The future of business is the future of public health

Crisis had been a feature of capitalism even before Marx gave it its name. The abundance of theories intended to explain crisis — from Marx to Keynes and beyond — demonstrates the centrality of disruption to production and profit.1 And, despite these many theories, cycles of crisis continue to mark our history: the Great Depression, the energy crises of the 1970s, the bust of the dot-com bubble, and the financial crisis we call the Great Recession.

The shock of crisis can give way to something better. The deprivation of the Great Depression ended in the social contract of the New Deal. The energy crisis gave birth to the modern environmental movement. The dot-com bust sowed the seeds for the transformative technologies that connect us today. The slow recovery and persistent inequality that followed the end of the Great Recession in 2008 suggest that we do not yet know what may come of this latest crisis.2

The future of business must overcome the social, environmental, and economic challenges of these crises. The transformation of business begins with the personal transformation3 of the leaders of companies, a conscious commitment to build a business as a participant in an ecosystem to endure disruption and move beyond profit to purpose.4 These leaders must find a way to meet the needs of all stakeholders, not just investors or shareholders by managing multiple bottom lines that track the impact on the well being of employees; the communities we touch; the environment and the resources we use; the crises we prevent; the services we provide: the health of the public.

When leaders consciously design their businesses to elevate society first, they help foster a more equitable and sustainable environment that promotes development and empowerment, builds capacity, and strengthens social networks and trust within a population. Positive social impact works well when it is participatory; it increases understanding of change and capacities to respond to change; it seeks to avoid and mitigate negative impacts and to enhance positive benefits; it engages in sustainable practices; it improves the skills of its workers, and it enhances the lives of vulnerable and disadvantaged people.5,6   

Public health is everyone’s responsibility, and no one is better equipped with the platform, the resources, and the access to markets than the business community. By infusing public health principles into a corporation’s mission and values, we all benefit.

  1. Shaikh, Anwar. “An introduction to the history of crisis theories.” US capitalism in crisis (1978): 219-241.
  2. “IMF fears ‘social explosion’ from world jobs crisis – Telegraph.” 2011. 30 Apr. 2016 <http://www.telegraph.co.uk/finance/financialcrisis/8000561/IMF-fears-social-explosion-from-world-jobs-crisis.html>
  3. “Whole Foods’ John Mackey: Self-awareness on Aisle 5 …” 2014. 30 Apr. 2016 <http://fortune.com/2013/03/08/whole-foods-john-mackey-self-awareness-on-aisle-5/>
  4. “Conscious Capitalism” Is Not an Oxymoron.” 2014. 30 Apr. 2016 <https://hbr.org/2013/01/cultivating-a-higher-conscious>
  5. Esteves, Ana Maria, Daniel Franks, and Frank Vanclay. “Social impact assessment: the state of the art.” Impact Assessment and Project Appraisal 30.1 (2012): 34-42.
  6. “CSV Explained – Institute For Strategy And Competitiveness …” 2014. 1 May. 2016 <http://www.isc.hbs.edu/creating-shared-value/csv-explained/pages/default.aspx>

 

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Preciva Strives to Make Cancer a Global Health Priority

I recently took the position of Director of Clinical Research at Preciva, an Oregon registered benefit company whose mission is to see that every woman and girl has a chance to live free of cervical cancer. Our goal is to make critical preventive screening affordable for women around the world and our first product is a field-portable electronic device designed to radically reduce the cost and increase the accessibility of cervical cancer screening.

Cervical cancer kills over 288,000 women annually, nearly 85% of them in low and middle income countries (LMICs).1 According to a report by the Cervical Cancer Free Coalition, approximately 26% of all cervical cancer deaths occur in India, accounting for more than any other country.2 Despite this significant burden of disease, India has no existing national cervical cancer screening program. Screening efforts are localized, opportunistic, and in many regions limited by the lack of available pathology resources and trained healthcare providers.3

It’s a troubling fact that the single greatest determinant of cancer survival is where you live. And for decades, complex comprehensive screening programs and cancer care have been neglected in areas of the world with weaker health systems, such as parts of India or in many nations of sub-Saharan Africa.4 However, it was also once thought that antiretroviral treatment and multi drug resistant tuberculosis therapy were not cost effective and too impractical to warrant wide scale administer in LMICs. Success in the fields of TB and HIV control have come mainly from coordination of financing and procurement strategies that have helped to streamline supply chains for therapeutics and diagnostics as well as integrate these advances into national agendas.4 The Clinton Health Access Initiative, for example, substantially increased access to generic HIV drugs and the government of South Africa drastically improved TB screening efforts through massive government-led campaigns.5,6

Despite the attention and advances in HIV, TB, and malaria, more deaths occur worldwide due to cancer than in these three diseases combined.7 However, donor funding available for cancer prevention and treatment is vastly disproportional to the growing worldwide need as this public radio international infographic displays.

cancer-funding-vs-mortality-lg

Barriers to the advancement of a global cancer strategy were a major focus at the Global Oncology Symposium at Fred Hutch Cancer Center in Seattle WA, “Making Cancer a Priority in Global Health.” This meeting brought together leaders and stakeholders in oncology, public health, industry, and foundations to discuss the current state of cancer prevention, screening, diagnostics, and treatment in a global context.

Through several presentations and panels, speakers worked towards defining priority areas in cancer research, advocating to build capacity in LMICs, and identifying gaps in knowledge and opportunities in funding. Much of the message was focused on looking beyond categorical programs and striving for broader system change. It’s widely acknowledged that in order to tackle global caner, we need better data systems for tracking, robust education on screening and prevention, greater investments in the healthcare workforce, and thorough program evaluation to understand what works and what does not.

The United Nations General Assembly will adopt the 2015 sustainable development agenda in September 2015 and this declaration is expected to include a strong stance on the reduction of non-communicable diseases. While this agenda is likely to result in new funding streams to combat cancer, it is critical that we build on the successes of HIV and TB and learn from what did not work well. I previously wrote about the unintended consequences of PEPFAR in Uganda, where despite its undeniable successes in improving access to anti retroviral therapy, this $15 billion investment also fostered the development of narrow disease-focused private programs and non governmental organizations that put strain on the greater public health system. The challenge to making cancer a global priority will be to invest in innovations that are reducing costs, improving access, and filling knowledge gaps while also supporting and strengthening the workforce and institutions needed to incorporate these advances into the broader health system. Further, countries must foster the political will to adopt screening and prevention initiatives as national policy and extend resources to link screening programs with treatment options.

At Preciva we hope to be part of the solution to improve access to affordable screening in areas of the world where cancer is disproportionally affecting the most vulnerable, starting with India, a country with a significant burden of cervical cancer. We strive to take a multi faceted approach through the development of better technology, the implementation and evaluation of our device, and by building partnerships with advocates and policymakers to integrate cervical cancer screening into a broader political landscape. To achieve these goals we are focused on initial clinical validation and design evaluation with partners at Apollo Institute of Medical Sciences and Research and St Johns Medical College in Hyderabad and Bangalore, India. Additionally we will work with Swasti, a Bangalore based international health resource center specializing in the social and management aspects of public health to develop an advocacy strategy for developing national and community-based cervical cancer screening programs and appropriate links to treatment opportunities. Through this research, Preciva strives to ensure that every woman has an equal chance to live free of cervical cancer.

  1. Singh M, Ranjan R, Das B et al. Knowledge, attitude and practice of cervical cancer screening in women visiting a tertiary care hospital of Delhi. Indian J Cancer. 2014; 51(3) 319-323.
  2. http://blogs.wsj.com/indiarealtime/2013/05/10/india-has-highest-number-of-cervical-cancer-deaths/.
  3. Nair M, Varghese C & Swaminathan R. Cancer: Current scenario, intervention strategies and projections for 2015. World Health Organization NCMH Background Papers Burden of Disease in India. 2015.
  4. Farmer P, Frenk J, Knaul F et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010; 376: 1186–93.
  5. Waning B, Kaplan W, King A et al. Global strategies to reduce the price of antiretroviral medicines: evidence from transactional databases. Bulletin of the World Health Organization2009; 87:520-528.
  6. http://allafrica.com/stories/201503250851.html
  7. Lozano R,Naghavi MForeman K et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.  2012 Dec 15;380(9859):2095-128.
  8. http://www.pri.org/stories/2012-12-02/global-cancer-infographics
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Hult Prize Challenges and Reflections

Last month I participated in the Hult Prize, a start-up accelerator competition funded by the Clinton Global Initiative and Hult International Business School to identify and launch social businesses that tackle the toughest health and development problems faced by the world’s most vulnerable. This year’s challenge was to design a business plan for a sustainable and scalable social enterprise to address non-communicable diseases of 25 million people living in urban slums by 2019.

 300 teams selected from 10,000 applicants in over 150 countries pitched their ideas at the Hult Prize regional finals on March 7 and 8 in Boston, San Francisco, London, Dubai, Shanghai and Sao Paulo. The Hult prize competition was initially designed for MBA students and aspiring entrepreneurs but in its 5th year, the challenge has grown to also draw participants from diverse backgrounds including public health, medicine, engineering, public policy, environmental science and others.

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 As a public health graduate of the University of Wisconsin School of Medicine and Public health I teamed up with 4 MBA students from the University of Wisconsin to design an ambitious plan to improve access to palliative care for urban slum dwellers. The palliative care landscape is extremely complex and opioids are some of most effective analgesic medications for the management of severe pain in end of life care. Several opioids are included on the World Health Organization list of essential medicines; however, due to restrictive regulations, gaps in medical knowledge and supply chain challenges, approximately 80% of the world’s population lacks adequate access to opioid medications for pain control.1 Our team’s goal was to develop a system that would better track and control opioid distribution with the hope of improving forecasting and country level supply. While we came up short at the regional finals in San Francisco, this experience gave us the opportunity to work closely with the UW Pain & Policy Studies Group and the group’s director Dr. Jim Cleary, a global leader in worldwide palliative care reform.

 In the public health community, the prevention of non-communicable disease is paramount for improving the health and well-being of the world’s population. However within the confines of this competition that focused only on treatment and care, the fundamental concept of prevention was off the table. As a health science researcher I am accustomed to attending conferences and meetings with likeminded people. The Hult prize experience, however, created a unique opportunity to bring together individuals from diverse backgrounds who all approach global health and development problems in very different ways.

I found that the nature of the competition highlighted an observed tension in global health between the desire to quickly address an urgent need with the value of an evidence based and evaluated intervention that requires great amounts of time and resources. The concept of an accelerator competition was quite new to me. In the grants based work of academic research, awards come when you have the science to back up your idea and clear roadmap of how to get there. The Hult prize judges, however, were looking for a  “million dollar idea” that they could throw support behind and help you figure out how to get there at a later time. For some teams, including my own, the product of this was a business model based on assumptions, speculation, and imagined benefit.

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 However not all ideas were conceived with the Hult Prize in mind. Worldwide Innovative Health care or WiCare, a women-led team from MIT presented a simple and easy to manufacture negative pressure wound pump to treat open wounds and infections that cause severe complications and sometimes death. This team is already well on their way to operating a successful business and has support form Massachusetts General Hospital, Partners in Health and Médecins Sans Frontières. WiCare’s pitch to the Hult judges was polished; they had an idea, a plan, efficacy data, and evidence of a clear demand for their product. They effectively convinced the judges that with Hult Prize support, their wound pump could scale up to improve the health of millions across the globe and they won the San Francisco regional round. WiCare along with 5 other teams will participate in the summer accelerator program. All six teams will meet in NYC on September 22, 2014 at the Clinton Global Initiative annual meeting and pitch their finalized ideas in front of President Clinton and other leaders in global health and innovation. One team will walk away with $1M in start-up funds.

 Many non-governmental organizations (NGOs) are already under pressure to perform in an increasingly competitive funding environment and numerous well-intended NGOs close up shop as soon as the funding dries up. The global health and development landscape needs to shift away form donor-based organizations to sustainable social enterprises to reduce or eliminate dependence on cash injections. And while Hult offers only one prize per year, this event fosters an environment where passionate individuals with diverse perspectives on health and innovation gather to debate a better way to improve health across the globe.

1. WHO Global Atlas of Palliative Care at the end of life, 2014

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Claire Wendland’s A Heart for the Work: Journeys through an African Medical School

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Medical anthropologist and physician, Claire Wendland’s A HeartFor the Work traces the development of medical students from their introduction into the University of Malawi, College of Medicine, through their preclinical training and into their lives as practicing physicians. Medical training is a distinct period of socialization that shapes the values and identities of trainees and influences how they will eventually practice medicine. While there is extensive literature on this topic in the developed world, there is a gap in the assessment of experiences of medical trainees from developing countries. Systemic injustices endemic in the global health community prevent biomedicine in sub-Saharan Africa from fully transitioning away from its colonial origins. When evaluating the lived experiences of young Malawian medical students, Wendland argues that medical training in a resource poor settings produces medical professionals whose moral attitudes are fundamentally distinct from clinicians in the developed world.

Doctors and scientists tend to view the stories they tell as objective, neutral, and transcending of culture. However, medicine and experimental results are hard to disentangle from the social and cultural structures that produce them. If knowledge is neutral, then how that knowledge is translated into practice and by whom, can reveal power structures and values in a society. How is the moral development of medical trainees shaped when the resources needed to practice biomedicine are unavailable? How are attitudes influenced when the lives of those who work in medicine are plagued by the same hardship and system failure that produces their patient’s suffering? Through rich narrative, detailed description, and personal anecdotes, Wendland offers insight to these questions.

In Malawi, traditional healing practices; witchcraft; colonization; the introduction of biomedicine; medical missions; and the creation of the first medical school represent a complex legacy of transnationalism and political struggle. The first Malawian medical students began their transformation into doctors at a time where the practice of biomedicine was seen as a tool for Africans moving towards independence and self-determination. The role of a physician was regarded as elite, humanitarian, and authoritarian and the class of Malawian medical students sampled in this work are mostly male, Christian, urban, educated, and unrepresentative of the country’s population. Primary motivations for entering medicine included altruism, pragmatism, and a sense of calling. Both the homogeneity in the group as well as the exceptionalities of the student population influenced how they came to view their role and their patients.

In chapter four, “Seeing Deeply and Seeing Through in the Basic Science Years,” Wendland describes how the medical students transform during the first few years as they began rigorous basic science training in their medical curriculum. Pressures to pass difficult barrier exams forced some students to choose between failing and cheating. Anatomy and physiology lessons gave students a new understanding of the body and many challenged traditional beliefs, giving them a sense of distinction from the general population and an identity as a scientist.

As the students transitioned into clinical trainees in “The World Made Flesh: Hospital Experience and Clinical Crisis,” Wendland describes how the social and economic realities of patients are fully intertwined with the workforce in the Malawian hospital. Staffing shortages and lack of basic supplies challenged student’s once held beliefs about the impact they may have on their patients and their community. As the developing clinician is confronted with nearly unbearable clinical challenges, hope and empowerment turned to doubt, anger, and resentment.

Wendlends argues that medicine has a moral economy that is constantly renegotiated based on social and economic conditions and those involved. Geographic, environmental, social, and economic determinants of population health vary vastly across the globe. Medical training cannot be regarded as universal, however, medical schools become accredited and physicians gain prestige by meeting “international” standards. These metrics, imported from the resource rich settings often include the number of papers published in elite journals, grant dollars funded, and awards won. Practically relevant matters like the number of lives saved and successful births under inadequate conditions do not count towards these standards. Therefore, the motivation to produce physicians of “international” caliber has left schools continuing colonial traditions relying on external exams and research “collaborations” that serve the interest of those seeking publication and funding over local needs.

While the modeling of standards imposed on medical institutions may stunt the progression of the Malawian health system, Wendland’s work reveals an inspiring key distinction between the Malawian students and doctors and their counterparts in the developed world. When clinicians in resource rich settings are pushed to the point of cynicism, they tend to become angry with their patients citing disgust and frustration with an individual’s treatment noncompliance, poor lifestyle habits, or an unwillingness to change behavior. The anger that Malawians feel is instead directed towards the inadequacies in the system claiming to care for their patients. While many clinicians in the developed world cope with this cynicism through emotional detachment or hardening, young Malawian doctors cling to emotion describing the “heart” needed to endure their work. This sense of solidarity with their patients is fundamental to the development of the Malawian doctor.

“When these doctors -to- be talked about their work, they used spirit (or love or heart) for the work interchangeably with spirit (or love or heart) for the people: ‘the people’ were Malawians, and the people were the work.”

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The President’s Emergency Plan for AIDS Relief (PEPFAR), a $15 billion commitment by former president GW Bush to fight the HIV/AIDs pandemic in resource-limited settings, has been hailed as the greatest bipartisan achievement of the Bush presidency. To date, it is also the largest health initiative by one single country to address one single disease. In sub-Saharan Africa, PEPFAR increased the number of HIV positive individuals receiving antiretroviral treatment from 50,000 in 2004 to at least 1.2 million by 2008 [1]. In addition, these funds improved health facilities, created numerous nongovernmental organizations (NGOs), trained tens of thousands of healthcare workers, and developed reliable drug supply chains across the African Continent.

Despite these exceptional achievements, researchers at Mbarara University of Science and Technology (MUST) in Uganda and Harvard Medical School have uncovered a PEPFAR-influenced unintended but significant consequence to the Ugandan health system. Recently, Bajunirwe et al published the results of a cross sectional survey among MUST medical school alumni who graduated before and after the influx of PEPFAR funding. They found that after PEPFAR, fewer Ugandan medical doctors were electing employment with government run public health facilities. This research offers empirical data on the distribution of the health workforce and the impact of multinational HIV funding.

The cohort analyzed in this study consisted of (n=796) MUST medical school graduates before and after 2005, a year when many large PEPFAR funded HIV programs launched in Uganda. The good news here is that these data showed a significant decrease in total brain drain. The number of Ugandan medical graduates who left the country to practice abroad before PEPFAR (15%) declined to (7.8%) after 2005. However, these post-PEPFAR graduates were 50% more likely to work at a newly funded HIV-related NGO instead of a public facility that provides free services to anyone in need [2]. Pull factors for NGO employment included higher salaries, better working conditions, and benefits. However this “internal brain drain” has exacerbated an enormous health workforce shortage in the public health system of Uganda.

With a rate of 1.8 health workers (including 0.1 physicians) per 1,000 population, Uganda is far below the World Health Organization’s standard of 2.5 workers per 1,000  [3, 4]. Further, those that access health services in public facilities tend to be the among the poorest and most vulnerable groups. With more medical graduates opting for NGO jobs that serve the wealthier proportion of the country and a rapidly growing total population, the health worker shortage in Uganda’s public facilities remains a significant barrier to meeting the needs of the population and improving health outcomes.

A recent call for redefining global health care delivery by Jim Kim et al emphasized the importance of consolidating services and integrating a shared delivery infrastructure to improve systems as a whole and take advantage of economies of scale. Shared infrastructure that consolidates public and private health facilities can improve effectiveness of preventative health measures by integrating essential health screenings such as HIV into a primary care model. Shared infrastructure also makes more efficient use of available human resources, equipment, facilities, and supplies [5].

Kim et al argue that a strengthened health system will not only improve health outcomes but bolster countrywide economic growth. Beyond the obvious notion that healthy people are more productive in the workforce, health systems provide jobs that build a middle class by employing not only skilled health workers but also support, maintenance, and community health staff. Further, health systems drive development through demands for local supplies, equipment, construction, and food service.

At this point in time foreign aid is a necessary component to accelerating the development of strong health systems in resource-limited settings. However, in Uganda, targeting singular diseases and creating private entities to combat them (as PEPFAR has done) is causing undue strain on a fragile health care system. Better health outcomes in places like Uganda will come only after improvements are made to the public health infrastructure through supporting ministries of health that prioritize staff recruitment and retention as well as efficient health service delivery.

1. Emanuel EJ. “PEPFAR and Maximizing the Effects of Global Health Assistance.” JAMA, May 16, 2012. Vol 307, No. 19.

2. Bajunirwe F, Twesigye L, Zhang M, et al. “Influence of the US President’s Emergency Plan for AIDS Relief (PEPfAR) on career choices and emigration of health- profession graduates from a Ugandan medical school: a cross-sectional study.” BMJ Open 2013

3. http://globalhealth.mit.edu/uganda-health/

4. http://data.worldbank.org/indicator/SH.MED.PHYS.ZS

5. Kim JY et al. “Redefining global health-care delivery.” The Lancet, 20 May 2013.

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The Role of Tryptophan Depletion on Depression in HIV-infected Ugandans

This morning at Mbarara University of Science and Technology in Uganda, Dr. Pricsella Martinez of UC Berkley gave a talk on the “Reversal of IDO-induced Tryptophan Catabolism to Improve Depression in ART-treated HIV-infected Ugandans.” She offered evidence to suggest that in addition to social determinants such as discrimination and stigma, immunological mechanisms might contribute to depression associated with HIV infection. In the developed world, HIV infected patients have decreased levels of the amino acid tryptophan despite evidence of adequate dietary consumption [1]. This problem is exacerbated in Uganda where a typical diet contains less than the recommended amount of protein [2]. Martinez and others sought to determine if HIV related tryptophan catabolism increases depression by depleting tryptophan that would be used for serotonin production in healthy adults. They sampled the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort to evaluate tryptophan catabolism as a potential indicator of depressive symptoms over one year. This analysis showed a strong association between tryptophan depletion and depression in HIV-infected Ugandans. In this cohort, when individuals were treated with antiretroviral therapy (ART), depression symptoms declined and tryptophan levels increased significantly [3]. While this certainly does not establish causality, these data offer a contributing biological explanation for HIV associated depression. However, a limitation to this analysis is a lack of baseline assessment of depression in the individuals sampled. Additionally, there was no evaluation of the impact that treatment in general may have on depressive symptoms. It is well established that receiving medical care of any sort—particularly for HIV—has a significant impact on and individual’s outlook and quality of life [4]. Nonetheless, this study draws attention to the vital role of nutrition and treatment of mental health in HIV positive individuals in rural Uganda. The speaker plans to confirm these findings with a randomized controlled intervention targeting protein consumption to see if increasing tryptophan may paly a role in mitigating HIV associated depression.

1. Murray MF (2003). “Tryptophan depletion and HIV infection: a metabolic link to pathogenesis” The Lancet Infectious Diseases – Volume 3, Issue 10.

2. http://www.fao.org/ag/agn/nutrition/uga_en.stm

3. Martinez, P.et al. Reversal of IDO-induced Tryptophan Catabolism May Mediate Antiretroviral Therapy-related Improvements in Depression in HIV-infected Ugandans. Program and Abstracts of the 19th Conference on Retroviruses and Opportunistic Infections, Seattle, WA, Abstract #462. 2012.

4. Sherbourne CD et al (2000). “Impact of Psychiatric Conditions on Health-Related Quality of Life in Persons With HIV Infection” Am J Psychiatry 2000;157:248-254.

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Effective mHealth Interventions Require Endorsement from Local Policymakers

Uganda has one of the highest maternal mortality ratios in the world where 435 mothers are estimated to die for every 100,000 live births.1 This compares to 16 per 100,000 in developed countries highlighting a vast global disparity and a need for strengthening of the Ugandan health system. Accurate characterization of the problem is essential for developing efficient policy to address system-wide deficiencies. The maternal mortality estimates we rely on are limited by variability, periodicity, and their wide confidence intervals.2

In recent years, researchers and developers have taken an interest in mobile communication technology to improve health-related services in the developing world. A huge surge in mobile phone (mHealth) projects across sub-Saharan Africa has emerged as mobile phones are penetrating the region in ways that healthcare infrastructure has not. Since public health and healthcare practitioners strive to provide and capturte accurate information in a timely fashion, mobile phones are an obvious message delivery and data collection tool.

As part of last summer’s family planning series in the Lancet, the authors called  for “infectious disease surveillance approaches” applied to maternal health. If every maternal death is reported in real-time via mobile phones then accurate, real-time, geographically stratified surveillance data could replace periodic estimates and improve data quality. Monitoring and evaluating the burden of maternal death and serious pregnancy complications is a key step in achieving Millennium Development Goal 5.

With the fast proliferation of mHealth projects across Uganda, the Ministry of Health (MoH) now recognizes significant gaps between these interventions and their outputs, evaluations, and results. To streamline and improve efficiency in this fast growing field, the MoH now requires approval before implementation of an mHealth project. Endorsement from policymakers and coordination between government, healthcare providers, researchers, and technology developers is essential to ensure interventions align with the objectives and priorities of the local stakeholders.

Investigators at the University of Wisconsin School of Medicine and Public Health and Mbarara University of Science and Technology are designing a pilot study to initiate a maternal health surveillance system in rural Uganda using mobile phones that connects output data with local decision makers. Here are a few words on the proposal from Ajay Sethi, PhD at the Wisconsin Global Heath Institute’s 2013 symposium.

  1. World Health Organization: Maternal Mortality Fact Sheet May 2012. http://www.who.int/mediacentre/factsheets/fs348/en/index.html accessed July 20, 2012.
  2. Gilmore K, Gebreyesus TA. What will it take to eliminate preventable maternal deaths? Lancet July 10, 2012, Vol 380.
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Ethical Foundations of Critical International Health

Recently, I attended the 10th annual Western Region International Health Conference at Oregon Health Science University, April 5-7, 2013 in Portland, OR. There, Dr. Chunhuei Chi of Oregon State University delivered the morning plenary talk: Against the Golden Rule- Ethical Foundations of Critical International Health. Chi described the “golden rule” as the ethical framework and political/economic structure that informs the current landscape of global health and development. Essentially, resource rich governments, organizations, and foundations hold the “gold” and therefore set priorities and make the “rules.”

Chi deconstructed traditional and neoliberal motivations behind participation in global heath, which are prominently dictated by compassion and human rights. Compassion, he argues, involves self-interest; ones own values; and a need for “similar possibility.” Priority setters tend to show greater compassion when the possibility for a problem is easy to conceptualized through the lens of their own lives and experiences. To illustrate this concept, Chi described how paranoia for the spread of the H1N1 in 2008-09 eclipsed the suicide epidemic of Indian farmers during that same time period. Although controversial, many believe this suicide spike was correlated with the World Bank’s policies that forced India to open its seed sector to terminal seeds from global corporations such as Monsanto, Syngenta, and others.1 Because the threat of flu felt more relevant and more likely to affect so called gold-holders, global resources flooded to the relatively tame H1N1 outbreak, while mental health and suicide remain sidelined.

While Dr. Chi certainly was not advocating for less benevolence in health policy, he did challenge the audience to critically examine how compassion from personal experience influences ones perception of a problem. Instead of emotion-based decision making, Chi advocates for a framework of ethical principles he calls “Critical International Health” which encompass human dignity, solidarity, and self-determinism. To further breakdown the golden rule, Chi suggests putting golden rule makers on the defense; holding developers, workers, and researcher accountable to the community they intend to serve; and reducing the need for “gold” by creating partnerships and building capacity.

This reimagined framework reminds us that as public health workers, clinicians, policymakers, educators, and citizens of the planet, we have a responsibility to act intentionally because the potential to do more harm than good is always looming.

1. http://www.huffingtonpost.com/vandana-shiva/from-seeds-of-suicide-to_b_192419.html

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Peak oil, food systems, and public health

Robert Lawrence, MD, from the Center for a Livable Future at Johns Hopkins Bloomberg School of Public Health spoke on “Peak oil, food systems, and public health” at Monday’s University of Wisconsin Population Health seminar series. Peak oil, introduced by Shell Oil Company in the 1950s, is the point in time when the maximum rate of oil extraction is reached. After this occurs, the global availability of petroleum will diminish indefinitely.1 While there is no consensus on when this peak will occur (if it hasn’t already), its certainty is well documented. Therefore, the cost of extraction—and thus food and oil prices—will rise substantially. Lawrence argued that without drastic changes to food consumption patterns and energy use in production, widespread food insecurity and famines are a realistic threat. Further, without  intervention, peak oil has the potential exacerbate existing disparities; US food insecurity disproportionately affects the poor and communities of color.1

The severity of this foreshadowed crisis will be determined by the level of global preparedness and food system resiliency. The public health community must play an active role to promote a fair transition to “lower oil agriculture” to devise a more sustainable food system. Lawrence went on to describe four mitigation strategies to adopt over time that will lessen the peak oil blow. He calls for reducing the use of oil in food production; increasing energy efficiency and renewable energy in the food system; changing food consumption patterns; and drastically reducing food transportation distances. Tropical fruits shipped to the US from Latin America will need to be a thing of the past. The question that remains, are policymakers, producers, and consumers willing to apply these adaptions before the effects of peak oil can no longer be ignored? You can view Dr. Lawrence’s April 1, 2013 talk here.

1. Neff RA et al. Peak oil, food systems and public health. The American Journal of Public Health September 2011, Vol 101, No. 9

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Health System Research in Rural Uganda: Perceptions from Local Leaders

This summer, I will spend 10 weeks in Mbarara Uganda working on a project with the University of Wisconsin Global Health Institute (GHI) and Mbarara University of Science and Technology (MUST). Here’s a little bit about what I plan to achieve there and why.

The World Health Organization’s (WHO) Millennium Development Goals (MDG) strive to improve public health by advancing social and economic conditions in the world’s most resource-limited settings. To achieve this goal, the WHO calls for strengthening of health systems and promoting interventions that focus on effective, efficient, and fair policies.1 Monitoring and evaluating the flow of information from policymakers to health workers and the impact these communication channels have on policy and health practice will reveal strengths and vulnerabilities in the current system. Participation and endorsement from local policymakers to develop health improvement programs will ensure that future projects align with the objectives of local stakeholders.2

While in the field, my goal is to perform a health system analysis designed to describe what health data is captured locally, how it is used to inform policy decisions, and where communication strengths and weakness lie between policymakers, healthcare workers and village residents. I will conducted this research in Sheema and Mbarara districts in Western Uganda (population 215,000 and 460,00 respectively) located approximately 300 km southwest of Kampala.

This analysis lays the groundwork for future interventions planned by the UW GHI and MUST. Within the next year, we plan to test whether providing real-time, aggregated surveillance data via mobile phone technology (mHealth) on pregnancy and related complications to policymakers will influence the allocation of resources to their constituencies. Phase 1 initiation begins May 20 and is planned to last through mid-July.

  1. World Health Organization: Maternal Mortality Fact Sheet May 2012. http://www.who.int/mediacentre/factsheets/fs348/en/index.html accessed July 12, 2012.
  2. Zikusooka CM, Loewenson R, Tumwine M, et al. (2010) Equity Watch: Assessing Progress towards Equity in Health, Uganda 2011, EQUINET, Kampala and Harare.
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