Notes from Reimagining Global Health

The following is notes from a book I read in September 2019 kicking off my academic journey into global health. Any views expressed are my own or notes from the book.

**these notes aren’t comprehensive by any means, and these views are all of the book and a few of my thoughts**

Biggest takeaways

• Vertical (disease specific) vs horizontal building (strengthening overall system) of healthcare systems — how can you take a diagonal approach to developing healthcare systems while working in the market-based frameworks of cost-effectiveness needed to attract dollars?
• Global health is biosocial — more than health & science, it’s about the historical, economic, and cultural perspectives that drive determinants and situations of health. Legacies of colonialism and international relations will always affect the discipline’s dynamics. How might social theory and history inform efforts to improve the delivery of health services?
• AIDS changed the way the world approached and funded global health initiatives in many ways: in the work of grass-roots and established advocacy groups internationally; in overcoming the socialization of scarcity of resources for global health; in the private-public agreements necessary to navigate massive decreases in drug prices; and in the deployment of those drugs to those that needed it most.
• The DALY metric is useful and helped draw attention to certain conditions, but comes with many assumptions that must be questioned, including age-weighting, role in family, life expectancy, and data sources.
• The transition from infectious to chronic disease isn’t totally true — developing countries still have significant disease burden in the chronic diseases we consider in developed markets, but it’s not considered as much of a priority.
• Being too top-down, and not locally relevant, with development initiatives doesn’t go well: malaria vs smallpox eradication.
• Life in Canada is pretty amazing in terms of access to healthcare, I should be more grateful and not complain about long wait times for specialists because there’s so much more room for huge improvement in many parts of the world — this is something I need to experience and also have the power to make impact in my lifetime.
• Provision of healthcare services in low-resource areas can be done with a community-focused delivery model. Providing conditional cash transfers, helping support with food packages, and developing adherence through frequent visits are all helpful strategies. Exhibited in rural Haiti, Rwanda, and can be transported back to developed regions to improve our healthcare delivery.
• I need to challenge the way I think about proposed frameworks, like the epidemiological transition that suggests that as countries transition from developing to developed, the burden of disease shifts from infectious to noncommunicable — when in reality, this isn’t fully true and obscures a lot of complexity in the patterns of disease burden in developing countries.
• Developed countries can integrate learnings from supporting developing countries back into their healthcare systems — learning isn’t just something that goes one way. Health inequity exists within the borders of developed nations as well. A great example of this is increasing community -based care in low-income areas, and promoting the accompagnateur model.
• Capability building with local public/private sector organizations is the way to go when using foreign aid to strengthen social systems in the long run.

Chapter 1: A Biosocial Approach to Global Health

• Taking a biosocial approach to global health: contextualizing health in the ‘resocializing disciplines’ of anthropology, sociology, history, political economy. How can history and political economy help us understand the skewed distributions of wealth and illness around the globe?
• Concept of praxis — traversing the space between reflection and pragmatic engagement as key to global health. Evident in the multi-disciplinary experience of the writers as academics, doctors, founders of non-profit Partners in Health, and more
• Leading causes of death (2004): heart disease, cardiovascular, respiratory, COPDs, diarrheal
• Leading causes of burden (2004) by DALYs: lower respiratory infections, diarrheal disease, depressive disorders, heart disease, HIV/AIDS
• Structural violence: the social, political, and economic forces that drive up the risk of ill health for some. poverty, inequality, and environmental degradation need to be considered when thinking about health
• all fields have myopias and biases — need to be combined in this biosocial approach to build a field of global health
• global health delivery is mainly about the provision of interventions and thinking about how a health system can efficiently provide health services to all who need them

Chapter 2: Unpacking Global Health, Theory and Critique

• Though many global health practitioners are focused on action, social theory can help cultivate self-reflection and design better programs
• Biosocial approach: biological and clinical processes are inflected by society, political economy, history, and culture. breaking down boundaries that separate disciplines, reconciliation of multiple frames of knowledge. Exists in context of malaria, mental health, AIDS, MDR-TB, etc.
• Berger & Luckmann, process of institutionalization: when a habitualized action becomes an object, knoweldge, an institution. examples: the DSM-V
• Merton, the unanticipated consequences of purposive social action: involves motives, a choice among alternative, a goal, and a process… but still may not achieve the desired aim and can have perverse outcomes. Rigidity of habit, institutional values, and imperious immediacy of interest (ex: UN response to 1994 Rwandan genocide setting up camps in DRC that became a base for the perpetrators) are potential causes
• Weber’s rationalization and three modes of authority: traditional, charismatic, and rational-legal. Traditional is derived from patriarchal, patrimonial, feudal power. Charismatic is from extraordinary leaders who can mobilize people. Rational-legal is from state, law, organized institutions that consisteny apply a set of rules, creates bureaucracy.
• The world is largely becoming rationalized — positive potential, yet also dangerous because it’s great for large and complex systems, but can also function like an ‘iron cage’.
• Foucault’s biopower: how biologic and medical data are used by the institutions of the modern world to discipline populations. Done at population level and individual level. Form of governmentality that deals with life. Life regulation through precise yet decentralized controls. At work any time quantification of life leads to categorization of life. Productive, not necessarily destructive. Examples of biopower across history dividing groups of people through medical measurements, caste systems, new state policies after natural disasters

• Kleinman, Das, Lock’s social suffering: what political, economic, and institutional power does to people and how these forms of power themselves influence responses to social problems. ex. intersection of medical and social problems in inner city areas, women living with AIDS in rural Haiti

Chapter 3: Colonial Medicine and its Legacies

• Global health, international health, and colonial medicine are all distinct terms
• Colonial medicine is the 19th century term that described medicine in the days of imperial rule and colonization
• Global health & empire have always been related — think Romans and the aqueducts, seaborne expeditions to the New World & the Columbian Exchange
• ecological imperialism: the exchange of organisms triggered by exploitation and conquest. Sharply different mortality rates between natives and Europeans (re: Guns, GERMS, and steel)
• the “white man’s grave” in the Gold Coast of West Africa, where many Europeans perished trying to ‘civilize’ the interior -> link between colonial medicine and imperial conquest, and the use of ‘the tropics’ as a laboratory
• colonial medicine originally designed to support military and protect health of labouring population
• 1835 study about mortality rates among troops of European descent, concluding the ‘black body was better suited for hot climates than the white’

• tropical medicine’s rise: controlling epidemic disease by fighting non-human vectors, dealing with native subjects as populations and not individuals, new paradigm of etiology…. though in practice, the ‘healthy carrier’ stereotype was still perpetrated through media and enabled the idea of the ‘diseased native’
• 1902 ‘cholera war’ US Army Health destroying villages in Philippines after the epidemic
• colonial medical practices still promoted a sense of inferiority among the colonized and focused on populations
• missionary medicine: focused on individuals, as a means of spreading religion, raised awareness about health issues. “what motivates people to exchange comfort and familiarity for a career dedicated to improving the well-being of distant populations?” “what is noble and what is perilous in these colonial legacies, for global health practioners and the populations they seek to help?”
• cholera outbreaks in 19th century aligned along trade routes, and affected global commerce
• 1854, our favourite first epidemiologist John Snow and how he stopped the cholera outbreak by mapping cases and removing the pump’s handle
• First official international health organization, PAHO, born as Panama Canal was being built. Americans had to keep the canal workers healthy, and so the Canal Zone became a ‘public theatre for the deployment of modalities of tropical medicine’. Yellow fever elimination project through mosquito protection.
• Two other health orgs emerged — Office International d’Hygiene Publique and League of Nations Health Committee — neither achieved universal relevance, suffered many of weaknesses of LoN
• Rockefeller Foundation, single largest funder of global health efforts in first half of 20th century. Eradicated hookworm in US. beginning of vertical interventions.
• Community involvement and locally-specific factors are really important in global health delivery, but formal global health bureaucracies often didn’t consider these at the time
• socialization for scarcity: the assumption that resources for poverty reduction and health will be in perpetually short supply
• post WWII, formerly colonized states embarked on ambitious development agenda, but often based on export crops of commodities. health systems, education suffered as a result of uncertainty.
• 1948: the WHO is formed, bringing together a bunch of other global health organizations. Was set apart from its predecessors by universal membership and decentralization. First time they stepped in was 1947 when cholera broke out in Egypt.
• McKeown hypothesis: control of infectious disease driven by 3 factors: medical measures, reduced exposure to infection, and improved nutrition, with last 2 playing more of a role-> encouraging us to examine broader approaches to consider social and political context. HIV/AIDS’ case was a direct challenge to this
• 1955: announced malaria and smallpox eradication campaigns, both ‘vertical’, disease-specific interventions
• Malaria: spraying every home annually with DDT, local teams did not have flexibility to adapt, by 1960 this looked way too expensive and parasite was developing resistance. abandoned program in 1969. Program failed because of overwhelming belief in technological fixes — did not consider biosocial aspects (irrigation patterns, living conditions, etc.)
• Smallpox: 1967, focused on large-scale vaccination (80%+, through single point and house to house teams), surveillance, and containment (both requiring strong reporting infrastructure and local health workers). Regarded as triumph of modern public health efforts as disease was eradicated in 1977. Challenges included case detection in rural areas, migration, and local resistance in certain countries. Key factors affected success of eradication in small pox like transmission, recurrence, latency, case-finding, prevention.
• But neither campaign built infrastructure for long-term impact, the approach was very top-down & tech-focused and did not understand social & economic roots of disease
• role of continuity between current global health efforts and former colonial rule; critical social history seeks to render the present unfamiliar and open to social critique

Chapter 4: Health for All, Competing Theories and Geopolitics

• 1978: international conference in Alma-Ata, Kazakstan — “HEALTH FOR ALL” and the aspiration of universal primary health care (PHC) → building off of the geopolitical environment of the time and the mixed successes of vertical interventions, a more comprehensive/horizontal approach to health was needed. Halfdan Mahler coined the phrase “health for all by the year 2000”
• Conference had 3000 people from 134 coutnries. Based around an all-compassing definition of PHC, “appropriate technology” for resource-poor settings, critique of “medical elitism”, and health as an avenue for social and economic development. Ambitious plans, but not translated into action — did not specify who would pay for or implement, no commitment to implementation; also 1980s debt crisis which supported cost containment and allowing the market to decide on healthcare
• Bellagio meeting of Rockefeller Foundation about selective primary health care as an interim strategy. Cost-effectiveness analysis, identifying high return for $ spent on a package of healthcare services, and donors could evaluate effectiveness of aid dollars.
• GOBI interventions came out of this: growth monitoring, oral rehydration therapy, breastfeeding, immunizations. Worry with this — does this bypass many components of strengthening health systems? Debate between PHC & SPHC. UNICEF & James Grant, and the World Bank backed SPHC
• Era of Thatcher and Reagan. Neoliberalist reforms (free markets, less government intervention) took over, putting faith in markets to efficiently deliver health care services. Tumultuous time for world economy. Governments of developing countries had taken out flexible interest rate loans and were squeezed by decreasing export demand and growing debt service
• IMF issued conditional “structural adjustment”loans where recipients had to shrink public deficits, open economies to trade, rigid macroeconomic policy. “stabilize, liberalize, privatize” of the Washington Consensus. Huge scale of lending, and many countries cut funding to their health sectors to meet requirements. Commodification of health care, World Bank promoted privatization of health services and charging patients to use them.
• Starting to charge user fees did not achieve the intended goals (revenue generation, privatization, increased efficiency, and subsidizing rural health care), and resulted in decrease of use of health services, deterring the poor. User fees actually raised expenditures and not revenues on average, and implementation of them was difficult.
• Late 1980s, attention was drawn to successful policy adjustments that had still undermined health outcomes — huge declines in per capita social spending. Widely acknowledged now that structural adjustment did little to achieve growth, reduce poverty, improve health because it didn’t address systemic problems
• UNICEF’s selective primary health care campaign in the mid 1980s: GOBI — FFF. Family planning & birth spacing, female literacy campaigns, food supplementation added. Program architects deemd this most likely to result in a major decrease in observed mortality. Could be delivered with minimal health care infrastructure and existing medical technology.
• National immunization days were held, sometimes even stopping civil wars for a day so that children could by immunized. UNICEF & WHO provided free basic vaccinations (smallpox, polio, measles). Example of Turkey — 45K vaccination posts, 12K trained health personnel, promoted the program, secured support of opinion formers at every societal level. by 1990, UNICEF announced it had met the goal of immunizing 80% of children in the developing world.
• GOBI -FFF introduced a lot of successful strategies — temporary vaccination sites with volunteers, access to oral rehydration therapy (from 1 to 20%), mobilized huge political will for child and maternal survival. Targeted nature was both its strength and weakness — it had minimal impact on health systems beyond infant mortality metrics, and was not sustainable — immunization rates have dropped in some countries. Band-Aid-like-solution.
• GAVI launched in 2000 at Davos with funding from Gates.
• Ascendance of SPHC also reinforced neoliberal ideology — re: cost-effectiveness as a principal tool. Are health interventions a means to economic growth, or vice versa? Are children ‘future agents for economic and social change’ or individuals with human rights?
• in the 1990s, World Bank became more involved in global health as a policymaker, lender, and funder. 1993, advocated for greater investment in health. Their report criticized the high % of funding to high cost tertiary care usually accessed by urban elites, and proposed cost-effectiveness as the appropriate tool. Introduced Global Burden of Disease project, in collaboration with the WHO and DALYs. Proposed a 12$ per capita per annum package to reduce burden of disease, and called for an increase in spending.

Chapter 5: Redefining the Possible, the global AIDS response

• the golden age of global health: development assistance skyrocketed from 2000 to 2007, from 10.69B to 21.79B, and a huge driver of this was US government supporting AIDS prevention and treatment. How did AIDS spark this surge, given the cost and complexity of its treatment regime?
• we had become socialized for scarcity, targeting the low-hanging fruit, constraint had become institutionalized
• US was an unlikely champion of AIDS in developing countries, variety of political and economic factors encouraged them to get behind it
• PEPFAR supported treatment for 2.5M people in 24 nations in 2009 and only a few hundred in 2000.
• Gates Foundation, Global Fund to Fight AIDS, TB, Malaria, World Bank, IMF
• 3 by 5 initiative launched by WHO & UNAIDS in 2003: ART to 3 M people w AIDS in low and middle income countries by end of 2005 — brought together a diverse set of donors, practitioners, governments, patients together and encouraged accountability. Was reached in 2007, but helped galvanize the global AIDS effort.
• 1980s/1990s, AIDS meant death in all countries. 1987, AZT which slowed replication of HIV got FDA approval, and was $8000 annually. AZT-resistant strains emerged; mortality rates in US increased 1987–1995 up to 18/100,000 people. Few AIDS activists understood the scale of the international pandemic.
• 1996, new class of antiretrovirals (non-nucleoside reverse transcriptase inhibitors) got FDA approval. Found that antiretroviral therapy, with multiple antiretrovirals, suppressed the virus and made AIDS into a manageable chronic disease. Price for a 3 drug cocktail was $10–15K USD a year.
• Debate in health and development circles about treating AIDS in poor countries. One side of the story was that prevention was more cost-effective and that there was no way to make HAART possible, and that it was too complex to deliver in resource-poor settings. Quote by Andrew Natsios, head of USAID, about “western means for telling time”. ART demands strict adherence to first line treatments — 2nd & 3rd far more expensive.
• Partners in Health did a study in Haiti that showed higher adherence rates than developed countries, MSF similar study in South Africa. Also when treatment became available, people were more engaged in preventative measures. Compelling arguments for treatment effort. Harvard consensus statement noted 2 barriers: 1) high price of antiretrovirals and 2) insufficient funding for implementation.
• medical apartheid: a health system that divided patients according to ability to pay for lifesaving drugs
• “intellectual property at the heart of first transnational battle for access to antiretrovirals” Brazil started importing generic retrovirals and decreased cost by 70%. South Africa passed Medicines Act in 1997, would allow compulsory licensing (with a royalty, but w/o permission of patent holder) and parallel importation from countries where drugs are sold at lower prices. 39 pharmaceutical companies tried to take government to court because of patent infrigement and decreasing R&D funds. Clinton administration initially sided with pharma companies. AIDS activists pressured Clinton admin to repeal at campaign events, and Clinton admin started to support South Africa’s Medicine Act. Pharma companies withdrew lawsuits in 2001.
• Allowed generic drugs to be produced, only for developing countries, at a price of $300 to $412 per person per year, 33x drop. CHAI’s precursors worked to generate demand for large orders of generic antiretrovirals at specified prices

• 2001 WHO’s report on Macroeconomics and Health, G8 summit Global fund -> more funding for AIDS, political capital of global health rapidly increased on university campuses, leaders, celebrities, organizations, even evangelists. Bush reinvented himself as a champion of AIDS relief and committed 15 billion over next 5 years to AIDS.
• Golden age of global health because challenged status quo perceptions with equity and lifesaving interventions previously thought to be too complex or expensive
• Idea that treatment IS prevention — ART reduces rate of transmission.
• Can we use ‘vertical’ AIDS programs to simultaneously provide ‘horizontal’ primary care services and strengthen health systems? Workers trained to support patients with HIV can simultaneously address other pathologies.

Chapter 6: Building an Effective Rural Health Delivery Model in Haiti and Rwanda

• how might social theory and history inform efforts to improve the delivery of health services? how are history and political economy of Haiti manifested as sickness in its inhabitants?
• Story of Partners in Health & Zanmi Lasante, and their efforts to address structural barriers to good health, including unemployment, access to food & water, high transport costs, poor housing… etc. Goal is to deliver care while bolstering public capacity to do so.
• Roots in rural Haiti — the book discusses a good amount of history about Haiti to give a background, discussing colonization by the French/Spanish, plantations, U.S. Marine Corps taking over, lack of education and fair land practices, lack of social services, export agriculture, Port-au-Prince vs rural divide, Duvalier, the ecological crisis, governmental instability
• Rural per capita income under $300 / year, people on edge of famine, only half of school-age children in school, life expectancy at 61 years, high childhood mortality rates at 72 / 1000 people, 10% of the number of physicians as the US.
• PiH clinic founded in Cange, a small squatter settlement of displaced peasant farmers, refugees of the building of a dam
• Book tells the story of Acephie, her life, partners, work, child, and contracting AIDS and TB — structural forces of poverty and violence that put her to risk
• TB in Haiti is at the highest prevalence in the hemisphere, and has been in Haiti for two centuries. Having AIDS puts you at very high risk for TB, high rate of co-infection. Emergence of resistance to first-line tuberculosis drugs
• Building out a TB control program, with a test group and two similar populations. Both groups were offered consultations with a physician, lab work, and medications without user fees. One group was also offered women’s health initiatives, vaccination campaigns, water protection efforts, and adult literacy groups. These efforts were also implemented by accompagnateurs, paid community health workers. These people could identify the sick and refer them to the clinic, and provide close follow up. The first group of residents also received financial aid, clinic visit $ honorarium, and nutritional supplements if they continually participated in the treatment program.
• looked at indirect economic indicators — years of school, owning a radio, access to a toilet, as well as age and background to see if the groups were similar
• Results were much more positive in the group that received community-based interventions, in mortality, test positivity, weight gained, return to work, clinic and home visits, cure rate, and conceptions about illness. Takeaway: patients fare better when the program addresses structural barriers to care.
• Trying to extend this delivery model into AIDS. Barriers included stigma, fear, and access to combo ART. Eventually, ZL/PiH implemented AIDS program. Lazarus effect — seeing someone rise up from the dead, was inspiring. Providing AIDS treatment improved the overall systems of care delivery in the Cange hospital and clinics, and gradually supported rebuilding of infrastructure.
• Scaling up in rural Haiti — how do you make this model work in other locations? Cange clinic had an overwhelming number of patients. by early 2000s, available resources of HIV/AIDS programs had increased, and Haiti was one of the first grant recipients. Worked with government and had 3 sites to scale to. Could ZL take a vertical program and make it simultaneously horizontal? Yes, and it worked, ZL was service more than 1.1 M people by 2009 through 10 public sector health facilities delivering comprehensive care.

Health care delivery model:

1. Strengthening access to primary health care (integrating infectious disease interventions and broad range of services)
2. Providing health care and education for the poor
3. Relying on community partnerships (accompagnateurs)
4. Addressing basic social and economic needs
5. Working in the public sector (governments can give health care, don’t establish parallel systems)
6. Focusing on women and children
7. Harnessing technology and communications
8. Disseminating lessons learned

• PiH helped rebuild largest hospital in Haiti after the 2010 earthquake in Port-au-Prince
• Switching to Rwanda and Inshuti Mu Buzima (PiH Rwanda) . Haiti and Rwanda have more in common than you’d initially guess — around 10M people, small, rural, agrarian, exporters of tropical produce, histories of structural violence, postcolonial instability, and disease burden along lines of multiple health indicators
• Today, Rwanda is the only country in sub-Saharan Africa on track to meet MDGs by 2015. High immunization rates, maternal death has declined
• History in brief of Rwanda — more social complexity than the Tutsi and the Hutu. Little systematic violence pre-colonial times. Hutu 83%, Tutsi 16%, cards given by the Belgians. Belgians switched ‘loyalty’ from tribe to tribe, Hutu elite portrayed Tutsis as cause of poverty. infrastructure programs supported certain parts of Rwanda more than others. Hutu militia killed 1 million Tutsis and some Hutus. Refugee camps established, but became sites for perpetrating violence, cholera outbreaks. Rwanda began rebuilding, invested, trying to become IT hub and a middle income country, increases in GDP.
• PiH in Rwanda’s (IMB) goal was to deliver comprehensive PHC in two rural resource poor districts. Sparked increases in HIV testing, high adherence to medications, again through the paid community health workers approach
• Had to run a large-scale international recruitment and training program for community health workers. Entire effort required coordination of efforts by a public sector.
• Rwanda launched mutuelle health insurance program in 2006, mandating that every citizen purchase insurance. Though IMB was originally providing free care, IMB facilities adopted the mutuelle system. But people getting certain HIV/TB/prenatal interventions aren’t charged the co-payment, or IMB helps pay premiums and co-payments for people whom local leaders deem too poor to pay, and for children under 5. Copayments are still a barrier to the poorest quintile of people
• 99% of IMB staff members are Rwandan. IMB tried to avoid technocratic reductionism, instead approaching health from a biosocial perspective
• By March 2011, IMB helped support or operate 3 hospitals and 36 healthcare centres in Rwanda. Built a long term partnership with the Rwandan government to strengthen health systems for other diseases. Patient outcomes CAN be improved if the government is committed to expanding access for the rural poor.
• Challenges remain: paying community workers & scaling that up as a public service, providing food to ART patients, and user fee debate
• After 2010 earthquake in Haiti: 25,000 people killed per million inhabitants. 2.5% of the population. More than half of US households contributed to the humanitarian response. This event was an ‘acute-on-chronic’ event — Haiti has long faced social and economic problems, but the earthquake brought them to the forefront.
• Only 10% of the ~6B in aid from bilateral/multilateral donors actually reached the Haitian government. Thousands of foreign contractors worked in parallel without much coordination. Cholera outbreak. Struggling to rebuild.
• What did Rwanda do well? 1. Transparency and accountability within the government 2. clear national development plans 3. development strategies that help the poor and reduce inequality.

Chapter 7: Scaling Up Effective Delivery Models Worldwide

• Case studies from Global Health Delivery Project at Harvard

Strategic framework for global health delivery:

1. Adapting to local context
2. Constructing a care delivery value chain
3. Leveraging shared delivery infrastructure
4. Improving both health delivery and economic development

• Adapting to local context: assessing local contours of disease burden, prevalence, and modes of transmission. Understanding infrastructure and political dynamics, economic conditions, social and cultural forces
• Constructing a care delivery value chain: choosing interventions based on value for patients, defined as overall health outcomes per cost — this is very different than cost-effectiveness of isolated interventions. CDVC considers care as a system, not individual interventions, and reflects a broad, biosocial conception of health care delivery.
• Leveraging shared delivery infrastructure: making things easier for providers and patients, using same storage and distribution mechanisms, generating economies of scale, helping patients out with a range of illnesses (and making it easier for them to navigate).
• Improving both health delivery and economic development: Long term health system sustainability needs modern infrastructure, workforce, school systems, water and sanitation, and an economy. conversely, health affects economic outcomes. Well-designed health programs can leverage a positive feedback loop between poverty reduction and health system strengthening

Case studies

• Polio in Uttar Pradesh: ethnographic research indicating residents did not see polio as leading health concern, skepticism towards outside intervention, needed to adapt to community context
• AMPATH HIV Care in Kenya: HIV counselling and testing, ART, TB care, and referred patients to oncology, reproductive health, antenatal care. Developed package of integrated interventions, and introduced home based counselling and testing to reach more people at this front end of care delivery. Huge program scale up to over 300K cumulative visits by 2006.
• BRAC’s Rural TB Program: Training a group of community health workers called shebikas to serve each 250 -300 households and screen for TB, case-find, refer to services, dispense minor medicines. Integrated into government health system.
• A to Z Textile Mills & Mosquito Nets: A Japanese textile manufacturer partnered with a textile mill in Tanzania to expand annual production of insecticide treated nets for the Roll Back Malaria initiative, creating local jobs at factory and in community.
• Health system strengthening building blocks: service delivery, health workforce, information, medical products/vaccines/technologies, financing, leadership & governance
• Dynamic relationships between health system and population (Julio Frenk): as patients, as consumers, as taxpayers, as co-producers of health, as citizens
• Diagonal approach: disease-specific interventions, when delivered well, can strengthen health systems. vertical programs can also be horizontal ones. idea of conditional cash transfer programs Opportunidades in Mexico, and the examples in Haiti and Rwanda
• Advantage of public sector health systems in democracies: rights, accountability, scope, sustainability, scale, efficiency, coordination, global commitment
• Effective public-sector health systems: Indian state of Kerala, Cuba, Rwanda
• Idea of accompaniment when building health systems — need to work alongside local governments and NGOs in a coordinated way. Can be challenging when NGOs and foreign initiatives bring in priorities and are accountable to their donors, and if governments are fragile and predatory. CHAI’s goal is working themselves out of a job by building local government capacity in the health sector. Private-public partnership capable of strengthening national health systems in the long term are the way to go
• Human resources for health are very important for delivery. Huge shortfall of 4M+ workers to meet MDGs. US has an average of 24.8 healthcare workers per 1000, Africa has 2.3. 66 medical schools in all of Africa, and many graduates emigrate for better pay and job stability, brain drain, often don’t want to work in under-resourced systems. Will require building up health systems in developing countries. High costs to bridging training gap. Task shifting to community health workers can help provide essential services.

Chapter 8: The Unique Challenges of Mental Health and MDRTB, Critical Perspectives on Metrics of Disease

• both associated with a significant share of the annual global toll of DALYs, resist straightforward categorization and complexities and short-comings of metrics for disease burden.
• MDRTB — contagious, airborne, often deadly, and complicated & expensive to treat

mental health

• 76% increase in prevalence of depression in US from 1980 to 2000, use of antidepressants tripled. 10.6% of women, 5.2% of men use an antidepressant monthly. Does the US health establishment medicalize normal sadness?
• Burden of mental disorders as % of DALYs ranges from 7.88% in low income countries to 21.37% in high income countries, whereas % of budget allocated to mental health ranged from 2.26% to 6.88%. Mental illness very prevalent in developing countries as well.
• Tough to quantify and report mental illness globally. Scarcity of mental health services to generate prevalence estimates. DSM-V’s validity mainly relevant in European and American populations, and can have limited clinical utility across diverse cultural and social contexts. Co-morbidities associated with mental illness — increases risk of both communicable and non-communicable diseases. Physical diseases also increase risk of developing mental illness.
• Patel & Kleinman’s 2003 study “ the experience of insecurity and hopelessness, rapid social change, and the risks of violence and physical ill health may explain the greater vulnerability of the poor to common mental disorders” — structural violence predisposing the poor, range of interrelated forces. socially marginalized groups also bear the brunt of the disease burden, i.e. in China women’s suicide rates are 25% higher than men, and higher in rural areas. Stigma and vulnerability attached to neuropsychological disease can lead to violations of basic human rights.

• Mental health professionals are in short supply around the world, but one way to fill the gap would be training primary health care workers in the community for basic support. Done in communities in Colombia, Ecuador, Nepal, Nigeria, Chile, Haiti.
• Kleinman’s quote about medicalization and searching for genetic roots and risk factors of conditions, it can stigmatize and protect, but can also obfuscate the political and economic problems that influence behaviours.
• Research in non-Western countries in mental health is underrepresented in high-impact psychiatry journals. The ways in which Western mental health practices can complicate the recognition of culture-specific experiences of mental distress and disability. Clinical medicine must be integrated with local knowledge and practice.

The DALY: strengths and limitations

• “the present value of the future years of a disability-free life that are lost as the result of premature deaths or cases occuring in a particular year”
• Designed by Christopher Murray, health economist in early 1990s, to help guide prioritization and resource allocation in global health, identifying disadvantaged groups, enabling better evaluation of interventions
• Revealed that TB, mental health, and road traffic accidents were three of the leading causes of DALYs
• Though not perfect, this metric has opened new terrain in global health and people use it frequently in policy making, also used frequently in cost-effectiveness analysis
• so many assumptions that had to be made!
• Researchers asked an independent panel of experts to rate classes of disability on a scale of 0 to 1
• Developed an age-weighting mechanism on the value of a person’s life increasing until 25 then slowly dropping down, ‘broad social preference’ but also economic productivity.
• Lack of data in rural or resource-poor areas — estimates for most of sub-Saharan Africa are from South Africa alone.
• “when objective indexes are used, they measure biological change as if it were separable from the experience of distress and the bearing of suffering, distorting the lived experiences of patients” — Kleinman
• Kleinman’s concept of social suffering — burden of disease falls on families and communities as much as individuals — not included in the DALY. Someone’s position in family can have a big impact. Age weighting and individual community responsibilities may also be different in various cultures — i.e. the elderly.
• Controversy about weighting of life expectancy re: women vs men, but also the cohort expected years of life lost. Because life expectancies are so much higher in developed countries, using a non-standardized life expectancy would decrease how significant DALYs in developing countries are as a portion of the metric, because it’s more heavily weighted to countries with higher life expectancies. So DALY uses a standard.

MDRTB

• TB claims 1.7M lives per year. MDRTB affects 500K, and is resistance to 2/4 first line drugs
• directly observed, short course was recommended by WHO for MDRTB treatment with first-line drugs in the 1990s. Very cost effective, but didn’t suggest second line drugs for people who had drug-resistant TB. This also increases drug resistance in populations.
• TB program in Peru used as a model for the region, but Socios en Salud found many MDRTB patients north of central Lima, because DOTS wasn’t effective against those strains. Global public health authorities didn’t recommend the effective regimen because it is is expensive.
• Socios en Salud built a DOTS-Plus treatment program, which added second line medications, monitoring, drug susceptibility testing, and individual therapy, along with the community health delivery approach which cut costs and reduced transmission.
• This MDRTB program has been adopted other places. WHO and Stop TB coordinated procurement and financing to achieve reductions in the cost of second line drugs… but approval is not the same as implementation. Many people still don’t receive the drugs they need. A few barriers: some second line drugs still remain expensive, and technical accompaniment is needed. Delivery is missing.
• Lessons learned — widespread use of any intervention, even if cost-effective, can have unintended and harmful consequences without feedback loops in implementation strategies. Biosocial complexity with diseases like MDRTB into quantifiable attribute that fit cost-effectiveness analysis.

Chapter 9: Values and Global Health

• this chapter really pushed my thinking by bringing up moral frameworks and forcing me to critically self-reflect
• “skills in critical self-reflection on the complexity and irony of what really matters in living can also enrich life beyond medicine”
• world, patient, and physician have divided and hidden values
• utilitarianism: ‘the greatest good for the greatest number’ . enduring logic of maximizing well-being that stimulates global health discourse… ~10M people die annually in poor countries from diseases to which treatments are readily available in rich countries. consider how we measure utility — is it pure happiness?
• Peter Singer — argument for utilitarianism in development discourse.. “if you don’t donate to aid agencies, you’re doing something wrong.” — provocative, and many believe he goes too far. Dependent on aid agencies preventing suffering. Can lead to slippery slope of helping everyone live a less miserable life without letting anyone live well?
• Utilitarianism can also push us in the direction of cost-effectiveness and the DALY, maximizing utility and assuming scarce resources
• liberal cosmopolitanism: “the idea that all human beings, regardless of their political affiliation, can belong to a single community and that this community should be cultivated” Important people: Thomas Pogge, student of John Rawls. Conception of justice as fairness to critique global institutional order… global economic system (reigning econ+ political systems actively harming the poor) as actively perpetuating a fundamentally unjust status quo. forced me to consider how do the institutions and status quo that I believe in support poverty but on a macro-level are still contributing to it?
• capabilities approach: Amartya Sen and Martha Nussbaum. capabilities are the components of flourishing, categories of human experience that enable well-being among individuals and justice among states and societies. Capabilities include life; bodily health; bodily integrity; sense, imagination, and thought; emotions; practical reason; affiliation; other species; play; control over one’s environment. Any individual lacking in these capabilities cannot be living a good life -big question here-
• GNP growth or rising incomes are the means to expanding development. Capabilities are the end of development… these are the substantive freedoms to choose a life one has reason to value. Development involves removing the barriers to these: poverty, discrimination, violence & repression, lack of access to healthcare. Expansion of freedom is viewed as both the primary end and the principal means of development
• “wealth is evidently not the good we are seeking; for it is merely useful and for the sake of something else”
• Two ways to increase life expectancy: “growth-mediated” and “support-led”. Growth must be wide-base and economically broad. Virtuous cycle between the two as long as wealth trickles down to poor.
• Example of A quiet revolution book in Bangladesh: discussion-based groups with rural women in common spaces were far more successful at boosting female literacy than just distributing resources
• One drawback of essentialism is disregarding local knowledge and custom — example of female genital alteration (risks bodily health) having acquired a defensive local meaning in some parts of Africa (i.e. enmeshed in postcolonial Kenyan nationalism) who has the right to tell someone what’s best for them? considerations of this practice in local and translocal discussions of it? (cultural relativism vs ethnocentrism perspective)
• Karl Marx conception of species-being: human flourishing is predicated on membership in communities, on work that benefits something larger than individual needs
• Tension between universal claims of human rights and local moral worlds — omnipresent. Example of Lee Kuan Yew rejecting Western premise that individuals have inalienable rights that trump the needs of society, Asian and Western values being different. Are there universal human rights?
• anthropology as a way to unite ethnography (local moral worlds) with large scale social forces and dominant discourses (such as human rights)
• “Why More Africans Don’t Use Human Rights Language” — Chidi Odinkalu argues that many NGOs/aid agencies restrict themselves to civil and political rights and don’t address widespread violations of social and economic rights

Chapter 10: Taking Stock of Foreign Aid

• 1997 to 2007, development assistance for health nearly tripled, from 8.42B to 21.79B; AIDS funding increased 25-fold in less than 2 decades; total development assistance more than doubled between 2000 and 2010
• brings up the question: has foreign aid improved the lives of its intended beneficiaries? how does aid work? Two big names, Jeffrey Sachs and William Easterly.
• Sachs said that 0.54% of the rich world’s GNP could help end extreme poverty by 2015. His argument rests on the theory of poverty traps: many families spend all their income on basic survival and can’t save or invest in productivity enhancements (seeds, farming tech), education, health. Differential burden or blessing of geography: a country that struggles with large disease burden because it has a tropical climate, or high transportation costs internally. These two things are the roots of economic stagnation according to Sachs.
• this argument stands in comparison to poor governance / corruption being the primary source of stagnation (re: Root Causes reading in class)
• Sachs says that aid can help reduce poverty, only if it is overhauled into an efficient, transparent, and accountable system that channels resources to people that need them
• Easterly doesn’t agree. Used cross-sectional statistics to compare and analyze aid delivery programs, argues aid failed to promote growth and has instead bred dependency and corruption in poor countries. Governments siphon off the money, operations costs consume a large %.
• Easterly says the underlying problem is that it’s all too top-down from Western organizations trying to cure poverty, when it’s really the individuals in poor countries who start businesses or find creative solutions to reducing poverty and solving social problems. Markets work, but not when planned from the top down, and democracy must emerge from the bottom up to avoid capture by dictators and elites. He proposes a way to avoid governments and get money either directly to dynamic individuals or to private sector.
• Both arguments force you to consider… how does foreign aid work?
• RCTs in development (book I will read soon: Poor Economics) comparing groups of people who receive a certain kind of aid vs who don’t. Work has helped people understand more about mechanics of implementing development programs. Raises troubling questions — we’ve already proven that certain interventions work in low resource settings.
• how do we deliver care better? how can we build systems that will provide quality care in the long-term independent of foreign aid flows and trigger virtuous social cycles and suitable economic development?
• Accompaniment approach: supporting developing country partners (public and private) until they have the capacity to deliver services and improve livelihoods in the long term. Needs to be adaptable to diverse local settings. Don’t build parallel aid structure, build the local capabilities. 8 principles:
• Favor institutions that the poor identify as representing their interests
• Fund public institutions to do the job
• Make job creation a benchmark of success
• Buy and hire locally
• Co-invest with governments to build strong civil services
• Work with governments to provide cash to the poorest
• Support regulation of international non-state service providers
• Apply evidence-based standards of care that offer the best outcomes

Chapter 11: Global Health Priorities for the Early 21st Century

• Heavy burden of cardiovascular disease, cancer, and mental illness in the developing world
• 2.5B people still live in less than 2 dollars a day, and an estimated 18M people still die from poverty-related causes every year
• Africa bears 24% of the global burden of disease and has only 3% of total healthcare personnel and 1% of the world’s financial resources for health
• diagonal approach: responding the specific leading causes of mortality and morbidity in ways that strengthen health systems in general
• MDGs (now the SDGs) → place to start the discussion. Maternal & child health. AIDS, TB, malaria; neglected tropical diseases
• Pneumonia, diarrhea, and malaria accounted for 36 percent of all deaths among children worldwide in 2011
• GAVI: 4 main goals: increase vaccination rates in poor countries that have low coverage, strengthen routine immunization capacity in poor countries, maintain multi-year, predictable financing for global immunization, and advance market commitments (securing purchase agreements to incentivize vaccine development of new vaccines and to lower costs)
• GAVI in a decade after 2000 founding spent nearly 3 billion helping to provide vaccines to more than 250M children and raising the immunization rate among children in low-income countries to 79%. Estimated averted 5M child deaths
• ready to use therapeutic foods (RUTFs) increasingly being used to help severely undernourished children, concern that there becomes a reliance on imported foods (though there is a vitamin nourished peanut butter out of Haiti creating jobs and boosting local production)
• “pets owned by the affluent can thus serve as a stronger driver of drug development than millions of poor people at risk for disabling disease”
• neglected tropical diseases — a huge issue that we don’t tackle as much. 20 such conditions, including dengue, sleeping sickness, river blindness, rabies, hookworm. market failure, little financial incentive to invest in new medicines to combat the diseases. Pharma companies have helped donate medicines that help against these diseases. estimated 1 billion people suffer from one or more NTDs. Annually, ~534,000 people die from them. No global strategy marshalling funds for this. There is a rapid-impact package of 3 drugs to help against some NTDs, but it doesn’t help against all.
• WHO estimates that 90% of the global disease burden (diseases of poverty)attracted only 10% of health related research around the world
• Epidemiological transition model that you know and love has issues! Many NCDs have infectious etiologies (cervical cancer to valvular heart disease). Double-burden of disease in low and middle income countries of both non communicable AND communicable diseases. NCDs cause more deaths worldwide than infectious diseases…60% of global mortality is NCDs, with 80% in developing countries.
• Burden of NCDs is compounded by endemic environmental conditions, malnutrition, and lack of access to care
• NCDs in developing countries follow the long-tail pattern… individual NCDs don’t account for a lot of burden, but when you add them all up it’s substantial
• Four lifestyle risk factors framed by global policymakers: tobacco use, unhealthy diet, unhealthy alcohol use, physical inactivity. Four diseases. heart, lung, cancer, and diabetes. Mental health needs to be in there!
• Cancer prevalence and incidence is on the rise in developing countries, and will account for 70% of burden in 2030. Arguments against advanced cancer care follow a similar story as AIDS — complex, expensive, scarce resources — and will need to be overcome to provide care
• The States can learn from a lot of this too — community-based care in low-resource settings, and even in more affluent communities. health inequity is a problem within the borders of developed countries as well. Prescribing social services, especially for low-income communities or patients with chronic disease that require lots of care