Antibiotic Resistance and the Threat to Human Health.

The World Health Organization has declared antibiotic resistance as the single most threat to the future of human health. The Economist writes: “When people hear about antibiotic resistance creating ‘superbugs’ they tend to think of new diseases and pandemics spreading out of control. The real threat is less flamboyant, but still serious: existing problems getting worse, sometimes dramatically. Infections acquired in hospital are a prime example. They are already a problem, but with more antibiotic resistance they could become a much worse one. Elective surgery, such as hip replacements, now routine, would come to carry what might be seen as unacceptable risk. So might Caesarean sections. The risks of procedures which suppress the immune system, such as organ transplants and cancer chemotherapies, would increase.”


And let’s not forget about poorer countries. If microbial resistance spreads to drugs against parasites, problems such as malaria and viruses like HIV disproportionately impact developing countries and countries affected by climate change. Multiple drug resistant tuberculosis is already killing 200,000 a year, and artemisinin resistant parasites (the drug used to treat malaria) are already a reality.

We are in for a horrendous backslide of human health advancements if we don’t act now to ensure the responsible use of antibiotics.

A link to the article:
The Grim Prospect.

Posted in Global Health, Public Health | Tagged | Leave a comment

Determinants of Traditional Bonesetting (TBS) Patronage in Developing Settings

Mayan Bone Setting Mural - Photography taken in San Juan la Laguna, Guatemala

Mayan Bone Setting Mural – Photography taken in San Juan la Laguna, Guatemala

Musculoskeletal injuries are a major public health concern and a leading cause of disability (1). Traditional bonesetters (TBSs) play a significant role in the primary care of sprains and fractures, existing alongside orthodox orthopaedic treatments. It is estimated that up to 40% of patients with fractures and dislocations worldwide are managed by TBSs (2), and this number is higher in developing countries (3). Many patients present to the hospital only after complications from primary treatment by TBSs, increasing the morbidity and mortality of musculoskeletal injuries. Investigating patients’ choices where both traditional and orthodox treatments co-exist is an important task in global public health.

TBS is an ancient healing art dating back thousands of years and has been observed in nearly every culture (2). It involves the manipulation of sprains, dislocations, and fracture through the use of splints, massage, and salves. In some settings, spiritual interventions such as incantations are made on the affected area to invoke or ward off spirits (4). Although modern technology and orthopaedic treatment have made TBS mostly obsolete in high-income countries, TBS continues to enjoy high levels of patronage and community confidence in developing settings – particularly in the Indian subcontinent, Africa, South America, and Southeast Asia.

No formal training is required to become a bonesetter. Techniques are passed on from generation to generation or are personally discovered through trial-and-error (5). Orthopaedic surgery, by contrast, is a highly specialized medical discipline first recognized as a distinct profession only 120 years ago (2). Tensions between orthopaedic surgeons and bonesetters exist globally. Lack of government regulation and formal training of TBSs is problematic to orthopaedic surgeons, who face diverse challenges in managing complications caused by TBS treatment. Complications include mal-union, non-union, delayed union, and loss of joint mobility (6). Extremity gangrene is the most serious complication, resulting from mismanagement of open fractures (7). These complications pose economic, physical, and social burdens to patients, society, and health systems (8).

This short report will provide an overview of the interrelationship between TBS and orthopaedic surgery in developing settings. Recommendations will be made as to how developing countries could approach the issue of TBS patronage within an integrated health systems framework to better patient outcomes and improve public health.

Continue reading

Posted in Global Health, Public Health | Tagged , , , , , , , , , , , , , , , , , , , | Leave a comment

Cash Transfer Programs and HIV Prevention in Malawi: A Review of the Evidence

 The use of cash transfers as an HIV prevention strategy engenders a simple yet profound question: Should we expect financial incentives to change sexual behavior at all?


This discussion will provide an analysis of the use of cash transfers as an HIV prevention strategy in Malawi. Cash transfer programs offer direct, regular cash payments that help poor and vulnerable households stabilize their income in order to alleviate poverty and promote behavior change. The use of cash transfer programs as a form of international development has been growing in popularity worldwide. The Department for International Development (DFID) has described cash transfer programs as a ‘quiet revolution’ among governments in developing countries. In 2011, it was estimated that 0.75 to 1 billion people were recipients of cash transfer programs worldwide (DFID 2011).

Since the beginning of the HIV epidemic in Sub-Saharan Africa, governments have employed numerous strategies to reduce the spread of infection. The three ‘pillars’ of HIV prevention were established in the 1980s to combat the generalized epidemic: condom promotion, voluntary counseling and testing (VCT), and treatment of other sexually transmitted infections (Potts et al. 2008). Twenty years later, there is not much evidence that the decline in the generalized AIDS epidemic can be attributed to any one of these three strategies (SDAC 2006; Shelton 2007; Gray and Wawer 2007)[1]. Vaccines and microbicides have begun to be tested, but so far have shown little promise (Cohen 2008)[2].

The use of cash transfer programs to target specific groups is a relatively new prevention strategy. Risky behaviors such as substance abuse, unprotected sex, sex at an early age, and sex work all contribute to the spread of HIV. Cash transfer programs assume that these behaviors are amenable to change if recipients are financially incentivized. National scale cash transfer programs to reduce HIV-related risk in Sub-Saharan Africa now exist in Kenya, Zimbabwe, South Africa, Mozambique, Zambia, and Malawi. Given the strong evidence in favor of cash transfer programs for poverty alleviation and school enrolment[3], it is hoped that cash transfers could be effective at reducing HIV risk behaviors – especially among vulnerable groups.

Continue reading

Posted in Global Health, Public Health | Tagged , , , , , , , , , | Leave a comment

Health Issues and Refugee Resettlement: A Guide for Caseworkers

Refugees are among the world’s most vulnerable populations. Displaced from home, unable to return and facing the daunting task of assimilating into a new society, they additionally suffer from a number of health problems. Many have not had access to necessary preventative health care and treatment in their home countries and countries of asylum. As a result, many refugees arrive to the United States with a host of unmet medical needs.

The personal history of a refugee is often marked by physical and emotional trauma. People from refugee backgrounds suffer disproportionate rates of infectious diseases, mental and social health problems, physical injuries, and undiagnosed chronic diseases. Some refugees are victims of torture and human trafficking. People who survive these experiences may have a profound sense of anxiety, hurt, and anger. Many refugees experience ongoing grief associated with the loss of friend, family and communities left behind.

While refugees are often in relatively poor health on arrival to the United States, the early resettlement period may expose them to further negative health consequences. Settling in a new country involves massive adjustments to a person’s way of living. These include learning a new culture and a new language, as well as gaining knowledge over practical tasks such as navigating public transportation and paying the rent. Refugees must also learn to navigate the complex health systems of the United States. These adjustments may be particularly overwhelming for refugees exposed to severe trauma, as many of the tasks of resettlement involve dealing with people in authority. Routine interactions with resettlement staff and health authorities may serve as painful reminders of past experiences, exacerbating underlying psychological problems.

Resettlement staff play a valuable role in optimizing the health of newly arrived refugees. With knowledge of the implications that different medical conditions can have on the process of resettlement, case workers can make a significant contribution to re-establishing the health, self-respect and dignity of their clients by ensuring an optimal delivery and coordination of health services.

“Medical Issues and Resettlement: A Guide to Common Conditions Among Refugee Clients” is a guide for caring for people from refugee backgrounds with medical conditions. This guide can serve as a resource for resettlement staff who play a vital role in coordinating the communication between clients and health service providers. Working together, we can support the health and wellbeing of refugees, enhance the participation and opportunities for those with disabilities, and overcome the barriers that limit full access and participation in society.

CLICK HERE to read the e-book:

ECDC cover

(NB: This guide was created by me while interning for the Ethiopian Community Development Council in Washington, D.C.  It is open for use by anyone who would find the information useful.)

Posted in Global Health, Public Health, Social Justice | Tagged , , , , , , | Leave a comment

The Use of m-Health in Sub-Saharan Africa: Health Systems Strengthening in the Digital Age

Community health worker using mobile phone. Credit:


Mobile health (m-Health) describes the use of mobile technologies[1] to deliver health services and information. As a subcategory of electronic health (e-Health), m-Health is related to telemedicine (the practice of medicine at a distance), but is also used in public health. Globally, m-Health has diverse applications including appointment reminders, treatment compliance, health promotion, survey data collection, drug supply monitoring in clinics, and diagnostic assistance to village health workers.

NOTE: This post is an adaptation of a paper written at the University of Sydney. If you wish to use this content, you must include a citation. Cite as follows: Counts Tanner, Amanda. (2013, Nov. 20). The Use of m-Health in Sub-Saharan Africa: Health Systems Strengthening in a Digital Age.  [Web log comment]. Retrieved from

The creative use of mobile technology has “the potential to reduce the cost of health care and improve health research and outcomes, [supporting] continuous health monitoring at the individual and population level” (Kumar et al. 2013:228). The potential of m-Health has not been limited to developed countries. Worldwide, governments in low- and middle-income countries have embraced m-Health as a complementary strategy for health systems strengthening, particularly with regard to health-related Millennium Development Goals (WHO 2011). M-Health has the potential to strengthen several of the WHO’s (2007) building blocks of health systems, including service delivery, information systems, medical technologies, and the workforce.

Whether nascent m-Health programs can meet the challenges of global health systems is in debate. Proponents of m-Health have highlighted the potential for m-Health to solve critical human resource shortages in a cost-effective manner. Sceptics question whether its potential can live up to its hype, especially with regard to scalable national programs, and call for more evidence. Pilot projects have provided early evidence, but m-Health is a burgeoning field and many questions remain.

The aim of this paper is to outline the issues surrounding m-Health in the context of Sub-Saharan Africa (SSA). First, I will discuss the history of m-Health in SSA. Second, I will highlight the common arguments arising from both sides of the debate. Lastly, I will offer my own perspective on the debate in light of the available evidence.

Continue reading

Posted in Global Health, Public Health | Tagged , , , , , , , , , , , | 2 Comments

Health Systems Strengthening in Guatemala: A Case Study of HIV/AIDs

Guatemala Flag

The strengthening of health systems in developing countries is considered a priority for the World Health Organization (WHO). The WHO Framework for Action, published in 2007 at the midpoint of the Millennium Development Goals (MDGs) countdown to 2015, is a call to action to strengthen what it has identified as the six building blocks of health systems worldwide. These building blocks include the following broad sectors: (1) Leadership and governance; (2) Health care financing; (3) Health workforce; (4) Medical products and technologies; (5) Information and research; and (6) service delivery (WHO 2007a). Each building block is interrelated with the others, making health systems strengthening in developing countries a complex challenge requiring a coordinated global effort.

The aim of this paper is to examine the components of the health system in Guatemala. First, I will outline the structure of the Guatemalan health system using the six WHO building blocks as a foundation. Second, I will examine the key challenges to the country’s health system with regard to the national response to HIV/AIDS. Lastly, I will present recommendations which could be taken to improve Guatemala’s health system response to HIV/AIDS.

Guatemala: A Health System in Transition
Guatemala is a lower-middle income country in Central America with a population of 14.38 million (World Bank 2013). An examination of its health system is of interest for several reasons. First, a high proportion of its population lives in poverty. Fifty-four percent live under the poverty line (Central Intelligence Agency 2013) and 37% of the population lives under $2 per day (World Bank 2006). This means that a high percentage of its population is vulnerable to economic shocks due to catastrophic health spending[1]

Continue reading

Posted in Global Health, Public Health | Tagged , , , , , , , , | Leave a comment

Reducing Maternal Mortality: A Case Study of Guatemala

Copyright: John Stormzand/

Copyright: John Stormzand/

The Millennium Development Goals (MDGs) are a set of interdependent goals and targets agreed to by all member nations of the United Nations, which aim to reduce global poverty and improve the quality of life among the world’s poor by 2015. The MDGs address a range of international development issues including poverty, hunger, gender equality, education, environmental sustainability, and health and disease. The Millennium Development Goals have been an important framework for guiding research and policy-making among the global health community and governments worldwide. Each MDG influences population health, and population health affects each MDG.  For example, education among women is essential to achieving better maternal health, and better maternal health leads to better educational outcomes in children, thus reducing further poverty (Baird, Garfein, McIntosh, and Ozler 2012; Grown, Gupta and Pande 2005).

The goal of Millennium Development Goal 5 is to improve maternal health. Maternal health is broadly defined as measurements of maternal mortality and access to reproductive health services. The first target for MDG 5 is to reduce the maternal mortality ratio by three-quarters between the years of 1990-2015 . The two main indicators for monitoring progress toward this target are the maternal mortality ratio (the number of maternal deaths per 100,000 live births) and the proportion of births attended by skilled health personnel. Following a review of the monitoring framework for MDG 5 at the 2005 World Summit, one new target and four new indicators were added to MDG 5. The second target, Target 5.B, is to achieve universal access to reproductive health by 2015. Target 5.B is a more compressive approach to addressing maternal health, and includes the following indicators: Contraceptive prevalence rate, adolescent birth rate, antenatal care coverage, and unmet need for family planning[1].

Continue reading

Posted in Global Health, Public Health | Tagged , , , , , , , | 1 Comment

On the Strength of Interdisciplinarity

I write to you now from Australia, where I have begun a Master of International Public Health at the University of Sydney. In my first few weeks, I have been astounded by the amount of global diversity within our program. I am privileged to share a classroom with students from Malawai, Nigeria, Ecuador, Nepal, Pakistan, Belize, Uganda, Congo, Rwanda, Papua New Guinea, Indonesia, and others. Adding further to this richness of global diversity is the diversity of the students’ academic backgrounds.

Where our students come from - Master of International Public Health at the University of Sydney

Where our students come from – Master of International Public Health at the University of Sydney

Interdisciplinary work in the academic setting is sometimes dismissed as lacking effectiveness, efficiency, or strategy, and the difficulty of doing interdisciplinary work is sometimes regarded as impractical. Yet interdisciplinarity in the field of international public health is one of our core strengths. In our program, we have medical doctors, social scientists, community workers, engineers, historians, policy makers, and even some veterinarians. In the classroom, we hold each other accountable for different types of knowledge and contexts, not only of situations on the ground, but also in methods of knowing. Research methodology, study designs, epistemologies, and measurements vary greatly between these fields, yet each perspective is crucial to solving the complex array of problems and promises affecting global health today.

Dalk, Grobstein and McCormack (2004) have written that “the very nature of interdisciplinarity, as we understand it, requires that those who engage in it will always be working beyond the edges of what they know how to do well; in conception and methodology, such work cannot become conventional” (1). The problems we face in global health are anything but conventional. They are multifaceted and constantly shifting; they involve a multitude of human sectors and non-human actors, from environmental variables to the ‘bugs’ that infect us; and they require sophisticated minds to parse out the interactions between them.

The strength of interdisciplinarity is when our “edges” fold together, overlap, and sometimes collide, in order to gain richer, more contextual understandings of the complex problems of human health.


Dalk, Grobstein and McCormack. (2004). “Theorizing interdisciplinarity: the evolution of new academic and intellectual communities.”

Posted in Academia, Global Health, Public Health, Sociology | Tagged , , , , , | Leave a comment

Biomedical Explanations & Social Ostracization: Cultural Differences and the Case of Schizophrenia

Within the field of medical sociology, there has been debate about whether biomedical diagnoses legitimate or stigmatize patient groups. Some argue that biomedically recognized diagnoses for ‘contested illnesses,’ such as Chronic Fatigue Syndrome (CFS), provide patients with a sense of relief – that their problems do not exist only in their heads (psychosomatically), but is medically recognized in their bodies. This is important insofar as it legitimizes and lends weight their experiences, which can be tested and subsequently treated in certain ways. Physicians, as well as employers, insurance companies, and family members, begin to take them seriously by socially recognizing their condition as ‘real.’

With other conditions, biomedical recognition works the other way around. For example, in eating disorders, patient groups have successfully advocated for a more holistic approach to treatment, arguing that the illness exists not only in their bodies (with regards to diagnostic criteria such as weight loss and amenorrhea), but also in their minds (i.e., obsessive thoughts, body dysmorphia, anxiety), which must be treated with psychotherapy.* For decades, eating disorder treatment consisted primarily of re-feeding and weight stabilization in psychiatric hospitals. Once patients reached a certain weight, they were released and presumed to have been “healed” of their illness. Patient advocacy groups and patients themselves, outraged over high relapse rates, pushed for longer treatment programs that incorporated in-depth psychotherapy and holistic modalities (such as art therapy). They successfully argued that eating disorders involve, at their root, deep and systemic disturbances in cognition and behavior patterns that can’t be fixed quickly. Tired of being told they should just “get over it,” or that eating disorders are just “a phase,” patients groups pushed to get their condition biomedically (and thus, socially) legitimized as a serious mental illness – not just something they can “turn off” with enough willpower. In many ways, this has led to better social acceptance and empathy for people struggling with disordered eating.

But what about biomedical explanations for mental health conditions that do not lead to social acceptance?

Continue reading

Posted in Sociology | Tagged , , , , , , , , , | Leave a comment

Giving What We Can – The Best Way We Can

The end of the year is a giving season for many. Reflecting over the blessings we receive during the holiday season, many of us turn our thoughts to how we might help the less fortunate. It is understandable to wonder whether our charitable donations do as much good as we’d like them to.

Many of us use administrative expenses and overhead figures as a measurement to determine what charity we give to, assuming it will tell us something about how much good the charity’s work actually does. But this may not be the proper measurement. As Dean Kanlan at Freakonomics suggests, the proper question to ask should be, “For every $1 I give, how much good is generated?”


Giving What We Can (GWWC) is an international organization dedicated to eliminating poverty in the developing world by evaluating the effectiveness of different charitable programs and providing practical advice on how to make your dollars help the most. In the area of global health, GWWC relies on data produced by the WHO and the Disease Control Priorities Project to determine which charities have the largest impact on Disability Adjusted Life Years (DALYs) on a dollar-by-dollar basis.

DALY is a measurement of loss of health due to illness used by the WHO. One DALY represents the equivalent to losing a year of life at full health. Since we can’t really “save” a life (as everyone will die at some point), perhaps it is best if we focus our efforts on extending someone’s life instead. This is why the DALY is such a useful measure.


So what does all this mean in jargonless speak? It means that with the help of GWWC, you can donate to charities that provide the most effective health interventions, taking into account improvements to both quantity and quality of life. In short, you know your dollar’s going far – farther than it might have by giving to another charity.

You can check out Giving What We Can’s list of recommended charities and read more about their mission statement here. You can even pledge to donate 10% of your income for the rest of your life.

Full disclosure: This year I gave to Amigos de Santa Cruz in Guatemala, due to a personal connection with the Mayan people in my recent visits there, and Dooley Intermed International‘s “Gift of Sight” program for people with preventable blindness in Laos and Nepal, due to the low-cost of providing a tangible person with cataracts surgery.

Posted in Charity, Global Health, Public Health, Social Justice | Tagged , , , , , | Leave a comment