Angie Bengtson

Last month our social justice (SJ) topic was on maternal health – a topic of particular interest to me as I will be starting my PhD at the University of North Carolina-Chapel Hill this fall in the maternal and child health department.  We had a great discussion, led by Francesca, on how maternal child health initiatives have often focused primarily on addressing maternal health as a means of improving birth outcomes or child health overall.  While child health is obviously critically important, a woman’s health also needs to be valued intrinsically, and not just because of her reproductive value.  Many people contributed with opinions, articles and blog entries and I wanted to share a few of them here.

One thing that added dramatically to our discussion was the fact that a paper was recently published in the Lancet indicating that maternal mortality rates have declined in recent years.  For a synopsis of the paper, check out this article in the NY Times.

While declining maternal mortality around the world is admittedly good news, some of the analysis of the paper coming out suggests that the lower estimates may have more to do with how the data was used and declining fertility rates, rather than the impact of concerted efforts to improve maternal health.  However, overall there is reason to be optimistic.

As Richard Horton, of the Lancet, points out:

“But a new analysis—new methods as well as the latest and, the authors believe, the most accurate estimates—now indicates that in 2008 maternal deaths had fallen from 526 300 in 1980 to 342  900 in 2008. There are wide uncertainty intervals around these numbers. But the overall message, for the first time in a generation, is one of persistent and welcome progress.”

If you’re interested in a bit more technical discussion of the methods used to create the new estimates, Karen Grepin’s blog has an excellent break-down.

However, regardless of whether or not these new estimates are better or worse than the old estimates, it is important to not loose sight of the fact that even the new lower estimate of maternal mortality is still REALLY HIGH.

Maternal health is important because women are so much more than just mothers – they are business owners, community leaders, friends, caregivers, wives and colleagues – and particularly in the developing world they bear an enormous burden of work and responsibility in daily life.  Therefore we need to keep women healthy during their reproductive years, not simply because they are mothers, but because they are mothers and much, much more.  Maternal health is a critical component of women’s health and women, regardless of what part of the world they live in, should have the right to a healthy life.

Two weeks ago, Clement and I had the privilege of attending the Connecting Health Organizations for Regional Disease Surveillance (CHORDS) meeting in Annecy, France.  The meeting was a follow-up to the one I had attended in Jordan in October, and brought together experts from regional disease surveillance networks all over the world.

Over the course of three days participants gathered to consider the idea of how they could work together to improve global infectious disease surveillance.  Through several presentations and discussions, it became clear that two of the key elements to improving surveillance efforts are also two of the most basic: trust and communication.

Offering welcoming remarks, Dr. Keiji Fukuda, Special Advisor on Pandemic Influenza to the Director-General of the World Health Organization, said that, “Networks build trust; trust alone does not make the world move, but without it the world can’t move. Having networks in place to move accurate and useful information among disease experts at the same speed the event is happening is revolutionary…”

Hosted at the beautiful Les Pensiers facility of the Fondation Merieux, the participants worked together to build connections as a group, brainstorm further collaboration and discuss the future direction of CHORDS.  At the end of the three days, many of the participants noted that one of the key successes of the meeting was that different networks had a chance to connect with one another and recognize they were not alone in their efforts to coordinate and improve regional disease surveillance.

One Health also emerged as an important theme in the future direction of CHORDS, and the groups that participate in it.  A One Health approach to disease surveillance means that wildlife, livestock and human health practitioners and surveillance systems are included and integrated to provide a more comprehensive and robust surveillance system for infectious disease, especially zoonoses.  SACIDS is currently the only network that was founded from a One Health perspective, and so continues to lead the way in promoting the importance of One Health in infectious disease surveillance.

One of the things that came out of the midyear retreat in Rwanda for the African-based fellows was the idea to have a small group of us host monthly discussions around different social justice and global health equity topics in an effort to increasingly get the GHC community dialoguing about health equity and justice topics.  In February we looked at the effectiveness of foreign aid & I’d share with the rest of the GHC community and our supporters what we covered:

The Effectiveness/Ineffectiveness of Foreign Aid

Within the international development community the debate over the effectiveness of foreign aid has been going on for decades, with supporters on one side arguing for more aid to developing countries and those on the other side who think aid is what is keeping developing countries poor.  Here is just a small sampling of some of the information out there on both sides of the debate:

Good aid; Bad aid

The recent book, Dead Aid, by Dambiysa Moyo, sparked a lot of discussion around the effectiveness of foreign aid.  In her book, Moyo calls for the end of foreign assistance within the next 5 years argues that foreign aid has actually hampered development by creating aid dependency among nations.  Check out her website (hotlinked above) for more info on the book and her point of view, or read a review of the book by Paul Collier, author of The Bottom Billion.

Or take a look at Ghanaian economist George Ayittey on “Dead Aid” At TED.  Check out his TED Talk and read an excerpt from an interview with him on Dead Aid, as well as the 6 institutions he thinks every African nation needs to develop.

In his interview, Ayittey brings up the doctrine of “odious debts”, which states that debts undertaken by corrupt regimes which ultimately are not used to not benefit the people of the state should not then be the responsibility of the citizen’s of that state to repay.  This argument has been used in favor of debt relief initiatives, such as the Jubilee Network, for countries who incurred huge foreign debt that was largely embezzled by corrupt dictators.

However, not everyone thinks aid should be decreased.   In a recent blog posting, Shanta Devarajan, Chief World Bank Economist for Africa, discusses why aid to Africa needs to increase, not decrease, during the global recession.

A recent article in Global Health Magazine, also brings up the difficulties NGOs face in trying to harmonize local needs with donor demands:

“In a country like Botswana where the majority of funding comes from international donors, it is challenging for organizations to keep in line with their original mandate. NGOs often shift their priorities to meet the needs of donors as opposed to the needs of the communities”

International efforts to improve aid effectiveness

Given the widely agreed upon difficulties with foreign aid, whatever side of the debate you are on, there have been international efforts to make aid more effective.  The Paris Declaration and Accra Agenda for Action (AAA) are two international efforts, led by the OECD, to coordinate foreign aid and improve aid effectiveness.   Specifically, the AAA, which builds on the Paris Declaration and was signed in 2008, calls for:

• Predictability – donors will provide 3-5 year forward information on their planned aid to partner countries.
• Country systems – partner country systems will be used to deliver aid as the first option, rather than donor systems.
• Conditionality – donors will switch from reliance on prescriptive conditions about how and when aid money is spent to conditions based on the developing country’s own development objectives.
• Untying – donors will relax restrictions that prevent developing countries from buying the goods and services they need from whomever and wherever they can get the best quality at the lowest price.

Monitoring the Effectiveness of Aid

There are many organizations that track the effectiveness of aid.  Just a couple examples are:

• AidWatchers.com – A blog by William Easterly, author of White Man’s Burden, which monitors aid; where it goes and how it’s used.  Check out this recent post for an interesting discussion on the recent disaster in Haiti and how the aid pouring in for relief efforts is being coordinated (or not).

(Plus don’t miss this hilarious post about African leaders advising Bono on reforming U2 – http://aidwatchers.com/2009/11/african-leaders-advise-bono-on-reform-of-u2/)

• The Center for Global Development – A Washington DC based think tank that has a number of resources and initiatives looking at the effectiveness of aid.  Check out this interesting blog post about the Center’s Cash on Delivery program, which links funding directly to outputs by developing nation governments.

The Center also has a HIV/AIDS Monitor: Tracking Aid Effectiveness initiative which evaluates the effectiveness of funding for HIV from the three biggest donors: PEPFAR, the Global Fund and the World Bank.  Check out this paper comparing the funding practices of all three.

Check out Paul Farmer, co-founder of GHC partner Partners In Health’s, recent congressional testimony on the opportunity that the horrific tragedy in Haiti represents to rebuild a stronger, more stable and more prosperous Haiti.  His remarks focus on the need to work with the Haitian government in rebuilding efforts and prioritize job creation as a means of not just rescuing Haiti from this current crisis, but investing in long-term development:

“In other words, if we focus the reconstruction efforts appropriately, we can achieve long-term benefits for Haiti. The UNDP is helping to organize programs of this kind, which should be supported and extended around the country. Putting Haitians back to work and offering them the dignity that comes with having a job and its basic protections is exactly what brought our country out of the Great Depression.

This was always the right thing to do, and aid programs persistently fail to get it right. So here is our chance: if even half of the pledges made in Montreal or other such meetings are linked tightly to local job creation, it is possible to imagine a Haiti building back better with fewer of the social tensions that inevitably arise as half a million homeless people are integrated into new communities.”

Check out this link on the importance of good management and leadership for improving health outcomes in the recent issue of Global Health magazine.

http://www.globalhealthmagazine.com/cover_stories/leadership_and_management

If 6 months ago you had told me I’d be posting articles about management on this blog, I probably would have politely nodded and internally thought you were nuts.  Management has never been my strength.  But this year I have become increasingly convinced of not just the importance of good management, but the centrality of it, for producing effective results.  Good management can look different in different countries, different organizations and with different personal styles, but whatever it looks like, I think strong management and leadership is essential for motivating a team, driving a vision forward, and making change happen.

Last week I had the privilege of attending the Connecting Health Organizations for Regional Disease Surveillance (CHORDS) meeting at the Dead Sea in Jordan.  CHORDS is a program of the NTI/Global Health Security Initiative, that connects regional disease surveillance networks to work together as a community of practice to reduce the threat posed by infectious diseases through enhanced surveillance.  CHORDS was born out of the Bellagio Call to Action, and subsequent advent of the International Health Regulations, which call improved to infectious disease surveillance as a necessary tool to control disease outbreaks in an increasingly globalized world.

The meeting included representatives from the Mekong Basin Disease Surveillance (MBDS) network and the Middle East Consortium on Infectious Disease Surveillance (MECIDS), as well as SACIDS, the WHO, Pro-Med and other organizations involved in infectious disease surveillance.  The group came together to in preparatory working session in anticipation of a meeting in March 2010 to lay out a plan to further support implementation of the Bellagio Call to Action.  A key goal of the meeting was to begin a discussion on how CHORDS could work together as a community of practice and draw from one another to improve infectious disease surveillance.

The structure of the meeting included working groups to tackle the specific issues of governance, laboratory and human resources and information and communications technology (ICT).  I had the opportunity to serve as rapporteur for the ICT group, where we discussed a number of the challenges and opportunities that emerging technologies hold for disease surveillance networks.

For example, mobile technology is opening up incredible opportunities for improving disease reporting, as well as connection among health professionals.  Yet, with a myriad of new technologies available, and the accompanying host of pilot projects to test them all individually, there is a risk of creating numerous independent vertical surveillance systems that are not integrated.  Providing a forum where networks can learn from one another about how to strategically choose and implement new technologies for maximum benefit is exactly the type of venue that CHORDS hopes to provide.

Listening to the discussions during the meeting, I was struck by the complexity of not only building an effective infectious disease surveillance system, but building one that is also flexible and responsive.  Disease surveillance systems are designed to be a chain of reporting, and thus by definition are linear and vertical.  Therefore figuring out how to make those systems interactive at the regional and global level so that data can be disseminated and shared quickly requires a great deal of collaboration, ingenuity, and most of all trust between partners to work together and share information.  CHORDS represents an innovative approach to bringing together practitioners from various arenas of health, including both human and animal, to work collaboratively improve global disease surveillance by strengthening regional disease surveillance.

The goal is to take a step towards making the world a healthier place and a safer place where infectious disease outbreaks happen less frequently.  Not bad for a two-day meeting in Jordan.  And getting to float in the Dead Sea?  Well, that was pretty rad too.

When I first arrived at SACIDS somewhere along the line of new information, concepts and acronyms I was introduce to the idea that SACIDS was a “One Health” organization.  Like a good and studious fellow when this was told to me I nodded and smiled; “One Health” sounded catchy, it sounded progressive, it sounded positive; I had no idea what it actually meant.

Luckily, in the past few months I have become much more acquainted with not only the work of SACIDS, but how the overarching framework of “One Health” fits into that.  Simply stated, the concept of “One Health” means adopting an integrated approach between the human, animal and plant health sectors to addressing infectious disease threats.

You can read much more about the official definition and how it was developed here, but in terms of SACIDS’ work, the concept of “One Health” often means trying to increase collaboration between the animal and human health sectors.

In the United States, we may not think about animal health as having a large impact on human health, but in rural (or not so-rural) Tanzania, animals and humans intermingle on a daily basis.  This routine contact between animals and humans can create a big problem when animals develop diseases that then transfer to humans, or what are called zoonoses.  According to the Foresight Study, 70 to 80% of new/emerging infectious diseases of humans had originated from animals. Diseases such as avian influenza, swine flu or Rift Valley Fever are all diseases that have started in animals and transferred to humans.

Yet, Tanzania, like most countries, has no official system for coordinating disease preparedness, surveillance or outbreak response across animal and health sectors.  Often when coordination does happen it is on an ad hoc basis, based largely on whether the person in the ministry of health happens to know their counterpart in the ministry of livestock (or vice versa).

Adopting a “One Health” framework means not only looking at how infectious diseases develop, spread and could potentially be stopped in one sector, but rather taking a comprehensive approach to how a disease is likely to be transmitted and who or what is likely to be effected overall.  Improving coordination in preparedness planning, data exchange and outbreak response between the human and animal health sectors could potentially dramatically reduce the severity of an outbreak and save both human and animal lives.

The concept of “One Health” is gaining traction, and just this past week the a new One Health Commission was announced in the US to increase coordination between the animal, human and environmental health sectors in addressing infectious diseases.   As scientists, veterinarians, epidemiologists and public health experts continue to work on mitigating the impact of infectious diseases in places all over the world, it’s exciting to be apart of an organization taking an innovative approach to enhancing those efforts here in southern Africa.

As I attempt to dive into my role here at SACIDS, one of primary tasks is getting myself up to speed on what is going on in the field of infectious disease (ID) surveillance.  With more of a background in the social sciences, I suddenly find myself surrounded by epidemiologists and veterinarians, who consider themselves scientists first and global health experts second.

One of my primary resources in beefing of my ID knowledge is a study that was conducted a few years ago called the “Foresight Study” (hyperlink).  The study’s aim was to “To use the best available science to evaluate the threats of infectious diseases in humans, animals and plants over the next 10-25 years; and to produce a vision for their management” and SACIDS’ Director, Mark Rweyemamu, was heavily involved in conducting the project.

One of the key recommendations of the Foresight Study was to develop detection, identification and monitoring (DIM) systems that use innovative new technology to manage disease outbreaks and mitigate their impacts.  One portion I recently read elucidated a number of scenarios where a disease outbreak had been drastically stemmed due to a comprehensive, effective and easy to use DIM system.

For a full reading of the scenarios, check out the study but one of them went something like this:

A famer in rural China notices that some of his chickens are dying.  He calls the vet, who shows up and with hand-held, mobile device and takes a sample from the chickens.  The information is then transmitted wirelessly to the national surveillance lab, as well as global reference databases, which confirm that the chickens have avian influenza, but additionally indicates that the viral sequence differs significantly from any other currently known strains of avian flu.  New strain of avian flu identified, and control and containment measures are then able to be put into action.  This all happens in about 20 minutes.

As Ameet would say…”That’s like, whoa”.  Maybe (probably), I’m sort of a big geek, but that kind of thing sounds pretty rad.  Stopping a global outbreak of avian influenza with something that resembles a cell-phone?  Apparently DIM systems could be pretty baller.

As I continued reading the report, there were additional scenarios that involved innovative technologies for doing things like diagnosing TB and HIV in one test or at-home test kits for STI’s.  These new technologies are exciting prospects, with the potential to change the way healthcare is accessed and delivered.

Yet as I was reading, the “public health” side of me couldn’t help but think, “It’s great if we can diagnose people with TB, but what about having the drugs stocked to treat them?  What the healthcare facilities existing to go to for treatment, or the availability of doctors to staff those facilities?  What about the massive amount of infrastructure (both health, human and civil) that goes into providing healthcare that simply doesn’t exist in many places?”

Those questions are not meant to detract from the excitement and promise that new technology can mean for not just ID surveillance, but all of global health.  But rather to highlight that we need people on all sides – social sciences, natural sciences, public health, technology, and many more – to not only create solutions to global health problems, but make sure those solutions can actually function effectively.

So for now, I’ll keep reading…but maybe that social science background will be useful after all.

Clement and I successfully make it to Morogoro last week and now are settling in.  We’ll be working with the Southern African Centre for Infectious Disease Surveillance (SACIDS), which is housed at Sokoine University of Agriculture (SUA) in Morogoro.  We’ve been warmly welcomed by the staff here and had a chance to meet some of SACIDS’ partners at the university.

Our specific duties are still being worked out, but one of the first things they’ve asked us to work on is helping to create a new website for SACIDS.  When we have a sample design of what it might look like, I’ll post it here so that people can comment on what they think!

In the mean time we’re just getting settled and trying to work out a number of important details, like how to get paid, housing, etc.  Morogoro is a small-ish city about 3 hours west of Dar and sits at the foot of the Uruguru mountains.  I’ll try to get some pictures up in the next couple of weeks.  This weekend we move into our house, which is a duplex just a few minutes walk from the university.  I’ll live on one side and Clement on the other.  Can’t wait to get moved in so I can stop lugging my luggage around!!!!!!  It feels good to be here.