Young Voices in Research for Health 2009 Winners of the 2009 essay competition for the under-30s © Global Forum for Health Research 2009 Published by the Global Forum for Health Research, October 2009 ISBN 978-2-940401-22-2 Suggested citation: Global Forum for Health Research, Young Voices in Research for Health, 2009 Keywords: 1. Research. 2. Health. 3. Innovation. 4. Poor. 5. Development. The reproduction of this document is regulated in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. The document may, however, be freely reviewed and abstracted with appropriate acknowledgement of the source, but not for sale or for use in conjunction with commercial purposes. Requests for permission to reproduce or translate the report, in part or in full, should be addressed to the Global Forum for Health Research (see address below). All reasonable precautions have been taken by the Global Forum for Health Research to verify the information contained in this document. However, it is being distributed without warranty of any kind, either expressed or implied. The responsibility for interpretation and use of the material lies with the reader. In no event shall the Global Forum for Health Research be liable for damages arising from its use. The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Global Forum for Health Research concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The authors alone are responsible for the views expressed in this document. Additional copies of Young Voices in Research for Health 2009 can be ordered (at no charge) via the web site: www.globalforumhealth.org or from Global Forum for Health Research 1-5 route des Morillons PO Box 2100 1211 Geneva 2 Switzerland
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Ann Gaspard. Rosario García. Instituto Nacional de Higiene y Epidemiología. Enrique Falceto de Barros. Instituto de Cardiología y Cirugía Cardiovascular. Sylvie Olifson. Benito Pérez. The committee reviewed all Spanish-language essays and identified the Cuban winner. Zoe Mullan. Daniel Savignon Marinho. Ibarra. Carlos García. Instituto de Investigaciones Culturales Juan Marinello. Red Telemática de Salud de Cuba. Le comité a examiné tous les textes espagnols et désigné le gagnant cubain. Jean-Jacques Monot. Celia Medina. Mercedes Rubén. They also express their gratitude to the Ministry of Public Health of Cuba for hosting a national competition and to the Cuban institutions from whose staff the national selection committee was made up: Asimismo. Teddy Tamargo. Tea Collins. Marame Ndour. Amita Mukho. Alexander Segura. Instituto Nacional de Endocrinología. El comité examinó todas las redacciones escritas en lengua española y eligió al ganador cubano. Christine Mauroux. Emma Grainger. Ivette Castillo. Ana Ma. Daniel LopezCevallos. Meghnath Dhimal. Ariadna González.
. Sophie North. María del González.3
Acknowledgements AgRAdecImIentos RemeRcIements
The organizers thank the following for their opinions and assistance: Los organizadores desean dar las gracias a las siguientes personas por sus opiniones y su ayuda: Les organisateurs remercient les personnes suivantes pour leurs opinions et collaboration : Andrea Bauler. Oana Penea. The Cuban committee was chaired by Nereida Rojo with: El comité cubano estuvo presidido por Nereida Rojo y contó con la participación de: Le comité cubain était présidé par Nereida Rojo avec la participation de: Magaly Caraballoso. Sarah Cash. expresan su gratitud al Ministerio de Salud Pública de Cuba por haber organizado un concurso nacional y a las instituciones cubanas cuyo personal compuso el comité de selección nacional: De plus. Obasogie Osamwonyi (Young Voices). Sasha Payagala. Kheyal Khalil. Melanie Brown. Erik Landriault. Dziedzom de Souza. Escuela Nacional de Salud Pública. ils expriment leur gratitude au Ministère de Santé publique de Cuba pour avoir organisé un concours national et aux institutions cubaines dont le personnel a composé le comité de sélection : Centro de Cibernética Aplicada a la Medicina. Tara Sarwal (The Lancet). Guillermo Díaz. Hospital Hermanos Almejeiras. Nandita Bhan. Gurbinder Maumi. Tiago Pinto Pereira (Global Forum for Health Research). Ana Serrano. Lester Sam Geroy.
One is an open letter to the President of the United States. This year’s theme was Innovating for the health of all. the crisis of human resources in health. some are very practical. Rebecca Lacroix (Sweden). The format of essays also varied. The 41 essays included in this anthology were shortlisted and eight were chosen as the winners: Bianca Brijnath (Australia).Introduction
For the fourth year running.
Head. Christian Rueda-Clausen (Colombia). the Global Forum for Health Research and The Lancet invited authors and researchers under 30 years of age to enter the Young Voices essay competition. Entrants certainly rose to this challenge. others highlighted their experiences abroad. Many are immensely personal texts. We hope these young voices will be heard. While some of the young professionals chose to discuss health problems in their home countries. media coverage of global health issues. External Relations Global Forum for Health Research
Senior Editor The Lancet
. but all tackled issues that they are clearly passionate about. Aakanksha Pande (India). health workers and researchers. The competition was opened to entries in Spanish this year. Okezie Uba-Mgbenena (Nigeria) and Rafael van den Bergh (Belgium). and international responses to public health emergencies. Over 400 entries were submitted – about 25% more than last year – from young people of 75 nationalities. biases in scientific publication. as well as in French and English. the intricate links between education and health. health promotion in schools. It is encouraging to see the next generation of health researchers make such heartfelt arguments about innovation and health equity. Authors were encouraged to take established practices to task and to write in an engaging and thought-provoking fashion. Finding innovative ways to distribute health resources and services fairly to populations in need should be a priority for policymakers. The topics covered are diverse: for example. others philosophical. Annia Martínez Massip (Cuba). others are narrative. Aina Palou Serra (Spain).
la promotion de la santé dans les écoles et les réponses internationales aux urgences de santé publique. Aina Palou Serra (Espagne). certains se penchent sur des aspects très pratiques. Les auteurs étaient encouragés à remettre en question certains usages établis et à rédiger un essai original. Il est extrêmement encourageant de voir que la nouvelle génération de chercheurs possède des arguments sincères en faveur de l’innovation et l’équité en matière de santé. la crise des ressources humaines en matière de santé. L’un est une lettre ouverte au Président des États-Unis.Young Voices in Research for Health 2009
Pour la quatrième année consécutive. Aakanksha Pande (Inde). Nous espérons que la Voix des jeunes sera écoutée. Les essais varient également dans leur format. le Global Forum for Health Research et The Lancet ont invité des auteurs et des chercheurs âgés de moins de 30 ans à participer au concours d’essais La voix des jeunes. Les participants se sont sans aucun doute montrés à la hauteur du défi. d’autres ont préféré s’appuyer sur leur expérience à l’étranger mais tous ont traité de problèmes qui visiblement les passionnent. l’étroitesse des liens entre éducation et santé. d’autres sont philosophiques. voire provocateur. ouvert aux soumissions en langue espagnole. Christian Rueda-Clausen (Colombie). La plupart de ces textes sont éminemment personnels.
Responsable des relations extérieures Global Forum for Health Research
Éditeur senior The Lancet
. Le thème de cette année était Innover pour la santé de tous. française et anglaise. les travailleurs du secteur de la santé et les chercheurs. Trouver des moyens innovants de répartir équitablement les ressources et les services de santé parmi les populations qui en ont besoin devrait être une priorité pour les décideurs. Annia Martínez Massip (Cuba). cette année. la couverture médiatique des problèmes mondiaux de santé. d’autres sont narratifs . Plus de 400 essais ont été présentés – soit 25 % de plus que l’an dernier – par des jeunes gens de 75 nationalités. la partialité dans les publications scientifiques. Le concours était. Cette anthologie inclus les 41 essais présélectionnés et ceux des huit gagnants : Bianca Brijnath (Australie). Alors que certains de ces jeunes professionnels ont choisi de parler des problèmes de santé dans leur pays d’origine. Rebecca Lacroix (Suède). Divers sujets ont été couverts : par exemple. Okezie Uba-Mgbenena (Nigeria) et Rafael van den Bergh (Belgique).
Okezie Uba-Mgbenena (Nigeria) y Rafael van den Bergh (Bélgica). claramente. el concurso se ha abierto a los trabajos escritos en español. Aakanksha Pande (India). las complejas relaciones entre la educación y la salud. Rebecca Lacroix (Suecia). la promoción de la salud en las escuelas y la respuesta internacional ante emergencias de salud pública. Desde luego. los sesgos en las publicaciones científicas. Se han recibido más de 400 redacciones —un 25 % más que el año anterior— escritas por jóvenes de 75 nacionalidades. Los temas abordados han sido diversos: por ejemplo. Es alentador ver la próxima generación de investigadores para la salud argumentar de manera tan sincera acerca de la innovación y la equidad en salud. Aina Palou Serra (España). otras son de carácter narrativo. otros han destacado sus experiencias en el extranjero. El tema de este año ha sido la Innovación para la salud de todos.Introducción
Por cuarto año consecutivo. Encontrar formas innovadoras de distribuir los recursos y servicios sanitarios equitativamente entre la población necesitada debe ser una prioridad para los responsables políticos. la cobertura mediática de las cuestiones de salud mundial. han tratado temas que. Una de ellas es una carta abierta al Presidente de los Estados Unidos. algunas son muy prácticas. el Foro Mundial sobre Investigaciones Sanitarias (Global Forum for Health Research) y The Lancet han invitado a autores e investigadores menores de 30 años de edad a participar en el concurso de redacciones Voces Jóvenes (Young Voices in Research for Health). todos ellos. les apasionan. no obstante. Muchos de los textos son sumamente personales. Christian Rueda-Clausen (Colombia). otras filosóficas. aparte de los redactados en lenguas francesa e inglesa. Se ha alentado a los autores a adoptar las prácticas establecidas para la tarea y escribir de un modo sugerente que induzca a la reflexión. los trabajadores de la salud y los investigadores. El formato de las redacciones también ha sido dispar. Se han preseleccionado los 41 ensayos incluidos en esta antología y ocho de ellos han sido elegidos como ganadores: Bianca Brijnath (Australia). Annia Martínez Massip (Cuba). la crisis de recursos humanos en materia de sanidad. Esperamos que se preste oído a estas jóvenes voces. Mientras que algunos de los jóvenes profesionales se han decantado por debatir los problemas sanitarios de sus países de origen.
Jefa de Relaciones Exteriores Global Forum for Health Research
Redactor jefe The Lancet
. los participantes han estado a la altura del desafío. Este año.
... ......... ... . ..... .... .... .. ... .. .. .. .. .. .. ... .. . . . . ... . ...... .. . . . . . ... . ....... . .... .. . Chile . ....
Pens and needles Bianca Brijnath. ..... ... cada paso cuenta Luz López Samaniego.. ... . .. ... .. . . . ... . . . .. ... . .... . Redefining the cycle: Systems. ... .. . .. ..... ..... . .. . New Zealand
...... . .... . . .. .. . . UK Health 2. .. .. . .. . ... .. . ..... . ... . ... . . . . . .... .... . .
Innovating for the health of all: Breaking the barriers Biraj Karmacharya.. ... . .. .. ........ . .. . ....... ... .... Nepal
De la nécessité de se méfier des fétichistes de la nouveauté Rebecca Lacroix. . ... ...... . .. . . ... .
Where are the global issues in our global media culture? Hannah Harvey. .. .. ... . . . .. . ..... .. .... .... .. . . ... ..... . ... .... . .. . ....... ..... . . . . . ..... .. . ... . ... . .. . . . . .. .... . . Brazil
.. . . . ... .... .. . . . . ... .. . ..... ... ... ... ... . . . .. . .. . . ... .. . . .. .. ... . ... . . .
Malnutrition and obesity: Closing the gap Amy Mathew.... ... .
Introduction en français Introducción en español
Deciphering the anatomy of organizations and the physiology of political will: The way forward for global health Najwan Abu Al-Saad.... .. .. ... . .. . ...... ... .. New Zealand ..... .. Retro innovation – The healthier way Liesl Harewood.... . .. . .. UK . ... ... ... .. .... . .. . . Inefficient innovation: The need to redirect funds from treatable and preventable diseases Damian Hacking. . .. . .. .. . . Innovando hacia dentro Annia Martínez Massip.. .. . .. .. . .. ..... Australia
.. Algeria Education: A simple way to improve health Fabio Botelho.. ....... .... .. ... . . .. . . . .. ..... ... . ... .. .... Lack of innovation in health promotion in schools schools: Educating the citizens of tomorrow with the methods and strategies of yesterday Abdelhamid Benalia. .... . .. . . . . ..... .. Innovating for the health of all: Searching for equity. ...... .. . . .... . ... . . . .. . . .. ... .. . . ..... . . .. .. . ...... . .. Guyana
. .. . .. ... . .. . . .. ...... ....... ... ... .. ... ... . .
From Asclepius to gene engineering: Have we gained a better understanding of health? Manik Gemilyan. ... . . . . .... .. ... . . Canada It takes more than a Band-Aid: A letter to president Obama Amanda Deatsch... Sweden Contra la violencia de género.. . . .... . . .... From lab to village: Catalysing global health entrepreneurship Justin Chakma. . . . Sierra Leone . ... . ......... . . ... .. .. .... . Silicon Brains Javier García Castro..... . .. .. ........ . ... . . . . . ... . .. .
Never let a disaster go to waste: Opportunities presented by swine flu for innovation in global public health emergency response Delford Doherty.. .. ...... ..... . . ... . ....... Uruguay . ..
3 5 6 7
... . . . . . .. . ... .. . ............... ... .. .. ... .. .. . . .. . ... . ...... .. . ........ .... . . ... . . . ..... .. . . . .... . .. .. . .. .. .. . ..... ...... . . .... . .. .. .. .. .. health by all Kate Jongbloed. .. .. .. ... ... ... . ... . . . .. ..... . ... .. .. USA . .. .. ..... . . ..... Redistribuir la locura: construcción de alternativas sociales y terapéuticas al encierro manicomial José Agustín Cano Menoni... . . .. .... . ... . .. ... . . . . . . ..... . . ... . . Taking the doctors back to where they belong: Achieving health for all in Bangladesh Tanvir Ahmed. Spain
...... . .. .. .... . Armenia .... .. ... . ... .. . . ... .. . . ... .. . . ... .... . ... . . .... ... ... . . .. . . . .. . . .. . . . ... .. .... . .. ... ... .. ... .. ... . ... ... . .... ... . ..... . .... ... . ... . .. ... .. ... ............. . ... .. . . . ... ... ... .. ..... .. . . . ..
Urgent global health innovation? Global human innovation first! Baltica Cabieses Valdéz. responsibility and truth in a divided world Hildy Fong.. .. .. . . .. ... .. Bangladesh ...... ..... . ...... . ... . . . South Africa .... . .... .... .. . .. ..... . . . ... ... . . . . .. ... . . .. . ... . .. ... .. . . .. India ... . . .... .
12 15 19 21 24 27 31 35 39 42 46 50 53 55 58 61 63 66 70 73 76 80 83 87
. .. . .. . .. .. Canada
.. . . .. . ..........Young Voices in Research for Health 2009
table of contents
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A mission for all: Increasing access to health products and services through innovative partnerships Priya Mannava.... .. .. . .. . . ... . .. .. ... .. . .. . . . ... .. . . .
. . . ... . .. .. . . Cuba
.. . . .. ... .. .. Spain
..... . .. .. .. .. . . health and child poverty Nicholas Fancourt... ..... . . ... USA
.. . . ....0: Health for all.. ... ...
. . . . . . . . . .. . . .. . . . . . . . comprehensive health-care model for all David Shulman. . . .. . . . . . .. . . . . . . . .. . USA . .9
Mobile phones. . . . . . . . . 138
Appropriate methods and technology in health: A round peg in a round hole Okezie Uba-Mgbenena. . . . . . . . .. . . Nigeria . . . . . . . . .. . . . . . . . . . . . . . . . . . . Uruguay .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. .. . . . . .. . . . . . . . . . . . .. . . . . . . 131 Plaidoyer pour des modèles économiques ambidextres et la promotion de l’éducation tertiaire dans les pays en voie de développement pour l’innovation en santé à la portée de tous Valérie Sabatier. . .. .. . . . . . . . . . . . .. . . . . . . . .
90 94 97 101
Health-care access and the solar-powered ambulance Rufaro Ndokera. . . . . . . . . . . ... . . . . . . . .. . . .. . . . . . . . Necesidad de tecnologías sociales para la mejora en prevención en salud Alejandro Vásquez Echeverría. . . . UK
Show me the money! From rhetoric to action in addressing the global human-resources-for-health crisis Brenda Ogembo. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . France . . . . . . . .. . . .. . . . . . .. . . . 142 Who is at the receiving end of our innovation? Rafael van den Bergh. .. . . 125 Let the machines do the work: Automation and the drive for global health innovation Erin Rayment. . . . 113 Can today’s health challenges be overcome? Why information. . . . . . . . . . . . . . . .. . . . . . . . . . .
Pensamiento temporal y salud. . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . .. .. . USA . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109 Business not as usual: Improving the quality of health care through innovation Aakanksha Pande. . . .. .. .. . . . . . . . . . . . . . . . Philippines . . . . . . . Innovation beyond individualism Jason Nagata. . . . . . . . . . . .. . 148
* Winning essays
. . . 134 Community empowerment for global health equity: Towards an innovative.. . . . . . . . .. . . . . . . . . . . . . . . . . . . Belgium
. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
International database of negative results in biomedical research: The need to shift a paradigm in scientific publication Christian Rueda-Clausen. . . . . . . . . . . . . . . .. . . . .. . . .. . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. ... . . . . . . . . . .. . .. India . . . .. . . . . . .. India . .. . . . . .. . . . . . . . .... . . . . . . . . . . . . . . . . . . . .. Cameroun . . . . . . . .. . . . . . .. . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . Kenya . . . .. . . . . . . . . . . . . .. USA
... . . . . . coordination and innovation matter Marian Angelica Panganiban. . . . . .. Spain . . . . . . . . . .. . . . women and girls: Engendering mHealth into an innovation for all Janna McDougall. . . 121 Disruptive innovation as the new paradigm of global health Soumya Rangarajan. .. . . . . . . . . . . .. . . . . . .. . . ... . . .. . . . .. .. Australia . . . . . . . . . . . . . . . . . .. . 117 Realigning interests and resources for health technology development in traditionally underserved markets Samuel Pickerill. . . . . . . . . . . . . ... . . Colombia . . . . . . Plaidoyer pour l’acceptation des déontologies non conventionnelles de recherche médicales Paul Wilfrid Armand Menye. . . . . . . . . . . . 105
La necesidad de tejer estrategias colectivas para una transformación social y sus consecuentes mejoras para la salud Aina Palou Serra. . . . . .. USA . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .
Young Voices in Research for Health 2009
Najwan Abu Al-Saad
Najwan Abu Al-Saad, United Kingdom
decIpHeRIng tHe AnAtomY of oRgAnIzAtIons And tHe pHYsIologY of polItIcAl wIll: tHe wAY foRwARd foR globAl HeAltH
There is much we already know about global public health, whether empirically or intuitively. The answer to improving health for all, especially for the world’s poorest, perhaps lies more in how to implement what we already know. We know that much of the burden of disease felt by the world’s poor is either entirely preventable or, if not preventable, easily amenable to effective treatment. We know that, even if we were to entirely ignore the area of health care for a moment and focus instead on providing the world’s entire population with access to clean running water, nutritious food, adequate sanitation, universal education and sufficient means to avoid abject poverty – all in a secure environment free from violence, persecution and conflict – then their health would probably be the better for it. We know that, not only would individuals and populations simply be less likely to become ill, but they would also be more likely to flourish. The importance of the underlying determinants of health has been extensively reviewed, most recently and comprehensively by the Commission on the Social Determinants of Health in 20081, and the recommendations for action are crystal clear. In the same way that much of the current burden of disease is preventable or treatable, the underlying determinants of health are amenable to simple, effective solutions. We know that the global status quo of inequity between and within countries is perpetuated and exacerbated by crucial elements within the current structure and function of the political, economic and social systems, whether these systems act at the global or local level. Numerous barriers exist within governments, ministries, public–private partnerships, intergovernmental and nongovernmental organizations that impede the implementation of change for the benefit of the populations served. Barriers exist even where consensus has already been reached on what needs to be achieved, such as with the United Nations Millennium Development Goals (MDGs). We know that there is often a discrepancy between what we expect in theory and what actually happens in practice. It is much easier to ‘talk the talk’ than to ‘walk the walk’ and that which seems the simplest is often the most difficult. Change does not come easily, and history shows many examples, particularly in health, where innovations, even as simple as washing your hands, often take decades to be taken seriously and implemented, often for a variety of reasons, not all of which are rational. In health research, it is increasingly known that the availability of effective treatments or of free health services does not necessarily translate to increased coverage if, for example, opportunity costs to individuals and families make genuine access prohibitively expensive. An efficacious treatment in a randomized trial does not
The way forward for global health
always translate into an effective treatment in the field because the level of care provided to those in the trial cannot be easily rolled out to the rest of the community for lack of resources. More systems research, be it quantitative or qualitative, is being done to elucidate the reasons for what is observed in real life. This may help introduce effective change (even if relatively minor) to authentically and feasibly improve an aspect of health-care provision or health promotion. However, research of this nature is often done at the community level. What about research into potential barriers to implementing effective measures to improve health higher up the chain? Political will is often cited as the driving force required to bring about change. It would be difficult to find an article to do with any aspect of health or social policy that does not stress the importance of political will, at whatever level, for policy to be implemented effectively and fairly. The importance of the role of researchers in presenting sound evidence for or against certain policies or priorities to policymakers is well recognized. However, if it were just sound evidence and common sense that were needed for effective policy-making, then the world would probably be a very different place. We know, intuitively, that the world is not that simple and that there is a multitude of reasons why political will is not focused on the health and well-being of the most disadvantaged. In this case, this is the ultimate, if perhaps most naive, question that needs to be answered with respect to the macro-social determinants of health: Are the current levels of iniquity and injustice perceived as an inevitable part of the human condition? Is power a zero-sum game such that, if I have power and choose to relinquish it, the other inevitably rules over me? Is a world where the health gap is closed in a generation or the MDGs are achieved in their entirety (even if not by 2015) actually attainable? As these are not easily answerable research questions, it is necessary to narrow the field of inquiry. One factor we may feel acts as one of the significant drivers behind political will is the effect of individual personality and outlook, particularly of those in positions of authority. Thinking shapes behaviour. A company director’s vision greatly determines the overall outcomes for a company because it determines the structures and processes that are put in place for the company to function. The overall ethos of an organization not only influences, as do the personalities working there, the formal structures and processes within it but also the informal processes, which may be as important if not more so in the overall functioning of the organization. The same influences are at play in middle management, with subsequent effects on the wellbeing and productivity of employees. Globally (and regardless of preference) there is an undoubted difference between the current President of the United States, Barack Obama, and the former President, George W Bush, in terms of their personality and outlook, with knock-on effects for the rest of the world. Political will acts at many levels and is not necessarily enforced by those who are directly elected. Within the global health architecture there is a plethora of actors, agencies and organizations acting internationally and at multiple levels with the potential to exercise considerable political influence to affect health outcomes. Those in non-health organizations, such as the World Bank, may also have as much, if not more, impact on the determinants of health and health outcomes.
Young Voices in Research for Health 2009
Najwan Abu Al-Saad
Answers to some of the following questions would go a long way towards identifying what needs to be done so that existing knowledge can be put into practice to improve health: • How does the behaviour of organizations, individually and collectively, affect the achievement of favourable health outcomes, in particular for the most disadvantaged? Can their behaviour be modified? • What is the relative importance of formal versus informal structures and processes in the overall productivity of these organizations? • What impacts do the personalities and outlooks of individuals and groups within these organizations have that may directly and indirectly affect health outcomes? • How do individuals (particularly in positions of relative authority) affect the informal processes that act within and between organizations? • What is the nature of the interactions between organizations? Do they help or hinder their respective achievement of common goals (if they exist)? The use of organizational research, with its focus on applied behavioural psychology and sociology, could reveal the answers to such questions. Ultimately the aim is to find out if barriers exist to the implementation and coordination of effective policy. If so, what is the nature of these barriers? Developing an evidence base surrounding the importance of organizational processes for health outcomes may encourage the more effective interorganizational and intersectoral cooperation needed to improve health and other development outcomes. If such research also pointed to the importance of political will at progressively higher echelons of power, then again an evidence base linking the macro sociopolitical determinants to health could be developed. At the moment, we already know enough to make massive improvements in global health. Where there is a will to achieve such improvements, there is a way to implement what we already know. The question then lies in how we attain this will. If research were needed in how to improve health for all, it would be to determine the direct effects on health outcomes of the organization of the existing multiplicity of actors within the current global health system. This could be achieved by a synthesis of organizational development research with health systems research. The evidence gained from this effort could be used to truly innovate for the health of all.
1 2 3
Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, World Health Organization, 2008. Labonte R, Schrecker T. Globalization and social determinants of health: introduction and methodological background (part 1 of 3). Globalization and Health, 2007, 3:5. Lee K, Sridhar D, Patel M. Bridging the divide: global governance of trade and health. Lancet, 2009, S16–22.
Najwan Abu Al-Saad qualified in medicine at the University of Newcastle upon Tyne, in the United Kingdom, in 2004. Currently, she is completing a Master’s in Tropical Medicine and International Health at the London School of Hygiene and Tropical Medicine, after which she will return to specialty training in anaesthesia and intensive care medicine in the east of England. With further experience, she hopes to apply her clinical practice to providing anaesthetic and critical care services in the contexts of both emergency settings and longer-term development in a way that contributes to strengthening health systems overall, wherever she may work in the future.
high maternal mortality and the poor health status of children still haunt our health system2. The government has designed a PHC-centred health system for service delivery but suffers a severe shortage of health workers. the low quality of care. Additionally. it should be evident that. the Government of Bangladesh built 12 000 community clinics to deliver services straight to the doorsteps of the people6.Achieving health for all in Bangladesh
Tanvir Ahmed. and about 60% of the union health and family welfare centres have no medical officers10. against 1:15 000 in rural areas9. This uneven progress in health indicators serves as evidence of the existing inequity that is a threat to health for all3 in Bangladesh. This is not a new idea. in spite of achievements. Placing these fresh graduates in the 2900 union subcentres that currently lack medical officers will surely strengthen the delivery of PHC services.58 formally trained health workers per 1000 people7 and is among the countries with a severe shortage of health workers8. making our dreams of achieving health for all more distant and far-fetched. immunization coverage and reduction in infant mortality and fertility rates1. As time progresses. Therefore I strongly believe that an innovative approach is needed to help the health workforce – in particular the doctors – to render services to rural areas that will not only facilitate the provision of PHC services but also contribute to achieving health for all the people of Bangladesh. However. A survey reported that 39% of the upazila (subdistrict) health complexes have no resident medical officers. Bangladesh
tAkIng tHe doctoRs bAck to wHeRe tHeY belong: AcHIeVIng HeAltH foR All In bAnglAdesH
Bangladesh’s race towards achieving the Millennium Development Goals (MDGs) has resulted in impressive quantitative health gains such as improvement in life expectancy. though these never functioned due to administrative and political complexities. Bangladesh has a density of 0. real inequity exists in the health sector of Bangladesh. the existing imbalance is getting wider. At present. “inadequate income” and “uncertainty of their
. An increased bias towards urban areas has also resulted in a doctor–population ratio of 1:1500 in urban areas. Health for all has been mandated by the Government of Bangladesh since the Declaration of Alma Ata. and primary health care (PHC) was the chosen strategy4. the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP) established several hundred non-bed community facilities (1400 for DGHS and 3500 for DGFP) at the ward or union level5. qualitatively critical issues like poor access to health services. Bangladesh produces more than 2500 doctors a year7. with an acute imbalance in rural-urban distribution. and attempts have been made before to assign doctors (mostly during internship) to rural areas. The vacancy rates are mostly higher in rural and poorer regions of the country7. But these attempts have failed. Why? According to the comments of dissatisfied doctors published in a recent Bangladesh health watch report. From the discussion above. To render PHC services.
doctors will be paid monetary remuneration equal to their internship stipend with a remote allowance. The need for monetary incentives can never be overlooked in an economy-driven society. Hence. I still strongly believe that doctors can be placed at the rural centres to render PHC services. During their stay. Nonetheless. But the model must reflect the needs of the doctors. Rajshahi and Sylhet7. The model. one cannot ignore the thirst of doctors to gain more knowledge and the desire to excel in their career path. This is the reason why. will definitely be able to attract fresh medical graduates to rural areas.Young Voices in Research for Health 2009
career path” are described as main reasons7. This. The training will provide them with a certificate
. the major incentive to the doctors would be the one-year service. Fresh medical graduates will be sent to union subcentres for a mandatory period of only one year. we have created an inequitably distributed and urban-focused health workforce. together with Ministry of Health and Family Welfare. They will also participate in monitoring the performance of these doctors. public health communication. doctors will be given extensive training on health system management. and there has to be monitoring involving all the stakeholders to keep the model viable. contributing to the urban bias. they will report to and be supervised by the corresponding upazila health and family planning administrator (UHFPA). and all are located in the four largest cities in the country: Dhaka. as life becomes complicated. over the years. The training will be provided weekly at the corresponding upazila health complex. At present. Bangladesh has 30 institutions offering a postgraduate degree or diploma in various areas of health. Additionally. The desire to obtain higher degrees is another important reason why doctors prefer to stay in urban areas. I believe. which will also involve the Bangladesh Medical and Dental Council (BMDC) and the Bangladesh College of Physicians and Surgeons (BCPS). health-care financing. The basic objective of this training would be to help doctors to enhance their managerial skills – help that is currently absent in our postgraduate clinical degree and diploma curriculum. The union subcentres will be contracted out to these medical bodies for the placement of the doctors. In the next few sections I would like to propose a new. During this one-year stay at the rural centres. with the increasing availability of opportunities. Components of the programme.e. this will serve as an excellent opportunity to provide basic health-administration skills to doctors who are often engaged later in their careers in active management and decision-making processes. Considering national resource constraints. and research methods for conducting small-scale monitoring and evaluation of health programmes. both the administrative bodies of the Ministry of Health and Family Welfare will be stakeholders in the programme. They will be placed at the subcentres of both DGHS and DGFP. Chittagong. doctors are getting more involved in the private and urban sectors. the doctors will be extensively exposed to the everyday health problems of the community and gain practical experience in how to manage them and respond accordingly. leaving the majority of potential recipients of the health services unattended and gravely neglected. Thus. which naturally grows with time. Incentives. at the community level. in consideration of their growing social responsibilities and associated financial needs. sustainable model that would encourage medical doctors to stay where the people are. However. which will be considered as postgraduate training. i. In the context of health workforce constraints. However.
Monitoring and supervision. Dhaka. BCPS and the Ministry of Health and Family Welfare before issuing a certificate upon the successful completion of the stay. World Health Organization. Responsibilities of the doctors at the subcentre. with a large share comprised of informal health-care providers7. local government representatives of the corresponding union will be involved in the process. doctors will report directly to the UHFPA of the corresponding upazila health centre for their services at the union subcentres. to be successful. accessed 25 August 2009). Health care delivery systems of Bangladesh. Dhaka.un. World Health Organization Bangladesh. org/health_system_bangladesh. newborn and child health in the South-east Asia region. Demographic implications for health human resources for Bangladesh. But. Bangladesh Health Watch. As mentioned above. the UHFPAs will also partly supervise their training.Achieving health for all in Bangladesh
that will help them to build their confidence in independent practice. 2009 (www. United Nations Public Administration Network. accessed 25 August 2009). policy-makers should actively take decisions. Geneva. Government of Bangladesh. Bangladesh Health Watch. BRAC University.html.
3 4 5 6 7 8 9
Osman FA. programmes and system in Bangladesh: achievements and challenges. The model also requires recognition from professional and academic medical bodies like BMDC and BCPS. in running the programme. increasing access to health services and improving referral practice. I believe that this model for engaging doctors to render PHC has high potential and would be acceptable. accessed 2 September 2009). gov. considering its high potential for reducing urban bias on the part of doctors. The Independent. as it will contribute to their postgraduate curriculum. 15(2):263–288. Paper presented
. Finally the inputs from UHFPAs and union chairmen will be analysed by a committee comprising members from BMDC. 2009 (www. 2006. 2009 (www. Improving maternal. 2007. Nath DK. For general practitioners.com/details. it provides a comprehensive understanding of community health-care needs. One of the major responsibilities of doctors at union subcentres will be to render primary health-care services to the community by joining hands with the local informal sector.pdf. theindependent-bd. They should not only attempt to reduce inequity in health but also benefit the doctors in such an agreeable way that they would join the rural health centres in pursuit of their own interest and contribute in achieving health for all. BRAC University. London.org/intradoc/groups/public/documents/ APCITY/UNPAN022523. Community clinic: a pro-poor initiative. Dhaka.aspx?val=2. the model would require active support from policy-makers. James P Grant School of Public Health. Health workforce in Bangladesh: who constitutes the health care system.php?nid=120412. as well as involving the community in running their own health centres. The additional gain will be hands-on experience in various aspects of health system management. Bangladesh has a pluralistic healthcare system. 2008. Additionally. However. Health policy. as it recommends changes in the postgraduate curriculum. ( http://unpan1. New York. It also guides young doctors in setting a career path and assists in postgraduate training. Mabud M. James P Grant School of Public Health. Dhaka. The world health report – Working together for health. The state of health in Bangladesh 2006: challenges of achieving equity in health. as it ensures the involvement of stakeholders.dghs. especially policy-makers. Thus these doctors will play a crucial role in bridging the formal and informal sectors. Training will be directly supervised by BCPS. Health system in Bangladesh.bd/App_Pages/Client/DGHS_Show. accessed 2 September 2009). South Asian Survey.whoban. However. 2008.
which he completed with a gold medal.
Tanvir Ahmed. witnessed the revolutionary drug policy of Bangladesh but never understood the true essence of public health until he joined medical school.
. 10 Primary health and family planning in Bangladesh: assessing service delivery. In addition to the health system. Later he joined the school as a researcher and won an international grant on comprehensive primary health care. Centre for Health. Social sector performance survey. His quest for “treating millions with just one prescription” led him to the James P Grant School of Public Health for further studies. Financial Management Reform Programme. Dhaka. Dhaka. born within a year of the Alma Ata Declaration. Independent University. investigating the sexual and reproductive health-related risk behaviour and the vulnerabilities of the marginalized.Young Voices in Research for Health 2009
at the International Workshop on Human Resources for Health in Bangkok. Bangladesh. Population and Development. Tanvir currently works at the International Centre for Diarrhoeal Disease Research. he is interested in the health of older people and nutrition research. 2005. 2005.
It can be based within the community. political and inexpensive. high blood pressure and high cholesterol are also expanding at a fast rate. Who is to blame? It is probably both researchers and the school community that need to take the blame for this lack of action. But. but very few of them are finally implemented. Algeria
lAck of InnoVAtIon In HeAltH pRomotIon In scHools: edUcAtIng tHe cItIzens of tomoRRow wItH tHe metHods And stRAtegIes of YesteRdAY
Innovation in health does not have to be high-tech and expensive.Lack of innovation in health promotion in schools
Abdelhamid Benalia. while thinking outside the box. and such associated conditions as diabetes. finally. There are many innovative research papers featuring and discussing innovative interventions. Thus. These are some of the health issues that expensive or high-tech equipment cannot and will not help to prevent. Substance abuse among young people has been observed as a growing phenomenon in several countries. target people and focus on preventive intervention. It is interesting to observe the distortion that exists between research and the practice of health promotion in schools. Thus. Despite being the one place where young people spend most of their time. a large number of interventions are unlikely to be applied in practice due to their high cost or the complete lack of information about them. Thus. Firstly. It can be ideological. In health-promotion literature. for example. high implementation costs and low cost–effectiveness should be clearly reported as a limitation of the research. What is urgently needed is to find innovative ways to address these issues. Innovation in health is not only about the clinical environment. Innovation in health does not have to be complex and the exclusive domain of politicians and academics. and a
. innovation in health should lead to a reduction in health inequalities and improve people’s health. Alarming statistics related to young people’s health are becoming more common in Europe. strategic. theories and ideas. This would ensure that research innovation makes it through to the implementation stage. innovation in health can take different forms and involve a wide range of professionals and people in the community. researchers need to completely change their approach in the area of cost and cost–effectiveness analysis. few research projects take into account the cost–effectiveness of their proposed interventions or even attempt to report on it. it is worth asking why schools are not embracing innovation and whether they should be pushed towards more innovative health promotion strategies or interventions. The percentage of young people who are overweight or obese has reached unprecedented levels in some European countries. the patient and curative medicine. It can be based on simple concepts and should be everybody’s business. schools seem not to be in a position to take on the old and new health challenges faced by young people. To be able to use research as a source of innovation.
Jamie Oliver.Young Voices in Research for Health 2009
failure to report cost–effectiveness in a research paper should be seen as an obvious limitation of the research. He is also actively involved in the Student and Early Career Network of the International Union for Health Promotion and Education and in the Education and Management Research Ethics Panel at King’s College London. on the other side. because improving children’s health is everybody’s business. so parents can. Innovation in health promotion is not easy and does not happen quickly. which then leads to this question: What is a favourable cost–benefit ratio? Costs associated with promoting health in schools are not always the source of the problem. In other schools. researchers and the community if schools do not foresee changes in society and act accordingly. Local authority or central government departments managing health-related policy in schools have to stop their hypocrisy. sex education has been implemented in several curricula but is not compulsory. However. Abdelhamid’s ambition is to develop a challenging international career with a focus on public health strategies that improve children’s health. There is no miracle solution to overcome these kinds of barriers apart from continued education on the subject. as the complacent habit of providing high-fat and high-sugar food was deeply rooted in both the school and home environment. introducing healthier menus was received like a hostile revolution. and. commitment from parents. Rather. It can be a real challenge that needs deep cultural and organizational changes. teachers. For instance. innovation in health promotion in schools is often seen as a threat by parents. tried to introduce a healthier menu in schools canteens. politicians. These are some examples of health innovation that is not implemented in the right way. which makes implementing new interventions difficult or impossible. teachers and children. For instance. having acquired a Master’s in Health and Society there and a Master’s in Psychopedagogy at Université Laval in Canada. Thus. they push for the implementation of new policies or school curricula based on evidence. a famous British chef. Abdelhamid works as a programme coordinator for the National Health Service at NHS Kingston. In other words. innovation in health promotion needs to be more targeted to take account of cost–effectiveness and employability. This welcome improvement led to some parents’ passing their children junk food through school gates at lunchtime. On the one side. I am not necessarily speaking about only such controversial issues as sex education courses in schools or about school nurses giving the emergency pill (also known as the ‘morning after pill’). it has to be stressed that parents too need to assume their responsibilities. especially when children are the beneficiaries. as well as parental and broad community involvement in every stage of any new project. politicians and schools is an essential ingredient needed for innovation. an opt-out option is always given to schools or parents. in south-west London. remove their child. My real aim is to try to make the reader aware of the potential of schools to improve young people’s health and how innovation at all levels is needed. Similarly. It will be a massive failure of leadership on the part of parents. if they want. the innovative health-promoting school programme is not compulsory but left to the discretion of schools or local authorities.
Abdelhamid Benalia is currently enrolled in a health education PhD programme at King’s College London. in the United Kingdom. Innovation is put in jeopardy by resistance to change and fear of innovation. The aim of this essay is not to stigmatize the different individuals or institutions that are not contributing to or are restraining innovation in health promotion in schools.
As a result. i. I am in the fifth year of the medical course (six years is the total in Brazil). you have to observe how it dies. integrality (the patient must be given a general examination independent of his particular disease. but sometimes I get upset with myself. complex procedures to prove to people that we are “special”. at 06:30. more than that. This late discovery happened to me. it is not uncommon to see students discovering what primary care is only in the fourth year of the course. or appear to do. observe its diseases. job. Sistema Único de Saúde. establishing a system based on universality (everyone has the right to access health services freely). I once heard a physician saying that we in the medical profession should do. I really like this routine. wondering when I will next have to do my 12-hour internship at an emergency hospital.e. with some classmates and also with some teachers. I wake up early. and have some practical and theoretical classes at a hospital for complex treatments. To know its health. Brazil
edUcAtIon: A sImple wAY to ImpRoVe HeAltH
“If you want to know how a population lives. considering the social background of the patient. Some of my medical school peers agree with this. family. This routine has been part of my life since I left the basic subjects of medical school. maybe we will not be valued. helping other students to understand more about the Brazilian health system. education level. was created to replace a failed health system that placed hospitals at the centre. The current Brazilian health system was formulated in 1988.”1
My story: Today is a normal day in my life. If we stick to simple procedures. And. study at the library and go home about 19:00. Well. or the Single Health System. which could resolve more than 80% of Brazilians’ demands. what upsets me is that. I hope that it will not be on Saturday. Brazilian universities have a programme based mainly on specialized subjects. access to transport. and I am also a health policy tutor at my university.Education: A simple way to improve health
. recreation habits and environment) and equity (policy actions must first prioritize people with lesser economic conditions). I have lunch with my friends. walk 30 minutes to my university. Now we are trying to shift the centre of the structure to primary care.
My child’s arm was getting redder. my two-year-old boy was bitten by a strange insect some days ago and got a bleeding wound on his arm. But. I would have hesitated less about choosing a graduate course because I would have had a course that considered health in school. as we try to consolidate a new system despite an enormous lack of information. she would still have taken her child to the primary care centre.” And another person’s story: “Honey. The mother in the second situation would not have put coffee on the child’s arm. I am going to sleep. Consequently. the physician working in emergency would have more time for his family and improving the quality of his life.
. this happens because. It is well known that good health improves education and good education improves health2. It is cheaper to mobilize populations with vaccination programmes and campaigns against such chronic diseases as hypertension and diabetes than to try to discover specific cures for specific diseases – which is also important but more expensive. one five years old and the other two. because she would have known some principles of basic care. One of them could be the principles of public health. which was full. knowledge should belong to everybody. but the wound got worse. They told me to go to my neighbourhood primary care centre. I would have seen more common diseases in the university than rare cases. in the end.Young Voices in Research for Health 2009
Another person’s story: “Today could be a typical day in my life. but I do not know where it is or how it works. languages and history but also about issues that will prepare the individual for practical life. In my opinion. I saw more than 40 children. Today the hospital was crazy. And even if she did put coffee on his arm. Of course. Imagine that all of us were taught some basic health principles in school when we were 15 years old. First of all. I am not proposing specific health education for the population. I’m really tired. I paid a private doctor to see my child. I put coffee in the wound (as my mother taught me]. hotter and bigger. if we want health for everybody. I have two children. Brazilian physicians would think more about running a general practice than a specialized practice. There were a lot of severely ill children there – worse than mine. “I took him to the paediatric emergency hospital. But I think that our schools should teach children and adolescents not only maths.” And now the way ahead. People always say that in the centre there is a lack of paediatricians. studies have confirmed that making simple changes in our habits and ways of living is an important. a lot of them could have been treated by the primary care service. Also. if not the most important. intervention to reduce mortality3. a subject that would explain how the health system works and some preventive actions people can take. I would normally have gone to work [as a public servant] and would have left the children with my neighbour [as their dad does not live with us]. The last two stories above are common in Brazil. So.
As the descendent of slaves. and his best friend (his brother) studies medicine too.
Fabio Botelho studies medicine at the Federal University of Minas Gerais. he has had the opportunity to live with different people and learn different cultures. Giugliani E. Furnée CA. instead of measuring our health with mortality rates. I believe that these problems are not specific to Brazil. An epidemiological model for health policy analysis. I really hope that one day. his mother is a social worker. Medicina ambulatorial – condutas de atenção primária baseadas em evidências [Ambulatory medicine – evidence-based primary health care]. Social Indicators Research. His father is a doctor. Artmed. Devers GEA. Condições de saúde da população Brasileira [Brazilian population’s health conditions]. The health effects of education: a meta-analysis. we can measure it by people’s access to education and other social values. In: Duncan B. Schmidt M.
. 2008. and Europeans. 2004. 3rd edition. 2(4):453–466. Groot W. rural workers from dry and poor areas in Brazil. ed. 1975.Education: A simple way to improve health
It is a simple idea that I have put forth here. I hope that one day we can rate our health situation based on the population’s quality of life. Porto Alegre. Fabio considers his family the keystone of his story. He was born in Belo Horizonte in 1987. Brink HM. where he is a health policy tutor. The European Journal of Public Health.
Rumel D et al. 18(4):417–421.
draw their dot. not knowing how to use one is the most powerful symbol of opportunities denied. We talk and play “Blind-man’s bluff ” and “Catch” for a while. chocolate or any of the other supplies – just empty water bottles for storing their water and pens for writing their names. make their mark. and the children are mesmerized. About a dozen children have descended seemingly out of nowhere. Aged between 5 and 10. didi. and write their names in Hindi. more income. the camels chew uninterestedly on either side. Literacy and knowledge leads to better jobs. Australia
pens And needles
“Didi. It is a hot August day. issue instructions.Young Voices in Research for Health 2009
Bianca Brijnath. It is a school day and none are at school. It is no coincidence that the poorest people in the world are the least educated and the most marginalized. as I am sitting in the middle of the Thar desert in Rajasthan. and sign his or her name. Though this is a popular tourist route for camel safaris. A pot of dal is boiling on the fire. Then we start to draw. the ability to make healthier choices. and are evidenced everyday in the interaction between a doctor and an illiterate patient. dying much earlier than others. the children ask only for my pen and our empty water bottles. instead they are herding goats through the arid scrub. Although I have an entire notebook only two sheets are used. The doctor can write a prescription. or scarf. People must know how to read and write before they can use more sophisticated technologies like calculators and computers. I make a ball out of my dupatta. greater lifespan and ultimately improved health and productivity for nations. I propose as a health innovation the distribution of pens to poor people. they are not interested in money. dust and sand but neither electricity nor
. and we have broken our journey for lunch. She must rely on other people to read the signs to tell her how to go to the hospital and where to go once she gets there. Using a pen is the most basic sign of literacy. they are poor children with sun-bleached hair and ragged clothes. They fight over the only pen I have. They are curious. But the illiterate patient cannot read this script or sign her name and must rely on memory and other people to correctly interpret the script. In the Thar desert there is heat. can you give us your pen?”
The pleading children call me “older sister” in Hindi. camels and little houses. They draw squiggles and straight lines. all keen to write their name. When we break camp to continue on our journey. and we throw it around. especially in resource-poor settings. The pen is the starting point on the literacy scale. The rivulets of inequality run deep. The connection between education and health is profound.
Giving children pens instead of sweets. to feed small mammals (without the needle) and to refill pens. invested with meaning beyond its functionality. Mothers could be given an immunization schedule with seasonal pictures to denote the time each immunization was to be given. needs to be created so that the hand muscles do not cramp. An educated child is a family member who can filter information for uneducated members. it is small. and through its bruises and scars we read immunizations. antiretroviral treatments or other drug regimes that require
. She is afraid of needles. Health and education have a shared history that can be traced back to ancient Egypt. The Epi-Pen. I meet a woman who refuses to get her children immunized. insulin pen. arthritis and multiple sclerosis have all been designed around the concept of the pen. The ink in pens leaves scratches and blotches among the words that describe the histories of our lives. for example. when they go to the doctor. A pen is a cheap. as a cultural artefact. connects the clinic and the schoolroom. clicks and springs. In other hospitals I meet people who insist on injections. The pen is a paper needle. People are rarely ambivalent about injections. It inspires fear and loathing. People need to be taught how to hold a pen. and they need the knowledge and the tools to practice. how to move their fingers and how to apply pressure. and auto-injectors for anaemia. The children there want to learn. Immunization. weak. Our lives are defined by fluid: the medicines and blood in syringes that are pushed into or pulled out of our bodies describe our condition – we are high. and the hypodermic needle was used to extract cataracts from people’s eyes. strong. Understanding the mechanics of pens and needles dispels some of the myths surrounding injections. pleasured or pained. the pen can be used to shift them from passive patients into active participants in their treatment. the syringe has since been used in cooking. Apart from medical purposes. Likewise. The community health nurse brings the vaccines and needles into the slum. Similarly. He or she is a human being who can begin to understand possibilities. inexpensive. they would know if they had missed an injection and when the next immunization was due. infusions and addictions. it is their cure for everything. others in his family can learn how to use it and write their names. The hypodermic syringe is. readily available piece of technology that anyone can provide. The needle is like a body pen. A stronger connection between the needle and the pen could counteract this. But this is not true. If they could mark these off. Ignorance about injections drives both phenomena. through practice. Designers have assumed that the ubiquity of the pen has made its use instinctive. what is this? How do I use it?”). the pen has been used in medicine and for new drug devices. and how people that have taken the pen as inspiration seem “automatically” more attuned with using other health technology. We read that history on paper and occasionally on our bodies. low. It is more effective than a battery-powered laptop. involves the administration of vaccines in early life. In a Delhi slum. It encourages children’s inquisitiveness (“Didi. A child can practice with that pen. the reed was used to record some of the earliest human languages. thereby reinforcing the importance of learning. durable and easily replaceable. just as the needle is a body pen. Strength. but still she will not come. There needs to be familiarity with pens and how they work – pen caps. the cost is less than 2 US cents. fascination and curiosity. This is how the use of the pen becomes instinctive.Pens and needles
running water. Among adults who have never learnt how to read and write. The instruments of both originated there.
But there is only one pen. Following graduation. We cannot leave our settings the way we found them. as well as tutoring university undergraduate and master’s students in public health. In every village I come across thereafter. newspapers and essay competitions. But where they have been applied and used. Patients would be empowered to monitor their own treatment. Knowledge dissemination is the aim. I have not given them my pen. bow-legged camel. But we must.
. and we strive to fulfil our potential. to be empathetic and open.
Bianca Brijnath grew up in the megacities of Calcutta and Delhi in India. a dozen pens cost 50 cents. I wish I had and had thereby started something. children gather round curious and playful. This is especially relevant in resource-poor settings where doctor–patient ratios are skewed and the systems are not yet in place for ongoing health surveillance. always recording data. and then hope someone will listen. the children scatter into the Thar. and not to interfere or change the status quo. And we can start by education – give poor people pens. But for those who go now. she migrated to Australia and in 2004 graduated with majors in Sociology and Women’s Studies from Monash University in Melbourne. and there are so many children who want it. wondrous things have happened. calculate and calibrate in books. As researchers. knowledge transfer must work both ways. Her interests centre on family dynamics. she worked on AIDS-related stigma and discrimination in the Asia Pacific and anaphylaxis management in Australian schools. draw. They all want pens and water bottles. As I get back on my cranky. the opportunity to come along on this journey to contribute to human knowledge? How often do we give our participants adequate compensation for the richness and depth of information they have given us? We are taught not to presume to know our participants’ lives. policies.Young Voices in Research for Health 2009
monitoring and adherence could use this model. journals. We do not have enough because we did not anticipate this. Please buy some. melting back into the scrub to herd their goats and tend their homes. especially poor people. Give them pens. When PhDs and Grade 5 passes meet. We must do. We write. equip them for their intellectual journey. We work on populations and with people. In 2000. They wave farewell and thank us for our empty bottles. She is currently pursuing her PhD at Monash University on dementia care in India. Empowerment and community involvement have made late entries into our methodologies. teach them just as so many of them have taught us. But how often do we give our participants. It is an innovation that anyone can act upon and does not need policy debates in the halls of government. we understand possibilities. cry foul in textbooks and seminars. care-giving practices and systemic responses to mental health needs in developed and developing countries.
There is also a health dimension. From an evolutionary perspective. some human challenges for health innovation. Millennium Challenges. but it is now facing the opportunity of becoming once more an integrated community. and an important influence on global health has been globalization. ecologists. In this global context. specifically. among others. Global Health Council. The purpose of this essay is to develop a critical reflection of how innovations for health require urgent human innovation as a precondition. This essay is organized into three sections: first. Social and cultural variations must be considered as strengths instead of threats. some implications and limitations of this reflection. At the same time. Chile
URgent globAl HeAltH InnoVAtIon? globAl HUmAn InnoVAtIon fIRst!
Our world is suffering from the over-exploitation of resources. Efforts to reduce global health problems by social leaders. which continues to be a complex and immediate problem. have been impressive. politicians. as societies are still divided from one another and within themselves despite relevant efforts made for additional international cooperation. Examples include the Millennium Development Goals. World Health Organization Social Determinants Programme. in order to support global health over time. These current global challenges have environmental. etc. huge social changes are under way. They have all made large investments of financial and human capital to work towards the goal of health for all in many noteworthy ways. and as a consequence humankind is currently facing major global challenges. Action for Global Health. described as the intensification of social relations with links to distant localities in a way that local happenings are shaped by events occurring miles away1.Urgent global health innovation?
Baltica Cabieses Valdéz. Several difficulties and challenges remain. Multicultural societies urgently need more understanding and acceptance from others. and finally. time and money invested in it over many decades. By human innovation I mean. second. and to reduce fear of what is perceived as different. economic and social dimensions. political. despite the enormous energy. developing further understanding of the fact that we need one another to survive and develop as groups and societies. three possible steps for human innovation.
Health innovation and human obstacles
Health challenges tend to change over time. health has emerged as one of the most relevant
. clinicians and researchers. Global Health Program. as they can enrich diverse possibilities for global health innovation and the improvement of health-related outcomes over time. scientists. humankind first united in a single continent and later dispersed into many different geographical settings. to increase trust in others. Global Health Strategy.
with the compliance of social leaders and politicians. Both active and passive immunization strategies could be included. We tend to resist what we fear and to fear what we perceive as different. Step one: Reducing fear to increase cultural tolerance. compared with findings on social integration in this country4. the fact that 90% of research on health concerns problems affecting 10% of the global population5. should disappear after some time as a consequence of repetitive social interactions. In other words. epidemiology and sociology. which needs to be understood along with its strong interactions with other human dimensions. We need one another as human kind to survive and develop in every possible dimension. Multilevel collaboration. how can we achieve global human innovation towards later global health innovation? Three steps are needed. However. One recent example is the debate in the United Kingdom about cultural segregation. even studies concerning health and migration have focused on the differences between cultures instead of their similarities for future integration. A broader example is the existing polarization of health problems between those countries defined as “developed” and as “developing”. Therefore. globalization – once considered the main contextual factor for international separation – could now become a useful exposure (immunization) for societies and individuals to what is perceived as dangerous. social interactions do not always occur. studied by scientists through measuring the secretion of cortical hormones by the sympathetic system. In this scenario of human division.Young Voices in Research for Health 2009
Baltica Cabieses Valdéz
issues. When we analyse the psychological aspects of fear and how to cope with and reduce it. it is known that sympathetic reactions.
Three steps for human innovation
So. reflections of natural human reactions and resistance to what is perceived as dangerous. a fear–rejection–marginalization cycle could arise and continue over time within different communities. global health innovations require human collaboration as an urgent precondition for success. recently described by Trevor Phillips3. could enable societies to become immunized to fear. While most deaths in the world happen in developing societies. In this sense. Step two: Increasing cultural tolerance to increase human collaboration. the alternative of “immunization against fear” emerges as an interesting idea. However. Differences and divisions among us are. most of the research and health service investment is made to save people in developed ones. politics. as some societies have found ways to avoid social contact with those different to themselves. Evidence of this has been reported by human rights initiatives in the past. After reviewing a wide range of literature on globalization and its implications for health from such disciplines as economics. A striking correlate of this is what is referred to as the “10/90 gap”. we still think and structure our arguments in terms of human divisions. utilizing settings such as primary care clinics and schools and mass media and political strategies. In this sense. Recent
. as with emotions of rejection of what is feared (in this case another human). This fear has physiological effects. in my opinion. I agree with the proposition that one of the major consequences of globalization is the unresolved tension caused by cultural differences between societies and within communities that often ignore and fear one another2.
Stanford University Press. many others.uk/finance/ financetopics/recession/4290154/Trevor-Phillips-warns-that-Britain-could-return-to-racism-as-recessionbites. Finney N. leads to positive self-esteem. To survive and develop as societies. However. Phillips T. and how that could affect our health over time and generations. Data covering countries all over the world consistently show that people have worse health outcomes if they live in countries with greater inequalities. Studies of social capital and social cohesion. all over the world.co. 2009. 1990. which leads to greater social integration.clacso. These. accessed 26 August 2009). more efficient ways to disseminate this knowledge in developing countries are urgently needed. Stefoni C. and. Current examples include civil war in Colombia. Mutual trust could.pdf.html). in turn. and as a consequence social collaboration at every level should become an urgent policy.Urgent global health innovation?
studies have reported the striking result that countries’ health-related outcomes tend to be poorer if part of their population is excluded. we need to trust one another. among many. University of Bristol. within both local and global contexts..
Innovation for global health requires human global innovation as a precondition. Liberia and Sudan. people are dying and the earth is being pushed to its limits. The consequences of modernity. for future local implementation. and a possible virtuous cycle of trust–self-esteem–integration might continue over time in communities. Sleepwalking to segregation? Challenging myths about race and migration. This is a final example of how we continue to divide and exclude one another. Simpson L. Bristol. Globalization and its potential contribution to reducing fear and increasing trust and mutual collaboration need more consideration. A clear example of current lack of mutual collaboration is global warming.telegraph. and there is relevant evidence to support the described steps for human innovation. 1st ed.
. health promotion and health inequalities have shown that improving trust leads to positive feelings of being useful and relevant to society. Social values such as communitarianism become relevant to human groups. unwanted or living in poverty.
1 2 3
Giddens A. Britain could return to racism as recession bites.org. and huge global currents shifting economic growth and international migration. Nations need to take more consideration of this evidence. Concrete steps to follow require the active participation of local and international social leaders. 2001 (http:// bibliotecavirtual. The Policy Press. while they decide whether and how to collaborate. These findings lead to the discussion of how connected we are with others. even after adjusting for their socioeconomic position6. instead. reflect the persistence of human division whenever possible. It could be argued that for some particular topics there is no need for further research. Stanford. We need to further understand how global health is affected by issues not related to health.ar/ar/libros/becas/2000/stefoni. Representaciones culturales y estereotipos de la migración peruana en Chile. Powerful countries have refused to reduce their carbon dioxide emissions. but that the use of an efficient strategy to allow every place in the world access to that knowledge would be relevant. Step three: Increasing human collaboration to increase social trust. This. the “war on terror”. therefore. be considered a central outcome for human innovation but also a significant intermediate outcome for health innovation. worldwide economic recession. 2009 (http://www. once again.
migration and global public health. Pickett K.Young Voices in Research for Health 2009
Baltica Cabieses Valdéz
The 10/90 report on health research. health-care providers. Allen Lane. a certificate in Nursing Education and a Master’s in Epidemiology from Pontificia Universidad Catolica de Chile. nursing education and research. United Kingdom. She has been awarded the Chilean governmental scholarship Beca Presidente de la Republica for her current studies. 2009. She is a faculty member of the Universidad del Desarrollo in Chile and is currently pursuing a PhD in Health Sciences. Wilkinson R.
Baltica Cabieses Valdéz holds a Bachelor’s in Nursing-Midwifery. Geneva. The spirit level: why more equal societies almost always do better. 1999. Her nursing education experience emphasized women’s health. vulnerable women and ethnic minorities on HIV prevention issues. Global Forum for Health Research. She has also coordinated various professional projects and conferences.
. Her current areas of interest are health inequalities. She has published over 15 articles in peerreviewed journals and has contributed works to 35 conferences. which highlighted health promotion. with an emphasis in health inequalities. at the University of York in the United Kingdom. she was co-investigator of the Mano a Mano research team for HIV prevention in Chile. Baltica is a qualified consultant on HIV and has experience in training university students. Additionally.
Este modelo genera cronificación de los cuadros psicopatológicos. y es que se ha transformado en la muletilla de un tipo de academia tecnocrática y ensimismada. cifra equivalente a tres personas cada diez mil habitantes1. esta cifra representa el mínimo histórico desde que existen registros. emanciparlas del mercado y de la lógica del capital. siempre presta a descubrir la pólvora para presentarla en congresos y seminarios. La misma consiste en un modelo de reinserción social de personas internadas en hospitales psiquiátricos. prevención y rehabilitación
. Una innovación que encarna la funcionalidad del quehacer científico-técnico respecto a la reproducción del orden social.
Descripción del problema
El sistema de salud mental del Uruguay no ha logrado aún superar el peso que en él tiene el modelo de institucionalización manicomial. Sobre todo en el campo de la salud. marginación social de las personas internadas. en consonancia con la aplicación de una política de rápido egreso por parte de las instituciones psiquiátricas. sino imaginación organizada. Concebir una innovación que ya no sea sofisticación del mundo tal cual es. e “innovación” no es más que sofisticación del mundo tal cual es. Tal es la vocación de la propuesta que se presenta a continuación. Pero esta política no fue acompañada por el desarrollo de estructuras de salud mental a nivel territorial. y violencias múltiples tanto para los internos como para los trabajadores de estos hospicios. violaciones a sus derechos humanos. La mayor caída de las tasas de internación se dio en los años noventa. a través de una red de cooperativas de vivienda existente en Uruguay. la población manicomial uruguaya ha decrecido considerablemente hasta alcanzar las cifras actuales en el año 2000. En 1950 las personas internadas en manicomios eran dieciocho por cada diez mil habitantes (una cifra que se encuentra entre las más altas de la época: Uruguay no solamente era campeón del mundo en fútbol).Redistribuir la locura
José Agustín Cano Menoni. así como también es necesario redistribuir la riqueza” Alfredo Mofatt
Sucede algo desafortunado con la palabra innovación. Una innovación que ya no sea transformación alienada. es necesario refundar la noción y las prácticas de innovación. Actualmente en Uruguay hay unas mil personas internadas en instituciones psiquiátricas. El sentido transformador del conocimiento está entonces alienado. No obstante ser muy alta. Uruguay
RedIstRIbUIR lA locURA: constRUccIón de AlteRnAtIVAs socIAles Y teRApéUtIcAs Al encIeRRo mAnIcomIAl
“Hay que redistribuir la locura. A partir de entonces. sino aporte científico-técnico fecundo para la acción vital del hombre en la tarea de transformar conciente y democráticamente su sociedad. ni por suficientes programas de asistencia.
Las dificultades que enfrentan las iniciativas que buscan revertir esta situación son numerosas. una sociedad integrada y un robusto Estado de bienestar. la participación de FUCVAM constituye tanto una posibilidad de vivienda como un contexto adecuado para el desarrollo de un programa terapéutico alternativo al modelo represivo-psicofarmacocéntricoinstitucionalizador. basado en un sistema de salud pública universal con fuerte descentralización y estructuración territorial. y con un conjunto de instrumentos legales y fiscales inexistentes en la realidad latinoamericana. permitiendo trabajar tanto con las personas que dejan el manicomio como con la comunidad que los recibirá. La experiencia cooperativa y el trabajo colectivo brindan a las personas un encuadre institucional que oficia como organizador de la personalidad más positivo que el encuadre autoritario del hospicio. significa el desafío de confrontarse con su parte loca hasta hace poco encerrada. Para los segundos.
Fundamentos Las cooperativas de vivienda contienen un importante potencial para una estrategia de rehabilitación.Young Voices in Research for Health 2009
José Agustín Cano Menoni
capaces de favorecer la reinserción social de estas personas. como el de los países escandinavos. demente. miedos. primero hay que parecerse a ella”. la Universidad de la República y FUCVAM en la conformación de una red que pueda construir y sostener una alternativa de vivienda y acompañamiento terapéutico fuera del manicomio. o el italiano. Es inviable la aplicación sin más de algunos de los modelos más notorios a nivel internacional. Expropia palabra e historia y modela cuerpo y alma en una identidad detenida e impotente. Puede afirmarse que la disminución de la población manicomial ha significado a menudo la reproducción del modelo de exclusión y abandono del hospicio. La internación psiquiátrica prolongada congela a la persona en el rol de desecho social. el Uruguay cuenta con instituciones públicas fuertes. Dentro de esta red. sólo que fuera del manicomio. e inventar modos de convivencia donde lo diverso no sea excluido. entender los propios prejuicios. El historiador JP Barran dijo una vez que “para cambiar la realidad.
Descripción de la propuesta
Responder a este reto no es sencillo en una sociedad donde el acceso a la vivienda es un problema social general.
. Entre estas se encuentra la Federación Uruguaya de Cooperativas de Vivienda por Ayuda Mutua (FUCVAM) que reúne actualmente unas 350 cooperativas de vivienda en todo el país. y ciertamente también que la nada desquiciante del abandono. las organizaciones de familiares de personas internadas en hospicios. resistencias. hay que partir de las condiciones materiales y culturales en las que tal modelo habrá de desarrollarse. y organizaciones sociales activas y solidarias. caracterizados por su bonanza económica. La participación en una dinámica de trabajo colectivo restituye a la persona un lugar productivo en el demos y contribuye a la generación de procesos de resingularización identitaria positivos y dignificadores. Una de las más complejas de resolver es la ausencia de alternativas de vivienda supervisada acordes a un programa de reinserción. esto significa el pasaje de la situación degradante de pasividad y aislamiento del hospicio a una situación positiva de trabajo colectivo. Pese a sus dificultades. Para los primeros. Esto tuvo consecuencias graves: altos índices de reingreso (50% anual en el principal hospital psiquiátrico de Montevideo) así como el aumento del número de pacientes psiquiátricos en situación de abandono en la calle. Se propone la articulación de acciones entre las instituciones de salud mental. Para forjar un modelo de desmanicomialización capaz de alcanzar realizaciones en Uruguay.
Franco Basaglia dijo una vez: “en el fondo. nosotros sólo representamos un momento de enlace entre lo que está a punto de desaparecer y lo que todavía tiene que nacer”. • La transformación del sistema de atención. Es necesario vincular a la Universidad con nuevas experiencias de modo de que ésta contribuya a su desarrollo. reduciendo al mínimo las situaciones de internación. para que esta experiencia sea sustentable y generalizable es necesario que se acompañe al menos de las siguientes iniciativas: • El desarrollo de programas laborales para las personas involucradas.Redistribuir la locura
Acciones Se propone realizar una experiencia piloto elaborando un Programa de Salud Psicosocial (PSP) a desarrollar en el marco de las cooperativas de vivienda. • La metamorfosis en la formación de los profesionales de la salud. y además forme los investigadores y profesionales que el nuevo modelo requiere. el PSP estará dirigido al conjunto de los habitantes de la cooperativa y abordará también las problemáticas psicosociales emergentes desde una perspectiva de prevención y promoción de la salud. Por último. miedos y prejuicios en juego. Las cooperativas que participen de la experiencia podrán contar con exoneraciones fiscales y otros incentivos. y su diseño e implementación estará a cargo del Equipo de Salud del Centro de Salud Territorial de referencia. Se apelará al dispositivo de taller buscando poner en marcha un proceso en el cual abordar las diferentes fantasías. El desarrollo del PSP supondrá la articulación de acciones entre los equipos de salud presentes en la zona. Dicho Plan de Trabajo deberá:
• Establecer espacios colectivos con participación de todos los cooperativistas para la reflexión sobre la experiencia en curso. El desarrollo del PSP implicará destinar al menos una vivienda de las cooperativas para la reinserción social de personas internadas en hospicios. El modelo organicista hospitalocéntrico formó los profesionales que necesitaba. generando posibilidades de internaciones breves por fuera de los hospicios (en policlínicas u hospitales generales). El proyecto terapéutico deberá contar con el acuerdo de las personas involucradas. Los mismos pueden enmarcarse en las propias cooperativas. en conjunto con equipos universitarios en el marco de experiencias de extensión. Para ello. elaborará un plan de trabajo que incluirá actividades en común con los cooperativistas así como el desarrollo de un proyecto terapéutico específico para las personas que participan del plan de reinserción. Léase esta propuesta como una contribución a la gestación de aquello que
. No obstante este cometido específico vinculado a las personas en proceso de reinserción. así como los conflictos emergentes del proceso grupal. • Desarrollar un proyecto terapéutico específico con las personas involucradas apelando a diversas estrategias psicoterapéuticas. El PSP tendrá el cometido específico de acompañar el proceso de inserción de las personas provenientes de situaciones de internación prolongada.
En 1999 emigró a Montevideo con el fin de ingresar a la Facultad de Psicología de la Universidad de la República.
Esta cifra no incluye a las personas internadas en el Hospital “Piñeiro del Campo” (para personas ancianas). En el 2007 se graduó como Licenciado en Psicología.
. donde se piensa se encuentran internadas al menos otras mil personas más. Ese mismo año obtuvo una beca para realizar estudios de posgrado en Roma.Young Voices in Research for Health 2009
José Agustín Cano Menoni
en Uruguay debe todavía nacer para construir un modelo de salud mental que no encierre a las personas. Italia. así como una intensa actividad gremial estudiantil. una pequeña ciudad situada en el litoral norte del Uruguay. iniciando una etapa de formación universitaria. de gestión privada. ni a las internadas en las llamadas “Casas de Salud”. ni las expulse a las calles y a la miseria.
José Agustín Cano Menoni nació en 1980 en Salto. A partir del año 2008 se desempeña como docente de la Universidad de la República.
After four long years of process innovation. Shantha’s success story has spawned dozens of other health biotechnology companies in India. successful research and development is taking place in several countries that are considered lower income. the technology to manufacture the vaccine did not exist within India and had to be imported at the high cost of US$ 23 per dose. India does not require vaccines. the cost was prohibitively high and the majority were not vaccinated. so Dr Varaprasad Reddy was forced to raise capital by selling his family’s property. are often unable to communicate their science internationally through
. Dr KI Varaprasad Reddy. your scientists cannot understand recombinant technology in the least”. We do not think of biomedical innovation in connection with health solutions for poor people. No Indian bank was willing to fund early-stage research without commercial activity. Few players are currently funding. The company now sells large quantities of vaccine to multilateral agencies at a price of 23 cents per dose – one hundredth of the original price.From lab to village
Justin Chakma. And even if you can afford to buy the technology. what come to mind are research-intensive universities such as the Massachusetts Institute of Technology or Stanford or initial public offerings on the NASDAQ. virtually all this innovation occurs in richer countries. engaging in or fostering relationships with researchers from lower-income countries who can innovate around local health needs. Shantha Biotechnics released the first recombinant product produced in India – a hepatitis B vaccine. Canada
fRom lAb to VIllAge: cAtAlYsIng globAl HeAltH entRepReneURsHIp
When we think of biomedical innovation and entrepreneurship. When he approached a company in a developed country for a technology transfer agreement he was told: “India cannot afford such high technology vaccines. Yet. They are cut off from advanced training. discovered this fact at a World Health Organization conference and became so outraged that he set out to assemble a team of brilliant scientists to create the vaccine in India. Significant investments are made by foundations such as the Bill and Melinda Gates Foundation at leading north American universities or independent research groups at the Institute for OneWorld Health or PATH. an electrical engineer by training. This occurs in spite of the fact that researchers in the developing world face numerous challenges. While undeniably making a positive impact. This makes the way we invest our global health research dollars in developed countries strange. In the early 1990s. Consider the case of the hepatitis B vaccine in India. With three doses of vaccine required per child and most families having large numbers of children. The example illustrates how affordable biomedical innovation can emerge independently from poor countries that targets local health needs when individuals are exposed to the right environment. let alone occurring in countries with poor people.
While many peer-reviewed academic journals offer subsidized or free subscriptions to scientists from lower-income countries. Second. One solution may be to take an open-source licensing approach to methodologies or platforms involved in health research similar to that of the software industry. Ironically. failure to participate actively in discovery and development may cause citizens in the developing world to become increasingly resentful about being excluded from improvements in wealth and capability that flow from innovation. Governments must coordinate efforts to develop global or regional “convergence centres” that provide such services by bringing together the required financiers. Identifying talented researchers and opportunities is the next challenge. face enormous difficulties in translating their research into real products to meet local needs. while simultaneously educating and training them. We also need more partnerships between the developed and developing world. Training programmes and research and development are expensive. These are often protected by patents that scientists themselves are unaware of. Most importantly. Creating a comprehensive global database of patents relevant to each neglected disease could help scientists navigate the complex intellectual property landscape. however. The consequences for the local population suffering from the disease in question are more immediate. The question then becomes how we can best harness the energies of this untapped innovative talent. of course. The first barrier to overcome is the dearth of research infrastructure. This would open the door to a wealth of new innovation simply by linking together existing technologies. First. while the scarcity of capital forces the researchers and entrepreneurs to be more capital efficient and productive. which taps into entrepreneurial best
. Governments of developed countries need to challenge their stereotypes of research capabilities in the developing world and support more rich-poor collaboration. the lower labour and other costs in developing countries can amplify the magnitude of the investment. Governments of developing countries need to be prepared to support local health research and help their people reconcile long-term investments with the apparent lack of impact on short-term problems. research institutions in poor countries emphasize peerreviewed publications and often let technologies sit on the shelf.Young Voices in Research for Health 2009
peer-reviewed journals and. A second barrier to overcome is regarding the actual conduct of the research itself. a prototype dipstick assay for the second most socioeconomically devastating disease after malaria – schistosomiasis – remains unused for lack of internal resources to evaluate market potential or support product development and field trials. Akin to their wealthier counterparts. This situation holds at dozens of research institutions in developing countries. In Ghana. entrepreneurs and scientists. a more important barrier is actually getting access to the methodological tools necessary to conduct experiments. like the Stanford BioDesign India programme. these local researchers who are left out of the global innovation cycle are arguably in the best position to not only break the cycle of poverty by becoming role models for their communities. but also to understand and develop products for local market needs and thereby create self-sustaining cycles of local delivery and development. local scientists and entrepreneurs are likely to have superior understanding of how to operate in a local environment.
These entrepreneurs gain access to a powerful knowledge base facilitated at multiple levels by other Endeavor entrepreneurs and leaders of multinationals and by the participation of students from leading Master’s of Business Administration (MBA) programmes. Multiple partnerships like this can form the basis for local and global networks that could help health entrepreneurs in lower-income countries overcome challenges in finding financing and human capital. Such cross-pollination of entrepreneurial know-how across countries. Engaging and involving communities in innovation and sharing the wealth will be critical to the long-term success of any entrepreneurial endeavour in a low-resource setting. venture capital or the private sector may not be the only route for proper dissemination. and the international cachet that Endeavor entrepreneurs gain from their selection helps ease financing. Publicizing success stories through local and global networks will inspire more young scientists to bring innovation to the village. which partners with leading multinationals in selected emerging economies and then identifies potential entrepreneurs. While increased aid and funding to tackle neglected diseases is badly needed. The accelerating challenges in global health that face us call for provocative ideas. Yet often it is hard to banish the traditional stereotypes of Africa and other developing regions as scientific backwaters. Governments and investors alike need to be wary of focusing solely on large investments and take into account empirical observations that smaller investments can have a much higher return on investment in both financial and social terms1. The world universally recognizes the move towards a knowledge-based economy. perhaps the way that we allocate many of these existing dollars is problematic. but this need not be the case. risk-takers and innovators who can initiate the rapid. Coupling the concepts of venture capital with ideas from microcredit suggests the need for a more patient social venture capital that accepts as a legitimate return on investment the social impact achieved through alleviating disease. Health innovation companies often require multiple rounds of financing. To be effective. With this idea of social impact and size in mind. wherever they are. Only 10% of the world’s pool of entrepreneurs is currently being utilized. The potential to form partnerships via networking.From lab to village
practices. One precedent is non-profit-making Endeavor. Entrepreneurs are the provocateurs. cultures and industries is sorely needed by health entrepreneurs in lowresource settings. these networks need to be coupled to innovative financing mechanisms. Venture capitalists are feared by entrepreneurs as “vulture capitalists”. know-how and the diaspora in Silicon Valley for affordable local biomedical device innovation back in India. This travesty cannot continue. but are the wealthy prepared to support them?
. These structures need not even be physical in nature. Developing and defining clear social metrics to measure performance will be critical to the effectiveness of this approach. Community approaches based on beneficiary-to-beneficiary dissemination may be more effective in some cases. The question should be reframed in terms of talent. The poor are ready to tackle their own problems. We therefore need to reevaluate the way we look at the “10/90 gap”. We need to harness the energies of the remaining 90% of the best and brightest. scalable change that is so badly needed for the developed world.
Before joining the programme. Most recently. In 2006. he represented Canada at the International Biology Olympiad in Argentina. Nature Biotechnology. 25:853–857. a critically acclaimed magazine focusing on entrepreneurship in the life sciences with a print circulation of 28 000.5 million biomedical innovation programme at the University of Toronto.
. he conceptualized and helped implement a new C$2. Justin has authored peer-reviewed articles in Nature Biotechnology and Science and is currently an undergraduate at the University of Toronto studying neuroscience and economics.
Justin Chakma is a researcher developing innovative resources for product development in low-resource settings at the McLaughlin-Rotman Centre for Global Health. 2007. When less is more.Young Voices in Research for Health 2009
Booth BL. he founded BioSynergy.
United States of America
It tAkes moRe tHAn A bAnd-AId: A letteR to pResIdent obAmA
“In the 21st century. Regrettably. we need to embrace and engage in global
. our lack of global governance has countries trapped in a realpolitik mindset that continues to dominate our foreign policy. and. and with these words you have won the hearts and minds of millions of people around the world. Less recognized or discussed are the negative ramifications that globalization has had on the developing world. disease flows freely across borders and oceans. I am curious to know why US government spending on global health still remains minuscule in comparison with the global need? Does your “integrated approach to global health” consist of sound policy to bolster the funding? Or does your plan mainly consist of donating foreign aid? Although ideals and values are prominently expressed by US administrations as significant aspects of foreign policy. health advocates everywhere are praising you. especially on the billions of the poorest of the poor residing in sub-Saharan Africa. in recent days.It takes more than a Band-Aid
Amanda Deatsch. The world is interconnected. You are a man of many great words. Foreign policy should no longer be seen solely through the lens of realpolitik. An outbreak in Indonesia can reach Indiana within days … We cannot simply confront individual preventable illnesses in isolation. nor ignore the public health challenges beyond our borders. In the face of this new transformation and interdependence. You have addressed the importance of global health in your presidential campaign. it has also left countries vulnerable to communicable diseases that do not respect borders. you have recently proposed a US$ 63 billion global health strategy to be completed over the next six years.” Barack Obama 5 May 20091 Dear Mr President. However. and presumably all nations. are primarily concerned with our own survival and national interests and the securing of those interests abroad. but globalization has brought changes to which our policies must be adapted. While globalization has positively impacted our world with respect to quicker connections. and you have advocated for the right to health for all people across the globe. and that demands an integrated approach to global health. It is true that we. where boundaries have been traded for wireless Internet connections. And. the 2009 H1N1 virus has reminded us of the urgent need for action. We cannot wall ourselves off from the world and hope for the best. In addition. as this way of viewing international relations no longer accommodates our globalized world. health is considered a high-politics issue only when it directly affects our national interests. for this initiative.
one child dies every three seconds. malaria and tuberculosis combined3. particularly in conflict areas and resource-poor environments”2. we can agree – each and every one of us – that we are all concerned about our health. effort and willpower – the will to make a difference through funding and policy. “poor” means living on less than US$21 200 a year for a family of four. without very basic care.Young Voices in Research for Health 2009
health diplomacy. most of these deaths are preventable. According to the Global Health Council. We cannot use foreign aid as a Band-Aid to heal the wounds in the world’s poorest countries in sub-Saharan Africa. colours. We cannot slap a few BandAids on Africa and hope that the wounds underneath will heal themselves. Ten million children under the age of five die every single year. The 1. While we are a world of many different nationalities. ties can be strengthened and new allies can be made despite the fact that countries may not agree or see eye-to-eye in the political realm.
. it just will not heal. Now is the time to use global health diplomacy to capture the hearts and minds of the billions of people around the world who suffer in poverty’s vicious cycle. Global health can be used as common ground to set the basis for diplomacy in other areas of foreign policy. considering that. These numbers are appalling. science and technology diplomacy – to combat the greatest challenge of our time: poverty. We must take part in global health diplomacy – including medical. In fact. We cannot stand back and allow preventable illnesses and malnourishment to take 30 000 children’s lives every single day. This new field in progress seeks to unite diplomats and health professionals to better understand common interests in global health and foreign policy. for many of us. Reversing poverty and bringing hope to the billions of people in need will take time. ideals and values. defined by Thomas E Novotny and Vincanne Adams as “a political activity that meets the dual goals of improving health while maintaining and strengthening international relations. the total number of child deaths is greater than the deaths caused by AIDS. Through global health diplomacy. We are one world.
Mr President. and the worse part has yet to be addressed. Nor can we simply rely on insignificant increases in funding to protect the world’s three billion living in poverty on less than a dollar a day. and while we may not share the same political ideologies or enjoy the same socioeconomic situation. A wound needs basic care – it must be cleaned and disinfected – before it is covered.4 billion poorest of the poor live under conditions that many Americans would have trouble imagining. We agree that all people deserve the right to live a healthy life. Offering only funding to countries in need in sub-Saharan Africa would be like bandaging a wound without taking care of it first. relations between states can be renewed.
Mr President. religions. Band-Aids do not heal. each year.
2 3 4
Obama B. 2006. with a Bachelor’s in Political Science. we would be inspired if the US president tackled poverty for humanitarian reasons. Global health diplomacy: a global health sciences working paper. Ohio. As health advocates. Washington. Creating the Ohio anti-poverty task force.
Amanda Deatsch graduated in 2007 from Baldwin-Wallace College in Berea. All countries need to work together to address the underlying socioeconomic factors of poverty if we truly want to make a difference and overcome this greatest challenge of our time. including weak rule of law. Washington. 2009 (www.governor. While reversing poverty would not be possible without funding. where she completed a Master’s in International Relations at Webster University Vienna.ucsd.edu/pdf/GH_Diplomacy. Getting back to global child health. Novotny TE. whitehouse.
. Poverty affects states’ economic stability. Austria.pdf. 2007 (http:// igcc. Strickland T. Columbus. DC. Adams V. overall health and education. 2008 (www. corruption and the lack of infrastructure or access to education and resources like clean water in developing countries.It takes more than a Band-Aid
Unless you take the Band-Aid off and treat it properly. as long as poverty becomes an issue of high political value. accessed on 27 August 2007).gov/ Portals/0/Executive%20Orders/Executive%20Order%202008-11S. Ohio. there is a good chance the wound will become infected. then please address poverty on the basis that poverty causes instability. Unstable countries pave the way for authoritarian leaders to take control. accessed 27 August 2009). It is important to introduce a plan of action that tackles the social dimensions of development that contribute to poverty. we desperately need to address and tackle the root causes of poverty and not merely cover them up with our funding. Sincerely. DC. accessed 2 September 2008). we would be satisfied. Statement by the president on global health initiative. Global Health Council. creating grounds for terrorism that would threaten US and international security.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/.
Mr President. If you cannot direct funding to the root causes of poverty based on humanitarian reasons.ohio. Poverty both causes states to fail and is a result of failed states.pdf. She is fluent in German. She then moved to Vienna. food security. but. This vicious cycle can be conquered only by adopting a bottom–up approach that addresses both the social and the political determinants of poverty through a framework for global health diplomacy. She has worked as an intern at the United Nations Office on Drugs and Crime and is currently researching global health diplomacy and development in the Division of Human Health at the International Atomic Energy Agency.
Consider the series of events that followed the swine flu outbreak on 24 April 2009. only a few actually stopped to think about the enormous opportunity presented by this swine flu outbreak. some spewing hate while others play the blame game. nor is it an attempt to criticize current policies. while Ghana and others banned the importation of pork. where Mexican citizens and Canadian students were “detained” or “quarantined” without due process. reacted illogically. New Zealand. nations quavered and while most responded appropriately others. Within 10 days. While researchers strive to understand the epidemiology of the recent outbreak of the H1N1 virus with the aim of devising a formidable response. and. the outbreak became a media frenzy resulting in a massive outpouring to the public of sometimes credible but mostly terrifying information. Throughout this saga. Germany. the outbreak had spread. This was the case in China. For example.Young Voices in Research for Health 2009
Delford Doherty. across the border in the United States of America. Meanwhile. Within a week. the Netherlands. but as a global network of nations interconnected and bound by a common fate – our desire to survive as a civilization. The most humbling aspect of this outbreak is that it emphasizes the reality of our common destiny. In a matter of days Mexican farmers were blamed for the genesis of swine flu. the
. calling them “mules” in what they saw as a bioterrorist attack on the USA. Israel. Switzerland and the United Kingdom. there were laboratory-confirmed cases in Austria. Within 24 hours of the World Health Organization (WHO) alert. stigmatizing Mexicans and illegal immigrants. ill prepared. In 10 days. conservative pundits seized the opportunity to pursue their fear mongering. Spain. to 16 countries with over 658 reported cases. not as individual nations. Canada. politicians and pundits use the opportunity to push their political agendas. despite our best efforts. Sierra Leone
neVeR let A dIsAsteR go to wAste: oppoRtUnItIes pResented bY swIne flU foR InnoVAtIon In globAl pUblIc HeAltH emeRgencY Response
The ongoing swine flu pandemic is another fierce reminder of our universal incapacity to respond to a global disaster. This is not an attempt to trivialize the efforts of those working hard on the frontlines to prevent a global pandemic. other nations overreacted and took steps that severely infringed individual liberties. Subsequently. In both cases the nations reacted without supporting evidence and took actions that were adverse to their national economies and to our universal interests. Egypt called for the slaughter of over 300 000 pigs at a time when millions around the world suffer starvation. across the globe. peoples or races. whilst claiming they were protecting national interests and their citizenry. The intention is to instigate innovation by highlighting recent facts.
The most vital provision of this blueprint is advocacy. a fund will be created to allocate resources across the globe to train researchers and health professionals. there is a need for scientists and researchers to become better advocates in order to inform policy-makers and taxpayers about the inherent and ethically justifiable need for global engagement and international
. illuminated the acute need for an all-inclusive approach to global emergency response. For trends to move towards innovation for global emergency preparedness. swine flu. have abdicated leadership and advocacy to function in traditional roles. most importantly. in which nations look out solely for their own interests. Furthermore.
Provisions for innovation
We are at a juncture in our history in which we must seize the opportunity to unite our efforts and prepare ourselves for unknown threats that may be lurking in the future. Under this provision. Building infrastructure would include strategically placing laboratories. The exclusionist mentality of the past. and developing a model response plan based on unique regional and national capacities. bioterrorism. develop mechanisms for the exchange of epidemiological and other data. No single nation can afford to act alone. stirred our deepest fears and. who may not have the technical background to fully appreciate the implications of scientific findings. With the gloom of natural disasters. Scientists have generally relegated advocacy to the realm of politicians and pundits. paramilitary. researchers and health professionals in advocacy. police and researchers – who will form a first response team that can be mobilized in a global emergency. is archaic.Never let a disaster go to waste
outbreak effectively exposed our global vulnerability. stockpiling vaccines and medications. This essay highlights major pathways to developing the shape of the blueprint. There is an acute lack of scientists. and exchange ideas about processes. unethical and unsustainable. This could be taken a step further by recruiting nations that can pledge personnel – health care. The first provision involves using the expertise and authority of WHO to build the global infrastructure to respond to global health threats from infectious diseases and bioterrorism. underestimating the political landscape. this initiative would evolve into a global forum where proactive and prevention strategies would be developed. along with global response policies with the aim of both standardizing and expediting response processes. Our public health preparedness can be only as strong as our weakest link. The following three provisions represent a possible pathway to innovation. This step is premised on the hope that wealthy nations understand the imperative for global inter-reliance and the ethical responsibility they have to assist less-fortunate and less-developed nations in building capacity to respond to local disasters. severe acute respiratory syndrome (SARS). Eventually. scientists and health professionals. especially those in less-developed nations. avian flu and myriad infectious diseases afflicting many in the developing world. The second provision involves global investment and the exchange of intangible resources. we now have a mandate to conduct an overhaul of our international public health system to build our global capacity to respond to future threats. There is a moral imperative for the cultivation of innovative ideas that will evolve into a blueprint for global public health emergency response.
one-size-fits-all blueprint in which industrialized nations control and dictate the agenda.Young Voices in Research for Health 2009
investment in building global capacity to respond to disasters. The key message. There is a moral imperative for this. and the recent rise in the potential for bioterrorism as a threat to the major cities of the world. The provisions in this essay identify these limitations and provide illustrative ideas to address components that can be influenced by external factors such as funding.
In addition to the advent of global warming and climate change. This threat should forge a realization among the political community in industrialized nations regarding potential threats to their individual interests. this is an array of recommendations for global preparedness with the first step being the unequivocal empowerment of WHO to use its platform and leadership to move forward in achieving the multipronged provisions presented here. nor does it take them for granted. which provides the impetus for a mandate to act decisively and act now. global security and the building of global capacity to both prevent and respond to emergencies. less-developed nations are still limited by such factors as political instability. The purpose of this essay is to assert an illustrative pathway to an innovative global initiative that will improve preparedness and standardize and strengthen response to global health emergencies to protect our collective interests as a global community. the focus on building strategic regional (rather than national) infrastructure. researchers and health professionals to be proactive and become leaders in advocacy. it is a call to action. it is crucial for nations to collectively engage in meaningfully securing our universal health and safety. We must either seize this opportunity to unite and strive. training and workforce development – for scientists. It is a moral imperative and a strategic necessity for WHO and other international advocacy organizations to create the means – through funding. this essay does not seek to address those possible impediments. As opposed to a global approach in dealing with the threat of a pandemic. This is not a proposal for a global. While these provisions have their limitations. advocates and policymakers have the attention of the public. is that these provisions can be met incrementally. With predictions of a possibly more virulent strain of H1N1 returning later in 20091.
The way forward
It is by no means obvious that these provisions necessarily herald a trend. This is not an ideology. then. where nations exist in a kaleidoscope of markets that are interdependent regarding resources and share common economic ambitions. This reawakening should shift the focus from personal and proprietary protection on the part of nations to a global approach that encompasses resource allocations and transformative policies that reflect ethical principles. or continue on our current path to potential peril.
. In this global economy. Rather. workforce development. etc. the potential for a global pandemic is immediate. while there is much discussion of and support for a model emergency response act in the USA and other industrialized nations. most nations have taken exclusionist steps to protect only their individual interests. For example. poor infrastructure and an almost nonexistent public health system.
Never let a disaster go to waste
Global alert and response (GAR) Situation updates – Pandemic (H1N1) 2009. Geneva, World Health Organization, 2009 (www.who.int/csr/disease/swineflu/updates/en/index.html, accessed 27 August 2009).
Delford Doherty moved, after surviving civil war in his homeland of Sierra Leone, to the Gambia in 1999, where he completed high school. In 2002 he moved to the United States of America to attend Wartburg College in Waverly, Iowa, and earned a Bachelor’s in Biochemistry. He is currently in the final year of earning doctorate in Pharmacy and Master of Public Health at the University of Minnesota College of Pharmacy and School of Public Health. His academic interests include health-care policy, clinical outcome evaluation and global health policy.
Young Voices in Research for Health 2009
Nicholas Fancourt, New Zealand
RedefInIng tHe cYcle: sYstems, HeAltH And cHIld poVeRtY
Social machinery drives health. This perspective on health care was anticipated in 1920 by public health expert Charles-Edward Winslow, effectively redefining the scope of public health. Since then we have become cognizant of the relationships between socioeconomic issues and health outcomes. Recognition has grown to the point where we understand that it is our collective response through effective systems that produces sustainable change. Despite this, societal progress trails scientific developments in improving health, particularly in developing nations. Nowhere is this more evident than in the effects of child poverty. Many demographic groups have become victims of poverty, but it is children, as the most vulnerable, on whom the health effects are most telling. As our common future, children are a barometer of the effectiveness of social policy. They are our ultimate investment, morally and economically, through which effective policy can influence us all, generation after generation. The global nature of poverty means it touches us all – as individuals, taxpayers, consumers, communities and nations looking to develop brighter futures. Billions of dollars are spent annually on attempts at poverty reduction. Billions more are spent on poverty’s health effects. Yet inequities persist, with poorer children and their families having consistently worse health outcomes. The deeply rooted injustices at the base of these inequities are as complex as they are concrete. The lack of health care as a social right, low coverage of health services in poor communities, government corruption, stagnating economies and low levels of education are some of the many factors that can influence the relationship between poverty and health. The great paradox of poverty is that it is a truly global phenomenon. Developed countries, usually symbols of wealth and security, still fail to adequately address poverty. In New Zealand, one in four children lives in significant hardship. The correlation with health is strong. For instance, New Zealand’s rheumatic fever rates for indigenous children parallel India’s and Mexico’s, with socioeconomic deprivation a significant risk factor1. In the United States, the costs of poverty-related child health problems have been estimated at over US$ 150 billion each year2. Innovation has brought us many gains in health care, and I believe it is our only way forward. The nature of disease and its many determinants are well described, yet we struggle to deliver lasting improvements in health for those who will follow us. There is often talk of a cycle of poverty, reflecting its perpetual nature. But the cycle metaphor also suggests that poverty is a closed loop, impossible to either enter or leave, driving false perceptions that eradicating it is a mirage for thirsty idealists. We
Redefining the cycle
have become complacent, believing that poor nations and impoverished citizens are necessary and stable facts of life. We need to revise the way we portray the problem. This requires a change of perspective to see not merely a cycle but a system that is driven by the failings of many social policies. Traditional social services – education, justice, tax, aid – work in silos, independent and frequently unaware of each other. But poverty-related poor health engages all of these sectors, involving important considerations of politics, ethics and economics. Addressing this burden mandates an appreciation that both poverty and health operate in interdependent and interrelated systems. As a trainee paediatrician, I witness too often the shortcomings of our systems: fragmented efforts between traditional social services, low household incomes leading to overcrowding and poor access to health care. Over a three-month period I admitted one girl who lived in significant hardship five times due to the exacerbation of her chest disease. She is clearly a victim of the shortcomings of our system. Her family were keen and motivated to improve her poverty-affected living environment and disease management, but sadly as a community we lack some of the social and financial tools required to make this a reality. The founding elements of a new perspective are not far from our grasp. Epidemiologist Geoffrey Rose, in his 1992 book on preventive medicine, stated: “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics can not and should not be kept apart.” If we are going to recognize and address the role of systems in child poverty and health care, then we inevitably need to use government processes to advance the cause. The political influence on health care is telling. In 2007, while I was studying in The Gambia, the small nation’s president announced through statecontrolled media that he had found a cure for AIDS. His treatment, a concoction of herbs and spices ceremonially administered, undermined international efforts to control the country’s HIV problem. Without access to open media or scrutiny, confusion grew and clinic attendance dropped at the hospital where I was based. Economics, intimately tied to political forces, play a central role in development, poverty reduction and health care. International aid, which supplies 70% of public funds in Africa, can be more Band-Aid than development aid. Corruption and poorly coordinated funding has halted any rise in per capita income in Africa over the past 30 years3. Without approaches that stimulate sustainable, locally driven systems for economic development, the impetus for action by governments is too often lost. That action must be the backbone of any wider social change to the tapestry of poverty and health. Just as the underlying problems can be illustrated as systems, so too can innovation in systems be the solution. The challenge remains to construct systems that are flexible enough both to adapt to social change and to deliver new approaches to health care and research. What if we rethought our traditional service barriers – those that separate research from policy, those that create silos of care – and sought to tune the whole machinery of health care? We may be able to realize Winslow’s goal of integrating the social with the scientific in health care. But I believe it is unrealistic and unproductive for each country to follow this path alone. All countries, developing and developed, face mounting pressure to treat a growing burden of disease. If we are to improve our systems, we must be open to truly international collaboration
Young Voices in Research for Health 2009
that reflects the weight of inequity faced by many countries. Aristotle asked us to “treat equals equally and unequals unequally”. We remain far from achieving that in our practice, either between countries or within them. Poverty has unequally stripped the voice of many developing nations, just as it unequally affects children. Strong direction and participation is required from these nations to ensure ownership and accountability regarding these goals. Fundamentally, the instruments and structures we have do not address the integrated and social context of many health problems. We must seek to overcome poverty and its related social issues at the same time that we seek to overcome its health effects. Our activities in health care do not always have this in mind. We offer a multitude of advocacy, action, research and funding groups to tackle child poverty and child health, yet combined these show much duplication and fragmentation of effort. Moreover, many of the efforts are reactive, rather than initiatives that prevent recurrence or drive change. What is needed is a productive network to link these activities. Innovation must deliver an international network for health systems, with the aim not only to advise on and develop local methods for improving health systems, but to participate actively in quality analysis and research into health and related social systems. Integrated information provides the most dimensions. Being able to address child health systems with combined efforts on education, housing, nutrition and primary care will better enable healthier communities than will a drive for single-issue solutions. We need to be able to provide for one another the tools to develop a robust architecture for local health systems. In order to have this security, any network for health systems needs to extend beyond the traditional paradigm of intergovernmental or charitable organizations. Instead, assistance from diverse areas that reflect the complexity of health and its determinants needs to be incorporated. Progress for health systems must continue to incorporate innovation from academia and venture capital funds, cultural resources and ministerial advisory groups. We must see not only a child’s pneumonia but also the poverty effects of poor nutrition, household stress and low access to care that seeded it. The reality of poverty and ill health shatters the peace of too many childhoods. In the past century we have seen frequent advances in knowledge of the social machinery of health. But we have been too slow to integrate this into a working model that can consign problems of child health and poverty to history. It is time to reorient ourselves, to build new perspectives on the relationships between poverty and health. If we focus on innovative systems, we have the ability to introduce sustainable change, not just for health but for child poverty and the many other social determinants that underlie it. Failure to do so is a wasted opportunity and a disservice to future generations.
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Jaine R, Baker M, Venugopal K. Epidemiology of acute rheumatic fever in New Zealand 1996–2005. Journal of Paediatrics and Child Health, 2008, 44(10):564–571. Holzer HJ et al. The economic costs of poverty in the United States: subsequent effects of children growing up poor. Washington, Center for American Progress, 2007. Moyo D. Why foreign aid is hurting Africa. New York, The Wall Street Journal, 21 March 2009 (http:// online.wsj.com/article/SB123758895999200083.html, accessed 28 August 2009).
. Nicholas worked for New Zealand’s Health and Disability Commissioner and completed an internship at the World Health Organization in Geneva.Redefining the cycle
Nicholas Fancourt is a paediatric trainee in New Zealand. He is a past president of the New Zealand Medical Students’ Association and currently volunteers with the Child Poverty Action Group. Alongside paediatrics he is interested in health systems and hopes to complete doctoral study in public health. He graduated from the University of Otago with a medical degree and a Bachelor’s in Medical Science with honours in Ethics and is currently completing his Master’s in Bioethics and Health Law. During his studies.
especially concerning health. We now know that wealthy nations are not immune to inequity and poor health status. Innovation thrives on independent curiosity. The United Nations found that nearly a quarter of children under the age of five were malnourished. Innovating for the health of all during conflict is a distant reality. Current global health problems stem from poverty and inequity. the Chinese immunized mildly infected people by inserting powdered smallpox scabs into their nostrils1. ResponsIbIlItY And tRUtH In A dIVIded woRld
Nothing under the sun is truly new. In the 1500s especially. Moreover. Joseph Needham devoted much of his life’s work to Chinese science and civilization. printing and gunpowder as being among China’s significant inventions. In Darfur. Our current economic crisis has magnified this. during the Song Dynasty. must be handled within the fragile boundaries of culture and society. violence between the Sudanese government and local rebel groups has led to over 1 million displaced people and crimes against humanity. As more become unemployed. It does not seem that innovating for health has placed Afghanistan at any competitive advantage. we face an almost certain divide. Today. If we are not. For example. Jeffrey Sachs describes the “innovative gap” as inevitable. We are stimulated by the past to be motivated in the present to create solutions for the future. Has innovation helped or hurt? For the poor.
. Rather. innovation has failed even to provide basic survival tools. the recent recession will likely reverse that trend5. “New innovation”. only 28% of adults are literate and life expectancy is only 44 years3. more than ever. In addition to identifying paper. but one cannot discredit Edward Jenner’s contribution to the smallpox vaccine in 1796. individuals are at risk of poorer health status. as the rich move from innovation to greater wealth to further innovation2. I believe that. war tension challenges the growth of innovation for health. although health insurance coverage made small gains in California from 2005 to 2007. While the United States of America has recently achieved the first near-total face transplant. China discovered many things western civilizations take credit for. we must be concerned with responsibility. there is a different perspective from which to understand innovating for the health of all. United States of America
InnoVAtIng foR tHe HeAltH of All: seARcHIng foR eqUItY. Research on the social determinants of health show a clear parallel gradient between position in social hierarchy and mortality4.Young Voices in Research for Health 2009
Hildy Fong. Nor can we question Europe’s influence on gun technology or Gutenberg’s development of the printing press. Concerning equity. philosophy and movements of human civilization. To truly provide health for all. one in every four children dies before the age of five. innovating for health must be concerned with equity. it is more constructive to observe innovation as a product of history. through a lens of collective innovation history. discovery and action but is also influenced by previous research. he revealed that vaccinating against smallpox may have been practised as early as the 10th century. in Afghanistan.
There is no excuse. It is. Among building blocks for advocacy. “Promotores” programmes train migrant community members to promote health. Chen Zhu. Chinese health reform plans to expand primary health care to 90% of the population. The simplest methods of health prevention rely on accessible health messages. After all. It necessitates culturally competent frameworks. through its ability to translate. China’s Health Minister. each person has his or her own personal belief systems. why has innovation failed us on such basic levels? We have vaccines for polio. Liberian President Ellen Johnson-Sirleaf has said that aid must be structured and focused while also supporting a government’s own development agenda. the key to truth. research is innovation. In innovating for the health
. Global societies filter technologies only when they have the basic resources and people to support them. public hospitals depend on capital from pharmaceutical companies to stay afloat. These programmes are valuable because they promote linguistically and culturally relevant primary care to vulnerable populations. On research.Innovating for the health of all
Despite our advances. Barefoot doctors in China during the Cultural Revolution built a formidable primary health-care system. Societies must address the challenge of innovation and social responsibility in the context of our global society. This leads to corrupt prescription practices and a host of inequitable aspects to health. Only when leaders acknowledge social responsibility being rightly on the national agenda can governments be in a better position to innovate for the health of all without stifling growth. Concerning civic engagement. It is the social responsibility of political leaders to promote development while also encouraging fairness. has decided to prioritize equality and justice in public health-care reform. At a community level. We can break down geographical barriers to reach remote populations. Time and time again. A major challenge is how to bring marginalized populations up to speed without holding back innovation. innovation in basic primary health care through civic engagement can provide sustainable health for all. measles and influenza. we must all do our part. In poor communities. Innovations must be sustainable in the environment in which they are introduced and fit cultural norms. We have surgery. Leadership must address this conflict. In the United States of America. It engages multiple partners in the provision of basic health needs. they will regulate pharmaceutical policy in the public sector while also making evidence-based investments in traditional Chinese medicine. It is an ethical responsibility for innovators in society to be the catalysts of true health reform. The Partners in Health model delivers health care to poor and remote areas such as squatter settlements in Haiti by relying on community health workers and partnerships that build economic and social capacity. There must be a distinction between health prevention and health technology. Concurrently. Innovation without social responsibility is not progressive. Health prevention is ideally improved by technological innovation but should not overshadow basic health needs like vaccinations and neonatal care. anaesthesia and penicillin. Civic engagement is the key to sustainable innovation. What principles must exist to innovate for the health of all? Concerning leadership. In China’s health-care system. research has strengthened the bridge between the impossible and action. We have networks to exchange information and investigate cultural differences.
Hildy Fong is from Raleigh. She is currently a PhD student at the Chinese University of Hong Kong. Nearly 6. Health in an unequal world. made it their mission to rid the country of capitalistic principles built on education and money. 2005. 1954. Preventing HIV/AIDS in young people: a systematic review of the evidence from developing countries. communications and behaviour can address complex social problems through ethnographic methods. In: Ross DA. Brown ER et al. ensuring health for all in this generation and all generations that follow. The lack of data from interviews with key informants. We have to be innovative in our modes of delivery so we do not reinvent the wheel of what we already possess. She is interested in health equity for vulnerable youths in Asia in the context of globalization and infectious disease policy. Sachs JD. Ferguson J. Their genocide of professionals and intellectuals has to this day affected health and economic stability.4 million Californians lacked health insurance in 2007 – Recession likely to reverse small gains in coverage. ruling Cambodia from 1975 to 1979. The Khmer Rouge. Marmot M.html . Los Angeles. 151–204. Dick B et al. we must be particularly concerned with qualitative research. If research is a foundation upon which civilizations thrive. there is still a need for country-specific data on behavioural interventions for young people aged 15–24.org/infobycountry/afghanistan_statistics. then it is not only our job to promote research. UCLA Center for Health Policy Research. Science and civilisation in China VI(6).Young Voices in Research for Health 2009
. We have a commitment to protect our collective health research. As an intern at a non-profit-making organization helping Cambodian children travel to Singapore for heart surgery. North Carolina. She has worked at the University of California. The end of poverty: how we can make it happen in our lifetime.unicef. Ensuring health for future generations. Responsibility in innovation can fuel the lives and existence of all of us on this earth. 368(9552):2081–2094. Los Angeles Center for Health Policy Research and also interned at the United States Senate. community surveys and health facilities creates a gap between research and practice. 2006. Dick B. in the United States of America. As the custodians of our own future. UNAIDS Inter-agency Task Team on Young People. Penguin. The Lancet. 2008. 2009 (www. UNICEF Afghanistan statistics.
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Needham J et al. Innovations allow us to prolong life. where she completed a policy project on HIV and young people. We need this type of research to address the population that represents 50% of all new HIV cases6. London. Health research emphasizing policy. She studied public health at the University of North Carolina at Chapel Hill and holds a Master of Health Science in Health Policy from the Johns Hopkins Bloomberg School of Public Health. Her research interests developed while assisting with medical programmes for children in poverty in South-East Asia and interning at the World Health Organization. 2006. accessed 28 August 2009). we have unprecedented power to control the flow of the discoveries that are brought to us. We have a duty to protect it. I saw first-hand that health systems broken by violent conflict are held back even more by the genocide of knowledge. World Health Organization. London. Cambridge University Press. United Nations Population Division and United Nations Statistics Division. eds. Review of the evidence for interventions to increase young people’s use of health services in developing countries. In the fight against HIV. Geneva. Wealthy nations have a responsibility to protect poorer ones because they are in a better position to do so. investigating health disparities among migrant children in China. ease suffering and control the growth of populations. Yet qualitative needs are not prioritized in countries that need them the most.
lo que hace que sujeto cognoscente y objeto conocido sean lo mismo. o para la resección de elementos nocivos. todavía no sabemos con certeza cómo funciona el cerebro y qué es lo que hacen las neuronas para sustentar los procesos de pensamiento complejo que posibilitan el variopinto caleidoscopio de la realidad humana. y dejemos volar la imaginación para alcanzar metas que hoy se antojan inalcanzables. En sí mismo es algo paradójico. ningún reto ha podido resistirse a la insaciable curiosidad de los hombres y. por supuesto. aunque todavía estemos lejos de una teoría general que lo explique todo. Spain
Las ciencias que estudian el cerebro están pidiendo a gritos una revolución desde hace algunos años. A pesar de ello. Esto ha posibilitado el avance tanto en psiquiatría como en neurología en el tratamiento de las enfermedades que afectan a este órgano pensante. Nadie sabe todavía cuál será ese punto de inflexión que permitirá hablar de “ciencia dura” cuando nos estemos refiriendo a la neurociencia. Y aquí es precisamente donde comienza mi reflexión.Silicon Brains
Javier García Castro. ¿Qué pasaría si lo que hiciese falta fuese algo estructural? ¿Y si hubiese que añadir algo? La realidad de las personas que sufren trastornos mentales o deterioro cognitivo no es tan ajena en nuestra vida cotidiana como posible. que no por utópicas tendrían por qué dejar de ser posibles. Gracias a los esfuerzos de disciplinas tan dispares como la medicina. estamos en posesión en nuestros días de una gran cantidad de datos sobre el cerebro. Sin embargo. la ingeniería o la psicología. en caso de algunas intervenciones neuroquirúrgicas. pero que mañana podrían ser realidad. que por aparatoso. Tan misterioso como cualquier otro reto al que se han podido enfrentar antes los seres humanos resulta el estudio del cerebro. estas intervenciones no pasan del empleo de fármacos que sirven para paliar defectos funcionales. tal y como hemos podido aprender a lo largo de la historia de la humanidad. Olvidémonos por un instante de lo posible y lo imposible. Porque a pesar de los grandes avances que se han alcanzado en su estudio. regulando al alza o a la baja la concentración de determinadas sustancias que hacen que las neuronas se comuniquen entre sí. el estudio y comprensión del cerebro no ha sido una excepción. pero me tomo la libertad de expresar aquí mis cábalas. se ha resistido a la investigación sistemática y a la formulación de explicaciones plausibles durante más tiempo que otras ramas de la ciencia. porque todos estamos
. por cuanto el objeto de estudio es el propio sujeto que conoce. la bioquímica. Yo tampoco.
España) el 30 de octubre de 1980. Existen casos documentados de personas que han perdido la capacidad de generar nuevos recuerdos. Con el trabajo aunado de la biología y la ingeniería. se transplantan órganos o se utilizan marcapasos. ni tampoco lo veo en poco tiempo formando parte de la cartera de servicios de la Seguridad Social. neurológicas o déficits cognitivos irreversibles. y no sabemos qué otras ventajas nos conferiría para alcanzar una mejor comprensión sobre cómo funciona este órgano como un todo. Se abrirían nuevas vías para entender el tratamiento de muchos trastornos psicológicos que son producto de un procesamiento de la información distorsionado. Se han documentado los más estrambóticos relatos sobre alteraciones sensoperceptivas o comportamentales. Durante los tres últimos años ha trabajado como psicólogo interno residente para el Servicio Navarro de Salud. Como en otras disciplinas médicas se cambian huesos por prótesis. No es un objetivo a corto plazo. para que el cerebro pudiera seguir con su actividad normal. y por otro. diseñar. Lo cierto es que perder las capacidades cognitivas puede sumir a una persona en un laberinto sin salida. producir e implantar esta nueva tecnología para reparar el funcionamiento alterado del cerebro. se podrían utilizar estos chips para suplantar áreas lesionadas o disfuncionales.Young Voices in Research for Health 2009
Javier García Castro
expuestos a padecerlos alguna vez en nuestra vida. está pensada inicialmente como paliativo para traumatismos de enfermedades como la epilepsia. para remendar cerebros. por un lado.
. impidiéndole recuperar su vida anterior. que ya se está ensayando en el laboratorio con animales. aunque utópicos en nuestro presente inmediato. ya justificarían todos nuestros esfuerzos. de personas que pierden el contacto con la realidad. Pero más interesante sería llevarla un paso más allá. de transformaciones radicales de personalidad. pero que no es la realidad. Esta ingeniería neuronal constituiría un enorme hito para el desarrollo de la medicina y una solución para todas aquellas personas que padecen enfermedades mentales. se podrían diseñar chips o unidades de procesamiento de información. Esta tecnología. desarrollando todo un cuerpo teórico y técnico que nos permitiera. formular teorías más completas y precisas del funcionamiento cognitivo complejo. que resultarían difíciles de creer si no fuera por la fidelidad de la fuente. la que denominamos normal.
Javier García Castro nació en Vigo (Galicia. bien en primera persona o en nuestros conocidos más cercanos. Realizó sus estudios en el Colegio Apóstol Santiago “Jesuitas” de Vigo y se licenció en psicología en la Universidad de Santiago de Compostela en el año 2004. para siempre. Actualmente se desempeña como becario-investigador en el Hospital Virgen del Camino. porque sólo pensar en los beneficios que esto podría generar para tantas personas en el futuro. como los utilizados en las placas de los ordenadores. pero es algo que se puede proponer y se puede intentar. Y todo ello porque el cerebro es el centro de operaciones que interpreta una realidad.
It was a result of his lack of strict discipline that he left the plates with bacteria out of the refrigerator. mental and social well-being and not merely the absence of disease or infirmity”. might be viewed as a bigger health innovator than Asclepius himself. Armenia
fRom AsclepIUs to gene engIneeRIng: HAVe we gAIned A betteR UndeRstAndIng of HeAltH?
When we think about what health is. If we understand what health is and put innovation and health research in this context. health was still associated only with healing diseases and physical well-being. those who had the power to heal people. However. In those times. what comes to mind first is the definition of the World Health Organization (WHO). we can search for ways to establish an environment conducive to true health equity – to innovating for the health of all people. but he brought fire to humans. something they had not had before and allowed them to heat their houses. allowing the mould to grow over them. among key factors leading to innovation
. not humans.From Asclepius to gene engineering
Manik Gemilyan. and taking care of peoples’ health was considered a job of gods. he would never have noticed that bacteria were not growing around the place where the fungi grew. Hygiea and Panacea – in other words. do we all view health in this holistic way? Would we consider healthy a poor man who has excellent physical health indicators but who is so short of money that he sells one of his kidneys to get means for living? Or would we consider healthy a wealthy woman who is unhappy when she looks at herself in the mirror and sees new wrinkles appearing every day? These questions are not merely theoretical. Some distinguishing characteristics of his ingenious innovation – the discovery of penicillin – were that he was not searching for that particular finding. which says: “Health is a state of complete physical. to cook food – an innovation that certainly improved the health of all. He was not aiming to heal the elite. but the answer to them is key to defining what health research would aim for and what innovating for the health of all means. Therefore. another Greek god. however. This definition is not new to anyone involved in the field of health. Prometheus. but if we give it a further bit of thought. if not for his outstanding researcher’s curiosity and attention. It was not until Hippocrates that medicine became more democratic. Asclepius was the god of medicine. as he laid the foundation of leaving successors by teaching medicine to other people. another helpful example would be that of Sir Alexander Fleming. In the context of the WHO definition of health. who sacrificed his own health for the sake of human well-being. The gods responsible for health were Apollo and the daughters of Asclepius. Continuing to look back in history in an attempt to identify the qualities and conditions for creating an environment supporting innovation for the health of all. Let us go back to ancient times and see what was happening in ancient Greece with regard to innovations for health.
increasing government support for not-for-profit projects aimed at improving everyone’s health is another way.Young Voices in Research for Health 2009
we might name chance. potent drug goes on the market priced such that it is available to only a limited number of people. there are some suggestions – otherwise this essay would only become a philosophical and historical observation. even to a small extent. new transplantation methods. But look what is happening in our pharmaceutical industry today. If Fleming had not had all those qualities. which it actually was in the dawn if its history. either penicillin would never have been discovered. A rule requiring the lifting of a new drug’s patent after sales have generated a certain profit would allow the manufacture of generic drugs that would be affordable to everyone. Later on. effective drug is created that has the potential to save many lives. The same happens with any new product or service developed for curing disease. Now let us return to the seemingly rhetorical questions of the beginning. to develop the idea of what health is and how to reach health equity. we might be able to see this gap narrow. Obviously. and the health indices were the highest in the region and among highest in the world – several decades ago. In that country. One suggestion is to have regulations for the pharmaceutical industry. It would be difficult to argue that Fleming was not a brilliant innovator for the health of all. such as a new surgical technique or device. having saved millions of lives since its discovery. never health equity ones. so that even those who have the money cannot receive highquality health care because the whole system has failed. etc. what happens with innovation is that not only does it not bring the world closer to health equity. Which would be a better solution to improve the health of the man wanting to sell his kidney? Sophisticated surgery with no complications to remove the kidney and get him some money in
. but it actually increases the gap between the health of the rich and of the poor. or it would be manufactured only as an elite drug to cure the rich. and maybe we could even have a world of health equity. If a new. Could another solution be universal health care? It is symbolic that the Global Forum for Health Research annual Forum will take place in Cuba this year. If we could change this. However. and the drug became available. It seemed to work then. but only if it is coupled with a sharp and thorough mind. things changed and the health indicators went down. Would any truly passionate health researcher believe this was the goal when they conceived of their innovations to improve health? I am confident the answer is no. A new. and the reason is that drug manufacturing is done in accordance to marketing rules. the system provided free health care for all. Therefore. As a result. I proceed with asking: What creates this gap between the researchers’ goals and passions and the dire reality of deepening health disparities? Another angle from which to look at this same problem is by asking: Is health care and medicine a business or a humanitarian enterprise? Unfortunately. it is not doing so. the correct answer in most parts of the world is the former. The next logical question is: How? Well. in the post-Soviet period. focused attention and a passion for improving the health of people. the price went down. as the volume of manufactured penicillin expanded.
in the United States of America. While in training. What we think of as innovation for health still refers to new drugs and new medical technologies. If any one part of the formula is missing. Currently she works at Yerevan State Medical University hospital as a physician and assistant professor in the Internal Medicine Department. She went into practice until 2004. when she joined World Vision Armenia as health programme coordinator. It would be more useful for all of us who work in health care to keep in mind that Prometheus was no less a health innovator than Asclepius or Hippocrates – even if we swear only the Hippocratic Oath. we still think about it in a mostly physical. Which would have been a better innovation to improve everyone’s health? The answer goes beyond just health research. In our era of gene engineering. we cannot achieve health equity for all. Georgia. even though we have learnt about the holistic definition of health in medical school.
. the next question of how to get there would be the topic of a totally new essay. she worked with the Emory School of Medicine residents’ performance-improvement project and afterwards at the Centers for Disease Control and Prevention as a health scientist. if we put together all these thoughts and attempt to answer the main question – how to narrow the gap and how to make research work for the health of everyone on this planet – we would arrive at the following solution: affordable health care in a world of justice. Cutting-edge technologies or “silver bullet” drugs will never improve the health of all as long as we are living in a world full of injustice. as we doctors and health-care workers understand it. for example.From Asclepius to gene engineering
exchange. or improving his social circumstances by. she got her Master of Public Health in Epidemiology from Emory University in Atlanta. As simple as this solution may seem. In 2008. finding him a job or giving him some credit support such as through microfinance? Would high-end plastic surgery improve the health of the aging woman. Now.
Manik Gemilyan graduated from Yerevan State Medical University in Armenia in 2001 and got her specialization in family medicine in 2003. medical way not much different than in Hippocrates’ time. or would she perhaps feel more attractive and helpful and less unhappy (and eventually healthy) if she could engage in some activity that would allow her to share her wealth with the man who wants to sell his kidney? Maybe she could establish a charitable fund or something similar to microfinance credit.
with the same trend being true for sub-Saharan Africa. particularly in developing nations. in the 16th century. global HIV prevalence reached its peak around 2001 and then began to contract. In 2001 approximately US$ 1. health-care institutions and people themselves to use more appropriately the effective tools science already offers them? The year 1996 saw the release of the first antiretroviral treatments3.Young Voices in Research for Health 2009
Damian Hacking. drug distribution and awareness campaigns. Whether this novel idea was intended to prevent childbirth or disease transmission remains unclear. are we thus robbing vital research and funding from neglected diseases for which there is no known cure or prevention and hence still cause substantial numbers of deaths? Finally. As of 2007. yet they are unlikely to be more economically viable or practical than condoms. where HIV is most rife. The overall difference in HIV prevalence from 2001 to 2007 is approximately 1% (a drop in global prevalence from 7% to 6%).62 billion was being spent on HIV research. It is possible that new innovations in HIV treatment could be distributed more effectively. yet if this innovation has been around for so long how is it that HIV has managed to spread so virulently? Lack of resources. yet there clearly appears to be a barrier preventing the effective use of these treatments that money cannot solve. just over a tenth of which went to research and development4. The question therefore naturally arises: If something as basic and economically viable as condoms cannot effectively contain the HIV pandemic. The Italian author Gabriele Falloppio describes the use of a treated cloth draped over the penis as an effective way to prevent the transmission of “the French disease”. The condom would seem to be the most potent weapon against HIV transmission. HIV has decreased at an almost constant rate since 2001. South Africa
IneffIcIent InnoVAtIon: tHe need to RedIRect fUnds fRom tReAtAble And pReVentAble dIseAses
About 15 000 years ago in France. otherwise known as syphilis2. how can we possibly expect the more complicated and expensive HIV treatments currently being developed to have an effect? Furthermore. are we as health science researchers even obligated to develop new and more effective treatments for global diseases. This almost tenfold increase in funding did not resulted in a tenfold decrease in the rate of HIV prevalence. The decrease in HIV prevalence suggests that condoms and antiretrovirals are effective in the treatment and prevention of HIV. The condom’s usefulness in disease prevention has again been highlighted with the emergence of HIV. According to a report by the Joint United Nations Programme on HIV/AIDS4. US$ 10 billion was being pumped into HIV. lack of education or just plain irresponsible behaviour could account for the failure of condoms. Since then HIV prevalence has been slowly declining. but the first documented medical use of condoms appears only much later. Even if we were to grant the
. prehistoric man had the bright idea to sheath his penis with the intestine of an animal during coitus1. This would imply that any breakthroughs in HIV research would have limited impact on global HIV prevalence. or is the onus on government.
politics and even individuals? If the treatment for. smoking or practicing unsafe sex. tuberculosis should receive 30% of funds. A more proportional distribution of funding based on a combination of need for innovation and global mortality rates is what needs to be addressed. HIV accounts for 3. nor do I wish to completely abolish funding for diseases such as HIV.3%. trumped by cardiovascular diseases (ischaemic. but those diseases that already have appropriate modes of treatment or prevention should receive much less funding than those diseases in desperate need of innovation. both private non-profit-making and governmental. Of course we do want to encourage developed countries to tackle those diseases afflicting the developing world. In many cases we even go so far as to accommodate these life choices. High-income countries fund a whopping 97% of all research and development7. respectively5. does HIV merit such huge research investments in the first place? Globally. Tuberculosis and malaria fall just below HIV at 2. due to factors such as historical abuses and the great disparity in wealth between developed and developing countries. or prevention of. such as a vaccine. With our current technology we can manage and prevent HIV. may have a big impact on HIV prevalence. respectively6. and in no way do I wish to reduce the amount of funding being offered by the developed world. so it is a fair statement that they decide which diseases are targeted and how much is invested in each disease.6%.5% of all deaths per year. If we are truly to be researchers that seek to find health breakthroughs for all.7%. While this may be admissible when it does not conflict with others’ interests.5% and 1. as we may be diverting resources away from other.3% investment in HIV is merited. This leads us to our last question: To what extent should science be culpable for the shortcomings of education. A possible reason for HIV research receiving what appears to be a disproportionately large percentage of funds could be the identification of HIV as the quintessential problem of the developing world. Perhaps most revealing is that diarrhoeal diseases result in more deaths than HIV yet receive only a tenth of the funding – a clear indicator that mortality figures do not appear to play a significant role in funding decisions. and diarrhoeal diseases at 3. HIV research receives 42. and we need instead to start investing in diseases that are in desperate need of innovation. There is increasing public opinion that the developed world has a moral obligation to provide assistance to the developing world. However we should not let this perhaps incorrect identification unduly influence our investment decisions. the recent antismoking laws passed in many countries have made it clear that this is not
. We do not discriminate against people for being obese.Inefficient innovation
premise that certain breakthroughs. respiratory diseases (excluding tuberculosis) at 7%. However.3% of global funding for communicable diseases. while malaria should receive 20%. nationality. age and economic development and focus instead on mortality figures alone. Mortality and disability-adjusted life years figures are important and provide a good guide for funding. Adjusted for mortality. while tuberculosis and malaria receive only 16% and 18. then surely we should disregard factors such as race. and assuming the 42. a given condition is available. more useful endeavours. It ranks number six on the global list of mortality causes. should we really be obliged to deal with the consequences of failure of treatment due to factors outside the scope of science? We live in a society where people are encouraged to make their own life choices. cerebrovascular and pulmonary) at 27%.
2007. I believe the indirect impact on the health of others. Geneva.pdf. NY. World Health Organization. Joint United Nations Programme on HIV/AIDS.globalforumhealth. history. World health statistics 2008. Malaria and tuberculosis. Lethality would be defined as the rate of mortality of a disease given that the afflicted individuals have full access to current medical services and follow medically responsible lifestyles. 2008 (www.co.
. 6(2). accessed on 28 August). 2009.org/en/KnowledgeCentre/HIVData/GlobalReport/2008.org/Media-Publications/Publications/Monitoring-Financial-Flows-forHealth-Research-2008-Prioritizing-research-for-health-equity. Psychosomatics. Antiretrovirals. while the distribution and effective use of these innovations should remain the concern of governments and health-care providers.who. His research focuses on the delineation of signalling pathways involved in protection against ischemic heart attacks. 2008 report on the global aids epidemic. accessed on 28 August 2009).google. on the other hand.5 billion each.unaids. 2008 (www. accessed on 28 August). Neglected disease research and development: how much are we really spending? Public Library of Science Medicine. One might argue we have a greater moral imperative to treat diseases that affect the young over the old. Monitoring financial flows for health research 2008. also at the University of Cape Town. This in turn has lead to cardiovascular disease becoming the leading cause of mortality. Geneva. Consequently. disparities between lethality and mortality would allow us to identify areas and diseases that require social and economic investments instead. approximately US$ 2. Falloppio G. receive a pittance of less than US$ 200 million each8. but as scientists we must surely prioritize involuntarily contracted diseases over those that are a consequence of lifestyle choice. health-care infrastructure and awareness campaigns.nih. gov/rcdc/categories/
Damian Hacking completed his undergraduate degree in Biochemistry and Genetics at the University of Cape Town. 1564 (http://books. Part 1: overview. is equally as damaging. the discovery and development of essential innovation is the essence of medical research.
3 4 5 6 7
Collier A. obesity rates in the developed world are skyrocketing. Wynn G et al. accessed on 28 August 2009). He went on to complete his honours in Physiology with the Hatter Cardiovascular Institute. such as drug distribution.za/books?id=8_NR SNHl1zMC&dq=de+morbo+gallico&printsec=frontcover&source=bl&ots=jmxdhYv66H&sig= fqpArGTW7p8LY-SwunFfkw5GCxg&hl=en&ei=x034ScLbMoqZkQW26dzPCg&sa=X&oi=book_ result&ct=result&resnum=7. After all. Prometheus Books. What is needed to do this is a “lethality index”. via the draining of funds to treat their subsequent ailments. the National Institute of Health invests roughly equivalent amounts in cardiovascular research as in HIV research. National Institute of Health Research Portfolio Online Reporting Tool (accessed at: http://report. Even so. De morbo gallico [The French disease]. Global Forum for Health Research. Moran M et al. Lethality data would allow investors to make informed decisions about those areas of health care that are in need of research innovation. For example.Young Voices in Research for Health 2009
the case when these behaviours directly impact on the health of others. 45:262–270. He is currently pursuing a Master’s in Medicine in collaboration with the Hatter Cardiovascular Institute at University College London. as opposed to economic or social investment. South Africa. The humble little condom: a history. or that mortality statistics may only present the immediate cause of death and not the root cause. if not more so. and focus on protease inhibitors. Amherst. lethality would still be a better indicator of need for funding than mortality or misinformed public opinion. Geneva. A lethality index would of course still have some limitations.int/whosis/whostat/ EN_WHS08_Full. Moreover. 2004. 2008 (http://www. The morality of poor life choices is a question for philosophers.
Knowledge is innovation.Retro innovation
Liesl Harewood. yet we rely on a doctor to tell us which pills to take 10 times a day. I believe that the greatest innovation in health would be relying on our knowledge and research to incorporate natural products for medicinal purposes. We no longer rely on the wonders of nature like the other animals and then use our man-made advantage to treat those ailments that we do not have a natural cure for. A friend of mine once posed the question. instead of taking the time to read and understand what exactly these pills are made of. This should become more obvious when we listen to most advertisements for drugs in the United States of America. organic product? In fact natural organic products are now being marketed as elite and available only to those who are well off and can afford to pay the higher prices – so. doctors are people too. Botox and fad celebrity diets? It is obvious that we need to make health “sexy” to have the mass appeal that would have the most impact on society. what the ingredients are going to do to our bodies and. Do not misunderstand my position. which speak of the latest wonder drug and then go on to list all the side effects and all the exclusions or reasons you should not take the drug. Perhaps. It is not that I am saying that modern medicine is bad. natural. So how do we acquire the same level of buy-in for being healthy and engaging in health practices for all as is enjoyed by liposuction. I realized there was some veracity to his statement. making them like Atlas carrying the globe. however. “Have you ever noticed that when a person is diagnosed with cancer and they start chemotherapy. whether these ingredients can be found in an alternative. In fact I am proud of the achievements humanity has made and the surgery that has been performed to save lives and make life better. quickly we have gone to the processed product rather than avail ourselves of what is there already. they die faster?” As I looked around at my parents’ friends who were suddenly becoming struck with the disease. What I am suggesting. only to fade away as our short attention span
. Also noteworthy are the strides made in reducing the infant mortality rate. Guyana
RetRo InnoVAtIon – tHe HeAltHIeR wAY
It should seem odd that a great weakness in health is our reliance on medicine and man-made drugs to cure even the simplest ailment. a lot of this being due to advances in medical technology and capability. we do not want to take the same worn path of other trends and fads. They just studied in a different field than most of us. Remember. most importantly. is that people need to take responsibility for their health and not place that entire burden on the shoulders of doctors. however.
as soon as I felt my body reacting to something. and has worked on consultancy projects across the Caribbean. Saint Lucia and Trinidad and Tobago. Far too often. Now. What do I mean by using my intuition in health? A few years ago.Young Voices in Research for Health 2009
is told by Twitter or Facebook what to move on to. instant society. which is ironic in the light of the plethora of information communication technologies we have at our fingertips. questioning and not just accepting the status quo presented by the medical professionals. including in the Bahamas. Would you believe that. when I felt I was catching a cold. This makes me consciously think about what I am eating. I decided to load up on vitamin C through fruit and juice and to drink lots of water. healthy people will no longer regarded as outcasts. She is a business development director and consultant with DYKON Developments Inc. How did this happen? Well. the earth – our internal beings. behind the curtains of my body. She has conducted extensive research on the Caribbean Community Single Market and Economy. I decided that getting sick was all in my mind. since they will be ingrained in our lifestyles. and “health products” no longer remain inaccessible and expensive. after my epiphany wherein I decided that being sick was all a mental thing. It may sound unbelievable. Prior to actively taking this decision. ingesting every form of cough and cold medicine available. That is innovative! – thinking. sometimes referred to as “intuition”. By getting mass support for this health campaign. and I know that. how do we use the technology that exists to harness this concept and make it a mass movement similar to the recent US presidential campaign? Whatever existing tools we use. So maybe I am not talking about using machines to help us communicate but once again returning to the root. Listening is critical. my internal organs were grateful for this new way of handling my ailments. I would say “Woe is me” and commit to bed. Barbados. but this actually worked. Law and Global Change from Coventry University. taking the example of the same cold that would previously have me bedridden and medicinally overloaded. the soul.
. I have become more conscious and aware that I really have only this one body. How is this innovative? Well it applies the knowledge that I have embraced based on listening to my body and taking it upon myself to be more informed about what I put into my temple. we need to market health as something that is invaluable. we have let our lifestyles become ruled by this new cut-and-paste. We tend not to do as much of it as we should lately. Innovating the way we communicate will play an important part in innovating for the health of all. accessible and achievable to all — and something that starts within you. I cannot upgrade it. curled up in a blanket with the determination to vegetate for a few days in my tragic condition – a dramatic and surefire way of ensuring I felt miserable and sick. but that does not mean I should accelerate its return to dust. drinking and inhaling. I actually did not become sick quite as often? I cannot count the number of times per year I am sick – usually it is once or zero.
Liesl Harewood completed both her undergraduate and postgraduate studies in the United Kingdom and holds a Bachelor of Laws with honors in European Commercial Law with French from the University of Sussex and a Master’s with merit in Diplomacy. Every day it is dying. I want to look as good on the inside as I do on the outside.
most significantly. United Kingdom
wHeRe ARe tHe globAl IssUes In oUR globAl medIA cUltURe?
“Change will not come if we wait for some other person or some other time. Illinois During this time of global unrest.Where are the global issues in our global media culture?
Hannah Harvey.” Barack Obama February 2008. Not only are these worthy of greater media coverage. nationally and. internationally is reaching unprecedented levels and must be urgently addressed. surely there are more persistent if overlooked issues facing leaders on the world stage. Yet. We are the change that we seek. all heads seem turned to US President Barack Obama. hailed by the media as a panacea and a symbol of hope in an ever-changing and increasingly unstable world. research priorities and the reality of health care provision – is not being tackled due to an apathetic attitude and a misguided public agenda. the increasing gap between the rich and the poor locally. Nevertheless. Mainstream reporting and powerful political representatives. an opportunity exists for persistence. who are reminded of such problems on a daily basis. widely implementable ways of reversing the dichotomy in health-care standards and provision across the world. The unwelcome truth for Obama and his counterparts is that there are no easy. The media and the voices of the leaders they idolize have underutilized their power to tackle these
. both of which have the ability and responsibility to bring these issues to the fore. We are the ones we’ve been waiting for. Now is the time to truly engage with the issues. the prevalence of poverty – which defines the chasm dividing health care resource allocation. More specifically. they also require an innovative journalistic approach so that hard-hitting subjects can permeate a news agenda dominated by more glamorous newsworthy themes. a paradigm shift does need to be initiated. determination and innovation in the quest to challenge the status quo and implement an improved global health strategy. Although not a vote-winner nor an easy sound-bite opportunity. all of which contribute to the apparent injustices that constitute our world. If there were. dedicate resources and directly confront a highly complex web of problems. have struggled to raise the profile of global inequality. Chicago. The present economic crisis and ongoing threat of terrorism have exposed vulnerabilities and exacerbated fears that resonate among media consumers. with such charismatic world leaders and the evolution of a vibrant media sector. But while the media seem preoccupied. legitimize and popularize the debate. perhaps this circular debate would have been laid to rest decades ago. reflecting on our immediate economic and security predicaments. juxtaposing them with an overzealous analysis of Michelle Obama’s outfit ensembles during political photo calls.
charged with acting as a watchdog and guardian of public interest. which targeted US voters using every conceivable media outlet. The heightened awareness and sense of social responsibility that accompanies increased coverage related to health as a basic human need is just as relevant to the progressive thinkers and grounded leaders who dominate our world stage as it is to the general public. By making problems more evidently relevant. have the power for action. collectively. epidemiology and the constraints limiting any sort of improvements can become more prevalent themes. Here. Most recently. The role of the media as a vehicle for change has long been acknowledged. The ultimate goal of such a strategy would be to encourage investment and provide more leverage to change policy in pursuit of fairer access to health services and research. albeit on a very short-term basis. Resistance is even seen by some. Using predominantly the media of television and the Internet. debate and action. offering almost limitless scope for information. The sense of alienation previously felt by many voters was diminished by popular journalism’s fully embracing the opportunity for political change. the media could do more to investigate and call into question established practices that perhaps direct resources away from pursuits that could help poorer nations. but not all. which in turn translated into success at the ballot box. important and reversible. While it is known that funding research is not always a transparent process and that the research agenda is not necessarily fair. It has also proved highly effective in charitable campaigns. which to my mind holds the key to a healthier and more equitable future for those most in need. the media has a role as the fourth estate. Creative. could and should do so much more to ensure health for all.Young Voices in Research for Health 2009
unglamorous issues with vigour and encourage public engagement. the media must strive for new angles and human interest stories from which to develop a sustained argument for greater collective action to share health-care knowledge and resources. Furthermore. The reluctance of the media to engage in debates involving the complex web of health care and politics is not confined to mainstream outlets. A similar disengagement that characterizes attitudes to poverty and injustice in the developing world could and should be tackled using media formats that have proven to be influential and successful. Annual appeals such as Comic Relief in the United Kingdom have brought health-related issues into the media spotlight. dynamic and attention-grabbing journalism. An improved media strategy has worked not only in a political domain. medical journals. finding ways to implement them to best effect. Not only did this allow Obama to amass significant cultural currency. Today’s media culture is all-consuming. extending from print journalism and television infotainment to the online medium. education. Comic Relief has been successful in transforming the overlooked plight of distant communities and bringing them into the living rooms of millions who. Acting as a mouthpiece for the medical profession. journals are the well-informed voices that should be broaching
. thus raising the profile of global health inequality. its power of persuasion has been harnessed by the Obama election campaign. coupled with innovative editors and media-savvy world leaders unafraid of challenge. and by targeting diverse audiences on a larger scale. it also made politics seem relevant and accessible to every US citizen. which engage more privileged audiences with conditions and realities faced by millions across the globe.
Where are the global issues in our global media culture?
controversial themes and vigorously campaigning for change, as opposed to shying away and sticking to safer issues within the medical remit. This perpetuates both our ignorance and the distance between our own health-care environment and those of distant communities who need our help. While many of us acknowledge that millions die unnecessarily in child birth and from communicable disease and malnutrition on a daily basis, there is still a severe stigma attached to these discourses. Etched in many minds are the stereotypical representations of the wide-eyed black African child with a swollen stomach and surrounded by flies. Trying to rewrite this clichéd representation and create a new perception of poverty and disease in developing countries will take courage and innovation but is nevertheless essential in altering attitudes and encouraging investment. To try to reconceptualize the developing world, and frame core issues in a way with which audiences can identify is particularly challenging in a society that seems fixated on celebrity culture. Iconic figures such as Barack Obama therefore need to actively direct the media spotlight onto these issues for a trickle-down media effect to occur. Overall, there needs to be a synergistic relationship uniting our influential leaders, the media and the public in trying to initiate real progress and turning our ignorance into activism. Innovation needs to be seen within the journalism that forms our public consciousness, boldly pushing for social change and mounting a challenge to the hegemony that dominates modern society. It is a well-known truism that the media cannot tell people what to think, but they can tell readers what to think about. When issues as emotive as gross injustice in health standards across the world are clear in voters’ minds and imprinted on their conscience, it translates into new political agendas that slowly turn words into actions. By placing more emphasis on global health inequality, incorporating increased scrutiny and applying more pressure on those agents capable of implementing change, perhaps we can make the future brighter at last and eventually realize, as Obama envisages, the change we seek.
Hannah Harvey began her medical studies at King’s College London in 2006. She has since become increasingly fascinated by the role of the media and its interplay with medicine and health care. To investigate this subject further, Hannah embarked upon a master’s degree at the University of Newcastle upon Tyne. As a result, she gained much insight into the complex political, cultural and social matrix that underpins health-care provision and its portrayal in modern media. Hannah hopes to become more involved in medical media over the course of her career after first focusing on completing her medical studies in London.
Young Voices in Research for Health 2009
Kate Jongbloed, Canada
HeAltH 2.0: HeAltH foR All, HeAltH bY All
The godparents of global health meeting in Alma Ata may not have had BlackBerrys or MacBooks, but if they were to meet again now, they would almost certainly include technology in their toolkit for promoting health for all. In the next few pages, we will look at how technology-driven health interventions are important tools to address the obstacles to health for all. As well, we will see how technology helps us move beyond health for all to enable health by all, where individuals become real actors in their own health. In September 1978 at the International Conference on Primary Health Care, participants laid out the principles of universal primary health care in the Declaration of Alma Ata. These principles were seen as steps to reaching an “acceptable level of health for all the people of the world by the year 2000”1. Nearly 10 years on from that deadline, the world still faces an overwhelming burden of infectious and chronic disease. According to the most recent World health report, “on the whole, people are healthier, wealthier and live longer today than 30 years ago… but the substantial progress in health over recent decades has been deeply unequal”2. The persistent inequality in health outcomes among and within countries has prevented the vision at Alma Ata from being realized. Newer targets, such as the Millennium Development Goals have also remained out of our reach. Yet, as we begin to stretch our legs in the new millennium, the tools at our disposal are changing. Even as weak health systems, too few health-care providers, and insufficient funding and commitment have worked as obstacles to reaching our health goals, we have an opportunity to overcome these obstacles by adapting our approach. In fact, the social media revolution at the start of the 21st century has allowed technology-based health tools to emerge that are changing the face of sickness and disease all over the world. In particular, technology is changing the relationship between patient and expert. What is so fundamental about the change to health brought by applications on the Internet (eHealth) and using mobile phones (mHealth)? Social media changes the timescale of surveillance, transforms the patient into the researcher, maximizes the reach and minimizes the cost of health promotion, and is measurable and adaptable. But perhaps the most transformative aspect of applying social media to health is that it puts the responsibility for health in everyone’s hands, not just those of doctors and nurses or administrators and epidemiologists. In fact, this technology is an innovation for health by all, as well as health for all. When we talk about social media for health, we are referring to the eHealth and mHealth interfaces. In developed countries, where Internet coverage is relatively
high, Internet-based eHealth initiatives are popular. For example, eHealth can include health promotion, remote health training, peer disease management, standardizing access to patient data and digitizing patient records. However, in much of the developing world, where mobile phone networks vastly outweigh Internet coverage, mobile phone-based mHealth applications are favourable3. Like eHealth, mHealth includes health promotion, as well as remote data collection, remote monitoring, communication and training for health-care workers, disease tracking, and diagnostic treatment and support. Next, we will look at some examples. Google, a brand almost synonymous with the Internet, started an eHealth initiative this year that focuses on disease detection and surveillance. Part of the company’s Predict and Prevent initiative, Google Flu Trends uses a correlation between certain search terms and rates of influenza in the United States of America to estimate influenza-related activity “up to two weeks faster than traditional systems”4. As yet, there has been no critical examination of Google’s approach by the health industry, so for now we will have to be content with the legitimacy provided by their affiliation with the US Centers for Disease Control and Prevention. On the other side of the world in South Africa, Project Masilueke has harnessed the power of “please call me” (PCM) text messages to raise awareness about HIV and promote voluntary counselling and testing. The PCM messages are free for senders, subsidized by advertising using the remaining characters in each text message. Project Masilueke sends 1 million awareness messages each day, tacked onto the end of these PCM messages, directing users to the national HIV helpline. During the pilot, the helpline experienced triple the usual call volume. Next steps will be to expand the service to include personalized medication and appointment reminders, as well as rolling out easy-to-use home HIV testing kits accompanied by telecounselling3. Google Flu Trends and Project Masilueke are just two examples of how social media is being applied to health. In these examples, we saw the power of technology to provide faster data on disease, and education about available health resources. Still, in the examples above we have not seen a drastic change in the relationship between health expert and health consumer. While the examples illustrate ways in which social media can maximize collaboration and reach, the process of health is still carried out by governments, nongovernmental organizations, corporations and health professionals. Let us look closer now at how social media can change the health role of the individual, paving the way for health by all as well as health for all. Google Health is a platform for individuals to manage their health very much like they would manage their e-mail correspondence. The first step is for individuals to access their medical records from doctors, pharmacies and hospitals using Google’s secure online partnerships. Next, users can indicate each of their medical conditions, allergies and medications. Google then uses this information to suggest online resources, check for potential drug interactions, and create a medication schedule. Users are given a platform to access all their health information in one place and share it with their doctor. Both the user and their health providers can use this centralized information to respond more effectively to health conditions as a team. Tools like Google Health change who controls patient information, freeing it from paper charts and giving the patient the opportunity to become more active in health decision-making5.
UN Foundation–Vodafone Foundation Partnership and Vital Wave Consulting. Patients Like Me supports the changing role of patients from passive consumers of health care to active participants in their own disease management and creators of valid health knowledge. World Health Organization.pdf. Dr Michael Massagli.
1 2 3
Declaration of Alma Ata. International Conference on Primary Health Care.org/flutrends. Geneva. DC. a social networking site for people with chronic disease based in the United States of America. Google Flu Trends. which is often generated far from hospitals and research facilities by those on the frontlines of health care and even by patients themselves. best practices in health are developed through clinical trials and care conventions. goes a step further than Google Health by supporting users to connect with others living with the same condition. With these new health applications. Users join and develop their profiles on the site. updates of their current status and narratives of their experience. the most active users input information about their condition on a weekly or daily basis.google. int/hpr/NPH/docs/declaration_almaata.who. including reactions to medications. The world health report – now more than ever. If this can be achieved. and Berkshire.who.pdf. accessed 1 September 2009). where they include diagnosis summaries. we are only scratching the surface of the opportunities made available through new Internet and mobile phone-based applications for health. 2009 (www.unfoundation. Traditionally. Other examples include users who participate in peer disease management and use shared data to drive treatment decisions. describes the service as helping users become active in their own care in three areas: share. It is also the responsibility of the health establishment to look critically at the real impact of these non-traditional responses on health outcomes. a social statistician at Patients Like Me. rather than dismiss them as a passing fad. 2008 (www. who are asked to recall their symptoms over several weeks or months. Washington. Their effectiveness remains contingent on how well the health establishment can integrate them and become responsive to real-time microdata. Aggregating this information provides an illustration of disease management based in real life experience over time. One member of the Patients Like Me HIV community shared the impact of a drug holiday on his profile: “Anyone who wants to see what happens on a 2 months drug holiday just have a look at my updated viral load and CD4 count [a measure of immune system health]”6. Linking with other patients on the site. Alma Ata.
. Mountain View. the decentralization of health that would accompany the adoption of social media by the health industry would create a new opportunity for health for all and health by all.org/global-issues/technology/mhealth-report. accessed 1 September 2009). mHealth for development: the opportunity of mobile technology for healthcare in the developing world.html. UK. Google. accessed 1 September 2009). California. 1978 (www. users are able to give advice or learn from others experiencing similar difficulties. Patients Like Me also provides an opportunity for evidence-based medicine for both health practitioners and pharmaceutical companies.Young Voices in Research for Health 2009
Patients Like Me. accessed 1 September 2009). Thousands of users reporting their experience of living with and treating a number of different diseases allows a more nuanced picture of each condition to develop than was previously accessible to the health industry. So far. int/entity/whr/2008/whr08_en. find and learn. new symptoms and the impact of lifestyle changes. Both of these approaches are dependent on relatively infrequent interactions with patients. 2009 (www.
Google Health Tour. California. she blogs weekly at UnpackingDevelopment.com on the arts. Her previous research includes investigating the role of microeconomic development in reducing HIV risk among adolescent orphan caregivers in Ethiopia. Patients Like Me.0 in Toronto. 2008. technology and global health. accessed 1 September 2009).com/intl/en-US/health/tour/ index.html.
Kate Jongbloed graduated from the University of Toronto’s International Development Studies Program in June 2008 and has since been working as a health and development writer. Kate is passionate about the role of Internet and mobile phone technology in international health and plans to pursue her graduate studies with a focus on this area. 2009 (www. Massagli M. Google.Health 2.google. Aside from serving as editor-in-chief of Undercurrent: Canadian Undergraduate Journal of Development Studies. Presented at Medicine 2.
Quality is a relative thing. It sometimes seems to me more like an abstract issue. I split the possible innovations into three different categories: innovations related to principles. As I try to find out what has already been done and planned to address these myriad issues. Commitment to quality is another principle that ultimately determines success and the life of a programme. It is the question of principle. and vice versa. it is extremely difficult to find any common characteristic in them all. who sees no future even with his hard-earned academic degrees. but complex and complicated. For an elderly couple staying alone in the desolate outskirts of a town. Nepal
InnoVAtIng foR tHe HeAltH of All: bReAkIng tHe bARRIeRs
What are the common health problems bothering mankind? A quick search of the literature will easily show that the diversity of these problems is startling. from the mental health problems of migrants to depression in the elderly. the question about quality is not the question to ask. But. One should work to give the same to others that one would expect for oneself in given circumstances. as I wish to find a magic wand that could solve all these problems with the same mantra. The list goes on. We all know this already. from HIV to swine flu. reinforcing this knowledge works as an innovation. but it is certain that the roads to attain it are different. I try my best to avoid the redundant repetition of the issues that are generally discussed elsewhere. the best medicine would be loving words from their children and grandchildren. It is indeed quite difficult to define health. Hence. It may sound so
. The innovation in principle regarding health care would be to consider it more as an outcome than an entity. to systems and to contents. and systems form the backbone of what constitutes health care. Health probably has a similar meaning to all. So. Whereas it is no doubt a difficult endeavor to try to define these unique innovations to the health of all. the best road to health would be to incorporate her in an income-generating microfinance scheme. For a young drug addict in a war-torn country. But in my disappointment. the best medicine would have been timely counseling. the best medicine would be a peaceful country with hopes for the future. The attempt to find similarity in them ultimately leads to an unsolvable maze. From the malnourished children of developing countries to the obesity-linked disorders of developed countries. For a teenager in a developed country who gets pregnant just because of fun she had in a party. there is no dearth of materials among the forums and declarations. For a poor woman in rural Nepal who struggles to find food everyday. Innovations should be in ideas. Principles form the mainstay of the systems. bringing out new ideas and approaches should be the mainstay of innovation. Principles.Young Voices in Research for Health 2009
Biraj Karmacharya. for ideas give birth to actions. Good quality for one person may be lower quality to another. a faint gleam of hope arises that shows a thread that links all these issues together and that can be applied to all.
attitudes. we rarely find instances where these people are taken into account. The essence of the community-based approach is to involve the community in identifying and addressing its problems. and this is sometimes too complicated. the scientific search for truth. There should be a separate way to get organizations and experts to care about information flow to lay people and bring them into the loop of research and information. or a veteran soldier who leads the neighborhood in something he has convictions about. the innovation would be to revisit the communitybased approach. Hence. All illustrate so much about community-based approaches. Most of the systems are not community oriented. changes do not happen just on the basis of facts. academia and research sectors in health. Rarely do big organizations reach them with a helping hand in times of struggle. and the rest. but things can be improved so that those dedicated to doing something are identified in a timely way. These barriers have to be broken down. Systems. It reveals the unseen heroes of communities and makes ordinary people do extraordinary things. or a religious leader who captures the attention of thousands of devotees. of course. let us think how many community health leaders would understand the great journals and have access to relevant information. The rules of game have been more in favor of the experts who are capable of playing with jargon. but truth prevails not just in science. This is not necessarily bad. and it is flexible enough to incorporate unforeseeable changes. which opens a new dimension in health care. This would be an innovation generations would remember. There is no doubt that science should lead. and it is of utmost importance that health planners understand this. It is only after they prove their capability that organizations willing to support them knock on the door. Every community has its own identity. and it is small enough to illuminate even the problems of the minorities. Stereotyping an approach is doomed to fail. all the rest will be taken care of. the approaches to communities differ as well.
. It creates heroes out of common people. In this context. It is now in the hands of research giants to break the barriers of research. The hero may be a poor.Innovating for the health of all
obvious and so simple. Great institutions have been built by simple people in resource-limited settings. but rather communities need to be oriented to the systems. The Declaration of Alma Ata is a milestone in terms of community-based health care. Truth prevails also in the unfathomable eyes and hearts of the people. passion. but the strength behind this is that it refrains from building up health care in an inequitable or compromised manner. However. The hero may be a school headmaster who polishes his students everyday for something better. from the issues of equitable distribution to sustainability. Once this is done. illiterate farmer who can persuade villagers change their habits. Research is. Also in relation to research. energy and dedication. but when we review various organizations. It is rigid enough not to deviate from the main points. because it would break the barrier between so-called experts and others. However. the history of the last 30 years shows that not all understood the same thing. when they are seeking even a ray of hope. for this is the foundation of facts. The community-based approach is unique because it is big enough to incorporate all the major issues of the particular community. Changes develop with understandings. from the worries of governance to the confusions of ownership.
trade and social services – internationally. but increasingly people are failing to realize that technologies succeed when they complement human values and strengths. in 2002 and his Master of Science in Tropical Medicine at Mahidol University. This is also the time when inequities are growing all over the world and new challenges hover in the health sector. Thailand. nationally and locally – is necessary to bring about a comprehensive package of health care. Contents. The new millennium is the era of globalization and technological feats. but as an integrated part of the continuum of health care (in terms of operational management as well) would significantly mitigate some of the major problems. An alliance in the sectors of education. Nepal. the capital of Nepal.
Biraj Karmacharya was born in Kathmandu. which are talked about so much elsewhere. Nobody doubts that this is the era of technology. Since 2006. the innovation in this context would be forging alliances between different sectors. not just in terms of referral but also of management and organization. However. There are many pertinent issues regarding contents related to health care.Young Voices in Research for Health 2009
It would be redundant to discuss commitments to cost reductions in health care as another innovation. His main responsibility is to create community health institutions in rural areas of Nepal. it is essential to develop a continuum. An example could be primary health care in a continuum with secondary and tertiary health care. it is the technology that should complement humans.
. One is the use of technology. agriculture. Nepal. It is not humans who complement the technology. in 2006. The innovations should be in shifting the paradigm and breaking the barriers invisible to the eyes of many. This will ensure a good flow of human resources and services throughout the system. he has worked as the chief of community programmes at Dhulikhel Hospital/Kathmandu University Hospital of the Kathmandu University School of Medical Sciences. and they fail when they try to replace them. and those that do are relatively slow to affect change. as this would encompass as well the issues of patents and globalization. Not many ideas rule the world. Most developing countries suffer because primary health care is poorly staffed and managed. which gets fragmented into separable units in most countries. Developing these centres not as separate centres. Machines do not replace the healing touch and the understanding of a person. He completed his Bachelor of Medicine and Bachelor of Surgery at the College of Medical Sciences in Chitwan. Rather. He is also responsible for planning and implementing various community programmes. Even within a health-care system.
n’existe hors du monde. avec quelles conséquences ? Plutôt que de louer les bienfaits de l’énergie solaire. à toutes ces choses qui ne sont à priori que positives. l’être humain adapte son milieu à ses besoins. ou. pour quoi. Pourtant. on applique le système D : on fait avec ce que l’on a. à la modernité. la première chose qui saute aux yeux est que l’innovation n’échappe pas aux relations de pouvoir qui déterminent les relations entre les pays riches et ceux qui le sont (souvent beaucoup) moins. peut ainsi créer l’illusion que quelque chose est fait. pour qui. il importe peu que le personnel compétent pour les utiliser et les entretenir manque (au cas où les pièces de rechange seraient disponibles) car ces machines ne fonctionneront pas. politiques. Quel genre d’innovation. Au final. Sur le terrain. bien plus souvent. l’innovation. Ces techniques méritent certainement d’être partagées à travers le monde pour mieux faire dans des contextes où les ressources manquent. dans quel contexte. nous font oublier pourquoi ces personnes doivent se débrouiller avec si peu à la base et pourquoi leurs besoins et droits économiques. d’autres le font par nécessité. Ainsi. Le manque chronique de moyens et de ressources humaines fait que la technologie. même mal adaptée au contexte.De la nécessité de se méfier des fétichistes de la nouveauté
Rebecca Lacroix. lorsque l’Italie fait don de magnifiques machines de radiologie à un hôpital rural. Alors que certains innovent par créativité. par manque d’électricité. par qui. il est question ici de l’innovation comme application de nouvelles connaissances. on stérilise le matériel médical avec la chaleur du soleil. ou de la téléphonie mobile qui rend possible le «e-health». Par la créativité et la technologie. L’innovation comme produit. Cela dit. sera rarement refusée. sociaux et en matière de santé sont bafoués. culturels. on épure l’eau par condensation. Alors bien sûr que les gens innovent. étant en contact quotidien avec les besoins réels de personnes réelles plutôt qu’avec des chiffres. Le problème survient lorsque l’émerveillement de ce que les personnes arrivent à faire dans des contextes difficiles « et avec si peu en plus (! ) ». au développement. Suède
de lA nécessIté de se méfIeR des fétIcHIstes de lA noUVeAUté
L’innovation est associée au progrès. pas plus que ces autres concepts. l’innovation doit-elle être nouvelle pour innover ?
Le pouvoir de l’innovation pour les uns et le système D pour les autres
En travaillant dans le renforcement des capacités de recherche dans un hôpital en République émocratique du Congo. les nouvelles idées ne sont jamais refusées et la flexibilité pour les appliquer rapidement est grande. Ces relations servent à légitimer tout ce qui vient des pays riches et à marquer les connaissances de ces pays « d’expertise» : ce qui est bon pour les autres doit être bon ici aussi.
. sans prendre en compte le contexte. avec ce que l’on n’a pas. à la science.
c’est l’homme. en totale infraction aux règles de la PAM : les gens vendent la nourriture ? Ils ont des revendications par rapport au type de grain si généreusement distribué ? Ils n’en ont donc pas besoin ! Lorsque nous arrivons dans le camp de Minova. Cela n’a pas été prévu dans les lignes budgétaires par les experts qui se basent sur les toutes dernières connaissances pour maximiser l’impact de leurs programmes. rendant Mama Azama très populaire dans le quartier. du bon sens et de l’écoute. mais ceux de ses voisins aussi. Si cet exemple soulève quelques questions quant à la composition du médicament de Mama Azama. Etant trop pauvre pour acheter du raticide.
. Comme si les problèmes tangibles de santé (mal de dos). elle utilise les médicaments pour son dos fournis gratuitement par une organisation non gouvernementale (ONG) internationale. La PAM (Programme Alimentaire Mondial) est responsable de la distribution alimentaire dans les camps de réfugiés autour du lac Kivu. Hiérarchisés. le chef de famille et celui qui décide. Chez Mama Azama il y avait des rats. L’innovation ce n’est pas un concept. en un mot. Ayant bien intégré les nouvelles connaissances en matière de genre. la nourriture reste dans les dépôts. n’importe quel/le congolais/e aurait pu informer la PAM qu‘ici. pouvaient être séparés de l’état de santé général (vulnérabilité) et des facteurs qui influent sur celui-ci (manque de nourriture. il n’y en a pas une pour donner du raticide à Mama Azama. mais des milliers. Il existe donc souvent un conflit d’intérêt entre la femme qui souhaite utiliser les rations pour nourrir la famille et l’homme qui souhaite les vendre pour gagner de l’argent. De plus. les « meilleurs pratiques » et les « meilleurs secteurs » reflètent déjà les priorités de ceux qui ont le pouvoir de déterminer les exemples à suivre pour les autres. Certains des produits se retrouvent sur les marchés locaux. Ou à défaut de cela. lourdes charges portées sur la tête. En attendant que la PAM applique ces « nouvelles » « nouvelles connaissances ». Mais et l’innovation dans tout ça ? L’application de nouvelles politiques qui prennent en compte les nouvelles connaissances sans prendre en compte le contexte peut avoir des conséquences désastreuses pour les gens qui dépendent de ces rations pour survivre.Young Voices in Research for Health 2009
L’innovation des uns pour les autres
Nous ne sommes pas plus égaux dans l’acte de créer que dans la sélection des créations qui doivent être appliquées. Non seulement les rats sont partis et ne contamineront plus ni ne mangeront sa nourriture. logement insalubre). Que cela plaise à la communauté internationale ou non. Parmi toutes les ONG (dont les logos et les 4x4 bouchent la seule route goudronnée de Goma) qui proposent des activités génératrices de revenus aux victimes de violences sexuelles pour l’intégration des femmes dans le développement. Je persiste et signe : la nouveauté ne peut être dissociée de l’application dans un contexte particulier. Dix minutes passées à discuter avec n’importe lequel des réfugiés auraient pourtant suffi à comprendre que 25 minutes pour cuire des graines c’est trop en l’absence de bois de chauffe et de cocotte-minute. aucune distribution n’a eu lieu depuis deux mois. il soulève également celle des priorités des ONG. L’innovation n’est pas un produit fini mais un processus qui doit être continuellement adapté en fonction des connaissances holistiques des réalités locales. la PAM innove en distribuant les rations aux femmes. de la pauvreté matérielle.
Plus de nouveauté ne doit pas servir à détourner l’attention des problèmes du présent. ne ferait pas de mal non plus. chassent. contenant de nombreuses recommandations sur les changements à effectuer au niveau du gouvernement. she spent two years working with international organizations in Geneva. Le fétichisme de l’innovation peut servir de poudre aux yeux et détourner l’attention des spécificités locales et du problème fondamental des inégalités. la nouveauté. les projets sociaux pour les étudiants de Goma (enfin. si l’on ne sait pas où l’on va il faut savoir d’où l’on vient. Je me demande quel est l’impact sur la population quand les forces de la MONUC. Democratic Republic of Congo. n’est pas forcément mieux. cimentent et peignent le sol. L’innovation peut parfois sonner bien creuse quand on peine à gérer ce qui est déjà en place . Papa Augustin donne un dollar par-ci par-là à la police depuis quelques temps mais il ne sait pas s’ils vont protéger sa famille quand les bandits reviendront. et puis distribuer la nourriture disponible à des gens qui ont faim et arrêter de la rendre conditionnelle à des faveurs sexuelles. soupçonnées d’échanger de la nourriture contre du sexe. la moitié puisque les filles ne l’utiliseront pas) ne peuvent être dissociés de la mission première de la MONUC qui est de protéger la population du Congo. pillent et violentent des personnes. Pendant que la Mission des Nations Unies en République démocratique du Congo (MONUC) s’adonne à cet exercice de relations publiques. Democratic Republic of Congo. Malgré une presse internationale qui s’offusque plus des rebelles tueurs de gorilles que de ces mêmes rebelles qui tuent. sont relâchés par leur gouvernement (l’Inde) par « manque de preuves » ? L’ironie du sort veut que la MONUC publie sa « Comprehensive Strategy on Combating Sexual Violence for DRC ». des bandits ont pillé ses voisins la semaine dernière. She is currently managing a programme working with vulnerable women at the grassroots level in Bukavu. si elle est plus.
. Puisque le vent semble favorable aux nouvelles idées pour être mieux acceptées par la population. Ils construisent un terrain de basket à l’Université de Goma. Depuis un mois.
Rebecca Lacroix is a gender analyst. à peine trois semaines après l’acquittement des soldats indiens. les casques bleus sont là. primarily researching the gendered dynamics of HIV. une trentaine de soldats stabilisent. Her main areas of interest include conflict resolution. Et si dans les contextes de postconflit. la vraie innovation était de tenir les promesses faites dans le passé ? Ah. dans le village de Papa Augustin à la périphérie de Goma.De la nécessité de se méfier des fétichistes de la nouveauté
Innover en tenant ses promesses
La RDC n’est pas oubliée de la communauté internationale. She has completed several missions focused on research capacity strengthening for a local hospital in Goma. Tokyo ou Genève. les viols des femmes et des filles sont très médiatisés et les discours sur le respect de la femme et l’égalité des genres abondent. Comme on dit par ici. L’innovation dans ce contexte. After obtaining a Bachelor’s in International Relations and a Master’s in Gender Analysis in Development with distinction. masculinities and risk-taking behaviours and of course. disability and the legal system. En DRC. j’en profite pour apporter une modeste contribution : soyez cohérents. en attendant que les experts se penchent sur la question dans les bureaux à Washington. Il y a un joli panneau pour les scores et des paniers flambant neufs. gender-based violence.
Eso sí. La violencia de género es un tema candente en la actualidad. pues sobreviven a estos hechos que podrían parecer narrados desde la hipérbole. pero tras meditarlo un poco relacionas que sólo un fantasma podría conseguirlo. “¡Pues quiero ser fantasma!” es el pensamiento que aflora en la mente para. pues es verdad! En realidad sí que se ha dado un paso. es decir. esa no puede ser la solución. Pasará a perder su identidad para ser la maltratada. hay olas que parece llegar hasta la pisada pero por falta de fuerza pueden no borrarla. de torturas sexuales… pero no muriesen? Mi enhorabuena a tantas mujeres que diariamente demuestran su inmortalidad. Cuando los informativos enfatizan el impacto de esta lacra social centrándose en las muertes ¿qué hace la sociedad entonces? Lanzar un mensaje: “denuncien señoras. cAdA pAso cUentA
Desear dar un paso sin dejar huella puede ser un deseo. denuncien”. ser empujado por otro… ¡los fantasmas no existen! Acto seguido los pensamientos se entremezclan. sí que se ha dejado huella pero se ha necesitado de una tercera fuerza. ¡Vaya. que tal y como tristemente ocurre. estar girando la cabeza o incluso el cuerpo entero para comprobar tal desaparición puede lentificar la carrera. Desventajas: correr por la orilla reiteradamente puede provocar lesiones. igual sí se podría dar un paso sin dejar huella y sin ser fantasma… ¿Dónde es posible hacer esto? En la orilla de la playa. enrocarse o ser invisibles por cuestiones de violencia de género? ¿Se podría girar la espalda y considerar que es saludable que alguien sufra de esta manera? ¿Una mente que quisiera abandonar su propio pensamiento. Spain
contRA lA VIolencIA de géneRo. del insulto. un anhelo. Desdichadamente el impacto de ésta se cuantifica con base en el número de muertes pero ¿y si esas mujeres fuesen inmortales. puede mantenerse sana y fuerte? La salud mental merece tanta nobleza en el cuidado como el acuoso pulmón o el fibroso corazón. ¿Alguien pregunta por qué cuesta tanto expresarlo. cual carnaval de ideas. además ir de espaldas al futuro es más cegador que el sol matinal del solsticio de verano. siempre será mejor que ser un fantasma… ¿Cuántas personas en el enramado árbol del mundo no habrán deseado desaparecer. denunciarlo? Mi respuesta tan crítica como personal sería la siguiente: porque en cuantiosas ocasiones aquellos que reivindican y exigen a las mujeres que denuncien son los mismos que estigmatizarán a la denunciante. Sin embargo. eclipsarse. ¿dejar de existir para poder avanzar sin dejar huella? No. su propia autonomía. La hipocresía social puede llegar a ponernos la venda que nos impide tener una noción real de cuán profundo es el tema y que acredita a sentir comodidad siendo lego en el asunto. de una ola espumosa que borre esa pisada. inmediatamente. como si un mismo patrón vistiese a todas las mujeres para desnudarlas ante semejante
.Young Voices in Research for Health 2009
Luz López Samaniego
Luz López Samaniego. sintiesen el dolor de un puño.
Por autoprotección se convertirán en actores de la película titulada vida real. se consiente socialmente que el resto entre esa diferencia sea el silencio. porque son los motores generadores de la misma y/o similares. como si la incisión contusa hubiese conquistado la arteria de la tristeza.provocan en mí cierta sensación de repulsa. Aquellos osados -independientemente de su ideología política. hijos e hijas que se impregnarán de esa filosofía desde su uso de razón. no deja de alegrarme que exista quien no haya sentido en su dermis o en su mente
. cuyo revés viene de la mano de aquellos que nunca han sentido de cerca este tipo de violencia o peor aún. Es decir ser fantasma o. sin interpretaciones.pertenecen en parte a la conducta innata. tan deseado. etc. No quisiera dejar durmiendo la siesta a otra reflexión: los niños y niñas.que denuestan este tipo de iniciativa -tachándola de innecesaria o disfuncional. pero silenciada. dejando a la suerte del oleaje la propia autoestima.. cuyo ápice es dirigido por una mujer. las técnicas de comunicación –asertividad. dar otro paso más obvio como es concienciarnos de que cada uno de nosotros/as somos parte de la sociedad. acciones individuales y gubernamentales. en el mejor de los casos. ¿No sería cuestión de educar primero a la sociedad? Y. pero bajo el paradigma humanista del psicólogo Carls Rogers toda persona puede llegar a aprenderlas. ¿Por qué ese silencio y cuáles son sus posibles consecuencias? La mejor respuesta es preguntar directamente a la víctima. Por otro lado. Paralelamente. tener que trasladarse diariamente a la orilla de una playa calculando que cada paso sea alcanzado por la ola adecuada. Sólo aquellos que nunca han sentido el látigo de la violencia de género podrían estimar de inservible estos avances. destacando una vez más la declaración de los derechos humanos adoptada por la Asamblea General de las Naciones Unidas en 1948. Ante tanto juez impostor es comprensible que se prefiera seguir en la sombra. es que ante la dicotomía se opta por volver a mi reflexión inicial. etc. respaldo.. Es la decisión de optar por dicho estado de linchamiento físico y/o mental a pasar al siguiente asalto. En el desgarro de este pensamiento reside en mí un reconocimiento al esfuerzo aportado por numerosas personas a lo largo de la historia. en un intento de concreción. una Ministra. tan trabajado. Reivindicaciones en pro de los derechos humanos. Las relaciones interpersonales.Contra la violencia de género. Aplaudo con fervor cada intento personal y/o colectivo. Otro ejemplo de mi aplauso. empatía. previamente. Eduquémonos primero. No denunciar ya no sólo para no perder la vida sino para no perder el rol social. casi me estremece escribirlo. investigación. aunque la estadística oficial de este tipo de violencia es muy inferior a la estadística real. Pedir ayuda es un reto con posibilidad de demasiadas punzadas de hoja afilada que sólo calma su sed derramando amargura abruptamente. el no dejar rastro de la huella. que tiene silueta pero no vida propia. Dejar de utilizar el término en tercera persona del singular para designarla como propia de un yo o de un nosotros. Una respuesta común. es la reciente creación de un Ministerio de Igualdad en mi país. el ya comentado estigma social. Hagamos balance de lo preparados que estamos para utilizar sin mayor dilación la balanza del juicio ajeno. cada paso cuenta
Cabría pues llevar siempre en el bolsillo un transportador de ángulos que permitiese medir el ángulo propio y el de la persona que padezca dichas tropelías.producen sobre esa persona una necesidad de superación personal. cuenten conmigo porque yo deseo contar con ustedes. un paso con huella. cuánta se está dejando de ganar a consecuencia del maquiavélico rompecabezas de la violencia de género? Es mi pregunta para la sociedad. de construir. sin que se llegue a tener conciencia de ese agradecimiento) la fusión entre la entrega desinteresada y la voluntad de superación personal. la posibilidad de aportar. niño/a. actualmente ser docente de enfermería psiquiátrica y salud mental en la Universidad de Alicante. la generosidad es un gesto que admiro entre quienes la ejercen y. Si alguna de las respuestas es seguir empoderando. En mi juventud tengo la fortuna de sentirme parte de la sociedad desde planos dispares pero conexos. Cuando los consigo o los rozo como reales no pierden el esplendor preconcebido en mi mente sino que se transforman en oportunidades que aprecio. en el marco del Foro Europeo de la
Luz López Samaniego se desempeña actualmente como profesora ayudante del Departamento de Enfermería de la Universidad de Alicante en el área de salud mental y enfermería psiquiátrica. Para concluir preguntaría ¿Cuánta salud mental se está perdiendo. construyendo positivamente y apostando por los derechos. es mi pregunta personal. con inquietudes por conocer cuanto está a mi alcance. En un mundo competitivo. Me considero una ciudadana del mundo. Cada uno de ellos ha despertado en mí inquietudes. representar a los jóvenes de mi país y de Europa en materia de salud a través del Consejo de la Juventud de España y de Europa. adolescente puede beneficiarse será de enorme calado para mí. es mi pregunta para nosotros. investigando. sino aquellos que sin estar presentes -sin siquiera saber de la existencia de alguien. como valor. Cuenta con postgrados en las áreas de enfermería. con su paso firme. por parte del maestro. Por esa admiración y aprendizaje se consigue (sin que haya nadie tangible a quien decirle gracias y. la salud y la felicidad.Young Voices in Research for Health 2009
Luz López Samaniego
estas injusticias. si una sola mujer. pero nunca puede ser excusa para dejar de ser empático con el paradigma de dicha realidad: sería negar la evidencia por no sentirla como propia. Mi teoría es que los grandes maestros de la humanidad son aquellos que no sólo transmiten a las personas cuando están junto a ellas. No olvido nunca cuánto esfuerzo y dedicación me supone cada uno de esos pequeños pero soñados objetivos. por tanto. Me permiten seguir aprendiendo y madurando con la única ambición de poder compartir lo aprendido con el mayor criterio posible y bajo el amplio paraguas del respeto. Participó. Antes de su desempeño como profesora trabajó durante cinco años como enfermera y dos años como coordinadora de salud del Consejo Nacional de la Juventud de España. Fue coordinadora de salud del Consejo de la Juventud de España durante dos años. Mi mente está abierta y deseo que esta apertura me permita conectar la realidad para poder trabajar en pro de la salud mental y. Es estudiante candidata al doctorado con mención europea en el mismo departamento y cursa estudios de ciencias políticas en la UNED (España). reivindicando. conseguir becas nacionales e internacionales -algunas en instituciones tan prestigiosas como la Organización Mundial de la Salud-. reflexiones y algo que es un sueño para mí. y otros tantos que valoro diariamente. Citaré algunos: realizar cuidados de enfermería en distintos hospitales. salud pública y drogodependencia. entiendo que debo compensarla con la mía propia.
publicado por el Ministerio de Salud Sanidad y Política Social de España
. del documento Win Health with Youth Ganar Salud con la Juventud. promovido por la Comisión Europea y tomó parte en la exposición de los resultados de dicha campaña ante el Parlamento Europeo en Estrasburgo. en el desarrollo del primer Manifiesto sobre Juventud y Tabaquismo.Contra la violencia de género. entre otros. Luz López Samaniego fue pasante durante tres meses en el Departamento de Salud Mental y Drogodependencia Sustancias de Abuso de la Organización Mundial de la Salud y es coautora. cada paso cuenta
infrastructure. policy and culture. high life expectancies and obesity. when funding for an HIV-prevention project I was involved with in India was discontinued after the first year of implementation. and “neglected diseases”. if I may say so – but was shelved before any impact could be shown. How does one address this problem? The conventional and perhaps most obvious answer would be to simply increase funding – and. I was a first-hand witness to the frustrations of the sudden withdrawal of support. rather. where it is mainly the fortunate that enjoy the fruits of development and innovation. treatments and services are delivered or distributed. if certain countries were able to achieve great strides in health. this vision of health for all remains unfulfilled. I believe that the core issue in addressing health inequalities is not the discovery of a cure or an effective service. The poor are afflicted by dual burdens: curable diseases for which they do not have access to vital drugs and diagnostics. Despite the numerous advances that have been made in the fields of science and health. while on the other there was polio. However. recognizing that health is a fundamental human right and that existing health inequalities were of concern to all. The project was the first of its kind in the country – an innovation. I realized then that initiatives seeking to increase access to health-care treatment. donor-driven programmes also have their drawbacks in that they are not sustainable. I wondered. products or services also necessitated new methods of management and delivery. such as the polio vaccine. why could not all? If the required product or service was available. nor do they always focus on capacity building and the engagement of the local community. as scientific creativity and talent is constantly harnessed in the laboratory and the field. world leaders. Growing up. why was a particular health problem still afflicting select populations? I learnt that the answers to such questions entail several different factors including economics. when
. financial aid – to tackle diseases ravaging the developing world. yes. On the one hand was one of the world’s best health-care systems. In other words. the reality is that we continue to live in a world of stark disparities. Yet. what is the use of developing antiretroviral drugs if millions of HIVpositive patients in Africa do not have access to the medication? These questions become more important during economic downturns such as the current one. is innovation in the process by which health products. I was often shocked by the contrasting environments of the country I lived in and my country of origin. After all.Young Voices in Research for Health 2009
Priya Mannava. high child malnutrition and lack of access to basic amenities such as clean water and adequate sewerage infrastructure. What is required. greater focus should be given to understanding how best to increase access. which fail to attract much of the research and funding resources they require. India
A mIssIon foR All: IncReAsIng Access to HeAltH pRodUcts And seRVIces tHRoUgH InnoVAtIVe pARtneRsHIps
Thirty years ago. pledged to achieve “a level of health that will permit all peoples to lead a socially and economically productive life” by 20001.
Having mentioned these examples. cross-sector partnerships that demonstrate the strides in health that potentially can be achieved.A mission for all
diversions of funds from treatment and prevention programmes further increases the vulnerability of the poorest patients. The entrepreneurship of the manufacturer. This is particularly important because the development and scaling up of social business partnership models. engineering and law. I recognize that social business models are fairly new and research still needs to be done to understand their true impact on health systems. resulted in the production of low-cost nets. economics. nutritionally fortified yoghurt to the children of Bangladesh as result of a partnership between business and philanthropy. for instance. Thus. the goal of the partnership would be optimization of the beneficiaries’ well-being. combined with the efforts of all partners involved. not only was affordable yoghurt made available for the benefit of those most in need. so the profits gained would be reinvested into the service – a phenomenon applied in social entrepreneurship and business. Understanding how delivery processes can be improved will shed light on the mechanisms or factors required for creating an enabling environment for innovation. How can we enhance processes to ensure that health products and services are available to those most in need? The answer lies in partnership models that translate ideas into realities on the ground. the willingness of the Japanese chemical company that had developed the technology to transfer knowledge and skills to African counterparts. There are existing social businesses. corporate and venture capital investors would need to be central stakeholders in order to provide the necessary resources. I see health for all realized as the product of various innovative partnerships. The life-saving products were brought to the continent with the support of multilateral organizations. Previously. This call for evaluative research also goes hand-in-hand with the need for a stronger emphasis on operational research on health. as these already exist in various forms in the health sector. whereby the success of the partnership would be driven by financial performance and market principles. and a loan given to a Tanzanian textile manufacturer for the production of the nets. providing the fertile soil for innovation will require venturing outside the circles of medicine and science to systematically engage experts from other domains such as business. I would like to emphasize that what I am advocating is not simply public–private partnerships. there is the example of the introduction of long-lasting insecticide-treated bed nets in Africa. has brought affordable. creativity and further innovation would also be fostered. In the process. The Danone-Grameen joint venture. I am arguing for a more defined role for economics. but the foundations for a sustainable business were also established2. who understood local sensitivities. efficiency. the free distribution of bed nets had meant that selected vulnerable groups were given priority to be recipients3. Combining the expertise of entrepreneurs in Danone and the staff of Grameen. The effective marketing of the nets at different prices to various targeted users helped to increase uptake and access to the products. As a result. Likewise. once
. allowed the development of a community-based production model and a differential pricing system. In a world where globalization has redefined determinants of health. empowerment. the private sector applying business and entrepreneurial principles to the products of research. At the same time. which are in turn brought to the common man using the infrastructure and knowledge of the public sector and civil society.
Priya hopes to build a career in addressing health inequities in developing countries. policy-makers will need to provide ongoing support and the appropriate incentives to encourage potential partners from the for-profit sector to pool their expertise and skills for social benefits.
Priya Mannava has a Bachelor of Science degree in Human Sciences from University College London and a Master of Science in Global Health Science from the University of Oxford. Accordingly. Muhammad Y. 1978 ( www. Health research must now move to inform the appropriate scaling up of partnerships that provide this adequate base. Thus far. is an innovative partnership that has potential. scientists will also need to be willing to engage in technology and knowledge transfers. and belief in the principles of the free market to drive health ventures. you get a perfect replica of the tallest tree. Muhammad Yunus: “When you plant the best seed of the tallest tree in a six-inch-deep flower pot. she previously worked as a consultant at the World Health Organization and in the area of capacity building and HIV prevention with a nongovernmental organization in India. Creating a world without poverty. will demand a change in the way health products are valued and distributed. only the soil base you provided was inadequate”2. Novogratz J. New York. What is now required is the appropriate nurture for all to sprout. International Conference on Primary Health Care. particularly when this involves developing countries.Young Voices in Research for Health 2009
proven to be effective by impact research.
1 2 3
Declaration of Alma Ata. Tuberculosis and Malaria.int/ LinkFiles/Health_Systems_declaration_almaata. To quote the founder and managing director of Grameen Bank. New York.searo. There is nothing wrong with the seed you planted. 2009.pdf.
. Existing collaborations have indicated that this is possible when various stakeholders have a common foundation of trust. The blue sweater: bridging the gap between rich and poor in an interconnected world. Public Affairs. Academics teaming up with social entrepreneurs to make available the fruits of research in the developing world. our approaches have fallen short of guaranteeing the fundamental right of health to all. for instance. 2007. shared values.who. Now at the Global Fund to Fight AIDS. With interests in disease epidemiology and international health. Likewise. accessed on 1 September 2009). but it is only inches tall. Rodale. The seeds of innovation exist. New methods must be adopted to ensure that developing countries can access the results of multimillion-dollar investments in researching and developing drugs and treatments.
Innovando hacia dentro
Annia Martínez Massip. ¿por qué las ciencias y las perspectivas se disputan el prestigio proficiente de sus feudos epistemológicos y metodológicos en pos de retos? Desafortunadamente. Se sabe que es fuerte y resistente la llamada superespecialización respaldada por estrategias institucionales. las modernas ciencias sociales se caracterizan por ser “usurpadoras” de métodos propios de las ciencias naturales. psicológicas. Desde la Ilustración. El positivismo se corona como el móvil representativo de la usurpación. las diversas barreras caprichosas que se inventan e institucionalizan en función del aprendizaje pormenorizado y fraccionado. estructuras. ¿por qué una ciencia fragmentada conlleva a una fragmentación de la realidad sin posibilidades de reconstrucción? Porque el sentido de apropiación del método en las ciencias. no poseen el mismo efecto en la aplicación práctica. organizacionales. funciones. de esa forma se asumen conceptos como orgánico. de construir o destruir. estrecheces y conveniencias disciplinarias choca con la profesionalización e institucionalización de la ciencia. sino la participación del científico en tales relaciones. Cuba
InnoVAndo HAcIA dentRo
¿Les ha pasado. Por tanto. Los científicos que se vanaglorian de poseer métodos propios en sus correspondientes
. ¿ pertenecen la observación. que poseen en común no sólo la interrelación con lo aprendido socialmente y su producto destinado al consumo social. medio. sin embargo. Si las disyuntivas naturales y sociales se mueven en relaciones más complejas que la bilateralidad. que innovan hacia una dirección específica y terminan transformando en diversos sentidos? El alcance inminente de la innovación sin apellidos. de igualar o desequilibrar. que está influida por factores del contexto propio. funciona y contempla diversos roles apoyados en procesos de profesionalización e institucionalización que forman estructuras internas para garantizar su desarrollo y perfeccionamiento. que las ciencias “blandas” necesitan con urgencia para representarse como “verdadera ciencia fuerte”? La ciencia tiene las facultades de ordenar o transformar. la experimentación y la cuantificación a un terreno prohibido o son formas prestadas o “robadas” de las ciencias “duras”. la sociedad y el pensamiento en límites rígidos. políticas científicas y conveniencias personales. especie. jurídicas. necesidad. La producción de conocimientos establece distintas relaciones intracientíficas: informativas. que conlleva a la segmentación de la naturaleza. mecánico. porque se adoptan postulados evolucionistas y deterministas. ideológicas. La riqueza y la solidez de las ciencias están dadas por la flexibilidad y la diversidad de métodos. constituye una relación de poder que presenta un carácter restringido y reducido de la realidad. Los métodos son herramientas y enfoques que dependen de las características en la articulación entre teoría y práctica. adaptación.
La capacidad y la disposición científicas desde la innovación epistemológica rompen con barreras de comodidad y complacencia. Cuando las ciencias desvirtúan su inherente carácter social. Las estructuras cognoscitivas y lingüísticas terminan moldeando la realidad a nuestros intereses profesionales. Ni se pretende privilegiar la acción del contexto y sus dinámicas socioeconómicas sobre el cambio científico. “robos” o ciencias inertes sino de naturalezas “desnudas” que esperan ser descubiertas. también en las ciencias hay que evitar las posiciones extremas. No se trata de propiedades particulares. préstamos. ni la inter.Young Voices in Research for Health 2009
Annia Martínez Massip
disciplinas. pero no borra sus diferencias respecto a ellas. no desde la conformista formación disciplinar sino desde las demandas y exigencias de una realidad compleja.
. comprendidas y transformadas. cuya relación con los intereses sociales es indiscutible. para articular coherentemente el cúmulo de innovaciones con apellidos. también le urge buscar los mecanismos que irracionalicen las pertinencias de las disciplinas que soltaron de la mano a la sociedad. Mas no se ignoran las particularidades de la ciencia que son vitales para comprender que su enfoque social permite las distintas articulaciones con las restantes formas de actividad humana. ¿cómo alcanzar que los productores adapten y avalen los descubrimientos científicos a la realidad particular y diferenciada? y ¿cómo los científicos. sistémica. La sociedad continuará demandando. tiende a suceder que la oferta sobrepasa las necesidades reales adquiriendo poder autónomo. sólo están cumpliendo con particularidades personales referidas a ostentación intelectual y pavoneo científico. no sólo los préstamos o los “robos” se hacen en un sentido. no por disciplinas constituidas dentro de las cuales se aprende a formular y resolver problemas. por ello la innovación epistemológica debe darse a nivel personal. sino por la capacidad de cambio de los sujetos. suficiente para dar sentido a su existencia desentendiéndose del factor humano. ni la transdisciplinariedad a niveles grupales sino una concepción de la vida y de la ciencia donde lo irracional y lo racional proponen y comprometen la producción cognoscitiva del científico con la comprensión y explicación de la naturaleza y la sociedad. Entender las condicionantes históricas-culturales y las consecuencias naturales y sociales del fenómeno científico y tecnológico le confieren a la ciencia un nivel de crítica constructiva dirigido a la ejecución de alternativas que respondan a soluciones pertinentes. Como en todo. agrónomos o no. enquistándola en concepciones altruistas y acabadas. apoyados en las ciencias. que limitan no sólo las posibilidades de acceso a la realidad. equitativas y participativas. deben comprender y aceptar la sociedad rural como punto de partida y final para la efectividad y sostenibilidad de los avances de las ciencias? Una idea: la innovación epistemológica busca no la multi. ni tampoco ennoblecer la autodeterminación de la ciencia y su autonomía para lograr una libertad que sólo beneficia a tecnócratas o que obedece a intereses particulares y egoístas. Entonces ¿cómo lograr que los productores adopten tecnologías u otros resultados científicos en sus prácticas cotidianas?. No obstante para los presuntuosos académicos. Así la ciencia se convierte en una fuerza social extraordinaria. sino que afectan al desarrollo de la ciencia. atravesada por factores que van más allá de lo disciplinar.
La dedicación a las flores y plantas ornamentales. El Programa de Innovación Agropecuaria Local del Instituto Nacional de Ciencias Agrícolas se propone fortalecer un sistema de innovación agropecuaria que incorpora la contribución y la capacidad de las productoras en la generación de beneficios sociales y ambientales. La conservación de alimentos y la divulgación de nuevas recetas económicas entre hombres y mujeres garantizan la variedad de frutas y verduras en el balance alimenticio de la familia. Se trata no sólo de innovar en lo técnico y en lo productivo. la participación y la calidad de vida. que vaya mucho más allá del propósito de aumentar la productividad. La terminación de un nivel de enseñanza o científico no instituye un punto final suficiente. por tanto no se aferren a hacer de la ciencia escudos o armas de supervivencia. talleres. violenta y prueba nuestras capacidades de resistencias y cambios con los sujetos y sus contextos.
. fortalecimiento de capacidades y actitudes de actores locales e institucionales. la proliferación de huertos familiares provocan un desarrollo de la cultura alimentaria hacia una vida más sana. porque el saber no es un producto dado. sino un punto de partida sin beneplácitos académicos que (des)(re)construye lo aprendido en función de la pertinencia social. Digo más. intercambios y aprendizajes con la participación equitativa de mujeres y hombres. además del aumento de la productividad. gracias a los abonos orgánicos y a las prácticas ecológicas desprovistas de químicos o de tecnología tradicional que destruya suelos y deforeste. reconocimientos. no sólo embellece y da estética al hogar. sino que se reconoce su poder terapéutico en contra del estrés. donde las familias rurales buscan ampliar su culinaria cotidiana con productos más diversos y de mayor calidad. quebrantando lo establecido que ciega y embrutece. de manera sistémica y sostenible. Sus metas son. Se logran resultados como la introducción. Se propone: no alzar la innovación como bandera de desarrollo en comunidades remotas. marco lógico. el enriquecimiento de la biodiversidad y el empoderamiento de los usuarios…”1. validación y diseminación de la diversidad de especies/ razas y cultivos/ variedades y de tecnología apropiada de importancia agropecuaria local. Todo esto “…exige pensar en las necesidades humanas de una forma diferente e innovadora. pero el impacto es más rico y amplio. Ejes temáticos. sino de reflexionar y transformar arraigados estereotipos y formalismos en el ámbito institucional y personal que obstaculizan la pluralidad de cosmovisiones y alternativas. estrategias. promoviendo la agro-diversidad en el contexto cubano con equidad de género. me atrevo a exigir desafíos tan importantes como los mencionados: superar los límites disciplinares para entender y relacionar en acción real la productividad. espacios conservadores si aún no se sabe implementarla contra normas institucionales y profesionales cuando la realidad lo exige. feudos de poder o simples fuentes de ingreso. los concursos de platos en las conocidas Ferias de Biodiversidad. la biodiversidad.Innovando hacia dentro
No es extraño la combinación entre la innovación epistemológica y el querer/conocer varias disciplinas a la vez. e informes se planifican esencialmente en función de este objetivo. Las pruebas de degustación. sino un proceso que mediante la innovación epistemológica.
Participó de un intercambio académico con la Univesidad Autónoma de Chiapas. INCA. Investiga en el Programa Nacional de Innovación Agropecuaria Local. Actualmente trabaja en la Universidad Central “Marta Abreu” de Las Villas.
. recibió cursos en diversos centros de estudios e investigación y ha participado en eventos nacionales e internacionales.
Annia Martínez Massip es hija de maestros.Young Voices in Research for Health 2009
Annia Martínez Massip
Vernos. 2006. et al (2006) “Semilla sin conocimiento no da rendimiento: hacia una nueva práctica de fitomejoramiento”. donde es Jefa de carrera de la facultad de sociología e imparte la cátedra de Género y Metodología. Los agricultores mejoran cultivos. 13. R. el 16 de noviembre de 1982. así como de un intercambio académico con la Universidad Autónoma de Chiapas. Desde la primaria hasta el preuniversitario asistió a concursos. Estudió sociología en la Universidad de La Habana. Humberto (editor): Fitomejoramiento participativo. Nació en la ciudad de Sancti Spiritus (Cuba). en: Ríos Labrada.. La Habana. Fue Premio Rector durante cuatro años. p. eventos científicos estudiantiles y talleres de niños escritores.
convenient food that tastes good continue to be the soul of our New Zealand society? The lightening of wallets has seen our waistbands continually expand. New Zealand
mAlnUtRItIon And obesItY: closIng tHe gAp
Vending machines on every corner. Fast food guaranteed. culture and finance. These cheap meals have resulted in obesity becoming excessively dominant in low-income groups. we would have found the safest way to health. pies and fizzy drinks accessible.” Hippocrates
In a society where everything is expected to be instant. as the Universal Declaration of Human Rights states. patience has grown weary. driven by convenience. These troubling trends pose pressing challenges to national economic resources. If we are what we eat. Auckland University is a hub where students spend their days and eat at least two vital meals. mood. where feeding out bodies is now a matter of combining taste. but at what expense? The alarming rise in the incidence of obesity and of the malnourished in New Zealand is lowering the quality of life for those suffering these problems and for their supporting families.
. and being seen with a can of energy drink in one hand and a meat pie in the other is as common as seeing a businessman on his cell phone. finances and the health-care system as associated noncommunicable diseases grow. including food”. If. then why does fast. Sushi not only out of reach but out of price. then what are we if we eat all this?
“If we could give every individual the right amount of nourishment and exercise. cheap. “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family. not too little and not too much. It seems now that food has lost all past value. The presence of obesogenic environments has turned health into a business. no longer can chronic diseases be labelled “diseases of affluence”. The evolution of fast food chains from common restaurants sees meals prepared in an instant for minimal cost. where people are now searching for cheaper petrol rather than healthier food. New Zealand is now a society where it has become easy to be overweight. yet the choices are limited. the speed of communication and lifestyle has caused our health to suffer. Only fries.Malnutrition and obesity
even in times of resource constraint such as economic recession. Selected local produce would include items from important dietary food groups such as fresh fruits and vegetables. The success of this initiative would depend critically on compliance with the principles of people’s participation and legislative capacity. The $200 incentive would be available only once per household. for this pilot study to succeed. such that they are now among the largest preventable causes of morbidity and mortality internationally. development and maintenance would be met and in compliance with human physiological needs at all stages throughout the course of life. such
. Subsidiary cards could be acquired for persons of appropriate age in the household. It would be delivered through all forms of media and local efforts. Nutritional deficiencies result from improper or inadequate diets. New Zealand education is centred on active lifestyles and “healthy” eating. people centred and system minded. Points would be acquired in a tiered fashion. the Food Point Programme (FPP). enabling people to finance their grocery shopping. obesity and nutritional deficiency have escalated to epidemic proportions. Measures must be taken to ensure that. The FPP would be created and provided in a way that did not negatively affect local producers and would be organized in ways that aided the return to food self-reliance of the beneficiaries. Produce included in the national FPP would be safe and culturally acceptable to the New Zealand population. according to sex and occupation. and initially credited with a $200 incentive for buying the specified fresh produce. education is crucial to aiding the reduction of inequality in health and bridging the gap between obesity and malnutrition and between socioeconomic groups. as food ideology has constantly changed. Points obtained would correspond to money. the FPP would still be available to the population. thus reducing the stigma of receiving a government handout. dairy. the focus has shifted to identifying new methods of controlling diet-related chronic diseases while also addressing nutritional deficiencies. would be given to those who surpass a defined point level. ethnicities and the sexes. This scheme would not only give people freedom of choice but also empower them to make decisions with regard to what is best for their own health. “Education is the most powerful weapon which one can use to change the world”. As Nelson Mandela once said. facilitate and provide food for New Zealand. The most appropriate way of implementing the right to adequate food would be to institute a multiphase intervention. FPP cards would be issued one per household. and meat and poultry. including subsidized gym memberships and cooking classes.Young Voices in Research for Health 2009
Over the decades. easily available and accessible for all. Further rewards. The FPP would use a reward card where accumulated points might be used only to buy certain selected local produce. Therefore. It is recognized that. protect. while obese individuals’ weight has increased to a point where it seriously endangers their health by increasing the risk of cardiovascular disease and other secondary complications. with the purchasing of fresh fruits and vegetables gaining the largest sum of points and the purchasing of meat and poultry gaining the least. it would need to be knowledge based. obesity and hunger. fulfil. to promote healthy eating and active lives. breads. While it is acknowledged that primary prevention is more successful and less of an economic burden on the country than tertiary intervention. cereals. The right to adequate food should be in combination with the governments’ obligation to respect. Dietary needs for physical and mental growth.
and she is a trained volunteer at Mercy Hospice Auckland. It is only through this realization that the inequalities seen in health.Malnutrition and obesity
as community. This – partnered with education. and consequently our bodies and our health are suffering. If we are all individual unique entities with the same basic human rights. majoring in International Health. we are abusing our bodies. then why are some falling through the gap? Should we not stand together to pick up those that fall and further strengthen those that stand? Policies to address structural nutritional deficiency and obesity are fundamental to the sustainable eradication of food inequality and insecurity. partnered with education. And who would fund this venture? This initiative would ideally be funded by the government through initiating a nationwide health tax. “Our food should be our medicine. But to eat when you are sick is to feed your sickness. The monetary contribution would not only fund the FPP but also fix current shortcomings in the public health system. Her passion is palliative care. A great advocate for the voice of youth. This is the call for us to return to our roots. from the University of Melbourne in 2010.
. empowerment and increased ease of access and financial capacity to buy healthy foods – shall see our nation’s food ideology and health dramatically turn for the better. facilitating individual empowerment and optimum population involvement. our medicine should be our food. Government support and participation in combination with a top–down approach filtered through the health hierarchy would be needed to alter obesogenic environments. We are now engaged in a war between the rich and the poor. the abundance and ease of access to food is now as ordinary and unthought-of as the air we breathe. a change in mindset would be essential. to realize that food is the sustenance of our bodies and not a factor of abuse. After centuries of fearing hunger day to day and rationing. Food has been taken for granted. closing this gap and ensuring equality. the obese and the malnourished. Cultural sensitivity and specificity with respect to indigenous social etiquette. as without money there can be no health reform. For the continued effectiveness of this initiative. This tax would be compulsory for all earners and be income adjusted. school and church groups. She is a keen toastmaster and has won the Competent Communicator Award. she was a facilitator for the health discussion in this year’s United Nations Youth Declaration in Auckland. As a developed nation. would underpin the success of the FPP. The national Food Point Programme provides a net.” Hippocrates
Amy Mathew will finish her Bachelor of Health Science at the end of this year at the University of Auckland and intends to pursue a Master’s in Public Health. quintessentially determined by what we consume. shall see a dramatic decline.
United States of America
mobIle pHones. remote data collection. Women also suffer greater negative consequences of disease than men. when pregnant women are infected with malaria. but there appears to be a sense of excitement – and perhaps hype – that mHealth can be the solution to many intractable health problems. maternal morbidity and mortality endanger the lives of women and generate significant costs to families and communities. of their families. the cruel consequences of widespread apathy for women’s health.
Women and mHealth
Six broad areas categorize mHealth efforts: using mobile applications to provide education and information. for example. women bear a disproportionate burden of disease. diagnostic and treatment support. and disease and epidemic outbreak tracking2. we know that women are the caregivers. mobiles also have vast potential to improve development outcomes1. Why should mHealth programmes target women to improve the health of all? First. An expanding array of mobile applications and programmes to address health problems. women And gIRls: engendeRIng mHeAltH Into An InnoVAtIon foR All
Mobile phones are ubiquitous in today’s digitalized world. communication and training for health workers. Second. and economic growth is one strategy to reduce poverty and poor health. While fundamentally a communication tool. have the potential to benefit those who are difficult to reach. remote monitoring. do mHealth programmes really reach all? More specifically. women transfer their good health.
. lower fertility and education to their children. so-called mHealth initiatives. But. we know that women are essential drivers of economic growth through their savings and investment in their households. particularly poor women. who play a central role in improving their own health as well as the health of their families and communities? For mHealth programmes to be truly transformative in improving health for all. they are more likely to develop serious malarial disease than men or non-pregnant women. helping to alleviate problems of inadequate infrastructure – like poor transportation or a shortage of health workers – in rural areas of developing countries. HIV prevalence among women can be up to six times as high as that among men. and girls are the future caregivers. are these programmes reaching women. Finally.Young Voices in Research for Health 2009
Janna McDougall. poor health and excess mortality. In sub-Saharan Africa. enrol and develop content. The field is young. Third. they must consider the excluded – especially women – in the way initiatives recruit. Their health is imperative to ensuring the health of future generations. In addition to their instrumental value in improving the health of others.
address women’s and girls’ reproductive health.and market-level facilitators. can they use men’s? When using mobile telephones. are women safe from violence or harassment? With what frequency do women and men call into hotlines or programmes similar to mHealth approaches? Through what mechanisms do facilitators or barriers enhance or limit women’s participation in mHealth initiatives? Some of these data may be available from mobile operators. barriers and consequences of women’s use of mobile phones for mHealth programmes. For example. Partnerships between research agencies and mobile phone operators can yield information fairly quickly to bolster the mHealth field. Yet mobile phones can deliver reproductive and sexual health information confidentially. if women do not own phones. Future studies should investigate gender-specific use and ownership patterns. for example. and a first order of business for these technology initiatives is devising a strategy and rolling it out to whichever populations are easiest to reach to test the efficacy of the approach. Many mHealth programmes are relatively new. while programmatic research in Africa identifies barriers. for example. Although few regional or global studies on mobile ownership and use exist (one exception is Zainudeen et al. women and girls
Yet the mHealth field does not appear to seriously consider women as potential users of mHealth or as a population with extreme need. seem to do so without particular attention to how women may best utilize services to improve their own health. This may help explain this lack of attention to women and girls in mHealth to date. In such an mHealth initiative. including violence against women. the report makes zero mention of the terms “gender” or “girls” and only four mentions of “woman”2. which can lead to their empowerment.
The approaches of mHealth programmes for women must be gender sensitive. beyond sourcing women as data collectors or health workers. of women’s mobile phone use5. including HIV. which makes them an ideal strategy to address these stigmatized subjects. research on technology ownership generally suggests that owners and users are likely to be individuals living in urban areas with enough resources to purchase and use mobiles – the majority of whom are urban men4.Mobile phones. families could access a remote education
. such as economic hardship. In addition. Few programmes. Although a recent review of mHealth programmes finds that many initiatives target female nurses and health-care staff. but it is difficult to mine and access. Furthermore. one neglected area of mHealth programming is maternal mortality and morbidity. comprehensive and crosscountry studies that build on current descriptions of women’s mobile use to examine the individual-. community. programme development and programme evaluation. Few initiatives and applications appear to address women and women’s health needs specifically. and consequences. 2008)3. mHealth interventions have yet to focus on many of the health burdens that women face. So how can such programmes respond to women’s health? Three important next steps emerge. in research.
Recent research from South and South-East Asia identify gendered mobile use and ownership patterns3. We now need rigorous. programmes that do address health challenges that disproportionately affect women.
exposure to risk and empowerment. resulting from participation in mHealth projects.
Lastly. Evaluation examining changes in women’s health and empowerment should use participatory. mHealth evaluations should first measure change in health outcomes. However. attitudes. infectious disease and maternal health. In evaluating mHealth programmes that provide information to women via their personal mobile phones. As such. But. as the programmes are by nature innovative and rapidly changing. or women’s efficacy in insisting on the use of condoms to protect themselves from sexually transmitted infections – to understand distal benefits resulting from mHealth initiatives. Further. can use to access information and services related to sexual and reproductive health. such as violence or theft. a major cause of maternal morbidity and mortality. for example. To address this. In terms of metrics. those personal mobile phones can be used to elicit information from women on their health. mHealth could reduce the first of the “three delays” leading to maternal mortality: the delay in seeking care. Data collection and analysis are expensive. unless mHealth programmes specifically address the gendered facilitators and barriers to women’s mobile phone use and create content that addresses women’s disproportionate health burden. including health knowledge. Evaluating mHealth presents three particular challenges – in metrics. they will not live up to the hype that they currently enjoy and will fail to be the innovation that improves health for all. The mHealth field needs mobile phone systems and curricula that all women. which make them poor candidates for traditional programme evaluation.Young Voices in Research for Health 2009
or diagnostics programme to identify the warning signs for obstructed labour. responsive and adaptive strategies that collect data at multiple time points to understand how and when women experience change. women are not only at risk of negative consequences. immediately raise cost issues. However. most use one or many data collectors equipped with a sophisticated mobile data collection device. Such designs. modifications and implementation. design and data collection. process evaluation is imperative to record programme components. evaluations must measure women’s experience of the gendered technology context. mHealth may also lead to improvements in women’s ability to make strategic life decisions. evaluations should track unintended negative consequences. behaviours and status. Considerable potential resides in mHealth as the innovation that changes the way we think about health throughout the world – in both developed and developing countries. Designing mHealth evaluations presents a particular challenge. which emphasize regular data collection. But. evaluations need to measure empowerment dimensions – such as women’s ability to participate in decisions about their fertility or sexuality. take financial resources from programme activities and divert the attention of programme staff. including young married women. Several mHealth interventions already use mobile devices to collect data and have done so with significant cost savings2. By quickly identifying early symptoms.
. who then interview individuals to collect data. we need rigorous evaluation of mHealth projects that incorporates a gender perspective. mHealth programmes have built into them a unique solution to monitoring and evaluation: the individual participants’ mobile phones.
Brighton. Europe. Gender and ICTs overview report: BRIDGE development-gender. The promise of ubiquity: mobile as media platform in the global south. designing monitoring and evaluation studies for health interventions. She enjoys working with public. HIV and tobacco use.Mobile phones. Janna is keenly interested in technologies to improve women’s and girls’ health and is especially interested in mobile phones as tools to address health challenges.ac.bridge.org/manworkshop. UN Foundation-Vodafone Foundation Partnership. accessed on 1 September 2009). Janna holds a Master’s in Public Health from the University of North Carolina at Chapel Hill. 2008. and measuring girls’ and women’s empowerment. Who’s got the phone? The gendered use of telephones at the bottom of the pyramid.pdf. mHealth for development: the opportunity of mobile technology for healthcare in the developing world. 2006 (www. The Internet and mobile telephony: implications for women’s development and empowerment in Zambia.htm. DC and Berkshire.lirneasia. Zainudeen A et al. 2004 (www. Washington. Now a research associate with the International Center for Research on Women. Her work has included researching reproductive health.net/wp-content/uploads/2008/05/ica-whos-got-the-phone-thegendered-use-v18.uk/reports/cep-icts-or. Wakunuma KJ. UK. 2009. UK.doc. accessed 1 September 2009). Gurumurthy A. women and girls
InterNews Europe. (www. private and non-profit-making partners. Institute of Development Studies.ids. InterNews Network. Presentation at the workshop Gender.
. nongovernmental organizations and global corporations to improve global health. Vital Wave Consulting. accessed 1 September 2009).womenictenterprise.
Janna McDougall has seven years of experience in global health and economic development. ICTs and Development. 2008. including research organizations. Manchester.
Innovation et santé pour tous. c’est que l’équité s’empare du terrain de la recherche scientifique. Innover. contraints à se laisser dépouiller de leur propre innovation qui.. Et si cette aventure semble être une véritable gageure. C’est en effet sur la diversité des origines de l’innovation qu’il faut mettre l’accent. Il est absolument impossible d’aborder la santé de tous d’un point de vue centralisé... le bon point de la diversité
Innover aujourd’hui. ce n’est plus s’organiser n’importe comment.Young Voices in Research for Health 2009
Paul Wilfrid Armand Menye
Paul Wilfrid Armand Menye. Le monde est organisé de manière à ce que l’innovation ne puisse jamais se déployer dans sa totalité et ainsi. tout en créant de nouvelles organisations des problématiques de santé.. Cameroun
plAIdoYeR poUR l’AcceptAtIon des déontologIes non conVentIonnelles de RecHeRcHe médIcAles
Innover pour. d’Asie ou d’Amérique Latine sont légions de ces « autres » sur qui sont effectués tests et expériences ou qui finalement ne parviennent pas à avoir accès à ce qu’on a innové pour eux.
. C’est que la justice s’empare de la redistribution des pôles de recherche scientifiques dans le monde. Voici venue l’heure de ces anciens temps oubliés. Voilà quelquefois où se situe le problème même de l’innovation en matière de santé. c’est une frange du monde qui se sent interpellée.. contraints d’accepter l’innovation des autres et à s’en réjouir. contraints au suivisme même. quand ils sont avec condescendance invités à « participer ». il faut se rappeler que la plupart des peuples ont au départ leurs propres outils et approches de recherches... ses propres outils et ses propres démarches expérimentales. ce n’est plus s’enfermer dans sa propre manière de faire. Le temps des pôles du monde régnant en maîtres absolus sur la santé est révolu. Une nécessité dans la mesure où l’évolution du monde. Et ces « autres ». ne peut pas apporter toutes les solutions efficaces et adéquates. concernée. investie de cette mission : ils innovent pour les autres.. ce qu’on appelle ailleurs « les médecines traditionnelles ». Les autres sont contraints de suivre. Et c’est cela qui manque cruellement au monde aujourd’hui. Mais c’est surtout s’organiser localement. Ce qu’il faut donc aujourd’hui.. en rend aussi la gestion plus complexe. où chaque société s’organisait comme elle pouvait. Parce que finalement.. C’est une nécessité. le sont à titre de cobayes ou de consommateurs des innovations. Les cas dans plusieurs pays d’Afrique. Avec ses propres repères. L’innovation dans ce contexte devient l’universalisation du langage des différents produits de la recherche médicale. dans les mains des autres.. seuls quelques points du monde possèdent des centres de recherche spécialisés avec tout l’équipement nécessaire. résoudre les problèmes de tous. avec un langage que tout le monde comprend. En effet..
Ce qui a été moins effectué sur ce terrain. il faut que le financement de la recherche en santé accepte de dépasser ses propres peurs. on donne la chance à une autre organisation de la gestion de la santé de se mettre en place. ont permis de donner une certaine reconnaissance à ces approches locales. tant au niveau des états que des bailleurs de fonds. En mettant à côté de tous. c’est la véritable prise en main de ce secteur dans les financements de la recherche en matière de santé. A coup de milliards. Ce que cette prudence a oublié. Ceci implique pour les instances qui encadrent l’éthique et la méthode en matière de recherche scientifique de reconnaître ces approches dites traditionnelles. Il le faut. conférences et séminaires. Il faut oser croire à des modèles nouveaux qui sont parfois forts anciens. Celui des approches plus classiques. avec un vrai statut médical. le terme « traditionnel » s’applique ici juste parce qu’il est en opposition avec ce qui dans d’autres parties du monde a été décidé et établi comme conventionnel. A ce niveau. avec ses chercheurs n’étant passés par aucune école classique de médecine.Plaidoyer pour l’acceptation des déontologies non conventionnelles de recherche médicales
En réalité. mais oubliés. Cela passe par l’équipement. Finalement.. fondées sur une mise en pratique rigoureuse de la méthode expérimentale de Gaston Bachelard. Cette universalisation des « méthodes traditionnelles » doit se faire avec les outils qui lui sont spécifiquement nécessaires. Il faut que la déontologie de la recherche se mette au défi des incertitudes que constitue le champ des recherches médicales traditionnelles. Mais aussi avec la formation et l’accompagnement adéquats. la possibilité de faire germer ce qu’il peut y avoir de riche en chacun. sorte de la considération exotique dont elle souffre aujourd’hui pour constituer carrément une nouvelle orientation médicale officielle. colloques et décisions. En effet. la prudence frileuse a fait son choix. En encourageant les travaux de recherche locaux dans ce sens. Il faut oser des fonds d’appuis innovants sur des terrains non conventionnels.
Se mettre à l’heure des possibilités non conventionnelles d’innovation
La santé pour tous commencera à devenir une réalité quand chaque peuple aura à sa portée les solutions médicales à ses problèmes de santé. Cela suppose que la médecine traditionnelle. d’où qu’elle soit. Le rêve est qu’une structure de recherches médicale dite traditionnelle. En d’autres termes. Il faut que les états et les bailleurs de fonds. finalement. puisse également
. une part qui aurait pu doper la santé pour tous. et encadrées par les formules biochimiques les plus rébarbatives. A travers le monde. cela suppose que des investissements conséquents.. la formation et l’accompagnement des unités de recherche locales. acceptent de s’engouffrer dans le puits des effervescences locales visant la santé pour tous. Il faut oser dépasser les clivages habituels de l’organisation de la recherche. officiels et massifs soient orientés vers les secteurs de médecine dits traditionnels. Donner un langage universel à ce traditionnel serait un premier pas pour s’approprier au profit de tous des innovations qui y sont produits. il est certain que des progrès ont été faits. Il faut oser rentrer dans la culture et l’histoire des peuples et faire appel à tout ce qu’ils ont comme systèmes et techniques de recherche médicales. c’est que c’est parfois sans Bachelard et sans formules écrites que se joue une part importante de l’innovation en matière de santé. souvent dites « traditionnelles ».
tous nous en bénéficierons. Throughout his work. Et effectivement.Young Voices in Research for Health 2009
Paul Wilfrid Armand Menye
bénéficier d’un appui et d’un regard attentif au même titre que les autres. before becoming involved with international NGOs in Eastern Europe. même dans des cadres autres que ceux qu’ils reconnaissent de coutume. sera l’affaire de tous. avec les fonds financiers et les accompagnements techniques nécessaires. Alors.
Paul Armand Menye has been involved with the social movement in his country from early in his career.. project management and social communication. He worked for several nongovernmental organizations (NGOs) in Cameroon and Chad. les plus traditionnels. health and social services..
Oui. Paul Armand has focused on practical alternatives for poor countries in the domain of education. les plus ancrés dans les paysages ruraux et urbains seront mis en branle. Quand tout le savoir traditionnel des peuples ne sera plus regardé avec un peu de condescendance. jusqu’aux niveaux les plus locaux. innover pour la santé de tous. Quand enfin les bailleurs de fonds et les états tendront la main à ce qui se fait tous les jours. Paul Armand holds a Master’s in Organizational Psychology and also has training in distance-learning applications..
.. avec cependant les accompagnements qu’il faut afin qu’au final. les fruits de ses travaux puissent se dire avec le même langage que les fruits des travaux des centres de recherche plus conventionnels. le rêve est permis !
Quand toute l’intelligence des peuples.
Modern innovators live and work in a culture of competition and individualism. or my young cousins in Hong Kong who agonize about university admission and whose numerous homework assignments include the memorization of entire books. like corporations in pursuit of profits and wealth. of illness and environment. Individualistic thinking emerges from our competitive educational and work environments. United States of America
InnoVAtIon beYond IndIVIdUAlIsm
During clinic hours at the Hospitalito Atitlán. I recall envying the machine-like discipline of the chemists who persisted in working after all-night experiments and were visible through the laboratory windows I passed while walking home in the brisk dawn mist. collectively made health decisions. these examples of family decision-making are reminders of the power of social solidarity and consideration of the greater good. often accompanied by extended family and friends. Research paradigms promote discovery and individual ownership. Tz’utujil Maya patients arrived in droves. We train innovators to love ownership of publications and patents. My principal investigator in a Los Angeles medical centre instigated a gag order on our laboratory’s recent experiments during an epigenetics conference so that none of his colleagues would “steal” the publication. we must shift away from individualism and work collaboratively to address human health in the broadest context. In order to improve the health of all. breathing the sterile yet smoky scent of donated medical supplies and wood fire. Early in our lives. While analyzing our data. institutionalized educational structures ingrain in us principles of independence and individuality. I have learnt how a narrow focus on the individual can often be detrimental to the health of all. I discovered that families and communities. while habitually neglecting long-term follow-through and adaptation to local contexts. To an aspiring physician raised with principles of autonomy and individualism at the forefront. Biomedical innovations often target individual problems with specific drugs and technologies but fail to appreciate the interconnectedness of health and society. While volunteering in this small Guatemalan hospital. Relatives endured the long queues and cramped wooden benches. exhausted after countless hours in my university’s main library. I succumb to competition as well. I am reminded of the disappointed faces of Kenyan primary school students whose parents punish them for a poor class ranking.Innovation beyond individualism
Jason Nagata. A costly medical procedure might mean that family members would ration food for a month or that neighbours would loan part of their earnings to help fund the treatment. Individuals rush to be the
. rather than lone individuals. laboratory members were encouraged to manipulate statistical methods until the desired result was achieved. From remote communities in Guatemala and Kenya to laboratories in urban universities.
When numerous Kenyan nongovernmental organizations (NGOs) aggressively compete for funding to operate similar HIV programmes. we often overlook sustainability and sufficient follow-through. selected chlorination as the method of treatment. but the day-to-day maintenance of a long-term project requires humility and silent dedication. giving the water an astringent taste and a chemical smell. In order to improve the health of all. One-size-fits-all solutions. The municipal government. however. faltering funding and lack of community participation weakened the programme’s mission. and when health clinics forbid the use of herbal medicines. At the height of the Guatemalan civil war in the early 1990s. Many distrustful residents began to believe the caustic water had been poisoned by the government or contaminated by the dead bodies of missing Tz’utujil Maya. Many covet ownership of ideas and projects. like donated clothing. biomedical innovation ignores local values. advised by international aid organizations. they frequently focus on their own gain rather than on benefit to the local community. initial interest in the campaign led to the eradication of malaria in many temperate countries and reductions of cases in India.Young Voices in Research for Health 2009
first to discover a cure or to develop a model intervention. mores and traditions. innovation requires teamwork and collaboration rather than individualism. The introduction of new health campaigns generates early excitement. Sri Lanka and other tropical countries. drug-resistant parasites and insecticide-resistant mosquitoes emerged. In addition to lacking follow-through. and philanthropist Bill Gates famously cites the fact that we currently devote more money to finding a cure for baldness than to developing drugs to treat malaria. While researching potable water issues in the western highlands of Guatemala. simply cannot fit everyone. In the global health scene. necessitating treatment of the tap water drawn from the azure shores of the adjacent lake. political. global health innovations require sufficient long-term follow-through. When newly constructed birthing centres exclude the presence of local midwives. Because of the intense drive for discovery. current technologies and innovations regularly overlook the importance of local contexts. over half the world’s population lives at risk of malaria. Four decades later. We must adapt innovations to particular social.
. The World Health Organization’s ambitious Global Malaria Eradication Programme is a prime example. Without sufficient follow-through. a cholera epidemic swept through the town of Santiago Atitlán. qualities not always rewarded in our competitive environment. physical and economic environments. but few intend to be followers. even at the expense of moral principles. This intense drive for ownership spawns unnecessary competition among individuals and hinders collaboration. The global explosion of new NGOs in the past decade demonstrates that many yearn to be leading innovators. Priorities have shifted. The World Health Organization abandoned the eradication campaign in 1969 as new cases in the tropics rebounded. but few care to share the credit. and every year brings half a billion clinical cases claiming 1 million lives. When it was inaugurated in 1955. In order to improve the health of all. cultural. I recollect the accusatory shouts of feuding Kenyan health employees of the government and three NGOs. fierce competition for the implementation of innovations exists. I learnt how technologies can fail if not properly introduced into a unique cultural environment. who all worked under the same corrugated iron roof.
promotes teamwork and understanding. “If you take antiretrovirals on an empty stomach.” Dozens of interview respondents echoed these sentiments: starving while on ART is an excruciating experience. but innovation must also address larger structural issues like lack of sanitation and clean water. for the locus of health is not the individual body but the relationships”. but will include nutritional nurturance and sustainable strategies for agriculture to address hunger holistically. Medical anthropologists Ann McElroy and Patricia Townsend write. We need a paradigm shift that de-emphasizes our culture of competition and individualism and. caring for others through solidarity as though they were family. I travelled to Mfangano Island to research food security among people living with HIV. Like the Maya of Guatemala. Drugs for specific syndromes and technologies for particular procedures improve health. they just burn. the hunger is so unbearable I simply skip taking the drugs and do not tell anyone. In order to improve the health of all. instead. I foresee a future where support for people living with HIV will not be limited to ART.
. The Ministry of Health clinic provided free antiretroviral therapy (ART) for residents living with HIV. residents produced poor harvests while problems of famine and hunger plagued the island. sanitation infrastructure. To this day. a third of the island’s population. I imagine intra. Indeed. Understanding the broader cultural context is only one step towards expanding our conceptions of innovation. while interviewing people on ART. global public health innovations can fail without proper integration into unique cultural environments. Despite their enormous humanitarian potential.and interdisciplinary innovation where laboratory scientists collaboratively conduct experiments. Only through collaboration and a broadening of our focus on individual innovations will we truly achieve health for all. the Suba people lacked access to clean water. when insects and wild vegetables abound. I learnt that they often skipped their treatment due to hunger. novel innovations must be informed by local expertise and introduced in a culturally flexible way. and educators empower with practical and theoretical knowledge. several Tz’utujil Maya still associate the taste and smell of chlorine with dead bodies in Lake Atitlán and refuse to drink the municipal tap water. Some days. who say that giving people medicine for tuberculosis and not giving them food is like washing their hands and drying them in the dirt. clinicians counsel on prevention and treatment. Pulitzer Prize-winning author Tracy Kidder recounts an adage from Haitian health workers. During the rainy season in western Kenya. we should learn to think collectively for the greater good. and laboratory competition in the United States all demonstrate why we must expand our narrow conceptions of innovation. Examples of hunger and ART in Kenya. paved roads or electricity. Without knowledge of sustainable agriculture techniques. NGOs negotiate with one another to share resources. anthropologists adapt interventions in culturally appropriate ways. however.Innovation beyond individualism
purportedly dumped in the lake by the military. “Patchwork solutions to provide a drug or other intervention to target a particular pathogen or bodily defect will never be sufficient to promote health for all. poorly implemented water interventions in Guatemala. As a Kenyan client explained.
where he majored as an undergraduate in Health and Societies and the Biological Basis of Behavior. His passion for global nutrition led him to the World Health Organization. In western Kenya. and attended the University of Pennsylvania. where he interned with the Department of Nutrition for Health and Development. The recipient of a Thouron Scholarship. conducting and publishing biocultural nutrition research through the Guatemala Health Initiative. California. He has also worked in the western highlands of Guatemala. he has worked on food insecurity among patients on ART through the Organic Health Response. he earned a Master of Science degree in Medical Anthropology at the University of Oxford and begins medical school at the University of California.
.Young Voices in Research for Health 2009
Jason Nagata grew up in Monterey Park. San Francisco in autumn 2009.
New and unique ideas are fundamental to improving healthcare situations. Widely dispersed rural communities make the logistics of placing such facilities very difficult and. various programmes have been initiated to improve this situation. Probably the most ideal solution. For many. United Kingdom
HeAltH-cARe Access And tHe solAR-poweRed AmbUlAnce
The aim of health-care innovation is to improve health care for demographically changing and demanding populations. and it may take several hours to reach a facility.3. the capacity for conventional methods to treat severe or prolonged illness is greatly diminished and often leads to a poor outcome. the reduced distance aims to reduce the impact of the barrier. Innovation. Many staff have difficulty working for prolonged periods in remote areas. some may choose to travel the distance. health care can be accessed only on foot. smaller facilities may be unable to provide comprehensive care. In addition. as the health afforded to developing populations becomes a global responsibility. In addition. but most are
. In an effort to provide equitable and effective health care. In health care a huge disparity exists across the globe. be that one’s own or those of a willing volunteer or two. This strategy has resulted in a number of rural clinics and health posts being constructed in various remote areas. an application component and an intended benefit”1. Physical access and transport to health-care facilities is often cited as an explanation for poor health-care attendance in remote communities2. especially in resource-poor settings. and one that has been scaled up in many communities. In the coming years the importance of innovation will be magnified. Although large revolutionary ideas have their place. novel ideas from unexpected places may be just as valuable. is moving health-care providers closer to the remote communities that require their services. This can lead to individuals receiving less than optimal health care or else a significant delay to seeking conventional health care. as a result. Although people may still be required to walk. innovation contributes to the advancement of medicine. it may be preferential to use traditional medicines available closer to home. many barriers have inhibited their universal success. aids progress. Various modes of transport are available. Once it becomes clear that traditional medicines are leading to no improvement. When such a person has then reached the facility. The distance travelled by some is dramatic.Health-care access and the solar-powered ambulance
Rufaro Ndokera. such facilities often do not fulfil their potential. Advancing technology and broadening medical knowledge increase the requirement of innovators to contribute to this field. Despite these facilities being ideally sited. and therefore people may be required to travel even larger distances to get the specific health care they need. the creation of new ideas. The idea I present here aims to demonstrate the three attributes of innovation while addressing an issue that continues to inhibit effective health-care provision in many resource-poor settings. The three salient characteristics of innovation are “novelty. For some.
Such bicycle ambulances have been shown to improve the health of participating communities. The vehicle functions by using solar-generated electricity to power an electric motor for the tricycle. Meanwhile. This development is significantly better than walking. Those of us living in a society where most learn to ride a bicycle at an early age may find it difficult to appreciate that one would have to be trained to ride one. In such instances. The dual-purpose canopy allows not only for power generation for the vehicle but also provides shade for the patient. such vehicles provide transport for only one patient. the speed reached is unlikely to be significantly less than that of the standard bicycle. they have not been widely used due to inefficiency of energy capture and storage7. Although this would reduce the maximum speed of the vehicle.Young Voices in Research for Health 2009
unsuitable when considering programmes to improve transport to health care. Although this 1:1 ratio is better than the 2:1 ratio afforded by stretcher-bearers. laying an
. transporting multiple patients with less physical strain. resulting in unused and abandoned cars. it is likely that this situation will continue to improve. reducing the top speed. assisting the cycling action of the individual operating it. Solar panels to harness solar energy in a practical way have been around since 1954. Although training is required. In addition. one can see that there is an opportunity for innovation. needless to say. Although this may seem a minor point. This ambulance takes the form of a tricycle with a large trailer attached to it with a canopy of solar panels forming the roof of the trailer. One idea that has proved highly successful is that of the bicycle ambulance3-6. Approximately 450 watts of solar power would allow the vehicle to reach speeds of 15–20 miles (24–32 kilometres) per hour10. Essentially. solar-powered vehicles are not widely considered as they would never match the speed and power of the cars we routinely use. this is a stretcher attached to a bicycle to allow transport to a health facility. both men and women are trained by the partners behind the bicycle ambulance initiatives4. This fall in price is probably due to an increased market and therefore improved economies of scale. but. With further development. in resource-poor settings with a high disease burden a more efficient method should be sought. Recent sustainable energy incentives have led to significant levels of research and development into solar panels with improved efficiency8. Ultimately. the solar energy would allow for a single individual to cycle. Motor vehicles would require refuelling. It is even an improvement on the current bicycle ambulance in a variety of ways. In addition. a concurrent drop in the price of solar cells allows the affordable manufacture of such a product9. However. the additional solar energy would allow the ambulance to be much faster than a standard bicycle. This is assuming both reasonable input from the rider and. the benefit is still apparent as the ratio of patients to transporters is higher. flaws were apparent6. motor vehicles especially would prove unsustainable with limited access to petrol in remote areas. both of these ideas create an unwelcome and sustained diversion of costs for the communities. The idea presented here is that of a solar-powered ambulance. However. the weight of an individual in the trailer. In the developed world. Primarily. allowing a faster transit to the facility. Horses and other animals would require feeding and care to remain useful over time. Putting knowledge of these different situations together.
Again. Solar power uses an energy source that many developing countries are rich in but do not tap. the prospect of receiving quality health care without the discomfort and disruption of alternative transport options could only be viewed as positive. its function as a bicycle ambulance with increased stability is retained.org/projects/malawiand-zambia.org/?id=bicycle_ambulances. The solar-powered tricycle ambulance is a way of improving access to health care for those who are still unable to benefit from even the simplest health care. other features would have to be considered in the research and development of such a vehicle. Malawi and Zambia. Innovation in health-care access is necessary. the vehicle would not work to its full capacity during the hours of dark. allowing more energy to be harnessed from the sun. Practical Action (www. Organizations have the chance to improve health-care access by addressing significant barriers.bikeradar. In turn this may help reduce the burden of disease left untreated and could improve the heath indicators of the relevant community. the tricycle-based design would allow for wider participation with regard to its operation. bicycle ambulances. 2006. this is an advantage over a car-based ambulance design. Despite the increased efficiency of solar cells. Bike Radar (www. Kayemba P. Although the solar-assisted feature of this product is what makes it unique.com/news/article/ african-bicycle-ambulances-are-making-a-difference-15807. accessed 1 September 2009). African bicycle ambulances are making a difference. 19(1):66–72.Health-care access and the solar-powered ambulance
incapacitated individual in the sun for any period of time may lead to deterioration. Innovating for the health of all requires consideration of the barriers that face such communities and coming up with acceptable ways of broaching them. accessed 1 September 2009). an enhanced suspension system to allow for negotiating tough terrain over long distances and a lightweight trailer would both be features worthy of consideration. The canopy would lessen this effect.php. Bicycle for health: appropriate mobility to improve access to Health. but what use are they to those who suffer unnecessarily because basic antibiotics are days away from home?
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Lansisalmi H et al. Nursing Science Quarterly. making it more versatile than a solar-powered car. As a result. issues relating to the efficiency of energy storage remain.transaid. mobilityandhealth.practicalaction.
. For example. It also reduces the environmental and social impact of introducing polluting vehicles into a clean environment and fragile infrastructure. allowing the vehicle to remain functional for transporting it to an area capable of maintaining it. New developments can be viewed from both a patient and an organizational perspective1. Innovation in healthcare: a systematic review of recent research. so this vehicle does not have provision for storage. accessed 1 September 2009). as it is something that significantly affects the provision of care to many communities worldwide. From an individual stance.org/case/case_af. (www. Nonetheless. Transaid (www. The main advantage of this product is its increased speed and ability to transport many individuals without the need to refuel and with no diverted costs to the community.-2003-2005.-bicycle-ambulances. Technological advancements are important and necessary. The solar-powered tricycle ambulance presented here would be considered a positive introduction to health care by both groups. This is also a relevant feature if the solar equipment were to fail. Furthermore. 2003–2005. Bicycle ambulances in Nepal.
org. 2008 (www. 7 Solar power and globalisation.com/bikes/bikes. She is continuing with her fourth year of a medical degree this September after spending the past year studying International Health at the University of Birmingham. Glass on web.html. accessed 1 September 2009).html. Bicycle ambulances.za/namibia/projects/ambulances. The past year has provided her with insights into global health issues and increased her desire to work in the area of international health in the future.com/tag/solar-panels. accessed 1 September 2009). She looks forward to completing her studies and seeing the grassroots effects of future health-care innovations. 8 Solar panels: increasing efficiency.electric-bikes. accessed on 1 September 2009. Device Daily (www. 6
Rufaro Ndokera is a medical student at the University of Leicester.com/rawmaterials/syndication/sample. The Globalist (www. Electric-bikes.devicedaily.Young Voices in Research for Health 2009
accessed 1 September 2009). Thin-film solar cells heading for $1 per Wp. accessed 1 September 2009). BEN Namibia (www.
. 10 Electric bicycles.com.theglobalist.com/ news/index/7986/.glassonweb. 9 Knoppers R. accessed 1 September 2009). (www.benbikes. htm.
The bliss of inaction does not stem from ignorance of the challenges faced by health workers. at the mention of such solutions as compensation. and because during tough economic times like these. At the heart of these systemic issues are poor governance and the lack of accountability among leaders in both the public and the private health sector. The current suggestions around a draft code of conduct for the recruitment of international health professionals present further opportunities to address the challenge of the migration of health workers4. particularly in health. Yet this intervention addresses only the issue of poaching health workers and does not address the issues of ailing and inadequate health systems in low. given the global burden of disease. Despite the known global shortage of over 4 million health workers1. The Canadian International Development Agency (CIDA). particularly in low. public health is further compromised.and middle-income countries. The need for innovative ideas. implementers and economists all join in a whistling chorus to say it is impossible to pay health workers enough. especially in countries where corruption is rampant. has hampered any real change in global and local governance. One of the areas of critical need is that of the health workforce. more recently. On the other hand. Now without sounding too pessimistic. the Kampala Declaration and Agenda for Global Action all speak to these efforts3. The hypersensitivity of political leaders to criticism. who receive health workers knowing full well that they are draining countries that badly need these very resources. the diminishing commitment of resource-rich countries only further constricts the limited resources available to combat poverty and address existing pandemics. not to mention new and emerging health challenges. The Joint Learning Initiative2 and subsequent HRH-related publications.and middle-income countries and in the destination countries that health workers often migrate to. remuneration or support of health systems. The lack of accountability in the management of resources has further hindered tangible progress even when resources have been made available. recently reduced its list of target countries
. for they have been well documented. Yet. The world health report 2006 – working together for health1 and. for example. the challenges faced by health-care workers have long been neglected. policy-makers. there have been strides made in the area of addressing the current human-resources-for-health (HRH) crisis. poorer nations bear a burden all the more severe. both in low.and middleincome countries that often deal with the compounded burdens of communicable and noncommunicable diseases and high maternal and child mortality. Kenya
sHow me tHe moneY! fRom RHetoRIc to ActIon In AddRessIng tHe globAl HUmAnResoURces-foR-HeAltH cRIsIs
As the effects of the global economic crisis are currently being experienced by the world’s richer nations. Accountability is lacking also on the part of rich destination countries.Show me the money!
Brenda Ogembo. is as critical as ever.
championing health-system support to low. This will undoubtedly affect the manner in which hypersensitive leaders interact with their developed-country counterparts and. Is the response to restrict movement? To do so would be a Band-Aid solution to a deepseated problem. Indeed. it is still better to have tried and failed than never to have tried at all. were conditions better. If the current global economic crisis is the result of faulty policies over the past eight or so years in the United States of America. it has also brought a tangible shift towards global governance. Hope? Despite the enormity of the problems faced in many countries. A multi-pronged. better pay and a better life. The election of US President Barack Obama has not only injected a surge of optimism around the world regarding what is possible when we all come together behind a cause. and that target both micro and macro aspects of the health system. excluding such countries as Kenya. It is time to address remuneration and provide direct monetary support to health workers as a budgeting priority. The solutions will therefore require careful short-term and long-term planning that are both overarching and context specific. Health system reform and health system research have not received much support. Health workers form the basic unit of a well-functioning system. European Union countries are not on track to fulfil their commitments to provide support7. the European Commission gave only 4% of its official development assistance to the health sector6. The continued undermining of health workers has led to increased migration in search of better working opportunities.Young Voices in Research for Health 2009
to 20. one expected outcome of the extended global economic crisis will be the increased migration of health and other professionals as demand for health-care workers increases in richer countries and conditions continue to diminish in poorer countries. the current global health crisis is the result of even worse policies over a much more prolonged period of time.and middleincome countries.and middle-income countries. by the same token. challenge developed countries regarding their role in supporting and. better yet. Few are able to provide for the basic needs of their families on their appallingly low salaries. These reductions and constrictions translate into poor health systems and further compromise the health status of populations in source countries. Moreover. Cameroon and Rwanda. yet most would rather stay in their home country. Empower the health workers and health users in low. multisectoral and integrated approach is not only necessary. Once immediate needs have been met. yet it is the health system that is responsible for delivering changes to the health status of the population. The Paris
. and reducing the number of countries that CIDA offers bilateral assistance from 14 to 65. longer-term solutions need to be sought through processes that include health workers at the decision-making table. The following are three areas if innovation towards strengthen health systems. Most health workers leave because they know they can earn more money elsewhere. it is critical to ensuring short-term and longer-term success in addressing the current health-care challenges in the context of the HRH crisis. particularly concerning negotiations with bilateral development partners. particularly for countries where the migration of health workers is rampant.
2008 (www.who. given the current shifts in global governance. In the past three years. There is an urgent need to tap into the available avenues of technology to improve the health of populations. Indeed. Joint Learning Initiative. Improve on working conditions for health workers. there has been an upsurge in hand-held electronic devices that brings a whole new meaning to the term personal computer. Yet. In the past 10 years.
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The world health report: working together for health. the upsurge in the use of mobile telephony has revolutionized communication in most low. in the health field. However. Addressing this critical area will make health workers safer. For how long will we tolerate close to 10 million child deaths a year due to preventable and controllable diseases? For how long will developed countries reap where they did not sow. All of these solutions cost money. Smart phones have made information available literally at our fingertips. Poor diagnoses and follow up have compromised the health of millions around the globe. particularly in health. innovating for health does not come cheap. The current HRH debates therefore need to evolve from policy to practice. Contrary to assertions about the use of information and communication technology in health being a luxury. and they might reconsider leaving. so as to ease the burden on already strained health systems – but also to improve the quality and quantity of information that is available and so improve surveillance mechanisms. It starts with valuing the men and women who support our health systems everyday by acknowledging the sacrifices they make and rewarding them accordingly for the much-needed work that they do. 2006 (www. Geneva. Paying them adequately is a necessary first step in showing that we appreciate them. Human resources for health: overcoming the crisis. 2004. This will result in healthsystem strengthening and will undoubtedly have an effect on the migration of health workers. I view it as a necessity. Harvard University Press. Kampala declaration and agenda for global action. World Health Organization. New cadres of non-clinical health workers need to be trained in data collection and analysis. The health of health workers needs to be safeguarded as a priority to prevent the loss of health workers due to injury or even death from exposure in the workplace. accessed 1 September 2009). the revolution has yet to be realized. Health workers in any setting are exposed to enormous occupational hazards. or else we will continue to meet and discuss problems rather than celebrate and replicate solutions. Cambridge.Show me the money!
Declaration on Aid Effectiveness needs to be implemented to prevent donor fatigue in governments and to harmonize external support8. Massachusetts.and middleincome countries. World Health Organization. poaching with one hand health workers from countries that so desperately need them and clenching the other hand into a fist that ought to provide the much-needed resources to build the very health systems they are undermining? There is a priceless window of opportunity. Adopt information and communication technologies for health. and their skills harnessed. Geneva.
.int/whr/2006/en. we are at a point in time when we need not be shy about making investments. this is exacerbated by poor working conditions particularly in the context of HIV and new and emerging infectious diseases such as ebola and swine flu.
acdi-cida. Sanders D.pdf. Canada moves on another element of its aid effectiveness.who. Canada. Brenda holds a Master of Science degree in Population and Public Health and in Global Health from Simon Fraser University. Brenda was a research awardee at the International Development Research Centre. accessed 1 September 2009).%20FINAL. 2008 (http://apps.gc. Commission urges member states to raise development aid.org/ dataoecd/11/41/34428351. European Union. 2009 (www. accessed 1 September 2009).
Brenda Ogembo is a passionate advocate of global health born and raised in Nairobi. 2005 (http://www. Schrecker T. Geneva. accessed 1 September 2009).eu/rapid/pressReleasesAction. Africa and Global Health. Labonte R. accessed 1 September 2009). she received the Mary M Young Global Citizen Award for International Students at the University of British Columbia. Brussels.
. exploring source-country health system priorities regarding the migration of health workers.do?reference=IP/08/535&format=HTML&aged=0&language=EN& guiLanguage=en. Canadian International Development Agency. World Health Organization. 2004. In 2008.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20file.ca/CIDAWEB/acdicida.oecd. Fatal Indifference: The G8. where she completed a Bachelor of Arts degree. DC. IDRC. Washington. Kenya. conducting research on physician migration from Uganda to South Africa and Canada. 2008 (http:// europa. Canada.int/gb/ebwha/pdf_files/EB124/B124_13-en. International recruitment of health personnel: draft global code of practice.pdf. Brenda’s personal and professional goal is improving the health of vulnerable populations by improving health systems. Gatineau.nsf/En/NAT-223132931-PPH. The Paris declaration on aid effectiveness. Quebec.pdf ). A Lester B Pearson United World College alumnus. She will begin her PhD in Population Health in September 2009 at the University of Ottawa. World Bank.Young Voices in Research for Health 2009
donde el desarrollo económico de una minoría de países se hace a expensas de la explotación de una mayoría. que analiza el comportamiento del individuo en su contexto. son insostenibles. nos encontramos en una sociedad que crece en valores decadentes. para mayor escarnio. Así pues. donde se carece del derecho a estar enfermo o a ir al médico. En ocasiones esta medicalización no da la oportunidad al propio cuerpo de autocurarse y (en la medida de lo posible) esforzarse por luchar contra sus crisis. ambientales. Aun así. a base de parches (o pastillas). que aparte de injustos. Hace tiempo que se advierte de las catástrofes que produce este coctel de desequilibrios. El eje central de las políticas sanitarias se enfoca en la enfermedad y no en la salud (no casualmente) y aún menos contempla la salud como un concepto social. inculcando la cultura del miedo. en el que hay que adaptarse constantemente a nuevos cambios. generando los consecuentes desequilibrios mentales que esto comporta. ignorando el origen del problema que. parece ser que esta definición se tenga poco en cuenta. el control social y la no aceptación de uno mismo.. tales como el individualismo. Hasta ahora los distintos síntomas de este estado patológico han sido tratados igual que la medicina moderna trata los síntomas de sus pacientes en la mayoría de los casos.usando la psicología. sin intención de hacer un cambio colectivo para transformar el contexto que oprime. La salud fue definida por la Organización Mundial de la Salud poco antes de los años cincuenta como un estado completo de bienestar físico. La violencia estructural y cultural que vivimos provoca un sistema inestable. Spain
lA necesIdAd de tejeR estRAtegIAs colectIVAs pARA UnA tRAnsfoRmAcIón socIAl Y sUs consecUentes mejoRAs pARA lA sAlUd
Vivimos en un mundo donde el 20% de la población consume el 80% de los recursos. pero la terapia sigue siendo individual. rompiendo culturas y hundiendo en la miseria a poblaciones enteras.) alarmantes. Estos. mental y social. que nos señalarían un estado enfermizo en una etapa avanzada y crítica. entre otros. y no solamente como la ausencia de enfermedad o invalidez. recayendo todo el peso de la curación en la propia persona. Si hiciéramos un análisis del mundo en el que vivimos podríamos detectar distintos indicadores (sociales. o -en el mejor de los casos.
. culturales. y que es el origen del problema. contaminando sus tierras. son automáticamente tratados con pastillas. desgraciadamente parece ser el mismo para todo este abanico de síntomas. en un mundo en el que aún existen situaciones laborales precarias.. si no queremos ir a la deriva. en la realidad de los países industrializados. la competitividad. robando sus recursos. el egocentrismo.La necesidad de tejer estrategias colectivas
Aina Palou Serra. sus aguas y alimentos. y se penaliza descontándolo del sueldo. el abuso de poder. Ahora ha estallado la crisis advirtiéndonos que es necesario un cambio de rumbo. Gelocatil o Iboprufeno) y menos. En el mundo acelerado y productivista en que vivimos1 tampoco hay tiempo para tal fin (¿tienes dolor de cabeza? Aspirina.
y en definitiva. que como antes hemos apuntado. Esta especialización en las distintas disciplinas hace que se pierda el sentido de un proyecto. En otros lugares donde la medicina social existe y se encuentra en un estadio más avanzado que en determinados países industrializados (concretamente en Latinoamérica.. No digo que la biomedicina no haya aportado beneficios al mundo de la salud. en el cual la responsabilidad en salud es de todos. pero estos no bastan. inventado. especialistas en medio ambiente. Estas desigualdades en salud (tanto entre países como dentro de un mismo país) afectan a los colectivos más explotados. laboral (condiciones precarias de trabajo. La consecuencia de eso es la aparición de especialistas que no contemplan la salud como un fenómeno social. desarrollado y sistematizado por el brasilero Augusto Boal en los años 60. así como en una consulta médica. Por otra parte. antropólogos. en la administración pública. sociólogos. políticas. La salud (como otros derechos fundamentales tales como la educación o la vivienda) ha caído en las manos del sistema capitalista. Existe un método teatral (con implicaciones pedagógicas. político. por una parte tienen menos recursos económicos y en consecuencia.. un proyecto para la sociedad requiere que trabajen juntos médicos. nos indican que al ser humano se le contempla por partes y no como a un todo. y les cuesta ver más allá del mundo de las moléculas. inmunológico. En las distintas ramas de educación en ciencias de la salud (así como en otras ciencias) veremos un enfoque biomédico que fomenta una visión científica.
. pedagogos.. Finalmente están expuestos a factores de riesgo perjudiciales para la salud. Al mismo tiempo tampoco ven al ser integrado en un ambiente. menos poder político (no hace falta recordar que vivimos en una sociedad donde el poder político lo tienen las empresas con mayor capital. son el grupo más vulnerable en el sistema de salud. biológica.). culturales y terapéuticas) que puede ser muy útil en bastantes de los factores observados anteriormente y sobretodo en el último. clínica.. sociales. contratos basura) o ambiental (contaminación). que fomenta la inversión en la industria biomédica. donde ésta es reconocida en el mundo académico. Estos grupos sufren las diversas consecuencias.Young Voices in Research for Health 2009
Aina Palou Serra
Los desequilibrios sociales originan las desigualdades en salud (problemas en salud cuyo origen es social. Este método está hecho para y por los oprimidos. y con la población oprimida) se habla también de la salud como un proceso de construcción colectivo. y donde trabaja junto a movimientos sociales y ecológicos. tienen peor atención sanitaria y menos servicios sociales. hormonal. bajos sueldos. y donde se penaliza y se reprimen los intentos del pueblo de alzar su voz y de participar en las políticas de su propia región). convirtiéndose así en uno de los mercados que más dinero genera y que más consecuencias negativas está soportando. los distintos departamentos en áreas de investigación.. tecnológica. despidos. con sistemas integrados entre sí (nervioso. económico y cultural) que podrían evitarse. oprimidos o excluidos de la sociedad. y son injustas2. creándose especialistas que ignoran la conexión que existe entre estos. químicos. es decir.. tecnológica y farmacéutica. ya sean de tipo social (violencia). Es por eso que la mayoría de proyectos en investigación y las políticas sanitarias están determinadas por las necesidades de las personas con mayor poder adquisitivo. biólogos. Se trata del Teatro del Oprimido. Además. artistas.
y busca estrategias para transformarlas en un planteamiento junto a la sociedad. Landaburu. También. Esta exploración será a través del cuerpo. explora sus causas. como lo mayoría de arte-terapias. eso servirá para trasladar el problema a la sociedad y hacerle partícipe del proceso de transformación. URL: http://www. prostitutas. personas sin techo. será vivencial y no a través de teorías. Joan y Muntaner. Arco Iris del deseo. Cómo nos venden medicamentos peligrosos y juegan con la enfermedad. En: Kaos en la Red . según el proyecto. abuelas.La necesidad de tejer estrategias colectivas
Un grupo que decide hacer un proyecto de Teatro del Oprimido. del ensayo. en la que se encuentra en condición de oprimido. Breilh J. Miguel. jóvenes. porque la finalidad del teatro del oprimido no es terapéutica (aunque también tenga sus efectos). Se colectiviza la opresión. detectando su origen social. En: Cuadernos de crítica de la Cultura. Barcelona: Alba editorial. algunas de éstas pueden materializarse en propuestas de ley. El colectivo busca y explora distintas estrategias para resolver tal situación y transformarla (rompiendo así con la carga de la individualización). Jara. después de este proceso que provoca confianza de grupo. “En el Teatro del Oprimido el espectador deja de ser pasivo (espect-actor) y pasa a ser protagonista de la acción dramática (sujeto creador). su realidad y sus opresiones. Barcelona: Ed. Juegos para actores y no actores. Waitzkin H. E. Archipiélago. Por una sanidad más humana y ecológica.
2 3 4 5 6
Benach. se explora colectivamente la opresión sufrida.. Barcelona: Alba Editorial. Así pues. Icaria. estimulándolo a reflexionar sobre su pasado. Iriart C. Actualmente existen muchos grupos que usan el Teatro del Oprimido para tratar distintos temas relacionados con la opresión que conllevan distintos riesgos para la salud: mujeres afectadas por las consecuencias de un sistema patriarcal (mujeres que sufren violencia de género. 2007. toxicómanos. Artes Escénicas.. 2004. Carles : “Desigualdades en salud: una epidemia que podemos evitar”. aunque se le esté responsabilizando de tal). se puede materializar este proceso en una pieza de teatro-foro (pieza de teatro que abre un debate interventivo). 2002. y como tal. En definitiva. Augusto. Estrada A y Merhy Emerson. Barcelona: Ed.25 / p71-74. valiéndose del talento del joker (curinga en portugués: nombre que recibe un dinamizador en el Teatro del Oprimido) puede explorar a través de un conjunto de juegos. o trastornos alimentarios). victimas de violencia sexual. es necesario contemplar la salud también como un fenómeno social. El grupo aprende a detectarlas (y a no auto-culpabilizarse de una situación conflictiva.net/noticia/entrevista-joanbenach-carles-muntaner-desigualdades-salud-epidemia-po Boal. se podría ejecutar el teatro legislativo. 31 de agosto del 2008. Medicina social latinoamericana: aportes
. inmigrantes. Pero lo más importante es que este proceso no terminará aquí. Será el propio colectivo que explorará su situación y no serán solamente especialistas en el tema que busquen soluciones a situaciones no sufridas. modificar la realidad en el presente y crear su futuro”3. dónde aparte de explorar las distintas intervenciones de la gente.kaosenlared. El colectivo escenifica sus opresiones. Eneko. Augusto. abandono de pensamientos mecánicos y que genera una serie de análisis. tendrá que ser tratada de forma social. personas con trastornos mentales. así como los distintos efectos que conlleva ( son ellos los protagonistas del análisis de sus realidades). encontrando estrategias para transformar las realidades sociales opresivas que conlleven riesgos para la salud de una forma colectiva y donde todos los participantes tengan la misma voz. El Teatro del Oprimido pretende ser un arma de transformación social. Boal. Automáticamente. num. refugiados políticos. Traficantes de Salud.
Vol. Social medicine in Latin America: productivity and dangers facing the major national groups.iacat. Tomas. En: Revista Recre@rte Nº3. Vol. En estos espacios ha ampliado su conocimiento acerca del potencial de la construcción colectiva y ha enfatizado críticamente diversos aspectos de las relaciones de poder. En: Revista Panamericana de Salud Pública. Motos. junio 2005 ISSN: 1699-1834 URL: http://www. Teatro imagen: una estrategia para la creatividad social. 358. Lamadrid S.com/Revista/recrearte/recrearte03/Motos/teatro_ imagen. Estrada A.
Aina Palou Serra nació en 1984.Young Voices in Research for Health 2009
Aina Palou Serra
y desafíos. En 2007 finalizó estudios de bioquímica en la Universitat Autónoma de Barcelona. Nordan Comunidad. Actualmente adelanta un doctorado en neurotoxicología en el Institut d’Investigacions Biomédiques de Barcelona” (CSIC-IDIBPAPS) y paralelamente forma parte del grupo de Teatro del Oprimido “Teatraviesas” y de otros movimientos sociales. Waitzkin H. 12(2). Salud y Autogestión. 2001. Luis. 1989. Iriart C.htm Weinstein. tales como las propias al modelo patriarcal o al sistema capitalista. Montevideo: Ed. En: The Lancet. 2002.
Peru and Uganda found that 35% of health workers were absent2. She was admitted four hours after arrival and was laid on a rusted metal table. To bridge it. it need not necessarily require large inputs of capital. India. Her husband earned less than a dollar a day. Would Parvati have been safer in her hut with a traditional birth attendant delivering her baby like previous generations of women in her family? Perhaps. studies on medical providers in the public sector in Ecuador. Studies in the United States of America show that only 54% of patients admitted to hospitals get the recommended medical care4. medical error results in the loss of 44 000 to 98 000 preventable hospital deaths per year5. It is simple interventions that fascinate
. She belonged to the Yadav caste. so her presence at the centre ostensibly meant a check in my spreadsheet. innovation is required – an ability to challenge the convention of doing business as usual. A gap exists between what we know and what is done. The programme was enabling access to health services for the poor and marginalized – a step towards the goal of health for all. she remained tragically unable to access health care. asked three questions and prescribed three medications (often unnecessarily)3. and significant geographic and racial disparities affect the quality of care7. In the developing world. Raw garbage was strewn around her. The mantra of “health for all” has undoubtedly resulted in an increase in access to health services in many contexts. My own fieldwork in India as a graduate student and later as a public health practitioner reinforced these findings. These problems are by no means limited to the public sector. while she could access the clinic. euphemistically classified as an “other backward class”. But was it? Parvati’s experience in terms of the quality of care she received speaks volumes. exposing her to dust and rain. the quality of care received remains unacceptably low in the developed and the developing world1. India
bUsIness not As UsUAl: ImpRoVIng tHe qUAlItY of HeAltH cARe tHRoUgH InnoVAtIon
Parvati came to give birth at a rural health centre in Bihar. I consistently found a shortage of certain types of health providers such as anaesthiologists and male nurses. The roof of the clinic was broken.6. For. She was 27 and could not read. A single nurse was overwhelmed with some 40 cases a day. While innovation conjures up images of hi-tech gadgets and expensive ideas. On rural visits. I was there to understand the government’s health programme as part of a World Bank team. Indonesia. There was no doctor at the clinic. the doctors surveyed spent three minutes with the patient. There was little medicine. Research in a middle-class neighbourhood in Delhi showed that the “Rule of three” governs doctor-patient interactions in private clinics – on average. however.Business not as usual
Aakanksha Pande. Yet poor quality of care afflicts the developed world as well.
In the United States of America. line insertion kit and dressing kit. These seem to be obvious steps. Teachers in Udaipur District in Rajasthan. The checklist has resulted in a 50% reduction in death and 40% reduction in surgeryrelated complications10. As a result. health clinics can formulate and post a patient’s bill of rights. an experiment from the education sector that can be applied to the health setting involves using disposable cameras to reduce teacher absence. In fact.Young Voices in Research for Health 2009
me – innovations of thought. the intervention halved provider absence. The innovations were not revolutionary – their impact was. Bollywood kept them entertained while stationed at remote outposts. I have come across small ideas with large impacts. A project in Afghanistan retained nurses in rural areas by providing them with DVD players and small generators. A maternal health programme in Pakistan allowed female health supervisors’ husbands or male relatives to be drivers in the programme. they achieved significant drops in mortality by standardizing the pre-procedure checklist. India. The charts should have symbols and pictures to convey the message to uneducated audiences. By drilling down to the source of each case. due to central line infection in intensive care units9. the United Kingdom. which informs patients what services they should receive. India. They are pioneering by looking at fields outside of health care to draw lessons. Teachers felt that they had the power to increase their salary through this impartial assessment. The hospital team looked beyond the medical field for inspiration. sustained over a three-year period. the United Republic of Tanzania and the United States of America. using quality-improvement principles pioneered by Toyota. you will be surprised at the items on it: “Confirm that all team members have been introduced by name and role” and “Confirm the patient’s identity. In the developing world. innovation can enhance the quality of care and save many lives. surgical site. a set of innovations introduced by Allegheny General Hospital resulted in a 95% reduction in deaths. Some innovations have had success in both the developed and the developing world. By understanding the main sources of poor quality and addressing them through often obvious ideas. were given disposable cameras and had to take a picture of themselves with their class at the start and end of each school day8. it already has. and procedure”. I have come up with a few ideas for public sector clinics in the developing world. A telephone hotline should be available to which patients can complain
. Teachers’ salaries and bonuses were partly based on the number of photographically proven days that they were at work. But they were not always being implemented. Through my experiences in global health. the presence of a “family-approved” male allowed them to travel to their field sites so they were more effective at their job. The innovations were simple and included scrutinizing data in real time and asking a set of “whys” as soon as a line infection was detected. Jordan. The World Health Organization recently introduced a 19-point Safe surgery checklist in hospitals in Canada. The cameras had a tamper-proof system that recorded the date and time the photograph was taken. If you look at the checklist. the Philippines. New Zealand. How then can such innovations be applied to improve Parvati’s plight? Based on these examples. Borrowing from the consumer movement. The list of innovations to improve health quality is not always documented.
Crossing the quality chasm: a new health system for the 21st century. efficient.
. Washington. Money for nothing: the dire straits of medical practice in Delhi. concurrently. Once people are in the health system they must get safe. National Academies Press. 2003. Brennan et al. Missing in action: teachers and health worker absence in developing countries. Corrigan JM. Kohn LT. an unachievable dream.Business not as usual
if a right is violated (such as a doctor not being present during working hours or the building not being maintained). Otherwise. effective and equitable health care11. The implications of regional variations in Medicare spending. We have to constantly question even the most obvious processes. Washington. saved lives. 353(13):1405–1409. Fisher ES et al. most patients can easily call and a register a complaint. A literature search on quality of care in the developing world brought up lists of indicators. empowering them and creating a body of evidence about poor quality of care that can be acted upon. A space has to be made for these types of innovation in the delivery of care. patient-centred. Incentives and promotions should also be based on attendance and certain quality measures (appropriately adjusted for the severity of the case mix). health for all will simply remain yet another catchy public health slogan. To err is human: building a safer health system. Donaldson MS. the questioning must relentlessly continue: Why is this happening? What can we do to change this? How can we innovate? Public health has made great strides in ensuring that more people are able to access the health system. 2007. Accidental deaths. The quality of health care delivered to adults in the United States. We now need to complete that compact. often in conflict with one another. Mc Glynn et al. 2003. Is the right patient being operated on? Are nurses washing their hands? Are doctors showing up at work? And. But. 2001. 2005. since they received a salary based solely on how many years of service they had logged.
Authors note: The patient interaction described is fictitious but is based on anecdotal and photographic evidence from meetings with non-profit-making health groups in Bihar in April 2006.
2 3 4 5 6 7
Quality is defined by the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge. DC. and accessibility of care. In addition. Hammer J. New England Journal of Medicine. Only then can women such as Parvati harness the health system and get access to the health care that they deserve. DC. the weaknesses have to be understood. quality. Journal of Economic Perspectives. National Academies Press. Part 1: the content. Institute of Medicine. Annals of Internal Medicine. if the answer is no. Chaudhury N et al. Interviews with doctors in the public sector in India conveyed that there was little incentive to show up at work. With the enormous penetration of cell phone technology in the developing world. The thrust of the argument was to standardize ways of measuring the quality of care towards creating a baseline. Data on performance can be partly based on hotline complaints. timely. 348 (26):2635–2645. 138(4):273–287. New England Journal of Medicine. Why does the process towards improvement have to be so linear? Measurement is important. 20(1):91–116. and improved quality. 1999. Das J. promotions in the medical sector should not be based just on tenure. 83(1):1–36. health systems need to be broken down into parts. as with the private sector. India. Journal of Development Economics.
10 Haynes AB et al. 2009. 32(9):479–487. DC. She specialized in monitoring and evaluation as a junior professional associate at the World Bank. focusing on health projects in India. National Academies Press. Aakanksha grew up in Bombay and South Korea. 360(5):491–499. Washington. 2006. “Wealth. 2004.
. Hong Kong and Bahrain. New England Journal of Medicine. Joint Commission Journal on Quality and Patient Safety. where she is researching disparities in the quality of care in Mexico at the Harvard Pilgrim Health Care Institute. double majoring in Molecular Biology and International Studies. and Health Services in Rural Rajasthan. An Indian citizen. A surgical safety checklist to reduce morbidity and mortality in a global population. Crossing the quality chasm: a new health system for the 21st century. Using real-time problem solving to eliminate central line infections.Young Voices in Research for Health 2009
Banerjee A. and E Duflo. Deaton A. 11 The SEPTEE criteria for quality as defined by the Institute of Medicine. Aakanksha graduated with distinction from Yale University. 9 Shannon RP et al. Institute of Medicine. 94(2). She was a Fox International Fellow at Cambridge University in the United Kingdom and holds a Master’s in Population and International Health from the Harvard School of Public Health. Department of Population Medicine. 2001.
Aakanksha Pande is a doctoral candidate in Health Policy at Harvard University. Health. Pakistan and Sri Lanka.” American Economic Review Papers and Proceedings. 326-330.
The need for coordination. much less carry out ambitious research projects. while very helpful. yet such attempts will be incomplete if the existing socioeconomic framework is unable to channel the scientific gains made to those who need them most. social innovation must also take place to enable technological innovation to fulfil its promise. we must remember that the challenges are only difficult. Nevertheless. To address this. Philippines
cAn todAY’s HeAltH cHAllenges be oVeRcome? wHY InfoRmAtIon. most of the time. However. can also be limiting.
. since they are restricted by limited budgets. such focus. cannot afford to support pricey health-care services. as in any medical intervention. weak institutions. the solutions we formulate can generate their own set of problems. cooRdInAtIon And InnoVAtIon mAtteR
The incentive to innovate. we also ask questions about access: How do we make sure that these technologies benefit those who really need them? And how do we transform what we discover. among other things. developing countries can prioritize implementing strategies that promote the efficient use of resources to improve health outcomes. but. How exactly can this take place? There can be as many possible solutions as there are problems. Higher levels of funding and intense public attention towards developing new cures and addressing the human body’s frailties manifest the increased centrality of health issues in our society. Improving health outcomes through the efficient use of resources in developing countries implies that we would have to contend with corrupt governance. We have to keep in mind that. we not only inquire about the progress of existing technologies and strategies to improve health outcomes. Attempts to deepen our understanding of the human body and the search for new and better responses to its diseases are vital starting points. Instead of focusing on devising expensive technologies or carrying out research that requires large initial investments. This challenge is particularly salient in developing countries. When we speak of innovation for the health of all. we should be wary of administering a policy cure that is worse than the disease.Can today’s health challenges be overcome?
Marian Angelica Panganiban. Yet such constraints can become opportunities for innovation – particularly social innovation. Most developing countries. Will developing countries have the incentive to innovate? My hopeful answer is yes. poorly devised or poorly implemented policies. develop and create in our laboratories into replicable and accessible products and services for everyone? The importance of medical research in terms of producing scientific and technological knowledge to help us tackle today’s health challenges is well established and much emphasized in public discourse. It is easy to become resigned amidst the complexity and enormity of the challenges that beset us. and powerful interest groups.
which improved the families’ overall health status2. Health objectives are now also incorporated in the conditional cash assistance programmes of some developing countries4. A priori knowledge. Thus. our policy and programmes must be as well informed as possible about social. If the goal is to ensure innovation for the health of all. most of the tools they have developed are infrequently used or ill used by policy-makers and implementing agencies when it comes to formulating social interventions. it is first imperative that we be able to determine what is efficient and effective. experience and intuition can guide us only to a certain extent. Strengthening coordination also encourages ongoing learning that informs policy and improves research. Our preliminary research last year on a gawad kalinga (caregiver) community that benefited from a private-sector-initiated programme rehabilitating the homes of squatter communities in the Philippines showed that the programme’s most significant welfare impact was made by providing households with access to clean water. there must be a concerted and coordinated effort among medical and social scientists. Promoting long-term relationships among researchers and implementing organizations can go a long-way when it comes to ensuring both the complementarity and sustainability of programmes and policies to be implemented. thereby enhancing their impact. this is already widely practised. Such knowledge allows us to customize technological innovations to suit the social and institutional setting where they will be applied. Other studies on people’s discounting behaviour have led researchers to design commitment contracts to combat smoking addiction in the Philippines3. For developing countries. deworming was found to be nearly 20 times as effective as hiring an extra teacher1. most social scientists conducting these kinds of research have shown tremendous creativity and insight in making sense out of the data they have collected. it is not the groundbreaking medical discoveries that produce the most impact but. When the impact of deworming was compared with other programmes for improving education outcomes. Sadly. a different kind of research would be needed. Take the case of the treatment of intestinal worms in schools in Kenya. and some non-medical programmes and tools have a direct impact on one’s health status. the availability of common cures and treatments to the large number of people who need them but could not previously afford them. A study showed that a deworming treatment that costs 49 US cents per child per year can reduce absenteeism in school by one quarter. This was largely because worms are transmitted by walking barefoot in places where other children have defecated. Instead of functioning merely as post hoc evaluators. economic and behavioural aspects of health in a given context. Coordination is made even more vital by the fact that most medical interventions have consequences that go beyond a person’s physical welfare. Before any intervention or proposed solution can be realized. rather. Fortunately. nongovernmental organizations and funding agencies to ensure success in this endeavour. But when resources are scarce and the challenges are plenty. public officials. researchers can very well be part of the process of developing the interventions to be made by answering policy-relevant questions. one that is conducted outside the controlled confines of our scientific laboratories and that requires us to creatively investigate through the messy world of field work. Hence. it is best that we be able to identify exactly what can help us produce the maximum positive impact with the least resources. Furthermore.Young Voices in Research for Health 2009
Marian Angelica Panganiban
not insurmountable. coordination also supports better information
as a research-based. researchers. This would help patients assume greater control over their own health affairs and assist them in making more informed decisions. If we believe that health is a complete state of well-being. As the challenges we encounter become almost inexorable. we are able to avoid the confusion that considerably thwarts our efforts to improve health for all. Apart from establishing functioning relationships among various sectors. Current policy debates on health issues in most developing countries usually sink into applying divisive labels that only serve to polarize the public and dissuade action. Panganiban M. Information is both powerful and empowering. Today’s health challenges require cooperative interactions. Taking this into account. Housing as a building block of welfare: an impact assessment of Gawad
. information can be exchanged among patients with similar experiences and among doctors who encounter related problems. Information campaigns can also help patients appreciate treatments and services that they otherwise would not have availed themselves of for lack of information. It is now apparent that the old physician-patient relationship. the goal of innovating for the health of all becomes more encompassing and the scope for relevant involvement expands. DP7037. CEPR Discussion Paper No. the health challenges we face are truly far from insurmountable. then it is important that we understand and address not only human vulnerabilities but also institutional and environmental vulnerabilities. multisectoral programme and policy framework clarifies the many aspects of health issues. 2008 (http://ssrn. the pertinent health challenge is getting people to avail themselves of less-costly preventive measures. is insufficient when it comes to effectively answering the health needs of the patient. Sometimes. accessed on 2 September). Our efforts. The importance of information. The ability of the Internet not only to tap a broad base of people but also to specifically respond to the information needs of individuals can be incorporated in our health-response frameworks. This insight is especially useful in the health sector. policy-makers. Before we can build effective national health-care systems. and devise suitable financing strategies and equity programmes. Perhaps we can utilize existing technologies ubiquitous on the World Wide Web. Initiating global doctor and patient networks akin to those formed through social networking sites and utilizing interactive platforms via the Internet may be helpful when it comes to dismantling information barriers and advancing equitable health-care access. in which the physician serves as the supreme source of knowledge. Duflo E. volunteers.Can today’s health challenges be overcome?
sharing. When information is credibly produced. where information asymmetries abound. the problem is not the under-provision of health services but underconsumption. health-care providers and citizens. With an intelligent and coordinated approach towards innovation. where platforms for networking and sharing user-generated content thrive. another key area of innovation – both social and technological – would be in instituting links for information-sharing. must always be guided by informed choices. properly communicated and effectively utilized. design appropriate incentives for increased private and public sector involvement in health.
Banerjee A. so our energies must be inexhaustible. since most people are not aware of the benefits these preventive measures bring. Baluyot B. develop and measure comparable health indicators across countries. we all need to become better-informed scientists. The experimental approach to development economics. They can be overcome. vis-à-vis the costs of future treatments. though. leaders.com/abstract=1311161.
Young Voices in Research for Health 2009
Marian Angelica Panganiban
Kalinga in Laura [thesis]. Put your money where your butt is: a commitment contract for smoking. 35.gov/be/workshops/microeconomics/docs/karlan. 2007 (www. accessed 2 September 2009). Her interests include health policy and systems research.pdf.ftc.pdf. Working Paper No. Conditional cash transfers in Brazil. Chile. 2008. Soares S et al. accessed 2 September 2009).
Marian Angelica Panganiban is currently a graduate student in Economics at the University of the Philippines School of Economics and a fellow at the Philippine Centre for Population and Development. 2008 (http:// www. and Mexico: impacts upon inequality. International Poverty Centre.org/pub/ IPCWorkingPaper35.
. priority setting. Xine G et al. She is an active volunteer in several organizations that aim to improve access to health and education in the Philippines. Diliman. Brasilia.undp-povertycentre. University of the Philippines School of Economics. and research communication.
This must change. I have seen that my experience there reflected a much larger problem with the basic relationship among corporations. which stems from the lack of incentives or practical collaboration among industry. where innovation is absent or is present only in fragmented forms of inappropriate technology in markets that are not invested in its use. In the clinics I visited. increasing success and impact. This is rarely done in low-income markets. innovators. United States of America
ReAlIgnIng InteRests And ResoURces foR HeAltH tecHnologY deVelopment In tRAdItIonAllY UndeRseRVed mARkets
My first taste of debilitating poverty and great inequality came during my first trip to South Africa. and there must be integration of research and development. First was a lack of corporate involvement in product development stemming from the perceived lack of economic viability and entrepreneurial opportunity for health-care products in poor areas. product development and health-care delivery for low-income populations. governments and larger networks of global health. funded by the Bill & Melinda Gates Foundation and partnering with Abbott Diagnostics. While working in South Africa with universities. marketing and product delivery. is developing new point-of-care technology for HIV diagnosis and control through rapid viral load testing and early-detection diagnosis for infants. Through this ongoing
. local and international nongovernmental organizations (NGOs) and government bodies.Realigning interests and resources for health technology development
Samuel Pickerill.and 20-year-old medical students and in public health clinics short of staff but carrying on despite the twin epidemics of HIV and tuberculosis. Profits can then flow into further product development and innovation. In the three years since that first trip to South Africa. In my experience key parts of this will be innovative partnerships and product development that reach profit targets through designs for underserved populations. I was struck and disheartened by how technology had failed to provide solutions for these health problems. After working in South Africa on public health implementation projects. United States of America. The process of technology innovation and product development in highincome markets involves the efficient coordination of ethnography followed by design. Although the primary goal is to bring technologies and improved health to areas in Africa. I recognized two fundamental problems with technology in the developing world. the rapid and lowcost diagnostic methods are also relevant to industrialized markets. the market is studied and stakeholders are prepared for delivery. the global health community and communities in need. This will require restructuring the relationship between industry and global health bodies so that both are focused on bringing innovation to communities in need. CIGHT. Second was the absence of any major effort to change this. I became a part of the Center for Innovation in Global Health Technology (CIGHT) at Northwestern University. During this trip I spent most of my time in mobile clinics run by 19. As products are designed. a flood of donated medical equipment lay unused in spare hallways or sprawled out into busy emergency rooms.
In my experience. This is a core step for the change model described by Richard Tanner Pascale and Jerry Sternin. This uncovers an intangible benefit of design for underserved markets: the promotion of a culture of change and innovation as well as entrepreneurial activity within an industry. BioUstar brings together diagnostic and biotech expertise developed in the United States of America. It also shows how technology can have success in multiple markets. By questioning the basic assumptions about how current molecular diagnostics are used and designed. and an
. human papillomavirus and other infectious diseases. where the founders were trained. CIGHT is one successful case study that reveals several compelling reasons for industry to design for developing world markets. Furthermore. Working with communities through ethnographic studies and design-specification development makes products not only more likely to meet a community’s need but also more likely to be accepted by the community and market. For instance. Design for development can help a company utilize existing intellectual property and off-the-shelf technology in new ways and combinations that might not have been realized before. the Harvard sociologist explains that the driving force behind sustained innovation in Silicon Valley is a unique combination of vast academic resources and skilled labor with a strong community and entrepreneurial culture. Abbott is allowed to market and commercialize these products or utilize the technology to develop new products but has agreed to take no profit from diagnostic sales in low-income markets. by Robert Putnam. new ways to drastically decrease the processing time and cost while improving the quality of results have been found. I was struck by the importance of community culture for both communities and businesses. This design challenge has created huge advances in diagnostic technology at CIGHT. which utilizes new ideas that question technological assumptions and provide a supportive culture for the growth of this idea. that has developed a platform of molecular diagnostics for tuberculosis. BioUstar is a company based in Hangzhou. Both business and community development strategies suggest this culture is best developed through a shared experience of overcoming an obstacle together. Just asking the question “Can we design a diagnostic that is more rapid and sensitive and can be used by almost anyone in Africa?” begins to change the way existing technology is viewed. In Bowling alone. innovation for underserved communities provides a perfect activity to build a new sense of community and a culture of change in both companies and communities. During my university studies and research in South Africa. the CIGHT partnership has identified new entrepreneurs and designers that have been trained through the process of innovating for the developing world. design for the developing world poses new design obstacles that challenge assumptions about technology and may lead to revolutionary products. China.Young Voices in Research for Health 2009
partnership. This innovation will continue to have relevance in both developing and developed markets. This process not only identifies new technologies but also identifies and cultivates highly creative individuals within the company or even potential new employees that are involved in the process. My experience with a start-up in China provides further evidence and shows that this new approach to partnership and innovation can be done in a developing country without foundation support.
Samuel Pickerill is a Fulbright scholar working to develop new tuberculosis design strategies in partnership with Fudan University in Shanghai. Economic barriers can be overcome. However. as suggested by my examples above. Industry involvement in low-income markets has been limited by economic and structural barriers. the markets that they originally set out to serve. structural barriers still need to be overcome. and one product is currently being used by the company BioHelix in its rapid nucleic amplification system. These barriers can be overcome. My argument is that economic incentives for health-care companies actually lie in the process of design and innovation for underserved populations. profit-makers and communities. they have had less success in reaching low-income markets in China. Yunus suggests that social motives do not need to be separated from profit motives and that a new type of business termed “social business” is possible. as well as the potential for revolutionary product development that serves both social and profit motives. health-care groups need to actively provide access to local needs and community participation. The payoff is a concrete way to promote new entrepreneurship and motivate changeagents on projects that matter. While completing his Master’s in Biomedical Engineering from Northwestern University. Beyond solely providing financial support. As seen by the CIGHT example. universities and the global health community access to productdevelopment assets. foundation support combined with university and company resources can bring solutions to complicated health problems. as well as to help prepare governments and health systems for technology innovation and introduction. Samuel worked with a team designing low-cost HIV
. lack of access to health-delivery organizations and poor coordination between those innovating and those providing care. provided by those who currently control health-care provision in these markets. Their products have also found a market in the United States of America. Unfortunately. Both governments and health-related organizations must begin providing incentives for companies looking to innovate for the poor. I have personally seen how companies can benefit from designing for the developing world and have witnessed the results of innovative partnerships and strong relationships among governments. non-profit-makers. Prahalad suggests that there is a “fortune at the bottom of the pyramid” that requires only a restructuring of business that is more efficient and understands low-income users’ needs. Their success has been in the form of new products that will bring needed diagnosis of infectious diseases. as well as work by CK Prahalad and Nobel Prize winner Muhammad Yunus. Only when these major actors begin aligning resources and interests will technology innovation begin providing health solutions for the poor and lead to real health improvement. Reflection on the past year suggests that this is due to a lack of services and resources for companies looking to serve low-income markets.Realigning interests and resources for health technology development
understanding of Chinese business and manufacturing. This will offer corporations the opportunity to tap into both internal and external resources previously unharnessed and will allow NGOs. The way forward is to integrate the most powerful innovators in the world with the most successful global health bodies in the world. as well as the training of local talent. but it will require a more active role in the process of innovation by the global health community. This can provide pressure for a large-scale restructuring of health-technology innovation. including limited access to market data for local populations.
From his farming hometown of Genoa. to urban China.Young Voices in Research for Health 2009
diagnostics. where he partnered with the University of Cape Town to design methods for developing world issues while investigating the ways technology affects health outcomes.
. Illinois. Samuel is driven by the vision that technology design in partnership with community organizations can catalyze social improvement and development. This degree built upon a yearlong Whitaker International Scholars Programme in South Africa.
in the earth’s other hemisphere. a major cause of death from bacterial meningitis in the developing world. such as the CD4 test. even prominent institutions like MIT cannot be spared from considering major tradeoffs in their research efforts. where a group of young boys and girls sit on the rocky floor of a narrow hut. The device is destined for regions like southern India. listening attentively to the schoolteacher presenting their beloved maths lesson. The public health community questions whether experimental technologies. little aware that the broken.
. Meanwhile. was able to find an innovative. I hold it up to the late evening sun that shines through the large glass windows and peer into the nanometric channels. Cuba. Cuba. an antigen used to detect T-cell levels and immune system health in HIV-positive patients. The chip is a microfluidic device for the rapid analysis of CD4. where HIV is spreading at an alarming rate. in the midst of a spiralling financial crisis in the United States of America. 1944 I step into a sparkling lab at the Massachusetts Institute of Technology (MIT).” Sir Victor Wellesley. In the 1990s. more cost-effective health interventions exist that can immediately save lives. a country with one of the lowest per-capita gross domestic products in the western hemisphere. cost-effective method to treat a deadly infectious disease affecting the world’s poorest children. Millions die every year in the developing and developed world alike because they lack access to basic needs like clean water and sanitation. which must be sold at or below their (significant) cost of manufacture2. can learn critical lessons from the hard-nosed business world? Research centres like the Carlos Finlay Institute in Havana. the few major vaccine producers in the US and European pharmaceutical industries remain chronically underfunded due to the “high-risk. is it possible that the global health community. have a revolutionary answer. In the midst of this controversy. This vaccine has become such a resounding success in Cuba that it is the only Haemophilus influenzae type B vaccine on the Essential Medicines List of the World Health Organization1. However. obsolete equipment that they will find there could dash their innovative dreams. They will one day carry this knowledge to engineering labs at their local university. low-reward” nature of vaccines. the same sun rises on a dusty village in southern India. dedicated to serving the most indigent populations and marginalized areas of the earth. India
dIsRUptIVe InnoVAtIon As tHe new pARAdIgm of globAl HeAltH
“No course is ever completely free from hazard. Meanwhile.Disruptive innovation as the new paradigm of global health
Soumya Rangarajan. where my guide hands me a device the size of a computer chip and seemingly as complex. are worth their cost when much simpler. this institute created the first completely synthetic vaccine against Haemophilius influenzae. but the greatest of all risks is when risk is shirked.
based at Harvard Medical School. Amyris has extended its innovation to the profitable and socially important area of renewable fuels. malaria or many other diseases we are not even aware of in the developed world. Such disruptive technologies abound in global health. a rare Chinese herb critical in combination therapies against drug-resistant strains of malaria. Amyris decided to tackle a difficult problem: creating high-yield synthetic products using inherently cost-efficient processes provided by nature. Silicon Valley. they open up tremendous new opportunities to address the needs of the world’s forgotten poor. but also that one technology can be used across various academic disciplines to solve diverse social problems. Amyris successfully mass-produced a precursor to artemisinin and has licensed this process to various non-profit-making organizations. calls forth a term often bandied about in high-technology and business circles (and more recently among policy-makers) but largely overlooked in public health: “disruptive technology”. The small start-up company Amyris Biotechnologies has demonstrated not only that profit need not be the primary motivation in an early-stage. This group sends unused lab equipment from major US medical centres to scientists in developing nations. This term was coined by Harvard Business School professor Clayton Christensen in his famous 1997 book The innovator’s dilemma to describe innovations that “underperform” compared to available market technologies but appeal to new groups of consumers due to their simplicity. This is the raison d’être for a small social enterprise called Seeding Labs. Founded in 2003 by a group of scientists with diverse backgrounds in environmental. The strategy of Seeding Labs negates the veritable dogma of public health that innovative research can occur only in the rich world and must be transferred to developing countries far downstream in the product cycle (e. across various disciplines and through partnerships between the public and private sectors.Young Voices in Research for Health 2009
This dichotomy between Cuba’s innovativeness and the risk-averse nature of the United States of America. Meanwhile. although research and products coming out of South America. these scientists can tackle diseases that are given little thought in the United States of America. The idea is bold: Scientists in the developing world set their own research priorities and use state-of-the-art equipment to create medical products that meet the needs of their own populations in a culturally sensitive manner. easeof-use and low cost3. Unfettered by the demands of shareholders or US government research grants. Innovation and global health can be integrated through cooperation on three levels: across national borders. Another example of a disruptive technology comes from the heart of US innovation. such as schistosomiasis. medical and engineering studies. I demonstrate that taking “high risks” in global health can reap huge rewards. Asia or Africa will not compete in US or European markets. They decided to test their synthetic biology process using artemisinin.g. including the Institute for OneWorld Health (itself an innovative global health venture). delivered as a finished vaccine to community health workers). the public health community has disregarded a critical set of tools that could directly save lives and lead to better health outcomes worldwide. By presenting examples of disruptive technologies I have come across in my own research and experiences.. Amyris’s work on artemisinin is a disruptive innovation because the product may not be as effective
. as long as it can be harnessed through available resources. By pitting innovation against cost–benefit analyses. This is a disruptive innovation because. Cuba’s development of the vaccine demonstrates that ingenuity is abundant in what can seem the most unlikely places. highrisk venture.
the chips will cost a dollar apiece. This quick. 1997. She received high honours for her political science senior thesis.us/PED118. and that obtain funding and resources from various organizations and sectors. accessed 2 September 2009). this means transferring leadership across all parts of the social-value chain to developing countries. but it provides a cheap and scalable way to manufacture a medicine essential to the battle against malaria in the tropics. In global health. Massachusetts. Vaccine availability in the US: problems and solutions. 2007 (www. Harvard Business School Press. This provides an opportunity for a sea-change in thinking among all types of global health practitioners. which analysed the role of science and technology in the developing world. in the United States of America and received her Bachelor of Science degree from the University of Michigan in 2006. from clean water to diabetes. Massachusetts.soumya. is no longer sustainable. the way public health has traditionally been practised.Disruptive innovation as the new paradigm of global health
as the pure (and very costly) herb. These two case studies demonstrate that international teams that include scientific. no country]: the development of health biotechnology in Cuba. They are also examples of disruptive technologies with the potential to transform the way global health is practised.
Soumya Rangarajan grew up in Cleveland. She subsequently received a Master of Public Policy degree from the Kennedy School of Government at Harvard University in 2008. Christensen C. and I cannot help but smile. Marcuse EK. 2004. Soumya will be starting medical school in 2009 and intends to become a physician-researcher and policy-maker focusing on using innovation to address major health policy issues in the United States of America and around the world. allowing them to be distributed en masse to extremely overburdened health clinics in the developing world. However. In the midst of the global financial crisis. Poland GA. True global health innovation will occur when scientists in university laboratories or science clusters in the developing world can conduct research and create products that will be profitably marketed by locally sustainable businesses to the individuals around the world that need them most. can reach innovative solutions to difficult global health problems. with a top–down. philanthropy-driven model. Sin azúcar no hay país [No sugar. the globalization of markets and the dissemination of knowledge and information through the Internet have dissolved the significance of national borders in science and society. the most critical aspect of ensuring the success of any disruptive technology is empowering a broad. I learn that once the manufacturing of the microfluidic CD4 devices can be scaled up to mass production. I picture those children in India in the near future. Back in the MIT laboratory.html. Ohio.
. John F Kennedy School of Government. Boston. In addition. 5(12):1195–1198. Harvard University. The innovator’s dilemma: when new technologies cause great firms to fail.
Rangarajan S. cheap way to track HIV-positive patients’ health could free up scarce labour and financial resources to address numerous other health concerns. Boston. their eyes wide with excitement as they look at the gleaming new equipment available in their local university to create high-tech microfluidic devices and improve the health of their own communities. Nature Immunology. clinical and socioeconomic experts in global health. majoring in political science and general biology. diverse population.
with the first successful bone-marrow transplant occurring in 1965. When you first consider how future health innovations may affect people from all parts of the globe. cell-based therapies may not be top of your list. wide-framed automated weaving looms were introduced in England to create textiles cheaply without the assistance of skilled workers. However. cerebrovascular disease and even certain forms of cancer. Nobody can argue against the fact that both science and medical research have advanced substantially in the past 30 years. The idea that a sample of blood could be taken in a small hospital in Mombasa and converted to an autologous treatment for ischaemic heart disease within a week seems like science fiction. While there seems to be no limit to the number of new ideas and solutions to many current health problems. smaller versions of bioreactors and similar fullyautomated cell culture machines will allow cells to be produced anywhere by anyone. let alone those in developing nations. cell-based therapies have been around for over 40 years. The key to this problem is automation. is at the top of that list. However. it may be closer than you think. Furthermore. Most
. More recently. Innovation in its purest sense is simply applying new ideas successfully. especially health innovation aimed at developing populations and marginalized communities. This is true for many things. But the price of these treatments is already out of the reach of many people living in rich economies. actual application and innovation appears to be constantly lacking. Automation and the use of machines to produce materials quickly and reliably is not a new concept. “You cannot depend on your eyes when your imagination is out of focus”. They are currently expensive. In such a technically demanding field as cell isolation and expansion. As early as the 1800s. Yet. I believe that through improved process design we can reduce costs and improve manufacturing times to produce innovative therapies for a reasonable price. the ability to use machines to accurately and reproducibly make the same product every time is critical. our understanding of cells and how they interact in the body is progressing at a startling rate. Australia
let tHe mAcHInes do tHe woRk: AUtomAtIon And tHe dRIVe foR globAl HeAltH InnoVAtIon
As Mark Twain said. The lack of money is often blamed for the lack of suitable therapies for many of the world’s most pressing health problems.Young Voices in Research for Health 2009
Erin Rayment. advances in adult and embryonic stem cell understanding means that therapies based on these cells are now seen to have the potential to treat many conditions for which conventional treatments are inadequate. time-consuming and generally for diseases of affluence. From the first child born from in vitro fertilization in 1984 to the isolation and growth of human embryonic stem cells in 1998 and the reprogramming of adult human cells into induced pluripotent stem cells only two years ago. like type 2 diabetes. but in my opinion health innovation. from treating malaria to managing cardiovascular disease.
providing improved products and reducing costs along the way. HIV and. Malaria. While it may be several years from completion. as history has shown. without the need for sophisticated collection and storage facilities or highly trained personnel. Another innovation in this field is the development of disposable bioreactors. released in 2008. tuberculosis. at number 20. noncommunicable disease will account for over three quarters of all deaths worldwide by 20301. Most vaccines are currently being produced either through roller bottle culture. to something as simple as M&M candies. According to the latest World health report. This brings us back to the important issue of cost. many could be treated by cell-based therapies. large accidents and terror attacks. Of course. This type of device could be used to create safe and clean blood supplies following natural disasters. This will not be the first time that a military innovation has the potential to directly affect everyday lives outside of the armed services. a single-use version that does not need to be sterilized or pre-prepared and can therefore be made to tight regulatory standards. this does not mean that money is not an important factor. Of the remaining chronic diseases. These types of automated cell culture units can be adapted to many different applications and are able to handle cell volumes from 12 000 litres to as little as 50 millilitres. ranked as the 13th leading cause of death in 2004. combined with our greater understanding of how human stem cells can be exploited in culture. once the technology is developed. Will automation be able to provide these cell-based therapies at a price that everybody can afford to pay? It is true that current treatments are certainly out of reach of many in the world’s population. will lead to health innovations that have the possibility to affect people worldwide. it could be used anywhere. they could be effectively treated all over the world by people who possess limited medical abilities.Let the machines do the work
people do not associate these noncommunicable diseases with developing countries and those most isolated from everyday medical care. However. where tiny particles are suspended in a larger spinner flask or bioreactor. a self-contained unit able to create transfusable amounts of blood in a battlefield situation would be somewhat unparalleled in applications. this current project is the perfect opportunity to develop a technology in an environment where costs may not always stand in the way. but they may also be useful when confronted with warfare and natural disasters. Most importantly. Not only are these systems ideal for culturing cells for chronic diseases. This technology. I disagree. the price is certain to fall when paired with improved economies of scale. The pharmaceutical industry realized many years ago that automation of mammalian cell culture could drastically improve cell numbers and reduce costs. or in microcarrier culture. with automation. money spent developing technology in the military has the ability to filter down into our wider society. From the creation of the global positioning system. Furthermore. However. is expected to drop as low as number 41. But
. where the cells attach to the inside of a bottle. And. there will be only 3 communicable diseases in the top 20 causes of death by this time – lower respiratory infections. For something as important as blood pharming. The US Department of Defense is currently conducting a research project through its Defense Advanced Research Projects Agency that is aimed at producing an automated unit that will be able to produce red blood cells in the field.
combined with our increased knowledge and improved machine design. Currently. This time will be converted to cost savings. Geneva. Competition will also be a significant driver. with that in mind. Both of these things could never have happened if only one company still dominated the market. 2008. manufacturing and cell processing. automation. I booked flights from the United Kingdom to Ireland for only 2 pence each way – quite incredible when you think about it. we can save time in designing. with larger demand for the machines themselves. If we can design systems that can culture cells in a controlled and reproducible manner. as many people know. And. In conclusion. However.
. health innovation can be difficult in the best situations. Being willing is not enough. Erin is a research associate in David J Williams’ translational research group in the Centre for Biological Engineering at Loughborough University in the United Kingdom. time is money. World Health Organization. there needs to be strong competition in cell-based automation.
World Health Report 2008. let alone in every situation in every corner of the world. I think Leonardo da Vinci said it best when he stated: “Knowing is not enough. Her doctoral research formed the basis of a patent application and also earned her the 2008 Postgraduate Student Medal at the Queensland Premier’s Awards for Health and Medical Research. Her main research focus is identifying barriers in cell characterization to allow the manufacture of safe and effective cell. Everyone knows that the first time you do something it is likely to take a lot longer than it will the next time and then the time after that. Erin aims to play an active role in the development of cellular therapies for widespread use. I believe that it is our responsibility to use novel technologies and our understanding of cells to affect people everywhere.
Erin Rayment completed a PhD in chronic wound healing with Zee Upton at the Institute for Health and Biomedical Innovation at the Queensland University of Technology in Australia. as has happened in the travel industry. and.Young Voices in Research for Health 2009
the key to this problem is improved process design and. with it.” So. we need to let the machines do the work. The airline business is a prime example of this concept. will guarantee a therapy to fit everyone’s financial situation. Ultimately. This. There may be some people who think that cell-based therapies will never reach global beneficiaries and that the idea of small bioreactors to create blood cells will always be science fiction. To those I ask this: Was it that long ago that mobile phones were being portrayed as fictional? Did anyone ever believe that you would be able to order groceries through your computer? Yet now these things are commonplace for many people. I also feel that it is through innovation in processing and improvements in automation that this will become possible. we must do.and tissue-based products. we must apply. Only the other month. I remember a time when it cost at least AUS$ 500 to fly from Brisbane to Sydney – something that now costs as little as AUS$ 50 if you book on the right day. there will be strong incentives to reduce individual unit prices.
5. This approach yields minimal enhancement of understanding and precludes conducting novel and risky studies that may provide scientific breakthroughs. question the technique. condemned to be filed in a forgotten bench or desk drawer. get a persevering. the sample size or the phase of the moon. Unfortunately. the interests of funding agencies (more willing to sponsor studies that are likely to obtain positive results) and the general perception that negative results equate with failure. the reality of negative results is that they constitute the most common outcome in scientific endeavours. In fact. or the person performing the analyses did not have the appropriate supervision.05 in a post-hoc analysis and then write a paper around that “p” value. accept your negative results and submit your paper to a lower-impact journal. Clearly. about 80% of experiments or studies conducted generate negative results. wait for the next paper reporting a positive result and add a few lines mentioning that the experiments with negative results were performed but that no statistical differences were observed (the classic “data not shown”). finally. Obtaining a negative result does not mean that the rationale behind the study was incorrect. They include the peer-review and editorial process (always looking for interesting titles that catch the public attention). the model. In my experience. are as important as positive results.
. This phenomenon may have its roots in several factors. such practices can create more misinformation than information and are unlikely to make any substantial contribution to the state of the art in any field. a major risk of trying to avoid negative results is that researchers will keep repeating the same experiments that are recognized for giving positive results but add some little variation to make them “original” and easy to publish. if none of the previous alternatives work. Given the constant pressure to publish well and fast. Although some of the “solutions” above increase the likelihood of negative results being published. one unavoidable question that needs to be addressed is what to do with negative results? I put this question to some friends working in science. transfer blame to whomever brought up the brilliant idea that led to the negative results.05]). the only correct interpretation for negative results is that the null hypothesis for that particular case could not be denied (the probability was higher than 5% that the differences observed between or among the groups were given by a random condition [p>0. motivated and creative statistician to obtain some “p” value <0. The first step towards avoiding this misperception of negative results is to have a clear understanding of their meaning. the instrument. 4.International database of negative results in biomedical research
Christian Rueda-Clausen. there are no records that let us estimate in an objective manner the proportion of results obtained in science that are negative. and the following are some of the answers that I received: 1. the time and resources used in those studies were futile. However. Colombia
InteRnAtIonAl dAtAbAse of negAtIVe ResUlts In bIomedIcAl ReseARcH: tHe need to sHIft A pARAdIgm In scIentIfIc pUblIcAtIon
Negative results in science have traditionally been perceived as data of little value. 2. and need to be reported and discussed with the same rigour and priority. 3.
Given this continued amplification of positive-results bias. a modest journal that has published around 70 articles since 2002 with a current estimated impact factor of 1.clinicaltrials. reviewers. provide their rationale and design. Good examples are international databases like the International Clinical Trials Registry Platform of the World Health Organization (www. However. support the decisions to proceed with large and expensive clinical trials. Indeed. only those preclinical studies that obtain positive results get well published. This type of bias has the snowball effect of pushing the available evidence towards positive findings throughout the different translational levels. Consequently. despite not being a high-priority project for any of these groups in the research community. Nonetheless. In fact. editors and readers alike to massively increase submissions to journals of negative results. preclinical or epidemiological studies. However. and reviewers and editors are more likely to accept. among the 6426 registered in the Journal citation report. and facilitate the publication of their results – whatever they are. the intriguing part of this publication dilemma is that.
.int/ictrp) and the Clinical Trial Registry of the National Institute of Health (www. dedicated to the publication of negative results2. this is the information used by policy-makers to make decisions regarding the allocation of health-care resources. from basic fundamental research to policy-making. a tremendous amount of effort would be required on the part of authors. To further amplify this bias. not everything in the publication system stands against reporting negative results.Young Voices in Research for Health 2009
The inability to publish negative results may have an enormous impact on the whole scientific and non-scientific community.38. This constitutes the only peer-reviewed journal. positive over negative results1. As a result of this kind of bias. The goals of these databases are to keep track of all clinical trials. those clinical trials with positive results are more likely to be published more quickly and in more-visible journals. Another brave initiative to deal with this issue of publishing negative results is led by the open-access publisher BioMed Central with its Journal of negative results in biomedicine. these registries cover only clinical trials and do not encompass basic.who. even though they may reflect only a minority of the relevant research. biomedical journals specialized in basic research are full of articles with colourful titles that highlight the positive findings but may not be a faithful reflection of all the results that were obtained. gov). these studies. some substantial initiatives have arisen in the past decade to deal with this situation. The positive-results bias is a common type of publication bias that occurs when authors are more likely to submit. Again. Going further into the effect of this publication bias. Creating more journals for the publication of negative results may not be a practical solution to this problem. efforts to synthesize the evidence through systematic reviews and meta-analyses may overestimate the effect of certain interventions or conditions and create a false perception that it could be beneficial or prejudicial when in fact it may not be. it should not be surprising when some clinical trials fail in reproducing the results obtained in earlier stages of research. Ultimately. In fairness. these exaggerated positive results form the foundations for the design of preclinical studies. they all need a repository of negative results to facilitate the ready accessibility of these important data at any given time.
2 Universal access to authors and consumers would need to be guaranteed. Beyond the creation of new databases. multi-language. Journal of negative results in biomedicine. persistent and synergistic participation of all the players in the game of biomedical science. In 2005. from students to policy-makers. In conclusion. In order to achieve success in this initiative. if necessary. The creation of this database may not only change the perception of what constitutes successful research. organizing. summarizing and disseminating negative results obtained in basic. 1:1–6. achieving this goal would require the active. when he moved to the University of Alberta in Canada to become a PhD student. The creation of electronic registries for negative results constitutes an interesting alternative to enhance the perception and divulgence of negative results because it could provide the scientific community with an opportunity to know what other groups have done and to discuss unexpected results. In 2004. open-access platform with no publication charge. 1979. where he worked designing and coordinating clinical and epidemiological studies.3 Database support staff would have to ensure that all manuscripts were organized in a multilevel classification system. he returned to Colombia to launch and manage a vascular reactivity laboratory. a concerted effort is required by the research community as a whole to emphasize the usefulness of negative results. clinical and epidemiological studies. 2002. This may have a significant beneficial impact.
Sackett DL. the challenge of changing the connotation of negative results is formidable because it entails breaking a long-term paradigm. but may also improve the quality and validity of the scientific evidence available. Prominent medical journals often provide insufficient information to assess the validity of studies with negative results. Therefore. Since then. critically reviewing. originality and methodological rigour behind every manuscript reporting them. There is strong reason to believe that the results would justify these efforts. there are some technical elements that would need to be considered:1 Any registry in this database would need to include a brief rationale supporting the study. he received a Spanish Agency for International Cooperation award and moved to the Universidad Complutence de Madrid in Spain to complete a training programme in basic sciences. a detailed methodology.International database of negative results in biomedical research
That being said.
. he has been studying the long-term cardiovascular effects of pregnancy complications. Additionally. Hebert RS et al. the perception of negative results as an undesirable product with little research value needs to be challenged at all levels of biomedical research. particularly in the realm of knowledge translation and medical practice. an electronic registry dedicated to filing. under the supervision of Sandra Davidge. having finished medical school in 2003. which he did until 2007.4 Powerful search engines would need to be incorporated to facilitate access to the information.
Christian Rueda-Clausen. Bias in analytic research. this registry would need to be a paper-free. the principle objective of this essay is to make a call to authors. Therefore. I would also like to propose the creation of the International Database of Negative Results in Biomedical Research. a description of the statistical analyses performed and an interpretation of the negative results. J Chronic Dis. 32:51–63. Therefore. editors. reviewers and readers of biomedical journals to erase the stigma surrounding negative results and to spend more time evaluating the rationale. enrolled at the Cardiovascular Foundation of Colombia.
Pour le rompre il faut aller au-delà de la problématique de transfert technologique et proposer une solution à la base du système: l’éducation tertiaire pour créer une classe intermédiaire qui sera à l’origine de l’innovation (médicaments.) et maître de son développement jusqu’au marché final (les patients). Il y a donc un certain antagonisme entre les deux propositions. Le second dépend des incitations des Etats : le modèle de pensée qui conçoit l’innovation dans les pays développés pour la transférer vers les PVD n’est plus viable. coûteux et extrêmement risqué d’un médicament doit être rétribué et il est normal.Young Voices in Research for Health 2009
Valérie Sabatier. est une promesse qui pour être réalisable nécessite deux grandes mesures : la possibilité d’avoir en entreprise des modèles économiques ambidextres et le développement de l’éducation tertiaire dans les PVD. France
PlaidoYeR PouR des modèles économiques ambidextRes et la PRomotion de l’éducation teRtiaiRe dans les PaYs en Voie de déVeloPPement PouR l’innoVation en santé à la PoRtée de tous
Innover pour tous.
Des modèles économiques ambidextres
Les entreprises reconnaissent l’importance d’amener des solutions innovantes pour tous mais doivent répondre à des impératifs de profitabilité et de rétribution des risques pris par les actionnaires. Le premier modèle se base sur une logique classique d’entreprise et cherche à créer de la valeur pour l’entreprise et ses parties prenantes alors que le second se base sur une logique d’organisation à but non lucratif et une création de valeur pour tous. avec b) un modèle économique basé sur l’accès à l’innovation pour tous: créer de la valeur pour tous à travers le développement des médicaments et capturer cette valeur grâce à l’amélioration des conditions de vie ou du taux de survie. que la prise de risque soit récompensée. Or innover pour tous implique d’apporter des solutions pour des marchés rentables – les pays développés– ainsi que pour des marchés moins rentables – les PVD. L’expérience nous donne aujourd’hui l’exemple de l’Orphan Drug Act (loi sur les médicaments orphelins). Cette mesure sort du premier cadre et se base sur la
. dans une certaine mesure. Le premier levier est lié à la gestion : permettre aux entreprises de biotechnologie et de pharmacie d’avoir des modèles économiques qui conduisent à l’innovation pour tous. matériel de diagnostic. vaccins. Il faut donc conjuguer deux modèles : a) un modèle économique basé sur du profit : créer de la valeur pour l’entreprise à travers le développement des médicaments et capturer cette valeur grâce aux marges sur la vente du produit . Investir dans le développement long. etc. au sens d’amener l’innovation en santé dans les pays développés comme dans les pays en voie de développement (PVD).
Par exemple un vaccin est découvert et développé en Europe ou aux Etats-Unis puis quelques années plus tard des unités locales de production seront implantées en Afrique. Outre le fait que la volonté de faire du transfert technologique
. La tentation d’utiliser les ressources de l’un pour financer l’autre est forte. En effet le seul financement par des fondations rencontre des difficultés comme le souligne Bill Gates dans sa lettre annuelle pour la fondation Bill & Melinda Gates. Pourtant une voie intermédiaire existe : il est possible de mener de front deux modèles économiques au sein de la même entreprise. Ce système de transfert vers les PVD semble logique puisque c’est dans les pays développés que les laboratoires de recherche sont implantés et financés et c’est aussi là que résident les marchés les plus attractifs pour les entreprises. Seule une gestion transparente et auditée peut garantir la bonne distribution des ressources. L’unique modèle lucratif ne conduit pas à l’innovation pour tous tandis que l’autre seul ne semble pas être la solution. Poussée à l’excès par certaines entreprises. Au regard du nombre de médicaments orphelins demandant la certification et arrivant sur le marché les gouvernements et les assurances ne pourront bientôt plus payer ces traitements. Le second est à destination du vaccin non lucratif : financement par des fondations et le retour sur investissement pour l’entreprise est équivalent aux coûts engagés pour le développement et la production. La création de valeur passe d’une logique de bénéfice pour tous à une logique de bénéfice pour l’entreprise. Pragmatiquement elle ne peut avoir un modèle lucratif sur le second vaccin. sans marge sur le vaccin. Elle peut développer d’une part un vaccin à destination des pays développés et d’autre part un vaccin pour les PVD. L’effet de synergie entre le monde des affaires et le monde des fondations au sein de structures ambidextres est une piste à explorer pour amener l’innovation à portée de tous. C’est par ailleurs un prérequis pour les entreprises qui reçoivent des donations de grandes fondations. cette voie est devenue un moyen stratégique de recentrer la capture de valeur sur l’entreprise. Ce double modèle économique est déjà faisable mais les entreprises qui le pratiquent doivent être rigoureuses dans la gestion et le financement des différents projets. Autre point délicat. Prenons le cas d’une entreprise qui développerait un vaccin contre le VIH. surtout lorsque les deux médicaments sont développés en parallèle et contre une même pathologie. La solution est la coexistence de deux modèles économiques. D’un point de vue de gestionnaire cela conduit des entreprises innovantes à se focaliser sur des marchés de niche : elles cherchent à minimiser leurs coûts et faciliter leur accès au marché.
Promouvoir l’éducation tertiaire
Jusqu’à présent l’innovation est générée dans les pays développés puis transférée vers les PVD. il faut que l’équipe qui mène les projets soit aussi investie dans l’un que dans l’autre.Plaidoyer pour des modèles économiques ambidextres
création de valeur pour tous plus que pour l’entreprise. L’ajustement des modèles économiques entre création de valeur pour l’entreprise et création de valeur pour tous est donc délicat. Grâce à l’Orphan Drug Act les entreprises bénéficient de procédures plus rapides et d’aides financières. Le premier est à destination d’un vaccin lucratif: des investisseurs financent le développement du vaccin et devront avoir un retour sur investissement à la mesure du risque pris.
Le management de l’innovation dans le secteur de la santé est si complexe qu’il requiert les interventions de beaucoup de métiers hors du traditionnel champ scientifique. Les structures privées d’éducation tertiaire à vocation sociale – c’est-à-dire visant à atteindre l’équilibre financier et s’engageant fortement dans le développement du pays et la montée en compétence de ses étudiants pour en faire des piliers de l’innovation – permettent d’accéder à cette transparence grâce au financement pour partie par des fondations et organismes internationaux. Ces deux propositions – faciliter les modèles économiques ambidextres et soutenir l’éducation tertiaire dans les PVD – doivent être mises en perspective avec la raréfaction actuelle des ressources financières à l’échelle mondiale : la baisse des fonds provenant des fondations et des pays donateurs rappelle l’urgence de la situation. et donner aux autres les moyens d’eux-mêmes innover. C’est donc le système dans sa globalité qu’il faut repenser et chercher dès aujourd’hui des solutions à long terme pour un développement durable et soutenable de l’innovation. En Europe et aux Etats-Unis cela est basé sur les réseaux d’innovation. De plus les trajectoires technologiques étant en construction dans les PVD celles-ci sont flexibles. les pôles de compétitivité. les PVD doivent également avoir leur propre manière d’innover. Pour que ces pays deviennent des sources d’innovation il faut prendre le problème à son origine. C’est aujourd’hui une opportunité pour préparer dès à présent les grandes transformations du secteur de la santé en apprenant les méthodes sans copier les modèles. Bien que ces deux recommandations ne soient pas directement liées elles servent le même but dans une optique de développement à long terme. Pour mettre fin au caractère unilatéral du transfert technologique. Les ressources limitées des pays ainsi que l’opacité des transactions dans certains d’entre eux rendent la tâche ardue. les grands laboratoires publics et les départements de R&D des entreprises. cela n’apporte pas de solution durable au problème et maintient le déséquilibre de la balance de l’innovation. L’éducation dans les PVD est aujourd’hui un des grands chantiers de l’humanité et doit permettre de fournir à ces pays une classe de scientifiques et managers capables d’être sources d’innovation. au niveau de l’éducation. Ces pays doivent être au cœur et acteurs de la mise en place de ces structures. Le défi est donc double : il faut proposer des formations de haut niveau en sciences et en management de la santé. Par conséquent le soutien aux structures éducatives locales est primordial.
. Mais ce modèle nécessite d’être adapté à la manière dont veulent innover les PVD. Les accréditations telles que l’AACSB (Association to Advance Collegiate Schools of Business) et les attributions de subventions sont conditionnées par des audits extérieurs qui obligent ces structures à la transparence.Young Voices in Research for Health 2009
vers les PVD soit tout à fait louable. Il faut permettre aux uns de monter des structures financières pour répondre aux impératifs économiques tout en donnant accès à l’innovation pour tous . La mise en place de structures éducatives tertiaires doit chercher à atteindre dès l’initiation les critères internationaux de qualité de l’enseignement et de transparence. C’est ici que le secteur privé de l’éducation apparait comme un levier car il peut être audité. les structures de transfert.
She conducts research at the Grenoble Applied Economics Laboratory and is also involved with a French biotech company named PX’Therapeutics. She graduated in biochemistry from University Montpellier 2 and holds a Master’s in Business Administration from Grenoble Ecole de Management. France. She now plans to establish a school in the Lao People’s Democratic Republic.
.Plaidoyer pour des modèles économiques ambidextres
Valérie Sabatier is finishing a PhD in business strategy entitled “Value chain and cost of drugs: transformations in the biotech industry” at Grenoble University. Born in South Africa of a French father and a Lao mother she grew up in France.
structural and human resource problems continue to plague health systems in resourcepoor countries. The results are predictable. which has resulted in the majority of the population lacking access to basic health-care services. As the health crisis worsened. pneumonia. clinicians are stifled by the work required to run a health facility with so little staffing. Between 1992 and 2004. continue to elude poor people around the world. Malawians referred to Neno as a “dead district”. In Neno. Malawi has one of the lowest densities of health-care workers in the world. In regions with failing health-care systems. While unprecedented resources are being dedicated to global health equity. The health-care system crumbled in the wake of the growing HIV pandemic. as families struggled to produce enough food and support sick and orphaned relatives. a handful of isolated health-care workers struggle to care for entire districts of people. Tuberculosis and Malaria have allocated vast sums of money to broaden the availability of health care in resource-poor settings. Malawi. Now the pharmacy warehouse coordinator for Partners in Health in Neno. Today. The Bill & Melinda Gates Foundation has invested heavily in the development of new technologies to benefit health in developing countries. delivery strategies have been overlooked. treatments for the aforementioned illnesses. However. The situation was similar throughout much of rural Malawi. Nurses and clinicians must invest significant time in laboratory and pharmacy services. average life expectancy dropped from 52 years to 411. like Steve.Young Voices in Research for Health 2009
David Shulman. Documentation and evaluation of such delivery strategies must become a priority in global health research. this place was down. little consensus exists on the most effective methods of delivering these fruits of modern medicine. an innovative health-care delivery system has been effectively implemented to strengthen and expand health services. which reduces the time available for patient care. Health facilities frequently lack sufficient stocks of medicines due to the lack of political will and poorly designed forecasting and procurement mechanisms. compReHensIVe HeAltH-cARe model foR All
“This place was down. and donors such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS. United States of America
commUnItY empoweRment foR globAl HeAltH eqUItY: towARds An InnoVAtIVe. I’m telling you. While funding and technology have advanced. most of which have been in existence for at least 10 years. the health-care workforce weakened. “everyone wanted to leave”. Experts in the field refer to this barrier as an “implementation bottleneck”. Facilities themselves are beginning to deteriorate due to the lack of maintenance. malaria. Malawians suffer predominantly from treatable illnesses. where I have worked. diarrheal disease and perinatal conditions compose the five most common causes of death2.” Steve explained as we counted bottles of albendazole. Steve recalls the desperation of day-to-day life during his childhood. Health
. Even when the proper medicines and tools are available. In rural areas across Malawi. The model draws heavily on people from the local community. AIDS.
and the Government of Malawi. funded primarily by the Global Fund. pharmacists and laboratory technicians to staff health facilities. the United Kingdom’s Department for International Development. Partners in Health has worked with MOH to develop community-based health care. a set of basic services costing US$ 17. these measures have not gone far enough. which reduces burnout and allows nurses and clinicians to provide higher-level services to patients. In 2004. the Ministry of Health (MOH) described the current state of human resources for health as “dangerously near collapse”. relying heavily on nurses. The human resource deficit presented an immediate obstacle to the implementation of services. Health-care implementation strategies in Malawi call for relatively conventional human resource frameworks. well-defined tasks to lay health workers lightens the burden on traditional health-care workers. However. the government implemented the Essential Health Package. hiring patients and people from the
. as health-care workers continue to work independently at rural posts. MOH established clinical officer and medical assistant positions. unsupported and unable to provide basic services to patients. Shifting appropriate. augment worker salaries. having overcome many of the same illnesses and challenges that face current patients. Communitybased health care may also be less costly than implementing a conventional healthcare model in resource-poor settings. to fill vacancies left by physicians and nurses. In Neno. Lastly. These strategies are effective in the developed world. physicians. Improvements in patient care can be achieved as community members. The goal was to ensure all citizens had access to basic care and was specifically geared towards poor rural Malawians. The World Health Organization recommends that regions with human resource deficits adopt task-shifting. provide crucial social support. Three years later the majority of health facilities around the country continue to be critically understaffed. Malawi’s health-care workforce remains fragile in spite of health policy reforms and foreign aid dedicated to the health sector. To date. allowing for the rapid implementation of services. The model draws on local human resources. we must investigate delivery strategies that can succeed in the current human resource environment. both of which require less than three years of formal training. In Malawi. where I have volunteered for the past nine months. Children with diarrheal diseases and pneumonia go untreated. The programme was designed to increase training capacity.53 per person per year. where large numbers of trained health-care workers exist. Workers are readily available in most resource-poor communities. the US$ 273 million Emergency Human Resource Programme was initiated. In 2006. The system builds little experience and is composed primarily of young health workers. There are several key benefits to such a model. and HIV and tuberculosis become further entrenched in rural communities. well-defined tasks are shifted to less-specialized health workers. hundreds of clinical officers and medical assistants have been trained and now outnumber the country’s population of physicians.Community empowerment for global health equity
workers turn over quickly. and provide incentives for working at rural posts. In 2004. While efforts to strengthen and expand the ranks of traditional health workers should continue. a process in which appropriate. succumbing to burnout or leaving in search of better jobs. These lay health workers receive onsite training to perform a wide range of supportive and basic clinical tasks.
int/ countryfocus/cooperation_strategy/ccsbrief_mwi_en. which new tasks can be delegated to CHWs. Geneva. This research has also helped to determine which tasks can be shifted from the clinical team to CHWs. pneumonia and AIDS-related causes. Neno district. these workers would be overwhelmed by the magnitude of the health crisis. the density of trained health-care staff in Neno remains below two workers per thousand people.
. a simple but time-consuming job in a place like Malawi. 2006 (www. Fewer people now die of malaria. In these programmes. such as the health system in Neno. as there is potential for a reduction in the quality of services. Individually. Community-based models have been utilized to successfully deliver HIV and tuberculosis treatment. This human resource framework has allowed for improvements in the capacity and quality of services. Geneva. District wide. As a result. this research must be used to build consensus on innovative delivery strategies for bringing health care to all. World Health Organization. Country health system fact sheet: Malawi. World Health Organization.pdf. accessed 2 September 2009). workflow. Operational research. We can no longer expect that health-care delivery models that evolved in the developed world will be effective in the developing world. has demonstrated the efficacy of community-based health care. Instead. we have worked with MOH to apply these strategies on many fronts. We must investigate these community-based programmes. these trained health workers make up less than one fifth of the total health workforce. Evidence from a variety of settings. In Neno.afro. And women now have a safe place to give birth.who. Pharmacy attendants have been hired locally and trained on site. int/home/countries/fact_sheets/malawi. has demonstrated the effectiveness of such models.who. The majority are lay workers from the community. have been built to meet the need for immediate intervention. and they now perform a range of stockroom management and dispensation tasks under the supervision of the pharmacy technician. patient capacity and outcomes. A variety of successful programmes. examining human resource structures. However. many involving the delivery of antiretroviral drugs and tuberculosis treatment. Many experts in the global health field are sceptical of such an approach. with a population of 125 000 people. ensure patients take their medicines and report side effects. involving the documentation of case studies and evaluation of patient outcomes.pdf.Young Voices in Research for Health 2009
communities being served promotes the economic health of individuals and the community as a whole. the technician can dedicate time to higher-level tasks such as district-wide procurement and distribution and the enforcement of rational prescribing. Laboratory attendants prepare malaria and tuberculosis tests. lay health workers have begun to support a significant portion of the workload. accessed 2 September 2009). Ultimately. Evidence from HIV and tuberculosis programmes has demonstrated the opposite to be true. now has a single pharmacy technician and two laboratory technicians. what methods of training are most effective and how CHWs should be paid. community health workers (CHWs) are trained to visit patients daily. but this scepticism highlights the importance of evaluating these programmes to understand the most beneficial frameworks for distributing tasks and designing workflow. 2006 (www.
Country cooperation strategy: Malawi.
David began his first year at Harvard Medical School as an MD candidate. United States of America. After graduating he spent 10 months volunteering for Partners in Health and its sister organization Abwenzi Pa Za Umoyo in southern Malawi. In August 2009.Community empowerment for global health equity
David Shulman graduated from Union College. While at Union.
. the United Kingdom and the United States of America. in 2008 with a Bachelor of Science in Biology and an interdisciplinary minor in Global Health. David conducted neurobiology research and studied health systems in Canada. the Netherlands. where he worked primarily on developing pharmacy management systems and clinical monitoring and evaluation.
I come from Nigeria. When the big thing stops working everything stops. the incidence of HIV continues to rise in young people. Appropriate methods and technology can be defined as practical. Sub-Saharan Africa and South-East Asia are home to about 20% of the world’s population and most of the developing nations of the world. it is not surprising that health-care services are equally poor. These two principles form the backbone of the success of any health-care system. the most pressing health problems in developing countries. The time is ripe for innovations in health care in Nigeria. allowing the words to sink in and then continued the guided tour of Awojobi Clinic in Eruwa. and some innovations that have been developed to solve them. the capital of Oyo State in Nigeria. a country
. deadly yet preventable childhood diseases like malaria and diarrhoeal illnesses ravage the under-fives. as most of the people live in abject poverty.Young Voices in Research for Health 2009
Okezie Uba-Mgbenena. As low socioeconomic status is a major determinant of health and the occurrence of disease. The clinic is named after him. diabetes mellitus and cancer terrorize the middleaged and elderly. The country has the world’s second-highest maternal mortality ratio. especially primary health care. many small things are better than one big thing. builder and “Chief Dreamer”. The infant mortality rate is 97 per 1000 live births.”
He paused. and hypertension. This essay will focus on the need for innovations in appropriate methods and technology in health. A stitch in time saves nine. as evidenced by dismal health indices. a country with a population of over 140 million people and a life expectancy from birth of 48 years for males and 49 years for females. the proprietor and consultant surgeon or architect. Although much of the world’s natural resources are found in these countries. With the help of local artisans. He surmounted the perennial challenges of water and electricity supply by harvesting rainwater. scientifically sound and socially acceptable approached and equipment that the community and country can afford to maintain at every stage of their development. It was a striking testimony to the triumph of ingenuity over impossibility. constructing reservoirs and maximizing natural light. second only to India’s. but it is unlikely for all the small things to stop working at the same time. as he has been variously called. a rural town 40 kilometres from Ibadan. Nigeria
AppRopRIAte metHods And tecHnologY In HeAltH: A RoUnd peg In A RoUnd Hole
“Always remember this. Dr Oluyombo Awojobi. a stark contrast exists. under-five mortality rate is 189 per 1000 live births and the maternal mortality ratio is 800–1500 per 100 000 live births. he has been able to design and fabricate most of the equipment in the hospital from local materials. In addition. developing countries and the world at large. No different is the story of Nigeria.
Appropriate methods and technology in health
that produces about 1. Several other areas will benefit from the application of suitable methods and technology. making it one of the largest producers of crude oil in the world. First of all. to bridge the gap between the rich and the poor in health care. The partograph has been recognized as a simple and inexpensive tool that can be used in identifying and referring complicated pregnancies for specialist care. While some of these processes are established but poorly implemented. The use of high ceilings and efficient cross-ventilation and the planting of trees for shade will reduce the need for airconditioning systems in the tropics. Therefore. Medical personnel need to be reoriented on the need for and appropriate use of the
. where there is poor health care coverage and resistance to foreign influences and interventions stem from local traditions and taboos. the rainy season spanning seven months and the dry season spanning five. and in Nigeria in particular. However. one of the main stumbling blocks to the provision of quality health-care services in developing countries. The health indices mentioned above point to the fact that the Nigerian health-care system is in desperate need of resuscitation – the kiss of life. other natural sources of water such as springs. The capacity of these reservoirs will depend on the needs of the health facility. In addition. one may say. as the different levels of government continue in their protracted efforts to solve the problem. About 51% live in rural areas. acceptable and affordable methods and technology have to be developed and implemented at all levels. Sadly. This necessitates more research into culturally acceptable and affordable methods and technology that can be employed in health-care delivery. sunlight can be maximized through the appropriate number and positioning of windows and by painting the walls with light colours. these sources should be subjected to regular chemical and microbiological analysis to verify their safety. The first group needs re-evaluation and rejuvenation. one has been staring us in the face all the while. This cannot continue if the Millennium Development Goal of reducing maternal mortality by three quarters by 2015 is to be realized. is the lack of availability of potable water or regular power supply to health facilities. which reflect light and help to brighten the place. several have been developed. I have no doubt that. recognition and introduction into the mainstream of health care. so that the water in the tanks can flow into water pipes assisted by gravity and thereby eliminating the need for power-consuming pumps. It is time to use them. rainwater can be harvested using rain channels on roofs and directed to a water tank positioned just a little lower than the level of the roof. These problems are longstanding and do not yet seem ready to pass. alternatives have to be explored. Fortunately. In all sincerity.8 million barrels of crude oil per day. others are new and not widely known. Nigeria has two main seasons. During the rainy season. to reduce the need for electricity during the day. such as maternal health. lakes and wells can be explored. when rainfall is abundant. effective. Large reservoirs can be built to store water so that water will be available during the dry season. Over half of the country’s population live on less than US$ 1 per day. streams. In this age of intense search and agitation for alternative sources of fuel and power. For billions of years the sun has emitted light and heat. which is a serious issue in developing countries. while the second needs evaluation. Its widespread use is still a mirage.
We have to learn to use small things to have a big impact. apart from poor immunization coverage. He is the chairman of the Action Group on Adolescent Health Ibadan. To solve this problem. when individuals and groups are encouraged to clear bush. Furthermore. He is also currently involved in the production of a radio programme that aims to reduce the stigmatization of people living with HIV and is aired by the Federal Radio Corporation of Nigeria in Ibadan. long since eradicated in most countries of the world. One of the reasons for this. This is but the tip of the iceberg of fresh ways of tackling health care in countries with resource-poor settings and populations of low socioeconomic status. Is it not possible to convert this into a vehicle of progress by standardizing their practice and then integrating them into the health-care system with adequate recognition? Such measures will go a long way towards bridging the sociocultural and religious gap between the community and health-care providers. for example rendering them infertile. development and implementation of new and acceptable methods and technology is imperative in this era of global financial crisis and the consequent call for maximizing resources. These rumours spread like wildfire and have serious adverse effect on the turnout of mothers and children for immunization. is the fact that some women actually reject the vaccines.
Okezie Uba-Mgbenena is a fifth-year medical student at the University of Ibadan. a large number of women and the community at large have a high regard for traditional birth attendants and maternity centres located in and owned by religious bodies.Young Voices in Research for Health 2009
partograph. This happens because rumours are spread that vaccines contain dangerous chemicals that have serious effects on the children. local traditional authorities and elders who are respected opinion-shapers in the community have to be centrally involved in disseminating information and dispelling such hearsay. His commitment to public health led him to become the health minister and chairman of the health committee of Nnamdi Azikiwe Hall at the University of Ibadan. especially through the prevention of HIV and other sexually transmitted infections among youth. More groundbreaking research into the creation. An award may even be given to the most efficient group in the community to encourage healthy competition. Also.
. He advocates for the enhancement of reproductive and sexual health. the prevention of other diseases such as malaria can be achieved by distributing insecticide-treated nets free of charge and organizing public sanitation days. Let us take solace in the fact that little drops of water make a mighty ocean. can easily be alleviated by the targeted teaching of mothers regarding the correct preparation of sugar-salt solution with locally available materials. Nigeria. is still a threat to child health in Nigeria. Diarrhoea. Child health is another sensitive area as several vaccine-preventable diseases are still a cause for public health concern in Nigeria. who hails from Anambra State. Polio. drains and other possible breeding sites for mosquitoes. another important cause of morbidity and mortality in children under five in Nigeria.
claiming without fail that these pioneering approaches will lead to a substantial improvement in the health-care situation of any number of patients. It is what makes research exciting and keeps researchers on their toes. recombinant fluorescently tagged viruses and magnetic cell separation techniques all day long. really the answer to the problems of the developing world? Or are we maybe fooling ourselves (and our funders). are these innovative. I am a molecular biologist working on HIV. I used to buy into this idea. an intellectually sterile task. during which we were shown a set of illustrations which piqued my interest – a map of sub-Saharan Africa showing the regions at risk for trypanosomiasis (in humans colloquially known as “sleeping sickness”) and a graph depicting the incidence of trypanosomiasis in – I think – the Democratic Republic of Congo over the past 80 years or so. the idea that in such a fast-moving field sufficient intellectual effort and highly advanced technology could make an actual contribution to the living standards in many of the worst-hit areas in the world. cutting-edge technology in resource-poor settings no more than a justification for us to use this technology without actually delivering a return for the people in the afflicted regions of interest? Certainly there are returns for the researchers in question. solid word. more importantly. patent applications and scientific status. Not as smarmy as many others in the lexicon of corporate buzz speak (“proactive”. without the continuous drive to approach problems in new and inventive ways. Innovation is what I do. that. I cannot help but wonder if it is not a hollowed-out term – a term designed to cash in on the grant money without necessarily delivering the goods. As applied to health care for all. without innovation. “incentivize” and the hardy perennial “empowerment”) but glitzy enough to get papers accepted. and is the application of ground-breaking. emerging – and yes. And rightfully so. A good. Allow me to clarify: biotech projects focussing on health-care challenges in the developing world (HIV being a case in point) tend to rely heavily on new. research would be reduced to nothing more than bookkeeping. Belgium
wHo Is At tHe ReceIVIng end of oUR InnoVAtIon?
Innovation. maybe. in terms of high-ranking publications. high-tech approaches to solve existing issues really what we are waiting for? I remember a drowsy course long ago in parasitology. but how much of this flows back to the people who are actually targeted? And. the constant development of new ways of doing science. After all. I remember choosing biotechnology at the university precisely for its cutting-edge allure. though. innovative – technologies.Who is at the receiving end of our innovation?
Rafael van den Bergh. What was striking is this:
. But do they? Do they really? Is innovation in research. I work with genome-wide microarray profiling systems. bring in grant money and successfully sell far-fetched concepts and ideas.
It is a terrible thing to say. many problems could actually be solved using existing knowledge and technologies (albeit decidedly unsexy ones).Young Voices in Research for Health 2009
Rafael van den Bergh
Risk for trypanosomiasis is strongly associated with political instability. trypanosomiasis dropped to its lowest incidence rates in that country during the relative political stability of the colonial years. Now. famine and war. Nevertheless. many diseases go hand-in-hand with poverty. and would be considerably reduced as social conditions are improved. i. focuses on HIV and tuberculosis coinfection in sub-Saharan Africa and is an intellectually challenging amalgam of advanced molecular and cellular strategies designed to unravel a specific disorder
. While money is being spent on academic. I am only too aware of the nightmares of our colonial history and would never dream of defending this period of national shame. A project we are collaborating on now. or if there is it will be along the predictable lines of “both approaches are needed to efficiently combat disease in resource-poor settings”. this is a dangerous thing to say. what these graphs suggest is that the underlying biology of the disease. is it better to fund an innovative molecular biological analysis of the interplay between the parasite and the host immune system in the hope that it will one day yield a possible (but probably expensive) therapeutic strategy? Or is it preferable to alleviate dire social conditions in the regions at risk using non-innovative approaches (prevention strategies. I think William Blake’s lines “Can I see another’s woe/And not be in sorrow too?/Can I see another’s grief/And not seek for kind relief?” even came to mind at some point. skipped the lengthy PhD process of scientific advancement and attempted to contribute something at the logistical level? I would like to stress that I do not know or pretend to know the answers to these questions.e. The greater the civil unrest in a specific region. Many. I cannot help but feel frustrated about our focus on technological innovation as the be-all and end-all solution for the developing world’s problems. when – despite the evils of colonialism – strict logistical measures were taken to control disease. To take it to the personal level: Should I really have studied biotechnology when I wanted to provide some form of aid to the disease-stricken regions of the world? (Young and naïve. logistical support. Presumably. publication-oriented questions (albeit interesting ones). in which new-fangled technologies are being pushed forward as the solution to all the developing world’s problems. there is no correct answer. etc. may not really be the challenge at hand. when in fact they are just the newest toys that we would like to play with. Incidence rates leapt up to staggering heights soon after independence and the onset of all the associated civil unrest. On the one hand is the frustration that opportunities are being missed. As a Belgian. Nevertheless. Should I simply have studied economics. Worse still.) that we already have at our disposal? – with the added benefit that trypanosomiasis is not the only disease that can be tackled in this fashion. the higher the rates of trypanosomiasis become. for instance.) This choice has so far not delivered any actual benefits to anyone in the field. the aspect that we are now targeting with our innovative and costly approaches. these data raise a set of simple yet fundamental questions: If you want to combat a disease such as trypanosomiasis. In other words. On the other hand is frustration (but this may merely be a private gripe of mine) concerning the dubious phrasing used in all project applications everywhere.
What I am questioning. is our focus on technological innovation as the quintessential solution to many of the developing world’s challenges.Who is at the receiving end of our innovation?
associated with antiretroviral therapy in a resource-poor setting. was it entirely honest of us to describe it in the project application as a direct contribution to HIV and therapy management in the field? Would it not have been more honest to say that we will. I have always believed. and continue to believe. it is not an overstatement to say that it may determine whether we have a future. with an accordingly high price tag. in the long run. In conclusion. However. He is working on his PhD at the Flanders Institute for Biotechnology. From a research point of view. may be more self-serving than public interest-serving. Indeed. a habit that. It is an innovative project. I would like to state that in no way am I advocating a reduction in research efforts in the context of health care for all. however. rather than improve standards of care? And would not the local population suffering from this disorder have been better off if the same kind of effort devoted to research were also devoted – again using non-innovative approaches – to improving their quality of life. and most of his actual work concerning HIV-host interactions at the molecular level is done in the labs of VUB and the Institute of Tropical Medicine in Antwerp. that scientific progress will shape the future. certainly. it concerns work that indubitably needs to be performed.
. in the first place. Selecting the best strategy for providing optimal health care for all while disregarding our own academic or other track records may be our biggest challenge yet.
Rafael van den Bergh was trained as a molecular biologist and immunologist at the Vrije Universiteit Brussel (VUB) in Belgium and has a long-standing interest in HIV research and care. improve our track record in this field of research. thus bridging the gap between their current situation and the 10–15 years down the road when our results are translated into actual solutions.
impulsivas o de negligencia sobre su propia salud. los esfuerzos sistemáticos en comprenderlo son recientes. Uruguay
pensAmIento tempoRAl Y sAlUd. presente o futuro. siendo especialmente utilizados la Escala de Consideración de Consecuencias Futuras y el Inventario de Perspectiva Temporal de Zimbardo.
La perspectiva temporal puede definirse como el grado en que una persona valora y determina su comportamiento en arreglo a consideraciones relativas a su pasado.
Pensamiento temporal y salud La dimensión temporal de la conducta ha sido una preocupación de algunos psicólogos desde el inicio de la disciplina. exclusivamente humana y fundamento epigenético de la cultura. con el propósito de que las campañas preventivas en salud sean más eficaces. Más allá de lo específico de cada medida. que va desde un pasado. el aporte de este ensayo se encuentra en el planteo de enfocar esfuerzos hacia el desarrollo de tecnologías e innovaciones sociales de intervención. La premisa de esta idea radica en que el aumento de la perspectiva temporal futura es la base del cambio conductual necesario para la mayoría de las conductas de riesgo que las campañas de prevención intentan combatir. específicamente el nivel preventivo. lo relevante es que estas han encontrado asociaciones entre la perspectiva temporal futura y conductas altamente relevantes para el bienestar y la salud. desde una perspectiva psicológica. Siendo así. necesIdAd de tecnologíAs socIAles pARA lA mejoRA en pReVencIón en sAlUd
En este ensayo propongo explorar las relaciones entre pensamiento temporal y la salud. Sin embargo. ha quedado rezagada. Existen varios estudios y medidas referidas en concreto al peso del futuro como modulador de la motivación. actúa en un presente y procura un futuro. La valoración de la influencia en la conducta de esta capacidad. Las asociaciones refieren a la regulación emocional frente a eventos negativos o
. Este vínculo –sin ser un clásico de las ciencias psicológicas-. no es novedoso y ya se han establecido correlaciones consistentes entre cómo ciertas personas perciben el tiempo subjetivo y conductas de riesgo.
El pensamiento temporal ¿Eje central de la motivación humana vinculada a procesos de salud?
Una de las mayores y más distintivas capacidades humanas es el sentido de tiempo personal o subjetivo. Los mismos han mostrado ser útiles para explicar una amplia gama de comportamientos y se ha argumentado que la naturaleza temporal de la conducta actúa como una de las fuerzas motivacionales más importantes.Young Voices in Research for Health 2009
Alejandro Vásquez Echeverría
Alejandro Vásquez Echeverría. que permitan incrementar el valor social del pensamiento futuro en poblaciones infantiles.
es un campo que desconocemos y sobre el cual los servicios educativos y sanitarios deberían exigir más de la comunidad científica. Se ha trabajado con paradigmas clásicos de aumento progresivo de la capacidad para postergar la gratificación y con simulación mental. Con todo.
Intervención psico-social sobre el pensamiento temporal. que produce consecuencias negativas y aún mayor desventaja social. gracias a los aportes del Modelo Transteórico del Cambio de Prochaska y DiClemente. la preferencia temporal y la función de utilidad intertemporal impide ver maximizaciones en la espera y las evaluaciones de los resultados futuros tienden a recibir menor valor. descansa en el supuesto de trabajar sobre un problema concreto que atañe a la población o grupo de riesgo. para ampliar el horizonte de las proyecciones de estados deseados. esto no es un tópico nuevo: numerosos trabajadores y profesionales en el campo de la asistencia social lo comprueban y lo viven día a día. como tampoco están sistematizados los procedimientos para poder replicarlos. las personas son más reacias a modificar o hacer sacrificios presentes en pro de evitar riesgos y peligros remotos.
La implementación de programas de prevención.
. sino que incluyen componentes socio-afectivos para producir la modificación o aversión a una conducta de riesgo. Sin embargo en contextos desfavorecidos o de pobreza. Las condiciones de existencia y las dificultades para acceder o alcanzar un nivel de vida adecuado durante varias generaciones pueden hacer que la perspectiva temporal de los adultos se haya visto reducida y esto se transmita a las generaciones jóvenes.Pensamiento temporal y salud
dañinos. El punto y auto-crítica está en preguntarnos: ¿Qué han hecho los servicios sociales o las ciencias de la salud al respecto? Ha habido experiencias aisladas para fomentar el desarrollo de la perspectiva temporal futura. el uso y abuso de sustancias y el alto índice de masa corporal1. configura una parte importante de la mejora en la eficiencia de estos programas y constituye la vía más segura hacia conductas de autocuidado permanentes en el tiempo. Esto configura una desventaja social. tal como el lector podría deducir del apartado anterior. ¿Qué sabemos? La tesis central de este ensayo la configura. Los mismos. no se conocen las razones de esta diferenciación. El desarrollo de programas para ampliar la perspectiva temporal futura en niños y adolescentes. Los padres son un canal de transmisión del pensamiento temporal. Respecto a la población infantil. se han hallado correlaciones entre la capacidad de postergar la gratificación en los años preescolares con el rendimiento académico posterior3. la conducción de riesgo.2. en la mayoría de las experiencias. que se necesita intervención psicosocial que fomente la capacidad de pensamiento temporal futuro en aquellas poblaciones de riesgo. ya no solamente se centran en aspectos informativos. que fomenten la asignación de valor a los resultados no inmediatos. como en el caso de la conducta sexual. a la par que se desarrollan los programas tradicionales de prevención. más aún cuando la satisfacción presente puede ser muy alta por la activación óptima de los circuitos de recompensa. Hasta donde estoy informado. Pero estos esfuerzos carecen de estudios empíricos que los avalen. Estimo que el desarrollo y fomento de esta capacidad. Desde una perspectiva económica. el uso de drogas o ciertas conductas extremas como la agresividad o la conducción de riesgo.
debo reflexionar sobre las implicaciones no estrictamente técnicas de la propuesta que aquí realizo y la posible violación de este principio. Desde mi trabajo en un plan de lucha contra la pobreza recuerdo la sorpresa de encontrar personas para las cuales el referente temporal “mes” –si bien les resultaba semánticamente conocido. más que un rasgo cultural suele estar asociado a estatus socio-económicos bajos o. de salir vencedora.Young Voices in Research for Health 2009
Alejandro Vásquez Echeverría
La ingeniería social del tiempo individual: Consideraciones éticas
Las diferentes culturas poseen cosmovisiones variadas en su relación con el tiempo. es más nocivo aceptar la hipótesis que intervenir en consecuencia. en otras palabras. En este sentido. La innovación está en el desarrollo de tecnología social que permita el desarrollo psicosocial equitativo de la población y le permita a la persona pensar. a través del proceso de socialización. la personalidad. la relación de ciertas poblaciones culturalmente diversas supone parte del patrimonio intangible de su cultura. a pobreza e indigencia. Por último. el desarrollo de investigación y la aplicación de programas que intervengan sobre la perspectiva temporal de las personas puede mejorar notablemente la eficiencia de todo el resto de las acciones preventivas y con efectos más sostenidos en el tiempo.
. la imposibilidad de movilizarse en marcos temporales amplios. El escrutinio cuidadoso me conduce a descartar cualesquier peligro en este sentido. dado el perfil de morbi-mortalidad de nuestras sociedades. Segundo. Primero. intentando incidir en aspectos de la constitución de la personalidad que se conectan con conductas de salud. donde la conducta humana juega un rol preponderante en la prevención de la mayoría de las formas de enfermar y de morir.
La promoción de programas de intervención para el desarrollo de aspectos psicosociales puede convertirse en un factor de prevención en salud. Esta modulación ocurre por medio de instituciones como la religión. los valores y conductas de quienes la integran. Cabe la posibilidad de que esta propuesta no aporte mucho en la resolución de los problemas que en materia de salud afronta el continente. Pero los indicios están y es una apuesta que. Esto implica dar un paso previo en la prevención. la diversidad y el trabajo inter-cultural. Por esto. En mis estudios fui formado en el respeto y admiración de los valores. A la par que se implementan programas específicos. las cuales moldean. a través del modelado y otros procesos psicosociales que tienen los medios de comunicación y otras fuentes que promueven el consumo. Estas diferencias parecen deberse más a la “cultura de la pobreza”. aceptar el supuesto de violación de la diferencia cultural implicaría negar la capacidad de diagramación social.era un espacio de tiempo que no les era útil para organizar su experiencia ni para proyectar actividades laborales. ofrecería muchos beneficios. La promoción del consumo es uno de los principales vehículos de la formación de subjetividad impulsiva y de orientación temporal presente-hedonista. basado en el relativismo. que a rasgos socioculturales o subculturales. conectar y valorar lo que hace hoy en relación con su bienestar de mañana. el trabajo y los temas culturales valorados.
Y. Se ha desempeñado como becario en el Ministerio de Desarrollo Social en un plan de lucha contra la pobreza y ha participado en diversas investigaciones dentro de la Universidad de la República. Time perspective. P. D. Time Perspective. En: Strathman A. (2005). 54. (pp: 85-107). Brit.. Actualmente es docente de Psicología Evolutiva y de Psicología del Trabajo de la misma Universidad y su interés en materia de investigación se centra en el análisis de la dimensión temporal de la conducta en el desarrollo y el trabajo. & Zimbardo.. J. W. Adams. & Nettle.
. Social Psychol. Pers. 14. (1988). J. Mahwah: LEA.Pensamiento temporal y salud
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Alejandro Vásquez Echeverría. & Joireman J. J. personality and smoking. Nació en 1981 en Montevideo. P. Mischel. Es licenciado en Psicología por la Universidad de la República y cuenta con un postgrado en Psicología de la Universidad del País Vasco/Euskal Herriko Unibertsitatea. 687-696. (2009). Health and Risk Taking.