AHW co-sponsored two events during Open Access Week at JHU to support our efforts to promote the concept of Open Science in the name of health equity.
Editor's note: In the third of a series of articles looking at each thematic area of the Alliance’s work, this month we shine the spotlight on our Transformative Technologies and Institutions (TTI) thematic area, led by Dr. Anthony So, and explain how the team's work supports health equity.
Innovation premised on access and co-production in the interests of health equity
In 2015, Gilead Sciences brought to market a life-saving medication called sofosbuvir (brand name: Sovaldi) that cures Hepatitis C. Gilead acquired this medication from another company, Pharmasset, but in so doing, priced the drug at $84,000 for a full course of treatment in the United States. While some parts of the world, notably India, have allowed the production of generics (drugs marketed without patented brand names) thereby reducing the cost of treatment in much of the world, treatment for Hepatitis C remains elusive. A 2018 WHO report showed, of the 71 million people affected by the disease, only about 1.5 million were able to access treatment.
How do we ensure that the remaining nearly 70 million people receive treatment? How do we reimagine processes of innovation and discovery to bring treatment to those who most need it? How do we ensure that the benefits of health technologies impact populations equitably?
In order to grapple with these issues, the Alliance for a Healthier World established the Transformative Technologies and Institutions (TTI) thematic area. Dr Anthony So, a veteran in addressing such challenges and a professor of the practice at the Bloomberg School of Public Health, leads this thematic area.
Addressing barriers to access
“We don’t think it’s enough to drop solutions into inequitable environments without some idea of how they can meaningfully be adopted,” Dr. So recently said in announcing the Alliance for a Healthier World’s sponsorship of the health equity prize at this year’s MedHacks 2018 health innovation competition.
This competition – drawing an anticipated 700 MedHack student participants from all over the country – will motivate students to think more deeply about how innovation reaches those in need. This is the first year the competition has a track focused exclusively on health equity.
A focus on health equity means aligning research and development (R&D) efforts with global health priorities, making discoveries affordable to those who need them, and ensuring that innovations physically reach those people. Through such approaches to increasing access, TTI focuses on how to unlock bottlenecks in the R&D pipeline, pioneering new ways of paying for innovations, and shifting how we deliver care to patients in need.
Open Access and health equity
Library costs worldwide for scientific journals and papers increased significantly between 1986 and 2001, with libraries paying 210% more for 5% fewer periodicals, as noted in a Lancet Commission report on the origins of health inequity. This “paywall” will continue to drive disparities between who can access scientific research and knowledge.
Nearly three quarters of all scholarly literature (research papers, review articles, etc.) is behind a paywall, inaccessible to those who cannot afford to pay the cost of a journal subscription. As an example, a basic search for all cancer articles available at the National Library of Medicine’s PubMed Database, a common repository for biomedical literature, shows that over half of all scholarly articles are behind a paywall.
As one of the world’s leading producers of knowledge, receiving over $2 billion in federal funding for research, Johns Hopkins University’s research output significantly contributes to the global knowledge pool. With the announcement of its open access policy in July 2018, the University is well placed to rapidly expand the public benefit of sharing its research.
In collaboration with the Welch Medical Library, TTI will organize a series of seminars and activities during Open Access Week (October 22-28, 2018) to deepen University-wide understanding of the potential benefits of open access and open science to advance health equity.
Open science to advance health equity
Open access is one part of open science, which includes open methodology, open source technology, open data, open access publishing, open peer review and open educational resources.
Early in September, the Alliance will sponsor the first-ever health equity track as part of the annual MedHacks health innovation tournament held at the East Baltimore campus of JHU. The theme of the prize is "open science to advance health equity." The aim is to open new avenues for student innovators to make the the processes of innovation production more accessible and transparent, and easier to share resulting outputs. These improvements would reduce the unequal impact of technology on target populations.
Anthony So’s commitment to knowledge sharing
Dr. So’s commitment to knowledge-sharing in the interest of health equity dates back to his days as the associate director of the health equity division at the Rockefeller Foundation.
There, he co-founded a cross-thematic program on charting a fairer course for intellectual property rights and helped shape the foundation’s work on policy regarding access to medicines in developing countries. His grant-making efforts supported groups that negotiated the global entry of a generic AIDS triple therapy combination, reducing the cost of treatment $10,000-15,000 per patient per year to just $350--lowering the price of hope to less than a dollar a day.
He has also been part of pioneering efforts to promote open access, co-signing the 2003 Bethesda Open Access Declaration. Together with two other major milestones -- the Budapest Open Access Initiative and the Berlin Declaration on Open Access to Knowledge in the Science -- these interventions have significantly shaped the move toward open access publication of scholarly content. He was also a member of PubMed Central’s Advisory Committee and has served on Open Society Institute’s Information Program Sub-board, as part of his deep commitment and passion to narrow the gap between those who have knowledge and those who need it.
Transforming technology and institutions collectively
More recently, through the Alliance’s planning grants, TTI, together with three other AHW thematic areas (Food & nutrition security, Healthy environments, Gender equity & justice), supported a project that typifies the Alliance’s multidisciplinary approach to innovation for health equity.
A team of researchers drawn from across the University -- from the Carey Business School, Krieger School of Arts & Sciences, Whiting School of Engineering, and Bloomberg School of Public Health -- joined forces to tackle the persistent problem of household air pollution caused by cooking with biomass fuel in Puno, a rural region of Peru. The wider problem of household air pollution is thought to contribute to 4.3 million premature deaths annually, disproportionately affecting women and children.
The multi-disciplinary Hopkins team, drawing on locally available materials, proposes "thermal cooking" as a solution. Their innovation involves using a new type of cook stove that uses liquid petroleum gas (LPG) instead of biomass fuel to heat the food for a short time at high temperature, before enclosing the pot in a heavily insulated container. This would cook the food, maintaining temperature for several hours, without releasing smoke.
If successful, this innovation would free biomass for alternative uses, thus saving money, and make available biomass as fertilizer for more nutritious crops. By using LPG, the cook stove reduces harmful agents emitted into households and external environments. It also reduces the effect of toxins released into the household, particularly on women and children, who disproportionately bear the consequences of biomass fuel use, as they spend up to six hours per day around a stove. By employing locally available materials, ensuring that the final cost of the stove would be affordable by those who would need to use it, and by serving a need with an identifiable benefit to the community, this proposed invention is truly transformative.
The project exemplifies an Alliance-wide approach to achieving health equity by combining the collective approaches we bring to tackling public health challenges and striving for a healthier and more equitable world.
Learn more about the work of AHW’s Transformative Technologies & Institutions here.
Read about the AHW's other research priorities, Food & Nutrition Security, Healthy Environments, and Gender Equity & Justice here.
This spotlight profile was written by Vinayak Bhardwaj, a Global Health Equity Scholar with the Alliance for a Healthier World.
Alliance's Peter Winch and Jess Fanzo join forces to examine the intersection of food, nutrition, and delivering health for all and highlight links to the 1978 Alma Ata Declaration.
The Alliance for a Healthier World was founded to build on the successes of multidisciplinary collaborations among faculty and researchers across Johns Hopkins, and to support initiatives that promote health equity around the world. To better understand the current work of Johns Hopkins faculty and researchers, we conducted a survey to gather information and gauge their interests in health equity.
“The goal of the survey was to get a better sense of what work is already being done in health equity across Johns Hopkins University,” said Anna Kalbarczyk, AHW Special Projects Advisor. “Each of us on the AHW team had an idea of who in our networks was doing what and where but the Alliance aims to reach beyond our basic networks, to build new relationships, and grow existing resources. This survey data, disseminated with the help of our interdisciplinary steering committee, reached a broad audience and offered unique insight into the health equity scene at Johns Hopkins.”
A whopping 248 faculty and staff across all Johns Hopkins divisions completed the survey during June 2017. One third of the respondents hailed from the Bloomberg School of Public Health, one fourth were affiliated with the Krieger School of Arts & Sciences and one fourth were from the School of Medicine. The remainder were spread across other divisions, including the Applied Physics Lab, Carey Business School, School of Nursing, and the Whiting School of Engineering. This university-wide interest demonstrates the diverse range of individuals with an interest in this common challenge – to address global health equity – a concept that requires engagement from a wide range of disciplines.
Working Across the Globe
Given our global focus, we wanted to find out which countries faculty have been working in for their projects. Of the 88 countries and areas recorded in the survey, the countries which respondents most frequently worked in are - in descending order - India, Uganda, China, South Africa, Kenya and Bangladesh. While most respondents reported working in Africa and South Asia, nearly 20% of the respondents have worked in East Asia/Pacific, and just over 10% have respectively worked in Latin America/Caribbean and Europe/Central Asia. JHU faculty are clearly engaged in impactful work in many corners of the world.
Partnerships, Partnerships, Partnerships
Partnerships are imperative for advancing health equity; this complex, multi-faceted challenge extends beyond public health and, so far, has not been accomplished by a single sector. We believe strategic partnerships and cross-sector collaborations are necessary to map out best practices to address what is happening on the ground in disadvantaged communities. We asked the respondents to share the nature of any partnerships they have established. Over 70% have in-country research partners, and about 50% of the respondents have education partners. Many have partnerships with policy stakeholders or networks and civil society organizations (over 30% of respondents, respectively).
The survey highlights our faculty and staff are engaged in a variety of partnerships around the globe, and present exciting opportunities for the Alliance to unite groups working towards a common goal.
Collaborative Opportunities Reign
To determine how to best serve the JHU community, the survey asked respondents to rank the types of activities that would interest them. They expressed the most interest in conducting collaborative multidisciplinary research, networking with others interested in global health equity, and collaborating for funding opportunities. Surprisingly, respondents expressed the least interest in receiving training for applying to collaborative funding opportunities and participating in social entrepreneurship challenges – both of which are fast growing sources of funding for innovative, interdisciplinary projects.
The survey reminded us that although faculty are interested in multidisciplinary collaborations, the work that goes into making these happen and to be successful are harder to implement and achieve. We are taking this into consideration as we look to how we can better support you, your colleagues and students to lead successful collaborations that incorporate engagement and input from other disciplines.
Onwards and Upwards
We’re sharing key data in an interactive summary report on our website - please view this for more detailed information on where your peers are working, how they are engaged with partners, and their interests in health equity opportunities.
One of the resounding impressions from the survey is that Johns Hopkins faculty across the university are clearly dedicated to tackling health equity. Our faculty know collaborative and multidisciplinary research works. Collectively, we know partnerships are the way forward to making the changes needed for addressing health equity.
Our team at AHW have our work cut out for us to engage you in meaningful ways to help you undertake these; we’re excited to lead the charge to work together as a unified force for change.
Article Compiled by The Alliance for a Healthier World Team
AHW would like to acknowledge Shirley Yan, MSPH 2019 candidate, who cleaned and analyzed the survey data.
Following my post on global to local learning opportunities from the first issue of the Health Equity Connector, let’s continue on the topic with more definition and clarity on what we mean by “global.” We’ll use this platform to engage in conversations with you about global health equity and intend for it to start conversations and spark new collaborations.
The term “global health” is imbued with grand scale and complexity, weightiness and aspiration. The phrasing is at once invitational and aspirational while also sounding technical and exclusive. Our Alliance for a Healthier World is built on the foundation of global health equity and we consider it our mission to make the concept, and the practical application, available and accessible to all. In other words, we want to explore the many ways you are already engaged in global health and health equity work, whether you use this specific language or other wording. While there are benefits in arriving at a unifying definition of global health, there is also value in the convenings and dialogue on this question that result in new understandings and new learning together, and we are excited to lean into that process.
In an effort to drive toward a shared understanding of global health, the Executive Board of the Consortium of Universities for Global Health (CUGH) published an article in The Lancet in 2009, “Towards a Common Definition of Global Health.” I’ve excerpted one section of the article here (boldface added for emphasis):
What is global? Must a health crisis cross national borders to be deemed a global health issue? We should not restrict global health to health-related issues that literally cross international borders. Rather, in this context, global refers to any health issue that concerns many countries or is affected by transnational determinants, such as climate change or urbanisation, or solutions, such as polio eradication. Epidemic infectious diseases such as dengue, influenza A (H5N1), and HIV infection are clearly global. But global health should also address tobacco control, micronutrient deficiencies, obesity, injury prevention, migrant-worker health, and migration of health workers. The global in global health refers to the scope of problems, not their location. Thus—like public health but unlike international health—global health can focus on domestic health disparities as well as cross-border issues.
In many instances, the challenges we address in public health and in global health are not defined by geography, but by social and structural determinants embedded in the fabric of our societies that profoundly shape our lives. It is precisely because global health seeks to establish causal linkages between the social and structural determinants of health and illness, and the resulting risks to entire communities and populations, that we start to see patterns emerge of similar risk profiles in unexpected places. A frequently cited Kaiser Health News article from 2016, with data from the Baltimore City Health Department and World Health Organization (WHO), looked at the metric of life expectancy at birth within different zip codes of Baltimore City and found an 18 year discrepancy between the highest life expectancy zip code (84 years) and the lowest one (66 years). What a staggering difference! As part of this investigation, the group generated this excellent infographic that overlays the name of the country that shares the same life expectancy with each Baltimore City zip code.
At the Johns Hopkins Center for Health Equity (JHCHE), led by Bloomberg Distinguished Professor and AHW Steering Committee member Dr. Lisa Cooper, adverse clinical outcomes experienced by individuals seeking care at the center are also physical manifestations of chronic and persistent poverty and lack of access to socio-economic opportunity. The Alliance has partnered with JHCHE to further understand and design programs to attack underlying social and structural barriers to health. In this partnership, the role of the Alliance is to bridge key findings and lessons from resource poor communities where our faculty work across the globe to the population served by JHCHE and the community leaders who help inform its programming. Stay tuned for upcoming interviews with Dr. Lisa Cooper and her team on this subject.
In rural Kenya and Rwanda where I lived and worked, chronic poverty is a feature of daily life and has been for many decades. Because of this, community members, public and private sector entities, have studied carefully the effects of chronic poverty on health outcomes and successfully experimented with public health, financial inclusion strategies and insurance structures to address the poor health outcomes.
The government of Kenya began an unconditional cash transfer program to the ultra-poor in Kenya in 2002. Unconditional cash transfers simply mean that the government sends recipient families the funds each month with no stipulations or conditions as to how the money is spent. The nongovernmental organization, GiveDirectly, began operations in Kenya in 2011 to augment the cash transfer program of the government and to analyze program results. The economic and psycho-social impacts of this program are well documented and are sufficiently dramatic to spur new thinking about global health and development work models.
In the early 2000’s, the government of Rwanda initiated a centrally planned national health care program to provide universal health access to all citizens. The financing mechanism designed to pay for the system halved the out-of-pocket cost per person, and the healthcare benefits resulted in the steepest decline in child mortality seen in the 20th century. As the U.S. wrangles with questions of new models for healthcare delivery, lessons from Rwanda can provide a case-study for one path forward.
New Series on Global to Local Learning
In future posts, we will dig deeper into specific examples of the global health programs and mechanisms mentioned above and share interviews with the frontline workers and community leaders implementing these health equity initiatives. We will also highlight the perspective of funding entities in the U.S. that are looking at this question of how best to harness lessons from global health across different settings and bring you voices from this sector.
We want to hear from you on this series of discussions about the role Johns Hopkins faculty, staff and students play as leaders, teachers and learners in the field of global health. Please be in touch with us via email: firstname.lastname@example.org.
We look forward to continuing this conversation in upcoming publications.
Ben Link is the Executive Manager at the Alliance for a Healthier World (AHW). He brings over 15 years of experience working in both the nonprofit and private sectors on initiatives related to global health and development in diverse settings across southern and eastern Africa, Latin America, the Caribbean and Navajo Nation.