Category Archives: Guest blog

Disney, measles, and parents’ choice not to vaccinate: Who’s to blame?

Guest bloggers: Brittany Seymour and Rebekah Getman

The recent challenges surrounding childhood vaccinations in the United States have received notable attention in both popular and scientific press, illustrating a spectrum of parental concerns and resultant attitudes ranging from vaccine hesitancy to outright refusal. The current measles outbreak traced to Disneyland has contributed to the highest number of US measles cases in fifteen years and resulted in the Centers for Disease Control and Prevention’s release of an official CDC Health Advisory in January this year. Over half of the individuals who have come down with the illness are unvaccinated; of those, more than 80% are old enough to receive the MMR vaccine but have not, leading many states to reevaluate their personal belief exemption policies. Unsurprisingly, this now multi-state outbreak has reignited the emotional debate over vaccine safety, efficacy, and policy in mainstream and social media. While vaccinations are likely one of the most prominent health debates in the United States right now, health officials are increasingly battling unfounded controversy regarding several of public health’s greatest achievements.  The field that is tasked with controlling global disease epidemics is now up against what have been dubbed “digital pandemics:” the far-reaching, rapid spread of unrestricted, scientifically inaccurate health information across the Internet through social networks.

Researchers at Harvard University recently studied this phenomenon over another common public health intervention: community water fluoridation. A lobby to end fluoridation pushes on in communities across America, despite more than 3,000 studies confirming its safety and benefits. The researchers’ findings indicate that, similar to the anti-vaccination community, a small but vocal and very tightly knit network is driving the anti-fluoridation lobby. A well-known social theory describes individuals in the world as connected by six degrees of separation, and Facebook’s one billion users are four degrees separated; the study found that individuals in the anti-fluoride community are separated by a mere two degrees. Often, highly connected networks develop a strict set of norms and values, and any person or information in violation of those norms, such as scientifically accurate pro-fluoride information, will be quickly rejected, making rational discourse nearly impossible. The researchers also traced online social conversations about fluoride through the network. Members of the anti-fluoride network frequently shared and cited scientific studies to back their arguments; however, in more than two-thirds of conversations, the actual study cited was buried two or three links away from the online discussion, or was not reachable at all. This is concerning because, under these circumstances, the risk of evidence becoming misrepresented or misinterpreted likely increases with each link that takes readers further away from the source.

The researchers’ findings support the theory that highly connected social networks, and not science or evidence, are driving digital pandemics of health information on openly accessible Internet sites. In the digital information age, scientific fact is only one piece of the complex health decision-making process. When capable, intelligent parents encounter the sea of voices online while researching how to make optimal decisions for their children’s health, of course they become concerned with what surfaces to the top of their Google search. The Harvard study suggests that perhaps we need to stop blaming parents for choosing not to vaccinate their children or for lobbying to end fluoridation in their communities, an approach that only alienates parents with questions and shuts down dialogue. Moreover, corrective scientific information inserted into existing social communities without respect for norms and values, even if in response to misinformation, runs the risk of insulting those not readily convinced solely by the prevailing science, an ultimately detrimental approach.  Rather, additional research is needed to discover new, social health communication strategies that are more inclusive and acknowledge social networks’ differing belief systems. Digital pandemics are a part of our current, connected reality. Rather than fight against this trend (which may prove impossible), public health communication approaches must empower and partner with parents so that the voices of expertise, evidence, and experience are the ones they trust, and share within their networks, once again.

Getman HeadshotRebekah Getman is the Senior Program Manager for Education at the Harvard Global Health Institute, tasked with creating and implementing multi-disciplinary curriculum for students that supplements their in-classroom learning. These curricula combine global health knowledge with other disciplines to provide students with a broad lens through which to study and assess global health interventions.

SeymourHeadshotBrittany Seymour is an Assistant Professor of Oral Health Policy and Epidemiology 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.

World Mental Health Day Forum by the Global Mental Health Advocacy Working Group: A Review

photo (2)Guest blogger: Socorro Lopez

Mental illness has proven to be one of society’s greatest invisible burdens, accounting for 4 of the 10 leading causes of disability worldwide. The Global Mental Health Advocacy Working Group recently honored World Mental Health Day by hosting a forum to discuss mental health needs amongst people in humanitarian crises, an extremely vulnerable group in terms of developing and dealing with mental illness.

The event’s panelists included Kelly Clements, the U.S. Department of State’s Deputy Assistant Secretary of the Bureau of Population, Refugees and Migration, Dr. Inka Weissbecker, the Global Mental Health Psychosocial Advisor for the International Medical Corp (IMC), and Dr. James Griffith, the Chairman in the Department of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences.

The discussion touched on three important themes in relation to mental health in emergency settings: the vulnerability of people suffering from mental illness, the critical gap in mental health services, and the detrimental social isolation that the mentally ill are frequently subjected to.

While approximately 10% of a population is traditionally at risk of developing a mental disorder under normal circumstances, this rate has the potential to double during a humanitarian crisis, meaning more people must deal with these disabilities in highly unstable environments. Furthermore, mentally ill individuals are more susceptible to stigma, discrimination, violence, abuse, and human rights violations in these circumstances.
Although there is a vast need for mental health services in emergency settings, there is a significant lack of access to quality care. The number of health professionals who can implement psychosocial interventions that effectively address mental illness is minimal during crises.

“There is a treatment gap between the people who need care and those who receive it,” said Dr. Weissbecker, who has monitored IMC’s mental health and psychosocial programs in countries such as South Sudan, Ethiopia, Sierra Leone, Syria, and Afghanistan.

A lack of healthcare professionals and mental health services often means that the burden of care for a mentally ill individual is placed on their families. Unfortunately, mental disorders are still fundamentally misunderstood around the world, causing many communities to be ill equipped to properly care for a portion of their citizens. In the absence of related health services, families resort to harmful traditional health practices that stem from local beliefs. These practices regularly call for extreme measures, such as chaining the mentally ill to trees or institutionalizing them in inept facilities, to isolate people dealing with mental disorders from the rest of the community.

By acting as natural buffers to instability and prejudice, Dr. James Griffith discussed the vital role that local caregivers, families and communities can play in treating mental illness. In accordance with this line of thought, IMC programs have integrated community involvement into their programs by hosting educational seminars that utilize local volunteers to raise awareness and social consideration for mental illness.

The panelists also addressed how this knowledge could be applied to two topics that have been making recent headlines: Ebola and the Islamic State in Iraq and Syria (ISIS). In terms of treating mental illness within extremist groups such as ISIS, the panelists were quick to correct the misconception that violence can commonly be associated with mental illness, a stereotype creating stigma and driving discrimination. According to the American Psychiatric Association, “the vast majority of people who are violent do not suffer from mental illness.”

In relation to Ebola, preventing and treating mental illness proved to be more applicable. In order to diminish emotional and psychological trauma, Weissbecker discussed the need to provide more education to people who contract the disease and their families, in order to decrease debilitating fear and prevent transmission. Reintegration services should also be offered to survivors who may be treated differently once they return to their communities. Finally, it is important to find ways to safely bury the dead, while ensuring that burials are still culturally significant.

Addressing mental health in emergencies is undoubtedly a multifaceted and complicated health challenge. Nevertheless, increased rates of mental disorders and the potential social ramifications of having such illnesses illustrate that mental illness in humanitarian crises is an urgent issue for global health. Reducing the current treatment gap and increasing communities’ understanding of mental disorders are two of the most promising tactics to improve the health status of the mentally ill in these situations. In doing so, devastating disability and demoralizing hardship can be prevented in populations that have already experienced immeasurable adversity in their lives.


Socorro Lopez is an undergraduate at the George Washington University, majoring in environmental studies and minoring in public health and geographic information systems. Her interests include environmental, reproductive, and global health. Prior to working at the American Public Health Association (APHA) as a Global Health Intern, she was part of the Collegiate Leaders in Environmental Health (CLEH) program at the Centers for Disease Control and Prevention (CDC). Socorro is originally from Roatan, Honduras and recently returned from Tanzania, where she was studying coastal ecology and doing research on water quality.

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.

How will a trade agreement – the TPP — impact global health?

Guest post by Mary Anne Mercer, Senior MCH Advisor for Health Alliance International and the IH Section’s liaison with the Trade and Health Forum. Mary Anne spoke at a recent activist rally in Seattle on January 31st about public health concerns related to the TPP.

Only six months ago, when the TPP, or the Trans-Pacific Partnership, was brought up in discussions, even well-informed activists generally gave blank stares.  TP what?  But in recent weeks it’s been the subject of increasing news coverage, along with exposure to the so-called fast track authority bill that would grant President Obama authority to sign the agreement without prior Congressional review.  Although extensive negotiations on the TPP have been going on in secret over the past several years, as information about the TPP becomes better known, activist groups around the world have organized to oppose it. Just what is the TPP, and why do we care about it?

The Trans-Pacific Partnership is a “trade” deal (but encompassing many other areas of corporate rights) among 12 countries of the Pacific Rim, including the United States. Official discussions are held behind closed doors without public information or input, and without input from our elected representatives in Congress, so little is known about the specific terms of the agreement.  However, WikiLeaks has published two chapters over the past few months detailing regulations concerning intellectual property and the environment. We have good reason to expect that the TPP will ratchet up terms that are prominent in existing trade agreements that have been signed between individual countries. So although only the negotiating committees, which include about 600 diplomats and corporate representatives, know the exact terms of the deal, we have substantial cause for concern.

National and international groups concerned about global health have voiced opposition to many terms of the agreement, believing that they would affect the health and quality of life of people around the world if enacted.  Some of the main health-related concerns about the TPP include:

  • Restrictions on individual countries’ abilities to pass and enforce laws protecting public health. Through a mechanism known as Investor-State Dispute resolution, corporations would be entitled to sue sovereign governments for passing laws that ‘restrict trade’ – even public health measures such as restricting tobacco advertising on cigarette packaging, which the Australian and other governments are now facing.
  • Intellectual property laws that would set up barriers to accessing generic medicines and other health commodities (including AIDS drugs), thus dramatically increasing their costs. By extending the already lengthy duration of patents and other corporate protections, Big Pharma will have an even stronger hold on the economic gains to be made from health problems around the world.
  • Detrimental effects on equity, including the distribution of income and other resources.  There is good evidence 20 years after NAFTA that poverty and inequality have increased in Mexico and wages in the US have stagnated.  The promises of NAFTA have not been kept.

But the TPP is far from a done deal.  Many progressive groups, including a number of labor, environmental and community organizations, as well as APHA’s Trade and Health Forum, are working to oppose the TPP and the Fast Track bill.

Sen. Harry Reid, Majority Leader in the U.S. Senate, recently indicated that he is not interested in having the Senate vote on legislation granting Fast Track Authority this year. There is no question that Reid’s decision is a result of mobilization of voters across the country. We need to continue to educate and inform as many people as possible about the content of the TPP and the negative impact it would have on jobs, the environment, and on public health in the US and globally.

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.