Global Health Exam 1 Review

Challenges of Animal Infections

Is this increase in incidence due to better surveillance (we don't believe this is true) How are dogs getting infected? Are they eating frogs or fish Can we interrupt transmission? Will we have to live with an animal reservoir? We can't eradicate guinea worm if there is still a reservoir

Foundations: Philanthropic organizations

Bill and Melinda Gates Foundation, Rockefeller, Clinton Foundation Both direct funding of programs as well as research funding

The new director general of the WHO is from which country?

Ethiopia: Dr. Tedros Adhanom Ghebreyesus

"Spill over event"

When Ebola gets transmitted to human

UK Government: Health is Global

"Health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions...Global health recognizes health is determines by problems, issues, and concerns that transcend national boundaries." Really focuses on "global aspect"

Advantages of oral vaccine

"Herd" immunity: attenuated virus, can actually be shed fecally or orally and go into community Ease of administration: Injectable requires more experienced healthcare workers and vaccine needs to be cold (Sometimes vaccines mutate and result in paralysis)

Difficulties of Polio

-Conflict areas -Mistrust of vaccine workers -Oral vaccine: there's a movement to completely rid of this and use inactivated vaccine -Ongoing transmission in Afghanistan, Pakistan, and Nigeria

Millennium Development Goals and Health (WHO 2000-2015)

-Eradicate extreme poverty and hunger (you could attempt to reduce the poverty in large countries and therefore reduce the global poverty rate) -Achieve universal primary education -promote gender equality and empower women -reduce child mortality improve maternal health -combat HIV/AIDS, malaria, and other diseases -ensure environmental sustainability -global partnership for development

When program was started, there was several assumptions

-No immunity to infection (if you drink water this year, you can get guinea worm this year but u can also get it next year) -No known curative drug or vaccine (they are questioning this) -No animal reservoir for the parasite (hoping this isn't true) Period of transmission is seasonal (when rains came and small ponds get left behind)

1980s Campaign for child survival (mortality rate for under 5 was very high)

-first time global goals set for health -international task force for child health and development--focus on immunizations (Now the Task Force for Global Health) September 30, 1990 (World Summit for Children): 10 point plan of action that set child-related human development goals for 2000 (reduction in infant mortality, child malnutrition and illiteracy, as well increased access to basic services: family and health planning, education, water, and sanitation)

WHO Challenges

1. Limited funding for core functions 2. Constituency: all UN member nations (different priorities depending on which country you are...we also have very strong regional offices) ex. Pan American Health Organization; this is underneath WHO but takes care of all the Americas 3. Contradiction: location in Switzerland, rich and expensive country, belies emphasis on poorest of the poor 4. Mismatch between need and allocation of WHO resources- human and financial 5. Changing burden of disease (Zika, Ebola, etc.) 6. WHO deals with ministries of health 7. Autonomous and ineffective regional office structure (ministry of health may put someone they know in a position they are not qualified for)

Multilateral (participated in by 3 or more partners) Development Banks

The World Bank: predominantly global health actor, provides funds for development of global health -regional development banks

The end game gets weird

Until 2010, there was little need to consider new tools and strategies However, the last four GW-endemic countries (Mali, Chad, South Sudan, and Gambala Ethiopia) present new challenges : Pushing us to understand the epidemiology of dracunculiasis and animal infections Intensify and focus use of existing tools (before we used ponds that were near villages and now we must use insecticide treatment as diligent as possible in ponds far from villages) Innovate: new tools, treatments and strategies

Global Health Elimination, Eradication, and Control

Webster say: Control: to reduce the incidence or severity to innocuous levels (not harmful or offensive) Elimination: the act or process of removing something or someone Eradication: the act of doing away with as completely as if by pulling up by root

Global Health Actors

Who are the major players in global health funding and planning

World Bank and Health: Seminal Policy Statement

Why invest in health? 1. In virtually all countries, a large share of GDP is devoted to health 2. Healthy, educated people are a foundation of sustainable development 3. Human capital 4. Because it's the right thing to do Deals with ministries of finance, treasury, and trade

How are new actors effecting the World Bank?

World Bank risks sliding into irrelevance But there are still strengths because world bank is behind the scene operator and facilitator; major focus on health system strengthening (more so than fighting individual diseases)

Intergovernmental Actors

World Health organization Unicef: UN Children's Fund UNDP: UN Development Programme WFP: World Food Programme International Monetary Fund FAO: Food and Agricultural Organizations UNFPA: UN Population Fund

Why should we question the assumption: Belief in biomedicine will correct local logic and concerns

You can't just feed people biomedical information and expect them to change Public health officials believe caring for the dead the way villagers do is irrational (this is showing a lack of geniune engagement in the social, material, and spiritual implications of changing social practices) Also traditional communities can't guarantee that biomedicine will work--health facilities have been places of Ebola transmission Lastly, these protocols are created on a national and international level and rarely in collaboration with the village leaders (who ultimately have the most knowledge about the occurrence of disease and the conditions of the village)

Why have a second set of goals when the MDG weren't met?

You have to keep people enthusiastic and keep momentum going (also SDG includes climate change, economy, work)

Suggestions from outsiders are incredibly valuable

Young woman who heard about the Ebola situation and said to print out digital images of people and putting them on their uniform so the patients and families can see their face

Groups see the hospital in different light (MSF diagram verses what people see)

Zingeser thought it was great Patients are restricted by chained fences around the tents...the land and grass has been bull dozed to make it clean, white tents are opaque and people go in and never come out. And u can't see the faces of nurses and physicians entering and leaving the camps

Global Health-Zingeser Countries of Research

Zingeser worked in Republic of Guinea and Sierra Leone (both very poor countries) and Liberia HDI (Human development index) of Republic of Guinea is 179/187 HDI of Sierra Leone is 183/187

Small Pox

Face to face contact (coughing)--> caused fevers, aches Left scars on victim In 20th century, estimated to have killed 300 million With vaccination, the number of cases decreased (isolating people with disease and vaccinating ALL of their possible contacts in that area) This virus could only infect humans--we are essential for the transmission of the virus Rash was easy to identify without lab test Effective intervention: the vaccine last 5-10 years so this gave physicians and health care officials time to halt the disease worldwide

How do eradication efforts help with control of future epidemics? How do they improve health infrastructure?

Facilities and personnel from a polio eradication team can utilize tools to assist in an Ebola epidemic

Guinea Worm Eradication

Female Copepod: Little insect that lives in water and ea

Disadvantages to polio

Unapparent Infection (200:1) Other diseases with similar symptoms

Other important principles of Elimination and Eradication

-Need to go EVERYWHERE disease is, no matter how remote (even if disease is not perceived as a major concern in an area) -Monitor both the disease occurrence as well as intervention (you have to know if their is progress) -Flexibility (if conflict or natural disaster force you to change course in efforts) -"Need for intense focus to interrupt transmission": even when costs go up dramatically -Start early in areas of highest burden -combination with other disease efforts increases political will

Key Strategies for Polio Eradication

-Routine childhood vaccinations (strengthen programs) and immunization campaigns to target un-vaccinated infants -Surveillance for wild-type polio virus (Analyzing cases of paralysis) -Mop-up campaigns to follow identification of a case

Two types of Polio Vaccine

Oral "Live" Injectable, "Inactivated"

What is the only disease to be eradicated

Small pox

Bilateral

government to government (significant source of funding) U.S global health budget providing programs for other places (Pepfar: U.S government supporting partner countries in controlling their HIV/AIDS epidemic)

What are examples of infectious diseases that have been "eliminated" in a given setting?

-United States: malaria, yellow fever -Measles (just declared eliminated), polio in the Americas

1990s

Decade of conferences on human rights

Effects of Ebola on Social, Economic aspects in society?

Disrupts families, communities, commerce (Village markets are closed down)

What was one of Dr. Margaret Chan's biggest challenges?

Financial crisis had impact and Ebola challenged WHO 2009: H1N1...what to call this? Is this a pandemic? U.S government pushed WHO to declare it as this

Other Diseases: Onchocerciasis in Americas

-Transmission suppressed in all but 2 foci (indigenous populations of Venezuela and Brazil) Malaria and LF in Hispaniola

1960s- decade of development

Most of the colonized countries became independent by this period

Advantages to Polio

No animal vector Effect tool: oral vaccine No chronic carrier state Survives poorly in environment

How will poorer countries be impacted by monitoring the health goals?

Poorer countries don't have the resources or technology to record data from each goal and its sub-specialties

NGOs

Red Cross Doctors Without Borders/Medecins Sans Frontieres (MSF) Partners in Health (Paul Farmer) CARE PATH These are only five well known NGOs; there are thousands of NGOs

Global Health Financing

Several different contributors (World Bank, NGOs, WHO, Unicef, etc.) And the total amount of financing has increased at an upward curve from the 90s

Why are we in West Africa fighting Ebola? (Mixed goals, priorities, and messages)

1. The worried wealthy: People who think Ebola virus will get on an airplane and go to London or Emory University. Work to stop the virus where it starts 2. Technical Assistance: interested in the technical details, in the set up, these make really good researchers and lab techs 3. Development workers: long term goal, interested in building community and working with others 4. Preventing disease outbreaks at their source (similar to the worried wealthy) 5. Social Justice

Bill and Melinda Gates

2014, gave 3.9 billion WHO's budget is about the same for the year so you can see how large of an actor the Bill and Melinda Gates Foundation is 4 divisions, including global health: focus on HIV/AIDS, tuberculosis and malaria Polio eradication Children's vaccines (GAVI Alliance) Neglected Tropical diseases (NTDs)

Dr. Tedros Adhanom WHO Appointment

At present, only half of the world has access to health care The sustainable dev. goals give WHO opportunity to increase access to health care How does WHO do its business? First, you want us to build effective partnerships but at the same time lead from front and center (we are the undisputed leaders) WHO must be more efficient, accountable...resources must be focused on the most fragile people who are most needy We need to work together: science, evidence and innovation will guide our actions WHO, as an intergovernmental organization, will work in its areas of comparative advantage (we all have one goal to improve health).

Yaws Success

Between 1952 and 1964, WHO and UNICEF provided assistance to 46 countries with the aim of eradicating treponematoses (Type of rare bacterial infection related to Syphilis--can be treated with one dose of penicillin. This was around the time that antibiotics were discovered) Mass campaigns (using Penicillin) in these countries examined over 300 million people and treated 50 million. By 1964, the prevalence of these diseases had decreased by 95% (2.5 million)

Response: Increase active surveillance Research: Possible role of paratenic host

Between 2012 and 2016, active surveillance increased Looks at possibility of guinea worms being transported through a second host (like a fish or dog)

Ebola Response Anthropology Platform, 2015

Caring for the sick and dead are intensely practical matters: you don't have dead people so you can hold funerals. You have funerals because you need to dispose of the dead person in the right way -failing to conduct funerals may cast family members as negligent or start rumors about malicious forms of death (funerals are an act of respect for family) Health education is value-laden and culturally biased You can't just disregard these points. We can't convey the message of "Traditions kill?"

MDGS to SDGS: Millennium Development Goals (2000-2015)

Child and Maternal Health had prominent place in MDGs

The New WHO

Dr. Gro Harlem Brundtland (July 1998) Reorganized WHO, clear priorities set, WHO determined to be major policy player in global health, and they actively engaged with other players instead of just trying to do their own thing

Director Generals of WHO

Dr. Halfdan Mahler (1973-88): Emphasis on 'holistic' health care, PHC (primary health care) Dr. Hiroshi Nakajima (1988-98): WHO lost its way ineffective leadership "Extra WHO" (outside or offshoot of WHO): Global Programme on Aids (GPA) Became more autonomous and WHO had smaller role being that it had ineffective leadership-->lead to jealousy Ascendancy of World Bank as most influential external health agency

World Bank: President

Dr. Jim Kim (co-founder of partners in health) Sign, engraved in marble, above the main entrance to the World Bank in Washington DC: "Our dream is a world free of poverty."

WHO in new millenium (Post Bruntland)

Election of Dr. J.W Lee (S Korea) in May 2003 who died suddenly in 2006 Election of Dr. Margaret Chan (Hong Kong) in November 2006 Era of Millennium Development Goals (and Sustainable Millenium Goals) Focus on inequalities in outcomes and access

Global Health Definitions: Elimination, Eradication, and Control

Elimination: "zero disease in a defined geographic area as a result of deliberate effort Eradication: "Zero disease globally as a result of deliberate efforts" Control: Efforts to reduce disease burden in a certain locale

PolioMyelitis

Enterovirus - influenza like illness that leads to paralysis in < 1% of affected individuals -Paralysis can affect one or more limbs or chest•Infected by "fecal-oral" route or by inhaling virus particles -People can shed virus for more than a month, starting before symptomatic and up to 14 days after illness resolves -Before vaccine introduced, 600,000 / year died *Disposal of human feces, hand washing are essential

Chad Response: Research Dog Ecology and Feeding studies

Environmental questionnaire and direct field observation GPS tracking of more than 130 dogs on collars (Proximity locators would indicate which dogs were close by)...look at gps tracking and see the geography of the location (water bodies nearby) Ten days of observation: looked at the social networking of dogs and stable isotope analysis (took dyed whiskers from the dogs and could see what those dogs were eating and when they ate it) Conclusions, Where do dogs go?: Dogs mainly remain around humans (this is important cause we can control human behavior) Some dogs wander away (need to determine who they are and why: are they males looking for mates) Dogs encounter many water sources What do dogs eat? Mostly boule (fed at home), eat feces and animals in the bush, eat fish and perhaps amphibians

Ebolavirus Ecology

Enzootic Cycle: transmitted from bats (but they don't get sick) and they can pass virus to non-human animals antelope and apes Right around July and August, disease exploded and went up dramatically in 2015

Before the MDGs: 1950s

Era of the mass disease campaign: Most important lesson to be learned that the people of Africa, Asia, and Latin America were not just a blank sheet of paper that industrialized countries could write their own version of progress on -discovery of antimalarial technologies in WWII -economic development assistance programs: Context: "If we eliminate disease, that will lead to economic development

WHO Beginnings

Established between 1945 and 1948 Early Decades focused on infectious disease control. WHO was the most significant external agency in the health sector (most prominent global health actor along with academic institutions) Primary focus in developing countries making transition from colonial rule Successes- Yaws control, smallpox eradication In the 50s, 60s, 70s, the focus shifted to primary health services (instead of large population base infectious disease programs)- Alma Ata 1978 Health for ALL by 2000 (built on the Alma Ata) The Alma-Ata Declaration of 1978 emerged as a major milestone of the twentieth century in the field of public health, and it identified primary health care as the key to the attainment of the goal of Health for All.

Merson et al

Global Health is the application of the principles of public health to problems and challenges that affect low and middle income countries and to the complex array of global and local forces that influence them *This definition is a little more restrictive. Even though aid is geared towards lower class individuals, diseases transcend borders (Zika, influenza, obesity). This def brings up the definition of public health--Is all global health public health or is all public health global health?

Health in the SDG Era (Sustainable Development Goals) 2015-2030

Goal 1. End poverty in all its forms everywhere Goal 2. End hunger, achieve food security and improved nutrition and promote sustainable agriculture *Separated poverty and hunger into two categories Goal 3. Ensure healthy lives and promote well-being for all at all ages Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Goal 5. Achieve gender equality and empower all women and girls (Gender inequality is still deeply entrenched, as manifested in the slow progress in women's representation in political life, in decision-making within their own households, and in the violence, most often with impunity, that women and girls face in all societies. ) Goal 6. Ensure availability and sustainable management of water and sanitation for all Goal 7. Ensure access to affordable, reliable, sustainable and modern energy for all Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all Goal 10. Reduce inequality within and among countries Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable Goal 12. Ensure sustainable consumption and production patterns (sound management of chemical wastes in the environment) Goal 13. Take urgent action to combat climate change and its impacts Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels (end abuse, trafficking and exploitation of children; provide legal identity for all) Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable development Reduce use of medication to combat antibiotic resistance, sustainable energy for everyone, etc...

Other Diseases: Lymphatic Filariasis

Goal to eradicate by 2020 as a public health issue -Mass drug administration -Some interrupted transmission in areas

What other diseases can be eradicated?

Guinea Worm (Dr. Zingeser), Polio, Measles

The epidemiology of Guinea Worm in Chad

Guinea worm has resurged in fishing communities along the Chari River Before 2009, No GWD reported for nearly 10 years 2010: GW solitary cases discovered (case surveillance re-established; cases seemed scattered along Chari and it was on an individual basis verses whole communities being affected by guinea worm) 2013: Surveillance of dog infections begins 2015: 9 human cases and 503 dog infections 2016: 16 human cases and 1011 dog infections Between 2012-2016, the incidence of GW infection in dogs increases from 24 to 1011 cases

What's striking about the headquarters of key players?

Headquarters are located in Washington DC, Atlanta, New York, Montreal, Canada, Paris, Madrid, London, Geneva, Vienna, Rome, Nairobi, Kenya ( one of the fastest and largest growing cities in Africa) The Hague, Netherlands, Bern, Switzerland High income locations but most of these groups are created to aid low income areas

Inequalities

Human Development Index Genie Coefficient: How unequal (If it's 0, it's equal; if its 1, there is inequality)

Countdown to Zero

Individuals treated until worm emerges (weeks-2 month process) Goal: find the water source and prevent the worm from further contaminating water sources Encourage filter use by showing people what is washed from filter Containment facility South Sudan is most difficult place to cure guinea worm because the population is so isolated and so entrenched with the virus Guinea worm larvae are in the water in a crustacean called cyclops or water fleas (copepods)--if we drink water, the larvae will get released in our intestines. They move into our bloodstream and eventually mate and migrate to the leg Adult larvae will induce painful blister when it want to lay its larvae (this will tempt individuals to poor water on their skin-->causing transmission of worm)

Global Polio Eradication

Initiative began in 1988 after success of elimination of polio in Americas -WHO, Unicef, Bill and Melinda Gates, CDC, Rotary International Three types of wildtype polio: 1,2,3 (Type 2 was eradicated in 1999)

The IMF (international monetary fund) and the World Bank

Known collectively as the Bretton Woods Institutions--founded in 1944 Both owned and directed by the governments of member nations (essentially all countries belong to these organizations) Country's voting power is proportional to the size of its economy relative to the world economy (so U.S has 17% of votes wielding a veto), based on the gross domestic product But these two organizations are fundamentally different: WB is development institution (provides money for purpose of development) IMF seeks to maintain an orderly system of payments and receipts between nations (way for country to get loans)

Koplan et al.

Main Points: equity in health, transnational health, many disciplines and collaboration, both local clinical care and community prevention efforts Definition: Global health is an area of study, research, and practice that places priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond health sciences and promotes collaboration. It's a synthesis of population based prevention and individual-level clinical care (ex. Paul Farmer)

Global Health Initiatives in the 21st Century: Roll Back Malaria

Malaria endemic countries: over 100 countries from malaria endemic regions of the world OECD donor countries: 11 bilateral donor programs NGOs: 22 NGOs including the African Medical and Research Foundation, International Red Cross, and doctors without borders Research and Academia: British Medical Journal, Earth Institute at Columbia University, African Malaria Network Trust (AMANET) Global Fund (GFATM) Foundations: fund for malaria, TB and HIV Private Sector: Private companies from across the world, coordinated by the World Economic Forum's Global Health Initiative WHO (multilateral development partners): The World Bank, Unicef, and the WHO with multiple regional offices and expert units Foundations: Bill and Melinda Gates Foundation, the Clinton Foundation, and the Novartis Foundation for Sustainable Development

Other Aspects of Global Health Initiatives

Mass Drug Administration Pharmaceutical Donations Grass roots/community based

UN-type Global Health Governance

Member countries elect director general and secretariat works under director general

Were the MDGs the first global goals that incorporated health goals?

No, the alma ata of 1978 set goals for primary health care. There were several multilateral goals and objectives

Moxidectin (Heart worm treatment)

Parasite prevention and treatment Monthly topical application, rapidly absorbing liquid

People in full protective yellow and white uniforms causes...?

People would go into clinic with mild fever and would come out dead Makes people go beyond reason: planes would be suspended and flight crews suspended Photo of fellow who died in streets and people are spraying him down with chlorine bleach

Smallpox eradication in WHOs South East Asia Region

People would pray to dieties to have mercy on them Will Darandt: The world would not know how to corporate unless everyone was endanger of an alien invasion Mobile teams with vehicles that would go everywhere (surveillance and containment...with good surveillance, the number of cases went up and people saw this as indications of failure and need to advocate)

Private companies

Pharmaceuticals, other healthcare related companies also donate a lot of money towards initiatives

User Fees Protection Mechanisms

Poor don't have to pay fee (but the fee is how u keep place clean, how u pay healthcare workers) Who's poor? How is the poverty status determined? Who makes this determination? Individual: Eligibility for protection is established on an individual basis Group: A collection of individuals is selected for protection based on location, ethnicity, gender, age, etc. By Type of Service: The poor tend to demand subsidized services more frequently than non-poor Self: service is demanded by those requiring protection or in dangerous areas--long awaiting lines, no amenities (non-poor will look for better, paid services elsewhere)

Conclusions

Proof of concept: Mass prophylactic treatment of dogs in rural Chad is feasible If we can surgically remove female worm from dog, we can determine the amount of larvae within it and if medication reduces this

GWEP Strategies: breaking transmission

Provide safe drinking water, filter drinking water, prompt detection and containment of cases (surveillance) Treat all cases rapidly and diligently (to prevent human cases from contaminating drinking water sources) -health education and case containment centers Vector Control: Abate (insecticide) treatment to kill copepods and water becomes safe to drink This has led to dramatic decline in the number of guinea worm cases (1986-2014)

Carlos del Rio (Chair of Global Health Department)

Reiterates Koplan's idea of what global health is -Addresses socio-contextual determinants -Interdisciplinary, systems-oriented, collaborative, based in partnership -incorporates clinical care -transnational Public Health "without a passport"

What makes a disease Eradicable?

Scientific feasibility: No non-human reservoirs (difficulty with yellow fever--carried in primates) Ease of spread Ease of diagnosis (if something isn't easily diagnosed, it'll be harder to target) Practical, effective intervention (vaccinations) -demonstrated feasibility of elimination (in a geographic area) Political will/ public support: -perceived burden of disease (morbidity, moratality, etc) -Economic feasibility-costs -Ability to combine effort with other disease control (nutritional intervention with vaccine; mother comes back for checkup after giving birth and give her child a vaccine as well) -"need for eradication" as opposed to control

1970s Era of Alternatives

Since economic growth did not automatically sweep poverty away, development analysts decided that a second development decade must help meet the basic needs for food, water, housing, health, and education for poor people Alama Ata Primary Health Care Declaration

Rethinking animal infections:

Some people just suggest killing the dogs...no Domestic animals are the buffer between humans and wildlife: Keep wildlife from filling an ecological niche close to human habitation -Easy to do surveillance and treatment on dogs (but if they are replaced by hyena or big cat, you can't fit gps collars on them) Dogs are not the problem; we should let the dogs lead us to the water sources where the copepods are (so we can get ahead of the worm)

Focus on Children: Unicef

Sustainable development starts with safe, healthy, and well-educated children; you cannot attained sustained growth and shared prosperity without investing in the people (above all children)

What is Global Health?

The spread of HIV, ebola outbreaks, and influenza have all brought attention to this Justice and human rights as its foundation. Study, research and practice dedicated towards achieving health equity all around the world. NOT international health which focuses on developing countries and international aid. Transportation and trade have increased the spread of disease. People of different cultures, religions, and ethnicities have to work together. It's also about poverty, education in young girls and mortality rates, obesity and food availability, the flow of goods, knowledge, money, technology, etc that have implications on our health. Engineers, teachers, business men, and many other professions working together to create healthier environment. We should all care about our fellow neighbor's health regardless of where they are from or who they are How do trade agreements affect health? What is the impact of urban planning? Does migration represent a challenge to health? In what ways will climate change affect health? What are the challenges for aging pop.? Who's voice counts in health organizations?

Wealthier people live longer: Why is life expectancy going down in Russia?

There is a huge wealth gap. For men, the life expectancy has decreased tremendously (alcoholism has increased)