A few sessions ago, we discussed primary health care and what exactly that term means to us. What services fall under the umbrella of providing primary health care? Most people would argue that primary health care includes the basics, providing immunizations, preventative care, and emergency care. But where does the category of mental health belong? I think the majority of the time, mental health tends to fall into the background amidst larger international efforts of trying to combat the global killers including HIV/AIDS, malaria, TB, etc. Unfortunately mental health is not only underrepresented in terms of allocated resources, but also in terms of recognition as a significant health issue.

Last summer, I spent some time traveling throughout Rwanda, and I was reminded of those memories as we discussed mental health in post-genocide Rwanda in the seminar. Walking through the streets of Kigali, it was difficult to imagine the destruction and horror that gripped the country in 1994. From an outsider's perspective, it appeared that everyone now identified as a Rwandan. Not once did we hear the words Tutsi or Hutu come up in casual conversations. It appeared the country had successfully moved on; the infrastructure was impressive in Kigali and a quiet peace seemed to resonate through the small city. But upon closer inspection and some deeper conversations with some Rwandans, it became apparent that many people had not forgotten--the hotel owner in Kigali who lost both his mother and father and most of his siblings--the young woman working at the Gikongoro genocide memorial where over 50,000 people, mostly women and children, were slaughtered and buried in mass graves. Now walking through the streets, I would look at each person and wonder the impact the genocide had on them. Were they old enough to remember seeing their parents killed? How many family members did they lose? Or how many people did they kill? As these thoughts and questions ran through my head, I began to wonder how oftenRwandans asked these same questions in their own heads, adn what effect these thoughts would have on their overall wellbeing and health. Many of the survivors stories have been shared at the Kigali Memorial Centre, and here are the words of 11-year-old survivor Chantal, "The killers should be put away where I'll never have to see them again. Life imprisonment would do. Just as long as I never have to come across them somewhere, looking after their children, after they took away our parents who brought us up so lovingly."

While post-genocide Rwanda provides a somewhat radical situation to consider the mental health needs of individuals, it is a good place to start. Making mental health a priority post-genocide in Rwanda was recognized as an important strategy for regrowth and rebuilding; however, how often is mental health regarded as a priority or key component in health initiatives in other countries with less drastic circumstances? The challenge remains that health is complex, and it becomes increasingly complex as we consider the impact that stress from poverty, violence, war, etc. can have on an individual's mental health and overall wellbeing.

News from the Front: Success and Failure of Malaria Fighters on Zanzibar

In 2005, 20% of children who presented at health clinics on Zanzibar, an island province of Tanzania off the coast of East Africa, tested positive for malaria. By 2008 less than one percent did. In 2004, 416,911 malaria cases were counted among a population of just over 1 million. By 2007, the number of cases dropped to 14,547.

Wiped from the United States by 1951, malaria remains an obstinate problem in Africa. It causes approximately 1 million deaths each year and drains an estimated $12 billion in annual medical costs and lost productivity in Africa. Since African countries began focused, systematic efforts to reduce prevalence and morbidity of malaria in the 1950s, there have been few bright spots. Zanzibar stands as one of the few places in the world where government efforts along with support from international organizations have brought the disease to its knees.

Zanzibar’s efforts to combat malaria represent a case study in the power and pitfalls of international efforts at disease eradication. The island’s first full-scale malaria control program began in 1958 as a collaboration between the national government, the WHO and UNICEF. By 1968 prevalence fell to 7.8 percent and malaria was no longer considered a health problem and the program was abandoned. Soon thereafter the dangers of this decision became apparent when prevalence rates were measured at 54% in 1973.

The next major attempt to combat malaria began in 1981. The joint initiative between USAID and the Zanzibar Malaria Control Program (ZMCP) lasted six years and was mired in problems from the start. Poor communication between USAID, ZMCP and island health ministries hampered efforts. Among other failings, the ZMCP procured agricultural insecticides unsuitable for use in homes and baseline surveys of disease prevalence were never made and it became difficult to monitor progress and make evidence-based decisions. Eventually the program was terminated without measurable, and certainly not lasting, benefits.

In 2005 the most recent, and so far most successful, effort to eradicate malaria began. Supported by resources and expertise from the African Development Bank, ZMCP, the WHO, Medecins Sans Frontiers and other international organizations, the program was centered around a combination of insecticide-treated bed nets, widespread home spraying, rapid diagnostic kits, lifesaving drugs and public education. Since the program started disease prevalence has been reduced to 1%.

The success of malaria reduction and elimination efforts on Zanzibar is heartening but should be taken with a grain of salt. Epidemiologists who debate the effectiveness of strategies to curb malaria in developing countries agree that islands like Zanzibar, which have a relatively low possibility for reintroduction of the disease, represent the “lowest of the low-hanging fruit”. Additionally, lower exposure to Plasmodium falciparum, the disease-causing parasite, in early childhood will reduce natural immunity, making future generations more susceptible to malaria epidemics. Finally, and vexingly, Zanzibar remains heavily reliant upon external funding for its efforts to control malaria.

Zanzibar has become a poster child for malaria eradication efforts. The most recent efforts showcase the finest that public health proponents and international organizations can hope to achieve in their efforts to eliminate the disease. The island is used on countless websites as an example of the good that international development organization can affect. Moving forward, it will become increasingly important that Zanzibaris and international organizations refuse to become complacent and allow the events of 1968 to repeat themselves. As one of the most famous and often-cited examples of the effectiveness of good global health policy, international organization won’t let that happen any time soon.

Leadership Brain Drain

“Who should be the ideal steward for health to best serve the public's interest?” – In my opinion, this question, raised during our policy seminar, focuses the problems of global health policy and foreign aid onto one salient topic: infrastructure. Infrastructure is a critical backbone to the delivery of any global health policy, and it relies on leadership. A significant amount of leadership behind global health policy and especially foreign aid is concentrated outside of the countries targeted with aid. It makes sense to me that this is unsustainable. We need homegrown leaders managing policy at the ground level. Physicians are probably the most important piece of infrastructure in the global health blueprint, and often enough the nations requiring their leadership to sustain global health advances find it absent.

Physicians are the highest trained leaders within medical society and can best direct the execution of global health policy. Too often, we find that these physicians are lost to developed nations. In Zambia, roughly 600 medical students have been trained at university, yet only 50 have remained to work within the Zambian public health sector. These forces are not unique to Zambia.

“Many Ugandan doctors are poorly paid and have left to

practise in the health systems of more affluent countries,

including South Africa where one of the medical schools

has several senior faculty members from Uganda. The

South African Medical Journal describes a “medical

carousel”, in which doctors seem to be continually moving

to countries with a perceived higher standard of living.4

Pakistani doctors move to the UK, UK doctors move to

Canada, and Canadians move to the USA.”

-quote from “Medical Migration…”

Obviously, the reasons for moving are incentive-based and not malicious in intent. Physicians leave for honorable reasons including economic opportunity, intellectual stimulation, family concerns, and even safety. What’s even more striking to me is the degree to which developed nations like Canada and the United states actively seek out foreign-trained doctors to fulfill their health system’s demand. This perpetuates the brain drain, with foreign doctors comprising the vast majority of the doctors practicing in inner-city hospitals. I think the bottom line is simple: without properly trained doctors, how can developing nations ever hope to properly execute global health policy and sustain health growth?

So how can we fix this? Perhaps soft power (name drop, woot!!!) could help. Developed nations behind the “drain” of “brain drain” must seek to train physicians at a number sufficient to satisfy the demand of their populations. The US could use policy to increase medical school seats and residency slots to satisfy demand and rely less on filling spots with foreign doctors. Developing countries could complement these moves by creating both incentives and policies to encourage physicians to remain in their home countries. At the very least, developed nations could compensate developing nations for the money lost in training a doctor that immigrates. These manners are only a few methods to encourage reduction in medical brain drain, but I like them because they require international collaboration between developed and developing nations to work. If we can begin to slow brain drain, maybe we can then build the infrastructure necessary for developing nations to wean themselves off foreign aid and become the stewards and champions of their own health reform.

Quick refs:

1. Bundred, P., and C. Levitt. "Medical Migration: Who Are the Real Losers?" The Lancet 356.9225 (2000): 245-46.

2. Pang, Tikki, Mary A. Lansang, and Andy Haines. "Brain Drain and Health Professionals A Global Problem Needs Global Solutions." BMJ 324 (2002).

FDA and Foreign Aid?

Ages ago we talked about foreign aid, particularly in regards to public health, as a help or a hinderance. I have all sorts of opinions, anecdotes, and even personal vendettas relating to this topic. Rather than subjecting readers to my inner madness, I will use this blog to share a specific example of the debate over the cost-effectiveness of foreign aid.

My personal interest in the field of global health is in what many call "neglected tropical diseases", a term that can be remixed with other terms like "poverty" or other similar ideas. We have all been bombarded with the war on malaria, HIV, TB, polio, etc. thanks to Bill & Melinda Gates, Partners in Health and the like, but there are many other diseases that we in the US consider rare, such as helminth infections, that millions of people suffer from despite the relative ease of curing and/or preventing them.

A recent FDA public hearing on neglected tropical diseases (September 23, 2010) prompted me to dig around the FDA website for info on the FDA and the international-medical-drug-money-all of the above scene. I found a slightly outdated document (June 23, 2010) that explains the FDA's role pretty thoroughly. http://www.fda.gov/NewsEvents/Testimony/ucm216991.htm

The FDA is primarily responsible for insuring that drugs coming into the US from other countries are regulated, and it has little to do with providing foreign aid. One important way the FDA is involved in international medical aid is by providing incentives for drug development. This is true of the FDA in all drug development research, but in the case of neglected tropical diseases, which are considered "rare" in the US, even more financial incentives are necessary in order for companies to invest in R&D. The document I read describes the use of the 1983 Orphan Drug Act, which provides funds for R&D of treatments for rare diseases ($15.2 million in FY2010), as well as exclusivity rights beyond those for normal drugs. In 2009 an amendment was passed allowing priority review for treatments pertaining to one of the 12 named neglected diseases of poverty. In addition, the FDA works closely with the WHO, especially recently, to change its focus from just controlling the quality of imports to producing and approving priority medications that are developed in the US but whose target populations are abroad.

Lovely little summary over. My thoughts on this are mixed. I did leave out some details about collaborations and review processes etc, but my main question, one that I have struggled with as a researcher myself, is: Are the enormous amounts of money, time, manpower, paperwork, and other resources that go into R&D really efficient and/or effective? Malaria was wiped out in the US almost 100 years ago not by vaccines or pills but by draining marches and soaking the country in DDT. Not that I am advocating this as a strategy now, but I think it is vital to remember that money may be better spent on simpler solutions than drug development. Not only is lab research expensive and low-yield, relying on drugs rather than public health- oriented solutions often causes even larger problems, such as multi-drug resistant strains.

While I recognize that R&D is inherently wasteful, I also partially believe that it has become a necessary evil. Especially now that resistant strains of many diseases have developed, eliminating pandemics will require fancy drugs to kill off the last strains. Also, when applied correctly, new drugs can be highly effective (check out river blindness and ivermectin). So, let the FDA spend money checking out new drugs, because it works really well at times.

At the end of the day, it is not that drug development should be excluded from budgets. What needs to happen is a re-allocation of resources toward education and delivery, both in the donor and recipient country. This job obviously does not fall under the FDA's responsibilities. What the FDA is doing by incentivizing drug development for rare diseases is a first step, but it is one that must be monitored (protecting a drug discovery can make that drug inaccessible and expensive) and supplemented with a more direct approach to foreign aid.

Aid and Development in Question

I think one would be hard-pressed to find an individual not in favor of a world with less HIV/AIDS, malaria, tuberculosis. Who wouldn't want to eliminate such broad-scale suffering? These diseases have proven to wreck so much damage economically, politically, and socially that in terms of the poverty and health level of many nations, development is hopelessly retrograde or stagnant unless something can be done to address the underlying health issues. As one aid organization's website notes with regard to Sub-Saharan Africa, "The most obvious effect of [the HIV/AIDS] crisis has been illness and death, but the impact of the epidemic has certainly not been confined to the health sector; households, schools, workplaces and economies have also been badly affected."

At a fundamental level then, it is difficult to see how anyone would be opposed to efforts taken to combat the major diseases affecting regions of our world, especially considering their broader implications. In reality, however, the delivery of aid is much more complex and contested than one could initially imagine. The Global Health Leader's Program discussed some of the issues that may arise with developmental aid in their September 20th seminar focused on health and development. Drawing from our broad personal experiences (volunteering in the Peace Corps, international service projects, internships with the WHO, etc.) and considering the insights of scholars like Dambisa Moyo (author of Dead Aid) we came to realize that achieving any sort of lasting success in improving health in any location requires local acceptance, cultural relevancy and sustainability among a number of other necessary qualities.

We talked also about the Millennium Development Goals set forth by the United Nations. Of note, the 6th Millennium Development Goal specifically aims at some of the major health crises in the world, namely HIV/AIDS and malaria. Other goals, such as reducing child mortality (#4) and improving maternal health (#5) also seek worldwide development by addressing the health status of (often) the most precarious individuals in the population: women and children. With specific objectives to be achieved by 2015, the MDGs represent a continued effort by the international community to move toward prolonged and sustainable development.

But in the end, I wonder. Moyo goes so far as to call for an aid-free Africa. What would that look like? Would it really lead to development? And are the MDGs achievable, effective and not imperialistic? I only hope that we can tell... before time will tell.

Welcome to the Global Health Leaders Program at UIC!

Vision

To increase the overall awareness of global health issues and to develop University of Illinois at Chicago College of Medicine student leadership in this field.

Mission

To provide the forum through which students will gain exposure to the global health field and to promote an exchange of ideas and skills to become global health leaders. We aim to promote a participatory community-oriented and responsible approach to global health issues.

History

As members of the UIC American Medical Student Association Global Health Committee, we saw the need and interest in creating opportunities for students to learn about global health issues. After learning about AMSA’s Curriculum-in-a-box, we felt that this should be implemented at UIC-COM.

This Blog will be used to post GHLP participant reflections on the seminars and the program as a whole.