Friday, May 31, 2013

The Most Forgotten Foundation of Health

What are the forgotten foundations of health? What, even, is a foundation of health? In my global health classes, we have discussed the concept of HSW—hygiene, sanitation, and water. In my previous travels, I have definitely noticed the issue of HSW and Ghana is no exception.

Trash, or rubbish as the Ghanaians call it, is littered along the streets or piled up in small areas near homes. I have seen one trash bin since arriving, and there is still nowhere to dispose of that garbage properly. Small mounds can be found in communities that mimic a landfill but are in inhabited areas. This has made me realize that the landfills we know in the states are isolated and monitored thoroughly, and for a reason nonetheless. When we visited one village, I learned that in the whole village there was not a single latrine and people had to openly defecate in fields. In Hohoe, there are trenches on either side of the road serving as gutters. These trenches have a questionable stagnant green liquid that sits in them and smells slightly off. Even the Ghanaians drink treated water from bottles or small water pouches. Needless to say, hygiene, sanitation, and water is a large source of health issues here in Ghana and in much of the developing world.

But, is there an even more forgotten foundation of health that is a foundation to hygiene, sanitation, and water? Forgotten foundation inception. I believe the answer to this question is yes, and more specifically, this foundation is education. This morning when I went over the surveys I used for my research, I realized that most people I spoke to either went to a few years of primary school or had no education whatsoever. One of CareNet’s missions is for universal primary education in Ghana. But is that enough? Do children learn principles of health in school? If villages were taught not to defecate in fields because bacteria could reach their crops creating a vicious cycle, would they put the money and energy into building latrines? How about making Ghana more sanitary? If the government were to be educated on the merits of isolated landfills, would they change infrastructure to create a sanitation system?

Regardless, the most forgotten foundation of health is education. With education comes knowledge about these little issues than can go a long way in decreasing diarrheal diseases, water borne diseases, and ultimately reduce morbidity and mortality. Every child has the right to education; with that right follows the right to health. By aiming for and achieving universal education, does that lead to more health education? Perhaps this is something the United States has gotten right. Overall, we have a pretty good health system not barred by most of the issues plaguing low-income countries. Perhaps, requiring schooling until the age of 16 has led to an increased understanding of health principles so that HSW is not even an issue in the states. I understand that universal education is by no means an easy feat, especially in such impoverished areas of the world. But these questions could one day lead to answers and forgotten foundations of health will no longer be forgotten; and even more hopeful, maybe one day these forgotten foundations of health will no longer be foundations of health. 

Thursday, May 30, 2013

TBA Training

This past Monday, I got a very unique opportunity. For the past year, I have been involved in GlobeMed at USC, a national student run non-profit aiming to increase worldwide health equity and teach university students the value of partnership and sustainability. Our project with CareNet Ghana, our partner organization that I am in Ghana working with, was funding the training and equipping of 50 traditional birth attendants in the Akatsi district. And on Monday, I got the privilege to observe part of the training process.

I learned some interesting aspects of the training process that I would have never known had I not worked onsite with CareNet. The training I observed was a follow up where CareNet calls upon the TBAs to learn other aspects of maternal health. TBAs can chose when they want to have a follow up training and are typically eager for these sessions because it gives them the opportunity to continue their education. In fact, several TBAs who have never been trained came to the session because they hope to be trained by CareNet in the future. I continue to be intrigued by this. The TBAs in the communities are extremely proud to be trained TBAs and often carry their TBA kits with them wherever they go so that everyone knows they are trained TBAs. I hope that in the future, CareNet and other organizations will have the funds to train even more TBAs and thus further disseminate more health education throughout more communities and districts in Ghana.

In this follow up training session, the TBAs were taught the principles of family planning and mothers' rights to health by the Akatsi hospital public health nurse. The nurse posed questions such as, "who needs family planning? Does one need family planning after menopause? What is the relevance of family planning in one's life? If a mother initially refuses your services but has a complication during labor, do you help her?" Since the training was in Ewe, I was only able to pick up on a few of the answers to these questions. In response to the question regarding menopause, many TBAs felt that you still must educate older women on family planning so that they can teach their children and grandchildren. It seemed that the consensus was that family planning education was a necessary right to female health because it allows women to further their health education before starting a family. Some families here have as many as ten children, close in age. Learning family planning helps mothers leave time between their children, or have less children all together, so that they can spend more time, energy, and money on their kids. The TBAs felt that this would help children to become more educated because they could spend more time in school instead of taking care of their siblings while their parents work. By having this training session, TBAs are now able to administer nonprescription contraceptives and give accurate family planning education sessions in their respective villages.

On another note, I am now in Hohoe, Ghana. Hohoe is a few hours drive north of Akatsi, near the boarder of Togo. The drive was rough because of the conditions of the roads here. There are many enormous potholes, so our driver did a lot of swerving. Not to mention the monsoon-like rain on the final leg of the drive. It made for an exciting ride, that's for sure. I will be working at the CareNet office with many of their other projects, as well as conducting interviews with the CareNet administrative staff for my research project. Hohoe is much more mountainous and lush than Akatsi was and I am definitely excited to explore! I've been told about some caves and hikes to check out in addition to the local monkey sanctuary. Nearby is the tallest waterfall in western Africa, which we are going to journey to sometime in the next two weeks. New adventures are on the horizon!

Wednesday, May 29, 2013

A Breathtaking Trip to the World Economic Forum

After yesterday's surprise by the charismatic Beatrice at the Global Fund, I was excited and curious to meet new people who are passionate about their work and learn how their organization operates during today's visit to the World Economic Forum (WEF). The organization is located in the Swiss town of Cologny which is at the northeast side of Geneva and by the east shore of Lake Geneva. After our frantic attempts to find the right bus stops and catch the right buses in the morning rain, we finally arrived at the inconspicuous, unassuming, gray-colored front security gate of WEF at 10 AM (if you do a Google Street View of WEF, you will know what I mean). Once we passed through the security check, we found ourselves standing on a futuristic, high-tech campus that was seemingly designed by a well-know architectural designer. Two main, minimally designed buildings  surrounded with large glossy windows were located on the campus. The building housing the reception/lobby area was no more than 14 years old, and the other was around 5 years old.

More to come ...

Tuesday, May 28, 2013

The Global Fund to fight AIDS, Tuberculosis, and Malaria

Today we had the opportunity to visit the Global Fund and speak to Beatrice Bernescut from Communications and Patricia Kehoe from Grant Management.  We learned that the Global Fund was started in 2002 with the main goal of investing the world's money to save lives of people suffering from HIV/AIDs, tuberculosis, and malaria.  

In the late 1990s, all political leaders started to acknowledge that HIV/AIDs was a problem and they had the responsibility to do something about it.  Thus, there was a huge movement to get antiretrovirals to people; however, they were very expensive and unaffordable by the developing countries.   In 2002, HIV/AIDs, tuberculosis, and malaria were still huge problems in many countries around the world and the Global Fund has had a profound influence in reversing this epidemic.  

The Global Fund is an innovative financing organization that provides funding to countries to support treatment and care of HIV/AIDs, tuberculosis, and malaria.  Since its inception, the Global fund has supported more than 100 programs in 151 countries, provided antiretroviral treatment to 3.6 million people, tuberculosis treatment for 9.3 million people, and provided more than 270 million bednets to prevent malaria infections. 

The Global fund facilitates partnerships between public and private sectors, civil society, and communities affected by the diseases.  The Global fund does not go into countries and manage or implement specific programs.  Instead it relies on the expertise of each country to ensure that money is spent in the most affective way to have the most impact on the individuals suffering from any of these three diseases.  What was interesting to me most was the fact that a person suffering from any of the three target diseases has a sit on the board of the Global Fund.  I find this highly important for gaining information specific to the needs of the target population. 

The Global Fund operates via three main objectives: country ownership, performance based funding, and partnership.  Country ownership means that countries decide for themselves what their best practices are. Performance based funding means that money is given based on the strength of the proposal each country writes.  In addition, countries must provide reports of where the previous money was spent and demonstrate positive impact.  Lastly, partnership refers to involving all stakeholders in decision making processes in the fight against these three deadly diseases.  

The Global Fund closely monitors all programs that funded countries implement to ensure that there is no fraudulent activity and corruption and that the money is spent in the most effective way.  The Global Fund expects countries to spend 7-10% of their budget on monitoring and evaluation of the program. This is highly important to track progress, evaluate the effectiveness, and learn what worked and what didn't work.  

Overall, it was very interesting to learn the operational structure of the Global Fund. I am looking forward to visiting the World Economic Forum tomorrow!

Fight On!
Ani Ginosyan

Monday, May 27, 2013

From Vaccines to NCDs: Our day at the GAVI Alliance & big news from WHA66!

Happy Monday! Today marks the beginning of the Week 2 for our USC Global Health team here in Geneva! As the World Health Assembly winds down this week, our focus has shifted to gaining additional perspectives from other key global health players. We are fortunate enough to have the opportunity to sit down with some of the most prominent organizations in the field of global health and learn about how their institutions are working to make a difference.

To jumpstart our week, our first visit was to the Global Alliance for Vaccines & Immunisations (GAVI) Alliance to meet with Dan Thomas, Head of Media & Communications. As Mr. Thomas explained, the GAVI Alliance works to accelerate the introduction of vaccines to the world's poorest countries. Their four strategic goals are to: 1.) accelerate the uptake and use of underused and new vaccines, 2.) contribute to strengthening the capacity of integrated health systems to deliver immunization, 3.) increase the predictability of global financing and improve the sustainability of national financing for immunization, and 4.) shape vaccine markets to ensure adequate supply of appropriate, quality vaccines at low and sustainable prices. To achieve these goals, the Alliance relies on a strong innovative partnership comprised of both public and private players, ranging from WHO and the World Bank to governments from donor countries and developing countries to civil society organizations and the vaccine industry. It was really interesting to see a public-private partnership of this magnitude after hearing about the importance of these partnerships throughout the discussions at the WHA last week, especially in reference to achieving development goals in post-2015. While hesitation still exists in the global health community, the GAVI Alliance holds that their public-private alliance is critical to their success because it brings together all the necessary players to achieve a common goal: to save children's lives and protect people's health by increasing access to immunizations. 
Another aspect of GAVI Alliance that I found extremely interesting was their emphasis on innovative financing. As achieving the Millenium Development Goals became increasingly more urgent over the last few years, increased attention was not only placed on how we were going to achieve them but how are we going to fund how we achieve them. Hence, innovative financing quickly gained hype throughout the global health community, with the acknowledgement that funding needs to be both sustainable and predictable. Since its inception in 2000, the GAVI Alliance has introduced two innovative financing mechanisms: the International Finance Facility for Immunization (IFFIm) and the Advance Market Commitment (AMC). Mr. Thomas informed us that through these mechanisms GAVI has raised over US$ 3.7 billion on capital market and accelerated access to pneumococcal vaccines in some of the world's poorest countries. To find out more about innovative financing & the GAVI Alliance models, click here.

Although I'd love to continue gushing about our wonderful meeting at GAVI, I think it's also important to highlight some big news from the WHA today! If you've been following us here or on Twitter, you know that one of our primary focuses has been on NCDs and the potential adoption of the NCD Omnibus Resolution. Our friends at the NCD Alliance just announced that the Omnibus Resolution & Global Action Plan were adopted today Committee A by ALL countries with a total of 41 co-sponsor countries! The Omnibus Resolution is a comprehensive resolution that encompasses the draft Global NCD Action Plan 2013-2029, the Global Monitoring Framework for NCDs, and the establishment of a Global Coordination Mechanism for NCDs. Together, these components establish the way by which countries can fulfill their commitments to the fight against NCDs and reach specified NCD targets, such as reducing NCD deaths by 25% by 2025. For more details on the Omnibus Resolution check out the NCD Alliance website here. The adoption of the NCD resolution was just one of a handful of events that took place today at the WHA. To find out what else happened today, check out WHO's daily notes center here

Overall it was an amazing day - both for us and the fight against noncommunicable diseases! Thanks to our inspiring meeting with the GAVI Alliance, we are excited for what the rest of the week brings! 

Be sure to check back tomorrow to find out about our visit to The Global Fund to Fight AIDS, Tuberculosis and Malaria!

Saturday, May 25, 2013

Be Interested

I was once told a quote that I find extremely compelling, especially for experiences such as this.
“If I may offer you a simple maxim, ‘Be interested.’ Everyone wants to be interesting but the vitalizing thing is to be interested. Keep a sense of curiosity. Discover new things. Care. Risk failure. Reach out.” –John Gardiner

Over the past few days, Jenn, Austin, and I have traveled to eight different villages in the Akatsi district of Ghana. I have had the opportunity to ask questions to the women and TBAs regarding my research, but more importantly, I have had the opportunity to listen to unbelievable stories.

In terms of my research study, I am surveying and interviewing women in each community, TBAs, and CareNet Ghana staff regarding their views of CareNet Ghana’s TBA training and equipping program. Historically, the WHO advocated for, and recommended the use of, traditional birth attendants in developing areas of the world. They were seen as a productive and efficient way to deliver knowledge and safety when it came to births in rural and developing areas of the world. However, in the late 1990s the WHO altered their stance on TBAs from an emphasis on the training of TBAs in developing countries to promoting professionally skilled attendance at all births. Many smaller changes have occurred throughout the history of the WHO, but the recommendation for professionally skilled attendance was the most drastic, especially considering the shortage of professionally skilled medics in developing countries. My research will focus on whether or not those working at CareNet and those affected by CareNet are familiar with the change in recommendation, how they feel about this change, and whether or not they feel the need to move in the direction of professionally skilled attendance at all births.
In the eight villages we have been welcomed into, I have been able to observe the ‘Women’s Club’ meetings, listen to their minutes, play with the children, and talk to them about their experiences with TBAs. One story a woman so faithfully told me was about the newborn girl she was holding in her arms. When she went into labor, it had been days since she had eaten. The TBA assisting her brought her food and coerced her to eat even though she had no appetite. When it became apparent that there might be complications with the delivery, the TBA called for a car to transport the expectant mother to the hospital—a journey that the TBA endured with the woman. The TBA never left her side. She held her hand through labor, spoke encouraging words, and helped the mother and baby girl get home safely. Without the caring and devotion of the TBA in that village, it is unclear whether or not the mother and baby would both be happy and healthy today.

When I had the chance to talk to a TBA in another village, he told us how becoming a trained TBA has changed his life. Being trained has made him feel more proficient in his work as a TBA and thus helped him to deliver the best possible care to the women of his village. As a result of this, the other villagers have increased their trust and respect in him, which has made him a happier person.

Not only have I been interested in the stories, but I have had the opportunity to open my eyes to life in Akatsi. Several bucket showers later, I can say that my view on the world has definitely expanded. Whether it’s the kids running around in underwear, the women with babies wrapped in scarves on their backs, or the roosters waking us up in the wee hours of the morning, I would not trade Ghana life for anything (as much as I might miss air conditioning…). This past Wednesday, we got to experience both Market Day and Weighing Day. At the weighing, women from all over Akatsi gather to have their babies weighed and given injections under a single roof. The scene was hectic and hot. Women sitting on benches with their children, a few women selling goods in the back, and a single scale hanging from the roof. The mothers undressed their children and put them in what were called, ‘weighing pants,’ which were pretty much cloth diapers with a long strap. The baby was then hung on the scale hung from the ceiling to be weighed. The child was then examined, in front of everyone, and given an injections he or she may have needed. The whole process would never fly in the US. However, the women did not seem to be bothered by any aspect of it, including sitting for hours in the heat. They were happy to make sure their babies were healthy! Later on Wednesday, we explore the market—sprawling, open air, and strangely not busy. Everything you could need was sold at the market: vegetables, fish, meat, fruit, kasava, roots, beads, cloth, clothing, shoes, cutlery and household items. You name it, it was there. Yet, the most culturally shocking thing to me was not the weighing or the market, it is the idea of credit. Credit is what we know as minutes, but here, credit is purchased off the baskets on women’s heads or in huts on the roadside. Perhaps it is because we are so used to the idea of, ‘unlimited,’ that I’ve never considered where minutes, or ‘credit’ comes from. Regardless, I’m still struggling to wrap my head around it.

Getting Started

From 5/21/13

Today, we got to have a conversation with Patrick about the social, cultural, and health benefits of traditional birth attendants. He started by clarifying that in the Akatsi District, there IS a difference between TBAs and professional midwives. Professional midwives are a type of health worker and work for the Ghana Health Service. TBAs are sometimes referred to as community midwives and serve a purpose far greater than simply delivering antenatal and postnatal care. TBAs are trusted and well respected in their communities. In fact, when CareNet trains TBAs they target already practicing but untrained TBAs in 20 communities within the Akatsi District. This way, people in the communities already feel comfortable seeking the care their community TBAs. Patrick told us that currently, TBAs are more important than ever because there is an extreme lack of professional midwives. In Akatsi alone, there are 13 professional midwives for a population of 200,000 people, all very spread out. We also found out that the one doctor in the Akatsi District recently quit and left the district! Scary thought!!

Beyond the roles of TBAs we also chatted about the reasoning behind hesitation to go to the hospital in Ghana. Compared to most African countries, Ghana’s government is extremely stable and there are many, many laws. However, when talking to one of CareNet’s staff, Sebastian, I learned that these many laws are rarely enforced, especially when it comes to health. Apparently, the attitudes of health workers in the hospitals of Ghana turns people away from seeking aid. Patrick described them as hostile, criminal, and having, “no patience for their patients.” Hospitals will often turn people away with severe ailments whom are close to death, because they do not want to be responsible for the death. Due to this fact, many pregnant women with severe complications, chose to stay home out of fear. Hospital deaths due to problems not associated with pregnancy are often preventable due to negligence. Patrick told us that pharmacists have a hard time reading the prescriptions and administer incorrect medication and injections. Once a death occurs at the hospital, no one questions how or why it occurred. Sadly, there is no system to check or enforce these issues.

Ultimately, TBAs hold a well-respected position in Ghana, whereas health workers do not. Yet, it remains a tough balance to walk because TBAs and health workers must work hand in hand in the case of extreme complications due to pregnancy.

Friday, May 24, 2013

"Knowing is not enough, we must apply..." Johann Wolfgang von Goethe

Whew, it's Friday! It's been an incredible week!! After all the preparation, interviewing and learning, our adventures at the 66th World Health Assembly has come to an end. It was quite amazing observing  how decisions and policies that are set this week affect lives all around the world.

The side event I attended today was Physical Activity, Sport and Health side hosted by the United Nations, Sport for Development and Peace (UNOSDP)  and the Group of Friends on Sport for Development and Peace.  I had been looking forward to this event for a few weeks and was super excited that the day had come! With NCDs on everybody's mind, physical activity, the most modifiable risk factor has become a major topic for discussion. Silva Poll, the first Olympic medalist for Costa Rica opened the discussion with a brief statement about the upcoming First Global Youth Summit in Costa Rica that will enroll 500 students to promote healthy living. She also mentioned that kids are spending too much time with electronics, which made me feel embarrassed that I am attached to my phone. Dr. Poul Hansen, Head of UNOSDP gave statements about the importance of physical education and activity that got me excited to continue to work in this area ,"Let's focus on bringing back Physical Education in our education systems," and " Physical education is the basis for creating a culture of physical activity in our societies." Dr. Douglas Bettcher, WHO Director Prevention of Noncommunicable Disease emphasized the importance of the initiative in getting more nations active, "Passing the NCDS Framework both the GAP and GMF is such an important milestone in Global Health history."  There were also testimonies by Tadesse Abraham, an Eritrean Distance Runner and Ms. Corinne Abrahams, a winner of the Melbourne Iron Man that encouraged the entire room to get active and reminded us of the influential power we have on others when we participate in healthy behaviors. To close the event, a Judo group with a couple of children awed the audience with flipping and tumbling moves and even got us to participate with them! The kids were so excited to be there but I think the audience was even more encouraged to see their joy when they performed and did what they loved to do most. Witnessing the work that UNOSDP has gotten me fired up to find more opportunities to merge what I am learning in Global Health and apply it to what I love in Kinesiology.

Ruby, Dr. Margaret Chan, Allyson and Trisa
The cherry on top of a wonderful was finally meeting and taking a picture of WHO Director General Margaret Chan!!! She has continued to inspire me with her passion for International health and her down to earth personality. It was actually kind of funny how the meeting happened...Me, Ruby and Trisa were turning a corner and I happened to see her cut in front of us in an empty hall. After a couple encouraging glances from Ruby and Trisa I ran up to her, introduced myself and asked for a picture. She paused and waved to me which I misinterpreted as a shoo. Disappointed we made our way to the escalators to a side a event when I heard some people hollering and waving, it was Dr. Chan, her assistant and body guard. I definitely accidentally pushed some people to catch up to her and she greeted me saying "I wanted to take a picture but not in the hallway and when I looked back you were gone!" I am shocked that a woman of such power and poise could have so much enthusiasm to want to take a picture with a couple of students. I am continually inspired by her and hope to some day be that same inspiration for another.

Here is a video of the Judo Demonstration

Thursday, May 23, 2013

If you quit smoking at any age, you will have a better life

Today was our fourth and second to last day at the 66th World Health Assembly. We know the building pretty well now and have oriented ourselves with the best laptop, phone, iPad charging spots in the café. The day consists of rushing between round tables, interviews and major committee events. One thing I have noticed is no matter where you are, the hallway, the café, a special event or a large committee meeting, you are likely to hear about tobacco as a major non-communicable disease (NCD) risk factor.  This had myself and many delegates and speakers reflecting on how such a well-known behavior-related danger is still so present worldwide in both developing and developed nations.

NCD Epidemic Panel

In a panel on the NCD epidemic there was a lot of discussion about current tobacco initiatives in Russia, South Africa, Ghana, Chile and Singapore. In this event the World Health Organization’s Assistant Director-General Oleg Chestov was unhappy with nation’s focusing on tobacco reduction percentages and suggested that instead of reducing tobacco use by 30% in the next five years, we should eradicate it immediately. We know it is dangerous; we have the evidence, and yet the goals presented are only delayed step-by-step attainments.

In this panel the Minister of Health in South Africa mentioned a proposal brought up at a previous conference suggesting the UN pass a regulation to ban smoking worldwide. This pitch seems extreme but he believes that although it would take time, tobacco could be completely gone by 2040.

Perhaps a ludicrous approach should be taken seriously, especially when many delegates this year are bringing up the major inconsistency that the WHA itself is not a smoke free event.

In the United States, Health and Human Services makes an effort to congratulate leaders in their smoking cessation efforts in local communities and schools. USC is not smoke free even though UCLA has recently taken the leap. Perhaps it is up to the MPH students to work towards passing university regulation and gain support from the student community to be a smoke free campus. In the NCD interventions panel, Dr. Howard Koh, Assistant Secretary for Health for the U.S. Department of Health and Human Services, made a strong statement for the future of tobacco, saying, “let’s not be a society that who thinks smoking is normal and instead be for health.”

Students with United States HHS Assistant Secretary Dr. Howard Koh