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We read with interest the recent analysis of Joint External Evaluations (JEE) to assess International Health Regulations (IHR) compliance in the WHO African region. It is fantastic to see the engagement in the African region with this voluntary process, with 40 of 47 countries having been evaluated to date and 41 published mission reports (including Zanzibar), the highest proportion of completed JEEs for any WHO region. We congratulate the WHO Regional Office for Africa (WHO AFRO) for its leadership of this critical process. We would like to add our perspective as a technical agency engaged with and supportive of the JEE process.
As part of Public Health England’s (PHE) IHR Strengthening Project we have been engaging with National Public Health Institutes (NPHIs) in four African countries namely: Ethiopia, Nigeria, Sierra Leone and Zambia. In addition, we work with regional public health institutions such as the Africa Centres for Disease Control and Prevention (Africa CDC), and WHO AFRO to extend our reach beyond the bilateral engagement countries listed. The JEE process, with the subsequent development of a National Action Plan for Health Security (NAPHS), has been instrumental in informing and shaping our areas of engagement. In each of our partner countries, we have worked closely with the leadership of the NPHI and the relevant government ministries to develop workplans that address the gaps and needs highlighted in the JEE and prioritised...
We read with interest the recent analysis of Joint External Evaluations (JEE) to assess International Health Regulations (IHR) compliance in the WHO African region. It is fantastic to see the engagement in the African region with this voluntary process, with 40 of 47 countries having been evaluated to date and 41 published mission reports (including Zanzibar), the highest proportion of completed JEEs for any WHO region. We congratulate the WHO Regional Office for Africa (WHO AFRO) for its leadership of this critical process. We would like to add our perspective as a technical agency engaged with and supportive of the JEE process.
As part of Public Health England’s (PHE) IHR Strengthening Project we have been engaging with National Public Health Institutes (NPHIs) in four African countries namely: Ethiopia, Nigeria, Sierra Leone and Zambia. In addition, we work with regional public health institutions such as the Africa Centres for Disease Control and Prevention (Africa CDC), and WHO AFRO to extend our reach beyond the bilateral engagement countries listed. The JEE process, with the subsequent development of a National Action Plan for Health Security (NAPHS), has been instrumental in informing and shaping our areas of engagement. In each of our partner countries, we have worked closely with the leadership of the NPHI and the relevant government ministries to develop workplans that address the gaps and needs highlighted in the JEE and prioritised in the NAPHS. An example of this is the support provided to operationalise the Nigeria Centre for Disease Control (NCDC) Emergency Operations Centre (EOC) and strengthen its coordination at subnational level through development of Standard Operating Procedures (SOPs) and facilitating multi-sectoral simulation exercises. This followed the identification of public health emergency response coordination as a priority area for improvement in their NAPHS. We share the authors’ opinion that ‘JEEs… are galvanising multiple stakeholders to work together on health security’. We would add that focusing on the JEE and using the NAPHS development process as a coordination mechanism promotes efficiencies and leads to support driven by the host country’s identified and owned priorities rather than by donor interest.
Our approach aims to build sustainable systems beyond the traditional technical training activities. We deliver our support through four main workstreams:
1. Workforce development through needs assessment, planning and strategy
2. Context-specific technical training and strengthening of existing systems
3. Peer support and mentoring for system leadership
4. Strengthening NPHI coordination, planning and strategic functions
Each of the workstreams is co-developed with our host NPHIs, ensuring that they remain in the driving seat. We remain open to adapting our contribution to reflect changing priorities and strengthened local skills and competencies. This approach ensures long term sustainability with internal and external monitoring and evaluation to ensure accountability. As a public health agency, we have been able to use the JEE indicators as a proxy measure for impact. We have mapped our logframe indicators to the JEE indicators in order to demonstrate focus on priorities and progress. We are exploring similar mapping of our activities against self-assessment reports in order to monitor progress between JEEs. The authors of this paper are rightly concerned about this approach potentially introducing bias into the assessment to suit funding needs. However, if all partners engage in the NAPHS process and use it to demonstrate shared progress, this will result in less bias and increase collaborative and complimentary working. As the JEE process becomes more standardised and embedded within the global health architecture, we anticipate a greater scope for using JEE indicators to help evaluate donor health security programmes and encourage other partners to take this approach, thereby increasing transparency and accountability.
As this paper demonstrates, there are still clear gaps in IHR compliance across the African region, especially around emergency preparedness and response capabilities. The JEE process has been a step in the right direction to identifying and addressing these gaps in a constructive, coordinated, country-led way. Tackling these using a collaborative, sustainable approach will be key to protect the WHO African region from global health security threats. The reorientation of global health around the country-driven JEE process, rather than an agenda driven by outside priorities, is a welcome and much needed change.
Finally, we wish to highlight the potential value in engaging NPHIs as partners alongside WHO, donor institutions and governments in the ambition to strengthen global health security. NPHIs have the technical expertise and organisational infrastructure and culture to take a long term approach to partnership and collaboration, working alongside their less well-resourced partners to strengthen public health systems for health security and resilience. Peer learning between institutions represents a powerful, yet flexible approach to strengthening that can empower all participants. The International Association of National Public Health Institutes (IANPHI - www.ianphi.org), a member organisation of public health agencies has the capacity to facilitate such partnerships in support of strengthening public health systems and global health security. NCDC and PHE, as leading members of IANPHI, are actively working to promote such collaboration towards global health security. Such networks have strong potential for complementing and partnering with WHO in its ambition to achieve strengthened global public health.(1)
References:
1. Verrecchia R, Dar O, Mohamed-Ahmed O, et al. Building operational public health capacity through collaborative networks of National Public Health Institutes. BMJ Global Health 2019;4:e001868.
DISCLAIMER: Views expressed in this letter are those of the authors only, and do not represent the views or interests of the Bill & Melinda Gates Foundation.
We enthusiastically agree with the Editor's observation that what underlies the growing concerns about imbalances in authorship are the questions of power asymmetries in the production and benefits of knowledge in global health.
Critical and open self-reflections and reflexivity on "gaze" (who we write for) and "pose" (position from which we write) are much needed steps towards moving beyond representation on the list of authors.
However, if what underlies the imbalances in authorship is in fact power asymmetries, solving the problem of imbalances in authors requires directly interrogating the relations of power. Indeed, in our recent article, we identified marginalization the scholarship that interrogates the relations of power represents one of the persistent manifestations of the dominant norms of global health along with democratic deficit and depoliticization of the discourse (Kim et al. 2019). These manifestations may overlap or confound the relation between country/community of origin. We further argue that these manifestations are ideological in character in that they are not merely tendencies but functional in naturalizing and universalizing the implicit assumptions and norms of the dominant narrative.
The editorial raises an extremely important poin...
DISCLAIMER: Views expressed in this letter are those of the authors only, and do not represent the views or interests of the Bill & Melinda Gates Foundation.
We enthusiastically agree with the Editor's observation that what underlies the growing concerns about imbalances in authorship are the questions of power asymmetries in the production and benefits of knowledge in global health.
Critical and open self-reflections and reflexivity on "gaze" (who we write for) and "pose" (position from which we write) are much needed steps towards moving beyond representation on the list of authors.
However, if what underlies the imbalances in authorship is in fact power asymmetries, solving the problem of imbalances in authors requires directly interrogating the relations of power. Indeed, in our recent article, we identified marginalization the scholarship that interrogates the relations of power represents one of the persistent manifestations of the dominant norms of global health along with democratic deficit and depoliticization of the discourse (Kim et al. 2019). These manifestations may overlap or confound the relation between country/community of origin. We further argue that these manifestations are ideological in character in that they are not merely tendencies but functional in naturalizing and universalizing the implicit assumptions and norms of the dominant narrative.
The editorial raises an extremely important point when it observes that "foreign gaze can corrupt the local expert’s own sense of reality" or “foreign gaze can make a local expert write like an expatriate”.
The key question is: what underlies this “corrupting” of the local perspectives? It’s certainly not the “ foreignness” per se but the power relations circumscribing the “foreign” and “ local” views. We argue that it is the ideological character of the dominant norms that shape our consciousness (foreign or local alike). The dominant narrative is ideological in that it naturalizes and universalizes its own implicit assumptions and norms, therefore perpetuates itself. As such, the dominant narrative functions to shape our consciousness, the knowledge we count as valuable and thus produce and reproduce, and ultimately serves the interests of the elites and dominant classes (Muntaner et al. 2016).
We salute the editor’s efforts to draw critical reflections to the “gaze” and “pose” embedded in the scholarship in global health, and the power asymmetries. We struggle, however, with how the necessary critique of relations of power can be located within the reflexivity matrix. We call on the community of global health researchers, practitioners, funders, and policy makers to extend the editor’s laudable efforts further by positing slightly different questions: What are the relations of power underlying the authorship and choice of research/programmatic questions? How do they affect the knowledge produced?
What is necessary in solving the problem of imbalances in authorship is directly contesting the dominant norms and implicit assumptions, and making power visible, towards the goal of democratizing the ownership and control of the knowledge production in global health.
Kim H, Novakovic U, Muntaner C and Hawkes MT. Global Health Action. 2019;12: 1651017
Muntaner, C, Chung H, Murphy K, Ng E. J Urban Health, 2012;89:915-24
Thank you for this extraordinary piece! It provides a more nuanced picture of the concern regarding unequal authorship in global health publishing. In the spirit of your argument, I would like to share my experience and thoughts on this with an example. I have recently received a reviewers comments on an article I submitted for publication that stated that the author is encouraged to review the article, especially if Cameroonian because more research on the topic from Cameroonians is necessary. The article needed more work, I am new to publishing and I am not arguing with that. However, I felt a lot of frustration with the comment about the piece being worth more if written by a Cameroonian as opposed to me a ‘foreigner’/’northerner’. To add to your wonderful piece, I have two reflections on my example: First, I echo your argument that sometimes ‘foreign’ researchers are better placed to conduct ‘local’ research. I conducted research on a very controversial global health project whereby millions of dollars disappeared. If a Cameroonian would ask the questions I asked, they would risk their life. My research took place in an authoritarian state, Cameroonian researchers select very carefully what they say and what they can’t say because of a simple well-founded fear of persecution. They also worry about how critiquing a health programme could affect their future job opportunities with these actors. Second, some Cameroonians don’t want to do the write up because they have sev...
Thank you for this extraordinary piece! It provides a more nuanced picture of the concern regarding unequal authorship in global health publishing. In the spirit of your argument, I would like to share my experience and thoughts on this with an example. I have recently received a reviewers comments on an article I submitted for publication that stated that the author is encouraged to review the article, especially if Cameroonian because more research on the topic from Cameroonians is necessary. The article needed more work, I am new to publishing and I am not arguing with that. However, I felt a lot of frustration with the comment about the piece being worth more if written by a Cameroonian as opposed to me a ‘foreigner’/’northerner’. To add to your wonderful piece, I have two reflections on my example: First, I echo your argument that sometimes ‘foreign’ researchers are better placed to conduct ‘local’ research. I conducted research on a very controversial global health project whereby millions of dollars disappeared. If a Cameroonian would ask the questions I asked, they would risk their life. My research took place in an authoritarian state, Cameroonian researchers select very carefully what they say and what they can’t say because of a simple well-founded fear of persecution. They also worry about how critiquing a health programme could affect their future job opportunities with these actors. Second, some Cameroonians don’t want to do the write up because they have several jobs to ensure job security in a very unstable job market. They choose not to publish or not to be first author. Unlike in my part of the world, employers in Cameroon don’t ask for a publication list in random ‘northern’ journals, they want to see evidence of work experience. The ‘north’ – ‘south’ publishing divide narrative is taking a dangerous trajectory, one in which context seems to matter very little and the focus on capturing the true understanding and reality of people’s lives with the most suitable research methods are unimportant. Maybe we should question our system – whereby publishing as many papers as possible has to be top priority for many academics if they want to progress –before we point our fingers at those not participating in this perverse system.
A common issue with Zika virus surveillance, including during the epidemic in the Americas, is the time gap between local virus establishment and detecting the first case. In the Americas, we found this gap to be about 1.5 years (https://www.cell.com/cell/fulltext/S0092-8674%2818%2930171-5).
As outlined in a blog on the making of the “Global Action Plan for healthy lives and well-being for all” published in June (http://g2h2.org/posts/still-not-amused/), the information on the GAP that are accessible on the WHO website (https://www.who.int/sdg/global-action-plan) have left us with many worries and unanswered questions. Today, and only two weeks ahead of its formal launch at an UNGA side event in New York, the final text of the GAP is still not available - and our questions and concerns remain unanswered. Instead of further coffee grounds reading, let us critically comment on the GAP once it is published, and let us critically watch its implementation, once the plan is in place.
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall shortage of mental health providers relative to need, primary care providers have been called upon to manage an increasing range of psychopathology. There is simultaneously a growing appreciation for the relationship between early life adversity and chronic physical illnesses: our sickest patients – whether encountered in the emergency department, primary care, specialty, or psychiatric settings -- are often those who have struggled with lifelong adversity. Engagement and adherence that can promote behavioral changes hinge upon mental health, and optimization of medical outcomes thus occur when mental health is integrated into evaluation and intervention. Minimizing the number of new providers, the number of transitions, the number of times one has to provide a medical (and trauma) history, are crucial for a trauma-informed medical system: continuity is key. Application of the program elements described by Schwarz and team can inform trauma-informed interventions that strive to support health equity world-wide.
Dear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevalence map used from WHO dated 2017 (4) identifies Pakistan as risk region with 5 – 49 cases of CCHF reported each year. Our laboratory performs clinical testing or CCHFV and reported 131 cases of CCHF in 2018. Testing is performed using a commercial assay from Altona Diagnostics, GmBH, and results are reported within 24 h of the specimen being received. This data indicates Pakistan is amongst the highest category of risk for CCHFV infections worldwide. Given that dengue fever is also prevalent in the same region and is part of differential diagnosis for CCHF in Pakistan, there is value in rapid diagnosis using a robust rapid RT-PCR assay in high risk cases even though it may be at an increased cost. Therefore, in CCHFV endemic regions having a rapid robust assay for diagnosis of acute infections is extremely important.
References
1. Mazzola LT, Kelly-Cirino C. Diagnostic tests for Crimean-Congo haemorrhagic fever: a widespread tickborne disease. BMJ Glob Health. 2019;4(Suppl 2):e001114.
2. Rai MA, Khanani MR, Warraich HJ, Hayat A, Ali SH. Crimean-Congo hemorrhagic fever in Pakistan. J Med Virol. 2008;80(6):1004-6.
3. Leblebicioglu H, Sunbul M, Memish ZA, Al-Tawfiq JA, Bodur H, Ozkul A, et al. Consensus report: Preventive measures for Crimean-Congo Hemorrhagic Fever during Eid-al-Adha festival. Int J Infect Dis. 2015;38:9-15.
4. WHO. Introduction to Crimean-Congo Haemorrhagic Fever. World Health Organization. Geneva, Switzerland2018. p. https://www.who.int/emergencies/diseases/crimean-congo-haemorrhagic-feve....
What the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that of urban areas and reported that rates of TB identified is 2.9 times higher in males compared with females. (1) The Multiple Indicator Cluster Survey from 2017 showed that 71.3% of people in urban areas have access to clean water versus 44.5% in rural areas. (2)
The differences between rural and urban areas matter, by any measure of health and development, which greatly influences DALYs. Of the raw data points, extracted from the 68 sources the paper reports that the Institute for Health Metrics and Evaluation used to create the DALYs portrayed in Table 2, only about 15% was from after 2009, which is when the majority of the publications used in this paper were from. Recent comprehensive surveys by the UN had not been updated by the data set, such as the Multiple Indicator Cluster Survey 2017 data, the TB Prevalence Survey 2015-2016, and the Socio-economic, Demographic, and Health survey 2014. (3) However, the publication included papers from 1998 to 2017 in their review. Interestingly, only 24 of the 26,179 data points used to develop the DALYs were from 2016, the year that Table 2 cites. (4)
The aid community has struggled with this paper’s conclusions about gaps in the evidence, as it is a daily battle. The amount of what is unknown versus known about public health nears a ratio of 99 to 1, with the UN, as in-country residential workers, having access to the majority of what is known about the population. When it comes to the amount of data that the UN has versus the NGOs working within the country or scientists visiting the DPRK, the UN has access to a much broader base of evidence than what is published, given its greater ability to negotiate for access. Accomplished researchers within the NGOs who work as aid workers have to make the choice to not publish any data about their work in the DPRK because of the political context. (5) Thus, the paper's argument that research and public health policies are not based on adequate evidence is a conclusion that seems out of touch with the realities on the ground. In more recent years, the DPRK government has shown greater openness to the idea of publishing their data, which is the basis for many UN publications and articles available today.
An interdisciplinary perspective to deconstruct the granularity of existing data will go a long way towards better community-centered public health initiatives, as it will unlock steps to navigating the political gridlock to achieve better public health outcomes. Despite the constraints of perspective this paper holds, it does generate more enthusiasm for others to get into the field. Ultimately, it is only by partnerships among the NGO community, international agencies, and scientists that we can catalyze progress towards addressing health in the DPRK.
Dear Editor,
We read with interest the recent analysis of Joint External Evaluations (JEE) to assess International Health Regulations (IHR) compliance in the WHO African region. It is fantastic to see the engagement in the African region with this voluntary process, with 40 of 47 countries having been evaluated to date and 41 published mission reports (including Zanzibar), the highest proportion of completed JEEs for any WHO region. We congratulate the WHO Regional Office for Africa (WHO AFRO) for its leadership of this critical process. We would like to add our perspective as a technical agency engaged with and supportive of the JEE process.
As part of Public Health England’s (PHE) IHR Strengthening Project we have been engaging with National Public Health Institutes (NPHIs) in four African countries namely: Ethiopia, Nigeria, Sierra Leone and Zambia. In addition, we work with regional public health institutions such as the Africa Centres for Disease Control and Prevention (Africa CDC), and WHO AFRO to extend our reach beyond the bilateral engagement countries listed. The JEE process, with the subsequent development of a National Action Plan for Health Security (NAPHS), has been instrumental in informing and shaping our areas of engagement. In each of our partner countries, we have worked closely with the leadership of the NPHI and the relevant government ministries to develop workplans that address the gaps and needs highlighted in the JEE and prioritised...
Show MoreDISCLAIMER: Views expressed in this letter are those of the authors only, and do not represent the views or interests of the Bill & Melinda Gates Foundation.
We enthusiastically agree with the Editor's observation that what underlies the growing concerns about imbalances in authorship are the questions of power asymmetries in the production and benefits of knowledge in global health.
Critical and open self-reflections and reflexivity on "gaze" (who we write for) and "pose" (position from which we write) are much needed steps towards moving beyond representation on the list of authors.
However, if what underlies the imbalances in authorship is in fact power asymmetries, solving the problem of imbalances in authors requires directly interrogating the relations of power. Indeed, in our recent article, we identified marginalization the scholarship that interrogates the relations of power represents one of the persistent manifestations of the dominant norms of global health along with democratic deficit and depoliticization of the discourse (Kim et al. 2019). These manifestations may overlap or confound the relation between country/community of origin. We further argue that these manifestations are ideological in character in that they are not merely tendencies but functional in naturalizing and universalizing the implicit assumptions and norms of the dominant narrative.
The editorial raises an extremely important poin...
Show MoreThank you for this extraordinary piece! It provides a more nuanced picture of the concern regarding unequal authorship in global health publishing. In the spirit of your argument, I would like to share my experience and thoughts on this with an example. I have recently received a reviewers comments on an article I submitted for publication that stated that the author is encouraged to review the article, especially if Cameroonian because more research on the topic from Cameroonians is necessary. The article needed more work, I am new to publishing and I am not arguing with that. However, I felt a lot of frustration with the comment about the piece being worth more if written by a Cameroonian as opposed to me a ‘foreigner’/’northerner’. To add to your wonderful piece, I have two reflections on my example: First, I echo your argument that sometimes ‘foreign’ researchers are better placed to conduct ‘local’ research. I conducted research on a very controversial global health project whereby millions of dollars disappeared. If a Cameroonian would ask the questions I asked, they would risk their life. My research took place in an authoritarian state, Cameroonian researchers select very carefully what they say and what they can’t say because of a simple well-founded fear of persecution. They also worry about how critiquing a health programme could affect their future job opportunities with these actors. Second, some Cameroonians don’t want to do the write up because they have sev...
Show MoreA common issue with Zika virus surveillance, including during the epidemic in the Americas, is the time gap between local virus establishment and detecting the first case. In the Americas, we found this gap to be about 1.5 years (https://www.cell.com/cell/fulltext/S0092-8674%2818%2930171-5).
Based on the sequence data published by the ICMR (https://www.sciencedirect.com/science/article/pii/S1567134819300048), we estimate that Zika virus was established in Rajasthan in early 2017, meaning that there was local transmission for ~1.5 years before the outbreak was detected in 2018 (http://virological.org/t/preliminary-origins-of-the-2018-zika-outbreak-i...). This suggests that the virus may have spread further during that time period and local surveillance networks should remain vigilant to detect other "silent" outbreaks.
Please email me at nathan.grubaugh@yale.edu if you have any questions about these comments.
As outlined in a blog on the making of the “Global Action Plan for healthy lives and well-being for all” published in June (http://g2h2.org/posts/still-not-amused/), the information on the GAP that are accessible on the WHO website (https://www.who.int/sdg/global-action-plan) have left us with many worries and unanswered questions. Today, and only two weeks ahead of its formal launch at an UNGA side event in New York, the final text of the GAP is still not available - and our questions and concerns remain unanswered. Instead of further coffee grounds reading, let us critically comment on the GAP once it is published, and let us critically watch its implementation, once the plan is in place.
The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.
The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.
Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...
Show MoreDear authors,
thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
thanks again and best regards,
Jan Peter
Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.
CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.
Of note, the CCHF prevale...
Show MoreWhat the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.
A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.
We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.
We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...
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