Global Health Topics - Visiting Speakers

• James Lavery, associate professor in the Department of Public Health Sciences and Joint Centre for Bioethics at the University of Toronto, spoke to the departing Downs Fellows about the challenges inherent in engaging communities in research. The students from the Yale schools of public health, medicine and nursing will each conduct original global health research around the globe this summer. “I am sure that you are going to have a huge impact on the world,” Lavery told the Fellows. 
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  “If you build it, they will come” may work in baseball, but it doesn’t work in healthcare says Dennis Walto. Instead, NGOs need to bring group care models to the people, whether they are in a sub-Saharan African village or a Syrian refugee camp.

  Walto, who is a senior advisor for innovations and revenue for the International Medical Corps (IMC), spoke to the Global Health Seminar at the Yale School of Public Health earlier this week.

  IMC is a global “first responder,” moving where needed, often within twenty-four hours of a natural disaster. However, the key to success is says Walto is before an emergency happens. Training, preparation and prevention measures can be put in place that can mitigate the extent of an event’s impact. Examples include building codes that differentiated the extent of devastation between Haiti and the Dominican Republic after the 2010 earthquake and coastal Japanese communities that were able to escape from the 2011 tsunami.

  An important part of the International Medical Corps work is to transfer skills to the local community and to “make sure countries are ready to stand alone,” says Walto. Part of that preparation is IMC’s worldwide logistics and supply chain that can quickly move fuel and supplies around the world when a natural disaster takes place or war disrupts an area’s infrastructure.

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  The defining issue for Latin American countries is inequality, said Keith Hansen, Human Development Director for the World Bank, during a lecture for the Global Health Seminar at the Yale School of Public Health.

  “Inequality is self-perpetuating with one generation after another facing lack of opportunity. This is the antithesis of development,” said Hansen, who is responsible for the World Bank’s activities in education, health, nutrition, population and social safety nets in the region.

  While Latin American countries have made great progress on the United Nations’ Millennium Development Goals, access to health care is not enough. For example, in Brazil, 95 percent of babies are now born in health care facilities, but the health outcomes are still radically disparate between the poor and the rich. The outcome is the same throughout the region.

  Overall, Latin American countries have invested around 7 percent of their gross domestic product into health care, rivaling western European countries, but without the same results. Poor accountability up and down the chain is starting to be addressed through the World Bank’s programs. Hansen noted that the potential fiscal threat as spending rises is also a concern. Similar to the United States, the region faces inefficient investment, aging populations, increased technology and the rise of chronic diseases. “Latin America is a microcosm and precursor to the rest of the world.”

  Looking toward the next set of Millennium goals, Hansen predicted a focus on insurance reforms, expanded coverage and improved quality of care.

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  Public health interventions need to be reconceived if they are to meet modern challenges such as proper nutrition, Mandana Arabi, founding director of the Sackler Insitute for Nutrition Science at the New York Academy of Sciences, said during a guest lecture this week at the Yale School of Public Health.

  The model of vertically delivered programs, which worked well for immunization, won’t work for nutrition. “You can’t deliver changes in nutrition one day a year in each village. The culture of community partnership has to be there,” she said.

  Arabi, MD, PhD, discussed an agenda for global nutrition adopted by The Sackler Institute. Established in 2010, the institute has identified several research gaps in nutrition science. These include understanding environmental and societal trends that affect price changes; addressing nutritional needs through the entire life cycle, including adolescence and gestation; and pragmatic delivery and implementation of nutritional interventions in different cultures. 

  Arabi’s visit to the School of Public Health was sponsored by the Global Health Concentration and the Office of Public Health Practice.

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  Public health at its best works with people in the countries it is trying to help, creating sustainable infrastructures to support health, says Joel Lamstein, co-founder and president of John Snow, Inc. (JSI). 

  Through its work both internationally and domestically, JSI has found that there are a lot of bilateral lessons to be learned, especially in areas like HIV/AIDS or vaccine distribution for health outbreaks like H1N1. “What developing countries know better are community-based activities.” Experts from Kenya and Namibia have a lot to offer to colleagues in the west about the fight against HIV/AIDS, he says.

  John Snow, Inc. is a global public health management consulting and research organization serving underserved populations. Lamstein spoke about the company’s depth of operations both in the United States and abroad to the Global Health Seminar.

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  “Everything about HIV/AIDS work is political and emotional,” says Robert Hecht, managing director of Results for Development Institute in a presentation on real world cases in global health. Hecht outlined an initiative to overhaul the Global Fund’s resource allocation model to countries in the fight against AIDS, TB and malaria as well as strategic work to transitions countries receiving Global Alliance for Vaccines and Immunizations assistance to becoming self sufficient.

  Hecht’s talk was sponsored by the Global Health Seminar.

• The Rise of Dengue The incidence and spread of dengue fever is growing at a rapid rate while traditional methods to combat the disease, such as insecticides, are becoming less effective against as mosquito vectors develop immunity. 
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  Buruli ulcer may be a neglected tropical disease, but it is a devastating one that is also an emerging health threat in West Africa. Caused by Mycobacterium ulcerans, the disease results in debilitating flesh-eating lesions on the skin. 

  It is found mainly in rural, aquatic environments and people who are at highest risk usually grow rice or make furniture with aquatic palms, said Pamela Small, who presented a guest lecture this week for the Department of Epidemiology of Microbial Diseases. 

  Historically, it has been treated with surgery and skin grafts, but since 2005 the WHO has used a long course of antibiotics. Topical heat therapy is alsobeing studied since the bacteria only survives within a narrow temperature range. Researchers are still trying to understand the transmission and incubation of the pathogen, which has been found in many invertebrate species. 

  Small, Ph.D., is a professor of microbiology at the University of Tennessee.

• Pulitzer Prize-winning journalist Mark Schoofs said that the tools to control the HIV/AIDS epidemic are at hand and that new infections could be reduced to a “trickle.” But, he added during a lecture at the Yale School of Public Health Wednesday, the tools are not being deployed. He said that male circumcision, a microbicidal gel for women and expanded use of a three-drug cocktail, used in concert, could result in a “radical” drop in new infections. However, cultural issues, budgetary concerns and political opposition are among the factors that stand in the way. Schoofs was a longtime reporter for The Wall Street Journal and now an editor at ProPublica. He has written extensively on the AIDS epidemic. 
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  China is likely to develop a vaccine for tuberculosis within the next twenty years, said Fabio Scano, MD, a Yale World Fellow and director of the World Health Organization’s (WHO) tuberculosis control program in China. 

  Scano spoke at the Yale School of Public Health as part of the Global Health Leadership Institute spotlight series on Tuesday and outlined the global status of tuberculosis control and the WHO’s goals for control of the disease. 

  A key challenge to TB eradication is the lack of a vaccine. China has already demonstrated its commitment to control of the disease, reducing the prevalence by half in the last twenty years, and like other BRIC nations (Brazil, Russia and India), has much to gain by continuing to minimize its incidence and mortality in the future, he said.

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  Anne Riederer, MSFS, MS, ScD, of Emory University opened the semester at the Yale School of Public Health with a discussion of pesticide exposure in pregnancy and early childhood for the Department of Environmental Health Sciences.

  Riederer reviewed a series of studies examining exposure of infants and small children to these toxins in vitro, and through food, breast milk, formula and household dust. A pilot study in Thailand showed that pesticides in young children’s urine are present year round but are seasonal. They also found that in addition to fruits and vegetables, grains contribute the majority of the pesticide burden in the diet. 

  Infants show reflex and motor skill deficits, indicative of neurological impact, in their Brazelton assessments performed at immediately after delivery.

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  Malnutrition remains a serious health problem for millions of children living in Sub-Saharan Africa, but infection and damage to the intestines has emerged as an even graver health threat, Andrew Prentice said in the first of three seminars this week at the Yale School of Public Health. 

  Meanwhile, chronic diseases are taking a growing toll on adults, and especially women. Several factors are contributing to this trend, including urbanization, an emerging economy based on remittances from emigration, and cultural norms that encourage a heavyset build among women, he said. The juxtaposition of malnourished children with a high prevalence of diabetes among women is especially striking in hospitals where the most common surgery is amputation of diabetic feet. 

  Prentice is head of the Medical Research Council (MRC) International Nutrition Group at the London School of Hygiene and Tropical Medicine and the group’s permanent West African field station director at MRC Keneba in rural Gambia.

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  Their work includes fighting systematic rape in Africa, challenging ingrained homophobia in the Caribbean and promoting the rights and empowerment of women everywhere. 

  “We’re pretty uncompromising in our views,” Stephen Lewis, co-founder and co-director of AIDS-Free World, told a gathering Monday at the Yale School of Public Health. “We don’t fool around. This is not an exercise in ambiguity.”

  Lewis outlined the various advocacy work done by AIDS-Free World, an outspoken international organization that works to promote more effective global responses to HIV/AIDS. 

  He said that government-sponsored rape in some African countries not only devastated large numbers of women, but contributed to the spread of HIV/AIDS. His group is working to end the culture of impunity and to bring perpetrators to justice. “It’s a pretty awful situation.” 

  Lewis also touched on funding cuts to The Global Fund to Fight AIDS, Tuberculosis and Malaria, a multinational group dedicated to fighting three of the world’s most deadly diseases. The cuts will result in innocent people dying. Such policy can be equated with “murder,” he said. 

  Despite the widespread despair and suffering caused by HIV/AIDS and other diseases, Lewis said that he draws strength from the spirit and resilience of the people that he works with. “It’s impossible not to feel hope,” he said. 

  Lewis's talk was sponsored by the Yale Global Health Leadership Institute, the Yale Center for Interdisciplinary Research on AIDS, the Yale World Fellows Program and the Yale AIDS Program.

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  India’s HIV/AIDS epidemic has reached critical proportions and is resulting in a “staggering loss of life and appalling suffering.” And victims of the disease continue to face severe stigma and discrimination. 

  “They are the new untouchables in our country,” said Sonali Kochhar, M.D., medical director of OneWorld Health in India. The organization seeks to develop and deliver new treatments and interventions for people with neglected infectious diseases in the developing countries, including HIV/AIDS. 

  Kochhar, a 2011 Yale World Fellow speaking at the School of Public Health, told the gathering of students Thursday that India has the third highest incidence of AIDS in the world (after South Africa and Nigeria) and that the epidemic has spread to all segments of Indian society. Factors such as widespread poverty (some 450 million people are classified as living below the poverty line), pervasive illiteracy, cultural taboos against discussing sexual practices and a poorly coordinated public health response all contribute to new cases of the disease. 

  Meanwhile, antiretroviral drugs remain unavailable for most patients. “We need to scale up our prevention efforts. So much more works needs to be done,” Kochhar said.

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  Medical providers are targets in the Syrian conflict, said Wael Khouli, MD, in a talk given to a group of community members and students at the Yale School of Public Health. 

  Activists have been killed or arrested in public hospitals by government forces, while in private hospitals medical providers have become targets after treating injured civilians. Dozens of doctors have been injured and many more detained and tortured. 

  Meanwhile, the flood of 2.5 million displaced people, disruption to water and sanitation, and destruction of medical manufacturing facilities have created a host of public health problems in the region. 

  Khouli, who is a physician practicing in Minnesota and a student in Yale SOM’s Executive MBA program, outlined his Medical Mapping Project, which is a model for more efficiently matching relief agencies to field hospitals that have been created along the Turkish border. The model has been developed in consultation with NGOs and providers in the region to provide more equal and cost effective distribution of supplies while protecting medical providers’ safety and security.

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  Non-governmental organizations work in the areas hardest hit by disaster and conflict and their efforts bring relief and resources to people who may otherwise be left without. 

  But NGOs face a host of challenges—financial, political, logistical and legal, among others—which hamper their effectiveness and ability to help those most in need. 

  Nimmi Gowrinathan, the director of South Asia Programs at Operation USA, an international relief organization focused on alleviating the effects of disaster, disease and poverty, discussed with students the difficulties faced by NGOs during a talk at the School of Public Health and sponsored by Yale’s Global Health Leadership Institute. The recent flooding in Pakistan, for instance, which displaced millions, drew little support from the public. “We feel very passionate, but weren’t able to do much,” she said. Gowrinathan oversees relief programs primarily in India, Sri Lanka and Pakistan.

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  While there has been some recent progress, tuberculosis, HIV and drug-resistant strains of TB remain critical health issues in South Africa as the diseases claim thousands of lives annually. 

  Gerald Friedland, M.D., professor at the Yale schools of medicine and public health, outlined how TB and HIV coinfection rates have risen sharply over the past decade and how integrating HIV treatment (through the use of antiretroviral drugs) into existing TB programs has achieved some success in places like Tugela Ferry, South Africa. 

  But around the middle of the decade, drug-resistant forms of TB started spreading rapidly, including in hospital wards, with high mortality rates as a result. “This is very, very bad news in a country just emerging from apartheid,” he said. While Friedland calls for the continued use of antiretorvirals in patients who are coinfected, he also said that a rapid and massive infusion of resources is needed in South Africa (and in other countries) to stem TB’s spread. There is also a need for modern TB diagnostic tools (which have been developed in the past year and can detect the disease in hours rather than weeks to months) and for new drugs and an effective vaccine. 

  Finally, increased and continuing efforts must be made to reduce poverty and health disparities, which are at the root of both TB and HIV globally. Friedland spoke Thursday (Dec. 8) at the School of Public Health as part of a seminar series for the Epidemiology of Microbial Diseases Division.

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  “Murder is a disease of poverty and inequality,” said Donnelly, M.D., who teaches at the University of St Andrews in Glasgow, Scotland. “It is a problem that is almost certainly going to get worse.” 

  Donnelly outlined a program known as the Community Initiative to Reduce Violence (CIRV) that is modeled on a public health intervention and has had marked success in the past few years in reducing Glasgow’s street-level violence that typically occurs between youthful and mostly male gang members.

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  “I would increase the cost of cigarettes 10 percent every three months. I would tax the hell out of it. I would price the hell out of it.” 

  “The 21st century must be the century of prevention.” 

  “Preventive death is largely avoidable. Epidemiology has to take up the challenge. We know how to do it. We need to figure out how to deliver it.” 

  “The time for hoping is past. We need to move into action.” 

  ~YSPH Adjunct Professor Peter Boyle in a lecture this week on global public health and the future of epidemiology. Boyle outlined some of the looming health, demographic and economic issues that will pose enormous challenges in the coming century.

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  In the year 2040, the largest population group in many developed countries will be people in their 80s, a different society than we live in today, said Lisa F. Berkman, Ph.D., in a seminar for the Yale Program on Aging and the Yale School of Public Health. 

  Already 90 percent of women with children are in the workforce and there is an expectation that women also will provide much of the care of the aged. Failure to restructure our society and develop appropriate policies for the expanding elderly population will lead to, among other problems, social exclusivity and “dis-integration” of demographic groups, such as senior citizens and young children. Tensions over funding for special interests—such as public education and social security—are already visible in congressional debates. “Rethinking intergenerational bonds and roles are critical,” Berkman told the audience gathered in Winslow Auditorium. 

  The lecture was dedicated to the late Adrian Ostfeld, former chair of the Department of Department of Epidemiology and Public Health. Berkman is the Thomas D. Cabot Professor of Public Policy and of Epidemiology and is director of the Harvard Center for Population and Development Studies. She is a former head of the Yale School of Public Health’s Department of Chronic Disease Epidemiology.

• “Plague is still with us,” said Michael Begon, PhD, in a seminar for the Department of Microbial Diseases at the Yale School of Public Health. Plague in Kazakhstan is transmitted to humans via fleas that have fed on the giant gerbil. The gerbils burrow in colonies throughout the dessert. Using satellite images of the area, Begon is focused on developing more accurate and cost effective prediction models for risk of the parasite by local health officials. Begon is professor and head of the Department of Evolution, Ecology and Behaviour at the University of Liverpool.