Coups and Contrecoups

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

View fullsize

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

Humanitarian Congress: A Workforce Self-Evaluates

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

View fullsize

Humanitarian Congress, Berlin. Photo Credit: Victoria Stanford

The 17th Humanitarian Congress - ‘Understanding Failure, Adjusting Practice’ - took place in early October this year. The stimulating two-day event in Berlin, Germany could not have occurred at a more appropriate moment for the international humanitarian movement, its workers and its supporters. Just six days previously on October 3rd, an MSF (Doctors without Borders) trauma centre in Kunduz, Afghanistan was bombed, killing over 30 people including 10 patients and 13 staff, and injuring over 30 (more are missing and/or unidentifiable; MSF).  The Conference began with a poignant moment of silence for the victims of this tragedy. Inevitably however, the agenda was overwhelmingly full of lectures and seminars shedding light on numerous serious, devastating, and urgent crises that call upon the attention of the humanitarian community; the ongoing instability in the Central African Republic and protracted crisis in the Democratic Republic of Congo, the war in Syria and its subsequent refugee crisis, to name a few.

The demand on the humanitarian system is ever-growing and events such as the Congress facilitate a reflection of its principles, priorities, objectives and effectiveness. The focus on ‘failure’, albeit with its negative connotations, helpfully directed discussions towards ideas for improvement. Importantly, this approach avoided blame and finger-pointing and instead flagged problems that applied to many agencies, in many situations. For example, speakers from the Treatment Action Campaign suggested that international agencies often use local agencies as subcontractors, outsourcing risk to those whose protection is less internationally observed. It was argued that this can often mean that the local workforce, and those directly involved in the crisis are not placed at the centre of decision-making processes. Instead, beneficiaries or those workers who are part of the vulnerable community are treated as “victims” without autonomy, who blindly receive assistance rather than self-remediate. This idea of working with communities rather than for them, expanded to a conference-wide discussion of responsibility. Questions like, whose role is it to alleviate suffering, who should provide the funding and resources, and who should decide policy and provide care for vulnerable people in crisis situations were discussed.

 Whilst the conference facilitated stimulating intellectual discussion on the ideas and concepts of today’s humanitarianism, it also showed the reality of human need. An engineer from Syria who came to Germany as a refugee, risking his safety along the highly publicised journey across the Mediterranean, spoke about his experiences. He spoke of the boat that took him across the sea slowly sinking while other passengers panicked, treading water for hours until an eventual coastguard rescue. A story such as his reminded all at the Conference that the jargonised political discussions about the refugee crisis create a rhetoric that often overlooks the human experience. Speakers from the Democratic Republic of Congo and Somalia also provided the weekend’s event with a more individualised, personalised view of the concepts and themes we were discussing; reminding us of the human aspect of an increasingly intellectualised and politicised field. 

The Congress also served as a pre-dialogue to the Humanitarian Summit, a novel event announced by the UN Secretary-General to be held in Istanbul in early 2016. The purpose is to discuss current challenges and decide on an agenda for future humanitarian action (ICVA, 2015). Many of the regional consultations which will contribute to the Summit have already taken place, and many of the speakers in Berlin commented on the predictability of the points which have been brought up thus far. For example, it was mentioned by many that staff security and safety in the field is likely to ignite serious discussion and debate, as is the issue of agency co-ordination and leadership. The example of the Ebola Crisis in West Africa provided an astute example of this need for a decision on establishing leadership and accountability in humanitarian action; the general rhetoric was that the WHO did not do enough, early enough, and NGOs such as MSF found themselves to be the principal driving force behind the response efforts.  

Increasingly complex humanitarian crises which involve both more agencies and beneficiaries than ever before, must be met with an efficient workforce that can respond to the challenges the humanitarian sector faces. The Conference seemed to bring about an understanding of the fact that the extent to which the sector can be successful may depend on how far the actors are willing to innovate and adapt, introduce creativity, and collaborate with non-traditional allies.  Humanitarianism is no longer a subjective theory with ad-hoc projects run by the adventurous few, it is a rapidly-expanding multidisciplinary system which should be based on rigorous evidence and carried out by legitimate actors who show consistent adherence to mutual humanitarian principles. If and how this will come about will rely on the humanitarian sector continuing to self-evaluate, a feat which will be facilitated by the upcoming Summit in 2016, which we all eagerly anticipate.

References:

MSF (2015) Afghanistan: Death toll from the MSF hospital attack in Kunduz still rising, www.msf.org, 23rd October 2015 [Online] Available at: http://www.msf.org/article/aghanistan-death-toll-msf-hospital-attack-kunduz-still-rising [Accessed 24 October 2015]

ICVA (International Council of Voluntary Agencies) (2015) World Humanitarian Summit 2016 [Online] Available at: https://icvanetwork.org/world-humanitarian-summit-0 [Accessed 09 November 2015] 

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

View fullsize

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.

Access to Toilets: Not as Common as You Might Think

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

There are over seven billion people on the planet and 2.4 billion of them do not have access to proper sanitation. Almost one billion people still defecate in the open. The risk of disease and malnutrition increases with poor sanitation, especially for women and children. This year’s World Toilet Day on November 19 highlights the impact of poor sanitation on malnutrition.

View fullsize

Figure 1 : World Toilet Day poster, 2015. http://www.worldtoiletday.info/wp-content/uploads/2015/10/wtd-artist-poster-724x1024.jpg

Every day, over 1,000 children die from preventable water and sanitation related diarrheal diseases. Half of all cases of under-nutrition associated with diarrheal or intestinal worm infections are directly due to inadequate water, sanitation, and hygiene. Stunting and wasting, which cause irreversible physical and cognitive damage, have been linked to poor (water, sanitation and hygiene (WASH) conditions. In 2014, almost 1 in 4 children under five years of age suffered from stunting globally. 58% of all cases of diarrheal disease are directly related to inadequate water, sanitation, and hygiene.

Access to proper sanitation, hygiene, and potable water is so important that it was included in the 2000 Millennium Development Goals (MDG). Since 1990 an additional 2.1 billion people have started using basic toilets, and today around 68% of people have access to proper sanitation. However, the final MDGs Assessment report shows that the world has fallen short of the MDG goal by 700 million people. This means that there is still work to be done, which is why access to sanitation and clean water is Goal 6 of the Sustainable Development Goals.

There are many innovations occurring in the WASH area. One example is a project by Give Water that promotes child health by developing child-sized latrines and teaching children about proper sanitation and hygiene practices in school. This ensures that proper WASH practices start from a young age. The WASH Impact Network website provides a lot of information about additional innovative WASH projects. 

Access to proper sanitation and clean water is a human right. While progress is being made towards this goal, there is still work to be done. World Toilet Day highlights the continued effort to provide proper sanitation facilities to every person on the planet.

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.

Technology is Changing the Way Infectious Diseases are Tracked

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

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

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

View fullsize

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

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

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

View fullsize

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

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

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

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

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

The Cinderella of Health Issues in Pakistan

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

Lahore Mental Hospital

Source: CNN.com Available at http://i2.cdn.turner.com/cnnnext/dam/assets/150812114127-01-cnnphotos-lahore-mental-hospital-restricted-super-169.jpg  

As a Global Health student with a background in medicine I find all health issues interesting. Especially interesting are the mental health issues because of their lack of somatic manifestation like other physical ailments. It is surprising to know that depression alone affects almost 350 million people worldwide (WHO 2015). Even though I have been related to the medical field for quite a while, I underestimated the state of mental health in Pakistan. The fact that I grew up with a family member who was under treatment for bipolar disorder for many years did not do much to change my opinion. I am also related to a few undiagnosed cases of clinical depression but I still did not consider mental health an issue. During my medical college, the clinical rotations in the psychiatric ward also failed to show me the true picture of the burden of mental disease partly due to its scarce patient numbers.

I realise my ignorance even after becoming a clinician reflects poorly on the level of awareness of this issue in the medical community and the general population. I would have continued to be ignorant had it not been for one particular day in the Outdoor Patient Department at Services Hospital Lahore with one of the heads of medicine.

As the last patient left, the professor looked around at all the junior doctors sitting around the table, picked up one of the physician samples and said that if it were up to him, he would make the drinking water of Lahore enriched with it. Surprised at what could possibly plague our part of the world and cure it according to him, we looked at the sample. It was an anxiolytic. An anxiolytic is sometimes prescribed for people suffering from stress and often given to patients with depression (Pietrangelo 2013).

The fact that the number of mental disorders is increasing worldwide is not a secret. According to some sources, the number of people suffering from mental issues in Pakistan is estimated to be around 15 million (Anwar 2015). Most of these remain undiagnosed, often in the shadows of stigma and shame. Pakistan has many reasons to have escalating mental illness; political unrest, internal conflict, economic instability, rising poverty and crime rates, unemployment, natural disasters, the list goes on.

Unfortunately most of these cases are attributed (by the general public, doctors or both) to black magic and evil spirits (Gadit and Callanan 2006). Many such people end up at shrines and the doorsteps of spiritual healers. Some receive holy verses to recite while others get beaten, to scare away the evil spirit or “jinn” as it is called in this part of the world. While religion is good for many reasons, the fact that mental health involves underlying biochemical pathophysiology that could be treated with medical intervention needs to be addressed urgently.

But what about the people who specialize in managing and treating such disorders? According to WHO there are less than 350 psychiatrists in Pakistan, only 0.2 per 100,000 (Jooma et al. 2009). The numbers are worse for pediatric psychiatrists. With only five psychiatric hospitals in the country, the state of psychiatric wards and mental institutions is appalling (Anwar 2015).

Although psychiatry might be an area of increasing interest in medicine in Pakistan, the availability of opportunities that provide better compensation and benefits abroad cause many of these doctors to leave the country to work in “greener” pastures (Imran et al. 2011). With the prevailing conditions for doctors in general, Pakistan might even become an exporter of psychiatrists, which will only worsen the situation within the country.

The time to deal with the multi-headed monster of mental health in Pakistan is now. Raising awareness about mental issues is primary but the need to remove the stigma associated with it is a bigger concern. The truth about fraudulent spiritual healers also needs to be addressed vehemently. The number of psychiatric wards needs to be increased. Finally, the medical workforce needs to be given better incentives to stay within the country.

References:

Anwar, Komal. “Mental Health Care: Mind Matters.” The Express Tribune. Web. 26 Oct. 2015.

Gadit, Amin A Muhammad, and T S Callanan. “Opinion and Debate Jinni Possession : A Clinical Enigma in Mental Health.” Journal of Pakistan Medical Association 56.10 (2006): 476–478. Print.

Imran, Nazish et al. “Brain Drain: Post Graduation Migration Intentions and the Influencing Factors among Medical Graduates from Lahore, Pakistan.” BMC Research Notes 4.1 (2011): 417. Web.

Jooma, Rashid, Fareed Aslam Minhas, and Shekhar Saxena. WHO-AIMS Report On Mental Health System In Pakistan. N.p., 2009. Print.

Pietrangelo, Ann. “Anxiolytics | Definition and Patient Education.” Healthline. N.p., n.d. (2013) Web. 26 Oct. 2015.

“WHO | Depression.” Fact sheet N°369. World Health Organization, n.d. Web. 26 Oct. 2015.

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Awaiting Death on a Heap Of Gold

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

In the far southeastern part of Pakistan lies an arid region with a gruesome past of disease and death. Despite this, it is considered a goldmine for black gold, establishing the Thar Desert as the 6th largest reserve of coal in the world. These reserves are estimated at 175 billion tonnes spanning over an area of 9000 sq. km enough to provide the country with energy for centuries to come. Perception about the treasure that lies beneath the scorching sand of Thar brings into question the existence of labour directed towards harnessing the gauged energy. It is exasperating to witness the indifference of the authorities to improving the conditions using its coal reserves, but the deaths of hundreds to date as a result of malnutrition in an area which has the potential to sustain itself and the rest of the country as well, is alarming. 

View fullsize

Source: The Express Tribune

The current scenario of drought emerged in 2013 and continues to prevail beyond any hope of reprieve, natural or otherwise. But this is not the first time the region of Tharparkar has seen such unforgiving conditions. Thar experienced the worst drought in its history from 1998-2002, which affected 1.2 million people, killed 127 people and 60% of the population migrated to irrigated land. The streak of drought did not end completely, albeit lessened, for Thar experienced a moderate drought in 2004/2005. Yet another drought came along in 2009/2010 followed by one of the worst floods in Pakistan’s history.

Current statistics report worse figures than the drought of 1998-2002. Government officials have confirmed the deaths of 159 men, 168 women and 726 children under 5. Over 3000 cattle have been reported dead. The number of affected individuals is an estimated 1.1 million. 175,000 people are projected to have migrated. The numbers continue to rise as the government attempts to alleviate the situation. Locals however fear that the worst is yet to come. With inadequate rainfall to sustain the flora and fauna, and the ground water level sinking, the steps taken by the government fall short. Massive relief projects focused on purifying the saline water have been planned but despite 375 Reverse Osmosis pumps being installed, only a handful have been reported to be operational due to a lack of trained manpower. As a result, efforts made towards relief for this region have not affected the escalating numbers of lives being lost every day.

View fullsize

Source: The Express Tribune

Besides the obvious malnutrition cases, another major complication is the rise in water borne diseases. These prove to be the largest contributors to mortality apart from birth asphyxia, pneumonia and sepsis. Thar has been attributed to have the highest under-five mortality rate in Pakistan with 90-100 deaths per 1000 live births. These statistics are distressing, however, doctors maintain that the figures have not changed in three decades, stressing the need for establishing a permanent solution for the region instead of episodic interest in chronic issues.

The need of the hour demands sustainable long-term development rather than multiple short bursts of temporary relief projects for an area that is recognised as prone to drought-like conditions.

Sources:

Latif A. Ray of light in Pakistan's drought-hit Thar desert (July 2015). BBC News Asia. Available at: http://www.bbc.com/news/world-asia-31851835

Hashim A. Pakistan's Thar residents living on the edge (March 2014). Aljazeera. Available at: http://www.aljazeera.com/indepth/features/2014/03/pakistan-thar-residents-living-edge-2014315121120904102.html

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.