The Global Health Emergencies Course Blog

Published on February 15, 2015
February 14, 2015 marked the first day of the annual Global Health Emergencies Course hosted by The Global Emergency Medicine Division at Weill Cornell Medical College / NewYork-Presbyterian. For the next nine days, various attendees will blog the event, sharing global health pearls and perspectives. Their posts will be updated below each evening.

Day #6 // Each in our own way

by Barbara Ma

Our course continued with a closer look at complex humanitarian emergencies. We met the very inspiring Dr. Hilarie Cranmer, the Director of Global Disaster Response at the Center of Global Health at Massachusetts General Hospital. Amongst her many accomplishments, she helped build one of the largest recovery and rehab centers in Haiti after the earthquake in 2010, which was recognized by the UN and the US government as being one of the best field recovery facilities, post disaster. After going through the current Level 3 emergencies in Syria, Iraq, South Sudan, Central Africa Republic, she shared some poignant experiences from her experiences abroad in Haiti – working with an indispensable team that included a super-nurse, logistician, security, and a Miami chef who was handy with languages and in the kitchen. It was this team that also picked up on when she overexerted herself while she was focused on taking care of everyone around her. There are many factors involved in running a field hospital - water, sanitation, food, nutrition, how to feed 1000 people 3x a day. But any lady whose nickname is l’homme (man in French) must be a powerful ally. A compelling anecdote that really resonated with me was when she stood up to a surgeon to stop an unnecessary amputation of the leg of a 9 year old boy who was agonally breathing. Though resources (including anesthesia) may be lacking, the human right to die with dignity remains the same.

The level of organization that goes into the response to a complex humanitarian emergency highlights the importance of professionalizing the humanitarian response. Dr. Balsari gave us an overview of International humanitarian law and the evolution of SPHERE standards. We reviewed the Geneva Conventions. As GHEC participants, we also get the unique opportunity to try out Humanitarian U (http://training.humanitarianu.com/), a professional online training program aimed at increasing preparedness and effectiveness of humanitarian actions. Even in the first module, it has already been quite educational.

Our day continued with a great talk about epidemics and outbreak control with Dr. Adam Levine (and no, NOT of Maroon 5 fame). Dr. Levine is an Assistant Professor of Emergency Medicine at Brown University and Emergency Medical Coordinator of the International Medical Corps. His work focuses on improving the delivery of emergency care in resource-limited settings and during humanitarian emergencies. Fun fact: one of our fellow GHEC participants, Meagan Hawes, who is currently pursuing her MPH at Johns Hopkins University, worked with Dr. Levine in Rwanda last year on the DHAKA (Dehydration: Assessing Kids Accurately) study, in which she specifically assessed whether mid-upper arm circumference could be used as a predictive marker of dehydration status. Dr. Levine gave a comprehensive review of clinical diagnoses of TB, cholera, malaria, diarrheal disease. He also shared some personal experiences with the Ebola epidemic, about the almost isolating feelings he got upon return to US. One can’t help but compare his experience to that of Dr. Craig Spencer, and think of the public's pendulum-like view of hero (for having a bleeding heart and helping those in need) vs villain (risk of possibly bringing Ebola into the US). What are the costs of standing up for doing work that you think is right?

Our day ended with Grand Rounds given by the esteemed Dr. Leslie Roberts, Associate Professor of Population and Family Health at Columbia University. He has a PhD in Environmental Engineering, has worked for WHO in Rwanda, and has led over 50 surveys in 17 countries, mostly measuring mortality in times of war. He brought up a very interesting comparison – the glorified prolific researcher who brings in $100 million in grants with the publish-or-perish mentality vs the clinician who brings in $1 million in grants with 10 publications in the past 10 years can have the same impact. Would an HIV vaccine bring one of the poorest countries into a developed nation within 50 years? How about a perfect 100% literacy rate in children? Then why are scientists mainly working on the HIV vaccine and not literacy program development? “No one thanks the biochemist. But we all love the doctors and nurses.” His challenge to us to impact the world more on the clinical side really makes one think.

The day gave me a sense of appreciation for the scope of global health and how we are all chipping away at the global burden of disease in our own ways. As a fourth year medical student going into internal medicine, I was interested in building my skill set and learn more about developing clinical skills in low-resource settings. Having been involved in therapeutic HPV vaccine development for several years and with a background in biomedical engineering, I’ve thought mostly in terms of academia. Each day, GHEC continues to broaden my perspectives and the speakers have really made me reshape my thoughts on how best to contribute to the common goal of lifting the universal burden of disease and helping our fellow man in times of need. I believe the underlying message is: Be compassionate, be flexible, and always stand up for what you think is right. That is how we can best make our impact.


Day #5 // Inquisitiveness

by Samir Rahman

“Ouch.” This was my initial thought as I heaved an approximately twenty-kilogram bucket filled with water on top of my head in front of my amused peers at the start of the seventh day of the Global Health Emergencies Course (GHEC). After the laughter died down and pictures were taken, Dr. Miriam Aschkenasy of the Harvard Humanitarian Initiative told us that women in crisis areas had to carry a similar water bucket on their heads and walk for miles to get water to their families. It was unpleasant having the bucket on my head for five minutes – walking miles with it on my head was inconceivable.

The water, sanitation, and hygiene (WaSH) portion of GHEC gave insight into a critical aspect of managing a complex humanitarian emergency: ensuring that clean water, waste disposal, and a cleanliness apparatus was available. Without proper WaSH techniques, most attempts at humanitarian aid are likely to fail. There is a reason that SPHERE standards, the minimum standards in a humanitarian response, include provisions such as: “15 Liters of water per person per day” or “maximum of 20 persons per latrine.” In situations such as the administration of Ebola treatment units (ETU), the SPHERE standards aren’t enough. On average, an ETU requires approximately 300 Liters of water per person per day. This is due to factors including, but not limited to, the intense amount of decontamination procedures that staff are subject to, cleaning water, and water used for food consumption. While the TIME’s 2014 Person of the Year article on the “Ebola Fighters in West Africa” didn't specifically mention the efforts of WaSH staff, their work is essential for the proper management of many complex humanitarian emergencies – the Ebola outbreak is no exception.

The five key points that Dr. Aschkenasy presented in her lecture were as follows: acknowledge culture, buckets for water storage/transport, more water is better than clean water if a choice is necessary, contain your feces, and dead people don't cause epidemics unless the epidemic is the crisis. These seemingly straightforward key points were then broken down into many logistical questions. The answers to each of those questions were broken down into more questions. This cycle went on for a while and it got me thinking about how breaking down key points and objectives was key for a proper WaSH response.

I realized that breaking down general themes and objectives into many questions is not only necessary for proper WaSH, but for all aspects of a proper global health emergency response. This has been a recurrent theme in the past few days of the GHEC course. To properly draft international humanitarian law, one must question the nature of complex humanitarian emergencies in order to see what needs to be addressed. In order to control an epidemic, one must question the types of data and diseases that are present so a proper plan could be produced. To make an ETU, one must question the nature of the Ebola virus and subconscious habits that people may have. To create accurate data, one must question their research method efficacy and biases. The more this question breakdown does not occur, the poorer a response will be. For example, if an ETU planner does not consider the subconscious habit of people touching their own face quite often, there is a chance that an aid worker could get infected with Ebola and unknowingly contaminate other healthy people.

A specific example of a question that resulted in an improvement in aid response is as follows: Why did the bucket hurt? One of the main reasons was because of a tiny plastic protrusion at the center of the bucket base that directed much of its weight into one point on my head. When this tiny detail was realized, an aid organization took steps to make buckets that did not have the tiny plastic protrusion and distributed them in crisis areas – making things better for the women who have to carry these water buckets on their head for miles.

If we ask more questions, we will have more answers. With every answer, there will be another round of questions. And so we produce more answers. Every answer is a piece of knowledge that can be utilized as needed. Every question is an attempt to do better and improve. The more questions that are asked, the better humanitarian responses can be.


Day #4 // Feb 17 // Global Health + Quality Improvement = Synergy?

Tristan Snider

I’ve noticed that as we discuss the approach to global health initiatives and research methods, there are many similarities to the approaches and methods I have encountered in the field of quality improvement.

Concerns regarding global health interventions:

  • Understanding the Problem and System
  • The need to be aware of the context in which you are implementing an intervention

Planning and Measuring Change

  • A shift to a more evidence based mindset
  • Quantitative and qualitative sampling methods and data analysis

Implementing Change

  • “Broken zipper problem”
  • Integrated (comprehensive/horizontal) approaches to healthcare delivery
  • The answer is often not just ‘more funding’
  • The need to engage all levels of communities, governments, healthcare providers
  • Sustained support

These are very similar to the themes and concepts I’ve seen currently utilized in successful QI projects:

  • Understanding the Problem and System

Qualitative

  • Process mapping, fishbone diagrams, stakeholder interviews

Quantitative

  • Baseline measurements

Planning and Measuring Change

  • Model for improvement: PDAC cycles
  • Decide on lead and lag process indicators, outcome, and balancing measures
  • Run charts/Control charts

Implementing Change

  • Create a climate amenable to change
  • Create a sense of urgency
  • Create a team/alliance
  • Formulate a shared vision

Engage and enable the whole organization

  • Communicate for understanding and ownership
  • Empower action
  • Create short term wins

Implementing and sustaining change

  • Never let up
  • Make it stick – A New Culture

A pervasive concern that arises in quality improvement work is that too often people have what they think is a great idea, and skip right to implementation. These plans often fail due to not following the core QI processes, and mirrors concerns that have arisen with unsuccessful global health interventions. I wonder if some of the answers to the questions on how to best create change globally can be found in the techniques that emergency physicians are already using to create change in our local emergency departments. Inversly, perhaps succesful global health practitioners would also be capable agents for change in our local emergency departments.

Day #3 // Feb 16 // Advocacy

by Meagan Hawes

Day three of the Global Health Emergencies Course (GHEC) included a spotlight on noncommunicable diseases, an introduction to survey and qualitative research methods, and a discussion on the consequences pharmaceutical patents have on access to medications.

What emerged as a link between the day’s presentations was a discussion on the power – and limitations – of advocacy.

In her overview of noncommnunicable diseases, Dr. Kavitha Kolappa, a psychiatry resident at the Massachusetts General/McLean program, opened, “Our goal is to also make activists out of you all.” She highlighted the connections between mental illness and the disease burden of cardiovascular, cancer, diabetes and respiratory disease. She noted the importance of choosing important indicators in program design -- as what gets measured gets done. Moreover, she challenged the group to consider how ideas get propagated.

Up next, Mr. Seun Adebiyi, Dr. Kolappa’s colleague at Young Professionals Chronic Disease Network, led the room through a workshop on planning effective advocacy campaigns. Mr. Adebiyi is an accomplished Nigerian-American lawyer, cancer survivor and 2018 Olympic hopeful and his energy is infectious, setting the room a-buzz with conversation. “The challenge for us as health advocates is bringing a multidisciplinary approach and being able to think outside the box,” commented Mr. Adebiyi, “It shouldn’t take an act of courage to do right by your people.”

In his afternoon talk “Data, Information & Knowledge: Research Overview” Dr. Greenough, an emergency physician and epidemiologist with the Harvard School of Public Health nuanced the theme. “Each of you will have to decide how strong an advocate for the thing you are doing you want to be,” he said. “Some things have a role in advocacy and some things have more power when they’re a bit more objective.” Is your audience able to hear or act on your argument? How do you want to be perceived? How strident do you want to – or should you – be? How do you pick your battles and moments?

Ms. Priti Radhakrishnan, who concluded the day with a discussion of her experience as a lawyer working towards increased access to medicines through the Initiative for Medicines, Access, and Knowledge (I-MAK), noted she was reflecting on how advocacy could evolve from reactionary steps to a comprehensive vision. Ms. Radharkirshnan has worked to successfully fight patent regulations to bring access to medicines to low and middle-income countries. When she thought of how to develop a sustainable price system, she noted creating such a vision wouldn't be easy and that she was inviting players from all industries – physicians, lawyers, pharmaceutical companies – to help her answer the question: how do we get there?

In the spirit of GHEC, these remain globally unanswered. Instead we were left with the questions to continue to percolate as we move into day four of the course.


Day #2 // Feb 15 // Learning To Ask Why

by Mackenzie Riggs

Katarina, a 24-month-old Honduran toddler, gazes at my stethoscope suspiciously as I listen to the foggy lung sounds in her tiny thorax. Her eyes bulge and she blinks very slowly as if closing her eyelids requires significant effort. She cries a high-pitched, painful cry that echoes through the exam room and appears completely void of energy. This very young girl weighs little more than an infant, and she conveys obvious symptoms of malnutrition. Why?

Nicoll teaches me Spanish slang and cuts my hair for free with a pair of purple scissors. Her mother migrated to escape violence, and her house has no refrigerator. Peers elected her class president, and she is my friend. Nicole celebrated her quinceanera in August and expects her first baby in June. They will both live in poverty for the rest of their lives. Why?

During the second day of the Global Health Emergencies course, Dr. Eliades, an experienced epidemiologist and international emergency physician, scrutinizes global health initiatives with obese budgets but emaciated focuses that never fully address the causes of clinical issues. He is a self-admitted cynic of most donor programs and explains the nonsensical functioning and covert purposes of many contemporary initiatives. Graphs and pie charts from his lecture depicting the positive relationship of GDP and health outcomes confirm what my experiences in Honduras have already taught me: the most wretched medical problems need not medical professionals nor medical solutions. Why is Katarina underweight? Why is Nicoll pregnant during adolescence? Because they receive only provisional fixes from alien providers and immediately re-enter the same hazardous communities that produced their poverty and disease. Sustainable and substantial improvements in healthcare require a consideration of every societal aspect-water sources, economic opportunities, cultural stigmas, faith affiliations, and educational structures.

I chose the career path of nursing and committed to a yearlong medical volunteer assignment with the intention of promoting human rights and alleviating misery. But lectures from Dr. Eliades and other health experts during this course challenge my commitment to the often capricious and impermanent behavior of the healthcare profession. Perhaps I should instead pursue engineering or hydrology or climatology in order to create better environments and prevent the sources of disease. Or maybe the answer is to support initiatives that desire more than short-term results and data. This course has taught me that there is not a single right answer-the only answer is to approach global health care with an acute awareness, an intention to collaborate, and a willingness to ask . . . why?


Day #1 // Feb 14 // Introduction

by Tristan Snider

To be honest, I personally have not had much experience with global health, but I am certainly interested in learning more. More specifically, I am interested in learning the underlying theory of providing global health assistance, gaining the knowledge to have the most impact, and to not accidentally do more harm than good. The participants are from a surprisingly diverse background. We are an international group of nurses, nurse practitioners, physicians, fellows, medical students, masters students, United Nations Relief and Works Agency chiefs and directors, and physician assistants. We hope this summary can provide a brief overview of the talking points and take home messages from our lectures and discussions.

Our first lecture, by Dr. Oliver Fein, a professor of clinical medicine and clinical public health at Weill Cornell, Highlighted was the description and comparison of the four main models for healthcare delivery:

  1. Bismark model (Funds provided by employers and workers)
  2. Beveridge model (Nationally controlled but private options available)
  3. National Health Insurance model (Single payer universal, no private allowed)
  4. Out of Pocket model (Market based)

It was noted the U.S. system most resembles a bismark model, but is actually mixed. Then, interestingly, we discussed and defined a few important terms: Empire, Colonialism, Neo-Colonialism and its associated institutions, Neo-Liberalism (Which is somewhat of a misnomer), Structural Adjustment, and Imperialism. Of note, it was mentioned that we must be careful with whom we form alliances in global health efforts in order to not accidentally create negative consequences. The concepts of vertical and horizontal global health efforts were discussed, along with the idea that international programs should aim to support local governments capacities to provide care (horizontal coverage).

The second lecture, by Dr. Ashwin Vasan, the deputy director of ACHeS (Advancing Research on Comprehensive Health Systems), emphasized the importance of the health system as a whole. We discussed the Alma Ata declaration where “Primary care is a human right” was first established. Difficulties with the implementation of their recommendations included their large scope, lack of discrete tangible steps, disagreement on locus of control, and the rise of verticalism. The ideal integration of vertical and horizontal approaches was described as the “Hamburger Theory” - where the delicious toppings on the burger are the vertical programs, but these toppings are all supported by the horizontal support of the local health system. It was highlighted that if you want to strengthen health systems, you have to strengthen all the different parts at once – great gains in Rwanda. Not integrating will limit impact, decrease sustainability of intervention. Helps if you integrate your intervention in to the governments previously established health system strengthening plan. This integrated approach, while very effective, is very resource intensive, expensive, and difficult. Research around this work is similarly difficult. The Way forward – more integrated projects, measure better/different metrics (Not just <5yo mortality), mutual investment in systems and vertical programs, prioritize implementation research methods.

The next lecture, "Policies and Public Health: Lessons from the Ebola Epidemic" was given by Dr. Craig Spencer, who is an associate professor of medicine at Columbia and also works with MSF in Guinea. In 2014, while working in Guinea, he became infected with ebola virus and was subsequently treated at Bellevue Hospital in NYC. Spencer discussed quarantines for asymptomatic health care workers returning from west Africa are not recommended by public health agencies. But they do have to be able to monitor themselves, be contactable, and close to a potential ebola treatment facility. Spencer discussed, first hand, that quarantines are not a benign intervention: Makes helping out more difficult for individuals – including financially. Also discussed was post quarantine policy implementation

  1. (Politically driven) many people backed out, academic medical centers banning travel for aid.
  2. ASTMH – American Society of Tropical Medicine & Hygene meeting cancelled due to fear.
  3. Makes people potentially lie about actual contacts with ebola patients
  4. Confusion about disease with public
  5. Undocumented people in U.S. less likely to come forward if sick
  6. Patients stigmatized
  7. Role of CDC/NIH – undermines these agencies
  8. Politicians as public health policy experts. May use fear of ebola as political fodder. Run the risk of compromising science for political expediency
  9. Media misinformation
  10. Civil liberties
  11. U.S. has spent more on setting up ebola treatment centers in U.S. (for less than a dozen actual patients), than the money allocated to combatting Ebola in west Africa.
  12. There are more physicians in Bellevue hospital than those fighting the epidemic in Guinea, Sierra Leone, Liberia
  13. A recent statement from a UN representative - Underlying principles of response to health crises haven’t changed in 10 years – the question is what will Ebola have taught us for the next crisis?

The keynote lecture was provided by Dr. Abdulrahman El-Sayed who is a population health scientist and fellow at Demos. El Sayed explained that "Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.” He discussed the major global health misconceptions:

  1. The overwhelming injustice in global health stems from the sheer burden of ill health
  2. Global health is about infectious diseases
  3. The best way to combat the global burden of disease is to provide direct medical care to the underserved
  4. Global health is about low-income countries

El-Sayed's 'Four Truths'

  1. The overwhelming injustice in global health stems from the systematically unequal burden of ill health.
  2. Non-communicable (chronic) diseases are the biggest (and growing) contributors to the burden of disease globally
  3. The best way to combat the global burden of disease is to target and shift the population determinants of disease.
  4. Global health starts locally
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