We put the Global to Local approach into in action during a recent trip to Africa.
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.
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: email@example.com.
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.
The first few days of a baby’s life is especially critical – each year, more than 2.5 million newborns die within their first month, primarily from preventable causes. A Johns Hopkins team is developing and piloting NeMo, a neonatal monitoring device that closely monitors a newborn’s key vital signs to reduce mortality rates in the baby’s first 7 days. The project empowers mothers from low-resource settings by educating them how to identify neonatal illnesses – mostly preventable illnesses such as sepsis, pneumonia, and hypothermia – and when to seek care from a community health worker.
Led by Soumyadipta Acharya, graduate program director of the Johns Hopkins Center for Bioengineering Innovation and Design (CBID), the project has tapped into a wide range of talents and skills from CBID graduate student teams and faculty. Ben Ostrander, CBID graduate student and the Alliance for a Healthier World (AHW) Global Health Equity Scholar for the Transformative Technologies and Institutions (TTI) theme, has contributed to testing and improving the NeMo prototype during the past year. He shares his perspective below about the project and the challenges and successes that come with collaborating with an interdisciplinary team.
Student Scholar Voice
Recent recipient of MSE in Bioengineering Innovation and Design + MD Candidate + AHW Global Health Equity Scholar
My experience with the NeMo project was stimulating and rewarding. I was attracted to the project’s approach to addressing the problem of neonatal mortality – which shifts the opportunity for identifying newborn illness from community health workers to mothers themselves. With more than 2.5 million newborn deaths each year, this is definitely a problem worth tackling. There are so many moving parts to creating and implementing a technology that can accomplish the project’s goal, and understanding how to make them fit together and work well is an enlightening and challenging task.
NeMo aligns well with AHW’s goal to support research to implement transformative technology and gender equity. Using a smartphone-based application and low cost wearable sensors, NeMo leverages technology to quickly identify newborn illness during the first week of life and to ultimately save lives. We envision increasing mothers’ ability to identify newborn illness early and at home as a step towards health equity. Since our intervention is dependent on a variety of technologies, from cell phones to novel sensor engineering, the project is a good example of what the Alliance’s transformative technologies and institutions thematic area strives to support. Additionally, since our system focuses on empowering and educating mothers, there is also a component of gender equity at play. We want to support womens’ opportunity to become knowledgeable about maternal and infant health, and to enable effective choices for their own and their infant’s health.
I learned so much about teamwork through my year in the CBID graduate program and through working on the NeMo team. Our core team was made of up three biomedical engineers, an electrical/mechanical engineer, and a medical student with an engineering and global health background. We were the most diverse team in our cohort and this turned out to be a huge advantage. We learned how to work with each other and play to our different strengths and weaknesses.
While our diverse and interdisciplinary backgrounds sometimes led to disagreement, this struggle made us a better team and actually improved our output in the long run. I found that our team functioned best when we were patient and understanding. We all became better listeners and collaborated more seamlessly as the year went on. Importantly, we also gave each other “free passes” - an understanding that sometimes people will be late or won’t meet a deadline or finish a deliverable, but as long as this was a rare occurrence we wouldn’t make a big fuss about it. Moving forward, I have a much better idea of how to create, manage, and participate in a highly functional and interdisciplinary team, and have learned many strategies and skills to do so.
NeMo - Winning Multiple Awards
The NeMo team’s hard work is paying off. In 2016, the team was awarded a $100,000 grant from the Bill & Melinda Gates Foundation for their Grand Challenges Explorations program. This past April 2018, Ben Ostrander joined his team in receiving the second place award, totaling $25,000, in the Global Social Venture Competition. The international competition had over 550 entries during the 2018 round from entrepreneurs who are scaling their projects for social or environmental impact.
Check out the video of the Johns Hopkins team receiving their 2nd place award at the Global Social Venture Competition finals in Milan, Italy.
As we focus future efforts on addressing health equity in low-and middle- income communities, there is value in reflecting on past approaches to health care for the world’s most disadvantaged people. Newly independent countries were emerging in mid-twentieth century – and along with new governments also came the need for new infrastructure, including health care. By the 1970s, the public health field recognized that Primary Health Care (PHC) was not being served or accessible to where many people live and work. Enter the Alma Ata Declaration, which urged governments, health and development workers, and the world community to protect and promote the health of all people.
To achieve the vision of Health for All, the Declaration advocated decentralizing power and decision-making away from government offices in the capital city and away from doctors and nurses providing care in hospitals, to the people at the grassroots level. In 1978 when the Declaration was adopted, Primary Health Care meant working with community members to take stock of their health and living conditions, and by taking maximum advantage of the commitment and skills of local people to achieve health. Now in 2018, in an era of global climate change and environmental degradation, it is no longer sufficient to empower local people to take action locally as a standalone approach.
The Commission on Planetary Health, led by The Lancet and Rockefeller Foundation, took the Alma Ata Declaration a step further with their Planetary Health program. They are investing in a new multidisciplinary field that incorporates global and local-level action to improve health and wellbeing of low-income communities and to reduce consumption by wealthy communities – all while also maintaining ecosystems and biodiversity for future generations.
Primary Health Care that incorporates Planetary Health must also work to reduce global consumption of fossil fuels and other resources, reduce the environmental impacts of food production, maintain ecosystems and promote biodiversity. For health systems, this means continuing to work toward decentralizing decision-making, empowering local stakeholders, and localizing health system inputs such as energy, construction materials and food.
The New Primary Health Care
This expanded concept of Primary Health Care is summarized in the following table. It animates and informs the work of several thematic areas in the Alliance for a Healthier World, particularly for the Healthy Environments area.
We are rapidly approaching the 40th anniversary of the International Conference on Primary Health Care held in September 1978, and that issued the Declaration. Carl Taylor, the Chair of the Department of International Health at the Johns Hopkins School of Public Health at the time, played a major role in drafting the Alma Ata Declaration.
Currently, Johns Hopkins faculty and students are spearheading a working group, the Alma Ata 40 Campaign to mark the anniversary in September 2018, and renew collective commitment to the vision of health for all and health equity enshrined in the Declaration. The global health community will mark the 40th anniversary of the Alma Ata Declaration with a conference on Oct 25–26, 2018 in Almaty, Kazakhstan.
Editor's Note: This article is the first in a series we’ll publish about the Health for All principles underpinning the Alma Ata Declaration and the roles that all members of the Johns Hopkins community can adopt to help achieve its vision.
Dalglish SL, Poulsen MN, Winch PJ. (2013). “Localization of health systems in low- and middle-income countries in response to long-term increases in energy prices.” Globalization and Health. 9:56.
United Nations Environment Programme. (2012). Global Environment Outlook: Environment for the future we want. Progress Press.
Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, de Souza Dias BF, Ezeh A, Frumkin H, Gong P, Head P, Horton R, Mace GM, Marten R, Myers SS, Nishtar S, Osofsky SA, Pattanayak SK, Pongsiri MJ, Romanelli C, Soucat A, Vega J, Yach D. (2015). “Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health.” The Lancet. 386(10007): 1973-2028.
Peter Winch is the Theme Leader for Healthy Environments at the Alliance for a Healthier World (AHW). As Professor in the Social and Behavioral Interventions Program in the Department of International Health at the Bloomberg School of Public Health, he teaches courses on qualitative and formative research and applied medical anthropology. His work aims to: 1) improve the health of mothers and children in areas where access to health facilities is poor or non-existent, and 2) develop and evaluate behavior change interventions and health system responses to global environmental threats.