Working toward a common health standard for everyone, everywhere.
Originally written for McGill University's research magazine HeadwayAll life is connected. As medical science advances, the more these underlying connections are seen and appreciated. “When it comes to health, we are realizing there’s no such thing as ‘their problem,’ says Dr. Timothy Brewer, director of the McGill Global Health Programs and Associate Professor of Medicine in the McGill Faculty of Medicine. “There is only ‘our problem.'
Needed: a multidisciplinary approach
Recruiting people from other disciplines is vital, because many global health problems require a multi-disciplinary approach. “Consider the challenge of treating a person with HIV/AIDS in sub-Saharan Africa,” says Dr. Brewer. “Patients there may not have access to essential medicines because of patent restrictions. We need our colleagues at the law school to help us find solutions.” At the heart of the McGill Global Health Programs is the commitment to sharing McGill’s expertise. Over 60 faculty members and dozens of graduate students are currently involved in projects in more than 30 different countries. These projects are diverse in aim, scope and focus. However, all are focused on health-related issues, all are transnational, and all involve partnerships. In one such partnership, Dr. Brewer and colleagues from McGill are working with Harvard Medical School and the International Society for Infectious Diseases to explore the use of informal information sources – newspapers, Web sites, blogs and so on – to detect disease outbreaks around the world. “We’ve created a huge database of reports of outbreaks,” says Dr. Brewer. “Now we’re trying to understand where and how the first reports appear. We’ve categorized about 400 outbreaks over a 10-year period and we’ve seen the time between first reports and formal recognition of an outbreak drop significantly. The study is important, because if we can find a way to recognize outbreaks sooner, we can contain them better.” Partnering with Panama to study nutrition and health
Another fruitful McGill partnership has been forged with the Government of Panama. Dr. Marilyn Scott, director of the McGill School of Environment and long-time colleague Dr. Kris Koski, director of the School of Dietetics and Human Nutrition, are currently directing research into the relationships between nutrition and health in Panama. The Ngobe-Bugle, the indigenous people of the Comarca in western Panama, are poor. An average family of about 10 people lives on 50 dollars a month. More than 60 per cent of children under five – the focus of Dr. Scott’s research – are shorter-than-average and have a range of infectious diseases as well. “One of our students went to Panama to learn whether nutritional interventions might reduce rates of reinfection in children,” says Dr. Scott. “She studied the Vitamin A supplementation program run by the Ministry of Health to learn whether it reduced rates of reinfection with the nematode parasite in children.” The outcome was surprising: supplementation helped children – but only those whose growth was not stunted. “Children whose growth is stunted lack not only Vitamin A but a whole range of micronutrients,” says Dr. Scott. “We suspect that, while the program improved their vitamin A status, other deficiencies impaired their immune systems.” Do transfer programs promote health for the very poor?
This research project was the first of several studies to evaluate the benefits of programs created by the Panamanian Ministry of Health. One such initiative, a conditional transfer program, offers families living in extreme poverty either a monthly cash supplement or food vouchers in return for agreeing to specific activities. “One of our PhD students documented the health benefits of this program,” says Dr. Scott. “Over a two-year period, she looked at about 150 children whose families received cash and a similar number from families who received vouchers. She monitored their diet to learn whether it was altered by having food vouchers or cash. Then, she tried to establish how dietary changes affected their nutritional status and their rates of infection with various diseases. We are now analyzing data from this study.” Officials in Panama are eager to translate research results into practical initiatives Dr. Scott and her colleagues work very closely with them to develop optimal policy changes “Because so many issues are inter-related, policy development has to be done with great care,” says Dr. Scott. “In global health, we often need to consider a range of issues, so we need to take a holistic, multidisciplinary approach.”
Trauma a huge problem in developing nations Nowhere is the need for a multidisciplinary approach more evident than in the area of trauma care. That is why Dr. Tarek Razek, director of the McGill University Health Centre Trauma Program, emphasizes the importance of building data bases and of training and educating first responders and non-physicians as well as trauma surgeons in under-resourced environments. “Trauma is a huge problem in developing nations,” says Dr. Razek. “Car crashes and traffic accidents involving pedestrians or cyclists are all increasing, due to increased road traffic and urbanization. Workplace injuries and violence are also major factors.” Dr. Razek and his colleagues have helped local partners in Tanzania, Uganda and other locations in Africa to set up trauma databases at major hospitals. Recently, they created a database in Dar es Salaam to help them understand what types of trauma patients were being treated and what types of injuries were most common. “Having this data is important on many levels,” Dr. Razek says. “ First, it’s vital to understand what the real problems are, so you can gauge policy and get the ‘biggest bang for your buck.’ Services, training and education must all be adjusted to cope with the realities of the situation. As data accumulates, you can see how the health system is doing in terms of outcomes. Finally, you can use trauma databases to develop injury prevention policies. A three-cent life saver
“For example, our database in Uganda showed a huge spike in pediatric injuries. Further investigation showed these injuries were taking place on the way to and from school. Huge numbers of kids were walking great distances pre-dawn and after dusk in an area with poor roads and no lighting or sidewalks. Knowing this, we were able to develop an intervention. The kids were given three-cent reflective armbands – super-cheap and really bright when headlights hit them. Since the program started, the injury rate for pediatric pedestrian injuries has plummeted. Building data bases is not just an academic pursuit. It actually translates into lives saved.” Training and education are also key activities for Dr. Razek and his colleagues. They work with local partners, using standardized educational programs to teach the skills needed to deal with emergency situations. Hundreds of people have received training through this program. Priorities include ‘train the trainers’ courses and teaching pre-hospital skills to first responders. “We train whoever is most appropriate to train in the local context,” explains Dr. Razek. What happens to child soldiers after the war?
Not all programs in the McGill Global Health Program are directly related to physical disease or injury. Sometimes, ‘health’ is a more holistic concept. To better understand and help child soldiers who are forcibly “recruited” by armed groups is the research focus of Dr. Myriam Denov, associate professor in McGill’s School of Social Work and author of The Making and Unmaking of Child Soldiers in Sierra Leone, Dr. Denov has been studying this difficult topic in Sierra Leone for some time, and is now beginning a similar study in Sri Lanka. “We are looking at how children are brought to engage in violence and how their identities are reconfigured,” says Dr. Denov. “We are also interested in the process of reintegration – what happens when the war is over. Finally, of course, we are studying what happens to these children post-conflict. Do they venture into crime or do they ‘find their way’ and reject violence?” To answer these questions, Dr. Denov and her colleagues have been studying former child soldiers who served with rebel militias during Sierra Leone’s brutal civil war, which ended in 2002. Working with Defense for Children International, a small local NGO, Dr. Denov has painstakingly built contacts with former child soldiers, and has interviewed or organized focus groups with hundreds of them. Some children recruited at age four
“My research is focused on boys and girls recruited by The Revolutionary United Front, the rebels in the civil war,” she says. “Some don’t even know how old they were when they were taken – perhaps as young as four. Most were recruited between ages seven and 14. They served not only as soldiers but in support roles – cooking, doing laundry and so on.” Some former child soldiers have been able to reintegrate successfully. “For example, a new category of job has been created by ex-combatants,” says Dr. Denov. “Most conventional taxis were destroyed during the war. When peace returned, a new form of transport emerged – the motorbike taxi. These can make their way through small spaces, and they are much cheaper. Motorbike taxis were pioneered by former child soldiers, who drive most of them. They have actually created a new job category and organized a labour union to represent themselves. They make an important contribution to the local economies.” Doing odd jobs and stealing to stay alive
However, Dr. Denov’s studies show reintegration has been difficult for many. Families often rejected children who had been with the rebels. “We found that young people in urban areas are much worse off than those in rural areas,” Dr. Denov says. “We began to work with small groups in the slums in Freetown. They are facing incredibly challenging conditions: no parents, no access to food, education or work, and high levels of violence. They make their way by doing odd jobs and stealing.” To empower these former child soldiers, Dr. Denov is experimenting with an intervention known as PhotoVoice. She and her colleagues have given cameras to a small group of young people and trained them in photography. The young people then take pictures of what they think is important in their community. Organizers plan to mount a large exhibition of photos and invite key officials from NGOs and community organizations to attend. “It’s a way to let these young people speak about issues that matter to them,” says Dr. Denov. “However, the limitations of an intervention of this sort and the ethical implications of those limits are challenging. If there are very few opportunities for employment or education, how much can you actually empower? We can help build awareness at the local level, and encourage policy change – but the needs are so great that these seem like small steps.” Small steps towards major change
Yet small steps, taken by many, can translate into major change over time. At McGill, top academics are working to improve global health in a variety of ways. Dr. Jody Heymann, founding director of McGill’s Institute for Health and Social Policy, continues to make significant contributions to understanding how social policy and social conditions affect global health. Dr. Timothy Geary, Director of McGill's Institute of Parasitology and colleague Dr. Eliane Ubalijoro of McGill’s Centre for Developing-Area Studies are helping to establish locally controlled pharmaceutical-research programs in Botswana and South Africa. Richard Gold, director of the Centre for Intellectual Property Policy at McGill, is looking for ways to make the AIDS drugs more accessible to people in underprivileged countries. Dr. Jim Torczyner, founder of the McGill Middle East Program in Civil Society and Peace Building, continues to promote social justice – including equal access to health care – in the Middle East. The list goes on and on. The range and complexity of global health issues is bewildering, or even at times overwhelming. Yet, step by step, progress is being made on many fronts. “Perhaps our biggest achievement so far has been raising awareness of global health issues both for the faculty and the wider university community,” says Dr. Brewer. “Although we operate with fewer resources than many of our counterparts in other universities, our programs have already chalked up notable successes around the world. But we need more resources and more involvement, because much remains to be done. We have big plans, because it’s a big world out there.”