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New Numbers On Tuberculosis Burden Must Galvanize India To Act

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Dr. Madhukar Pai

Last week, WHO released its 2016 Global TB Report. The news, unfortunately, is not good. The report shows that the TB burden is actually higher than previously estimated, mainly because of new data from India. In 2015, there were an estimated 10.4 million new TB cases worldwide. Six countries accounted for 60 per cent of the total burden, with India accounting for 27 per cent of the global cases, followed by Indonesia, China, Nigeria, Pakistan and South Africa.

An estimated 1.8 million people died from TB in 2015, of whom 0.4 million were co-infected with HIV. Gaps in testing for TB and reporting new cases remain major challenges, as they have in the past. Of the 10.4 million new cases, WHO estimated that only 6.1 million were detected and officially notified in 2015, leaving a huge gap of 4.3 million cases that are “missing” — either not diagnosed, or managed in large unregulated private sectors and not notified to TB programs.

Global TB elimination is an impossible goal without significant progress in this emerging superpower.

India continues to bear the brunt of the TB epidemic, with 2.8 of the 10.4 million new TB cases that occurred in 2015. TB is also a major killer of Indian people. The latest Global Burden of Disease estimates from Institute of Health Metrics and Evaluation, published earlier this month, show TB to be the sixth leading cause of deaths in India. In 2005, TB was the sixth leading cause of deaths in India, and ten years later, in 2015, it holds its place as a leading killer of people in India.

These new estimates from WHO and GBD are disappointing and underscores the need for greater investments in global TB control. In particular, India really needs to wake up to the enormity of the epidemic in the country, and put some serious money behind its under-funded TB program. Global TB elimination is an impossible goal without significant progress in this emerging superpower.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000, while India was estimated to have over 79,000. TB is no longer a major killer of people in China, and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centres (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

So, why does India struggle with a much higher TB burden? There are many reasons. For one, India has many social determinants that fuel the TB epidemic — poverty, malnutrition, smoking, and indoor air pollution. Secondly, India has under-funded TB control for a very long time. And much of the focus was only on the public TB program. It is only recently that the national TB program has seriously started to address the problem of TB in India’s large, dominant, private sector.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done (unlike China and other high TB burden countries). Furthermore, the Indian national TB program was (and still is) heavily reliant on insensitive diagnostic tools such as sputum microscopy. India is “fighting the TB war with 19th century cannons.” All of this meant that India has been under-diagnosing and under-reporting the burden of TB for a long time.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

In addition, although India made TB notification mandatory in 2012, it has taken a few years for private sector notifications to accumulate. Now, thanks to several public-private partnership programs, significant increases are being noticed in case notifications from private sector.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem. This will not happen without high-level political commitment.

Last week, on the same day of the WHO TB report release, The Lancet published a comment by the Indian Health Minister Mr Jagat Prakash Nadda and Dr Poonam Khetrapal Singh, head of India’s WHO Regional Office for South East Asia.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem.

In their Comment, they acknowledged that TB is a bigger problem than imagined in India and other Asian countries, and suggested that TB should be made a top priority on national agendas. They also argue that political commitment should be translated into a comprehensive national TB control plan, and such a plan must be fully funded and implemented promptly by an empowered body that reports to the highest levels of government.

These statements by the Indian Health Minister is very impressive and progressive, as is the commitment from Dr Soumya Swaminathan, India’s Secretary of the Department of Health Research about India’s plans conduct prevalence surveys, develop innovative new tools for TB, address social determinants such as malnutrition, and create an India TB Research Consortium.

Hopefully, these leaders will deliver on the vision that they have articulated, and make TB a national priority in India. In fact, India has already started the process for creating the National Strategic Plan for TB Control in India (2017-2023). This plan must be ambitious, and fully funded by the Indian government. Otherwise, future TB reports will continue to bring bad news.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)


This article was originally published in The Huffington Post. See the original article here.

Photo Essay: Working at the Myungsung Christian Medical Center in Ethiopia

Angela Lee

My project was a practicum and a research project at Myungsung Christian Medical Center (MCM). MCM is a private, non-profit hospital, where I was under the supervision of a pediatric surgeon. I took part in both the clinics and the surgeries within the hospital, and I also participated in community outreach programs by MCM, such as the free of charge mobile clinics in rural communities. The research project was a retrospective study to calculate the backlog of defined pediatric surgeries at MCM, in order illustrate the gross lack of surgical accessibility in low and middle income countries in Africa.

Picture 1: Myungsung Christian Medical Center which is located in Addis Ababa, the capital of Ethiopia. The hospital consists of 2 wings: Shalom Wing and Grace Wing. The Shalom Wing is the original hospital complex. The Grace Wing was build in 2011, in order to accommodate more patients.

Picture 1: Myungsung Christian Medical Center which is located in Addis Ababa, the capital of Ethiopia. The hospital consists of 2 wings: Shalom Wing and Grace Wing. The Shalom Wing is the original hospital complex. The Grace Wing was build in 2011, in order to accommodate more patients.

Picture 2: The operating rooms at Myungsung Christian Medical Center and surgical team. Far left – Pediatric surgeon. Middle – 4th year medical student as first asssist. Right middle – Scrub nurse. Far right – Anesthesiologist. There are currently no medical residents affiliated with Myungsung Medical College as the medical program is only 4 years old. Therefore, it is not unusual to have the 4th year medical student as the first assist in non-complicated surgeries.

Picture 2: The operating rooms at Myungsung Christian Medical Center and surgical team. Far left – Pediatric surgeon. Middle – 4th year medical student as first asssist. Right middle – Scrub nurse. Far right – Anesthesiologist. There are currently no medical residents affiliated with Myungsung Medical College as the medical program is only 4 years old. Therefore, it is not unusual to have the 4th year medical student as the first assist in non-complicated surgeries.

Picture 3: Mobile clinic in Hawassa: Day 1. Patient triage and blood pressure readings. Volunteers with the help of interpreters take down the chief complaint and basic patient information. I was the designated team member to take blood pressure measurements on Day 1.

Picture 3: Mobile clinic in Hawassa: Day 1. Patient triage and blood pressure readings. Volunteers with the help of interpreters take down the chief complaint and basic patient information. I was the designated team member to take blood pressure measurements on Day 1.

Picture 4: Mobile clinic in Hawassa: Day 2. Dressing change of an infected ulcer under the supervision of Dr. Shin (center).

Picture 4: Mobile clinic in Hawassa: Day 2. Dressing change of an infected ulcer under the supervision of Dr. Shin (center).

Picture 5: Mobile clinic in Hawassa: Day 3 Ethiopian medical students teaching the children about hand washing and dental hygiene. More than 125 children participated in the teachings and activities.

Picture 5: Mobile clinic in Hawassa: Day 3 Ethiopian medical students teaching the children about hand washing and dental hygiene. More than 125 children participated in the teachings and activities.

Picture 6: Interventional angiography inauguration ceremony. Opening address by Reverend Kim (far left). I served as Korean to English translator (second from the left).

Picture 6: Interventional angiography inauguration ceremony. Opening address by Reverend Kim (far left). I served as Korean to English translator (second from the left).

 

Angela Lee was awarded the Medical Class of ’84 Student Bursary in Spring 2016. She is currently a 3rd year medical student who believes everyone has the right of access to quality health care. Angela chose to travel abroad because she wanted a better understanding of the social and medical struggles that both the people and the medical staff face in low resource settings.

Post-Travel Perspectives: Working for the Kigezi Health Foundation in Kabale, Uganda

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Neil Verma

I traveled to Uganda and joined the Kigezi Health Foundation primarily to expand my knowledge of global health disparities, community empowerment and rural medicine. Adequate nutrition remains a challenge for several families in the Kabale area with several diseases having clear associations with malnutrition. My work involved studying the impact of rabbit breeding in low-income families as a means to provide adequate nutrition and additional income. The ultimate goal remains to expand knowledge and resources to address public health issues and maximize population health.

My father and grandmother were born and raised in Kabale and these personal ties to Uganda have specifically drawn me to this community. My family’s experiences have provided me perspective on the impact of disease within this community while fostering my desire to provide medical service to the local population.

My experience with the KIHEFO reinforced my desire to engage in rural medicine and global health, addressing healthcare issues through improving the social determinants of health and community empowerment.

I had limited proficiency in Ruchiga–the local language–and a greater proficiency with the local language would undoubtedly help address the cultural and linguistic barriers and build rapport with patients. Local medical professionals are already faced with a demanding clinical workload, and learning the language and cultural practices partially alleviates the ethical responsibility of having the clinical staff host foreign medical trainees. Cultural attitudes towards medicine also have an impact on healthcare delivery in Uganda, particularly given that 80% of the population exclusively seek out traditional healers as their primary care providers. The KIHEFO has attempted to partner with traditional healers in order to encourage Ugandans to seek out modern medical services. The differences in particular disease treatment protocols and regimen add to the ethical conflict between my own perspective on healthcare and the approach in Kabale. To cope with these realities, I have relied on a network of former global health students and local professionals to better understand Ugandan healthcare along with their unique approach to addressing disease and suffering in a resource-limited setting.

My work with the KIHEFO will contribute to an academic relationship with McGill University and provide a mutually beneficial opportunity to expand knowledge and resources to address public health issues such as malnutrition and HIV prevention. Furthermore, an ongoing partnership between both parties will allow for expansion of available medical resources, services and additional opportunities for knowledge exchange and learning. The benefits of partnering with North American universities are already visible in the KIHEFO’s maternal clinic, which enjoys the use of a donated portable ultrasound machine. As services continue to grow, medical trainees and residents rotating through Kabale will provide additional training to local staff and counselling to community members in order to improve quality of care and maximize population health.

As a practicing physician, I will be able to use the knowledge gained working with the KIHEFO to advocate for policy changes locally and globally that also focus on the social determinants of health including food security and housing that will reduce health inequities. Learning the practice of rural medicine in Uganda allowed me to develop my awareness of the organization of healthcare in a resource-limited setting. It will give me the skills to strive to become a physician who remains conscious of the challenges of healthcare delivery and to provide the most efficient patient care.

As I have embraced the significance of public health to communities, I am optimistic that I will continue to engage in global rural medicine initiatives and devote myself to career and life as an advocate for global health.

My work with the KIHEFO presents challenges and learning opportunities that will improve my understanding of the disparities in global health, the value of community empowerment in healthcare and the challenges of rural medicine in a developing nation. These skills will serve as a foundation for my desire to pursue a career focusing on global health service and the development of global health policy.

Neil Verma was the recipient of the Ashworth Student Travel Award. Neil is a third-year medical student primarily interested in understanding the social, cultural and economic aspects of health and disease to improve global health.

Understanding the Past and Future of Infectious Diseases: A Book Review of Laurie Garrett’s The Coming Plague

Claire Styffe

Laurie Garrett’s The Coming Plague: Newly Emerging Diseases in a World Out of Balance is a worthy read for anyone interested in either an account of infectious diseases or future global health threats alike.   While the text is very in depth, it cannot be called narrow; with reports on a range of infectious diseases from Bolivian Haemorrhagic Fever to Hantavirus to Lassa fever, the author succeeds in providing a rich and comprehensive guide on multiple major illnesses.  Drawing tales from a number of different countries including Brazil, Zaire, India and the United States, Garrett creates an account that examines infectious diseases from a truly global point of view.

The Coming Plague presents pathogens and viruses in an interesting and detailed manner, but the true strength of the book lies in its ability to showcase the human side of global health.

“The Coming Plague” by Laurie Garrett

Chapters are devoted not only to the mechanisms of the disease, but more prominently to the outstanding efforts of the “infectious disease cowboys” [1], the researchers and the nurses who interacted first hand with the illnesses.  Reports are written in an almost story-like manner, with physicians and patients presented like characters and dramatic cliffhangers at the end of chapters.  At times, it is easy to forget that this text is not fiction, but rather a detailed work of research that took ten years to compile [2].  While the sheer size of The Coming Plague may first appear daunting, it reads easily and is often interjected with humour, making for a book that is not only highly informative, but also one that is extremely enjoyable.

 

While The Coming Plague was published in 1994, much of the information and insights provided still hold true over twenty years later.  Garrett’s warnings about unsterilized needles, antibiotic resistance and unpurified drinking water are not echoes we can resign to the past, but rather public health challenges we face today.  In fact, what was once considered controversial when first published is now viewed as conventional [3].

 The Coming Plague is a text that masterfully intertwines both infectious diseases and human endeavour, providing a rich framework for understanding not only our past efforts combatting communicable diseases, but also those we must take in our future.

 

Claire Styffe is a U2 student currently pursuing a degree in Cell and Molecular Biology as well as Urban Systems Geography. She is fascinated by global health and has a particular interest in preventing and minimizing the spread of infectious diseases.  

References

[1] Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Straus and Giroux, 1994), 29

[2] “The Coming Plague”, Laurie Garrett, http://lauriegarrett.com/the-coming-plague/

[3] Ibid.

Canada is Leading the Fight to End AIDS, TB and Malaria for Good

 

Introduction by Patrick Bidulka 

McGill University was fortunate to participate in the Global Fund Replenishment conference held in Montreal this September. The Global Fund side event at McGill, organized by the McGill Global Health Programs office, saw a high turn-out of world-class global health researchers and students. With its contribution of nearly $800 million, Canada has repositioned itself as a key contributor to the field of global health, and a stakeholder in the mission of the Global Fund to end HIV/AIDS, TB, and Malaria for good. However, as the Honorable Jane Philpott said as she addressed the event, these goals will not translate into tangible results until society collectively deems current health disparities as “outrageous, and solvable”. It is outrageous that a third of the world is infected with TB, with the majority of those infected being in developing countries. It is outrageous that here in Canada, we have a TB epidemic concentrated in our Aboriginal communities, where the rate of TB in Indigenous populations is 34 times higher than in non-Indigenous Canadians. It is outrageous that here in Canada, there are 50 new infections of HIV every week, and this rate has not changed in the last two decades. And so, it is these glaring inequalities that must be recognized, and deemed outrageous by more than just researchers and health care workers, but collectively by the global population. Progress has been paralyzed by barriers such as stigma, racism, gender inequality, and prejudice against LGBTQ people. It is not until these basic issues surrounding human rights are resolved that we can truly put an end to AIDS, TB and Malaria. As Mark Dybul, CEO of The Global Fund said at the McGill side event, “To end these diseases, we must become better humans”.

Panelists at the McGill event (from left to right): the Honourable Jane Philpott, Mark Dybul, Lucica Ditiu, Peter Singer, Mark Wainberg, Philippe Gros, and Marcel Behr.

Panelists at the McGill event (from left to right): the Honourable Jane Philpott, Mark Dybul, Lucica Ditiu, Peter Singer, Mark Wainberg, Philippe Gros, and Marcel Behr.

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Dr. Madhukar Pai & Dr. David Eidelman

As Montreal gears up to host the biggest leaders in global health, it is our hope that Canada will go well beyond provision of international aid, and find a way to harness the abundant scientific talent in Canada. Doing so will not only amplify the financial contributions by Canadians, but also show our global solidarity.

The past year has seen the re-emergence of Canada in the international development arena. In addition to maternal and child health, if there is one area where Canada is showing tremendous leadership, it is in the fight against the “big three” — AIDS, tuberculosis, and malaria — infections that kill over 3 million people each year.

To tackle the big three, The Global Fund to Fight AIDS, TB and Malaria was created in 2002. The Global Fund raises resources, engages a variety of partners, and invests funds in supporting programs to tackle the epidemics. Programs supported by theGlobal Fund have saved 20 million lives, by providing 9.2 million people with antiretroviral therapy for HIV, 15.1 million people with testing and treatment for TB, and 659 million mosquito bed nets to prevent malaria.

Canada is blessed with some of the best academic researchers and innovators working in global health.

If the Global Fund is to continue making progress towards ending these epidemics for good, it needs to be replenished by donor governments, private foundations, corporations, and philanthropists — and Canada is showing the world how to get this done!

On September 16-17, 2016, the Government of Canada will host the Fifth Replenishment Conference in Montreal that will bring world leaders to set funding for the next three years. The Global Fund has set a target of raising US$13 billion. Canada has already pledged CAN$785 million, a 20 increase compared to the last round. The USA has pledged up to US$4.3 billion, France has pledged €1.08 billion, and Germany has pledged €800 million. These pledges, hopefully, will inspire others to contribute and meet the target of US $13 billion which can save an additional 8 million lives.

In addition to supporting the Global Fund, the Government of Canada has made a renewed investment of CAN$85 million for the Stop TB Partnership’s TB REACH initiative, to reach, treat and cure many of the 3.6 million people affected by TB who every year go without proper care. The Government of Canada has also invested inGrand Challenges Canada, an agency that is funding several innovative projects in TB, HIV and Malaria.

We can be proud of all these developments that show commitment and leadership from the Canadian Government. However, in addition to providing development assistance, Canada has much more to offer. Canada is blessed with some of the best academic researchers and innovators working in global health. For example, an experimental Ebola vaccine developed by Canadian scientists has already attracted international attention.

In the area of HIV, TB and Malaria, Canadian researchers are making valuable contributions. Canada has led the way in identification of anti-retroviral drug targets, development and promotion of the Treatment as Prevention strategy, development and evaluation of new diagnostics, treatment of HIV and hepatitis co-infections, and leadership roles in prestigious societies to influence policy and advocacy.

Epidemics such as SARS, Ebola and Zika have shown us that infectious diseases respect no boundaries.

Canada has a rich history of research in tuberculosis, a disease that still affects our Aboriginal communities. Canadian researchers have identified the genetic basis of susceptibility to TB, used innovative DNA fingerprinting methods to track the epidemic, evaluated novel tests for TB, conducted clinical trials to develop shorter drug therapies, and contributed to international policies. Canadian researchers have identified promising malaria drug targets, documented malaria strain variations, and developed a global molecular surveillance system for drug-resistant malaria.

McGill University and its affiliated hospitals are home to several teams that focus on HIV, TB and parasitic diseases. With over 100 scientists working on infectious diseases, McGill has much to offer in global health, from fundamental science to policy, and, in particular, training of the next generation of researchers. McGill Global Health Programs coordinates the University’s global health work, and is making strategic investments and partnerships to make sure McGill’s faculty and students are actively engaged as global citizens, in solving the biggest global health challenges.

Epidemics such as SARS, Ebola and Zika have shown us that infectious diseases respect no boundaries. We are excited that Canada is showing impressive leadership in global health, and particularly thrilled that the Global Fund Replenishment Conference is being held in Montreal. We hope the Global Fund replenishment targets will be met, and Canadian researchers will be actively engaged to translate the dollars into saved lives.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)

David Eidelman is the Vice Principal of Health Affairs at McGill University, and Dean of the Faculty of Medicine. (@VPDeanEidelman)

This article was originally published in The Huffington Post. See the original article here.

Notes from the AIDS2016 Conference in Durban, South Africa

Kara Leigh Redden

In July, I had the amazing opportunity to not only participate in the AIDS2016 International AIDS Conference in Durban, South Africa, but to also present my research on the prevention of mother-to-child transmission of HIV with my Haitian co-investigator.

Kara and her co-investigator presenting their work at the AIDS2016 conference in Durban, South Africa.

Kara and her co-investigator presenting their work at the AIDS2016 conference in Durban, South Africa.

It was our first time in South Africa and our first time at such an internationally organized event focused on HIV/AIDS. The weeklong conference was jam packed with activities, events, speaker series, presentations and much more—so much more that it was impossible to fit everything in the five days we were there.

Among the many leaders speaking, we heard from Charlize Theron on the importance of recognizing HIV/AIDS as a human rights issue.

Actress Charlize Theron speaking on human rights issues surrounding HIV/AIDS.

Actress Charlize Theron speaking on human rights issues surrounding HIV/AIDS.

We also heard from Elton John and Prince Harry remarking on the importance of recognizing youth’s voices and vulnerability in efforts to end the burden of HIV/AIDS.

Sir Elton John speaking at the AIDS2016 conference.

Sir Elton John speaking on youth vulnerability at the AIDS2016 conference.

Most impressive was the participation of some of the most vulnerable groups affected by HIV—healthcare workers, trans-men and -women, sex workers, homeless populations, and members of aboriginal communities as well as the lesbian and gay community. While we still have a long way to go to ensure that the voices of these groups are represented, it was refreshing to be among those who are the most affected by HIV and the barriers that affect access to HIV care and services.  Because of this, we were graced by many leading HIV/AIDS activists who have spent their life standing up to big corporations and governments to make sure that those who need care the most can get access to that care.

Any trip to South Africa would not have been complete without paying homage to the great Nelson Mandela. We visited Mandela’s capture site where a monument was erected in his honour, constructed out of the very bars that held him captive for over 27 years.  I hope that he would have been proud of the great work being done in his country.

The monument marking Nelson Mandela's capture site in the South African province of KwaZulu-Natal.

The monument commemorating Nelson Mandela’s capture site in the South African province of KwaZulu-Natal.

Kara graduated in May 2016 with a Masters of Nursing and a concentration in Global Health Studies. During her studies, she travelled to Haiti to conduct research on the prevention of mother-to-child transmission in collaboration with their partner site, Zanmi Lasante. Kara has been involved in various Global Health activities since 2012 and hopes to continue to contribute to this field as a nurse.

“Tīng bù dǒng”: Reflections on conducting international field work with language barriers

Sierra Clark

While conducting my Master’s thesis field work in rural China this Summer, the most common string of Chinese-Mandarin words that were either said to me, said about me, or I said myself, were “Tīng dǒng”, which roughly translates to “I hear you but I don’t understand you”. That phrase most concisely characterizes the communication challenges I faced, while also reflecting mine and others willingness to communicate across a difficult language and cultural barrier. My blog is a reflection on the challenges, but also unique opportunities that arise, when conducting research based international field work in the context of a language barrier.

Photo 1

Sierra standing in front of one of her favourite views in the region. The study site is 1000-13000 meters above sea level on the edge of the Tibetan Plateau.

To provide some context: I arrived in China in May 2016, equipped with a lonely planet guide book to Chinese, a translation dictionary on my phone, and an undergraduate research assistant who was fluent in both languages (she was with me for 1 month out of 3). I had also prepared this year by playing Chinese language games, keeping a journal in Pinyin (way of writing Chinese using the Roman alphabet) and I listened to Chinese podcasts (with little success). Needless to say, I felt pretty good about myself and ready to take on Zhōngguó [China]. My confidence in my abilities was soon shattered after I arrived. I had been teaching myself the wrong pronunciation for almost every letter (or combination of letters), and I was utterly failing at enunciating the tones correctly. When I reached my small village in Sichuan Province, an additional barrier arose as I now had to translate from English, to common Chinese-Mandarin, to the local dialect spoken in Sichuan. I had the help of my research assistant for one month (she literally saved my life), and I lived with a Chinese colleague who was functional in English, but soon enough I was on my own with the challenge, but also the amazing opportunity, to tackle this communication conundrum and hopefully learn something from it.

I am now a master of the game Charades

Standard communication when there is a language barrier is difficult to overcome, and trying to communicate research terms, research equipment, and research protocol is even more intricate in this context. When communicating with the field staff in Chinese, I was at a loss for how to ask for things like: “where is the flow-rate calibration Rotameter” or “does the grease on the impaction surface have any air bubbles in it?” (the grease catches the larger Particulate Matter (PM) particles so that we can collect PM in aerodynamic diameter <2.5 μm on our filters for analysis). Additionally, I implemented a questionnaire that asked questions about participants use of the intervention cook stove (1) and their likes, dislikes, and preference for it over other stoves in the household. It took me and the team a week of piloting, and five iterations, to finally get a questionnaire that could be translated into the local dialect and the questions were locally and contextually relevant. However, even months after the piloting phase, I am still finding that some questions and responses are interpreted differently then I intended them. For example, a stoves “a. cleanliness” was meant that the surface was clean (i.e., devoid of grime) but many participants interpreted that to mean the stove emitted less smoke. Troubleshooting these issues in the field with the team required patience and persistence, and an ability to find creative ways to communicate the solution to each other (did I mention phone translation dictionaries are amazing).

I also ran into troubles when I was the one collecting the data directly with the participants. Often I took on the task of taking blood pressure measurements. Our standard protocol was that participants had to sit quietly in a restful state for five minutes before the measurement began. Sometimes when I tried to communicate this, I ran into more trouble when when I said to the participants xiūxí wǔ fēnzhōng [rest five minutes] or bù shuōhuà [no talking] as they would get more excited because a wàiguó rén [foreigner] was talking to them in Chinese! I found using my body to indicate what I wanted was very effective. I could direct someone to stand on the weigh scale, sit down and put their right arm on a pillow, rest for 5 minutes, and tell them that their blood pressure was low [bù gāo]/ a little high [yidiǎn gāo]/ high [gāo], all by becoming a master at the game Charades.

Both lǎoshī [teacher] and xuéshēng[student]

Photo 2

The field staff are preparing the equipment for the day. They are cleaning the Personal Exposure Monitors (PEMs) and placing filters inside them. When the PEMs are attached to an active pump and worn around the waist in a waist pack, they collect data on how much air pollution (PM2.5) someone was exposed to over 48hrs.

I took the ease and convenience of casual conversation in a familiar environment for granted before I came to China. I now know that when you are the one speaking the foreign language, the time that people give you is precious. My perspective changed after I asked my neighbors to repeat their sentence for the 4th time, when they patiently listened while I tried to stumble my way through a terribly pronounced sentence (which likely made me sound like a child), and every word was enunciated wrong so when I was really asking for the toilet they probably heard me say “why is the dog wearing my t-shirt”? The village became my classroom and the villagers were my teachers.

I also came to appreciate the way that I was learning Chinese in Sichuan. If I was working with a tutor in Canada, or speaking to someone who had excellent Chinese and English, there would be no mutual benefit (except for the monetary transaction for their services). Recently, two of the field staff I work with have really taken to learning Yīngwen [English]. When I first arrived, they could say a total of three phrases: “hello”, “goodbye”, and “it’s lunch time!”. Two months later, if I talk slowly, enunciate purposefully, refrain from using jargon, and play a little game of Charades, I can get almost any point across. When we hop into our van and head out to do our work for the day, we each come equipped with our “how to learn Chinese/ English” books. If I ask a question in Chinese, they will try to respond in English. If I want to know the Chinese name for something, they then need to know what it is in English. I love this mode of learning. Neither of us are experts in both languages, we are Lǎoshī in one and Xuéshēng in the other. Its fun, its playful, and its mutually beneficial. The other day one of the staff told me (written on her phone translator) that she was “gradually learning to love the English language”, and I could have jumped for joy I was fēicháng gāo xíng [E: very happy].

Photo 3

Sierra and the field team head out for the day to collect air pollution and health data in the Tibetan Plateau. Car rides are a prime time to practise Chinese and English for the team.

 

Acknowledgements: Much thanks to the wonderful field staff who continue to teach me new words every day, the villagers whom have included me into their lives, and my research assistant who helped me survive my first month. Funding for my research this Summer was provided by McGill Global Health’s “Norman Bethune Award’, The National Geographic Societies “Young Explorers Award Program” and Mitac Canada’s “Globalink Research Award Program”. Funding for the larger project was provided by the US Environmental Protection Agency (EPA) STAR program. The opinions in this blog are entirely my own and do not reflect those of the granting agencies.

 

Sierra is a second year Master’s student in Epidemiology and an Institute for Health and Social Policy graduate intern at McGill University. She is currently in rural China collecting data for her thesis on the air pollution and health impacts of a clean cook stove intervention which is aimed at reducing household sources of pollution. Sierra received her BA (Hon) in Geography from McGill, focussing her research on climate change and infectious disease in rural Uganda. Sierra is currently a National Geographic Young Explorer and a Mitacs Globalink International research award holder, and she is an active member of the Baumgartner Research Group at McGill. 

 


(1) Among a study population of 204 homes in 6 rural villages in Sichuan Province, we installed intervention semi-gasifier biomass burning cook stoves that take processed biomass pellets (processed at a nearby factory) as fuel into 117 homes (the other homes act as controls). The intervention stove emitted less PM2.5 during lab tests. We are now testing how the intervention preforms in real life conditions in the field: i.e., whether people use the intervention stove, whether people are exposed to less, the same, or more air pollution, and if their cardiovascular health is improved.

Julie in India: Post-Travel Report

Julie Vanderperre

Award:

AID India (Magasool) Internship, through the McGill Faculty of Arts Internship Office

Project Overview:

Last summer, I traveled to Tamil Nadu, India, where I conducted a research project with Magasool, a non-profit organization based in Chennai. My research was focused on the negative socioeconomic and health effects of alcoholism, an illness which plagues many low-income men within the state.

Vanderperre_photo_editWith the help of another intern, I created a survey and administered it to over 700 people throughout the state to gain insight on rates of alcoholism, and the ways in which addiction affected low-income families. The aim of the study was to quantify the many and varied medical costs attributed to alcohol addiction, including: hospitalizations for illnesses related to drinking, accidents that took place under the influence, domestic abuse related to alcohol consumption, productivity losses, and costs of rehabilitation. We also investigated the determinants of drinking, such as distance from a state-run liquor store, correlation between father and son drinking, and the correlation between income and drinking. Our data revealed startlingly high rates of alcohol addiction among men, especially in slums of Chennai, where 75% of men reported consuming liquor on a daily basis. A lack of awareness of the health risks of alcoholism, as well as inadequate access to health facilities and rehabilitation centers has led to a serious drinking problem in Tamil Nadu. Education and improved access to healthcare, in combination with restrictions on the availability of alcohol, are required to combat alcoholism within the state and mitigate the negative social and financial impact that alcohol addiction has on many low-income families throughout the state.

Impact:

My experience working with Magasool allowed me to expand my data analysis skills, which I hope to further develop in the future. I was also able to conduct a follow-up research project, under the supervision of McGill’s Professor Kuhonta, which allowed me to conduct in-depth research and provide policy prescriptions. Most importantly, my internship experience allowed me to visit and speak with people throughout the state of Tamil Nadu who feel the effects of alcoholism, and to hopefully improve their situations through my research.

 

julie

Julie is a recent graduate in Political Science from McGill. She is interested in international politics, economics, and policy, and is currently working in the field of journalism.

Cooking with solid fuels, household air pollution, and health in the Tibetan Plateau, China

Sierra Clark

Background and research:

Almost half the world’s population cooks with biomass fuels in inefficient stoves that emit high concentrations of toxic pollutants (Bonjour et al. 2013). The resulting household solid fuel combustion is thought to be a major contributor to ambient pollution with regional and global climate impacts and is a leading environmental health risk factor (Lim et al 2013, Amann et al 2008). Notably, use of solid fuels in China is the leading environmental health risk factor and contributes to an estimated 37% of the country’s total ambient Particulate Matter (PM2.5)emissions (Amann et al 2008). Ambient air quality in China and the surrounding regions have rapidly deteriorated in recent decades with high concentrations of ambient PM and other health and climate-relevant air pollutants (Zhang et al 2011, Heald et al. 2006). Further, black carbon aerosols from household solid fuel use in the Tibetan Plateau are thought to significantly contribute to glacial melting (Xu et al 2009).

Cleaner-burning stoves and fuels can potentially reduce household air pollution concentrations and exposure (Ezzati 2002). My research measures the potential environmental and health benefits of transitioning households to low-polluting semi-gasifier stoves and processed biomass fuels in a study site located on the eastern edge of the Tibetan Plateau, China.

Photo 1

Photo 1: Water is heated on a traditional chimney stove in Shanxi Province, China. Coal is used as fuel which, when burnt, can release a large amount of toxic air pollution into the home through inefficient combustion.

Photo 2

Photo 2: A traditional chimney stove in a rural village in Sichuan Province, China. These traditional stoves use biomass (wood and/ or crop residues) as fuel for burning in an open chamber which release smoke into the kitchen.

Photo 3

Photo 3: A woman in a small village in Sichuan collects wood (fuel) to burn in her traditional stove. Harvesting and collecting firewood can put an additional burden on households as it requires time that could have been spent doing other things.

Photo 4

Photo 4: Myself and another researcher go into homes to talk with women about their household cooking practises. Above me, smoke is being partially vented out of the kitchen by a chimney, but the unvented smoke remained in the kitchen with the cook.

Photo 5

Photo 5: Household burning of solid fuels for cooking and heating contributes to about 30% of China’s ambient air pollution.

Photo 6

Photo 6: A woman participant is having her blood pressure taken by a member of our field staff. Research shows that chronic as well as acute exposure to air pollution is associated with both short and long-term changes in blood pressure, which is a known risk factor for adverse cardiovascular events.

Photo 7

Photo 7: A woman participant is having her pulse wave velocity taken by a member of our field staff. Some research indicates that exposure to air pollution is associated with increases in pulse wave velocity, which is an indicator of cardiovascular health.

Photo 8

Photo 8: A woman participant in our study is wearing a waist pack with a Personal Exposure Monitor (PEM) inside. The PEM actively collects 48hrs of PM2.5 mass on a filter which is later analysed. Woman are often the most exposed to household air pollution, particularly in this setting, as they spend the most time near the sources of pollution (i.e., cooking-heating stoves).

Photo 9_1

Photo 9: Young children are particularly vulnerable to the health impacts of indoor air pollution. Not only are they biologically more vulnerable than adults, but they may also spend more time near the sources of pollution – indoors and alongside women in the household who are cooking.

 

 

sierra clark

Sierra Clark is a second year Master’s student in Epidemiology and an Institute for Health and Social Policy graduate intern at McGill University. She is currently in rural China collecting data for her thesis on the air pollution and health impacts of a clean cook stove intervention which is aimed at reducing household sources of pollution. Sierra received her BA (Hon) in Geography from McGill, focussing her research on climate change and infectious disease in rural Uganda. Sierra is currently a National Geographic Young Explorer and a Mitacs Globalink International research award holder, and she is an active member of the Baumgartner Research Group at McGill. 

 

Ethics and consent for photos: Ethics approval was granted (10-05-2016) in a REB amendment for a consent procedure which gave participants the opportunity to give oral informed consent for their photo to be used in presentations or media pertaining to this research project (REB A01-E01-14A). All identifiable person’s featured in this photo journal have provided informed oral consent.

Acknowledgements: Much thanks to all of the subjects in my photos who graciously agreed to allow me to use their images to help highlight and translate my research findings. Funding for my research this Summer was provided by McGill Global Health’s “Norman Bethune Award’, The National Geographic Societies “Young Explorers Award Program” and Mitac Canada’s “Globalink Research Award Program”. Funding for the larger project was provided by the US Environmental Protection Agency (EPA) STAR program.

How Drug-Resistance TB Can Show The Path To Tackling Antimicrobial Resistance

Madhukar Pai

India, TB, MDR-TB, XDR, drug resistance, tuberculosis

Antimicrobial resistance (AMR) is a global health threat, and it is estimated that by 2050, 10 million lives a year and a cumulative 100 trillion USD of economic output are at risk due to the rise of drug-resistant infections, if we do not find solutions to tackle the rise of drug resistant pathogens.

Since the introduction of antibiotics, microbes have evolved a variety of methods to resist antibiotics. We are now dealing with ‘superbugs’ that are virtually untreatable, including colistin-resistant E. coli, drug-resistant gonorrhea, carbapenem-resistant enterobacteriaceae, methicillin-resistant Staphylococcus aureus, extensively drug-resistant tuberculosis, and extended-spectrum-beta-lactamase producing strains. The antibiotic pipeline is running dry, and AMR is threatening to undo major gains made in the control of infectious diseases.

AMR is driven by several factors, but major causes include over-use of antibiotics, poor adherence to standard treatment protocols, over-use of antibiotics in livestock, poor infection control in health facilities, poor sanitation, and challenges with new antibiotic R&D.

According to the State of the World’s Antibiotics report (2015), antibiotic consumption is increasing globally, with 20-50% estimated to be inappropriate. Countries like India and China are rapidly becoming the most important consumers of antibiotics.

Drug-resistant tuberculosis (DR-TB) is a prime example of the threat posed by AMR. The most common form drug-resistant TB is multi-drug resistant TB (MDR-TB), which refers to TB that is resistant to two key first-line antibiotics – isoniazid and rifampicin. Globally in 2014, WHO estimated 3.3% of new cases and 20% of previously treated cases to have MDR-TB. Drug resistance surveillance data show that an estimated 480 000 people developed MDR-TB in 2014 and 190 000 people died. Even children are impacted by DR-TB, with recent estimates suggesting that MDR-TB in children may be far more prevalent than previously understood.

It is much smarter and cheaper to prevent DR-TB than treat it.

Extensively drug-resistant (XDR-TB) strains are resistant to at least four of the core anti-TB drugs [i.e. isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin)], and XDR-TB has been reported by 105 countries in 2014. About 10% of people with MDR-TB have XDR-TB. Some studies have also reported totally drug-resistant strains of TB, resistant to all antibiotics tested. This scary form of TB takes us back to the pre-antibiotic era, where TB patients were managed in sanatoria, and mortality rates were extremely high.

Why should we care about DR-TB? Drug-resistant TB requires extensive treatment (for 2 years or longer) with multiple, potentially toxic drugs and outcomes are poor. One in two patients with drug-resistant TB die because of it. Treatment of DR-TB is also very expensive because of the high cost of second-line TB drugs. Thus, it is much smarter and cheaper to prevent DR-TB than treat it.

WHO has proposed 5 priority actions to tackle the global DR-TB crisis:

1) prevent the development of drug-resistance through high quality treatment of drug-susceptible TB;

2) expand rapid testing and detection of DR-TB cases;

3) provide immediate access to effective treatment and proper care;

4) prevent transmission through infection control; and

5) increase political commitment with financing.

Unfortunately, high TB burden countries are yet to seriously address these priority actions to tackle DR-TB. In many countries, not even half of all patients with DR-TB are on second-line drug therapy. Quality of TB care for even drug-susceptible TB remains suboptimal in many countries, especially in countries with large numbers of private health care providers. In such settings, doctors prescribe irrational drug regimens, and adherence monitoring is poor.

TB is a low priority for many developing countries, and current TB budgets are insufficient to make progress in addressing DR-TB.

Empirical antibiotic use is widespread in many countries with weak regulation, and healthcare providers tend to use antibiotics as diagnostic tools; this further increases the risk of AMR. Also, over-the-counter (OTC) antibiotic abuse is widespread in many high TB burden countries. OTC use of fluoroquinolones, a widely used antibiotic, can delay the diagnosis of TB, and also increase the risk of DR-TB. This is particularly relevant, since some of the emerging new TB drug regimens contain fluoroquinolones (i.e. Moxifloxacin).

Xpert cartridges [1032133]

Xpert cartridges

While highly accurate and rapid molecular tests such as Xpert MTB/RIF are now available to quickly detect TB as well as drug-resistance, most high-burden countries are still reliant on sputum smear microscopy, a technology that is not only insensitive but also incapable of detecting drug-resistance. This means patients are often managed with no information on drug-susceptibility test results. This approach of treating TB ‘blindly’ is no longer tenable in places such as Mumbai, where DR-TB is a widespread problem.

A recent report called ‘Out of Step‘ by MSF and Stop TB Partnership surveyed 24 high TB burden countries, to see how already existing TB policies and interventions are being implemented. This survey found major gaps in how TB tools and policies are implemented. For example, only 8 countries included in the survey had revised their national policies to include Xpert MTB/RIF as the initial diagnostic test for all adults and children with presumptive TB, replacing smear microscopy. Six of 24 countries, including India, still recommended intermittent treatment for drug-sensitive TB (which is less effective than daily therapy). Even simple interventions such as fixed dose combination pills to improve treatment adherence are not routinely used in all countries. Such implementation gaps are most definitely generating DR-TB and have to be urgently addressed.

A major reason behind poor TB control is the fact that TB is a low priority for many developing countries, and current TB budgets are insufficient to make progress in addressing DR-TB. Most National TB Programs in high burden countries are seriously under-funded, and, sadly, even emerging economies such as India are not spending enough on TB.

It may be more impactful for DR-TB control to be seen as one component of a comprehensive strategy to address AMR.

In this context, it may be more impactful for DR-TB control to be seen as one component of a comprehensive strategy to address AMR. Unlike TB, AMR is increasingly seen as a global health emergency and a security threat. Policy makers and donor agencies have prioritized AMR as a key issue for the global health security agenda. The door is wide open for the TB community to leverage this interest, and advocate for a well-funded, comprehensive AMR initiative that includes DR-TB as a key component. In fact, DR-TB could well be a pathfinder for successfully tackling AMR in low and middle income countries, and help make the case for greater investments.

The End TB Strategy and the Global Plan to End TB offer excellent blueprints for ending the epidemic of TB, including DR-TB. It is time for the TB community to step up and make sure TB features prominently in the broader agenda to tackle AMR globally, and receives adequate funding and support.

Dr_Pai

Madhukar Pai is director, Global Health Programs, McGill University, Montreal, Canada. Twitter: @paimadhu

Author’s competing interests: None declared.

This blog post was first published on the Huffington Post website.

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