NIGH Perspective: A Student’s View of the Conference
06/16/2010
Takudzwa Shumba, a Stanford medical student from Zimbabwe, blogs from the conference
June 16
We are now midway through the conference, and I just presented my poster (yay!). This afternoon, I watched an interesting MTV Stay Alive/ Ignite Production of a short film titled "Shuga." The film was set in Nairobi, featured a ritzy set of 20-something-year-olds and showed how their lifestyles put them at risk of contracting HIV. The film was intended to create a discussion platform for youth and also increase awareness about VCT, male circumcision, condom use, alcohol abuse and other risk factors such as multiple partners and intergenerational relationships (with the so-called "sugar daddies"). Interestingly, although the film had a decided urban bent in terms of the characters, it resonated with rural youth as well. Furthermore, MTV's network allowed distribution to 22 other countries in sub-Saharan Africa, where connecting threads were still found among the youth. The film is to be used as one component of a multi-pronged approach of targeting the vulnerable 15-24 age group, and with the appropriate mix of street credibility, social acceptability and public health accuracy, it has already been an effective tool for generating dialogue around these important themes. A survey of 1,000 Nairobi youth showed that 75 percent had watched the three part series. This is a novel way of presenting an oft-repeated but still inadequately disseminated message about the importance of safe sex practices and of testing and knowing your status.
I also went to a book talk by Dr. Susan Raymond, who spoke about what steps were needed to make financing for non-profits possible given the global recession. The theme of making resources available has been a recurrent one throughout the conference. Even while there is continuous discussion about metrics and how to define progress and project achievement, there is an under-current of concern because global health funding will experience cuts, and there is already a dearth of resources. This evening, I attended a heated session where the relative merits of SWAps were being debated. On the one hand were staunch supporters of the effectiveness this approach, who pointed out that it was unrealistic to focus on vertical programs if the infrastructure and human capacity to implement these programs was not available. The proponents argued that SWAps were not particularly effective, with reference to Action's 2010 "Aid without Impact" report that looked at the extent to which the World Bank and its development partners had supported TB control in low-income sub-Saharan Africans between 2001-2008. Both sides had valid assertions to support their stance, which further highlighted the quagmire that exists in achieving integration in global health.
A ray of light came during a plenary session on the initial response to the Haiti crisis. There, Haiti's Minister of Health, Alex Larsen, commented on the swift response to the earthquake, how numerous countries across the globe had come to Haiti's aid, and how the situation was beginning to stabilize thanks to these efforts. Though not perfect, it was possible to provide emergency aid in spite of the structural limitations. However, there were also instances of well-intentioned aid being misdirected, for example with three cartons of unneeded suppositories being sent to Haiti (showing the importance of communication with recipients prior to making donations). Other panelists were from Partners in Health, Catholic Medical Mission Board, Direct Relief International and Miami's Miller School of Medicine. They were part of the groups able to respond promptly when the need arose, and also provide a sustained response. According to Minister Larsen, the main challenge in the future lies with bolstering the existing human capital so that Haiti would be able to address the long-term sequelae, such as increasing rehabilitative services for the maimed, and also providing mental health services for the survivors. However, the panel showed that integrated efforts could help in the aftermath of a state of emergency that overwhelmed existing systems.
June 15
Today was mostly spent speaking to fellow conference participants, which made it less frantic, but made more time for "hard solid thinking" and trying to put together all the threads from sessions so far. The morning plenary session addressed whether the increase in global health resources had a positive impact on health. On a global level there have been improvements in mortality, but with apparent regional differences. An interesting idea introduced by Mead Over of the Center for Global Development was one of providing cash on delivery for HIV prevention to ensure that "rewards" flowed to areas where there was measurable impact on the ground. This would add social incentives to the personal drive to maintain good health by, for example, building a soccer stadium in a community where HIV incidence had declined. Interestingly, an alternate version of this was introduced during the MDG goal panel on Monday, when the Norwegian Ambassador to the U.S., Wegger Chr. Strommen suggested that cash incentives be provided for women who delivered children at clinics, or with skilled birth attendants present. Mr. Strommen's suggestion was met with derision from those who thought the intrinsic value of positive health behavior at an individual level should be sufficient. However, Mead Over's suggestion made me wonder why it seemed more acceptable to apply the same concept of incentivization if it were at a community level. Perhaps it is because the gains from changing social norms in the HIV prevention program would potentially accrue to the point where the funding was no longer necessary, whereas babies are always going to be born, and it would be difficult to commit to such a program for all women in remote areas into perpetuity.
The focus on women's health has been clear, and is a particular focus of the health-related MDGs. After my morning sessions, I attended a presentation on TB and women's health that featured lessons on survival from South Africa and the U.S. The South African story was that of Gerry Elsdon, the IFRC global TB advocate, whose involvement began when she found out that she had been rendered infertile by the bacterium. There is much focus on the disparities in global North and South, but the in-country differences are sometimes starker - South Africa's Gini coefficient bears testament to that. However Elsdon found that although she was a national celebrity, TB was a "great equalizer" and she also found herself in queues at 6am, where she would start at position 162 and spend most of the day in line. Through her experience she became a staunch advocate fighting for stigma reduction, greater awareness of TB and its manifestations (localized in the meninges or uterus, for example), and an understanding of the life-changing nature of a diagnosis of active TB, particularly among poor women, who would then have to decide between isolation or taking care of their families.
For the global comparison, I have my experience with a positive PPD when I was an undergraduate. The NP conceded that it might have been due to the BCG vaccine, the chest x-ray was clear, but I was encouraged to take the isoniazid course. I spent no more than 10 minutes in line for pills during the 9 month period, and Connecticut state covered the treatment costs. Vastly different scenarios. However, with the agendas for global health aid becoming more cohesive, it is possible for these gaps to be narrowed, and innovative ways found for making the scarce resources stretch further. This was the theme of the last panel I attended today, where the speakers spoke about the role of international NGOs in a changing development landscape. With greater country ownership, NGOs should be able to "work themselves out of the job" and with less duplication of effort and more integration, they should be able to do so faster. Although I sometimes think that global health has a number of buzz words that have almost lost their meaning in repetition, there are always examples of people doing good work, and accomplishing it well. The poster sessions were an example of this, as were conversations with other participants, whose passion for global health and commitment to positive change were apparent. This conference has brought together an amazing group of people ready to inspire and be inspired.
June 14
This morning's attendee welcome meeting was swamped. A number of program participants clutched their conference bags, frantically leafing through their programs and trying to decide between a number of appealing sessions in the same time slot. I had similar concerns - each time I went through the schedule, I highlighted at least one more thing that I "had" to attend! As we were skillfully guided through the program during the attendee orientation, I wondered how I would fit it all in!
The first session was on developing health schemes targeted at the poor. The talk reviewed how the poor were less likely to enroll in insurance plans, and once enrolled, less likely to utilize the services than their richer counterparts. What came as a surprise, though, was data showing that poorer individuals were actually subsidizing the wealthy because health systems are not structured to explicitly benefit the poor. This provided much food for thought and discussion - we are all so concerned about making insurance available because of the importance of risk pooling, but there needs to be more focus in insuring equity in delivery.
Still on the theme of improving health service delivery, I attended part of the Open Educational Resources Network session. This participatory network aims to make adaptable, downloadable internet resources available to fulfill curricular needs in health professional training and ultimately be a reciprocal learning venue for African and non-African partners.
After the morning sessions, all participants attended the welcome reception lunch, which also featured stations demarcated by regions, where people working in these areas could mingle. In the lull before afternoon sessions, I watched the short film "Foul Water/ Fiery Serpent." This is the 30th year since the eradication of small pox, and guinea worm could very well be the next disease on the list, with a strategy that does not involve use of drugs, but instead focusing on de-worming existing cases and preventing future infestation.
Following that, I dashed over to the next session - "Can country ownership work?" with much enthusiasm. I am still desperately seeking the key to improving population health, particularly in developing countries. The panelists provided a government and NGO perspective, focusing on the role of civil society in all stages of the health policy formulation, implementation and evaluation process. A key point was that "country ownership" did not equate to "government ownership" (particularly in countries like Nigeria where 70 percent of the health services are covered by non-state actors). It will be many years before developing country governments can fully finance their health systems, so it is of crucial importance to find ways to effectively bring together the various stakeholders and try to make their goals align. However, there cannot be a one-size-fits all approach, so my search for a magic bullet is perhaps futile.
My last session was the plenary session, which looked at the health-related MDGs and how far we had come. What resonated most with me was how the least progress had been made in sub-Saharan Africa, and how maternal and infant mortality remained appallingly high. The lifetime risk of death in child-birth for a woman in sub-Saharan Africa is 1 in 22, whereas that in industrialized countries is 1 in 8,000. Furthermore, disparities continued to exist in the other MDGs, particularly as regards infectious disease, water and sanitation (although some gains had been made).
However, if there is something to be learned, it is that the "big picture" view of things is not always the full picture. My last session of the day was the ACCESS Family Planning Program end of project meeting. Representatives from Bangladesh, Kenya, India and Nigeria spoke about their efforts to incorporate effective approaches for post-partum planning. They achieved major successes in the correct use of the lactational amenorrhea method, transitioning to other forms of contraception, and were also able to get male partner involvement. The mood of the session was very upbeat, and one could sense the buzz of approval as the presenters showed their data and spoke of how child spacing provided clear and definite improvements for mothers and children.
As I type these last few sentences and prepare to tackle the smorgasbord that is tomorrow's sessions, I am confident that there is a way to effect positive change, and although the small steps are not always clearly visible in the big picture, they definitely bring us much closer to our desired destination.
June 11
This week, I will be blogging my experiences as one of the New Investigators in Global Health at this year's conference. I just completed my first year in medical school at Stanford and after a whirlwind of packing and making summer arrangements, I am D.C.-bound for the conference.
I am from Zimbabwe, and first came to the U.S. when I began college. I have always been interested in global health - based on personal experiences in childhood, but increasingly so after being exposed to classmates from diverse backgrounds in college. My first "public health" experience came in my sophomore year, where I was one of eight students selected for a year-long Yale-China Association program where we partnered with students from the Chinese University of Hong Kong, shared information about the U.S. and Hong Kong health systems and organized reciprocal visits. Following that, I went to China three more times, working on projects that focused on men who have sex with men and HIV transmission.
At this year's conference, I will be presenting from my MPH thesis on the Zimbabwean response to the HIV epidemic, and to what extent the political and economic climate have influenced the disease trajectory. I am very interested in reproductive health, infectious disease and vulnerable populations. In this regard, the interface between policy and research, health and governance is increasingly important as a good balance is necessary for building strong systems that ensure a safety net for the most vulnerable and disproportionately affected.
At this year's conference, I hope to learn more about sustainable methods of improving health systems and be exposed to current thought on development aid, how best it can empowers individuals locally and learn from the other participants' experiences on the ground. I also hope to better understand how to navigate constraints in resource allocation - a key challenge in health and medicine is the stark contrast between systems with state of the art technology and others where the largest limitation is resource availability, allowing treatable infections to go unchecked. Finding a balance that allows good health to truly be spread globally, with a focus on each populations risk factors and available resources will be a lifelong challenge.
Lastly, I am keen to once more immerse myself in public health thought - and address problems through a population rather than individual level lens (particularly after a year of anatomy and microbes!) I am also looking forward to learning a great deal from my fellow participants, becoming more globally aware and finding new ways to think about and approach improving health, especially in the developing world.
Takudzwa Shumba is a medical student at Stanford University.
Taku, sounds like u having a good time
— tina on 2010-06-16
Thank you for sharing information about your interest specially in HIV/AIDS prevention in Africa. Your work in Zimbabwe is interesting and good. More well-trained public professionals like you are needed to help the HIV/AIDS prevention efforts in Africa even if they are studying or working in foreign countries.
The new book title: STD/HIV Prevention Action. Let’s Protect Each Other. Available at http://www.amazon.com; http://www.iuniverse.com; http://www.barnesandnobles.com is an example of such efforts and contributions needed to prepare people to avoid HIV/AIDS and prepare a new generation of youth and young adult who will say no to a new HIV infection and the high cost of treatment and disease complications.
— Samuel Frimpong MD MPH on 2010-06-25
Takudwa,
It is encouraging to have a sense of your views on the conference and from what you say is a fruitful experience you are having. It is crucial that at some point you relate these global experiences to the situation in Zimbabwe. i worked as District Medical Officer, Provincial Medical Officer, Principal Medical Director in the Ministry of Health & Child Welfare and as well as the Permanent Secretary between 1996-2001. I witnessed the rise and fall of the health system in Zimbabwe. Probably disgruntled and feeling unappreciated and not being able to make much progress to improve the situation - I have increasingly involved my self in global health issues but still “cry my beloved country and health system. I decided to chronicle the rise and fall of the Zimbabwe Health delivery system in a publication published by Trafford Publishing (http://www.trafford.com) - should you feel nostalig about the Zimbabwe health system -the title is “Challenges in Reforming The Health Sector in Africa: Reforming Health Systems under Economic Siege. The Zimbabwean Experience”. Good luck and enjoy your studies
Paulinus
— Dr Paulinus Sikosana on 2010-07-16