Tag Archive for Global Health

Starting Out Early

It is a hot, humid day in mid-June, 2011 in this remote village in Niger state, Nigeria. The state is in a low development region with poor health indicators. I am a newly qualified doctor and have just concluded a Lot Quality Assurance Sampling (LQAs) assignment for the state office of the World Health Organization (WHO). The LQAs is a method of assessing the vaccination coverage after the supplementary polio immunization campaigns. I am at the home of Mallam Adamu, a middle aged, poor peasant farmer. Adamu is married with 6 children, 3 of which are under the age of five and therefore eligible for the polio immunization.

He is visibly angry and in a loud voice yells “tefi” in Hausa, the local language to myself and my translator. “Tefi” means “go away”. My translator tells me that for the past 6 months, he has barred his 3 eligible children from receiving polio immunization. He has been reported to the Mai angwa (the local community chief) but he is adamant.

When he learnt I was a doctor, he visibly relaxed and we sat down on a mat in front of his mud house to chat. He has 6 kids and they have all received routine immunization. However, he wonders why the need for the yearly polio immunizations and wonders when they will cease. He has heard the rumours; these polio vaccines were created by the West to cause sterility among his people and he would never compromise the safety of his children. “Lekita, do you have kids?” he asked and I replied “no”. He shook his head slowly.

I proceeded to explain that the rumours are untrue. The vaccines are safe and nobody would deliberately administer a vaccine that can harm kids including myself. Perhaps I answered his questions satisfactorily or he believed me as a medical person but I learnt that on the next round of polio immunization he had allowed his kids to be vaccinated. The encounter however made me realise that I did not have enough answers myself!

As a healthcare provider, just how well did I know these vaccines that I confidently recommended for babies? How is their safety and effectiveness assessed? Yes, while undergoing paediatrics and family medicine training in medical school, I had received lectures on vaccination but there was a knowledge gap that could impact my ability to perform in this field. Three years after this encounter another incident would motivate me to gain more expertise in vaccinology.

This time, I was working at the paediatrics department of a large district hospital in another state in northern Nigeria. One morning a neonate who had been delivered at the hospital, given his first dose of birth vaccines which included the Bacillus Calmette Guerin (BCG) vaccine against tuberculosis and discharged home the previous day was rushed to the paediatric emergency room where I was stationed. His parents were visibly distraught- their son had a fever and a large swelling on his left upper arm, the BCG vaccine injection site. My team had admitted the baby for observation and he was discharged home 3 days later. Before being discharged, his father, a teacher in one of the state owned secondary schools confided in me that he may be unwilling to let the child receive further childhood vaccination and I had to spend considerable time reassuring him. Vaccines are administered to healthy people, usually kids, so there is a low tolerance for any risk and moreover, despite being generally very safe, an Adverse Event Following Immunization (AEFI) can occur, although not usually caused by the vaccine.

Vaccination has been a useful tool in the control of infectious diseases. It led to the eradication of small pox, the first disease to be eradicated through vaccination. Equally, progress is being made towards the elimination of another disease, polio. However, these feats recorded by vaccination paradoxically are beginning to lead to a tendency from the public to question the need for further vaccination and in some cases have led to outright refusal of parents to have their children vaccinated. Tragically this could lead to the resurgence of previously controlled diseases, for example, measles is resurfacing in some high income countries.

All of this must be a wake up call for Global Health. Across Africa, there are instances where rumours have derailed vaccination campaigns requiring intense advocacy to regain public trust and restart the campaigns.  Derailment is not only a political problem, derailment is a matter of life and death.

There is a need for a pool of well-trained local scientists in all spheres-research and development, academia, national regulatory agencies to engage with their communities and advocate for vaccination. Everyone has a right to know and to hear in their own language.  The public will need to be constantly reassured by their own sons and daughters. We cannot afford to wait until it is too late.

 

Dr Edem Bassey is an online scholar of the MSc in Global Health and Infectious Diseases at the University of Edinburgh. He works at the Medical Research Council, Unit the Gambia at the London School of Hygiene and Tropical Medicine (MRCG at LSHTM) as a research clinician where he is involved in the clinical trial of life saving vaccines for the developing world. 

 

The Caravan: health challenges, forced displacement and humanitarian responses in Central America

Since the middle of October 2018, over 7,000 Central Americans have been making their way by foot and overcrowded cars to reach the United States border. They have travelled together in the so-called “migrants’” caravan from the so-called Northern Triangle (Honduras, Guatemala, and El Salvador). We use the word “migrant” once and very reluctantly. Words matter and the semantics of the caravan hide and allow for discriminatory anti-migrant discourses (e.g. juxtaposing the need for prevention of economic migration and the right to protection of ‘legitimate’ asylum seekers). The mass-displacement of people has renewed attention to the needs that push Central Americans on a dangerous journey to seek a safer and dignified life. In this blog, we would like to reflect on some of the health challenges that they have faced, are facing, and may face in their journey.

family travelling with the caravan

“Fanny Cortés, 23, carries her daughter, Escarlett, two years old, while her partner, Jonny Ramírez, 22, carries the only suitcase with the family’s belongings. The couple started their journey in San Pedro Sula. Photo Credit: Simone Dalmasso, Plaza Pública”

Brief background to Central America

Central America is a beautiful and diverse region between Mexico and Colombia. Though small in size, it is densely populated and hosts rich ethnolinguistic diversity. The region, with a long history of internal conflict, authoritarianism and exclusionary politics, was ‘pacified’ between the late 80’s and 90’s with the demobilisation of guerrilla fighters and a process of democratisation of its military regimes. However, violence remains rampant which is only one of the many health challenges that are driving displacement and affecting those who have stayed.

Most Central Americans in the caravan come from El Salvador, Honduras and Guatemala where homicide rates have been at ‘epidemic’ levels for decades. These countries rank as the 2nd, 4th, and 17th most violent in the world. The rate of violent deaths in the three countries stands at 99.7 (El Salvador), 67.7 (Honduras) and 32.7 (Guatemala) per 100,000. In this blog, we focus on examples in Guatemala, mainly because it is a country close to our hearts, but needless to say, circumstances have become unbearable across the region.

Health (and other) challenges at home

In Guatemala, malnutrition and violence are the two most important risk factor for premature deaths. Malnutrition is rife, 50% of children <5 years are stunted, yet 28% of school-age children are overweight and obesity among adults is on the increase with a third of the population expected to be obese by 2025. Preventable lower respiratory infections are the leading cause of deaths. However, non-communicable diseases, such as cardiovascular diseases, cancers, and diabetes, are also common, accounting for approximately 59% of all deaths, which are closely associated with inadequate living conditions and access to healthy lifestyles.

The concerning gap between rural and urban populations has a significant impact on health. Most concerning is the fact that the likelihood of favourable health outcomes or access to healthcare are defined by ethnicity. The indigenous population faces disproportionate rates of poverty, is directly affected by the destruction of the environment through development projects (e.g. hydroelectric or mining), poor access to public services, and the added challenge of language barriers.

The state has historically failed to provide basic services to face such challenges. Guatemala still has the lowest fiscal revenue (as % of GDP) in Latin America, and is the third lowest in social spending (as % of GDP). As a result, health services are chronically under-resourced, pushing medical doctors to go on strike for months due to low or lack of payment, most recently since August 2018.

Health challenges during the journey

This is not the first mass attempt to leave Central America, nor are the thousands of refugees in a unique situation. Most often, people risk their few possessions, their physical integrity and their life to make the perilous journey North. Taking the journey in small groups via the services of coyotes (smugglers) helps travel undetected. However, it makes refugees more vulnerable to violence or sexual abuse, being tricked by coyotes and held against their will as modern slaves.

Travelling in a large group has allowed perhaps to reduce the vulnerability of refugees, who have not had to put themselves at the mercy of coyotes. The size of the group has stirred emotive acts of solidarity, such as the mobilisation of Mexican human rights organisations to negotiate safe passage through police blocks along the route. Yet, the health of many has deteriorated during the rough conditions during the journey: severe dehydration, sunburns, blisters are affecting people of all ages. Children are suffering from heat exhaustion and acute respiratory infections and two adults have reported to have died after falling from overcrowded vehicles. These conditions proved to be too much for the thousands who decided to return to their country of origin.

Health challenges at the destination

At the end of November, at the border, US-bound refugees were faced with tear gas. Much of the coverage of the ‘caravan’ has focused on the US reaction. The US President has securitised the issue and stoked fears of insecure borders, mass uncontrolled migration and waves of dangerous criminals arriving.

Unsurprisingly, evidence contradicts the image the US President is trying to paint. While the number of asylum seekers (what we could reluctantly call ‘legal’ migration) is up, ‘irregular’ migration (measured in the number apprehensions at the US-Mexico border) is at a historic low. In addition, the current US president has called for an end to foreign aid to the Northern Triangle countries, since he claims they generate rather than meet humanitarian needs. This posturing, again, gives a misleading impression of misspent, ineffective aid. In fact, Guatemala and El Salvador are considered the two top ‘forgotten’ humanitarian crises given the scale of need, coping capacity, media attention to the crisis and public aid per capita.

The extent to which Central Americans who make it to the US enjoy a better health there will depend on their financial means and legal status. Latinos in the US are at great risk of negative health outcomes and are generally less likely to have health insurance, though this varies by state of destination. Mental health problems, associated with challenges during the journey and abuse prior to departure and stresses associated with establishing a new life in the US are likely to have a large and detrimental impact on their well-being.

A humanitarian response to the current Central American displacement crisis has now been mounted. Yet, effective and sustainable interventions in the region are long overdue. The caravan is a group of forcibly displaced populations enduring challenging situations that pose risks to their health, livelihoods and mere survival. In the short term, protection measures can and should be offered to those fleeing misery. For those who continue to displace, provision of humanitarian response in transportation, shelter, WASH, and nutrition are essential. Legal protection aid and security warranties should also be provided so that those seeking asylum can do so as provided by international law (which, so far, binds the US government at least on paper). In the long term, an urgently needed recognition that health systems improvement requires investment – we hope – can be translated into equally urgently needed action by Central American governments and peoples.

By Evelyn Balsells and Daniel Herrera Kelly

Evelyn Balsells is a PhD candidate at the University of Edinburgh. Her research focuses on the burden of infectious diseases globally and she is interested in issues affecting vulnerable populations and humanitarian settings. Daniel Herrera Kelly is a PhD candidate at the School of International Relations in the University of St Andrews. His research is on collective violence in Central America. All the views shared in this post are held personally by the authors and do not represent the views of the institutions they are affiliated with.

If somebody had a crystal ball: The paradox of a self-defeating health policy.

When I was a new graduate student of health policy, I was once asked by a professor whose class I took, why I had left clinical practice to study health policy. I replied naively, ‘I migrated from clinical practice because I don’t like the idea of working in a place where I can make one mistake and kill a person.’

‘I see,’ he said, ‘so you decided to come over to policy and kill thousands?’

His response, delivered in jest, was tacitly instructive about the importance of getting health policy right, because of the scale at which the impact can be felt. Indeed, one of the central tenets of governance in healthcare is the identification and rectification of problematic policies (WHO, 2017).

Even after learning at graduate school that policy work tends to be an arduous, convoluted and often contentious process, I still intuitively considered policy work to be safer, more elegant and less stressful than clinical work. It was experiences ‘from the trenches’ that revealed otherwise. Within a year of completing my masters, I was battling to pilot an intervention aimed at mitigating the undesirable effects of a well-intentioned health policy that has outlived its relevance in its context; a process which was the diametric opposite of ‘elegant and less stressful’!

 

When a health policy endangers health

Pharmacies in Zimbabwe, a low income country in Sub-Saharan Africa plagued by a protracted economic recession and a dilapidated health system (Meldrum, 2008), are prohibited by law from advertising their inventory to the general public unfettered like conventional businesses do (Health Professions Act, 2004; Medicines and Allied Substances Control Act, 2001; Pharmaceutical Professional Conduct Regulations, 1989). Given the information asymmetry characteristic of a typical healthcare market, and the potential severity of the consequences of such asymmetry, advertising restrictions are rightly intended to protect members of the public from product claims they are unequipped to evaluate objectively. However, to the extent that advertising restrictions interfere with information provision and transparency when accessing health care, they themselves are a health hazard and this is what the medicine advertising regulations in Zimbabwe have become. The fine line between availing information about care and protecting the public from exaggerated claims should be carefully navigated. Interventions which mitigate the deleterious effects of health information control policies can and should be developed.

In well-served health systems, restricting advertising in and of itself does not constitute a problem because a patient can reasonably expect to find the medicine(s) s/he requires after only one stop or at most few stops at pharmacies in his/her vicinity. However, in Zimbabwe today, systemic economic challenges are causing generalised medicine shortages. These challenges are, in the main, beyond the control of the pharmaceutical sector. As a result, the largest referral hospitals suspended elective surgeries (United Bulawayo Hospitals, 2016; Harare Hospital, 2016). Pharmacies that happen to have a particular medicine that is in short supply everywhere else, are precluded from overtly advertising this fact. Patients therefore have to rely on door-to-door enquiries at multiple pharmacies, serendipitous coincidences, intuition and the benevolence of some pharmacists who sometimes offer to help by contacting colleagues within their professional networks on behalf of patients. Electronic prescribing is not yet widely used in Zimbabwe so patients or their carers are the ones tasked with transmitting prescriptions between prescribers and the pharmacies that will ultimately dispense them. They therefore bear the transaction cost of this process and have to trudge from one pharmacy to the next until they eventually get to a pharmacy that can fill their prescriptions. When pharmacists turn away prescriptions but offer no additional information about where patients can get those prescriptions filled, they become the human face of a system that seems unresponsive to the plight of the ill. Once, I remarked to my colleagues, ‘If somebody had a crystal ball, they would be the oracle that informs patients where exactly to go to get their prescriptions filled and reduce the burden of medicine access.’

 

The intervention: Controlled democratisation of pharmaceutical inventory information

Accessing medicines should not depend on unsystematic methods of search and we most certainly shouldn’t have to look to clairvoyance to make health systems more efficient and transparent – especially when advances in health informatics and Web 2.0 coupled with the ubiquity of portable information and communication devices have increased the interconnectedness of actors and rendered faster sharing of information across large networks possible. After a content analysis of the statutory instruments governing the practice of pharmacy in Zimbabwe, with the view to finding a legal workaround for the advertising rules, I discovered a loophole. While advertising inventory to the general public is prohibited in Zimbabwe, advertising to another health professional is not. Therefore, if a vertical search engine that is populated by real-time crowdsourced inventory data from retail pharmacies all over the country was set up, and if the back-end of that search engine was managed by a pharmacist, then it could be used by that pharmacist to advise patients, on a case by case basis, even remotely via the internet, about the exact locations of pharmacies stocking specified medicines. A prototype meant to achieve this was designed and the three statutory bodies that regulate healthcare practice in Zimbabwe were approached for approval before launch.

The unfavourable response received from them, was unexpected. An email communication was circulated to all the registered practitioners, cautioning them against what the chief regulatory institution considered an ‘illegal project’ that was tantamount to advertising. I was explicitly informed that I was risking censure by setting the ball rolling with it and was sufficiently intimidated. Of all the illegal things a health professional in Zimbabwe can do, outside of malpractice, experimenting with advertising is considered the most negligent because it is so easy to avoid. It is seared onto our minds right from pre-qualification training that advertising by health professionals is simply not acceptable, so it is almost a reflex response for healthcare providers to stonewall anything that bears advertising connotations.

Regulators were re-engaged because their endorsement is crucial. Without this it is not possible to persuade pharmacies to volunteer the essential crowdsourced data needed to populate the vertical search engine that drives the intervention. Although they acknowledged unreservedly the existence of the problem that the advertising policy has given rise to, regulators remained steadfast in their position that the proposed vertical search platform solution was illegal and ‘was not in the best interests of the public’. The judiciary arm of the state was therefore invoked in the hope that it could rule on the legality of the proposed intervention.

The intermediate goal became to obtain a court judgement that would compel the regulatory bodies to allow this intervention to be tried. A High Court application (Herald, 2016a) citing the health minister and all three relevant regulatory entities as respondents, was filed. We currently await a judgement pronouncement but continue to keep the discussion about the matter alive, for example through the press (Herald, 2016b). Meanwhile, one of the regulatory bodies has responded to our court application with a counter-suit for costs because according to it, we ‘brought a case before the Court prematurely.’

 

The Future

Towards the end of 2016 a press announcement notified the public of the healthcare regulators’ intention to relax draconian advertising policies (Herald, 2016c), having recognised the need for the public to access information about healthcare providers and services. I count this a small victory and look forward to the green light to implement the ‘Crystal ball’ project with much optimism. Lessons from its implementation could bode well for health systems facing similar governance problems.

Determined to build my credibility with policymakers and take forward my academic studies, I enrolled for a PhD with the Global eHealth research group at the University of Edinburgh and am now 10 months into a three-year programme. Taking this parallel pathway, whilst continuing to fight the case for better information sharing about community pharmacy stocks in Zimbabwe, has forced me to critically examine my assumptions and proposition and to mentally separate my personas as an objective researcher of eHealth innovation and as an innovator/entrepreneur. It has provided an opportunity take an in-depth look at the technical and legal feasibility of alternative approaches, and their ethical, legal and governance implications, as well as to study a wider range of innovative digital approaches for supporting pharmacy practice and strengthening health systems. This transition has been guided and encouraged by my PhD supervisors Dr Claudia Pagliari and Dr Raluca Bunduchi, who have kept my feet on the ground and combine expertise in health technology assessment, health policy and innovation studies. Our new opinion piece in BMJ Global Health (June, 2017), aims to draw wider attention to the challenges facing Zimbabwe and seeks ideas and opinions from researchers, policymakers and practitioners facing similar problems elsewhere in the world.

 

By Dudzai Mureyi, Global eHealth PhD student

Dudzai Mureyi is a first year PhD student on the Global eHealth programme at the University of Edinburgh, supervised by Dr Claudia Pagliari (eHealth Research Group) and Dr Raluca Bunduchi (Entrepreneurship and Innovation Group).

 

  1. Harare Central Hospital (2016). Internal memo: Suspension of Elective Lists-Drug Shortages. Harare. [WWW] Available from https://zimnews.net/zimbabwe-suspends-surgeries-harare-hospital/ Accessed 06 February 2017.
  2. Meldrum A, (2008). Zimbabwe’s health-care system struggles on. Lancet 371(9615); 1059-1060.
  3. Parliament of Zimbabwe (2001) Medicines and Allied Substances Control Act [15:03]. Harare. Parliament of Zimbabwe.
  4. Parliament of Zimbabwe (2004) Health Professions Act [27:19]. Harare. Parliament of Zimbabwe.
  5. Parliament of Zimbabwe (1989) Statutory instrument 232 Pharmaceutical Professional Conduct Regulations. Harare. Parliament of Zimbabwe.
  6. The Herald (2016a). Pharmacist Seeks Court Order for private pharmacy stocks database. [WWW] Available from  http://www.herald.co.zw/pharmacist-seeks-court-order-for-private-pharmacy-stocks-database/  Accessed 06 February 2017.
  7. The Herald (2016b). When regulation is outpaced by technology. [WWW] Available from  www.herald.co.zw/when-regulation-is-outpaced-by-technology/ Accessed on 06 February 2017.
  8. The Herald (2016c). Zimbabwe: Govt relaxes Medical advertising rules. [WWW] Available from http://allafrica.com/stories/201611280215.html Accessed 06 February 2017
  9. United Bulawayo Hospitals (2016). Internal memo: Cancellation of Elective Surgical Operations. [WWW] Available from http://www.africanews.com/2016/10/15/drug-shortage-hits-zimbabwe-hospitals-suspends-some-surgical-operations// Accessed 06 February 2017.
  10. WHO (2017) Governance. [WWW] Available from http://www.who.int/healthsystems/topics/stewardship/en/ Accessed 06 February 2017.
  11. Mureyi D, Pagliari C, Bunduchi R (2017) Drug advertising riles and the patient safety paradoc in Zimbabwe. BMJ Global Health (Opinions), June 8th 2017 http://blogs.bmj.com/bmj/2017/06/08/dudzai-mureyi-et-al-drug-advertising-rules-and-the-patient-safety-paradox-in-zimbabwe/ Accessed on 10 June 2017

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