Briefing: Ebola-myths, realities, and structural violence

Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

In low-income and middle-income countries, such as those in sub-Saharan Africa and Latin America, the COVID-19 pandemic has had substantial implications for women's wellbeing. Policy responses to the COVID-19 pandemic have highlighted the gendered aspect of pandemics; however, addressing the gendered implications of the COVID-19 pandemic comprehensively and effectively requires a planetary health perspective that embraces systems thinking to inequalities. This Viewpoint is based on collective reflections from research done by the authors on COVID-19 responses by international and regional organisations, and national governments, in Latin America and sub-Saharan Africa between June, 2020, and June, 2021. A range of international and regional actors have made important policy recommendations to address the gendered implications of the COVID-19 pandemic on women's health and wellbeing since the start of the pandemic. However, national-level policy responses to the COVID-19 pandemic have been partial and inconsistent with regards to gender in both sub-Saharan Africa and Latin America, largely failing to recognise the multiple drivers of gendered health inequalities. This Viewpoint proposes that addressing the effects of the COVID-19 pandemic on women in low-income and middle-income countries should adopt a systems thinking approach and be informed by the question of who is affected as opposed to who is infected. In adopting the systems thinking approach, responses will be more able to recognise and address the direct gendered effects of the pandemic and those that emerge indirectly through a combination of long-standing structural inequalities and gendered responses to the pandemic.

The Lancet Commission on cancer and health systems: harnessing synergies to achieve solutions

Fat of the land

Global health 2035: a world converging within a generation

As this editorial goes to press, the expanding African Ebola outbreak is a rapidly evolving international health and humanitarian crisis. Indeed, on October 13, 2014, the World Health Organization issued a warning that the current Ebola outbreak represents ‘‘the most severe, acute health emergency seen in modern times’’. In addition to the accounts of dehumanizing suffering and loss of life (i.e., mortality rates estimated to be 70% in West Africa), the outbreak is growing with an estimated 10,000 new cases appearing per week. This healthcare crisis demands attentive response and resources from all levels of governmental and non-governmental organizations. The World Bank estimates that, if the crisis is limited to even 200,000 cases, the economic costs will exceed 32 billion dollars; if it extends into 2015, the economies of West Africa will contract significantly. Thus, the crisis not only threatens to wipe out large swaths of an already impoverished African population, but it also further threatens to fragment their countries’ already fragile economies and governments. Recent reports of the disease spreading to Europe and North America have added to the complexity and urgency of the growing Ebola situation. Though the number of infected patients reported pales in comparison with its thousands of African victims, additional concern has been voiced regarding the growing risk to healthcare workers. There have now been a number of documented cases of transmission from patients to healthcare workers, both in North America and abroad this despite the advantages offered by our first-world modern healthcare facilities. North American nurses and physicians have very limited knowledge of the disease and its implications. Prior Ebola outbreaks in remote reaches of Africa over the past few decades have been largely self-limited, evoking little concern in most Western healthcare workers. Now, with documented spread to Western Europe and North America, a lack of both knowledge and preparedness is increasingly provoking anxiety amongst hospital administrators and staff alike. In an effort to provide information on the disease and its management, this issue of the Journal features an article by Funk and Kumar that serves to provide a comprehensive

COVID-19 boosters and building trust among UK minority ethnic communities

The prevailing prevention literature has increasingly expanded the scope of HIV/AIDS drivers beyond the behavioural and social to encompass an increasing focus on the structural drivers of AIDS. Throughout the structural drivers literature is an emphasis on the need for upstream interventions that shape policy and influence political processes (Gibbs et al 2012; Hunsman 2012; Parkhurst 2013. Some of the literature recommends an emphasis on promoting political processes that catalyse political change and address underlying forms of inequality (Heise and Watts 2013; Gibbs et al 2012). This literature dovetails with literature that advocates for an increasing emphasis on the political determinants of health in health promotions programming (Ottersen et al 2014). At the same time new directions in the HIV/AIDS preventative community mobilization literatures has emphasized the need to rethink and re-conceptualise community mobilization in the 21st century (Campbell 2014). More broadly systematic reviews of the literature suggest the need for an increasing focus on community mobilization efforts that respond to and influence the political context of health (Cornish et al 2014). This dissertations aims to influence and inform the space between these literatures through an empirical look into the convergence of the Nelson Mandela Foundations (NMF) Community Conversations political animus and a historical and present day reading of the ways in which structural forms of violence (Galtung 1969) continue to be inscribed into the life trajectories of residents/citizens living in Ingquza Hill, South Africa. The findings in this dissertation are based on narrative analyses of N = 63 life histories and semi-structured interviews conducted with residents, CC facilitators and participants, and local influential stakeholders that directly experienced, lived, and embodied this convergence throughout the dialogical and actioned oriented phases of the Community Conversations process. Findings suggest that the basis for re-conceptualising of community mobilization for the 21st century be predicated on a more politicized framing of HIV/AIDS along with a more explicit and intentional valuation of the intersection between the social and political determinants of health in programmes that employ community mobilization. Intersecting social and political power dynamics play a significant role in both opening up and the cultivation of civic spaces that promote responsive and inclusionary forms of local governance and decision-making. This in part entails an increased emphasis on the creation of accompaniment oriented socio-political technologies that intentionally support the cultivation of health enabling democracy.

In October 2014, nearly 2000 people from 125 countries shared and debated issues that are critical to improving the performance of health systems, at the Third Global Symposium on Health Systems Research, in Cape Town, South Africa.1 Such research was barely visible on the global health agenda until 1996, when the World Health Organization’s (WHO’s) Ad Hoc Committee on Health Research identified health systems research as an important but neglected field.2 Now, as shown by the success of three global symposia, governments worldwide clearly recognize the need for such research to build resilient health systems. A wide range of public health disasters – including the current Ebola epidemic – have drawn attention to the devastation that can rapidly develop in countries with weak health systems. The three global symposia, WHO’s development of a strategy on health policy and systems research in 20123 and the 2013 world health report on research for universal health coverage4 represent some important milestones in the field. Within the last decade, many collaborations and partnerships have emerged and dedicated entities – such as the Alliance for Health Policy and Systems Research and the professional society Health Systems Global – have been developed. The participation of the United States of America’s Global AIDS Coordinator in the Cape Town symposium is one indicator that health policy and systems research is valued by actors who have historically identified with specific disease areas. Such actors are now turning to systems sciences and applying the methods of health policy and systems research to overcome the common challenges of implementation, integration and sustainability. Although political engagement will be critical to the strengthening of health systems, it must go beyond those decision-makers who act at national level. Most changes to health systems occur at subnational levels because it is district health officers and senior programme managers who are largely responsible for the implementation of national policies. Policy and systems research – including implementation research – must be able to respond to the needs of the system. The recently published Statement on advancing implementation research and delivery science called for greater engagement of implementers.5 While the health-systems landscape of today is a stark contrast to that of the 1980s, the resources available for health policy and systems research remain less than those available for many other areas of health research.6 There is a particular need for efficiency, through alignment, coordination and collaboration. Thematic working groups within the Health Systems Global organization, the use of tools such as the Health policy and systems research: a methodology reader,7 and its related implementation research guide,8 offer opportunities for learning and synergies. Exercises for setting research priorities – such as those led by the Alliance for Health Policy and Systems Research9 – can greatly enhance the impact of existing efforts and minimize duplication of work. Now that the field has the long-sought attention of the global health community, the key actors need to demonstrate that they can deliver the potential that they have promised. The Alliance for Health Policy and Systems Research, Health Systems Global and WHO – bringing, respectively, a history of funding this research, broad membership and global convening power – are committed to working together to ensure that the full potential of health policy and systems research is realized. As the nature of the challenges experienced by health systems continues to evolve, so too will this field. All key actors will have to engage and collaborate to the fullest extent to ensure that health systems reap the maximum benefits of such research.

The Limits of Rapid Response

In a PloS Medicine article of September 2005, J. Jaime Miranda and Vikram Patel ask: “Achieving the Millennium Development Goals [MDGs]: Does Mental Health Play a Role?” [1]. We agree with their concern that “there is no health without mental health.” However, we do not feel mental health is ignored in the health agenda, nor do we share their pessimism about the potential to reach the MDGs in general. Skepticism about the success of the MDGs is based on the poor track record of past international goals such as the Universal Declaration of Human Rights or the Declaration of Alma-Ata. Indeed, the MDGs were adopted with these pitfalls in mind. Emphasis was given to setting bold but realistic goals, with quantifiable, time-bound targets. For example, the aim to “reduce by two-thirds, between 1990 and 2015, the under-five mortality rate,” calls for a practical plan with concrete, monitorable guideposts. Many assessments have shown how these health goals can be achieved over the next ten years. The fact that progress on under-5 mortality and disease control has been too slow and that previous goals have not been met is why the world needs the MDGs. Without these targets that hold poor and rich countries accountable, poor countries will miss the benchmarks laid out in the Millennium Declaration, even though the objectives are attainable. The reason that the MDGs do not explicitly address noncommunicable diseases such as cardiovascular or psychiatric diseases is that the MDGs focus on the gap in health status between rich and poor countries, a gap mainly accounted for by infectious diseases, malnutrition, and unsafe childbirth. The goals were crafted to address these large gaps rather than to solve all pressing health problems. We agree that “mental illness is closely associated with social determinants, notably poverty and gender disadvantage, and with poor physical health, including having HIV/AIDS and poor maternal and child health.” About 2.6% of disability-adjusted life years in sub-Saharan Africa are attributable to psychiatric conditions, which is about the same proportion attributable to nutritional deficiencies, or tuberculosis, or maternal complications from childbirth [2]. There are many areas in which governments are using MDG-based strategies to tackle problems that are not explicitly mentioned by the MDGs, such as electrification, road construction, increased agricultural yields, and more. The author's contention that “the MDGs do not address strengthening of health systems” is not correct, as readers of the UN Millennium Project recommendations (http://www.unmillenniumproject.org) can see. There is no chance to achieve any health MDGs without strengthening the health systems. Low-income countries are placing a important emphasis on strengthening health systems in their MDG-based planning. This will provide an important foundation for expanded access to critical mental health programs. The authors question “national ownership” of MDGs and therefore question their legitimacy. The MDGs are strongly supported throughout the low-income countries, both by civil society as well as by governments, many of whom are developing MDG-based policies. National ownership was vividly displayed in September 2005, when government leaders throughout the developing world protested vociferously and successfully a short-lived attempt of US negotiators to remove the term “Millennium Development Goals” from the UN 2005 World Summit agreement. Columbia University is involved in the Millennium Village Project, a proof of concept that the MDGs can be achieved in rural Africa by undertaking a holistic approach of integrated interventions in increasing food production, improving access to health care, water, and education, and improving infrastructure. Although the primary focus of health intervention is prevention and treatment of the major killers such as infectious diseases and malnutrition, we are exploring ways to integrate mental health care within the health systems, and we welcome practical suggestions for successful models that merit replication. The approach focuses on community-led development that takes into account social determinants of mental disease, as well as accessible mental health interventions. The MDGs are a matter of life and death for millions of adults and children. We must do our utmost to ensure their success. The development and public health communities—including mental health professionals—need to work together and not undermine the only shared global development goals we have. Since their adoption in the year 2000, the MDGs have garnered support around the word. If this broad global movement continues to gain momentum and to apply proven solutions to our most pressing problems, the MDGs can be achieved, and with them, so too a significant improvement in mental health around the world.

Global Development, Converging Divergence and Development Studies: A Rejoinder

Learning From the Past and Working in the Present to Create an Antiracist Future for Academic Medicine.

The large number of cases and wide geographical spread distinguish the current 2014 outbreak of Ebola virus disease in west Africa from all known earlier outbreaks.1 In the past, outbreaks of this disease have been stopped by identifying all cases, tracing all contacts and making sure that those caring for patients use correct protective gear at all times. However, the success of such methods depends on the presence of: (i) functional health systems; (ii) health workers who are trained, paid, willing to be deployed and adequately protected in a dangerous work environment; (iii) experts in public health with the skills needed to manage the tracing of people and monitor the evolution of the disease effectively; and (iv) people with solid skills in social engagement and development who are available to work with at-risk communities.2 Such systems and individuals were largely absent from the area where the current outbreak of Ebola virus disease is believed to have begun – a border area between three countries that all have fragile health systems and that are emerging from the traumas of civil war. Encouragingly, research efforts over the past decade have led to the development, for the first time, of a range of potential treatments and vaccines that could support efforts to control Ebola virus disease. However, although some of these interventions have proven effective in animal models, none has completed clinical testing in humans – a step that is indispensable for the registration of any medical intervention as proven and safe. Why have there been no clinical trials, given that we have known the Ebola virus for 40 years? Why is there no effective registered vaccine or treatment available? At the onset of the current Ebola outbreak – despite some resources provided by the governments of Canada and the United States of America – substantial financial investment was still needed to evaluate and develop several interventions for the control and treatment of Ebola virus disease. Until now – as seen with several other neglected diseases – this disease has received little attention because it was affecting mostly poor people in poor countries. The above shortcomings aggravate an ethical dilemma. If the treatments for Ebola virus disease that are currently under development could save lives – as the results of animal studies indicate – should they not be used immediately, since far too many people have already died? On the other hand, if there is a possibility that a treatment might cause substantial adverse effects in humans that have not been seen in animal testing, should it not be withheld?3 On 11 August 2014, the World Health Organization (WHO) convened a consultation to consider and assess the ethical implications of the potential use of unregistered interventions, such as drugs, vaccines and passive immunotherapy, in the current Ebola outbreak. The results of this consultation have been widely discussed in the media.4 In summary, the consultation’s panel of experts advised WHO that, in the particular circumstances of the current outbreak – and provided certain conditions are met – it would be ethical to offer unproven interventions – with as yet unknown efficacy and adverse effects – for the potential treatment or prevention of Ebola virus disease. One of the conditions that need to be met is that ethical principles must guide the provision of such interventions. For example, there must be transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity, and involvement of the community. To understand the safety and efficacy of these interventions, the panel of experts advised that – when and if any of the unregistered interventions is used to treat patients – there is a moral obligation to collect and share all of the data generated, including data arising from any treatment provided for compassionate use – i.e. the use of an unregistered drug outside of a clinical trial.5 What can we learn from this crisis? Robust health systems are key for controlling disease outbreaks. Let us make sure that development efforts are designed to strengthen health systems. Well trained and motivated health workers are indispensable. They should be paid and receive the support they need to carry out their duties. And, finally, increasing investment into research and development for the treatment, control and prevention of diseases that currently mostly affect poor people and poor countries should be a key priority for policy-makers worldwide. Let us not forget these lessons when the current Ebola outbreak no longer appears on the front pages of our newspapers.

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion