Category Archives: Guest blog

Contagions, content, and confusion in the digital age of health information

SeymourHeadshotGuest blogger: Brittany Seymour, DDS, MPH

Sixteen years ago, a study alleged an association between the MMR vaccine and autism. The authors disclosed in their publication that they could not claim a causal link, and the paper was eventually found to be faulty and was retracted. Nonetheless, flaws and all, the information was made visible and still today, anti-vaccine sentiments continue to rekindle the paper’s alarming claims, plus additional concerns. Anxious parents persistently echo one another’s worries through blogs, video-sharing websites, and other social media platforms, which too often contradict scientific consensus and current knowledge. A small but mighty group of doubting individuals are dismantling decades of life-saving research and successful health policy.

Disturbingly, content errors and false information tend to linger, even following subsequent correction. Particularly in the face of highly charged and emotional topics, individuals can become even more unwilling to revise their beliefs. When virtually anyone anywhere can publish anything online, people have little difficulty finding support to back any belief, creating a digital “corrupted information environment” one blog, share, and tweet at a time. We are entering an age of digital pandemics: rapid spread of misguided and incomplete online health information that has resulted in unsubstantiated confusion around some of public health’s greatest achievements, such as vaccines, contraception, and fluoridated drinking water.

We are witnessing an accentuated Kruger and Dunning effect, namely that unskilled people are also unaware that they are unskilled. Individuals are crafting convincing and persuasive arguments riddled with empirical citations and links to scientific studies. However, they ultimately lack the sophisticated skillset required for deeper interpretation of their own sources within the context of the larger issue. Without formal expertise, they are unable to move from the basic stages of knowledge, comprehension, and even application to advanced strategies for accurate analysis, synthesis and evaluation of the subtle yet significant complexities embedded in the scientific method. Put simply, a clever compilation from Google does not qualify one as a health expert any more than possession of a fine camera makes one a photographer.

These shortcomings go unnoticed while their confidence motivates readers to action. Ultimately, they are unable to recognize the larger harm their social media “publications” are causing in the absence of information porters such as the peer-review process or expert consensus. Now that over half of adults turn to the internet for health information, including using social networking sites, the hosts of these digital pandemics are becoming easily accessible and their content is proving contagious. Conversely, the most competent experts often underestimate their own competence, the “burden of expertise;” in part because scientific competence requires open acknowledgment of limitations in order to discover accurate truths. But on a public forum, citing any limitation, even as a requisite for the scientific process, attracts the naysayers who predictably share it across the web without context, and thus without accurate meaning. When searching #fluoride on Twitter for example, we discover, at surface level, an evenly matched digital Clash of the Titans: the proficient yet restrained domain expert versus the unskilled but vociferous lay person touting content that is masquerading as science but is actually nothing more than shallow advocacy. It’s no wonder the public has become confused and distrustful.

Clearly, social media is an expanding worldwide phenomenon. Yet, little is known about the precise mechanisms at play at the interface of social media and high-level global health strategies. Why does some content “go viral” when others don’t? Key findings include factors like an innate desire to share, emotion, storytelling, and public access- aspects that are perfectly ripe for success across social media. Yet, these aspects are also in direct conflict with the gold standard for acquiring, conveying, and applying scientific knowledge: objectivity, avoidance of conclusions based on anecdotal accounts, and publication in private peer-reviewed journals.

Despite its shortcomings, social media can provide public health experts with answers that once were private yet now are public: individuals, along with sharing misinformation, are also sharing their most intimate sentiments about that information.  In the past, interviews and conversations would have been necessary to uncover the numerous and highly nuanced reasons why individuals oppose particular public health interventions. Today, on the very websites publishing information that infuriate the experts also exist literally thousands of personal concerns made public for all to see, and minus researcher bias. The public nature of social media is perhaps our utmost barrier to information accuracy and yet a tremendous untapped resource for public health research, innovation, and intervention.

Brittany Seymour is an Instructor on Global Health at the Harvard School of Dental Medicine’s Department of Oral Health Policy and Epidemiology and the Inaugural Harvard Global Health Institute Fellow. Her research includes interdisciplinary global health curriculum development and pedagogy, capacity strengthening for oral health delivery systems in resource-challenged regions, and digital information transfer and impacts on health.

An emerging threat of “digital pandemics”- lessons learned from the anti-vaccine movement

SeymourHeadshotGuest blogger: Brittany Seymour, DDS, MPH

During the 20th century alone, the world experienced a larger gain in life expectancy than in all the previously accumulated history of humankind. This triumph has been dubbed one of the greatest achievements in global health and is largely attributed to the 20th century success of vaccines. However, a digital assault (one that began with autism but has ballooned to numerous other concerns) regarding the safety and importance of vaccines has permeated the Internet. Anti-vaccine sentiments, derived from this study – now retracted – perpetuated by celebrities such as Jenny McCarthy and Kristin Cavallari, and other concerned citizens, have gone viral. A “digital pandemic” is underway, and like a game of telephone, the truth has morphed, facts were lost in translation, and the story of vaccines today boggles the mind. Public acceptance and trust in their safety and utility has waned. Regions of the world, including the United States, are experiencing their worst disease outbreaks in nearly two generations (IOW since the invention of the associated vaccines), and many of these are attributed to exemptions from the recommended vaccine schedule. As rotavirus vaccine inventor (and recipient of death threats due to his pro-vaccine work) Paul Offit describes it, every story has a hero, victim, and villain; in this story gone viral, Jenny McCarthy is the hero, the children the victims, which leaves one role for public health experts: the villain.

More recently, is public health at the forefront of yet another digital assault, susceptible once again to the label of villain? Last month, a study with known limitations was released naming fluoride as one of six newly identified developmental toxins in children. Ironically, this followed the American Dental Association’s announcement only two weeks prior that it has changed its longstanding guidelines for the use of fluoride in young children, recommending an increase in fluoride exposure before the age of two years old, as compared to the former recommendations. Yet, within a matter of hours from the release of the study, the story of fluoride as a new threat to normal child development created a flood of posts on Twitter (just search #fluoride) and was covered in popular media news stories for CNN,USA Today, Forbes, and Time. These news sources alone generated over 54,000 views and shares over social media by the end of the weekend. Does fluoride share the same vulnerabilities as vaccines?

To many public health experts, these stories trigger bewildering thoughts. How is it possible that such misguided health information can spread so far so fast, painting public health experts as villains? Is there a way we can reverse our role in this story and emerge the heroes? Lessons learned from the vaccine story provide insights into an emerging threat of digital pandemics and the power of social media as the medium. Public health is encountering an unfamiliar menace, a rising global pandemic of rapid and unrestricted information transfer.

In today’s global society undergoing tremendous technological advances, new and emerging media modalities are greatly affecting health by influencing policy decisions, direction of philanthropic aid, and individual health behaviors. No doubt, due to the power of handheld technology and online social networking,social media and “citizen journalist”have played a role in propagating potential detriment to what is revered as one of public health’s greatest triumphs (vaccines). Thomas Patterson explains that information accuracy is becoming obscured, “The internet is at once a gold mine of solid content and a hellhole of misinformation.” As Nicco Mele illustrates, the internet makes David the new Goliath, where citizens are capitalizing on the power of social media’s velocity and reach, disarming the traditional gatekeepers of information quality.

Even when presented with corrective information, it’s no wonder the public continues to be confused, and concerned, about potential dangers of our intentional public health interventions. But what triggers a digital pandemic, and where is the threshold between an outbreak of bad health information versus a true online pandemic wrought with content persuasion? In a world of expanding voices sharing health information online through social media, how can we ensure that the cream still rises to the top and the public is making health decisions based on the most accurate information possible?These are the big “opportunity” questions we as public health experts need to be addressing under our responsibility to keep today’s citizens, their children, and our societies healthy.

Brittany Seymour is an Instructor on Global Health at the Harvard School of Dental Medicine’s Department of Oral Health Policy and Epidemiology and the Inaugural Harvard Global Health Institute Fellow. Her research includes interdisciplinary global health curriculum development and pedagogy, capacity strengthening for oral health delivery systems in resource-challenged regions, and digital information transfer and impacts on health.

Motivating and Retaining Community Health Workers: The 2011 Annual CBPHC-WG workshop

By: Dr. Paul Freeman

Prior to the recent APHA Annual Meeting, the CBPHC-WG held a day long workshop focusing on Community Health Workers. There were over 110 attendees including presenters and organizers. This was the largest workshop our group has held in the 13 years we have been conducting these workshops. It was a great feeling to see APHA functioning at its best in providing a venue where those from MCHIP, CORE group, academics, members of other NGOs, not-for-profit and for-profit organizations and consultants could share their views in an open, mutually respectful environment and learn from each other. This year JSI personnel, under the leadership of Mary Carnell, worked in partnership with Working Group members in all stages of workshop planning and implementation. The work of Agnes Guyon (who lead the workshop), Sandee Minovi and Kimberley Farnham, all from JSI, and our own Sandy Hoar, Vina Hulamm, Melissa Freeman, Laura and David Paragon, Tonio Martinez and Larry Casazza were outstanding.

Leban Tsuma MCHIP leading. Photo credit: Paul Freeman.

Our norms were: use of an evidence-based approach, the right for all participants to be heard and for their viewpoints to be respected. At this time, renewed attention is being given to the role of CHWs with recognition becoming more widespread now that the Millennium Development Goals, especially those for women and children, cannot be met without community involvement.  The 8 large group presentations and 16 small group discussion sessions covered well a wide range of perspectives on CHW motivation, retention and performance. I am sure some participants were being exposed to different points of view from their own for the first time.

Samuel Yalew, Urban Health Extension Project/JSI (Ethiopia) leading. Photo credit: Paul Freeman.

I would especially like to highlight the area of internal motivation of CHWs. Through Pink’s book “Drive” many of us are becoming acquainted with the “modern” approach to the importance of autonomy, mastery and purpose in motivation. Yet several NGO presentations, such as those by Tom Davis of Care Groups and Connie Gates of Jamkhed, demonstrated that these elements have already been addressed by NGOs for decades as appropriate to local circumstances.

Sarah Shannon from Hesperian facilitating. Photo credit: Paul Freeman

Melissa and I will prepare a report of the workshop to be disseminated early next year. There were many lessons to learn from conducting this workshop that should remain with the International Health Section for years to come. One of the key lessons was that with enough goodwill and cooperation from individual members – things work best with at least 8 volunteers for such an event – memorable events can be implemented by the Section. With enough “hands” each contributing a relatively small amount, things go much more smoothly than if all sit back waiting for a few to do all the work.

Paul Freeman is a physician with advanced training in tropical disease control and general public health, health personnel education, and health program management and evaluation. He has over two and a half decades of experience in capacity building and the design, planning, implementation, monitoring and evaluation of primary health care, child survival and malaria control programs in developing countries and for deprived rural indigenous populations in developed countries. He is a Clinical Assistant Professor at the University of Washington School of Global Health and the Chair-Elect of the International Health Section.

Strengthening of Public Health Associations (SOPHA) Evaluation

By: Dr. Paul Freeman

For 25 years the Canadian Public Health Association, with support from the American Public Health Association, has been facilitating ongoing processes to establish and/or strengthen Public Health Associations in developing countries. In November 2011, SOPHA has organized a mission to evaluate its program through field visits to three countries currently receiving assistance and through the results of a questionnaire answered in 5 other country partner Associations. Omar Khan and I were part of this evaluation process through field visits to Nicaragua, Mozambique and Congo Brazzaville. I accompanied Drs Henri Delatour and Deo Sekimpi to the Congo. It was inspiring to see how enthusiastic the members of the local Public Health Association – L’Association Congolese Pour La Santé Publique et Communautaire (ACSPC) – were. In the midst of poverty they devoted a lot of their own time to establish their association and to conduct ongoing activities that established the credibility of their organization with the community and government.

We huddle to discuss Public Health Association business. Photo credit: Paul Freeman.

The SOPHA program has resulted in both individual and group capacity strengthening and knowledge sharing.  Formal training was given in key aspects of strategic planning and project planning, implementation, monitoring and evaluation. SOPHA support of participation in international conferences and networking improved the profile of the organization and led to learning through sharing. In 2008 and 2010 ACSPC organized scientific conferences where different stakeholders participated. ACSPC members have built both personal and institutional capacity by attended many international meetings.  ACSPC also collaborated with municipal and national health authorities, thus contributing to strengthening the health system at those levels.  The projects contributed to public health capacity building across many health programs, such as sanitation, immunization, road safety, TB control, HIV/AIDS control and malaria control.

They appreciate what can be achieved through association. Photo credit: Paul Freeman.

Institutional capacities were adequately strengthened and they are sufficient to ensure sustainability in the short term, but better fund raising activities are needed for the mid to long term. The ACSPC staff were trained on results based management (RBM) tools which were applied in the development of project plans.   New knowledge was applied in financial management to prepare annual, midterm and final financial reports to CPHA, and strategic planning was used to prepare the strategic plan 2012-2016. Funding is not sufficient; the association is using the skills and tools acquired with the SOPHA program to look for other donors and prepare projects.

Supplying latrines and clean water to schools, a typical project. Photo credit: Paul Freeman

There were several key lessons learned. SOPHA capacity building contributes to increase the confidence and the credibility of the association. Advocacy needs to be undertaken to increase the involvement of other health professionals (doctors, nurses) and government officials in the association and develop their interest for public health issues. The main challenge and issue for project implementation was that the multi-disciplinary and multi-sectoral dimension of public health is not yet understood by many stakeholders and decision makers and, partly as a consequence of this, there are few doctors, nurses, or government (Ministry of Health and local health authority) members in ACSPC.

We talked for hours, often by gaslight in small rooms – their offices – in just adequate private housing, that we reached through dirt streets awash with water from recent rain. It was heartening to see what had been achieved and how these pioneer members, with only a few trained health professionals amongst their numbers, had established and barely kept afloat, their own Public Health Associations. Perhaps we could establish links with them for solidarity and to support their growing skill and knowledge base.

Paul Freeman is a physician with advanced training in tropical disease control and general public health, health personnel education, and health program management and evaluation. He has over two and a half decades of experience in capacity building and the design, planning, implementation, monitoring and evaluation of primary health care, child survival and malaria control programs in developing countries and for deprived rural indigenous populations in developed countries. He is a Clinical Assistant Professor at the University of Washington School of Global Health and the Chair-Elect of the International Health Section.

The Business of Benevolence

by Dr. Sosena Kebede

The Global Fund (an international financing organization that pools resources to fight against the top three leading infectious diseases in the world: AIDS, TB and Malaria, to date has committed $22.4 billion) just announced that, due to the current financial crisis, it is canceling round 11 of grant renewals for recipient countries. Most of the recipient countries are in the sub-Saharan Africa and the United States has been the single largest donor (traditionally about 33% of all donations through the GF come from the US) since the organization’s inception in 2002.

My initial reaction on hearing this news mirrors that of most of my colleagues in global health – let’s do something, anything; this can be catastrophic and may mean winding the clock back to when hundreds with HIV were perishing because they didn’t have access to drugs. Other thoughts that flash through my head include: What does this mean to governments of poor nations, NGOs, other donor agencies, pharmaceutical companies, health care workers in poor nations, business people, rich people with the disease, or poor people with the disease?  Will this mean drug rationing? Will this give rise to drug resistance if some treatments are stopped due to lack of funding? Will this mean a lucrative business for someone out there who will stand to gain big when resources shrink, and the rich will find a way to get access?  Speculations, speculations.

Some, all or none of the feared may come to pass. However, the more I think about it, the more I am bothered by the commentary this issue makes rather than the potential outcome, however grim it may (or may not) end up being.

It is deeply saddening to face the fact that the very livelihood of millions of poor people can often depend on the benevolence of the rich. Our world is changing fast; emerging economies are flexing their muscles and contending with Western powers for influence in poor countries. Yet, millions of the world’s poor will have no say on how this phenomenon called globalization will affect their lives. Poor nations have also been below the radar detection when debates rage all over the world about the global mess that years of fiscal irresponsibility and corporate greed has brought. For millions of the world’s poor, our new world order and the concept of globalization, the shift in power/wealth etc., whether good or bad, might as well be happening in another planet for all they have any part in it. Unfortunately, their lack of participation in the process does not shield them from the consequences – they stand to lose the most having no means or power for self-determination.

Poverty, health and human rights are inextricably intertwined. We can’t truly advocate for global health equity when the world continues to have millions of voiceless people and people will not have a voice unless they are economically empowered. The business of benevolence, however generous and much needed it may be, is only a temporary measure for the poor that merely affirms to us our implicit sense of moral superiority.

Sosena Kebede, MD, MPH is an assistant professor of medicine in the department of medicine at Johns Hopkins University in Baltimore, MD. She is also an associate faculty at the Johns Hopkins Bloomberg School of Medicine in the department of International Health. Her work in global health focuses on health systems strengthening works such as directing a hospital management training program in Ethiopia for Yale University as well as doing consultancy work for the World Bank. Her professional memberships include being a section counsilor for APHA’s international health advocacy and policy committee, as well as member of the advisory board for the international Association in Technology, Education and Development.

Putting Students to Work Writing APHA Policy Papers

By: Dr. Amy Hagopian 

University of Washington faculty members in the Department of Global Health have found opportunities to do double duty as teachers and APHA activists.  For two years, faculty have assigned students to write APHA position papers on important policy areas, while at the same time offering valuable learning opportunities for students.  In the last couple of years, students have written four policy papers approved by APHA’s Governing Council:

  1. Transporting nuclear waste (20107)
  2. Cleaning up the Hanford nuclear reservation (20105)
  3. Improving housing for farmworkers (adopted in 2011, not yet given a number)
  4. Creating citizenship opportunities for undocumented workers in the U.S. (number pending, adopted in 2011).

Students have also written two additional policy proposals for submission in 2012:

  1. Reducing non-point pollution run-off into coastal waters
  2. Modernizing the Clean Water Act to improve its ability to address modern point-source water pollution hazards

Now two UW faculty members, inspired by the “Occupy” movement and the brief statement of support for it adopted by the governing council at the annual meeting in DC this year, have invited two students to work on a new policy.  Faculty members Stephen Bezruchka and Amy Hagopian will work with UW graduate students Valerie Pacino and Nathan Furukawa to write a position paper on the health hazards of income inequality, but within and between nations.

Authors of the position paper are inspired by populist movements, including the ones that preceded Occupy protests–especially the Arab Spring actions in Tunisia, Egypt, Libya, and beyond.  These efforts used narratives on income inequality, wealth inequality and social inequality to spur direct action.

We invite International Health section members with ideas about how to contribute to these position statements, or who can refer us to literature citations, to be in touch. Please contact Dr. Amy Hagopian (hagopian [dot] amy [at] gmail [dot] com) for more information.

Occupational Health – The Need to Go Global

Guest blogger: Dr. Isobel Hoskins

I never come away from the APHA meeting without being inspired.

This year, the inspiring speech for me came right at the end. I attended the closing session almost by chance when I realised I had a little time. The theme was occupational health so as someone keen on global health I didn’t think it would be all that relevant. When the second speaker took the stand I realised how wrong I was.

Leo Gerard from the United Steelworkers Union showed how health and safety is a global issue and exactly why we need to address occupational health worldwide to match the globalisation of trade. Have you ever thought about who made the clothing you wear, the conditions they work under and the impact that has on their health?

He showed a short video about the Triangle fire – a fire that happened in 1911 in New York at a garment factory. Fire broke out in the factory and panicked workers rushed to the two exits only to find them blocked by fire or locked. The workers couldn’t get out and in desperation some even threw themselves from the upper floors to escape the fire. 146 of them died. This event was one of the drivers of health and safety regulation in theUSA. Those workers were low paid and not allowed to unionise and so negotiate their conditions.

Fast forward to 2010. Gerard described a fire at a garment factory in Bangladesh and guess what? The exits were locked. 29 people died trying to get out, some threw themselves from the upper floors. No regulations prevented this accident in Bangladesh and there was no union to help protect the low paid workers.

Nothing has changed except the geography.

In the rush of globalization, developed country companies are getting round regulation at home by exploiting places where there is none. What does this mean for regulation at home? It means it is under pressure. We could lose all that has been gained since the Triangle fire. In the race to the bottom and the lowest prices, people’s health is being put on the line.

Trade regulations preventing import into the US of goods made in sweatshops or by children, for example, could be a way of forcing global companies to adopt safe working conditions, said Gerard. Having stronger more global unions is another way. Leo’s union the United Steelworkers Union has just gone global – forging partnerships and mergers with other unions worldwide.

Individually I think we can make a difference as well- reading the label and knowing the reputation of companies you buy from could help prevent exploitation. Consumers have power….

Triangle fire:
Bangladesh fire:

Dr Isobel Hoskins manages the Global Health database at CABI.

Annual Meeting, Day 3: Governing Council Action and Section Goals

Apologies for the delay in posting this, but it has taken us all a little while to regroup after the Annual Meeting.

The major event every year on Tuesday of the Annual Meeting is the Governing Council session.  The IH section was, as always, active and vocal in this year’s session.  Nominations Committee Chair and Governing Councilor Amy Hagopian provides a great summary of this year’s session:

The governing council meetings this year were the usual mix of deadly dull and rivetingly interesting. On Saturday we had a lively candidates’ forum, hearing from the six candidates for executive board and the two candidates for chair-elect. The governing council is the electoral body for these positions (although we did vote on a proposal this year to allow the full APHA membership to vote for chair-elect….um, that failed). The candidates for these positions were very high quality this year, and it was hard to choose! Our section was very happy with the results of the election, which took place on Tuesday: Adewale Troutman for chair-elect; and 3 winners for executive board, Lisa Carlson, Durrell Fox and Paul Meissner.

Tuesday’s full-day governing council meeting opened with a riveting (not) discussion of detailed bylaws changes. We did vote on changes to the membership categories, which will favor members who join during their student years and transition into “new professionals.” We voted on the theme for the 2013 conference, and chose (by 54%): “Think Global, Act Local: Best Practices Around the World.”

We adopted 23 resolutions on a variety of policy matters, including six sponsored by the International Health Section:
B1: Improving Access to Higher Education Opportunities and Legal Immigration Status for Undocumented Immigrant Youth and Young Adults
B2: Improving Housing for Farmworkers in the U.S. is a public health Imperative
C1: Prioritizing non communicable disease prevention and treatment in global health
C3: Call to Action to Reduce Global Maternal, Neonatal & Child Morbidity and Mortality
C7: Highlighting the health of men who have sex with men in the global HIV/AIDS response
D1: APHA Endorses the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel

We also approved two policies supported by the IH section:
B6: Reducing PVC in Facilities with Vulnerable Populations (sponsored by our friends in the Occupational Health Section)
LB2: Opposing the DHS-ICE “Secure Communities” Program (in support of immigrant rights)

The governing board also made some changes to the policy submission process. Some highlights:
1) Late-breakers now must be submitted 10 days before the conference
2) There are no longer two categories of policy submissions (short resolutions vs. policy statements); now all policies should be about 10 pages with plenty of evidence and background

Further, we accepted the report of the ad hoc “Policy Working Group,” which worked for two years to discuss how to manage policy resolutions that can be characterized as largely based on qualitative data or are values-based.

And, finally, there was a fun “wild card” vote on a statement to support the Occupy movement. It passed, 76% to 24%:
“The Occupy Wall Street movement is now active in more than 1,000 cities in the US and has related protests around the world. APHA supports its call for greater social equality, social justice, reducing income inequality, and its demand that corporate crime be investigated and prosecuted. We ask members to identify opportunities to build on the energy and enthusiasm of the nationwide Occupy movement and its synergies with public health.”

The governing council meetings are always open to the general membership at the annual conference. Next year, stop in and watch for a while–it’s always interesting! Even during the bylaws conversations!

The section also held its third and final business meeting, during which members discussed the section goals that emerged from the most recent Strategic Plan and ways to implement those in a concrete way.  The leadership will continue this discussion in more detail during the next conference call, which (as always) is open to any member who wishes to call in.

How much education does it take to learn to wash people’s feet?

By Barbara Waldorf RN, MPH (candidate)
Boston University School of Public Health
Recently, in a health policy class at BUSPH, I listened to Dr. Jim O’Connell describe how, as a hot-shot young doctor fresh from being the chief resident at MGH, he was told that to start his new job at the Pine Street Inn, he would be washing the feet of the homeless clients at the nursing clinic. The struggle with his (and the medical profession’s) ego was palpable. To his credit and the benefit of thousands of homeless people over the next 20 years, he chose, in that moment, to not know, to trust the nurses and to learn a in new way.

Ruth Stark, in her training manual for working abroad, speaks of the critical importance of learning to listen when in a another country or culture. Her advice to everyone who ventures beyond their boundaries, who wishes to have an impact in a different cultural context, is to spend significant time asking questions rather than assuming prior knowledge, and to cultivate humility.

There is no doubt that facts and figures, economic theory and the scientific process are important. These can be taught. Graduate education in public health gives us the tools for financial analysis, the application of management principles and the rigor of epidemiology and biostatistics. These are the building blocks of the profession.

Yet, without the more intangible skills of listening, humility, curiosity about the unknown and a profound respect for the deep threads of humanity that bind us together, we will not be able to make the right decisions. Paradoxically, the depth of respect for, and willingness to learn from, other people’s wisdom and knowledge is based in the confidence and knowledge of one’s own culture, experience and education. Without grounding in self-respect, how can we access that which needs to be given? In order to become an advocate for real change and have the discernment to make important decisions, we need to know ourselves.

I washed the feet of homeless women at the Pine Street Inn the same year as Jim O’Connell. As a student nurse at UMass/Boston, it was my community health placement. I was young, suburban, and middle class with noe xperience of inner city, drug addicted, alcoholic or mentally ill homeless folks. I was scared and felt I had nothing to give. But as I sat with them, day after day, soaking their feet, listening, being with them as a human being, something happened.

Something was touched that opened my eyes, both inner and outer, to a very different way of being. It changed me in a fundamental way and shifted both the trajectory and context of my professional life. I owe the homeless women who allowed me to wash their feet for an education I have utilized all my life. It has taken me throughout the world, and allowed me to be with people I could not speak with; to work in situations I did not understand and to take risks and move into arenas I did not know.

That thread has led me to now pursue a Masters degree in public health, where new vistas are opening up. Understanding how economic theory explains the provision of care, finding a new perspective on health care systems and gaining the building blocks to decide when and where to intervene in complex emergencies. Something has come together here, which is the place where my education from the university meets my education from the women of Pine Street, from the Tibetan refugees I cared for in the mountains of Nepal and from my schizophrenic clients in Boston.

To answer the question, it takes a lot of education to wash people’s feet, to be present for them, to be a true advocate and to understand when to speak and when to listen.

Barbara Waldorf is an RN and working on her MPH at Boston University School of Public Health with a concentration in International Health. Having lived and worked in Asia, Europe and Australia, her current interest is in the emerging field of Global Health nursing and learning from other nurses who are active in this field.

A Golden Moment: Global Partners Unite to Expand Access to Skilled Birth Attendants

Guest Contributor: Conrad Person, Director of Corporate Contributions, Johnson & Johnson
As a record-setting 3,000 delegates from more than 111 countries gathered last week in Durban, South Africa for the 2011 International Confederation of Midwives Congress, I believe that we are witnessing a “golden moment” for the global campaign to realize the right of every woman to have access to the best possible health care during pregnancy and childbirth.

Two things give me hope. First, a new analysis from the United Nations Population Fund verifies what we’ve known for decades – only by expanding access to quality midwifery services, especially in the world’s most needy countries, can we curb maternal and newborn mortality. Second, the groundbreaking Millennium Cities Initiative (MCI) is demonstrating what is possible when we focus on improving health in the world’s poorest cities.

This “golden moment” was on full display on a recent blazing hot afternoon in the Jamestown section of Accra, Ghana. With the Jamestown Lighthouse looming in the background, I was reminded that this Ga fishing community was once the heart of historic Accra. But now, it is a poor neighborhood in a city where the mean household income is less than $4 U.S. a day. In a brick courtyard, about 300 women wearing the distinctive colors and patterns of West Africa sat beneath a canvas tent. While Ga drummers, famous the world over, quickly attracted an overflow crowd and the First Lady of Ghana and Accra’s Mayor also inspired the audience, the stars of the show were the babies these women held in their arms.

Five of the midwives took their places in the center of the courtyard. One pretended to be in labor and from beneath a blanket another extracted a mannequin baby. “The baby is not breathing,” she announced. The team quickly went into action to resuscitate the baby.

At this point a regional director for MCI, Abenaa Akuamoa-Boateng, whispered into my ear, “This is the golden minute. Success depends on acting swiftly.” In a minute or so, the mannequin seemed to give a cry like a lamb’s bleat. Even with babies in their arms, the audience clapped.

Each year, an estimated one million babies die from birth asphyxia, or the inability to breathe right after delivery. But skilled birth attendants can change that. More golden moments would be successful if more midwives and skilled attendants had the authority and support of their government to attend these births. MCI is working to tackle one aspect of this global campaign – bringing critical health care services to the most vulnerable mothers and newborns in the world’s poorest urban centers.

Much is made, rightly, of the plight of rural women and children, but MCI makes the case that the urban poor represent a great challenge as well. MDGs 4 and 5 simply can’t be achieved if major African population centers have persistently poor health outcomes for mothers and babies.

MCI addresses this problem through a Neonatal Survival Program, piloted during the past year in Accra and Kumasi, Ghana. This program has incorporated training for 120 frontline caregivers in neonatal resuscitation and infant care with follow-up outreach to and health education of more than 1,500 new mothers, demonstrably saving newborn lives. This program has had the support of Johnson & Johnson, AmeriCares, the American Academy of Pediatrics and local and national health agencies. Statistically, it’s all but certain that without this program, some of those 1,500 children would not have survived.

I left Jamestown with the strong conviction that if we are to meet the MDGs, we must treat every minute that we have left as a “golden minute.” I hope we take full advantage of this unique – and critical – moment to act.

Safe motherhood, now on a mobile device

Sharon D’Agostino, Vice President, Worldwide Corporate Contributions and Community Relations, Johnson & Johnson
It’s a well-known phenomenon: on Mother’s Day, long distance and international call volume spikes higher than on any other day of the year. Collectively, we reach across countries or oceans to send our love and thanks to the wonderful women who brought us into the world. Technology allows us to let our mothers know that we are thinking about them even if we can’t be with them on Mother’s Day. For women who live in some of the most challenging places on earth to give birth, the same technology – the phone – can help women have safer pregnancies and healthier babies.

Today, one billion women in low and middle-income countries own mobile phones, but 48 million give birth every year without the help of a skilled birth attendant. In some countries in Africa and Asia, the lifetime risk of dying in childbirth is greater than 1 in 20. Without access to basic health care or critical information during pregnancy, a woman might not recognize signs of trouble or know when to visit a health clinic. She faces the threat of infection and preventable complications that can lead to death before she even has the chance to meet the baby whose due date she anxiously awaits.

This Mother’s Day, I was excited to be part of the team that unveiled a program to bring crucial health information to pregnant women and new mothers in low-resource countries. USAID and Johnson & Johnson have partnered with the United Nations Foundation, mHealth Alliance and the White House Office of Science and Technology Policy to launch the Mobile Alliance for Maternal Action (MAMA). This initiative, announced by Secretary of State Clinton last week, will reach women in South Africa, India and Bangladesh with customized text messages timed to the stage of their pregnancy or age of their new baby. We are also committed to collaborating with similar initiatives in order to encourage a global exchange of information and best practices, accelerating efforts to reach the women who most need vital health information.

True public-private partnerships are rare, and this one is special because it applies each partner’s expertise and resources to leverage
an infrastructure that is already in place. Mobile Alliance for Maternal Action’s goal is to raise US$10 million to support country-led sustainable programs to scale up mobile health services in some of the hardest-to-reach places in the world.

If you are one of the millions who picked up a mobile phone to call your mother on Mother’s Day to show your appreciation, it is my hope that you will also take a moment to appreciate the technology that made your call possible – and that holds the promise of be the gateway to a healthier pregnancies for millions of women.

Global HIV Prevention—Check!

by Kate McQuestion E-mail
In 2006, an article in the New England Journal of Medicine cited the substantial success of the implementation of a routine checklist on reducing catheter-related infections in the Intensive Care Unit of a Michigan Hospital. This story was shortly followed by media uptake the WHO Patient Safety Checklist, which, when utilized, reduced surgery-related mortality by almost 50%. The clinical use of checklists has become a hot topic for clinical quality improvement advocates, and as such, they been generally embraced in some areas of clinical practice.

Could this kind of tool be effective in public health?

The concept of a checklist is, intentionally, simple. The checklist serves as a mechanism to combat human failures of attention or memory—particularly in high stress or repetitive environments. The overall goal of a checklist is not only to ensure that each item is checked-off as prescribed, but to ensure an environment that promotes teamwork and professional discipline. Due to the ability of checklists to make complex systems approachable, they have already been widely used in industries such as aviation and construction, and now are advancing in medicine as well.

HIV prevention efforts, too, involve complex systems consisting of dynamic target populations, multiple programmatic efforts, and a lack of measurable quality indicators—all in all, making sustainable quality improvement challenging.

Checklists might provide a standardized method to ensure basic quality improvement and program management practices in an environment where pressing need may often lead to deficits in consistent and quality programming. Furthermore, they can be used as a tool to increase quality by improving communication, both internally within an organization, but also with the members of the target population being served.

It is a common complaint that too little emphasis falls of clinical delivery sciences, but it is fair to say that even less falls of preventative services delivery. NGOs working in HIV prevention need to keep better track of both the outcomes and impact of their programs. With out measuring results, it is hard to identify best practices and improve quality standards. HIV Quality Improvement Checklist tools could serve as a constant reminder for NGOs to monitor and evaluate results, thus improving health of communities world-wide.


  • Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006; 355: 2725–32.
  • Gawande A. The Checklist Manifesto: How to Get Things Right. Henry Holt and Co: New York, 2009.
  • Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population [published online ahead of print January 14, 2009]. N Engl J Med. 2009; 360(5):491-499.

Kate McQueston is a Master of Public Health Student at The Dartmouth Institute for Health Policy and Clinical Practice and Intern at the WHO Regional Office for Europe Division for Communicable Diseases.

Waiting for Handouts

by Ibrahim Kargbo E-mail LinkedIn Twitter

On a recent trip to Haiti to conduct program monitoring and evaluation, I was taken aback by the statement of a woman who was forced to relocate due to the 2010 earthquake. When asked why she continues to attend HIV/AIDS education programs, her response was “…because I was promised a house and money”. Upon further interaction with the woman, I learned that she was told by a responding aid organization that she would be given a house and money to help her recover. Hearing her comment, I was left to question whether or not the responsibility of post-disaster recovery is made clear and rightly shared.

I very much support the massive global response to environmental disasters such as the 2004 Indian Ocean tsunami, the 2010 Haiti earthquake, and the recent 2011 Japan earthquake and tsunami. As a global community, we share the tremendous responsibility of assisting each other with disaster recovery efforts. Regardless of the disaster, we donate money, time, technical assistance, and other resources to countries in need, either because we are expected to do so or because we are emotionally impelled to assist; whichever is the case, we manage to step up to the plate to provide recovery assistance.

But at what point should disaster recovery become more of the effected country’s responsibility than that of assisting countries? As we overwhelmingly respond to disasters, we forget to remind countries that emergency assistance they receive is only temporary and as citizens, it is they and their governments who are ultimately responsible for recovery efforts and long-term reconstruction. Donors and disaster response agencies should refrain from promising and or providing long-term resources for disaster recovery, doing so may potentially create an environment which citizens and country governments do not take initiative and responsibility for long-term recovery efforts, further handicapping the people’s ability to recover from future disasters.

In a perfect world, country citizens and their governments do not wait for handouts from donors and other countries, but instead, respond to disasters with pride for their country and support of one another. We all should work towards a perfect world.

Ibrahim Kargbo is a Master of Public Health student at George Mason University.

And The Band Played On: Politics, People and the AIDS Epidemic (Book Review)

Guest blogger: Barbara Waldorf, RN
For everyone concerned about public health, HIV-AIDS, MSM and human rights are key issues. Homosexuality is illegal in 80 countries worldwide. A major battle is brewing in Uganda, with a virulent anti-homosexuality bill in parliament and donors like Sweden threatening to cut all aid if it is passed. There are implications for all public health projects. Randy Shilts wrote eloquently about these issues at the beginning of the AIDS epidemic. Despite the extraordinary progress that has occurred over the last 30 years, what he explored is as relevant today as it was when it was written.

Marginalized groups of people die while the world does nothing, despite key players being able to stop the slaughter. Randy Shilts states he wrote this book, so “…it will never happen again, to any people, anywhere.” “Never again” was said after the holocaust in Europe. The AIDS epidemic can be seen as another holocaust. The overarching issues this book reveals are universal. It forces us to contemplate: What would I do? What is the impact of our prejudices? How do we treat the “other”? And how do we care for those that society has disenfranchised – whether they were Jews in Europe in the 1930s, American gay men in the 1980s or undocumented aliens today?

And the Band Played On is a compelling account of the first five years of the AIDS epidemic. Shilts takes us on a journey, starting with an unknown disease in Africa, to the first CDC case report of unusual pneumonia appearing in young gay men, to the growing awareness of the disease by the mainstream society. The breadth of research is staggering, covering the growing controversy within the gay community; the scientists researching a cause while competing for fame; the politicians more worried about popularity than people dying; and the impact of the conservative fiscal policies of Ronald Reagan that cut funding for the CDC and government health facilities, just when they needed to engage the biggest pubic health threat of the century. Shilts delineates the complex response to the emergence of AIDS that was impacted by prejudice against gays and other marginalized people. He was a journalist, and wrote this book to catalogue the lack of response, that caused a huge number of deaths and allowed the virus to spread virtually unchecked for years.

His premise was that because the virus emerged in groups the mainstream culture wanted to ignore, scientists, doctors and politicians were blinded and failed to halt the spread of AIDS. Shilts forces us to question the social and political milieu this medical crisis arose within, which prevented any unified response. It always takes enormous energy and commitment to see our own blind spots. For anyone interested in public health, the important questions that arise are: Who is the “other” now? Do I have the vision and courage to respond to the next crisis, no matter where it arises? Given these questions, this book becomes a contemporary cautionary tale. Shilts warns us to chronicle the ways that AIDS was ignored so that we can have the humility not to repeat history with the next disease that appears among the disenfranchised. He makes the point that despite apparent differences, we are all human beings, intimately connected. He leaves us to contemplate how to create a world where there is no “other.”

Barbara Waldorf is an RN and working on her MPH at Boston University School of Public Health with a concentration in International Health. Having lived and worked in Asia, Europe and Australia, her current interest is in the emerging field of Global Health nursing and learning from other nurses who are active in this field.

Cuban Disaster Preparedness: Lessons Learned

Guest blogger: Joe Vargas

The California Disaster Medical Services Association, in conjunction with the Medical Education Cooperation with Cuba (MEDICC), provided an opportunity for 17 health care professionals to be part of an exciting research team to examine Cuba’s acclaimed public health system, including its renowned disaster preparedness and medical response systems. The research group traveled to Havana, Cuba in December 2010 for nine full days of lectures, educational presentations and interchange with Cuban medical professionals and public health response teams. Although the United States has not had diplomatic relations with Cuba and travel is restricted, the group was allowed permission under the US treasury’s general license for professional research that includes full-time health and emergency response professionals doing research in Cuba.

During the visit, the group examined Cuba’s elaborate yet unsophisticated system for population protection during disasters. Given their limited physical, technical and transportation resources, the Cuban people, including school children, are taught at an early age about their role and responsibility in a disaster. Education is compulsory up to the 12th grade. Cuba’s hurricane-prone geographical location has necessitated an efficient and coordinated approach with an emphasis on accurate, early and frequent communication information. These internationally recognized measures include prioritized evacuation procedures for vulnerable populations that include high-risk seniors, pregnant women, disabled and individuals living in remote areas where flooding occurs. Transportation is prearranged using city buses to evacuate large communities to safer ground until the storm diminishes. Other preparatory efforts include frequent meteorological reports, monitoring and the shutdown of power and utilities days before the storm arrives. Cuba is one of the few countries that offer early advisories and information phases as preludes to the hurricane watch. Historically, very few deaths and injuries have occurred as a result of the many powerful hurricanes (Charlie, Wilma, Ivan) that have struck Cuba using this preparation approach.

The group also toured several medical facilities including Havana’s polyclinics (neighborhood clinics). At these facilities, the research team was able to view Cuba’s robust primary prevention-focused medical system and understand its critical ties to civil defense teams and meteorological and information sharing systems. Highlights included meeting with grassroots organizations in disaster preparation, response and recovery, including neighborhood organizations and the neighborhood-based physician medical team. The Ministry of Public Health directs all health sectors to support a comprehensive system of healthcare specifically oriented to prevention activities and primary care. Family physicians work in residential neighborhoods where they are provided a home and a functional clinic. Working alongside a nurse, they are responsible for approximately 80-130 families in their community. This closeness allows healthcare professionals to provide immediate emergency and personal care to their neighbors. Physicians develop an overall understanding of all their community needs, which contributes to their overall wellness and whose population health indicators are comparable to developed countries like the US and Canada.

Team members will be sharing their experiences throughout the country at conferences and workshops. To schedule a presentation or for further information you may contact Joe Vargas at jvargas [at] ochca [dot] com.