Friday, April 18, 2014

The Relevance of Global Health in the Post-2015 Era

(This post is based on a talk given at a Globemed USC event April 12, 2014)

Nearly 15 years ago the nations of the world came together at the dawn of the new century and took a look around them. They were not happy with what they saw. Hundreds of millions of people around the world continued to live in extreme poverty, millions of children were dying before they reached their 5th birthday and millions of those who did survive lacked access to education. Mothers were dying at alarming rates during childbirth, hunger and avoidable communicable disease ravaged communities, and sub-Saharan Africa stood in the midst of a horrific uncontrolled epidemic of HIV. Basic human rights—the rights of each person on the planet to health, education, shelter, and security—were lacking for over a billion members of the global community.
In response, at the Millennium Summit in September 2000 the largest gathering of world leaders in history adopted the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets, with a deadline of 2015. These targets have become known as the Millennium Development Goals, or MDGs. The MDGs gained international credibility and have facilitated laudable poverty-reduction outcomes.
Notably, health held prominence within the MDGs framework.  Four of the eight goals were health focused – eradicating extreme hunger, reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other disease. Moreover, a fifth goal, ensuring environmental sustainably, referred in practice to improving access to clean water and sanitation. Consequently, support for health work in low-income countries, particularity around those specific issues identified in the goals, has grown significantly over the past decade and a half with substantial increases in funding and political attention. This investment has even reached universities, with hundreds of new institutes and centers dedicated to promoting health in developing countries popping up around the world–including here at USC.
The investment in the health of the world’s poorest has yielded significant results. Between 2000 and 2010, mortality rates from malaria fell by over 25 percent, averting some 1.1 million deaths, and between 1995 and 2011, a total of 51 million tuberculosis patients were treated, saving 20 million lives. Globally, new HIV infections declined by 33% between 2001 and 2012 and in 2010, the world met the MDG target on access to safe drinking water. Between 2000 and 2010, over 200 million slum dwellers gained access to improved water sources, sanitation facilities, durable housing or sufficient living space exceeding the MDG goals of bringing 100 million people out of extreme poverty,
However, as the MDGs enter into the last year before their deadline, countries are falling short on other targets. Despite progress in the reduction of preventable infant and maternal mortality, limited access to antenatal care and skilled birth attendance remains problematic in rural areas, particularly in sub-Saharan Africa. 
There is clearly unfinished work from the MDGs to be carried forward into the next generation of global development. Today, the international community is actively engaged in consultations and conferences developing a new vision for global development.  This next generation of global development goals is often referred to as the post-2015 development agenda. The global context through which the post-2015 development agenda is being configured is markedly different from that which framed the MDG era. Key features of our changing world include the economic shift of many populous countries into middle-income status; the dramatic rise in life expectancy; ubiquitous connectivity through transportation and communications technologies; rapid urbanization; and the rise of environmental threats that affect every person on earth – the greatest among them being climate change.  
Given today’s pressing global challenges, the post-2015 development goals will speak to much more than just the completion of the MDG agenda. A key shift in the post-2015 development agenda is the mergence of the MDGs with the Sustainable Development Goals (SDGs)—based on the agenda articulated in the 2013 UN Conference on Sustainable Development (Rio+20).  Rather than focusing only on poverty-reduction in low- and middle-income countries, the new global development agenda, as framed through the SDGs, is global, addressing the global implications of development for all states, and integrating economic development, social inclusion, environmental sustainability, and good governance. While the work of the MDGs transforming low-income countries will need to be continued, and extended to meet the basic needs of the billion poor in middle-income countries, the emerging SDGs will also make universal claims to economic development, environmental sustainability, and social inclusion – implying the need to create change in even the richest countries on earth.
The question becomes, where will health feature in the new broader global development agenda? There is much speculation that health has had its moment in the spotlight and that it is likely to succumb to competition from other issues demanding attention.  In the final report of the High-Level Panel of Eminent Persons on the Post-2015 agenda, health was relegated to the annex – along with all other specific targets. Instead the report focused on five transformative shifts that were central to their vision of global change – equity, sustainable development, economic growth and jobs, peace and governance, and a new global partnership.
Of course, health can be readily subsumed within such a framework. However, if health is to retain its prominence in the post-2015 development era, it must be demonstrated to be integral to, and not merely an indicator of, social sustainability. In other words, not only does economic, social and environmental sustainability create health and wellbeing – but that the active protection of the health and well-being of a population is integral to its social, economic and environmental sustainability.
I often speak to USC students about what "global health" means. Is it the same as tropical medicine of the 1950s? Or international health of the 1970s and 1980s?  I argue, sometimes un-popularly within the broader global health community, the field of global health is fundamentally different from past international health work.  It is within the context of the post-2015 development agenda that the difference and significance of this definitional debate becomes apparent.
On the one hand, we have traditional international health approaches reflected in the siloed, disease-specific goals and targets encompassed with the MDGs.  Although this approach has served some specific areas of intervention well, approaches to sustainable organizational and individual behavior change have largely failed. The approach is often based on a traditional understanding of international aid – an understanding rooted in the dated and defunct notion of helping those who can’t help themselves – (people much different from you and me) and on delivering a technical "fix" off a checklist (think vaccines, nets, drugs, housing and water pumps). The inability of international health programs to integrate with broader sustainable development approaches threatens to sideline health within the emerging development agenda.
On the other hand, our understanding of global health as taught here at USC emphasizes the strategic shifts required to retain health within the SDG vision of the future. Global health reframes health in terms of social sustainability, addresses health universally in our inter-connected world, and demands close collaboration with colleagues in other technical sectors including energy, law, finance, and governance.  It is a natural progression in the way we have approached health over time – from clinical medicine in the 1800s, to public health in the 1900s, to sustainable development in the 21st century.
Students, you are graduating into a post-2015 world. Health must be integrated into each element of sustainable development – economic, social and environmental – not quarantined from them.  You must be ready to bring global health into this new paradigm – to present health and your training and skills as a precondition for social sustainability, critical for the natural environment, and key to progress and prosperity. You can start here at USC where every discipline comes together on campus – together our Trojan community can find the answers to the "World We Want."
I would like to close by emphasizing that environmental sustainability is under “severe threat” as growth of global emissions of carbon dioxide continues to accelerate. Emissions today are approximately 50 percent higher than in 1990. The 2013 UN report on the state of the world warned, “Forests continue to be lost at an alarming rate. Overexploitation of marine fish stocks is resulting in diminished yields […] birds, mammals and other species are heading for extinction at an ever faster rate, with declines in both populations and distribution.”  
With climate change and environmental degradation threatening global growth and security— and consequently all of our health—the global community must prioritize the issue and global health can and should strongly contribute to this agenda. To date, however, discussions on climate change have failed to prioritize the impact of climate change on health – particularly in least developed countries. This failure to anticipate climate-related disease burdens is likely to be extremely costly for health interests.
Recently many of you had the opportunity to meet with Stephen Lewis as part of the USC Institute for Global Health’s lecture series. Lewis is a key figure in global health and human rights, having spent his career fighting at the highest level of politics for women and those suffering from HIV. His message to you was clear – the earth is dying and as a consequence so are we all. He urged you, and I am going to echo his call, to focus your careers on ensuring that the earth and human kind survives. The global health community will not be able to do this alone. However, it will be an essential partner in collecting the evidence-base, translating the evidence into effective policy solutions, and advocating like mad to ensure that policy changes are made before human health as we know it is lost forever.  

Friday, February 28, 2014

Purnima Mane Event

On February 20, Pathfinder International CEO Purnima Mane came to USC as a part of the Global Health Lecture Series, hosted by the USC Institute for Global Health. I was particularly inspired by her words, and decided to write a post on my own blog summarizing Dr. Mane's points so I can collect my own thoughts and also share them with others. Click below to read more!

Balancing Idealism and Pragmatism—CEO Purnima Mane speaks at USC

One of my favorite parts about attending USC is the Trojan network—not only do we have access to a diverse set of professionals, but we are also offered countless opportunities to learn directly from the pioneers spanning many industries. Thanks to USC’s Institute for Global Health, I had the privilege of hearing global health leader Purnima Mane speak on campus. Read my blog »

Watch the lecture:

Sunday, August 18, 2013

The Last Day

As quick as my time in Nairobi had begun it was about to come to a bitter-sweet end. I had one final day in Nairobi to collect 93 more surveys for my study. Due to the error of the following day, the Changamka team helped me phone and confirm the participants that were misled about the date to come that night to the same venue. The early morning until the hour before the time of the meeting with the participants were filled with “hello”, “is this…?”, “are you still available today?” and “thank you very much”. By noon, the confirmation list still didn’t look very good. Many participants were reluctant due to the lateness in calling, the distance of the venue, and the importance to them. At this point, I knew there was only so much I could do. Rather then worry about what I had no more control over I decided to concentrate on the other piece of my research study—the stakeholder interviews. I spent the rest of the afternoon engaging in conversation with the stakeholders of Linda Jamii and I was happy to learn many intriguing new information about the company, its business model, and the environment in which it was created. More importantly to me, the stakeholders were very enthusiastic when speaking to me about Linda Jamiii and it’s potential to improve the health of their country. It was very uplifting to see the amount of pride that exuded from the stakeholders when speaking of Linda Jamii because they had so much high hopes for the future health and wellness of their country.

As 4 pm struck it was time for me and some of the Changamka team to head into town to the venue we had chosen. Once we got there we took a few minutes to set our station up and by 5 pm we sat nervously waiting to see if any of the participants we confirmed earlier that day would actually show up. Slowly, participants started to trickle in around 5:30 pm and as each participant sat down I came over to run over the protocol, gather their consent, and conduct the survey. Each time I conducted the survey I learned a little bit more about how to conduct it more smoothly so that the participant would be less confused over the questions each time. Also, since the survey was quite extensive, I had to try and keep the participant engaged and entertained in order to maintain their attention throughout so they would not give up on the survey midway. Luckily many of the participants spoke English as well so I did not have to utilize translators which also gave me the added opportunity to ask more in-depth questions beyond what the survey asked. If I were to do the surveys again I would definitely take out some questions that I found to not to be applicable to the population I was surveying since those questions tended to tire out the participant before we even got to the more valuable questions. From this experience I learned a lot about the target population and how to create better surveys to get at the real questions the study is interested in. Below is a picture of a few participants filling out the survey as I was reading the questions a loud.

At the end of my last day, I had only collected a total of 20 participant surveys for the entire week—13 participants showed up to the venue the last day. Yes, I am still 80 short of reaching my target goal however, I don’t believe the whole week was a total loss; rather it was an amazing learning experience. Since my arrival in Kenya, I have truly met some amazing and wonderful people at Changamka that have shown me nothing but kindness. I have learned so much about not only the company from Sam Agutu, founder and CEO of Changamka and Linda Jamii, and his talented staff but the culture and the people that call Kenya their home. All in all, I met, spoke, worked and built relationships with many people that have made my journey to Nairobi a wonderful one.

Following are a couple of pictures from the office that I worked in for the week I stayed in Kenya.
The first photo is with Sam Agutu, founder and CEO of Changamka Microhealth Limited, who made sure that I was provided anything I might need to conduct my study during the week I was there.

This is a picture with Scholastica who I worked closely with to develop strategies to find participants for the survey.

This is a photo with Colby who is an MBA student from Duke who was there to help Changamka analyze their data.

This picture is of Solomon who is in charge of the Changamka database and who also helped me a lot by explaining how the company operated.

This photo is of Edwin (right) and Mercy (left) who were both key to helping me call and gather participants for the study.
This photo is with Nehemiah who is the head accountant at Changamka.

Lastly, the final photo is of the amazing Changamka Microhealth Limited team who I truly am honored to meet and work with.

My journey to Nairobi is definitely one I will always remember and very fortunate to have; thank you to Heather Wipfli and the Institute of Global Health for making it all possible.

Traffic in Nairobi

Traffic has its moments of smoothness and blocked madness, its stops and go’s, just as all things in life. Similar to the chaotic traffic in Nairobi where the flow can never be predicted, my research project had come to an unpredicted halt on my second to last day in Nairobi; not that it was going anymore smoothly before this car collision type catastrophe. Such as life, the plan the Changamka team and myself had come up with to gather the one hundred participants selected from the Changamka database came across an unfortunate miscommunication mishap in which participants were ill-informed by third-party translators to show up Friday for the survey rather then on the Thursday the survey was planned to happen. Due to this unfortunate error, many people did not arrive at the scheduled venue in which money had been used to reserve the room and food. So rather then gathering one hundred people we were fortunate to have seven participants show up to complete the survey. The participants that did volunteer to do the survey seemed very interested in the subject of the study. From conducting the survey and speaking to each participant, I gained a lot of insight above and beyond what the survey had asked for given that I had a lot of one-on-one time with a lot of them. 

The unfortunate mix-up of days definitely set us back and had hurt any confidence I had in reaching my one hundred survey mark by the end of this week—or more specifically, tomorrow. Rather then give up, I chose to look at the situation more optimistically. I, with the help of a Changamka employee, negotiated a lower price for the venue and food since we did not reach the number of participants we expected and therefore did not utilize all the space that was reserved for us. Luckily, the manager of the venue sympathized with us and gave us a large proportion of the money back and we were able to set aside enough money to reserve the venue again for Friday—in hopes that all the participants that did not know to show up today (Thursday) will show up tomorrow (Friday) because that was what they were told by the translators.

As I am quickly starting to learn, unplanned events are a part of life. Traffic in Nairobi is without a doubt a part of life. But, traffic eventually flows again and life is the same way. Rather then give up and throw my hands up in the air, frustrated that all my plans had not gone the way I had imagined, I believe that the only thing I can do when the road is blocked ahead is to re-route myself and find a clearer path.  So at the end of the day, I am looking forward to the outcomes of tomorrow whatever they may be.

Journey to Kenya

When the idea was first proposed about getting involved on a team headed by the USC Institute of Communication Technology Management in collaboration with the USC Institute of Global Health to study Changamka, a Kenya-based micro-health insurance company, I never thought I would actually get to go to Kenya to meet and be involved with the team--ever. The study involved researching the uptake and health impact of Linda Jamii, a family micro-health insurance plan created by Changamka along with four partnering companies. Interest is being garnered towards Linda Jamii because their use of innovative technologies such as a mobile savings mechanism to provide an accessible and affordable insurance plan to their low-income working class target population. Furthermore, Linda Jamii costs about two-thirds less than the average private health care plan while also being just as comprehensive. Linda Jamii also takes advantage of Kenya’s high mobile phone penetration to deliver their product—users can subscribe to Linda Jamii and save little by little towards their premium all on their mobile phone. The affordability and accessibility of Linda Jamii makes the insurance plan the first of its kind and countries with similar high mobile phone and low health insurance concentrations will benefit greatly if the plan becomes successful in Kenya. 

The journey from California to Kenya took a total of 35 hours and loss of 10 hours and my sanity. I was completely delirious as I picked up my luggage and exited the Nairobi airport. The sights, sounds, and smells of Nairobi were completely different than the world I had just left. However, I was relieved to find that my taxi driver spoke fluent and clear English and that almost everyone I came to meet in Nairobi did as well. 

Arriving in Kenya, I did not know what to expect. It seemed at this point, anything was possible and plans can not always be counted on—especially in a different country and even more so on a entirely different continent. Unfortunately, I learned the hard way that not everything can be planned for in advance, mostly when those preparations were made thousands of miles away from the field. For example, before I arrived to Kenya I was under the assumption that Linda Jami would have had its national debut a week before my arrival, however, it did not. As a result, not many Kenyans knew about Linda Jamii which as you could predict, caused issues when trying to find participants to survey about Linda Jamii. No longer could I count on just dong a convenience survey on a pre-selected street corner to collect one hundred surveys. In order to collect or even come close to gathering one hundred surveys, I had to revise my strategy. 

Luckily, the team at Changamka offered helpful suggestions on how to collect my goal of one hundred surveys. Suggestions included phone surveys, internet surveys, phoning participants and having them meet us or vice versa. In the end, a combination of the suggestions would be utilized in order to gather as many participant participation as possible in the short week I was there. Linda Jamii subscribers were randomly chosen from the Changamka database, phoned and given three options to complete the survey, by internet, phone, or by meeting at a pre-specified venue. The last option gave participants the incentive of being fed a light dinner if they completed the survey.  The operation would be tedious and time-consuming but necessary and the only real option at the time. However, there was a large glitch in the plan. There was very limited funding for this study to begin with but now money was needed in order to phone participants, reserve a venue, and pay for participant’s meals. Luckily, Changamka agreed to fund the venue and the incentives but only for one day. Therefore participants were asked to come to the venue only on the Thursday that week anytime from 5 pm to 8 pm. With this plan, I knew I had only one day—more like just 3 hours--to collect my goal of one hundred surveys since many of the Linda Jamii subscribers were not too responsive to the other two options due to the length of the survey.

Although I've come across many challenges as I try to conduct the surveys in Nairobi, the challenges have helped me think more quickly on my feet. I only have a few days left in Kenya, 2 to be exact, and I have not been able to conduct a single survey due to the complications realized since being physically in Kenya but I, and the staff here remain confident that the solution we have come up with will help me get closer to achieving my goal of one hundred stay tuned to see if I am successful on Thursday!

Wednesday, August 7, 2013

Mezungu diary...

Ole o tea friends!

Lake Victoria, smiling kids, singing, dancing, traffic, chili sauce, chimpanzees, painting, sitting in the dark, a carbohydrate infused diet, education sessions, pit latrines, laughing, African concerts, Mpigi health center, our neighbors Subi and Jolly and 'broccoli!', are just a few words to describe my once in a life time experience in rural Uganda. I am blogging back in the states and wanted to share the highlights of my trip.

From the moment I arrived in Uganda I was captivated by it's beauty, green space, culture and by it's welcoming people. Myself and a group of 10 USC students traveled to various health centers in Uganda, conducting sanitation/hygiene and nutrition/breastfeeding assessments, and education sessions on HIV/AIDS, nutrition and sanitation.

There are many stories I can share with you, going to a clinic and seeing babies and children get tested for HIV, to sharing our first HIV/AIDS education session, to playing with school children,  or the story of painting the maternity ward for the  clinic, but the time we went into a village to visit people's homes, is the part of this trip I will never forget.

I knew going to Africa I was going to see poverty, but it was not what I expected.  What I saw was extreme poverty, children without shoes, little to no clothes, homes no larger then a closet, animals living inside their homes, barely any food, and water, had you boiled it ten times, still would not be clean enough to drink. However, in spite all of this, the children of that village still managed to find fruit and offer it to us as a sign of respect for visiting their village, and that is a moment I will not forget. Despite their hardships the children remain the light of Uganda.


These are experiences that you can not learn in a classroom, that you can not really fully comprehend until you see it first hand and experience it.  I came away from this trip learning about the health care system in a third world country, medical services, and government funded clinic facilities, but most importantly, I learned about innate survival; water, shelter, and food. In this country you are not defined by what you wear, or the car you drive, but by how you treat others, by the respect that you show to every person you meet.

As I reflect on my experiences now, I am truly humbled and appreciate everything that I have, the opportunities that are presented to me on a daily basis, access to healthcare, fruits and vegetables and plumbing. This was truly a remarkable experience and I wanted to thank the Institute of Global Health, Dr. Wipfli and Dr. Samet, Rukia, Nivvy, Robert (aka 'Coach Bob'), and Sande for coordinating this trip and my fellow classmates who also shared the experience.


Sunday, July 28, 2013

Lovers' Park lunch

Lunch with AUA public health team 
On my last day of work, we went to have lunch at a beautiful café at Lovers’ Park (Siraharneri Aigi), which is located right across the street from AUA. This park has a smoke free playground for kids to play at, which was made possible by AUA’s Tobacco Control Team. This was amazing for me, as it was the only outdoor location I had been to in Armenia where smoking was not allowed. Some indoor restaurants had smoke free sitting areas; however, it was nice to see that the outdoor café we went to at the Lovers’ Park also had a smoke free sitting area. I applaud AUA Tobacco Control Team’s efforts in making this possible, and I hope that I can help them with such endeavors in the future.

Having the opportunity to conduct this research project at AUA has been a wonderful experience for me in various ways. I have met and worked with some amazing people here that I hope to have the opportunity to collaborate with in the future. They have been extremely helpful and supportive every step of the way.

I also greatly enjoyed applying all the skills I learned in my MPH classes and putting them into practice in a real world setting.  I got to experience first hand how difficult recruiting study participants can be; however, I do think that my phone skills improved throughout the weeks and I became better at convincing people to participate in my study.

Smoke-free playground for the kids
Traveling to Armenia in itself was a unique experience for me because I got to experience living and working in a completely different country with very different conditions for the first time in my life.  During the first week of my stay, I lived with my cousin in a city called Armavir, about 45 minutes away from Yerevan. I took the “marshutka” to AUA, which is a small bus and a very common mode of transportation in Armenia.  After the first week, I moved to stay with another cousin in Yerevan.  This was more convenient as I had more time to work and explore the city. I took the metro from the Republic Square to AUA each morning, which was extremely convenient.  I definitely enjoyed being able to use public transportation and take a break from all the driving we do in LA!

At the smoke-free playground with Arus (left) and Narine (right)
I would like to thank Dr. Movsisyan, Dr. Petrosyan, and Dr. Harutyunyan for hosting me at the AUA and helping make my time there productive and enjoyable. I want to thank Dr. Movsisyan and Dr. Petrosyan for working with me during the months before my travel, and giving me useful feedback and recommendations on my grant application.  I would like to thank Dr. Lourdes Baezconde-Garbanati, who was my USC mentor and was also very willing to review my grant application and give useful feedback. Lastly, I would like to thank Heather Wipfli and Jonathan Samet for providing me with the grant to make this project come to life.

In front of AUA