Craig Janes

Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context.

Abstract Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

Microclimate and Human Factors in the Divergent Ecology of Aedes aegypti along the Arizona, U.S./Sonora, MX Border

This study examined the association of human and environmental factors with the presence of Aedes aegypti, the vector for dengue fever and yellow fever viruses, in a desert region in the southwest United States and northwest Mexico. Sixty-eight sites were longitudinally surveyed along the United States–Mexico border in Tucson, AZ, Nogales, AZ, and Nogales, Sonora during a 3-year period. Aedes aegypti presence or absence at each site was measured three times per year using standard oviposition traps. Maximum and minimum temperature and relative humidity were measured hourly at each site. Field inventories were conducted to measure human housing factors potentially affecting mosquito presence, such as the use of air-conditioning and evaporative coolers, outdoor vegetation cover, and access to piped water. The results showed that Ae. aegypti presence was highly variable across space and time. Aedes aegypti presence was positively associated with highly vegetated areas. Other significant variables included microclimatic differences and access to piped water. This study demonstrates the importance of microclimate and human factors in predicting Ae. aegypti distribution in an arid environment.

Emerging infectious diseases: the role of social sciences

1884 www.thelancet.com Vol 380 December 1, 2012 Popular and scientifi c representations of research into emerging infectious disease often focus on the pathogen itself—its molecular machinery, processes of reassortment and mutation, and how these factors indicate risk for human-to-human transmission. How ever, social and ecological processes that facilitate infection also deserve close attention, as emphasised in the Lancet Series on zoonoses. Present models of pathogen emergence and spread do not identify underlying drivers with suffi cient clarity to allow eff ective prevention of disease. More robust models that encompass the complex interface between pathogen biology and human, Emerging infectious diseases: the role of social sciences are known to harbour pathogens that have previously emerged and focus eff orts on the regions where most contact between wildlife and humans occurs. A microbe in a primate population is more likely to become zoonotic than is a microbe from a rodent, because we are more likely to have similar cell surface receptors to the primate owing to our shared evolutionary history. But at what point does contact override phylogeny? If a hunter catches a primate once a year, but the staple diet in his village is bush rats, which of these is the high-risk species? These are the questions that disease ecologists can answer, and that are being applied to the new science of pandemic prediction. How ever, the prediction and prevention of a pandemic is not straightforward. Although molecular techniques exist that can identify novel microbes carried by these high-value wildlife targets, our predictive ability can be overwhelmed by the many novel microbial sequences discovered. For example, how can we identify, from the genetic sequences of ten new paramyxoviruses from bats, which one is most likely to be a virulent pathogen of human beings, capable of spillover and sustained human-to-human transmission? This is the biggest of the grand challenges for pandemic prevention, and one that I believe we are not strategically addressing. Morse and colleagues describe a strategy for the so-called known unknowns—novel microbes closely related to known agents. But what of the unknown unknowns—novel microbes that have no known close relative? This challenge, of prediction of viral virulence from a sequence, for example, should be a major focus of basic virology research in every developed country. A global programme for pandemic prevention based on improved risk forecasting, surveillance, and pathogen discovery will be expensive. Who should pay and how would it work? The answer might lie in the underlying socio economic drivers of disease emergence. Pandemics are a product of our economic development—they emerge when we domesticate new species, open up new trade routes, build roads into forests, or expand air travel networks. Perhaps these industries should insure themselves against the rare but devastating pandemics their activities can sometimes cause. Additionally, health-impact assess ments, already used in many large development projects, could calculate and assess the pandemic risk of a project. The ultimate public health programme would work with, and be funded by, high-risk development projects to develop better clinics, pathogen discovery, and surveillance programmes that prevent pandemics at their source.

Failed Development and Vulnerability to Climate Change in Central Asia: Implications for Food Security and Health:

This article presents results of research undertaken to identify factors that affect the vulnerability of rural Mongolian herders to climate change. Findings suggest that models of market development instituted since 1990 have failed to recognize and support key elements of the pastoralist adaptive strategy. A retreating state presence has led to the collapse of regulatory regimes needed to safeguard critical common resources. This in turn has produced considerable social differentiation in the countryside, a breakdown in cooperative institutions, and conflicts over water and pasture. In a context of climate change, these changes seriously threaten the sustainability of the rural economy, leading to livelihood insecurity, growing rural poverty, and increasing rates of migration to shantytowns surrounding the capital city of Ulaanbaatar. The newly vulnerable poor are at higher risk for poor health and malnutrition.

Belief in ghost month can help prevent drowning deaths: a natural experiment on the effects of cultural beliefs on risky behaviours

Studies have suggested that cultural beliefs, such as those underlying religious social occasions and superstitions, have both positive and negative effects on mortality rates. Many people in Southern China believe that there are wandering ghosts who were released from hell during the lunar month of July (ghost month: mostly August in the Gregorian calendar): people therefore avoid unnecessary risky activities during ghost month. The aim of this study was to examine whether unintentional drowning deaths decreased during ghost month, using a matched control design and mortality data of Taiwan between 1981 and 2005. Results show that overall days-adjusted monthly death rate in ghost month days in Gregorian August was 1.37 (per 1,000,000). This was significantly lower than those in non-ghost month days, which was 1.67. The mean number of deaths in ghost months was lower than that in the matched controls, which was -3.2 deaths (-2.6 to -3.5) during weekends and -4.5 deaths (-2.2 to -7.2) during weekdays. The differences were more prominent in men than in women. For other main causes of death, we did not find persistent significant differences throughout the four matched controls. In conclusion, our findings support the death-dip hypothesis. Possible mechanisms are that people who believe in the ghost month might either decrease their exposure to water-related activities or involve themselves less in risky behaviours during ghost month, as a kind of risk compensation, consequently resulting in a reduction in the number of drowning deaths. As such we conclude that cultural factors should be taken into consideration when designing injury prevention programs.

Vitamin D deficiency in reproductive age Mongolian women: a cross sectional study.

Vitamin D production is critical not only for rickets prevention but for its role in several chronic diseases of adulthood. Maternal vitamin D status also has consequences for the developing fetus. This study assessed the prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D]<20ng/ml) and insufficiency [25(OH)D=20-29ng/ml] in spring, among reproductive age Mongolian women. Blood was drawn in March and April, 2009 from 420 Mongolian women, 18-44 years of age. Serum 25(OH)D concentrations were measured, anthropometric measurements were performed and information was collected by interview on lifestyle, dietary and reproductive factors. Logarithm-transformed 25(OH)D levels were compared across risk factor categories by analysis of variance. Linear regression analysis was used to assess the independent associations of factors with vitamin D status. Cutaneous vitamin D3 synthesis was assessed between December and July using a standard 7-dehydrocholesterol ampoule model. The vast majority of women 415 (98.8%) had serum 25(OH)D<20ng/ml (50nmol/l) with an additional 4 women (<1%) in the insufficient range (20-29ng/ml); only one women (0.2%) had sufficient levels (>30ng/ml or 75nmol/l). 25(OH)D concentrations were positively and independently associated with educational status and use of vitamin D supplements, but not with other demographic, lifestyle, reproductive, or anthropometric factors. 25(OH)D levels were not associated with dietary factors in this population, as there is little access to foods containing vitamin D in Mongolia. No production of previtamin D3 was observed until March and was maximally effective in April and was sustained through July. These data suggest that the prevalence of vitamin D deficiency in spring among reproductive age women in Mongolia is high. Given the lack of naturally vitamin D-rich food in the diet and limited use of vitamin D supplements, food fortification and/or supplementation with vitamin D should be considered among these women.

The behavioural research agenda in global health: An advocate's legacy

Abstract Two of the disciplines that have come to infuse global health with some of its current vibrancy are epidemiology and anthropology, disciplines that focus, in one way or another, on the causal importance of human behaviour in socio-political, ecological, evolutionary, and cultural context. One of the little-known stories in the history of twentieth century global health involves the works of a number of pioneering interdisciplinary scholar–practitioners, who urged a synthesis of epidemiological and anthropological perspectives in what was then called ‘tropical medicine’. One of these pioneers was Frederick L. Dunn, who forwarded lasting insights about the importance of human behavioural research in understanding infectious disease. This article provides a historical-biographical accounting of Dunns contributions to public health in the second half of the twentieth century, arguing that his persistent advocacy of multi-level, social behavioural research and his notion of ‘causal assemblages’ were critical in the early development of the twentieth century discipline of global health.

Outbound medical tourism from Mongolia: a qualitative examination of proposed domestic health system and policy responses to this trend

BackgroundMedical tourism is the practice of traveling across international boundaries in order to access medical care. Residents of low-to-middle income countries with strained or inadequate health systems have long traveled to other countries in order to access procedures not available in their home countries and to take advantage of higher quality care elsewhere. In Mongolia, for example, residents are traveling to China, Japan, Thailand, South Korea, and other countries for care. As a result of this practice, there are concerns that travel abroad from Mongolia and other countries risks impoverishing patients and their families.MethodsIn this paper, we present findings from 15 interviews with Mongolian medical tourism stakeholders about the impacts of, causes of, and responses to outbound medical tourism. These findings were developed using a case study methodology that also relied on tours of health care facilities and informal discussions with citizens and other stakeholders during April, 2012.ResultsBased on these findings, health policy changes are needed to address the outflow of Mongolian medical tourists. Key areas for reform include increasing funding for the Mongolian health system and enhancing the efficient use of these funds, improving training opportunities and incentives for health workers, altering the local culture of care to be more supportive of patients, and addressing concerns of corruption and favouritism in the health system.ConclusionsWhile these findings are specific to the Mongolian health system, other low-to-middle income countries experiencing outbound medical tourism will benefit from consideration of how these findings apply to their own contexts. As medical tourism is increasing in visibility globally, continued research on its impacts and context-specific policy responses are needed.

Bringing health impact assessment to the Mongolian resource sector: a story of successful diffusion

Following the 2009 signing of the stability agreement between the Mongolian Government and Canadian mining company Turquoise Hill Resources (formerly known as Ivanhoe Mines), researchers from Simon Fraser University secured funding from the Canadian Institutes for Health Research to conduct applied knowledge translation (KT) research that introduces health impact assessment (HIA) to Mongolias rapidly emerging resource sector. HIA is a highly regarded informed decision-making tool that helps to identify, assess and mitigate (or promote) potential positive and negative human health impacts of policies, projects and programs. We engaged in a series of knowledge synthesis, KT and dissemination activities with key public and private sector stakeholders as well as community representatives. Our goals were to develop consensus on a socially and culturally appropriate approach to equity-focused HIA, draw on this consensus to develop a contextualized HIA toolkit, build local HIA capacity based on this toolkit, strengthen the HIA regulatory environment and provide evidence-based support for efforts to institutionalize HIA in the resource sector. These efforts have resulted in the inclusion of HIA in the environmental impact assessment law of Mongolia, and the focus has now shifted from KT to further supporting HIA institutionalization and practice.

A comparison of migrants to, and women born in, urban Mongolia: demographic, reproductive, anthropometric and lifestyle characteristics.

BACKGROUND Mongolia has experienced vast migration from rural to urban areas since the 1950s. We hypothesized that women migrating to Ulaanbaatar, the capital, would differ in factors related to future chronic disease risk compared with women who were born in Ulaanbaatar. METHODS Premenopausal mothers (aged <44 years) of children attending two schools (one in the city centre and one in the outskirts) in Ulaanbaatar were recruited for the study. During April and May 2009, 420 women were interviewed about migration, reproductive history and lifestyle factors and anthropometric measurements were taken. RESULTS Women born in (n=178) and outside (n=242) Ulaanbaatar were similar in education and marital status, but the latter appeared to have a more traditional lifestyle including being more likely to have lived as a nomadic herder (22.3% vs 5.6%; p<0.001) and to currently live in a traditional yurt or ger (40.1% vs 29.2%). Ever-use of hormonal contraception was more common in women born outside Ulaanbaatar (52.1% vs 38.2%; p=0.005) and their age at first live birth was older (26.0% vs 20.8% for ≥ 25 vs <25 years). Although the number of pregnancies was similar, the number of live births was greater for those born outside Ulaanbaatar (p=0.002). Women born in Ulaanbaatar were more likely to have smoked cigarettes (24.7% vs 11.2%; p<0.001). Women born outside Ulaanbaatar were more likely to consume the traditional meat and dairy diet. CONCLUSION Rural migrants to Mongolias capital have retained a traditional lifestyle in some, but not all, respects. Internal migrant populations may provide the opportunity to assess the effect of changes in isolated risk factors for subsequent chronic disease.