Global Health

Books

Brian Nicholson, Judy McKimm & Ann K Allen

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    About the Editors

    Brian D. Nicholson is a GP and Clinical Fellow based at the Nuffield Department for Primary Care Health Sciences at the University of Oxford. He intercalated in International Health as a medical student and worked as a research assistant to Professor John Walley at the Nuffield Centre for International Health and Development. He co-founded almamata.org.uk, a not-for-profit network providing information on training, careers, education and research in global health. His current research focuses on the optimization of systems for cancer diagnosis and understanding differences in cancer outcomes between countries. He has received funding from the National Institute for Health Research and Cancer Research UK. Brian sees cancer control in low- to middle-income countries as a one of the major global health challenges ahead.

    Judy McKimm is Director of Strategic Educational Development and Professor of Medical Education at Swansea University, working internationally in health professions education. From 2011–2014, she was Dean of Medical Education at Swansea and, from 2007–2011, worked in New Zealand at the University of Auckland and as Pro-Dean, Health and Social Care, at the Unitec Institute of Technology. She trained as a nurse and worked in medical education from 1994–2004, latterly as Director of Undergraduate Medicine at Imperial College, London, leading the development and implementation of a new undergraduate medical programme. From 2004–2005, as Higher Education Academy Senior Adviser, she was responsible for developing and implementing the accreditation of professional development programmes for teachers in higher education. She has worked on over 60 international health workforce and education reform projects in Central Asia, Portugal, Greece, Bosnia and Herzegovina, Macedonia, Australia, the Pacific and the Middle East. She publishes widely on medical education and leadership.

    Ann K. Allen retired from her post as Senior Lecturer at the Institute of Medical Education, Cardiff University, in 2013. Previously she was Director of Cardiff University's Master of Public Health Programme. She holds postgraduate degrees in sociology, anthropology, education and development management and has worked in many developing countries as a consultant for project evaluation, health promotion and curriculum design. Her book Research Skills for Medical Students was published by Sage in 2012. As a consultant with the Open University, she worked with Ethiopian academics from 2013 until 2014 to develop the curriculum and learning materials for a Master of Human Resources for Health course. She continues to contribute (as a member of the leadership group and an online tutor) to the online People's Open Access Education Initiative (Peoples-uni), which aims to offer high-quality and low-cost education in public health to assist with public health capacity-building.

    About the Contributors

    Stephen Allen Professor of Paediatrics, Liverpool School of Tropical Medicine, Liverpool, UK, and International Officer, Royal College of Paediatrics and Child Health, London, UK.

    Stefi Barna Lecturer in Global Health, Norwich Medical School, University of East Anglia, UK.

    Philippa K. Bird Principal Research Fellow, Bradford Institute for Health Research, UK.

    Colin S. Brown Academic Clinical Fellow in Infectious Diseases, Centre of Clinical Infection and Diagnostics Research, Department of Infectious Diseases and Infectious Diseases Lead for the King's Sierra Leone Partnership, King's Centre for Global Health, King's College London, UK.

    Philip Cotton Principal, College of Medicine and Health Sciences, University of Rwanda, Rwanda, Africa.

    Subodh Dave Associate Dean, Royal College of Psychiatrists, and Honorary Associate Professor, University of Nottingham, and Consultant Psychiatrist, Derby, UK.

    Nisha Dogra Professor of Psychiatry Education and Honorary Consultant in Child and Adolescent Psychiatry, Greenwood Institute of Child Health, University of Leicester, UK.

    Alison Fiander Professor and Honorary Chair in Obstetrics and Gynaecology, School of Medicine, Cardiff University, UK, and Clinical Lead for Leading Safe Choices, a RCOG initiative to improve global women's health.

    Trevor Gibbs Independent Professor of Medical Education and Primary Care and WHO Consultant in Medical Education, Adolescent Health and Primary Care.

    Anu Goenka Registrar in Paediatrics, Royal Manchester Children's Hospital, UK.

    Jason Horsley Consultant in Public Health, Sheffield City Council, and Honorary Senior Lecturer in Public Health, University of Sheffield, Sheffield, UK.

    Rachel Jenkins Emeritus Professor of Epidemiology and International Mental Health Policy, Institute of Psychiatry, King's College London, UK.

    Ann John Clinical Associate Professor, Swansea University Medical School, Wales, UK and Honorary Consultant in Public Health, Public Health Wales.

    Chris Lavy Professor of Orthopaedic and Tropical Surgery, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK.

    Dan Magnus Paediatrician, Bristol Children's Hospital, Bristol, UK.

    David Mant Emeritus Professor of General Practice, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

    Michelle McLean Professor and Associate Dean of External Engagement and International Marketing, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.

    Tolib Mirzoev Associate Professor of International Health Policy and Systems, Nuffield Centre for International Health and Development, University of Leeds, UK.

    Nyengo Mkandawire Professor of Orthopaedics and Head of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi, Africa.

    Rosemary Morgan Research Fellow, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

    Godfrey Muguti Professorial Chair, Department of Surgery, College of Health Sciences, University of Zimbabwe, Africa.

    Rob Mitchell Emergency Medicine Registrar, Royal Brisbane and Women's Hospital, Australia. Associate Lecturer, School of Medicine, University of Queensland, Australia.

    Amy Neilson Medical Doctor, Médecins Sans Frontières, Health Delegate, Australian Red Cross, and General Practitioner and Locum Senior Medical Officer (Emergency Medicine), Australia.

    William Newsholme Consultant in Infectious Diseases, General Medicine and Infection Control, Guy's and St Thomas’ Hospital, London, UK. Honorary Senior Lecturer, King's Centre for Global Health, King's College London, UK.

    Georgina Phillips Emergency Physician, Coordinator of International Programmes, St Vincent's Hospital, Melbourne, Australia, and Honorary Lecturer, University of Melbourne, Australia.

    Kate E. Pickett Professor of Inequalities in Health, Department of Health Sciences, University of York, UK.

    Sarah Walpole NIHR Academic Clinical Fellow in Medical Education at Hull York Medical School and Cardiology Specialist Registrar at Hull Hospitals.

    Dileep Wijeratne Senior Registrar in Obstetrics and Gynaecology Registrar, Bradford Royal Infirmary, Yorkshire, UK, and former Resident Obstetrician and Gynaecologist, Bawku Hospital, Northern Ghana, Africa.

    Merlin Willcox Clinical Researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

    Bhanu Williams Consultant Paediatrician, London North West Healthcare NHS Trust, Harrow, UK.

    Rhys Williams Emeritus Professor of Clinical Epidemiology, Swansea University Medical School, Wales, UK.

    Andrea Williamson Senior Clinical University Teacher, University of Glasgow, Scotland, UK.

    List of Acronyms

    ADHD   attention deficit hyperactivity disorder

    AFEM   African Federation for Emergency Medicine

    AMR   antimicrobial resistance

    ART   antiretroviral therapy

    CD4   cluster of differentiation 4 – a glycoprotein found on the surface of immune cells

    CHD   coronary heart disease

    CHE   complex humanitarian emergencies

    CHN   community health nurse

    CHPS   community-based health and planning services

    CHWs   community health workers

    CO2   carbon dioxide

    COPD   chronic obstructive pulmonary disease

    COSECSA   College of Surgeons of East Central and Southern Africa

    CSOs   civil society organizations

    D&C   dilatation and curettage

    DAH   development assistance for health

    DALYs   disability-adjusted life years

    DFID   Department for International Development

    DOT-HAART directly   observed therapy with highly active antiretroviral therapy

    DOTS   directly observed treatment, short-course

    DSM   Diagnostic and Statistical Manual of Mental Disorders

    EC   emergency care

    ECDC   European Centre for Disease Prevention and Control

    ELRHA   Enhancing Learning and Research for Humanitarian Assistance

    EM   emergency medicine

    EOC   essential obstetric care

    EPI   Expanded Programme on Immunization

    ETAT   Emergency Triage Assessment and Treatment

    FBOs   faith-based organizations

    FMTs   foreign medical teams

    GBD   Global Burden of Disease

    GDP   gross domestic product

    GEC   global emergency care

    GECC   Global Emergency Care Collaborative

    GHWA   Global Health Workforce Alliance

    GOBI FFF   growth monitoring, oral rehydration, breastfeeding, immunization, family spacing, food supplements and female education

    HAI   hospital-acquired infection

    HCAI   healthcare-associated infection

    HIC   high-income countries

    HIV/AIDS   human immunodeficiency virus and acquired immune deficiency syndrome

    HMIS   health management information systems

    HRH   human resources for health

    IASC   Inter-Agency Standing Committee

    ICD   International Classification of Diseases

    ICRC   International Committee of the Red Cross

    ICU   intensive care unit

    IEM   international emergency medicine

    IFEM   International Federation for Emergency Medicine

    IFMSA   International Federation of Medical Students’ Associations

    IFRC   International Federation of Red Cross and Red Crescent Societies

    IMCI   Integrated Management of Childhood Illness

    INGOs   international non-governmental organizations

    IPCC   Intergovernmental Panel on Climate Change

    IPT   intermittent preventive therapy

    IT   information technology

    ITNs   insecticide-treated bed nets

    JFS   Joint Funding Scheme

    KEHPCA   Kenya Hospices and Palliative Care Association

    LICs   low-income countries

    LMICs   low- and middle-income countries

    LTCs   long-term conditions

    MCH   maternal and child health

    MDGs   Millennium Development Goals

    MDR   multi-drug resistant

    MDR-TB   multi-drug resistant tuberculosis

    MERS-CoV   Middle East respiratory syndrome coronavirus

    MMR   maternal mortality ratio

    MOHSW   Ministry of Health and Social Welfare (Tanzania, Ethiopia)

    MRSA   meticillin-resistant Staphylococcus aureus

    MSF   Médecins Sans Frontières

    NCDs   non-communicable diseases

    NDM1   New Delhi metallo-beta-lactamase-1

    NGO   non-governmental organization

    NHS   National Health Service

    NSPCC   National Society for the Prevention of Cruelty to Children

    NTDs   neglected tropical diseases

    OCHA   Office for the Coordination of Humanitarian Affairs

    PCV   pneumococcal conjugate vaccines

    PEPFAR   President's Emergency Plan for AIDS Relief (USA)

    PHC   primary healthcare

    PLWHA   people living with HIV or AIDS

    PM   project management

    PMTCT   prevention of mother-to-child transmission

    PPE   personal protective equipment

    ProMED   Programme for Monitoring Emerging Diseases

    RAS   refused asylum seekers

    RDTs   rapid diagnostic tests

    SAM   severe acute malnutrition

    SAP   sustainable action planning

    SARS   severe acute respiratory syndrome

    SDGs   Sustainable Development Goals

    SSCL   surgical safety checklist

    START   strategic timing of antiretroviral treatment

    STAR   CHPS Supportive Technical Assistance for Revitalizing Community-based Health Planning and Services

    SWAps   Sector Wide Approaches

    TB   tuberculosis

    TBAs   traditional birth attendants

    TDR-TB   totally drug resistant tuberculosis

    TRPCCC   Trent Region Palliative and Continuing Care Centre

    UASC   unaccompanied asylum-seeking child

    UFM   under-five mortality

    UHC   universal health coverage

    UK   United Kingdom

    UN   United Nations

    UNDP   United Nations Development Programme

    UNFPA   United Nations Population Fund

    UNICEF   United Nations Children's Fund

    USAID   United States Agency for International Development

    VRE   vancomycin-resistant Enterococcus

    VSO   Voluntary Service Overseas

    WACS   West African College of Surgeons

    WHO   World Health Organization

    WHO-AIMS   World Health Organization Assessment Instrument for Mental Health Systems

    WISN   workload indicators of staffing need

    XDR-TB   extensively drug resistant tuberculosis

    YLDs   years lived with disabilities

    YLLs   years of life lost

    Foreword

    It is appropriate that the publication of this excellent book should coincide with the launch of the United Nations’ Sustainable Development Goals (SDGs). The UN has hailed its predecessor, the Millennium Development Goals (MDGs) ‘the most successful anti-poverty movement in history’. Some might not agree entirely but the MDGs have undoubtedly had a significant impact in reducing extreme poverty, delivering safe water, improving access to health care and increasing the number of children going to school and much more.

    The SDGs take a broader view of global well-being but the challenges for the next 15 years will be even greater and the human resources needed to achieve these goals will challenge us all. In addition a growing global population, persistent conflict and warfare and an increasingly unstable climate will add to the barriers to achieving health equity. I am delighted to see a growing interest in global health among students who have grown up in a much more connected and a smaller world. It is our duty to nurture this interest, guide these students with their careers and ensure that their education and professional development is embedded in a socially accountable approach.

    Global health is now firmly on undergraduate curricula, yet much still needs to be done to prepare our students for a more ‘local’ world where students not only need to understand global health issues but also need to develop cultural competences required to work in a multifaceted environment. While some students will choose to work in low- and middle-income countries, all will live and work in a multicultural and multiethnic society with diverse problems previously alien to past generations of health care workers. The migration of vast numbers of refugees and displaced people across continents has ensured that other people's health issues have now become everyone's.

    Some of the greatest challenges will be in the rural and remote areas. We increasingly view the world from an urban-centric perspective, despite that fact that nearly half the world's population is rural and the greatest concentrations of extreme poverty remain at the periphery of health care in isolated communities. It will be these areas, which will offer the biggest challenges to the goal of Universal Health Coverage (UHC). The WONCA (World Organization of Family Doctors) Working Party on Rural Practice has developed a Rural Medical Education Guidebook; designed for educators to develop appropriate rurally based undergraduate and postgraduate education aimed at promoting rural practice and rural choices for students and doctors in training. It is also committed to developing global student networks as a way of fostering an understanding of global rural health. I was delighted that the needs of rural and isolated communities are highlighted as a challenge in the text.

    I must congratulate the editors and authors for producing a much-needed book, which fills a gap and meets the increasing need for global health educational material. The book provides the ideal introductory text for global health with highlighted key points, contextual references, case studies and guides to further study. I will certainly recommend it to my students as a gateway to global health. The book will also become a resource for postgraduate students and those health care professionals planning to work abroad.

    Much success has already been achieved but this book will help consolidate global heath in undergraduate and postgraduate curricula across higher education and professional development.

    Dr John Wynn-Jones

    Chair WONCA Working Party on Rural Practice

    Past President and Founder European Rural and Isolated Practitioners Association

    Senior Lecturer in Rural and Global Health, Keele Medical School

    Introduction

    Background and context

    Most healthcare students and professionals spend some time working or studying overseas, whether it is on an elective, a year out, an exchange or a study visit. International agencies, such as the World Bank, United Nations Development Programme (UNDP), as well as international non-governmental organizations (INGOs), retain health and population as key development themes that attract graduates from social science and engineering disciplines. For universities and the students who study in them, social accountability is becoming more important, not only at the level of governance and community engagement but also for individuals who are developing their professional identities (Woollard and Boelen, 2012). An understanding of global health issues and health management is therefore essential. It is equally vital that students and professionals understand the impact of global health on medicine and healthcare in the UK and other countries.

    Globalization and technological developments are changing both professional and social practices in ways that require graduates to be able to live and work in settings that are culturally diverse and subject to environmental and disease threats arising from industrial and urban growth that can only be managed through international collaboration. Demographic change (the ageing, growth and urbanization of populations) is taking place in circumstances that are resource-constrained. The importance of empowering both individuals and communities to improve conditions that impact health is increasingly recognized. Many health professionals work and travel in countries outside those in which they were born or trained and, with increasing international travel and migration patterns, health issues that were once seen only in certain countries are now encountered by health professionals around the world.

    We live and work in a ‘global village’, so students and health professionals need to be aware of the health issues that people around the world face because of poverty, inequalities, climate change, famine, conflict, migration patterns and demographic shifts. They need also to understand how policy decisions relating to trade, land use and energy interact with these to compound deprivation further. Understanding and engaging with global health concerns thus form part of the social accountability, diversity and inclusivity agendas of health and health education organizations worldwide.

    Global health is high on the agenda

    In professional standards’ frameworks (such as UK General Medical Council, 2009; UK Nursing and Midwifery Council, 2010; UK Public Health Skills and Knowledge Framework, 2014) around the world, graduates are required to demonstrate understanding of and adherence to strategies for addressing global and wider public health issues, including those of indigenous peoples. The presence of global health at the top of the political agenda for high-income countries (such as Crisp, 2007), supported by a stream of documents and resources from the World Health Organization (such as, WHO, 2007; WHO Global Health Observatory www.who.int/gho/en), shows that governments and policymakers recognize moves to address drastic international health and development inequalities are becoming more important for the wider public, too. There is a consequent desire for accessible information about the challenges that really face healthcare provision in low-income countries beyond propaganda and media hysteria, which can obscure important messages, such as those underpinning famine in Africa and swine flu. Health professionals need to understand the perspectives of different countries as they strive to achieve the Millennium Development Goals (MDGs), for example contrasting the ‘obesity epidemic’ found in many Western countries with extreme poverty, starvation and death through famine and other climate changes in others, understanding differences in access to healthcare or variations in maternal and child health and addressing the chronic disease ‘epidemic’.

    MDGs and Sustainable Development Goals

    The eight MDGs were produced with the aim of eradicating or alleviating key issues for the world's poorest people by 2015 (see www.un.org/millenniumgoals). They were agreed by all the world's countries and leading development institutions and are to:

    • eradicate extreme poverty and hunger
    • achieve universal primary education
    • promote gender equality and empower womenreduce child mortality
    • improve maternal health
    • combat HIV/AIDS, malaria and other diseases
    • ensure environmental sustainability
    • develop a global partnership for development.

    In 2015, the United Nations (UN) coordinated efforts to develop Sustainable Development Goals (SDGs) to take forward the work already done around the MDGs. The primary aims are to end poverty, promote prosperity and well-being for all, protect the environment and address climate change (www.un.org/sustainabledevelopment). As well as human health issues, the SDGs consider a much wider range of interrelated aspects, such as establishing safe, dignified and fairly paid jobs, disaster risk reduction, agricultural production, animal diseases and conflict prevention.

    Health issues are global

    The concept of global health has moved on from focusing solely on the problems of low- and middle-income countries (LMICs) to encompass health problems with global impact. Problems of non-communicable disease control linked to alcohol, tobacco consumption and obesity, such as cardiovascular diseases and cancer, together with mental health, are joining the more familiar communicable diseases of human immunodeficiency virus (HIV), malaria and tuberculosis (TB) at the top of the research agenda. Environmental issues, too, have expanded beyond concern for the provision of clean water supplies, sanitation and promoting hygiene to include the management of risks associated with trade in food and the misuse of pharmaceuticals, as well as the impact of growing global pollution. Variations in the economic status of individuals and communities with respect to access to maternal and child health reflect differences in the social status of women that also may be exacerbated by technological developments, such as ultrasound or IVF. Whether health professionals work internationally or with people from different countries and cultures in their own country, global health issues impact local health care delivery and professional practice daily.

    New public–private partnerships, such as the Bill & Melinda Gates Foundation, a growing awareness of climate change and unpredictable politico-economic environments exert new pressures and influence on global health and its governance. Consequently we observe significant shifts in research and development funding worldwide. Diseases that have recently been neglected (such as hookworm, schistosomiasis, trachoma and leprosy) are moving back up the global agenda and new specialties that require refreshed international collaboration and new expertise appear.

    Becoming and being a global practitioner

    Individuals are increasingly urged to be global citizens and health professionals to be ‘global practitioners’ (McKimm and McLean, 2011). More than ever before, individual health professionals have the means – and, with it, the responsibility – to increase awareness and action through informing colleagues and themselves about global issues, lobbying governments and international actors, forming and supporting global health pressure groups, volunteering and researching global health puzzles (Frenk et al., 2014).

    Health professionals and non-health professionals alike take time out of training to study Masters’ and Diploma programmes focused on the challenge of providing equitable healthcare on a global scale. Medical schools have produced hundreds of graduates with additional qualifications in international health, the International Federation of Medical Students’ Associations (IFMSA) and Medsin UK have ensured global health is climbing up the agenda on most undergraduate medical curricula and Alma Mata (www.almamata.org.uk) works with the Royal Colleges, lobbies government and informs members on how best to integrate relevant international experience into postgraduate training. There is still, however, much to do to consolidate global health as a core element of undergraduate and postgraduate health professions programmes.

    Our approach

    The approach in the book highlights throughout why an understanding of international/global health issues is important and relevant to medicine and healthcare students and trainees, as well as practitioners involved in public health programmes in their own practice in local contexts and those working in other countries and cultures. Although the book discusses global issues, it clearly spells out the links to local practice – indeed, the theme and structure of each chapter is ‘local–global–local’ (the ‘act local, think global’ approach).

    The book is broken down into three main sections as follows:

    Part 1: Providing Care Globally

    Chapter 1: Studying and Working in Global Health

    Chapter 2: Health Systems

    Chapter 3: Human Resources for Health

    Part 2: Global Health in Context

    Chapter 4: Health Inequalities

    Chapter 5: Human Health and the Global Environment

    Chapter 6: Climate Change, Long-term Conditions and Sustainable Healthcare

    Part 3: Global Health in Practice

    Chapter 7: Working with Migrants, Refugees and Asylum Seekers

    Chapter 8: Primary Healthcare

    Chapter 9: Communicable Diseases

    Chapter 10: Non-communicable Diseases, Injuries, Suicide and Self-harm

    Chapter 11: Mental Health, Mental Illness and Disability

    Chapter 12: Maternal Health

    Chapter 13: Child and Adolescent Health

    Chapter 14: Global Surgery

    Chapter 15: Global Emergency Care and Disaster Health

    Chapter 16: Project Planning and Evaluation

    Chapter structure

    Each chapter provides a short overview and introduction that sets out the main areas of coverage and context. Case studies are used to illustrate relevant global issues or stories included that refer to both the local and global contexts. ‘What is the evidence?’ boxes highlight key policy, strategy or clinical innovations and movements. Health promotion and preventive medicine is a theme throughout the book (rather than a separate chapter in its own right) so is woven into each chapter. Issues arising from the management of change and the significance of cultural differences for understanding social behaviour are also common threads. The book introduces relevant theory clearly focused on practical applications in public health and clinical practice. Many acronyms are used in global health so a list of these is givesn at the beginning of the book.

    Finally

    As we have described, this book provides an introductory text to the challenges and solutions to a range of global health issues for healthcare professionals and practitioners from any discipline (particularly those new to working in international health) wherever they work in the world. We hope that you find it useful and enjoy working in global health as much as we do.

    References
    Crisp, N. (2007) Global Health Partnerships. The UK Contribution to Health in Developing Countries. Summary and Recommendations. COI. Available at: www.aspeninstitute.org/sites/default/files/content/images/Global%20Health%20Partnerships%20-%20Crisp%20Report_0.pdf (accessed 8 October 2015).
    Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D. and Zurayk, H. (2010) ‘Health professionals for a new century: transforming education to strengthen health systems in an interdependent world’, The Lancet, 376(9756): 192358.
    General Medical Council (2009) Tomorrow's Doctors. London: General Medical Council.
    McKimm, J. and McLean, M. (2011) ‘Developing a global practitioner: Time to act? Medical Teacher, 33: 626631.
    Nursing and Midwifery Council (2010) Standards for Pre-registration Nursing Education. London: Nursing and Midwifery Council.
    Public Health Skills and Knowledge Framework (2014) London: Skills for Health. Available at: www.skillsforhealth.org.uk/resources (accessed 8 October 2015).
    Woollard, R. and Boelen, C. (2012) ‘Seeking impact of medical schools on health: Meeting the challenges of social accountability’, Medical Education, 46: 2127.
    World Health Organization (2007) Everybody's Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva: World Health Organization.

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