Young Voices in Research for Health 2009 Winners of the 2009 essay competition for the under-30s Global

l Forum for Health Research 2009 Published by the Global Forum for Health Research, October 2009 ISBN 978-2-940401-22-2 Suggested citation: Global Forum for Health Research, Young Voices in Research for Health, 2009 Keywords: 1. Research. 2. Health. 3. Innovation. 4. Poor. 5. Development. The reproduction of this document is regulated in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. The document may, however, be freely reviewed and abstracted with appropriate acknowledgement of the source, but not for sale or for use in conjunction with commercial purposes. Requests for permission to reproduce or translate the report, in part or in full, should be addressed to the Global Forum for Health Research (see address below). All reasonable precautions have been taken by the Global Forum for Health Research to verify the information contained in this document. However, it is being distributed without warranty of any kind, either expressed or implied. The responsibility for interpretation and use of the material lies with the reader. In no event shall the Global Forum for Health Research be liable for damages arising from its use. The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Global Forum for Health Research concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The authors alone are responsible for the views expressed in this document. Additional copies of Young Voices in Research for Health 2009 can be ordered (at no charge) via the web site: www.globalforumhealth.org or from Global Forum for Health Research 1-5 route des Morillons PO Box 2100 1211 Geneva 2 Switzerland
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Acknowledgements AgRAdecImIentos RemeRcIements

The organizers thank the following for their opinions and assistance: Los organizadores desean dar las gracias a las siguientes personas por sus opiniones y su ayuda: Les organisateurs remercient les personnes suivantes pour leurs opinions et collaboration : Andrea Bauler, Melanie Brown, Sarah Cash, Tea Collins, Ann Gaspard, Erik Landriault, Christine Mauroux, Jean-Jacques Monot, Sylvie Olifson, Oana Penea, Tiago Pinto Pereira (Global Forum for Health Research); Nandita Bhan, Enrique Falceto de Barros, Dziedzom de Souza, Meghnath Dhimal, Lester Sam Geroy, Kheyal Khalil, Daniel LopezCevallos, Amita Mukho, Daniel Savignon Marinho, Marame Ndour, Sophie North, Obasogie Osamwonyi (Young Voices); Emma Grainger, Gurbinder Maumi, Zoe Mullan, Sasha Payagala, Tara Sarwal (The Lancet). They also express their gratitude to the Ministry of Public Health of Cuba for hosting a national competition and to the Cuban institutions from whose staff the national selection committee was made up: Asimismo, expresan su gratitud al Ministerio de Salud Pblica de Cuba por haber organizado un concurso nacional y a las instituciones cubanas cuyo personal compuso el comit de seleccin nacional: De plus, ils expriment leur gratitude au Ministre de Sant publique de Cuba pour avoir organis un concours national et aux institutions cubaines dont le personnel a compos le comit de slection : Centro de Ciberntica Aplicada a la Medicina, Escuela Nacional de Salud Pblica, Hospital Hermanos Almejeiras, Instituto de Cardiologa y Ciruga Cardiovascular, Instituto de Investigaciones Culturales Juan Marinello, Instituto Nacional de Endocrinologa, Instituto Nacional de Higiene y Epidemiologa, Red Telemtica de Salud de Cuba. The Cuban committee was chaired by Nereida Rojo with: El comit cubano estuvo presidido por Nereida Rojo y cont con la participacin de: Le comit cubain tait prsid par Nereida Rojo avec la participation de: Magaly Caraballoso, Ivette Castillo, Mara del Gonzlez, Guillermo Daz, Carlos Garca, Rosario Garca, Ariadna Gonzlez, Ana Ma. Ibarra, Celia Medina, Benito Prez, Mercedes Rubn, Alexander Segura, Ana Serrano, Teddy Tamargo. The committee reviewed all Spanish-language essays and identified the Cuban winner. El comit examin todas las redacciones escritas en lengua espaola y eligi al ganador cubano. Le comit a examin tous les textes espagnols et dsign le gagnant cubain.

Introduction

IntRodUctIon

For the fourth year running, the Global Forum for Health Research and The Lancet invited authors and researchers under 30 years of age to enter the Young Voices essay competition. This years theme was Innovating for the health of all. Authors were encouraged to take established practices to task and to write in an engaging and thought-provoking fashion. Entrants certainly rose to this challenge. The competition was opened to entries in Spanish this year, as well as in French and English. Over 400 entries were submitted about 25% more than last year from young people of 75 nationalities. The 41 essays included in this anthology were shortlisted and eight were chosen as the winners: Bianca Brijnath (Australia), Rebecca Lacroix (Sweden), Annia Martnez Massip (Cuba), Aina Palou Serra (Spain), Aakanksha Pande (India), Christian Rueda-Clausen (Colombia), Okezie Uba-Mgbenena (Nigeria) and Rafael van den Bergh (Belgium). While some of the young professionals chose to discuss health problems in their home countries, others highlighted their experiences abroad, but all tackled issues that they are clearly passionate about. The topics covered are diverse: for example, the crisis of human resources in health, biases in scientific publication, the intricate links between education and health, media coverage of global health issues, health promotion in schools, and international responses to public health emergencies. The format of essays also varied. One is an open letter to the President of the United States, others are narrative; some are very practical, others philosophical. Many are immensely personal texts. It is encouraging to see the next generation of health researchers make such heartfelt arguments about innovation and health equity. Finding innovative ways to distribute health resources and services fairly to populations in need should be a priority for policymakers, health workers and researchers. We hope these young voices will be heard.

Susan Jupp
Head, External Relations Global Forum for Health Research

Udani Samarasekera
Senior Editor The Lancet

Young Voices in Research for Health 2009

Introduction

IntRodUctIon

Pour la quatrime anne conscutive, le Global Forum for Health Research et The Lancet ont invit des auteurs et des chercheurs gs de moins de 30 ans participer au concours dessais La voix des jeunes. Le thme de cette anne tait Innover pour la sant de tous. Les auteurs taient encourags remettre en question certains usages tablis et rdiger un essai original, voire provocateur. Les participants se sont sans aucun doute montrs la hauteur du dfi. Le concours tait, cette anne, ouvert aux soumissions en langue espagnole, franaise et anglaise. Plus de 400 essais ont t prsents soit 25 % de plus que lan dernier par des jeunes gens de 75 nationalits. Cette anthologie inclus les 41 essais prslectionns et ceux des huit gagnants : Bianca Brijnath (Australie), Rebecca Lacroix (Sude), Annia Martnez Massip (Cuba), Aina Palou Serra (Espagne), Aakanksha Pande (Inde), Christian Rueda-Clausen (Colombie), Okezie Uba-Mgbenena (Nigeria) et Rafael van den Bergh (Belgique). Alors que certains de ces jeunes professionnels ont choisi de parler des problmes de sant dans leur pays dorigine, dautres ont prfr sappuyer sur leur exprience ltranger mais tous ont trait de problmes qui visiblement les passionnent. Divers sujets ont t couverts : par exemple, la crise des ressources humaines en matire de sant, la partialit dans les publications scientifiques, ltroitesse des liens entre ducation et sant, la couverture mdiatique des problmes mondiaux de sant, la promotion de la sant dans les coles et les rponses internationales aux urgences de sant publique. Les essais varient galement dans leur format. Lun est une lettre ouverte au Prsident des tats-Unis, dautres sont narratifs ; certains se penchent sur des aspects trs pratiques, dautres sont philosophiques. La plupart de ces textes sont minemment personnels. Il est extrmement encourageant de voir que la nouvelle gnration de chercheurs possde des arguments sincres en faveur de linnovation et lquit en matire de sant. Trouver des moyens innovants de rpartir quitablement les ressources et les services de sant parmi les populations qui en ont besoin devrait tre une priorit pour les dcideurs, les travailleurs du secteur de la sant et les chercheurs. Nous esprons que la Voix des jeunes sera coute.

Susan Jupp
Responsable des relations extrieures Global Forum for Health Research

Udani Samarasekera
diteur senior The Lancet

Introduccin

IntRodUccIon

Por cuarto ao consecutivo, el Foro Mundial sobre Investigaciones Sanitarias (Global Forum for Health Research) y The Lancet han invitado a autores e investigadores menores de 30 aos de edad a participar en el concurso de redacciones Voces Jvenes (Young Voices in Research for Health). El tema de este ao ha sido la Innovacin para la salud de todos. Se ha alentado a los autores a adoptar las prcticas establecidas para la tarea y escribir de un modo sugerente que induzca a la reflexin. Desde luego, los participantes han estado a la altura del desafo. Este ao, el concurso se ha abierto a los trabajos escritos en espaol, aparte de los redactados en lenguas francesa e inglesa. Se han recibido ms de 400 redacciones un 25 % ms que el ao anterior escritas por jvenes de 75 nacionalidades. Se han preseleccionado los 41 ensayos incluidos en esta antologa y ocho de ellos han sido elegidos como ganadores: Bianca Brijnath (Australia), Rebecca Lacroix (Suecia), Annia Martnez Massip (Cuba), Aina Palou Serra (Espaa), Aakanksha Pande (India), Christian Rueda-Clausen (Colombia), Okezie Uba-Mgbenena (Nigeria) y Rafael van den Bergh (Blgica). Mientras que algunos de los jvenes profesionales se han decantado por debatir los problemas sanitarios de sus pases de origen, otros han destacado sus experiencias en el extranjero; todos ellos, no obstante, han tratado temas que, claramente, les apasionan. Los temas abordados han sido diversos: por ejemplo, la crisis de recursos humanos en materia de sanidad, los sesgos en las publicaciones cientficas, las complejas relaciones entre la educacin y la salud, la cobertura meditica de las cuestiones de salud mundial, la promocin de la salud en las escuelas y la respuesta internacional ante emergencias de salud pblica. El formato de las redacciones tambin ha sido dispar. Una de ellas es una carta abierta al Presidente de los Estados Unidos, otras son de carcter narrativo; algunas son muy prcticas, otras filosficas. Muchos de los textos son sumamente personales. Es alentador ver la prxima generacin de investigadores para la salud argumentar de manera tan sincera acerca de la innovacin y la equidad en salud. Encontrar formas innovadoras de distribuir los recursos y servicios sanitarios equitativamente entre la poblacin necesitada debe ser una prioridad para los responsables polticos, los trabajadores de la salud y los investigadores. Esperamos que se preste odo a estas jvenes voces.

Susan Jupp
Jefa de Relaciones Exteriores Global Forum for Health Research

Udani Samarasekera
Redactor jefe The Lancet

Young Voices in Research for Health 2009

table of contents
Acknowledgements Introduction
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3 5 6 7

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Introduction en franais Introduccin en espaol

essaYs
Deciphering the anatomy of organizations and the physiology of political will: The way forward for global health Najwan Abu Al-Saad, UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Taking the doctors back to where they belong: Achieving health for all in Bangladesh Tanvir Ahmed, Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lack of innovation in health promotion in schools schools: Educating the citizens of tomorrow with the methods and strategies of yesterday Abdelhamid Benalia, Algeria Education: A simple way to improve health Fabio Botelho, Brazil
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12 15 19 21 24 27 31 35 39 42 46 50 53 55 58 61 63 66 70 73 76 80 83 87

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Pens and needles Bianca Brijnath, Australia

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Urgent global health innovation? Global human innovation first! Baltica Cabieses Valdz, Chile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Redistribuir la locura: construccin de alternativas sociales y teraputicas al encierro manicomial Jos Agustn Cano Menoni, Uruguay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . From lab to village: Catalysing global health entrepreneurship Justin Chakma, Canada It takes more than a Band-Aid: A letter to president Obama Amanda Deatsch, USA
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Never let a disaster go to waste: Opportunities presented by swine flu for innovation in global public health emergency response Delford Doherty, Sierra Leone . . . . . . . . . . . . . . . . . . . . Redefining the cycle: Systems, health and child poverty Nicholas Fancourt, New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Innovating for the health of all: Searching for equity, responsibility and truth in a divided world Hildy Fong, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Silicon Brains Javier Garca Castro, Spain
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From Asclepius to gene engineering: Have we gained a better understanding of health? Manik Gemilyan, Armenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inefficient innovation: The need to redirect funds from treatable and preventable diseases Damian Hacking, South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Retro innovation The healthier way Liesl Harewood, Guyana
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Where are the global issues in our global media culture? Hannah Harvey, UK Health 2.0: Health for all, health by all Kate Jongbloed, Canada

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Innovating for the health of all: Breaking the barriers Biraj Karmacharya, Nepal

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De la ncessit de se mfier des ftichistes de la nouveaut Rebecca Lacroix, Sweden Contra la violencia de gnero, cada paso cuenta Luz Lpez Samaniego, Spain

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A mission for all: Increasing access to health products and services through innovative partnerships Priya Mannava, India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Innovando hacia dentro Annia Martnez Massip, Cuba
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Malnutrition and obesity: Closing the gap Amy Mathew, New Zealand

Mobile phones, women and girls: Engendering mHealth into an innovation for all Janna McDougall, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plaidoyer pour lacceptation des dontologies non conventionnelles de recherche mdicales Paul Wilfrid Armand Menye, Cameroun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Innovation beyond individualism Jason Nagata, USA
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90 94 97 101

Health-care access and the solar-powered ambulance Rufaro Ndokera, UK

Show me the money! From rhetoric to action in addressing the global human-resources-for-health crisis Brenda Ogembo, Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

* *

La necesidad de tejer estrategias colectivas para una transformacin social y sus consecuentes mejoras para la salud Aina Palou Serra, Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Business not as usual: Improving the quality of health care through innovation Aakanksha Pande, India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Can todays health challenges be overcome? Why information, coordination and innovation matter Marian Angelica Panganiban, Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Realigning interests and resources for health technology development in traditionally underserved markets Samuel Pickerill, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Disruptive innovation as the new paradigm of global health Soumya Rangarajan, India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Let the machines do the work: Automation and the drive for global health innovation Erin Rayment, Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

International database of negative results in biomedical research: The need to shift a paradigm in scientific publication Christian Rueda-Clausen, Colombia . . . . . . . . . . . . . . . . 131 Plaidoyer pour des modles conomiques ambidextres et la promotion de lducation tertiaire dans les pays en voie de dveloppement pour linnovation en sant la porte de tous Valrie Sabatier, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Community empowerment for global health equity: Towards an innovative, comprehensive health-care model for all David Shulman, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

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Appropriate methods and technology in health: A round peg in a round hole Okezie Uba-Mgbenena, Nigeria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Who is at the receiving end of our innovation? Rafael van den Bergh, Belgium
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145

Pensamiento temporal y salud. Necesidad de tecnologas sociales para la mejora en prevencin en salud Alejandro Vsquez Echeverra, Uruguay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

* Winning essays

essAYs

Young Voices in Research for Health 2009

Najwan Abu Al-Saad

Najwan Abu Al-Saad, United Kingdom

decIpHeRIng tHe AnAtomY of oRgAnIzAtIons And tHe pHYsIologY of polItIcAl wIll: tHe wAY foRwARd foR globAl HeAltH

There is much we already know about global public health, whether empirically or intuitively. The answer to improving health for all, especially for the worlds poorest, perhaps lies more in how to implement what we already know. We know that much of the burden of disease felt by the worlds poor is either entirely preventable or, if not preventable, easily amenable to effective treatment. We know that, even if we were to entirely ignore the area of health care for a moment and focus instead on providing the worlds entire population with access to clean running water, nutritious food, adequate sanitation, universal education and sufficient means to avoid abject poverty all in a secure environment free from violence, persecution and conflict then their health would probably be the better for it. We know that, not only would individuals and populations simply be less likely to become ill, but they would also be more likely to flourish. The importance of the underlying determinants of health has been extensively reviewed, most recently and comprehensively by the Commission on the Social Determinants of Health in 20081, and the recommendations for action are crystal clear. In the same way that much of the current burden of disease is preventable or treatable, the underlying determinants of health are amenable to simple, effective solutions. We know that the global status quo of inequity between and within countries is perpetuated and exacerbated by crucial elements within the current structure and function of the political, economic and social systems, whether these systems act at the global or local level. Numerous barriers exist within governments, ministries, publicprivate partnerships, intergovernmental and nongovernmental organizations that impede the implementation of change for the benefit of the populations served. Barriers exist even where consensus has already been reached on what needs to be achieved, such as with the United Nations Millennium Development Goals (MDGs). We know that there is often a discrepancy between what we expect in theory and what actually happens in practice. It is much easier to talk the talk than to walk the walk and that which seems the simplest is often the most difficult. Change does not come easily, and history shows many examples, particularly in health, where innovations, even as simple as washing your hands, often take decades to be taken seriously and implemented, often for a variety of reasons, not all of which are rational. In health research, it is increasingly known that the availability of effective treatments or of free health services does not necessarily translate to increased coverage if, for example, opportunity costs to individuals and families make genuine access prohibitively expensive. An efficacious treatment in a randomized trial does not

The way forward for global health

13

always translate into an effective treatment in the field because the level of care provided to those in the trial cannot be easily rolled out to the rest of the community for lack of resources. More systems research, be it quantitative or qualitative, is being done to elucidate the reasons for what is observed in real life. This may help introduce effective change (even if relatively minor) to authentically and feasibly improve an aspect of health-care provision or health promotion. However, research of this nature is often done at the community level. What about research into potential barriers to implementing effective measures to improve health higher up the chain? Political will is often cited as the driving force required to bring about change. It would be difficult to find an article to do with any aspect of health or social policy that does not stress the importance of political will, at whatever level, for policy to be implemented effectively and fairly. The importance of the role of researchers in presenting sound evidence for or against certain policies or priorities to policymakers is well recognized. However, if it were just sound evidence and common sense that were needed for effective policy-making, then the world would probably be a very different place. We know, intuitively, that the world is not that simple and that there is a multitude of reasons why political will is not focused on the health and well-being of the most disadvantaged. In this case, this is the ultimate, if perhaps most naive, question that needs to be answered with respect to the macro-social determinants of health: Are the current levels of iniquity and injustice perceived as an inevitable part of the human condition? Is power a zero-sum game such that, if I have power and choose to relinquish it, the other inevitably rules over me? Is a world where the health gap is closed in a generation or the MDGs are achieved in their entirety (even if not by 2015) actually attainable? As these are not easily answerable research questions, it is necessary to narrow the field of inquiry. One factor we may feel acts as one of the significant drivers behind political will is the effect of individual personality and outlook, particularly of those in positions of authority. Thinking shapes behaviour. A company directors vision greatly determines the overall outcomes for a company because it determines the structures and processes that are put in place for the company to function. The overall ethos of an organization not only influences, as do the personalities working there, the formal structures and processes within it but also the informal processes, which may be as important if not more so in the overall functioning of the organization. The same influences are at play in middle management, with subsequent effects on the wellbeing and productivity of employees. Globally (and regardless of preference) there is an undoubted difference between the current President of the United States, Barack Obama, and the former President, George W Bush, in terms of their personality and outlook, with knock-on effects for the rest of the world. Political will acts at many levels and is not necessarily enforced by those who are directly elected. Within the global health architecture there is a plethora of actors, agencies and organizations acting internationally and at multiple levels with the potential to exercise considerable political influence to affect health outcomes. Those in non-health organizations, such as the World Bank, may also have as much, if not more, impact on the determinants of health and health outcomes.

Young Voices in Research for Health 2009

Najwan Abu Al-Saad

Answers to some of the following questions would go a long way towards identifying what needs to be done so that existing knowledge can be put into practice to improve health: How does the behaviour of organizations, individually and collectively, affect the achievement of favourable health outcomes, in particular for the most disadvantaged? Can their behaviour be modified? What is the relative importance of formal versus informal structures and processes in the overall productivity of these organizations? What impacts do the personalities and outlooks of individuals and groups within these organizations have that may directly and indirectly affect health outcomes? How do individuals (particularly in positions of relative authority) affect the informal processes that act within and between organizations? What is the nature of the interactions between organizations? Do they help or hinder their respective achievement of common goals (if they exist)? The use of organizational research, with its focus on applied behavioural psychology and sociology, could reveal the answers to such questions. Ultimately the aim is to find out if barriers exist to the implementation and coordination of effective policy. If so, what is the nature of these barriers? Developing an evidence base surrounding the importance of organizational processes for health outcomes may encourage the more effective interorganizational and intersectoral cooperation needed to improve health and other development outcomes. If such research also pointed to the importance of political will at progressively higher echelons of power, then again an evidence base linking the macro sociopolitical determinants to health could be developed. At the moment, we already know enough to make massive improvements in global health. Where there is a will to achieve such improvements, there is a way to implement what we already know. The question then lies in how we attain this will. If research were needed in how to improve health for all, it would be to determine the direct effects on health outcomes of the organization of the existing multiplicity of actors within the current global health system. This could be achieved by a synthesis of organizational development research with health systems research. The evidence gained from this effort could be used to truly innovate for the health of all.

1 2 3

Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, World Health Organization, 2008. Labonte R, Schrecker T. Globalization and social determinants of health: introduction and methodological background (part 1 of 3). Globalization and Health, 2007, 3:5. Lee K, Sridhar D, Patel M. Bridging the divide: global governance of trade and health. Lancet, 2009, S1622.

Najwan Abu Al-Saad qualified in medicine at the University of Newcastle upon Tyne, in the United Kingdom, in 2004. Currently, she is completing a Masters in Tropical Medicine and International Health at the London School of Hygiene and Tropical Medicine, after which she will return to specialty training in anaesthesia and intensive care medicine in the east of England. With further experience, she hopes to apply her clinical practice to providing anaesthetic and critical care services in the contexts of both emergency settings and longer-term development in a way that contributes to strengthening health systems overall, wherever she may work in the future.

Achieving health for all in Bangladesh

15

Tanvir Ahmed, Bangladesh

tAkIng tHe doctoRs bAck to wHeRe tHeY belong: AcHIeVIng HeAltH foR All In bAnglAdesH

Bangladeshs race towards achieving the Millennium Development Goals (MDGs) has resulted in impressive quantitative health gains such as improvement in life expectancy, immunization coverage and reduction in infant mortality and fertility rates1. However, qualitatively critical issues like poor access to health services, the low quality of care, high maternal mortality and the poor health status of children still haunt our health system2. This uneven progress in health indicators serves as evidence of the existing inequity that is a threat to health for all3 in Bangladesh. Health for all has been mandated by the Government of Bangladesh since the Declaration of Alma Ata, and primary health care (PHC) was the chosen strategy4. To render PHC services, the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP) established several hundred non-bed community facilities (1400 for DGHS and 3500 for DGFP) at the ward or union level5. Additionally, the Government of Bangladesh built 12 000 community clinics to deliver services straight to the doorsteps of the people6, though these never functioned due to administrative and political complexities. At present, Bangladesh has a density of 0.58 formally trained health workers per 1000 people7 and is among the countries with a severe shortage of health workers8. An increased bias towards urban areas has also resulted in a doctorpopulation ratio of 1:1500 in urban areas, against 1:15 000 in rural areas9. From the discussion above, it should be evident that, in spite of achievements, real inequity exists in the health sector of Bangladesh. The government has designed a PHC-centred health system for service delivery but suffers a severe shortage of health workers, with an acute imbalance in rural-urban distribution. A survey reported that 39% of the upazila (subdistrict) health complexes have no resident medical officers, and about 60% of the union health and family welfare centres have no medical officers10. The vacancy rates are mostly higher in rural and poorer regions of the country7. As time progresses, the existing imbalance is getting wider, making our dreams of achieving health for all more distant and far-fetched. Therefore I strongly believe that an innovative approach is needed to help the health workforce in particular the doctors to render services to rural areas that will not only facilitate the provision of PHC services but also contribute to achieving health for all the people of Bangladesh. Bangladesh produces more than 2500 doctors a year7. Placing these fresh graduates in the 2900 union subcentres that currently lack medical officers will surely strengthen the delivery of PHC services. This is not a new idea, and attempts have been made before to assign doctors (mostly during internship) to rural areas. But these attempts have failed. Why? According to the comments of dissatisfied doctors published in a recent Bangladesh health watch report, inadequate income and uncertainty of their

Young Voices in Research for Health 2009

Tanvir Ahmed

career path are described as main reasons7. The need for monetary incentives can never be overlooked in an economy-driven society, which naturally grows with time, as life becomes complicated. This is the reason why, with the increasing availability of opportunities, doctors are getting more involved in the private and urban sectors, contributing to the urban bias. However, one cannot ignore the thirst of doctors to gain more knowledge and the desire to excel in their career path. The desire to obtain higher degrees is another important reason why doctors prefer to stay in urban areas. At present, Bangladesh has 30 institutions offering a postgraduate degree or diploma in various areas of health, and all are located in the four largest cities in the country: Dhaka, Chittagong, Rajshahi and Sylhet7. Hence, over the years, we have created an inequitably distributed and urban-focused health workforce, leaving the majority of potential recipients of the health services unattended and gravely neglected. Nonetheless, I still strongly believe that doctors can be placed at the rural centres to render PHC services. But the model must reflect the needs of the doctors, and there has to be monitoring involving all the stakeholders to keep the model viable. In the next few sections I would like to propose a new, sustainable model that would encourage medical doctors to stay where the people are, i.e. at the community level. The model. Fresh medical graduates will be sent to union subcentres for a mandatory period of only one year, in consideration of their growing social responsibilities and associated financial needs. They will be placed at the subcentres of both DGHS and DGFP. Thus, both the administrative bodies of the Ministry of Health and Family Welfare will be stakeholders in the programme, which will also involve the Bangladesh Medical and Dental Council (BMDC) and the Bangladesh College of Physicians and Surgeons (BCPS). The union subcentres will be contracted out to these medical bodies for the placement of the doctors. They will also participate in monitoring the performance of these doctors, together with Ministry of Health and Family Welfare. Components of the programme. During this one-year stay at the rural centres, the doctors will be extensively exposed to the everyday health problems of the community and gain practical experience in how to manage them and respond accordingly. During their stay, they will report to and be supervised by the corresponding upazila health and family planning administrator (UHFPA). Additionally, doctors will be given extensive training on health system management, health-care financing, public health communication, and research methods for conducting small-scale monitoring and evaluation of health programmes. The basic objective of this training would be to help doctors to enhance their managerial skills help that is currently absent in our postgraduate clinical degree and diploma curriculum. In the context of health workforce constraints, this will serve as an excellent opportunity to provide basic health-administration skills to doctors who are often engaged later in their careers in active management and decision-making processes. The training will be provided weekly at the corresponding upazila health complex. Incentives. Considering national resource constraints, doctors will be paid monetary remuneration equal to their internship stipend with a remote allowance. However, the major incentive to the doctors would be the one-year service, which will be considered as postgraduate training. This, I believe, will definitely be able to attract fresh medical graduates to rural areas. The training will provide them with a certificate

Achieving health for all in Bangladesh

17

that will help them to build their confidence in independent practice. The additional gain will be hands-on experience in various aspects of health system management. Responsibilities of the doctors at the subcentre. Bangladesh has a pluralistic healthcare system, with a large share comprised of informal health-care providers7. One of the major responsibilities of doctors at union subcentres will be to render primary health-care services to the community by joining hands with the local informal sector. Thus these doctors will play a crucial role in bridging the formal and informal sectors, increasing access to health services and improving referral practice, as well as involving the community in running their own health centres. Monitoring and supervision. As mentioned above, doctors will report directly to the UHFPA of the corresponding upazila health centre for their services at the union subcentres. Training will be directly supervised by BCPS, as it will contribute to their postgraduate curriculum. However, the UHFPAs will also partly supervise their training. Additionally, local government representatives of the corresponding union will be involved in the process. Finally the inputs from UHFPAs and union chairmen will be analysed by a committee comprising members from BMDC, BCPS and the Ministry of Health and Family Welfare before issuing a certificate upon the successful completion of the stay. I believe that this model for engaging doctors to render PHC has high potential and would be acceptable, as it ensures the involvement of stakeholders, especially policy-makers, in running the programme. It also guides young doctors in setting a career path and assists in postgraduate training. For general practitioners, it provides a comprehensive understanding of community health-care needs. However, to be successful, the model would require active support from policy-makers, as it recommends changes in the postgraduate curriculum. The model also requires recognition from professional and academic medical bodies like BMDC and BCPS. But, considering its high potential for reducing urban bias on the part of doctors, policy-makers should actively take decisions. They should not only attempt to reduce inequity in health but also benefit the doctors in such an agreeable way that they would join the rural health centres in pursuit of their own interest and contribute in achieving health for all.

1 2

3 4 5 6 7 8 9

Osman FA. Health policy, programmes and system in Bangladesh: achievements and challenges. South Asian Survey, 2008, 15(2):263288. Improving maternal, newborn and child health in the South-east Asia region. New York, United Nations Public Administration Network, ( http://unpan1.un.org/intradoc/groups/public/documents/ APCITY/UNPAN022523.pdf, accessed 25 August 2009). Bangladesh Health Watch. The state of health in Bangladesh 2006: challenges of achieving equity in health. Dhaka, BRAC University, James P Grant School of Public Health, 2007. Health system in Bangladesh. Dhaka, World Health Organization Bangladesh, 2009 (www.whoban. org/health_system_bangladesh.html, accessed 2 September 2009). Health care delivery systems of Bangladesh. Dhaka, Government of Bangladesh, 2009 (www.dghs. gov.bd/App_Pages/Client/DGHS_Show.aspx?val=2, accessed 25 August 2009). Nath DK. Community clinic: a pro-poor initiative. London, The Independent, 2009 (www. theindependent-bd.com/details.php?nid=120412, accessed 2 September 2009). Bangladesh Health Watch. Health workforce in Bangladesh: who constitutes the health care system. Dhaka, BRAC University, James P Grant School of Public Health, 2008. The world health report Working together for health. Geneva, World Health Organization, 2006. Mabud M. Demographic implications for health human resources for Bangladesh. Paper presented

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Tanvir Ahmed

at the International Workshop on Human Resources for Health in Bangkok. Dhaka, Centre for Health, Population and Development, Independent University, 2005. 10 Primary health and family planning in Bangladesh: assessing service delivery. Social sector performance survey. Dhaka, Financial Management Reform Programme, 2005.

Tanvir Ahmed, born within a year of the Alma Ata Declaration, witnessed the revolutionary drug policy of Bangladesh but never understood the true essence of public health until he joined medical school, which he completed with a gold medal. His quest for treating millions with just one prescription led him to the James P Grant School of Public Health for further studies. Later he joined the school as a researcher and won an international grant on comprehensive primary health care. Tanvir currently works at the International Centre for Diarrhoeal Disease Research, Bangladesh, investigating the sexual and reproductive health-related risk behaviour and the vulnerabilities of the marginalized. In addition to the health system, he is interested in the health of older people and nutrition research.

Lack of innovation in health promotion in schools

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Abdelhamid Benalia, Algeria

lAck of InnoVAtIon In HeAltH pRomotIon In scHools: edUcAtIng tHe cItIzens of tomoRRow wItH tHe metHods And stRAtegIes of YesteRdAY

Innovation in health does not have to be high-tech and expensive. It can be ideological, strategic, political and inexpensive. Innovation in health is not only about the clinical environment, the patient and curative medicine. It can be based within the community, target people and focus on preventive intervention. Innovation in health does not have to be complex and the exclusive domain of politicians and academics. It can be based on simple concepts and should be everybodys business. Thus, innovation in health can take different forms and involve a wide range of professionals and people in the community. But, finally, innovation in health should lead to a reduction in health inequalities and improve peoples health. Alarming statistics related to young peoples health are becoming more common in Europe. The percentage of young people who are overweight or obese has reached unprecedented levels in some European countries, and such associated conditions as diabetes, high blood pressure and high cholesterol are also expanding at a fast rate. Substance abuse among young people has been observed as a growing phenomenon in several countries. These are some of the health issues that expensive or high-tech equipment cannot and will not help to prevent. What is urgently needed is to find innovative ways to address these issues, while thinking outside the box. Despite being the one place where young people spend most of their time, schools seem not to be in a position to take on the old and new health challenges faced by young people. Thus, it is worth asking why schools are not embracing innovation and whether they should be pushed towards more innovative health promotion strategies or interventions. It is interesting to observe the distortion that exists between research and the practice of health promotion in schools. There are many innovative research papers featuring and discussing innovative interventions, theories and ideas, but very few of them are finally implemented. Who is to blame? It is probably both researchers and the school community that need to take the blame for this lack of action. Firstly, few research projects take into account the costeffectiveness of their proposed interventions or even attempt to report on it. Thus, a large number of interventions are unlikely to be applied in practice due to their high cost or the complete lack of information about them. To be able to use research as a source of innovation, researchers need to completely change their approach in the area of cost and costeffectiveness analysis. This would ensure that research innovation makes it through to the implementation stage. In health-promotion literature, for example, high implementation costs and low costeffectiveness should be clearly reported as a limitation of the research, and a

Young Voices in Research for Health 2009

Abdelhamid Benalia

failure to report costeffectiveness in a research paper should be seen as an obvious limitation of the research. In other words, innovation in health promotion needs to be more targeted to take account of costeffectiveness and employability, which then leads to this question: What is a favourable costbenefit ratio? Costs associated with promoting health in schools are not always the source of the problem. Rather, innovation in health promotion in schools is often seen as a threat by parents, teachers and children, which makes implementing new interventions difficult or impossible. I am not necessarily speaking about only such controversial issues as sex education courses in schools or about school nurses giving the emergency pill (also known as the morning after pill). For instance, in the United Kingdom, Jamie Oliver, a famous British chef, tried to introduce a healthier menu in schools canteens. This welcome improvement led to some parents passing their children junk food through school gates at lunchtime. In other schools, introducing healthier menus was received like a hostile revolution, as the complacent habit of providing high-fat and high-sugar food was deeply rooted in both the school and home environment. Innovation is put in jeopardy by resistance to change and fear of innovation. There is no miracle solution to overcome these kinds of barriers apart from continued education on the subject, as well as parental and broad community involvement in every stage of any new project. However, it has to be stressed that parents too need to assume their responsibilities, because improving childrens health is everybodys business. Local authority or central government departments managing health-related policy in schools have to stop their hypocrisy. On the one side, they push for the implementation of new policies or school curricula based on evidence, and, on the other side, an opt-out option is always given to schools or parents. For instance, the innovative health-promoting school programme is not compulsory but left to the discretion of schools or local authorities. Similarly, sex education has been implemented in several curricula but is not compulsory, so parents can, if they want, remove their child. These are some examples of health innovation that is not implemented in the right way. Thus, commitment from parents, politicians and schools is an essential ingredient needed for innovation, especially when children are the beneficiaries. The aim of this essay is not to stigmatize the different individuals or institutions that are not contributing to or are restraining innovation in health promotion in schools. My real aim is to try to make the reader aware of the potential of schools to improve young peoples health and how innovation at all levels is needed. Innovation in health promotion is not easy and does not happen quickly. It can be a real challenge that needs deep cultural and organizational changes. It will be a massive failure of leadership on the part of parents, politicians, teachers, researchers and the community if schools do not foresee changes in society and act accordingly.

Abdelhamid Benalia is currently enrolled in a health education PhD programme at Kings College London, having acquired a Masters in Health and Society there and a Masters in Psychopedagogy at Universit Laval in Canada. Abdelhamid works as a programme coordinator for the National Health Service at NHS Kingston, in south-west London. He is also actively involved in the Student and Early Career Network of the International Union for Health Promotion and Education and in the Education and Management Research Ethics Panel at Kings College London. Abdelhamids ambition is to develop a challenging international career with a focus on public health strategies that improve childrens health.

Education: A simple way to improve health

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Fabio Botelho, Brazil

edUcAtIon: A sImple wAY to ImpRoVe HeAltH

If you want to know how a population lives, you have to observe how it dies. To know its health, observe its diseases.1

My story: Today is a normal day in my life. I wake up early, at 06:30, walk 30 minutes to my university, and have some practical and theoretical classes at a hospital for complex treatments. I have lunch with my friends, study at the library and go home about 19:00, wondering when I will next have to do my 12-hour internship at an emergency hospital. I hope that it will not be on Saturday. This routine has been part of my life since I left the basic subjects of medical school. I am in the fifth year of the medical course (six years is the total in Brazil), and I am also a health policy tutor at my university, helping other students to understand more about the Brazilian health system. I really like this routine, but sometimes I get upset with myself, with some classmates and also with some teachers. The current Brazilian health system was formulated in 1988, establishing a system based on universality (everyone has the right to access health services freely), integrality (the patient must be given a general examination independent of his particular disease, considering the social background of the patient, i.e. education level, job, family, access to transport, recreation habits and environment) and equity (policy actions must first prioritize people with lesser economic conditions). Sistema nico de Sade, or the Single Health System, was created to replace a failed health system that placed hospitals at the centre. Now we are trying to shift the centre of the structure to primary care, which could resolve more than 80% of Brazilians demands. Well, what upsets me is that, Brazilian universities have a programme based mainly on specialized subjects. And, more than that, I once heard a physician saying that we in the medical profession should do, or appear to do, complex procedures to prove to people that we are special. If we stick to simple procedures, maybe we will not be valued. Some of my medical school peers agree with this. As a result, it is not uncommon to see students discovering what primary care is only in the fourth year of the course. This late discovery happened to me.

Young Voices in Research for Health 2009

Fabio Botelho

Another persons story: Today could be a typical day in my life. I have two children, one five years old and the other two. I would normally have gone to work [as a public servant] and would have left the children with my neighbour [as their dad does not live with us]. But, my two-year-old boy was bitten by a strange insect some days ago and got a bleeding wound on his arm. I put coffee in the wound (as my mother taught me], but the wound got worse. My childs arm was getting redder, hotter and bigger. I took him to the paediatric emergency hospital, which was full. There were a lot of severely ill children there worse than mine. They told me to go to my neighbourhood primary care centre, but I do not know where it is or how it works. People always say that in the centre there is a lack of paediatricians. So, in the end, I paid a private doctor to see my child. And another persons story: Honey, I am going to sleep. Im really tired. Today the hospital was crazy. I saw more than 40 children; a lot of them could have been treated by the primary care service. And now the way ahead. The last two stories above are common in Brazil, as we try to consolidate a new system despite an enormous lack of information. In my opinion, this happens because, if we want health for everybody, knowledge should belong to everybody. Of course, I am not proposing specific health education for the population. But I think that our schools should teach children and adolescents not only maths, languages and history but also about issues that will prepare the individual for practical life. One of them could be the principles of public health, a subject that would explain how the health system works and some preventive actions people can take. It is well known that good health improves education and good education improves health2. Also, studies have confirmed that making simple changes in our habits and ways of living is an important, if not the most important, intervention to reduce mortality3. It is cheaper to mobilize populations with vaccination programmes and campaigns against such chronic diseases as hypertension and diabetes than to try to discover specific cures for specific diseases which is also important but more expensive. Imagine that all of us were taught some basic health principles in school when we were 15 years old. First of all, Brazilian physicians would think more about running a general practice than a specialized practice. I would have seen more common diseases in the university than rare cases. I would have hesitated less about choosing a graduate course because I would have had a course that considered health in school. The mother in the second situation would not have put coffee on the childs arm, because she would have known some principles of basic care. And even if she did put coffee on his arm, she would still have taken her child to the primary care centre. Consequently, the physician working in emergency would have more time for his family and improving the quality of his life.

Education: A simple way to improve health

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It is a simple idea that I have put forth here. I believe that these problems are not specific to Brazil. I really hope that one day, instead of measuring our health with mortality rates, we can measure it by peoples access to education and other social values. I hope that one day we can rate our health situation based on the populations quality of life.

2 3

Rumel D et al. Condies de sade da populao Brasileira [Brazilian populations health conditions]. In: Duncan B, Schmidt M, Giugliani E, ed. Medicina ambulatorial condutas de ateno primria baseadas em evidncias [Ambulatory medicine evidence-based primary health care]. 3rd edition. Porto Alegre, Artmed, 2004. Devers GEA. An epidemiological model for health policy analysis. Social Indicators Research, 1975, 2(4):453466. Furne CA, Groot W, Brink HM. The health effects of education: a meta-analysis. The European Journal of Public Health, 2008, 18(4):417421.

Fabio Botelho studies medicine at the Federal University of Minas Gerais, where he is a health policy tutor. He was born in Belo Horizonte in 1987. Fabio considers his family the keystone of his story. As the descendent of slaves, rural workers from dry and poor areas in Brazil, and Europeans, he has had the opportunity to live with different people and learn different cultures. His father is a doctor, his mother is a social worker, and his best friend (his brother) studies medicine too.

Young Voices in Research for Health 2009

Bianca Brijnath

Bianca Brijnath, Australia

pens And needles

Didi, didi, can you give us your pen?

The pleading children call me older sister in Hindi, as I am sitting in the middle of the Thar desert in Rajasthan. It is a hot August day, and we have broken our journey for lunch. A pot of dal is boiling on the fire, the camels chew uninterestedly on either side. About a dozen children have descended seemingly out of nowhere. Aged between 5 and 10, they are poor children with sun-bleached hair and ragged clothes. It is a school day and none are at school; instead they are herding goats through the arid scrub. They are curious. We talk and play Blind-mans bluff and Catch for a while. I make a ball out of my dupatta, or scarf, and we throw it around. Then we start to draw, and the children are mesmerized. They draw squiggles and straight lines, camels and little houses, and write their names in Hindi. They fight over the only pen I have, all keen to write their name, draw their dot, make their mark. Although I have an entire notebook only two sheets are used. When we break camp to continue on our journey, the children ask only for my pen and our empty water bottles. Though this is a popular tourist route for camel safaris, they are not interested in money, chocolate or any of the other supplies just empty water bottles for storing their water and pens for writing their names. The connection between education and health is profound. Literacy and knowledge leads to better jobs, more income, the ability to make healthier choices, greater lifespan and ultimately improved health and productivity for nations. Using a pen is the most basic sign of literacy; not knowing how to use one is the most powerful symbol of opportunities denied. It is no coincidence that the poorest people in the world are the least educated and the most marginalized, dying much earlier than others. The rivulets of inequality run deep, especially in resource-poor settings, and are evidenced everyday in the interaction between a doctor and an illiterate patient. The doctor can write a prescription, issue instructions, and sign his or her name. But the illiterate patient cannot read this script or sign her name and must rely on memory and other people to correctly interpret the script. She must rely on other people to read the signs to tell her how to go to the hospital and where to go once she gets there. I propose as a health innovation the distribution of pens to poor people. The pen is the starting point on the literacy scale. People must know how to read and write before they can use more sophisticated technologies like calculators and computers. In the Thar desert there is heat, dust and sand but neither electricity nor

Pens and needles

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running water. The children there want to learn, and they need the knowledge and the tools to practice. A pen is a cheap, readily available piece of technology that anyone can provide. It is more effective than a battery-powered laptop; it is small, inexpensive, durable and easily replaceable. Giving children pens instead of sweets, when they go to the doctor, connects the clinic and the schoolroom. It encourages childrens inquisitiveness (Didi, what is this? How do I use it?), thereby reinforcing the importance of learning. A child can practice with that pen; others in his family can learn how to use it and write their names. An educated child is a family member who can filter information for uneducated members. He or she is a human being who can begin to understand possibilities. Health and education have a shared history that can be traced back to ancient Egypt. The instruments of both originated there; the reed was used to record some of the earliest human languages, and the hypodermic needle was used to extract cataracts from peoples eyes. Apart from medical purposes, the syringe has since been used in cooking, to feed small mammals (without the needle) and to refill pens. Likewise, the pen has been used in medicine and for new drug devices. The Epi-Pen, insulin pen, and auto-injectors for anaemia, arthritis and multiple sclerosis have all been designed around the concept of the pen. Designers have assumed that the ubiquity of the pen has made its use instinctive. But this is not true. People need to be taught how to hold a pen, how to move their fingers and how to apply pressure. Strength, through practice, needs to be created so that the hand muscles do not cramp. There needs to be familiarity with pens and how they work pen caps, clicks and springs. This is how the use of the pen becomes instinctive, and how people that have taken the pen as inspiration seem automatically more attuned with using other health technology. Understanding the mechanics of pens and needles dispels some of the myths surrounding injections. The hypodermic syringe is, as a cultural artefact, invested with meaning beyond its functionality. It inspires fear and loathing, fascination and curiosity. People are rarely ambivalent about injections. In a Delhi slum, I meet a woman who refuses to get her children immunized. The community health nurse brings the vaccines and needles into the slum, the cost is less than 2 US cents, but still she will not come. She is afraid of needles. In other hospitals I meet people who insist on injections; it is their cure for everything. Ignorance about injections drives both phenomena. A stronger connection between the needle and the pen could counteract this. Our lives are defined by fluid: the medicines and blood in syringes that are pushed into or pulled out of our bodies describe our condition we are high, low, weak, strong, pleasured or pained. The needle is like a body pen, and through its bruises and scars we read immunizations, infusions and addictions. The ink in pens leaves scratches and blotches among the words that describe the histories of our lives. We read that history on paper and occasionally on our bodies. The pen is a paper needle, just as the needle is a body pen. Among adults who have never learnt how to read and write, the pen can be used to shift them from passive patients into active participants in their treatment. Immunization, for example, involves the administration of vaccines in early life. Mothers could be given an immunization schedule with seasonal pictures to denote the time each immunization was to be given. If they could mark these off, they would know if they had missed an injection and when the next immunization was due. Similarly, antiretroviral treatments or other drug regimes that require

Young Voices in Research for Health 2009

Bianca Brijnath

monitoring and adherence could use this model. Patients would be empowered to monitor their own treatment. This is especially relevant in resource-poor settings where doctorpatient ratios are skewed and the systems are not yet in place for ongoing health surveillance. As researchers, we understand possibilities, and we strive to fulfil our potential. We work on populations and with people, always recording data. We write, draw, calculate and calibrate in books, policies, journals, newspapers and essay competitions. Knowledge dissemination is the aim. But how often do we give our participants, especially poor people, the opportunity to come along on this journey to contribute to human knowledge? How often do we give our participants adequate compensation for the richness and depth of information they have given us? We are taught not to presume to know our participants lives, to be empathetic and open, and not to interfere or change the status quo. But we must. When PhDs and Grade 5 passes meet, knowledge transfer must work both ways. We cannot leave our settings the way we found them, cry foul in textbooks and seminars, and then hope someone will listen. We must do. And we can start by education give poor people pens, equip them for their intellectual journey, teach them just as so many of them have taught us. Empowerment and community involvement have made late entries into our methodologies. But where they have been applied and used, wondrous things have happened. As I get back on my cranky, bow-legged camel, the children scatter into the Thar, melting back into the scrub to herd their goats and tend their homes. They wave farewell and thank us for our empty bottles. I have not given them my pen. I wish I had and had thereby started something. But there is only one pen, and there are so many children who want it. In every village I come across thereafter, children gather round curious and playful. They all want pens and water bottles. We do not have enough because we did not anticipate this. But for those who go now, a dozen pens cost 50 cents. Please buy some. It is an innovation that anyone can act upon and does not need policy debates in the halls of government. Give them pens.

Bianca Brijnath grew up in the megacities of Calcutta and Delhi in India. In 2000, she migrated to Australia and in 2004 graduated with majors in Sociology and Womens Studies from Monash University in Melbourne. Following graduation, she worked on AIDS-related stigma and discrimination in the Asia Pacific and anaphylaxis management in Australian schools, as well as tutoring university undergraduate and masters students in public health. She is currently pursuing her PhD at Monash University on dementia care in India. Her interests centre on family dynamics, care-giving practices and systemic responses to mental health needs in developed and developing countries.

Urgent global health innovation?

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Baltica Cabieses Valdz, Chile

URgent globAl HeAltH InnoVAtIon? globAl HUmAn InnoVAtIon fIRst!

Introduction
Our world is suffering from the over-exploitation of resources, and as a consequence humankind is currently facing major global challenges. These current global challenges have environmental, political, economic and social dimensions. There is also a health dimension, which continues to be a complex and immediate problem, despite the enormous energy, time and money invested in it over many decades. Efforts to reduce global health problems by social leaders, politicians, scientists, ecologists, clinicians and researchers, among others, have been impressive. Examples include the Millennium Development Goals, Action for Global Health, World Health Organization Social Determinants Programme, Global Health Council, Global Health Program, Global Health Strategy, Millennium Challenges, etc. They have all made large investments of financial and human capital to work towards the goal of health for all in many noteworthy ways. At the same time, huge social changes are under way. Multicultural societies urgently need more understanding and acceptance from others, in order to support global health over time. From an evolutionary perspective, humankind first united in a single continent and later dispersed into many different geographical settings, but it is now facing the opportunity of becoming once more an integrated community. Social and cultural variations must be considered as strengths instead of threats, as they can enrich diverse possibilities for global health innovation and the improvement of health-related outcomes over time. Several difficulties and challenges remain, as societies are still divided from one another and within themselves despite relevant efforts made for additional international cooperation. The purpose of this essay is to develop a critical reflection of how innovations for health require urgent human innovation as a precondition. By human innovation I mean, specifically, developing further understanding of the fact that we need one another to survive and develop as groups and societies, to increase trust in others, and to reduce fear of what is perceived as different. This essay is organized into three sections: first, some human challenges for health innovation; second, three possible steps for human innovation; and finally, some implications and limitations of this reflection.

Health innovation and human obstacles

Health challenges tend to change over time, and an important influence on global health has been globalization, described as the intensification of social relations with links to distant localities in a way that local happenings are shaped by events occurring miles away1. In this global context, health has emerged as one of the most relevant

Young Voices in Research for Health 2009

Baltica Cabieses Valdz

issues, which needs to be understood along with its strong interactions with other human dimensions. After reviewing a wide range of literature on globalization and its implications for health from such disciplines as economics, politics, epidemiology and sociology, I agree with the proposition that one of the major consequences of globalization is the unresolved tension caused by cultural differences between societies and within communities that often ignore and fear one another2. Differences and divisions among us are, in my opinion, reflections of natural human reactions and resistance to what is perceived as dangerous. This fear has physiological effects, studied by scientists through measuring the secretion of cortical hormones by the sympathetic system. In this sense, it is known that sympathetic reactions, as with emotions of rejection of what is feared (in this case another human), should disappear after some time as a consequence of repetitive social interactions. However, social interactions do not always occur, as some societies have found ways to avoid social contact with those different to themselves. Therefore, a fearrejectionmarginalization cycle could arise and continue over time within different communities. In this scenario of human division, global health innovations require human collaboration as an urgent precondition for success.

Three steps for human innovation

So, how can we achieve global human innovation towards later global health innovation? Three steps are needed. Step one: Reducing fear to increase cultural tolerance. We tend to resist what we fear and to fear what we perceive as different. Evidence of this has been reported by human rights initiatives in the past. One recent example is the debate in the United Kingdom about cultural segregation, recently described by Trevor Phillips3, compared with findings on social integration in this country4. However, even studies concerning health and migration have focused on the differences between cultures instead of their similarities for future integration. In other words, we still think and structure our arguments in terms of human divisions. A broader example is the existing polarization of health problems between those countries defined as developed and as developing. While most deaths in the world happen in developing societies, most of the research and health service investment is made to save people in developed ones. A striking correlate of this is what is referred to as the 10/90 gap, the fact that 90% of research on health concerns problems affecting 10% of the global population5. When we analyse the psychological aspects of fear and how to cope with and reduce it, the alternative of immunization against fear emerges as an interesting idea. In this sense, globalization once considered the main contextual factor for international separation could now become a useful exposure (immunization) for societies and individuals to what is perceived as dangerous. Both active and passive immunization strategies could be included, utilizing settings such as primary care clinics and schools and mass media and political strategies. Multilevel collaboration, with the compliance of social leaders and politicians, could enable societies to become immunized to fear. Step two: Increasing cultural tolerance to increase human collaboration. We need one another as human kind to survive and develop in every possible dimension. Recent

Urgent global health innovation?

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studies have reported the striking result that countries health-related outcomes tend to be poorer if part of their population is excluded, unwanted or living in poverty. Data covering countries all over the world consistently show that people have worse health outcomes if they live in countries with greater inequalities, even after adjusting for their socioeconomic position6. These findings lead to the discussion of how connected we are with others, within both local and global contexts. Nations need to take more consideration of this evidence, and as a consequence social collaboration at every level should become an urgent policy. A clear example of current lack of mutual collaboration is global warming. Powerful countries have refused to reduce their carbon dioxide emissions, and, while they decide whether and how to collaborate, people are dying and the earth is being pushed to its limits. Step three: Increasing human collaboration to increase social trust. To survive and develop as societies, we need to trust one another. Studies of social capital and social cohesion, health promotion and health inequalities have shown that improving trust leads to positive feelings of being useful and relevant to society. This, in turn, leads to positive self-esteem, which leads to greater social integration. Social values such as communitarianism become relevant to human groups, and a possible virtuous cycle of trustself-esteemintegration might continue over time in communities. Mutual trust could, therefore, be considered a central outcome for human innovation but also a significant intermediate outcome for health innovation. We need to further understand how global health is affected by issues not related to health. Current examples include civil war in Colombia, Liberia and Sudan; worldwide economic recession; the war on terror; and huge global currents shifting economic growth and international migration, among many, many others. These, once again, reflect the persistence of human division whenever possible, all over the world.

Final implications
Innovation for global health requires human global innovation as a precondition. Globalization and its potential contribution to reducing fear and increasing trust and mutual collaboration need more consideration. Concrete steps to follow require the active participation of local and international social leaders, and there is relevant evidence to support the described steps for human innovation. However, more efficient ways to disseminate this knowledge in developing countries are urgently needed. It could be argued that for some particular topics there is no need for further research, but that the use of an efficient strategy to allow every place in the world access to that knowledge would be relevant, instead, for future local implementation. This is a final example of how we continue to divide and exclude one another, and how that could affect our health over time and generations.

1 2 3

Giddens A. The consequences of modernity. Stanford, Stanford University Press, 1990. Representaciones culturales y estereotipos de la migracin peruana en Chile. Stefoni C, 2001 (http:// bibliotecavirtual.clacso.org.ar/ar/libros/becas/2000/stefoni.pdf, accessed 26 August 2009). Phillips T. Britain could return to racism as recession bites. 2009 (http://www.telegraph.co.uk/finance/ financetopics/recession/4290154/Trevor-Phillips-warns-that-Britain-could-return-to-racism-as-recessionbites.html). Finney N, Simpson L. Sleepwalking to segregation? Challenging myths about race and migration, 1st ed., Bristol, The Policy Press, University of Bristol, 2009.

Young Voices in Research for Health 2009

Baltica Cabieses Valdz

5 6

The 10/90 report on health research. Geneva, Global Forum for Health Research, 1999. Wilkinson R, Pickett K. The spirit level: why more equal societies almost always do better. United Kingdom, Allen Lane, 2009.

Baltica Cabieses Valdz holds a Bachelors in Nursing-Midwifery, a certificate in Nursing Education and a Masters in Epidemiology from Pontificia Universidad Catolica de Chile. She is a faculty member of the Universidad del Desarrollo in Chile and is currently pursuing a PhD in Health Sciences, with an emphasis in health inequalities, at the University of York in the United Kingdom. She has been awarded the Chilean governmental scholarship Beca Presidente de la Republica for her current studies. Baltica is a qualified consultant on HIV and has experience in training university students, health-care providers, vulnerable women and ethnic minorities on HIV prevention issues. Additionally, she was co-investigator of the Mano a Mano research team for HIV prevention in Chile. Her nursing education experience emphasized womens health. She has also coordinated various professional projects and conferences, which highlighted health promotion, nursing education and research. She has published over 15 articles in peerreviewed journals and has contributed works to 35 conferences. Her current areas of interest are health inequalities, migration and global public health.

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Jos Agustn Cano Menoni, Uruguay

RedIstRIbUIR lA locURA: constRUccIn de AlteRnAtIVAs socIAles Y teRApUtIcAs Al encIeRRo mAnIcomIAl

Hay que redistribuir la locura, as como tambin es necesario redistribuir la riqueza Alfredo Mofatt

Prembulo: Innovacin
Sucede algo desafortunado con la palabra innovacin, y es que se ha transformado en la muletilla de un tipo de academia tecnocrtica y ensimismada, siempre presta a descubrir la plvora para presentarla en congresos y seminarios. Una innovacin que encarna la funcionalidad del quehacer cientfico-tcnico respecto a la reproduccin del orden social. El sentido transformador del conocimiento est entonces alienado, e innovacin no es ms que sofisticacin del mundo tal cual es. Sobre todo en el campo de la salud, es necesario refundar la nocin y las prcticas de innovacin, emanciparlas del mercado y de la lgica del capital. Concebir una innovacin que ya no sea sofisticacin del mundo tal cual es, sino aporte cientfico-tcnico fecundo para la accin vital del hombre en la tarea de transformar conciente y democrticamente su sociedad. Una innovacin que ya no sea transformacin alienada, sino imaginacin organizada. Tal es la vocacin de la propuesta que se presenta a continuacin. La misma consiste en un modelo de reinsercin social de personas internadas en hospitales psiquitricos, a travs de una red de cooperativas de vivienda existente en Uruguay.

Descripcin del problema

El sistema de salud mental del Uruguay no ha logrado an superar el peso que en l tiene el modelo de institucionalizacin manicomial. Este modelo genera cronificacin de los cuadros psicopatolgicos, marginacin social de las personas internadas, violaciones a sus derechos humanos, y violencias mltiples tanto para los internos como para los trabajadores de estos hospicios. Actualmente en Uruguay hay unas mil personas internadas en instituciones psiquitricas, cifra equivalente a tres personas cada diez mil habitantes1. No obstante ser muy alta, esta cifra representa el mnimo histrico desde que existen registros. En 1950 las personas internadas en manicomios eran dieciocho por cada diez mil habitantes (una cifra que se encuentra entre las ms altas de la poca: Uruguay no solamente era campen del mundo en ftbol). A partir de entonces, la poblacin manicomial uruguaya ha decrecido considerablemente hasta alcanzar las cifras actuales en el ao 2000. La mayor cada de las tasas de internacin se dio en los aos noventa, en consonancia con la aplicacin de una poltica de rpido egreso por parte de las instituciones psiquitricas. Pero esta poltica no fue acompaada por el desarrollo de estructuras de salud mental a nivel territorial, ni por suficientes programas de asistencia, prevencin y rehabilitacin

Young Voices in Research for Health 2009

Jos Agustn Cano Menoni

capaces de favorecer la reinsercin social de estas personas. Esto tuvo consecuencias graves: altos ndices de reingreso (50% anual en el principal hospital psiquitrico de Montevideo) as como el aumento del nmero de pacientes psiquitricos en situacin de abandono en la calle. Puede afirmarse que la disminucin de la poblacin manicomial ha significado a menudo la reproduccin del modelo de exclusin y abandono del hospicio, slo que fuera del manicomio. Las dificultades que enfrentan las iniciativas que buscan revertir esta situacin son numerosas. Una de las ms complejas de resolver es la ausencia de alternativas de vivienda supervisada acordes a un programa de reinsercin.

Descripcin de la propuesta
Responder a este reto no es sencillo en una sociedad donde el acceso a la vivienda es un problema social general. Es inviable la aplicacin sin ms de algunos de los modelos ms notorios a nivel internacional, como el de los pases escandinavos, caracterizados por su bonanza econmica, una sociedad integrada y un robusto Estado de bienestar, o el italiano, basado en un sistema de salud pblica universal con fuerte descentralizacin y estructuracin territorial, y con un conjunto de instrumentos legales y fiscales inexistentes en la realidad latinoamericana. El historiador JP Barran dijo una vez que para cambiar la realidad, primero hay que parecerse a ella. Para forjar un modelo de desmanicomializacin capaz de alcanzar realizaciones en Uruguay, hay que partir de las condiciones materiales y culturales en las que tal modelo habr de desarrollarse. Pese a sus dificultades, el Uruguay cuenta con instituciones pblicas fuertes, y organizaciones sociales activas y solidarias. Entre estas se encuentra la Federacin Uruguaya de Cooperativas de Vivienda por Ayuda Mutua (FUCVAM) que rene actualmente unas 350 cooperativas de vivienda en todo el pas. Se propone la articulacin de acciones entre las instituciones de salud mental, las organizaciones de familiares de personas internadas en hospicios, la Universidad de la Repblica y FUCVAM en la conformacin de una red que pueda construir y sostener una alternativa de vivienda y acompaamiento teraputico fuera del manicomio. Dentro de esta red, la participacin de FUCVAM constituye tanto una posibilidad de vivienda como un contexto adecuado para el desarrollo de un programa teraputico alternativo al modelo represivo-psicofarmacocntricoinstitucionalizador.

Fundamentos Las cooperativas de vivienda contienen un importante potencial para una estrategia de rehabilitacin, permitiendo trabajar tanto con las personas que dejan el manicomio como con la comunidad que los recibir. Para los primeros, esto significa el pasaje de la situacin degradante de pasividad y aislamiento del hospicio a una situacin positiva de trabajo colectivo. Para los segundos, significa el desafo de confrontarse con su parte loca hasta hace poco encerrada, entender los propios prejuicios, miedos, resistencias, e inventar modos de convivencia donde lo diverso no sea excluido. La experiencia cooperativa y el trabajo colectivo brindan a las personas un encuadre institucional que oficia como organizador de la personalidad ms positivo que el encuadre autoritario del hospicio, y ciertamente tambin que la nada desquiciante del abandono. La internacin psiquitrica prolongada congela a la persona en el rol de desecho social. Expropia palabra e historia y modela cuerpo y alma en una identidad detenida e impotente, demente. La participacin en una dinmica de trabajo colectivo restituye a la persona un lugar productivo en el demos y contribuye a la generacin de procesos de resingularizacin identitaria positivos y dignificadores.

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Acciones Se propone realizar una experiencia piloto elaborando un Programa de Salud Psicosocial (PSP) a desarrollar en el marco de las cooperativas de vivienda. El desarrollo del PSP implicar destinar al menos una vivienda de las cooperativas para la reinsercin social de personas internadas en hospicios. Las cooperativas que participen de la experiencia podrn contar con exoneraciones fiscales y otros incentivos. El PSP tendr el cometido especfico de acompaar el proceso de insercin de las personas provenientes de situaciones de internacin prolongada. Para ello, elaborar un plan de trabajo que incluir actividades en comn con los cooperativistas as como el desarrollo de un proyecto teraputico especfico para las personas que participan del plan de reinsercin. Dicho Plan de Trabajo deber:
Establecer espacios colectivos con participacin de todos los cooperativistas para la reflexin sobre la experiencia en curso. Se apelar al dispositivo de taller buscando poner en marcha un proceso en el cual abordar las diferentes fantasas, miedos y prejuicios en juego, as como los conflictos emergentes del proceso grupal. Desarrollar un proyecto teraputico especfico con las personas involucradas apelando a diversas estrategias psicoteraputicas. El proyecto teraputico deber contar con el acuerdo de las personas involucradas, y su diseo e implementacin estar a cargo del Equipo de Salud del Centro de Salud Territorial de referencia. No obstante este cometido especfico vinculado a las personas en proceso de reinsercin, el PSP estar dirigido al conjunto de los habitantes de la cooperativa y abordar tambin las problemticas psicosociales emergentes desde una perspectiva de prevencin y promocin de la salud. El desarrollo del PSP supondr la articulacin de acciones entre los equipos de salud presentes en la zona, en conjunto con equipos universitarios en el marco de experiencias de extensin. Por ltimo, para que esta experiencia sea sustentable y generalizable es necesario que se acompae al menos de las siguientes iniciativas: El desarrollo de programas laborales para las personas involucradas. Los mismos pueden enmarcarse en las propias cooperativas. La transformacin del sistema de atencin, reduciendo al mnimo las situaciones de internacin, generando posibilidades de internaciones breves por fuera de los hospicios (en policlnicas u hospitales generales). La metamorfosis en la formacin de los profesionales de la salud. El modelo organicista hospitalocntrico form los profesionales que necesitaba. Es necesario vincular a la Universidad con nuevas experiencias de modo de que sta contribuya a su desarrollo, y adems forme los investigadores y profesionales que el nuevo modelo requiere.

Eplogo
Franco Basaglia dijo una vez: en el fondo, nosotros slo representamos un momento de enlace entre lo que est a punto de desaparecer y lo que todava tiene que nacer. Lase esta propuesta como una contribucin a la gestacin de aquello que

Young Voices in Research for Health 2009

Jos Agustn Cano Menoni

en Uruguay debe todava nacer para construir un modelo de salud mental que no encierre a las personas, ni las expulse a las calles y a la miseria.

Esta cifra no incluye a las personas internadas en el Hospital Pieiro del Campo (para personas ancianas), ni a las internadas en las llamadas Casas de Salud, de gestin privada, donde se piensa se encuentran internadas al menos otras mil personas ms.

Jos Agustn Cano Menoni naci en 1980 en Salto, una pequea ciudad situada en el litoral norte del Uruguay. En 1999 emigr a Montevideo con el fin de ingresar a la Facultad de Psicologa de la Universidad de la Repblica, iniciando una etapa de formacin universitaria, as como una intensa actividad gremial estudiantil. En el 2007 se gradu como Licenciado en Psicologa. Ese mismo ao obtuvo una beca para realizar estudios de posgrado en Roma, Italia. A partir del ao 2008 se desempea como docente de la Universidad de la Repblica.

From lab to village

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Justin Chakma, Canada

fRom lAb to VIllAge: cAtAlYsIng globAl HeAltH entRepReneURsHIp

When we think of biomedical innovation and entrepreneurship, what come to mind are research-intensive universities such as the Massachusetts Institute of Technology or Stanford or initial public offerings on the NASDAQ. We do not think of biomedical innovation in connection with health solutions for poor people, let alone occurring in countries with poor people. Yet, successful research and development is taking place in several countries that are considered lower income. This makes the way we invest our global health research dollars in developed countries strange. Significant investments are made by foundations such as the Bill and Melinda Gates Foundation at leading north American universities or independent research groups at the Institute for OneWorld Health or PATH. While undeniably making a positive impact, virtually all this innovation occurs in richer countries. Few players are currently funding, engaging in or fostering relationships with researchers from lower-income countries who can innovate around local health needs. Consider the case of the hepatitis B vaccine in India. In the early 1990s, the technology to manufacture the vaccine did not exist within India and had to be imported at the high cost of US$ 23 per dose. With three doses of vaccine required per child and most families having large numbers of children, the cost was prohibitively high and the majority were not vaccinated. Dr KI Varaprasad Reddy, an electrical engineer by training, discovered this fact at a World Health Organization conference and became so outraged that he set out to assemble a team of brilliant scientists to create the vaccine in India. When he approached a company in a developed country for a technology transfer agreement he was told: India cannot afford such high technology vaccines. India does not require vaccines. And even if you can afford to buy the technology, your scientists cannot understand recombinant technology in the least. No Indian bank was willing to fund early-stage research without commercial activity, so Dr Varaprasad Reddy was forced to raise capital by selling his familys property. After four long years of process innovation, Shantha Biotechnics released the first recombinant product produced in India a hepatitis B vaccine. The company now sells large quantities of vaccine to multilateral agencies at a price of 23 cents per dose one hundredth of the original price. Shanthas success story has spawned dozens of other health biotechnology companies in India. The example illustrates how affordable biomedical innovation can emerge independently from poor countries that targets local health needs when individuals are exposed to the right environment. This occurs in spite of the fact that researchers in the developing world face numerous challenges. They are cut off from advanced training, are often unable to communicate their science internationally through

Young Voices in Research for Health 2009

Justin Chakma

peer-reviewed journals and, of course, face enormous difficulties in translating their research into real products to meet local needs. Ironically, these local researchers who are left out of the global innovation cycle are arguably in the best position to not only break the cycle of poverty by becoming role models for their communities, but also to understand and develop products for local market needs and thereby create self-sustaining cycles of local delivery and development. First, local scientists and entrepreneurs are likely to have superior understanding of how to operate in a local environment. Second, the lower labour and other costs in developing countries can amplify the magnitude of the investment, while the scarcity of capital forces the researchers and entrepreneurs to be more capital efficient and productive. Most importantly, failure to participate actively in discovery and development may cause citizens in the developing world to become increasingly resentful about being excluded from improvements in wealth and capability that flow from innovation. The question then becomes how we can best harness the energies of this untapped innovative talent. The first barrier to overcome is the dearth of research infrastructure. Training programmes and research and development are expensive. Governments of developed countries need to challenge their stereotypes of research capabilities in the developing world and support more rich-poor collaboration. Governments of developing countries need to be prepared to support local health research and help their people reconcile long-term investments with the apparent lack of impact on short-term problems. A second barrier to overcome is regarding the actual conduct of the research itself. While many peer-reviewed academic journals offer subsidized or free subscriptions to scientists from lower-income countries, a more important barrier is actually getting access to the methodological tools necessary to conduct experiments. These are often protected by patents that scientists themselves are unaware of. Creating a comprehensive global database of patents relevant to each neglected disease could help scientists navigate the complex intellectual property landscape. One solution may be to take an open-source licensing approach to methodologies or platforms involved in health research similar to that of the software industry. This would open the door to a wealth of new innovation simply by linking together existing technologies. Identifying talented researchers and opportunities is the next challenge. Akin to their wealthier counterparts, research institutions in poor countries emphasize peerreviewed publications and often let technologies sit on the shelf. The consequences for the local population suffering from the disease in question are more immediate, however. In Ghana, a prototype dipstick assay for the second most socioeconomically devastating disease after malaria schistosomiasis remains unused for lack of internal resources to evaluate market potential or support product development and field trials. This situation holds at dozens of research institutions in developing countries. Governments must coordinate efforts to develop global or regional convergence centres that provide such services by bringing together the required financiers, entrepreneurs and scientists, while simultaneously educating and training them. We also need more partnerships between the developed and developing world, like the Stanford BioDesign India programme, which taps into entrepreneurial best

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practices, know-how and the diaspora in Silicon Valley for affordable local biomedical device innovation back in India. Multiple partnerships like this can form the basis for local and global networks that could help health entrepreneurs in lower-income countries overcome challenges in finding financing and human capital. These structures need not even be physical in nature. One precedent is non-profit-making Endeavor, which partners with leading multinationals in selected emerging economies and then identifies potential entrepreneurs. These entrepreneurs gain access to a powerful knowledge base facilitated at multiple levels by other Endeavor entrepreneurs and leaders of multinationals and by the participation of students from leading Masters of Business Administration (MBA) programmes. The potential to form partnerships via networking, and the international cachet that Endeavor entrepreneurs gain from their selection helps ease financing. Such cross-pollination of entrepreneurial know-how across countries, cultures and industries is sorely needed by health entrepreneurs in lowresource settings. Publicizing success stories through local and global networks will inspire more young scientists to bring innovation to the village. To be effective, these networks need to be coupled to innovative financing mechanisms. Health innovation companies often require multiple rounds of financing. Venture capitalists are feared by entrepreneurs as vulture capitalists, but this need not be the case. Coupling the concepts of venture capital with ideas from microcredit suggests the need for a more patient social venture capital that accepts as a legitimate return on investment the social impact achieved through alleviating disease. Developing and defining clear social metrics to measure performance will be critical to the effectiveness of this approach. Governments and investors alike need to be wary of focusing solely on large investments and take into account empirical observations that smaller investments can have a much higher return on investment in both financial and social terms1. With this idea of social impact and size in mind, venture capital or the private sector may not be the only route for proper dissemination. Community approaches based on beneficiary-to-beneficiary dissemination may be more effective in some cases. Engaging and involving communities in innovation and sharing the wealth will be critical to the long-term success of any entrepreneurial endeavour in a low-resource setting. The world universally recognizes the move towards a knowledge-based economy. Yet often it is hard to banish the traditional stereotypes of Africa and other developing regions as scientific backwaters. This travesty cannot continue. The accelerating challenges in global health that face us call for provocative ideas. Entrepreneurs are the provocateurs, risk-takers and innovators who can initiate the rapid, scalable change that is so badly needed for the developed world. We therefore need to reevaluate the way we look at the 10/90 gap. While increased aid and funding to tackle neglected diseases is badly needed, perhaps the way that we allocate many of these existing dollars is problematic. The question should be reframed in terms of talent. Only 10% of the worlds pool of entrepreneurs is currently being utilized. We need to harness the energies of the remaining 90% of the best and brightest, wherever they are. The poor are ready to tackle their own problems, but are the wealthy prepared to support them?

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Justin Chakma

Booth BL. When less is more. Nature Biotechnology, 2007, 25:853857.

Justin Chakma is a researcher developing innovative resources for product development in low-resource settings at the McLaughlin-Rotman Centre for Global Health. Before joining the programme, he founded BioSynergy, a critically acclaimed magazine focusing on entrepreneurship in the life sciences with a print circulation of 28 000. Most recently, he conceptualized and helped implement a new C$2.5 million biomedical innovation programme at the University of Toronto. In 2006, he represented Canada at the International Biology Olympiad in Argentina. Justin has authored peer-reviewed articles in Nature Biotechnology and Science and is currently an undergraduate at the University of Toronto studying neuroscience and economics.

It takes more than a Band-Aid

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Amanda Deatsch, United States of America

It tAkes moRe tHAn A bAnd-AId: A letteR to pResIdent obAmA

In the 21st century, disease flows freely across borders and oceans, and, in recent days, the 2009 H1N1 virus has reminded us of the urgent need for action. We cannot wall ourselves off from the world and hope for the best, nor ignore the public health challenges beyond our borders. An outbreak in Indonesia can reach Indiana within days We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health. Barack Obama 5 May 20091 Dear Mr President, You are a man of many great words, and with these words you have won the hearts and minds of millions of people around the world. You have addressed the importance of global health in your presidential campaign, and you have advocated for the right to health for all people across the globe. In addition, you have recently proposed a US$ 63 billion global health strategy to be completed over the next six years. And, for this initiative, health advocates everywhere are praising you. However, I am curious to know why US government spending on global health still remains minuscule in comparison with the global need? Does your integrated approach to global health consist of sound policy to bolster the funding? Or does your plan mainly consist of donating foreign aid? Although ideals and values are prominently expressed by US administrations as significant aspects of foreign policy, our lack of global governance has countries trapped in a realpolitik mindset that continues to dominate our foreign policy. It is true that we, and presumably all nations, are primarily concerned with our own survival and national interests and the securing of those interests abroad, but globalization has brought changes to which our policies must be adapted. Regrettably, health is considered a high-politics issue only when it directly affects our national interests. Foreign policy should no longer be seen solely through the lens of realpolitik, as this way of viewing international relations no longer accommodates our globalized world, where boundaries have been traded for wireless Internet connections. While globalization has positively impacted our world with respect to quicker connections, it has also left countries vulnerable to communicable diseases that do not respect borders. Less recognized or discussed are the negative ramifications that globalization has had on the developing world, especially on the billions of the poorest of the poor residing in sub-Saharan Africa. In the face of this new transformation and interdependence, we need to embrace and engage in global

Young Voices in Research for Health 2009

Amanda Deatsch

health diplomacy, defined by Thomas E Novotny and Vincanne Adams as a political activity that meets the dual goals of improving health while maintaining and strengthening international relations, particularly in conflict areas and resource-poor environments2. This new field in progress seeks to unite diplomats and health professionals to better understand common interests in global health and foreign policy. Through global health diplomacy, relations between states can be renewed, ties can be strengthened and new allies can be made despite the fact that countries may not agree or see eye-to-eye in the political realm. Global health can be used as common ground to set the basis for diplomacy in other areas of foreign policy.

Mr President, Now is the time to use global health diplomacy to capture the hearts and minds of the billions of people around the world who suffer in povertys vicious cycle. We must take part in global health diplomacy including medical, science and technology diplomacy to combat the greatest challenge of our time: poverty. Ten million children under the age of five die every single year. In fact, one child dies every three seconds. According to the Global Health Council, each year, the total number of child deaths is greater than the deaths caused by AIDS, malaria and tuberculosis combined3. These numbers are appalling, and the worse part has yet to be addressed; most of these deaths are preventable. We cannot stand back and allow preventable illnesses and malnourishment to take 30 000 childrens lives every single day. Nor can we simply rely on insignificant increases in funding to protect the worlds three billion living in poverty on less than a dollar a day. The 1.4 billion poorest of the poor live under conditions that many Americans would have trouble imagining, considering that, for many of us, poor means living on less than US$21 200 a year for a family of four. While we are a world of many different nationalities, colours, religions, ideals and values, and while we may not share the same political ideologies or enjoy the same socioeconomic situation, we can agree each and every one of us that we are all concerned about our health. We are one world. We agree that all people deserve the right to live a healthy life. Reversing poverty and bringing hope to the billions of people in need will take time, effort and willpower the will to make a difference through funding and policy.

Mr President, Band-Aids do not heal. We cannot use foreign aid as a Band-Aid to heal the wounds in the worlds poorest countries in sub-Saharan Africa. We cannot slap a few BandAids on Africa and hope that the wounds underneath will heal themselves. A wound needs basic care it must be cleaned and disinfected before it is covered. Offering only funding to countries in need in sub-Saharan Africa would be like bandaging a wound without taking care of it first; without very basic care, it just will not heal.

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Unless you take the Band-Aid off and treat it properly, there is a good chance the wound will become infected. While reversing poverty would not be possible without funding, we desperately need to address and tackle the root causes of poverty and not merely cover them up with our funding. All countries need to work together to address the underlying socioeconomic factors of poverty if we truly want to make a difference and overcome this greatest challenge of our time. It is important to introduce a plan of action that tackles the social dimensions of development that contribute to poverty, including weak rule of law, corruption and the lack of infrastructure or access to education and resources like clean water in developing countries. Poverty both causes states to fail and is a result of failed states. Poverty affects states economic stability, food security, overall health and education. This vicious cycle can be conquered only by adopting a bottomup approach that addresses both the social and the political determinants of poverty through a framework for global health diplomacy.

Mr President, If you cannot direct funding to the root causes of poverty based on humanitarian reasons, then please address poverty on the basis that poverty causes instability. Unstable countries pave the way for authoritarian leaders to take control, creating grounds for terrorism that would threaten US and international security. As health advocates, we would be inspired if the US president tackled poverty for humanitarian reasons, but, as long as poverty becomes an issue of high political value, we would be satisfied. Sincerely, Amanda Deatsch

2 3 4

Obama B. Statement by the president on global health initiative. Washington, DC, 2009 (www. whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/, accessed 27 August 2009). Novotny TE, Adams V. Global health diplomacy: a global health sciences working paper. 2007 (http:// igcc.ucsd.edu/pdf/GH_Diplomacy.pdf, accessed on 27 August 2007). Getting back to global child health. Washington, DC, Global Health Council, 2006. Strickland T. Creating the Ohio anti-poverty task force. Columbus, Ohio, 2008 (www.governor.ohio.gov/ Portals/0/Executive%20Orders/Executive%20Order%202008-11S.pdf, accessed 2 September 2008).

Amanda Deatsch graduated in 2007 from Baldwin-Wallace College in Berea, Ohio, with a Bachelors in Political Science. She then moved to Vienna, Austria, where she completed a Masters in International Relations at Webster University Vienna. She is fluent in German. She has worked as an intern at the United Nations Office on Drugs and Crime and is currently researching global health diplomacy and development in the Division of Human Health at the International Atomic Energy Agency.

Young Voices in Research for Health 2009

Delford Doherty

Delford Doherty, Sierra Leone

neVeR let A dIsAsteR go to wAste: oppoRtUnItIes pResented bY swIne flU foR InnoVAtIon In globAl pUblIc HeAltH emeRgencY Response

Background
The ongoing swine flu pandemic is another fierce reminder of our universal incapacity to respond to a global disaster. While researchers strive to understand the epidemiology of the recent outbreak of the H1N1 virus with the aim of devising a formidable response, politicians and pundits use the opportunity to push their political agendas, some spewing hate while others play the blame game. Throughout this saga, only a few actually stopped to think about the enormous opportunity presented by this swine flu outbreak. The most humbling aspect of this outbreak is that it emphasizes the reality of our common destiny, not as individual nations, peoples or races, but as a global network of nations interconnected and bound by a common fate our desire to survive as a civilization. Consider the series of events that followed the swine flu outbreak on 24 April 2009. Within 24 hours of the World Health Organization (WHO) alert, the outbreak became a media frenzy resulting in a massive outpouring to the public of sometimes credible but mostly terrifying information. In a matter of days Mexican farmers were blamed for the genesis of swine flu, and, across the border in the United States of America, conservative pundits seized the opportunity to pursue their fear mongering, stigmatizing Mexicans and illegal immigrants, calling them mules in what they saw as a bioterrorist attack on the USA. Within a week, there were laboratory-confirmed cases in Austria, Canada, Germany, Israel, the Netherlands, New Zealand, Spain, Switzerland and the United Kingdom. Meanwhile, across the globe, nations quavered and while most responded appropriately others, ill prepared, reacted illogically. For example, Egypt called for the slaughter of over 300 000 pigs at a time when millions around the world suffer starvation, while Ghana and others banned the importation of pork. In both cases the nations reacted without supporting evidence and took actions that were adverse to their national economies and to our universal interests. Subsequently, other nations overreacted and took steps that severely infringed individual liberties, whilst claiming they were protecting national interests and their citizenry. This was the case in China, where Mexican citizens and Canadian students were detained or quarantined without due process. Within 10 days, the outbreak had spread, despite our best efforts, to 16 countries with over 658 reported cases. This is not an attempt to trivialize the efforts of those working hard on the frontlines to prevent a global pandemic, nor is it an attempt to criticize current policies. The intention is to instigate innovation by highlighting recent facts. In 10 days, the

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outbreak effectively exposed our global vulnerability, stirred our deepest fears and, most importantly, illuminated the acute need for an all-inclusive approach to global emergency response. Our public health preparedness can be only as strong as our weakest link. The exclusionist mentality of the past, in which nations look out solely for their own interests, is archaic, unethical and unsustainable. No single nation can afford to act alone. There is a moral imperative for the cultivation of innovative ideas that will evolve into a blueprint for global public health emergency response. This essay highlights major pathways to developing the shape of the blueprint.

Provisions for innovation

We are at a juncture in our history in which we must seize the opportunity to unite our efforts and prepare ourselves for unknown threats that may be lurking in the future. With the gloom of natural disasters, bioterrorism, swine flu, severe acute respiratory syndrome (SARS), avian flu and myriad infectious diseases afflicting many in the developing world, we now have a mandate to conduct an overhaul of our international public health system to build our global capacity to respond to future threats. The following three provisions represent a possible pathway to innovation. The first provision involves using the expertise and authority of WHO to build the global infrastructure to respond to global health threats from infectious diseases and bioterrorism. Building infrastructure would include strategically placing laboratories, stockpiling vaccines and medications, and developing a model response plan based on unique regional and national capacities. This could be taken a step further by recruiting nations that can pledge personnel health care, paramilitary, police and researchers who will form a first response team that can be mobilized in a global emergency. The second provision involves global investment and the exchange of intangible resources. This step is premised on the hope that wealthy nations understand the imperative for global inter-reliance and the ethical responsibility they have to assist less-fortunate and less-developed nations in building capacity to respond to local disasters. Under this provision, a fund will be created to allocate resources across the globe to train researchers and health professionals, develop mechanisms for the exchange of epidemiological and other data, and exchange ideas about processes. Eventually, this initiative would evolve into a global forum where proactive and prevention strategies would be developed, along with global response policies with the aim of both standardizing and expediting response processes. The most vital provision of this blueprint is advocacy. There is an acute lack of scientists, researchers and health professionals in advocacy. Scientists have generally relegated advocacy to the realm of politicians and pundits, who may not have the technical background to fully appreciate the implications of scientific findings. Furthermore, scientists and health professionals, especially those in less-developed nations, have abdicated leadership and advocacy to function in traditional roles, underestimating the political landscape. For trends to move towards innovation for global emergency preparedness, there is a need for scientists and researchers to become better advocates in order to inform policy-makers and taxpayers about the inherent and ethically justifiable need for global engagement and international

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investment in building global capacity to respond to disasters. It is a moral imperative and a strategic necessity for WHO and other international advocacy organizations to create the means through funding, training and workforce development for scientists, researchers and health professionals to be proactive and become leaders in advocacy.

The way forward

It is by no means obvious that these provisions necessarily herald a trend. For example, while there is much discussion of and support for a model emergency response act in the USA and other industrialized nations, less-developed nations are still limited by such factors as political instability, poor infrastructure and an almost nonexistent public health system. The provisions in this essay identify these limitations and provide illustrative ideas to address components that can be influenced by external factors such as funding, the focus on building strategic regional (rather than national) infrastructure, workforce development, etc. The key message, then, is that these provisions can be met incrementally. With predictions of a possibly more virulent strain of H1N1 returning later in 20091, advocates and policymakers have the attention of the public, which provides the impetus for a mandate to act decisively and act now. This is not a proposal for a global, one-size-fits-all blueprint in which industrialized nations control and dictate the agenda. Rather, this is an array of recommendations for global preparedness with the first step being the unequivocal empowerment of WHO to use its platform and leadership to move forward in achieving the multipronged provisions presented here.

Conclusion
In addition to the advent of global warming and climate change, and the recent rise in the potential for bioterrorism as a threat to the major cities of the world, the potential for a global pandemic is immediate. This threat should forge a realization among the political community in industrialized nations regarding potential threats to their individual interests. This reawakening should shift the focus from personal and proprietary protection on the part of nations to a global approach that encompasses resource allocations and transformative policies that reflect ethical principles, global security and the building of global capacity to both prevent and respond to emergencies. There is a moral imperative for this. As opposed to a global approach in dealing with the threat of a pandemic, most nations have taken exclusionist steps to protect only their individual interests. In this global economy, where nations exist in a kaleidoscope of markets that are interdependent regarding resources and share common economic ambitions, it is crucial for nations to collectively engage in meaningfully securing our universal health and safety. While these provisions have their limitations, this essay does not seek to address those possible impediments, nor does it take them for granted. The purpose of this essay is to assert an illustrative pathway to an innovative global initiative that will improve preparedness and standardize and strengthen response to global health emergencies to protect our collective interests as a global community. We must either seize this opportunity to unite and strive, or continue on our current path to potential peril. This is not an ideology; it is a call to action.

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Global alert and response (GAR) Situation updates Pandemic (H1N1) 2009. Geneva, World Health Organization, 2009 (www.who.int/csr/disease/swineflu/updates/en/index.html, accessed 27 August 2009).

Delford Doherty moved, after surviving civil war in his homeland of Sierra Leone, to the Gambia in 1999, where he completed high school. In 2002 he moved to the United States of America to attend Wartburg College in Waverly, Iowa, and earned a Bachelors in Biochemistry. He is currently in the final year of earning doctorate in Pharmacy and Master of Public Health at the University of Minnesota College of Pharmacy and School of Public Health. His academic interests include health-care policy, clinical outcome evaluation and global health policy.

Young Voices in Research for Health 2009

Nicholas Fancourt

Nicholas Fancourt, New Zealand

RedefInIng tHe cYcle: sYstems, HeAltH And cHIld poVeRtY

Social machinery drives health. This perspective on health care was anticipated in 1920 by public health expert Charles-Edward Winslow, effectively redefining the scope of public health. Since then we have become cognizant of the relationships between socioeconomic issues and health outcomes. Recognition has grown to the point where we understand that it is our collective response through effective systems that produces sustainable change. Despite this, societal progress trails scientific developments in improving health, particularly in developing nations. Nowhere is this more evident than in the effects of child poverty. Many demographic groups have become victims of poverty, but it is children, as the most vulnerable, on whom the health effects are most telling. As our common future, children are a barometer of the effectiveness of social policy. They are our ultimate investment, morally and economically, through which effective policy can influence us all, generation after generation. The global nature of poverty means it touches us all as individuals, taxpayers, consumers, communities and nations looking to develop brighter futures. Billions of dollars are spent annually on attempts at poverty reduction. Billions more are spent on povertys health effects. Yet inequities persist, with poorer children and their families having consistently worse health outcomes. The deeply rooted injustices at the base of these inequities are as complex as they are concrete. The lack of health care as a social right, low coverage of health services in poor communities, government corruption, stagnating economies and low levels of education are some of the many factors that can influence the relationship between poverty and health. The great paradox of poverty is that it is a truly global phenomenon. Developed countries, usually symbols of wealth and security, still fail to adequately address poverty. In New Zealand, one in four children lives in significant hardship. The correlation with health is strong. For instance, New Zealands rheumatic fever rates for indigenous children parallel Indias and Mexicos, with socioeconomic deprivation a significant risk factor1. In the United States, the costs of poverty-related child health problems have been estimated at over US$ 150 billion each year2. Innovation has brought us many gains in health care, and I believe it is our only way forward. The nature of disease and its many determinants are well described, yet we struggle to deliver lasting improvements in health for those who will follow us. There is often talk of a cycle of poverty, reflecting its perpetual nature. But the cycle metaphor also suggests that poverty is a closed loop, impossible to either enter or leave, driving false perceptions that eradicating it is a mirage for thirsty idealists. We

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have become complacent, believing that poor nations and impoverished citizens are necessary and stable facts of life. We need to revise the way we portray the problem. This requires a change of perspective to see not merely a cycle but a system that is driven by the failings of many social policies. Traditional social services education, justice, tax, aid work in silos, independent and frequently unaware of each other. But poverty-related poor health engages all of these sectors, involving important considerations of politics, ethics and economics. Addressing this burden mandates an appreciation that both poverty and health operate in interdependent and interrelated systems. As a trainee paediatrician, I witness too often the shortcomings of our systems: fragmented efforts between traditional social services, low household incomes leading to overcrowding and poor access to health care. Over a three-month period I admitted one girl who lived in significant hardship five times due to the exacerbation of her chest disease. She is clearly a victim of the shortcomings of our system. Her family were keen and motivated to improve her poverty-affected living environment and disease management, but sadly as a community we lack some of the social and financial tools required to make this a reality. The founding elements of a new perspective are not far from our grasp. Epidemiologist Geoffrey Rose, in his 1992 book on preventive medicine, stated: The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics can not and should not be kept apart. If we are going to recognize and address the role of systems in child poverty and health care, then we inevitably need to use government processes to advance the cause. The political influence on health care is telling. In 2007, while I was studying in The Gambia, the small nations president announced through statecontrolled media that he had found a cure for AIDS. His treatment, a concoction of herbs and spices ceremonially administered, undermined international efforts to control the countrys HIV problem. Without access to open media or scrutiny, confusion grew and clinic attendance dropped at the hospital where I was based. Economics, intimately tied to political forces, play a central role in development, poverty reduction and health care. International aid, which supplies 70% of public funds in Africa, can be more Band-Aid than development aid. Corruption and poorly coordinated funding has halted any rise in per capita income in Africa over the past 30 years3. Without approaches that stimulate sustainable, locally driven systems for economic development, the impetus for action by governments is too often lost. That action must be the backbone of any wider social change to the tapestry of poverty and health. Just as the underlying problems can be illustrated as systems, so too can innovation in systems be the solution. The challenge remains to construct systems that are flexible enough both to adapt to social change and to deliver new approaches to health care and research. What if we rethought our traditional service barriers those that separate research from policy, those that create silos of care and sought to tune the whole machinery of health care? We may be able to realize Winslows goal of integrating the social with the scientific in health care. But I believe it is unrealistic and unproductive for each country to follow this path alone. All countries, developing and developed, face mounting pressure to treat a growing burden of disease. If we are to improve our systems, we must be open to truly international collaboration

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Nicholas Fancourt

that reflects the weight of inequity faced by many countries. Aristotle asked us to treat equals equally and unequals unequally. We remain far from achieving that in our practice, either between countries or within them. Poverty has unequally stripped the voice of many developing nations, just as it unequally affects children. Strong direction and participation is required from these nations to ensure ownership and accountability regarding these goals. Fundamentally, the instruments and structures we have do not address the integrated and social context of many health problems. We must seek to overcome poverty and its related social issues at the same time that we seek to overcome its health effects. Our activities in health care do not always have this in mind. We offer a multitude of advocacy, action, research and funding groups to tackle child poverty and child health, yet combined these show much duplication and fragmentation of effort. Moreover, many of the efforts are reactive, rather than initiatives that prevent recurrence or drive change. What is needed is a productive network to link these activities. Innovation must deliver an international network for health systems, with the aim not only to advise on and develop local methods for improving health systems, but to participate actively in quality analysis and research into health and related social systems. Integrated information provides the most dimensions. Being able to address child health systems with combined efforts on education, housing, nutrition and primary care will better enable healthier communities than will a drive for single-issue solutions. We need to be able to provide for one another the tools to develop a robust architecture for local health systems. In order to have this security, any network for health systems needs to extend beyond the traditional paradigm of intergovernmental or charitable organizations. Instead, assistance from diverse areas that reflect the complexity of health and its determinants needs to be incorporated. Progress for health systems must continue to incorporate innovation from academia and venture capital funds, cultural resources and ministerial advisory groups. We must see not only a childs pneumonia but also the poverty effects of poor nutrition, household stress and low access to care that seeded it. The reality of poverty and ill health shatters the peace of too many childhoods. In the past century we have seen frequent advances in knowledge of the social machinery of health. But we have been too slow to integrate this into a working model that can consign problems of child health and poverty to history. It is time to reorient ourselves, to build new perspectives on the relationships between poverty and health. If we focus on innovative systems, we have the ability to introduce sustainable change, not just for health but for child poverty and the many other social determinants that underlie it. Failure to do so is a wasted opportunity and a disservice to future generations.

1 2 3

Jaine R, Baker M, Venugopal K. Epidemiology of acute rheumatic fever in New Zealand 19962005. Journal of Paediatrics and Child Health, 2008, 44(10):564571. Holzer HJ et al. The economic costs of poverty in the United States: subsequent effects of children growing up poor. Washington, Center for American Progress, 2007. Moyo D. Why foreign aid is hurting Africa. New York, The Wall Street Journal, 21 March 2009 (http:// online.wsj.com/article/SB123758895999200083.html, accessed 28 August 2009).

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Nicholas Fancourt is a paediatric trainee in New Zealand. He graduated from the University of Otago with a medical degree and a Bachelors in Medical Science with honours in Ethics and is currently completing his Masters in Bioethics and Health Law. During his studies, Nicholas worked for New Zealands Health and Disability Commissioner and completed an internship at the World Health Organization in Geneva. He is a past president of the New Zealand Medical Students Association and currently volunteers with the Child Poverty Action Group. Alongside paediatrics he is interested in health systems and hopes to complete doctoral study in public health.

Young Voices in Research for Health 2009

Hildy Fong

Hildy Fong, United States of America

InnoVAtIng foR tHe HeAltH of All: seARcHIng foR eqUItY, ResponsIbIlItY And tRUtH In A dIVIded woRld

Nothing under the sun is truly new. Joseph Needham devoted much of his lifes work to Chinese science and civilization. In addition to identifying paper, printing and gunpowder as being among Chinas significant inventions, he revealed that vaccinating against smallpox may have been practised as early as the 10th century, during the Song Dynasty. In the 1500s especially, the Chinese immunized mildly infected people by inserting powdered smallpox scabs into their nostrils1. China discovered many things western civilizations take credit for, but one cannot discredit Edward Jenners contribution to the smallpox vaccine in 1796. Nor can we question Europes influence on gun technology or Gutenbergs development of the printing press. Rather, it is more constructive to observe innovation as a product of history. Innovation thrives on independent curiosity, discovery and action but is also influenced by previous research, philosophy and movements of human civilization. We are stimulated by the past to be motivated in the present to create solutions for the future. I believe that, through a lens of collective innovation history, there is a different perspective from which to understand innovating for the health of all. New innovation, especially concerning health, must be handled within the fragile boundaries of culture and society. Today, more than ever, we must be concerned with responsibility. If we are not, we face an almost certain divide. Concerning equity. To truly provide health for all, innovating for health must be concerned with equity. Current global health problems stem from poverty and inequity. Has innovation helped or hurt? For the poor, innovation has failed even to provide basic survival tools. Jeffrey Sachs describes the innovative gap as inevitable, as the rich move from innovation to greater wealth to further innovation2. While the United States of America has recently achieved the first near-total face transplant, in Afghanistan, one in every four children dies before the age of five, only 28% of adults are literate and life expectancy is only 44 years3. It does not seem that innovating for health has placed Afghanistan at any competitive advantage. We now know that wealthy nations are not immune to inequity and poor health status. Research on the social determinants of health show a clear parallel gradient between position in social hierarchy and mortality4. Our current economic crisis has magnified this. As more become unemployed, individuals are at risk of poorer health status. For example, although health insurance coverage made small gains in California from 2005 to 2007, the recent recession will likely reverse that trend5. Moreover, war tension challenges the growth of innovation for health. In Darfur, violence between the Sudanese government and local rebel groups has led to over 1 million displaced people and crimes against humanity. The United Nations found that nearly a quarter of children under the age of five were malnourished. Innovating for the health of all during conflict is a distant reality.

Innovating for the health of all

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Despite our advances, why has innovation failed us on such basic levels? We have vaccines for polio, measles and influenza. We have surgery, anaesthesia and penicillin. We can break down geographical barriers to reach remote populations. We have networks to exchange information and investigate cultural differences. There is no excuse. Societies must address the challenge of innovation and social responsibility in the context of our global society. What principles must exist to innovate for the health of all? Concerning leadership. It is an ethical responsibility for innovators in society to be the catalysts of true health reform. It is the social responsibility of political leaders to promote development while also encouraging fairness. Innovation without social responsibility is not progressive. A major challenge is how to bring marginalized populations up to speed without holding back innovation. There must be a distinction between health prevention and health technology. Health prevention is ideally improved by technological innovation but should not overshadow basic health needs like vaccinations and neonatal care. Leadership must address this conflict. In Chinas health-care system, public hospitals depend on capital from pharmaceutical companies to stay afloat. This leads to corrupt prescription practices and a host of inequitable aspects to health. Chinas Health Minister, Chen Zhu, has decided to prioritize equality and justice in public health-care reform. Chinese health reform plans to expand primary health care to 90% of the population. Concurrently, they will regulate pharmaceutical policy in the public sector while also making evidence-based investments in traditional Chinese medicine. Only when leaders acknowledge social responsibility being rightly on the national agenda can governments be in a better position to innovate for the health of all without stifling growth. Concerning civic engagement. At a community level, we must all do our part. Global societies filter technologies only when they have the basic resources and people to support them. Liberian President Ellen Johnson-Sirleaf has said that aid must be structured and focused while also supporting a governments own development agenda. Innovations must be sustainable in the environment in which they are introduced and fit cultural norms. Civic engagement is the key to sustainable innovation. It engages multiple partners in the provision of basic health needs. It necessitates culturally competent frameworks. After all, each person has his or her own personal belief systems. The simplest methods of health prevention rely on accessible health messages. In the United States of America, Promotores programmes train migrant community members to promote health. These programmes are valuable because they promote linguistically and culturally relevant primary care to vulnerable populations. Barefoot doctors in China during the Cultural Revolution built a formidable primary health-care system. The Partners in Health model delivers health care to poor and remote areas such as squatter settlements in Haiti by relying on community health workers and partnerships that build economic and social capacity. In poor communities, innovation in basic primary health care through civic engagement can provide sustainable health for all. On research. Among building blocks for advocacy, research is innovation. Time and time again, research has strengthened the bridge between the impossible and action. It is, through its ability to translate, the key to truth. In innovating for the health

Young Voices in Research for Health 2009

Hildy Fong

of all, we must be particularly concerned with qualitative research. Health research emphasizing policy, communications and behaviour can address complex social problems through ethnographic methods. Yet qualitative needs are not prioritized in countries that need them the most. In the fight against HIV, there is still a need for country-specific data on behavioural interventions for young people aged 1524. The lack of data from interviews with key informants, community surveys and health facilities creates a gap between research and practice. We need this type of research to address the population that represents 50% of all new HIV cases6. If research is a foundation upon which civilizations thrive, then it is not only our job to promote research. We have a duty to protect it. The Khmer Rouge, ruling Cambodia from 1975 to 1979, made it their mission to rid the country of capitalistic principles built on education and money. Their genocide of professionals and intellectuals has to this day affected health and economic stability. As an intern at a non-profit-making organization helping Cambodian children travel to Singapore for heart surgery, I saw first-hand that health systems broken by violent conflict are held back even more by the genocide of knowledge. We have a commitment to protect our collective health research. Wealthy nations have a responsibility to protect poorer ones because they are in a better position to do so. Ensuring health for future generations. Innovations allow us to prolong life, ease suffering and control the growth of populations. We have to be innovative in our modes of delivery so we do not reinvent the wheel of what we already possess. As the custodians of our own future, we have unprecedented power to control the flow of the discoveries that are brought to us. Responsibility in innovation can fuel the lives and existence of all of us on this earth, ensuring health for all in this generation and all generations that follow.

1 2 3 4 5 6

Needham J et al. Science and civilisation in China VI(6). London, Cambridge University Press, 1954. Sachs JD. The end of poverty: how we can make it happen in our lifetime. London, Penguin, 2005. UNICEF Afghanistan statistics. United Nations Population Division and United Nations Statistics Division, 2009 (www.unicef.org/infobycountry/afghanistan_statistics.html , accessed 28 August 2009). Marmot M. Health in an unequal world. The Lancet, 2006, 368(9552):20812094. Brown ER et al. Nearly 6.4 million Californians lacked health insurance in 2007 Recession likely to reverse small gains in coverage. Los Angeles, UCLA Center for Health Policy Research, 2008. Dick B et al. Review of the evidence for interventions to increase young peoples use of health services in developing countries. In: Ross DA, Dick B, Ferguson J, eds. Preventing HIV/AIDS in young people: a systematic review of the evidence from developing countries. Geneva, World Health Organization, UNAIDS Inter-agency Task Team on Young People, 2006, 151204.

Hildy Fong is from Raleigh, North Carolina, in the United States of America. She is currently a PhD student at the Chinese University of Hong Kong, investigating health disparities among migrant children in China. She studied public health at the University of North Carolina at Chapel Hill and holds a Master of Health Science in Health Policy from the Johns Hopkins Bloomberg School of Public Health. She is interested in health equity for vulnerable youths in Asia in the context of globalization and infectious disease policy. Her research interests developed while assisting with medical programmes for children in poverty in South-East Asia and interning at the World Health Organization, where she completed a policy project on HIV and young people. She has worked at the University of California, Los Angeles Center for Health Policy Research and also interned at the United States Senate.

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Javier Garca Castro, Spain

sIlIcon bRAIns

Las ciencias que estudian el cerebro estn pidiendo a gritos una revolucin desde hace algunos aos. Porque a pesar de los grandes avances que se han alcanzado en su estudio, todava no sabemos con certeza cmo funciona el cerebro y qu es lo que hacen las neuronas para sustentar los procesos de pensamiento complejo que posibilitan el variopinto caleidoscopio de la realidad humana. Nadie sabe todava cul ser ese punto de inflexin que permitir hablar de ciencia dura cuando nos estemos refiriendo a la neurociencia. Yo tampoco, pero me tomo la libertad de expresar aqu mis cbalas, que no por utpicas tendran por qu dejar de ser posibles. Olvidmonos por un instante de lo posible y lo imposible, y dejemos volar la imaginacin para alcanzar metas que hoy se antojan inalcanzables, pero que maana podran ser realidad, tal y como hemos podido aprender a lo largo de la historia de la humanidad. Tan misterioso como cualquier otro reto al que se han podido enfrentar antes los seres humanos resulta el estudio del cerebro, que por aparatoso, se ha resistido a la investigacin sistemtica y a la formulacin de explicaciones plausibles durante ms tiempo que otras ramas de la ciencia. En s mismo es algo paradjico, por cuanto el objeto de estudio es el propio sujeto que conoce, lo que hace que sujeto cognoscente y objeto conocido sean lo mismo. Sin embargo, ningn reto ha podido resistirse a la insaciable curiosidad de los hombres y, por supuesto, el estudio y comprensin del cerebro no ha sido una excepcin. Gracias a los esfuerzos de disciplinas tan dispares como la medicina, la bioqumica, la ingeniera o la psicologa, estamos en posesin en nuestros das de una gran cantidad de datos sobre el cerebro, aunque todava estemos lejos de una teora general que lo explique todo. Esto ha posibilitado el avance tanto en psiquiatra como en neurologa en el tratamiento de las enfermedades que afectan a este rgano pensante. A pesar de ello, estas intervenciones no pasan del empleo de frmacos que sirven para paliar defectos funcionales, regulando al alza o a la baja la concentracin de determinadas sustancias que hacen que las neuronas se comuniquen entre s, o para la reseccin de elementos nocivos, en caso de algunas intervenciones neuroquirrgicas. Y aqu es precisamente donde comienza mi reflexin. Qu pasara si lo que hiciese falta fuese algo estructural? Y si hubiese que aadir algo? La realidad de las personas que sufren trastornos mentales o deterioro cognitivo no es tan ajena en nuestra vida cotidiana como posible, porque todos estamos

Young Voices in Research for Health 2009

Javier Garca Castro

expuestos a padecerlos alguna vez en nuestra vida, bien en primera persona o en nuestros conocidos ms cercanos. Lo cierto es que perder las capacidades cognitivas puede sumir a una persona en un laberinto sin salida, impidindole recuperar su vida anterior, la que denominamos normal, para siempre. Existen casos documentados de personas que han perdido la capacidad de generar nuevos recuerdos, de transformaciones radicales de personalidad, de personas que pierden el contacto con la realidad. Se han documentado los ms estrambticos relatos sobre alteraciones sensoperceptivas o comportamentales, que resultaran difciles de creer si no fuera por la fidelidad de la fuente. Y todo ello porque el cerebro es el centro de operaciones que interpreta una realidad, pero que no es la realidad. Con el trabajo aunado de la biologa y la ingeniera, se podran disear chips o unidades de procesamiento de informacin, como los utilizados en las placas de los ordenadores, para remendar cerebros. Como en otras disciplinas mdicas se cambian huesos por prtesis, se transplantan rganos o se utilizan marcapasos, se podran utilizar estos chips para suplantar reas lesionadas o disfuncionales, para que el cerebro pudiera seguir con su actividad normal. Esta tecnologa, que ya se est ensayando en el laboratorio con animales, est pensada inicialmente como paliativo para traumatismos de enfermedades como la epilepsia. Pero ms interesante sera llevarla un paso ms all, desarrollando todo un cuerpo terico y tcnico que nos permitiera, por un lado, formular teoras ms completas y precisas del funcionamiento cognitivo complejo, y por otro, disear, producir e implantar esta nueva tecnologa para reparar el funcionamiento alterado del cerebro. Esta ingeniera neuronal constituira un enorme hito para el desarrollo de la medicina y una solucin para todas aquellas personas que padecen enfermedades mentales, neurolgicas o dficits cognitivos irreversibles. Se abriran nuevas vas para entender el tratamiento de muchos trastornos psicolgicos que son producto de un procesamiento de la informacin distorsionado, y no sabemos qu otras ventajas nos conferira para alcanzar una mejor comprensin sobre cmo funciona este rgano como un todo. No es un objetivo a corto plazo, ni tampoco lo veo en poco tiempo formando parte de la cartera de servicios de la Seguridad Social, pero es algo que se puede proponer y se puede intentar, porque slo pensar en los beneficios que esto podra generar para tantas personas en el futuro, aunque utpicos en nuestro presente inmediato, ya justificaran todos nuestros esfuerzos.

Javier Garca Castro naci en Vigo (Galicia- Espaa) el 30 de octubre de 1980. Realiz sus estudios en el Colegio Apstol Santiago Jesuitas de Vigo y se licenci en psicologa en la Universidad de Santiago de Compostela en el ao 2004. Durante los tres ltimos aos ha trabajado como psiclogo interno residente para el Servicio Navarro de Salud. Actualmente se desempea como becario-investigador en el Hospital Virgen del Camino.

From Asclepius to gene engineering

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Manik Gemilyan, Armenia

fRom AsclepIUs to gene engIneeRIng: HAVe we gAIned A betteR UndeRstAndIng of HeAltH?

When we think about what health is, what comes to mind first is the definition of the World Health Organization (WHO), which says: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. This definition is not new to anyone involved in the field of health, but if we give it a further bit of thought, do we all view health in this holistic way? Would we consider healthy a poor man who has excellent physical health indicators but who is so short of money that he sells one of his kidneys to get means for living? Or would we consider healthy a wealthy woman who is unhappy when she looks at herself in the mirror and sees new wrinkles appearing every day? These questions are not merely theoretical, but the answer to them is key to defining what health research would aim for and what innovating for the health of all means. If we understand what health is and put innovation and health research in this context, we can search for ways to establish an environment conducive to true health equity to innovating for the health of all people. Let us go back to ancient times and see what was happening in ancient Greece with regard to innovations for health. Asclepius was the god of medicine, and taking care of peoples health was considered a job of gods, not humans. The gods responsible for health were Apollo and the daughters of Asclepius, Hygiea and Panacea in other words, those who had the power to heal people. It was not until Hippocrates that medicine became more democratic, as he laid the foundation of leaving successors by teaching medicine to other people. In those times, health was still associated only with healing diseases and physical well-being. In the context of the WHO definition of health, however, another Greek god, Prometheus, who sacrificed his own health for the sake of human well-being, might be viewed as a bigger health innovator than Asclepius himself. He was not aiming to heal the elite, but he brought fire to humans, something they had not had before and allowed them to heat their houses, to cook food an innovation that certainly improved the health of all. Continuing to look back in history in an attempt to identify the qualities and conditions for creating an environment supporting innovation for the health of all, another helpful example would be that of Sir Alexander Fleming. Some distinguishing characteristics of his ingenious innovation the discovery of penicillin were that he was not searching for that particular finding. It was a result of his lack of strict discipline that he left the plates with bacteria out of the refrigerator, allowing the mould to grow over them. However, if not for his outstanding researchers curiosity and attention, he would never have noticed that bacteria were not growing around the place where the fungi grew. Therefore, among key factors leading to innovation

Young Voices in Research for Health 2009

Manik Gemilyan

we might name chance, but only if it is coupled with a sharp and thorough mind, focused attention and a passion for improving the health of people. If Fleming had not had all those qualities, either penicillin would never have been discovered, or it would be manufactured only as an elite drug to cure the rich, which it actually was in the dawn if its history. Later on, as the volume of manufactured penicillin expanded, the price went down, and the drug became available, having saved millions of lives since its discovery. It would be difficult to argue that Fleming was not a brilliant innovator for the health of all. But look what is happening in our pharmaceutical industry today. If a new, effective drug is created that has the potential to save many lives, it is not doing so, and the reason is that drug manufacturing is done in accordance to marketing rules, never health equity ones. A new, potent drug goes on the market priced such that it is available to only a limited number of people. The same happens with any new product or service developed for curing disease, such as a new surgical technique or device, new transplantation methods, etc. As a result, what happens with innovation is that not only does it not bring the world closer to health equity, but it actually increases the gap between the health of the rich and of the poor. Would any truly passionate health researcher believe this was the goal when they conceived of their innovations to improve health? I am confident the answer is no. Therefore, I proceed with asking: What creates this gap between the researchers goals and passions and the dire reality of deepening health disparities? Another angle from which to look at this same problem is by asking: Is health care and medicine a business or a humanitarian enterprise? Unfortunately, the correct answer in most parts of the world is the former. If we could change this, even to a small extent, we might be able to see this gap narrow, and maybe we could even have a world of health equity. The next logical question is: How? Well, there are some suggestions otherwise this essay would only become a philosophical and historical observation. One suggestion is to have regulations for the pharmaceutical industry. A rule requiring the lifting of a new drugs patent after sales have generated a certain profit would allow the manufacture of generic drugs that would be affordable to everyone. Obviously, increasing government support for not-for-profit projects aimed at improving everyones health is another way. Could another solution be universal health care? It is symbolic that the Global Forum for Health Research annual Forum will take place in Cuba this year. In that country, the system provided free health care for all, and the health indices were the highest in the region and among highest in the world several decades ago. It seemed to work then. However, in the post-Soviet period, things changed and the health indicators went down, so that even those who have the money cannot receive highquality health care because the whole system has failed. Now let us return to the seemingly rhetorical questions of the beginning, to develop the idea of what health is and how to reach health equity. Which would be a better solution to improve the health of the man wanting to sell his kidney? Sophisticated surgery with no complications to remove the kidney and get him some money in

From Asclepius to gene engineering

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exchange, or improving his social circumstances by, for example, finding him a job or giving him some credit support such as through microfinance? Would high-end plastic surgery improve the health of the aging woman, or would she perhaps feel more attractive and helpful and less unhappy (and eventually healthy) if she could engage in some activity that would allow her to share her wealth with the man who wants to sell his kidney? Maybe she could establish a charitable fund or something similar to microfinance credit. Which would have been a better innovation to improve everyones health? The answer goes beyond just health research, as we doctors and health-care workers understand it. In our era of gene engineering, even though we have learnt about the holistic definition of health in medical school, we still think about it in a mostly physical, medical way not much different than in Hippocrates time. What we think of as innovation for health still refers to new drugs and new medical technologies. It would be more useful for all of us who work in health care to keep in mind that Prometheus was no less a health innovator than Asclepius or Hippocrates even if we swear only the Hippocratic Oath. Now, if we put together all these thoughts and attempt to answer the main question how to narrow the gap and how to make research work for the health of everyone on this planet we would arrive at the following solution: affordable health care in a world of justice. If any one part of the formula is missing, we cannot achieve health equity for all. Cutting-edge technologies or silver bullet drugs will never improve the health of all as long as we are living in a world full of injustice. As simple as this solution may seem, the next question of how to get there would be the topic of a totally new essay.

Manik Gemilyan graduated from Yerevan State Medical University in Armenia in 2001 and got her specialization in family medicine in 2003. She went into practice until 2004, when she joined World Vision Armenia as health programme coordinator. In 2008, she got her Master of Public Health in Epidemiology from Emory University in Atlanta, Georgia, in the United States of America. While in training, she worked with the Emory School of Medicine residents performance-improvement project and afterwards at the Centers for Disease Control and Prevention as a health scientist. Currently she works at Yerevan State Medical University hospital as a physician and assistant professor in the Internal Medicine Department.

Young Voices in Research for Health 2009

Damian Hacking

Damian Hacking, South Africa

IneffIcIent InnoVAtIon: tHe need to RedIRect fUnds fRom tReAtAble And pReVentAble dIseAses

About 15 000 years ago in France, prehistoric man had the bright idea to sheath his penis with the intestine of an animal during coitus1. Whether this novel idea was intended to prevent childbirth or disease transmission remains unclear, but the first documented medical use of condoms appears only much later, in the 16th century. The Italian author Gabriele Falloppio describes the use of a treated cloth draped over the penis as an effective way to prevent the transmission of the French disease, otherwise known as syphilis2. The condoms usefulness in disease prevention has again been highlighted with the emergence of HIV, particularly in developing nations. The condom would seem to be the most potent weapon against HIV transmission, yet if this innovation has been around for so long how is it that HIV has managed to spread so virulently? Lack of resources, lack of education or just plain irresponsible behaviour could account for the failure of condoms. The question therefore naturally arises: If something as basic and economically viable as condoms cannot effectively contain the HIV pandemic, how can we possibly expect the more complicated and expensive HIV treatments currently being developed to have an effect? Furthermore, are we thus robbing vital research and funding from neglected diseases for which there is no known cure or prevention and hence still cause substantial numbers of deaths? Finally, are we as health science researchers even obligated to develop new and more effective treatments for global diseases, or is the onus on government, health-care institutions and people themselves to use more appropriately the effective tools science already offers them? The year 1996 saw the release of the first antiretroviral treatments3. According to a report by the Joint United Nations Programme on HIV/AIDS4, global HIV prevalence reached its peak around 2001 and then began to contract. Since then HIV prevalence has been slowly declining, with the same trend being true for sub-Saharan Africa, where HIV is most rife. In 2001 approximately US$ 1.62 billion was being spent on HIV research, drug distribution and awareness campaigns. As of 2007, US$ 10 billion was being pumped into HIV, just over a tenth of which went to research and development4. This almost tenfold increase in funding did not resulted in a tenfold decrease in the rate of HIV prevalence. HIV has decreased at an almost constant rate since 2001. The overall difference in HIV prevalence from 2001 to 2007 is approximately 1% (a drop in global prevalence from 7% to 6%). The decrease in HIV prevalence suggests that condoms and antiretrovirals are effective in the treatment and prevention of HIV, yet there clearly appears to be a barrier preventing the effective use of these treatments that money cannot solve. It is possible that new innovations in HIV treatment could be distributed more effectively, yet they are unlikely to be more economically viable or practical than condoms. This would imply that any breakthroughs in HIV research would have limited impact on global HIV prevalence. Even if we were to grant the

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premise that certain breakthroughs, such as a vaccine, may have a big impact on HIV prevalence, does HIV merit such huge research investments in the first place? Globally, HIV accounts for 3.5% of all deaths per year. It ranks number six on the global list of mortality causes, trumped by cardiovascular diseases (ischaemic, cerebrovascular and pulmonary) at 27%, respiratory diseases (excluding tuberculosis) at 7%, and diarrhoeal diseases at 3.6%. Tuberculosis and malaria fall just below HIV at 2.5% and 1.7%, respectively5. If we are truly to be researchers that seek to find health breakthroughs for all, then surely we should disregard factors such as race, nationality, age and economic development and focus instead on mortality figures alone. However, HIV research receives 42.3% of global funding for communicable diseases, both private non-profit-making and governmental, while tuberculosis and malaria receive only 16% and 18.3%, respectively6. Adjusted for mortality, and assuming the 42.3% investment in HIV is merited, tuberculosis should receive 30% of funds, while malaria should receive 20%. Perhaps most revealing is that diarrhoeal diseases result in more deaths than HIV yet receive only a tenth of the funding a clear indicator that mortality figures do not appear to play a significant role in funding decisions. High-income countries fund a whopping 97% of all research and development7, so it is a fair statement that they decide which diseases are targeted and how much is invested in each disease. There is increasing public opinion that the developed world has a moral obligation to provide assistance to the developing world, due to factors such as historical abuses and the great disparity in wealth between developed and developing countries. A possible reason for HIV research receiving what appears to be a disproportionately large percentage of funds could be the identification of HIV as the quintessential problem of the developing world. However we should not let this perhaps incorrect identification unduly influence our investment decisions, as we may be diverting resources away from other, more useful endeavours. With our current technology we can manage and prevent HIV, and we need instead to start investing in diseases that are in desperate need of innovation. Of course we do want to encourage developed countries to tackle those diseases afflicting the developing world, and in no way do I wish to reduce the amount of funding being offered by the developed world, nor do I wish to completely abolish funding for diseases such as HIV. A more proportional distribution of funding based on a combination of need for innovation and global mortality rates is what needs to be addressed. Mortality and disability-adjusted life years figures are important and provide a good guide for funding, but those diseases that already have appropriate modes of treatment or prevention should receive much less funding than those diseases in desperate need of innovation. This leads us to our last question: To what extent should science be culpable for the shortcomings of education, politics and even individuals? If the treatment for, or prevention of, a given condition is available, should we really be obliged to deal with the consequences of failure of treatment due to factors outside the scope of science? We live in a society where people are encouraged to make their own life choices. We do not discriminate against people for being obese, smoking or practicing unsafe sex. In many cases we even go so far as to accommodate these life choices. While this may be admissible when it does not conflict with others interests, the recent antismoking laws passed in many countries have made it clear that this is not

Young Voices in Research for Health 2009

Damian Hacking

the case when these behaviours directly impact on the health of others. I believe the indirect impact on the health of others, via the draining of funds to treat their subsequent ailments, is equally as damaging, if not more so. For example, obesity rates in the developed world are skyrocketing. This in turn has lead to cardiovascular disease becoming the leading cause of mortality. Consequently, the National Institute of Health invests roughly equivalent amounts in cardiovascular research as in HIV research, approximately US$ 2.5 billion each. Malaria and tuberculosis, on the other hand, receive a pittance of less than US$ 200 million each8. The morality of poor life choices is a question for philosophers, but as scientists we must surely prioritize involuntarily contracted diseases over those that are a consequence of lifestyle choice. What is needed to do this is a lethality index. Lethality would be defined as the rate of mortality of a disease given that the afflicted individuals have full access to current medical services and follow medically responsible lifestyles. Lethality data would allow investors to make informed decisions about those areas of health care that are in need of research innovation, as opposed to economic or social investment. Moreover, disparities between lethality and mortality would allow us to identify areas and diseases that require social and economic investments instead, such as drug distribution, health-care infrastructure and awareness campaigns. A lethality index would of course still have some limitations. One might argue we have a greater moral imperative to treat diseases that affect the young over the old, or that mortality statistics may only present the immediate cause of death and not the root cause. Even so, lethality would still be a better indicator of need for funding than mortality or misinformed public opinion. After all, the discovery and development of essential innovation is the essence of medical research, while the distribution and effective use of these innovations should remain the concern of governments and health-care providers.

1 2

3 4 5 6 7

Collier A. The humble little condom: a history. Amherst, NY, Prometheus Books, 2007. Falloppio G. De morbo gallico [The French disease]. 1564 (http://books.google.co.za/books?id=8_NR SNHl1zMC&dq=de+morbo+gallico&printsec=frontcover&source=bl&ots=jmxdhYv66H&sig= fqpArGTW7p8LY-SwunFfkw5GCxg&hl=en&ei=x034ScLbMoqZkQW26dzPCg&sa=X&oi=book_ result&ct=result&resnum=7, accessed on 28 August 2009). Wynn G et al. Antiretrovirals, Part 1: overview, history, and focus on protease inhibitors. Psychosomatics, 2004, 45:262270. 2008 report on the global aids epidemic. Geneva, Joint United Nations Programme on HIV/AIDS, 2008 (www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008, accessed on 28 August). World health statistics 2008. Geneva, World Health Organization, 2008 (www.who.int/whosis/whostat/ EN_WHS08_Full.pdf, accessed on 28 August). Moran M et al. Neglected disease research and development: how much are we really spending? Public Library of Science Medicine, 2009, 6(2). Monitoring financial flows for health research 2008. Geneva, Global Forum for Health Research, 2008 (http://www.globalforumhealth.org/Media-Publications/Publications/Monitoring-Financial-Flows-forHealth-Research-2008-Prioritizing-research-for-health-equity, accessed on 28 August 2009). National Institute of Health Research Portfolio Online Reporting Tool (accessed at: http://report.nih. gov/rcdc/categories/

Damian Hacking completed his undergraduate degree in Biochemistry and Genetics at the University of Cape Town, South Africa. He went on to complete his honours in Physiology with the Hatter Cardiovascular Institute, also at the University of Cape Town. He is currently pursuing a Masters in Medicine in collaboration with the Hatter Cardiovascular Institute at University College London. His research focuses on the delineation of signalling pathways involved in protection against ischemic heart attacks.

Retro innovation

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Liesl Harewood, Guyana

RetRo InnoVAtIon tHe HeAltHIeR wAY

It should seem odd that a great weakness in health is our reliance on medicine and man-made drugs to cure even the simplest ailment. This should become more obvious when we listen to most advertisements for drugs in the United States of America, which speak of the latest wonder drug and then go on to list all the side effects and all the exclusions or reasons you should not take the drug. We no longer rely on the wonders of nature like the other animals and then use our man-made advantage to treat those ailments that we do not have a natural cure for. I believe that the greatest innovation in health would be relying on our knowledge and research to incorporate natural products for medicinal purposes. Knowledge is innovation, yet we rely on a doctor to tell us which pills to take 10 times a day, instead of taking the time to read and understand what exactly these pills are made of, what the ingredients are going to do to our bodies and, most importantly, whether these ingredients can be found in an alternative, natural, organic product? In fact natural organic products are now being marketed as elite and available only to those who are well off and can afford to pay the higher prices so, quickly we have gone to the processed product rather than avail ourselves of what is there already. A friend of mine once posed the question, Have you ever noticed that when a person is diagnosed with cancer and they start chemotherapy, they die faster? As I looked around at my parents friends who were suddenly becoming struck with the disease, I realized there was some veracity to his statement. Do not misunderstand my position. It is not that I am saying that modern medicine is bad. In fact I am proud of the achievements humanity has made and the surgery that has been performed to save lives and make life better. Also noteworthy are the strides made in reducing the infant mortality rate, a lot of this being due to advances in medical technology and capability. What I am suggesting, however, is that people need to take responsibility for their health and not place that entire burden on the shoulders of doctors, making them like Atlas carrying the globe. Remember, doctors are people too. They just studied in a different field than most of us. So how do we acquire the same level of buy-in for being healthy and engaging in health practices for all as is enjoyed by liposuction, Botox and fad celebrity diets? It is obvious that we need to make health sexy to have the mass appeal that would have the most impact on society. Perhaps, however, we do not want to take the same worn path of other trends and fads, only to fade away as our short attention span

Young Voices in Research for Health 2009

Liesl Harewood

is told by Twitter or Facebook what to move on to. Far too often, we have let our lifestyles become ruled by this new cut-and-paste, instant society. Innovating the way we communicate will play an important part in innovating for the health of all. Listening is critical. We tend not to do as much of it as we should lately, which is ironic in the light of the plethora of information communication technologies we have at our fingertips. So maybe I am not talking about using machines to help us communicate but once again returning to the root, the soul, the earth our internal beings, sometimes referred to as intuition. What do I mean by using my intuition in health? A few years ago, I decided that getting sick was all in my mind. Prior to actively taking this decision, when I felt I was catching a cold, I would say Woe is me and commit to bed, ingesting every form of cough and cold medicine available, curled up in a blanket with the determination to vegetate for a few days in my tragic condition a dramatic and surefire way of ensuring I felt miserable and sick. Would you believe that, after my epiphany wherein I decided that being sick was all a mental thing, I actually did not become sick quite as often? I cannot count the number of times per year I am sick usually it is once or zero. How did this happen? Well, taking the example of the same cold that would previously have me bedridden and medicinally overloaded, as soon as I felt my body reacting to something, I decided to load up on vitamin C through fruit and juice and to drink lots of water. It may sound unbelievable, but this actually worked, and I know that, behind the curtains of my body, my internal organs were grateful for this new way of handling my ailments. How is this innovative? Well it applies the knowledge that I have embraced based on listening to my body and taking it upon myself to be more informed about what I put into my temple. I have become more conscious and aware that I really have only this one body. I cannot upgrade it. Every day it is dying, but that does not mean I should accelerate its return to dust. I want to look as good on the inside as I do on the outside. This makes me consciously think about what I am eating, drinking and inhaling. That is innovative! thinking, questioning and not just accepting the status quo presented by the medical professionals. Now, how do we use the technology that exists to harness this concept and make it a mass movement similar to the recent US presidential campaign? Whatever existing tools we use, we need to market health as something that is invaluable, accessible and achievable to all and something that starts within you. By getting mass support for this health campaign, healthy people will no longer regarded as outcasts, and health products no longer remain inaccessible and expensive, since they will be ingrained in our lifestyles.

Liesl Harewood completed both her undergraduate and postgraduate studies in the United Kingdom and holds a Bachelor of Laws with honors in European Commercial Law with French from the University of Sussex and a Masters with merit in Diplomacy, Law and Global Change from Coventry University. She is a business development director and consultant with DYKON Developments Inc. and has worked on consultancy projects across the Caribbean, including in the Bahamas, Barbados, Saint Lucia and Trinidad and Tobago. She has conducted extensive research on the Caribbean Community Single Market and Economy.

Where are the global issues in our global media culture?

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Hannah Harvey, United Kingdom

wHeRe ARe tHe globAl IssUes In oUR globAl medIA cUltURe?

Change will not come if we wait for some other person or some other time. We are the ones weve been waiting for. We are the change that we seek. Barack Obama February 2008, Chicago, Illinois During this time of global unrest, all heads seem turned to US President Barack Obama, hailed by the media as a panacea and a symbol of hope in an ever-changing and increasingly unstable world. The present economic crisis and ongoing threat of terrorism have exposed vulnerabilities and exacerbated fears that resonate among media consumers, who are reminded of such problems on a daily basis. But while the media seem preoccupied, reflecting on our immediate economic and security predicaments, juxtaposing them with an overzealous analysis of Michelle Obamas outfit ensembles during political photo calls, surely there are more persistent if overlooked issues facing leaders on the world stage. Not only are these worthy of greater media coverage, they also require an innovative journalistic approach so that hard-hitting subjects can permeate a news agenda dominated by more glamorous newsworthy themes. Although not a vote-winner nor an easy sound-bite opportunity, the increasing gap between the rich and the poor locally, nationally and, most significantly, internationally is reaching unprecedented levels and must be urgently addressed. More specifically, the prevalence of poverty which defines the chasm dividing health care resource allocation, research priorities and the reality of health care provision is not being tackled due to an apathetic attitude and a misguided public agenda. Mainstream reporting and powerful political representatives, both of which have the ability and responsibility to bring these issues to the fore, have struggled to raise the profile of global inequality. Yet, with such charismatic world leaders and the evolution of a vibrant media sector, an opportunity exists for persistence, determination and innovation in the quest to challenge the status quo and implement an improved global health strategy. The unwelcome truth for Obama and his counterparts is that there are no easy, widely implementable ways of reversing the dichotomy in health-care standards and provision across the world. If there were, perhaps this circular debate would have been laid to rest decades ago. Nevertheless, a paradigm shift does need to be initiated. Now is the time to truly engage with the issues, legitimize and popularize the debate, dedicate resources and directly confront a highly complex web of problems, all of which contribute to the apparent injustices that constitute our world. The media and the voices of the leaders they idolize have underutilized their power to tackle these

Young Voices in Research for Health 2009

Hannah Harvey

unglamorous issues with vigour and encourage public engagement, which to my mind holds the key to a healthier and more equitable future for those most in need. Creative, dynamic and attention-grabbing journalism, coupled with innovative editors and media-savvy world leaders unafraid of challenge, could and should do so much more to ensure health for all. The role of the media as a vehicle for change has long been acknowledged. Most recently, its power of persuasion has been harnessed by the Obama election campaign, which targeted US voters using every conceivable media outlet. Not only did this allow Obama to amass significant cultural currency, which in turn translated into success at the ballot box, it also made politics seem relevant and accessible to every US citizen. The sense of alienation previously felt by many voters was diminished by popular journalisms fully embracing the opportunity for political change. A similar disengagement that characterizes attitudes to poverty and injustice in the developing world could and should be tackled using media formats that have proven to be influential and successful. By making problems more evidently relevant, important and reversible, and by targeting diverse audiences on a larger scale, epidemiology and the constraints limiting any sort of improvements can become more prevalent themes, thus raising the profile of global health inequality. The ultimate goal of such a strategy would be to encourage investment and provide more leverage to change policy in pursuit of fairer access to health services and research. An improved media strategy has worked not only in a political domain. It has also proved highly effective in charitable campaigns, which engage more privileged audiences with conditions and realities faced by millions across the globe. Annual appeals such as Comic Relief in the United Kingdom have brought health-related issues into the media spotlight, albeit on a very short-term basis. Using predominantly the media of television and the Internet, Comic Relief has been successful in transforming the overlooked plight of distant communities and bringing them into the living rooms of millions who, collectively, have the power for action. The heightened awareness and sense of social responsibility that accompanies increased coverage related to health as a basic human need is just as relevant to the progressive thinkers and grounded leaders who dominate our world stage as it is to the general public. Here, the media must strive for new angles and human interest stories from which to develop a sustained argument for greater collective action to share health-care knowledge and resources, finding ways to implement them to best effect. Todays media culture is all-consuming, extending from print journalism and television infotainment to the online medium, offering almost limitless scope for information, education, debate and action. Furthermore, the media has a role as the fourth estate, charged with acting as a watchdog and guardian of public interest. While it is known that funding research is not always a transparent process and that the research agenda is not necessarily fair, the media could do more to investigate and call into question established practices that perhaps direct resources away from pursuits that could help poorer nations. The reluctance of the media to engage in debates involving the complex web of health care and politics is not confined to mainstream outlets. Resistance is even seen by some, but not all, medical journals. Acting as a mouthpiece for the medical profession, journals are the well-informed voices that should be broaching

Where are the global issues in our global media culture?

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controversial themes and vigorously campaigning for change, as opposed to shying away and sticking to safer issues within the medical remit. This perpetuates both our ignorance and the distance between our own health-care environment and those of distant communities who need our help. While many of us acknowledge that millions die unnecessarily in child birth and from communicable disease and malnutrition on a daily basis, there is still a severe stigma attached to these discourses. Etched in many minds are the stereotypical representations of the wide-eyed black African child with a swollen stomach and surrounded by flies. Trying to rewrite this clichd representation and create a new perception of poverty and disease in developing countries will take courage and innovation but is nevertheless essential in altering attitudes and encouraging investment. To try to reconceptualize the developing world, and frame core issues in a way with which audiences can identify is particularly challenging in a society that seems fixated on celebrity culture. Iconic figures such as Barack Obama therefore need to actively direct the media spotlight onto these issues for a trickle-down media effect to occur. Overall, there needs to be a synergistic relationship uniting our influential leaders, the media and the public in trying to initiate real progress and turning our ignorance into activism. Innovation needs to be seen within the journalism that forms our public consciousness, boldly pushing for social change and mounting a challenge to the hegemony that dominates modern society. It is a well-known truism that the media cannot tell people what to think, but they can tell readers what to think about. When issues as emotive as gross injustice in health standards across the world are clear in voters minds and imprinted on their conscience, it translates into new political agendas that slowly turn words into actions. By placing more emphasis on global health inequality, incorporating increased scrutiny and applying more pressure on those agents capable of implementing change, perhaps we can make the future brighter at last and eventually realize, as Obama envisages, the change we seek.

Hannah Harvey began her medical studies at Kings College London in 2006. She has since become increasingly fascinated by the role of the media and its interplay with medicine and health care. To investigate this subject further, Hannah embarked upon a masters degree at the University of Newcastle upon Tyne. As a result, she gained much insight into the complex political, cultural and social matrix that underpins health-care provision and its portrayal in modern media. Hannah hopes to become more involved in medical media over the course of her career after first focusing on completing her medical studies in London.

Young Voices in Research for Health 2009

Kate Jongbloed

Kate Jongbloed, Canada

HeAltH 2.0: HeAltH foR All, HeAltH bY All

The godparents of global health meeting in Alma Ata may not have had BlackBerrys or MacBooks, but if they were to meet again now, they would almost certainly include technology in their toolkit for promoting health for all. In the next few pages, we will look at how technology-driven health interventions are important tools to address the obstacles to health for all. As well, we will see how technology helps us move beyond health for all to enable health by all, where individuals become real actors in their own health. In September 1978 at the International Conference on Primary Health Care, participants laid out the principles of universal primary health care in the Declaration of Alma Ata. These principles were seen as steps to reaching an acceptable level of health for all the people of the world by the year 20001. Nearly 10 years on from that deadline, the world still faces an overwhelming burden of infectious and chronic disease. According to the most recent World health report, on the whole, people are healthier, wealthier and live longer today than 30 years ago but the substantial progress in health over recent decades has been deeply unequal2. The persistent inequality in health outcomes among and within countries has prevented the vision at Alma Ata from being realized. Newer targets, such as the Millennium Development Goals have also remained out of our reach. Yet, as we begin to stretch our legs in the new millennium, the tools at our disposal are changing. Even as weak health systems, too few health-care providers, and insufficient funding and commitment have worked as obstacles to reaching our health goals, we have an opportunity to overcome these obstacles by adapting our approach. In fact, the social media revolution at the start of the 21st century has allowed technology-based health tools to emerge that are changing the face of sickness and disease all over the world. In particular, technology is changing the relationship between patient and expert. What is so fundamental about the change to health brought by applications on the Internet (eHealth) and using mobile phones (mHealth)? Social media changes the timescale of surveillance, transforms the patient into the researcher, maximizes the reach and minimizes the cost of health promotion, and is measurable and adaptable. But perhaps the most transformative aspect of applying social media to health is that it puts the responsibility for health in everyones hands, not just those of doctors and nurses or administrators and epidemiologists. In fact, this technology is an innovation for health by all, as well as health for all. When we talk about social media for health, we are referring to the eHealth and mHealth interfaces. In developed countries, where Internet coverage is relatively

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high, Internet-based eHealth initiatives are popular. For example, eHealth can include health promotion, remote health training, peer disease management, standardizing access to patient data and digitizing patient records. However, in much of the developing world, where mobile phone networks vastly outweigh Internet coverage, mobile phone-based mHealth applications are favourable3. Like eHealth, mHealth includes health promotion, as well as remote data collection, remote monitoring, communication and training for health-care workers, disease tracking, and diagnostic treatment and support. Next, we will look at some examples. Google, a brand almost synonymous with the Internet, started an eHealth initiative this year that focuses on disease detection and surveillance. Part of the companys Predict and Prevent initiative, Google Flu Trends uses a correlation between certain search terms and rates of influenza in the United States of America to estimate influenza-related activity up to two weeks faster than traditional systems4. As yet, there has been no critical examination of Googles approach by the health industry, so for now we will have to be content with the legitimacy provided by their affiliation with the US Centers for Disease Control and Prevention. On the other side of the world in South Africa, Project Masilueke has harnessed the power of please call me (PCM) text messages to raise awareness about HIV and promote voluntary counselling and testing. The PCM messages are free for senders, subsidized by advertising using the remaining characters in each text message. Project Masilueke sends 1 million awareness messages each day, tacked onto the end of these PCM messages, directing users to the national HIV helpline. During the pilot, the helpline experienced triple the usual call volume. Next steps will be to expand the service to include personalized medication and appointment reminders, as well as rolling out easy-to-use home HIV testing kits accompanied by telecounselling3. Google Flu Trends and Project Masilueke are just two examples of how social media is being applied to health. In these examples, we saw the power of technology to provide faster data on disease, and education about available health resources. Still, in the examples above we have not seen a drastic change in the relationship between health expert and health consumer. While the examples illustrate ways in which social media can maximize collaboration and reach, the process of health is still carried out by governments, nongovernmental organizations, corporations and health professionals. Let us look closer now at how social media can change the health role of the individual, paving the way for health by all as well as health for all. Google Health is a platform for individuals to manage their health very much like they would manage their e-mail correspondence. The first step is for individuals to access their medical records from doctors, pharmacies and hospitals using Googles secure online partnerships. Next, users can indicate each of their medical conditions, allergies and medications. Google then uses this information to suggest online resources, check for potential drug interactions, and create a medication schedule. Users are given a platform to access all their health information in one place and share it with their doctor. Both the user and their health providers can use this centralized information to respond more effectively to health conditions as a team. Tools like Google Health change who controls patient information, freeing it from paper charts and giving the patient the opportunity to become more active in health decision-making5.

Young Voices in Research for Health 2009

Kate Jongbloed

Patients Like Me, a social networking site for people with chronic disease based in the United States of America, goes a step further than Google Health by supporting users to connect with others living with the same condition. Dr Michael Massagli, a social statistician at Patients Like Me, describes the service as helping users become active in their own care in three areas: share, find and learn. Users join and develop their profiles on the site, where they include diagnosis summaries, updates of their current status and narratives of their experience. Linking with other patients on the site, users are able to give advice or learn from others experiencing similar difficulties. One member of the Patients Like Me HIV community shared the impact of a drug holiday on his profile: Anyone who wants to see what happens on a 2 months drug holiday just have a look at my updated viral load and CD4 count [a measure of immune system health]6. Other examples include users who participate in peer disease management and use shared data to drive treatment decisions. Patients Like Me supports the changing role of patients from passive consumers of health care to active participants in their own disease management and creators of valid health knowledge. Patients Like Me also provides an opportunity for evidence-based medicine for both health practitioners and pharmaceutical companies. Traditionally, best practices in health are developed through clinical trials and care conventions. Both of these approaches are dependent on relatively infrequent interactions with patients, who are asked to recall their symptoms over several weeks or months. With these new health applications, the most active users input information about their condition on a weekly or daily basis, including reactions to medications, new symptoms and the impact of lifestyle changes. Aggregating this information provides an illustration of disease management based in real life experience over time. Thousands of users reporting their experience of living with and treating a number of different diseases allows a more nuanced picture of each condition to develop than was previously accessible to the health industry. So far, we are only scratching the surface of the opportunities made available through new Internet and mobile phone-based applications for health. Their effectiveness remains contingent on how well the health establishment can integrate them and become responsive to real-time microdata, which is often generated far from hospitals and research facilities by those on the frontlines of health care and even by patients themselves. It is also the responsibility of the health establishment to look critically at the real impact of these non-traditional responses on health outcomes, rather than dismiss them as a passing fad. If this can be achieved, the decentralization of health that would accompany the adoption of social media by the health industry would create a new opportunity for health for all and health by all.

1 2 3

Declaration of Alma Ata. Alma Ata, International Conference on Primary Health Care, 1978 (www.who. int/hpr/NPH/docs/declaration_almaata.pdf, accessed 1 September 2009). The world health report now more than ever. Geneva, World Health Organization, 2008 (www.who. int/entity/whr/2008/whr08_en.pdf, accessed 1 September 2009). mHealth for development: the opportunity of mobile technology for healthcare in the developing world. Washington, DC, and Berkshire, UK, UN FoundationVodafone Foundation Partnership and Vital Wave Consulting, 2009 (www.unfoundation.org/global-issues/technology/mhealth-report.html, accessed 1 September 2009). Google Flu Trends. Mountain View, California, Google, 2009 (www.google.org/flutrends, accessed 1 September 2009).

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5 6

Google Health Tour. Mountain View, California, Google, 2009 (www.google.com/intl/en-US/health/tour/ index.html, accessed 1 September 2009). Massagli M. Patients Like Me. Presented at Medicine 2.0 in Toronto, 2008.

Kate Jongbloed graduated from the University of Torontos International Development Studies Program in June 2008 and has since been working as a health and development writer. Aside from serving as editor-in-chief of Undercurrent: Canadian Undergraduate Journal of Development Studies, she blogs weekly at UnpackingDevelopment.com on the arts, technology and global health. Her previous research includes investigating the role of microeconomic development in reducing HIV risk among adolescent orphan caregivers in Ethiopia. Kate is passionate about the role of Internet and mobile phone technology in international health and plans to pursue her graduate studies with a focus on this area.

Young Voices in Research for Health 2009

Biraj Karmacharya

Biraj Karmacharya, Nepal

InnoVAtIng foR tHe HeAltH of All: bReAkIng tHe bARRIeRs

What are the common health problems bothering mankind? A quick search of the literature will easily show that the diversity of these problems is startling. From the malnourished children of developing countries to the obesity-linked disorders of developed countries, from HIV to swine flu, from the mental health problems of migrants to depression in the elderly, it is extremely difficult to find any common characteristic in them all. As I try to find out what has already been done and planned to address these myriad issues, there is no dearth of materials among the forums and declarations. The attempt to find similarity in them ultimately leads to an unsolvable maze. But in my disappointment, as I wish to find a magic wand that could solve all these problems with the same mantra, a faint gleam of hope arises that shows a thread that links all these issues together and that can be applied to all. Innovations should be in ideas, for ideas give birth to actions. Hence, bringing out new ideas and approaches should be the mainstay of innovation. I split the possible innovations into three different categories: innovations related to principles, to systems and to contents. Principles form the mainstay of the systems, and systems form the backbone of what constitutes health care. Whereas it is no doubt a difficult endeavor to try to define these unique innovations to the health of all, I try my best to avoid the redundant repetition of the issues that are generally discussed elsewhere. Principles. It is indeed quite difficult to define health. It sometimes seems to me more like an abstract issue, but complex and complicated. The innovation in principle regarding health care would be to consider it more as an outcome than an entity. We all know this already. But, reinforcing this knowledge works as an innovation. For a poor woman in rural Nepal who struggles to find food everyday, the best road to health would be to incorporate her in an income-generating microfinance scheme. For a young drug addict in a war-torn country, who sees no future even with his hard-earned academic degrees, the best medicine would be a peaceful country with hopes for the future. For a teenager in a developed country who gets pregnant just because of fun she had in a party, the best medicine would have been timely counseling. For an elderly couple staying alone in the desolate outskirts of a town, the best medicine would be loving words from their children and grandchildren. The list goes on. Health probably has a similar meaning to all, but it is certain that the roads to attain it are different. Commitment to quality is another principle that ultimately determines success and the life of a programme. Quality is a relative thing. Good quality for one person may be lower quality to another, and vice versa. So, the question about quality is not the question to ask. It is the question of principle. One should work to give the same to others that one would expect for oneself in given circumstances. It may sound so

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obvious and so simple, but the strength behind this is that it refrains from building up health care in an inequitable or compromised manner. Systems. In this context, the innovation would be to revisit the communitybased approach, which opens a new dimension in health care. The essence of the community-based approach is to involve the community in identifying and addressing its problems. Once this is done, all the rest will be taken care of, from the issues of equitable distribution to sustainability, from the worries of governance to the confusions of ownership, and the rest. The Declaration of Alma Ata is a milestone in terms of community-based health care. However, the history of the last 30 years shows that not all understood the same thing. Every community has its own identity, and it is of utmost importance that health planners understand this. Hence, the approaches to communities differ as well. Stereotyping an approach is doomed to fail. The community-based approach is unique because it is big enough to incorporate all the major issues of the particular community, and it is small enough to illuminate even the problems of the minorities. It is rigid enough not to deviate from the main points, and it is flexible enough to incorporate unforeseeable changes. It reveals the unseen heroes of communities and makes ordinary people do extraordinary things. It creates heroes out of common people. The hero may be a poor, illiterate farmer who can persuade villagers change their habits, or a veteran soldier who leads the neighborhood in something he has convictions about. The hero may be a school headmaster who polishes his students everyday for something better, or a religious leader who captures the attention of thousands of devotees. All illustrate so much about community-based approaches, but when we review various organizations, academia and research sectors in health, we rarely find instances where these people are taken into account. The rules of game have been more in favor of the experts who are capable of playing with jargon. There is no doubt that science should lead, for this is the foundation of facts. However, changes do not happen just on the basis of facts. Changes develop with understandings, attitudes, passion, energy and dedication. Great institutions have been built by simple people in resource-limited settings. Rarely do big organizations reach them with a helping hand in times of struggle, when they are seeking even a ray of hope. It is only after they prove their capability that organizations willing to support them knock on the door. This is not necessarily bad, but things can be improved so that those dedicated to doing something are identified in a timely way. Most of the systems are not community oriented, but rather communities need to be oriented to the systems, and this is sometimes too complicated. These barriers have to be broken down. Also in relation to research, let us think how many community health leaders would understand the great journals and have access to relevant information. It is now in the hands of research giants to break the barriers of research. Research is, of course, the scientific search for truth, but truth prevails not just in science. Truth prevails also in the unfathomable eyes and hearts of the people. There should be a separate way to get organizations and experts to care about information flow to lay people and bring them into the loop of research and information. This would be an innovation generations would remember, because it would break the barrier between so-called experts and others.

Young Voices in Research for Health 2009

Biraj Karmacharya

It would be redundant to discuss commitments to cost reductions in health care as another innovation, as this would encompass as well the issues of patents and globalization, which are talked about so much elsewhere. However, the innovation in this context would be forging alliances between different sectors. An alliance in the sectors of education, agriculture, trade and social services internationally, nationally and locally is necessary to bring about a comprehensive package of health care. Even within a health-care system, which gets fragmented into separable units in most countries, it is essential to develop a continuum, not just in terms of referral but also of management and organization. This will ensure a good flow of human resources and services throughout the system. An example could be primary health care in a continuum with secondary and tertiary health care. Most developing countries suffer because primary health care is poorly staffed and managed. Developing these centres not as separate centres, but as an integrated part of the continuum of health care (in terms of operational management as well) would significantly mitigate some of the major problems. Contents. There are many pertinent issues regarding contents related to health care. One is the use of technology. Nobody doubts that this is the era of technology; but increasingly people are failing to realize that technologies succeed when they complement human values and strengths, and they fail when they try to replace them. Machines do not replace the healing touch and the understanding of a person. It is not humans who complement the technology. Rather, it is the technology that should complement humans. The new millennium is the era of globalization and technological feats. This is also the time when inequities are growing all over the world and new challenges hover in the health sector. Not many ideas rule the world, and those that do are relatively slow to affect change. The innovations should be in shifting the paradigm and breaking the barriers invisible to the eyes of many.

Biraj Karmacharya was born in Kathmandu, the capital of Nepal. He completed his Bachelor of Medicine and Bachelor of Surgery at the College of Medical Sciences in Chitwan, Nepal, in 2002 and his Master of Science in Tropical Medicine at Mahidol University, Thailand, in 2006. Since 2006, he has worked as the chief of community programmes at Dhulikhel Hospital/Kathmandu University Hospital of the Kathmandu University School of Medical Sciences, Nepal. His main responsibility is to create community health institutions in rural areas of Nepal. He is also responsible for planning and implementing various community programmes.

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Rebecca Lacroix, Sude

de lA ncessIt de se mfIeR des ftIcHIstes de lA noUVeAUt

Linnovation est associe au progrs, au dveloppement, la modernit, la science, toutes ces choses qui ne sont priori que positives. Pourtant, linnovation, pas plus que ces autres concepts, nexiste hors du monde. Quel genre dinnovation, pour qui, pour quoi, par qui, dans quel contexte, avec quelles consquences ? Plutt que de louer les bienfaits de lnergie solaire, ou de la tlphonie mobile qui rend possible le e-health, il est question ici de linnovation comme application de nouvelles connaissances. Au final, linnovation doit-elle tre nouvelle pour innover ?

Le pouvoir de linnovation pour les uns et le systme D pour les autres

En travaillant dans le renforcement des capacits de recherche dans un hpital en Rpublique mocratique du Congo, la premire chose qui saute aux yeux est que linnovation nchappe pas aux relations de pouvoir qui dterminent les relations entre les pays riches et ceux qui le sont (souvent beaucoup) moins. Ces relations servent lgitimer tout ce qui vient des pays riches et marquer les connaissances de ces pays dexpertise : ce qui est bon pour les autres doit tre bon ici aussi. Cela dit, tant en contact quotidien avec les besoins rels de personnes relles plutt quavec des chiffres, les nouvelles ides ne sont jamais refuses et la flexibilit pour les appliquer rapidement est grande. Le manque chronique de moyens et de ressources humaines fait que la technologie, mme mal adapte au contexte, sera rarement refuse. Ainsi, lorsque lItalie fait don de magnifiques machines de radiologie un hpital rural, il importe peu que le personnel comptent pour les utiliser et les entretenir manque (au cas o les pices de rechange seraient disponibles) car ces machines ne fonctionneront pas, par manque dlectricit. Linnovation comme produit, sans prendre en compte le contexte, peut ainsi crer lillusion que quelque chose est fait. Sur le terrain, on applique le systme D : on fait avec ce que lon a, ou, bien plus souvent, avec ce que lon na pas. Alors bien sr que les gens innovent, on strilise le matriel mdical avec la chaleur du soleil, on pure leau par condensation. Par la crativit et la technologie, ltre humain adapte son milieu ses besoins. Ces techniques mritent certainement dtre partages travers le monde pour mieux faire dans des contextes o les ressources manquent. Le problme survient lorsque lmerveillement de ce que les personnes arrivent faire dans des contextes difficiles et avec si peu en plus (! ) , nous font oublier pourquoi ces personnes doivent se dbrouiller avec si peu la base et pourquoi leurs besoins et droits conomiques, politiques, culturels, sociaux et en matire de sant sont bafous. Alors que certains innovent par crativit, dautres le font par ncessit.

Young Voices in Research for Health 2009

Rebecca Lacroix

Linnovation des uns pour les autres

Nous ne sommes pas plus gaux dans lacte de crer que dans la slection des crations qui doivent tre appliques. Chez Mama Azama il y avait des rats. Etant trop pauvre pour acheter du raticide, elle utilise les mdicaments pour son dos fournis gratuitement par une organisation non gouvernementale (ONG) internationale. Non seulement les rats sont partis et ne contamineront plus ni ne mangeront sa nourriture, mais ceux de ses voisins aussi, rendant Mama Azama trs populaire dans le quartier. Si cet exemple soulve quelques questions quant la composition du mdicament de Mama Azama, il soulve galement celle des priorits des ONG. Comme si les problmes tangibles de sant (mal de dos), pouvaient tre spars de ltat de sant gnral (vulnrabilit) et des facteurs qui influent sur celui-ci (manque de nourriture, lourdes charges portes sur la tte, logement insalubre), en un mot, de la pauvret matrielle. Parmi toutes les ONG (dont les logos et les 4x4 bouchent la seule route goudronne de Goma) qui proposent des activits gnratrices de revenus aux victimes de violences sexuelles pour lintgration des femmes dans le dveloppement, il ny en a pas une pour donner du raticide Mama Azama. Cela na pas t prvu dans les lignes budgtaires par les experts qui se basent sur les toutes dernires connaissances pour maximiser limpact de leurs programmes. Linnovation ce nest pas un concept, mais des milliers. Hirarchiss, les meilleurs pratiques et les meilleurs secteurs refltent dj les priorits de ceux qui ont le pouvoir de dterminer les exemples suivre pour les autres. Je persiste et signe : la nouveaut ne peut tre dissocie de lapplication dans un contexte particulier. La PAM (Programme Alimentaire Mondial) est responsable de la distribution alimentaire dans les camps de rfugis autour du lac Kivu. Ayant bien intgr les nouvelles connaissances en matire de genre, la PAM innove en distribuant les rations aux femmes. Certains des produits se retrouvent sur les marchs locaux, en totale infraction aux rgles de la PAM : les gens vendent la nourriture ? Ils ont des revendications par rapport au type de grain si gnreusement distribu ? Ils nen ont donc pas besoin ! Lorsque nous arrivons dans le camp de Minova, aucune distribution na eu lieu depuis deux mois. Dix minutes passes discuter avec nimporte lequel des rfugis auraient pourtant suffi comprendre que 25 minutes pour cuire des graines cest trop en labsence de bois de chauffe et de cocotte-minute. De plus, nimporte quel/le congolais/e aurait pu informer la PAM quici, le chef de famille et celui qui dcide, cest lhomme. Que cela plaise la communaut internationale ou non. Il existe donc souvent un conflit dintrt entre la femme qui souhaite utiliser les rations pour nourrir la famille et lhomme qui souhaite les vendre pour gagner de largent. Mais et linnovation dans tout a ? Lapplication de nouvelles politiques qui prennent en compte les nouvelles connaissances sans prendre en compte le contexte peut avoir des consquences dsastreuses pour les gens qui dpendent de ces rations pour survivre. Linnovation nest pas un produit fini mais un processus qui doit tre continuellement adapt en fonction des connaissances holistiques des ralits locales. Ou dfaut de cela, du bon sens et de lcoute. En attendant que la PAM applique ces nouvelles nouvelles connaissances , la nourriture reste dans les dpts.

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Innover en tenant ses promesses

La RDC nest pas oublie de la communaut internationale. Malgr une presse internationale qui soffusque plus des rebelles tueurs de gorilles que de ces mmes rebelles qui tuent, chassent, pillent et violentent des personnes, les casques bleus sont l. Ils construisent un terrain de basket lUniversit de Goma. Depuis un mois, une trentaine de soldats stabilisent, cimentent et peignent le sol. Il y a un joli panneau pour les scores et des paniers flambant neufs. Pendant que la Mission des Nations Unies en Rpublique dmocratique du Congo (MONUC) sadonne cet exercice de relations publiques, dans le village de Papa Augustin la priphrie de Goma, des bandits ont pill ses voisins la semaine dernire. Papa Augustin donne un dollar par-ci par-l la police depuis quelques temps mais il ne sait pas sils vont protger sa famille quand les bandits reviendront. Linnovation dans ce contexte, les projets sociaux pour les tudiants de Goma (enfin, la moiti puisque les filles ne lutiliseront pas) ne peuvent tre dissocis de la mission premire de la MONUC qui est de protger la population du Congo. Plus de nouveaut ne doit pas servir dtourner lattention des problmes du prsent. Puisque le vent semble favorable aux nouvelles ides pour tre mieux acceptes par la population, jen profite pour apporter une modeste contribution : soyez cohrents. En DRC, les viols des femmes et des filles sont trs mdiatiss et les discours sur le respect de la femme et lgalit des genres abondent. Je me demande quel est limpact sur la population quand les forces de la MONUC, souponnes dchanger de la nourriture contre du sexe, sont relchs par leur gouvernement (lInde) par manque de preuves ? Lironie du sort veut que la MONUC publie sa Comprehensive Strategy on Combating Sexual Violence for DRC , contenant de nombreuses recommandations sur les changements effectuer au niveau du gouvernement, peine trois semaines aprs lacquittement des soldats indiens. Linnovation peut parfois sonner bien creuse quand on peine grer ce qui est dj en place ; la nouveaut, si elle est plus, nest pas forcment mieux. Le ftichisme de linnovation peut servir de poudre aux yeux et dtourner lattention des spcificits locales et du problme fondamental des ingalits. Comme on dit par ici, si lon ne sait pas o lon va il faut savoir do lon vient. Et si dans les contextes de postconflit, la vraie innovation tait de tenir les promesses faites dans le pass ? Ah, et puis distribuer la nourriture disponible des gens qui ont faim et arrter de la rendre conditionnelle des faveurs sexuelles, en attendant que les experts se penchent sur la question dans les bureaux Washington, Tokyo ou Genve, ne ferait pas de mal non plus.

Rebecca Lacroix is a gender analyst. After obtaining a Bachelors in International Relations and a Masters in Gender Analysis in Development with distinction, she spent two years working with international organizations in Geneva. She has completed several missions focused on research capacity strengthening for a local hospital in Goma, Democratic Republic of Congo, primarily researching the gendered dynamics of HIV, disability and the legal system. She is currently managing a programme working with vulnerable women at the grassroots level in Bukavu, Democratic Republic of Congo. Her main areas of interest include conflict resolution, masculinities and risk-taking behaviours and of course, gender-based violence.

Young Voices in Research for Health 2009

Luz Lpez Samaniego

Luz Lpez Samaniego, Spain

contRA lA VIolencIA de gneRo, cAdA pAso cUentA

Desear dar un paso sin dejar huella puede ser un deseo, un anhelo, pero tras meditarlo un poco relacionas que slo un fantasma podra conseguirlo. Pues quiero ser fantasma! es el pensamiento que aflora en la mente para, inmediatamente, ser empujado por otro los fantasmas no existen! Acto seguido los pensamientos se entremezclan, cual carnaval de ideas, dejar de existir para poder avanzar sin dejar huella? No, esa no puede ser la solucin. Sin embargo, igual s se podra dar un paso sin dejar huella y sin ser fantasma Dnde es posible hacer esto? En la orilla de la playa. Vaya, pues es verdad! En realidad s que se ha dado un paso, s que se ha dejado huella pero se ha necesitado de una tercera fuerza, de una ola espumosa que borre esa pisada. Desventajas: correr por la orilla reiteradamente puede provocar lesiones, hay olas que parece llegar hasta la pisada pero por falta de fuerza pueden no borrarla, estar girando la cabeza o incluso el cuerpo entero para comprobar tal desaparicin puede lentificar la carrera, adems ir de espaldas al futuro es ms cegador que el sol matinal del solsticio de verano. Eso s, siempre ser mejor que ser un fantasma Cuntas personas en el enramado rbol del mundo no habrn deseado desaparecer, eclipsarse, enrocarse o ser invisibles por cuestiones de violencia de gnero? Se podra girar la espalda y considerar que es saludable que alguien sufra de esta manera? Una mente que quisiera abandonar su propio pensamiento, su propia autonoma, puede mantenerse sana y fuerte? La salud mental merece tanta nobleza en el cuidado como el acuoso pulmn o el fibroso corazn. La violencia de gnero es un tema candente en la actualidad. Desdichadamente el impacto de sta se cuantifica con base en el nmero de muertes pero y si esas mujeres fuesen inmortales, es decir, que tal y como tristemente ocurre, sintiesen el dolor de un puo, del insulto, de torturas sexuales pero no muriesen? Mi enhorabuena a tantas mujeres que diariamente demuestran su inmortalidad, pues sobreviven a estos hechos que podran parecer narrados desde la hiprbole. La hipocresa social puede llegar a ponernos la venda que nos impide tener una nocin real de cun profundo es el tema y que acredita a sentir comodidad siendo lego en el asunto. Cuando los informativos enfatizan el impacto de esta lacra social centrndose en las muertes qu hace la sociedad entonces? Lanzar un mensaje: denuncien seoras, denuncien. Alguien pregunta por qu cuesta tanto expresarlo, denunciarlo? Mi respuesta tan crtica como personal sera la siguiente: porque en cuantiosas ocasiones aquellos que reivindican y exigen a las mujeres que denuncien son los mismos que estigmatizarn a la denunciante. Pasar a perder su identidad para ser la maltratada, como si un mismo patrn vistiese a todas las mujeres para desnudarlas ante semejante

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circunstancia. No sera cuestin de educar primero a la sociedad? Y, previamente, dar otro paso ms obvio como es concienciarnos de que cada uno de nosotros/as somos parte de la sociedad. Dejar de utilizar el trmino en tercera persona del singular para designarla como propia de un yo o de un nosotros. Eduqumonos primero. Las relaciones interpersonales, las tcnicas de comunicacin asertividad, empata, etc- pertenecen en parte a la conducta innata, pero bajo el paradigma humanista del psiclogo Carls Rogers toda persona puede llegar a aprenderlas. Hagamos balance de lo preparados que estamos para utilizar sin mayor dilacin la balanza del juicio ajeno. Ante tanto juez impostor es comprensible que se prefiera seguir en la sombra, que tiene silueta pero no vida propia. Es la decisin de optar por dicho estado de linchamiento fsico y/o mental a pasar al siguiente asalto, el ya comentado estigma social. No quisiera dejar durmiendo la siesta a otra reflexin: los nios y nias, hijos e hijas que se impregnarn de esa filosofa desde su uso de razn. Por autoproteccin se convertirn en actores de la pelcula titulada vida real. Pedir ayuda es un reto con posibilidad de demasiadas punzadas de hoja afilada que slo calma su sed derramando amargura abruptamente, como si la incisin contusa hubiese conquistado la arteria de la tristeza. Por otro lado, aunque la estadstica oficial de este tipo de violencia es muy inferior a la estadstica real, se consiente socialmente que el resto entre esa diferencia sea el silencio. Por qu ese silencio y cules son sus posibles consecuencias? La mejor respuesta es preguntar directamente a la vctima, sin interpretaciones. Una respuesta comn, pero silenciada, es que ante la dicotoma se opta por volver a mi reflexin inicial, el no dejar rastro de la huella. No denunciar ya no slo para no perder la vida sino para no perder el rol social, tan deseado, tan trabajado... Es decir ser fantasma o, en el mejor de los casos, tener que trasladarse diariamente a la orilla de una playa calculando que cada paso sea alcanzado por la ola adecuada, dejando a la suerte del oleaje la propia autoestima. En el desgarro de este pensamiento reside en m un reconocimiento al esfuerzo aportado por numerosas personas a lo largo de la historia. Reivindicaciones en pro de los derechos humanos, respaldo, investigacin, acciones individuales y gubernamentales, etc. cuyo revs viene de la mano de aquellos que nunca han sentido de cerca este tipo de violencia o peor an, casi me estremece escribirlo, porque son los motores generadores de la misma y/o similares. Aplaudo con fervor cada intento personal y/o colectivo, destacando una vez ms la declaracin de los derechos humanos adoptada por la Asamblea General de las Naciones Unidas en 1948. Otro ejemplo de mi aplauso, en un intento de concrecin, es la reciente creacin de un Ministerio de Igualdad en mi pas, cuyo pice es dirigido por una mujer, una Ministra. Aquellos osados -independientemente de su ideologa poltica- que denuestan este tipo de iniciativa -tachndola de innecesaria o disfuncional- provocan en m cierta sensacin de repulsa. Slo aquellos que nunca han sentido el ltigo de la violencia de gnero podran estimar de inservible estos avances. Paralelamente, no deja de alegrarme que exista quien no haya sentido en su dermis o en su mente

Young Voices in Research for Health 2009

Luz Lpez Samaniego

estas injusticias, pero nunca puede ser excusa para dejar de ser emptico con el paradigma de dicha realidad: sera negar la evidencia por no sentirla como propia. Cabra pues llevar siempre en el bolsillo un transportador de ngulos que permitiese medir el ngulo propio y el de la persona que padezca dichas tropelas. En mi juventud tengo la fortuna de sentirme parte de la sociedad desde planos dispares pero conexos. Cada uno de ellos ha despertado en m inquietudes, reflexiones y algo que es un sueo para m; la posibilidad de aportar, de construir. Citar algunos: realizar cuidados de enfermera en distintos hospitales, representar a los jvenes de mi pas y de Europa en materia de salud a travs del Consejo de la Juventud de Espaa y de Europa, conseguir becas nacionales e internacionales -algunas en instituciones tan prestigiosas como la Organizacin Mundial de la Salud-, actualmente ser docente de enfermera psiquitrica y salud mental en la Universidad de Alicante, y otros tantos que valoro diariamente. Me considero una ciudadana del mundo, con inquietudes por conocer cuanto est a mi alcance. No olvido nunca cunto esfuerzo y dedicacin me supone cada uno de esos pequeos pero soados objetivos. Cuando los consigo o los rozo como reales no pierden el esplendor preconcebido en mi mente sino que se transforman en oportunidades que aprecio. Me permiten seguir aprendiendo y madurando con la nica ambicin de poder compartir lo aprendido con el mayor criterio posible y bajo el amplio paraguas del respeto. En un mundo competitivo, la generosidad es un gesto que admiro entre quienes la ejercen y, como valor, entiendo que debo compensarla con la ma propia. Mi mente est abierta y deseo que esta apertura me permita conectar la realidad para poder trabajar en pro de la salud mental y, si una sola mujer, nio/a, adolescente puede beneficiarse ser de enorme calado para m. Mi teora es que los grandes maestros de la humanidad son aquellos que no slo transmiten a las personas cuando estn junto a ellas, sino aquellos que sin estar presentes -sin siquiera saber de la existencia de alguien- producen sobre esa persona una necesidad de superacin personal. Por esa admiracin y aprendizaje se consigue (sin que haya nadie tangible a quien decirle gracias y, por parte del maestro, sin que se llegue a tener conciencia de ese agradecimiento) la fusin entre la entrega desinteresada y la voluntad de superacin personal. Para concluir preguntara Cunta salud mental se est perdiendo, cunta se est dejando de ganar a consecuencia del maquiavlico rompecabezas de la violencia de gnero? Es mi pregunta para la sociedad, por tanto, es mi pregunta personal, es mi pregunta para nosotros. Si alguna de las respuestas es seguir empoderando, investigando, reivindicando, construyendo positivamente y apostando por los derechos, la salud y la felicidad, cuenten conmigo porque yo deseo contar con ustedes, con su paso firme, un paso con huella.

Luz Lpez Samaniego se desempea actualmente como profesora ayudante del Departamento de Enfermera de la Universidad de Alicante en el rea de salud mental y enfermera psiquitrica. Es estudiante candidata al doctorado con mencin europea en el mismo departamento y cursa estudios de ciencias polticas en la UNED (Espaa). Cuenta con postgrados en las reas de enfermera, salud pblica y drogodependencia. Antes de su desempeo como profesora trabaj durante cinco aos como enfermera y dos aos como coordinadora de salud del Consejo Nacional de la Juventud de Espaa. Fue coordinadora de salud del Consejo de la Juventud de Espaa durante dos aos. Particip, en el marco del Foro Europeo de la

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Juventud, en el desarrollo del primer Manifiesto sobre Juventud y Tabaquismo, promovido por la Comisin Europea y tom parte en la exposicin de los resultados de dicha campaa ante el Parlamento Europeo en Estrasburgo. Luz Lpez Samaniego fue pasante durante tres meses en el Departamento de Salud Mental y Drogodependencia Sustancias de Abuso de la Organizacin Mundial de la Salud y es coautora, entre otros, del documento Win Health with Youth Ganar Salud con la Juventud, publicado por el Ministerio de Salud Sanidad y Poltica Social de Espaa

Young Voices in Research for Health 2009

Priya Mannava

Priya Mannava, India

A mIssIon foR All: IncReAsIng Access to HeAltH pRodUcts And seRVIces tHRoUgH InnoVAtIVe pARtneRsHIps

Thirty years ago, world leaders, recognizing that health is a fundamental human right and that existing health inequalities were of concern to all, pledged to achieve a level of health that will permit all peoples to lead a socially and economically productive life by 20001. Despite the numerous advances that have been made in the fields of science and health, this vision of health for all remains unfulfilled. Growing up, I was often shocked by the contrasting environments of the country I lived in and my country of origin. On the one hand was one of the worlds best health-care systems, high life expectancies and obesity, while on the other there was polio, high child malnutrition and lack of access to basic amenities such as clean water and adequate sewerage infrastructure. I wondered, if certain countries were able to achieve great strides in health, why could not all? If the required product or service was available, such as the polio vaccine, why was a particular health problem still afflicting select populations? I learnt that the answers to such questions entail several different factors including economics, infrastructure, policy and culture. Yet, the reality is that we continue to live in a world of stark disparities, where it is mainly the fortunate that enjoy the fruits of development and innovation. The poor are afflicted by dual burdens: curable diseases for which they do not have access to vital drugs and diagnostics, and neglected diseases, which fail to attract much of the research and funding resources they require. How does one address this problem? The conventional and perhaps most obvious answer would be to simply increase funding and, yes, financial aid to tackle diseases ravaging the developing world. However, donor-driven programmes also have their drawbacks in that they are not sustainable, nor do they always focus on capacity building and the engagement of the local community. I was a first-hand witness to the frustrations of the sudden withdrawal of support, when funding for an HIV-prevention project I was involved with in India was discontinued after the first year of implementation. The project was the first of its kind in the country an innovation, if I may say so but was shelved before any impact could be shown. I realized then that initiatives seeking to increase access to health-care treatment, products or services also necessitated new methods of management and delivery. I believe that the core issue in addressing health inequalities is not the discovery of a cure or an effective service, as scientific creativity and talent is constantly harnessed in the laboratory and the field. What is required, rather, is innovation in the process by which health products, treatments and services are delivered or distributed. In other words, greater focus should be given to understanding how best to increase access. After all, what is the use of developing antiretroviral drugs if millions of HIVpositive patients in Africa do not have access to the medication? These questions become more important during economic downturns such as the current one, when

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diversions of funds from treatment and prevention programmes further increases the vulnerability of the poorest patients. How can we enhance processes to ensure that health products and services are available to those most in need? The answer lies in partnership models that translate ideas into realities on the ground. In a world where globalization has redefined determinants of health, providing the fertile soil for innovation will require venturing outside the circles of medicine and science to systematically engage experts from other domains such as business, economics, engineering and law. I see health for all realized as the product of various innovative partnerships, the private sector applying business and entrepreneurial principles to the products of research, which are in turn brought to the common man using the infrastructure and knowledge of the public sector and civil society. I would like to emphasize that what I am advocating is not simply publicprivate partnerships, as these already exist in various forms in the health sector. I am arguing for a more defined role for economics, whereby the success of the partnership would be driven by financial performance and market principles. At the same time, the goal of the partnership would be optimization of the beneficiaries well-being, so the profits gained would be reinvested into the service a phenomenon applied in social entrepreneurship and business. Thus, corporate and venture capital investors would need to be central stakeholders in order to provide the necessary resources. In the process, empowerment, efficiency, creativity and further innovation would also be fostered. There are existing social businesses, cross-sector partnerships that demonstrate the strides in health that potentially can be achieved. The Danone-Grameen joint venture, for instance, has brought affordable, nutritionally fortified yoghurt to the children of Bangladesh as result of a partnership between business and philanthropy. Combining the expertise of entrepreneurs in Danone and the staff of Grameen, who understood local sensitivities, allowed the development of a community-based production model and a differential pricing system. As a result, not only was affordable yoghurt made available for the benefit of those most in need, but the foundations for a sustainable business were also established2. Likewise, there is the example of the introduction of long-lasting insecticide-treated bed nets in Africa. The life-saving products were brought to the continent with the support of multilateral organizations, the willingness of the Japanese chemical company that had developed the technology to transfer knowledge and skills to African counterparts, and a loan given to a Tanzanian textile manufacturer for the production of the nets. The entrepreneurship of the manufacturer, combined with the efforts of all partners involved, resulted in the production of low-cost nets. The effective marketing of the nets at different prices to various targeted users helped to increase uptake and access to the products. Previously, the free distribution of bed nets had meant that selected vulnerable groups were given priority to be recipients3. Having mentioned these examples, I recognize that social business models are fairly new and research still needs to be done to understand their true impact on health systems. This call for evaluative research also goes hand-in-hand with the need for a stronger emphasis on operational research on health. Understanding how delivery processes can be improved will shed light on the mechanisms or factors required for creating an enabling environment for innovation. This is particularly important because the development and scaling up of social business partnership models, once

Young Voices in Research for Health 2009

Priya Mannava

proven to be effective by impact research, will demand a change in the way health products are valued and distributed. Accordingly, policy-makers will need to provide ongoing support and the appropriate incentives to encourage potential partners from the for-profit sector to pool their expertise and skills for social benefits. Likewise, scientists will also need to be willing to engage in technology and knowledge transfers, particularly when this involves developing countries. Academics teaming up with social entrepreneurs to make available the fruits of research in the developing world, for instance, is an innovative partnership that has potential. Thus far, our approaches have fallen short of guaranteeing the fundamental right of health to all. New methods must be adopted to ensure that developing countries can access the results of multimillion-dollar investments in researching and developing drugs and treatments. Existing collaborations have indicated that this is possible when various stakeholders have a common foundation of trust, shared values, and belief in the principles of the free market to drive health ventures. The seeds of innovation exist. What is now required is the appropriate nurture for all to sprout. To quote the founder and managing director of Grameen Bank, Muhammad Yunus: When you plant the best seed of the tallest tree in a six-inch-deep flower pot, you get a perfect replica of the tallest tree, but it is only inches tall. There is nothing wrong with the seed you planted; only the soil base you provided was inadequate2. Health research must now move to inform the appropriate scaling up of partnerships that provide this adequate base.

1 2 3

Declaration of Alma Ata. International Conference on Primary Health Care, 1978 ( www.searo.who.int/ LinkFiles/Health_Systems_declaration_almaata.pdf, accessed on 1 September 2009). Muhammad Y. Creating a world without poverty. New York, Public Affairs, 2007. Novogratz J. The blue sweater: bridging the gap between rich and poor in an interconnected world. New York, Rodale, 2009.

Priya Mannava has a Bachelor of Science degree in Human Sciences from University College London and a Master of Science in Global Health Science from the University of Oxford. Now at the Global Fund to Fight AIDS, Tuberculosis and Malaria, she previously worked as a consultant at the World Health Organization and in the area of capacity building and HIV prevention with a nongovernmental organization in India. With interests in disease epidemiology and international health, Priya hopes to build a career in addressing health inequities in developing countries.

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Annia Martnez Massip, Cuba

InnoVAndo HAcIA dentRo

Les ha pasado, que innovan hacia una direccin especfica y terminan transformando en diversos sentidos? El alcance inminente de la innovacin sin apellidos, estrecheces y conveniencias disciplinarias choca con la profesionalizacin e institucionalizacin de la ciencia, que conlleva a la segmentacin de la naturaleza, la sociedad y el pensamiento en lmites rgidos. Si las disyuntivas naturales y sociales se mueven en relaciones ms complejas que la bilateralidad, por qu las ciencias y las perspectivas se disputan el prestigio proficiente de sus feudos epistemolgicos y metodolgicos en pos de retos? Desafortunadamente, las diversas barreras caprichosas que se inventan e institucionalizan en funcin del aprendizaje pormenorizado y fraccionado, no poseen el mismo efecto en la aplicacin prctica. Desde la Ilustracin, las modernas ciencias sociales se caracterizan por ser usurpadoras de mtodos propios de las ciencias naturales, porque se adoptan postulados evolucionistas y deterministas; de esa forma se asumen conceptos como orgnico, mecnico, necesidad, adaptacin, funciones, estructuras, medio, especie. El positivismo se corona como el mvil representativo de la usurpacin. Por tanto, pertenecen la observacin, la experimentacin y la cuantificacin a un terreno prohibido o son formas prestadas o robadas de las ciencias duras, que las ciencias blandas necesitan con urgencia para representarse como verdadera ciencia fuerte? La ciencia tiene las facultades de ordenar o transformar, de igualar o desequilibrar, de construir o destruir, funciona y contempla diversos roles apoyados en procesos de profesionalizacin e institucionalizacin que forman estructuras internas para garantizar su desarrollo y perfeccionamiento. La produccin de conocimientos establece distintas relaciones intracientficas: informativas, organizacionales, jurdicas, psicolgicas, ideolgicas, que poseen en comn no slo la interrelacin con lo aprendido socialmente y su producto destinado al consumo social, sino la participacin del cientfico en tales relaciones, que est influida por factores del contexto propio. Se sabe que es fuerte y resistente la llamada superespecializacin respaldada por estrategias institucionales, polticas cientficas y conveniencias personales, sin embargo, por qu una ciencia fragmentada conlleva a una fragmentacin de la realidad sin posibilidades de reconstruccin? Porque el sentido de apropiacin del mtodo en las ciencias, constituye una relacin de poder que presenta un carcter restringido y reducido de la realidad. Los mtodos son herramientas y enfoques que dependen de las caractersticas en la articulacin entre teora y prctica. La riqueza y la solidez de las ciencias estn dadas por la flexibilidad y la diversidad de mtodos. Los cientficos que se vanaglorian de poseer mtodos propios en sus correspondientes

Young Voices in Research for Health 2009

Annia Martnez Massip

disciplinas, slo estn cumpliendo con particularidades personales referidas a ostentacin intelectual y pavoneo cientfico, que limitan no slo las posibilidades de acceso a la realidad, sino que afectan al desarrollo de la ciencia, enquistndola en concepciones altruistas y acabadas. No obstante para los presuntuosos acadmicos, no slo los prstamos o los robos se hacen en un sentido. No se trata de propiedades particulares, prstamos, robos o ciencias inertes sino de naturalezas desnudas que esperan ser descubiertas, comprendidas y transformadas, no por disciplinas constituidas dentro de las cuales se aprende a formular y resolver problemas, sino por la capacidad de cambio de los sujetos, apoyados en las ciencias. As la ciencia se convierte en una fuerza social extraordinaria, cuya relacin con los intereses sociales es indiscutible. Cuando las ciencias desvirtan su inherente carcter social, tiende a suceder que la oferta sobrepasa las necesidades reales adquiriendo poder autnomo, suficiente para dar sentido a su existencia desentendindose del factor humano. La sociedad continuar demandando, tambin le urge buscar los mecanismos que irracionalicen las pertinencias de las disciplinas que soltaron de la mano a la sociedad. Mas no se ignoran las particularidades de la ciencia que son vitales para comprender que su enfoque social permite las distintas articulaciones con las restantes formas de actividad humana, pero no borra sus diferencias respecto a ellas. Entender las condicionantes histricas-culturales y las consecuencias naturales y sociales del fenmeno cientfico y tecnolgico le confieren a la ciencia un nivel de crtica constructiva dirigido a la ejecucin de alternativas que respondan a soluciones pertinentes, equitativas y participativas. Como en todo, tambin en las ciencias hay que evitar las posiciones extremas. Ni se pretende privilegiar la accin del contexto y sus dinmicas socioeconmicas sobre el cambio cientfico, ni tampoco ennoblecer la autodeterminacin de la ciencia y su autonoma para lograr una libertad que slo beneficia a tecncratas o que obedece a intereses particulares y egostas. Entonces cmo lograr que los productores adopten tecnologas u otros resultados cientficos en sus prcticas cotidianas?, cmo alcanzar que los productores adapten y avalen los descubrimientos cientficos a la realidad particular y diferenciada? y cmo los cientficos, agrnomos o no, deben comprender y aceptar la sociedad rural como punto de partida y final para la efectividad y sostenibilidad de los avances de las ciencias? Una idea: la innovacin epistemolgica busca no la multi, ni la inter, ni la transdisciplinariedad a niveles grupales sino una concepcin de la vida y de la ciencia donde lo irracional y lo racional proponen y comprometen la produccin cognoscitiva del cientfico con la comprensin y explicacin de la naturaleza y la sociedad, no desde la conformista formacin disciplinar sino desde las demandas y exigencias de una realidad compleja, sistmica, atravesada por factores que van ms all de lo disciplinar. La capacidad y la disposicin cientficas desde la innovacin epistemolgica rompen con barreras de comodidad y complacencia. Las estructuras cognoscitivas y lingsticas terminan moldeando la realidad a nuestros intereses profesionales, por ello la innovacin epistemolgica debe darse a nivel personal, para articular coherentemente el cmulo de innovaciones con apellidos.

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No es extrao la combinacin entre la innovacin epistemolgica y el querer/conocer varias disciplinas a la vez, quebrantando lo establecido que ciega y embrutece. Se trata no slo de innovar en lo tcnico y en lo productivo, sino de reflexionar y transformar arraigados estereotipos y formalismos en el mbito institucional y personal que obstaculizan la pluralidad de cosmovisiones y alternativas. El Programa de Innovacin Agropecuaria Local del Instituto Nacional de Ciencias Agrcolas se propone fortalecer un sistema de innovacin agropecuaria que incorpora la contribucin y la capacidad de las productoras en la generacin de beneficios sociales y ambientales, promoviendo la agro-diversidad en el contexto cubano con equidad de gnero. Ejes temticos, marco lgico, estrategias, talleres, e informes se planifican esencialmente en funcin de este objetivo, pero el impacto es ms rico y amplio. Se logran resultados como la introduccin, validacin y diseminacin de la diversidad de especies/ razas y cultivos/ variedades y de tecnologa apropiada de importancia agropecuaria local, fortalecimiento de capacidades y actitudes de actores locales e institucionales, reconocimientos, intercambios y aprendizajes con la participacin equitativa de mujeres y hombres. Las pruebas de degustacin, los concursos de platos en las conocidas Ferias de Biodiversidad, la proliferacin de huertos familiares provocan un desarrollo de la cultura alimentaria hacia una vida ms sana, donde las familias rurales buscan ampliar su culinaria cotidiana con productos ms diversos y de mayor calidad, gracias a los abonos orgnicos y a las prcticas ecolgicas desprovistas de qumicos o de tecnologa tradicional que destruya suelos y deforeste. La conservacin de alimentos y la divulgacin de nuevas recetas econmicas entre hombres y mujeres garantizan la variedad de frutas y verduras en el balance alimenticio de la familia. La dedicacin a las flores y plantas ornamentales, no slo embellece y da esttica al hogar, sino que se reconoce su poder teraputico en contra del estrs. Todo esto exige pensar en las necesidades humanas de una forma diferente e innovadora, que vaya mucho ms all del propsito de aumentar la productividad. Sus metas son, adems del aumento de la productividad, el enriquecimiento de la biodiversidad y el empoderamiento de los usuarios1. Digo ms, me atrevo a exigir desafos tan importantes como los mencionados: superar los lmites disciplinares para entender y relacionar en accin real la productividad, la biodiversidad, la participacin y la calidad de vida, de manera sistmica y sostenible; por tanto no se aferren a hacer de la ciencia escudos o armas de supervivencia, feudos de poder o simples fuentes de ingreso. Se propone: no alzar la innovacin como bandera de desarrollo en comunidades remotas, espacios conservadores si an no se sabe implementarla contra normas institucionales y profesionales cuando la realidad lo exige. La terminacin de un nivel de enseanza o cientfico no instituye un punto final suficiente, sino un punto de partida sin beneplcitos acadmicos que (des)(re)construye lo aprendido en funcin de la pertinencia social; porque el saber no es un producto dado, sino un proceso que mediante la innovacin epistemolgica, violenta y prueba nuestras capacidades de resistencias y cambios con los sujetos y sus contextos.

Young Voices in Research for Health 2009

Annia Martnez Massip

Vernos, R.; et al (2006) Semilla sin conocimiento no da rendimiento: hacia una nueva prctica de fitomejoramiento, en: Ros Labrada, Humberto (editor): Fitomejoramiento participativo. Los agricultores mejoran cultivos, INCA, La Habana, 2006, p. 13.

Annia Martnez Massip es hija de maestros. Naci en la ciudad de Sancti Spiritus (Cuba), el 16 de noviembre de 1982. Desde la primaria hasta el preuniversitario asisti a concursos, eventos cientficos estudiantiles y talleres de nios escritores. Estudi sociologa en la Universidad de La Habana, recibi cursos en diversos centros de estudios e investigacin y ha participado en eventos nacionales e internacionales, as como de un intercambio acadmico con la Universidad Autnoma de Chiapas. Fue Premio Rector durante cuatro aos. Actualmente trabaja en la Universidad Central Marta Abreu de Las Villas, donde es Jefa de carrera de la facultad de sociologa e imparte la ctedra de Gnero y Metodologa. Investiga en el Programa Nacional de Innovacin Agropecuaria Local. Particip de un intercambio acadmico con la Univesidad Autnoma de Chiapas.

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Amy Mathew, New Zealand

mAlnUtRItIon And obesItY: closIng tHe gAp

Vending machines on every corner. Fast food guaranteed. Sushi not only out of reach but out of price. Only fries, pies and fizzy drinks accessible. Auckland University is a hub where students spend their days and eat at least two vital meals, yet the choices are limited, and being seen with a can of energy drink in one hand and a meat pie in the other is as common as seeing a businessman on his cell phone. If we are what we eat, then what are we if we eat all this?

If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health. Hippocrates

In a society where everything is expected to be instant, patience has grown weary; the speed of communication and lifestyle has caused our health to suffer. New Zealand is now a society where it has become easy to be overweight. The presence of obesogenic environments has turned health into a business, driven by convenience. The evolution of fast food chains from common restaurants sees meals prepared in an instant for minimal cost. These cheap meals have resulted in obesity becoming excessively dominant in low-income groups; no longer can chronic diseases be labelled diseases of affluence. It seems now that food has lost all past value, where people are now searching for cheaper petrol rather than healthier food, where feeding out bodies is now a matter of combining taste, mood, culture and finance. If, as the Universal Declaration of Human Rights states, everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, then why does fast, cheap, convenient food that tastes good continue to be the soul of our New Zealand society? The lightening of wallets has seen our waistbands continually expand, but at what expense? The alarming rise in the incidence of obesity and of the malnourished in New Zealand is lowering the quality of life for those suffering these problems and for their supporting families. These troubling trends pose pressing challenges to national economic resources, finances and the health-care system as associated noncommunicable diseases grow.

Young Voices in Research for Health 2009

Amy Mathew

Over the decades, as food ideology has constantly changed, obesity and nutritional deficiency have escalated to epidemic proportions, such that they are now among the largest preventable causes of morbidity and mortality internationally. Nutritional deficiencies result from improper or inadequate diets, while obese individuals weight has increased to a point where it seriously endangers their health by increasing the risk of cardiovascular disease and other secondary complications. While it is acknowledged that primary prevention is more successful and less of an economic burden on the country than tertiary intervention, the focus has shifted to identifying new methods of controlling diet-related chronic diseases while also addressing nutritional deficiencies, obesity and hunger. The most appropriate way of implementing the right to adequate food would be to institute a multiphase intervention, the Food Point Programme (FPP), to promote healthy eating and active lives. The FPP would use a reward card where accumulated points might be used only to buy certain selected local produce. Selected local produce would include items from important dietary food groups such as fresh fruits and vegetables, breads, cereals, dairy, and meat and poultry. Points would be acquired in a tiered fashion, with the purchasing of fresh fruits and vegetables gaining the largest sum of points and the purchasing of meat and poultry gaining the least. Points obtained would correspond to money, enabling people to finance their grocery shopping. FPP cards would be issued one per household, easily available and accessible for all, and initially credited with a $200 incentive for buying the specified fresh produce. Subsidiary cards could be acquired for persons of appropriate age in the household. The $200 incentive would be available only once per household. Further rewards, including subsidized gym memberships and cooking classes, would be given to those who surpass a defined point level. This scheme would not only give people freedom of choice but also empower them to make decisions with regard to what is best for their own health, thus reducing the stigma of receiving a government handout. The right to adequate food should be in combination with the governments obligation to respect, protect, fulfil, facilitate and provide food for New Zealand. The success of this initiative would depend critically on compliance with the principles of peoples participation and legislative capacity. Measures must be taken to ensure that, even in times of resource constraint such as economic recession, the FPP would still be available to the population. The FPP would be created and provided in a way that did not negatively affect local producers and would be organized in ways that aided the return to food self-reliance of the beneficiaries. Produce included in the national FPP would be safe and culturally acceptable to the New Zealand population. Dietary needs for physical and mental growth, development and maintenance would be met and in compliance with human physiological needs at all stages throughout the course of life, according to sex and occupation. It is recognized that, for this pilot study to succeed, it would need to be knowledge based, people centred and system minded. As Nelson Mandela once said, Education is the most powerful weapon which one can use to change the world. Therefore, education is crucial to aiding the reduction of inequality in health and bridging the gap between obesity and malnutrition and between socioeconomic groups, ethnicities and the sexes. New Zealand education is centred on active lifestyles and healthy eating. It would be delivered through all forms of media and local efforts, such

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as community, school and church groups, facilitating individual empowerment and optimum population involvement. For the continued effectiveness of this initiative, a change in mindset would be essential. Government support and participation in combination with a topdown approach filtered through the health hierarchy would be needed to alter obesogenic environments. Cultural sensitivity and specificity with respect to indigenous social etiquette, partnered with education, would underpin the success of the FPP. And who would fund this venture? This initiative would ideally be funded by the government through initiating a nationwide health tax. This tax would be compulsory for all earners and be income adjusted. The monetary contribution would not only fund the FPP but also fix current shortcomings in the public health system, as without money there can be no health reform. As a developed nation, we are abusing our bodies. After centuries of fearing hunger day to day and rationing, the abundance and ease of access to food is now as ordinary and unthought-of as the air we breathe. Food has been taken for granted, and consequently our bodies and our health are suffering. We are now engaged in a war between the rich and the poor, the obese and the malnourished. If we are all individual unique entities with the same basic human rights, then why are some falling through the gap? Should we not stand together to pick up those that fall and further strengthen those that stand? Policies to address structural nutritional deficiency and obesity are fundamental to the sustainable eradication of food inequality and insecurity. This partnered with education, empowerment and increased ease of access and financial capacity to buy healthy foods shall see our nations food ideology and health dramatically turn for the better. The national Food Point Programme provides a net, closing this gap and ensuring equality. This is the call for us to return to our roots, to realize that food is the sustenance of our bodies and not a factor of abuse. It is only through this realization that the inequalities seen in health, quintessentially determined by what we consume, shall see a dramatic decline. Our food should be our medicine; our medicine should be our food. But to eat when you are sick is to feed your sickness. Hippocrates

Amy Mathew will finish her Bachelor of Health Science at the end of this year at the University of Auckland and intends to pursue a Masters in Public Health, majoring in International Health, from the University of Melbourne in 2010. She is a keen toastmaster and has won the Competent Communicator Award. A great advocate for the voice of youth, she was a facilitator for the health discussion in this years United Nations Youth Declaration in Auckland. Her passion is palliative care, and she is a trained volunteer at Mercy Hospice Auckland.

Young Voices in Research for Health 2009

Janna McDougall

Janna McDougall, United States of America

mobIle pHones, women And gIRls: engendeRIng mHeAltH Into An InnoVAtIon foR All

Mobile phones are ubiquitous in todays digitalized world. While fundamentally a communication tool, mobiles also have vast potential to improve development outcomes1. An expanding array of mobile applications and programmes to address health problems, so-called mHealth initiatives, have the potential to benefit those who are difficult to reach, helping to alleviate problems of inadequate infrastructure like poor transportation or a shortage of health workers in rural areas of developing countries. But, do mHealth programmes really reach all? More specifically, are these programmes reaching women, particularly poor women, who play a central role in improving their own health as well as the health of their families and communities? For mHealth programmes to be truly transformative in improving health for all, they must consider the excluded especially women in the way initiatives recruit, enrol and develop content.

Women and mHealth

Six broad areas categorize mHealth efforts: using mobile applications to provide education and information; communication and training for health workers; diagnostic and treatment support; remote data collection; remote monitoring; and disease and epidemic outbreak tracking2. The field is young, but there appears to be a sense of excitement and perhaps hype that mHealth can be the solution to many intractable health problems. Why should mHealth programmes target women to improve the health of all? First, we know that women are the caregivers, and girls are the future caregivers, of their families. Their health is imperative to ensuring the health of future generations. Second, we know that women are essential drivers of economic growth through their savings and investment in their households, and economic growth is one strategy to reduce poverty and poor health. Third, women transfer their good health, lower fertility and education to their children. In addition to their instrumental value in improving the health of others, women bear a disproportionate burden of disease, poor health and excess mortality. In sub-Saharan Africa, HIV prevalence among women can be up to six times as high as that among men. Women also suffer greater negative consequences of disease than men; for example, when pregnant women are infected with malaria, they are more likely to develop serious malarial disease than men or non-pregnant women. Finally, maternal morbidity and mortality endanger the lives of women and generate significant costs to families and communities, the cruel consequences of widespread apathy for womens health.

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Yet the mHealth field does not appear to seriously consider women as potential users of mHealth or as a population with extreme need. Few initiatives and applications appear to address women and womens health needs specifically, beyond sourcing women as data collectors or health workers. Although a recent review of mHealth programmes finds that many initiatives target female nurses and health-care staff, which can lead to their empowerment, the report makes zero mention of the terms gender or girls and only four mentions of woman2. Furthermore, mHealth interventions have yet to focus on many of the health burdens that women face. Few programmes, for example, address womens and girls reproductive health. Yet mobile phones can deliver reproductive and sexual health information confidentially, which makes them an ideal strategy to address these stigmatized subjects. In addition, programmes that do address health challenges that disproportionately affect women, including HIV, seem to do so without particular attention to how women may best utilize services to improve their own health. Many mHealth programmes are relatively new, and a first order of business for these technology initiatives is devising a strategy and rolling it out to whichever populations are easiest to reach to test the efficacy of the approach. Although few regional or global studies on mobile ownership and use exist (one exception is Zainudeen et al. 2008)3, research on technology ownership generally suggests that owners and users are likely to be individuals living in urban areas with enough resources to purchase and use mobiles the majority of whom are urban men4. This may help explain this lack of attention to women and girls in mHealth to date. So how can such programmes respond to womens health? Three important next steps emerge, in research, programme development and programme evaluation.

Research
Recent research from South and South-East Asia identify gendered mobile use and ownership patterns3, while programmatic research in Africa identifies barriers, such as economic hardship, and consequences, including violence against women, of womens mobile phone use5. We now need rigorous, comprehensive and crosscountry studies that build on current descriptions of womens mobile use to examine the individual-, community- and market-level facilitators, barriers and consequences of womens use of mobile phones for mHealth programmes. Future studies should investigate gender-specific use and ownership patterns; for example, if women do not own phones, can they use mens? When using mobile telephones, are women safe from violence or harassment? With what frequency do women and men call into hotlines or programmes similar to mHealth approaches? Through what mechanisms do facilitators or barriers enhance or limit womens participation in mHealth initiatives? Some of these data may be available from mobile operators, but it is difficult to mine and access. Partnerships between research agencies and mobile phone operators can yield information fairly quickly to bolster the mHealth field.

Programme development
The approaches of mHealth programmes for women must be gender sensitive. For example, one neglected area of mHealth programming is maternal mortality and morbidity. In such an mHealth initiative, families could access a remote education

Young Voices in Research for Health 2009

Janna McDougall

or diagnostics programme to identify the warning signs for obstructed labour, a major cause of maternal morbidity and mortality. By quickly identifying early symptoms, mHealth could reduce the first of the three delays leading to maternal mortality: the delay in seeking care. The mHealth field needs mobile phone systems and curricula that all women, including young married women, can use to access information and services related to sexual and reproductive health, infectious disease and maternal health.

Programme evaluation
Lastly, we need rigorous evaluation of mHealth projects that incorporates a gender perspective. Evaluating mHealth presents three particular challenges in metrics, design and data collection. In terms of metrics, mHealth evaluations should first measure change in health outcomes, including health knowledge, attitudes, behaviours and status. Further, evaluations must measure womens experience of the gendered technology context; for example, evaluations should track unintended negative consequences, such as violence or theft, resulting from participation in mHealth projects. But, women are not only at risk of negative consequences; mHealth may also lead to improvements in womens ability to make strategic life decisions. As such, evaluations need to measure empowerment dimensions such as womens ability to participate in decisions about their fertility or sexuality, or womens efficacy in insisting on the use of condoms to protect themselves from sexually transmitted infections to understand distal benefits resulting from mHealth initiatives. Designing mHealth evaluations presents a particular challenge, as the programmes are by nature innovative and rapidly changing, which make them poor candidates for traditional programme evaluation. To address this, process evaluation is imperative to record programme components, modifications and implementation. Evaluation examining changes in womens health and empowerment should use participatory, responsive and adaptive strategies that collect data at multiple time points to understand how and when women experience change. Such designs, which emphasize regular data collection, immediately raise cost issues. Data collection and analysis are expensive, take financial resources from programme activities and divert the attention of programme staff. But, mHealth programmes have built into them a unique solution to monitoring and evaluation: the individual participants mobile phones. Several mHealth interventions already use mobile devices to collect data and have done so with significant cost savings2. However, most use one or many data collectors equipped with a sophisticated mobile data collection device, who then interview individuals to collect data. In evaluating mHealth programmes that provide information to women via their personal mobile phones, those personal mobile phones can be used to elicit information from women on their health, exposure to risk and empowerment. Considerable potential resides in mHealth as the innovation that changes the way we think about health throughout the world in both developed and developing countries. However, unless mHealth programmes specifically address the gendered facilitators and barriers to womens mobile phone use and create content that addresses womens disproportionate health burden, they will not live up to the hype that they currently enjoy and will fail to be the innovation that improves health for all.

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1 2

InterNews Europe. The promise of ubiquity: mobile as media platform in the global south. Europe, InterNews Network, 2008. Vital Wave Consulting. mHealth for development: the opportunity of mobile technology for healthcare in the developing world. Washington, DC and Berkshire, UK, UN Foundation-Vodafone Foundation Partnership, 2009. Zainudeen A et al. Whos got the phone? The gendered use of telephones at the bottom of the pyramid. 2008. (www.lirneasia.net/wp-content/uploads/2008/05/ica-whos-got-the-phone-thegendered-use-v18.doc, accessed 1 September 2009). Gurumurthy A. Gender and ICTs overview report: BRIDGE development-gender. Brighton, Institute of Development Studies, 2004 (www.bridge.ids.ac.uk/reports/cep-icts-or.pdf, accessed on 1 September 2009). Wakunuma KJ. The Internet and mobile telephony: implications for womens development and empowerment in Zambia. Presentation at the workshop Gender, ICTs and Development, Manchester, UK, 2006 (www.womenictenterprise.org/manworkshop.htm, accessed 1 September 2009).

Janna McDougall has seven years of experience in global health and economic development. Her work has included researching reproductive health, HIV and tobacco use; designing monitoring and evaluation studies for health interventions; and measuring girls and womens empowerment. Now a research associate with the International Center for Research on Women, Janna is keenly interested in technologies to improve womens and girls health and is especially interested in mobile phones as tools to address health challenges. She enjoys working with public, private and non-profit-making partners, including research organizations, nongovernmental organizations and global corporations to improve global health. Janna holds a Masters in Public Health from the University of North Carolina at Chapel Hill.

Young Voices in Research for Health 2009

Paul Wilfrid Armand Menye

Paul Wilfrid Armand Menye, Cameroun

plAIdoYeR poUR lAcceptAtIon des dontologIes non conVentIonnelles de RecHeRcHe mdIcAles

Innover pour... Voil quelquefois o se situe le problme mme de linnovation en matire de sant. Parce que finalement, cest une frange du monde qui se sent interpelle, concerne, investie de cette mission : ils innovent pour les autres. Et ces autres , quand ils sont avec condescendance invits participer , le sont titre de cobayes ou de consommateurs des innovations. Les cas dans plusieurs pays dAfrique, dAsie ou dAmrique Latine sont lgions de ces autres sur qui sont effectus tests et expriences ou qui finalement ne parviennent pas avoir accs ce quon a innov pour eux. Innover. Cest une ncessit. Une ncessit dans la mesure o lvolution du monde, tout en crant de nouvelles organisations des problmatiques de sant, en rend aussi la gestion plus complexe. Il est absolument impossible daborder la sant de tous dun point de vue centralis. Le temps des ples du monde rgnant en matres absolus sur la sant est rvolu. Voici venue lheure de ces anciens temps oublis, o chaque socit sorganisait comme elle pouvait. Avec ses propres repres, ses propres outils et ses propres dmarches exprimentales.

Innovation et sant pour tous... le bon point de la diversit

Innover aujourdhui, ce nest plus sorganiser nimporte comment; ce nest plus senfermer dans sa propre manire de faire. Mais cest surtout sorganiser localement, avec un langage que tout le monde comprend. Linnovation dans ce contexte devient luniversalisation du langage des diffrents produits de la recherche mdicale. Cest en effet sur la diversit des origines de linnovation quil faut mettre laccent. Et cest cela qui manque cruellement au monde aujourdhui. Le monde est organis de manire ce que linnovation ne puisse jamais se dployer dans sa totalit et ainsi, rsoudre les problmes de tous. En effet, seuls quelques points du monde possdent des centres de recherche spcialiss avec tout lquipement ncessaire. Les autres sont contraints de suivre... contraints au suivisme mme... contraints daccepter linnovation des autres et sen rjouir... contraints se laisser dpouiller de leur propre innovation qui, dans les mains des autres, ne peut pas apporter toutes les solutions efficaces et adquates. Ce quil faut donc aujourdhui, cest que lquit sempare du terrain de la recherche scientifique. Cest que la justice sempare de la redistribution des ples de recherche scientifiques dans le monde. Et si cette aventure semble tre une vritable gageure, il faut se rappeler que la plupart des peuples ont au dpart leurs propres outils et approches de recherches... ce quon appelle ailleurs les mdecines traditionnelles .

Plaidoyer pour lacceptation des dontologies non conventionnelles de recherche mdicales

95

En ralit, le terme traditionnel sapplique ici juste parce quil est en opposition avec ce qui dans dautres parties du monde a t dcid et tabli comme conventionnel. Donner un langage universel ce traditionnel serait un premier pas pour sapproprier au profit de tous des innovations qui y sont produits. Cette universalisation des mthodes traditionnelles doit se faire avec les outils qui lui sont spcifiquement ncessaires. Mais aussi avec la formation et laccompagnement adquats. Ceci implique pour les instances qui encadrent lthique et la mthode en matire de recherche scientifique de reconnatre ces approches dites traditionnelles. A ce niveau, il est certain que des progrs ont t faits. A travers le monde, confrences et sminaires, colloques et dcisions, ont permis de donner une certaine reconnaissance ces approches locales. Ce qui a t moins effectu sur ce terrain, cest la vritable prise en main de ce secteur dans les financements de la recherche en matire de sant. En effet, tant au niveau des tats que des bailleurs de fonds, la prudence frileuse a fait son choix. Celui des approches plus classiques, fondes sur une mise en pratique rigoureuse de la mthode exprimentale de Gaston Bachelard, et encadres par les formules biochimiques les plus rbarbatives. Ce que cette prudence a oubli, cest que cest parfois sans Bachelard et sans formules crites que se joue une part importante de linnovation en matire de sant... une part qui aurait pu doper la sant pour tous.

Se mettre lheure des possibilits non conventionnelles dinnovation

La sant pour tous commencera devenir une ralit quand chaque peuple aura sa porte les solutions mdicales ses problmes de sant. En encourageant les travaux de recherche locaux dans ce sens, on donne la chance une autre organisation de la gestion de la sant de se mettre en place. Cela passe par lquipement, la formation et laccompagnement des units de recherche locales, souvent dites traditionnelles . En dautres termes, il faut que le financement de la recherche en sant accepte de dpasser ses propres peurs. Il faut que la dontologie de la recherche se mette au dfi des incertitudes que constitue le champ des recherches mdicales traditionnelles. Il faut que les tats et les bailleurs de fonds, finalement, acceptent de sengouffrer dans le puits des effervescences locales visant la sant pour tous. A coup de milliards. Il le faut. Il faut oser dpasser les clivages habituels de lorganisation de la recherche. Il faut oser des fonds dappuis innovants sur des terrains non conventionnels. Il faut oser croire des modles nouveaux qui sont parfois forts anciens, mais oublis. Il faut oser rentrer dans la culture et lhistoire des peuples et faire appel tout ce quils ont comme systmes et techniques de recherche mdicales. En mettant ct de tous, la possibilit de faire germer ce quil peut y avoir de riche en chacun. Finalement, cela suppose que des investissements consquents, officiels et massifs soient orients vers les secteurs de mdecine dits traditionnels. Cela suppose que la mdecine traditionnelle, do quelle soit, sorte de la considration exotique dont elle souffre aujourdhui pour constituer carrment une nouvelle orientation mdicale officielle, avec un vrai statut mdical. Le rve est quune structure de recherches mdicale dite traditionnelle, avec ses chercheurs ntant passs par aucune cole classique de mdecine, puisse galement

Young Voices in Research for Health 2009

Paul Wilfrid Armand Menye

bnficier dun appui et dun regard attentif au mme titre que les autres... avec cependant les accompagnements quil faut afin quau final, les fruits de ses travaux puissent se dire avec le mme langage que les fruits des travaux des centres de recherche plus conventionnels.

Oui, le rve est permis !

Quand toute lintelligence des peuples, jusquaux niveaux les plus locaux, les plus traditionnels, les plus ancrs dans les paysages ruraux et urbains seront mis en branle, avec les fonds financiers et les accompagnements techniques ncessaires. Quand tout le savoir traditionnel des peuples ne sera plus regard avec un peu de condescendance. Quand enfin les bailleurs de fonds et les tats tendront la main ce qui se fait tous les jours, mme dans des cadres autres que ceux quils reconnaissent de coutume. Alors, innover pour la sant de tous... sera laffaire de tous. Et effectivement, tous nous en bnficierons.

Paul Armand Menye has been involved with the social movement in his country from early in his career. He worked for several nongovernmental organizations (NGOs) in Cameroon and Chad, before becoming involved with international NGOs in Eastern Europe. Throughout his work, Paul Armand has focused on practical alternatives for poor countries in the domain of education, health and social services. Paul Armand holds a Masters in Organizational Psychology and also has training in distance-learning applications, project management and social communication.

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Jason Nagata, United States of America

InnoVAtIon beYond IndIVIdUAlIsm

During clinic hours at the Hospitalito Atitln, Tzutujil Maya patients arrived in droves, often accompanied by extended family and friends. Relatives endured the long queues and cramped wooden benches, breathing the sterile yet smoky scent of donated medical supplies and wood fire. While volunteering in this small Guatemalan hospital, I discovered that families and communities, rather than lone individuals, collectively made health decisions. A costly medical procedure might mean that family members would ration food for a month or that neighbours would loan part of their earnings to help fund the treatment. To an aspiring physician raised with principles of autonomy and individualism at the forefront, these examples of family decision-making are reminders of the power of social solidarity and consideration of the greater good. From remote communities in Guatemala and Kenya to laboratories in urban universities, I have learnt how a narrow focus on the individual can often be detrimental to the health of all. Modern innovators live and work in a culture of competition and individualism. Early in our lives, institutionalized educational structures ingrain in us principles of independence and individuality. Research paradigms promote discovery and individual ownership, while habitually neglecting long-term follow-through and adaptation to local contexts. Biomedical innovations often target individual problems with specific drugs and technologies but fail to appreciate the interconnectedness of health and society, of illness and environment. In order to improve the health of all, we must shift away from individualism and work collaboratively to address human health in the broadest context. Individualistic thinking emerges from our competitive educational and work environments. I am reminded of the disappointed faces of Kenyan primary school students whose parents punish them for a poor class ranking, or my young cousins in Hong Kong who agonize about university admission and whose numerous homework assignments include the memorization of entire books. I succumb to competition as well. I recall envying the machine-like discipline of the chemists who persisted in working after all-night experiments and were visible through the laboratory windows I passed while walking home in the brisk dawn mist, exhausted after countless hours in my universitys main library. We train innovators to love ownership of publications and patents, like corporations in pursuit of profits and wealth. My principal investigator in a Los Angeles medical centre instigated a gag order on our laboratorys recent experiments during an epigenetics conference so that none of his colleagues would steal the publication. While analyzing our data, laboratory members were encouraged to manipulate statistical methods until the desired result was achieved. Individuals rush to be the

Young Voices in Research for Health 2009

Jason Nagata

first to discover a cure or to develop a model intervention, even at the expense of moral principles. This intense drive for ownership spawns unnecessary competition among individuals and hinders collaboration. In the global health scene, fierce competition for the implementation of innovations exists. When numerous Kenyan nongovernmental organizations (NGOs) aggressively compete for funding to operate similar HIV programmes, they frequently focus on their own gain rather than on benefit to the local community. I recollect the accusatory shouts of feuding Kenyan health employees of the government and three NGOs, who all worked under the same corrugated iron roof. The global explosion of new NGOs in the past decade demonstrates that many yearn to be leading innovators, but few intend to be followers. Many covet ownership of ideas and projects, but few care to share the credit. In order to improve the health of all, innovation requires teamwork and collaboration rather than individualism. Because of the intense drive for discovery, we often overlook sustainability and sufficient follow-through. The introduction of new health campaigns generates early excitement, but the day-to-day maintenance of a long-term project requires humility and silent dedication, qualities not always rewarded in our competitive environment. The World Health Organizations ambitious Global Malaria Eradication Programme is a prime example. When it was inaugurated in 1955, initial interest in the campaign led to the eradication of malaria in many temperate countries and reductions of cases in India, Sri Lanka and other tropical countries; however, faltering funding and lack of community participation weakened the programmes mission. Without sufficient follow-through, drug-resistant parasites and insecticide-resistant mosquitoes emerged. The World Health Organization abandoned the eradication campaign in 1969 as new cases in the tropics rebounded. Four decades later, over half the worlds population lives at risk of malaria, and every year brings half a billion clinical cases claiming 1 million lives. Priorities have shifted, and philanthropist Bill Gates famously cites the fact that we currently devote more money to finding a cure for baldness than to developing drugs to treat malaria. In order to improve the health of all, global health innovations require sufficient long-term follow-through. In addition to lacking follow-through, current technologies and innovations regularly overlook the importance of local contexts. We must adapt innovations to particular social, cultural, political, physical and economic environments. One-size-fits-all solutions, like donated clothing, simply cannot fit everyone. When newly constructed birthing centres exclude the presence of local midwives, and when health clinics forbid the use of herbal medicines, biomedical innovation ignores local values, mores and traditions. While researching potable water issues in the western highlands of Guatemala, I learnt how technologies can fail if not properly introduced into a unique cultural environment. At the height of the Guatemalan civil war in the early 1990s, a cholera epidemic swept through the town of Santiago Atitln, necessitating treatment of the tap water drawn from the azure shores of the adjacent lake. The municipal government, advised by international aid organizations, selected chlorination as the method of treatment, giving the water an astringent taste and a chemical smell. Many distrustful residents began to believe the caustic water had been poisoned by the government or contaminated by the dead bodies of missing Tzutujil Maya,

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purportedly dumped in the lake by the military. To this day, several Tzutujil Maya still associate the taste and smell of chlorine with dead bodies in Lake Atitln and refuse to drink the municipal tap water. Despite their enormous humanitarian potential, global public health innovations can fail without proper integration into unique cultural environments. In order to improve the health of all, novel innovations must be informed by local expertise and introduced in a culturally flexible way. Understanding the broader cultural context is only one step towards expanding our conceptions of innovation. Drugs for specific syndromes and technologies for particular procedures improve health, but innovation must also address larger structural issues like lack of sanitation and clean water. During the rainy season in western Kenya, when insects and wild vegetables abound, I travelled to Mfangano Island to research food security among people living with HIV. The Ministry of Health clinic provided free antiretroviral therapy (ART) for residents living with HIV, a third of the islands population; however, the Suba people lacked access to clean water, sanitation infrastructure, paved roads or electricity. Without knowledge of sustainable agriculture techniques, residents produced poor harvests while problems of famine and hunger plagued the island. Pulitzer Prize-winning author Tracy Kidder recounts an adage from Haitian health workers, who say that giving people medicine for tuberculosis and not giving them food is like washing their hands and drying them in the dirt. Indeed, while interviewing people on ART, I learnt that they often skipped their treatment due to hunger. As a Kenyan client explained, If you take antiretrovirals on an empty stomach, they just burn. Some days, the hunger is so unbearable I simply skip taking the drugs and do not tell anyone. Dozens of interview respondents echoed these sentiments: starving while on ART is an excruciating experience. Examples of hunger and ART in Kenya, poorly implemented water interventions in Guatemala, and laboratory competition in the United States all demonstrate why we must expand our narrow conceptions of innovation. Medical anthropologists Ann McElroy and Patricia Townsend write, Patchwork solutions to provide a drug or other intervention to target a particular pathogen or bodily defect will never be sufficient to promote health for all, for the locus of health is not the individual body but the relationships. We need a paradigm shift that de-emphasizes our culture of competition and individualism and, instead, promotes teamwork and understanding. I foresee a future where support for people living with HIV will not be limited to ART, but will include nutritional nurturance and sustainable strategies for agriculture to address hunger holistically. I imagine intra- and interdisciplinary innovation where laboratory scientists collaboratively conduct experiments, NGOs negotiate with one another to share resources, anthropologists adapt interventions in culturally appropriate ways, clinicians counsel on prevention and treatment, and educators empower with practical and theoretical knowledge. Like the Maya of Guatemala, we should learn to think collectively for the greater good, caring for others through solidarity as though they were family. Only through collaboration and a broadening of our focus on individual innovations will we truly achieve health for all.

Young Voices in Research for Health 2009

Jason Nagata

Jason Nagata grew up in Monterey Park, California, and attended the University of Pennsylvania, where he majored as an undergraduate in Health and Societies and the Biological Basis of Behavior. The recipient of a Thouron Scholarship, he earned a Master of Science degree in Medical Anthropology at the University of Oxford and begins medical school at the University of California, San Francisco in autumn 2009. His passion for global nutrition led him to the World Health Organization, where he interned with the Department of Nutrition for Health and Development. He has also worked in the western highlands of Guatemala, conducting and publishing biocultural nutrition research through the Guatemala Health Initiative. In western Kenya, he has worked on food insecurity among patients on ART through the Organic Health Response.

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Rufaro Ndokera, United Kingdom

HeAltH-cARe Access And tHe solAR-poweRed AmbUlAnce

The aim of health-care innovation is to improve health care for demographically changing and demanding populations. Advancing technology and broadening medical knowledge increase the requirement of innovators to contribute to this field. In addition, innovation contributes to the advancement of medicine. In the coming years the importance of innovation will be magnified, as the health afforded to developing populations becomes a global responsibility. Innovation, the creation of new ideas, aids progress. Although large revolutionary ideas have their place, novel ideas from unexpected places may be just as valuable. In health care a huge disparity exists across the globe. New and unique ideas are fundamental to improving healthcare situations, especially in resource-poor settings. The three salient characteristics of innovation are novelty, an application component and an intended benefit1. The idea I present here aims to demonstrate the three attributes of innovation while addressing an issue that continues to inhibit effective health-care provision in many resource-poor settings. Physical access and transport to health-care facilities is often cited as an explanation for poor health-care attendance in remote communities2,3. For many, health care can be accessed only on foot, be that ones own or those of a willing volunteer or two. The distance travelled by some is dramatic, and it may take several hours to reach a facility. For some, it may be preferential to use traditional medicines available closer to home. This can lead to individuals receiving less than optimal health care or else a significant delay to seeking conventional health care. Once it becomes clear that traditional medicines are leading to no improvement, some may choose to travel the distance. When such a person has then reached the facility, the capacity for conventional methods to treat severe or prolonged illness is greatly diminished and often leads to a poor outcome. In an effort to provide equitable and effective health care, various programmes have been initiated to improve this situation. Probably the most ideal solution, and one that has been scaled up in many communities, is moving health-care providers closer to the remote communities that require their services. Although people may still be required to walk, the reduced distance aims to reduce the impact of the barrier. This strategy has resulted in a number of rural clinics and health posts being constructed in various remote areas. Despite these facilities being ideally sited, many barriers have inhibited their universal success. Many staff have difficulty working for prolonged periods in remote areas. Widely dispersed rural communities make the logistics of placing such facilities very difficult and, as a result, such facilities often do not fulfil their potential. In addition, smaller facilities may be unable to provide comprehensive care, and therefore people may be required to travel even larger distances to get the specific health care they need. Various modes of transport are available, but most are

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unsuitable when considering programmes to improve transport to health care. Horses and other animals would require feeding and care to remain useful over time. Motor vehicles would require refuelling. In addition, motor vehicles especially would prove unsustainable with limited access to petrol in remote areas, resulting in unused and abandoned cars. Ultimately, both of these ideas create an unwelcome and sustained diversion of costs for the communities. One idea that has proved highly successful is that of the bicycle ambulance3-6. Essentially, this is a stretcher attached to a bicycle to allow transport to a health facility. Such bicycle ambulances have been shown to improve the health of participating communities, but, needless to say, flaws were apparent6. Those of us living in a society where most learn to ride a bicycle at an early age may find it difficult to appreciate that one would have to be trained to ride one. Although training is required, both men and women are trained by the partners behind the bicycle ambulance initiatives4. However, such vehicles provide transport for only one patient. Although this 1:1 ratio is better than the 2:1 ratio afforded by stretcher-bearers, in resource-poor settings with a high disease burden a more efficient method should be sought. Solar panels to harness solar energy in a practical way have been around since 1954. However, they have not been widely used due to inefficiency of energy capture and storage7. Recent sustainable energy incentives have led to significant levels of research and development into solar panels with improved efficiency8. Meanwhile, a concurrent drop in the price of solar cells allows the affordable manufacture of such a product9. This fall in price is probably due to an increased market and therefore improved economies of scale. With further development, it is likely that this situation will continue to improve. In the developed world, solar-powered vehicles are not widely considered as they would never match the speed and power of the cars we routinely use. Putting knowledge of these different situations together, one can see that there is an opportunity for innovation. The idea presented here is that of a solar-powered ambulance. This ambulance takes the form of a tricycle with a large trailer attached to it with a canopy of solar panels forming the roof of the trailer. The vehicle functions by using solar-generated electricity to power an electric motor for the tricycle, assisting the cycling action of the individual operating it. Approximately 450 watts of solar power would allow the vehicle to reach speeds of 1520 miles (2432 kilometres) per hour10. This is assuming both reasonable input from the rider and, reducing the top speed, the weight of an individual in the trailer. This development is significantly better than walking. It is even an improvement on the current bicycle ambulance in a variety of ways. Primarily, the additional solar energy would allow the ambulance to be much faster than a standard bicycle, allowing a faster transit to the facility. In addition, the solar energy would allow for a single individual to cycle, transporting multiple patients with less physical strain. Although this would reduce the maximum speed of the vehicle, the speed reached is unlikely to be significantly less than that of the standard bicycle. In such instances, the benefit is still apparent as the ratio of patients to transporters is higher. The dual-purpose canopy allows not only for power generation for the vehicle but also provides shade for the patient. Although this may seem a minor point, laying an

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incapacitated individual in the sun for any period of time may lead to deterioration. The canopy would lessen this effect. Furthermore, the tricycle-based design would allow for wider participation with regard to its operation. Despite the increased efficiency of solar cells, allowing more energy to be harnessed from the sun, issues relating to the efficiency of energy storage remain, so this vehicle does not have provision for storage. As a result, the vehicle would not work to its full capacity during the hours of dark. Nonetheless, its function as a bicycle ambulance with increased stability is retained, making it more versatile than a solar-powered car. This is also a relevant feature if the solar equipment were to fail, allowing the vehicle to remain functional for transporting it to an area capable of maintaining it. Again, this is an advantage over a car-based ambulance design. Although the solar-assisted feature of this product is what makes it unique, other features would have to be considered in the research and development of such a vehicle. For example, an enhanced suspension system to allow for negotiating tough terrain over long distances and a lightweight trailer would both be features worthy of consideration. The main advantage of this product is its increased speed and ability to transport many individuals without the need to refuel and with no diverted costs to the community. Solar power uses an energy source that many developing countries are rich in but do not tap. It also reduces the environmental and social impact of introducing polluting vehicles into a clean environment and fragile infrastructure. New developments can be viewed from both a patient and an organizational perspective1. The solar-powered tricycle ambulance presented here would be considered a positive introduction to health care by both groups. Organizations have the chance to improve health-care access by addressing significant barriers. In turn this may help reduce the burden of disease left untreated and could improve the heath indicators of the relevant community. From an individual stance, the prospect of receiving quality health care without the discomfort and disruption of alternative transport options could only be viewed as positive. The solar-powered tricycle ambulance is a way of improving access to health care for those who are still unable to benefit from even the simplest health care. Innovating for the health of all requires consideration of the barriers that face such communities and coming up with acceptable ways of broaching them. Innovation in health-care access is necessary, as it is something that significantly affects the provision of care to many communities worldwide. Technological advancements are important and necessary, but what use are they to those who suffer unnecessarily because basic antibiotics are days away from home?

1 2 3 4 5

Lansisalmi H et al. Innovation in healthcare: a systematic review of recent research. Nursing Science Quarterly, 2006, 19(1):6672. Kayemba P. Bicycle for health: appropriate mobility to improve access to Health. (www. mobilityandhealth.org/case/case_af.php, accessed 1 September 2009). African bicycle ambulances are making a difference. Bike Radar (www.bikeradar.com/news/article/ african-bicycle-ambulances-are-making-a-difference-15807, accessed 1 September 2009). Malawi and Zambia, bicycle ambulances, 20032005. Transaid (www.transaid.org/projects/malawiand-zambia,-bicycle-ambulances,-2003-2005, accessed 1 September 2009). Bicycle ambulances in Nepal. Practical Action (www.practicalaction.org/?id=bicycle_ambulances,

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accessed 1 September 2009). Bicycle ambulances. BEN Namibia (www.benbikes.org.za/namibia/projects/ambulances.html, accessed 1 September 2009). 7 Solar power and globalisation. The Globalist (www.theglobalist.com/rawmaterials/syndication/sample. htm, accessed 1 September 2009). 8 Solar panels: increasing efficiency. Device Daily (www.devicedaily.com/tag/solar-panels, accessed 1 September 2009). 9 Knoppers R. Thin-film solar cells heading for $1 per Wp. Glass on web, 2008 (www.glassonweb.com/ news/index/7986/, accessed on 1 September 2009. 10 Electric bicycles. Electric-bikes.com, (www.electric-bikes.com/bikes/bikes.html, accessed 1 September 2009). 6

Rufaro Ndokera is a medical student at the University of Leicester. She is continuing with her fourth year of a medical degree this September after spending the past year studying International Health at the University of Birmingham. The past year has provided her with insights into global health issues and increased her desire to work in the area of international health in the future. She looks forward to completing her studies and seeing the grassroots effects of future health-care innovations.

Show me the money!

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Brenda Ogembo, Kenya

sHow me tHe moneY! fRom RHetoRIc to ActIon In AddRessIng tHe globAl HUmAnResoURces-foR-HeAltH cRIsIs

As the effects of the global economic crisis are currently being experienced by the worlds richer nations, poorer nations bear a burden all the more severe. The need for innovative ideas, particularly in health, is as critical as ever, given the global burden of disease, and because during tough economic times like these, public health is further compromised, particularly in low- and middle-income countries. One of the areas of critical need is that of the health workforce. Despite the known global shortage of over 4 million health workers1, the challenges faced by health-care workers have long been neglected. The bliss of inaction does not stem from ignorance of the challenges faced by health workers, both in low- and middle-income countries and in the destination countries that health workers often migrate to, for they have been well documented. Yet, at the mention of such solutions as compensation, remuneration or support of health systems, policy-makers, implementers and economists all join in a whistling chorus to say it is impossible to pay health workers enough. Now without sounding too pessimistic, there have been strides made in the area of addressing the current human-resources-for-health (HRH) crisis. The Joint Learning Initiative2 and subsequent HRH-related publications, The world health report 2006 working together for health1 and, more recently, the Kampala Declaration and Agenda for Global Action all speak to these efforts3. The current suggestions around a draft code of conduct for the recruitment of international health professionals present further opportunities to address the challenge of the migration of health workers4. Yet this intervention addresses only the issue of poaching health workers and does not address the issues of ailing and inadequate health systems in low- and middleincome countries that often deal with the compounded burdens of communicable and noncommunicable diseases and high maternal and child mortality. At the heart of these systemic issues are poor governance and the lack of accountability among leaders in both the public and the private health sector. The hypersensitivity of political leaders to criticism, especially in countries where corruption is rampant, has hampered any real change in global and local governance. The lack of accountability in the management of resources has further hindered tangible progress even when resources have been made available. Accountability is lacking also on the part of rich destination countries, who receive health workers knowing full well that they are draining countries that badly need these very resources. On the other hand, the diminishing commitment of resource-rich countries only further constricts the limited resources available to combat poverty and address existing pandemics, not to mention new and emerging health challenges. The Canadian International Development Agency (CIDA), for example, recently reduced its list of target countries

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to 20, excluding such countries as Kenya, Cameroon and Rwanda, and reducing the number of countries that CIDA offers bilateral assistance from 14 to 65. Moreover, the European Commission gave only 4% of its official development assistance to the health sector6. European Union countries are not on track to fulfil their commitments to provide support7. These reductions and constrictions translate into poor health systems and further compromise the health status of populations in source countries. Health system reform and health system research have not received much support, yet it is the health system that is responsible for delivering changes to the health status of the population. Health workers form the basic unit of a well-functioning system. The continued undermining of health workers has led to increased migration in search of better working opportunities, better pay and a better life. Indeed, one expected outcome of the extended global economic crisis will be the increased migration of health and other professionals as demand for health-care workers increases in richer countries and conditions continue to diminish in poorer countries. Is the response to restrict movement? To do so would be a Band-Aid solution to a deepseated problem. If the current global economic crisis is the result of faulty policies over the past eight or so years in the United States of America, the current global health crisis is the result of even worse policies over a much more prolonged period of time. The solutions will therefore require careful short-term and long-term planning that are both overarching and context specific, and that target both micro and macro aspects of the health system. A multi-pronged, multisectoral and integrated approach is not only necessary, it is critical to ensuring short-term and longer-term success in addressing the current health-care challenges in the context of the HRH crisis. Hope? Despite the enormity of the problems faced in many countries, it is still better to have tried and failed than never to have tried at all. The election of US President Barack Obama has not only injected a surge of optimism around the world regarding what is possible when we all come together behind a cause, it has also brought a tangible shift towards global governance. This will undoubtedly affect the manner in which hypersensitive leaders interact with their developed-country counterparts and, by the same token, challenge developed countries regarding their role in supporting and, better yet, championing health-system support to low- and middleincome countries. The following are three areas if innovation towards strengthen health systems. Empower the health workers and health users in low- and middle-income countries. Most health workers leave because they know they can earn more money elsewhere, yet most would rather stay in their home country, were conditions better. Few are able to provide for the basic needs of their families on their appallingly low salaries. It is time to address remuneration and provide direct monetary support to health workers as a budgeting priority, particularly for countries where the migration of health workers is rampant. Once immediate needs have been met, longer-term solutions need to be sought through processes that include health workers at the decision-making table, particularly concerning negotiations with bilateral development partners. The Paris

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Declaration on Aid Effectiveness needs to be implemented to prevent donor fatigue in governments and to harmonize external support8. Improve on working conditions for health workers. Health workers in any setting are exposed to enormous occupational hazards; this is exacerbated by poor working conditions particularly in the context of HIV and new and emerging infectious diseases such as ebola and swine flu. The health of health workers needs to be safeguarded as a priority to prevent the loss of health workers due to injury or even death from exposure in the workplace. Addressing this critical area will make health workers safer, and they might reconsider leaving. Adopt information and communication technologies for health. Poor diagnoses and follow up have compromised the health of millions around the globe. Contrary to assertions about the use of information and communication technology in health being a luxury, I view it as a necessity. In the past 10 years, the upsurge in the use of mobile telephony has revolutionized communication in most low- and middleincome countries. In the past three years, there has been an upsurge in hand-held electronic devices that brings a whole new meaning to the term personal computer. Smart phones have made information available literally at our fingertips. Yet, in the health field, the revolution has yet to be realized. There is an urgent need to tap into the available avenues of technology to improve the health of populations. New cadres of non-clinical health workers need to be trained in data collection and analysis, and their skills harnessed, so as to ease the burden on already strained health systems but also to improve the quality and quantity of information that is available and so improve surveillance mechanisms. This will result in healthsystem strengthening and will undoubtedly have an effect on the migration of health workers. All of these solutions cost money. Indeed, innovating for health does not come cheap. However, we are at a point in time when we need not be shy about making investments, particularly in health. For how long will we tolerate close to 10 million child deaths a year due to preventable and controllable diseases? For how long will developed countries reap where they did not sow, poaching with one hand health workers from countries that so desperately need them and clenching the other hand into a fist that ought to provide the much-needed resources to build the very health systems they are undermining? There is a priceless window of opportunity, given the current shifts in global governance. The current HRH debates therefore need to evolve from policy to practice, or else we will continue to meet and discuss problems rather than celebrate and replicate solutions. It starts with valuing the men and women who support our health systems everyday by acknowledging the sacrifices they make and rewarding them accordingly for the much-needed work that they do. Paying them adequately is a necessary first step in showing that we appreciate them.

1 2 3

The world health report: working together for health. Geneva, World Health Organization, 2006 (www.who.int/whr/2006/en, accessed 1 September 2009). Human resources for health: overcoming the crisis. Joint Learning Initiative, Cambridge, Massachusetts, Harvard University Press, 2004. Kampala declaration and agenda for global action. Geneva, World Health Organization, 2008 (www.

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6 7

who.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20file.%20FINAL.pdf, accessed 1 September 2009). International recruitment of health personnel: draft global code of practice. Geneva, World Health Organization, 2008 (http://apps.who.int/gb/ebwha/pdf_files/EB124/B124_13-en.pdf, accessed 1 September 2009). Canada moves on another element of its aid effectiveness. Gatineau, Quebec, Canadian International Development Agency, 2009 (www.acdi-cida.gc.ca/CIDAWEB/acdicida.nsf/En/NAT-223132931-PPH, accessed 1 September 2009). Labonte R, Sanders D, Schrecker T. Fatal Indifference: The G8, Africa and Global Health. IDRC, 2004. Commission urges member states to raise development aid. Brussels, European Union, 2008 (http:// europa.eu/rapid/pressReleasesAction.do?reference=IP/08/535&format=HTML&aged=0&language=EN& guiLanguage=en, accessed 1 September 2009). The Paris declaration on aid effectiveness. Washington, DC, World Bank, 2005 (http://www.oecd.org/ dataoecd/11/41/34428351.pdf ).

Brenda Ogembo is a passionate advocate of global health born and raised in Nairobi, Kenya. A Lester B Pearson United World College alumnus, she received the Mary M Young Global Citizen Award for International Students at the University of British Columbia, where she completed a Bachelor of Arts degree. Brenda holds a Master of Science degree in Population and Public Health and in Global Health from Simon Fraser University, Canada. In 2008, Brenda was a research awardee at the International Development Research Centre, Canada, conducting research on physician migration from Uganda to South Africa and Canada. Brendas personal and professional goal is improving the health of vulnerable populations by improving health systems. She will begin her PhD in Population Health in September 2009 at the University of Ottawa, exploring source-country health system priorities regarding the migration of health workers.

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Aina Palou Serra, Spain

lA necesIdAd de tejeR estRAtegIAs colectIVAs pARA UnA tRAnsfoRmAcIn socIAl Y sUs consecUentes mejoRAs pARA lA sAlUd

Vivimos en un mundo donde el 20% de la poblacin consume el 80% de los recursos, donde el desarrollo econmico de una minora de pases se hace a expensas de la explotacin de una mayora, robando sus recursos, contaminando sus tierras, sus aguas y alimentos, rompiendo culturas y hundiendo en la miseria a poblaciones enteras. Hace tiempo que se advierte de las catstrofes que produce este coctel de desequilibrios, que aparte de injustos, son insostenibles. Ahora ha estallado la crisis advirtindonos que es necesario un cambio de rumbo, si no queremos ir a la deriva. Si hiciramos un anlisis del mundo en el que vivimos podramos detectar distintos indicadores (sociales, ambientales, culturales...) alarmantes, que nos sealaran un estado enfermizo en una etapa avanzada y crtica. Hasta ahora los distintos sntomas de este estado patolgico han sido tratados igual que la medicina moderna trata los sntomas de sus pacientes en la mayora de los casos, a base de parches (o pastillas), ignorando el origen del problema que, desgraciadamente parece ser el mismo para todo este abanico de sntomas. En ocasiones esta medicalizacin no da la oportunidad al propio cuerpo de autocurarse y (en la medida de lo posible) esforzarse por luchar contra sus crisis. En el mundo acelerado y productivista en que vivimos1 tampoco hay tiempo para tal fin (tienes dolor de cabeza? Aspirina, Gelocatil o Iboprufeno) y menos, en un mundo en el que an existen situaciones laborales precarias, donde se carece del derecho a estar enfermo o a ir al mdico, y se penaliza descontndolo del sueldo. La salud fue definida por la Organizacin Mundial de la Salud poco antes de los aos cincuenta como un estado completo de bienestar fsico, mental y social, y no solamente como la ausencia de enfermedad o invalidez. Aun as, en la realidad de los pases industrializados, parece ser que esta definicin se tenga poco en cuenta. El eje central de las polticas sanitarias se enfoca en la enfermedad y no en la salud (no casualmente) y an menos contempla la salud como un concepto social. As pues, nos encontramos en una sociedad que crece en valores decadentes, tales como el individualismo, la competitividad, el egocentrismo, el abuso de poder; inculcando la cultura del miedo, el control social y la no aceptacin de uno mismo, entre otros. La violencia estructural y cultural que vivimos provoca un sistema inestable, en el que hay que adaptarse constantemente a nuevos cambios, generando los consecuentes desequilibrios mentales que esto comporta. Estos, para mayor escarnio, son automticamente tratados con pastillas, o -en el mejor de los casos- usando la psicologa, que analiza el comportamiento del individuo en su contexto; pero la terapia sigue siendo individual, recayendo todo el peso de la curacin en la propia persona, sin intencin de hacer un cambio colectivo para transformar el contexto que oprime, y que es el origen del problema.

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Los desequilibrios sociales originan las desigualdades en salud (problemas en salud cuyo origen es social, es decir, poltico, econmico y cultural) que podran evitarse, y son injustas2. Estas desigualdades en salud (tanto entre pases como dentro de un mismo pas) afectan a los colectivos ms explotados, oprimidos o excluidos de la sociedad. Estos grupos sufren las diversas consecuencias; por una parte tienen menos recursos econmicos y en consecuencia, menos poder poltico (no hace falta recordar que vivimos en una sociedad donde el poder poltico lo tienen las empresas con mayor capital, y donde se penaliza y se reprimen los intentos del pueblo de alzar su voz y de participar en las polticas de su propia regin). Por otra parte, tienen peor atencin sanitaria y menos servicios sociales. Finalmente estn expuestos a factores de riesgo perjudiciales para la salud, ya sean de tipo social (violencia), laboral (condiciones precarias de trabajo, bajos sueldos, despidos, contratos basura) o ambiental (contaminacin). La salud (como otros derechos fundamentales tales como la educacin o la vivienda) ha cado en las manos del sistema capitalista, convirtindose as en uno de los mercados que ms dinero genera y que ms consecuencias negativas est soportando. Es por eso que la mayora de proyectos en investigacin y las polticas sanitarias estn determinadas por las necesidades de las personas con mayor poder adquisitivo. En las distintas ramas de educacin en ciencias de la salud (as como en otras ciencias) veremos un enfoque biomdico que fomenta una visin cientfica, tecnolgica, clnica, biolgica... y en definitiva, que fomenta la inversin en la industria biomdica, tecnolgica y farmacutica. La consecuencia de eso es la aparicin de especialistas que no contemplan la salud como un fenmeno social, y les cuesta ver ms all del mundo de las molculas. No digo que la biomedicina no haya aportado beneficios al mundo de la salud, pero estos no bastan. Adems, los distintos departamentos en reas de investigacin, as como en una consulta mdica, nos indican que al ser humano se le contempla por partes y no como a un todo, con sistemas integrados entre s (nervioso, inmunolgico, hormonal...), crendose especialistas que ignoran la conexin que existe entre estos. Al mismo tiempo tampoco ven al ser integrado en un ambiente. Esta especializacin en las distintas disciplinas hace que se pierda el sentido de un proyecto; un proyecto para la sociedad requiere que trabajen juntos mdicos, bilogos, socilogos, qumicos, antroplogos, especialistas en medio ambiente, pedagogos, artistas... En otros lugares donde la medicina social existe y se encuentra en un estadio ms avanzado que en determinados pases industrializados (concretamente en Latinoamrica, donde sta es reconocida en el mundo acadmico, en la administracin pblica, y donde trabaja junto a movimientos sociales y ecolgicos, y con la poblacin oprimida) se habla tambin de la salud como un proceso de construccin colectivo, en el cual la responsabilidad en salud es de todos. Existe un mtodo teatral (con implicaciones pedaggicas, sociales, polticas, culturales y teraputicas) que puede ser muy til en bastantes de los factores observados anteriormente y sobretodo en el ltimo. Se trata del Teatro del Oprimido, inventado, desarrollado y sistematizado por el brasilero Augusto Boal en los aos 60. Este mtodo est hecho para y por los oprimidos, que como antes hemos apuntado, son el grupo ms vulnerable en el sistema de salud.

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Un grupo que decide hacer un proyecto de Teatro del Oprimido, valindose del talento del joker (curinga en portugus: nombre que recibe un dinamizador en el Teatro del Oprimido) puede explorar a travs de un conjunto de juegos, su realidad y sus opresiones. El grupo aprende a detectarlas (y a no auto-culpabilizarse de una situacin conflictiva, en la que se encuentra en condicin de oprimido, aunque se le est responsabilizando de tal). Automticamente, despus de este proceso que provoca confianza de grupo, abandono de pensamientos mecnicos y que genera una serie de anlisis, se explora colectivamente la opresin sufrida, detectando su origen social, as como los distintos efectos que conlleva ( son ellos los protagonistas del anlisis de sus realidades). Se colectiviza la opresin. El colectivo busca y explora distintas estrategias para resolver tal situacin y transformarla (rompiendo as con la carga de la individualizacin). Esta exploracin ser a travs del cuerpo, del ensayo; ser vivencial y no a travs de teoras. Ser el propio colectivo que explorar su situacin y no sern solamente especialistas en el tema que busquen soluciones a situaciones no sufridas. Pero lo ms importante es que este proceso no terminar aqu, como lo mayora de arte-terapias, porque la finalidad del teatro del oprimido no es teraputica (aunque tambin tenga sus efectos). El Teatro del Oprimido pretende ser un arma de transformacin social. As pues, se puede materializar este proceso en una pieza de teatro-foro (pieza de teatro que abre un debate interventivo); eso servir para trasladar el problema a la sociedad y hacerle partcipe del proceso de transformacin. En el Teatro del Oprimido el espectador deja de ser pasivo (espect-actor) y pasa a ser protagonista de la accin dramtica (sujeto creador), estimulndolo a reflexionar sobre su pasado, modificar la realidad en el presente y crear su futuro3. Tambin, segn el proyecto, se podra ejecutar el teatro legislativo, dnde aparte de explorar las distintas intervenciones de la gente, algunas de stas pueden materializarse en propuestas de ley. Actualmente existen muchos grupos que usan el Teatro del Oprimido para tratar distintos temas relacionados con la opresin que conllevan distintos riesgos para la salud: mujeres afectadas por las consecuencias de un sistema patriarcal (mujeres que sufren violencia de gnero, o trastornos alimentarios), toxicmanos, personas con trastornos mentales, inmigrantes, personas sin techo, abuelas, jvenes, prostitutas, refugiados polticos, victimas de violencia sexual... El colectivo escenifica sus opresiones, explora sus causas, y busca estrategias para transformarlas en un planteamiento junto a la sociedad. En definitiva, es necesario contemplar la salud tambin como un fenmeno social, y como tal, tendr que ser tratada de forma social, encontrando estrategias para transformar las realidades sociales opresivas que conlleven riesgos para la salud de una forma colectiva y donde todos los participantes tengan la misma voz.

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Benach, Joan y Muntaner, Carles : Desigualdades en salud: una epidemia que podemos evitar. En: Kaos en la Red , 31 de agosto del 2008. URL: http://www.kaosenlared.net/noticia/entrevista-joanbenach-carles-muntaner-desigualdades-salud-epidemia-po Boal, Augusto. Juegos para actores y no actores. Barcelona: Alba editorial. Artes Escnicas, 2002. Boal, Augusto. Arco Iris del deseo. Barcelona: Alba Editorial, 2004. Jara, Miguel. Traficantes de Salud. Cmo nos venden medicamentos peligrosos y juegan con la enfermedad. Barcelona: Ed. Icaria, 2007. Landaburu, Eneko. Por una sanidad ms humana y ecolgica. En: Cuadernos de crtica de la Cultura. num.25 / p71-74. Barcelona: Ed. Archipilago. Iriart C, Waitzkin H, Breilh J, Estrada A y Merhy Emerson, E. Medicina social latinoamericana: aportes

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y desafos. En: Revista Panamericana de Salud Pblica. Vol. 12(2), 2002. Motos, Tomas. Teatro imagen: una estrategia para la creatividad social. En: Revista Recre@rte N3, junio 2005 ISSN: 1699-1834 URL: http://www.iacat.com/Revista/recrearte/recrearte03/Motos/teatro_ imagen.htm Weinstein, Luis. Salud y Autogestin. Montevideo: Ed. Nordan Comunidad, 1989. Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine in Latin America: productivity and dangers facing the major national groups. En: The Lancet, Vol. 358, 2001.

Aina Palou Serra naci en 1984. En 2007 finaliz estudios de bioqumica en la Universitat Autnoma de Barcelona. Actualmente adelanta un doctorado en neurotoxicologa en el Institut dInvestigacions Biomdiques de Barcelona (CSIC-IDIBPAPS) y paralelamente forma parte del grupo de Teatro del Oprimido Teatraviesas y de otros movimientos sociales. En estos espacios ha ampliado su conocimiento acerca del potencial de la construccin colectiva y ha enfatizado crticamente diversos aspectos de las relaciones de poder, tales como las propias al modelo patriarcal o al sistema capitalista.

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Aakanksha Pande, India

bUsIness not As UsUAl: ImpRoVIng tHe qUAlItY of HeAltH cARe tHRoUgH InnoVAtIon

Parvati came to give birth at a rural health centre in Bihar, India. She was 27 and could not read. Her husband earned less than a dollar a day. She belonged to the Yadav caste, euphemistically classified as an other backward class. I was there to understand the governments health programme as part of a World Bank team, so her presence at the centre ostensibly meant a check in my spreadsheet. The programme was enabling access to health services for the poor and marginalized a step towards the goal of health for all. But was it? Parvatis experience in terms of the quality of care she received speaks volumes. She was admitted four hours after arrival and was laid on a rusted metal table. The roof of the clinic was broken, exposing her to dust and rain. Raw garbage was strewn around her. There was no doctor at the clinic. There was little medicine. A single nurse was overwhelmed with some 40 cases a day. Would Parvati have been safer in her hut with a traditional birth attendant delivering her baby like previous generations of women in her family? Perhaps. For, while she could access the clinic, she remained tragically unable to access health care. The mantra of health for all has undoubtedly resulted in an increase in access to health services in many contexts; however, the quality of care received remains unacceptably low in the developed and the developing world1. In the developing world, studies on medical providers in the public sector in Ecuador, Indonesia, Peru and Uganda found that 35% of health workers were absent2. My own fieldwork in India as a graduate student and later as a public health practitioner reinforced these findings. On rural visits, I consistently found a shortage of certain types of health providers such as anaesthiologists and male nurses. These problems are by no means limited to the public sector. Research in a middle-class neighbourhood in Delhi showed that the Rule of three governs doctor-patient interactions in private clinics on average, the doctors surveyed spent three minutes with the patient, asked three questions and prescribed three medications (often unnecessarily)3. Yet poor quality of care afflicts the developed world as well. Studies in the United States of America show that only 54% of patients admitted to hospitals get the recommended medical care4, medical error results in the loss of 44 000 to 98 000 preventable hospital deaths per year5,6, and significant geographic and racial disparities affect the quality of care7. A gap exists between what we know and what is done. To bridge it, innovation is required an ability to challenge the convention of doing business as usual. While innovation conjures up images of hi-tech gadgets and expensive ideas, it need not necessarily require large inputs of capital. It is simple interventions that fascinate

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me innovations of thought. They are pioneering by looking at fields outside of health care to draw lessons. By understanding the main sources of poor quality and addressing them through often obvious ideas, innovation can enhance the quality of care and save many lives. In fact, it already has. In the developing world, an experiment from the education sector that can be applied to the health setting involves using disposable cameras to reduce teacher absence. Teachers in Udaipur District in Rajasthan, India, were given disposable cameras and had to take a picture of themselves with their class at the start and end of each school day8. The cameras had a tamper-proof system that recorded the date and time the photograph was taken. Teachers salaries and bonuses were partly based on the number of photographically proven days that they were at work. Teachers felt that they had the power to increase their salary through this impartial assessment. As a result, the intervention halved provider absence. In the United States of America, a set of innovations introduced by Allegheny General Hospital resulted in a 95% reduction in deaths, sustained over a three-year period, due to central line infection in intensive care units9. The hospital team looked beyond the medical field for inspiration, using quality-improvement principles pioneered by Toyota. The innovations were simple and included scrutinizing data in real time and asking a set of whys as soon as a line infection was detected. By drilling down to the source of each case, they achieved significant drops in mortality by standardizing the pre-procedure checklist, line insertion kit and dressing kit. The innovations were not revolutionary their impact was. Some innovations have had success in both the developed and the developing world. The World Health Organization recently introduced a 19-point Safe surgery checklist in hospitals in Canada, India, Jordan, New Zealand, the Philippines, the United Kingdom, the United Republic of Tanzania and the United States of America. The checklist has resulted in a 50% reduction in death and 40% reduction in surgeryrelated complications10. If you look at the checklist, you will be surprised at the items on it: Confirm that all team members have been introduced by name and role and Confirm the patients identity, surgical site, and procedure. These seem to be obvious steps. But they were not always being implemented. The list of innovations to improve health quality is not always documented. Through my experiences in global health, I have come across small ideas with large impacts. A project in Afghanistan retained nurses in rural areas by providing them with DVD players and small generators; Bollywood kept them entertained while stationed at remote outposts. A maternal health programme in Pakistan allowed female health supervisors husbands or male relatives to be drivers in the programme; the presence of a family-approved male allowed them to travel to their field sites so they were more effective at their job. How then can such innovations be applied to improve Parvatis plight? Based on these examples, I have come up with a few ideas for public sector clinics in the developing world. Borrowing from the consumer movement, health clinics can formulate and post a patients bill of rights, which informs patients what services they should receive. The charts should have symbols and pictures to convey the message to uneducated audiences. A telephone hotline should be available to which patients can complain

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if a right is violated (such as a doctor not being present during working hours or the building not being maintained). With the enormous penetration of cell phone technology in the developing world, most patients can easily call and a register a complaint, empowering them and creating a body of evidence about poor quality of care that can be acted upon. In addition, as with the private sector, promotions in the medical sector should not be based just on tenure. Interviews with doctors in the public sector in India conveyed that there was little incentive to show up at work, since they received a salary based solely on how many years of service they had logged. Incentives and promotions should also be based on attendance and certain quality measures (appropriately adjusted for the severity of the case mix). Data on performance can be partly based on hotline complaints. A space has to be made for these types of innovation in the delivery of care. A literature search on quality of care in the developing world brought up lists of indicators, often in conflict with one another. The thrust of the argument was to standardize ways of measuring the quality of care towards creating a baseline. Why does the process towards improvement have to be so linear? Measurement is important. But, concurrently, health systems need to be broken down into parts; the weaknesses have to be understood. We have to constantly question even the most obvious processes. Is the right patient being operated on? Are nurses washing their hands? Are doctors showing up at work? And, if the answer is no, the questioning must relentlessly continue: Why is this happening? What can we do to change this? How can we innovate? Public health has made great strides in ensuring that more people are able to access the health system. We now need to complete that compact. Once people are in the health system they must get safe, efficient, timely, patient-centred, effective and equitable health care11. Only then can women such as Parvati harness the health system and get access to the health care that they deserve. Otherwise, health for all will simply remain yet another catchy public health slogan, an unachievable dream.

Authors note: The patient interaction described is fictitious but is based on anecdotal and photographic evidence from meetings with non-profit-making health groups in Bihar in April 2006.

2 3 4 5 6 7

Quality is defined by the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine. Washington, DC, National Academies Press, 2001. Chaudhury N et al. Missing in action: teachers and health worker absence in developing countries. Journal of Economic Perspectives, 20(1):91116. Das J, Hammer J. Money for nothing: the dire straits of medical practice in Delhi, India. Journal of Development Economics, 2007, 83(1):136. Mc Glynn et al. The quality of health care delivered to adults in the United States, New England Journal of Medicine, 2003, 348 (26):26352645. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC, National Academies Press, 1999. Brennan et al. Accidental deaths, saved lives, and improved quality. New England Journal of Medicine, 2005, 353(13):14051409. Fisher ES et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Annals of Internal Medicine, 2003, 138(4):273287.

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Banerjee A, Deaton A, and E Duflo, Wealth, Health, and Health Services in Rural Rajasthan, American Economic Review Papers and Proceedings, 2004, 94(2), 326-330. 9 Shannon RP et al. Using real-time problem solving to eliminate central line infections. Joint Commission Journal on Quality and Patient Safety, 2006, 32(9):479487. 10 Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 2009, 360(5):491499. 11 The SEPTEE criteria for quality as defined by the Institute of Medicine. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC, National Academies Press, 2001.

Aakanksha Pande is a doctoral candidate in Health Policy at Harvard University, where she is researching disparities in the quality of care in Mexico at the Harvard Pilgrim Health Care Institute, Department of Population Medicine. Aakanksha graduated with distinction from Yale University, double majoring in Molecular Biology and International Studies. She was a Fox International Fellow at Cambridge University in the United Kingdom and holds a Masters in Population and International Health from the Harvard School of Public Health. She specialized in monitoring and evaluation as a junior professional associate at the World Bank, focusing on health projects in India, Pakistan and Sri Lanka. An Indian citizen, Aakanksha grew up in Bombay and South Korea, Hong Kong and Bahrain.

Can todays health challenges be overcome?

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Marian Angelica Panganiban, Philippines

cAn todAYs HeAltH cHAllenges be oVeRcome? wHY InfoRmAtIon, cooRdInAtIon And InnoVAtIon mAtteR

The incentive to innovate. When we speak of innovation for the health of all, we not only inquire about the progress of existing technologies and strategies to improve health outcomes, we also ask questions about access: How do we make sure that these technologies benefit those who really need them? And how do we transform what we discover, develop and create in our laboratories into replicable and accessible products and services for everyone? The importance of medical research in terms of producing scientific and technological knowledge to help us tackle todays health challenges is well established and much emphasized in public discourse. Higher levels of funding and intense public attention towards developing new cures and addressing the human bodys frailties manifest the increased centrality of health issues in our society. However, such focus, while very helpful, can also be limiting. Attempts to deepen our understanding of the human body and the search for new and better responses to its diseases are vital starting points, yet such attempts will be incomplete if the existing socioeconomic framework is unable to channel the scientific gains made to those who need them most. This challenge is particularly salient in developing countries. To address this, social innovation must also take place to enable technological innovation to fulfil its promise. Will developing countries have the incentive to innovate? My hopeful answer is yes. Most developing countries, since they are restricted by limited budgets, cannot afford to support pricey health-care services, much less carry out ambitious research projects. Yet such constraints can become opportunities for innovation particularly social innovation. Instead of focusing on devising expensive technologies or carrying out research that requires large initial investments, developing countries can prioritize implementing strategies that promote the efficient use of resources to improve health outcomes. The need for coordination. How exactly can this take place? There can be as many possible solutions as there are problems, but, as in any medical intervention, we should be wary of administering a policy cure that is worse than the disease. We have to keep in mind that, most of the time, the solutions we formulate can generate their own set of problems. Improving health outcomes through the efficient use of resources in developing countries implies that we would have to contend with corrupt governance, poorly devised or poorly implemented policies, weak institutions, and powerful interest groups, among other things. It is easy to become resigned amidst the complexity and enormity of the challenges that beset us. Nevertheless, we must remember that the challenges are only difficult,

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Marian Angelica Panganiban

not insurmountable. Before any intervention or proposed solution can be realized, it is first imperative that we be able to determine what is efficient and effective. A priori knowledge, experience and intuition can guide us only to a certain extent. But when resources are scarce and the challenges are plenty, it is best that we be able to identify exactly what can help us produce the maximum positive impact with the least resources. Hence, our policy and programmes must be as well informed as possible about social, economic and behavioural aspects of health in a given context. Such knowledge allows us to customize technological innovations to suit the social and institutional setting where they will be applied, thereby enhancing their impact. Thus, a different kind of research would be needed, one that is conducted outside the controlled confines of our scientific laboratories and that requires us to creatively investigate through the messy world of field work. Fortunately, this is already widely practised; most social scientists conducting these kinds of research have shown tremendous creativity and insight in making sense out of the data they have collected. Sadly, most of the tools they have developed are infrequently used or ill used by policy-makers and implementing agencies when it comes to formulating social interventions. If the goal is to ensure innovation for the health of all, there must be a concerted and coordinated effort among medical and social scientists, public officials, nongovernmental organizations and funding agencies to ensure success in this endeavour. Coordination is made even more vital by the fact that most medical interventions have consequences that go beyond a persons physical welfare, and some non-medical programmes and tools have a direct impact on ones health status. For developing countries, it is not the groundbreaking medical discoveries that produce the most impact but, rather, the availability of common cures and treatments to the large number of people who need them but could not previously afford them. Take the case of the treatment of intestinal worms in schools in Kenya. A study showed that a deworming treatment that costs 49 US cents per child per year can reduce absenteeism in school by one quarter. This was largely because worms are transmitted by walking barefoot in places where other children have defecated. When the impact of deworming was compared with other programmes for improving education outcomes, deworming was found to be nearly 20 times as effective as hiring an extra teacher1. Our preliminary research last year on a gawad kalinga (caregiver) community that benefited from a private-sector-initiated programme rehabilitating the homes of squatter communities in the Philippines showed that the programmes most significant welfare impact was made by providing households with access to clean water, which improved the families overall health status2. Other studies on peoples discounting behaviour have led researchers to design commitment contracts to combat smoking addiction in the Philippines3. Health objectives are now also incorporated in the conditional cash assistance programmes of some developing countries4. Promoting long-term relationships among researchers and implementing organizations can go a long-way when it comes to ensuring both the complementarity and sustainability of programmes and policies to be implemented. Strengthening coordination also encourages ongoing learning that informs policy and improves research. Instead of functioning merely as post hoc evaluators, researchers can very well be part of the process of developing the interventions to be made by answering policy-relevant questions. Furthermore, coordination also supports better information

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sharing, as a research-based, multisectoral programme and policy framework clarifies the many aspects of health issues. Current policy debates on health issues in most developing countries usually sink into applying divisive labels that only serve to polarize the public and dissuade action. When information is credibly produced, properly communicated and effectively utilized, we are able to avoid the confusion that considerably thwarts our efforts to improve health for all. The importance of information. Information is both powerful and empowering. This insight is especially useful in the health sector, where information asymmetries abound. Apart from establishing functioning relationships among various sectors, another key area of innovation both social and technological would be in instituting links for information-sharing. Perhaps we can utilize existing technologies ubiquitous on the World Wide Web, where platforms for networking and sharing user-generated content thrive. The ability of the Internet not only to tap a broad base of people but also to specifically respond to the information needs of individuals can be incorporated in our health-response frameworks. It is now apparent that the old physician-patient relationship, in which the physician serves as the supreme source of knowledge, is insufficient when it comes to effectively answering the health needs of the patient. Todays health challenges require cooperative interactions; information can be exchanged among patients with similar experiences and among doctors who encounter related problems. Initiating global doctor and patient networks akin to those formed through social networking sites and utilizing interactive platforms via the Internet may be helpful when it comes to dismantling information barriers and advancing equitable health-care access. This would help patients assume greater control over their own health affairs and assist them in making more informed decisions. Information campaigns can also help patients appreciate treatments and services that they otherwise would not have availed themselves of for lack of information. Sometimes, the problem is not the under-provision of health services but underconsumption; the pertinent health challenge is getting people to avail themselves of less-costly preventive measures, since most people are not aware of the benefits these preventive measures bring, vis--vis the costs of future treatments. If we believe that health is a complete state of well-being, then it is important that we understand and address not only human vulnerabilities but also institutional and environmental vulnerabilities. Taking this into account, the goal of innovating for the health of all becomes more encompassing and the scope for relevant involvement expands. As the challenges we encounter become almost inexorable, so our energies must be inexhaustible. Our efforts, though, must always be guided by informed choices. Before we can build effective national health-care systems, design appropriate incentives for increased private and public sector involvement in health, develop and measure comparable health indicators across countries, and devise suitable financing strategies and equity programmes, we all need to become better-informed scientists, researchers, policy-makers, leaders, volunteers, health-care providers and citizens. With an intelligent and coordinated approach towards innovation, the health challenges we face are truly far from insurmountable. They can be overcome.

1 2

Banerjee A, Duflo E. The experimental approach to development economics. CEPR Discussion Paper No. DP7037, 2008 (http://ssrn.com/abstract=1311161, accessed on 2 September). Baluyot B, Panganiban M. Housing as a building block of welfare: an impact assessment of Gawad

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3 4

Kalinga in Laura [thesis]. Diliman, University of the Philippines School of Economics, 2008. Xine G et al. Put your money where your butt is: a commitment contract for smoking. 2008 (http:// www.ftc.gov/be/workshops/microeconomics/docs/karlan.pdf, accessed 2 September 2009). Soares S et al. Conditional cash transfers in Brazil, Chile, and Mexico: impacts upon inequality. Brasilia, International Poverty Centre, Working Paper No. 35, 2007 (www.undp-povertycentre.org/pub/ IPCWorkingPaper35.pdf, accessed 2 September 2009).

Marian Angelica Panganiban is currently a graduate student in Economics at the University of the Philippines School of Economics and a fellow at the Philippine Centre for Population and Development. Her interests include health policy and systems research, priority setting, and research communication. She is an active volunteer in several organizations that aim to improve access to health and education in the Philippines.

Realigning interests and resources for health technology development

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Samuel Pickerill, United States of America

ReAlIgnIng InteRests And ResoURces foR HeAltH tecHnologY deVelopment In tRAdItIonAllY UndeRseRVed mARkets

My first taste of debilitating poverty and great inequality came during my first trip to South Africa. During this trip I spent most of my time in mobile clinics run by 19- and 20-year-old medical students and in public health clinics short of staff but carrying on despite the twin epidemics of HIV and tuberculosis. I was struck and disheartened by how technology had failed to provide solutions for these health problems. In the clinics I visited, a flood of donated medical equipment lay unused in spare hallways or sprawled out into busy emergency rooms. In the three years since that first trip to South Africa, I have seen that my experience there reflected a much larger problem with the basic relationship among corporations, innovators, the global health community and communities in need. While working in South Africa with universities, local and international nongovernmental organizations (NGOs) and government bodies, I recognized two fundamental problems with technology in the developing world. First was a lack of corporate involvement in product development stemming from the perceived lack of economic viability and entrepreneurial opportunity for health-care products in poor areas. Second was the absence of any major effort to change this, which stems from the lack of incentives or practical collaboration among industry, governments and larger networks of global health. The process of technology innovation and product development in highincome markets involves the efficient coordination of ethnography followed by design, marketing and product delivery. As products are designed, the market is studied and stakeholders are prepared for delivery, increasing success and impact. This is rarely done in low-income markets, where innovation is absent or is present only in fragmented forms of inappropriate technology in markets that are not invested in its use. This must change, and there must be integration of research and development, product development and health-care delivery for low-income populations. This will require restructuring the relationship between industry and global health bodies so that both are focused on bringing innovation to communities in need. In my experience key parts of this will be innovative partnerships and product development that reach profit targets through designs for underserved populations. After working in South Africa on public health implementation projects, I became a part of the Center for Innovation in Global Health Technology (CIGHT) at Northwestern University, United States of America. CIGHT, funded by the Bill & Melinda Gates Foundation and partnering with Abbott Diagnostics, is developing new point-of-care technology for HIV diagnosis and control through rapid viral load testing and early-detection diagnosis for infants. Although the primary goal is to bring technologies and improved health to areas in Africa, the rapid and lowcost diagnostic methods are also relevant to industrialized markets. Profits can then flow into further product development and innovation. Through this ongoing

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Samuel Pickerill

partnership, Abbott is allowed to market and commercialize these products or utilize the technology to develop new products but has agreed to take no profit from diagnostic sales in low-income markets. CIGHT is one successful case study that reveals several compelling reasons for industry to design for developing world markets. Design for development can help a company utilize existing intellectual property and off-the-shelf technology in new ways and combinations that might not have been realized before. This process not only identifies new technologies but also identifies and cultivates highly creative individuals within the company or even potential new employees that are involved in the process. For instance, the CIGHT partnership has identified new entrepreneurs and designers that have been trained through the process of innovating for the developing world. This uncovers an intangible benefit of design for underserved markets: the promotion of a culture of change and innovation as well as entrepreneurial activity within an industry. During my university studies and research in South Africa, I was struck by the importance of community culture for both communities and businesses. In Bowling alone, by Robert Putnam, the Harvard sociologist explains that the driving force behind sustained innovation in Silicon Valley is a unique combination of vast academic resources and skilled labor with a strong community and entrepreneurial culture. Both business and community development strategies suggest this culture is best developed through a shared experience of overcoming an obstacle together. In my experience, innovation for underserved communities provides a perfect activity to build a new sense of community and a culture of change in both companies and communities. Working with communities through ethnographic studies and design-specification development makes products not only more likely to meet a communitys need but also more likely to be accepted by the community and market. Furthermore, design for the developing world poses new design obstacles that challenge assumptions about technology and may lead to revolutionary products. This is a core step for the change model described by Richard Tanner Pascale and Jerry Sternin, which utilizes new ideas that question technological assumptions and provide a supportive culture for the growth of this idea. Just asking the question Can we design a diagnostic that is more rapid and sensitive and can be used by almost anyone in Africa? begins to change the way existing technology is viewed. This design challenge has created huge advances in diagnostic technology at CIGHT. By questioning the basic assumptions about how current molecular diagnostics are used and designed, new ways to drastically decrease the processing time and cost while improving the quality of results have been found. This innovation will continue to have relevance in both developing and developed markets. My experience with a start-up in China provides further evidence and shows that this new approach to partnership and innovation can be done in a developing country without foundation support. It also shows how technology can have success in multiple markets. BioUstar is a company based in Hangzhou, China, that has developed a platform of molecular diagnostics for tuberculosis, human papillomavirus and other infectious diseases. BioUstar brings together diagnostic and biotech expertise developed in the United States of America, where the founders were trained, and an

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understanding of Chinese business and manufacturing. Their success has been in the form of new products that will bring needed diagnosis of infectious diseases, as well as the training of local talent. Their products have also found a market in the United States of America, and one product is currently being used by the company BioHelix in its rapid nucleic amplification system. However, they have had less success in reaching low-income markets in China, the markets that they originally set out to serve. Reflection on the past year suggests that this is due to a lack of services and resources for companies looking to serve low-income markets, provided by those who currently control health-care provision in these markets. Industry involvement in low-income markets has been limited by economic and structural barriers. Economic barriers can be overcome, as suggested by my examples above, as well as work by CK Prahalad and Nobel Prize winner Muhammad Yunus. Prahalad suggests that there is a fortune at the bottom of the pyramid that requires only a restructuring of business that is more efficient and understands low-income users needs. Yunus suggests that social motives do not need to be separated from profit motives and that a new type of business termed social business is possible. My argument is that economic incentives for health-care companies actually lie in the process of design and innovation for underserved populations. Unfortunately, structural barriers still need to be overcome, including limited access to market data for local populations, lack of access to health-delivery organizations and poor coordination between those innovating and those providing care. These barriers can be overcome, but it will require a more active role in the process of innovation by the global health community. Both governments and health-related organizations must begin providing incentives for companies looking to innovate for the poor. As seen by the CIGHT example, foundation support combined with university and company resources can bring solutions to complicated health problems. Beyond solely providing financial support, health-care groups need to actively provide access to local needs and community participation, as well as to help prepare governments and health systems for technology innovation and introduction. This can provide pressure for a large-scale restructuring of health-technology innovation. The payoff is a concrete way to promote new entrepreneurship and motivate changeagents on projects that matter, as well as the potential for revolutionary product development that serves both social and profit motives. This will offer corporations the opportunity to tap into both internal and external resources previously unharnessed and will allow NGOs, universities and the global health community access to productdevelopment assets. I have personally seen how companies can benefit from designing for the developing world and have witnessed the results of innovative partnerships and strong relationships among governments, non-profit-makers, profit-makers and communities. The way forward is to integrate the most powerful innovators in the world with the most successful global health bodies in the world. Only when these major actors begin aligning resources and interests will technology innovation begin providing health solutions for the poor and lead to real health improvement.

Samuel Pickerill is a Fulbright scholar working to develop new tuberculosis design strategies in partnership with Fudan University in Shanghai. While completing his Masters in Biomedical Engineering from Northwestern University, Samuel worked with a team designing low-cost HIV

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Samuel Pickerill

diagnostics. This degree built upon a yearlong Whitaker International Scholars Programme in South Africa, where he partnered with the University of Cape Town to design methods for developing world issues while investigating the ways technology affects health outcomes. From his farming hometown of Genoa, Illinois, to urban China, Samuel is driven by the vision that technology design in partnership with community organizations can catalyze social improvement and development.

Disruptive innovation as the new paradigm of global health

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Soumya Rangarajan, India

dIsRUptIVe InnoVAtIon As tHe new pARAdIgm of globAl HeAltH

No course is ever completely free from hazard; but the greatest of all risks is when risk is shirked. Sir Victor Wellesley, 1944 I step into a sparkling lab at the Massachusetts Institute of Technology (MIT), where my guide hands me a device the size of a computer chip and seemingly as complex. I hold it up to the late evening sun that shines through the large glass windows and peer into the nanometric channels. Meanwhile, in the earths other hemisphere, the same sun rises on a dusty village in southern India, where a group of young boys and girls sit on the rocky floor of a narrow hut, listening attentively to the schoolteacher presenting their beloved maths lesson. They will one day carry this knowledge to engineering labs at their local university, little aware that the broken, obsolete equipment that they will find there could dash their innovative dreams. The chip is a microfluidic device for the rapid analysis of CD4, an antigen used to detect T-cell levels and immune system health in HIV-positive patients. The device is destined for regions like southern India, where HIV is spreading at an alarming rate. However, in the midst of a spiralling financial crisis in the United States of America, even prominent institutions like MIT cannot be spared from considering major tradeoffs in their research efforts. Millions die every year in the developing and developed world alike because they lack access to basic needs like clean water and sanitation. The public health community questions whether experimental technologies, such as the CD4 test, are worth their cost when much simpler, more cost-effective health interventions exist that can immediately save lives. In the midst of this controversy, is it possible that the global health community, dedicated to serving the most indigent populations and marginalized areas of the earth, can learn critical lessons from the hard-nosed business world? Research centres like the Carlos Finlay Institute in Havana, Cuba, have a revolutionary answer. In the 1990s, this institute created the first completely synthetic vaccine against Haemophilius influenzae, a major cause of death from bacterial meningitis in the developing world. Cuba, a country with one of the lowest per-capita gross domestic products in the western hemisphere, was able to find an innovative, cost-effective method to treat a deadly infectious disease affecting the worlds poorest children. This vaccine has become such a resounding success in Cuba that it is the only Haemophilus influenzae type B vaccine on the Essential Medicines List of the World Health Organization1. Meanwhile, the few major vaccine producers in the US and European pharmaceutical industries remain chronically underfunded due to the high-risk, low-reward nature of vaccines, which must be sold at or below their (significant) cost of manufacture2.

Young Voices in Research for Health 2009

Soumya Rangarajan

This dichotomy between Cubas innovativeness and the risk-averse nature of the United States of America, calls forth a term often bandied about in high-technology and business circles (and more recently among policy-makers) but largely overlooked in public health: disruptive technology. This term was coined by Harvard Business School professor Clayton Christensen in his famous 1997 book The innovators dilemma to describe innovations that underperform compared to available market technologies but appeal to new groups of consumers due to their simplicity, easeof-use and low cost3. Such disruptive technologies abound in global health. By pitting innovation against costbenefit analyses, the public health community has disregarded a critical set of tools that could directly save lives and lead to better health outcomes worldwide. Innovation and global health can be integrated through cooperation on three levels: across national borders, across various disciplines and through partnerships between the public and private sectors. By presenting examples of disruptive technologies I have come across in my own research and experiences, I demonstrate that taking high risks in global health can reap huge rewards. Cubas development of the vaccine demonstrates that ingenuity is abundant in what can seem the most unlikely places, as long as it can be harnessed through available resources. This is the raison dtre for a small social enterprise called Seeding Labs, based at Harvard Medical School. This group sends unused lab equipment from major US medical centres to scientists in developing nations. The strategy of Seeding Labs negates the veritable dogma of public health that innovative research can occur only in the rich world and must be transferred to developing countries far downstream in the product cycle (e.g., delivered as a finished vaccine to community health workers). The idea is bold: Scientists in the developing world set their own research priorities and use state-of-the-art equipment to create medical products that meet the needs of their own populations in a culturally sensitive manner. Unfettered by the demands of shareholders or US government research grants, these scientists can tackle diseases that are given little thought in the United States of America, such as schistosomiasis, malaria or many other diseases we are not even aware of in the developed world. This is a disruptive innovation because, although research and products coming out of South America, Asia or Africa will not compete in US or European markets, they open up tremendous new opportunities to address the needs of the worlds forgotten poor. Another example of a disruptive technology comes from the heart of US innovation, Silicon Valley. The small start-up company Amyris Biotechnologies has demonstrated not only that profit need not be the primary motivation in an early-stage, highrisk venture, but also that one technology can be used across various academic disciplines to solve diverse social problems. Founded in 2003 by a group of scientists with diverse backgrounds in environmental, medical and engineering studies, Amyris decided to tackle a difficult problem: creating high-yield synthetic products using inherently cost-efficient processes provided by nature. They decided to test their synthetic biology process using artemisinin, a rare Chinese herb critical in combination therapies against drug-resistant strains of malaria. Amyris successfully mass-produced a precursor to artemisinin and has licensed this process to various non-profit-making organizations, including the Institute for OneWorld Health (itself an innovative global health venture). Meanwhile, Amyris has extended its innovation to the profitable and socially important area of renewable fuels. Amyriss work on artemisinin is a disruptive innovation because the product may not be as effective

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as the pure (and very costly) herb, but it provides a cheap and scalable way to manufacture a medicine essential to the battle against malaria in the tropics. These two case studies demonstrate that international teams that include scientific, clinical and socioeconomic experts in global health, and that obtain funding and resources from various organizations and sectors, can reach innovative solutions to difficult global health problems. They are also examples of disruptive technologies with the potential to transform the way global health is practised. However, the most critical aspect of ensuring the success of any disruptive technology is empowering a broad, diverse population. In global health, this means transferring leadership across all parts of the social-value chain to developing countries. In the midst of the global financial crisis, the way public health has traditionally been practised, with a topdown, philanthropy-driven model, is no longer sustainable. In addition, the globalization of markets and the dissemination of knowledge and information through the Internet have dissolved the significance of national borders in science and society. This provides an opportunity for a sea-change in thinking among all types of global health practitioners. True global health innovation will occur when scientists in university laboratories or science clusters in the developing world can conduct research and create products that will be profitably marketed by locally sustainable businesses to the individuals around the world that need them most. Back in the MIT laboratory, I learn that once the manufacturing of the microfluidic CD4 devices can be scaled up to mass production, the chips will cost a dollar apiece, allowing them to be distributed en masse to extremely overburdened health clinics in the developing world. This quick, cheap way to track HIV-positive patients health could free up scarce labour and financial resources to address numerous other health concerns, from clean water to diabetes. I picture those children in India in the near future, their eyes wide with excitement as they look at the gleaming new equipment available in their local university to create high-tech microfluidic devices and improve the health of their own communities, and I cannot help but smile.

2 3

Rangarajan S. Sin azcar no hay pas [No sugar, no country]: the development of health biotechnology in Cuba. Boston, Massachusetts, John F Kennedy School of Government, Harvard University, 2007 (www.soumya.us/PED118.html, accessed 2 September 2009). Poland GA, Marcuse EK. Vaccine availability in the US: problems and solutions. Nature Immunology, 2004, 5(12):11951198. Christensen C. The innovators dilemma: when new technologies cause great firms to fail. Boston, Massachusetts, Harvard Business School Press, 1997.

Soumya Rangarajan grew up in Cleveland, Ohio, in the United States of America and received her Bachelor of Science degree from the University of Michigan in 2006, majoring in political science and general biology. She received high honours for her political science senior thesis, which analysed the role of science and technology in the developing world. She subsequently received a Master of Public Policy degree from the Kennedy School of Government at Harvard University in 2008. Soumya will be starting medical school in 2009 and intends to become a physician-researcher and policy-maker focusing on using innovation to address major health policy issues in the United States of America and around the world.

Young Voices in Research for Health 2009

Erin Rayment

Erin Rayment, Australia

let tHe mAcHInes do tHe woRk: AUtomAtIon And tHe dRIVe foR globAl HeAltH InnoVAtIon

As Mark Twain said, You cannot depend on your eyes when your imagination is out of focus. This is true for many things, but in my opinion health innovation, especially health innovation aimed at developing populations and marginalized communities, is at the top of that list. Innovation in its purest sense is simply applying new ideas successfully. While there seems to be no limit to the number of new ideas and solutions to many current health problems, actual application and innovation appears to be constantly lacking. The lack of money is often blamed for the lack of suitable therapies for many of the worlds most pressing health problems, from treating malaria to managing cardiovascular disease. However, I believe that through improved process design we can reduce costs and improve manufacturing times to produce innovative therapies for a reasonable price. Nobody can argue against the fact that both science and medical research have advanced substantially in the past 30 years. From the first child born from in vitro fertilization in 1984 to the isolation and growth of human embryonic stem cells in 1998 and the reprogramming of adult human cells into induced pluripotent stem cells only two years ago, our understanding of cells and how they interact in the body is progressing at a startling rate. Yet, cell-based therapies have been around for over 40 years, with the first successful bone-marrow transplant occurring in 1965. More recently, advances in adult and embryonic stem cell understanding means that therapies based on these cells are now seen to have the potential to treat many conditions for which conventional treatments are inadequate. But the price of these treatments is already out of the reach of many people living in rich economies, let alone those in developing nations. The key to this problem is automation. Automation and the use of machines to produce materials quickly and reliably is not a new concept. As early as the 1800s, wide-framed automated weaving looms were introduced in England to create textiles cheaply without the assistance of skilled workers. In such a technically demanding field as cell isolation and expansion, the ability to use machines to accurately and reproducibly make the same product every time is critical. Furthermore, smaller versions of bioreactors and similar fullyautomated cell culture machines will allow cells to be produced anywhere by anyone. The idea that a sample of blood could be taken in a small hospital in Mombasa and converted to an autologous treatment for ischaemic heart disease within a week seems like science fiction. However, it may be closer than you think. When you first consider how future health innovations may affect people from all parts of the globe, cell-based therapies may not be top of your list. They are currently expensive, time-consuming and generally for diseases of affluence, like type 2 diabetes, cerebrovascular disease and even certain forms of cancer. Most

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people do not associate these noncommunicable diseases with developing countries and those most isolated from everyday medical care. However, I disagree. According to the latest World health report, released in 2008, noncommunicable disease will account for over three quarters of all deaths worldwide by 20301. Malaria, ranked as the 13th leading cause of death in 2004, is expected to drop as low as number 41. Furthermore, there will be only 3 communicable diseases in the top 20 causes of death by this time lower respiratory infections, HIV and, at number 20, tuberculosis. Of the remaining chronic diseases, many could be treated by cell-based therapies. And, with automation, they could be effectively treated all over the world by people who possess limited medical abilities. The pharmaceutical industry realized many years ago that automation of mammalian cell culture could drastically improve cell numbers and reduce costs. Most vaccines are currently being produced either through roller bottle culture, where the cells attach to the inside of a bottle, or in microcarrier culture, where tiny particles are suspended in a larger spinner flask or bioreactor. These types of automated cell culture units can be adapted to many different applications and are able to handle cell volumes from 12 000 litres to as little as 50 millilitres. Another innovation in this field is the development of disposable bioreactors, a single-use version that does not need to be sterilized or pre-prepared and can therefore be made to tight regulatory standards. This technology, combined with our greater understanding of how human stem cells can be exploited in culture, will lead to health innovations that have the possibility to affect people worldwide. Not only are these systems ideal for culturing cells for chronic diseases, but they may also be useful when confronted with warfare and natural disasters. The US Department of Defense is currently conducting a research project through its Defense Advanced Research Projects Agency that is aimed at producing an automated unit that will be able to produce red blood cells in the field. While it may be several years from completion, a self-contained unit able to create transfusable amounts of blood in a battlefield situation would be somewhat unparalleled in applications. This type of device could be used to create safe and clean blood supplies following natural disasters, large accidents and terror attacks. Most importantly, it could be used anywhere, without the need for sophisticated collection and storage facilities or highly trained personnel. This will not be the first time that a military innovation has the potential to directly affect everyday lives outside of the armed services. From the creation of the global positioning system, to something as simple as M&M candies, money spent developing technology in the military has the ability to filter down into our wider society, providing improved products and reducing costs along the way. For something as important as blood pharming, this current project is the perfect opportunity to develop a technology in an environment where costs may not always stand in the way. Of course, this does not mean that money is not an important factor. However, as history has shown, once the technology is developed, the price is certain to fall when paired with improved economies of scale. This brings us back to the important issue of cost. Will automation be able to provide these cell-based therapies at a price that everybody can afford to pay? It is true that current treatments are certainly out of reach of many in the worlds population. But

Young Voices in Research for Health 2009

Erin Rayment

the key to this problem is improved process design and, with it, automation. Everyone knows that the first time you do something it is likely to take a lot longer than it will the next time and then the time after that. And, as many people know, time is money. If we can design systems that can culture cells in a controlled and reproducible manner, we can save time in designing, manufacturing and cell processing. This time will be converted to cost savings, and, with larger demand for the machines themselves, there will be strong incentives to reduce individual unit prices. Competition will also be a significant driver. The airline business is a prime example of this concept. I remember a time when it cost at least AUS$ 500 to fly from Brisbane to Sydney something that now costs as little as AUS$ 50 if you book on the right day. Only the other month, I booked flights from the United Kingdom to Ireland for only 2 pence each way quite incredible when you think about it. Both of these things could never have happened if only one company still dominated the market. However, as has happened in the travel industry, there needs to be strong competition in cell-based automation. This, combined with our increased knowledge and improved machine design, will guarantee a therapy to fit everyones financial situation. In conclusion, health innovation can be difficult in the best situations, let alone in every situation in every corner of the world. I believe that it is our responsibility to use novel technologies and our understanding of cells to affect people everywhere. I also feel that it is through innovation in processing and improvements in automation that this will become possible. There may be some people who think that cell-based therapies will never reach global beneficiaries and that the idea of small bioreactors to create blood cells will always be science fiction. To those I ask this: Was it that long ago that mobile phones were being portrayed as fictional? Did anyone ever believe that you would be able to order groceries through your computer? Yet now these things are commonplace for many people. I think Leonardo da Vinci said it best when he stated: Knowing is not enough, we must apply. Being willing is not enough, we must do. So, with that in mind, we need to let the machines do the work.

World Health Report 2008. Geneva, World Health Organization, 2008.

Erin Rayment completed a PhD in chronic wound healing with Zee Upton at the Institute for Health and Biomedical Innovation at the Queensland University of Technology in Australia. Her doctoral research formed the basis of a patent application and also earned her the 2008 Postgraduate Student Medal at the Queensland Premiers Awards for Health and Medical Research. Currently, Erin is a research associate in David J Williams translational research group in the Centre for Biological Engineering at Loughborough University in the United Kingdom. Her main research focus is identifying barriers in cell characterization to allow the manufacture of safe and effective cell- and tissue-based products. Ultimately, Erin aims to play an active role in the development of cellular therapies for widespread use.

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Christian Rueda-Clausen, Colombia

InteRnAtIonAl dAtAbAse of negAtIVe ResUlts In bIomedIcAl ReseARcH: tHe need to sHIft A pARAdIgm In scIentIfIc pUblIcAtIon

Negative results in science have traditionally been perceived as data of little value, condemned to be filed in a forgotten bench or desk drawer. This phenomenon may have its roots in several factors. They include the peer-review and editorial process (always looking for interesting titles that catch the public attention), the interests of funding agencies (more willing to sponsor studies that are likely to obtain positive results) and the general perception that negative results equate with failure. However, the reality of negative results is that they constitute the most common outcome in scientific endeavours, are as important as positive results, and need to be reported and discussed with the same rigour and priority. The first step towards avoiding this misperception of negative results is to have a clear understanding of their meaning. Obtaining a negative result does not mean that the rationale behind the study was incorrect, the time and resources used in those studies were futile, or the person performing the analyses did not have the appropriate supervision. In fact, the only correct interpretation for negative results is that the null hypothesis for that particular case could not be denied (the probability was higher than 5% that the differences observed between or among the groups were given by a random condition [p>0.05]). Clearly, a major risk of trying to avoid negative results is that researchers will keep repeating the same experiments that are recognized for giving positive results but add some little variation to make them original and easy to publish. This approach yields minimal enhancement of understanding and precludes conducting novel and risky studies that may provide scientific breakthroughs. In my experience, about 80% of experiments or studies conducted generate negative results. Unfortunately, there are no records that let us estimate in an objective manner the proportion of results obtained in science that are negative. Given the constant pressure to publish well and fast, one unavoidable question that needs to be addressed is what to do with negative results? I put this question to some friends working in science, and the following are some of the answers that I received: 1. question the technique, the model, the instrument, the sample size or the phase of the moon; 2. transfer blame to whomever brought up the brilliant idea that led to the negative results; 3. wait for the next paper reporting a positive result and add a few lines mentioning that the experiments with negative results were performed but that no statistical differences were observed (the classic data not shown); 4. get a persevering, motivated and creative statistician to obtain some p value <0.05 in a post-hoc analysis and then write a paper around that p value; 5. finally, if none of the previous alternatives work, accept your negative results and submit your paper to a lower-impact journal. Although some of the solutions above increase the likelihood of negative results being published, such practices can create more misinformation than information and are unlikely to make any substantial contribution to the state of the art in any field.

Young Voices in Research for Health 2009

Christian Rueda-Clausen

The inability to publish negative results may have an enormous impact on the whole scientific and non-scientific community. The positive-results bias is a common type of publication bias that occurs when authors are more likely to submit, and reviewers and editors are more likely to accept, positive over negative results1. This type of bias has the snowball effect of pushing the available evidence towards positive findings throughout the different translational levels, from basic fundamental research to policy-making. As a result of this kind of bias, biomedical journals specialized in basic research are full of articles with colourful titles that highlight the positive findings but may not be a faithful reflection of all the results that were obtained. Nonetheless, these exaggerated positive results form the foundations for the design of preclinical studies. To further amplify this bias, only those preclinical studies that obtain positive results get well published. Again, these studies, even though they may reflect only a minority of the relevant research, support the decisions to proceed with large and expensive clinical trials. Given this continued amplification of positive-results bias, it should not be surprising when some clinical trials fail in reproducing the results obtained in earlier stages of research. Going further into the effect of this publication bias, those clinical trials with positive results are more likely to be published more quickly and in more-visible journals. Consequently, efforts to synthesize the evidence through systematic reviews and meta-analyses may overestimate the effect of certain interventions or conditions and create a false perception that it could be beneficial or prejudicial when in fact it may not be. Ultimately, this is the information used by policy-makers to make decisions regarding the allocation of health-care resources. In fairness, not everything in the publication system stands against reporting negative results. In fact, some substantial initiatives have arisen in the past decade to deal with this situation. Good examples are international databases like the International Clinical Trials Registry Platform of the World Health Organization (www.who.int/ictrp) and the Clinical Trial Registry of the National Institute of Health (www.clinicaltrials. gov). The goals of these databases are to keep track of all clinical trials, provide their rationale and design, and facilitate the publication of their results whatever they are. However, these registries cover only clinical trials and do not encompass basic, preclinical or epidemiological studies. Another brave initiative to deal with this issue of publishing negative results is led by the open-access publisher BioMed Central with its Journal of negative results in biomedicine, a modest journal that has published around 70 articles since 2002 with a current estimated impact factor of 1.38. This constitutes the only peer-reviewed journal, among the 6426 registered in the Journal citation report, dedicated to the publication of negative results2. Creating more journals for the publication of negative results may not be a practical solution to this problem. Indeed, a tremendous amount of effort would be required on the part of authors, reviewers, editors and readers alike to massively increase submissions to journals of negative results. However, the intriguing part of this publication dilemma is that, despite not being a high-priority project for any of these groups in the research community, they all need a repository of negative results to facilitate the ready accessibility of these important data at any given time.

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That being said, the principle objective of this essay is to make a call to authors, editors, reviewers and readers of biomedical journals to erase the stigma surrounding negative results and to spend more time evaluating the rationale, originality and methodological rigour behind every manuscript reporting them. Additionally, a concerted effort is required by the research community as a whole to emphasize the usefulness of negative results. Therefore, I would also like to propose the creation of the International Database of Negative Results in Biomedical Research, an electronic registry dedicated to filing, critically reviewing, organizing, summarizing and disseminating negative results obtained in basic, clinical and epidemiological studies. In order to achieve success in this initiative, there are some technical elements that would need to be considered:1 Any registry in this database would need to include a brief rationale supporting the study, a detailed methodology, a description of the statistical analyses performed and an interpretation of the negative results.2 Universal access to authors and consumers would need to be guaranteed. Therefore, this registry would need to be a paper-free, multi-language, open-access platform with no publication charge.3 Database support staff would have to ensure that all manuscripts were organized in a multilevel classification system.4 Powerful search engines would need to be incorporated to facilitate access to the information. The creation of this database may not only change the perception of what constitutes successful research, but may also improve the quality and validity of the scientific evidence available. This may have a significant beneficial impact, particularly in the realm of knowledge translation and medical practice. In conclusion, the perception of negative results as an undesirable product with little research value needs to be challenged at all levels of biomedical research, from students to policy-makers. The creation of electronic registries for negative results constitutes an interesting alternative to enhance the perception and divulgence of negative results because it could provide the scientific community with an opportunity to know what other groups have done and to discuss unexpected results, if necessary. Beyond the creation of new databases, the challenge of changing the connotation of negative results is formidable because it entails breaking a long-term paradigm. Therefore, achieving this goal would require the active, persistent and synergistic participation of all the players in the game of biomedical science. There is strong reason to believe that the results would justify these efforts.

1 2

Sackett DL. Bias in analytic research. J Chronic Dis, 1979, 32:5163. Hebert RS et al. Prominent medical journals often provide insufficient information to assess the validity of studies with negative results. Journal of negative results in biomedicine, 2002, 1:16.

Christian Rueda-Clausen, having finished medical school in 2003, enrolled at the Cardiovascular Foundation of Colombia, where he worked designing and coordinating clinical and epidemiological studies. In 2004, he received a Spanish Agency for International Cooperation award and moved to the Universidad Complutence de Madrid in Spain to complete a training programme in basic sciences. In 2005, he returned to Colombia to launch and manage a vascular reactivity laboratory, which he did until 2007, when he moved to the University of Alberta in Canada to become a PhD student. Since then, under the supervision of Sandra Davidge, he has been studying the long-term cardiovascular effects of pregnancy complications.

Young Voices in Research for Health 2009

Valrie Sabatier

Valrie Sabatier, France

PlaidoYeR PouR des modles conomiques ambidextRes et la PRomotion de lducation teRtiaiRe dans les PaYs en Voie de dVeloPPement PouR linnoVation en sant la PoRte de tous

Innover pour tous, au sens damener linnovation en sant dans les pays dvelopps comme dans les pays en voie de dveloppement (PVD), est une promesse qui pour tre ralisable ncessite deux grandes mesures : la possibilit davoir en entreprise des modles conomiques ambidextres et le dveloppement de lducation tertiaire dans les PVD. Le premier levier est li la gestion : permettre aux entreprises de biotechnologie et de pharmacie davoir des modles conomiques qui conduisent linnovation pour tous. Le second dpend des incitations des Etats : le modle de pense qui conoit linnovation dans les pays dvelopps pour la transfrer vers les PVD nest plus viable. Pour le rompre il faut aller au-del de la problmatique de transfert technologique et proposer une solution la base du systme: lducation tertiaire pour crer une classe intermdiaire qui sera lorigine de linnovation (mdicaments, vaccins, matriel de diagnostic, etc.) et matre de son dveloppement jusquau march final (les patients).

Des modles conomiques ambidextres

Les entreprises reconnaissent limportance damener des solutions innovantes pour tous mais doivent rpondre des impratifs de profitabilit et de rtribution des risques pris par les actionnaires. Investir dans le dveloppement long, coteux et extrmement risqu dun mdicament doit tre rtribu et il est normal, dans une certaine mesure, que la prise de risque soit rcompense. Or innover pour tous implique dapporter des solutions pour des marchs rentables les pays dvelopps ainsi que pour des marchs moins rentables les PVD. Il faut donc conjuguer deux modles : a) un modle conomique bas sur du profit : crer de la valeur pour lentreprise travers le dveloppement des mdicaments et capturer cette valeur grce aux marges sur la vente du produit ; avec b) un modle conomique bas sur laccs linnovation pour tous: crer de la valeur pour tous travers le dveloppement des mdicaments et capturer cette valeur grce lamlioration des conditions de vie ou du taux de survie. Le premier modle se base sur une logique classique dentreprise et cherche crer de la valeur pour lentreprise et ses parties prenantes alors que le second se base sur une logique dorganisation but non lucratif et une cration de valeur pour tous. Il y a donc un certain antagonisme entre les deux propositions. Lexprience nous donne aujourdhui lexemple de lOrphan Drug Act (loi sur les mdicaments orphelins). Cette mesure sort du premier cadre et se base sur la

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cration de valeur pour tous plus que pour lentreprise. Grce lOrphan Drug Act les entreprises bnficient de procdures plus rapides et daides financires. Dun point de vue de gestionnaire cela conduit des entreprises innovantes se focaliser sur des marchs de niche : elles cherchent minimiser leurs cots et faciliter leur accs au march. Pousse lexcs par certaines entreprises, cette voie est devenue un moyen stratgique de recentrer la capture de valeur sur lentreprise. La cration de valeur passe dune logique de bnfice pour tous une logique de bnfice pour lentreprise. Au regard du nombre de mdicaments orphelins demandant la certification et arrivant sur le march les gouvernements et les assurances ne pourront bientt plus payer ces traitements. Lajustement des modles conomiques entre cration de valeur pour lentreprise et cration de valeur pour tous est donc dlicat. Pourtant une voie intermdiaire existe : il est possible de mener de front deux modles conomiques au sein de la mme entreprise. Prenons le cas dune entreprise qui dvelopperait un vaccin contre le VIH. Elle peut dvelopper dune part un vaccin destination des pays dvelopps et dautre part un vaccin pour les PVD. Pragmatiquement elle ne peut avoir un modle lucratif sur le second vaccin. Cest par ailleurs un prrequis pour les entreprises qui reoivent des donations de grandes fondations. La solution est la coexistence de deux modles conomiques. Le premier est destination dun vaccin lucratif: des investisseurs financent le dveloppement du vaccin et devront avoir un retour sur investissement la mesure du risque pris. Le second est destination du vaccin non lucratif : financement par des fondations et le retour sur investissement pour lentreprise est quivalent aux cots engags pour le dveloppement et la production, sans marge sur le vaccin. Ce double modle conomique est dj faisable mais les entreprises qui le pratiquent doivent tre rigoureuses dans la gestion et le financement des diffrents projets. La tentation dutiliser les ressources de lun pour financer lautre est forte, surtout lorsque les deux mdicaments sont dvelopps en parallle et contre une mme pathologie. Seule une gestion transparente et audite peut garantir la bonne distribution des ressources. Autre point dlicat, il faut que lquipe qui mne les projets soit aussi investie dans lun que dans lautre. Lunique modle lucratif ne conduit pas linnovation pour tous tandis que lautre seul ne semble pas tre la solution. En effet le seul financement par des fondations rencontre des difficults comme le souligne Bill Gates dans sa lettre annuelle pour la fondation Bill & Melinda Gates. Leffet de synergie entre le monde des affaires et le monde des fondations au sein de structures ambidextres est une piste explorer pour amener linnovation porte de tous.

Promouvoir lducation tertiaire

Jusqu prsent linnovation est gnre dans les pays dvelopps puis transfre vers les PVD. Par exemple un vaccin est dcouvert et dvelopp en Europe ou aux Etats-Unis puis quelques annes plus tard des units locales de production seront implantes en Afrique. Ce systme de transfert vers les PVD semble logique puisque cest dans les pays dvelopps que les laboratoires de recherche sont implants et financs et cest aussi l que rsident les marchs les plus attractifs pour les entreprises. Outre le fait que la volont de faire du transfert technologique

Young Voices in Research for Health 2009

Valrie Sabatier

vers les PVD soit tout fait louable, cela napporte pas de solution durable au problme et maintient le dsquilibre de la balance de linnovation. Cest donc le systme dans sa globalit quil faut repenser et chercher ds aujourdhui des solutions long terme pour un dveloppement durable et soutenable de linnovation. Pour que ces pays deviennent des sources dinnovation il faut prendre le problme son origine, au niveau de lducation. Lducation dans les PVD est aujourdhui un des grands chantiers de lhumanit et doit permettre de fournir ces pays une classe de scientifiques et managers capables dtre sources dinnovation. Le management de linnovation dans le secteur de la sant est si complexe quil requiert les interventions de beaucoup de mtiers hors du traditionnel champ scientifique. Le dfi est donc double : il faut proposer des formations de haut niveau en sciences et en management de la sant. Les ressources limites des pays ainsi que lopacit des transactions dans certains dentre eux rendent la tche ardue. La mise en place de structures ducatives tertiaires doit chercher atteindre ds linitiation les critres internationaux de qualit de lenseignement et de transparence. Cest ici que le secteur priv de lducation apparait comme un levier car il peut tre audit. Les structures prives dducation tertiaire vocation sociale cest--dire visant atteindre lquilibre financier et sengageant fortement dans le dveloppement du pays et la monte en comptence de ses tudiants pour en faire des piliers de linnovation permettent daccder cette transparence grce au financement pour partie par des fondations et organismes internationaux. Les accrditations telles que lAACSB (Association to Advance Collegiate Schools of Business) et les attributions de subventions sont conditionnes par des audits extrieurs qui obligent ces structures la transparence. Pour mettre fin au caractre unilatral du transfert technologique, les PVD doivent galement avoir leur propre manire dinnover. En Europe et aux Etats-Unis cela est bas sur les rseaux dinnovation, les ples de comptitivit, les structures de transfert, les grands laboratoires publics et les dpartements de R&D des entreprises. Mais ce modle ncessite dtre adapt la manire dont veulent innover les PVD. Ces pays doivent tre au cur et acteurs de la mise en place de ces structures. Par consquent le soutien aux structures ducatives locales est primordial. De plus les trajectoires technologiques tant en construction dans les PVD celles-ci sont flexibles. Cest aujourdhui une opportunit pour prparer ds prsent les grandes transformations du secteur de la sant en apprenant les mthodes sans copier les modles. Ces deux propositions faciliter les modles conomiques ambidextres et soutenir lducation tertiaire dans les PVD doivent tre mises en perspective avec la rarfaction actuelle des ressources financires lchelle mondiale : la baisse des fonds provenant des fondations et des pays donateurs rappelle lurgence de la situation. Il faut permettre aux uns de monter des structures financires pour rpondre aux impratifs conomiques tout en donnant accs linnovation pour tous ; et donner aux autres les moyens deux-mmes innover. Bien que ces deux recommandations ne soient pas directement lies elles servent le mme but dans une optique de dveloppement long terme.

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Valrie Sabatier is finishing a PhD in business strategy entitled Value chain and cost of drugs: transformations in the biotech industry at Grenoble University, France. She conducts research at the Grenoble Applied Economics Laboratory and is also involved with a French biotech company named PXTherapeutics. She graduated in biochemistry from University Montpellier 2 and holds a Masters in Business Administration from Grenoble Ecole de Management. Born in South Africa of a French father and a Lao mother she grew up in France. She now plans to establish a school in the Lao Peoples Democratic Republic.

Young Voices in Research for Health 2009

David Shulman

David Shulman, United States of America

commUnItY empoweRment foR globAl HeAltH eqUItY: towARds An InnoVAtIVe, compReHensIVe HeAltH-cARe model foR All

This place was down, Im telling you, this place was down, Steve explained as we counted bottles of albendazole, everyone wanted to leave. Now the pharmacy warehouse coordinator for Partners in Health in Neno, Malawi, Steve recalls the desperation of day-to-day life during his childhood. The health-care system crumbled in the wake of the growing HIV pandemic, as families struggled to produce enough food and support sick and orphaned relatives. Malawians referred to Neno as a dead district. The situation was similar throughout much of rural Malawi. Between 1992 and 2004, average life expectancy dropped from 52 years to 411. As the health crisis worsened, the health-care workforce weakened. Malawi has one of the lowest densities of health-care workers in the world, which has resulted in the majority of the population lacking access to basic health-care services. Today, Malawians suffer predominantly from treatable illnesses. AIDS, pneumonia, malaria, diarrheal disease and perinatal conditions compose the five most common causes of death2. In Neno, where I have worked, an innovative health-care delivery system has been effectively implemented to strengthen and expand health services. The model draws heavily on people from the local community, like Steve. Documentation and evaluation of such delivery strategies must become a priority in global health research. While unprecedented resources are being dedicated to global health equity, structural and human resource problems continue to plague health systems in resourcepoor countries. The Bill & Melinda Gates Foundation has invested heavily in the development of new technologies to benefit health in developing countries, and donors such as the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have allocated vast sums of money to broaden the availability of health care in resource-poor settings. However, treatments for the aforementioned illnesses, most of which have been in existence for at least 10 years, continue to elude poor people around the world. While funding and technology have advanced, delivery strategies have been overlooked. In regions with failing health-care systems, little consensus exists on the most effective methods of delivering these fruits of modern medicine. Experts in the field refer to this barrier as an implementation bottleneck. In rural areas across Malawi, a handful of isolated health-care workers struggle to care for entire districts of people. Health facilities frequently lack sufficient stocks of medicines due to the lack of political will and poorly designed forecasting and procurement mechanisms. Even when the proper medicines and tools are available, clinicians are stifled by the work required to run a health facility with so little staffing. Nurses and clinicians must invest significant time in laboratory and pharmacy services, which reduces the time available for patient care. Facilities themselves are beginning to deteriorate due to the lack of maintenance. The results are predictable. Health

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workers turn over quickly, succumbing to burnout or leaving in search of better jobs. The system builds little experience and is composed primarily of young health workers. In 2004, the Ministry of Health (MOH) described the current state of human resources for health as dangerously near collapse. Children with diarrheal diseases and pneumonia go untreated, and HIV and tuberculosis become further entrenched in rural communities. Malawis health-care workforce remains fragile in spite of health policy reforms and foreign aid dedicated to the health sector. In 2004, the government implemented the Essential Health Package, a set of basic services costing US$ 17.53 per person per year. The goal was to ensure all citizens had access to basic care and was specifically geared towards poor rural Malawians. The human resource deficit presented an immediate obstacle to the implementation of services. In 2006, the US$ 273 million Emergency Human Resource Programme was initiated, funded primarily by the Global Fund, the United Kingdoms Department for International Development, and the Government of Malawi. The programme was designed to increase training capacity, augment worker salaries, and provide incentives for working at rural posts. Three years later the majority of health facilities around the country continue to be critically understaffed. While efforts to strengthen and expand the ranks of traditional health workers should continue, we must investigate delivery strategies that can succeed in the current human resource environment. Health-care implementation strategies in Malawi call for relatively conventional human resource frameworks, relying heavily on nurses, physicians, pharmacists and laboratory technicians to staff health facilities. These strategies are effective in the developed world, where large numbers of trained health-care workers exist. The World Health Organization recommends that regions with human resource deficits adopt task-shifting, a process in which appropriate, well-defined tasks are shifted to less-specialized health workers. In Malawi, MOH established clinical officer and medical assistant positions, both of which require less than three years of formal training, to fill vacancies left by physicians and nurses. To date, hundreds of clinical officers and medical assistants have been trained and now outnumber the countrys population of physicians. However, these measures have not gone far enough, as health-care workers continue to work independently at rural posts, unsupported and unable to provide basic services to patients. In Neno, where I have volunteered for the past nine months, Partners in Health has worked with MOH to develop community-based health care. The model draws on local human resources. These lay health workers receive onsite training to perform a wide range of supportive and basic clinical tasks. There are several key benefits to such a model. Workers are readily available in most resource-poor communities, allowing for the rapid implementation of services. Shifting appropriate, well-defined tasks to lay health workers lightens the burden on traditional health-care workers, which reduces burnout and allows nurses and clinicians to provide higher-level services to patients. Improvements in patient care can be achieved as community members, having overcome many of the same illnesses and challenges that face current patients, provide crucial social support. Communitybased health care may also be less costly than implementing a conventional healthcare model in resource-poor settings. Lastly, hiring patients and people from the

Young Voices in Research for Health 2009

David Shulman

communities being served promotes the economic health of individuals and the community as a whole. Community-based models have been utilized to successfully deliver HIV and tuberculosis treatment. In these programmes, community health workers (CHWs) are trained to visit patients daily, ensure patients take their medicines and report side effects. Operational research, involving the documentation of case studies and evaluation of patient outcomes, has demonstrated the effectiveness of such models. This research has also helped to determine which tasks can be shifted from the clinical team to CHWs, which new tasks can be delegated to CHWs, what methods of training are most effective and how CHWs should be paid. In Neno, we have worked with MOH to apply these strategies on many fronts. Neno district, with a population of 125 000 people, now has a single pharmacy technician and two laboratory technicians. Individually, these workers would be overwhelmed by the magnitude of the health crisis. Instead, lay health workers have begun to support a significant portion of the workload. Pharmacy attendants have been hired locally and trained on site, and they now perform a range of stockroom management and dispensation tasks under the supervision of the pharmacy technician. As a result, the technician can dedicate time to higher-level tasks such as district-wide procurement and distribution and the enforcement of rational prescribing. Laboratory attendants prepare malaria and tuberculosis tests, a simple but time-consuming job in a place like Malawi. Many experts in the global health field are sceptical of such an approach, as there is potential for a reduction in the quality of services. Evidence from HIV and tuberculosis programmes has demonstrated the opposite to be true, but this scepticism highlights the importance of evaluating these programmes to understand the most beneficial frameworks for distributing tasks and designing workflow. District wide, the density of trained health-care staff in Neno remains below two workers per thousand people. However, these trained health workers make up less than one fifth of the total health workforce. The majority are lay workers from the community. This human resource framework has allowed for improvements in the capacity and quality of services. Fewer people now die of malaria, pneumonia and AIDS-related causes. And women now have a safe place to give birth. We can no longer expect that health-care delivery models that evolved in the developed world will be effective in the developing world. Evidence from a variety of settings, many involving the delivery of antiretroviral drugs and tuberculosis treatment, has demonstrated the efficacy of community-based health care. A variety of successful programmes, such as the health system in Neno, have been built to meet the need for immediate intervention. We must investigate these community-based programmes, examining human resource structures, workflow, patient capacity and outcomes. Ultimately, this research must be used to build consensus on innovative delivery strategies for bringing health care to all.

1 2

Country cooperation strategy: Malawi. Geneva, World Health Organization, 2006 (www.who.int/ countryfocus/cooperation_strategy/ccsbrief_mwi_en.pdf, accessed 2 September 2009). Country health system fact sheet: Malawi. Geneva, World Health Organization, 2006 (www.afro.who. int/home/countries/fact_sheets/malawi.pdf, accessed 2 September 2009).

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David Shulman graduated from Union College, United States of America, in 2008 with a Bachelor of Science in Biology and an interdisciplinary minor in Global Health. While at Union, David conducted neurobiology research and studied health systems in Canada, the Netherlands, the United Kingdom and the United States of America. After graduating he spent 10 months volunteering for Partners in Health and its sister organization Abwenzi Pa Za Umoyo in southern Malawi, where he worked primarily on developing pharmacy management systems and clinical monitoring and evaluation. In August 2009, David began his first year at Harvard Medical School as an MD candidate.

Young Voices in Research for Health 2009

Okezie Uba-Mgbenena

Okezie Uba-Mgbenena, Nigeria

AppRopRIAte metHods And tecHnologY In HeAltH: A RoUnd peg In A RoUnd Hole

Always remember this, many small things are better than one big thing. When the big thing stops working everything stops, but it is unlikely for all the small things to stop working at the same time.

He paused, allowing the words to sink in and then continued the guided tour of Awojobi Clinic in Eruwa, a rural town 40 kilometres from Ibadan, the capital of Oyo State in Nigeria. The clinic is named after him, Dr Oluyombo Awojobi, the proprietor and consultant surgeon or architect, builder and Chief Dreamer, as he has been variously called. With the help of local artisans, he has been able to design and fabricate most of the equipment in the hospital from local materials. He surmounted the perennial challenges of water and electricity supply by harvesting rainwater, constructing reservoirs and maximizing natural light. It was a striking testimony to the triumph of ingenuity over impossibility. I come from Nigeria, a country with a population of over 140 million people and a life expectancy from birth of 48 years for males and 49 years for females. The infant mortality rate is 97 per 1000 live births, under-five mortality rate is 189 per 1000 live births and the maternal mortality ratio is 8001500 per 100 000 live births. The country has the worlds second-highest maternal mortality ratio, second only to Indias. In addition, deadly yet preventable childhood diseases like malaria and diarrhoeal illnesses ravage the under-fives; the incidence of HIV continues to rise in young people; and hypertension, diabetes mellitus and cancer terrorize the middleaged and elderly. The time is ripe for innovations in health care in Nigeria, developing countries and the world at large. A stitch in time saves nine. Appropriate methods and technology can be defined as practical, scientifically sound and socially acceptable approached and equipment that the community and country can afford to maintain at every stage of their development. These two principles form the backbone of the success of any health-care system, especially primary health care. This essay will focus on the need for innovations in appropriate methods and technology in health, the most pressing health problems in developing countries, and some innovations that have been developed to solve them. Sub-Saharan Africa and South-East Asia are home to about 20% of the worlds population and most of the developing nations of the world. Although much of the worlds natural resources are found in these countries, a stark contrast exists, as most of the people live in abject poverty. As low socioeconomic status is a major determinant of health and the occurrence of disease, it is not surprising that health-care services are equally poor, as evidenced by dismal health indices. No different is the story of Nigeria, a country

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that produces about 1.8 million barrels of crude oil per day, making it one of the largest producers of crude oil in the world. Over half of the countrys population live on less than US$ 1 per day. About 51% live in rural areas, where there is poor health care coverage and resistance to foreign influences and interventions stem from local traditions and taboos. This necessitates more research into culturally acceptable and affordable methods and technology that can be employed in health-care delivery. The health indices mentioned above point to the fact that the Nigerian health-care system is in desperate need of resuscitation the kiss of life, one may say. In all sincerity, I have no doubt that, to bridge the gap between the rich and the poor in health care, effective, acceptable and affordable methods and technology have to be developed and implemented at all levels. Fortunately, several have been developed. While some of these processes are established but poorly implemented, others are new and not widely known. The first group needs re-evaluation and rejuvenation, while the second needs evaluation, recognition and introduction into the mainstream of health care. Sadly, one of the main stumbling blocks to the provision of quality health-care services in developing countries, and in Nigeria in particular, is the lack of availability of potable water or regular power supply to health facilities. These problems are longstanding and do not yet seem ready to pass. Therefore, as the different levels of government continue in their protracted efforts to solve the problem, alternatives have to be explored. Nigeria has two main seasons, the rainy season spanning seven months and the dry season spanning five. During the rainy season, when rainfall is abundant, rainwater can be harvested using rain channels on roofs and directed to a water tank positioned just a little lower than the level of the roof, so that the water in the tanks can flow into water pipes assisted by gravity and thereby eliminating the need for power-consuming pumps. Large reservoirs can be built to store water so that water will be available during the dry season. The capacity of these reservoirs will depend on the needs of the health facility. In addition, other natural sources of water such as springs, streams, lakes and wells can be explored. However, these sources should be subjected to regular chemical and microbiological analysis to verify their safety. In this age of intense search and agitation for alternative sources of fuel and power, one has been staring us in the face all the while. For billions of years the sun has emitted light and heat. It is time to use them. First of all, to reduce the need for electricity during the day, sunlight can be maximized through the appropriate number and positioning of windows and by painting the walls with light colours, which reflect light and help to brighten the place. The use of high ceilings and efficient cross-ventilation and the planting of trees for shade will reduce the need for airconditioning systems in the tropics. Several other areas will benefit from the application of suitable methods and technology, such as maternal health, which is a serious issue in developing countries. The partograph has been recognized as a simple and inexpensive tool that can be used in identifying and referring complicated pregnancies for specialist care. Its widespread use is still a mirage. This cannot continue if the Millennium Development Goal of reducing maternal mortality by three quarters by 2015 is to be realized. Medical personnel need to be reoriented on the need for and appropriate use of the

Young Voices in Research for Health 2009

Okezie Uba-Mgbenena

partograph. Also, a large number of women and the community at large have a high regard for traditional birth attendants and maternity centres located in and owned by religious bodies. Is it not possible to convert this into a vehicle of progress by standardizing their practice and then integrating them into the health-care system with adequate recognition? Such measures will go a long way towards bridging the sociocultural and religious gap between the community and health-care providers. Child health is another sensitive area as several vaccine-preventable diseases are still a cause for public health concern in Nigeria. Polio, long since eradicated in most countries of the world, is still a threat to child health in Nigeria. One of the reasons for this, apart from poor immunization coverage, is the fact that some women actually reject the vaccines. This happens because rumours are spread that vaccines contain dangerous chemicals that have serious effects on the children, for example rendering them infertile. These rumours spread like wildfire and have serious adverse effect on the turnout of mothers and children for immunization. To solve this problem, local traditional authorities and elders who are respected opinion-shapers in the community have to be centrally involved in disseminating information and dispelling such hearsay. Furthermore, the prevention of other diseases such as malaria can be achieved by distributing insecticide-treated nets free of charge and organizing public sanitation days, when individuals and groups are encouraged to clear bush, drains and other possible breeding sites for mosquitoes. An award may even be given to the most efficient group in the community to encourage healthy competition. Diarrhoea, another important cause of morbidity and mortality in children under five in Nigeria, can easily be alleviated by the targeted teaching of mothers regarding the correct preparation of sugar-salt solution with locally available materials. This is but the tip of the iceberg of fresh ways of tackling health care in countries with resource-poor settings and populations of low socioeconomic status. Let us take solace in the fact that little drops of water make a mighty ocean. More groundbreaking research into the creation, development and implementation of new and acceptable methods and technology is imperative in this era of global financial crisis and the consequent call for maximizing resources. We have to learn to use small things to have a big impact.

Okezie Uba-Mgbenena is a fifth-year medical student at the University of Ibadan, Nigeria, who hails from Anambra State. His commitment to public health led him to become the health minister and chairman of the health committee of Nnamdi Azikiwe Hall at the University of Ibadan. He advocates for the enhancement of reproductive and sexual health, especially through the prevention of HIV and other sexually transmitted infections among youth. He is the chairman of the Action Group on Adolescent Health Ibadan. He is also currently involved in the production of a radio programme that aims to reduce the stigmatization of people living with HIV and is aired by the Federal Radio Corporation of Nigeria in Ibadan.

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Rafael van den Bergh, Belgium

wHo Is At tHe ReceIVIng end of oUR InnoVAtIon?

Innovation. A good, solid word, that. Not as smarmy as many others in the lexicon of corporate buzz speak (proactive, incentivize and the hardy perennial empowerment) but glitzy enough to get papers accepted, bring in grant money and successfully sell far-fetched concepts and ideas. And rightfully so, maybe. It is what makes research exciting and keeps researchers on their toes; without innovation, without the continuous drive to approach problems in new and inventive ways, research would be reduced to nothing more than bookkeeping, an intellectually sterile task. As applied to health care for all, though, I cannot help but wonder if it is not a hollowed-out term a term designed to cash in on the grant money without necessarily delivering the goods. Allow me to clarify: biotech projects focussing on health-care challenges in the developing world (HIV being a case in point) tend to rely heavily on new, emerging and yes, innovative technologies, claiming without fail that these pioneering approaches will lead to a substantial improvement in the health-care situation of any number of patients. I used to buy into this idea. After all, I am a molecular biologist working on HIV. I work with genome-wide microarray profiling systems, recombinant fluorescently tagged viruses and magnetic cell separation techniques all day long. Innovation is what I do. I remember choosing biotechnology at the university precisely for its cutting-edge allure, the idea that in such a fast-moving field sufficient intellectual effort and highly advanced technology could make an actual contribution to the living standards in many of the worst-hit areas in the world. But do they? Do they really? Is innovation in research, the constant development of new ways of doing science, really the answer to the problems of the developing world? Or are we maybe fooling ourselves (and our funders), and is the application of ground-breaking, cutting-edge technology in resource-poor settings no more than a justification for us to use this technology without actually delivering a return for the people in the afflicted regions of interest? Certainly there are returns for the researchers in question, in terms of high-ranking publications, patent applications and scientific status, but how much of this flows back to the people who are actually targeted? And, more importantly, are these innovative, high-tech approaches to solve existing issues really what we are waiting for? I remember a drowsy course long ago in parasitology, during which we were shown a set of illustrations which piqued my interest a map of sub-Saharan Africa showing the regions at risk for trypanosomiasis (in humans colloquially known as sleeping sickness) and a graph depicting the incidence of trypanosomiasis in I think the Democratic Republic of Congo over the past 80 years or so. What was striking is this:

Young Voices in Research for Health 2009

Rafael van den Bergh

Risk for trypanosomiasis is strongly associated with political instability. The greater the civil unrest in a specific region, the higher the rates of trypanosomiasis become. Worse still, trypanosomiasis dropped to its lowest incidence rates in that country during the relative political stability of the colonial years, when despite the evils of colonialism strict logistical measures were taken to control disease. Incidence rates leapt up to staggering heights soon after independence and the onset of all the associated civil unrest. Now, this is a dangerous thing to say. It is a terrible thing to say. As a Belgian, I am only too aware of the nightmares of our colonial history and would never dream of defending this period of national shame. Nevertheless, what these graphs suggest is that the underlying biology of the disease, i.e. the aspect that we are now targeting with our innovative and costly approaches, may not really be the challenge at hand. In other words, these data raise a set of simple yet fundamental questions: If you want to combat a disease such as trypanosomiasis, is it better to fund an innovative molecular biological analysis of the interplay between the parasite and the host immune system in the hope that it will one day yield a possible (but probably expensive) therapeutic strategy? Or is it preferable to alleviate dire social conditions in the regions at risk using non-innovative approaches (prevention strategies, logistical support, etc.) that we already have at our disposal? with the added benefit that trypanosomiasis is not the only disease that can be tackled in this fashion. Many, many diseases go hand-in-hand with poverty, famine and war, and would be considerably reduced as social conditions are improved. To take it to the personal level: Should I really have studied biotechnology when I wanted to provide some form of aid to the disease-stricken regions of the world? (Young and nave, I think William Blakes lines Can I see anothers woe/And not be in sorrow too?/Can I see anothers grief/And not seek for kind relief? even came to mind at some point.) This choice has so far not delivered any actual benefits to anyone in the field. Should I simply have studied economics, skipped the lengthy PhD process of scientific advancement and attempted to contribute something at the logistical level? I would like to stress that I do not know or pretend to know the answers to these questions. Presumably, there is no correct answer, or if there is it will be along the predictable lines of both approaches are needed to efficiently combat disease in resource-poor settings. Nevertheless, I cannot help but feel frustrated about our focus on technological innovation as the be-all and end-all solution for the developing worlds problems. On the one hand is the frustration that opportunities are being missed. While money is being spent on academic, publication-oriented questions (albeit interesting ones), many problems could actually be solved using existing knowledge and technologies (albeit decidedly unsexy ones). On the other hand is frustration (but this may merely be a private gripe of mine) concerning the dubious phrasing used in all project applications everywhere, in which new-fangled technologies are being pushed forward as the solution to all the developing worlds problems, when in fact they are just the newest toys that we would like to play with. A project we are collaborating on now, for instance, focuses on HIV and tuberculosis coinfection in sub-Saharan Africa and is an intellectually challenging amalgam of advanced molecular and cellular strategies designed to unravel a specific disorder

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associated with antiretroviral therapy in a resource-poor setting. It is an innovative project, certainly, with an accordingly high price tag. From a research point of view, it concerns work that indubitably needs to be performed. However, was it entirely honest of us to describe it in the project application as a direct contribution to HIV and therapy management in the field? Would it not have been more honest to say that we will, in the first place, improve our track record in this field of research, rather than improve standards of care? And would not the local population suffering from this disorder have been better off if the same kind of effort devoted to research were also devoted again using non-innovative approaches to improving their quality of life, thus bridging the gap between their current situation and the 1015 years down the road when our results are translated into actual solutions. In conclusion, I would like to state that in no way am I advocating a reduction in research efforts in the context of health care for all. I have always believed, and continue to believe, that scientific progress will shape the future. Indeed, it is not an overstatement to say that it may determine whether we have a future. What I am questioning, however, is our focus on technological innovation as the quintessential solution to many of the developing worlds challenges, a habit that, in the long run, may be more self-serving than public interest-serving. Selecting the best strategy for providing optimal health care for all while disregarding our own academic or other track records may be our biggest challenge yet.

Rafael van den Bergh was trained as a molecular biologist and immunologist at the Vrije Universiteit Brussel (VUB) in Belgium and has a long-standing interest in HIV research and care. He is working on his PhD at the Flanders Institute for Biotechnology, and most of his actual work concerning HIV-host interactions at the molecular level is done in the labs of VUB and the Institute of Tropical Medicine in Antwerp.

Young Voices in Research for Health 2009

Alejandro Vsquez Echeverra

Alejandro Vsquez Echeverra, Uruguay

pensAmIento tempoRAl Y sAlUd. necesIdAd de tecnologAs socIAles pARA lA mejoRA en pReVencIn en sAlUd

Introduccin
En este ensayo propongo explorar las relaciones entre pensamiento temporal y la salud, especficamente el nivel preventivo, desde una perspectiva psicolgica. Este vnculo sin ser un clsico de las ciencias psicolgicas-, no es novedoso y ya se han establecido correlaciones consistentes entre cmo ciertas personas perciben el tiempo subjetivo y conductas de riesgo, impulsivas o de negligencia sobre su propia salud. Siendo as, el aporte de este ensayo se encuentra en el planteo de enfocar esfuerzos hacia el desarrollo de tecnologas e innovaciones sociales de intervencin, que permitan incrementar el valor social del pensamiento futuro en poblaciones infantiles, con el propsito de que las campaas preventivas en salud sean ms eficaces. La premisa de esta idea radica en que el aumento de la perspectiva temporal futura es la base del cambio conductual necesario para la mayora de las conductas de riesgo que las campaas de prevencin intentan combatir.

El pensamiento temporal Eje central de la motivacin humana vinculada a procesos de salud?

Una de las mayores y ms distintivas capacidades humanas es el sentido de tiempo personal o subjetivo, que va desde un pasado, acta en un presente y procura un futuro. La valoracin de la influencia en la conducta de esta capacidad, exclusivamente humana y fundamento epigentico de la cultura, ha quedado rezagada.

Pensamiento temporal y salud La dimensin temporal de la conducta ha sido una preocupacin de algunos psiclogos desde el inicio de la disciplina. Sin embargo, los esfuerzos sistemticos en comprenderlo son recientes. Los mismos han mostrado ser tiles para explicar una amplia gama de comportamientos y se ha argumentado que la naturaleza temporal de la conducta acta como una de las fuerzas motivacionales ms importantes.
La perspectiva temporal puede definirse como el grado en que una persona valora y determina su comportamiento en arreglo a consideraciones relativas a su pasado, presente o futuro. Existen varios estudios y medidas referidas en concreto al peso del futuro como modulador de la motivacin, siendo especialmente utilizados la Escala de Consideracin de Consecuencias Futuras y el Inventario de Perspectiva Temporal de Zimbardo. Ms all de lo especfico de cada medida, lo relevante es que estas han encontrado asociaciones entre la perspectiva temporal futura y conductas altamente relevantes para el bienestar y la salud. Las asociaciones refieren a la regulacin emocional frente a eventos negativos o

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dainos, la conduccin de riesgo, el uso y abuso de sustancias y el alto ndice de masa corporal1,2. Respecto a la poblacin infantil, se han hallado correlaciones entre la capacidad de postergar la gratificacin en los aos preescolares con el rendimiento acadmico posterior3.

Intervencin psico-social sobre el pensamiento temporal. Qu sabemos? La tesis central de este ensayo la configura, tal como el lector podra deducir del apartado anterior, que se necesita intervencin psicosocial que fomente la capacidad de pensamiento temporal futuro en aquellas poblaciones de riesgo. Estimo que el desarrollo y fomento de esta capacidad, a la par que se desarrollan los programas tradicionales de prevencin, configura una parte importante de la mejora en la eficiencia de estos programas y constituye la va ms segura hacia conductas de autocuidado permanentes en el tiempo.
La implementacin de programas de prevencin, en la mayora de las experiencias, descansa en el supuesto de trabajar sobre un problema concreto que atae a la poblacin o grupo de riesgo. Los mismos, gracias a los aportes del Modelo Transterico del Cambio de Prochaska y DiClemente, ya no solamente se centran en aspectos informativos, sino que incluyen componentes socio-afectivos para producir la modificacin o aversin a una conducta de riesgo. Sin embargo en contextos desfavorecidos o de pobreza, las personas son ms reacias a modificar o hacer sacrificios presentes en pro de evitar riesgos y peligros remotos, ms an cuando la satisfaccin presente puede ser muy alta por la activacin ptima de los circuitos de recompensa, como en el caso de la conducta sexual, el uso de drogas o ciertas conductas extremas como la agresividad o la conduccin de riesgo. Desde una perspectiva econmica, la preferencia temporal y la funcin de utilidad intertemporal impide ver maximizaciones en la espera y las evaluaciones de los resultados futuros tienden a recibir menor valor. Hasta donde estoy informado, no se conocen las razones de esta diferenciacin. Las condiciones de existencia y las dificultades para acceder o alcanzar un nivel de vida adecuado durante varias generaciones pueden hacer que la perspectiva temporal de los adultos se haya visto reducida y esto se transmita a las generaciones jvenes. Los padres son un canal de transmisin del pensamiento temporal. Esto configura una desventaja social, que produce consecuencias negativas y an mayor desventaja social. Con todo, esto no es un tpico nuevo: numerosos trabajadores y profesionales en el campo de la asistencia social lo comprueban y lo viven da a da. El punto y auto-crtica est en preguntarnos: Qu han hecho los servicios sociales o las ciencias de la salud al respecto? Ha habido experiencias aisladas para fomentar el desarrollo de la perspectiva temporal futura. Se ha trabajado con paradigmas clsicos de aumento progresivo de la capacidad para postergar la gratificacin y con simulacin mental, para ampliar el horizonte de las proyecciones de estados deseados. Pero estos esfuerzos carecen de estudios empricos que los avalen, como tampoco estn sistematizados los procedimientos para poder replicarlos. El desarrollo de programas para ampliar la perspectiva temporal futura en nios y adolescentes, que fomenten la asignacin de valor a los resultados no inmediatos, es un campo que desconocemos y sobre el cual los servicios educativos y sanitarios deberan exigir ms de la comunidad cientfica.

Young Voices in Research for Health 2009

Alejandro Vsquez Echeverra

La ingeniera social del tiempo individual: Consideraciones ticas

Las diferentes culturas poseen cosmovisiones variadas en su relacin con el tiempo, las cuales moldean, a travs del proceso de socializacin, la personalidad, los valores y conductas de quienes la integran. Esta modulacin ocurre por medio de instituciones como la religin, el trabajo y los temas culturales valorados. En este sentido, la relacin de ciertas poblaciones culturalmente diversas supone parte del patrimonio intangible de su cultura. En mis estudios fui formado en el respeto y admiracin de los valores, la diversidad y el trabajo inter-cultural, basado en el relativismo. Por esto, debo reflexionar sobre las implicaciones no estrictamente tcnicas de la propuesta que aqu realizo y la posible violacin de este principio. El escrutinio cuidadoso me conduce a descartar cualesquier peligro en este sentido. Primero, aceptar el supuesto de violacin de la diferencia cultural implicara negar la capacidad de diagramacin social, a travs del modelado y otros procesos psicosociales que tienen los medios de comunicacin y otras fuentes que promueven el consumo. La promocin del consumo es uno de los principales vehculos de la formacin de subjetividad impulsiva y de orientacin temporal presente-hedonista. Segundo, la imposibilidad de movilizarse en marcos temporales amplios, ms que un rasgo cultural suele estar asociado a estatus socio-econmicos bajos o, en otras palabras, a pobreza e indigencia. Desde mi trabajo en un plan de lucha contra la pobreza recuerdo la sorpresa de encontrar personas para las cuales el referente temporal mes si bien les resultaba semnticamente conocido- era un espacio de tiempo que no les era til para organizar su experiencia ni para proyectar actividades laborales. Estas diferencias parecen deberse ms a la cultura de la pobreza, que a rasgos socioculturales o subculturales. Por ltimo, dado el perfil de morbi-mortalidad de nuestras sociedades, donde la conducta humana juega un rol preponderante en la prevencin de la mayora de las formas de enfermar y de morir, es ms nocivo aceptar la hiptesis que intervenir en consecuencia.

Reflexiones finales
La promocin de programas de intervencin para el desarrollo de aspectos psicosociales puede convertirse en un factor de prevencin en salud. A la par que se implementan programas especficos, el desarrollo de investigacin y la aplicacin de programas que intervengan sobre la perspectiva temporal de las personas puede mejorar notablemente la eficiencia de todo el resto de las acciones preventivas y con efectos ms sostenidos en el tiempo. Esto implica dar un paso previo en la prevencin, intentando incidir en aspectos de la constitucin de la personalidad que se conectan con conductas de salud. La innovacin est en el desarrollo de tecnologa social que permita el desarrollo psicosocial equitativo de la poblacin y le permita a la persona pensar, conectar y valorar lo que hace hoy en relacin con su bienestar de maana. Cabe la posibilidad de que esta propuesta no aporte mucho en la resolucin de los problemas que en materia de salud afronta el continente. Pero los indicios estn y es una apuesta que, de salir vencedora, ofrecera muchos beneficios.

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Boyd, J., & Zimbardo, P. (2005). Time Perspective, Health and Risk Taking. En: Strathman A. & Joireman J. (Eds) Understanding behavior in the context of time, (pp: 85-107). Mahwah: LEA. Adams, J. & Nettle, D. (2009). Time perspective, personality and smoking, body mass, and physical activity: An empirical study. Brit. J. Health Psychol., 14, 83-105. Mischel, W., Shoda, Y. & Peake, P. (1988). The nature of adolescents competencies predicted by preschool delay of gratification. J. Pers. Social Psychol., 54, 687-696.

Alejandro Vsquez Echeverra. Naci en 1981 en Montevideo, Uruguay. Es licenciado en Psicologa por la Universidad de la Repblica y cuenta con un postgrado en Psicologa de la Universidad del Pas Vasco/Euskal Herriko Unibertsitatea. Se ha desempeado como becario en el Ministerio de Desarrollo Social en un plan de lucha contra la pobreza y ha participado en diversas investigaciones dentro de la Universidad de la Repblica. Actualmente es docente de Psicologa Evolutiva y de Psicologa del Trabajo de la misma Universidad y su inters en materia de investigacin se centra en el anlisis de la dimensin temporal de la conducta en el desarrollo y el trabajo.