Archive for Uncategorized

My Ugandan Global Health Academy, Summer School Experience!

When I received the invitation for the Global Health Academy summer school in Uganda, I have to admit I was hesitant.

After just finishing my first year on the MPH course, I wondered if I could muster the motivation to do one more minute of work until the next term. However, after re-reading the course itinerary numerous times, I finally persuaded myself it was the right decision to go.  The itinerary was just too tempting; 4 days of summer school and 2 bonus days of chimp tracking in the forests of Budongo?

With flights booked, I ran over the checklist for Kampala and Budongo again and packed my things. Budongo was going to be quite different from Kampala and we needed to be prepared for that environment. We were given the link to the Budongo Wildlife website beforehand which gave full information on where we would be staying and everything we needed, including how to behave whilst visiting the forest.

The university discussion page went over accommodation and transport in both Kampala and Budongo and all my questions were answered quickly and informatively.

To be honest, I didn’t know what to expect from the school. I felt quite out of my depth at first, with my limited global health experience, and having only just completed my first year? However, my fears were soon put to rest as this scary bunch actually turned out to be some of the friendliest and motivational, individuals I have had the pleasure to share a room with, staff and lecturers included.

Makerere University pic 1 Makerere University pic 2

 

 

 

 

 

 

 

 

My co-students were a group of professionals, from all over the world, studying a number of different disciplines at various stages in their studies, however, it soon became evident that no matter what background we came from, we all shared a passion for making the world a better place.   I felt immediately at ease.

Dr Ricky Okwir, University of Edinburgh Alumni

Dr Ricky Okwir, University of Edinburgh Alumni

 

 

 

 

 

 

 

 

To briefly summarize: The lectures were inspiring; the activities were thought provoking and the teamwork brilliant! Everyone got stuck in and shared all they had to share.  There were many brave people who stood up to give presentations on their topics, (myself not included, but I will certainly be on the list for next year) and we received lectures from faculty ranging from epidemiology to simply how to reference properly.  There were many questions and many discussions, but we always had time for a laugh, cup of tea and deep fried cup cake!!

The summer school not only taught me a great deal academically, but also gave me the opportunity to learn from other cultures and nationalities, the value they put on their environments, from a social, medical and environmental perspective. There were so many ideas and all added something to the wealth of knowledge the summer school brought about.

Of course, our experience in the Makerere University was just the start of our adventures. We still had the trip to Budongo to look forward to.

Accommodation at Nyabyeya Forestry College

Accommodation at Nyabyeya Forestry College

Accomm Budongo 2

After a few hours bus trip (stopping off to investigate the local culture on the way) we arrived at what I would describe as a little haven, right out of a holiday magazine. Our very basic but comfortable accommodation set amidst the luscious forest at the Nyabyeya Forestry College. It was certainly a sharp contrast to the hustle and bustle of Kampala.

We travelled a little way to the Budongo Wildlife Reserve after settling in, where we were welcomed with dinner, tea and coffee, a very informative introduction to the reserve and a briefing on what we could expect from the next couple of days.

What a couple of days we had! We participated in monkey and chimp tracking with highly skilled staff who also gave us an introduction to the whole ecosystem of the forest.  We met other visiting teams who were studying the forest and the surrounding areas and enjoyed discussing their experiences, having been based there for the last 4 weeks.

We were not just treated as passive visitors, but expected to report back on the day’s findings. Our feedback was very much valued and gave us a chance to really get thinking in groups, about things that would contribute to the continued success of the research centre and surrounding areas.  We discussed improving awareness and promotion of the project, and ways that would promote the engagement of the community.  I suddenly found myself utilizing a number of concepts we had learnt throughout the MPH course and the lectures we had received earlier in the week.
Budongo 1Budongo 2

 

 

 


 

 

 

Following this we followed our guides into the forest for a spot of snare patrol, where we were taught how to find and identify snares often set by hunters. These ranged from small wires to huge mantraps, all an extreme hazard to creatures living in the forest, and also forest rangers.

Budongo 5

 

We later visited local villages where we were given a talk about the on-going battle bco-existence of humans and wildlife. We learnt about sustainable crop development and the setting of buffer zones in order to control the disruption of local communities by the chimpanzees and other animals living in the forest, which frequently visit to crop raid when food levels are low in the forest.

Only too soon, it was time to return to Kampala and make our way home to our respective countries, to take back all that we had learned and apply it not only to our studies but to our everyday lives and those around us.   I couldn’t wait to get started!

To say I have learned a great deal would be an understatement and it is with great pleasure that I write to inspire others to join in the next one.


 

Seonaid Biagioni, Masters of Public Health, University of Edinburgh

Building our collaboration with Stanford

The event New Perspectives in Compassion held at Stanford University California on 16th March was the first academic collaboration between CCARE and the Global Health Academy (GHA) following the launch of our Compassion Initiative in September in Edinburgh by the Principal. We are very grateful to Dr Monica Worline , deputy director, and Professor Jim Doty director at CCARE for their impeccable organisation. It was attended by just over 200 individuals including Edinburgh and Stanford faculty, students and alumni, and those living in the Bay Area and provided a series of short presentations by Stanford  and Edinburgh academics from a number of disciplines in the sciences and humanities.

New Perspectives in Compassion Panel

New Perspectives in Compassion Panel

 

http://ccare.stanford.edu/events/perspectives-on-compassion-new-thinking-from-stanford-university-and-the-university-of-edinburgh/

It was part of the Edinburgh University’s pop-up week in the Bay area of California, which also included events on big data, veterinary medicine, and history.

We were really fortunate to have the active engagement of the Principal, Sir Timothy O’Shea for the afternoon. After an introduction by Jim Doty and Liz Grant, the first session included a short talk and reading of a poem by John Gillies (written by a Stanford medical graduate) from the second edition of ‘Tools of the Trade’. This is a small volume of poems gifted to all new medical graduates in Scotland for the past two years.

Prof Paul Gilbert, an Edinburgh alumnus, and the psychologist who helped to kickstart research and education in compassion over two decades ago, gave an overview of his developing work including psychological tools to help people with moderate to severe problems of anxiety and self esteem.  Monica Worline introduced the theme of compassion in the workplace, the importance of shifting the balance of efficiency and effective measures from material linear outputs to relational outputs, the satisfaction, the ability to enjoy work, the opportunity to grow and flourish in a work environment. Following Monica was one of CCARE’s research partners, Professor Anne-Birgitta Pessi, a visiting Professor of Church and Social Studies from Finland. She summarised a novel approach based on Ricoeurian theory and using specific training to improve compassionate behaviour in leadership and workforce in large corporations in Finland, based on a novel approach called Co-Passion training -http://blogs.helsinki.fi/copassion/copassion-seminar/

The second session had a recorded contribution from Dr Paul Brennan, Co –Director of the Edinburgh GHA Compassion Initiative on the effects of neurosurgery on compassion in patients. Brian Knutson, associate professor of psychology at Stanford spoke on the neural basis of emotions, and we finished with a fascinating talk by associate professor Firdhaus Dhabhar , a Stanford psychiatrist who spoke about the ill effects of chronic stress on immunity and accelerating ageing, and how these can be mitigated by social support, mindfulness and meditation.

 

Professor James Doty, Dr Liz Grant, Dr John Gillies

Professor James Doty, Dr Liz Grant, Dr John Gillies

The second half of the afternoon was a distinguished panel, moderated by Jim Doty on The Compassionate Robot: myth, nightmare or solution. We selected this subject because of the rapidly developing technology around robots and their increasing use in healthcare and social settings across the world.  Principal Sir Tim O’Shea suggested that while a non human robot could not provide truly human compassion, it could provide ‘artificial compassion’ where that would be of utilitarian benefit. However, human compassion also had its inauthentic side as well, he suggested. Rev Professor Jane Shaw, Dean of Religious Life at Stanford gave a Humanities based perspective on what it means to be human: having what Adam Smith called ‘fellow-feeling’ or sympathy. In society today this she argued is often characterised by the shared construct we know either as compassion (which is based on a Buddhist model) or grace ( the word that encapsulates compassion emerging within the Christian tradition). Our understanding of compassion in robots can be much enhanced by looking through the lens of arts and humanities.    Alastair Boyle, Global Client partner of Google and head of strategy at the company Essence looked at compassion in advertising, illustrating this with the ‘Dove’ soap campaign which purposefully set out to make women feel better about themselves. He admitted that the strategy used by all companies now of tailoring advertisements though individual’s internet searches could in fact provide inappropriate and unhelpful targeting at times. He also touched on the ‘uncanny valley’ problem of life-like robots making people feel uncomfortable.

Jon Oberlander, professor of Epistemics here at the University of Edinburgh talked about robotic developments which enabled them to perceive and respond to human emotion, also the benefits and problems associated with robotic carers providing ‘care’ but reducing interaction with human carers. Ultimately, he said, ‘robots just don’t care’, in the metaphoric sense, however the responsibility to care lies not with the robot but with the creator.

The afternoon provided both a breadth of disciplinary approaches and, at times, a surprising depth of insight into the rapidly developing area of academic work on compassion. There was a great deal for our Global Health Academy’s Global Compassion Initiative to build on for the future; much more to come!

 


Dr John Gillies,  Senior Adviser Global Health Academy, Co-Director GHA Compassion initiative

Dr Liz Grant, Director, Global Health Academy, Co-Director GHA Compassion Initiative

The world is changing – will your PhD matter?

At the dawn of the Sustainable Development Goals (SDGs) – which ushers in 17 new goals in a global agenda to “end poverty, protect the planet, and ensure prosperity for all”, most countries will be realigning their national development goals to be in tune with these global goals to realize specific targets over the next 15 years. As a researcher, one thing will soon become obvious in the midst of this global effort to bring about change – that is future research grants will be awarded primarily around these 17 SDG goals. An important question – “how your research fits in this global agenda?” arises for you and other PhD researchers who will soon be applying for these grants to drive your respective fields forward with whatever piece of the bigger science puzzle you will be solving.

It will not be an easy task to find one’s footing in the fast changing terrain of global goals and priorities, and Dr Liz Grant of the Global Health Academy at Edinburgh University is not shy to point this out. But, thankfully, not without some pointers to a way forward. Dr Grant has had extensive research experience at the level of Global Health with her many years of research in palliative care around the globe. In her talk on the ‘Impact of PhD Researchers on Global Health’ which she delivered at the Global Health PhD Network event in October 2015, she had a lot to share.

In a talk that was neatly supplemented with real life examples of her own research, Dr Grant carefully led the thoughts of the PhD researchers in the room on a number of issues, which in her opinion will soon become important in their researching career in the light of the new SDGs.

Top of her list was the need for PhD researchers to start thinking of where to find other pieces of evidence for their research. “What matters in your PhD”, she said, “is pulling materials from connected disciplines and connected areas and making sure you draw them in – use the materials out there…network pieces of information together”. In truth, that is how science works in our day through extensive bridge building across multiple disciplines and you probably have come across this a number of times already in your field. The rewards of this approach is long term and may not be immediate which in the little time space of a PhD makes it appear impractical. But in Dr Grant’s view, your research questions are still questions because there have not been enough conversations around them for others before you to have answered them. This is a brilliant way to look at things because in a way it challenges you to start expanding the discourse around your research to span more than just the area of your interest, to generate interest in other relevant fields.

But what good might all that knowledge you obtain as a result be, if not for the good of mankind. “Knowledge for knowledge sake is wonderful”, she says, “but knowledge to make a difference is why you are here and why I am here and why the university is here”. The message here is pretty simple – don’t let your PhD be only just another addition to the vast collection of information sitting on shelves around the world and only collecting dust. But it should be one that works and makes a difference. And she thinks you can achieve this by starting to think about your PhD research in terms of who the constituents are (i.e. those directly affected by what you are doing), how you will engage the public on important issues like the burden of the problem you are dealing with or trying to help solve, and also the economics involved and equally importantly why your research needs to be prioritised in the face of other competing research.

Huge task, but is it beyond you? Of course not. A big step forward in making any of the impact that would make your PhD research matter is through advocacy. Because the impact is kind of often seen through advocacy, she said, in doing things like, writing blogs, getting local workshops, and communicating what you are studying to people who have the connections to make things work. “People built systems and people can take it down,” she says in reference to the perpetual ‘brick walls’ of resistance that bureaucracies will mount on your path. Keep talking to as many people as possible and never ever underestimate the power of networking because you can change things in partnerships.

In bringing all this home, Dr Grant urges PhD researchers to think once again about their PhD and ask themselves what are the core components of what they are doing. For instance in her own research in palliative care then this would be about the core components of a health care system. Ask yourself if your research is around the core components. If not, what can you do to create the conditions necessary for change? Are you getting the right materials at the right time to create these conditions? And will these conditions support a sustainable system? Also what is the national architecture like in your country that will mean your piece of research can fit in. Answers to these questions and a lot more which couldn’t fit in this piece are what in Dr Grant’s expert opinion would make your PhD make an impact.

“Never forget why we research, you and I – it’s our communities, it’s our families, it’s people.” Dr Liz Grant

Dr Grant’s talk was preceded by a lively PhD poster session that saw four PhD students from the University of Edinburgh present their research work from four different regions around the globe. The first poster by Sara Valencia looked at vaccine trials in Southern and Central America (Colombia, Brazil and Mexico). A second poster that looked at the prevalence of Non-communicable Diseases and the entitlement to and the use of health services in the Gaza strip was presented by Majdi Ashour. Mkululi Wami presented the findings of a research work he carried out in Sub Saharan Africa in Zimbabwe which used antibody responses based on parasite egg counts to estimate infection prevalence of schistosomiasis in young children. The last poster was presented by Ai Oishi on a research that sort to identify patients for palliative care approach in primary care settings in Japan.

The Global Health PhD Network started, in October 2014, as a student-driven interest group within the Global Health Society, University of Edinburgh, with the express aim of bringing together like-minded postgraduate researchers from the three colleges in the university for research sharing, knowledge and skills exchange, networking and shared global health career development. The Network has hosted a series of events during the past year to bring together PhD researchers in the university to listen to and to share thoughts on important issues surrounding global health. And their most recent event (the one I just described) was yet another opportunity for the Network to reiterate its vision of creating an environment that supports and promotes cross-disciplinary networking by inviting PhD poster presenters from all three colleges of the university.

Again, looking back at some of the key points in Liz’s talk on the importance of networking and advocacy for PhD researchers, you realise that the Global Health PhD Network has its priorities well placed, doing things right as it should be and is already on the right bus into the future.


Richard F Oppong, Institute of Evolutionary Biology, University of Edinburgh

Rewarding research: Social Science and Health Research in Zambia

Rewarding research: Using my ‘self’, psychotherapeutic perspectives and reflection in social science and health research in Zambia

Following a long career in the NHS in Scotland as an Art Psychotherapist and leading several projects training mental health staff in Ghana and Zambia, I embarked on an MSc in Africa and International development at the University of Edinburgh.

My MSc incorporated a work-based placement at ZAMBART[1] in Zambia where I conducted a secondary analysis of case studies of households caring for patients with TB /HIV – from a mental health perspective. This gave me the opportunity to include my ‘self’ and my professional knowledge and stance as elements which worked in dialogue with each other as to inform and shape my dissertation. .

This was no mean task and required both reflection and personal challenge – an acceptance of painful self-realisations – in order to expose the normalised assumptions endemic in my attitudes. I judged men as ‘bad men’ – when their risk taking behaviours impacted on their families. Recognising this and then understanding these behaviours from a non-judgmental psychotherapeutic stance enabled the complex systemic relationships around men’s mental health in rural Zambia to no longer be hidden in a blind spot – beginning their exposure to greater understanding and analysis.

Such fruitful discoveries from such a self-reflective approach and a psychotherapeutic stance point add to the enhanced value of practitioners engaging in research and the blending of psychotherapeutic stances with research objectives.

More detail on this aspect of my work-based placement is given in  Who Cares about Mr Mubanga

 


Lesley Hill, MSc Africa and International Development (2014)

 

References

[1] ZAMBART – a non-for profit research organisation based within the University of Zambia that is also a research collaborating centre for the London School of Hygiene and Tropical Medicine

 

The Lancet Commission On Global Surgery

Surgeons have long felt that the importance of surgery has been lost in past efforts to impact on global health issues. The Lancet Commission on Global Surgery seeks to address deficiencies in surgical and anaesthetic care, provide evidence and solutions for achieving health, as well as welfare and economic development through the strengthening of surgical health systems in Low and Middle income Countries (LMIC).

Twenty five commissioners have worked for almost 2 years consulting extensively in over 100 countries in 6 continents. Their report may not please all but is a significant achievement. Surveys, epidemiological studies, estimates, audits and mapping programmes helped to provide evidence and to highlight further disparities in surgical care through 5 key messages at their recent London and Boston launches:

  • 5 billion people lack access to safe affordable surgical services when needed. Nine of ten people in low-income and lower-middle-income countries cannot access basic surgical care.
  • 143 million additional surgical procedures are needed each year to save lives and prevent disability. Only 6% of 313 million procedures that are undertaken worldwide annually, are performed in the poorest countries.
  • 33 million individuals face catastrophic health expenditure to pay for surgical services.
  • Investment in surgical and anaesthetic services saves lives, is affordable and promotes economic growth.
  • Surgery is an indispensible part of health care and should be an integral component of a national health system in countries at all levels of development.

map image web

The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

The Commission’s stated targets for 2030 are daunting:

  • A minimum of 80% coverage of essential surgical and anaesthesia services per country.
  • 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians, per 100,000 population.
  • 100% of countries tracking surgical volume, a minimum of 5000 procedures per 100,000 population.
  • 100% of countries tracking perioperative mortality.
  • 100% protection against impoverishment from out of pocket payments for surgical care.
  • 100% protection against catastrophic expenditure from out of pocket payments for surgical care.

Some might see these as challenging for some developed countries so how can these objectives be met in developing countries where increasing funding of health care still results in disparities.

We know that targeting specific health care issues through philanthropic support in the developing world has brought about mixed success. Numerous philanthropists and charities have stumbled in attempting to deliver sustainable solutions when investing in facility or service. Outreach programmes from well intended overseas surgical teams may actually impact adversely on the very environment that they hope to support. Essential emergency provision of surgical care may be compromised when, for example, limited facility is set aside for the orchestrated elective missionary surgery. The conditions or surgical pathology targeted or technology being shared may seem entirely appropriate to the visiting team but may be largely irrelevant to the needs of the local population.

Investment in infrastructure may seem to produce a tangible legacy for the donor but it is challenging to maintain such quality facilities when these are seen by some as a source of material to be plundered to support their families in desperate financial need. Furthermore, some initiatives have been been criticized for focusing too narrowly on the capacity of science and in neglecting the importance of economic, social, and political factors. Such surgical initiatives require significant funding and need to be considered in parallel with improvements in public health, education and the health system. Pressurised surgical services dealing with trauma in the developing world might rather welcome greater health and safety regulation, improvements in street lighting, better maintained roads and greater driver regulation.

So where to start? Records often do not exist so reliable surgical audits or death rate statistics for surgery do not exist in LMIC. Investment in information technology is limited in most developing countries but finance is required to obtain key information that would identify clearly the needs of surgical services in the LMIC. GlobalSurg is a collaboration supported by Clinical Surgery at the University of Edinburgh (http://globalsurg.org/get-involved/). The group is currently using an international network of training and qualified surgeons to study variation in outcome of emergency intra-abdominal surgery across various clinical settings. It will determine whether globally relevant quality improvement strategies are needed within acute surgical units. This project would serve to provide much needed information in an area of acute surgical care and will allow development of regional, national and international surgical networks. The group recently published on the benefits of these networks in the Lancet. There is no reason why the group cannot establish key global studies, including the opportunity for randomised trials.

 bullet image

The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

Humanitarian and global surgical outreach programmes have been supported by surgical colleagues in Edinburgh at considerable personal social and psychological sacrifice. Such direct support has undoubtedly had significant impact on the lives of those affected by conditions including those arising from complications of obstructed labour. The social stigmata attached to this condition are considerable and the repair transforms the patient’s existence. And yet, the procedure to correct a vesicovaginal fistula is categorized as a ‘can do’ rather than a ‘must do’ surgical procedure. Where should the priorities lie when the challenge is so immense? How can such outreach programmes deliver a legacy in a developing country?

The target set by the Commission that 100% of countries should have at least 20 surgical, anaesthetic, and obstetric physicians per 100,000 population is formidable. We have experience supporting surgical training in Malawi which produces some 100 medical graduates per year. However, for a population of 17 million people, there are currently only some 15 trained surgeons in practice since many move overseas when they are exposed to the opportunities that exist for well-trained doctors in the developed world. The Lancet Commission requirement by 2030 is projected at 60 specialists per 100,000 population. It is difficult to imagine where the additional 10,000 or so specialists will emerge for Malawi without substantial investment.

Scotland has a strong tradition of investing in education on Africa. Gordon Brown as UN Special Envoy for Global Education, and through the Office of Gordon and Sarah Brown, has promoted and initiated education programmes in Africa. Edinburgh University has invested strongly in postgraduate educational initiatives that have benefited LMIC. The huge success of our own surgical distance learning programmes has allowed us to support more trainees from these countries.

Our surgical Masters programmes currently have over 450 students enrolled in 40 different countries. In 2009, the Scottish Government and J&J/Ethicon supported the University of Edinburgh and the Royal College of Surgeons of Edinburgh to deliver free postgraduate educational support to training surgeons in Malawi. Since then, the first three students have graduated from the three-year distance learning course which supports the educational and professional needs of the young training surgeon. Six more Malawian trainees are currently in the programme. Surgical trainees have been supported without the need to remove them from the area of greatest need. The programme content adds value to their in-the-workplace training and allows the young surgeon to attend to local service needs. We are also aware that educational resource has been extended to medical assistant practitioners who are a vital link in the surgical care chain.

The Lancet Global Commission has ensured that surgery can no longer be overlooked as a health need for the world’s poorest people. The Commission has set itself ambitious targets but no one initiative will address the current unmet need. Better global surgical and anaesthesia care will only be realised through increased investment in human and physical resources. Early and urgent domestic and external investment in surgical and anaesthesia care is needed to realise these returns. Our group sees itself as being in a strong position to invest in the postgraduate education of the surgical workforce in these countries.

Similarly, research, monitoring, and assessment will have to play an increasing and crucial part in the future of global surgical and anaesthesia care. There is a paucity of scientific rigor around implementation science, and an absence of globally accepted surgical metrics which have contributed to past neglect of surgical and anaesthesia care within global health. A commitment to better understand the problems and solutions should be a priority for those dedicated to improvement of surgical and anaesthesia care worldwide. We will continue to invest primarily in the training surgeons in these LMIC through postgraduate education. In this way, we should empower the very body that can engineer change locally so that we might yet see some practical light at the end of a very long tunnel.


Professor O James Garden, Regius Professor of Clinical Surgery and Honorary Consultant Surgeon, University of Edinburgh

Why it is critical to genotype the causative agents of tuberculosis

Sun Tzu, a Chinese military philosopher in the 6th century BC, said “ if you know your enemy and yourself, you will not be imperiled in hundred battles”.

If not taken in literal terms, it would suggest that learning more about the humanity and livestock’s arch enemy Tuberculosis (TB), with whom we have been battling for millennia, can only arm us all the better for the fight.  As part of this battle, The University of Edinburgh has long been contributing to the research and development arm of the World Health Organisation’s “Stop TB Global Strategy”. 

The WHO has achieved the 2015 Millennium Goal of halting and reversing the incidence of the disease.  Despite this great acheivement, in 2013 alone the WHO registered 9 million cases of TB, half a million of which succumbed to the disease.  Horrifyingly this latter number loosely translates to four super jumbo jets crashing every day for the entire year.  Going forward to 2035, the WHO has set yet more ambitious goals to end the global TB epidemic with corresponding targets of 95% and 90% reduction in TB deaths and incidence respectively.

Knowing your enemy

In order to achieve this mighty aim, now more than ever, it is critical for the definitive diagnostics to not only reveal the mycobacterial species but also the genotype.  The majority of cases of human TB are caused by Mycobacterium tuberculosis, however a small, but significant geographically-limited, proportion is due to Mycobacterium bovis the causative agent of bovine tuberculosis. The latter is what is commonly referred to as zoonotic tuberculosis. The current statistics shows that when considered as a proportion of the global TB burden, zoonotic tuberculosis accounts for a small proportion however, if reported in absolute terms it translates to between 95,000 and 150,000 cases of which 15% succumb to this disease form globally. It is noteworthy that 9 out of the 22 high-burden TB countries are responsible for ~70% of the global zoonotic TB cases.

Vaccination as a defence against infection

In general, vaccination is an effective method of controlling infectious diseases.  The BCG vaccine, developed agianstM. bovis, is the most widely administered TB vaccine in the world.  However its varied efficacy globally has always been a challenge to the TB control strategy.  If the endemic population of infective bacteria is different from that contained in the vaccine, this can lead to vaccine failure.  Vaccines that target a narrow range of phenotypes may not offer sufficient prevention against infections in settings where multiple different strains of the infective agent may be present.

This is particularly relevant to areas where several different strains of M. bovis are prevalent, and where the TB burden is correspondingly high. It is also reasonable to argue that some of the TB treatment failures in these areas are likely due to species and genotypes un-accounted for in the treatment protocols.  Thus it is critical to document the diversity of M. bovis, and use this data to increase the phenotypic range in novel vaccines, thereby improving patient immunity.

Sequencing the genomes of the bacteria that cause TB

The currently documented genotypes of M. bovis in high-burden settings lack “granularity” because they are based on PCR methods that target less than 0.005% of the genome.  It is therefore likely that niche and host-specific polymorphisms that are critical for population-based vaccine implementation, are left unused in determining these genotypes.

This disparity in genotype diversity and breadth of target phenotype is likely part of the reasons why the efficacy of BCG vaccination is lowest in Africa.  A solution to this comes in the form of whole genome SNPs based genotyping, which offers high definition genotyping power capable of revealing subtle niche and host specific diversity.

Large international collaboration fighting the disease

Researchers from the University of Edinburgh are now part of a large international collaboration that will sequence and genotype 254 isolates of Mycobacterium bovis from eight African high burden countries.

They will be working alongside colleagues from eight African research institutions, and from the United States Department of Agriculture, Colorado State University, the University of Georgia, the University of Tromsø, theNorwegian Veterinary Institute, and the Norwegian University of Life Sciences.

The new data the team generates will be made freely available for researchers and industry involved in TB vaccine, diagnostics and therapeutics development.  By piecing together more and more information about the strains of Mycobacteria causing TB in different areas, researchers will generate the ammunition needed to finally defeat TB.


adrian m a

            

                    Adrian Muwonge (DVM, MSc, PhD), Research Fellow, Roslin Institute, 

                   Edinburgh Infectious Diseases, University of Edinburgh, UK

 

 

 


Links

 

 

 

Unhealthy investments

I have been involved with the fossil fuel divestment movement over the past year, both with the University and through Healthy Planet UK, after coming to terms with the enormity of climate change and the need for urgent action. As a medical student I am compelled by a similar duty of care towards our ecosystem, on which our health depends, and am called to respond to its current symptoms of distress. Divestment offers a way to treat one of the root causes of these symptoms – the continued burning of fossil fuels – through moving investments away from the fossil fuel industry whose business model relies upon burning reserves which currently hold over five times that which is safe to burn if we are to stay below the 2 degrees celsius limit of global warming[1] Akin to the health sector leading divestment from the tobacco industry, there is a similar narrative in the response to the health threat of climate change further weighted by tactics utilised by the fossil fuel industry to thwart climate mitigation policy and mar public perception of the reality of climate science[2]. UK universities hold around £5.2 billion worth of investments through their endowment funds in the fossil fuel industry[3]. However, divestment is not simply a matter of money, most divestment decisions have been driven by a moral case. It rests on a simple principle -if it is wrong to wreck the planet, then it is wrong to profit from that wreckage. For the medical tradition investing in fossil fuels can be seen to contradict the fundamental principle to “first do no harm”. So far 21 universities, 35 cities, 65 religious organisations and numerous other organisations from around the world including the British Medical Association have committed to divesting from fossil fuels[4].

 

Medical institutions and the health community have a unique awareness of climate change through its current and future impacts on human health, but also through the potential immense health co-benefits of tackling climate change such as reducing the disease burden of air pollution, which has been attributed to 2000 premature deaths annually in Scotland[5], and encouraging active travel through reducing our reliance on fossil fuel guzzling cars. This gives an important dimension to the divestment dialogue and the engagement of medical schools and health organisations is sure to be very valuable. On the 3rd February, Healthy Planet are publishing their report “Unhealthy Investments”, co-authored with MedAct, The Climate and Health Council, Medsin and the Centre for Sustainable Healthcare. This will be a crucial step towards further engagement on fossil fuel divestment from the health sector. It will involve a panel of expert speakers to discuss the question of whether organisations which work to improve health should continue to invest in fossil fuel extraction and production companies. Should the health sector be taking more of a lead in this issue? There is certainly great potential in engaging with the process and evaluating how best our pension and endowment funds can be invested towards a healthier and more sustainable future.

 

More information on the report launch can be found here: http://www.eventbrite.co.uk/e/unhealthy-investmentsshould-health-organisations-divest-from-fossil-fuels-tickets-15237083527


 

References

[1] http://www.carbontracker.org/

[2] http://www.greenpeace.org/usa/en/campaigns/global-warming-and-energy/polluterwatch/Dealing-in-Doubt—the-Climate-Denial-Machine-vs-Climate-Science/

[3] http://peopleandplanet.org/fossil-free

[4] http://gofossilfree.org/commitments/

[5] http://www.foe-scotland.org.uk/air-pollution


 

 

Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.

http://www.healthyplanetuk.org/

 

Critically Analysing the IFC’s Health in Africa initiative’s opportunistic strategy to reach the poor.

Introduction

 In September 2014 Oxfam released a report entitled: Investing For the Few: The IFC’s Health in Africa Initiative. Their report highlights the lack of transparency within the International Finance Corporation’s (IFC) Health in Africa (HiA) strategy and the overall lack of monitoring and evaluative (M&E) institutions.1 Concluding that the IFC has done little to demonstrate the role of the private health sector in pro-equity health system strengthening.1

Earlier in 2014, I had completed my own research attempting to answer: To what extent has the IFC’s HiA initiative improved financial protection and access to quality health goods and services for the poor?

My research objectives were to map the IFC’s HiA activities by workstream, then use peer-reviewed and grey-literature (including World Bank monitoring and evaluation data) to investigate the extent to which HiA interventions (from analysis, to policy, to type of investment) improved health outcomes for the Sub-Saharan Africa’s poor.

This proved to be a difficult endeavour, as the IFC’s lack of transparency in HiA’s operational strategy, access/publication of information, and results frameworks, made it difficult to understand how the IFC was taking an opportunistic approach in HiA’s analytic, policy, and investment interventions to improve financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.

Lack of Transparency

In Spring 2014 I had requested (via the World Bank and the IFC’s online information request portals) the following documents: (1) A country/client specific operational plans and corresponding Results Measurements Frameworks; and (2) HiA’s Equity Investments Framework. These M&E institutions were chosen for request, as the nature of these documents fall under SECTION III, Information Routinely Made Available by IFC, in IFC’s (2012) Access to Information Policy.2 Within a week of the request, the World Bank responded with directions to forward this request through the IFC portal. Unfortunately the IFC has yet to respond, although had initially promised a response within 30-working days of a request.

Interesting to note, Oxfam (2014) has reportedly requested HiA’s Results Framework, only to be unsuccessful in their request as well. Oxfam (2014) and the Health in Africa Mid-Term Report (MTR) (2012) have both commented on the lack of transparency within the IFC and their trouble with defining HiA’s anticipated results. Leading to difficulties in understanding, measuring, and evaluating HiA’s opportunistic pathway in order to measure the extent to which the HiA initiative is reaching the poor.1,3 The Independent Evaluation Group (2014) have also recognized this lack of transparency and how little the IFC is engaged with creating M&E institutions.4

In line with my own findings, both Oxfam and the MTR have recognized the difficulties in measuring the extent to which HiA was improving financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor.1,3

HIA performing Poorly

Overall, the HiA initiative is implemented over three workstreams (Analyses, Policy, and Investment) to: provide analytic products on Sub-Saharan Africa’s public and private health sectors, assist governments with health policy, and to improve access to credit for private health small- to medium-sized enterprises through equity funds, debt financing and technical assistance.5 In 2011, foreign direct investments were included/added in the HiA Factsheet as a new component of HiA’s investment workstream.6

Research revealed HiA’s Analytic workstream failed to provide a direct analysis linking the IFC’s private health sector interventions with improved health outcomes for the poor.2 Failure to provide this analytic link prompted the IFC to take an opportunistic operational strategy to understand which pathway (from analysis, to policy, to type of investment) works best to meet the IFC’s stated HiA development objectives.7

Consequently, the IFC’s HiA analytic and policy workstream activities were implemented based on the opportunistic strategy that they would create a sustainable investment climate and encourage a socially responsible private health sector to facilitate investments and help meet the estimated US$11-20billion in demand for private health goods and services.8 My findings, however, revealed that the IFC’s HiA investment activities have so far demonstrated little to no capacity to achieve the IFC’s stated HiA development objectives.

Additionally, without any of the IFC’s M&E institutions available (either publicly or upon request) I was unable to understand how the IFC was taking an opportunistic approach to find the best pathway/mechanism (from analysis to policy to type of investment) best improved financial protection and access to quality health goods and services for the poor.

Based on these findings, I question how the IFC is investing its resources for future HiA activities. Without available M&E institutions, the workstream activities which fail to improve financial protection or fail to improve access to health services may be insufficiently monitored and could potentially be continued and/or built-upon. Thus without published M&E institutions, it is possible for HiA activities to weaken Sub-Saharan Africa’s health systems and consequentially move it away from improving financial protection and access to quality health goods and services for the poor.9

Conclusions

If the IFC had adequate evidence to suggest it was improving health outcomes for the underserved through the HiA initiative, this would provide insight into the positive role of the private health sector in pro-equity health system strengthening. However, the evidence presented in my report suggested HiA is performing poorly to achieve the IFC’s stated HiA development objectives. Until M&E institutions are released, research will be unable to understand the extent to which HiA is increasing financial protection and access to quality health goods and services for Sub-Saharan Africa’s poor. 

Publishing the IFC’s Health in Africa activities to Date


 

References

 

  1. Oxfam (2014) Investing for the Few – The IFC’s Health in Africa initiative. London: Oxfam Great Britain.
  2. International Finance Corporation (2012e) IFC Access to Information Policy. Washington: Office for International Finance Corporation World Bank Group.
  3. Brad Herbert Associates (2012) Health in Africa Mid-term Evaluation Final Report. Maryland: Office of Brad Herbert Associates prepared for the International Finance Corporation.
  4. Independent Evaluation Group (2014) World Bank Group Support to Health Financing for Improving Health Systems Performance FY03-FY12.Washington: World Bank.
  5. International Finance Corporation (2013) The Health in Africa Initiative – Improving the Role of Private Sector in Healthcare. Washington: Office for the International Finance Corporation World Bank Group. [Online]. Available at: https://www.wbginvestmentclimate.org/advisory-services/health/health-in-africa/upload/HiA-Factsheet_October-2013.pdf [Accessed: 10 May 2014].
  6. International Finance Corporation (2011a) IFC – History. [Online]. Available at: http://ifcext.ifc.org/ifcext/masterinternet.nsf/AttachmentsByTitle/ifctFS.htm/$FILE/ifctFS.htm [Accessed: 30 May 2014].
  7. World Bank Group (2012) World Bank Group Management Response: Health in Africa Independent Mid-Term Evaluation. Washington: Office for International Finance Corporation World Bank Group.
  8. International Finance Corporation (2007a) The Business of Health in Africa – Partnering with the Private Sector to Improve People’s Lives. Washington: Office for the International Finance Corporation World Bank Group.
  9. Kutzin, J. (2013) Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization, 91(8), p.602-611. PubMed Central [Online]. DOI: 10.2471/BLT.12.113985 [Accessed: 26 May 2014].

DanielleHowe_photo

Danielle Howe is a recent graduate from the University of Edinburgh MSc in Global Health and Public Policy

The health & environmental impact of global health research

“How does one cross the Atlantic in an environmentally-friendly way?” I asked myself.* A few weeks earlier I had been challenged by a fellow student who had attended a university-run course “Carbon Conversations”. I then began to reflect on the health and environmental impact of my global health research and to consider ways in which I might reduce my climate change burden. Struggling to find a satisfactory answer to my question, I approached a local sustainability advisor who explained that the alternatives to “door-to-door” air travel were likely to involve significant time costs and/or financial costs. No feasible alternatives. It was a disappointing response, especially after reflecting on the potential global health cost of spending over 20 hours on aeroplanes for my research. Could a solution be found to minimise the global health impact of overseas travel which remains essential for many studying and working in global health with limited time and restricted budgets?

It is widely accepted that high carbon usage and emission contributes to global climate change. Studies have reported that the likely direct health impacts of global climate change include those associated with an increase in heatwaves and a rise in vector-borne diseases such as malaria. Indirect health impacts may include sanitation problems secondary water shortages and malnutrition due to a rise in food costs as a result of reduced food production. People living in less developed regions are predicted to experience the greatest direct and indirect health impacts of climate change.

Hard policies are already being implemented by national and global bodies to reduce carbon emissions through initiatives such as improving rail networks and increasing taxes on fuel and high-emission vehicles. Could “softer” approaches at a local level be effectively employed by individual members of the working and studying global health community in order to tackle the problem of climate change which threatens to have a negative health impact on many populations? It is certainly never too late to consider this suggestion. It was only in 2013 that the UN Development Programme for Europe and Asia for the first time assessed the carbon footprint of one of its global health projects. We know that travel and transportation are important contributors to the climate change problem, and that many staff and students in global health are likely to travel for work purposes. Perhaps responsible travel is an approach and practice that could be promoted more widely and emphasised more strongly within the global health community.

Practically speaking, adopting this approach might mean that within academic departments of global health, individuals who plan to travel would be encouraged to consider and attempt to address the issue of climate change when writing project proposals, funding applications, dissertations, and theses. For example, a postdoctoral researcher applying for funding to attend a global health conference in Brussels might choose to budget for the additional time and financial cost of travelling to Paris by ferry and train. At the same time she could be offset these extra costs against savings made by booking more modest accommodation. Similarly, a PhD student involved in global health data collection in Asia might include a reflective paragraph in his thesis acknowledging the health impact of climate change due to travel. He could also describe the challenges encountered and steps taken to reducing the travel-related carbon emissions associated with his research.

Finally, we need to consider not only the immediate costs of changing our travel habits, but also the longer-term global health costs of not taking action to promote a low carbon future worldwide. Time and money are important and even when both are limited, global health workers and students can still explore and consider more responsible ways of travelling. If we choose to spend years studying and working to improve global health today, let us also choose to leave a shrinking carbon footprint that will have not have a significant negative impact on global health tomorrow .

 


 

Dr Anne Aboaja

Dr Anne Aboaja, is a Global Health PhD Researcher, Psychiatrist and Member of the Global Health PhD Network at the University of Edinburgh


 

Foot note

*When I asked this question, I did not have in mind ticking a box during an online airline booking in order to offset my carbon emissions. Instead I entertained the idea of spending a couple of weeks on a low-cost transatlantic crossing followed by a scenic, and possibly bumpy, road trip on public transport to my destination, sensibly using the time to read and critically review journal articles, write papers for publication, practise language skills, and creatively think through research problems encountered. Unrealistic? Maybe. Maybe not. In the spirit of sustainable global health? Definitely.