Public Health in Tel Aviv


Jessica

By Jessica Hoffen

As a GlobeMed member, I had sat through presentation after presentation on the many study abroad opportunities available, anxiously awaiting my chance to board an airplane and, briefly, wave goodbye to America.  My turn finally came in the spring of 2015 when I landed in Tel Aviv as part of the Public Health and Society in Israel program run by Northwestern and Tel Aviv University.  As a student interested in the impact of culture and conflict on health equity, I hoped that through experiencing this region I would be able to better understand what has worked and failed in implementing health initiatives across ethnic lines. While public health was the focus of my studies in the region I found that what Palestinians and Israelis were most passionate about teaching me, was simultaneously the pervasiveness of those ethnic lines in everything they did and the joy and pride they found in their lives and their cultures despite these.

As an English-speaking American, the Israel-Palestine I had access to included Israelis and Palestinians, Sudanese and Eritreans, Thais and Filipinos; it was multi-ethnic, multi-religious and deeply, painfully divided. Through my program I visited a range of public and private health institutions that collectively provide for this diverse population.  All Israeli citizens, regardless of employment status, pre-existing conditions, ethnicity etc., have health insurance and access to the same basic care package. This covers a range of potential needs including; chronic disease treatment, transportation to the hospital, in vitro fertilization, and drug and alcohol rehab.  Notably missing from the list is mental health care, something that is simultaneously needed, due to the high rates of trauma experienced by people in the region, and taboo, because the prevalence of the trauma has led to the expectation that people should be able to “cope” on their own.

One of the aspects of the health system that I was most impressed by was the emphasis on adherence to care. Everyone has insurance so everyone’s health is monitored. As “big brother” as this may sound, it is very effective in containing disease outbreaks and in ensuring people attend their yearly check-ups and adhere to prescribed treatments. Early childhood nurses make home visits if patients miss an appointment, and tele-medicine, in which nurses regularly check in with patients over the phone, is used to keep track of the needs of chronic disease patients.

Despite these impressive initiatives, for the 25% of Israeli citizens who are not Jewish, the health system fails to provide consistent and equitable care.  In GlobeMed we frequently speak about the social determinants of health, specifically how issues such as trust between care providers and care recipients, distance of populations from hospitals, and responsiveness of the health system to certain populations, all influence health outcomes.  In my experience, Israel-Palestine is a case study in this reality. One example of this is the NephroLife clinic in Umm al-Fahm a primarily Muslim Palestinian town in the center of the country. The director of the clinic had tried to get the government to fund a dialysis center in the town so residents would not have to make the one-hour journey by bus to the nearest hospital. When the government failed to establish a dialysis center he founded NephroLife, a private clinic, that charges for its services. He is now working on bringing a hospital to the area, however, this too will be private, because he was unable to obtain government support.

Before visiting this region I had always held up universal health care as the gold standard of health systems.  However, the clinics I visited and the people I met while abroad made me realize how much this system of government oversight relies on trust between the people and government; trust that is easily broken through conflict and discrimination. Though I did not return to America with answers about how to improve cross-cultural care, I did come away with the firm belief that the first step to improving health outcomes anywhere in the world starts with building relationships that are rooted in respect, dignity, and recognition of history. 

Jessica 2

 


Vaccines, Herd Immunity, and Disease Re-Emergence – What’s the Deal?

By Michael Zingman

We hear about immunizations in the news. We are encouraged to get vaccinated. We hear friends and family talking about how they just “never got vaccinated” for something.

We then hear about outbreaks and re-emergence of vaccine-preventable diseases. So what is causing this re-emergence exactly?

Vaccines are one of the most crucial global health resources and are significant tools that can be utilized to protect large populations in both developed and developing nations from disease. Many diseases are vaccine-preventable, meaning if hypothetically everyone were to be vaccinated, the disease would become eradicated.

One of such eradicable diseases is measles. Measles was once “eliminated” from the United States; however, recently, there has been extensive media coverage over a measles outbreak within the country. Measles was eliminated but not eradicated because of a slight minority of people who went unvaccinated, and this number has increased and allowed the disease to return. These cases were found to be from parents who chose not to vaccinate their children, which ultimately harmed others.

Other parts of the world have also seen a re-emergence of vaccine-preventable diseases. One interesting case is that of Syria and the re-emergence of polio this past October. Polio had come extremely close to eradication in that area of the world; unfortunately, it has re-appeared. This was due to two key factors: 1) because of the ongoing civil war, the normal childhood vaccination routines have been altered or disrupted, and 2) polio has spread from Pakistan (which is one of the three remaining countries in which polio is still active), particularly through children, including those in refugee camps and those displaced in Syria. Polio has even spread to Iraq from Syria, and there is growing fear over proliferation of the crippling disease.

So why can just a handful of unvaccinated people lead to a wide-spread re-emergence of these preventable diseases? The key is herd immunity.

Herd immunity is defined by the Centers for Disease Control as when “a sufficient proportion of a population is immune to an infectious disease to make its spread from person to person unlikely; even individuals not vaccinated are offered some protection because the disease has little opportunity to spread within the community.” This concept of herd immunity is why widespread vaccination is necessary for prevention of these diseases. In an ideal world, everyone would be vaccinated for all of the vaccine-preventable diseases. However, that is not a practical situation (at least not at the current time). Herd immunity can be very effective in protecting large populations from these diseases, but often can be difficult to achieve as some diseases require greater than 90% of the population to be vaccinated. This threshold is frequently not met and populations are left vulnerable.

With a growth of anti-vaccination movements in the United States and around the world, some parents have stopped vaccinating their children. This has led to a decrease in herd immunity for these vaccine-preventable diseases, permitting their re-emergence. These movements have surfaced due to a growing fear that vaccines can have adverse effects on children. This fear has been augmented by conflicting information regarding vaccinations, as well as personal accounts of negative vaccine effects, including those by physicians. Misinformation has even led a significant portion of the U.S. population to believe that autism can be caused by vaccines. This belief became prominent in the 1990s and was one of the reasons cited for the growth of this anti-vaccination movement.

Two key aspects of the debate over vaccinations include a lack of information (or misinformation) and a mistrust of governments, health institutions and research agencies. These are major problems in the United States, but also in many countries throughout the developing world, including those countries in which GlobeMed partner organizations are located. A lack of research to disprove these supposed negative vaccine effects has made it hard for the public health community to convince people that no link exists. Furthermore, much of this research comes from pharmaceutical companies, leading to mistrust of this research due to potential biases. An overabundance of information also has prevented people from receiving direct information from health institutions regarding vaccine effectiveness and has caused them to educate themselves from other sources that are less reliable. On a similar note, there is a lack of public understanding about vaccinations that stems from a mistrust of health institutions. It can often be more difficult to vaccinate people in developing countries in which people view vaccinations as a corrupt government program. Some people even believe that required vaccinations for schools are done for the economic benefit of the government.

All of these issues discussed have increased fear of vaccines in many locations around the world, including in those places with GlobeMed partner organizations. Vaccine education needs to be expanded and effective national vaccination action plans need to be both developed and carried out to increase herd immunity. GlobeMed and its partner organizations, as well as similar global health organizations, need to empower communities around the world in order to enhance vaccination efforts. Education through vaccine information is necessary to present to the public why population immunization is essential and why a decrease in herd immunity can have tremendous negative effects.


World AIDS Day

To celebrate World AIDS Day, take a listen to the following inspirational StoryCorps presentation:

http://www.npr.org/2012/11/30/166162027/a-lifes-ministry-springs-from-a-dilemma-over-aids

For more coverage of the day’s events, news, stories, and to get involved, visit http://www.worldaidsday.org/

In the spirit of giving, please consider donating to GlobeMed at Northwestern: http://www.globalgiving.org/projects/increase-public-health-and-sanitation-in-uganda/


Malaria Vaccine Breakthrough: Implications for Global Health?

Malaria, transmitted by infected Anopheles mosquitoes, causes more than 780,000 deaths each year. The deaths occur disproportionately in Africa, particularly Sub-Saharan Africa. Conventional malaria prevention methods include insecticide-treated mosquito nets (ITNs) and indoor residual spraying (IRS).

Earlier this week, the results of a Phase III study in 7 African nations showed that RST,S/AS01 (vaccine against P. Falciparum – deadliest of the four malaria types) reduces the risk of severe malaria in children by 47 per cent. The drug is developed by GlaxoSmithKline in partnership with the PATH Malaria Vaccine Initiative, and funded by the Gates Foundation. It has taken 24 years since the drug development process started to get to this point.

What seems to be the world’s first malaria vaccine is well under way, with final results expected in 2014. However, amidst all the excitement and hope, one can’t help but wonder the implications of this vaccine on Global Health. Granted this is a significant health care and scientific progress, but most vaccines in use today have an efficacy of at least 90-95% (e.g. influenza vaccine). Can this malaria vaccine, and should it, be used by doctors in developing countries in the long term? How do you think public policy in developing countries, especially African nations, will change? Furthermore, how do you think the availability of this vaccine will affect the use of other and much cheaper malaria prevention methods such as ITNs and IRS?

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Organization Spotlight: Tiyatien Health

A worthy organization recently brought to the chapter’s attention is Tiyatien Health, a not-for-profit that works to rebuild the failed health system of Liberia.  Liberia is still struggling to recover from a horrific civil war that ended in 2003. Tiyatien Health, headed by the liberian-born doctor Rajesh Panjabi, strives to provide what it terms “justice in health”, health equity for all Liberians.  It focuses on providing free medicine and health care to those who need it. Rajesh and all involved place great importance on teaching Liberians how to care for themselves and administer to others in order to create a health system that won’t only help those in need, but will sustain itself. Tiyatien also works with the Liberian Government to create a permanent, functioning health system and supports sustainable economic ventures in order to combat poverty. Check out Tiyatien’s website at http://www.tiyatienhealth.org/, or the GlobeMed website for the chapter at University of Michigan, who partners with Tiyatien Health, at http://www.globemed.org/[uofm] .


A perspective from Paris

In many ways, Paris is not so different from New York, Chicago, or any major city in the United States. There are all the modern amenities, locals are chic and cosmopolitan and pop culture in Europe has largely molded itself around American media. The one thing people tend to point out is that the French tend to take their time to enjoy the ordinary. The lifestyle is slower, whether it’s how long it takes a waiter to bring over a check or the way Parisians linger over three-hour dinners of bread, wine, cheese and espresso even on weekdays.

In time, I realized that this way of life reflects the lengthy scope of European history and, in turn, the principles around which many European societies are organized. Unlike the United States, many EU member states have over a thousand years of history, have waged countless wars with their neighbors, and have often redrawn messy national borders. With this sense of history comes a sage understanding of the life course, of personal success, and of mortality; not everyone is exceptional, and no one is exceptional when it comes to death at the end of one’s life.

There seems to be more of a collective sense of the past, a true focus on the present, and generally less anxiety about the immediate future. The socialist redistribution of wealth and development of the welfare state demonstrate the importance of enhancing the lives of all citizens in the present rather than focusing on future gains trickling down from a small elite. The French welfare state ensures that one has the tools to be a productive member of society, and, in the case of illness or unemployment, that he or she will be offered social assistance.

It would be essentializing to say that there is only to live, work and enjoy in France. But I think the U.S. as a state and as a culture has a lot to learn from France in terms of approaches to life, success, and an individual’s place in the society. It is a preoccupation with being the best and having it all that has characterized and shattered the American economy. So while we bemoan the demise of American exceptionalism, Americans need to understand the falsehood of individual exceptionalism and rethink the notion of what it means to live a happy life. The sooner we realize that the vast majority of us are ordinary, that it’s good to be ordinary, and that–even in a capitalist society–ordinary people deserve protection from market failure, the sooner we can start working towards reducing health and other inequalities in America. –TIFFANY WONG

Tiffany Wong is a former co-president of GlobeMed at Northwestern and is studying on the Northwestern International Program Development Public Health in Europe Program.


GROW 2010 Team: Margaret Asante’s thoughts and impressions

The members of the GlobeMed at Northwestern GROW 2010 trip with Margaret Asante. Photo courtesy of Reema Ghatnekar / GlobeMed at Northwestern.

When I received a mail from the outgoing executives of GlobeMed 2009 introducing the next batch of students who will be visiting Hope Center in Ghana in 2010, I was really thrilled and at the same time curious. I wanted to know the caliber of students and how they can fit into our activities at the center like their predecessors. Mails were exchanged and my anxiety heightened by each day.

Between 13th June to 25th June Allyson arrived first, followed by Kathleen and Reema, then lastly Joey.

Allyson Westling
I christened Allyson, “Mother Allyson” due to her humility, wisdom and her approach to work; my anxiety and fears evaporated immediately as Allyson, the first to arrive quickly, grasped the whole concept of activities at the center. She soon took charge and started planning activities of her colleagues with such an ease that surprised every staff at the center. Her main objectives were to help develop the phase four of the nutrition program for the center and also help revise the partnership agreement between GlobeMed and Ghana Health Service. She worked tirelessly to achieve the objectives.

Reema Ghatnekar
The ‘wide-eyed’ Reema was full of enthusiasm, zeal and have a great passion to work with us at the center. Her objectives were community mapping, and help with the continuation of phase three of the nutrition program. Her passion for the community work brought her closer to the two rural communities we serve, Ando and Kodzobi where she did a lot of interviewing to project the work at the center to the communities. Her final work is being used as a guide for our programs.

Kathleen Leinweber
Adorable Kathleen’s volunteering spirit brought enthusiasm and youthful exuberance into our work at the center. She was always asking questions that helped her to achieve her objectives in helping to evaluate the Sexual Reproductive Health for Adolescents program and community-mapping. She braced the odds and worked among the rural communities we serve, and also made friends among the children.

Joey Gill
Baby Joey, as I nicknamed him during his stay was the youngest. He continued with the electronic medical records and the community-mapping. He also worked hard among the two communities to bring out the way the community live, type of housing, water and sanitation, food, fuel used and family size. This information is essential for the center and we are using them to guide us in preparing community profile for the rest of the communities we serve.

The GROW 2010 team not only worked on their individual project but helped in most of the child welfare clinics by weighing babies and updating their records in the registers. They really fit into our system and worked very well. How we wish we could have them all year round

Yes, they did really had fun alongside their busy schedule, a trip to Wli waterfalls in Hohoe District, Kakum Park, the castles in Cape Coast, Kpetoe kente weaving town and of course, Kathleen’s birthday party at Sky Plus Hotel.

They were also ardent supporters of Black Stars, our national football team during the world Cup in South Africa 2010. Notwithstanding their “temporal” Ghanaian citizenship, they never forgot home whilst here. On the American Independence Day, I visited them in the house where they lived and we all sang the national anthem of their Home Country, USA. It was really a nostalgic moment!

I can still hear their voices giggling and their crazy music as I look forward to welcome GROW 2011, I really missed them. -MARGARET ASANTE, NURSE IN-CHARGE, HOPE HEALTH CENTER, HO.

Photo courtesy of Allyson Westling / GlobeMed at Northwestern.


A smoggy day in Beijing town: public health in Beijing

Traditional Chinese herb-picking alongside the Great Wall. Photo courtesy of Chi-chi Uichanco / GlobeMed at Northwestern.

For the past seven weeks, I’ve had the amazing opportunity to study in the crazy, crowded capital of the most populous country on earth: Beijing, China! The IPD program in Beijing is designed to allow us to witness the lasting impressions of Traditional Chinese Medicine (TCM) and learn about the basic public health structures in the country. Meanwhile, this lively, bustling city is our oyster to explore; it’s not too hard to blend in with a population exceeding twenty-two million.

The TCM half of the program was …interesting, to say the least. I came into this program with an open mind, excited to learn how other cultures viewed common health practices. After the first lecture we learned that, essentially, TCM revolves around the basic tenets of Yin-Yang Theory, the Five Elements, and Visceral Theory. Interestingly, they have quite a hold on modern Chinese culture as well. For example, Yin-Yang Theory dictates that every single entity on Earth exists as Yin or Yang, where Yin and Yang are two opposite but inter-related areas of life. Yang can be daytime, hot soup, or summer; yin can be night time, ice cream, or winter. Whether something is considered yin or yang will dictate how you treat it — that is, in TCM, whether a symptom is considered a yin or yang-symptom dictates whether you prescribe a yin or yang treatment. A common occurrence in China (especially for older people) is to refrain from drinking hot soup in fear of upsetting the body’s balance of yin and yang. Of course much of Chinese traditional thought has made way for modern habits, but much of the older generation is still quite resistant to complete westernization.

For a more hands-on experience, several students got to try out some traditional methods, such as acupuncture, moxibustion and cupping. All these practices serve to remedy imbalances of the body’s qi (or the energy which flows throughout channels in the body), but it seemed that acupuncture was China’s answer to every problem possible — migraines, cramps, even cervical cancer. Myself, I subtlety avoided the needles and opted for two small cups on my back which suctioned off a large portion of my skin for thirty minutes, branding me with got two large, red welts. I’ll tell you how my qi feels in a month. All this only scratches the surface of TCM — these practices go back ages in history!

Getting cupping done in the TCM ward of a Geriatric/Rehab Center. Photo courtesy of Chi-chi Uichanco / GlobeMed at Northwestern.

The second half of the program moved on to public health in China. This consisted of several hospital/health center/clinic visits, where we got to experience firsthand what Chinese citizens undergo to receive health care. Most practices were pretty standard, save for the occasional TCM ward or herbal pharmacy — it was great to see the growth of such an integrative approach, where doctors combined both Western and TCM techniques with their patients. Moreover, it was cool to see how the Chinese population worried about such different health problems than America does. Of course, we learned of the soaring number of cases of infectious diseases rampant in third world China. However, the leading causes of death area changing, especially in the more developed areas of China. For example, one of the most prevalent preventable risk factors in Chinese adult health is hypertension, or high blood pressure. This is due to certain aspects of the Chinese lifestyle, such as the enormous daily salt intake inherent in the cuisine. Equally as surprising was the lack of privacy in all the hospitals. Imagine, you’re prepping to receive a handful of acupuncture needles on your tender behind, and in comes a crowd of loud American students, furiously scrawling observations into notepads and snapping pictures. This was a fairly common occurrence wherever we went, but most patients didn’t seem to mind. Funny, how Chinese street decorum translated so seamlessly into Chinese hospital decorum…

I’m also excited to jump back into the health care debate going on States-side. Interestingly enough, there’s a health care reform currently under development in China as well. The majority of Chinese citizens are presently under government insurance programs, which are separated into rural and urban populations. However, the problem is that the majority of Chinese live in rural areas, while the majority of government health spending is allotted to urban health centers. Also, analysts have recognized a gap in health care coverage affecting the large population of migrant workers in China. Furthermore, the allotment system has suffered from inefficiency, requiring most health financing to come from out-of-pocket expenses. Currently, reforms are underway to alleviate these problems, but it will be interesting to see how these unfold in the coming years.

Aside from the academic setting, I think the true appeal of this program is tapping into the Chinese mindset. At first, my silly American manners prevented me from recognizing charm on the trash-ridden, polluted Beijing sidewalks: the fountain of loogies, public urination, exposed beer-bellies… it’s definitely an acquired taste. But after a while, you begin to realize that there’s nothing wrong with throwing politeness out the window. Of course, nothing’s personal; human interaction in this high-energy city is just very simple and straightforward… and simplicity can be a beautiful thing.

Of course, when I return to the States in a week, I’ll have to get re-accustomed to my ‘thank you’s,’ ‘excuse me’s’ and astronomical American prices. After weeks of painstakingly honing my bargaining skills (a cute flowy top down from 300 kuai to 80 kuai, fake Louboutins down from 4,000 to 250 kuai — how I’d love to bargain for my college tuition) I guess I’ll just have to accept that I’ll be paying four dollars for a cappuccino and there’s absolutely nothing I can do about it. -CHI-CHI UICHANCO


Deepa’s updates from Spain

A view from Plaza de Colon in Madrid, Spain. Photo courtesy of Deepa Ramadurai / GlobeMed at Northwestern.

Over the summer, the GlobeMed Grapevine will also feature updates from GlobeMed members traveling abroad. GlobeMed at Northwestern Director of Individual Giving, Deepa Ramadurai, recently returned from a six week study abroad program in Barcelona, Spain. While in Barcelona, Deepa studied Spanish language, conversation, modern culture and other political issues; Deepa also had the opportunity to briefly visit Madrid, Valencia and Milan while in Europe.

The healthcare system in Spain is really interesting. For one of the classes I was taking we had a special unit on immigration within Spain because it has a huge effect on Barcelona (since Barcelona is very much considered a commercial city and not necessarily as “Spanish” as some of the other cities in Spain). Specifically, it’s really interesting that a lot of foreigners, even from the United States, come to Spain to have big medical procedures done/have expensive treatment done because the Spanish government covers healthcare for foreigners. It was really interesting thinking about that system versus the system we have here and what it would be like if we adopted a similar system.

Other than that I couldn’t have asked to be in Spain at a better time — especially with the World Cup. It was incredible! Seeing the country unite behind their team was something I am never going to forget. I was in Madrid at the time in the Plaza de Colon, which is what they probably showed on TV a lot here in the U.S. There were thousands of people there and the atmosphere was incredible. Something even more incredible was how divided the whole country was over the win. There is a lot of separation between regions in Spain so the celebration in Barcelona (the capital of Catalonia) was practically nonexistent compared to that in Madrid because of Catalonia’s general anti-Spain sentiment at all times. It was actually really sad to see how 40-year-old sentiments of anger are still carried over today. It really makes you realize how much internal struggle a lot of other countries are going through and how they idealize the American government and American legislation. A lot of my teachers would tell us that the American policy of governing was ideal for Spain and they wished Spain would adopt our system. It just made me think how much the actions and practices of each nation affects those of another and how we might not even realize this among countries we believe are considered significant world powers.

The experience all around was something I will never forget. Experiencing the Spanish culture and lifestyle firsthand was something I have always hoped to do and I’m so lucky to have been able to do so this past summer. I’m hoping to go back to Spain sometime very soon and getting more familiar with their healthcare system and the practice of medicine there as compared with what we do here. -DEEPA RAMADURAI