Contemporary Global Health Research Articles

Geneva Health Forum: The Forum of Innovative Practices in Global Health.

In the past years, Global Health has interfaced with important challenges related to several dynamic changes. Technological progress, the digital revolution and the emergence of new actors in the field of health, increase the possibility of finding solutions to these unprecedented challenges. Starting from these assumptions, the idea of providing an adequate platform for good management of the health system has flowed into the creation of a meeting place that would allow a wide exchange of information, ideas sharing and proposals for new collaborations: the Geneva Health Forum (GHF). The GHF is a global health conference that aims to promote critical reflections and constructive debates on contemporary global health issues, thus influencing and informing policy formulation with experience from the field. The profile and impact of the Geneva Health Forum has grown year on year, establishing itself as a unique forum, ranging from more traditional sessions to innovative events.

Falling, Dying Sheep, and the Divine: Notes on Thick Therapeutics in Peri-Urban Senegal.

Peri-urban Senegal lies outside the influence of both the nation's historic public mental health model and contemporary global mental health. This paper examines how cultural logics in this underserved region spill over from social domains to widen the therapeutic sphere of psychoses and epilepsy. Observations and 60carer and/or patientinterviews concerning 36patients afflicted by one or both conditions illustrate how the "crisis of the uncanny", a spectacular eruption of psychoses and seizures into the everyday, triggers trajectories across these domains. To resolve the crisis, patients and carers mobilize debts and obligations of extended kin and community, as well as a gift economy among strangers. The therapeutic and non-therapeutic are further linked through the semantics of falling, which associates this local term for the crisis with divine ecstasy and the slide from human to non-human forms of life. We introduce the concept of thick therapeutics to capture how the logics of sheep- other animal-human relationality, secular-divine politics of giving, and payment/sacrifice for healing imbue a therapeutic assemblage continually constructed through actions of patients, carers and healers. We ask what implications therapeutic thickening might have for mental health futures, such as monetized payment under global mental health.

Tool of economic development, metric of global health: Promoting planned families and economized life in Nepal.

In contemporary global health and development discourses, contraception is cast in multiple roles: an antipoverty tool at the household level, a tool of economic development at the national level, a smart investment with net gains, a means of empowering women, a way of lowering maternal mortality ratios. In order to examine such discursive uses of contraception - and their implications for women - in a concrete way, I use a compelling case of the history of the promotion of planned families in Nepal and a recent social and behavior change communication contraception campaign designed in the US. Using social text analysis to examine this multi-year, multi-platform campaign in Nepal, I found that the advertisements present idealized images of "smart couples:" progressive, middle-class families engaged in rationalistic family planning to delay and space their offspring. A major theme identified, aspirations to be middle class, links these specific family planning behaviors to upward economic mobility. The small-family ideal previously promoted in the global South had outlived its relevance as Nepal and other countries reached near replacement-level fertility rates. The gradual historical refashioning in Nepal of a discourse that promotes the "small family" to one that promotes the modern "smart couple" is an illustrative example of the global trend in which a message of replacement-level fertility is repackaged as a message of delaying and spacing births under the guise of health, as funding agencies promote contraceptive adoption as a women's health issue. Underlying this discursive repackaging, however, is a continued economization of life and health.

Envisioning, Evaluating and Co-Enacting Performance in Global Health Interventions

The notion of performance has become dominant in health programming, whether being embodied through pay-for-performance schemes or through other incentive-based interventions. In this article, we seek to unpack the idea of performance and performing in a dialogical fashion between field-based evaluation findings and methodological considerations. We draw on episodes where methodological reflections on performing ethnography in the field of global health intersect with findings from the everyday practices of working under performance-based contracts in the Senegalese supply chain for family planning. While process evaluations can be used to understand contextual factors influencing the implementation of an intervention, we as anthropologists in and of contemporary global health have an imperative to explore and challenge categories of knowledge and practice. Making room for new spaces of possibilities to emerge means locating anthropology within qualitative global health research.

Quantifying the Evolutionary Conservation of Genes Encoding Multidrug Efflux Pumps in the ESKAPE Pathogens To Identify Antimicrobial Drug Targets

Increasing rates of antibiotic-resistant bacterial infection are one of the most pressing contemporary global health concerns. The ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) have been identified as the leading global cause of multidrug-resistant bacterial infections, and overexpression of multidrug efflux (MEX) transport systems has been identified as one of the most critical mechanisms facilitating the evolution of multidrug resistance in ESKAPE pathogens. Despite efforts to develop efflux pump inhibitors to combat antibiotic resistance, the need persists to identify additional targets for future investigations. We evaluated evolutionary pressures on 110 MEX-encoding genes from all annotated ESKAPE organism genomes. We identify several MEX genes under stabilizing selection-representing targets which can facilitate broad-spectrum treatments with evolutionary constraints limiting the potential emergence of escape mutants. We also examine MEX systems being evaluated as drug targets, demonstrating that divergent selection may underlie some of the problems encountered in the development of effective treatments-specifically in relation to the NorA system in S.aureus. This study provides a comprehensive evolutionary context to efflux in the ESKAPE pathogens, which will provide critical context to the evaluation of efflux systems as antibiotic targets. IMPORTANCE Increasing rates of antibiotic-resistant bacterial infection are one of the most pressing contemporary global health concerns. The ESKAPE pathogen group represents the leading cause of these infections, and upregulation of efflux pump expression is a significant mechanism of resistance in these pathogens. This has resulted in substantial interest in the development of efflux pump inhibitors to combat antibiotic-resistant infections; however, no widespread treatments have been developed to date. Our study evaluates an often-underappreciated aspect of resistance-the impact of evolutionary selection. We evaluate selection on all annotated efflux genes in all sequenced ESKAPE pathogens, providing critical context for and insight into current and future development of efflux-targeting treatments for resistant bacterial infections.

The Gothic Origins of Global Health

AbstractGlobal health traces its origins back to a single moment in 1854 when John Snow eradicated cholera with a map. It is a nice story, but it’s a myth, a fantasy of empiricism. The modern global health approach did begin with the nineteenth-century, worldwide cholera pandemics, but cartography was not the principal form associated with this paradigm; it was the gothic. Turning back to the mid-nineteenth-century pandemics, this essay explores the contours of an emergent global health approach on both sides of the Atlantic. It demonstrates why the gothic was the form through which this approach was narrated, how the form worked, and the effects of the genre on popular and medical knowledge. Contemporary global health has been reorganized around scientific empiricism, but elements of its gothic history remain. I conclude by suggesting the value of recuperating these gothic origins for global health today.

The Internationalisation of Tobacco Control, 1950-2010.

This article explores the internationalisation of tobacco control as a case study in the history of international health regulation. Contrary to the existing literature on the topic, it argues that the history of international anti-smoking efforts is longer and richer than the making of the World Health Organisation’s Framework Convention on Tobacco Control in the early twenty-first century. It thereby echoes the point made by other scholars about the importance of history when making sense of contemporary global health. Specifically, the article shows how the internationalisation of tobacco control started in the 1950s through informal contacts between scientists working on cancer research and how these initial interactions were followed by a growing number of more formal initiatives, from the World Conferences on Tobacco or Health to the Bloomberg Initiative to Reduce Tobacco Use. Rather than arranging these efforts in a linear narrative of progress culminating with the Framework Convention on Tobacco Control, we take anthropological claims about global health’s uneven terrain seriously and portray a history of international tobacco control marked by ruptures and discontinuities. Specifically, we identify three successive periods, with each of them characterised by specific understandings of international action, tobacco control expertise, advocacy networks and funding strategies.

Research on help-seeking for mental illness in Africa: Dominant approaches and possible alternatives.

There is growing concern within the global mental health arena that interventions currently being executed to scale up mental health services in Africa will be ineffective unless simultaneous steps are taken to address people's help-seeking behaviour. Drawing upon two conceptual tools arising from science and technology studies (STS), those of a "classification system" and "the black box," this paper looks critically at discursive constructions of help-seeking in Africa within mental health research over the last decade. Research in this area can be divided into two dominant traditions: the knowledge-belief-practice survey and indigenous-knowledge-system approaches. Although the content and value-codes between these approaches differ, structurally they are very similar. Both are mediated by the same kind of system of classification, which demarcates the world into homogenous entities and binary oppositions. This system of ordering is one of the most stubborn and powerful forms of classification buried in the "black box" of the modernist/colonial knowledge archive and is fraught with many questionable Eurocentric epistemological assumptions. I consider whether there might be other ways of understanding help-seeking for mental illness in Africa and discuss two studies that illustrate such alternative approaches. In conclusion, I discuss some of the challenges this alternative kind of research faces in gaining more influence within contemporary global mental health discourse and practice.

Nottingham Trent University and Makerere University School of Public Health partnership: experiences of co-learning and supporting the healthcare system in Uganda.

Partnerships between developed and developing country institutions are increasingly becoming important in addressing contemporary global health challenges faced by health systems. Inter-university health collaboration such as the Nottingham Trent University (UK) and Makerere University School of Public Health (Uganda) partnership provide opportunities for working together in training, research and service delivery while strengthening health systems. This paper shares the experiences, achievements and opportunities of this partnership in co-learning and supporting the health system in Uganda. This includes a project being implemented to strengthen the training, supervision and motivation of community health workers in rural Uganda. Training and research are a key focus of the partnership and have involved both staff and students of both institutions including guest lectures, seminars and conference presentations. The partnership’s collaboration with stakeholders such as the Ministry of Health (Uganda) and local health authorities has ensured participation necessary in supporting implementation of sustainable interventions. The partnership uses several channels such as email, telephone, Skype, Dropbox and WhatsApp which have been useful in maintaining constant and effective communication. The challenges faced by the partnership include lack of funding to support student mobility, and varying academic schedules of the two institutions. The experiences and prospects of this growing partnership can inform other collaborations in similar settings.

What can imaging tell us about cognitive impairment and dementia?

Dementia is a contemporary global health issue with far reaching consequences, not only for affected individuals and their families, but for national and global socio-economic conditions. The hallmark feature of dementia is that of irreversible cognitive decline, usually affecting memory, and impaired activities of daily living. Advances in healthcare worldwide have facilitated longer life spans, increasing the risks of developing cognitive decline and dementia in late life. Dementia remains a clinical diagnosis. The role of structural and molecular neuroimaging in patients with dementia is primarily supportive role rather than diagnostic, American and European guidelines recommending imaging to exclude treatable causes of dementia, such as tumor, hydrocephalus or intracranial haemorrhage, but also to distinguish between different dementia subtypes, the commonest of which is Alzheimer's disease. However, this depends on the availability of these imaging techniques at individual centres. Advanced magnetic resonance imaging (MRI) techniques, such as functional connectivity MRI, diffusion tensor imaging and magnetic resonance spectroscopy, and molecular imaging techniques, such as 18F fluoro-deoxy glucose positron emission tomography (PET), amyloid PET, tau PET, are currently within the realm of dementia research but are available for clinical use. Increasingly the research focus is on earlier identification of at risk preclinical individuals, for example due to family history. Intervention at the preclinical stages before irreversible brain damage occurs is currently the best hope of reducing the impact of dementia.

ASSESSMENT OF A POINT-OF-CARE DEVICE FOR MEASURING CREATININE IN A COMMUNITY SCREENING PROGRAM FOR CHRONIC KIDNEY DISEASE

ABSTRACT Background: Chronic kidney disease (CKD) is a major contemporary global health problem. Creatinine measurement for the calculation of estimated glomerular filtration rate is an important component of assessing CKD risk. A point-of-care test for creatinine using capillary sampling is required as part of a screening assessment. Objectives: Evaluate the analytical performance of a modified point-of-care testing method for whole blood creatinine (Nova Biomedical StatSensor whole blood creatinine analyser) relative to a laboratory method. Design and methods: Conduct a patient comparison study between the point-of-care testing and laboratory methods in a rural community setting. Calculate measures of imprecision and assess the ability of the POCT method to determine staging of CKD compared to the laboratory. Results: Between-device imprecision averaged 8.8%. The StatSensor devices showed a positive bias of approximately 14% for whole blood creatinine measurement compared to the laboratory method, leading to more than 40% of community patients being staged differently for CKD risk with approximately 25% more abnormal results. Conclusions: The StatSensor whole blood creatinine point-of-care device remains analytically unsound for use as a screening device for CKD.

The biopolitics of global health: Life and death in neoliberal time

The opening years of the 21st century have witnessed the rise of ‘global health’ as the preferred label for attempts to govern the health of the global population. In this article, I locate the epistemological origins of global health in the introduction of the Disability Adjusted Life Year (DALY) metric in the World Bank’s Investing in Health report. I argue that the DALY metric accomplishes an economization of life by disaggregating lifetimes into component units of time and reassembling life as a revenue stream to be maximized through practices of self-investment in one’s own health – configured here as human capital. Life is reimagined as time and the individual as a neoliberal homo oeconomicus: as an entrepreneur of the self. I argue that the DALY metric is best conceived as a biopolitical technology of power that underpins the contemporary neoliberal global health regime.

The governmentalization of living: calculating global health

The contemporary global health agenda has shifted emphasis from mapping disease patterns to calculating disease burden in efforts to gauge ‘the state of world health’. In this paper, we account for this shift by showing how a novel epidemiological style of thought emerged in the closing decades of the twentieth century. As is well known, the compilation and tabulation of vital statistics – death-rates, birth-rates, morbidity rates – contributed to the birth of the ‘population’ in the eighteenth and nineteenth centuries. The population is reformatted from the middle of the twentieth century by ‘modified life tables’ made up of disability weightings, health state valuations, quality of life scores, disease burden estimates, etc. The problem of morbid death gives way to that of morbid living, made calculable through a metrics of ‘severity’, ‘disability’ and ‘impairment’. A series of new indices and scales (e.g. the QALY and DALY) has contributed to a governmentalization of living, in the course of which the social and personal consequences of living with disease come to be an object of political concern, and made knowable, calculable and thereby amenable to various strategies of intervention. We conclude by showing how this style of epidemiological thought has generated a new global visibility for brain disorders as their impact on individuals, health care systems and nations are calculated in novel ways.

MERS and global health governance

The contemporary global health governance system has evolved over 150 years to facilitate cooperation among states in dealing with cross-border health concerns. This article uses the current outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) to examine global health governance’s history, evolution, and status within the political science literature. In particular, the article focuses on the International Health Regulations and the World Health Organization as leading elements of the global health governance system in order to examine both how the system operates and what its shortcomings are.

Troubling Objectivity: The Promises and Pitfalls of Training Haitian Clinicians in Qualitative Research Methods

Building research capacity is a central component of many contemporary global health programs and partnerships. While medical anthropologists have been conducting qualitative research in resource-poor settings for decades, they are increasingly called on to train “local” clinicians, researchers, and students in qualitative research methods. In this article, I describe the process of teaching introductory courses in qualitative research methods to Haitian clinicians, hospital staff, and medical students, who rarely encounter qualitative research in their training or practice. These trainings allow participants to identify and begin to address challenges related to health services delivery, quality of care, and provider-patient relations. However, they also run the risk of perpetuating colonial legacies of objectification and reinforcing hierarchies of knowledge and knowledge production. As these trainings increase in number and scope, they offer the opportunity to reflect critically on new forms of transnational interventions that aim to reduce health disparities.

Hesitance towards voluntary medical male circumcision in Lesotho: Reconfiguring global health governance

Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention – voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of ‘partnerships’ has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.

The Pharmaceutical Commons: Sharing and Exclusion in Global Health Drug Development.

In the last decade, the organization of pharmaceutical research on neglected tropical diseases has undergone transformative change. In a context of perceived “market failure,” the development of new medicines is increasingly handled by public-private partnerships. This shift toward hybrid organizational models depends on a particular form of exchange: the sharing of proprietary assets in general and of intellectual property rights in particular. This article explores the paradoxical role of private property in this new configuration of global health research and development. Rather than a tool to block potential competitors, proprietary assets function as a lever to attract others into risky collaborative ventures; instead of demarcating public and private domains, the sharing of property rights is used to increase the porosity of that boundary. This reimagination of the value of property is connected to the peculiar timescape of global health drug development, a promissory orientation to the future that takes its clearest form in the centrality of “virtual” business models and the proliferation of strategies of deferral. Drawing on the anthropological literature on inalienable possessions, we reconsider property’s traditional exclusionary role and discuss the possibility that the new pharmaceutical “commons” proclaimed by contemporary global health partnerships might be the precursor of future enclosures.

Is the agenda for global mental health a form of cultural imperialism?

The contemporary agenda for global mental health has met with sustained criticism from some commentators. This article evaluates one important strand of such appraisal: that in which the dissemination of...

In Reply to Loh and Lin

We agree with Drs. Loh and Lin regarding reframing current global health experiences and programs to balance the interests of the sending institutions, learners, and the receiving communities. Drs. Loh and Lin reflect upon a pilot program utilizing a “crowdsourcing” model to help coordinate multiple short-term volunteer and educational activities into more cohesive longitudinal efforts. Crowdsourcing may offer a number of potential benefits, including (1) eliminating redundancies and improving efficiency, (2) developing consistent program goals, (3) bridging discontinuity in the provision of local care, and (4) improving innovation with diverse sets of eyes and perspectives. In fact, crowdsourcing has been used effectively across medical fields, especially with the advent of online-based collaboration platforms.1 However, a few pragmatic issues must be considered with this model. Despite common project goals, multiple handoffs between short-term cohorts may fragment attempts at establishing continuity. Even with online-based support, full-time staff from an intermediary organization may still be required to optimize care transitions. Another hurdle is that program evaluation becomes more challenging with increasing numbers of participants and groups. Attempts to create uniform programs may restrict individual sending institutions’ preferences and tailored learning and clinical focus. Ideally, the integration of historically fragmented efforts by outsiders would not only be coordinated amongst the external actors but also coordinated with the existing health system, even if the system is or appears to be limited in nature. This approach has further benefits by aligning the goals of visitors with local systems’ priorities, workforce realities, and capacities. Likewise, integrating previously disjointed activities into the existing local health system may facilitate local capacity building, helping to ensure that impacts of global health activities endure beyond the duration of short-term outsider presence.2 Regardless of potential limitations, as we attempt to develop contemporary impact-driven global health education and engagement, novel collaborative approaches provide important avenues to harnessing the collective strengths of medical professionals, institutions, and trainees.

EPA-1438 – USA Health System Performance

Innovative health research and highly performing, academic health centers of excellence abound in the United States. They coexist in marked contrast with the contemporary US health system that is fragmented, with a secondary and tertiary prevention, specialty focus, with little or no primary prevention, and an insufficient populations’ health focus. The consequence of such a model are unsustainable health care and health systems’ costs, rising burdens of diseases by non-communicable diseases (NCDs), multiple comorbidities, chronicity, disability, insufficient access to care. Furthermore, a sizable cluster of Americans, now in the tens of millions, who lack health insurance coverage, resort to hospitals’ emergency rooms care to meet their health care needs. It is an ineffective, discontinuous and expensive pathway exacerbating the health system's sustainability. The Affordable Care Act (ACA) enacted by the US Congress in 2009/2010, reconfirmed by the US Supreme Court in June 2012 is to be launched in January 2014. It represents a bold attempt by President Obama and his Administration to rectify the status quo. The author reviews America's health system's performance through a SWOT analysis and the solutions that are beginning to emerge in response to contemporary and urgent American and global health challenges. He presents highlights of the ACA and new American models of health promotion, illness prevention and care that are integrated, team based, responsive, continuous, of quality, accessible and affordable. Among them are the medical home, the medical neighborhood, and accountable care organizations. They are predicated on primary care, mental health and public health integration, the catalytic role that psychiatry should play in such models, and the positive consequences of such models for training, services, research and policy.