Africa Health Systems Initiative Research Competition

I would like to share this with anyone who may be interested in receiving a grant to conduct a research related to global health. If interested, please see the article below. For additional information, please visit: http://www.idrc.ca/en/ev-114684-201-1-DO_TOPIC.html

Funding Opportunities: Africa Health Systems Initiative Research Competition

The Global Health Research Initiative Launches a New Research Grants Competition!

The Global Health Research Initiative (GHRI) is a partnership formed by five Canadian agencies - the Canadian Institutes of Health Research; the Canadian International Development Agency, Health Canada; the International Development Research Centre; and the Public Health Agency of Canada- to strengthen Canada’s role on the global health research scene.

The research component of the “Africa Health Systems Initiative” (AHSI-RES) is a 5-year research program (2008-2013) that forms one component of the Africa Health System Initiative (AHSI) supported by the Canadian International Development Agency (CIDA).

This Call for Proposals invites teams of researchers and decision-makers to submit research proposals focusing on: Human Resources for Health (HRH) and/or Health Information Systems (HIS). Equity is a cross-cutting theme.

• Registration due: March 13 2009
• Full application due: April 22 2009
• Geographic areas of focus: - Francophone West Africa - Mali, Burkina Faso, Benin - Great Lakes and Eastern Africa - Tanzania, Uganda, Kenya - Southern Africa - Malawi, Mozambique, Zambia
• All enquiries should be addressed to ahsi-res@idrc.ca

Human right to water.

Some quick details and online resources about water and sanitation, as released by RESULTS-Canada:

Sharing info. about the right to water, and the need for it to be included in the UN Universal Declaration of Human Rights, as article 31!

About Water
Of the 6 billion people on earth, 1.1 billion do not have access to safe, clean drinking water.
(www.charitywater.org)

The U.S. Environmental Protection Agency currently does not regulate 51 known water contaminants. (www.foodandwaterwatch.org)

While the average American uses 150 gallons of water per day, those in developing countries cannot find five.
(www.charitywater.org)

The water and sanitation crisis claims more lives through disease than any war claims through guns.
(www.water.org)

According to the National Resources Defense Council, in a scientific study in which more than 1,000 bottles of 103 brands of water were tested, about one-third of the bottles contained synthetic organic chemicals, bacteria, and arsenic. (www.nrdc.org)
Water is a $400 billion dollar global industry; the third largest behind electricity and oil.

CBS News, FLOW (www.flowthefilm.com)
There are estimates that from five hundred thousand to seven million people get sick per year from drinking tap water.

Our own little pieces of Coltan . . .

What do you do when you're complicit in war . . .

Please read more about how we carry a little piece of the bloodshed and unrest in our pockets in an article about Coltan, the civil war, and the Congo in a piece by Johann Hari

http://www.independent.co.uk/opinion/commentators/johann-hari/johann-hari-how-we-fuel-africas-bloodiest-war-978461.html

Prejudice in medicine

Our role in creating health care disparities

Can Fam Physician
Vol. 54, No. 11, November 2008, pp.1511 - 1513
Copyright © 2008 by The College of Family Physicians of Canada

John Guilfoyle, MD FCFP
Family physician in Sioux Lookout, Ont, and an Associate Professor for the Northern Ontario School of Medicine and the University of Manitoba

Len Kelly, MD MClinSc FCFP
Family physician and an Associate Professor of Family Medicine at the Northern Ontario School of Medicine and McMaster University in Sioux Lookout

Natalie St Pierre-Hansen
Research intern at the Northern Ontario School of Medicine in Sioux Lookout

Correspondence: Dr J. Guilfoyle, Northern Ontario School of Medicine, Box 489, Sioux Lookout, ON P8T 1A8; e-mailfjguilfoyle@mac.com

How welcome is the patient in our office and waiting room who is different from ourselves? Does the patient who is less educated, poor, or from a different culture feel comfortable? How do these differences affect their care, if in fact they do?

Current emphasis on evidence-based medicine and its application in the arenas of clinical treatment and health policy development have been noteworthy. Its antithesis, prejudice-based medicine, is not as well-studied and is not considered as carefully in current medical practice. Prejudice—making assumptions and decisions based on inaccurate or faulty information and assumptions—is the stuff of history. At various times we have shown ourselves capable, through a variety of psychological maneuvers, of parlaying spurious data about the objects of prejudice into discriminatory practices. This discrimination has run the gamut, from denial of various rights and services to genocide. No one is immune from prejudice; thus, it is hardly surprising that it has an effect on how we practise medicine.

Recent work, particularly by the Institute of Medicine—an American nonprofit organization that provides evidence-based information and advice on matters of medicine and health—has suggested that prejudice and discrimination directly affect the receipt of much needed health care services in certain groups. Commissioned by the US Congress to study racial and ethnic disparities in health care, they found that health care providers’ behaviour, assumptions, and attitudes can have a detrimental influence on the health of those who seek care.¹

What is prejudice?

Prejudice is both an attitude and a cognitive process, the identifiable and measurable outcome of which is the practice of discrimination. A standardized definition of discrimination does not exist. Even within the framework of the law definitions vary: some jurisdictions focus on intent and others on effect.¹ For the purposes of health care, the Institute of Medicine defines it as "differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention." It identified discriminatory health care practices on 2 levels: the health care structure (systemic discrimination) and discrimination that results from "biases, prejudices, stereotyping, and uncertainty in clinical communication."¹

Many American studies have demonstrated that minorities in the United States receive lower quality health services and are less likely to receive medical procedures than white Americans are.^2–5 Disparities in access and quality of care exist even when income and sociodemographic factors are controlled.² African Americans, for example, are less likely than whites to receive surgery for early stage lung, colon, or breast cancer.³ A study by Laditka et al of delivery outcomes in South Carolina (N = 26 866) revealed substantially higher rates of "potentially avoidable delivery complications" in African Americans and Hispanic Americans compared with whites, even when health care insurance was controlled.⁴ Similarly, a study by Chung et al of deliveries in Long Beach, Fla, (N = 37 688) found that blacks and Hispanics were 75% and 22% more likely to undergo cesarean deliveries, respectively.⁵

In Canada

Despite Canada’s universal health care system, health disparities on the basis of race and immigrant status persist. A handful of Canadian studies have found that aboriginal and foreign-born Canadians face barriers to access. There is ample discussion around these barriers, as well as the importance of effective communication strategies, but there are few studies that examine the measurable differences in health care delivery based on race or ethnicity.

In a 2004 study, Tonelli et al (N = 4333) discovered that aboriginal renal dialysis patients were significantly less likely to receive renal transplantations than nonaboriginal patients, even after adjusting for potential confounders (hazard ratio 0.43, 95% confidence interval 0.35 to 0.53).⁶ A later study by Tonelli and colleagues (N = 835) found that aboriginal patients were half as likely to be activated on the transplant waiting list, owing to difficulties in the process of completing the workup rather than because they were medically unsuitable (P < .01).⁷

Heaman and colleagues’ 2005 study⁸ compared survey responses about prenatal care received by aboriginal and nonaboriginal women in Manitoba (N = 652). Aboriginal women were 4 times more likely to receive inadequate prenatal care than nonaboriginal women were (15.7% vs 3.6%). After controlling for relevant confounders a difference still persisted. When socioeconomic status was factored into the analysis, the authors discovered that the most important predictor of inadequate care was poverty.⁸ In 2007, a province-wide study of prenatal care in Manitoba (N = 149 291) examined disparities among geographic districts: the highest rates of inadequate prenatal care were in the lowest income neighbourhoods.⁹ These areas also had the highest proportion of recent immigrants and aboriginal populations.¹⁰

On the other hand, some Canadian studies found no differences in care based on race or ethnicity. Reime et al, for example, found no significant association between ethnicity and treatment of patients (N = 20 488) in neonatal intensive care units.¹⁰ Wenman and colleagues’ comparison of aboriginal women and nonaboriginal women (N = 2047) revealed that aboriginal women were more likely to have low-birth-weight infants; however, after controlling for socioeconomic status, smoking, and poor nutrition, the differences were not statistically significant.^9,11

Poverty, culture, and access to care

These studies highlight the interconnectedness of ethnic or racial disparities and socioeconomic status as they relate to quality of health care and health care outcomes. Confounders aside, these disadvantaged groups face barriers to health care. New federal initiatives are beginning to address access-related barriers for aboriginal people in Canada. For example, the federal government is responding to First Nations and Inuit access barriers in remote and isolated areas by establishing patient wait times guarantees.¹² In 2006, the diabetes care pilot project was announced, followed by the prenatal care pilot project to increase early interventions.¹²

Janet Smylie, past chair of the Society of Obstetricians and Gynaecologist of Canada’s Aboriginal Health Issues Committee, underscores the importance of examining the surrounding sociopolitical factors that affect health, rather than simply attributing explanations to the "aboriginal" variable.^13,14 Similar barriers to access were identified for foreign-born Canadians who face language and cultural barriers to accessing care.^11,15 One study examined the sociodemographic factors associated with low rates of cervical cancer screening (N = 24 584). The lowest rates of screening were seen in areas with the highest immigrant population.¹⁶ The length of time living in Canada was also an important contributing variable: Papanicolaou smear rates for recent immigrants were 36.9% compared with 60.9% for other immigrants.^16,17

The disparities in the health of minorities in Canada—particularly with regard to aboriginal health—are well documented.^17,18 In 2000, the life expectancy of First Nations men was recorded as 7 years shorter than the overall national life expectancy for men, and in 1997, the prevalence of diabetes among First Nations women 65 years of age and older was documented as being more than 3 times the national figure.¹⁹ In fact, the rate of chronic illness overall among aboriginal people is 3 times higher than the national average.²⁰

The complexity of these reduced health outcomes requires the implications of sociopolitical and historical factors be considered. Analysis of the marginalization that emerges from inequities in health care systems examines the interconnectedness of these factors.

Caregiver attitudes

Canadian studies of caregiver attitudes and measurable differences in care based on ethnicity are rare. No Canadian studies were found when using the search term prejudice on major research databases. Some scholars argue that by focusing on attitudinal and behavioural levels of discrimination for explanations, we are overlooking the contribution of systemic discrimination in creating persistent inequities.¹³ Nevertheless, inquiries isolating the role of prejudice on the part of the care-giver might provide us with valuable insight into ourselves and our institutions.

Scott Plous, author of Understanding Prejudice and Discrimination, suggests that prejudice is amenable to intervention strategies.²¹ These include education and other efforts to expose those who practise prejudice to information and role play that allow exploration of issues and the development of attitudes to prevent discrimination.²¹ The developing concept of cultural safety has emerged in continuing health education and institutional practices. The concept, which developed out of the nursing education context in New Zealand, is predicated on the understanding that a caregiver’s own culture, and the assumptions that follow, affect how a clinical encounter plays out, subsequently affecting the patient’s care. This approach acknowledges that all attitudes and behaviour—extending beyond blatant displays of prejudice and measurable discriminatory practices—can have serious implications for minority care and health.

Naming and blaming strategies toward caregivers are not constructive; rather, the development of a climate where prejudice is recognized as possible is a priority so that efforts directed toward understanding and empathy can be emphasized and reinforced. Concomitant measures within health care systems to remove barriers that can create discrimination would also be helpful.

Defining and measuring attitudes and behaviour is difficult. Understanding the complex determinants of minority health is perhaps even more challenging; blatant acts of prejudice or racism are only a small part of the problem. Studies that isolate these aspects of care (such as those seen in the American body of literature) provide measurable outcomes, which serve as valuable reference points in the Canadian context. When confounders such as socioeconomic status and education levels are controlled, we might be left with a stark mirror image of caregiver attitudes. The determination of relevant indicators of discrimination, the measurements of those indicators, and regular reporting of progress will assist efforts to reverse the deleterious effects of discrimination.

Canadian primary health care awakens to health disparities at home

With the re-emphasis on primary health care worldwide, no doubt helped by the WHO's renewal of Alma Ata, the College of Family Physicians Canada (CFPC) is certainly reflecting this trend. Understanding that the practice of medicine in a first world nation is drastically different than providing care in low-income countries, it is nice to see that at the heart of it, the principles of medicine are still universal; that disparities and need do not know boundaries and regional divisions, nor should our approach to care. Here are two articles from recent editions of Canadian Family Physician.

Addressing health inequities

A case for implementing primary health care

Can Fam Physician
Vol. 54, No. 11, November 2008, pp.1515 - 1517
Copyright © 2008 by The College of Family Physicians of Canada

Carmel M. Martin, MB BS MSc PhD MRCGP
Associate Professor of Family Medicine in the Clinical Sciences Division at the Northern Ontario School of Medicine in Ottawa, Ont

Terry Kaufman, LLB
Member of the Board of Directors of Canadian Alliance of Community Health Centre Associations

Correspondence: Dr Carmel Martin, Northern Ontario School of Medicine, Clinical Sciences Division, 238 Bruyère St, Ottawa, ON K1N 5E3; telephone 613 878-7372; fax 613 482-4609; e-mail cmartin@NorMed.ca

The year 2008 is the 30th anniversary of the World Health Organization’s 1978 Declaration of Alma-Ata on primary health care.¹ This declaration draws our attention to the global burden of health inequities not only in poor underdeveloped countries but also in rich developed countries; these health inequities constitute a considerable barrier to improving the health status of the overall population. The literature demonstrates that addressing health inequities has the potential to contain escalating health costs as well as to develop a healthy and peaceful civil society.² Specifically, Marmot, in a consensus statement based on international research findings with the Commission on Social Determinants of Health, asserts the following:

Strengthening health equity—globally and within countries—means going beyond contemporary concentration on the immediate causes of disease .... The time for action is now, not just because better health makes economic sense, but because it is right and just.²

Reduced focus

Primary care is a patient’s first point of entry into the health system. Traditionally, it is organized around family practices and family physicians, but it is being practised increasingly by nurses and other health care providers.³ Family physicians provide first-contact treatment in offices and also deliver services in the home and in long-term care facilities—as well as a substantial amount of secondary and tertiary care, particularly in rural and remote settings.⁴ Primary health care, a term derived from the 1978 Alma-Ata declaration,¹ is the strategy most likely to address the social determinants of health and health inequalities in health systems internationally. The declaration integrated the strategy of primary care as a level of first-contact health care services into a broader strategy for equitable health development for all.

Key policy makers have advocated system redesign for primary health care with a multidisciplinary work force.^5,6 Since 2000, federal, provincial, and territorial governments have substantially invested in a Primary Health Care Transition Fund.⁷ Internationally, ongoing reforms to primary care services have brought improvements, including better management of some common diseases, some shorter wait times, and faster electronic communication.⁸ However, these reforms in countries such as the United Kingdom have had unintended outcomes (eg, generating little or no effect on widening health disparities) and have been associated with undesired shifts in care for some chronic conditions.^9,10 Yet renewed interest and debate about the primary health care transition have focused on expanding the breadth of primary care and increasing health care accountability, with little attention to addressing health inequalities and social determinants of health.¹¹

Canada has been a world leader in research related to the social determinants of health. According to the Canadian Population Health Initiative of the Canadian Institute for Health Information, however, "Canada has fallen behind countries, such as the United Kingdom and Sweden and even some jurisdictions in the United States, in applying the population health knowledge base that has been largely developed in Canada."¹² In the United Kingdom, there have long been aspirations to address the determinants of health and health inequities.¹³ However, emerging evidence reveals that the reform strategies focusing on implementing primary care, such as pay-for-performance based on selected performance indicators, are not necessarily addressing health inequities.¹⁴

Reasons to consider

A range of compelling evidence from Canada and other countries indicates that the social and economic circumstances of individuals and groups influence their health status and mortality as much as or more than health care. These circumstances affect the success rate of interventions to change personal health behaviour, such as smoking and diet,^12,15,16 or of improved outcomes of chronic disease management.¹⁷ Addressing health inequities is strongly associated with the improvement of health care outcomes.¹⁷

Social determinants of health have a direct effect on the health of individuals and populations, are the best predictors of individual and population health, structure lifestyle choices, and work interactively to produce health.¹⁶ In terms of the health of populations, it is well known that disparities—the size of the gap of inequality in social and economic status between groups within a given population—greatly affect the health status of the whole: the larger the gap, the lower the health status of the overall population.¹⁸

Health has been defined as "the extent to which an individual, family or community is able to realize aspirations and satisfy needs to cope with their environment."¹ Health inequities or disparities of health are the "systematic differences (potentially remediable) in one or more aspects of health across population groups defined socially, economically, demographically, or geographically."^19,20

Social determinants of health include the following: income and social status; social support networks; education and literacy; employment and working conditions; and social and physical environments. Other health determinants include personal health practices and coping skills, healthy child development, biology and genetic endowment, and gender and culture. The presence and quality of health services are also recognized as determinants of health.²¹

The evidence for the value of primary health care to address the social, economic, and political determinants of poor health has emerged during the 20th century^22,23; in more recent times, relevant analyses by many—including Starfield et al and De Maeseneer et al, culminating in a synthesis paper by the Health Knowledge Network of the World Health Organization, repeatedly demonstrated better health outcomes.^24–26 In 2005, Canada and the other government members of the Pan American Health Organization affirmed their commitment to new orientations for primary health care by signing the Declaration of Montevideo.²⁰

Taking part

We propose a local primary health care approach, derived from the Pan American Health Organization’s declaration,²⁰ that builds on the care currently provided by individual practitioners and community health centres and moves toward addressing health inequities. At the core of the system is an understanding of local population health determinants and inequities of health outcomes, as well as local primary care demands for services. With the developments in information technology, the horizontal interconnecting of local providers is realistic and feasible; such interconnecting is essential to collectively address local needs, rather than, as at present, individuals and groups working in local organizational silos. This networking would build on existing and successful collective enterprises to deliver after-hours care, improve quality and safety of individual disease management, and link with public health initiatives to extend toward implementing strategies that address the factors contributing to the genesis and evolution of disease and health outcomes.²⁵

The following are ways in which family physicians in partnerships within adaptive networks of primary health care providers can take a broader role in other aspects of primary health care:

• Lead and participate in community partnerships to identify health disparities in local populations, and prioritize and address these disparities.
  
• Ensure each primary health care system explicitly addresses local public health problems related to non-medical determinants of health (eg, lifestyle factors) and, where feasible, secondary and tertiary health care disparities.
  
• Develop and support interconnected programs to explicitly address social and economic barriers to adherence to common chronic disease treatment and self-management (eg, diabetes, arthritis, chronic obstructive pulmonary disease, congestive heart failure, mental illness) outside of the practice, which address the determinants of health.
  
• Develop and support programs that explicitly address barriers to access and health care adherence for "hard to reach" populations.
  
• Ensure undergraduates, residents, and practising physicians have resources to develop the appropriate skills and competencies to reduce gaps in health disparities in partnership with other agencies.
  
• Stimulate and participate in the intersectorial arrangements and programs in each primary health care system to address the needs of each of the disadvantaged groups (eg, homeless, recent immigrants, drug addicts, adolescents with legal and educational problems), according to local context and priorities.
  
• Participate in and collaborate on community partnerships, identifying and solving health-related problems with vertical integration in relation to the community’s social environment (eg, violence, lack of day care) and physical environment (eg, personal security, housing, nonmedical social determinants).
  

The lack of an articulated pan-Canadian framework for primary health care leaves serious potential gaps in any future transition to an effective primary health care system. In order to address the publicly stated goals of improving health, attention needs to be paid to the principles of equity, access, empowerment, community self-determination, and vertical and horizontal integration within the system. The unintended consequences of resources being directed to improving the average quality of primary care ultimately leads to widening health inequities.

By taking up the challenge of the new orientations of primary health care, which have already been agreed upon by the government of Canada through its international commitments, family physicians can take a leading role in addressing health inequities.

Challenges of Development: Turning On The Tap in Niger

So, with 2 blogs to contribute to, I had to decide which one to blog on first, which, apart from laziness, is one of the reasons I've procrastinated for so long. For some reason, I've found it so much easier to write from a global health and development perspective, as opposed to the more reader friendly and general blog about my experiences interning in Niger. And, while I'm not gifted at story telling, spewing out my thoughts is certainly something I can do (perhaps to the dismay of those who read/listen!).

I've been in Niger for over a month now, on a 6 month CIDA (Canadian International Development Agency) sponsored internship with Samaritan's Purse Canada (SPC). Though I was sad to leave my SUNSIH duties early (including working with such an incredible committee on the Western Regional Global Health Conference in Edmonton this past weekend :) ), I feel truly lucky for this opportunity. As a "Water for Life Intern," I am working on the SP Household Water Program (HWP), which largely entails the specific use of the Biosand Water Filter (BSF) technology in areas of the world where a clean water source is not an option for those living there. Alongside my partner and national staff, I am to conduct monitioring and evaluation of previously installed filters (and if needed, maintenance and repair), work on the building and installation of new filters, as well as help in facilitating accompanying health and hygiene education for the beneficiaries and the youngs girls who live in the villages where Samaritan's Purse Niger work (SPN). By the end of this year, SPN will have installed 900 new filters, totalling 1800 over the past 3 years, in households averaging 8-12 people.

One of the major draws for me in working on this internship was the opportunity for hands-on experience in the field, and working alongside nationals towards participatory community development in the area of public health. I had always admired the work of SPC: their ability to appropriately respond to international crises, as well as to implement sustainable community development. In particular, my research on the effectiveness of the BSF in reducing the incidence of diarrheal diseases got me more interested in this internship and the SP HWP in general. While I was no expert on water, nor am I one now, the statistics on diarrheal diseases grasp my full attention: 90% of all diarrheal deaths are seen in children under the age of 5, and that 4, 500 children die every day from diseases associated with lack of safe water, sanitation, and hygiene. Not only that, but, as many of you already know, without clean water, in general, health is poor. School attendance decreases. Potential to work is lessened. Without generating income, the cycle continues. To me, addressing the issue of water is part of community development 101. It's an initial step towards any kind of social, economic, and cultural change. I wanted to learn first-hand what sustainable development could look like.

Niger is truly a country one could gain an understanding of development. Niger is no stranger to foreign aid and involvment. Approximately 50 % of the goverment budget is attributed to foreign aid (from the World Bank, the International Monetary Fund, France, the European Union, among others). In the past 3 years, Niger has ranked as one of the bottom 3 nations on the UNDP Human Development Index (HDI). In 2006, it was ranked number 177 out of 177 nations, shortly following the Food Crisis (Niger famine) of 2005. The poverty is apparent, especially in the villages. Garbage and animal waste litter the sandy ground. Many children run around with tattered or no clothes on. Many children have distended bellies, because they're malnutrioned (and may also have bellies full of worms). The river water where many bathe, wash dishes and clothing, and use for drinking and giving their animals is the colour of mud. In the capital city of Niamey, driving down the road, sign after sign is for another NGO. I often wonder if any of these organizations are creating change. Are they doing anyone any good? Am I?

While SPN is a great organization to work with (not to mention with fantastic staff) and I have already learned much in the way of development, I think one of the most important things I've discovered is that development is hard. I have to keep reminding myself that it is a process. I have always been an admirer of African women. In Niger, the women are no exception. They carry babies on their backs, have heavy things they're carrying on their heads, take care of the children (sometimes, they're doing these 3 things all at once!), cook, clean, work the farms, fetch the water...essentially everything. Many of their male counterparts, on the other hand, don't do so much...Much of the day is spent sitting under trees, talking to one another and drinking tea. They recognize that the women suffer, yet do nothing about it (of course, not true about everyone!!! I have met many hard-working men). Not only that, but while the children suffer from malnutrition, like many countries in the global south, everyone has a cellphone. Where are your priorities?! Alas, the frustrations of development. While all of these things are certainly not black and white, and things are far more complicated when you bring in the issues of culture, religion, the history of colonialism, neo-colonialism and poor policy making of the past, you can't help but wonder...what now?? How can we bring about change together when so many factors are just slowing it down? Can we make a difference? While one can usually keep light about the challenges of this work, with sayings like TIA (This is Africa), or WAWA (West Africa Wins Again), it's still so difficult not to feel frustrated sometimes, especially when you see things that break your heart.

But, after all this frustration, I still can't help but love the work and the people. There have been changes in people's lives because of the filters. For some families, their kids don't get sick anymore. People are so proud to show you how well they remember their training for maintaining their filters. People actually want latrines and fight off neighbours from using theirs. They love their children and want the best for them. Even with all the struggles I've faced looking at development, I try to keep in mind all the things I appreciate about Niger and Nigeriens. They've only shown me kindness, generosity, patience (mostly with my French and Zarma), and a friendly demeanor (especially now that the month of fasting for Ramadan has just ended). And, of course, there is truly nothing like going into a village and and everyone making fun of you because of your bad Zarma. But, at the same time it's that bad Zarma that helps people connect with you :)

But, I still have lots more to learn...Back to the villages tomorrow. I'm hoping to learn how to ride a camel!

Note: I will add pictures when I figure out how to do so...

Health for all- Is it really possible?

I recently returned home from a global health and social justice conference we hosted in Edmonton this weekend with our colleagues from the University of Alberta's Rural Economic Student's Association (REGSA) and the Student's International Health Association (SIHA).

Like many of you I'm sure, I usually come away from interdisciplinary conferences feeling a mixture of exhaustion and inspiration. This time around was no exception. I feel especially compelled to bring up the topic of universal access to health care- a topic that transpired through many of this year's panels and sessions. We of course are the privileged few in the world who don't have to think twice about medical care- but what about the billions of people who are not so fortunate? What do multilateral policies, development initiatives, and international projects really mean to those living in poverty? What about hidden populations? And what about those who are predisposed to a lower quality of life? Are the social determinants of health really taken into account when designing health and social outreach programs?

So many questions! Questions that mostly bring up even further inquiry. But the fact is that all around the world people from a diversity of disciplines and backgrounds, young people especially, are asking these questions, challenging current paradigms, and holding those in charge of our systems of governance accountable. That was the main message I took home after two days of debate and discussion at the SUNSIH/REGSA/SIHA 1st annual Western Conference.

Are you passionate about global health? Do you have answers to these questions?
Send us your thoughts and project ideas at general@sunsih.ca.

Before signing off I wanted to share an article with you that I came across about a month ago. I think that it is especially relevant to global health as it draws on the importance of the social determinants of health. It is also very topical considering that the Alma Ata Convention, which established the importance of social determinants of health and championed the concept of "health for all", is celebrating it's 30th anniversary this year. Look for related events, such as the Canadian Conference on International Health's review of Alma Ata (Checking In: Health for All or Health for Some?", hosted by the CSIH, October 26th-29th,2008 in Ottawa), which will be taking place throughout the year to celebrate and evaluate this landmark in global health.

And now for the article- hope you enjoy it.


Source: http://www.economist.com/world/international/displaystory.cfm?story_id=12009974

The price of being well

Aug 28th 2008 | NEW YORK | From The Economist print edition

Is it time for a new paradigm for health and development? A heavyweight panel with an egalitarian ideology claims to have found one

Panos

“SOCIAL justice is a matter of life and death.” Thus begins a long, provocative report released on August 28th by a group of grandees with an impressive range of expertise in health and development. The pundits, who include Amartya Sen, an Indian-born economist and Nobel laureate, were asked by the World Health Organisation (WHO) to take a broad look at the question of inequality and health. After more than two years’ work, the panel has issued a call to arms with a sonorous title: “Closing the gap in a generation”.

Which gap, exactly? That the life of a slum dweller in Caracas is generally shorter, nastier and more brutish than the earthly span of a rich person in Cologne or Chicago is hardly surprising. But why, asks the panel, do men born in Calton, a rough part of Glasgow, tend to die more than two decades sooner (see chart below) than men from the dormitory town of Lenzie a few miles away? Why do America’s Asian females live, on average, to 87, while the life expectancy of black males is only 69? The explanation, according to the WHO’s Commission on Social Determinants of Health, is not merely a matter of income. Nor can it be reduced to the varying capacities of health systems. In addition to those factors, says the report, there are social, political and economic forces that ostensibly have little to do with health but can still end up determining “whether a child can grow up and develop to its full potential and live a flourishing life, or whether its life will be blighted.”

To reduce the risk of the latter, the experts have drawn up a long wish list. They call on governments to improve the quality of everyday life, particularly for women and girls in poor countries, through investment in child care and education, and by insisting on better working conditions. They stress the need to “tackle the inequitable distribution of power, money and resources”—through better governance, support for civil society, and more equitable economic policies. A final element in their proposal to make the world a fairer and healthier place is transparency, and better measurement of progress in tackling inequities in health. The manifesto is a new paradigm for development, claims Sir Michael Marmot, a professor at University College London, who chaired the panel.

Sweeping the proposal certainly is, and the idea of ending health inequality in one generation is ambitious, to put it mildly. But does it amount to anything more than a pious expression of worthy hopes?

At least on a first reading, there are good reasons to take the report with a fistful of salt. First, the authors exaggerate the originality of their ideas; theirs is not an entirely new paradigm. Second, by stressing the “social determinants” of health they may have gone too far to one extreme and underplayed the more obvious link between health and income. And finally, railing against the distribution of power and money may not be much help to anyone who faces practical decisions about how to allocate scarce medical resources.

But for anyone who is willing to look past the report’s ideological slant, there are plenty of things in it that deserve to be taken seriously. Ruth Levine of the Centre for Global Development, an American think-tank, describes the manifesto as imperfect but still useful. On one hand, she notes, the report fails to provide any ranking for its laundry list of laudable aims. But it makes a worthwhile point, in her view, by urging a rediscovery of an earlier view of global health that was more prevalent before 2000. That was the year when a different WHO-inspired panel—convened by Jeffrey Sachs of Columbia University—put a controversial emphasis on the way in which poor health leads to bad economic performances by individuals and nations.

With the latest report, says Ms Levine, “we can see the pendulum swinging back.” In other words, there is renewed stress on the way that poverty and inequality lead to worse health. Julio Frenk, a former Mexican health minister now working with the Gates Foundation, a charity, says the new report offers a way out of a “sterile debate” about whether poor health causes poverty, or vice

versa. What about the other possible flaw in the new report—that it downplays the link between income (as opposed to inequality) and health? Adam Wagstaff, a World Bank economist, says he still believes income “is causal” when it comes to health—so that faster economic growth is likely to benefit the health of society as a whole, even if income inequality is constant. As an example of the benign effects of money, he cites data from South Africa, where the health of older people improved after they started receiving pensions at the age of 65.

Still, Mr Wagstaff credits the reports’ authors with making a nuanced contribution to global-health debates. The authors don’t dismiss the role of growth—which they describe as “without question important”—though they do say it can lead to greater inequity unless there are policies specifically designed to improve public health.

One of the points that emerge from the report has been the subject of a lifetime’s research by the panel’s chairman. Sir Michael argues that even in rich societies people get healthier as they climb the social gradient in ways that cannot be explained by wealth alone. Hence his interest, and the report’s focus, on “social determinants” of health that are non-monetary.

One example: job insecurity, and the resulting stress, have a proven link with mental health (see chart). So does the immunisation of children, even in countries with free and universal access to vaccines. The report lists many reforms—ranging from the extension of social safety-nets to the education of girls and better public information about nutrition—that might boost the chances of better health.

The structure of a country’s health services plainly matters too. The commission points out that societies with universal medical coverage enjoy better health than places of comparable wealth that choose a different approach. That gives the citizens of, say, Costa Rica an advantage which many uninsured Americans lack.

But whether people are well or sick also depends on factors and policies that lie far beyond the remit of any health minister. For example, a health ministry may try to get villagers to wash their hands before preparing food, but that is unlikely to happen unless there is running water, something the ministry cannot control.

The report may be right to look at the full range of causes, broad and narrow, that determine people’s physical condition. But it seems, at times, to be baying at the moon when it attacks global imbalances in the distribution of power and money. Especially when you recall that health ministers are often weak figures in a cabinet; they can’t hope to change everything.

One other niggle. Amid the report’s musings on the social causes of health problems, what about individual choice? A fat glutton can hardly blame a cruel society, or liberal trade policies, for his predicament—yet the report says too little about people’s responsibility to look after themselves.

Still, Dr Frenk for one believes it is possible to welcome the report without endorsing the nanny state. He recalls that as Mexico’s health minister he successfully made the argument that raising taxes on the sort of cigarettes smoked by the poor would in the long run help the worst off. As he sees it, such a tax need not imply a rejection of choice: diehard smokers can still puff away, but they must pay a price that reflects the cost to society of their habit.

Some people might quibble with his economics. But as Dr Frenk implies, it would be a pity if the new report’s saner ideas were obscured by the authors’ quixotic determination to achieve perfect political, economic and social equity.

Copyright © 2008 The Economist Newspaper and The Economist Group. All rights reserved.