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. 

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

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

Also published on Global Contagions

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

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

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

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

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

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

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

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

Vulnerability of Urban Populations to Ambient Air Pollution

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

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Dannenberg et al. 2011

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

Also published on VaxTrac blog

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

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

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

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

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


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

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

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

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

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

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

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

We found key insights:

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

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

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

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Callback List. Source: VaxTract

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

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VaxTrac staff training health workers. Source: VaxTrac

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

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

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

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

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

________________________________________
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.

Health Promotion: An Effective Approach to Achieve the Sustainable Development Goals

~Written by Karen Hicks, Senior Health Promotion Strategist & Lecturer, New Zealand (Contact: karen_ahicks@hotmail.com)

In September 2015 the United Nations adopted seventeen sustainable development goals (SDGs) (Figure 1) as part of the 2030 Agenda for Sustainable Development; which aims to end poverty, fight inequality, injustice, and tackle climate change. These SDGs are acknowledged as going beyond the previous Millennium Development Goals (MDGs) as they aim to address, ‘The root cause of poverty and a universal need for development that will work for all people’ (United Nations, 2015).

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Figure 1. Sustainable Development Goals. Source: http://wfto.com/sites/default/files/field/image/2015-07-21-SDGs.png

Each of the SDGs relate to health and wellbeing with aims, approaches and principles that are concomitant to the discipline of health promotion; a discipline that acknowledges the complexity of health and is based on the principles of human rights, equity and empowerment (Williams, 2011). Consequently, such principles imply that health promotion is an effective approach toward achieving the SDGs. This approach is supported by the global framework and described in “The Ottawa Charter for Health Promotion” (WHO, 1986) (Figure 2) which identifies five key action areas: building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills and reorientating health services through advocacy, enabling mediation for effective practice.

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Figure 2. The Ottawa Charter for Health Promotion Logo. Source: http://www.who.int/healthpromotion/conferences/previous/en/hpr_logo.jpg 

An example of a collaborative initiative that illustrates health promotion as defined in the Ottawa Charter is the International Network of Health Promoting Hospitals & Health Services (HPH). The initiative works to reorient health care towards an active promotion of health for patients, staff, and communities. Further detail on the approach can be accessed on the HPH website.  

The principles and actions illustrated alongside the interdisciplinary approach of health promotion that empowers people and communities (Health Promotion Forum of New Zealand, 2014) and focuses on equity and the broader determinants of health (Davies, 2013) is acknowledged by the World Health Organisation, “Health promotion programmes based on principles of engagement and empowerment offer real benefits. These include: creating better conditions for health, improving health literacy, supporting independent living and making the healthier choice the easier choice” (WHO, 2013 p 16).  The value associated with the approach clarifies how health promotion can effectively contribute to achieving the seventeen SDGs where the SDGs can guide the delivery of effective health promotion to improve health, wellbeing and personal development throughout the global community.

References:

Clinical Health Promotion Centre. The International Network of Health Promoting Hospitals & Services.  http://www.hphnet.org/ Accessed 22/1/2016. Bispebjerg University Hospital Denmark.

Davies, J.K. 2013. Health Promotion: a Unique Discipline? Health Promotion Forum of New Zealand.

Health Promotion Forum of New Zealand. 2014. http://www.hauora.co.nz/defining-health-promotion.html#sthash.5sStc8VF.dpuf.

United Nations. 2015. http://www.un.org/sustainabledevelopment.

Williams, C. 2011. Health promotion, human rights and equity. Keeping up to date. Health Promotion Forum of New Zealand.

World Health Organisation. 1986. The Ottawa Charter for Health Promotion. WHO.

WHO (2013) Health 2020: a European policy framework and strategy for the 21st century Copenhagen, World Health Organisation.

The Environmental Cost that Living in this World Puts on Our Health

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

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Source: Environmental Health, World Health Organization (WHO)

As revolting as it sounds, there are places in the world where the chances of consuming one’s neighbours’ faeces are quite high if one is not vigilant regarding sanitation and hygiene. That being the condition of many areas in low and lower-middle income countries does not mean that high and higher-middle income countries are exempt from any environmental conditions that are harmful to health.

But, what is environment health? The World Health Organization (WHO) defines the term as, “All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours”. It, however, excludes genetics and the social and cultural environment.

In low-income settings, concerns for environmental health may arise in the context of sanitation and hygiene, as well as indoor and outdoor pollution. In high-income countries, many chronic diseases like diabetes and cardiovascular disease, are associated with sedentary lifestyles. While these might be attributed to behaviour, one must consider that such behaviours can arise from changes in the environment. Over 80% of communicable and non-communicable diseases can be attributed to environmental hazards.  Overall, conservative estimates indicate that about one quarter of the total global burden of disease is owing to this cause (WHO, 2011). Furthermore, the biggest killers of children under 5 years are all environmental-related diseases, including diarrhoea, respiratory infections, and malaria.

Other diseases of concern are helminthic infections, trachoma (a bacterial eye infection), Chagas disease, leishmaniosis, onchocerciasis, and dengue fever. All of which are associated with impoverished conditions and can be mitigated by improving sanitation, hygiene, and housing. Although conflicts and natural disasters might be catastrophic for any country, struggling economies tend to suffer more because disasters worsen the poor conditions which directly affect sanitation and hygiene practices, creating conducive conditions for various infectious diseases, and ultimately feeding into the vicious cycle of poverty.

Many interventions are underway to address these conditions, including Water, Sanitation and Hygiene (WASH) initiatives, Integrated Vector Management, Programme on Household Air Pollution, International Programme on Chemical Safety, Health and Environment Linkages Initiative, and Intersun Programme for the effects of UV radiation. The acknowledgement of the effects of the environment has grown. One of the Millennium Development Goals (MDGs) was, “To ensure environmental sustainability.” The Sustainable Development Goals (SDGs) are more extensive and thorough in placing focus on the environment. Goal 1 is to end poverty, goal 6 is to make provision of clean water and sanitation possible, and goal 13 is to stop climatic change resulting in floods and drought (United Nations, 2014).

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The Sustainable Development Goals. Source: United Nations System Staff College

It is encouraging to see steps being taken to control environmental hazards; however, the journey to measuring and eradicating such conditions still remains a challenge, which will hopefully be overcome through future endeavours.

References:

United Nations (2014). Sustainable Development Goals. doi:10.1017/CBO9781107415324.004

World Health Organization (2011). WHO Public Health & Environment Global Strategy Overview

Recent Therapeutic Advancements in Combating Dengue and Glioma

~Written by Kate Lee, MPH (Contact: kate@recombine.com)

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Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit: European Pharmaceutical Review

Infectious and chronic diseases are some of the top priorities in global health. Abundant funding, both from the government and private sector, is poured into therapeutics research to help decrease morbidity and mortality from both types of diseases. For example, recent news has highlighted two promising therapies with the potential to alleviate the global burden of two diseases: dengue fever, an infectious disease, and glioblastoma, a chronic disease.

After 20 years of research, Sanofi, a French pharmaceutical company, developed Dengvaxia, a vaccine to prevent dengue. Mexico is the first country to approve the vaccine for use in children over the age of nine and adults under the age of 45. A clinical trial last year found the vaccine to have an effectiveness of 60.8% against four strains of the virus[1]. Sanofi bypassed European and US regulations and sought regulatory approval for Dengvaxia in dengue-endemic countries. According to their press release, the vaccine, “will be priced at a fair, affordable, equitable, and sustainable price... and may be distributed for free in certain countries”[2].

Dengue is a febrile viral illness that is spread via the bite of an infected mosquito, and is endemic to tropical and sub-tropical climates. According to the World Health Organization (WHO), about 400 million people globally are infected with the dengue virus each year. Prevention has been limited to effective mosquito control and appropriate medical care[3]. These measures are often either ineffectively implemented, or there are limited, or no available medical resources in the community. Dengvaxia has the potential to reduce the burden of dengue, especially in developing countries that are particularly hard-hit with the disease. Future research could be directed towards making the vaccine more effective in children, as severe forms of dengue are the leading cause of illness and death in children in Asian and Latin American countries[3].

As one tropical virus is being prevented, another virus is being used to combat brain cancer. Researchers at Harvard and Yale have teamed up to use vesicular stomatitis virus (VSV) and Lassa virus, to search for and destroy cancer cells in mice[4]. Lassa is a febrile illness, usually transmitted by rodents, and is endemic to tropical and subtropical regions of the world[5]. VSV has been studied for many years and is generally effective in killing cancer cells; it becomes deadly to the patient when it reaches the brain[4,6]. Interestingly, including Lassa virus appears to make VSV safe for cancer therapy in the brain.

Researchers created a Lassa-VSV chimera, an organism that includes the genetic codes of two different organisms, to target glioma, one of the deadliest forms of brain cancer, which accounts for more than 80% of primary malignant brain tumors[7]. Glioblastoma is the most common form of glioma and is associated with poor survival, making this chimeric treatment a potential life saver for many patients. The next step in the treatment development process is primate research to evaluate safety. This is still a long way from the initiation of human trials, and eventual market, but promising nevertheless, for the millions of people globally who are affected by brain cancer.

Dengvaxia and the Lassa-VSV chimera represent recent advancements in therapeutics with potentially significant global impact for brain cancer and dengue respectively - diseases that affect populations in many nations.

References:

1.     Sanofi's Dengvaxia, World's First Dengue Vaccine, Approved For Use In Mexico. International Business Times. http://www.ibtimes.com/sanofis-dengvaxia-worlds-first-dengue-vaccine-approved-use-mexico-2219515. Published December 10, 2015. Accessed December 20, 2015.

2.     World’s First Dengue Vaccine Approved After 20 Years of Research. Bloomberg Business. http://www.bloomberg.com/news/articles/2015-12-09/world-s-first-dengue-vaccine-approved-after-20-years-of-research. Published December 9, 2015. Accessed December 20, 2015.

3.     Dengue and severe dengue. World Health Organization. http://www.who.int/mediacentre/factsheets/fs117/en/. Updated May 2015. Accessed December 20, 2015.

4.     Using a deadly virus to kill cancer: Scientists experiment with new treatment. The Washington Post. https://www.washingtonpost.com/national/health-science/using-a-deadly-virus-to-kill-cancer-scientists-experiment-with-new-treatment/2015/12/07/7d30bc5a-9785-11e5-8917-653b65c809eb_story.html. Published December 7, 2015. Accessed December 20, 2015.

5.     Lassa fever. World Health Organization. http://www.who.int/mediacentre/factsheets/fs179/en/. Updated March 13, 2015. Accessed December 20, 2015.

6.     Viral Therapy in Treating Patient with Liver Cancer. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01628640. Updated July 2015. Accessed December 20, 2015.

7.     Schwartzbaum J A, Fisher J L, Aldape K D, Wrensch M. Epidemiology and molecular pathology of glioma. Nature Clinical Practice Neurology (2006) 2, 494-503. doi:10.1038/ncpneuro0289

Coups and Contrecoups

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

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Source: Federation Internationale de l'Automobile

Back while I was doing my house job, what most people would call a clinical internship, I worked for six months in the surgical ward of a government hospital in Lahore. Working in the surgical emergency meant witnessing, receiving, and managing patients with surgical injuries, ranging from minor wounds, to firearm injuries (FAI) and road traffic accidents (RTAs) besides other conditions requiring a clinical diagnosis. Indeed studies indicate that most of the cases presented in the emergency department are due to RTAs (Khalid et al., 2015).

Some of the worst cases I remember seeing were RTAs. Most of these patients ended up in neurosurgery as a consequence of head trauma. If one were to take a tour of the neurosurgery ward and go through case files or talk to the attendants, one would discover that most of the cases have a history of RTA. If you were on call and were awakened during the night by women crying, you would speculate that it is probably a life lost on the neurosurgery floor. Patients often stayed in the ward for long periods with an uncertain prognosis.

With urbanization of an exploding population and motorization, the world has also witnessed an increase in RTAs (Atubi, 2012). In Pakistan, the number of motor vehicles on the roads is high and the implementation of traffic rules is low. Road safety is not a prevalent concept and in some places it appears to be completely non-existent. Road injuries rank 9th among the top Disability Adjusted Life Years (DALYs) per 100,000 in Pakistan. Since men are the primary bread-winners, the proportion of male to female casualties is disproportionate; more males suffer disability and death than females (Abdul & Tehreem, 2012). Therefore disability, hospital bills, death and funeral expenses often leave families in bankruptcy.

The situation of road traffic injuries is not very hopeful worldwide either. According to WHO 1.25 million people lose their lives as a result of road injuries and most of these casualties are in low and middle-income countries. Sufficient to say that road traffic injuries are a rather neglected area of global health. Recently there have been efforts to rectify this oversight as RTAs have now been identified as a major cause of death and disability besides communicable and non-communicable diseases. The Sustainable Development Goals (SDGs) presented in September 2015 show an advance towards recognition of the dilemma of RTAs and aims to decrease the number of deaths by 2020 (Cossio et al., 2015). Steps will hopefully be taken towards creating policies that make roads and vehicles safer for people across the world. One can hope that these policies will ultimately rub off in low and middle-income countries where the most lives are lost due to RTAs.

References:

Abdul, M. K., & Tehreem, A. (2012). Causes of Road Accidents in Pakistan. J. Asian Dev. Stud, 1(1), 22–29. Retrieved from ISSN 2304-375X

Atubi, A. (2012). Determinants of Road Traffic Accident Occurrences in Lagos State : Some Lessons for Nigeria. International Journal of Humanities and Social Science, 2(6), 252–259

Cossio, M. L. T., Giesen, L. F., Araya, G., Pérez-Cotapos, M. L. S., VERGARA, R. L., Manca, M., … Héritier, F. (2015). Global Status Report on Road Safety 2015. World Health Organization (Vol. XXXIII). doi:10.1007/s13398-014-0173-7.2

Khalid, S., Bhatti, A. A., & Burhanulhuq. (2015). Audit of surgical emergency at Lahore General Hospital. Journal of Ayub Medical College, Abbottabad : JAMC, 27(1), 74–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26182742

Will We Witness the End of HIV in Our Lifetime?

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

December 1st of every year is designated as World AIDS Day, a day devoted to increasing knowledge and awareness about the impact of HIV/AIDS around the world. This year is no different, and over the last few months and years some exciting things have been happening regarding HIV/AIDS.

The year 2013 has become known as the “turning point” or “tipping point” in the HIV/AIDS epidemic. This describes the fact that 2.3 million people began anti-retroviral medication in 2013 while only 2.1 million new infections were diagnosed. In other words, more people are receiving treatment and fewer people are becoming infected than ever before. If we keep this accelerating HIV scale-up through 2020, UNAIDS predicts we could see the end of HIV/AIDS by 2030

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Figure 1. WHO infograph detailing the impact of expanding ART (antiretroviral therapy)

In the United States there has been a lot of media coverage, over the last year or two, surrounding pre-exposure prophylaxis (PrEP) for use by HIV-negative people to prevent HIV infection. PrEP is daily medication regimen utilizing an HIV drug called Truvada. Studies have shown that people who take PrEP as directed were 92% less likely to contract HIV. However, although it is increasing, PrEp usage remains lower than anticipated. Some barriers include a lack of PrEP awareness in people who are most at risk for HIV, some medical provider resistance to prescribing PrEP and some inconsistent insurance coverage. Additionally, PrEP continues to suffer from an image problem. When PrEP first became available, many critics were skeptical of its effectiveness in real-world settings and thought that it would undo years of work to educate folks about the dangers of HIV/AIDS. Critics also thought that being able to take a daily drug to prevent HIV would promote promiscuity and unsafe sex. A recent study in JAMA Internal Medicine proves the critics wrong on some of their fears.

An HIV/AIDS vaccine has been on the horizon ever since the epidemic was discovered. However, as we learned more about HIV, it became apparent that developing a vaccine was going to be a challenging effort. While there continue to be many HIV vaccines at various stages of development, scientists are excited about one being developed by one of the scientists who identified HIV as the cause of AIDS, Dr. Robert Gallo. His team at the University of Maryland School of Medicine’s Institute of Human Virology is beginning human trials on a potentially groundbreaking HIV vaccine. Instead of targeting different HIV viral markers to help the immune system recognize and eliminate HIV-infected cells, Dr. Gallo and his team’s vaccine targets HIV when it enters the body to prevent it from infecting cells.

All of these promising developments relating to HIV/AIDS should not overshadow the challenges that still lie ahead. Many people do not know they have HIV because they’ve never been tested. The Berkshire town of Reading in the UK is expanding its HIV testing program by offering free tests because it has more than double the UK average of HIV-positive people. The number of HIV-positive people in Russia continues to increase and has reached almost 1 million people. Some countries are passing anti-gay legislation and there is a direct link between criminalizing laws and increased rates of HIV. These are the challenges some parts of the world face in the efforts to end the HIV/AIDS epidemic.

World AIDS Day provides a way for everyone to get involved in the fight against HIV/AIDS. It’s an annual day to think about the people who’ve lost their lives to AIDS-related illnesses and to champion efforts to prevent more people from losing their lives due to HIV/AIDS related causes. This December 1st do a little research, learn about the burden of HIV/AIDS in your community, and decide how to get involved. Together we can end HIV/AIDS in our lifetime.