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Activities and Benefits of International Health Partnerships 150 150 Endeavour Medical

Activities and Benefits of International Health Partnerships

AUTHOR: BERNARD OKEAH

International health partnerships (IHPs) play a pivotal role in global health by implementing programmes to help prevent disease, promote health, and prolong the life of populations across the globe (1–4). This article gives a brief introduction to the activities and benefits of UK-based international health partnerships to patients, staff, and health organisations across the partnering countries.

A recent report by the UK Tropical Health Education Trust (THET) noted that a significant proportion of UK-based IHPs tend to be largely managed by volunteer healthcare professionals who devote their expertise to realise the mandate of their respective organisations (2). Though volunteers help minimise the staff-related costs of the IHPs, their commitment to the partnerships can be limited by other competing priorities such as their main jobs thus impacting on the management of IHPs.  

IHPs partnerships work across four main sectors namely academic institutions, the National Health Service (NHS), within life sciences or commercial sector organisations, and non-governmental institutions including charities. Some IHPs provide international placement opportunities for healthcare professionals as well as students pursuing health-related courses (5). They involve a UK-based institution collaborating with organisations domiciled in other countries across the globe to achieve a global health objective. Despite the triple challenge of the coronavirus, pandemic, Brexit, and cuts by the UK government to overseas development assistance (ODA) that have significantly affected global health activities, UK international health partnerships have shown great resilience and have adapted to innovative working approaches during the post-COVID-19 period with increased elements of remote working now in place for volunteers (3,6).

Activities of International Health Partnerships

IHPs engage in various activities including conducting research, delivering healthcare services, training and capacity building of healthcare workers, implementing community based global health interventions such as hygiene and sanitation programmes, providing technical support to healthcare organisations, and consultancy in global health. Training of healthcare professionals is a significant contribution made by UK-based academic institutions to both the local and international health workforce that improves universal health coverage in line with the United Nations Sustainable Development Goals (7,8), because many international students return to their home countries to take up roles as healthcare workers. 

Health-related programmes offered by UK universities are world-renowned, attracting healthcare professionals from across the globe to pursue full-time, part-time, and distance-learning professional courses. These programmes include medicine, nursing, pharmacy, dentistry, public health, psychology, sociology, and other life sciences. Partner institutions in resource-limited settings also provide placement opportunities for UK healthcare professionals making it possible for them to gain international health experience. Moreover, universities and other academic institutions offer professional development opportunities through short courses available to healthcare workers globally either virtually or through face-to-face sessions. UK-based institutions, specifically universities, provide an excellent research base that supports innovation and boosts productivity across industries largely funded by the UK government and its partners.

The NHS contributes to international health working by providing training opportunities for the global health workforce, research and innovation, as well as engagement in voluntary / humanitarian activities through NHS-based charities / organisations. Professional courses delivered by NHS organisations attract professionals from other countries while some NHS organisations provide attachment opportunities for the health professionals. These partnerships are equally beneficial to developing the workforce of the NHS  such as the Global Fellowship programme for GP trainees which is useful in bringing learning back to the NHS. NHS-based charities provide opportunities for NHS staff to work as volunteers in charities of their interest with some staff working as international health volunteers supporting capacity building activities in partner organisations. NHS organisations also work closely with international partners in conducting collaborative research such as trials on new treatments and interventions that are useful in improving access to quality, safe, and affordable healthcare.

Life science / commercial companies are engaged in manufacturing and distribution of health products to global markets, training and capacity building healthcare workers, international research collaborations, and delivering healthcare services. Some products manufactured by the life sciences or commercial companies include diagnostics and imaging equipment, medical and surgical equipment, pharmaceutical products, providing digital support solutions, and sterilisation as well as cleaning products. Though largely driven by profit, the work of commercial sector organisations may increase access to life-saving technologies and products such as vaccines and affordable medicines. They create potential opportunities for knowledge exchange between healthcare professionals, thus contributing to the development of the global health workforce. Moreover, the commercial sector plays a role in funding research activities in their countries of operation allowing for international collaboration between global health experts. 

Charities and trusts, some of which are registered as part of public sector organisations or as independent organisations, engage in a wide range of activities including training of healthcare workers, implementation of specific projects in maternal and neonatal health, supply of medical equipment, provision of clean water, sanitation and hygiene products, sexual and menstrual health projects, as well as development of healthcare infrastructure. Some charities such as Cancer Research UK provide funding opportunities for international health partners though this is comparatively lower compared to other funding streams for overseas development assistance.

Benefits of International Health Partnerships

Some international health partnerships working in marginalised communities with limited access to healthcare services have a far-reaching impact on the overall health and wellbeing of those communities (10). The partnerships complement mainstream healthcare services and create unique knowledge exchange opportunities for healthcare professionals in both resource-limited and highly resourced countries as they apply their knowledge and skills to improve the health of communities (11). This further strengthens ethical partnerships between resource-constrained and highly resourced countries and facilitates ongoing needs assessment tailored to the respective communities.

IHPs support education of the global health workforce by providing opportunities for knowledge exchange and skills acquisition that may not be available in the healthcare professional’s country. Furthermore, healthcare professionals are exposed to different models of teaching and patient care through their involvement in IHPs to become global health workforce agents of change in their home institutions. IHPs promote bidirectional learning and provide opportunities for reverse innovation (12,13) where learning from a low-income setting could be adapted and implemented in a high income setting e.g. effective models of community health working (14). IHPs also allow for new collaborations in education and research through exchange programmes that are useful in developing the global health workforce while providing opportunities for global health experts to undertake collaborative research (15). The intercultural learning gained through involvement with IHPs broadens the scope of healthcare professionals in providing person-centred care to patients from different cultures which mutually benefits individuals from all involved partner organisations. 

Personal experience in International Health Partnerships

I have worked as a volunteer in an international health partnership providing technical expertise to the Betsi-Kenya Health link in my previous role within the NHS as an infection prevention practitioner. During the COVID-19 pandemic, the partnership implemented a COVID-19 surveillance project in the rural parts of western Kenya through a community health working model that proved beneficial in managing the spread of coronavirus in a resource-limited setting. The intervention involved developing the capacity of community health workers through training in identifying risk events that could trigger outbreaks within their communities and reporting to public health authorities for appropriate actions to limit the spread of the virus. While working remotely, we were able to share key lessons and experiences in managing the pandemic which was very satisfying, especially when the World Health Organisation declared that the COVID-19 pandemic was eventually under control.

International Health Partnerships : Key points

International health partnerships work across four major sectors namely academic institutions, the NHS, life sciences / commercial sector, and charities that are geared towards improving the health and well-being of communities (7). They tend to be mainly managed by volunteer healthcare professionals who work above and beyond their contracted job requirements to achieve the objectives of the IHPs (16–18). The IHPs improve access to services especially within marginalised communities. The work undertaken by IHPs is beneficial to both health care professionals and partnering institutions in the following ways:

  • It improves the international profile of NHS bodies which is useful in the recruitment of international talent through available opportunities attracting high quality staff thus strengthening the diversity in the NHS.
  • It allows staff to access innovative educational and cultural experiences, promoting intercultural learning and communication
  • It improves the skills of healthcare professionals as agents of change within their respective organisations.
  • It increases the opportunities for shared learning and knowledge transfer of skills through participation in studies and exposure to other health care systems. This gives opportunities for healthcare professionals to experience working in resource-poor environments, and to develop training competencies and confidence. This has also been useful in building resilience in the NHS.
  • It promotes retention of staff through increased opportunity for education and career progression; an interest in international initiatives can also promote job satisfaction and retention.
  • It boosts the workforce morale and mobility across the international health partners
  • It increases the opportunities for multidisciplinary working with great insight into different cultures, equality, global citizenship awareness.

Are you interested in learning more about international health partnerships and global health?

If so, why not check out our Global Health and Wildlife Conservation course? Whilst you’re there, why don’t you take a look at our other courses too?

References

  1. UK Government. Health Partnership Scheme  [Internet]. 2013 [cited 2023 Jul 23]. Available from: https://www.gov.uk/guidance/health-partnership-scheme
  2. Jones A. Envisioning a Global Health Partnership Movement [Internet]. Vol. 12, Globalization and Health. BioMed Central Ltd.; 2016 [cited 2023 Jul 23]. p. 1–3. Available from: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-015-0138-4
  3. Crisp LN. Global Health Partnerships:The UK Contribution to Health in Developing Countries. Public Policy Adm [Internet]. 2008 Apr 1 [cited 2023 Jul 23];23(2):207–13. Available from: https://journals.sagepub.com/doi/abs/10.1177/0952076707086256?journalCode=ppaa
  4. Rummery K. Healthy partnerships, healthy citizens? An international review of partnerships in health and social care and patient/user outcomes. Soc Sci Med. 2009 Dec 1;69(12):1797–804.
  5. Buse K, Harmer A. Power to the partners?: The politics of public-private health partnerships. Development [Internet]. 2004 Jun 8 [cited 2023 Jul 23];47(2):49–56. Available from: https://link.springer.com/article/10.1057/palgrave.development.1100029
  6. THET. Research and reports [Internet]. 2016 [cited 2023 Jul 23]. Available from: https://www.thet.org/resource-category/research-and-reports/
  7. Carter C, Notter J. Evaluation of an international health partnership to capacity build emergency, trauma and critical care nurse education and practice in Zambia: An experience from the field. Int Nurs Rev [Internet]. 2022 [cited 2023 Jul 23]; Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/inr.12813
  8. United Nations. Sustainable Development Goals. [Internet]. 2018 [cited 2023 Jul 23]. Available from: https://unfoundation.org/what-we-do/issues/sustainable-development-goals/?gclid=Cj0KCQjwn_OlBhDhARIsAG2y6zOHxKb23v19xjRd3ndzyuEvSmMygmsnxprG8dWnetI8Fx20OKan6LoaAhiqEALw_wcB
  9. Higher Education Funding Council for Wales. International Comparative Performance of the Welsh Research Base 2013 [Internet]. 2013. Available from: https://www.elsevier.com/__data/assets/file/0007/53368/WalesReport2013-Public.pdf
  10.   Booth FW, Chakravarthy M V., Gordon SE, Spangenburg EE. Waging war on physical inactivity: Using modern molecular ammunition against an ancient enemy. Vol. 93, Journal of Applied Physiology. American Physiological Society; 2002. p. 3–30.
  11.   Wright J, Walley J, Philip A, Petros H, Ford H. Research into practice: 10 years of international public health partnership between the UK and Swaziland. J Public Health (Bangkok) [Internet]. 2010 Jun 1 [cited 2023 Jul 23];32(2):277–82. Available from: https://dx.doi.org/10.1093/pubmed/fdp129
  12.   Arora G, Russ C, Batra M, Butteris SM, Watts J, Pitt MB. Bidirectional Exchange in Global Health: Moving Toward True Global Health Partnership. Am J Trop Med Hyg [Internet]. 2017 Jul 7 [cited 2023 Jul 23];97(1):6. Available from: /pmc/articles/PMC5508910/
  13.   Kulasabanathan K, Issa H, Bhatti Y, Prime M, del Castillo J, Darzi A, et al. Do International Health Partnerships contribute to reverse innovation? A mixed methods study of THET-supported partnerships in the UK. Global Health [Internet]. 2017 Apr 18 [cited 2023 Jul 23];13(1):1–11. Available from: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-017-0248-2
  14.   Matthew H. From Brazil to Westminster: learning from a community health worker model [Internet]. Imperial Medicine blogs. 2021 [cited 2023 Sep 3]. Available from: https://blogs.imperial.ac.uk/imperial-medicine/2021/04/07/from-brazil-to-westminster-learning-from-a-community-health-worker-model/
  15. Ritman D. Health partnership research and the assessment of effectiveness. Global Health [Internet]. 2016 Jul 29 [cited 2023 Jul 23];12(1):1–3. Available from: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-016-0181-9
  16.   Aveling EL, Zegeye DT, Silverman M. Obstacles to implementation of an intervention to improve surgical services in an Ethiopian hospital: A qualitative study of an international health partnership project. BMC Health Serv Res [Internet]. 2016 Aug 17 [cited 2023 Jul 23];16(1):1–12. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1639-4
  17.   Chalmers K. Wales’s Health Partnerships with Africa: Maximising potential for mutual benefit [Internet]. 2021 [cited 2023 Jul 23]. Available from: https://www.thet.org/resources/waless-health-partnerships-with-africa-maximising-potential-for-mutual-benefit/
  18.   Chalmers K, Okeah B. International health activity in Wales: Rapid review [Internet]. 2021. Available from: https://www.thet.org/resources/international-health-activity-in-wales-rapid-review/
Climate Change 150 150 Endeavour Medical

Climate Change

AUTHOR: DR MADELEINE BELL

Climate change is the most pressing global health threat predicted to alter the lives of everyone on Earth in the next 10 to 30 years [1]. Soaring temperatures, and the vast array of environmental changes that follow, impact all of the social and economic determinants of health: drinking water, clean air, food resources and housing, amongst many others. Low to middle income countries (LMICs) are experiencing the first wave of these effects with increasingly extreme weather fronts, food and vector borne diseases, and gaps in supply chains. It is estimated that there will be an extra 250,000 deaths per year from 2030 to 2050 [1], and a 540% increase in premature deaths due to global warming [1], placing increased stress on health services.

As the sea and air temperatures rise, disease patterns are set to change, and so will the patients we expect to see in our hospitals. Moreover, hospitals will require more energy to maintain an environment suitable to care for patients in, as well as weather threatening our ability to provide care at all. The first example of this was seen in the UK in 2020, as Whipps Cross hospital in north London saw its first flood, forcing evacuation and diversion of services to nearby hospitals.

Climate Change : how the global warming affects on Health

Global temperatures have already risen by 0.6 degrees since the 1950s and there is evidence of acceleration of this, with sea levels rising an average of 10-20cm and rising sea temperatures. This causes soil degradation, loss of agricultural produce, reduced biodiversity, ecosystem breakdown, and ultimately depletion of the protective ozone layer. Human health is intimately connected with these factors as extreme weather events become more frequent with temperature rises: in the long term water resources shrink, pollution rises, and habitats favourable to vector-borne diseases grow in prevalence. People in LMICs and low-lying land are first to see these effects [2].

Extreme weather has both direct and indirect effects. Immediately, there is the disruption caused, including floods, droughts, high risk of contaminated water supplies, and loss of crops and livestock, the impact of which may be felt worldwide. Psychological impacts are complex and many-fold, including post-traumatic stress disorder, with a rising incidence of 30-40% after acute weather events [3]. Excess mortality occurs with heatwaves, especially in countries with colder climates [4]. 

The climate is intimately connected to infectious diseases, with more water pollution following floods and warmer water better for bacterial growth [5]. Rising temperatures speeds tick reproduction cycles and has been theoretically linked to increasing incidence of tick-borne encephalitis [6]. Vector-borne diseases are another example of where LMIC populations face the brunt of global warming, as associated mortality is 300 times greater than in higher income countries [7].

Healthcare’s Carbon Footprint: Time for Change

Not only must we manage the results of climate change, healthcare is also responsible for 5-10% of all emissions globally. This is predominantly due to medicines and medical equipment, but also to our use of resources.  As a single example, annually we use 1.5 million trees in GP discharge summaries in the NHS [8]. There are simple things that can be done well, and consistently, to reduce our carbon footprint, for example a shift to electronic discharge summaries and letters. This will allow us to meet the 2040 NHS net zero target and better adhere to the guiding medical principle of ‘Do No Harm’, which underscores the green agenda.

Some specialities have made more headway than others. Anaesthetics has examined the global warming potential (GWP) of the gases it uses in daily procedures [9]. With CO2 as a comparison, with a GWP of 1, the relative environmental impact of desflurane is highlighted,  with a GWP 2540 (meaning 1g of desflurane is equivalent to 2540g CO2 [10]), compared to isoflurane (GWP 510), sevoflurane (130) and nitrous oxide (265) [11]. Subsequently, there has been a shift towards total intravenous anaesthesia due to the high carbon burden of inhaled anaesthetic gases [12]. 

Similarly, nephrology acknowledges that the footprint of its speciality is also extremely high, with specific reference to haemodialysis [12]. It is estimated that in a 4-hour dialysis session 500l of water is consumed, in addition to the power needed, waste generated, and medical equipment necessary [13]. Extreme heat affects renal patients disproportionately, due to decreased renal reserve to manage dehydration, and a rise in chronic kidney disease expected to come in the next few years [13], so there is reason to invest in more environmentally-friendly options. A number of renal departments have been involved with the Green Ward competition across the UK, working on utilising wastewater from dialysis, better disposal of waste, and promoting home dialysis [14]. Grassroots changes are being seen across hospitals, but they cannot happen soon enough.

Development of sustainable Quality Improvement Frameworks (QAFs) is making it much easier to measure the impact of everything from an appendicectomy to the running of a psychiatric ward. These QAFs inform policy-makers and heads of departments about which parts of the daily running of a hospital have the highest carbon footprint, and allow consideration of changes accordingly. The NHS supply chains are being asked to change their products to comply with the 2040 net zero target, with all suppliers expected to produce a carbon reduction plan by April 2024 [15]. These top-down changes must be matched by cultural changes within hospitals to ensure the profession as a whole complies with the green agenda. Simple changes such as minimising unnecessary glove and cannula use, low carbon transport to and from hospitals, and promotion of low meat meals for patients have been shown to make enormous savings [16]. Single-use pieces of equipment have little to evidence of superiority over their predecessors, and re-establishing sterilisation techniques is likely to provide both environmental and economical benefits [17].

Take home messages

Climate change is the biggest, most rapidly growing threat to health on Earth.

In healthcare we are faced with managing the victims of rising global temperatures but are also a major contributor. We can anticipate a wealth of changes for our patients and in the way we work due to global warming, and the best we can do is be on the front foot: being prepared to act proactively to change our practice to be as sustainable as possible as early as we can.

Are you interested in learning more about global health?

If so, why not check out our Global Health and Conservation course? Whilst you’re there, why don’t you take a look at our other expedition medicine courses too?

References

  1. WHO, (2021), Climate Change and health, [online] Available at: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679631/ 
  3. Solow AR. Global warming: A call for peace on climate and conflict. Nature. 2013;497:179–80.
  4. A Walinski, J Sander, G Gerlinger, V Clemens, A Meyer-Lindenberg, A Heinz, (2023), The Effects of Climate Change on Mental Health. Available via: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10154789/
  5. Bezirtzoglou C, Dekas K, Charvalos E. Climate changes, environment and infection: facts, scenarios and growing awareness from the public health community within Europe. Anaerobe. 2011;17:337–40.
  6. Zeman P, Bene C. A tick-borne encephalitis ceiling in central Europe has moved upwards during the last 30 years: possible impact of global warming? Int J Med Microbiol. 2004;293
  7. Rossati A. Global warming and its health impact. Int J Occup Environ Med 2017;8:7-20
  8. Suffolk & North East Essex Integrated Care System (2021), Can Do Health & Care, [online] Available at: https://sneeics.org.uk/resources/flipbooks/thinking-differently-together-march-2021/ 
  9. F McGain, J Muret, C Lawson, J D Sherman, (2020) Sustainability in anaesthesia and critical care, BR J Anaes. [online]. Available via: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7421303/
  10. Sulbaek Andersen M.P., Nielsen O.J., Karpichev B., Wallington T.J., Sander S.P. Atmospheric chemistry of isoflurane, desflurane, and sevoflurane: kinetics and mechanisms of reactions with chlorine atoms and OH radicals and global warming potentials. J Phys Chem A. 2011;116:5806–5820. 
  11. Sherman J., Le C., Lamers V., Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg. 2012;114:1086–1090.
  12. Barraclough KA, Agar JWM. Green nephrology. Nat Rev Nephrol. 2020;16(5):257–68.
  13. S Cheng Yeo, X Yan Ooi, T S Mun Tan, (2022), Sustainable kidney care delivery and climate change- a call to action. [online]. Available via: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-022-00867-9
  14. GreenTeam competition 2018, Royal Devon & Exeter hospital, Centre for Sustainable Healthcare, [online]. Available via: https://sustainablehealthcare.org.uk/sites/default/files/26th_february_ob_final_devon_green_ward_competition_evaluation_2018.pd
  15. NHS Suppliers, Greener NHS website. [accessed 20/07/23] Available via: https://www.england.nhs.uk/greenernhs/get-involved/suppliers/
  16. E Mahase, Sixty seconds on…gloves off (2019), BMJ, [online]. Available at: https://www.bmj.com/content/366/bmj.l4498.long
  17. V Pegna, S A McNally, (2021), Are single use items the biggest scam of the century?, The Bulletin of the Royal College of Surgeons of England, [online]. Available via: https://publishing.rcseng.ac.uk/doi/10.1308/rcsbull.2021.89
Air pollution 150 150 Endeavour Medical

Air pollution

AUTHOR: DR MADELEINE BELL

Air Pollution: Components, Particulate Matter, and Health Impacts

Air pollution occurs in both the indoor and outdoor environments with 11.65% of deaths globally being accredited to it [1]. It is the third greatest mortality risk factor across the world [3], after hypertension and smoking. The burden of disease is seen predominantly in low to middle income countries (LMICs) where indoor air pollution is a much bigger problem due to reliance on solid fuel for cooking. There have been significant reductions in the last 20 years in the use of these fuels, with a corresponding fall in the death rates associated with air pollution [10], as more countries make the transition towards ‘clean fuels’ (bioethanol, natural gas, electricity.)

Air pollution is made up of gaseous components (carbon monoxide, carbon dioxide, nitric oxide, sulphur dioxide, ozone), organic compounds (acetetone, benzene) and particulate matter (PM). There are three types of particulate matter, PM10 (<10μm), PM 2.5 (<2.5μm) and UFP (<100nm). The smaller the size of particle, seemingly the more pro-oxidative they are and the higher risk to health [1]. There’s a closer positive association between high PM 2.5 levels and rates of hospitalisation as well as all cause mortality [1]. The health impacts seen are both acute, causing pneumonia and airway irritation, and more chronic. It is thought that PM 10 particles are generally deposited in the upper airway with associated respiratory disease, while PM 2.5 is engulfed by the bronchiolar and alveolar macrophages before being absorbed into the bloodstream. From here the fine particulate matter has a wealth of systemic effects. These appear to be predominantly due to mitochondrial dysfunction, inflammation and oxidative stress, due to increased propensity for formation of free radicals which are associated with a range of chronic illnesses [11].

Air Pollution’s Impact on the Cardiovascular System

With regards to the cardiovascular system, studies correlate air pollution with higher incidence of ST-elevation myocardial infarction, sudden cardiac death and peripheral arterial disease [3]. The strongest association is with heart failure as admissions increase proportionally to air pollution exposure [2]. There’s a suggestion that PM 2.5 in particular could be detrimental to cardiac function inducing arrhythmias [3]. This is mainly mediated by oxidative stress, coagulation dysfunction, autonomic disturbance, and inflammation. PM 10 and PM 2.5 are thought to upregulate sympathetic tone therefore leading to vasoconstriction, hypertension and endothelial dysfunction. Increased systemic oxidative stress and inflammation can then lead to atherosclerosis progression, plaque instability and a prothrombotic state [3].

Air Pollution’s Impact on the Gastrointestinal system

The gut is also affected as particulate matter is cleared from the lungs to the gastrointestinal tract through mucociliary clearance into the oropharynx [3]. Here the larger PM 10 particles are swallowed. Moreover, gaseous components can cause inflammation of the gut, causing oxidation of intraintestinal lipids, alongside impacting the intestinal microbiome [3]. The rising body of evidence regarding the importance of the microbiome in supporting the immune system [4] attests to the compromise this puts on human health.

Air Pollution’s Impact on pregnancy and infancy

Exposure to air pollution prenatally and in childhood is associated with worse neurological outcomes and foetal growth restriction (FGR) [5]. Black carbon and other particles have been detected in placentas which could reduce placental function [6]. Black carbon has been seen to alter brain development in animal models and is a possible mechanism for impaired neurological development in foetuses [7]. This is in addition to the known increase in oxidative stress and inflammation that comes with air pollution. These are two factors well established to cause FGR due to interference with growth hormone release. MRIs of children in a study from the Netherlands have proven changes in brain morphology with air pollution exposure prenatally [8]. Throughout life there continues to be evidence of the detrimental impact of poor air quality: for example, with increased exposure to air pollution, 9-12 year olds had an increase in amygdala and cerebellum size, and a smaller corpus callosum when compared to their less-exposed peers [9].

Take home messages

Air pollution is one of the more established, well-researched effects of climate change. Researchers are becoming increasingly concerned with the systemic effects of particulate matter, especially affecting people of LMICs where solid fuel use in the home is common. With increasing understanding of the risks, and as some of these countries increase their economic power, the shift towards cleaner fuels has been seen. As the maps in figure 1 illustrate, from 1990 to 2019 the number of deaths from indoor air pollution is falling, so all is not lost. However, biomass still makes up a significant proportion of fuel resources as electricity cannot be relied upon globally [12]. Harnessing natural resources is an enormous challenge to ensure we can remove the need for traditional energy sources in every community. Now is the critical time to act.

Figure 1: deaths from indoor air pollution in 1990 and 2019.

Maps reproduced from Our World in Data (https://ourworldindata.org/indoor-air-pollution)

A remote clinic in North-Eastern Kenya

Are you interested in learning more about global health?

If so, why not check out our Global Health and Conservation course? Whilst you’re there, why don’t you take a look at our other courses too?

References 

  1. H Ritchie & M Roser (2022), Indoor Air Pollution, [online]. Available at: https://ourworldindata.org/indoor-air-pollution
  2. A Shah, J Langrish, H Nair, D McAllister, A Hunter, K Donaldson, D Newby, N Mills, (2013), Global association of air pollution and heart failure: a systematic review and meta-analysis, [online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809511/ 
  3. N Martinelli, O Oliveri, D Girelli (2013), Air particulate matter and cardiovascular disease: A narrative review [online]. Available at: https://www.sciencedirect.com/science/article/pii/S0953620513001040
  4. J Feng, S Cavallero, T Hsiai, R Li, (2020), Impact of air pollution on intestinal redox lipidome and microbiome, [online]. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0891584919322749?via%3Dihub
  5. R Hills,, B Pontefract, H Mishcon,  C Black, S Sutton, C Theberge (2019), Gut microbiome: Profound implications for diet & disease [online]. Available at: https://pubmed.ncbi.nlm.nih.gov/31315227/ 
  6. B Bos, B Barratt, D Batalle, O Gale-Grant, E Hughes, S Beevers, L Cordero-Grande, A Price, J Hutter, J Hajnal, F Kelly, A Edwards, S Counsell, (2023), Prenatal exposure to air pollution is associated with structural changes in the neonatal brain [online]. Available at: https://www.sciencedirect.com/science/article/pii/S0160412023001940
  7. H. Bové, E. Bongaerts, E. Slenders, E.M.Bijnens, N.D. Saenen, W. Gyselaers, P. van Eyken, M. Plusquin, M.B.J. Roeffaers, M.Ameloot, T.S. Nawrot, (2019), Ambient black carbon particles reach the fetal side of human placenta, [online]. Available at: https://www.nature.com/articles/s41467-019-11654-3
  8. D. Batalle, E. Muñoz-Moreno, A. Arbat-Plana, M. Illa, F. Figueras, E. Eixarch, E.Gratacos, (2014), Long-term reorganization of structural brain networks in a rabbit model of intrauterine growth restriction [online]. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1053811914004509
  9.  M.J. Lubczyńska, R.L. Muetzel, H. el Marroun, G. Hoek, I.M. Kooter, E.M.Thomson, M. Hillegers, M.W. Vernooij, T.White, H. Tiemeier, M. Guxens (2021), Air pollution exposure during pregnancy and childhood and brain morphology in preadolescents. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0013935120313438 
  10.  Our World in Data (https://ourworldindata.org/indoor-air-pollution)
  11. L Pham-Huy, H He, C Pham-Huy, (2008), Free radicals, antioxidants in disease and health. [online]. Available at: https://pubmed.ncbi.nlm.nih.gov/23675073/#:~:text=They%20are%20produced%20either%20from,a%20phenomenon%20called%20oxidative%20stress
  12. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels, M Romanello, The Lancet 2022: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01540-9/fulltext
Health Scoping in North Eastern Kenya 150 150 Endeavour Medical

Health Scoping in North Eastern Kenya

Introduction of Health Scoping Mission

You’ve just landed in Jomo-Kenyatta International Airport, Nairobi. It’s 11pm local-time and a driver is waiting outside to take you to your hotel room for the night. Tomorrow you’ll be embarking on an eight-hour drive to Lewa Wildlife Conservancy, an incredible safari destination nestled at the base of Mt. Kenya. You’ll be meeting a senior health advisor (that you’ve only ever met online) to assist them in a health scoping mission with the Northern Rangelands Trust (NRT) in remote parts of North-Eastern Kenya…

This was the exciting situation I found myself in back in July 2022. Together, we will retrace my steps to discover what a health scoping mission is, how ‘needs’, ‘demands’, and ‘supply’ interact (1), and consider how outcomes can be effectively communicated to stakeholders to ensure investment in sustainable healthcare interventions.

Your Brief

You’ve been asked to assist in a health scoping mission in North-Eastern Kenya on behalf of NRT. This is a remote and austere area suffering from a recent drought, and little is known of their healthcare requirements. At the end of the mission, you will be asked to present your findings to NRT, community leaders, and government officials.

What information would you like to know beforehand?

Who would you like to be involved in the mission?

What questions will you ask?

Pre-Departure Reading

Before boarding your flight to Kenya, you’ve already done some pre-departure reading on what will be expected of you, a summary of the context, and who you will be working for:

Health scoping is the process of:

  1. Determining the health needs of a community or region
  2. Communicating with relevant stakeholders
  3. Considering appropriate interventions given available funding and support. 

Health scoping missions are often conducted by charitable organisations or governments to allocate resources towards sustainable and impactful projects. 

Kenya is a country in the Horn of Africa, bordered by Somalia, South Sudan, Ethiopia, Uganda, and Tanzania (Figure 1). As well as ongoing conflict in South Sudan, Ethiopia and Somalia, this region has recently experienced its worst drought since 1984, leaving remote communities in increasingly harsh environments (2). In North-Eastern Kenya, pastoralists are left without running water, without a stable source of revenue, and prone to malnutrition and infection. Given the isolated location, little is known about healthcare provision in this region.

Horn of Africa

Figure 1: A map of the countries in the Horn of Africa. Image from: https://commons.wikimedia.org/wiki/File:Horn_of_Africa_map.png

The Northern-Rangelands Trust (NRT) (3) is a community-based conservation organisation that encourages and supports communities to protect wildlife, enhance livelihoods and promote peace. Local leaders have expressed healthcare provision as a top priority within conservancies, prompting NRT to assess health needs in these areas.

Arriving in Lewa

You’ve just arrived in Lewa Conservancy. Enroute you’ve spotted an elephant, two rhinos, a herd of zebra, and a few grazing giraffes. A meeting has been organised between you, the senior health advisor, NRT officials, conservancy leaders and public health officers from the Government of Kenya. The itinerary is discussed, and final plans are put in place. It’s time to get started!

Before to start a health scoping mission : discussion with health leaders

Discussions with conservancy leaders, public health officials and nurses outside a clinic

What You Find

The first thing that strikes you is how austere the region is. The landscape is incredibly dry and livestock carcasses line the dirt road. Access is limited and you travel in convoy along remote tracks in four-by-four vehicles. What would take an hour in the UK, takes four or five here. 

The clinics you visit have no running water, no stable form of electricity, and limited drug supplies. Staff struggle with low-morale, delayed pay cheques, and unsafe living environments. Each clinic serves a large population with a wide catchment area. The most common conditions are respiratory, diarrhoeal, and malnutrition. In addition, there is a high demand for improved maternal services. 

At night, you set up camp on the grounds of a very basic accommodation spot. Food is local cuisine of chapati, tea, goat stew and beans, and one of the NRT team finds you a Tusker Beer to enjoy as a sundowner.

rural camp in Africa

Campside number two in rural Isiolo County

enjoying a sundowner : tusker beer

Enjoying a Tusker beer for sundowners

Needs, Demands and Supply

When undergoing a health scoping mission, or indeed any evaluation of healthcare services, it’s useful to consider the needs, demands and supply (1):

  • Needs: What the community require from their healthcare service
  • Demands: What the community want from their healthcare service
  • Supply: What is currently being provided 

The difference between needs and demands is subtle, yet important to appreciate. For example, in the UK patients may demand antibiotics for a viral illness but it isn’t what they need. Instead, they need good public health education on antibiotic stewardship but that’s not what they are demanding from their healthcare service. 

These can be depicted as a Venn-Diagram (Figure 2). The goal of your mission is to identify an intervention that fits within the centre star; something that is wanted, required, and can be realistically supplied.

health scoping mission : Venn Diagram

Figure 2: A Venn-Diagram depicting the overlap of Needs, Demands and Supply as outlined by Stevens A, Gabbay J 1991(1).

Can you think of healthcare interventions that fall into each of the Venn-Diagram numbered parts?

In most instances, needs and demands will largely overlap. During your mission in North-Eastern Kenya, interviewed communities want better water provision, electricity supply, drug supply and maternal services – all of which are clearly required. What is being supplied are buildings and general infrastructure, some solar electricity to power vaccine fridges, basic drug supply, and a workforce. Now it’s time to consider what interventions NRT can provide.

A maternal suite at a rural clinic

A maternal suite at a rural clinic

End of Health Scoping Mission Meeting

 

Time to highlight what you’ve found and present to government officials and NRT. Your presentation needs to be concise, considerate of a language barrier, and indicate clear recommendations going forward.

InfrastructureCommoditiesWorkforce and Capacity Building
AccessAmbulanceAdequate staffing
Water supplyPoint of care testing equipmentHealth management training
PowerDrug supplyAdequate pay for all staff
Waste disposalCold chainSecurity to keep staff safe
Fencing

Table 1: A table highlighting the identified Needs and Demands from our health-scoping mission and categorised into three groups.

Following our mission in July 2022, we broadly categorised needs and demands into three groups: infrastructure, commodities, and workforce and capacity building (Table 1). We talked about ‘low-hanging fruit’, i.e. interventions that are relatively cheap and easy to organise, such as health management / leadership training, point-of-care testing equipment, and infrastructure like fencing or living quarters. Although useful, these fail to meet very basic demands of the clinics and communities – water, electricity, access. 

How can healthcare thrive without these fundamental components? 

You can build all the clinics you want, but if there is no water for cleaning in labour or during a procedure, no electricity to power lights at night or store medications appropriately, and no means of getting to the clinic, then will the clinic function at all? Addressing these elements will require long-term commitment and investment, which is why we have recommended a health-advocate role within NRT and solidified an ongoing positive relationship between NRT and the government.

waiting for treatment outside a remote clinic in north eastern Kenya

Women and children awaiting treatment for Visceral Leishmaniasis (Kala-Azar) outside a remote clinic in North-Eastern Kenya

A remote clinic in North-Eastern Kenya

A remote clinic in North-Eastern Kenya

Health Scoping Mission : Final Reflections

 

Overall, the mission felt like a success. Together, we were able to see first-hand what is needed in this region and findings were effectively communicated back to both NRT and government officials. Conservancy leaders, local healthcare staff, and people from the community were given a space to discuss what they want from their healthcare service and advocate for change. The hope going forward is that interventions will focus on those basic requirements (water, electricity, and access) that are fundamental to health and wellbeing.

Going Back…

Since the health scoping mission in July 2022, I have been back to North-Eastern Kenya in January 2023 with a team of three other Global Health doctors. We re-visited one clinic, and were surprised to find that funding from a charitable organisation had gone into construction of a new ward despite there continuing to be no running water and limited electricity provision.

Unfortunately, poor resource allocation is a widespread challenge in aid delivery for numerous reasons. Here, it was a combination of the charity being specific in how they wanted their money to be used, and the government wanting to promote the clinic to a higher facility. In Kenya, healthcare facilities are categorised into ‘levels’ with specific criteria – the higher the level the more services are provided. By having the new inpatient ward, the clinic was re-categorised to a higher level facility. Ultimately, that inpatient ward will not be used given the lack of basic provision of water, electricity, access, staffing, lab equipment, drug supply and so on. 

As a result, we are now in the process of developing a new ‘checklist’ or categorising system to encourage basic needs to be met before promotion to higher facilities. We hope this will facilitate better resource allocation and improve healthcare provision in the region. Watch this space!

Are you interested in learning more about global health?

If so, why not check out our Global Health and Conservation course? Whilst you’re there, why don’t you take a look at our other expedition medicine courses too?

Further Reading

  1. NRT Building Livelihoods – livelihoods-enterprise
  2. ‘It’s Our Turn to Eat’ – Michaela Wrong – ISBN: 9780007241972
  3. ‘Flowers for Elephants’ – Peter Martell – ISBN: 9781787386938

References

  1. Stevens A, Gabbay J. Needs assessment [Internet]. U.S. National Library of Medicine Health Trends; 1991; 23(1): 20-3. [cited 2023 Jun 6]. Available from: https://pubmed.ncbi.nlm.nih.gov/10113881/
  2. Drought and food insecurity in the Greater Horn of Africa [Internet]. World Health Organization; 2023 [cited 2023 Jun 26]. Available from: https://www.who.int/emergencies/situations/drought-food-insecurity-greater-horn-of-africa
  3. Northern Rangelands Trust [Internet]. 2023 [cited 2023 Jun 6]. Available from: https://www.nrt-kenya.org/ 
An Introduction to the Concept of Global Health 150 150 Endeavour Medical

An Introduction to the Concept of Global Health

AUTHOR: AARON PRITCHARD

Global health offers a lens on the intricacies, dynamics and interdependencies of healthcare systems, disease distribution and susceptibilities to illness on a planetary scale. It is an inherently layered and multidisciplinary field, one which draws together the expansive disciplines of the social sciences; epidemiology, economics, sociology and politics, as well as being informed by and informing clinical and biomedical perspectives. For this reason, global health may be approached as an academic or policy-informing stance on matters of health and health system significance internationally, The facilitation of global health partnerships serve as an example of how this approach can be operationalised, drawing on the insights and expertise of differing geographical contexts to enable and sustain mutual learning, innovation and skills exchange.

Global health as a way of thinking 

Whilst global health may be considered an academic discipline of increasing prominence, it can also be perceived as a mindset: a way of thinking about how trends and patterns in human healthcare are unfolding globally. It may prompt us to think about how our interaction with nature and the environment has sequelae far outreaching our own doorsteps, as well as the influences of policy and macroeconomic events on health systems. Global health perspectives stimulate us to think about cause and its inseparability from consequence. In the same way as we may think about a pathophysiological process on a biological level, the multi-factorial intricacies of causality and sequelae apply too on a population scale, often with an equivalently insidious course. Being interested in and astute to these complex relationships brings us closer to appreciating our place in the dynamic social and environmental ecologies of which we are a part, and resultantly better able to respond to the challenges we may face.

Naturally, this presentation of global health may lead us to question its distinction from public health with an international focus (or international public health). International public health has been distinguished from global health by its argued emphasis on communicable disease, maternal and child health in less economically advantaged contexts (1). Congruently, others have asserted the derivation of international public health from tropical medicine with global health representing a more recent evolution of this domain (2). On this basis it may be considered that global health represents an attempt to re-conceptualise traditionally disease-focused or philanthropically-driven interest in tackling disease inequalities globally. Global health is offering less of a medically deterministic view on or of human health, its influences and determinants across the world – it is becoming a way of seeing. Establishment of the seventeen Sustainable Development Goals (SDGs) in 2015, adopted by all UN Member States (3) provide high level leverage for directing the broader fields of health risk mitigation and healthcare provision globally, reflecting the growing recognition of the inseparability of the local from the global.

Applied global health

Extending the concept of global health as a predominantly academic domain, it may also be useful to recognise ways in which thinking globally has directed the establishment and activity of health partnerships between health providers, institutions and facilities, typically between low and middle income countries (LMICs) and comparably higher income countries (HICs). Many such partnerships have made much progress in supporting healthcare initiatives and provision in resource limited healthcare settings (4) whilst drawing on health needs assessments to plan future activity with mutual learning. In order to ensure LMIC healthcare empowerment, ownership and sustainability, it is crucial to consider ways in which partnerships can construct themselves as equitable crucibles of learning and skills exchange in times of ever-pressingly evident healthcare challenges. Such considerations have been clearly articulated in recent work (5) and remind us of the potential within global health, as a disciplinary field, to drive carefully considered and needs-led practice in the execution of applied global health work. The broad framework offered by the UN SDGs offer a valuable platform from which to collaboratively achieve this.

Key learning points

  • Global health is an inherently multidisciplinary field drawing on perspectives from social, environmental and health sciences. 
  • Global health can be challenging to define and has been presented as distinct from international public health
  • Global health helps us to understand the complex interdependence of human health in an increasingly connected world.

Are you interested in learning more about global health?

If so, why not check out our Global Health and Conservation course? Whilst you’re there, why don’t you take a look at our other courses too?

Further points to consider

  • In what ways does the inherently multidisciplinary nature of global health help us to better identify and respond to emerging global health priorities?
  • How can the study of global health help us to address the UN Sustainable Development Goals (SDGs)?

References

  1. Beaglehole R, Bonita R. What is global health?. Global Health Action. 2010;3.
  2. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN. Towards a common definition of global health. The Lancet. 2009 Jun 6;373(9679):1993-5.
  3. The Sustainable Development Agenda (UN) available at: https://www.un.org/sustainabledevelopment/development-agenda/#:~:text=The%2017%20Goals%20were%20adopted,plan%20to%20achieve%20the%20Goals. (accessed 28/06/2023)
  4. Crisp LN. Global health partnerships: the UK contribution to health in developing countries. Public policy and administration. 2008 Apr;23(2):207-13.
  5. Binagwaho A, Allotey P, Sangano E, Ekström AM, Martin K. A call to action to reform academic global health partnerships. bmj. 2021 Nov 1;375.