Global Public Health Policy Research Articles

World Health Organization and disease surveillance: Jeopardizing global public health?

Health issues now evolve in a global context. Real-time global surveillance, global disease mapping and global risk management characterize what have been termed 'global public health'. It has generated many programmes and policies, notably through the work of the World Health Organization. This globalized form of public health raises, however, some important issues left unchallenged, including its effectiveness, objectivity and legitimacy. The general objective of this article is to underline the impacts of WHO disease surveillance on the practice and theorization of global public health. By using the surveillance structure established by the World Health Organization and reinforced by the 2005 International Health Regulations as a case study, we argue that the policing of 'circulating risks' emerged as a dramatic paradox for global public health policy. This situation severely affects the rationale of health interventions as well as the lives of millions around the world, while travestying the meaning of health, disease and risks. To do so, we use health surveillance data collected by the WHO Disease Outbreak News System in order to map the impacts of global health surveillance on health policy rationale and theory.

The impact of Fogarty International Center research training programs on public health policy and program development in Kenya and Uganda

BackgroundThe Fogarty International Center (FIC) has supported research capacity development for over twenty years. While the mission of FIC is supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs, research capacity may impact health policies and programs and therefore have positive impacts on public health. We conducted an exploratory analysis of how FIC research training investments affected public health policy and program development in Kenya and Uganda.MethodsWe explored the long term impacts of all FIC supported research training programs using case studies, in Kenya and Uganda. Semi-structured in-depth interviews were conducted with 53 respondents and 29 focus group discussion participants across the two countries. Qualitative methods were supplemented by structured surveys of trainees and document review, including a review of evidence cited in policy documents.ResultsIn the primary focal areas of FIC grants, notably HIV/AIDS, there were numerous examples of work conducted by former FIC trainees that influenced national and global policies. Facilitators for this influence included the strong technical skills and scientific reputations of the trainees, and professional networks spanning research and policy communities. Barriers included the fact that trainees typically had not received training in research communication, relatively few policy makers had received scientific training, and institutional constraints that undermined alignment of research with policy needs.ConclusionsWhile FIC has not focused its programs on the goal of policy and program influence, its investments have affected global and national public health policies and practice. These influences have occurred primarily through strengthening research skills of scientists and developing strong in-country networks. Further success of FIC and similar initiatives could be stimulated by investing more in the training of policy-makers, seeking to better align research with policy needs through more grants that are awarded directly to developing country institutions, and grants that better incorporate policy maker perspectives in their design and governance. Addressing structural constraints, for example supporting the development of national research agendas that inform university research, would further support such efforts.

Intradermal powder immunization with protein-containing vaccines

The central importance for global public health policy of delivering life-saving vaccines for all children makes the development of efficacious and safe needle-free alternatives to hypodermic needles, preferably in a thermostable form, a matter of pressing urgency. This paper comprehensively reviews past in vivo studies on intradermal powder immunization with vaccine formulations that do not require refrigeration. Particular emphasis is given to the immune response in relation to antigen adjuvantation. While needle-free intradermal delivery of vaccines induces a predominantly Th2-type immune response, adjuvants powerfully enhance and modulate the magnitude and nature of the elicited immune response at various effector sites.

An international legal strategy for alcohol control: not a framework convention—at least not yet

The perceived success of the Framework Convention on Tobacco Control (FCTC) in influencing national and global public health policies has led to growing interest in promulgating new international legal instruments to address global health issues-including calls for a Framework Convention on Alcohol Control (FCAC). Despite broad support in the public health community, the authors caution that an analysis of the value of lawmaking for alcohol control cannot rest solely on the character of the underlying public health challenge and the similarities between alcohol control and tobacco control. Other factors must be considered, including the relative political feasibility for global health lawmaking. The potential contribution of non-binding international legal instruments to advancing global alcohol control, in particular, deserves strong consideration. The authors propose a gradual international legal strategy for alcohol control, starting with a non-binding code of practice focusing on areas of critical concern with wide political consensus, leading over time to a comprehensive binding treaty. Although often dismissed as ineffective relative to treaties, non-binding international legal instruments have particular strengths and can create both norms and processes that impact the behavior of states and other actors, overcoming a number of limitations of more rigid legally binding strategies. Ultimately, the authors contend that the negotiation and adoption of a non-binding international legal instrument as a first step in a long-run legal strategy offers a more politically realistic, and potentially superior, alternative to immediate efforts to achieve a Framework Convention on Alcohol Control.

Global public health policy transfer and dengue fever in Putrajaya, Malaysia: a critical discourse analysis

This study critically analyzed the operationalization and materialization of globally hegemonic dengue fever discourse at the local level in the city of Putrajaya, Malaysia. Textual analysis of the World Health Organization's First report on neglected tropical diseases (NTDs) (2010) identified three discursive strategies in the WHO's effort to set the agenda for research and action on neglected diseases: the nomination of dengue fever as a disease of the impoverished and voiceless other; the predication of neglected disease status on environmental and behavioural uncleanliness; and the framing of so-called ‘pro-poor’ neglected tropical disease discourse as a new paradigm under which targeting these othered people, behaviours and environments is a key strategy for NTD management and control. Further analysis of the transcripts of 14 key informant interviews conducted with experts in public health, governance and urban development in Putrajaya found that discursive links between dengue and poverty contributed to the inappropriate transfer of globally dominant dengue control strategies to Putrajaya's non-poor local environment. These findings indicate that endemic dengue emerged in Putrajaya in part because planners, health officials and residents reproduced in their plans, policies and behaviours the construction of the disease as one of the other. The findings call into question the characterization of dengue fever as a disease of poor people, unclean spaces and unsanitary behaviours, and raise new questions about the appropriateness of targeting NTD initiatives to the poor. The findings also highlight the need for locally appropriate public health policies for infectious disease control in non-poor environments.

How federal health-care policies interface with urban and rural areas: A comparison of three systems

Global public health policies span national borders and affect multitudes of people. The spread of infectious disease has neither political nor economic boundaries, and when elevated to a status of pandemic proportions, immediate action is required. In federal systems of government, the national level leads the policy formation and implementation process, but also collaborates with supranational organisations as part of the global health network. Likewise, the national level of government cooperates with sub-national governments located in both urban and rural areas. Rural areas, particularly in less developed countries, tend to have higher poverty rates and lack the benefits of proper medical facilities, communication modes and technology to prevent the spread of disease. From the perspective of epidemiological surveillance and intervention, this article will examine federal health policies in three federal systems: Australia, Malaysia and the USA. Using the theoretical foundations of collaborative federalism, this article specifically examines how collaborative arrangements and interactions among governmental and non-governmental actors help to address the inherent discrepancies that exist between policy implementation and reactions to outbreaks in urban and rural areas. This is considered in the context of the recent H1N1 influenza pandemic, which spread significantly across the globe in 2009 and is now in what has been termed the ‘post-pandemic era’.

10 best resources on … the current effects of global health initiatives on country health systems

This article outlines ten of the best resources that focus on the current effects of global health initiatives (Global Fund to Fight AIDS Tuberculosis and Malaria PEPFAR MAP GAVI Alliance) on country health systems. It lists and describes the usefulness of the ten resources which include: The Systems-Wide Effects of the Global Fund to Fight AIDS Tuberculosis and Malaria: A Conceptual Framework; Global health initiatives and public health policy; Center for Global Developments HIV/AIDS Monitor; Global HIV/AIDS Initiatives Network (GHIN) website; The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control; What impact do Global Health Initiatives have on human resources for antiretroviral treatment roll-out? A qualitative policy analysis of implementation processes in Zambia; Interactions between Global Health Initiatives and Health Systems; An assessment of interactions between global health initiatives and country health systems The Impact of Collective Efforts on the Reduction of the Disease Burden of AIDS Tuberculosis and Malaria; and Global health partnerships in practice: taking stock of the GAVI Alliances new investment in health systems strengthening.

Working ‘off the record’: polio eradication and state immunity in Chad

The reappearance of polio in Chad generates anxieties about governance as well as public health. Since Chad was declared polio-free in 2003, at least 180 cases of paralytic polio have been linked to importations of wild poliovirus from Nigeria. In efforts to eradicate polio through house-to-house vaccination campaigns, international agencies have aggressively implicated political leaders, placing those authorities in a bind. On the one hand, governments are required to demonstrate compliance in the form of universal vaccination. On the other hand, the legitimacy of political leaders and of local authorities in particular depends upon their ability to show compassion for their populations and to be responsive to individual circumstances and concerns about the drops. This article looks at how the obligation of the African state to adopt global public health policy as its own becomes problematic when the goals and protocols of international agencies rely on the assumption that the state controls its population. Under pressure to render account to international agencies, state officials deploy high-level politicians to enforce vaccination mandates at critical moments, create administrative forms to record campaign progress that conceal difficulties in vaccinating children, and use statistics to portray the campaigns as success stories. Local authorities, who feel the bind most acutely, grant exceptions to the mandate of universal vaccination to certain subjects and work with local vaccinators and supervisors to keep cases of unvaccinated children ‘off the record’. These efforts allow the vaccination campaigns to be carried out without incident even as they work against the goal of polio eradication.

Neglected malarias: The frontlines and back alleys of global health

Among the public health community, ‘all except malaria’ is often shorthand for neglected tropical diseases. The Bill and Melinda Gates Foundation's cause célèbre, malaria receives a tremendous amount of funding, as well as scientific and policy attention. Malaria has, however, divergent biological, behavioural and socio-political guises; it is multiply implicated in the environments we inhabit and in the ways in which we inhabit them. The malaria that focuses our attention crops up in the back alleys of Dar es Salaam, brought into being by local labour and municipal governance – a version of malaria that, we argue, is increasingly excluded in current eradication campaigns. This article considers the cycles of public health amnesia, memory and neglect that construe the parasitological exchange between man and mosquito. It begins by exploring the political concerns and technical capacities that have transformed malaria into a global enemy. Combining these historical accounts with ethnographic material, we suggest how malaria is disentangled from or conflated with particular places. Ultimately, our aim is to reflect upon the relationship between scale of malaria control and its social consequence, attending to the actors and relations that fall outside of contemporary global public health policy.

Challenging Custom: Rethinking National Population Surveillance Policy in a Global Public Health Age

This article examines the current state of disease surveillance and reporting in the United States and seeks to answer two central questions: first, whether the increasing emphasis on the global importance of public health policies compels a fundamental reexamination of the long-standing deferential approach to state power where matters of population health surveillance are concerned and, second, how the nation's long-standing deferential legal customs might be modified to address the growing emphasis on global public health policy that is undergirded by technological advances. We examine the International Health Regulations, or IHR (2005), and suggest that these regulations offer a powerful impetus for reevaluating U.S. legal custom concerning the policy and practice of population health surveillance, not only as a matter of U.S. law but also as a core dimension of U.S. legal obligations to other nations, as embodied in international agreements and treaties. We find that if the political will exists to change the domestic disease surveillance and reporting system, the federal government has the power to act. Questions remain, however, about whether the public health and legislative communities are willing to challenge current customs or even if they desire to do so.

Incorporating uncertainty in aggregate burden of disease measures: an example of DALYs-averted by a smoking cessation campaign in the UK

BackgroundSummary measures of population health (SMPH) combine information about morbidity and mortality as a means of describing the health of a population and allow for the comparison between otherwise incomparable...

Problems, policies and politics: A comparative case study of contraband tobacco from the 1990s to the present in the Canadian context

Contraband tobacco has been and continues to be a global public health policy concern, with special manifestations in Canada. Over the past 20 years, in two noteworthy instances the Canadian government has battled contraband - in the early 1990s, and for much of the past decade. In the 1990s, when contraband cigarettes flooded the Canadian market, the government rapidly responded, using policy measures such as implementing a tobacco export tax and cutting domestic sales tax. Unfortunately, contraband made a strong comeback in recent years, but this time the government has hesitated to act, owing to a change in the source of the contraband. Using John Kingdon's streams theory to frame our arguments, we suggest that lack of congruence between different policy stakeholder groups' perceptions of the problem, policy solutions, and political feasibility has road-blocked the implementation of anti-contraband policy in the 2000s.

“Manifesto” for Advancing the Control and Elimination of Neglected Tropical Diseases

Neglected tropical diseases (NTDs) are the most common infections of the world's poorest people and the leading causes of chronic disability and poverty in low- and middle-income countries [1]–[3]. NTDs (Table 1) especially affect children and young women of reproductive age [4], and consequently deprive them of their health and economic potential [3]. NTDs also impair agricultural productivity and are an important reason why the world's poorest 1.4 billion people who live below the poverty line cannot escape destitution and despair [3]. Despite the devastating effect of these diseases on health and development, with evidence that their global burden is as great as that of any other serious disease [1]–[3], financial support for control and elimination efforts, as well as research and development (R&D), have been inadequate [2], [5]. Indeed, in Millennium Development Goal 6 (to “combat HIV/AIDS, malaria and other diseases”), NTDs were not even specifically mentioned but merely considered as part of the “other diseases” [6]. However, policy makers are slowly beginning to appreciate the importance of NTDs. Table 1 Neglected tropical diseases. The World Health Organization (WHO) has a new Department of Neglected Tropical Diseases, and WHO-TDR (Special Programme for Research and Training in Tropical Diseases) has a new 10-year strategic plan with support from UN agencies, member states, and private philanthropies. At the same time, funding for integrated NTD preventive chemotherapy control from the governments of the US and UK has increased dramatically and is approaching US$100 million annually, while support remains strong for product development partnerships from the Bill & Melinda Gates Foundation, Medecins Sans Frontieres (MSF), and a few European governments. Recently, the new Director of the US National Institutes of Health, Francis Collins, has targeted NTDs as a research priority, and the UK charity Wellcome Trust has agreed with the multinational pharmaceutical company Merck & Co. to allocate substantial funds for a joint, not-for-profit research center in India to develop inexpensive “antipoverty” vaccines against neglected diseases [7], [8]. Additional efforts to combat NTDs are also being shared among major multinational pharmaceutical companies (i.e., Novartis, GlaxoSmithKline, Pfizer, Sanofi-Aventis, Merck & Co.) and others who have also committed resources and made investments in research and development for these conditions. Thus, although at present only about 10% of the global funds required for preventive chemotherapy and NTD mass drug administration have been committed, and although R&D for NTDs has not even reached the so-called 10/90 gap [9], (meaning only 10% of available global R&D spending is committed for diseases that disproportionately affect 90% of the world living in low-income and middle-income countries), there is cautious optimism that such disparities could diminish in the coming decade. With a combination of funds from the group of eight (G8) nations, emerging economies (e.g., Brazil, India), multinational companies, and private philanthropic sources, together with a community of scientists, physicians, and other healthcare workers, global public health experts and policy makers committed to NTDs have begun to deliberate about how future resources and investments should be best allocated, particularly in terms of an appropriate balance between implementation and R&D. The leadership of key international agencies such as WHO, ministries of health in disease-endemic countries, and the communities themselves is key to achieve any ambitious strategy. With a global dialogue now underway, this is an appropriate time to present an eight-point manifesto (“a public declaration of motives and intentions by a government or by a person or group regarded as having some public importance” [2], [11]) for NTDs.

Reconstructing the epidemic history of HIV-1 circulating recombinant forms CRF07_BC and CRF08_BC in East Asia: The relevance of genetic diversity and phylodynamics for vaccine strategies

HIV-1 CRF07_BC and CRF08_BC are closely related circulating recombinant forms (CRFs) with serious public health consequences in China. The temporal and spatial dynamics of these CRFs were determined by estimating their times of divergence, using phylogenetic and Bayesian coalescent methods. Studies of the timelines of CRF07_BC and CRF08_BC trace the expansion of these strains back their origins to Yunnan province. The present study highlights the relevance of incorporating evolutionary and molecular epidemiological analyses into an in- depth understanding of the genesis of HIV epidemic, providing information for determining regional and global public health policies, including future vaccine strategies.

World Cancer Declaration: a need for partnership

In the September issue of The Lancet Oncology, Franco Cavalli outlined the revised World Cancer Declaration. This declaration—a central objective of the International Union Against Cancer (UICC)—outlines 11 targets that must be tackled if the global cancer burden is to be decreased substantially. Cancer health-care providers and advocates have long-forewarned of an impending cancer epidemic. This message has often fallen on deaf ears outside of health communities; indeed, it has often been under-appreciated even in other health specialties. This apocalyptic vision of the future, however, is not an exercise in melodramatics; the stark truth is cancer kills more people than tuberculosis, malaria, and AIDs combined, and over two-thirds of all deaths occur in low-to-middle income countries where resources are scant or non-existent. Depressingly, most of these deaths are needless: if the knowledge and options available today were exploited to their maximum eff ect, most cancers could be avoided or cured. If the World Cancer Declaration is to have demonstrable eff ects, the UICC can not be expected to work in isolation. The declaration needs to be adopted by governments, health authorities, non-governmental organisations, philanthropic organisations, and other involved parties worldwide. The WHO, in particular, has a large part to play and must reverse the silence that has come out of its departments for far too long on cancer control. The World Cancer Declaration is an ambitious affi rmation that needs to resonate with an intensity far greater than that achieved with the Framework Convention on Tobacco Control—the only notable success story up to now in implementing a global public-health policy with potential to decrease the cancer burden. The eff ect of cancer diff uses across all aspects of humanity. The consequences of this disease are not restricted to just the acute treatment needs within a health-care system. Governments need to provide a unifi ed strategy that shapes policies, not just in health, but also in economics; trade and industry; innovation; education; employment; transportation; food and the environment; communities and local government; culture, media, and sports; international aff airs; and justice. The compartmentalised debates that permeate politics about how resources and infrastructure are allocated need to end, and wide-ranging positive actions taken. We can no longer aff ord to sit on our hands and watch people die needlessly. We all have a personal and common responsibility to help overcome this global challenge and I encourage you to read the World Cancer Declaration, endorse the policy via the UICC website, and think carefully about what changes you can do, however small, in your private and professional lives to bring about change, before we live to regret this moment in history.

Syphilis in Immigrants and the Canadian Immigration Medical Examination

Immigrants to Canada must undergo screening for syphilis. This study presents the results of syphilis screening from 2000 to 2004 and describes its impact on Canadian syphilis reporting and epidemiology. The study identifies migrant groups at risk of syphilis disease. All permanent resident applicants 15 years of age or older; younger individuals who have syphilis risk factors, and long-term temporary resident applicants are required to have non-treponemal syphilis screening done. Reactive results were confirmed. Immigration-related syphilis screening results were analyzed for year, migrant origin, migrant age and classification. A total of 2,209 individuals were found with positive syphilis serology from the screening of 2,001,417 applicants. The sex ratio of positive cases was M:F = 1.4. Rates per 100,000 applicants were: refugees 286, refugee claimants 267, family class 187, temporary residents 85, and economic class 63. Age and geographic distribution reflected sexual transmission, known international prevalence, and the Canadian processes of immigration. Certain immigration class applicants from syphilis high-prevalence source countries are a significant source of syphilis notifications in Canada. Identifiable populations and the immigration application medical processes represent global public health policy and program opportunities at the national level.

Commentary: The Preston Curve 30 years on: still sparking fires

Samuel H Prestons classic paper The Changing Relation between Mortality and Level of Economic Development published in 1975 remains a cornerstone of both global public health policy and academic discussion of public health. Prestons paper illuminates two central stylized facts. The first is a strong positive relationship between national income levels and life expectancy in poorer countries though the relationship is non-linear as life expectancy levels in richer countries are less sensitive to variations in average income. The second is that the relationship is changing with life expectancy increasing over time at all income levels. Preston examined the relationship between life expectancy and income in three different decades: the 1900s 1930s and 1960s. In each decade the association between the two measures held true; more recent research shows that the income-life expectancy relationship still applies and continues to move upwards (although the AIDS epidemic in Sub-Saharan Africa has reduced life expectancy at the low end of the income scale in recent years). Although the basic facts set out by Preston are generally accepted there is still a great deal of dispute about the mechanisms that lie behind the relationships and the policy implications we can draw from them. (excerpt)

Health, security and foreign policy

Over the past decade, health has become an increasingly important international issue and one which has engaged the attention of the foreign and security policy community. This article examines the emerging relationship between foreign and security policy, and global public health. It argues that the agenda has been dominated by two issues – the spread of selected infectious diseases (including HIV/AIDS) and bio-terror. It argues that this is a narrow framing of the agenda which could be broadened to include a wider range of issues. We offer two examples: health and internal instability, including the role of health in failing states and in post-conflict reconstruction; and illicit activities. We also argue that the relationship between global public health, and foreign and security policy has prioritised the concerns of the latter over the former – how selected health issues may create risks for (inter)national security or economic growth. Moreover the interests of the West are prominent on this agenda, focusing (largely though not exclusively) on how health risks in the developing world might impact upon the West. It is less concerned with the promotion of global public health.