What is Global Health? Towards an Updated, Universal Definition

April 5, 2016 Maria Wilson Leave a Comment

By: Maria Wilson

Global Health Office Outreach Assistant

Global Health is an attractive and high profile field. We encounter global health issues on a daily basis, often without even realizing. In 2014, the West African Ebola outbreak was sensationalized in the media for months, featured heavily on every major Canadian media outlet. Several of the world’s largest charitable organizations – which you may work with, donate to, or benefit from – target global health issues. Poverty and health inequities continue to affect both our local and global communities. Students are being encouraged more and more to engage in international experiences in order to become well-rounded “global citizens.” Global health is all around us.

But what does “global health” really mean? If we asked five experts in the field to define global health, chances are each would provide a different response. Why? Because global health has grown over the years to encompass a variety of ideas and notions, including interdisciplinary cooperation, infectious and non-infectious disease, international development, social justice, food security, maternal and newborn child health, and environmental issues…and the list goes on. Global health is broad in scope, and each one of us may approach our work in slightly different way.

Academics have tried to define global health in past. Perhaps the most well-known and widely accepted definition of global health is that of Koplan et al. from 2009:

“Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide” [1].

While this definition touches on many important aspects of global health like equity, and a worldwide reach, it fails to address the “how.” We can study, research and practice global health, but what are the best ways to engage in our work? How do we find common ground?

I must admit, I don’t have the answers to these complex questions (yet), but I’m hoping that in the near future the global health community comes together to arrive at a solution. Until then, these are questions we should all be cognizant of when we approach our work in global health. Just like Koplan et al. called for the adoption of a common definition in global health in 2009, I am calling for an updated, universal definition of global health in 2016.

Why is it important to come to a consensus on what global health means? As global health continues to grow and become a part of our everyday lives, we must come together to determine a more clear purpose, and path for the future. With everyone working with a common framework in mind, towards shared goals, we will achieve the best outcomes moving forward.

Health Care Teams Addressing Poverty and Determinants of Health

March 16, 2016 Maria Wilson Leave a Comment

The Dalhousie Global Health Office, in collaboration with the Healthy Populations Institute, The National Collaborating Centre for Determinants of Health and Upstream, hosted the “Health Care Teams Addressing Poverty and Determinants of Health” event on March 3^rd. This event featured three speakers, who shared stories of addressing the social determinants of health in their work, and participated in a panel discussion.

Dr. Hamilton-Hinch, Dr. Forbes and Dr, Meili, our panel for the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Ryan Meili, the Executive Director of Upstream and a family doctor in Saskatoon, shared his experience as both a doctor treating patients in inner city Saskatoon affected by poverty, and as an advocate for health equity. Dr. Cindy Forbes talked about her experiences in advocating for health equity as the President of the Canadian Medical Association. Dr. Barb Hamilton-Hinch provided local context to this global issue, by discussing the barriers to healthcare faced by the African Nova Scotian population. All three speakers had common themes in their work: the need for policy change, the importance of story sharing to drive impact, and of course, the priority of addressing the social determinants of health in healthcare.

Dr. Meili speaking at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Meili sharing stories from his work with Upstream at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Meili shared the story of one of his HIV-positive Aboriginal patients who was facing several barriers to proper healthcare access. “She’s not sick with HIV,” Dr. Meili said after introducing us to her story, which was initially puzzling. However, if you take a moment to ponder this statement, it makes a lot of sense. By listening to her story, we learned that his patient has been sick with poverty, historic marginalization, poor living conditions, low education and addictions throughout her life. These factors have contributed to her HIV infection, and subsequent difficulty accessing care. This way of thinking is the fundamental to addressing the social determinants of health, and to the upstream approach. For a refresher on the social determinants of health in Canada, see our blog post from January. To learn about the upstream approach, check out this video created by Upstream, where Dr. Meili acts as the Executive Director. Upstream thinking requires us to reframe the public discourse around addressing the social determinants of health. We should be focusing more resources on the things that have the greatest influence on our health, including income, education, housing and nutrition, rather than pouring our resources into the healthcare system down the line.

Dr. Cindy Forbes, President of the Canadian Medical Association, at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Building a body of evidence, and sharing these findings are both important pieces to guiding policy change. But as Dr. Forbes noted “evidence doesn’t make people feel empathy.” Upstream also aims to share stories through a variety of media in order to creatively engage citizens, showing them they have a personal stake in the social determinants of health. Citizen engagement can lead to a political push for evidence-based, forward-looking policy innovations to address these determinants so people can live longer, fuller and healthier lives.

Dr. Hamilton-Hinch highlighted the importance of not only addressing policy change, but ensuring that power dynamics shift to reflect the diverse makeup of our Canadian population. Dr. Hamilton-Hinch is involved with PLANS (Promoting Leadership in Health for African Nova Scotians) at Dalhousie. PLANS seeks to improve health outcomes within the African Nova Scotian community (about 2.3% of the NS population), while creating mentoring and outreach opportunities. In order to facilitate access to healthcare for African Nova Scotians, Dr. Hamilton-Hinch discussed the need for change in our healthcare system. Change to the way healthcare professionals are educated by challenging curriculum, change to the way healthcare professionals practice in order to reflect cultural proficiency, and most importantly, change in the disparity between the small numbers of African Nova Scotian healthcare professionals and the much larger population they serve.

Dr. Barb Hamilton-Hinch of Dalhousie University, discussing the health of African Nova Scotians at the Healthcare Teams Addressing Poverty and Determinants of Health event.

The Global Health Office would like to thank Dr. Meili, Dr. Forbes and Dr. Hamilton-Hinch for sharing their stories with over 80 attendees. The stories you have shared will go on to impact the way that we approach our learning, practice and advocacy.

World Tuberculosis Day Part III – Treatment & Drug Resistance

March 8, 2016 Maria Wilson Leave a Comment

The World Health Organization (WHO) has declared March 24, 2016 as World Tuberculosis (TB) Day [1]. Over the month of March, the Global Health Office will be publishing a series of blog posts about TB in hopes of raising awareness of its worldwide impact. WHO’s “End TB Strategy” has a goal of ending the TB epidemic by 2030, by targeting poverty, improving testing and treatment, ending stigma and discrimination, and driving research and innovation. Put simply, TB is not yet a disease of the past, but if we unite and focus our efforts, we can make TB history.

Last week we talked about diagnosing TB, and the importance of determining an appropriate treatment course along with that diagnosis. But how is TB treated, and why is drug resistance an issue with TB in particular?

Although those with latent TB infection do not present symptoms, and cannot spread TB bacteria to others, treatment can still be provided to stop them from developing TB disease. This step is important in eliminating and controlling TB around the world, but should only be initiated once the possibility of TB disease has been excluded. In the United States, four treatment regimens are approved, using combinations of isoniazid, rifampicin and rifapentine. Treatment for latent TB can last anywhere from 3 months to 9 months, necessitating between 12 and 270 doses (minimum) of anti-TB drugs [2].

Treating those with active TB disease is a much more pressing matter, as they have the potential to spread the disease to others. Treatment regimens for active TB disease can last between 6 and 30 months depending on resistance, a process which burdens patients and treatment providers alike [3]. With a treatment course this long, some patients inevitably fail to complete the full regimen, for many reasons including finances, social pressures and inadequate access to proper treatment. To provide a glimpse at the financial burden of TB, each case in Canada cost the healthcare system $47,290 [4]. This can lead to acquired drug resistance, which can then be passed on to others when the infected person, coughs, sneezes or spits, releasing TB bacteria into the air [5].

There are two types of drug-resistant TB: multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). MDR-TB bacteria does not respond to (at least) the two most widely used and powerful first line TB drugs: isoniazid and rifampicin [6]. XDR-TB involves resistance to isoniazid and rifampicin, in addition to resistance to any of the fluoroquinolones (ofloxacin, etc.), and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin) [7]. Both MDR-TB and XDR-TB take longer than regular TB to treat (at least 18 months) and have lower treatment success rates. Furthermore, patients often experience more harsh side effects from treatment, leading to increased hospitalization [8]. In order to maximize the potential for positive treatment outcomes, it is important that further tests are undertaken after initial diagnosis to determine whether bacteria is drug-resistant, and provide appropriate treatment [7].

According to the WHO Global TB Report, in 2014 an estimated 3.3% of new TB cases and 20% of previously treated cases had MDR-TB. More than half of these cases occur in India, China and the Russian Federation. Additionally, an estimated 190,000 people died of MDR-TB in 2014. As of 2015, XDR-TB had been reported in 105 countries. The map below shows the number of patients in these countries with laboratory-confirmed XDR-TB who started treatment in 2014 [9].

Map of the world, showing the number of laboratory-confirmed cases of XDR-TB receiving treatment by country, 2014. (Source: World Health Organization).

In response to treatment non-adherence, and to combat the spread of drug-resistant TB, the directly observed therapy, short-course (DOTS) strategy was developed by WHO in 1994. Health workers meet with patients regularly to help with treatment, adherence, and to provide support and education. This strategy also advocates for increased allocation of domestic and international funding and resources to combat TB [10]. Tuberculosis is also highlighted in two recent worldwide strategies, the WHO End TB Strategy, and the UN Sustainable Development Goals (SDGs), which will be discussed in our next post.

World Tuberculosis Day Part I – What is TB?

March 1, 2016 Maria Wilson Leave a Comment

Tuberculosis (TB), caused by the bacillus Mycobacterium tuberculosis, is an airborne disease that primarily affects the lungs (pulmonary TB) [2]. This means that when people with pulmonary TB cough, sneeze or spit, TB bacteria are propelled into the air, giving them the potential to spread from person to person via inhalation. TB can affect other sites as well, including the brain, the kidneys and the bones [3]. An ancient disease, TB has affected humans for over 4,000 years [2].

In many cases, the immune system will fight off the TB bacteria, and no infection occurs. If the immune system is not able to completely fight off the bacteria, some inactive bacteria may stay in the body, leading to latent TB infection (no symptoms). If the immune system does not respond sufficiently, active TB infection occurs (TB disease), and symptoms begin to manifest [4]. People with latent TB infection cannot spread TB bacteria to others, but can go on to develop active TB over time. WHO estimates that about one-third of the world’s population is infected with latent TB [5]. Symptoms of TB disease include a persistent cough of 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness or fatigue, weight loss, loss of appetite, chills, fever and night sweats [6].

The burden of TB is mainly concentrated in low and middle income countries, where 95% of TB deaths occur. In 2014, there were 1.5 million TB deaths, and 9.6 million people developed TB disease [5]. TB is one of the leading causes of deaths from infectious diseases worldwide [7]. The map below, produced by WHO, shows estimated TB incidence rates, by country, in 2014.

Map of the world showing estimated TB incidence rates, by country, in 2014 (Source: World Health Organization).

This map provides a visual representation of the worldwide burden of TB, with the lowest rates in Western Europe, Canada, the United States of America, Australia and New Zealand. This has led to a common misperception in higher income countries that TB is a disease of the past. However, in many countries, including Lesotho, South Africa, Swaziland and Mozambique, rates are still above 500 cases per 100,000 population [7].

Keep reading our series of blog posts on TB to learn more about risk factors, diagnosis, treatment and much more.

Global Health Office Photo Contest

February 16, 2016 Maria Wilson 1 Comment

Each year, the Dalhousie Global Health Office hosts the Global Health Photo Contest. This contest is designed to recognize and share the beautiful images and inspiring stories that students, residents, faculty and staff at Dalhousie have from their global health experiences.

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Honduras. 2015 1st place GHO Photo Contest winner. Photo by: Laura Stymeist.

THERE ARE PRIZES!

Faculty/Resident First prize: $50 gift card and photo featured on the global health office website
Student First prize: $50 gift card and photo featured on the global health office website
Faculty/Resident Second prize: $25 gift card and photo featured on the global health office website
Student Second prize: $25 gift card and photo featured on the global health office website

Photos will be judged on the following criteria:

Artistic and visual appeal
Conveyance of global health through photographic imagine
Entries must be an original work taken by the individual submitting the photo; and permission of all individuals in the photo must be acquired;
Entries must be appropriate for a general audience.

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Ho Chi Minh Commute. 2015 GHO Photo Contest runner up. Photo by: Carolyn Reardon.

The deadline for submissions is March 1, 2016 at midnight. Photos must be accompanied by an entry form, and submitted digitally in a jpeg file (300 dpi at 8×10 inches) format to gho@dal.ca. Entrants can submit up to two photographs for consideration.

International Electives: A Student Perspective

January 18, 2016 Maria Wilson Leave a Comment

PASADA, Area 1 (Photo: Braden Kingdon)

The deadline to apply for a 2016 summer Global Health Elective is February 5 at 4pm. These programs allow you to work on an interprofessional team with one of our international partner organizations, and to be mentored by a Dalhousie faculty member. These programs are available to students in Medicine (first & second year), Health Professions and Dentistry. We offer pre-departure training sessions for all students participating in international electives, and students complete in-country orientation. These elective opportunities (observerships) are available for the summer months in Tanzania, Ghana and Thailand.

The Tanzania Summer Program offers hands-on experience to learn about the Tanzanian healthcare system with our partner, Pastoral Activities and Services for People with AIDS Dar es Salaam Archdiocese (PASADA). While at PASADA, you’ll see an innovative community-based model for providing HIV and AIDS services, while working with highly-skilled Tanzanian staff.

Dalhousie student Braden Kingdon was a PASADA intern during the summer of 2015. In order to give you a better idea of what the PASADA internship entails, we asked him a few questions about his experience.

Bongoyo Island, 20 minute Ferry ride from Dar es Salaam (Photo: Braden Kingdon).

1. How did you hear about the PASADA internship?

The program manager at the time contacted me personally through email about the opportunity. I am President of the Recreation Department Society at Dalhousie; she requested that I spread the word through our program. After spreading the word and thinking hard about it, I decided to apply myself as well.

2. What was your role as an intern at PASADA? What projects did you work on?

I was a part of a wide range of projects while at PASADA. I was initially sent out there with the intent of working with children who were living with HIV/AIDS, running health and safety clinics. This all changed upon my arrival in Dar es Salaam. I was working with the children yes, but only on Tuesdays for half of the day. For most of the other days I was working in the Key Populations (KP) Department, we tested and treated people within the marginalized communities of men who have sex with men (MSM), female sex workers (FSW), and injection drug users (IDUs). The KP department team would travel out into the communities to meet people at their homes with a mobile clinic. While back from the community, in the office I was mainly doing research. I was helping the medical director at PASADA put his dissertation together for publication in the Tanzanian Journal of Health Research. While helping him, I was also developing a research proposal for PASADA to help gain some funding and further their understanding of the MSM community. This was done through focus groups, personal interviews, and questionnaires. The overarching goal was to keep pushing towards increases in access to healthcare for the MSM community in Tanzania.

3. Was pre-departure training helpful in enriching your experience in Tanzania?

I believe it was helpful in enriching my experience in Tanzania. The material covered in the training was great at outlining safety precautions and travelling tips. The cultural aspect was a brief overview of what I was to expect, but it did not prepare me for the vast difference in way of living. In my opinion, this portion of the experience must be gained from actual exposure to the culture; no book or story will truly prepare you for the greatness that is the Tanzanian culture.

4. What have you learned from your experience in Tanzania? Has this impacted your day to day in Halifax?

My experience in Tanzania has taught me about the importance of living in the moment. Growing up in Canada we are all driven on this straight path towards success, if you fall off it you are often considered a failure. My time in Tanzania opened my mind up to the journey as opposed to just the end goal. If I ever had a bad day, my colleagues would lift me up and make me realize that I can only change what I can control, everything else is not worth worrying about. This has definitely followed me back to Halifax. Without the stress of worrying about uncontrollable factors I am able to focus on the tasks at hand, while enjoying the journey through life.

5. Drawing on your experience partnering with PASADA through the Global Health Office, how would you define a successful partnership?

I would define a successful partnership as one that has continual open communication, trust, and a mutually beneficial outcome. This is definitely something I feel the Global Health Office and PASADA had throughout my internship. I was able to contact anyone from the Global Health Office while in Tanzania, and the team at PASADA was an exceptional group of hosts. From teaching me Kiswahili to taking me to the beach for a sunset, it was a successful partnership inside and outside the walls of the clinic.

6. What advice do you have for Dalhousie students who are interested in the PASADA internship program?

My first piece of advice would be definitely apply because it will be the best summer (or term) of your life! I would also advise them to leave any preconceptions in Canada, it is likely that everyday will be a surprise and different from the last. It is also important to conquer your fears while you are there. Especially if you are in my case and you are by yourself for a while. Leave your comfort zone and go outside, walk around the city, there is so much to do! I found great friends in the American Peace Corp group who is always in Tanzania, and travels through Dar es Salaam regularly. But, do not limit yourself to this group of people. The staff at PASADA is very friendly and love to have fun, go to the movies with them, go to the beach with them, all you have to do is ask.

Local fish and chips on the beach (Photo: Braden Kingdon).

Thank you to Braden for taking time out of his busy schedule to share his PASADA experience with all of us! Braden has also kindly offered to answer any further questions you may have about the internship and his experience via e-mail.

Interested in International Electives? You can find more information on our offerings, as well as apply online, on our website. Remember – the deadline to apply is February 5 at 4pm!

The History Behind the Holidays

December 29, 2015 Maria Wilson Leave a Comment

By: Maria Wilson

Global Health Office Outreach Assistant

The Global Health Office (GHO) would like to wish the Dalhousie community, as well as all of our partners and blog readers, a Happy Holidays! For students, we hope your exams went well, and that you will be able to take this time to relax with your loved ones. If you are interested in becoming more involved with the GHO in the New Year, please contact us at gho@dal.ca.

It wouldn’t be a holiday post from the GHO without profiling some of the holidays celebrated in different countries, cultures and religions around the world in December and early January.

Kwanzaa (December 26-January 1)

Dr. Maulana Karenga, professor and chairman of Black Studies at California State University Long Beach created Kwanzaa in 1966. Dr. Karenga was searching for a way to bring African-Americans together as a community to celebrate family, community and culture. The name Kwanzaa is derived from the phrase “matunda ya kwanza”, which in Swahili means, “first fruit.” It is based on the year-end harvest festivals that have taken place throughout Africa for thousands of years [1].

Celebrations vary from family to family, but often include songs and dances, African drums, storytelling and a large traditional meal. The celebration lasts seven nights, one for each Nguzo Saba (seven principles in Swahili) that contributes to building and reinforcing community among those of African heritage [2]. The Nguzo Saba are values of African culture: Umoja (Unity), Kujichagulia (Self-determination), Ujima (Collective Work and Responsibility), Ujamaa (Cooperative Economics), Nia (Purpose), Kuumba (Creativity) and Imani (Faith). There are also seven symbols of Kwanzaa, often used to decorate one’s table: kikombe cha umoja (the unity cup), kinara (the candleholder), mazao (fruits, nuts and vegetables), mishumaa saba (seven candles to represent the seven principles), mkeka (placemat), vibunzi (ear of corn), and zawadi (gifts). Kwanzaa’s colours are red, black and green, symbolizing the bloodshed in the struggle for freedom, the colour of the people and the fertile land of Africa, respectively [3].

Though created and primarily celebrated in the United States, the holiday has also spread to Canada and to descendants of Africa who reside outside of the continent [1].

Christmas (December 25)

Christmas has been celebrated for two millennia with traditions and practices that are both secular and religious in nature. For Christians, Christmas Day is celebrated as the anniversary of the birth of Jesus Christ. Easter was the main holiday in the early years of Christianity; however, in the fourth century, Pope Julius I chose December 25 to celebrate the birth of Jesus, as a date for the event is not mentioned in the Bible. By holding Christmas at the same time as winter solstice celebrations, church officials increased the chance that the holiday would be popularly embraced. In Greek and Russian orthodox churches, Christmas is celebrated on January 6^th and is called the Epiphany. People celebrate Christmas by exchanging gifts, decorating a Christmas tree, sharing meals with family and friends, and attending church [4].Additionally, there is the story of Santa Claus who brings gifts in his sleigh (if you’ve been good of course)! The legend of Santa Claus can be traced all the way back to 280 A.D., when a monk named St. Nicholas was born. He was admired for his piety, giving away all of his inherited wealth while traveling the countryside helping the poor and the sick. Since the 19^th century, Santa’s gift giving centered mainly around children has been a staple of Christmas celebrations. This generous gift giver is known by many different names worldwide, Christkind, Kris Kringle, Babouschka, La Befana, Père Noël and, of course, Santa Claus [5].

Las Posadas (December 16-24)

Las Posadas, celebrated in Mexico, commemorates the journey that Joseph and Mary made from Nazareth to Bethlehem. Joseph and Mary sought shelter in a stable in Bethlehem, where Jesus Christ was born.On each evening of the festival, a child dressed as an angel leads a parade through the streets of towns and cities where the celebration occurs. The procession visits selected homes and asks for lodging for Joseph and Mary, and they are traditionally refused. However, the hosts often provide refreshments, read passages of scripture and sing Christmas carols. After the procession, mass is held, and children break open piñatas filled with candy and toys [6].

Mawlid Al-Nabi (December 23)

Mawlid Al-Nabi celebrates the birthday of the Prophet Muhammad, the founder of Islam. The celebration date varies on the Gregorian calendar, with the occasion being marked twice in 2015 (most recently on December 23^rd). It is fixed as the 12^th day of the month of Rabi al-Awwal on the Islamic calendar [7]. This celebration goes back to the early days of Islam, when the Tabi’in would hold sessions to compose songs and poems to honour the Messenger of Allah and recite them to crowds in major cities in Islamic Civilization [8].

Festivities include keeping with the tradition of reciting devotional songs and poems and handing out sweets and candies. Mawlid Al-Nabi is considered a spiritual occasion, where Muslims who choose to celebrate are encouraged to revisit the Sirah (the life story of the Prophet) [8].

Bodhi Day (December 8)

Buddhists around the world celebrate the enlightenment of Buddha on December 8^th each year. After trying different methods, practices and religions unsuccessfully, Siddhartha Gautama vowed to sit under a peepal tree in Bodh Gaya until he achieved the full enlightenment he was looking for. He sat in meditation for 49 days under what is now known as the Bodhi tree, with the last 8 days spent in deep meditation. On the final day he achieved enlightenment. Since then, he was known as the Buddha (Awakened One) [9]. Buddhists mark this day by meditating, studying the Dharma, chanting sutras (Buddhist texts) and performing acts of kindness [10].

GHO Pre-Departure Training Sessions

December 8, 2015 Maria Wilson Leave a Comment

Are you a Dalhousie student in Health Professions, Dentistry or Medicine planning an education experience abroad? The Global Health Office is here to help make your experience as meaningful as possible.

We offer one of the most advanced pre-departure training sessions available to students in Canada. Students must complete two sessions before departure, which are scheduled for Saturdays February 22, March 5 and March 26, 2016, 9:00am-3:30pm. In Halifax, these sessions will be held in Tupper Room G36 and in Saint John, they will be held in DMNB Room 218.

The pre-departure curriculum has been developed to help make the most of your experience, no matter where you plan to do an elective. Topics covered will include safety, logistics, ethics and cultural competency. We have also included a pre-departure checklist on our website, to guide you as you organize your international educational experience.

To register, please contact us at gho@dal.ca.

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