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Elise in Haiti: Post-Travel Report

 
 
 
 
 
 
 
 
 
By: Elise Vuille-Lessard

Award won:

The Global Health Travel Award for Postgraduate Medical Residents

Bio:

I am a PYG-3 in internal medicine based at the Royal Victoria Hospital. What made me want to participate in the McGill Internal Medicine Global Health Initiative in Haiti was the idea of a long-term partnership between McGill and Haitian doctors and of capacity building, rather than a one-time intervention.

Project Overview:

elise_photo

Elise in Haiti

This project is a one-month elective rotation where a team composed of internal medicine senior residents and staff from McGill works at Hopital St-Nicolas (HSN) in St-Marc, Haiti. This involves collaborating with local residents and staff as well as Zanmi Lasante/Partners in Health (ZL/PIH), the largest non-government health care provider in Haiti. The goal of this project is to maintain a partnership with ZL and the family medicine program at HSN (including exchanging knowledge, teaching, mentoring), while developing competencies for McGill residents in global health.

Lessons learned:

Change is so difficult to implement. Last year’s team had tried to implement the concept of a patient list on the ward, using whiteboards where you put the patient age, sex, diagnosis and plan. Unfortunately, the first day we arrived to the hospital, the whiteboards were empty. We re-emphasised this concept and did some positive reinforcement throughout the month, and finally the boards were being used when we left. Our fear was that residents would stop using them after we left, but 1 month later we were excited to learn that they were still in use. Change IS possible! I was sometimes discouraged thinking what we were doing was a wasted effort, that those interventions we were making would not stay. But when I learned that the whiteboards were still in use after we were gone, I suddenly felt like I had done something good and valuable.

Advice:

Students looking for a global health experience need to find a project that involves a long-term relationship with the local workers and try to avoid sporadic interventions. The main reason for that is that the time spent on-site is limited and maintaining the change afterwards becomes the most difficult challenge. One of the terms I learned with this project is “capacity building”, which includes finding ways of making an intervention sustainable.

 

This experience influenced my future career plans in many ways. I don’t know when I will participate again in a global health initiative, maybe not in the near future, but possibly later in my professional life. One thing this experience did reinforce is my desire to be a teacher. I certainly want to work in an academic setting and teach young people how to become better doctors, in regards to the medicine itself but also the human side of it.

 

Mental Health Recovery in Different Contexts: Lessons Learned from the Field

Jessica Maria-Violanda Spagnolo

The mental health recovery movement emerged in order to counter the overly biomedical view of mental illness that littered the era before deinstitutionalization (Anthony, 1993). After this era, community-based services for people living with mental illness were strongly encouraged, as illness is not merely the absence of disease, but a state of holistic well-being that goes beyond physicality (WHO, 1948). Therefore, mental health recovery includes ways of “living a satisfying, hopeful, and contributing life even with limitations caused by illness”; as well as finding “new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993, p. 527).

I have always been interested in understanding how this concept is seen and understood around the world. This post will report on examples of the cultural representation of mental health recovery in local communities where I worked.

Picture 1 (McGill Blog)

Photo 1

At a shelter in a small village in the Caribbean, mental health recovery meant developing new skills by learning how to plant vegetables, pineapple, and flowers, as well as care for chickens. This manual labor encouraged the presence of a daily routine, which can easily falter when one is affected by illness; learning through trial and error, which promotes patience and perseverance; as well as interacting with others, which can often be a limitation caused by illness. Photo 1 shows the chickens that the residents took care of until they were either sold to local community members or were used to feed the residents at the shelter. These same residents highlighted the importance of religion in their lives, which helped them find new meaning after illness. For example, when asked what inspired them, the majority of the residents said “God.” This reality is also apparent when visiting the shelter, as the walls are painted with religious images and symbols by local artists (Photo 2).

Picture 2 (McGill Blog)

Photo 2

In a small village in Central America, where many refugees sought protection after experiencing hardships in another country, often showing signs of post-traumatic stress, mental health recovery was seen through the development of new social ties. Arriving as strangers, women leaned on each other for support as well as hope for the future. Their children, through play, would do the same (Picture 3).

Picture 3 (McGill Blog)

Photo 3

The beauty of the mental health recovery movement is that it ensures the focus is not solely on mental disorders or symptoms. Not once during my work in these 2 communities did the residents mention the word “sick” or “ill,” but spoke about what was important in their own, unique, personal recovery journey from illness: developing new skills; generating hope for the future, creating social support and networks. These things are what innately make us human, and are anchored in what can help people living with any type of illness enjoy a satisfying and fulfilling life, despite symptoms.

 

Jessica Spagnolo is a Doctorate Candidate at the School of Public Health at the University of Montreal. Her research focuses on building system capacity for the integration of mental health at the level of primary care in Tunisia. Jessica is funded by les Fonds de recherche du Québec – Santé (FRQS) and MITACS Globalink. Jessica holds a Bachelor and a Masters of Social Work from McGill University.

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.

Why The World Needs An Essential Diagnostics List

Lee Schroeder, Timothy Amukele and Madhukar Pai

This article was originally posted on Forbes website. See the original post here.

Without diagnostics, medicine is blind. And yet, diagnostics receive much less attention than vaccines and drugs. Imagine a sick infant with bacterial sepsis in sub-Saharan Africa. Without diagnostics, they will likely get incorrectly treated for malaria. Every year, 1 million patients with TB in India are either not diagnosed or not reported. Pregnant women with anemia, syphilis and diabetes are often missed in low-income countries where laboratory capacity is severely lacking. And where there is testing, it is often of low quality.

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Hepatitis and HIV diagnostic tool. Photo by Dr. Nitika Pai.

recent NEJM article proposes a simple way to improve access to critical diagnostics: make a list. In 1977, the World Health Organization started (and has since maintained) a Model List of Essential Medicines (EML). The EML, a global health success, has improved access to medicines. Sadly, there is no equivalent Model List of Essential Diagnostics (EDL). Such a list would be impactful for these reasons:

1.  Improve patient care and clinical outcomes

Patients will get consistent access to quality essential diagnostics that will be affordable and always available. When a diagnostic is added to an EDL, governments, funders and manufacturers will work to ensure availability and access.

2. Help detect emerging infectious threats

The Ebola and Zika epidemics have underscored the need for surveillance. While many countries have reference laboratories, laboratory capacity at lower health system tiers is often weak. By increasing laboratory capacity at all tiers, an EDL could help countries better prepare for epidemics and implement international health regulations.

3. Increase affordability

Bulk and advanced purchasing, volume discounts and pooling mechanisms are widely used for vaccines and drugs. Without such mechanisms, quality diagnostics can be unaffordable. Xpert MTB/RIF is a good TB test, but affordability is limited. An EDL could promote group purchasing by international organizations (e.g., Global Fund). With larger, predictable volumes, manufacturers can lower prices. Countries can use EDL to impose price controls and waive import duties to ensure affordability.

4. Reduce antimicrobial resistance (AMR)

Indiscriminate antimicrobial use drives AMR. Without adequate diagnosis,antimicrobials get widely abused. In half of malaria-endemic African countries over 80% of malaria treatments are applied without diagnostic testing, leading to legitimate concern for the emergence of drug resistance.

5. Improve regulation and quality of diagnostics

Unlike developed countries, regulatory agencies that approve the accuracy of diagnostic devices either do not exist or are weak in resource-poor settings. An EDL could focus such agencies on priority tests and help to harmonize regulation at the regional level. An EDL could aid in the identification of sub-standard diagnostics, as is already occurring formalaria rapid tests.

6. Facilitate laboratory accreditation and training

Even if a diagnostic test is of high quality, its impact can be crippled by improper use. In Kampala, Uganda, 95% of all laboratories failed to get the lowest score on the WHO laboratory quality checklist. Country-level laboratory accreditation groups could use the EDL to establish targeted and appropriate quality assurance programs. An EDL could also help shape in-country training of laboratorians.

7. Improve supply chain and laboratory infrastructure

As is too often the case in low-income settings, poor infrastructure and inconsistent supply chains render laboratory devices unusable. An EDL could encourage ministries of health to strengthen necessary infrastructures and develop targeted supply chains for the essential tests.

8. Facilitate change in healthcare provider behavior

Healthcare professionals trained in countries where laboratory testing is either unavailable or of low quality are likely to treat based on clinical suspicion. The impact of the Xpert MTB/RIF TB test has been blunted because of such issues. Likewise, in several settings, providers continue to give anti-malarial therapies, despite negative rapid test results. An EDL could improve providers’ confidence in test results and strengthen thediagnostic-treatment cascade.

9. Inform new technology development

Several teams are now developing point-of-care diagnostics for global health. An EDL could help develop target product profiles that can inform new product development. In fact, such initiatives already exist for several key diagnostics.

10. Facilitate epidemiological surveys, program evaluation and disease elimination

Policy makers need data on disease burden. An EDL could support national surveys and help track changes in disease burden and efficacy of interventions (e.g., diagnostics to support polio elimination).

Xpert cartridges [1032133]

TB diagnostic tools. Photo by Dr. Madhukar Pai.

In summary, essential medicines require essential diagnostics. The NEJM article has proposed an EDL to set the ball rolling. While many agencies could establish an EDL, WHO is the obvious choice, since they maintain the EML, make health policies, run prequalification programs and oversee international health regulations. So, we call upon WHO to take the lead in creating a List of Essential Diagnostics. We also call on key stakeholders (e.g., FINDPATHTDRCHAIASLMGHTCStop TB PartnershipRoll Back MalariaUNAIDS), civil society (e.g., MSFTAGACTION) and donors (e.g., Global FundBill & Melinda Gates FoundationUNITAIDUSAID) to support WHO to make this happen.

 

Dr. Lee Schroeder is assistant professor at the University of Michigan,  where he is director of Point-of-Care Testing and associate director of Chemical Pathology. Dr. Timothy Amukele is an assistant professor at the Johns Hopkins University School of Medicine, where he is the director of the Bayview Medical Center Clinical Laboratories. Dr. Madhukar Pai is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal, Canada. He serves as the director of McGill Global Health Programs and associate director of the McGill International TB Centre.

 

This article was originally posted on Forbes website. See the original post here.

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.

No Immunity from Cholera: the UN’s Role in the 2010 Haitian Outbreak

Madlen Nash

The United Nations cannot claim to address and prevent human rights violations while simultaneously failing to acknowledge the culture of impunity and alarming lack of accountability within the organization. Immunity should exist solely to ensure the security of UN peacekeepers during their missions. Instead, the UN uses absolute immunity as a bureaucratic tactic to avoid responsibility when their soldiers violate the human rights of the citizens they are mandated to protect. The UN continues to hide behind its shield of impunity despite its recent unequivocal violation of human rights in the case of the cholera outbreak in Haiti.

the-artibonite-river-is-the-suspected-source-of-the-cholera-outbreak-in-haiti-725x482

The Artibonite River: the suspected source of the cholera outbreak in Haiti. Source: Kendra Helmer, USAID.

In October 2010, an outbreak of cholera appeared in Haiti for the first time in nearly a century (1). As of February 2016, there have been 770,000 reported cholera cases and 9,200 deaths (2). The first reported cases coincided directly with the arrival of peacekeepers from the United Nations Stabilization Mission in Haiti (MINUSTAH). The troops were deployed from an area of Nepal, a cholera endemic country, which had just experienced a major outbreak in the month prior to their departure (3). Evidence overwhelmingly confirmed that the source of the Haitian cholera outbreak was due to “contamination of the Méyè Tributary of the Artibonite River with a pathogenic strain of South Asian type Vibrio cholerae as a result of human activity” (4). The evidence not only confirms that the UN was responsible for bringing cholera into Haiti, but that it did so recklessly, allowing human waste from the peacekeeping base to be discharged into the tributary leading to Haiti’s principle water source (5). Despite the knowledge of the recent cholera outbreak in Nepal, the organization only tested symptomatic soldiers for cholera, even though 75% of cholera cases present as asymptomatic (6).

The latest of three class-action lawsuits, seeking compensation and reparations on the behalf of the Haitian cholera victims, was filed against the UN in October 2013. Despite ample, convincing evidence pointing to the UN as the singular cause of this epidemic, the UN Secretary-General Ban Ki-moon, issued a statement saying “the claims are not receivable, pursuant to Section 29 of the Convention on the Privileges and Immunities of the United Nations”. The statement subsequently redirected the narrative to the UN’s commitment to eliminating cholera from the country and strengthening Haiti’s water and sanitation infrastructure (7). The UN leadership blatantly disregarded the rights of the cholera victims to pursue legal action and compensation for the hardship they suffered due to the UN’s gross negligence.

The way the UN has handled cholera in Haiti has not only been a grave miscarriage of justice, but has challenged the very ethos of the organization itself.

 

The UN and the Haitian government signed a Status of Forces Agreement (SOFA) granting broad immunity to MINUSTAH for crimes committed in the country (8). SOFA dictates the establishment of a Standing Claims Commission as the procedure for victims to seek redress from harms committed in the course of peacekeeping (9). The UN’s failure to create such a commission is a breech of its own agreement and has resulted in an egregious violation of Haitians’ human rights. In fact, despite the existence of 32 SOFAs, a standing claims commission has never once been established (10).

Haiti Earthquake Relief

The United Nations Stabilization Mission in Haiti (MINUSTAH). Source: Tech. Sgt. James L. Harper, Jr, USAF.

The true reason for the UN’s unwillingness to take responsibility for its actions in Haiti lies at the heart of the defense, U.S. attorney Ellen Blain argued on behalf of the UN. She argued that the court ruling in favour of the plaintiffs would “create and open up a huge set of claims to the United Nations. Private parties around the world would be able to sue the United Nations for violations of — perceived violations and breaches of the treaty” (11). Yet it is not liability for its actions that will compromise the UN’s ability to fulfill its mandate. Rather it is the UN’s immoral and inhumane denial of the devastation they caused to innocent people that is undermining the integrity of the international body. The cholera case is only one demonstration of the human rights violations for which the UN should be held accountable, including, but not limited to, many reported cases of systemic sexual exploitation and abuse committed by peacekeepers (12).

In accordance with Article 6, Section 23 of Convention on the Privileges and Immunities of the United Nations, the Secretary General has not only the right but the duty, to waive immunity in cases where it would impede “the course of justice” (13). The way the UN has handled cholera in Haiti has not only been a grave miscarriage of justice, but has challenged the very ethos of the organization itself. The United Nations has undeniably proven that its bureaucratic self-protective instincts painfully outweigh those to protect and uphold the human rights of all.

nash_blogphoto

 

 

Madlen Nash is a U3 microbiology and immunology student at McGill University. Her global health interests are infectious disease prevention and diagnosis in high-burden, low-resource settings and health and social justice. 

 

 

Works Cited

Agreement Between the United Nations and the Government of Haiti Concerning the Status of the United Nations Operation in Haiti. Volume 2271, 1-40460. 261-262. Web. 15 Nov. 2014. http://www.ijdh.org/wp-content/uploads/2014/03/MINUSTAH-SOFA-English.pdf

Carla Ferstman. “Criminalizing Sexual Exploitation and Abuse by Peacekeepers.” Special Report 335. United States Institute for Peace. September 2013. Web 15 Nov. 2014.http://www.usip.org/sites/default/files/SR335Criminalizing%20Sexual%20Exploitatio%20and%20Abuse%20by%20Peacekeepers.pdf

Convention of the Privileges and Immunities of the United Nations. 13 February 1946. 28. Web15 Nov. 2014. http://www.un.org/en/ethics/pdf/convention.pdf

Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata and Alejandro Cravioto. “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti.” 29-30. Web. 15 Nov 2014. http://www.un.org/News/dh/infocus/haiti/UN- cholera-report-final.pdf

Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata and Alejandro Cravioto. “The Cholera Outbreak in Haiti: Where and how did it begin?” Current Topics in Microbiology and Immunology. Springer-Verlag Berlin Heidelberg 2013. 1. Web. 15 Nov 2014. http://www.ncbi.nlm.nih.gov/pubmed/23695726

Georges v. United Nations et al. No. 1:13-cv-07146-JPO, S.D.N.Y. 23 Oct 2014. 52: lines 12-15. Web. 15 Nov. 2014. http://www.ijdh.org/wp-content/uploads/2014/10/Oral-Argument_Cholera-Case-10.23.pdf

Ministère de la Santé et de la Population (MSPP). “Rapport Choléra 10 Sept 2014”. 2014. Web.15 Nov 2014. http://mspp.gouv.ht/newsite/documentation.php

Piarroux, Renaud. “Understanding the Cholera Epidemic, Haiti.” National Center for Biotechnology Information. U.S. National Library of Medicine. July 2011. Web. 15 Nov. 2014. http://www.ncbi.nlm.nih.gov/pubmed/21762567.

United Nations Press Release. “Haiti Cholera Victims’ Compensation Claims ‘Not Receivable’ under Immunities and Privileges Convention, United Nations Tells Their Representatives.” 21 February 2013. Web. 15 Nov. 2014. http://www.un.org/press/en/2013/sgsm14828.doc.htm

United Nations Press Release. ”Security Council Establishes Un Stabilization Mission In Haiti For Initial Six-Month Period.” 30 April 2004. Web. 15 Nov. 2014. http://www.un.org/press/en/2004/sc8083.doc.htm

World Health Organization. “Cholera.” February 2014. Web. 15 Nov. 2014. http://www.who.int/mediacentre/factsheets/fs107/en/

Yale Law School Transnational Development Clinic, et al. “Peacekeeping with Accountability: The United Nations’ Responsibility for the Haitian Cholera Epidemic.” 2013. 18. Web 15 Nov. 2014. http://www.law.yale.edu/documents/pdf/Clinics/Haiti_TDC_Final_Report.pdf

Yale Law School Transnational Development Clinic, et al. Peacekeeping with Accountability: The United Nations’ Responsibility for the Haitian Cholera Epidemic. 2013. 27. Web 15 Nov. 2014. http://www.law.yale.edu/documents/pdf/Clinics/Haiti_TDC_Final_Report.pdf


Notes

(1) Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata and Alejandro Cravioto. May 2013. Abstract.

(2) Ministère de la Santé et de la Population (MSPP). 2016. 1.

(3) Yale Law School Transnational Development Clinic, et al. 2013. 18.

(4) Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata and Alejandro Cravioto. 29-30.

(5) Renaud Piarroux. July 2011. Abstract.

(6) World Health Organization. February 2014.

(7) Haiti Cholera Victims’ Compensation Claims ‘Not Receivable’ under Immunities and Privileges Convention, United Nations Tells Their Representatives. February 2013.

(8) Security Council Establishes UN Stabilization Mission in Haiti for Initial Six-Month Period. April 2004.

(9) Agreement Between the United Nations and the Government of Haiti Concerning the Status of the United Nations Operation in Haiti. July 2004. 261-262.

(10) Yale Law School Transnational Development Clinic, et al. 2013. 27.

(11) Oral Argument Cholera Case. October 2014. 52.

(12) Carla Ferstman. September 2013. 1.

(13) Convention of the Privileges and Immunities of the United Nations. February 1946. 28.

 

Photo Sources:

Helmer, Kendra. USAID. From Public Domain Images. http://www.public-domain-image.com/free-images/nature-landscapes/river/the-artibonite-river-is-the-suspected-source-of-the-cholera-outbreak-in-haiti-725×482.jpg

Tech. Sgt. James L. Harper, Jr., USAF. From WikiMedia. https://upload.wikimedia.org/wikipedia/commons/0/04/Aid_airdrop_over_Mirebalais_2010-01-21_3.JPG

McGill Summer Institute 2016 – An Infectious Series of Presentations!

groups together 1

Patrick Bidulka

And that’s a wrap! The 2nd annual Summer Institute on Infectious Diseases and Global Health has ended after two weeks of exciting discussion covering a variety of topics including TB, HIV, worms, malaria, and more worms. With the addition of two courses to the Summer Institute arsenal, things got pretty busy!

small group

TB Research Methods Small Group Session

As a member of the organizing team for the Summer Institute, I had the opportunity to observe the mechanics of what goes on front and back stage. As participants got to hear from an extensive lineup of top-quality researchers and diagnostic industry specialists, the Institute’s top-notch organizing committee worked tirelessly to ensure operations went as smoothly as possible — easier said than done. Between organising the catering, and dashing between classrooms pretending to be an AV specialist, I managed to slip into a few lectures to get a feel for what the Summer Institute is all about.

The 2016 edition of the Summer Institute offered 5 different week-long courses:

1. Global Health Diagnostics

2. TB Research Methods

3. Advanced TB Diagnostic Research

4. Molecular & Genetic Epidemiology *New*

5. Tropical & Parasitic Diseases (including Ultrasound and Microscopy tutorials) *New*

ultrasound

Clinical Ultrasound course at the Summer Institute

All the courses provided lectures in varying format, including tech pitches from industry specialists, clinical case studies, panel discussions, and small group sessions. During breaks, participants from all different courses had the chance to mingle, and discuss the hottest topics in global health research (all while drinking record amounts of coffee!)

panel

Global Health Diagnostics Course Panel Discussion

Some personal highlights from the Summer Institute:

• Having my entire abdomen, from bladder to heart, examined via ultrasound in front of the Tropical and Parasitic Disease Ultrasound class, held at the Glen Site

• Being reassured that everything in my ultrasound was normal (phew!)

• Seeing my global health-fanatic McGill professors Drs Pai and Gyorkos debating diagnostics and treatment centre stage

• Lunch!

• And finally, being introduced to so many accomplished global health professionals, and hearing the energetic debate these people brought to the conference

lunch SI

Lunch at the Summer Institute

Boasting about 400 participants from 46 different countries, the Summer Institute was a huge success. The conference fostered a welcoming environment for global health experts and novices alike, to engage in academic discussions centred around pertinent global health issues the world faces today. See the Summer Institute 2016 Dashboard for a brief overview of the conference statistics.

I’m glad I had the opportunity to be a part of such a fast-paced and information-packed two weeks! Taking part in the conference gave me valuable insight into the many different facets of global health, and allowed me to envision which stream I would like to pursue as I move towards my own post-graduate education.

Planning is already underway for 2017’s Summer Institute – stay tuned at the Summer Institute and the McGill Global Health Programs websites for more details to come!

patrick

 

About the author:

Patrick is a recent graduate from the undergraduate pharmacology program at McGill. Now working at the GHP office, Patrick is happy to be immersed in the field of global health. His interests include infectious diseases, learning languages, and ‘The Office’.

The Biography of Malaria: Sonia Shah and “The Fever” Book Review

Vaidehi Nafade

It bears no explaining that malaria is a major global health issue today. According to WHO, in 2015 there were over 200 million cases, and 400,000 deaths, mainly in Sub-Saharan Africa (1). WHO has set ambitious goals for the elimination of malaria, but it is a difficult disease for many reasons – and it has always been.

"The Fever" by Sonia Shah

“The Fever” by Sonia Shah

Sonia Shah says it aptly in her novel, “The Fever: How Malaria has Ruled Humankind for 500,000 Years”: “Despite the fact that we’ve known about malaria since ancient times, and have the drugs, killing chemicals, and know-how to avoid it, something about this disease still short-circuits our weaponry” (2). “Fever” tells the story of malaria, from its evolution into a parasite from a photosynthesising predecessor to its unrelenting presence in today’s world and the public health problem it poses.

Despite being factually dense, “Fever” does not read like a typical nonfiction. The editorialized style of writing can seem jarring at first, especially in comparison to academic texts or articles – but Shah’s journalistic style brings the book to life, making it into a true biography of Plasmodium. The result is a genuinely enjoyable, relatively light read, despite its heavy topic, that remains accessible to the global health professional or enthusiast alike.

However, even malaria experts will likely find some new information in “Fever”, as its greatest strength is its thoroughness. In true investigative journalist style, Shah’s research for the novel is expansive. While she covers the basics of malaria, such as the different species of the parasite and its clinical features, Shah does not stop there. The novel also describes malaria’s effects on shaping the Roman Empire or colonial America (greater than you would expect), its contributions to humankind’s genetic evolution (much more than just the infamous sickle cell gene), and the pharmaceutical struggle from quinine to artemisinin. It provides a long history of public health interventions and a persisting cultural divide between Western health authorities and malaria-afflicted countries that makes public health interventions so difficult.

Ultimately, “Fever” provides a captivating and detailed story of malaria that will leave any reader with a greater appreciation of a very formidable parasite, and an intellectual concern for how public health will tackle this parasite next.

vaidehi cropped

 

Vaidehi is an U3 pharmacology student and an avid reader and writer. Her passion for global health stems from an interest in immigrant and refugee health and cross-cultural medicine.

 

References

1. “Malaria Fact Sheet,” WHO, accessed June 13, 2016. http://www.who.int/mediacentre/factsheets/fs094/en/

2. Sonia Shah, The Fever: How Malaria has Ruled Humankind for 500,000 Years (New York: Picador, 2010). 9.

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.

Jackie in South Africa: Post-Travel Report

 
 
 
 
 
 
 
 
 
Jacqueline Roberge-Dao

Award won:

SPOT Global Health Travel Award

Bio:

DCIM101GOPRO

Jackie in South Africa

I am Jackie Dao, about to graduate from a master’s in Occupational Therapy (M2). I’ve always been fascinated with travelling and meeting new people. A previous trip to rural Peru working at a centre for children with disabilities gave me the travel bug and motivated me to discover new cultures.

Project Overview:

In Cape Town, I had the opportunity to intern in the largest public hospital of the Western Cape, the Groote Schuur Hospital. I split my 8 weeks between 3 different rotations: neurology, paediatrics and general medicine. As the beds needed to be cleared quickly in general medicine, my role was to quickly assess and discharge with outpatient referrals, assistive equipment and/or self-management education. In neuro and peds, cases were much more intense which required intensive daily rehab for remediation of function.

A story I would like to share happened one day on the neuro ward. An elderly woman was admitted displaying total body paralysis, but brain scans revealed everything was working normally; the team didn’t know what to do. I spent three hours just talking to her about her life experiences and my own (therapeutic use of self). I learned that her husband had passed a couple of years ago, that she was carrying an enormous burden of responsibility for her multi-generational family, and that she had just been diagnosed with HIV. As we explored her grief, guilt and attachments, she revealed to me that this was the first time in many years that she was able to express herself and feel heard. The next day, I returned to see her and a miracle happened: slowly but surely, I was able to get her out of the bed – she was no longer paralyzed. We took a walk outside that day, and she cried thanking me. This made me appreciate that no matter where we are born or what experiences we’ve been through, we are, at our core, the same. And sometimes magical things can occur when we remember that love is real and that connection and empathy can go a long way.

Looking ahead:

This field work has influenced my future career plans in that I will be extremely willing to accept an opportunity that takes me abroad. I overcame many personal fears during this trip which helps me move forward and push my boundaries of what is possible in terms of working whilst travelling. I have witnessed disparities in health and realized the immense need for powerful figures that will advance the system and humanity as a whole.

 

See also the McGill School of Physical and Occupational Therapy (SPOT) blog, and their website!
 
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