The Wellcome Trust Approach to Capacity Building

September 22, 2010

Val Snewin opened the session describing The Wellcome Trust, a global charity based in the UK dedicated to achieving extraordinary improvements in human and animal health, and how they fund different programs around the world to help build up health services workers, especially researchers. The Wellcome Trust funded seven consortia involving 70 institutes, of which the session highlighted funded work that impacts India, Kenya and Africa. Speakers from each country explained about how their programs are structured and their learnings – the speakers all agreed that the consortia need to focus on the long-term success like career paths in order to establish the right supporting programs, especially mentorship, that ultimately build up capacity and maintain it.

Andrew Haines from the London School of Hygiene and Tropical Medicine said the priorities of the consortia in Africa are developing mentorship, MSc training, supporting PhD students, professional development and career planning, and establishing research support centers in the region. They face many challenges though in making the consortia successful – money, Internet bandwidth, expectations and the government’s visa restrictions are all hurdles. Haines said there is no real financial reward for the staff’s time in research from universities so they actually have a net loss. With limited bandwidth in Africa, it makes distance learning a serious problem. They’ve implemented several approaches to try to address the challenges including sharing resources like research methods add staff development in region, they are doing more courses taught by LSHTM staff based in the country, and they are licensing distance learning courses.

For India, Srinath Reddy of the Public Health Foundation of India, spoke about the foundation’s focus on improving health outcomes through education;  research, policy and advocacy; training; and public health practice. PHFI is in partnership with the Wellcome Trust for capacity building – they began doing annual meetings in 2007, in which seven institutions participated – these groups had never previously collaborated. In 2008, that number has grown to 12. Its proposal to the Wellcome Trust is nurturing young faculty, fostering research, and active sharing of resources.

 Sam Kinyanjui of the Kenya Medical Research Institute walked through how they’ve managed to implement a program that has shown a strong track record of its students in the program going on to get PhDs or to Masters tracks – many of those in the Masters tracks have even submitted and were chosen for fellowships from the Wellcome Trust. The KEMRI does demographic and epidemiological surveillance for 240,000 people, clinical surveillance and investigation, and utilizes high quality labs and data centers. Kinyanjui showed a startling image of the KEMRI first research facility, a dilapidated small shed where they squeezed 20 members in, located in the middle of overgrown grass. Now, 20 years later, the research capacity is s large, high quality building with multiple spaces for training and which houses 750 staff.

 Prepared by Erika Bitzer


The Know-Do Gap: We know what needs to happen, but now we need to scale up and do something

September 22, 2010

The Know-Do gap was a recurring theme in this afternoon’s session, Health Systems and Implementation Science, focused on universities and researchers going beyond identifying the issues in global heath to implementing solutions which can scale and be sustained. Getting from knowing what to do, to actually doing it is a tough challenge facing health systems worldwide.

Dr. David Peters, the director of the Health Systems Program at John Hopkins University, approached the challenge by outlining a system that programs can follow along with the principles that need to be followed for it to be successful. His guidance on the principles were to focus on the purpose of the system, build on interventions that have already proved to be successful, scrap the blueprint, engage the key stakeholders, incorporate incentives, and use data for systematic learning. He also noted there can be unintended consequences.

Later in the session, Dr. James Blanchard, director if the Center for Global Public Health at the University of Manitoba spoke, and reiterated the concern of unintended consequences which is an oversight on the lack of complexity these “systems” have.

A student from the audience who had just returned from Zambia wondered if government programs or NGO run programs were more effective at implementing systems. Dr. Peters answered saying it depends. “ Both can be successful, but in many ways both can fail,” said Dr. Peters. He explained that sometimes NGOs can deal with things governments may not want to deal with, but there are other things those NGOs are weaker at. More than any which type of organization doing the work, he said it’s important to “Do it, measure it, show it, revise it.”

Dr. Rashad Massoud, the director of USAID Health Care Improvement Project, talked about applying improvement science to strengthen health systems. He reminded the group of the adage that if we continue to do what we are doing, we’ll keep getting the results we are getting; if we want something different, we must do something different. “Change must happen, but you don’t necessarily need to change everything,” explained Dr. Massoud.

He told us about work done in Niger to reduce post-partum hemorrhage – they know that when a woman receives three specific elements, one of which is a drug, they are able to essentially stop the hemorrhages from occurring. The new procedure was implemented but the drug needs to be refrigerated. Well, how accessible are refrigerators in Niger? Not very. They tend to be locked after hours, when many women go into labor. So while the solution was identified, they weren’t able to implement it consistently. So the teams started brainstorming and came up with the ideas of keeping the medicine in coolers or keeping the syringes on hand and bringing them to the delivery center. This solution effectively curbed the hemorrhages.

Prepared by Erika Bitzer


Engineering, Innovative Technologies and Global Health

September 22, 2010

The four panelists for the “Engineering, Innovative Technologies, and Global Health” session looked at ways that bioengineering is driving advances in global health.

 Joseph Hughes of Georgia Tech said that more 1.5 million children die each year because of preventable water- and sanitation-related diseases, but solving this problem isn’t easy. Water sanitation requires many things, including infrastructure, capital, and regulation. While there is no “silver bullet” technology yet for the developing world, there are promising developments, Hughes said.  Water can now be decontaminated by using UV rays from the sun to kill germs; Hughes is also looking at ways to sanitize water in bottles using visible light, which is a more abundant light source.

Catherine Klapperich of Boston University demonstrated a prototype of a small, portable tool that could be used to test a patient for HIV on the spot, or at “point-of-care.”  The tool, which is about the size of a student microscope, doesn’t require a power supply. The sample pops out of the tool so it can be processed and then shipped and stored. 

University of Washington professor Paul Yager showed slides of a point-of-care diagnostic tool prototype developed as part of the Gates Foundation-funded Grand Challenges in Global Health initiative. The tool, called DxBox, can detect six different pathogens and is about the size of a Netbook. “We want to be able to backpack it into a small village somewhere,” said Yager. DxBox is being developed by Seattle-area company Micronics. Yager also talked about what his lab envisions as the next step in point-of-care diagnostics – using a cell phone to run the diagnostic code or sending the data elsewhere for analysis.

The fourth speaker, panel moderator Sakti Srivastava of Stanford , described how students in the Biodesign program at Stanford prioritize clinical needs and then seek to address them through prototypes . Students in the program recently helped develop the Stanford-Jaipur Knee, a prosthetic limb now in trial in India.  Billed as the $20 knee, it was recognized by Time magazine as one of the best inventions of 2009.

The panel made numerous joking references throughout the session to the “valley of death.” This was described as the long, difficult passage between an idea or even the prototype and the product  actually being made and put to use. Does that mean that the need should always be identified first, someone in the audience asked? One of the panelists said there was no perfect answer. It’s important to have a need in mind, but you don’t want to suppress the innovation that comes out of brainstorming either.

Prepared by Mary Janisch


Chronic Diseases, Innovations in Health Systems and Data for Decision Making

September 22, 2010

The participants in this session all reinforced the need for using innovative approaches to address global health issues. In describing the problem of rising cancer incidence in developing countries, Sofia Merajver quoted the gospel of Matthew, “The harvest is plentiful, but the workers are few.” She pointed out that the vast burden of cancer deaths is borne by low and middle-income countries, which have the fewest resources to deal with cancer and other chronic diseases. Recognizing that strategies for addressing cancer deaths in high income countries are not appropriate for low income countries, her team developed local cancer registries, which allowed them to better understand the types of breast cancer affecting women in North Africa and the Middle East. This in turn led to dramatic reductions in stage 4 breast cancer.  

In a similar way, Pamela Andreatta and colleagues were able to use cell phone technology to show that use of bimanual uterine compression can reduce deaths from post-partum hemorrhage. Her team trained illiterate traditional birth attendants in rural Ghana to collect data and report it via SMS messaging. A spinoff of this research was the growing sense of empowerment of the traditional birth attendants.

Woutrina Miller provided another example of ways in which technology can be borrowed from one arena and used to meet global health challenges. She described an innovative and cost-effective way of detecting water-borne pathogens which uses the principles of hemodialysis technology to concentrate pathogens from large water sources. 

Two of the panelists reported on efforts to address chronic diseases in Brazil. Beatriz Carlini spoke about a study on the impact of telephone counseling for those wishing to quit smoking in Brazil, and James Macinko presented some work showing that Brazil’s roll-out of a strong, universal primary health system was associated with a dramatic reduction in hospitalization rates.

Finally, Erika Arteaga, from the People’s Health Movement, gave some provocative comments on how policy decisions based on the principle of economic growth can actually lead to worsening health, and gave the example of the 3-fold increase in cancer incidence among indigenous people impacted by the Texaco Oil Spill in the Amazon. She alluded to the need for stronger advocacy for the rights of vulnerable populations, and promoted a political ecology framework for looking at global health issues.

Prepared by David Roesel


A System Approach to Prevention and Control of Diabetes, Cardiovascular Disease

September 21, 2010

Diabetes is one of the top ten non-communicable diseases worldwide with an increased risk of death.  Current treatment systems support curative medicine but they fail to include lifestyle interventions.

To reduce the risk of death in developing countries, interventional programs must be seen as a top priority in disease management. The qualities of systems using interventional programs include data measurement; decision-making, low cost options and scalability. 

By adding prevention strategies such as blood glucose screenings, symptoms of metabolic syndrome can be diagnosed.  Early treatment of metabolic syndrome reduces the risk of diabetes and other co-morbidities associated with non-communicable diseases.  

Lifestyle interventions such as screenings by local lifestyle coach’s support healthy living, are cost effective and sustainable.  Great work in being done but more evidence is needed from developing countries about the benefits and feasibility of these programs. Universities can support the development of studies that provide additional information needed to support future investments in system infrastructure and program growth.

Prepared by Anita Beninger


Health of Women, Mothers and Children

September 20, 2010

State-of-the-art medicines and technologies won’t help people in poor, medically- underserved countries unless the people can gain access to those benefits, panelists said. 

Dr. Keith Martin, who is also a member of Canada’s Parliament, talked about feeling helpless in Africa while a patient “died of bloody worms, for the want of a few pennies worth of meds.”

He noted that 344,000 pregnant women die each year from preventable causes because of lack of access to the right help. Twenty times that number of pregnant women suffer life-altering injuries annually. About 8.8 million children die each year. Meanwhile, 90 percent of the world’s health research focuses on diseases affecting Western nations, Martin said.

Martin contended that a focus on primary caregivers can funnel and unify research, donations, patients and support to “one unifying place.” 

But James Kiarie, senior lecture for obstetrics and gynecology at the University of Nairobi, warned that people tackling these problems need to know that teamwork is a key, troubles must be addressed on several levels, and they should be aware that no single “silver bullet” solutions exist for any problems. Also, solutions won’t necessarily be cheap, he added.

Meanwhile, Mike English, a senior researcher for the KEMRI-Wellcome Trust Research Program in Nairobi, Kenya, said that medical research needs to take into account the complexity and context of how it will be applied in poor nations. Also, much thought must be given on how to measure starting points and progress in dealing with specific health problems in poverty-stricken countries, he said.

The nations themselves need to be involved in planning how aid should be provided to primary caregivers and their patients, said Kiarie and Jaime Sepulveda, director of special initiatives at the Bill & Melinda Gates Foundation.

In Kenya, experiences show that the nation’s universities would be good places to expand health care, Kiarie said. But primary caregivers and other medical people must buy into whatever plans are mapped out. Access, cultural appropriateness and participation by men are crucial to HIV screening and treatment, plus pregnancy care, he said.

In the Democratic Republic of Congo, war, rebellion banditry rule — with rape being widespread. No accurate statistics have been kept, but it is estimated that roughly 6 million people have died because of the conflicts in the eastern part of the country — the majority from health problems due to the violence, said Nancy Glass, an associate professor at Johns Hopkins University’s School of Nursing and an associate director of the college’s Center for Global Health. 

Rape survivors — women and a growing number of men — have limited access to health care.

Besides improving medical access, other measures include social and medical workers trying to mediate between victims and families dealing with the stigma of rape. Another health measure — economically improving lifestyles — is hampered by the fact that even a $50 loan is considered too big and scary by many eastern Congolese families, Glass said.

The answer has been Pigs for Peace. Livestock is a major money source for eastern DRC families, and is a major plank of the economy. But the culture forbids women from selling many types of animals. The exception is pigs.

Working through village associations, Pigs for Peace will provide a pig to a person with that individual to repay with two piglets from the first litter. A $14,000 investment has sent pigs to 186 families in 14 villages since December 2008. Another 700 families are on a waiting list. 

Glass noted that the people are taught how to care for their pigs, and that a danger exists of a virus potentially wiping out an entire village’s pig population.

A Washington State University veterinarian student asked how she could help with the project’s veterinary needs.

Glass replied: “Anytime you’re ready to come to the Congo.”

Prepared by John Stang.


Derek Yach: Now’s the time to start thinking about chronic diseases

September 20, 2010
Derek Yach

Derek Yach, PepsiCo

Most informed people still equate “global health” almost solely with communicable diseases such as AIDS, malaria and tuberculosis as well as maternal and child health. The reality however is that non-communicable diseases (NCD), especially comprising heart disease, diabetes, cancers and chronic lung diseases are today by far the major causes of death and disability in all WHO regions with the exception of Africa. Even more concerning is that the underlying causes of these diseases including tobacco use, unhealthy diets and obesity, alcohol, and physical inactivity are increasing as risks in all developing countries.  

Today I will be moderating a session at CUGH on Prevention and Control of Chronic Diseases and am excited to see so many of the top academia and global health leaders on these issues coming together to discuss such crucial topics as the tobacco epidemic, diabetes and mental health.

These conversations will be critical as we are just one year away from the UN Summit in New York during which heads of state will address non-communicable diseases and hopefully agree on actions to prevent further increases. Having spent many years at the World Health Organization where I addressed chronic disease prevention and control, and now being at a major food company, it has been clear that the potential for innovative private public partnerships will remains an untapped and crucially needed route to successful public health impact. Over the last decade we have seen how such partnerships have spearheaded new product development for infectious diseases, new funding mechanisms that have created markets for needed vaccines for developing countries and effective ways of leveraging corporate capabilities to address micronutrient needs. We now need to apply lessons learned from partnerships such as the Global Alliance for Vaccinations and Immunizations (GAVI), Global Alliance for Improved Nutrition (GAIN), Medicines for Malaria Venture (MMV) to chronic diseases and their common risks.

So now is the time to get organized for next year’s Summit.  CUGH members and conference participants, academia and researchers, food and other industry leaders: now is the time to start thinking about what your role is so we can put the strongest data, ideas and commitments on the table and have a strong clear voice at the UN Summit next year.  New UNICEF and WHO data have shown how much progress has been made over the last decade in addressing key MDG targets.  Let’s use the extraordinary breadth and depth of committed global health leaders present in Seattle to chart a new path for NCD control that rests upon academic excellence and capability 

Dr. Derek Yach, Senior Vice President, Global Health Policy, PepsiCo, Inc. will be moderating Prevention and Control of Chronic Disease at the conference at 1:45 pm in room Kane 220. His recent summary of industry actions to address chronic diseases is available at: http://www.globalizationandhealth.com/content/pdf/1744-8603-6-10.pdf

 


K.M. Venkat Narayan: Chronic Diseases – a Major Global Challenge that Threatens Health and Economies Alike

September 20, 2010

Venka Narayan

The impact of chronic diseases to the health and well-being of the world is a growing threat – not only to the health and well-being of people from all countries but to all economies – rich and poor —  as well.

Already, Mexico is overtaking the United States in the proportion of people obese and overweight. And in India and China, the prevalence of diabetes is much higher than the United States. In urban India the prevalence rate of diabetes is about 16-18% and in the United States it’s about 9%.

In fact, six of the top 10 risk factors for mortality worldwide are chronic disease not infectious diseases, according to a recent report from the World Health Organization. They include high blood pressure, tobacco use, high blood glucose levels, physical inactivity, overweight or obesity and high cholesterol levels.

These risk factors pervade countries of all income levels, even in low-income countries.

A lot of the solutions are going to require active global cooperation, such as what’s being done in climate change. But the awareness is not there yet. Most governments and funders believe that in developing countries the most pressing issues are only with infectious diseases, undernutrition and maternal mortality. People with chronic diseases are most vulnerable to infectious diseases. People with undernutrition are vulnerable to chronic diseases. So, these are all inter-connected problems. The biggest impact on Millennium Development Goals (MDGs) for HIV and tuberculosis reduction and infant andchild mortality could be to invest in chronic diseases – may sound counter-intuitive and paradoxical, but data support these assertions. Although chronic diseases are not part of the MDGs, we cannot meet the MDGs unless we invest in chronic disease prevention and reduce their impact on mortality. Without a huge investment in chronic disease prevention, economic activity will greatly decline because of the loss to workforce and health care costs. This will affect high-, middle-, and low-income countries all alike. 

Solutions need to come in three main forms: 1) At the policy level, major economic lenders like the International Monetary Fund, World Trade Organization and national governments need to address chronic diseases with a sense of urgency.  2) At a consumer level, transfats should be banned like cigarettes; salt in processed foods should be reduced; there needs to be stringent regulations on food labeling; strategies need to focus on reducing intake of refined carbohydrates, and there needs to be promotion of healthy fruit and vegetables. 3) At the health-system level, more attention needs to be given to chronic diseases. This means health systems need to be strengthened and reoriented toward prevention and management of chronic diseases. Trials have shown that 50-60-% of diabetes could be prevented if there were prevention-oriented clinical systems focused to chronic diseases rather than an acute medicine model of care.

For more on this topic, see the perspectives article “Global Noncommunicable Diseases — Where Worlds Meet” published in the New England Journal of Medicine Sept. 15 by Emory researchers, including myself, Mohammed K. Ali and Dr. Jeffrey P. Koplan.


David Fleming: Global Health: A Two-way Street

September 19, 2010

David Fleming

As budget constraints tighten and we think about how to invest our education dollars at universities, tax payers have a right to expect a return on that investment.  When it comes to global health studies at universities, that return is not always obvious.  As I talk to people across King County and the country, I find that they tend to think of “global health” as something that benefits people overseas.  Yet, we increasingly find that global health is a two-way street.  What we learn and the strategies we use in global health can also greatly improve health in our own country.

Reality check: Although the United States has the world’s best medical system, we do not live as long or as well as Bosnians or Jordanians.  The U.S. is not even one of the top 25 countries with respect to indicators of health.  Why?  Because although we have poured money into our clinical health care system, we have neglected community health.  As a consequence, communities across America have health indicators on a par with those in developing countries.

What global health strategies might also work at home to improve health?  One example is community health workers–people from the community who are trained to deliver frontline health information to their neighbors.  It’s low cost and highly effective, particularly for reaching communities that have been marginalized on the basis of culture or language, and whose members may have difficulty understanding or accessing health care professionals.

Global health also teaches us that technology can leapfrog over barriers in delivery.  For example, across much of the developing world, cell phone technology is filling in for a lack of physical infrastructure—like roads and health clinics.  We could make some of the same leaps: video phones can be used to watch people take their tuberculosis medicine rather than having to send an expensive healthcare worker to the patient’s house.  Or we can use cell phones to deliver messages in an emergency in languages that are understandable to non-English speakers. 

Additionally, we should borrow a page from global health in our approach to linking health and economic development.  We know that poor health is strongly linked to poverty. Globally, micro-credit loans are being used to improve family income and health.  Why not do the same here?  For example, microloans could even pay for citizenship applications—which cost $700.  The benefit: citizenship is linked to higher incomes and higher incomes are linked to better health.  But many who are qualified and would like to become U.S. citizens cannot afford the application fee.  And all loans need not be “micro”.  Larger low interest loans could enable corner groceries in poor neighborhoods to invest in the equipment for stocking healthy, nutritious fresh fruits and vegetables. 

Let’s use the conference of the Consortium of Universities for Global Health to build out such ideas and to establish the collaborations that can make them happen.  Global health and local health is a two-way street.  The job in front of us is to make it well traveled in both directions.

David Fleming, M.D.
Director and Health Officer for Seattle and King County Public Health


Hon. Keith Martin: How Universities Can Save 9 Million Lives a Year

September 15, 2010
The Honorable Keith Martin

The Honorable Keith Martin

A lack of capacity is one of the major restrictions to development and human security in low income countries (LICs).  Only 10% of the world’s research is done on the disease burden shouldered by the worlds poorest.  Building and retaining the human skill sets needed by LICs is one of the great challenges of our time. 

There is a way to tackle this problem by utilizing the highly skilled individuals in universities in the West to train people in LICs.  I have a proposal for universities in the West to develop Centers for International Health and Development (CIHD) in their institutions. These centers will act as a conduit to link their universities with institutions in the south and facilitate North/South and South/South partnerships. By using a multidisciplinary approach, doctors, nurses, engineers, public management specialists, social scientists, and others, our universities can be used to develop these skill sets in LICs.  The private sector, NGOs and government institutions can also be brought together to fund and implement these activities.

Building and retaining the skill sets needed for a competent and incorrupt public service, judiciary, and private sector is essential for any country to develop. Guided by the recipient nation our universities can play a crucial role to make this happen and in so doing will help developing nations break the shackles of poverty.

Hon. Keith Martin, M.D., M.P.
Parliament of Canada


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