconsistently, Relief Watch has offered a similar solution. It also uses mobile technology, but the application allows workers to not only track supplies but also disease (http://www.reliefwatch.com/). The easy and free setup is invaluable to developing countries that have previously relied on paper spreadsheets and forms. Giving workers data at their fingertips gives them more control over their health facility and their patients. These technological innovations are not only crucial for immediate supply tracking and disease surveillance, but they provide research institutions and governing bodies more accurate data. After all, it is data that public health professionals and policy-makers rely on to make decisions and plan strategies. 

The aforementioned plan to improve health systems is by no means novel. Public health practitioners have stressed the importance of training more workers, creating a steady supply chain of treatments, and addressing surveillance shortcomings for decades. Adhering to these solutions requires cooperation and active coordination that extend from the public to the private sector. This is something that cannot be over-emphasized. Empowerment—of individuals, community health workers, and governing bodies of fragile states—is an important foundation from which a better health infrastructure can grow.


Resources:

The impact of HIV/AIDS on the health workforce in developing countries http://www.who.int/hrh/documents/Impact_of_HIV.pdf
Healthcare logistics: delivering medicines to where they're needed most
http://www.theguardian.com/global-development-professionals-network/2013/jul/29/healthcare-logistics-best-practice
SMS for Life http://www.malaria.novartis.com/innovation/sms-for-life/
Relief Watch http://www.reliefwatch.com/
Avert: Universal access to HIV treatment http://www.avert.org/universal-access-hiv-treatment.htm

Values and Global Health Governance: Lessons from the Ebola 2014 Outbreak

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Values are critical in shaping the global health (GH) dialogue and landscape. Values and the actions that arise from them (virtues) underlie the policies that ensure universal access to necessary health services, adequate responses to health emergencies and resource allocation. Similarly, the values of health governing bodies can create chasms between people and their health necessities. This truth has been unfolding poignantly on an international level during the handling of the Ebola virus disease (EVD) outbreak in West Africa. 
 

What values did the actions or inaction of the international GH community endorse in handling the current EVD outbreak? Although the uniqueness of the outbreak in terms of location and challenges in diagnosis should be considered, many experts agree that the greatest force contributing to the rapid spread of EVD was inaction (1-4). In June 2014, signs that EVD was spiraling out of control throughout Guinea were flashing brightly but the response from the international community remained slow. The exception was Doctors without Borders (MSF), whose staff was already on the ground, helped to diagnose the first case and pleaded for a more robust response from international health governing bodies (3). 
 

Criticisms of health regulatory bodies grew stronger when EVD entered rich countries, which appeared to produce a marked increase in global support efforts. It is hard to say unequivocally, whether this heightened interest and commitment was inevitable or whether the cases in the US and Europe were the impetus. But it is fair to say that many mistakes were made in terms of prioritizing EVD eradication and surveillance. It may also be accurate to say that major economies responded when EVD was perceived as an immediate threat to their economy. This, I believe, is inevitable in a GH system that is built upon a market-driven approach.
 

Can a GH agenda that is framed around economics prioritize the eradication of emerging diseases and neglected diseases of poverty? Although there are compelling arguments for why high-income countries should help to combat EVD and similar diseases, it is unlikely that great achievements will be made without a values shift (5). 
 

A market driven approach inherently prioritizes the need of a few versus the need of many. This model enables the interests of major economies to outweigh the greater good of the whole, if left unchecked. The most important consequence of this approach is that it undermines international health regulatory bodies, whose actions and budgets are heavily influenced by larger economies. This is a problem which, when combined with poor health systems, harmful microbes and permeable borders will inevitably lead to threats in local communities and global security. More importantly, with the movement of people forming a major characteristic of this era, the market driven approach is an unsustainable value upon which to build GH interventions. 
 

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There are many points worth considering (schematic above). Major questions moving forward should consider creating a GH model that is more oriented toward equity, security and creativity. Resolutions that create a space in which poor nation states help to set the GH agenda without being threatened by the loss of aid from larger economies must be discussed. Additionally, addressing ways in which the GH dialogue can be re-framed to include stakeholders that currently operate based on virtues stated above should be considered. For example, is there a way to ensure a more official decision-making role for organizations like MSF?

What is next for GH governance and what will the values shift towards? EVD 2014 is a strong indicator of the limits of theoretical values, political indifference and passivity in achieving health and well-being for all. But the stories emerging from West Africa provide an opportunity for EVD 2014 to serve as a “meaning making” event in GH. It provides an impetus for changing priorities from passive verbiage of values of human dignity to a model of creativity, equity and accountability which proactively contextualizes GH policies, innovation and interventions. 

References
1. Gostin LO and Friedman EA 2014 Ebola: a crisis in global health leadership. The Lancet, 384; 1323-1324. 
2. Cohen J 2014.Ebola vaccine: Little and late. Science, 345 (6203): 1441-1442. 
3. Ebola: Massive Deployment Needed to Fight Epidemic in West Africa: http://www.doctorswithoutborders.org/news-stories/press-release/ebola-massive-deployment-needed-fight-epidemic-west-africa
4. Farrar JJ and Piot P 2014. The Ebola Emergency-Immediate Action, Ongoing Strategy N. Engl J Med 371(16):1545-1546.
5. Rid, A., & Emanuel, E. J. (2014). Why Should High-Income Countries Help Combat Ebola? JAMA, 312(13), 1297-1298.

Global Health and Post-2015 Agenda: Making a Case for Vulnerable Populations

~Written by Hussain Zandam, Health Systems and Policy Researcher (Contact: huzandam@gmail.com) 

The health-related Millennium Development Goals (MDGs) has made relative progress in improving access to essential healthcare. The next step, as suggested by many professionals in the development arena, is to consolidate on the gains and address the existing wide gap in quality healthcare among populations, especially in LMICs.  This can be tackled by addressing the challenges faced by a range of vulnerable populations. Vulnerable groups are defined as social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality. The group is represented by different categories of people including; women, children, elderly people, ethnic minorities, displaced people, people suffering from illnesses, people with disabilities and others. Together, these groups makes up a very significant population. For example, according to World Bank’s report on disability, PWDs makes up about 20% of world population equivalent to over billion people.

There is ample evidence confirming that access to effective health care is a major problem in the developing world. Many millions of people suffer and die from conditions for which there exist effective interventions. Vulnerable populations make up majority of these people. While some challenges are similar across different vulnerable people, others are specific to a particular vulnerable group. Selected factors to categorize groups should reflect specific subgroups of the population - such as poor rural women, or members of an ethnic minority - that require particular awareness due to their underlying social characteristics, which afford them less opportunity to be healthy than their more privileged counterparts. As a group, they also tend to be the least healthy and most probably have the most to benefit from health care. The fact that those most in need make least use of health care is widely considered inequitable.

Insufficient resources, inappropriate allocation, and inadequate quality are major impediments to the delivery of effective health care that reaches this group. The access problem cannot be solved without tackling each of these deficiencies. Even with limited resources, services should aim for equity, emphasizing the individual and their dignity rather than their merits, economic circumstances or ethnicity. Equitable access has been defined as ‘‘care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographical location and socio-economic status.  Adequate access is also linked to timeliness and the quality of services.

According to Organization for Economic Cooperation and Development/World Health Organization (OECD/WHO) DAC guidelines, the development of equitable financing through increasing pre-payment and risk pooling is one of four priorities for the development of a pro- poor health system delivering quality, accessible health services to the poor. The extension of health insurance cover is a long-term goal. At low levels of development, a more feasible policy is to maintain reliance on out-of-pocket payments but to grant exemptions to groups, principally the poor, for which price is a major deterrent to use. Policy initiatives can accelerate the process, however it is important for health policies to include not only commitments to core concepts of human rights ‘for all’, but also whether for vulnerable groups in a way which takes account of their ‘vulnerabilities’.

A general strategy can be defined at the global level, while policy measures should be heterogeneous, varying with the local conditions in which they are implemented. Finally, as nations and the entire world accept more and more responsibility for the health of human beings, the discussion on ‘‘universal health coverage’’ as the successor to health-related millennium development goals, global health should have a strong focus on the health of the poor and vulnerable.