Eduardo Missoni

Mobile cell-phones (M-phones) in telemicroscopy: increasing connectivity of isolated laboratories

BackgroundThe development of modern information telecommunication (ITC) technology and its use in telemedicine plays an increasingly important role in facilitating access to some diagnostic services even to people living in the most remote areas. However, physical and economical constraints in the access to broad band data-transmission network, still represent a considerable obstacle to the transmission of images for the purpose of tele-pathology.MethodsIndifferently using m-phones of different brands, and a variety of microscopic preparations, images were taken without the use of any adaptor simply approaching the lens of the mobile cell phone camera to the ocular of common optical microscopes, and subsequently sent via Multimedia Messaging Services (MMS) to distant reference centres for tele-diagnosis. Access to MMS service was reviewed with specific reference to the African information communication technology (ICT) market.ResultsImages of any pathologic preparation could be captured and sent over the mobile phone with an MMS, without being limited by appropriate access to the internet for transmission (i.e. access to broad-band services). The quality of the image was not influenced by the brand or model of the mobile-phone used, but only by its digital resolution, with any resolution above 0.8 megapixel resulting in images sufficient for diagnosis.Access to MMS services is increasingly reaching remote disadvantaged areas. Current penetration of the service in Africa was mapped appearing already available in almost every country, with penetration index varying from 1.5% to 92.2%.ConclusionThe use of otherwise already widely available technologies, without any need for adaptors or otherwise additional technology, could significantly increase opportunities and quality diagnostics while lowering costs and considerably increasing connectivity between most isolated laboratories and distant reference center.

'BRICS without straw'? A systematic literature review of newly emerging economies' influence in global health

BackgroundSince 2010, five newly emerging economies collectively known as ‘BRICS’ (Brazil, India, Russia, China and South Africa) have caught the imagination, and scholarly attention, of political scientists, economists and development specialists. The prospect of a unified geopolitical bloc, consciously seeking to re-frame international (and global) health development with a new set of ideas and values, has also, if belatedly, begun to attract the attention of the global health community. But what influence, if any, do the BRICS wield in global health, and, if they do wield influence, how has that influence been conceptualized and recorded in the literature?MethodsWe conducted a systematic literature review in (March-December 2012) of documents retrieved from the databases EMBASE, PubMed/Medline, Global Health, and Google Scholar, and the websites of relevant international organisations, research institutions and philanthropic organisations. The results were synthesised using a framework of influence developed for the review from the political science literature.ResultsOur initial search of databases and websites yielded 887 documents. Exclusion criteria narrowed the number of documents to 71 journal articles and 23 reports. Two researchers using an agreed set of inclusion criteria independently screened the 94 documents, leaving just 7 documents. We found just one document that provided sustained analysis of the BRICS’ collective influence; the overwhelming tendency was to describe individual BRICS countries influence. Although influence was predominantly framed by BRICS countries’ material capability, there were examples of institutional and ideational influence - particularly from Brazil. Individual BRICS countries were primarily ‘opportunity seekers’ and region mobilisers but with potential to become ‘issue leaders’ and region organisers.ConclusionThough small in number, the written output on BRICS influence in global health has increased significantly since a similar review conducted in 2010 found just one study. Whilst it may still be ‘early days’ for newly-emerging economies influence in global health to have matured, we argue that there is scope to further develop the concept of influence in global health, but also to better understand the ontology of groups of countries such as BRICS. The BRICS have made a number of important commitments towards reforming global health, but if they are to be more than a memorable acronym they need to start putting those collective commitments into action. Keywords BRICS, global health, influence, newly emerging economies, Brazil, Russia, India, China, South Africa.

Degrowth and health: local action should be linked to global policies and governance for health

Volume and increase of spending in the health sector contribute to economic growth, but do not consistently relate with better health. Instead, unsatisfactory health trends, health systems’ inefficiencies, and high costs are linked to the globalization of a growth society dominated by neoliberal economic ideas and policies of privatization, deregulation, and liberalization. A degrowth approach, understood as frame that connects diverse ideas, concepts, and proposals alternative to growth as a societal objective, can contribute to better health and a more efficient use of health systems. However, action for change of individual and collective behaviors alone is not enough to influence social determinants and counteract powerful and harmful market forces. The quality and characteristics of health policies need to be rethought, and public policies in all sectors should be formulated taking into consideration their impact on health. A paradigmatic shift toward a more caring, equitable, and sustainable degrowth society will require supportive policies at national level and citizens’ engagement at community level. Nevertheless, due to global interdependence and the unavoidable interactions between global forces and national systems, a deep rethinking of global health governance and its reformulation into global governance for health are essential. To support degrowth and health, a strong alliance between committed national and global leaderships, above all the World Health Organization, and a well-informed, transnationally interconnected, worldwide active civil society is essential to include and defend health objectives and priorities in all policies and at all levels, including through the regulation of global market forces.

BRICS? role in global health and the promotion of universal health coverage: the debate continues

The acronym BRIC was coined in 2001 by Jim O’Neill, a senior executive at Goldman Sachs, to denote four emerging national economies: Brazil, the Russian Federation, India and China.1 The acronym was subsequently extended – to BRICS – to include South Africa. Together, the nations in the BRICS group, which are widely considered to represent the most important emerging economies, hold approximately 40% of the world’s population. Although BRICS and other multinational groupings may be useful to policy-makers involved in the development of some foreign policies, it remains unclear if such groupings have a role in the study and development of global health policy. We examine the debate around this issue and focus on the potential role of BRICS in the promotion of universal health coverage – an “umbrella” goal for health in the post-2015 development framework.2

G8 Summit 2009: what approach will Italy take to health?

In the past decade, the G8 played an important part in the establishment or support of global health initiatives that are at risk today of becoming part of the problem rather than the solution for granting health coverage to disadvantaged populations. The fragmentation of fi nancing for global health and increased transaction costs contrast with the need for effi cient and eff ective health systems, and underline the need for a review of quick-fi x and selective approaches. In view of the present economic crisis, a heightened commitment from wealthy countries to sustain global health will be needed. As chair of the G8 Summit 2009, Italy will have a unique opportunity to renew its commitment to global health and orient action towards a more eff ective approach. Italy’s Offi cial Development Assistance continues to suff er from structural weaknesses, characterised by an absence of clear political direction, weak management, and inadequate and unstable funding. The health sector has been no exception. Nevertheless, two aspects deserve to be noted. First, as the result of contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria, launched at the Genoa G8 Summit in 2001, the donations of Italian Offi cial Development Assistance for Health tripled between 2001 and 2007 (Italy is the fourth largest contributor to the Global Fund along with Japan, after France, the USA, and the UK). Italy also engaged in new fi nancing mechanisms, including the International Financial Facility for Immunisation and the Advance Market Commitment for vaccines initiatives, by pledging substantial funds. Arguably, this shift towards vertical initiatives has not been accompanied by attempts to address concerns about potential consequences for global health governance and the negative system-wide eff ects at a country level. The shift also contrasts with the longstanding guiding principles of the Italian Development Cooperation in the health sector—characterised by a comprehensive rather than a selective approach to health—and also with the domestic experience of the Italian National Health Service that provides universal and comprehensive care. Second, Italy’s contribution to global health already goes beyond traditional Offi cial Development Assistance. The Italian National Health Service and the decentra lised public institutions (regions and municipalities) are increasingly engaged in development cooperation. Civil society is very active (in Italy, 1433 not-for-profi t organisations are associated with international cooperation and solidarity activities, has produced a study that in every respect rivals those in diseases for which research receives vastly superior funds.

Reforming the World Health Organization: what influence do the BRICS wield?

The World Health Organization (WHO) is currently undergoing fundamental reform that is intended to impact its programmes and priority setting and its financial and governing structures. Within the reform debates, new relations of powers are emerging among traditional donors and emerging economies such as the ‘BRICS’: Brazil, Russia, India, China and South Africa. These five emerging economies have formally committed ‘to strengthen and legitimise the WHO as the coordinating authority in global health’ through the principle of multilateralism. In this paper, the results of a qualitative study – based on 21 key informant interviews – that seeks to better understand BRICS’ engagement in this organisation and the extent to which their action enables these countries to influence the reform process were presented. The results show that individual BRICS countries found natural pairings with each other on both particular elements of the reform, notably governance and WHO financing, and specific health issues. While numerous examples of individual BRICS countries seeking to raise the profile of specific health issues were found, some evidence of a coordinated effort to influence reform as a bloc was also found. Although this was largely limited to rhetorical announcements of support in formal Declarations and Communiqués, it nevertheless articulates a vision of the WHO as an organisation with a broad mandate delivered with sufficient, predictable funding.

Mobile Diagnosis: Bridging Sociocultural Gaps and Empowering Women

I n a recent article, published in the journal Telemedicine and e-Health, Mark Terry reports about Dr. Levia Bellina’s field experience in the use of m-phones in telemicroscopy, based on our initial observation that any mobile phone with an in-built camera can be an excellent tool to take and share diagnostic images taken directly from the microscope and other optical devices, without the need to recur to adapters or other additional devices. We have been testing this method also as a training tool for laboratory technicians and other healthcare workers in low-resource or otherwise disadvantaged settings, such as health units in rural Uganda and Bangladesh, and currently in a hospital in Afghanistan. Regardless of their previous experience in the laboratory and/or with an m-phone, all trainees easily and quickly learn to take and send microscopic field images. However, the most interesting aspect from an educational perspective is the considerable reduction in the time needed to reach satisfactory diagnostic skills through the participatory approach allowed by the shared use of m-phone, compared with our previous experience with more traditional teaching approaches. An unexpected confirmation of the potential of the method came from the recent experience in the Pediatric Hospital of Herat. Two women coming from a distant rural village were waiting for some laboratory testing to be done on their sick children. Fascinated by the work of Dr. Bellina, who was taking images from the microscope with her m-phone, notwithstanding the absence of an interpreter, the women made themselves understood and they wanted to try. The illiterate women, who possibly never had an m-phone in their hands, immediately understood the method and, after a few attempts, were proudly showing good results (Fig. 1). This episode adds arguments for the technological appropriateness of mobile phones regardless of education and socioeconomic status of the user. Facilitating the use of m-phones for diagnosis at community and family levels (i.e., taking pictures of dermatological lesions, oral cavity, stool aspect, and others) may facilitate early diagnosis and increase access to treatment by connecting the community with local health services (sending images via multimedia messaging service) and/or enabling the sharing of the images on the m-phone with the medical staff at the point service. In a context such as Afghanistan, where women’s access to a maledominated health system is restrained, the independent use of an m-phone may also prove to be a valid empowering tool for women.

2009 was not a “dead year” for G8's health agenda

In calling for coordinated development policies inspired by the Paris Declaration, the G8 does respond to Hortons concern for “the catastrophic failure in progress towards the Millennium Development Goals”.1 However, statements cannot stimulate progress unless working methods change. To “walk the talk”, global leaders must abandon rhetoric-driven communiqués and engage in verifiable, binding agreements based on medium-term and long-term plans with financial coverage. Strong commitment and effective action for universal health coverage is possibly the single most significant and concrete objective to be pursued.

The first description of how to take a picture from the microscope with an m-phone.

To the Editor , In their recent letter in the JCP , Morrison and Gardner claim having been the first in the English literature ‘describing in detail a hands-free technique for smartphone photomicroscopy’. In their letter, they rightly quote our 2009 work recognizing that we ‘were the first to describe using mobile phone cameras to capture microscope images by focusing the camera of the phone through the microscope ocular’.1 Surprisingly, however, they tribute themselves (and curiously only to the first author) the merit referring to ‘The Morrison technique’.2 Indeed, in 2014 (paper accepted for publication on October, 3) they had published an article on the Archives of Pathology & Laboratory Medicine describing the method, claiming: ‘To our knowledge, detailed instructions for obtaining quality smart phone microscopic photographs have not been previously published’.3 Probably in their bibliographic search, Morrison and Gardner must have overlooked our previous original paper, entitled ‘M-learning: mobile phones’ appropriateness and potential for the training of laboratory technicians in limited-resource settings’, published in 2011 in the ‘Health and Technology’ journal. In that paper, we carefully described the method step-by-step after testing it with health workers in Afghanistan, Bangladesh and Uganda.4 In addition, patent of the technique was requested as early as April 10, 2008 and had been filed for patent since April 6, 2009 by the European Patent Office (EP 2 116 884 A1). They must also have missed the 2011 WHO, Compendium of new and emerging technologies, as well as Mark Terry’s 2011 review of medical connectivity, where our work is quoted and further described (including pictures for the field).5 Finally, our work has been recognized in most recent comprehensive reviews of mobile health, and we hope that this communication will avoid future claims regarding the paternity of the approach. On the positive side, we are happy to see that the method we presented, and that we never dared to call the ‘Bellina–Missoni method’, is being increasingly widely used, because this was from the beginning our purpose: to ensure that even in the most remote areas health workers and their communities could appreciate and appropriately manage the complete potential of their m-phones. With that purpose, Dr Bellina, especially, has extensively explored additional applications of the method and of the use of the m-phone as an educational tool and an appropriate technology to promote universal access to healthcare.

Italy’s contribution to global health: the need for a paradigm shift

This paper reviews Italian Development Assistance for Health and overall contribution to Global Health from 2001 to 2012. It analyses strategies and roles of central and decentralized authorities as well as those of private non-profit and corporate actors. The research illustrates a very low and unstable official contribution that lags far behind internationally agreed upon objectives, a highly fragmented institutional scenario, and controversial political choices favouring “vertical” global initiatives undermining national health systems, and in contrast with Italian deep-rooted principles, traditional approaches and official guidelines.Italy’s contribution to global health goes beyond official development aid, however. The raising movement toward Universal Health Coverage may offer an extraordinary opportunity for a leading role to a country whose National Health System is founded on the principles of universal and equitable access to care. At the same time, the distinctive experience of Italian decentralized cooperation, with the involvement of a multiplicity actors in a coordinated effort for cooperation in health with homologous partners in developing countries, may offer – if adequately harnessed - new opportunities for an Italian “system” of development cooperation. Nevertheless, the indispensable prerequisite of a substantial increase in public funding is challenged by the current economic crisis and domestic political situation. For a renewed Italian role in development and global health, a paradigm shift is needed, requiring both conceptual revision and deep institutional and managerial reforms to ensure an appropriate strategic direction and an efficient and effective use of resources.ResumenEste artículo analiza la contribución de Italia a la Salud Global y su Ayuda para el Desarrollo en Salud desde 2001 hasta 2012. Se analizan las estrategias y los roles de las autoridades centrales y descentralizadas, así como de los actores privados lucrativos y no lucrativos. La investigación muestra una contribución oficial muy baja e instable, muy por debajo de los objetivos internacionales acordados; un escenario institucional altamente fragmentado y líneas políticas controvertidas que han favorecido iniciativas globales “verticales” que por un lado socavan los sistemas nacionales de salud, y por el otro están en contradicción con arraigados principios, enfoques tradicionales y las líneas guías oficiales de Italia.Pero la contribución de Italia a la salud global va más allá de la ayuda oficial al desarrollo. El creciente movimiento para la Cobertura Universal de Salud puede ofrecer una oportunidad extraordinaria de liderazgo para un país cuyo Sistema Nacional de Salud se funda en los principios del acceso universal y equitativo a la atención. Al mismo tiempo, si adecuadamente aprovechada, la peculiar experiencia italiana de cooperación descentralizada, que involucra una multiplicidad de actores en un esfuerzo coordinado de cooperación en salud con sus homólogos en los países en desarrollo puede ofrecer nuevas oportunidades par el “sistema” italiano de cooperación al desarrollo. Sin embargo, la actual crisis económica y la situación política nacional representan un desafío para el prerrequisito indispensable consistente en un substancial aumento de financiamientos públicos. Un rol renovado de Italia en temas de desarrollo y salud global, requiere un cambio paradigmático. Este necesita tanto un revisión conceptual, como profundas reformas institucionales y gerenciales, para asegurar una dirección estratégica apropiada y un uso eficiente y eficaz de los recursos.