Vanessa B. Kerry

Rwanda 20 years on: investing in life

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwandas health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Meeting cholera's challenge to Haiti and the world: a joint statement on cholera prevention and care.

Cholera in Haiti: Acute-on-Chronic Long before the devastating earthquake on January 12, 2010, Haiti struggled beneath the burdens of intractable poverty and ill health. The poorest country in the Western Hemisphere, Haiti also faces some of the highest rates of maternal and infant mortality—widely used indicators of the robustness of a health system—in the world ([S1] in Text S1; [2], [3]). The October 2010 cholera outbreak is the most recent of a long series of affronts to the health of Haitis population; it is yet another acute symptom of the chronic weakness of Haitis health, water, and sanitation systems. Water and sanitation conditions highlight these systemic weaknesses. In 2002, Haiti ranked last out of 147 countries for water security [4], [5]. Before the earthquake struck, only half of the population in the capital, Port-au-Prince, had access to latrines or other forms of modern sanitation, and roughly one-third had no access to tap water [6]. Across the country, access to sanitation and clean water is even more limited: only 17% of Haitians had access to adequate sanitation in 2008, and 12% received treated water [7]. Not surprisingly, diarrheal diseases have long been a significant cause of death and disability, especially among children under 5 years of age [6]. The cholera outbreak began less than a year after a 7.0-magnitude earthquake took the lives of more than 300,000 people and left nearly 1.5 million homeless [6]. Almost 1 million Haitians still live in spontaneous settlements known as internally displaced persons (IDP) camps [8]. While post-earthquake conditions in Haiti were ripe for outbreaks of acute diarrheal illness, cholera was deemed “very unlikely to occur” by the United States Centers for Disease Control and Prevention (CDC) and other public health authorities [9]. Cholera had never before been reported in Haiti [S2] [10], [11]; health providers were unprepared for an influx of patients presenting with acute watery diarrhea. The cholera epidemic has been most severe in rural areas and large urban slums. Rural communities were charged with hosting hundreds of thousands of displaced people after the earthquake, placing greater demands on their already-scarce resources, including water. Surface water drawn directly from the source or piped from rivers and streams constitutes the principal supply of drinking water in rural Haiti. The lack of adequate piping, filtration, and water treatment systems (including chlorination) made these rural regions vulnerable to the rapid spread of waterborne disease. While most IDP camps have been supplied with potable water, large urban slums have had to rely on existing water sources—some of them containing Vibrio cholerae—and have therefore been vulnerable to rapid disease spread. Most slums also have poor sanitation infrastructure. Since the first cases were reported in Saint-Marc and Mirebalais, cholera has spread to every department in Haiti, and to other countries, too [S3] [12]–[14]. Public suspicion (ultimately validated by genomic sequence analyses [15]) of the strains link to South Asia, home to a group of United Nations peacekeepers stationed in central Haiti, triggered blame and violence that interfered with response efforts. As we have learned from the global AIDS pandemic and other infectious disease epidemics, cycles of accusation can continue for years, diverting attention and resources from the delivery of care and prevention services [16]. Systemic problems that brought cholera to epidemic levels in Haiti will (unless addressed) continue to facilitate its spread. As a disease of poverty, cholera preys upon the bottom of the social gradient; international trade, migration, and travel—from South Asia or elsewhere—open direct channels for pathogens that follow social fault lines.

Managing the demand for global health education.

Vanessa Kerry and colleagues discuss how to manage the unprecedented growth in and demand for global health programs in the United States, Europe and other high-income countries.

US medical specialty global health training and the global burden of disease

Background Rapid growth in global health activity among US medical specialty education programs has lead to heterogeneity in types of activities and global health training models. The breadth and scope of this activity is not well chronicled. Methods Using a standardized search protocol, we examined the characteristics of US medical residency global health programs by number of programs, clinical specialty, nature of activity (elective, research, extended curriculum based field training), and geographic location across seven different clinical medical residency education specialties. We tabulated programmatic activity by clinical discipline, region and country. We calculated the Spearmans rank correlation coefficient to estimate the association between programmatic activity and country–level disease burden. Results Of the 1856 programs assessed between January and June 2011, there were 380 global health residency training programs (20%) working in 141 countries. 529 individual programmatic activities (elective–based rotations, research programs, extended curriculum–based field training, or other) occurred at 1337 specific sites. The majority of the activities consisted of elective–based rotations. At the country level, disease burden had a statistically significant association with programmatic activity (Spearmans ρ = 0.17) but only explained 3% of the total variation between countries. Conclusions There were a substantial number of US medical specialty global health programs, but a relative paucity of surgical and mental health programs. Elective–based programs were more common than programs that offer longitudinal experiences. Despite heterogeneity, there was a small but statistically significant association between program location and the global burden of disease. Areas for further study include the degree to which US–based programs develop partnerships with their program sites, the significance of this activity for training, and number and breadth of programs in medical specialty global health education in other countries around the world.

Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices.

Corrado Cancedda and colleagues outline a framework for health professional training initiatives in low-income countries.

Influence of the US President's Emergency Plan for AIDS Relief (PEPfAR) on career choices and emigration of health-profession graduates from a Ugandan medical school: a cross-sectional study

Objective The purpose of this study was to determine the current work distribution of health professionals from a public Ugandan medical school in a period of major donor funding for HIV programmes. We explore the hypothesis that programmes initiated under unprecedented health investments from the US Presidents Emergency Plan for AIDS Relief have possibly facilitated the drain of healthcare workers from the public-health system of countries like Uganda. Design Cross-sectional study conducted between January and December 2010 to survey graduates, using in-person, phone or online surveys using email and social networks. Logistic regression analysis was applied to determine ORs for association between predictors and outcomes. Setting Located rurally, Mbarara University of Science and Technology (MUST) is one of three government supported medical schools in Uganda. Participants Graduates who completed a health-related degree at MUST. Main outcome measure Location of health profession graduates (Uganda or abroad) and main field of current job (HIV-related non-governmental organisation (NGO) or others). Results We interviewed 85.4% (n=796) of all MUST alumni since the university opened in 1989. 78% (n=618) were physicians and 12% (n=94) of graduates worked outside Uganda. Over 50% (n=383) of graduates worked for an HIV-related NGO whether in Uganda or abroad. Graduates receiving their degree after 2005, when large HIV programmes started, were less likely to leave the country, OR=0.24 (95% CI 0.1 to 0.59) but were more likely to work for an HIV-related NGO, OR=1.53 (95% CI 1.06 to 2.23). Conclusions A majority of health professionals surveyed work for an HIV-related NGO. The increase in resources and investment in HIV-treatment capacity is temporally associated with retention of medical providers in Uganda. Donor funds should be channelled to develop and retain healthcare workers in disciplines other than HIV and broaden the healthcare workforce to other areas.

Global Health Service Partnership: building health professional leadership

Shortages of nurses, doctors, and health professionals in resource-poor countries challenge the success of many health initiatives and health-system strengthening. In many of these countries, medical and nursing schools are few and severely short of faculty, limiting their capacity to scale-up and increase the number of skilled graduates and professionals to support the health system. In an eff ort to address this problem, the US Peace Corps has partnered with Seed Global Health, a non-profi t organisation with expertise in education for health professions, to launch an innovative new programme that sends faculty to medical and nursing schools in under-resourced settings. The programme, called the Global Health Service Partnership, placed 31 American clinical faculty—dedicated educators— in medical and nursing schools in Tanzania, Uganda, and Malawi in July, 2013. In collaboration with the schools, the partnership hopes to help to train new health professionals and to retain those already working. It is partly funded by the President’s Emergency Plan For AIDS Relief and is augmented by private philanthropy. The programme is expected to increase the numbers of faculty they place in medical and nursing schools, the countries involved, and the health disciplines included. The Global Health Service Partnership is a targeted response to a well documented and tenacious global crisis in global health workforce that was dramatically exacerbated by the HIV/AIDS pandemic in many parts of the world. Recent eff orts to stem pandemics such as those of HIV and malaria, have helped to uncover an underlying, but profound issue; too few health professionals are available to tackle the health needs of populations in which disease burden is highest. Additionally, trained professionals from a mix of specialties are needed to address the long-term health needs of a country. A two-fold approach is needed to address these problems: more professionals should be trained and more should practice where the health problems are most pronounced. National governments, donors, and health leaders now understand that the health-care workforce is crucial to strengthen health systems, deliver care, tackle epidemics such as HIV, and address the rapidly growing challenges for chronic disease management. The President’s Emergency Plan For AIDS Relief includes a focus on training new healthcare workers, as do the plans of several other countries responding to the same concern. For example, Ethiopia has substantially increased the numbers of health profession schools and students. The Malawi Government has devoted substantial proportions of their national health budget to its health workforce, and Mozambique has opened two new medical schools, which will eventually triple the number of medical graduates. Expansion of human resources will not only need increased numbers of staff , but also an appropriate mix of health professionals and their specialties. A recent report from South Sudan outlined a full range of national specialty needs, showing the absence of advanced medical training in the country. In recognition, countries are increasingly working to develop more specifi c train ing for clinical expertise and leadership. Shortage of faculty in many resource-poor settings limits their ability to expand education, graduate basic medical and nurse clinicians, and to produce specialists and health system leaders. This shortcoming has been shown by a recent commission of professional medical education, which noted that health professional education has faltered because of burgeoning health challenges, and that faculty are essential to the investment of future health dividends through training of the next generation of health professionals. Sustainability and selfsuffi ciency of a country’s health systems will depend on building a pipeline of new doctors and nurses trained to continue teaching of future generations. But faculty and specialist shortages in resource-poor settings are exacerbated by emigration of graduates to countries in North America, Europe, and the Gulf region. In addition to job insecurity, safety, and low salaries, emigration is aff ected by large teaching loads, lack of professional development opportunities, and scarce career options. Any meaning ful response to increase health leadership and promote a sustainable pipeline of highly trained phys icians, nurses, and other health professionals will need broad investments in professional opportunity and faculty. The Global Health Service Partnership support for African health professional faculties is intended to improve the educational environments of medical and nursing schools. Improvements in degree training for nurses and basic and post-graduate training for medical doctors will help to address the ubiquitous need for more practitioners and faculty. Global Health Service Partnership doctors and nurses will bring with them experiences and links that can be of assistance to colleagues in host countries, such as innovative teaching methods, clinical guidelines, treatment protocols, and interprofessional collaboration. The Global Health Service Partnership aims to contribute to a pipeline of health professionals that are invested in the health education systems of their countries and focused on the disease burden aff ecting their population. After a review of factors, including the capacity of Peace Corps posts, other partners in the countries, and the interest and commitment of host governments, the Published Online December 18, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)61683-9

Scope of global health training in U.S. obstetrics and gynecology residency programs.

OBJECTIVE: To enumerate global health training activities in U.S. obstetrics and gynecology residency programs and to examine the worldwide distribution of programmatic activity relative to the maternal and perinatal disease burden. METHODS: Using a systematic, web-based protocol, we searched for global health training opportunities at all U.S. obstetrics and gynecology residency programs. Country-level data on disability-adjusted life-years resulting from maternal and perinatal conditions were obtained from the Global Burden of Disease study. We calculated Spearmans rank correlation coefficients to estimate the cross-country association between programmatic activity and disease burden. RESULTS: Of the 243 accredited U.S. obstetrics and gynecology residency programs, we identified 41 (17%) with one of several possible predefined categories of programmatic activity. Thirty-three residency programs offered their residents opportunities to participate in one or more elective-based rotations, eight offered extended field-based training, and 18 offered research activities. A total of 128 programmatic activities were dispersed across 64 different countries. At the country level, the number of programmatic activities had a statistically significant association with the total disease burden resulting from maternal (Spearmans &rgr;=0.37, 95% confidence interval [CI] 0.14–0.57) and perinatal conditions (&rgr;=0.34, 95% CI 0.10–0.54) but not gynecologic cancers (&rgr;=−0.24, 95% CI −0.46 to 0.01). CONCLUSIONS: There are few global health training opportunities for U.S. obstetrics and gynecology residents. These activities are disproportionately distributed among countries with greater burdens of disease. LEVEL OF EVIDENCE: II

Politics and Universal Health Coverage — The Post-2015 Global Health Agenda

What political, social, and economic factors allow a movement toward universal health coverage to take hold in some low- and middle-income countries? Can we use that knowledge to help other such countries achieve health care for all?

A cross-case comparative analysis of international security forces' impacts on health systems in conflict-affected and fragile states

BackgroundDestruction of health systems in fragile and conflict-affected states increases civilian mortality. Despite the size, scope, scale and political influence of international security forces intervening in fragile states, little attention has been paid to array of ways they may impact health systems beyond their effects on short-term humanitarian health aid delivery.MethodsUsing case studies we published on international security forces’ impacts on health systems in Haiti, Kosovo, Afghanistan and Libya, we conducted a comparative analysis that examined three questions: What aspects, or building blocks, of health systems did security forces impact across the cases and what was the nature of these impacts? What forums or mechanisms did international security forces use to interact with health system actors? What policies facilitated or hindered security forces from supporting health systems?ResultsWe found international security forces impacted health system governance, information systems and indigenous health delivery organizations. Positive impacts included bolstering the authority, transparency and capability of health system leadership. Negative impacts included undermining the impartial nature of indigenous health institutions by using health projects to achieve security objectives. Interactions between security and health actors were primarily ad hoc, often to the detriment of health system support efforts. When international security forces were engaged in health system support activities, the most helpful communication and consultative mechanisms to manage their involvement were ones that could address a wide array of problems, were nimble enough to accommodate rapidly changing circumstances, leveraged the power of personal relationships, and were able to address the tensions that arose between security and health system supporting strategies. Policy barriers to international security organizations participating in health system support included lack of mandate, conflicts between security strategies and health system preservation, and lack of interoperability between security and indigenous health organizations with respect to logistics and sharing information.ConclusionsThe cases demonstrate both the opportunities and risks of international security organizations involvement in health sector protection, recovery and reconstruction. We discuss two potential approaches to engaging these organizations in health system support that may increase the chances of realizing these opportunities while mitigating risks.