Global Health in the Humanities

Maternal Health in Rural Central Uganda: Cross-Sectional Assessment of Family Planning Usage and Attitudes

Primary Researchers and Authors: John Bollinger and Catherine Yang

DGHI Faculty Mentor: Dr. Sumedha Ariely

Project Mentors and Coordinators: Dr. Christopher Kigongo, Robinah Jevelah

February 26, 2018

Introduction

Background

Maternal and child health poses unique challenges to the global health community and has received much attention in terms of policy. As such, the Millennium Development Goals specifically target these health challenges. Goal 4 simply states, “Reduce child mortality” (“United Nations Millennium Development Goals” 2017). In 2016 the infant, child, and overall under-5 mortality rates in Uganda were 43, 22, and 64 per 1,000, respectively (Uganda Bureau of Statistics 2016).  These mortality rates are driven by global health factors, including anemia, malaria, soil-transmitted helminth infection, and malnutrition. Anemia is a condition that results from a lack of red blood cells, such that the number of red blood cells cannot support the needs of the individual’s body (WHO 2011). Malaria is a prominent disease caused by plasmodium parasites spread by mosquito vectors. The African Region has a disproportionately high burden of malaria cases and deaths, 90% and 91%, respectively(“WHO | Malaria” 2017). Soil-transmitted helminth infection is one of the most common infections globally, particularly in sub-Saharan Africa, the Americas, and East Asia. These infections can lead to adverse nutritional and developmental effects as well as anemia (“WHO | Soil-Transmitted Helminth Infections” 2017). Malnutrition often compounds susceptibility to other illnesses, resulting in situations of comorbidity. In developing regions such as Uganda, malnutrition poses a severe threat to maternal and child health, especially in the presence of other disease burdens such as anemia, malaria, and helminth infection (Uganda Bureau of Statistics 2016). Naturally child health is closely related to maternal health, and MDG goal 5 reads, “Improve maternal health.” This goal is broken down into subcategories and includes universal access to reproductive health, including meeting the unmet need for family planning products and services (“United Nations Millennium Development Goals” 2017). In the North Central Region of Uganda, 24.1% of women have an unmet need for family planning (Uganda Bureau of Statistics 2016). With the presence of comorbidity between diseases and the strong connection between maternal and child health, future research that incorporates the connection between these areas should be pursued moving forward.

Family Planning

Family planning includes any and all conscious efforts by a couple towards limiting or spacing the number of children they have through modern or traditional contraceptive methods. The modern and traditional classifications for contraceptive methods refer to the manner in which couples pursue family planning. Modern methods include female or male sterilization, birth control pills, implants, injections, condoms, etc. Traditional contraceptive methods include rhythm, withdrawal and other techniques considered folk methods. In the North Central Region of Uganda, 47.4% of women use family planning methods, including modern and traditional methods (Uganda Bureau of Statistics 2016). Of this group, 39% of currently married women are using a method of family planning, with 35% employing a modern method and 4% choosing a traditional method. Among modern methods, injections and implants are the two most common choices due to convenience and their long-lasting effects. However, 24.1% of women still have an unmet need for family planning methods. Having an unmet need includes women who wish to postpone their next birth for two or more years or want to stop childbearing altogether but are not using family planning methods. If a woman’s previous pregnancy was unplanned or unwanted, that is also considered to be an unmet need (Uganda Bureau of Statistics 2016). Currently, family planning employs a facilities-based approach, requiring women to go to a clinic or hospital to obtain or continue using most family planning methods (Schecter, Ciraldo, and Paccione 2016). Moving forward, VHTs may be able to play a practical and vital role in helping overcome the gap between interest and unmet need for family planning methods.

2017 General Aims

  1. Describe family planning knowledge and interest in a sample of current mothers.
  2. Investigate the effect of side effects and social factors on attitudes towards family planning and reproductive outcomes.

Methodology

Both the Duke University Institutional Review Board and Uganda’s Mityana District Health Officer, Dr. Fred Lwasampijja, approved this study and the following methodology.  Participants were consented and ethical procedures were followed as specified both by Duke IRB and DGHI faculty mentors.

Study Setting

Data collection began in June 2017 and concluded in August 2017. The location was a rural parish of fourteen villages located about 50 miles from the capital city, Kampala, in Mityana District, Central Region 2, Uganda. The number of households in each village ranges from 54 to 247, with an average of 105 households per village.

Participants

In the summer of 2013, 69 women who were either pregnant or had recently delivered were recruited to participate in this now 5-year study. The women were either recruited through a village register or through an annual community health fair. Every year since, as many of these women have been re-recruited, as well as new participant mothers. The new mothers were women who had recently delivered and were recruited by their village health workers to be interviewed. In 2017, 59 mothers who had previously participated in this study were recruited, as well as 17 new mothers for a total sample of n=76.

Table 4. 2017 Demographics of Mothers (N=76)

In the summer of 2017, the mothers answered questions on their use of family planning and cell phones. No blood or stool samples were collected from the mothers in 2017.

Procedures

Consent

A trained translator read and explained the approved consent form in Luganda, the local language, to participating mothers. Written consent was obtained from the mother at the place of survey, either her home or common space selected by their village health worker.

Survey Tool

A trained translator administered the survey by asking the questions in Luganda, the local language, and translating the mother’s response directly to English after every utterance. The responses were recorded in a notebook and later coded. The surveys were administered at either the mother’s home or at a central location in the village. Each survey took approximately 30 minutes per participant.

Measures

The survey contained demographic questions, various questions about family planning use, experience, attitudes, and reproductive outcomes, and questions regarding the mothers’ use of cell phones. The researchers developed the survey questions after reviewing relevant literature and consulting with research mentors, including a Ugandan physician. The translators were consulted regarding the wording of questions prior to finalizing and administering the survey. The survey was printed in English but administered in Luganda, the local language.

Results

Of the 76 women surveyed in 2017 (ages 18-45 years), 81.6% (62/76) were married, and 18.4% (14/76) were single at the time of the survey. The median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. This average age of first pregnancy is comparable but slightly higher than the Central 2 region average of 18.3 years (DHS, 2011).

The average number of pregnancies for women in our sample was 4.12. Of the women in our sample with 2 or more children, 91.2% (62/68) felt that they had waited long enough between the births of any of their children, whereas 18.8% (6/68) felt that they had not waited long enough between births. However, when asked about the intentionality of their previous or current pregnancy, 78.9% (60/76) of women wanted to be pregnant then, 19.7% (15/76) wanted to be pregnant later, and 1.3% (1/76) did not want to be pregnant at all. This can be seen in Figure 4 below.

Figure 4. Pregnancy Intentionality, N=76

All 76 women who participated in the survey were asked questions on family planning use and perceptions. When asked about family planning usage, 47.4% (36/76) reported that they were currently using a contraceptive method, 40.8% (31/76) said that they have used contraceptive methods in the past but not currently, and 11.8% (9/76) indicated that they have never used a contraceptive method. This can be seen in Figure 5 below.

Figure 5. Mother’s Contraceptive Use, N=76

Of the 67 mothers in our sample who currently or previously used a contraceptive method, the most common methods were injections and implants. Some women used multiple types of contraception, resulting in a total response number of 78 contraceptive types. 62.8% (49/78) used or currently use an injection, and 25.6% (20/78) used or currently use some form of implant. This breakdown can be seen in Figure 6 below.

Figure 6. Types of Contraception Used by Mothers, N=78

While 25% 1 of the 4 women in our sample who were currently pregnant had unintentional pregnancies, overall: 28% (21/76) had experienced at least one unplanned pregnancy at some point. Of those women reporting an unplanned pregnancy, 52.4% (11/21) reported that the pregnancy was due to unprotected sex, 14.3% (3/21) mentioned contraceptive failure, 23.8% (5/21) stated that they were still breastfeeding when they became pregnant, 4.8% (1/21) reported that she did not need family planning, and 4.8% (1/21) said that she was not aware of family planning at the time of the pregnancy.

Figure 7. Unplanned Pregnancy, N=76

Higher than the reported number in our sample, 43.7% of births in Uganda were wanted at a later time or not at all (DHS, 2011). Given that the number of unintentional pregnancies remains high, various factors were explored, including the age at first birth and age at the start of contraceptive use. As previously stated, the median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. The median age at the start of contraceptive use was 22 years, whereas the average age was 22.32 years. Statistical analysis comparing the age at which women report their first pregnancy and initiating contraceptive use shows that there is a significant difference between the age at which women are first pregnant and when they begin family planning methods. Therefore, women are starting family planning methods after their first pregnancy.

Figure 8. Comparison of age at first birth and age at the start of contraceptive use, N=67

As stated earlier, 41% of mothers in our sample previously used at least one form of contraception in the past but do not currently use any family planning method. Of these 31 women, 45.2% (14/31) wanted another child, and 32.3% (10/31) stopped use due to side effects.

Figure 9. Reasons for Stopping Contraception, N=31

Based on our data and recommendations from 2016, we took a closer look at women who stopped contraception due to side effects. We analyzed whether or not women who stopped contraception due to side effects report significantly greater levels of side effect severity when compared to women who stopped contraception due to any other reason. We found that women in our sample who stopped contraceptive use due to side effects reported significantly more severe side effects (t=2.3208, df=20.543, p=0.03068). Figure 10 below visualizes the difference in reported side effect severity between the two groups of women, one indicating that they halted contraceptive use due to side effects and the other stopping use due to any other reason.

Figure 10. Comparison of women who stopped contraceptive use, N=31

From the 2011 Ugandan Demographic Health Survey, 56% of current contraceptive users were given information about potential side effects or complications that may be associated with the contraceptive method that they use. 53% of women were told what steps to take if they experienced these side effects, and 59% obtained information about one or more alternative contraceptive method. As side effects were a significant reason for halting contraceptive use, the severity of side effects based on whether or not information was provided to the patient was analyzed.

We analyzed whether or not provider information made a difference in the painfulness of side effects reported due to contraceptive use. To do so, we grouped participants into two groups. One group reported that they had received any information at all about family planning methods, which was not limited to information about side effects associated with the contraceptive method the participant was using. Women in our sample were asked to rank the severity of the side effects the experienced on a scale from 1 to 10, with 1 being not a bother and 10 being so painful that the participant had to immediately discontinue use of her contraceptive method. For the group of women who received information from their provider, the median painfulness of side effects reported was 6, with an average score of 5.8. For the group of women who did not receive information from their provider, the median painfulness of side effects reported was 7, with an average score of 7.2. Statistical analysis revealed a trending towards significant difference between the two groups, indicating that women who did not receive information from their provider may report more severe side effects associated with contraceptive use.

Figure 11. Painfulness of Side Effects, N=47

To further assess whether or not there are mitigating factors for side effect severity, we analyzed the social support women received from female friends. Contrary to what we would expect, in terms of friends, women with more supportive friends have a median side effect severity score of 8, with an average score of 7.2. Women with unsupportive friends have a median side effect severity score of 6, with an average score of 6. While this trend is opposite of what we would expect, it is not statistically different indicating that the support of friends may not act as a mitigating factor for side effect severity associated with contraceptive use.

Another assessment of social support exists in the form of support from female family members. Therefore, we analyzed this type of social support participants have to investigate whether or not having supportive female family members may mitigate the severity of side effects associated with contraceptive use. Women with supportive female family members had a median reported side effect severity of 7, with an average score of 6.3. Women with unsupportive female family members had a median reported side effect severity of 10, with an average score of 8.6. Statistical analysis showed that there was a significant difference between the two groups of women, indicating that women with more supportive female family members report significantly less severe side effects associated with contraceptive use.

Figure 12. Reported Side Effect Severity Grouped by Family Support, N=28

One final measure of social support that we explored was partner’s perception of contraceptive use. We asked women in our sample how she thinks her partner feels about contraceptive methods. Of women in our sample with a partner, 55.9% (38/68) reported that their partner supports contraceptive methods, 19.1% (13/68) said that their partner does not support contraceptive use, 16.2% (11/68) responded that they do not know how their partner feels, and 8.8% (6/68) stated that their partner does not know that they currently or previously used a contraceptive method. This breakdown can be seen in Figure 13 below. Note that some women gave multiple answers to this question.

Figure 13. Partner Perception of Contraceptive Methods, N=68

Discussion

The women in our sample show a high level of contraceptive use. However, almost 1 in 3 mothers have experienced an unplanned pregnancy. This remains the case even though women mostly report that the primary use for contraception seems to be family spacing as opposed to individual reproductive control. In Uganda, contraceptives are free and available in local clinics, but the problems of transportation, service availability, and social support are still prevalent. The largest barrier to access for women who want to use contraceptive methods may be side effects. Many women in our sample reported that they had experienced side effects and discontinued use of their contraceptive method due to these side effects. Furthermore, the lack of information by providers is concerning, particularly as it may be a factor that may mitigate the severity of side effects women associate with contraceptive use. When discussing patient education with health workers in a few of the local clinics in Naama, we were informed that it is required for them to provide information about the contraceptive method the patient desires, along with side effects associated with that family planning method and general information about other available methods.

Boosting family planning education for patients serves as a promising prospect for a policy piece in the future. Policies should aim to mitigate misperceptions about the types and effects of contraception, which are potentially due to social networks perpetuating more information than health systems. As women with more supportive family networks report lower side effect severity, this idea has some degree of support. Therefore, a policy piece that aims to boost education provided at the point of procurement of family planning services as well as a community-based model that incorporates VHTs perpetuating information about family planning methods and associated side effects may be the best way to move forward.

Limitations

There are several limitations to our analysis of family planning perceptions and method use. Firstly, our survey relied on self-report method. It is very possible that women have forgotten the age at which they began contraceptive use along with the timeline of other questions. Furthermore, self-report measures for side effect severity may be skewed with time. If women have experienced these side effects more recently, they may be perceived as more severe. On the other hand, women who experienced side effects many years ago may not remember exactly what side effects they had and time may make those they do remember feel less severe. Secondly, we attempted to understand differences between the numbers of actual versus desired children for mothers in Naama. However, our sample only consisted of women who were still of childbearing age. We could not accurately draw conclusions from this sample because they may have more children in the future. A sample that included women beyond childbearing years should have been included to assess actual versus desired numbers of children. Broadening the sample would also allow for some degree of assessment in terms of a generational shift, determining whether or not a trend exists in the number of children desired by age group. Thirdly, we wanted to analyze birth spacing over time for mothers to see if there was a change as time went on or if the start of family planning methods increased birth spacing. However, we did not ask about the birthdays of all children, which prevented us from assessing these measures. Lastly, we did not separate or ask questions about modern versus traditional contraceptive methods. Many women in our sample mentioned that they had an unplanned pregnancy while they were still breastfeeding. Additional analysis would have been helpful to understand perceptions of modern versus traditional family planning methods.

References

Bachou, H., and Demetre Labadarios. 2002. “The Nutrition Situation in Uganda.” Nutrition 18 (4):356–58. https://doi.org/10.1016/S0899-9007(01)00722-5.

Brooker, S., A. C. A. Clements, and D. A. P. Bundy. 2006. “Global Epidemiology, Ecology and Control of Soil-Transmitted Helminth Infections.” In Advances in Parasitology, edited by Simon I. Hay, Alastair Graham, and David J. Rogers, 62:221–61. Global Mapping of Infectious Diseases: Methods, Examples and Emerging Applications. Academic Press. http://www.sciencedirect.com/science/article/pii/S0065308X05620076.

Hotez, Peter J., and Aruna Kamath. 2009. “Neglected Tropical Diseases in Sub-Saharan Africa: Review of Their Prevalence, Distribution, and Disease Burden.” PLOS Neglected Tropical Diseases 3 (8):e412. https://doi.org/10.1371/journal.pntd.0000412.

Mbonye, Anthony K., Ib Bygbjerg, and Pascal Magnussen. 2008. “Intermittent Preventive Treatment of Malaria in Pregnancy: A Community-Based Delivery System and Its Effect on Parasitemia, Anemia and Low Birth Weight in Uganda.” International Journal of Infectious Diseases 12 (1):22–29. https://doi.org/10.1016/j.ijid.2006.10.008.

Pelletier, D. L., E. A. Frongillo, D. G. Schroeder, and J. P. Habicht. 1995. “The Effects of Malnutrition on Child Mortality in Developing Countries.” Bulletin of the World Health Organization 73 (4):443–48.

Schecter, A., K. Ciraldo, and G. Paccione. 2016. “Meeting Unmet Need for Family Planning in Rural Uganda through Village Health Worker Distribution of Emergency Contraception: Assessing Attitudes and Use.” Annals of Global Health 82 (3):499. https://doi.org/10.1016/j.aogh.2016.04.360.

Shapiro, Adrienne E., Edridah M. Tukahebwa, Jennifer Kasten, Siân E. Clarke, Pascal Magnussen, Annette Olsen, Narcis B. Kabatereine, Richard Ndyomugyenyi, and Simon Brooker. 2005. “Epidemiology of Helminth Infections and Their Relationship to Clinical Malaria in Southwest Uganda.” Transactions of the Royal Society of Tropical Medicine and Hygiene 99 (1):18–24. https://doi.org/10.1016/j.trstmh.2004.02.006.

Uganda Bureau of Statistics. 2016. “Uganda Demographic Health Survey 2016.” 2016. https://dhsprogram.com/pubs/pdf/PR80/PR80.pdf.

“United Nations Millennium Development Goals.” 2017. 2017. http://www.un.org/millenniumgoals/.

WHO. 2011. “Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity.” 2011. http://www.who.int/vmnis/indicators/haemoglobin.pdf.

“WHO | Malaria.” 2017. WHO. 2017. http://www.who.int/mediacentre/factsheets/fs094/en/.

“WHO | Soil-Transmitted Helminth Infections.” 2017. WHO. 2017. http://www.who.int/mediacentre/factsheets/fs366/en/.

Call for Papers–Special Issue: Fostering Ethical Engagement in Global Health

You are invited to submit a paper for possible inclusion in a special issue of the Duke Student Global Health Review (DSGHR), Fostering Ethical Student Engagement in Global Health

At Duke University, students have the opportunity to engage in global health work through a variety of programs on campus, including Duke-sponsored programs, student-run organizations, and independently organized projects. The number and breadth of these programs has placed Duke as one of the premier institutions in global health. However, these programs and organizations function relatively autonomously, with little communication between them. As a result, there is little consensus on general expectations for engagement in global health work, particularly relating to the ethics of engagement. 

In Spring 2019, The Duke Student Global Health Review hosted a Roundtable event in which experienced undergraduate students and graduate students convened to discuss current challenges to ethical engagement and potential solutions to surmount these barriers. This Roundtable established common themes surrounding ethics of engagement and areas for growth, and led to the formation of a framework for future direction and a position paper. 

The goal of this work is to situate ethical student engagement at the center of discourse about global health at Duke and to encourage student engagement in a way that does not pose a risk to the student, patient, or community in which experiences occur. 

Our special issue aims to expand the conversation surrounding ethics in global health research at Duke. Areas of interest for this special issue include, but are not limited to, the following topics: 

  • Reflections on global health fieldwork, including ethical challenges and dilemmas 
  • Case studies on “ethical” student engagement in global health 
  • Building strong partnerships with community partners 
  • Pre-departure training and competency development 
  • Ethics of documenting and sharing global health experiences 
  • Perspective pieces on cultural competency, power dynamics, and privilege 
  • Intersection between global health ethics and policy 
  • Global health and human rights 
  • Review articles on ethical frameworks for global health engagement 
  • The role of humanities in promoting ethical engagement  

You will need to indicate your intention to submit your abstract by email to dukestudentglobalhealthreview@gmail.com

Important Dates: 

Full Paper Submission by: January 15, 2020 

Decision Date: February 1st, 2020 

Paper Revision: March 1st 

Issue Released: March 15th

Best, 

DSGHR Exec Board 

Sahil, Evi, Hope, Angela

Policy and Technology Development in Healthcare: The Case of Telemedicine in China

By Natalie Yu

Digital health has become the new frontier that big business is striving to conquer. In both China and America, large corporations traditionally involved in the technology, pharmaceuticals or insurance industries are converging on the emerging field of digital health. Not only are they developing novel services, they are also working to disrupt traditional models of service delivery.

During my summer DukeEngage project, I conducted research in Shanghai on telemedicine initiatives aimed at improving the accessibility and affordability of medical services. Through analyzing the regulatory and market environment in China, I discovered the importance of the private sector’s involvement in healthcare, as well as the role of government policy in creating favorable conditions for the development of financially viable solutions to long-standing inefficiencies. In this article, I will lay out the context behind innovation in telemedicine by providing an overview of healthcare challenges in China, and the policy shifts that have shaped the evolution of telemedicine’s definition and legal boundaries. My discussion of these issues will culminate in an in-depth examination of how policy has influenced the activities of three Chinese conglomerates Tencent, Alibaba and Ping An—and, in turn, how these big businesses have changed the government’s posture towards health technology.

The Rise of Telemedicine in China

Figure 1: Major challenges facing the Chinese healthcare system based on data from the New York Times1 and Collective Responsibility2

China’s burgeoning population has exposed fault lines in its healthcare system. The growing chasm between urban and rural popoulations clearly manifests itself in healthcare: city-dwellers in cities such as Beijing and Shanghai are able to access multiple top-tier hospitals while villagers rely on clinics that may be hundreds of miles from where they live1. Although China achieved universal insurance coverage in 2011 through a basic social insurance scheme, disparities in insurance coverage are inextricably tied to geography. Rural residents pay lower premiums but receive significantly fewer benefits3—there is little conclusive evidence to show that public insurance has reduced out-of-pocket expenses among rural residents4. However, most people in China still rely on state-sponsored insurance, with commercial insurance remaining in the early stages of market penetration5. The public sector continues to shoulder much of the burden in service delivery as well, with the number of visits to public hospitals and number of patients discharged from these hospitals accounting for 90% of volume nationwide6. Public hospitals are overworked, resulting in up to 13.5 hour wait times for individuals who need specialist appointments1. On the other hand, the primary healthcare system is weak, with just  general practitioner per 6,666 patients1. Mounting tensions between doctors and patients due to deep-set mistrust culminate in physical violence, resulting in a vicious circle of mutual suspicion1.

The myriad of systemic issues in healthcare present a set of golden opportunities for the private sector. In particular, as patients are both the main payers and burden-bearers in the healthcare system7, the most straightforward solution for big business would be to directly target disgruntled patients and provide services they are willing to pay for. Given their expertise in consumer engagement, large corporations in technology, e-commerce and insurance have been propelled to the fore of this wave of innovation. Over the years, this “Internet-based healthcare” (direct translation) has come to more closely approximate “telemedicine” as it is understood in English. While there is no clear consensus on a precise definition of telemedicine, the WHO characterises it as:

“The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities8.”

In line with this definition, big businesses in China have been devising various Internet-based healthcare services, from physician-physician online consultations to novel solutions that connect patients to medical consultations, medication delivery and health information on demand9. The beginnings of this service delivery transformation can be traced back to 20144. Since then, the government has responded to private sector developments in telemedicine by enacting regulations that served to monitor the technology and test its efficacy by pilot—namely by designating the province of Yin Chuan as a testbed10. The reactive nature of policy evolution reflects a preference to err on the side of caution, taming the explosive growth of telemedicine and putting it through the crucible. At the same time, however, the experimental phase that lasted from 2014 to the summer of 2018 was a period of uncertainty, during which even the very definition of “telemedicine” as well as its legal boundaries were unclear, resulting in the death of many businesses that were hamstrung by the lack of regulatory clarity. In the following section, I will outline the main phases of policy development relevant to telemedicine.

Policy Evolution

Figure 2: Key milestones in the development of telemedicine policy in China based on data from VCBeat6

Government regulations governing technology in China tend to be concretised only after tightly-controlled observation periods11. In practical terms, this means that while the private sector started to bring in new interventions in 2014, the telemedicine scene in China only took off in the summer of 2018 due to the lag time in policy development11. The pilot phase in telemedicine began in 2014, during which the government permitted the digitisation of select non-medical services. A variety of telemedicine models existed in this early phase. Public hospitals began to launch “Internet Hospitals” that offered non-medical services such as registration and informal consultations with physicians online. Private companies seized on the opportunity to collaborate with public hospitals and set up joint “Internet hospitals”, or decided to establish their own physical hospitals. In tandem with Internet Hospital development, other companies even offered fully virtual medical services.

However, the noose began to tighten around the field of telemedicine with greater government scrutiny. It was at this time that the government began suspending the operations of private companies that were otherwise abiding by regulations. A case in point was the penalisation of e-commerce giant Alibaba’s medication sales service, which was forced to shut down12. In 2016, the Yin Chuan province positioned itself as a testbed for telemedicine, enacting policies that permitted more experimentation with telemedicine operating models. Despite this, the legal definition of telemedicine remained hazy. As such, businesses were hesitant to expand and experiment unless they had been explicitly permitted to do so by the government13. The period that followed saw dwindling investments in telemedicine and fewer operational companies14. At the beginning of April 2017, the Yin Chuan local government facilitated the establishment of 15 Internet Hospitals. However, at the same time, regulations were at their strictest as the government announced its intentions to formulate new telemedicine governance guidelines. Party officials conducted site visits to monitor telemedicine companies in the closest way possible. At the end of 2017, only about 50 of the 5000 original telemedicine companies set up in 2014 survived both regulatory scrutiny and the dearth of investments11. From 2014 to 2018, the majority of telemedicine providers stuck closely to the safe model of providing non-medical online services; however, these were not financially sustainable. The sweet spot of maximum consumer convenience and profitability for providers was found in medical services that could be reimbursed by insurance, be it public or private. Yet, without clearly delineated legal boundaries specifying what the government would condone, businesses did not dare to diversify their offerings to consumers and tackle some of the more pressing issues in healthcare.

Fortunately, the industry reached an inflexion point in the summer of 2018, when the Chinese government published three key policy documents signalling the release of the telemedicine industry from the evaluation phase. These regulations define key boundaries clarifying the legality of various telemedicine services15. Firstly, they lay out three main forms of telemedicine: remote medical services, Internet medical services and Internet Hospitals. Remote medical services refer to instructional or informational services provided to patients or other hospitals for training and education; Internet medical services refer to medical consultations for common illnesses and follow-up appointments for chronic diseases provided by licensed doctors; Internet Hospitals refer to hospitals that provide their services online. Second, the new regulations stipulate that only returning patients whose health records are accessible to the consulting physician can receive online medical consultations. Third, the policies delegate the monitoring of telemedicine activities to local governments, as telemedicine providers are required to have physical hospital facilities to take legal responsibility for services rendered. Concrete approval processes through which licenses for each telemedicine subtype can be obtained are fleshed out in the document. Taken together, these key clauses on terms of operation have helped to dispel the uncertainty hanging over the field of telemedicine, allowing both public and private sector actors to chart their next steps without fear of being penalised due to erroneous interpretation of the rules.

Private Sector Development

Three notable corporations active in telemedicine are Tencent, Alibaba and Ping An. Through my analysis of the market landscape, funding data and government policies, I studied these companies’ growth trajectories and I realised that their developments in the healthcare space have been heavily influenced by policy developments. I will illustrate the main insights I drew in the vignettes below.

Tencent

Tencent has quietly risen to become one of the world’s top 10 companies by market capitalization. Like its competitor Alibaba, it has joined the ranks of US tech giants Apple, Alphabet, Microsoft and Amazon. Sheltered by the great firewall that prevents American tech firms from operating in China, Tencent has built an entire ecosystem that encompasses the operations of multiple American tech giants put together. Tencent has three core pillars undergirding its business—the messaging app WeChat that services 1 billion active monthly users16; the mobile gaming franchise that is the largest globally16; and the network of video, payment, music and other services that is comparable to those offered by Netflix, PayPal, Spotify and more combined17. The company has leveraged its all-encompassing technology platform and ecosystem and consumer base to back WeDoctor, an online registration and consultation application, in 201418.

Figure 3: How Chinese and American giants stack up based on data from Statista19  (May 2018)

 WeDoctor had humble beginnings in 2010 as a free registration service known as “Gua Hao Wang” that patients could use to make appointments with doctors in hospitals20. The company saw this as a public good and pledged never to charge anyone for the service. In its initial years, WeDoctor faced similar challenges to other telemedicine companies in figuring out a viable means to continue providing free registration. In 2015, it pivoted to become an Internet Hospital, pairing its online registration and non-medical consultation services with Wuzhen Hospital, the physical hospital that it set up. By operating through this new private hospital, WeDoctor could legally expand its service offering to medical services and, more importantly, secure collaborations with insurance companies. Today, WeDoctor allows its 27 million regular users easy access to doctors across different specialties20. Patients are thus able to receive medical attention in a timely fashion and choose the doctors they want to see. Doctors, on the other hand, are rewarded proportionally to services rendered, instead of drawing a standardised salary as they would within the public hospital system. In order to offer more seamless telemedicine services, WeDoctor has been laying the groundwork for cloud-based storage of medical data as well as concretising insurance reimbursement arrangements with both national and private insurance organisations. The latest developments in policy have confirmed that these plans lie within the legal scope of operation for Internet Hospitals. This has given WeDoctor more confidence to build on its telemedicine business and become a comprehensive health maintenance organization, offering medical services, medication and insurance on its cloud-based platform.

Taken together, the greater strength of the WeDoctor group will promote the growth of Tencent’s ecosystem. In the same way that Alphabet is a holding company that comprises Google, WeDoctor is but one of the many companies under Tencent’s umbrella, which span the domains of healthcare imaging analysis, information provision and consultations. With the green light from the government, Tencent can continue developing a seamless platform that allows consumers to access health and medical services on demand. By empowering large corporates to grow the telemedicine industry, the government also stands to gain from the greater efficiencies in the healthcare system brought about by the private sector.

Alibaba

Alibaba is China’s dominant e-commerce behemoth, often likened to Amazon. However, Alibaba’s operations extend far beyond the digital marketplace. The company owns both of China’s top marketplaces (Tmall and Taobao), which handle over 80% of the country’s online sales21. In addition, it runs the mobile payments system Alipay that is used by over 900 million people worldwide (for comparison, Apple Pay has 127 million active users22) and controls Ant Financial Services, the leading money market fund that is at the forefront of fintech innovation21. The company’s reach extends to the public sector, as it works with governments to build smart cities23. Since 2014, Alibaba has decided to make healthcare a priority. The company announced its “Initiative for Future Hospitals”, which involves the integration of online consultations, medication purchases and mobile payments into a single platform24, AliHealth. Although similar to WeDoctor’s vision, Alibaba planned to target rural areas as well25.

However, regulations on telemedicine penalised AliHealth in 2014. Despite AliHealth’s overall compliance with licensing requirements, the government suspended sales of over-the-counter medications on its online health marketplace26. This alarmed many other telemedicine providers and forced the company to rework its strategy. Instead of operating a purely online marketplace, it decided to pursue an online-to-offline (O2O) model by forming partnerships with pharmacy chains and smaller medication stores that had a shopfront presence27. These brick-and-mortar stores are charged with delivering purchases of prescription medications made on AliHealth’s platform to customers, in line with government policy favouring such online-offline collaborations. AliHealth has since built up a repertoire of services surrounding medication sales, including offering patients virtual consultations with pharmacists to obtain prescriptions, and offering pharmacies medication supply chain management. The latest policy developments will allow it to build on the O2O agreements it has with 20,000 pharmacies across 200 cities to create an end-to-end marketplace powered by big data and replete with generic and specialty medications. This would address the key last mile challenge of getting medications to patients at scale, an issue that the healthcare system and government itself have struggled for decades. In turn, with greater regulatory clarity, Alibaba’s strengths as a logistics and technology provider will be further consolidated in the healthcare domain. As it continues to work on artificial intelligence tools for providers as well as cloud applications through the other businesses under its wing, Alibaba is contending with Tencent28 to build the most comprehensive telemedicine platform that will serve patients by the billion.

Ping An

Ping An is a holding company that dominates insurance and financial technology. As China’s largest insurer, Ping An Insurance is second only to Berkshire Hathaway in global market capitalisation19. Meanwhile, Ping An Technology sits at the top of the FinTech Top 100 leaderboard. The corporation has built an ecosystem based on its strengths in finance, technology and insurance, bridging them most notably to the domain of healthcare via offshoots Ping An Good Doctor and Ping An Health and Technology. Through the former, Ping An was able to offer telemedicine services to clients purchasing its insurance plans. This represents a new business model in China, where the market remains open as most patients do not own commercial insurance. Prospective clients would thus find this attractive as they stand to benefit from subsidised online medical services if they buy Ping An’s insurance.

Figure 4: Ping An’s multi-sector ecosystem that has been built upon its traditional strengths in insurance and banking29

However, the journey has not always been smooth for Good Doctor. Like its counterparts in the telemedicine industry, the company had been struggling to ensure the financial viability of its business, relying instead on its parent company’s resources. Converting customers from free non-medical consultations to paid medical services has remained challenging, even as the number of users rose from 30 million to 1.93 billion from 2015 to 201830. After receiving free non-medical advice from doctors on the Good Doctor platform, patients often head to physical hospitals, where they pay for medical services such as formal consultations and medications31. Unfortunately, Good Doctor’s hands were bound—the regulatory environment at the time did not favour the development of such value-adding medical services on its platform, thus it could not act to prevent the leakage of cash flow to traditional healthcare institutions. As the company was prevented from building an all-encompassing healthcare platform, revenue generation remained a key problem.

In the months that followed the establishment of new regulations in 2018, a flurry of activity ensued. Good Doctor went public on the Hong Kong stock exchange in late April and became the first listed health technology company in the world32, raising a total of over USD 1.12 billion. Moreover, the clarification of the government’s position on telemedicine bodes well for Good Doctor because of its alignment with the company’s core healthcare offering in home-based healthcare. Good Doctor’s “One-Minute Consultation + One-Hour Medication Delivery”33 aims to speed up the provision of medical attention to patients wherever they may be and to target the last-mile problem of getting medication into patients’ hands. As of June 2018, the program has been rolled out in 62 cities, providing 24-hour services in collaboration with 4150 pharmacies. The company plans to increase the comprehensiveness of its offering by adding features such as chronic disease management to its model of “insurance + teleconsultation + medication”, making Good Doctor a convenient one-stop platform that allows patients to bypass long wait times and inefficient prescription mechanisms endemic to the conventional healthcare system. This vision is driven by Ping An’s larger business in insurance, technology and financial services, and puts Ping An in a mutually supportive relationship with the governmental agenda. On one hand, Ping An has the technical expertise and resources to transform the government’s goals for telemedicine into a reality; on the other hand, the government creates the right regulatory environment that permits the growth of Ping An’s telemedicine venture into a financially sustainable business.

Summary

This close examination of Tencent, Alibaba and Ping An’s forays into telemedicine has shown me the ways in which policy evolution shapes the private sector’s growth trajectory. I began to understand the tensions introduced by the experimental, testing and strict governance phases that lasted from 2014 to mid-2018. These policy shifts challenged the corporations’ business models, while providing limited flexibility for further experimentation. As such, the private sector had to persist in shrewd manoeuvring to eventually win the government’s support for their telemedicine programs. During and after my DukeEngage experience, I had the privilege of witnessing the fruits of these efforts, as the government opened the doors for more innovation and growth in telemedicine by clarifying its legal boundaries.

Conclusion

In sum, my DukeEngage experience clearly demonstrated how regulation acts an interface between the government and the private sector. The regulatory environment is controlled by the government, thus giving it the power to decide the boundaries of big business’ involvement in healthcare. Paradoxically, policy change in China is reactive, and depends on demonstrated successes by businesses willing to deviate from the status quo. As such, the corporate world is able to push for change by innovating in a way that addresses national priorities and catches the government’s attention. At the same time, this makes for a tumultuous journey as regulatory boundaries are often fuzzy initially, affecting the rate at which businesses develop viable, diversified solutions. Thankfully, the preliminary successes of telemedicine companies has spurred the Chinese government to open up this space in order to leverage the private sector’s expertise in technology and consumer engagement, in the hopes that this will transform the healthcare system more quickly and effectively than top-down measures. As such, regulation is a process of negotiation that has to occur between the government and stakeholders so that good ideas can gain traction and scale up. As the field develops, the Chinese government would do well to bring other stakeholders such as patients to the table. Although this would make policy creation more unwieldy, patients are the ultimate target whose interests should protected in the current conversation between government, big business and healthcare institutions. 

References

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Contextualization of the Global Medical Brain Drain in Sub-Saharan African Countries

by Christiana Oshotse

Introduction

The ‘medical brain drain’ refers to the mass movement of health care workers from low and middle-income countries (LMICs) to high-income countries (1). Driving forces such as poverty and political instability intensify the mass emigration of health care workers from LMICs, resulting in critical shortages of remaining workers to meet the basic health needs of citizens in these countries. Widespread agreement exists that the medical brain drain severely undermines the capacity of LMICs to develop competent healthcare systems (2-4). Despite efforts at the national and international levels to impose policies encouraging against the medical brain drain, these policies have lacked implementation and have remained largely ignored (2). As LMICs increasingly suffer the harmful effects of the medical brain drain, a debate continues over the morality and legality of international health care workers migration and of the policies appropriate to address this phenomenon. 

The medical brain drain is a pressing issue that requires complex analysis of the ethical components characterizing the factors exacerbating this phenomenon. Such consideration of the brain drain is necessary in order to disentangle the relationships and circumstances requiring interventions to reverse existing shortages and develop international health care systems. This article focuses specifically on the context of medical workers emigrating from LMICs experiencing critical shortages of health care workers. Nigeria and Malawi are provided as case studies to effectively contextualize the causes, effects, and attempts to mitigate the health care worker shortage amidst the often-burgeoning attempts of these countries to remain relevant and powerful in the global economy as post-colonial nations. This paper does not examine all countries affected by the medical brain drain. LMICs are in dire need of solutions, and this paper delves into several policy recommendations. The need for viable policy recommendations is critical due to challenges in creating policy that mitigates the conflict between individual rights to migrate and LMICs need for these medical workers to stay. 

Global Context

The migration of medical workers is part of the current global health workforce crisis characterized by the severe shortage of health care workers in countries suffering from high burdens of disease (5). Attempts to accurately quantify the migration of health care workers is difficult in part because of challenges such as missing emigrant/immigrant registration data from source and destination countries and inconsistent use of proper definitions of migration statuses for emigrating medical workers (1). Existing data on health care workforce migration patterns is not entirely reliable, but the legitimacy of this issue is evident and efforts to research the extents of the medical brain drain have continued. 

The World Health Organization (WHO) estimates that over 4.3 million additional health care workers are needed to reach the Millennium Development Goals, objectives set by the United Nations to combat HIV/AIDs and other diseases, reduce child mortality and improve maternal health (3, 6-7). Though this figure appears high, the WHO’s estimate only accounts for shortages of health care workers in 57 countries experiencing “critical shortages,” and does not account for countries experiencing shortages in the capacity to provide basic health services (see Figure 1) (5-6, 8).  Thirty-six of the 57 countries are in Africa, a continent experiencing 25% of the global burden of disease yet possessing far less of a capacity to provide care to its inhabitants compared to the demand of its inhabitants for access to care (see Table 1) (6).  In LMICs such as Ghana, 29% of doctors work abroad, and in Mozambique, there are 3 doctors for every 100,000 people (3). 

It is necessary to identify the factors engendering the emigration of medical workers in order to appropriately contextualize the experiences of these workers and to identify necessary solutions to the problems posed. Medicals workers may emigrate for better employment opportunities, to earn higher wages, and to secure the future of their families (3, 6). Other factors include a desire of safer working conditions with greater resources (6). This is relevant especially in Sub-Saharan African countries whose immense burden of HIV/AIDs and resource limited settings overburden medical staff, who work long hours in conditions often lacking proper protective medical equipment (3, 7, 9). Paradoxically, the emigration of these medical workers further exacerbates the problems that served as the initial driving forces for their migration. Political instability and war are other significant factors that spark high migration rates from medical workers.

The health care workers who emigrate tend to be among the most skilled and educated in the source country; therefore, the migration of these workers represents a financial loss to the source country that has invested heavily in their education and training. It has been estimated that LMICs spend up to $500 million annually to educate medical workers who emigrate (6). A recent study calculated the cost of training medical professionals in Kenya and estimated that the country loses $517,931 for every doctor and $338,868 for every nurse who emigrates (9). These losses represent immense benefits to the destination countries that receive highly trained health professionals for free. The magnitude of this loss of human capital stunts the capability of LMICs to achieve long-term economic development. 

The migration of medical workers from LMICs disproportionately concentrates medical workers in high-income countries. Hospitals and clinics in LMICs are left understaffed and overflowing with individuals seeking healthcare. Existing staff is overburdened by the massive amounts of patients seeking care, which decreases the overall standard of care that each patient receives. These countries typically have high rates of HIV/AIDs, tuberculosis (TB), malaria, and other communicable diseases (3, 5).Furthermore, the limited staff tending to these populations are often more susceptible to burnout and stressful conditions which may contribute to medical errors and to safety mistakes that cause staff to accidentally contract the disease from their patients (3). 

The critical shortage of medical workers challenges the ability of source countries to effectively implement health interventions aimed at addressing the high rates of HIV/AIDs, TB, and maternal and child mortality rates. For instance, the Zimbabwean government has faced challenges in administering antiretroviral therapy (ART) to its HIV/AIDs patients in part because of the medical brain drain (10). The health system lacks the workers necessary to provide the sustainable care crucial to help HIV/AIDs patients achieve the proper adherence required to suppress the virus. 

In response to these issues, countries such as the Philippines, Thailand, and Vietnam have enforced mandatory national service periods for recently matriculated health care workers as measures to slow the brain drain (11). Additionally, the WHO collaborated with partners such as the Global Health Workforce Alliance (GHWA) and the Health Worker Migration Policy Initiative (HWMPI), to develop the Global Code of Practice on the International Recruitment of Health Personnel (12). This code is an ethical framework developed to govern the recruitment and migration of health care workers from shortage countries. When asked about the impact of the code, a Sudanese official remarked that, “as far as the WHO Code is voluntary and as far as beneficiary countries in the region do not have media or civil groups pressures, they will not be part of this code, I do not think there is hope!” Implementation of the code is left to the WHO Member States, which has allowed the migration of health care workers into high-income nations to continue (2).

The migration of medical workers is part of the current global health workforce crisis characterized by the severe shortage of health care workers in countries suffering from high burdens of disease (5). Attempts to accurately quantify the migration of health care workers is difficult in part because of challenges such as missing emigrant/immigrant registration data from source and destination countries and inconsistent use of proper definitions of migration statuses for emigrating medical workers (1). Existing data on health care workforce migration patterns is not entirely reliable, but the legitimacy of this issue is evident and efforts to research the extents of the medical brain drain have continued. 

The World Health Organization (WHO) estimates that over 4.3 million additional health care workers are needed to reach the Millennium Development Goals, objectives set by the United Nations to combat HIV/AIDs and other diseases, reduce child mortality and improve maternal health (3, 6-7). Though this figure appears high, the WHO’s estimate only accounts for shortages of health care workers in 57 countries experiencing “critical shortages,” and does not account for countries experiencing shortages in the capacity to provide basic health services (see Figure 1) (5-6, 8).  Thirty-six of the 57 countries are in Africa, a continent experiencing 25% of the global burden of disease yet possessing far less of a capacity to provide care to its inhabitants compared to the demand of its inhabitants for access to care (see Table 1) (6).  In LMICs such as Ghana, 29% of doctors work abroad, and in Mozambique, there are 3 doctors for every 100,000 people (3). 

It is necessary to identify the factors engendering the emigration of medical workers in order to appropriately contextualize the experiences of these workers and to identify necessary solutions to the problems posed. Medicals workers may emigrate for better employment opportunities, to earn higher wages, and to secure the future of their families (3, 6). Other factors include a desire of safer working conditions with greater resources (6). This is relevant especially in Sub-Saharan African countries whose immense burden of HIV/AIDs and resource limited settings overburden medical staff, who work long hours in conditions often lacking proper protective medical equipment (3, 7, 9). Paradoxically, the emigration of these medical workers further exacerbates the problems that served as the initial driving forces for their migration. Political instability and war are other significant factors that spark high migration rates from medical workers.

The health care workers who emigrate tend to be among the most skilled and educated in the source country; therefore, the migration of these workers represents a financial loss to the source country that has invested heavily in their education and training. It has been estimated that LMICs spend up to $500 million annually to educate medical workers who emigrate (6). A recent study calculated the cost of training medical professionals in Kenya and estimated that the country loses $517,931 for every doctor and $338,868 for every nurse who emigrates (9). These losses represent immense benefits to the destination countries that receive highly trained health professionals for free. The magnitude of this loss of human capital stunts the capability of LMICs to achieve long-term economic development. 

The migration of medical workers from LMICs disproportionately concentrates medical workers in high-income countries. Hospitals and clinics in LMICs are left understaffed and overflowing with individuals seeking healthcare. Existing staff is overburdened by the massive amounts of patients seeking care, which decreases the overall standard of care that each patient receives. These countries typically have high rates of HIV/AIDs, tuberculosis (TB), malaria, and other communicable diseases (3, 5).Furthermore, the limited staff tending to these populations are often more susceptible to burnout and stressful conditions which may contribute to medical errors and to safety mistakes that cause staff to accidentally contract the disease from their patients (3). 

The critical shortage of medical workers challenges the ability of source countries to effectively implement health interventions aimed at addressing the high rates of HIV/AIDs, TB, and maternal and child mortality rates. For instance, the Zimbabwean government has faced challenges in administering antiretroviral therapy (ART) to its HIV/AIDs patients in part because of the medical brain drain (10). The health system lacks the workers necessary to provide the sustainable care crucial to help HIV/AIDs patients achieve the proper adherence required to suppress the virus. 

In response to these issues, countries such as the Philippines, Thailand, and Vietnam have enforced mandatory national service periods for recently matriculated health care workers as measures to slow the brain drain (11). Additionally, the WHO collaborated with partners such as the Global Health Workforce Alliance (GHWA) and the Health Worker Migration Policy Initiative (HWMPI), to develop the Global Code of Practice on the International Recruitment of Health Personnel (12). This code is an ethical framework developed to govern the recruitment and migration of health care workers from shortage countries. When asked about the impact of the code, a Sudanese official remarked that, “as far as the WHO Code is voluntary and as far as beneficiary countries in the region do not have media or civil groups pressures, they will not be part of this code, I do not think there is hope!” Implementation of the code is left to the WHO Member States, which has allowed the migration of health care workers into high-income nations to continue (2).

Case 1: Nigeria’s Shortage of Health Care Workers

Lagos is a major city, but in the midst of the daily movement of its approximately 21 million inhabitants, no reliable network of emergency care exists (4). Consequently, fatalities from car accidents and other medical emergencies are frequent. When individuals with chronic or communicable diseases are able to reach one of the few major public hospitals, they confront long lines to receive care. Current statistics show that there are 1.95 medical workers per 1,000 individuals in Nigeria (4). This shortage is worsened further by the inequitable distribution of workers within the nation. There are no policies regulating the distribution of workers, so public agencies deploy workers at their own discretion, which complicates the situation because these agencies often have conflicting interests in where to assign workers (4).  

Historical Background

Nigeria has one of the largest economies in Africa, developing its economy on trading crude oil with foreign nations (29).  With a population of 190 million individuals, there is a lack of prioritization of the health care needs of citizens despite the resources available from the country’s sizable GDP (28).Yet decades of poor economic management, military rule, and corruption have left the country with high levels of poverty and poor infrastructure to meet its needs (29). 

Plans to expand the health care infrastructure and develop the strength of curative medicine in Nigeria led to the implementation of primary health care (PHC) in the 1960s (30, 31). In 1975, strides towards a primary health care system were made with the development of the National Basic Health Services Scheme (NBHSS) (30). The NBHSS intended to improve access to health care through addressing issues of accessibility and affordability of care, prevention and cure of diseases, and provision of health care to the needy. However, the NBHSS never reached its final stage of implementation, leaving many without access to PHC. 

Under the leadership of Professor Olikoye Ransome-Kuti, Nigeria’s first national health policy implementing PHC took place in 1988. Professor Ransome-Kuti expanded PHC responsibility to all local governments and attained an 80% immunization rate for all Nigerian children (32) as an attempt to implement the tenets of the Alma Alta Declaration of 1978, which identified primary health care as a key to addressing health-related inequalities. Between 1958 and 1992, Ransome-Kuti introduced comprehensive health policies that provided preventative medicines and health care services, breast-feeding practices, free immunization, and compulsory vaccination to all Nigerians (32). Under his leadership, an effective HIV/AIDS campaign was implemented in the early 1990s, and in 1992 the National Primary Health Care Development Agency (NPHCDA) was created to continue the implementation of PHC related policies (30, 32). 

Current Health Care in Nigeria 

The Nigerian government experienced a military takeover in 1993, which brought the progress made by Ransome-Kuti and others to a screeching halt. It has been 25 years since progress such as Ransome-Kuti’s has been pursued in order to transform Nigeria’s desperate health care system into one able to meet the needs of its inhabitants. Currently, Nigeria’s health care system only operates with 20% of the 30,000 PHC facilities available due to lack of infrastructure to provide quality and effective care to its patients (33). Nigeria spends less than $5 USD per capita on health care, which pales in comparison to the WHO recommendation of $34 USD per capita on health care for developing countries (30).Analysis of the allocations of the Federal Government budget allocations show allocations on health care rose from 2.55% in 1996 to 2.99% in 1998 under the leadership of Ransome-Kuti (30, 34). In 1999, health care’s share of the budget declined to 1.95% and rose to 2.5% in 2000 (30, 34). 

Despite Nigeria’s menial expenditure on health care, there are ample funds in the federal budget for Nigeria to invest in its health care sector. Without such funding, issues of poor infrastructure, inadequate equipment and inefficient health care services were prevalent. Nigerian health care workers, who sought to serve their country, experienced immense job dissatisfaction and low motivation while attempting to provide adequate care to individuals—lack of resources doomed these health care workers from the start (30, 35). 

The Nigerian government implemented the Commonwealth Code of Practice for the International Recruitment of Health Workers in an effort to stem the flow of health care workers out of Nigeria (30). Meanwhile, tenets of the Abuja Declaration of 2001—including allocation of at least 15% of a country’s annual budget to the healthcare sector—remain unfulfilled in Nigeria. (36). Implementing the Abuja Declaration would increase resources for the development of PHC services for all Nigerians, but it is unclear now whether fulfilling this policy is a priority on the agenda of the Nigerian government.

Case 2: Malawi’s Efforts to Address Capacity Issues Due to the Medical Brain Drain

Malawi a landlocked country of approximately 19 million individuals in southeast Africa (37), is another one of the sub-Saharan countries severely affected by the medical brain drain. Malawi, where 85% of the population survives on less than $2 per person per day, relies largely on its agricultural productions to stimulate the economy, though the country’s food supply has suffered due to precarious climate events (38). While Malawi’s health care worker shortage situation mirrors those of its geographic neighbors, this country has taken unique aims to address its health care capacity issues. 

Migration of Health Workers

The migration of health workers out of Malawi began in the early 1990s (39). Previously, Malawian health care workers who emigrated from the country remained in OECD countries after obtaining their medical training. In the 1990s, the country experienced severe economic turmoil as the government attempted to expand its medical training and health care services capacity with the creation of nursing and medical schools (39). During this time, Malawi’s usually strict control of movement of its citizens and civil servants devolved. Before 1993, individuals needed government clearance to go abroad, but as the country experienced political and economic turmoil, these conditions relaxed (39). The lasting effects of this were newly trained health care workers without the health care facilities to perform their duties. Many opted to emigrate abroad.  

Malawi has an overall vacancy of health care workers of 33% (40). For surgeons, among other specialties needed, the vacancy reaches up to 100%. In 2004, the country lacked 64% of the nurses it needed to fill the 6,084 posts it had established around the country to serve its citizens (41). These shortages have since grown to a 75% vacancy for nurses. Malawi also lacks the capacity to provide quality obstetric care, as it lacks 115 of the 126 positions for Obstetricians/Gynecologists it has established (42, 44).Midwives and clinical officers who typically step in to fill the gap in obstetrics care are also in severe shortage. This has left the country with a high maternal and child mortality rate, with 16 women dying every day in Malawi from childbirth-related complications. 

Mitigation Attempts

The Malawian government implemented a six-year Emergency Human Resources Program (EHRP) in 2005 in an attempt to address its shortage of health care workers (40). The program implemented financial and structural incentives to train health workers through a 52% salary increase for health professionals and heavily recruited volunteer doctors and nurses as short-term fillers (49). The country created the Kamuzu College of Nursing and the School of Medicine to increase production of nurses and doctors (39). These efforts were made to tackle the glaring vacancies of health care workers and disparities in existing health care workers between the urban and rural areas of the country. From 2004 to 2009, the country has approximately doubled its output of physician graduates and clinical officers and quintupled its output of laboratory technicians while also decreasing the migration of nurses (43). Despite these necessary gains, the country still requires massive additions to its capacity deficits. The EHRP is an example that more targeted interventions to increase the capacity of health care services are necessary to alleviate one of the main push factors of health care workers who emigrate—lack of resources and capacity to provide the care they desire to administer in their country. 

Ethics and the Misdistribution of Burdens and Benefits 

Human Rights and the Ethicality of the Global Medical Brain Drain

Individuals in source countries have a right to healthcare that cannot be fulfilled by the individual alone (16). The fulfillment of this human right requires an extensive organization of government systems, institutions, and medical personnel to coordinate an adequate level of accessible care (17). The duty of care for these individuals falls primarily on the source country’s government who must maintain an adequate supply of medical workers who can provide care to individuals (18). Medical workers are crucial to healthcare systems; therefore they are the secondary duty-bearers of individuals’ rights to healthcare (16, 18). Medical workers are duty-bound to contribute to the government’s ability to uphold access to health care as a human right. When the medical brain drain depletes the availability of medical staff in a country to a critical level, emigration becomes unethical because it leaves citizens of the source country without access to an adequate standard of medical care. A sufficient standard of care is not reached when a critical shortage of medical workers robs inhabitants of access to the most basic of healthcare, such as primary care (5-6). 

The primary causes inducing the migration of workers—poverty, poor working conditions, low pay, etc.—are engendered by inequalities partly rooted in larger macroeconomic trends of economic development and international trade, which subsequently makes the medical brain drain itself unjust The migration of these medical workers is a symptomof fundamental structural inequalities between LMIC and high-income countries (5). The extreme poverty and deprivation of human capabilities evident in LMICs must be addressed on the grounds that the condition of individuals in LMICs are not being made better in existing inequalities (14, 19). Taking into account the broader causes and effects of global inequality (of which this paper does not have the space to detail) allows us to understand the medical brain drain as an outcome of existing global injustices. High-income countries and LMICs must work together towards more global justice. As LMICs make efforts to address the vulnerabilities in their health systems, high-income countries have responsibility to address the medical brain drain, as it is a symptom of global injustice (5).

Misdistribution of Burdens and Benefits 

The benefits and burdens of this migration flow are differentially accrued: the source country and its inhabitants largely receive burdens and minimal benefits, and the destination country and the migrants’ primarily receive benefits (see Table 2) (15). This inequitable distribution of benefits and burdens causes significant harm to the source countries.  

Healthcare workers from countries experiencing critical shortages accomplish the greatest good in terms of lives saved and economic return on investment to the home country when they remain in their home country to work (5). These individuals have important medical skills, which when combined with their local knowledge, make them uniquely capable to provide care in their home country (5, 15). The utility of health care workers remaining in their home country can be extended to entire regions around the world. The millions of lives suffering, billions of dollars lost to the source country in emigrated workers, and immense burden of disease represent a gross imbalance representation of the burdens accrued to source countries who lose healthcare workers. 

Source and destination countries disproportionately experience the distributions of benefits and burdens of the medical brain drain. The former part of this paper details some of the detrimental effects source countries endure due to the medical brain drain. On the other hand, destination countries experience numerous benefits of added medical workers to strengthen their health systems without undergoing the cost of training these professionals. These benefits include: less need to meet the growing demand of health care workforce, added stability of health systems, and less need to invest in national medical education (9). 

Policy Recommendations 

The following policy recommendations are proposed to rectify the harms endured by source countries and to introduce sentiments of justice into the emigration of health care workers to destination countries. The international community has taken an important step in adopting the WHO Global Code to tackle shortages in LMICs by acknowledging that ethical norms must be used to guide cooperation on the issue of the migration of health care workers. However, the code has been ineffective because of its non-binding nature and lack of incentives to guide destination countries to adopt national policy changes consistent with the code (12). The WHO should employ pressure through the media to mobilize national civil groups as a tactic to prompt destination countries to employ policy changes that address these countries’ roles as passive recruiters of foreign health care workers (2).        

A mechanism of reimbursement should be developed to address the issues of “reverse aid” in which poor source countries provide ready-trained medical professionals to wealthy destination countries (5, 6). Source countries also have some obligation to address the medical brain drain by improving the education and training of medical professionals and by increasing their quality of health care systems (6). Poor working conditions and low wages are issues that source countries must rectify. Ghana is recent example that increasing wages is effective in incentivizing medical workers to remain in source countries (24). Malawi’s implementation of the EHRP program included a 52% increase in salary for health professionals that partially contributed to the country’s ability to retain its health workers. In 2003, Kenya’s health minister, Charity Ngilu, worked to increase its salaries for starting physicians from $250 to $500, and reported that the salaries drew some physicians from the private sector back to the public sector and partly contributed to the country’s ability to retain the increased numbers of physicians it had recently graduated (52). These countries serve as evidence that any country’s attempt to address its lack of health workers should consider wage increase as part of its policy solution. 

Countries experiencing a shortage of health workers are often resource-poor countries experiencing declining public health budgets and increasing debt. Efforts to implement health systems strengthening-focused policies must take this reality into account. This may necessitate destination countries and international NGOs to collaborate with source countries to provide the funding and support necessary for source countries to successfully implement sustained policies to address the deficiencies of its health sectors. Development of a global health resource fund is a policy proposal that is slowly gaining traction among researchers and policy analysts (53). This fund would be coordinated by the WHO and the World Bank to implement cost-sharing and reimbursement mechanisms for source countries to fund programs targeting health systems strengthening and other policies to address the brain drain. This fund would be financed by a global fee structure against destination countries and private sectors that benefit from the migration of health workers from source countries (53). This policy proposal devises a sustainable mechanism of supporting the development of health systems in source countries. 

An increase in salaries to satisfactory levels may have no significant effect in retaining workers if dangerous working conditions persist. It is crucial for countries to prioritize the safety and wellbeing of its health workers. Improved health infrastructure and efficient health systems management are necessary to increase the ability of health workers to provide services in a risk-free environment. This can be accomplished through source-destination country collaborations to repair and upgrade existing health facilities to have up-to-date physical infrastructures, technology, drugs, and supplies/equipment (52).Destination countries should assist source countries with the development of efficient and sustainable health system management approaches that train source countries to develop country appropriate methods of drug distribution systems, emergency medical services, and health information management systems (52).

Other tactics such as task shifting to less specialized health care workers should be employed to expand the coverage of the health systems (25). The WHO recently launched the WHO/OGAC Task Shifting Project as a measure to expand the capacity of existing health care workers in African countries especially experiencing the burden of HIV/AIDS (45). Under this program, tiered level of workers are recruited to serve as field officers, community antiretroviral therapy supporters, antiretroviral therapy aides, and community health workers and trained to provide education on HIV prevention, treatment, and adherence, to provide assistance to nurses, and to follow-up with individuals receiving antiretroviral therapy. Seven countries—Ethiopia, Haiti, Malawi, Namibia, Rwanda, Uganda, and Zambia—have begun to implement task-shifting approaches. In Uganda in particular, there is only one doctor for every 22,000 patients, so Uganda’s nurses are now trained to fulfill the tasks that were formerly accomplished by doctors in order to expand its human resources capacity to deliver HIV/AIDs treatments to its population (45).  

Source countries should consider imposing a compulsory service requirement, which makes access to education contingent upon health care workers temporarily agreeing to remain in the source country for two years (26). Countries such as Nigeria have employed this tactic in order to reduce the flow of health care workers (27). Of the countries who measure the impact of a compulsory service requirement on the level of health workers in the country are Puerto Rico, Indonesia, Turkey, and South Africa, which report positive impacts of the program (46).  Before implementing a service requirement, 16 out of 78 municipalities in Puerto Rico lacked a physician (47). After the requirement, every municipality had at least one physician. Some countries, such as Indonesia, may requirement incentivized-based requirement programs in order to retain health workers. In Indonesia’s case, incentivizing the compulsory requirement increased the amount of new doctors inclined to work in rural areas experiencing shortages (48).Often times, compulsory service requirement programs are challenged by many health professionals due to the poor execution of the program leading to high costs, low utility of the programs, and high turn-over rates after required service period has ended. But it is necessary to implement quality management teams, be transparent and clear about the intent of the program, and to provide proper support for participating health workers in order to increase the efficacy of the program (48).  

Conclusion  

There is no quick fix to address the push and pull factors contributing to the global medical brain drain. This complex phenomenon has drawn on-going debates about ethicality of its persistence and of the most sustainable methods to curtail the brain drain. Nigeria and Malawi are among the many African nations experiencing the most severe brunt of the shortage of health care workers. These countries, among others experiencing gross shortages of health care workers, are often plagued with extensive economic inequalities rooted in their history as post-colonial countries. 

A rightful response to the global medical brain drain is not to turn an eye from the suffering of these countries but to prioritize the development and implementation of ethical policies aimed at rectifying the harms experienced by source countries and the greater social and economic injustice these countries endure. Source countries and destination countries must continue to work together to rebuild the foundations of structural inequality in source countries that make it vulnerable to these critical shortages. Efforts such as task shifting, the WHO Global Code, and funding for health systems strengthening of source countries fall short if not supported by sustainable international efforts. Intermittent funding of health programs and short-lived policies will not address the complex phenomenon of the global medical brain drain. It is necessary that countries remain committed and hold one another accountable in rectifying the damages caused by the brain drain.  

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Zika: A Call for Reproductive Justice

In light of the Zika epidemic, is El Salvador ready to reconsider its prevailing anti-abortion law?

by Revathi Sahajpal, Nowrin Hoque, and Kiko Ho.

Abstract

Since 2015, the Zika virus has spread at an alarming rate throughout Latin America. The virus is primarily transferred through the bite of an infected Aedesmosquito, where perinatal and sexual routes of transmission are also possible. Infection during pregnancy is associated with birth defects including microcephaly and other severe neurological sequelae such as the Guillain-Barré syndrome. In response to the widespread Zika epidemic, the Ministry of Health of El Salvador issued a governmental advisory to “postpone pregnancy until 2018”. However, such a recommendation may be considered unrealistic given the current state of reproductive injus­tice in El Salvador. Not only are abortions illegal under all circumstances but also access to safe con­traceptives is limited. Lack of access to sexual and reproductive education, along with the country’s high rates of sexual violence and unin­tended teen pregnancies, further disadvantages young women in protecting themselves from the virus. 

Thisreview articleexamines the interac­tions between El Salvador’s absolute abortion ban and safeguarding maternal and child health during the Zika epidemic. The impact of such interactions will be examined with respect to the effect of Zika, both on the two main individuals concerned – the mother and the child – and on the rest of the house­hold with regard to health-related matters.Herein, we argue that the restrictive anti-abortion law is a barrier to managing the Zika epidemic effect­ively and propose alternative infection-control mea­sures that would be advisable. 

Visual Abstract

Introduction

Whenever a nation confronts a fast-spreading epi­demic with fatal consequences, a multifaceted strategy to controlling the outbreak is needed to minimize the spread of the infection. Appropriate interventions would include 1) educating the affected population on prevention, etiology and treatment; 2) providing access to high-quality preventive measures, diagnostics and drugs; and 3) maintaining efforts of vector control(1).

In the wake of the recent Zika epidemic, travel warn­ings and guidelines were issued towards the most vulnerable countries. Governments and health agencies in countries such as El Sal­vador, Colombia, Ecuador and Jamaica responded by advising women to postpone pregnancy until more evidence regarding the risks of Zika could be gath­ered. The present review article focuses on the govern­mental advisory issued by El Salvador, where such a delay in pregnancy was advised for up to two years. Despite the good intentions underlying that advice, it may yield consequences harmful to those concerned. 

This review article will describe barriers to successfully man­a­ging the Zika epidemic in El Salvador, in relation to the current state of “reproductive injustice” that is present. We will first examine the implications of the prevailing abortion ban on child and maternal health. Secondly, the financial impact of raising a Zika-infected child will be evaluated. We will then explore the motivations for issuing such a contro­versial advisory and how it has sparked public discus­sion of the prevailing policies that impede women’s rights with regard to human reproduction. Finally, we will discuss alternative efforts to contain the Zika epidemic, and we will compare El Salvador to Columbia where the relaxation of the abortion ban has been implemented in response to the Zika outbreak.

Background:The Zika Virus Epidemic

The Zika virus (ZIKV) is a flavivirus that is pri­marily transmitted to humans through the bite of infected Aedesmosquitos, and also by direct human-to-human transmission perinatally, sexually, throughbreastfeeding or through blood transfusion. In 2015 in Brazil, the largest Zika outbreak (so far) occurred and resulted in 440,000-1,300,000 sus­pected cases by the end of that year (6). The most noteworthy feature of this outbreak was the rise in the number of babies born with ZIKV-associated microcephaly, which is defined as the head-circumference at birth being lower than the 3rdpercentile for gestational age and sex (10); by February 2016 more than 4000 such cases were reported. 

Since its emergence in Brazil, ZIKV infection has spread to more than 69 countries and territories in the Ameri­cas, Caribbean, Asia and the Pacific (6). In El Salvador, the first three cases of ZIKV oc­curred in 2015 (7). From 2016 to 2017, the highest incidence rates were in the regions Chala­tenango (341 cases per 100, 000 population), Cabañas (254 per 100, 000) and Cuscatlán (253 cases per 100, 000). In 2017, 297 suspected Zika cases were reported in El Salvador (7). 

In some cases, ZIKV infection is asymptomatic. In others, symptoms tend to appear within six to eleven days of infection (3). The general symptoms include maculopapular rash, subjective fever, red eyes, joint pain and headache. ZIKV infection has also been linked to increased risk for severe neurological sequelae, GBS, as well as meningoenceph­alitis and acute myelitis (2). The virus can be isolated from blood, urine, saliva, semen, amniotic fluid, and brain tissues (8). The infection can be diagnosed by the direct de­tec­tion of the virus and/or viral components or in­directly through the detection of antibodies produced in response to the ZIKV infection. 

In April 2016, the Center for Disease Control and Prevention (CDC) established a causal link between ZIKV infection during pregnancy and severe birth defects, primarily microcephaly. The risk of ZIKV associated microcephaly is 1 per 100 in the first tri­mester of pregnancy, but low to negligible there­after (3). 

No vaccine or antiviral drug against ZIKV in­fec­tion has yet been developed. Treatment aims at relieving symptoms. The fever and pain due to ZIKV infec­tion are treated with symptom-specific medi­cines like acetaminophen (Tylenol) (3).

Child health outcomes

Since October 2015, ZIKV has affected pregnancies in 29 countries. Its manifestations in children are dependent on the route of transmission (6). Peri­natal infectionoccurs when the mother acquires the virus two weeks before delivery and transmits it to the fetus during labor; this results in children ex­peri­­encing symptoms similar to those experienced in adults. Congenital infectionoccurs when a woman is infected earlier in her pregnancy and transmits ZIKV to the fetus. This can cause still- birth, miscarriages and/or a distinctive pattern of birth-defects amongst fetuses and infants (10,11). 

In February 2016, the World Health Organization (WHO), in view of the Zika epidemic in Brazil and the resulting cluster of microcephaly cases and other neuro­logical dis­orders, declared Zika a Pub­lic Health Emer­gency of International Concern (13). The WHO also began to issue statements about Con­genital Zika Syndrome (CZS) in this year (11). A Zika-Epidemiological Report for El Salvador was published in September 2017 by the Pan American Health Organization (PAHO) and WHO. It was based on the data published by El Salvador’s Ministry of Health and is still today the country’s most up-to-date publicly available relevant report. In this report, from Epidemiological Week (EW) 47 of 2015 to EW 33 of 2017, a total of 391 preg­nan­cies with suspected ZIKV infection had been re­ported (7); that between EW 46 of 2015 and EW 5 of 2017, 313 cases of GBS, including four deaths, had occurred; that as of EW 31 of 2016, 109 cases of microcephaly had been reported, including four cases associated with laboratory-confirmed ZIKV infection; and that as of EW 35 of 2017, no deaths due to Zika had been reported by the El Salvador Health authorities (7). 

Maternal outcomes

While the effects of ZIKV infection can be fatal for the child, an infected pregnant mother experiences psychological as well as physical distress. Psy­cho­logical dis­tress can be caused by fear of miscar­riage as well as by fear of CZS (14); and, because abor­tion is illegal in El Salvador, an unintended or unex­pected mis­carriage may put a women at risk of criminal charges (15). 

A pregnant woman infected with the virus who wishes to terminate the pregnancy in order to avoid having a child with fatal birth defects may thus choose to opt for an unsafe, “back-alley” abortion. These tend to pose several threats to a woman’s health, including hemorrhage and risk of sepsis (16). After PAHO declared Zika a health emergency in Latin America in November 2015, online requests for abortion medications increased for most of the affected countries, demonstrating women’s desire to terminate their pregnancies despite the risks (17).

Among Latin American countries, El Salvador has the highest rate of unintended adoles­cent pregnancy and femicide: amongstthe women surveyed in El-Salvador between 1996-2013, 12.5% reported having experienced sexual and/or other physical violence. Despite this, the abortion-ban has continued (18). Given this reality, a woman’s choice to abstain from sex to delay pregnancy, in wake of the Zika outbreak, may not be respected, particularly when limited access to contraceptive measures complicates matters even more.  

Early childbearing can lead to a higher risk of maternal death and physical impairment, and is asso­ci­ated with poverty and the inability of these young mothers to attain higher education (19). In 2013, when compared to countries with liberal abortion policies, countries with restrictive abortion policies had three times higher average adolescent and higher unsafe abortion and total fertility rates (19).  Also, countries with restric­tive abortion policies had an average maternal mor­tal­ity ratio of 223 maternal deaths per 100,000 live births, whereas countries with liberal abortion poli­cies had 77 maternal deaths per 100,000 live births (18). As such, ZIKV compromises maternal health more significantly in countries where restrictive abortion policies are present.  

 The psychological impact of raising a severely disabled child is all the more notable if the mother does not have access to affordable medical care(20). A child stricken with CZS may require, at the onset, multiple imaging tests to con­firm the diagnosis. During this time, the uncertainty of the diagnosis may cause great dis­tress in the family. If the diagnosis is confirmed, the mother may feel guilty about not having done enough to protect against mosquito bites during her pregnancy (20). 

Ifit is the case thata country’s public-health sys­tem offers services to affected families, parents sometimes have to travel hundreds of miles to take their sick children for treatment (21). It is likely to be very stressful and challenging for parents to take care of such children. Excessive fatigue can lead to depression and anxiety in parents (22).

Financial and household outcomes

Employed mothers of such children are likely to have to give up such em­ployment and dedicate themselves entirely to caring for their child, thus reducing household income (21). It has been shown in Brazil that microcephaly cases are more prevalent in low-income than in high-income families (23). The extra expenditures involved in caring for the affected children can thus exacerbate notably the financial situation of these families. They not only are more susceptible (than affluent families) to ZIKV, but also face a heavier financial burden as they often cannot pay for the necessary support and care (24). 

Whereas the national average monthly household income in El Salvador is equivalent to $540 (in cities it is equivalent to $640; in rural areas, to $357; see apropos Figure 1), the total lifetime monetary costs of each microcephaly case in El Salvador is estim­ated to exceed $700,000 (23, 24). The exact estimates break down, given an assumed life-expectancy of 70 years for individuals with microcephaly, to more than $870 per month (see Table 1) (24). This is much more than the average income of urban families,and more than twice the average incomefor rural families. 

In ZIKV-affected countries, the mothers of these sick babies may abandon their other children to give their full atten­tion to the sick child(20). Moreover, it is not un­common for husbands to abandon their wives with such sick children. Such mothers receive very little financial support from out­side the family (21). For children with severe disabilities, they and their families often confront social discrimina­tion. Some mo­thers have stated that they hide the heads of their children with microcephaly to avoid stares and ques­tions by the community (25). Furthermore, full-time caregiving greatly reduces the opportunities for normal social experiences for parents. By devoting themselves exclusively to the needs of the sick child, these families are particularly vulnerable to social isolation (20).

Table 1: Per-case lifetime costs of microcephaly in El Salvador.

Type of cost(1) Direct medical costs per case (2) Direct non-medical costs per case (3) Indirect costs per caseTotal cost per case (1+2+3)
Cost in 2015 US$88,29365,635579,851733,778

Reference: A Socio-Economic Impact Assessment Of The Zika Virus In Latin America And The Caribbean: With a focus on Brazil, Colombia and Suriname (pp. 1-92, Rep.). (2017). New York: United Nations Development Programme.

Figure 1: Average monthly household income in El Salvador (in US$) in 2014

Reference: Encuesta de Hogares de Propósitos Múltiples (p. 49, Rep.). (2015). Delgado: Dirección General de Estadística y Censos

Preventive Intervention Strategy

In order to reduce the spread of ZIKV and to minimise the number of microcephaly-afflicted newborns, El Salvador’s Ministry of Health has advised women to postpone pregnancy for up to two years, in addition to setting place certain vector-control measures. However, there is a particular issue in place: a Penal Code wasimposed in 1998 that includes an anti-abortion law. The law is described as follows:  

“Aperson who performs abortion with the woman’s consent, or a woman who self-induces or consents to some­one else inducing her abortion, can be imprisoned for two to eight years. A person who performs an abortion to which the woman has not consented can be sentenced to four to ten years in jail; if the per­son is a physician, pharmacist, or other health care worker, he or she is instead subject to between six and twelve years.”(27)

Relatedly, under the influence of the Christian Democratic party, El-Salvador amended its constitution in January 1999 to recognise human life from the moment of conception (27).

Currently, in light of the Zika epidemic, the necessity of this prevention strategy is questioned by El Salvadorian women and the ongoing debate onamending the country’sabortion-ban is heating up (1).

Challenges to Intervention Strategy 

It is often challenging for women in El Salvador to delay, and even prevent, pregnancies for various reasons. Firstly, there are high rates of sexual violence that commonly lead to unintended pregnancies (24). Moreover, El Salvador has the highest adolescent pregnancy rate in Latin America,accounting for approximately 32% of all births, ac­cord­ing to the Ministry of Health (28). Adoles­cent girls are particularly vulnerable to un­planned preg­nancy since they may face discrimination for access­ing to contraceptive and family-planning services. This situation is the worst among low-income groups, where the coverage of family plan­ning services is especially low and the rate of un­intended teenage pregnancies are high. The United Nations Population Fund has estimated that unin­tended pregnancies would de­crease by some 65% if the need for contraceptives were met (26). Further­more, since the rate of sexual vio­lence in El Salvador ishigh; two-thirds of the victims are less than 15 years old; and an unwanted pregnancy can result from rape. Given the high incidence of unplanned pregnancies, sexual violence, and difficulty in accessing reproductive and sexual health-services, there is concern that women may be unable to comply with the governmental recom­mendation to wait for two years before risking pregnancy (24).

The absolute anti-abortion ban was enacted without any public consultation (24). This law allows no excep­tions, not even in the circumstances of rape, the mo­ther’s life being endangered, or the fetus being severely deformed. As such, a ZIKV-infected fetus is not an exception to this law, and both maternal and child health may be compromised. The Salvadorian Citizens’ Group for the Decriminalization of Abortion arguesthat the illegalization of abortion putsthe well-being of thousands of women and girls at risk. Many young women are afraid to seek medical help or even to talk about their concerns during preg­nancy. Between 2000and 2004, 250 women were reported to the police for doing so. Among those 250 women, 147 were prosecuted and 49 imprisoned – 23 of them were charged for abortion and 26 of them were charged for murder– with sentences of up to 50 years (27). Most of these women were young, poor and single, and were reported to police by public hospitals. 

According to government data, suicide is the cause of some 60% of the deaths of pregnant girls between 10 and 19 years old (28). For example, a19-year-old woman who had becomepregnant as a result of rape was sentenced to 30 years of impris­onment for “aggravated homicide” after having received emergency obstetric treatment during delivery (29). She suffered a spontaneous obstetric complication which resulted in a stillbirth. She was charged with manslaughter, i.e. of intentionally fail­ing to save the baby. When she was at the hospital, she was not allowed to speak with her family, and she was not able to hire a lawyer (27). 

Theprevalence of criminal violence in El Salva­dor puts remark­able pressure on the judicial system. Becauseprosecutinga gang-member willlikely to entail threats of violence from the gang,prosecutors are more likely to prosecute women seeking abortion, many of whom haveno money to hire a defense attorney, noway to threaten pro­secutors, and can readily be arrested while re­cover­ing in hospital from an obstetrical emer­gency (30). The criminalization of abortion thus not only leads to women toseekunsafe abortions, but also incitesanxiety in women who experience miscar­riage or other obstetric complications (29).

Alternative Efforts to Avoid Infection with Zika

We argue that alternatives to the  delay-pregnancy recommendation would prove more effective in controlling the spread of ZIKV. Current alternative efforts proposed by public health officials include vector control, sexual/reproductive health education and services, as well as improved diagnostics (1).Aedes aegyptimosquitoes often breed and live in or around people’s living area. This supports the notion that local communities are crucial in the execution of Zika prevention. The El-Salvadorian government should provide education on vector-control strategies such as removing standing water, where mosquitoes lay eggs, and by holding insecticide-spraying campaigns (24). How­ever, since Zika can also be spread via sexual trans­mission, it is important that the government provide sexual and reproductive health services and educa­tion at primary- and secondary-school level. This inclu­des providing information and access to safe contraceptives. Such services could reduce a great deal of unplanned pregnancies, espe­cially among teenagers (27). 

Proper laboratory diagnostic testing of Zika is usually in­ac­cessible in El Salvador (26). It is often diffi­cult to detect the disease since most of the infected individuals are asymptomatic (only some 20% of them have noticeable symptoms.) It is essential for the country to have diagnostic tools available to reduce human-to-human transmission and to prevent the long-term consequences of Zika (25). Less strict anti-abortion legislation is also needed. The latest WHO report in 2017 on Zika shows that Brazil has reported 2211 cases of microcephaly, whereas Colombia has only reported only 60. Some experts have suggested that this difference between Brazil and Colom­bia may be due to the less restrictive anti-abortion laws in the latter country (31). In 2015, health officials in Columbia agreed to accept Zika infection as a rationale for legal abortions. By relaxing the anti-abortion ban, this reduced Zika-associated microcephaly cases to 47, whereas 700 cases had been predicted (1).

Future Implications

Given the existing laws and policies that limit access to contraception and abortion in El Salvador, the issued advisory in face of the Zika epidemic is a challenging guideline to follow. Many women have little authority in their house­hold and are unable to participate in decisions regarding their own sexual behavior. Multisectoral interventions are essential to protect maternal and pediatric health. In accordance with WHO recom­mendations, access to health interventions and ser­vices should include family planning, contraception, safe abortion, appropriate care for high risk preg­nan­cies, psycho-social support, gender-based vio­lence-prevention programs, and sex education (32). It is crucial to ensure enhanced delivery of such services and to reduce bar­riers to accessing quality diag­nostics and drugs. Currently, a 24-monthlongstudy is monitoring the current trends of contraception and abortiondemands in ZIKV-affected areas(33). This is achieved through the development of a sur­veillance sentinel-site net­work, where sentinel sites will begin in El Salvador and Columbia (33). The WHO has recommended that countries adopt this monitoring approach in order to inform policy-makers to help build the infra­structure needed to meet the growing demand for these services. This will strengthen the health system response to community needs in sexual and reproductive health.

Conclusion

The Zika epidemic has paved the way for a much-needed discussion regarding the current state of reproductive injustice in El-Salvador. The Ministry of Health has issued a contro­versial ad­visory that women should delay preg­nancy for up to two years. This form of infection-containment effort dimin­ishes the re­pro­ductive rights of women in El Salvador given the strict anti-abortion legislation that is currently operative there. There are three main ways in which those rights are there­by limited:1) thegovernmentalapproach does not considerintersection of gender and poverty, where it disregards the needs of poverty-stricken women. Indeed, the effect of an epidemic is generally more likely to be pronounced for the poor because of their limited purchasing power, their often unsanitary living condi­tions and their relatively limited ac­cess to healthcare; 2) this recommendationalsoignores the prevalence in the region of gender-based vio­lence whereby women are often subjected to unwanted pregnancies in the case of rape; and 3) the recommendation ig­nores the lack of ac­cess to contra­ception and safe abortion. 

Due to this myopic public-health response by the government, Zika infection in El Salvador has significantly impacted maternal mortality and child morbidity. An increase in illegal and unsafe abortions continues. And yet, an in­crease in the rates of microcephaly and other develop­mental disorders in children may not effectively be prevented (34). This articleis an effort to provide compelling evidence to support the need to decriminalise abortion in El-Salvador in order to safeguard maternal and child health in the foreseeable future.

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Evaluation of a Peer-Based Sexual Health Education Program in Quito, Ecuador

Emily Nagler

April 24, 2018

Ecuador is a socially conservative and predominantly Catholic nation, with the second-highest teenage pregnancy rate in Latin America and a climbing rate of sexually transmitted infections (STIs). Abortion is criminalized, which contributes to high rates of clandestine abortions that cause female morbidity and mortality. Because of this, President Lenin Moreno mandated in May 2017 that sexual health education in public schools be medically accurate and without ideological influence, though he has yet to enforce this policy. The Ecuadorian government has made many strides to improve health in recent years; however, it continues to fall short in promoting sexual and reproductive health. Non-governmental organizations (NGOs), such as El Centro Médico de Orientación y Planificación Familiar/The Family Planning and Counseling Clinic (CEMOPLAF), work to fill these gaps by improving access to reproductive healthcare and education. The CEMOPLAF Adolescenteprogram educates adolescents and trains Youth Health Promoters (Promotores) to share sexual health information and distribute contraceptives to their peers. CEMOPLAF also works to promote the discussion of adolescent sexual health through their online resource, Mucha Nota. 

In the present study, we surveyed and interviewed Promotores in four different CEMOPLAF centers throughout the city of Quito, Ecuador to determine their attitudes towards this program. Participants revealed that the program is beneficial to adolescents who cannot come to a center themselves and are unwilling to speak to adults about sexual health. From our observations, we recommend that CEMOPLAF should continue expanding to more schools and leading interactive workshops with Promotores. Furthermore, we suggest the addition of an interactive forum to Mucha Nota and implementation of a pre- and post-program test to evaluate the knowledge gained by Promotores. Future research should analyze teenage pregnancy and STI rates by neighborhood in Quito to quantify the benefits of CEMOPLAF Adolescente.

Background

Sexual and Reproductive Health in Ecuador

Although the Ecuadorian Constitution proclaimed sexual and reproductive health a human right to all in 1998, gender inequality and stigma against sexuality persist. In 2008, the president of Ecuador, Lenin Moreno, amended the Constitution to recognize life from the moment of conception, reaffirming the criminalization of abortion. About 65% of Ecuadorians support decriminalizing abortion, although 75% of citizens self-identify as Catholic, a faith that is traditionally anti-abortion.1Despite these reported attitudes, promotion of family planning remains controversial and contentious. 

Partially due to limited access to contraceptives, teenage pregnancy rates in Ecuador are the second highest in all of Latin America, where 29,000 teenage girls gave birth in 2014.1This lack of readily available contraceptives mainly impacts young, poor and indigenous women. Due to legal restictions, abortions are often performed in unsafe, clandestine conditions. Complications from these underground abortions are the leading cause of female morbidity in Ecuador, and a significant cause of maternal mortality.2Lack of access to contraceptives and safe abortion is particularly detrimental to the health of women facing sexual violence, which is highly prevalent: of women over 15 years old, 38% have experienced physical and/or sexual violence from an intimate partner at least once in their lifetimes.3

In effort to rectify poor sexual health outcomes in Ecuador, President Lenin Moreno mandated in May 2017 that sexual health education in public schools be medically accurate and without ideological influence. This policy has not yet been implemented, and does not coincide with any current governmental plans to improve sexual and reproductive health throughout the country. To redress this inaction, non-governmental organizations (NGOs) must take on a larger role to provide comprehensive sexual health education.

CEMOPLAF History

CEMOPLAF (El Centro Médico de Orientación y Planificación Familiar/The Family Planning and Counseling Clinic) was established in Quito, Ecuador in 1978. Today there are 26 CEMOPLAF centers in 11 provinces of Ecuador, staffed by 342 people.4The NGO’s main objectives are to raise awareness about sexual health issues and provide health services to marginalized populations, particularly mothers, youth, and families in underserved rural and urban areas. Currently, 25% of CEMOPLAF services are provided to youth under 19 years old and 51% of services are provided to adults under 25 years old.4CEMOPLAF services include low-cost basic healthcare screenings, gynecological services, psychological services, and more. Women comprise 90% of clients, while family planning and gynecology comprise 57% of provided services.4

In 1995, CEMOPLAF launched the CEMOPLAF Adolescente program for local teens. In this program, professional educators work with adolescents to improve knowledge of sexual health and lower STI and teen pregnancy rates. This program also trains Youth Health Promoters (Promotores), ages 10-19, to share sexual health information with their peers, thereby improving access to information among adolescents. Some Promotores are trained to distribute contraceptive methods to adolescents, including male condoms and the emergency contraceptive pill. This program operates in 18 CEMOPLAF centers, with 480 Promotores trained thus far. In 2017, CEMOPLAF launched Mucha Nota: a website, Facebook page, and YouTube channel that provide sexual health information for adolescents and parents online.

Statement of Purpose & Hypothesis

The purpose of this study is to determine how CEMOPLAF Adolescente can better meet the needs of adolescents in the city of Quito. It aims to explore which strategies would make peer-based sexual health education efforts more likely to succeed, or whether professional-led programs are more beneficial. We hypothesize that Promotores trust the staff and enjoy their time at CEMOPLAF, but that many face pushback from skeptical peers and family members. We thus predict that adolescents prefer peer-based to professional-led education.

Methodology

This project received ethical approval from the Institutional Review Board at Duke University in Durham, North Carolina. The research participants are 33 Promotores ages 13-22, who voluntarily visit CEMOPLAF once a week for workshops and trainings. They live in four different neighborhoods in Quito and attend workshops at four different CEMOPLAF centers: Comité del Pueblo, Cuero y Caicedo (17 out of the 33 participants), El Inca, and Chillogallo. Those who had been in the program for less than a month were excluded, as were friends or partners who attended workshops inconsistently. CEMOPLAF Adolescente staff helped determine which students attended workshops frequently enough (once a week for more than a month or at least twice a month for more than two months) to qualify for the study. Of the Promotores surveyed, 7 self-identified as male and 25 as female.

Those who qualified for the study and gave verbal consent to participate were asked to fill out a 21-question survey. Some volunteered to participate in 5-10 minute interviews guided by 13 main questions. Due to the overlap in responses to these tools, the findings are reported together. 

Since Promotores are not required to come to CEMOPLAF, attendance varies day-to-day within each center. Over the course of two weeks, they were asked to complete this survey when they arrived at CEMOPLAF before engaging in any activities. Before completing the survey, participants were read the consent script, were offered the chance to ask questions, and received a contact card. If they agreed to the interview, participants were taken to a quieter area of the room or separate room to discuss the adolescent program for 5-10 minutes. After administering 33 surveys and 9 interviews, trends among all responses were analyzed. The interviews were translated from Spanish to English for our purposes. 

Results

Before CEMOPLAF

Before coming to CEMOPLAF, 65.6% of participants had never spoken with a counselor, health professional, or teacher about sexual health. The rest had spoken with siblings, other Promotores, professionals, or CEMOPLAF staff who had led workshops in their high schools. They had discussed sexuality, bodily changes that occur during adolescence, and how to protect themselves against STIs, HIV/AIDS, and/or unplanned pregnancy. As shown in Figure 1, 71.9% of participants heard about CEMOPLAF at their high school (many through CEMOPLAF’s presentations), 12.5% from family members (mainly parents and siblings), 12.5% from friends, and 3.1% on the Internet.

When asked about why they first decided to come to CEMOPLAF, 41.2% of participants said they had a sexual-health-related concern, 32.4% at a friend’s suggestion, 20.6% due to non-parental family member’s suggestion, and 5.9% prompted by parental suggestion. Seven students provided alternative reasons for coming, including: CEMOPLAF had come to their high school and the program seemed interesting, they believed it was important to learn about sexual health, and they wanted to know more about these topics.

Figure 1: Where did you hear about CEMOPLAF?

Typical Promotor Involvement

Interviewees emphasized that many Promotores had friends, partners, or siblings already in the program that encouraged or inspired them to join and that many others were interested after attending CEMOPLAF talks in their schools. During a typical month, Promotores came to CEMOPLAF anywhere from once a week to once a month, depending on their availability. Once school ended for summer vacation, many choose to spend time at the centers beyond scheduled workshop days, some coming up to 4 days per week for several weeks. Through workshops, they learned about topics such as STIs, how to put on a male and female condom, proper use of other contraceptive options (such as injections, implants, the patch, IUDs, the emergency contraceptive pill, and the 21 and 28-day pills), how to react to a friend who says she wants an abortion, Ecuador’s specific abortion policies, and the importance of pap smears, self-esteem, communication, and related information. They also learned to how to share information with others, such as classmates, friends, and family members, focusing on helping those who are unable to come into CEMOPLAF themselves. Some learned how to “counsel” friends who need contraceptives, and are trained to give out condoms, emergency contraceptive pills, or referrals for injections, along with all necessary information about the contraceptive method. 

Curriculum Gaps, Likes and Dislikes

Since the participants had been attending workshops for different amounts of time, ranging from several weeks to over five years, individual levels of sexual health knowledge varied. Some students (4) reported that they did not have questions about any topics, while others wanted to learn more about abortion (1), pregnancy (2), STIs (5), sexuality (1), menstruation (1), contraceptive methods (4), and sexual/gender identity (1).

Participants enjoyed the structure, topics, and social aspect of the program, as well as  how the teachers explained complex topics, the dynamic activities and interactive demonstrations, and the conversations in which they could participate and ask questions. Their favorite topics were contraceptive methods and how to avoid STIs and teenage pregnancy. They also appreciated that the program allowed them to meet other types of people and teens from other centers, who they would not know otherwise, to discuss their issues with people of similar ages. They enjoyed CEMOPLAF social events, especially the annual 3-day national retreat with Promotores from around the country. 

Fifteen Promotores responded that they liked “everything” in the program. Others mentioned that they did not like “when we mess up or make mistakes during a workshop or chat,” “that there are not enough boys in the program,” “when there are just lectures and we do not get to interact as much,” “the short time” spent in the centers, “when we don’t do anything,” and “when the workshops are confusing and hard to understand.” 

Adolescents’ Sentiments on Communicating About Sexuality

Twenty-three participants said the only external resource they use for information on sexual health is Mucha Nota (Figure 2). Others ask friends (1), family (6), learn in school (6), or use magazines/books (1). Every participant would invite a friend to CEMOPLAF, and the majority felt neutral, a little comfortable, or very comfortable sharing the information they learn with peers and family (Figure 3). One Promotor reported: “My friends think it’s a little funny, but my family likes [that I go to CEMOPLAF] since my mom and aunt don’t have a lot of time to explain things about sexual health to me.” 

Figure 2: Where do you go for sexual health information?

All participants felt that their communities benefit from CEMOPLAF Adolescente. Their families and friends were generally supportive of their participation, though some had initially been hesitant to let them join the program. Participants speak most frequently about sexual health with friends and siblings, and speak more frequently with their mothers than fathers. Teachers and guidance counselors serve as a resource for a few of the respondents, but always infrequently (Figure 4). 

Figure 3: How comfortable do you feel sharing sexual health information with friends and family?


Many interviewees expressed that it was difficult to discuss sexual health with their parents, many of whom are “traditional” and do not want to discuss it. It was evident that many teens felt uncomfortable bringing up these topics with their older, socially conservative and Catholic parents as well as their cousins, siblings, or friends who typically do not have the knowledge to provide useful advice. Adolescents often lacked the trust to speak with teachers, felt their guidance counselors only want to discuss mental health, and thought their doctors only want to discuss disease prevention. Therefore, they often turned to online resources, where Mucha Nota, the center’s website, is valuable. Though many expressed a strong desire to communicate better with their parents and family members, they did not know how to improve communication.

Figure 4: How frequently do you speak to different people about sexual health topics?

Promotores’ Suggestions

Twenty-two Promotores offered suggestions to improve the program, including that the program should expand to more schools, help more teens, become better known, and continue incentivizing schools and students to participate in the program. Others wanted to meet with Promotores from other centers more frequently, have longer workshops, spend more time at CEMOPLAF (more than once per week), review the advanced activities, and create a mascot or logo for CEMOPLAF Adolescente.

Some offered suggestions to improve CEMOPLAF’s online presence. They agreed that Mucha Nota does a great job serving its purpose: it a comprehensive resource that is especially valuable to adolescents who are too embarrassed to ask adults about sexual health or who cannot come into CEMOPLAF. Some suggested that it should become more interactive, serving as a forum where adolescents could post their questions, professionals could respond, and everyone who visited the page could see the answers and post concerns and follow-up questions.

Discussion

Recommendations for CEMOPLAF Adolescente

Based on this data and our observations of CEMOPLAF Adolescente, we have developed several recommendations for the program. CEMOPLAF should encourage more adolescents to join the program, especially by leading workshops in more schools. They should focus on expanding the program into schools that are farther from CEMOPLAF centers. Since school presentations appeared to be the most effective way of recruiting adolescents, expanding the range of schools will spread awareness of the services CEMOPLAF offers and recruit more Promotores.

CEMOPLAF Adolescente should improve options for students who cannot visit every week. This includes expanding Mucha Nota to create an interactive forum, so that students can participate in conversations about sexual health without being in-person at a center. This would reduce the workload of CEMOPLAF doctors and counselors: since all users would be able to view all question threads, CEMOPLAF staff would have to respond to fewer personal questions through the existing “chat” mechanism. CEMOPLAF Adolescente should ensure that workshops remain productive, interactive, and interesting for students at various knowledge levels. Workshops should emphasize strategies to improve communication with parents, teachers, family members, doctors, and guidance counselors.

CEMOPLAF Adolescente should also implement a pre- and post-assessment to ensure that Promotores retain the most important parts of the curriculum. Every Promotor would take this assessment upon entering the program to evaluate existing knowledge and avoid re-learning information. Before being allowed to counsel peers and distribute contraceptive methods, Promotores would retake this test to ensure they were adequately prepared to teach.

Limitations

Although we read the consent script to each Promotor and they all expressed verbal understanding of its contents before beginning the survey, some factors may have impacted their responses. Due to the confined setting, we were unable to separate some Promotores while filling out their responses, so they likely heard others’ ideas. Although we were present and ready to answer questions, some preferred to ask the CEMOPLAF Adolescente staff for help with the survey, which may have influenced responses.

We hoped that our role as foreign interns would encourage the Promotores to be more honest when critiquing the program than they would be with regular staff members. However, it is possible that the Promotores did not want to give us honest and extensive critiques since they knew we would be discussing their responses in the United States (where much of the program’s funding comes from). We also could not guarantee that every response remained fully anonymous since some Promotores filled out the survey alone (when no one else had visited the center that day), so they knew we could look at the survey immediately after and identify that it was theirs. To address this issue,  we assured them we would wait to review the surveys in aggregate. Additionally, since we used a convenience sample of only 33 eligible Promotores who volunteered, this data is not generalizable to all adolescent populations in Ecuador receiving CEMOPLAF services.

Implications and Future Research

Although this data is specific to the CEMOPLAF Adolescente program, it has relevant implications for other sexual health education initiatives. This study supports prior observations that adolescents prefer to discuss sexual health with their peers, and that many are more likely to consult friends, siblings, or the Internet than they are to consult books, parents, teachers, or guidance counselors. Sexual health education programs for adolescents should include peer-based initiatives, such as CEMOPLAF’s Promotores program, which allows adolescents to discuss issues with people of similar ages, meet new people, and create social spaces in which sexuality is not stigmatized. In areas where contraceptives are inaccessible or expensive, these programs improve access for adolescents who lack other means to acquire them. Peer-based initiatives also encourage referrals to reproductive healthcare clinics for adolescents who may otherwise be too embarrassed or afraid to visit on their own.

Future studies should evaluate and quantify the impacts of the CEMOPLAF Adolescente program and the benefits of Promotores within their communities. They should compare rates of STIs and teen pregnancies in neighborhoods in Ecuador that do and do not have CEMOPLAF centers, and more specifically compare neighborhoods that do and do not have CEMOPLAF Adolescente and/or Promotores. In addition, obtaining the perspectives of adolescents’ parents would improve centers’ understanding of what parents want their children to gain from sexual health education programs. Such studies would provide a stronger basis to increase funding for CEMOPLAF and promote their expansion into more communities in Ecuador.

References

  1. Guidi, R. (2015). As Pope Francis visits Ecuador, women there say they’re losing ground[online]. Public Radio International. Available at: https://www.pri.org/stories/2015-07-04/pope-francis-visits-ecuador-women-there-say-theyre-losing-ground
  2. Human Rights Watch (2013). Rape Victims as Criminals. Illegal Abortion after Rape in Ecuador[online]. Human Rights Watch. Available at:  https://www.hrw.org/report/2013/08/23/rape-victims-criminals/illegal-abortion-after-rape-ecuador
  3. UN Women (2016). Ecuador: Prevalence Data on Different Forms of Violence against Women[online]. UN Women Global Database on Violence against Women. Available at: http://evaw-global-database.unwomen.org/en/countries/americas/ecuador#1
  4. CEMOPLAF (2017). Sexual and Reproductive Health NGO- CEMOPLAF. 

Hidden casualties of war: Cutaneous leishmaniasis and the Syrian civil war

Joshua Grubbs

March 20, 2017

The Syrian civil war has resulted in a public health emergency marked by a rising incidence of infectious diseases, including cutaneous leishmaniasis (CL). Historically endemic in Syria, the number of CL cases has significantly increased as a consequence of the country’s deteriorating health care systems amid the current civil war. Public health officials in Syria and neighboring countries should be concerned as the influx of refugees may facilitate the spread of disease throughout the region. Effective monitoring and treatment offer the best strategy towards reducing the burden of CL among this population.

Background

In March 2011, sectarian violence erupted in Syria resulting in one of the world’s most pressing humanitarian crises that continues to affect millions of Syrians today (1). Recent violence has exacerbated negative health outcomes not only in terms of injury and violence, but also communicable diseases. Notably, cutaneous leishmaniasis (CL), which has been historically endemic in Syria, has seen its incidence of infection increase again amid the current civil war (2).

CL presents public health officials with a unique challenge because of its prolonged treatment schedule, making compliance difficult in a setting that suffers from resource scarcity and social unrest. The current standard of care is daily injections of pentavalent antimonial drugs administered for 20 to 28 consecutive days (3). To complicate the situation, CL is a neglected tropical disease placing the disease among the ranks of other debilitating diseases that affect 1.6 billion of the world’s most disenfranchised people (4). Even though the disease disproportionately affects poor populations in endemic regions, such as the Middle East, the implications are far-reaching as CL can reach epidemic proportions if left unchecked.

The disease is not fatal, but can cause significant morbidity and reduce the quality of life. Transmitted by the female phlebotomine sandfly, parasites of the Leishmania genus are responsible for infection, which manifests itself in ulcerative lesions on the skin (3). Depending on the species of Leishmania, transmission can be zoonotic or anthroponotic (5), thus requiring different approaches to disease control depending on which species are endemic to the region.

The Health Effects of War: Risk Factors and Determinants

The combination of deteriorating health care systems, severe hunger, and a complete lack of sanitation services predisposes Syrians to suffer from infectious diseases like CL at an alarmingly high rate (6). Epidemiological bulletins from 2016 report incidence to be over 25,000 nationally, though it should be noted that not all districts have been able to report their cases each week (7). Recent developments in the conflict would suggest an even greater burden of disease, but CL monitoring efforts have been difficult amid current violence.                           

Despite the many risk factors for infectious disease, CL still cannot spread without the presence of a vector. The species primarily responsible for the disease in Syria is L. tropica. Unlike many other species of Leishmania, the reservoir for L. tropica is humans (6). Accordingly, the disease is “anthroponotic” and transferred between humans and sandflies without relying on an animal reservoir to continue the parasitic life cycle (5). Therefore only two populations are necessary for CL to become endemic in a region—humans and sandflies. Consequently, mass migration does not result in a decrease in infections. As long as the sandfly vector is still present, the disease follows groups of people to continue the cycle of infection.

Because the sandfly vector does not respect national borders, public health officials in Syria and neighboring countries should be alarmed. As large numbers of refugees seek asylum in neighboring countries, like Lebanon, they may continue to suffer from diseases prevalent back in Syria. The relatively long incubation period for CL ranges from approximately two to six months (8) with reported instances of incubation periods up to four years long (9). The long incubation period complicates disease control because cases could be left undetected during initial screenings (2). Treating people for CL is one of the most effective methods of prevention since humans also act as reservoirs for the disease (5), so failing to detect it early on can lead to significantly higher incidence. In fact, a recent study conducted among Syrian refugees in Lebanon showed that approximately 85% of the cases were caused by L. tropica, rather than other species more prevalent in Lebanon. Further, the study revealed that the incidence of CL in this population was significantly greater than that of Lebanon, which has a better established monitoring system (10). The risk factors identified by the team—malnutrition, inadequate housing, and poor sanitation—were just as relevant in the refugee camps as they were back in war-torn Syria.

As the incidence of CL continues to climb and new cases are reported in neighboring countries, CL has become a regional issue that extends beyond Syria’s borders. Most notably, the number of new CL cases in Lebanon underscores the severity of the outbreak over the past few years. Between 2000 and 2012, less than 6 cases of CL were reported each year. In contrast, 1,033 CL cases were reported in 2013, 998 of which were of Syrian refugees in Lebanon (11). The actual number of cases is likely much greater due to underreporting, given the barriers to health care services that refugees face. The vast majority of cases were caused by L. tropica, which causes the majority of Syrian CL cases, but the presence of other vectors—including L. major and L. infantium—and individuals infected by them could result in outbreaks of zoonotic CL due to other species outside of endemic areas (6,11).

Moving Forward: The Importance of Refugee Health

Current efforts to reduce the burden of CL in Syria have primarily consisted of vector control programs, relying on insecticides to reduce the number of phlebotomine sandflies (12). Under the auspices of the WHO, Syrian health officials also initiated the Early Warning Alert and Response System in 2012 to monitor epidemic prone diseases, including CL (7). Both of these developments are certainly steps in the right direction, but the complexity of the situation demands further action. Vector control programs should continue to remain central to the effort against CL, but the importance of effective diagnosis and treatment cannot be emphasized enough. As is the case for any infectious disease, treatment and prevention go hand in hand. Furthermore, future studies ought to consider the potential for comorbidity with other infectious diseases because of the observed increase in cholera, measles, and tuberculosis among Syrian refugees (10). Public health workers could combine treatment for CL with attention for other infections, reducing the burden of disease in their communities and preventing further infection.

A number of countries now face a critical decision regarding refugees: they can choose (1) to fully accept them and their health-related implications or (2) to deny them asylum. The nationalistic argument for limiting refugee healthcare and directing resources towards citizens is seductive, but deeply flawed. Migration is not going away and ignoring this reality does not serve national or international interests (13). CL and other diseases defy borders, affecting the health of entire regions whether refugees are accepted or not. To receive refugees and offer treatment proactively combats the spread of disease. Turning them away may delay the presence of disease, but cannot prevent it. Controlling diseases in any population, regardless of immigration status, upholds the health of all people.

References

  1. Taleb ZB, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country undergoing tragic transition. Int J Public Health. 2015 Jan 1;60(1):63–72.
  2. Leblebicioglu H, Ozaras R. Syrian refugees and infectious disease challenges. Travel Med Infect Dis. 2015 Nov 1;13(6):443–4.
  3. Reithinger R, Dujardin J-C, Louzir H, Pirmez C, Alexander B, Brooker S. Cutaneous leishmaniasis. Lancet Infect Dis. 2007 Sep;7(9):581–96.
  4. NTD Overview [Internet]. [cited 2017 Mar 20]. Available from: http://www.end.org/whatwedo/ntdoverview
  5. Prevention C-C for DC and. CDC – Leishmaniasis – Resources for Health Professionals [Internet]. [cited 2017 Mar 20]. Available from: http://www.cdc.gov/parasites/leishmaniasis/health_professionals/index.html
  6. Petersen E, Baekeland S, Memish ZA, Leblebicioglu H. Infectious disease risk from the Syrian conflict. Int J Infect Dis. 2013 Sep;17(9):e666–7.
  7. WHO | Syrian Arab Republic situation reports [Internet]. WHO. [cited 2017 Mar 20]. Available from: http://www.who.int/hac/crises/syr/sitreps/en/
  8. Elhadj H, Ziari YK, Selmane S. Cutaneous Leishmaniasis Modeling: the case of Msila Province in Algeria. Int J Innov Appl Stud. 2015 Jan 10;10(1):149–54.
  9. Weiss F, Vogenthaler N, Franco-Paredes C, Parker SRS. Leishmania tropica–Induced Cutaneous and Presumptive Concomitant Viscerotropic Leishmaniasis With Prolonged Incubation. Arch Dermatol. 2009 Sep 1;145(9):1023–6.
  10. Al MS et. Ongoing Epidemic of Cutaneous Leishmaniasis among Syrian Refugees, Lebanon1 – Volume 20, Number 10—October 2014 – Emerging Infectious Disease journal – CDC. [cited 2017 Mar 20]; Available from: https://wwwnc.cdc.gov/eid/article/20/10/14-0288_article
  11. Alawieh A, Musharrafieh U, Jaber A, Berry A, Ghosn N, Bizri AR. Revisiting leishmaniasis in the time of war: the Syrian conflict and the Lebanese outbreak. Int J Infect Dis. 2014 Dec;29:115–9.
  12. Hayani K, Dandashli A, Weisshaar E. Cutaneous Leishmaniasis in Syria: Clinical Features, Current Status and the Effects of War. Acta Derm Venereol. 2015 Jan 15;95(1):62–6.
  13. Lancet T. Adapting to migration as a planetary force. The Lancet. 2015 Sep 12;386(9998):1013.

Obesity’s Rise to the Top of the Policy Agenda

Christina Schmidt

March 20, 2017

With a plethora of health issues competing for the attention of policymakers, the politics of which diseases become national priorities is complex. Why do some health challenges receive broad support from policymakers, while others remain widely ignored? 

Introduction

Obesity has received increasing recognition in the health policy space over the past decade, providing an interesting case study for analyzing how political priorities are established in global health. In 2001, the United States Surgeon General, Dr. David Stacher, issued a “Call to Action to Prevent and Decrease Overweight and Obesity.” Citing the “epidemic proportions” of overweight and obese Americans, the call affirmed obesity’s significance on the national health agenda (1). Now the Centers for Disease Control (CDC) estimates the prevalence of obesity in the United States to be 36.5% (2). As Tom Frieden, the director of the CDC, described, obesity is considered “among the most urgent health challenges facing our country today” (3).

Kingdon’s Three Streams Model of Policy Analysis:

In an attempt to elucidate the intricacies of policy making, scholars have developed various frameworks to analyze why certain issues “rise to the top” of the political agenda.

The three streams model, developed by renowned political scientist John Kingdon, is a policy change framework that has been used in global health to analyze policy environments (4). The three streams model asserts that the convergence of three independent “streams” determines whether a particular policy issue will prompt political action. The problem stream involves persuading policymakers to prioritize a particular issue above other potential problems that policymakers could tackle. The policy stream concerns whether a feasible solution to the problem exists. Finally, the politics stream consists of the political factors and the political environment in which a policy is brought forth. While each of these streams acts independently, a policy will only reach the top of the political agenda when all the three simultaneously come together. Through the convergence of the three streams, a “policy window” emerges, providing an opportunity for political action.

As applied to the case of obesity in the United States, Kingdon’s three streams model of policy analysis reveals how problem, policy, and politics converged to push obesity onto the policy agenda, culminating in First Lady Michelle Obama’s “Let’s Move” campaign in 2010.

Problem Stream:

With the doubling of obesity rates in adults and tripling in children between 1980 and 2000, politicians and the general public quickly accepted obesity as an escalating concern at the turn of the 21st century (2). Its dominance on the health agenda was sustained in the early 2000s by steady climbs in obesity’s prevalence, which reached over 36% in adults and 17% in children by 2014 (2). With links to some of the nation’s leading causes of death—including heart disease, stroke, various cancers, and diabetes—obesity became a pressing concern in the U.S. public health arena (3). More so, in 2013 obesity was first recognized as a disease by the American Medical Association, solidifying the condition as a target for policymakers (5)

Beyond its high prevalence and detrimental health implications, obesity’s cost to society provided an impetus for political action. Alongside its increasing prevalence, the medical costs of obesity climbed from an estimated $78.5 billion in 1998 to $147 billion in 2008 (6). Medicare/Medicaid provided roughly half of this spending, making obesity a concern for taxpayers and politicians alike. Backed by research demonstrating obesity’s widespread morbidity and financial burden, obesity advocates constructed a convincing case for investing in obesity prevention, solidifying Kingdon’s problem stream.

Policy Stream:

Within the policy stream, the acknowledgement that external factors contribute to an individual’s obesity created an acceptable space for developing effective obesity prevention policies. Historically, the obesity epidemic has been framed as a health issue rooted in “personal responsibility,” with the dominant narrative asserting that avoiding unhealthy eating behaviors is the duty of each consumer. By placing the burden of change on individuals, the “personal responsibility” frame lends itself to “soft” policies, like nutritional education. The personal responsibility frame also discourages legislative action. Why should a government support those who are “unable to control their self-destructive appetites?” (7).

However, as obesity rates continued to climb and evidence confirmed that many obesity educational campaigns were ineffective, this view began to shift (7,8). The newer “obesogenic-environment” frame emphasizes that modern environments have created an “induced demand” for unhealthy foods, and that many individuals lack control over their diet. This frame prompted a new emphasis on developing policies regulating the availability of unhealthy foods (7).

Throughout the early 2000s, the policy stream was strengthened by the development of viable policy solutions to combat obesity. Currently, obesity is listed as one of the CDC’s six “winnable battles” due to the availability of evidence-based, cost-effective strategies for fighting the epidemic (9). Dominant multi-sectorial groups, such as the Healthy Eating Active Living Convergence Partnership, have been instrumental in developing policies to combat obesity (10). From increasing access to healthy fruits and vegetables in schools to improving opportunities for physical activity, evidence-based strategies to support healthy eating and active living emerged. Through collective action and research, the policy community began to build a consensus that regulation of food and activity environments would be necessary. The development of cost effective, evidence-based interventions to combat obesity strengthened the policy stream.

Politics Stream:

As feasible solutions to the obesity epidemic were developed, a favorable political environment was simultaneously established. By the mid 2000s, public opinion reflected a desire to address obesity. A 2005 poll conducted by the Harvard School of Public Health revealed that three-fourths of Americans regarded obesity as an extremely (34%) or a very (41%) serious public health concern (11). The National Alliance for Nutrition and Activity Coalition, unifying 300 high-interest organizations, was instrumental in pushing for early legislation regarding wellness policies and nutrition standards (8). By 2009, forty-three states had specific plans in place to lower the prevalence of obesity and related diseases (12). Among both the general public and public health interest groups, obesity had become a widely recognized national health problem, meriting large-scale political action.

Convergence of the Streams: Let’s Move

Public health agencies, advocates, researchers and politicians built the foundations of the obesity movement. With widespread recognition of the obesity epidemic and the availability of feasible policy solutions, obesity was poised to rise to the top of the policy agenda. In 2010, First Lady Michelle Obama leveraged the convergence of favorable problem, policy and politics streams to launch her “Let’s Move” campaign (8). Given her high profile and favorability, Mrs. Obama successfully pushed obesity to the top of the health policy agenda.

“Let’s Move” sought to combat obesity by improving school food environments, expanding access to healthy and affordable foods, and increasing physical activity. Results of the campaign included the United States Department of Agriculture’s revamp of nutritional labeling standards, and improvements to the National School Lunch Program. The campaign was accompanied by President Obama’s formation of the Task Force of Childhood Obesity, which convened twelve federal agencies to develop recommendations for reduction of obesity (8).

While Mrs. Obama was successful in bringing obesity to the forefront of the United States’ public health agenda, the effect of “Let’s Move” on obesity reduction has been debated. In 2014, researchers from the CDC released a report showing a slight decline in obesity among low-income children, and a sharp drop (43%) among children aged 2-5 years old (13). However, the prevalence among youth and adults has remained stagnant (13). Whether “Let’s Move” will contribute to sustained reductions in rates of obesity in the United States over the next few decades remains to be seen.

Conclusion

Through leveraging the convergence of the problem, policy, and politics streams, Michelle Obama successfully launched an initiative that gave new prominence to obesity prevention initiatives. While the long-term implications of the campaign will continue to emerge, “Let’s Move” exemplifies how problem recognition, the development of viable policy solutions, and political support can facilitate the implementation of large-scale health reforms. In the underfunded sphere of preventative public health, advocates constantly compete for limited resources. A deeper understanding of the conditions that produce policy change is vital for those seeking to (1) garner support for their health initiatives and (2) ensure that their own causes “rise to the top” of the policy agenda.

References

  1. Office of the Surgeon General (US). The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity [Internet]. Rockville (MD): Office of the Surgeon General (US); 2001 [cited 2016 Jan 24]. (Publications and Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK44206/
  2. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, 2011-2014. NCHS Data Brief. 2015 Nov;(219):1–8.
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