We read with great interest the original research by Coll CVN, Ewerling F, García-Moreno C, et al which found that domestic violence in low- and middle-income countries was more prevalent amongst certain groups of women.
The ongoing COVID-19 pandemic has already ravaged countries within Asia, Europe and the United States, defined as high-income by the World Bank Group. [1] Actions taken to prevent the spread of the virus has meant a large proportion of the population in these countries is currently under some degree of confinement, and consequently, an alarming increase in domestic violence has been reported by the news. [2]
Coll CVN, Ewerling F, García-Moreno C, et al recognises Africa and SouthEast Asia to have a higher prevalence of domestic violence. At the time of writing (29/03/2020), the WHO has already reported 3005 cases and 51 deaths in Africa and 3709 cases and 139 deaths in SouthEast Asia, with no doubt that these numbers will continue to grow. [3]
Resources to fight the COVID-19 epidemics in these regions are limited and thus, efforts aiming to curb the transmission will soon undoubtedly follow other countries’ mitigation plans; police enforcing a lockdown, healthcare workers treating COVID-19 patients and government officials attempting to gather the necessary equipment for the care of its citizens. This means an extensive proportion of the workforce needed to help women undergoing domestic violence will already be si...
We read with great interest the original research by Coll CVN, Ewerling F, García-Moreno C, et al which found that domestic violence in low- and middle-income countries was more prevalent amongst certain groups of women.
The ongoing COVID-19 pandemic has already ravaged countries within Asia, Europe and the United States, defined as high-income by the World Bank Group. [1] Actions taken to prevent the spread of the virus has meant a large proportion of the population in these countries is currently under some degree of confinement, and consequently, an alarming increase in domestic violence has been reported by the news. [2]
Coll CVN, Ewerling F, García-Moreno C, et al recognises Africa and SouthEast Asia to have a higher prevalence of domestic violence. At the time of writing (29/03/2020), the WHO has already reported 3005 cases and 51 deaths in Africa and 3709 cases and 139 deaths in SouthEast Asia, with no doubt that these numbers will continue to grow. [3]
Resources to fight the COVID-19 epidemics in these regions are limited and thus, efforts aiming to curb the transmission will soon undoubtedly follow other countries’ mitigation plans; police enforcing a lockdown, healthcare workers treating COVID-19 patients and government officials attempting to gather the necessary equipment for the care of its citizens. This means an extensive proportion of the workforce needed to help women undergoing domestic violence will already be significantly stretched.
We propose that countries of low- and middle income must quickly recognise and prevent this likely occurrence by raising awareness of the matter and putting in place a special human resource, whose sole focus would be to identify and help women who find themselves in these difficult circumstances, whilst at the same time considering the implications of the country's epidemic on such interventions. More specifically, we call for particular attention to be given to the groups of women identified by Coll CVN, Ewerling F, García-Moreno C et al. as being at an increased risk of domestic violence.
We are in complete agreement with Coll CVN, Ewerling F, García-Moreno C et al.’s policy of leaving no one behind and through our rapid response, hope to have highlighted the need for preventing rather than mitigating domestic violence in low- and middle income countries, especially amongst more vulnerable groups of women, during these uncertain and unsettling times.
While liking the idea, I find two main problems with the suggested definition of global health as "public health somewhere else": 1) it is too narrow and 2) it sounds dismissive. In "global health", the word "global" is inclusive and suggests a health agenda embracing all the communities of the rest of the world. This is lost in the definition. Then there is the dismissive sound of "somewhere else" ("You can join our club or go somewhere else", "This could be Paradise or it could be somewhere else", etc.). I may be thin-skinned, but disdaining to specify a location sounds to me like a slur. For these reasons, and for all the other good reasons offered in the original Commentary, I suggest amending the definition to "public health everywhere else". This follows the original in asserting "elseness", while being inclusive and positive.
Why the first sentence of this article with its exaggerated claim about the health outcomes of Aboriginal and Torres Strait Islander Australians? The reference cited, 1 does not support the comparison with other populations globally, and the article itself seeks to move beyond negative images of Aboriginal and Torres Strait Islander people. Beginning with this negative statement – regardless of its veracity - continues the long history of deficit discourse used in discussing Aboriginal and Torres Strait Islander people. Rather than contribute to improved outcomes deficit discourse can actually reinforce and perpetuate approaches and behaviours such as those the article seeks to address. 2
Overall the article presents important new research moving beyond negative stereotypes of Aboriginal and Torres Strait Islander people, highlighting their perspectives and insights, and encouraging a more culturally driven approach. This makes the opening even more inappropriate and unnecessary.
References
1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-74.
2. Fogarty W, Bulloch H, McDonnell S et al. Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitja Institute; 2018 [cited 20 Jan 2020]. Available from:...
Why the first sentence of this article with its exaggerated claim about the health outcomes of Aboriginal and Torres Strait Islander Australians? The reference cited, 1 does not support the comparison with other populations globally, and the article itself seeks to move beyond negative images of Aboriginal and Torres Strait Islander people. Beginning with this negative statement – regardless of its veracity - continues the long history of deficit discourse used in discussing Aboriginal and Torres Strait Islander people. Rather than contribute to improved outcomes deficit discourse can actually reinforce and perpetuate approaches and behaviours such as those the article seeks to address. 2
Overall the article presents important new research moving beyond negative stereotypes of Aboriginal and Torres Strait Islander people, highlighting their perspectives and insights, and encouraging a more culturally driven approach. This makes the opening even more inappropriate and unnecessary.
References
1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-74.
2. Fogarty W, Bulloch H, McDonnell S et al. Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitja Institute; 2018 [cited 20 Jan 2020]. Available from: https://www.lowitja.org.au/page/services/resources/Cultural-and-social-d....
United States withdrawal from the Iran nuclear deal in May 2018 has led to increasing pressure on all members of society (1). Economic sanctions against Iran have not formally targeted health care or access to drugs and ordinary people, but they have indirectly serious impact on health services and consequently on research programs. Economic sanctions resulted in decline in the value of Iran's currency and government faced big budget deficit. Therefore, the cost of research programs and initial equipments for conducting any projects will increase too much. In this case they are unaffordable by institutions (1-3). Based the on Kokabisaghi et al. paper published in BMJ Global Health in 2019, the economic sanctions imposed more problems on Iran’s research and publishing. Also they claimed that academic boycotts violate researchers’ freedom and curtail progress (2). Free exchange of ideas irrespective of creed is needed to optimize global scientific progress (2). But it seems that another factor can indirectly effects on research programs in Iran. Economic sanctions and scientific boycotts are among the most important problems for researchers on Iran. In the meantime importance of domestic political crisis due to economic sanctions has been ignored. This is not mentioned in this study. With decreased national budget and GDP (gross domestic product) per capita, the government was forced to raise prices of energy and oil carriers; as a result, it created a major political c...
United States withdrawal from the Iran nuclear deal in May 2018 has led to increasing pressure on all members of society (1). Economic sanctions against Iran have not formally targeted health care or access to drugs and ordinary people, but they have indirectly serious impact on health services and consequently on research programs. Economic sanctions resulted in decline in the value of Iran's currency and government faced big budget deficit. Therefore, the cost of research programs and initial equipments for conducting any projects will increase too much. In this case they are unaffordable by institutions (1-3). Based the on Kokabisaghi et al. paper published in BMJ Global Health in 2019, the economic sanctions imposed more problems on Iran’s research and publishing. Also they claimed that academic boycotts violate researchers’ freedom and curtail progress (2). Free exchange of ideas irrespective of creed is needed to optimize global scientific progress (2). But it seems that another factor can indirectly effects on research programs in Iran. Economic sanctions and scientific boycotts are among the most important problems for researchers on Iran. In the meantime importance of domestic political crisis due to economic sanctions has been ignored. This is not mentioned in this study. With decreased national budget and GDP (gross domestic product) per capita, the government was forced to raise prices of energy and oil carriers; as a result, it created a major political crisis. Therefore, that global internet access was disrupted (4). Based on Netblocks.org, worldwide internet access has been less than 20% for almost a week, then continued with severe censorship and restrictions (4). In such a situation it is very difficult to have research activities and publish scientific papers. Higher educational institutions and researchers faced with great challenges and difficulties and communication with the world was limited. Similarly in China, internet restrictions, known as the ‘great firewall of China’, have often been an issue for Chinese academics who find their access to overseas research restricted (5). Unfortunately, researchers in Iran encounter with similar restrictions which are not mentioned in this article or other articles presented by Iranian scholars. For example, access to YouTube and many internet resources is restricted. However, the impact of sanctions is far greater.
1. Hassani M. Impact of Sanctions on Cancer Care in Iran. Arch Bone Jt Surg. 2018 Jul;6(4):248-249.
2. Kokabisaghi F, Miller AC, Bashar FR, Salesi M, Zarchi AAK, Keramatfar A, Pourhoseingholi MA, Amini H, Vahedian-Azimi A. Impact of United States political sanctions on international collaborations and research in Iran. BMJ Glob Health. 2019 3;4(5):e001692.
3. Arab-zozani M. Health sector evolution in Iran; a short review. Evid Based Health Policy Manag Econ. 2017; 1(3):193-7.
4. Internet disrupted in Iran amid fuel protests in multiple cities.(2019). https://netblocks.org/reports/internet-disrupted-in-iran-amid-fuel-prote...
5. Research could suffer as internet controls tightened. (2017). https://www.universityworldnews.com › post › story=20170713140950894
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 Editor,
We read with great interest the original research by Coll CVN, Ewerling F, García-Moreno C, et al which found that domestic violence in low- and middle-income countries was more prevalent amongst certain groups of women.
The ongoing COVID-19 pandemic has already ravaged countries within Asia, Europe and the United States, defined as high-income by the World Bank Group. [1] Actions taken to prevent the spread of the virus has meant a large proportion of the population in these countries is currently under some degree of confinement, and consequently, an alarming increase in domestic violence has been reported by the news. [2]
Coll CVN, Ewerling F, García-Moreno C, et al recognises Africa and SouthEast Asia to have a higher prevalence of domestic violence. At the time of writing (29/03/2020), the WHO has already reported 3005 cases and 51 deaths in Africa and 3709 cases and 139 deaths in SouthEast Asia, with no doubt that these numbers will continue to grow. [3]
Resources to fight the COVID-19 epidemics in these regions are limited and thus, efforts aiming to curb the transmission will soon undoubtedly follow other countries’ mitigation plans; police enforcing a lockdown, healthcare workers treating COVID-19 patients and government officials attempting to gather the necessary equipment for the care of its citizens. This means an extensive proportion of the workforce needed to help women undergoing domestic violence will already be si...
Show MoreWhile liking the idea, I find two main problems with the suggested definition of global health as "public health somewhere else": 1) it is too narrow and 2) it sounds dismissive. In "global health", the word "global" is inclusive and suggests a health agenda embracing all the communities of the rest of the world. This is lost in the definition. Then there is the dismissive sound of "somewhere else" ("You can join our club or go somewhere else", "This could be Paradise or it could be somewhere else", etc.). I may be thin-skinned, but disdaining to specify a location sounds to me like a slur. For these reasons, and for all the other good reasons offered in the original Commentary, I suggest amending the definition to "public health everywhere else". This follows the original in asserting "elseness", while being inclusive and positive.
Why the first sentence of this article with its exaggerated claim about the health outcomes of Aboriginal and Torres Strait Islander Australians? The reference cited, 1 does not support the comparison with other populations globally, and the article itself seeks to move beyond negative images of Aboriginal and Torres Strait Islander people. Beginning with this negative statement – regardless of its veracity - continues the long history of deficit discourse used in discussing Aboriginal and Torres Strait Islander people. Rather than contribute to improved outcomes deficit discourse can actually reinforce and perpetuate approaches and behaviours such as those the article seeks to address. 2
Overall the article presents important new research moving beyond negative stereotypes of Aboriginal and Torres Strait Islander people, highlighting their perspectives and insights, and encouraging a more culturally driven approach. This makes the opening even more inappropriate and unnecessary.
References
1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-74.
Show More2. Fogarty W, Bulloch H, McDonnell S et al. Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitja Institute; 2018 [cited 20 Jan 2020]. Available from:...
United States withdrawal from the Iran nuclear deal in May 2018 has led to increasing pressure on all members of society (1). Economic sanctions against Iran have not formally targeted health care or access to drugs and ordinary people, but they have indirectly serious impact on health services and consequently on research programs. Economic sanctions resulted in decline in the value of Iran's currency and government faced big budget deficit. Therefore, the cost of research programs and initial equipments for conducting any projects will increase too much. In this case they are unaffordable by institutions (1-3). Based the on Kokabisaghi et al. paper published in BMJ Global Health in 2019, the economic sanctions imposed more problems on Iran’s research and publishing. Also they claimed that academic boycotts violate researchers’ freedom and curtail progress (2). Free exchange of ideas irrespective of creed is needed to optimize global scientific progress (2). But it seems that another factor can indirectly effects on research programs in Iran. Economic sanctions and scientific boycotts are among the most important problems for researchers on Iran. In the meantime importance of domestic political crisis due to economic sanctions has been ignored. This is not mentioned in this study. With decreased national budget and GDP (gross domestic product) per capita, the government was forced to raise prices of energy and oil carriers; as a result, it created a major political c...
Show MoreDear 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...
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