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By Nadeem Hasan

I’m five months into a year-long stint in Sierra Leone as one of the global health fellows for 2016/17. I hope to blog about the positives of the experience, hence the format ‘in praise of’.

After all, there’s enough negativity around as it is.

I’ll be working in the Ministry of Health and Sanitation (MoHS) in Freetown, supporting their mission to strengthen the health system following Ebola, and learning as much as I can along the way.

Predictably, I’ve already learned a lot more than I’ve contributed.

I’m engaging with the financial and capacity challenges in the MoHS; the political challenges; and the complexity of operating alongside the World Health Organisation, the World Bank, UN agencies, and hundreds of NGOs and private sector implementing partners. And all of that before even getting to the content of the day-to-day work of the ministry.

Accordingly, I don’t feel too bad about the learning overshadowing my own contributions.

Not being sure what to expect when I got to my office, what first struck me was the sheer number of international staff embedded in the MoHS. I found technical experts from the Clinton Health Access Initiative (CHAI), Oxford Policy Management (OPM), Overseas Development Institute (ODI), USAID and others – all with desks inside the ministry, working hand-in-hand with national staff.

Foreigners everywhere. And now here I was adding to their number.

The ability of the ministry to pursue its goals should be improved by international experts working together with their national counterparts: on the face of it, it’s a win-win situation. However, the sheer number of international staff also leads to challenges for sustainability and country ownership of health policies and programmes – and if not managed carefully could have a negative impact in the long-term.

So what’s the appropriate balance?

Three months in, it’s clear that these long-term embedded experts have had the time to build strong relationships with their national counterparts. Through these relationships, they’ve been able to develop a deep understanding of the local context – including the enablers and barriers to successful design and implementation of policies and programmes.

Crucially, a lot of this information isn’t written down anywhere (for very good reasons), and can only be gathered through living in the country.

As a result, these individuals end up being highly skilled in their ability to compare and contrast what the evidence and data says should be done to improve health outcomes, with what can actually be achieved on the ground at any given time. Importantly, this requires taking into account the personal relationships that exist between key individuals.

Compared with short-term consultants that ‘parachute in and helicopter out’, they’re highly valued by senior national staff in the MoHS for their expertise and sensitivity to the local context. And, I think, rightly so.

All of this is fine of course, but what about the questions of country ownership (what happens after external ‘experts’ have done their bit) and sustainability (what happens when they leave)?

Well, I’ve watched how some of the more seasoned experts resist the temptation to look at the evidence and data and write the ‘ideal’ policy or strategy, presented with a shiny bow, only for it to sit gathering dust on a shelf.

Instead, they work on the sidelines; gathering the relevant data on a topic and developing the questions for discussion by national actors. They support the process of convening national actors to discuss the best way forwards without taking too active a role in those discussions themselves. They therefore support leadership by national staff, which in turn generates the momentum and wider ownership required for success.

The ‘capacity building’ aspect is harder to see at the central level than in a health facility, where the traditional ‘teaching and mentoring’ approach is more appropriate.

At the MoHS, knowledge and skills are shared (both ways) through building trusting relationships with national staff and working together on routine aspects of the job. The mutual respect that this generates in turn increases the rate of knowledge and skills transfer.

Accordingly, the longer the expert is embedded in the team, the more effective the process. In this way, the sustainability of the work done and approaches taken by international staff is to some extent ensured.

A major challenge comes in the form of convincing donors focused on results that this long-term, ‘softly, softly’ approach with no concrete ‘measurable’ outputs is worth the investment – but that’s a whole other issue.

This is of course a rose-tinted view, but the blog is, after all, entitled ‘in praise of’.

Thinking back to practice in the UK, I wonder whether there is a broader relevance of this approach for ‘health in all policies’. Embedding public health specialists in non-health teams on a long-term basis can have two major benefits. First, the use of a robust evidence and data-led approach to policy making that considers the health impacts of non-health policies. Second, the contextual understanding of how to do achieve this effectively under the leadership of the host team (thereby ensuring sustainability).

Comparing Sierra Leone to, for example, the Department for Education in Whitehall might seem odd at first glance. However, for a public health specialist they’re both new contexts that have to be learned and understood before being able to operate and influence effectively, and both places where our skillset and approach could lead to significant improvements in health outcomes.

I know this is already happening in some places such as Transport for London. If it is anywhere near as effective as it is in Sierra Leone, then we could do with a lot more of it.

Nadeem Hasan is a public health registrar

By Professor John Ashton

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The statue near the site of the Christmas truce football match.

Granny Ashton’s half brother, my great uncle Arthur Anderton, died on the Somme in 1918.

According to the Commonwealth War Graves Commission, ‘Private Arthur John Anderton 283444, serving with the 2nd/ 4th Battalion, London Regiment (Royal Fusiliers), died on 25 April. Sadly he has no known grave and therefore he is commemorated by name … on Panel 86 on the Pozieres Memorial, France. Pozieres is a village about 6 kilometres north-east of Albert.’

Great uncle Arthur was from Liverpool but unlike many of his fellow Liverpudlian victims of the First World War his name does not appear with the thousands of others on the walls of the memorial room in Liverpool Town Hall. Rather, at the time of his death resisting the last German attempted push to Paris in the dying months of the war, he found himself in a London regiment.

Reading the daily log of his commanding officer, as we retraced his final weeks’ footsteps some years ago, the reason becomes clear. A typical morning entry would record that two or three hundred men had joined the regiment and an evening entry would record that at least a similar number were missing presumed dead, with no body to be found.

The result was a constant forming and reforming of battalions.

Spending several days immersed in the tragedy of such inhumanity, I was struck by the relatively small size of the battle area of the river Somme; space which saw so much death and maiming.

I was also reminded that this tragedy affected so many nations and people. Arriving at the cemetery at Poitiers we were surprised by the arrival of two young Germans on a motorbike whose relative was remembered in a British cemetery. Tears were never far from my eyes.

That trip made a lasting impression on me and the fragility of the peace of 1918 and that of 1945 has become ever more apparent as our 21st century world fragments, instability and ancient hatreds return and battle lines are drawn up. On average, in recent years around 200,000 people have been killed in conflict each year.

In the First World War 90% of those killed were soldiers and 10% civilians. Today that ratio is nearer 25%:75%. Never has it been more important to learn the lessons of history.

So this year when political biographer Sir Anthony Seldon decided to do something about establishing the Western Front as a cultural reference point for peacemaking, I was up for the challenge.

While writing a book about the First World War, Sir Anthony came across the story of Douglas Gillespie who was killed in the Battle of Loos in September 1915. Shortly before his death, Douglas had suggested in a letter home the creation of a ‘Via Sacra’ when the war was over. He wanted it to run from Switzerland to the English Channel, a secular pilgrim route to help future generations understand the need for peace.

And so, on 22 June this year, a varied group of us met on the steps of the Mairie in Pfetterhouse, close by the Swiss-German-French border, and set off to walk north to the Channel. It was a remarkable experience. It was bitter-sweet; poignant and sad; a significant challenge; great fun; and a unique opportunity to share in an adventure with some remarkable people.

In some ways it felt like a contemporary re-run of Chaucer’s Pilgrims Tales; everyone had stories to tell, including Gillespie’s descendants and others who had lost family or had family members taken prisoner of war.

But it was also a three dimensional education.

On the second day we got lost in the Vosges mountains in temperatures well into the 30s and discovered the price the French paid to hold the Germans in the south, dug in for the freezing winter of 1914 at 3000 feet.

On the last day of June we reached the Somme itself, ready for the centenary ceremonies near Albert the next day and I felt the spirit of Great Uncle Arthur once again. We moved on to Vimy, Armentieres, Ypres and Passchendale; past the spot where a British soldier spared Adolf Hitler’s life and where Winston Churchill served his country.

We passed by the ever so poignant field of the Christmas truce and the football match, now part of folklore (the statue commemorating the truce is in the photograph above). We walked on past the Menin Gate with English schoolchildren laying wreaths at the sound of the Last Post; and finally to the coast at Diksmuide, where a local farmer had the presence of mind to open the sluice gates, flood the marshes and cut off the German troops.

Sir Anthony’s vision is of a long distance path which will be trodden for hundreds of years to come; perhaps long after the Commonwealth War Graves Commission has ceased to exist.

It is a necklace-like path punctuated by educational oases – like the remarkable little museum created out of a German medical field station in Cernay, where we were shown such hospitality by the local mayor. A path which will engage with future generations and steer them away from the path of intolerance, hatred, war and death. A path which will mean no more great uncle Arthurs cut down in the prime of life.

It is Sir Anthony’s intention to repeat this year’s walk in 2017 and 2018. You can find details on the Via Sacra website (http://www.viasacrawalk2016.org.uk/).

John Ashton 7 November 2016

 

vitamin-d

By Dr Amrita Jesurasa

Ever since our most ancient ancestors left Africa to populate the rest of the world the appearance of their descendants has changed.

Height, facial features, hair type, body size and shape, and invisible genes that can protect from or predispose to disease have developed and differentiated racial groups. But the most profound (and superficial) change has to be in the colour of our skin as people migrated and settled around the world.

Skin colour forms a strong part of our physical and social identity, at times unifying people but more distressingly, causing division. The legacy of this evolutionary change has left its scars on human history in the last few hundred years and continues to cause tension in the present. Ethnic inequalities in health are well recognised and yet we perhaps fail to recognise the true message from history: why did skin colour change?

Current theory suggests that this phenomenon arose as a result of our need for vitamin D. As our early ancestors migrated to northern latitudes, they experienced the severe consequences of vitamin D deficiency. These included bone deformities that affected their ability to walk, breathe and – crucially – to give birth (the latter the result of changes to the female pelvis).

In Europe, natural selection began to favour lighter skin that allowed ultraviolet radiation to be more readily absorbed, vitamin D to be synthesised and ultimately our species to survive in Europe and other northern climes.

Fast-forward to the 21st century and rapid technological advances have transformed the way we live. Some of these developments, including air travel, have facilitated evolutionary shortcuts, enabling the humans of today to live in environments that are totally different to that of even the previous generation. But other advances have affected the behaviour of us all by encouraging a more indoor lifestyle than that of our ancestors, creating fear of the adverse effects of the sun and altering our dietary habits.

This perfect storm has allowed vitamin D deficiency to become a population-wide issue, but one which has the greatest impact on those with darker skin. The irony is that this disproportionate effect within the population marginalises the issue of vitamin D deficiency, creating an ethnicity-related health inequality.

To raise the profile of vitamin D deficiency, universal issues need to be addressed and universal solutions provided. While improving access to vitamin D supplements must be part of this strategy, there are worrying common pitfalls associated with an exclusively medical approach.

Instead, a simple message may resonate more with both the public and policy-makers. This could mean promoting a basic principle that “like plants, we need food, water and sunshine to thrive”. With a more holistic approach we can relate prevention of vitamin D deficiency to other important and well-recognised public health concerns, thereby raising the priority of this historically important issue.

  • Dr Jesurasa is a Specialty Registrar in Public Health Medicine/ Honorary Clinical Lecturer in Public Health, University of Sheffield
By Philip Daniels, Health Education England Global Health Fellow

Over the next year I will be working within the Public Health England Global Health Team. Based in London and Freetown, I’ll be supporting the development of the Sierra Leone National Public Health Agency, working with colleagues from Sierra Leone, USA and China.

Being awarded a Health Education England Global Health Fellowship is an enormous privilege. It gives me the chance to work with colleagues from a diverse range of backgrounds, disciplines and nationalities. I’ll be blogging regularly to help me record what I see and learn.

It is an incredibly exciting time to be involved in Global Public Health. Issues such as pandemic disease, outbreaks such as Ebola and Zika, as well as the growing threat of antimicrobial resistance (AMR) and climate change are increasingly informing the UK’s approach to Public Health.

The UK is a signatory of both the International Health Regulations (2005) and the Sustainable Development Goals (2015) – the latter of which include an explicit commitment to ensure healthy lives and promote wellbeing for all at all ages.

The UK Aid strategy (2015) restructured Overseas Development Aid (ODA), on which the UK spends 0.7% of its GDP, to ensure that it is spent on tackling the great global challenges. As part of this, the UK government has established:

  • The Ross Fund, a £1 billion initiative to tackle the most dangerous infectious diseases such as Ebola, malaria, neglected tropical diseases and drug resistant infections
  • A £500 million ODA crisis reserve to enable effective cross-government responses to crises as they happen
  • A Global Challenges research fund of £1.5 billion over the next five years to ensure UK science takes a leading role in addressing the problems faced by developing countries – such as building resilience during emergencies and tackling AMR.

In addition, the government has committed to increasing UK climate finance for developing countries by at least 50%, to reduce emissions, increase access to energy, build resilience of the poorest and most vulnerable people, and to reduce deforestation.

All of this reflects an awareness that what happens internationally and globally affects health security in the UK. It’s also apparent that the expertise based in the UK has much to offer the rest of the world, as illustrated by PHE’s successful efforts to give public health and science a bigger role within the Sendai Framework for Disaster Risk reduction (2015-2030).

Reflecting this, Public Health England and the Faculty of Public Health have published Global Health Strategy. It highlights not only the complexity of the problems faced, but also the enormous contribution that will be made in the coming years by UK Public Health. It is within this context that I begin my Global Health Fellowship.

It is set to be a challenging and rewarding year; I look forward to sharing it with you.

 

Tomorrow (11 October) marks a day of mourning and sadness to many Muslims across the world. It is Ashoura – a day which not only has sad connotations for many Muslims but also sees increasing numbers of people making potentially dangerous cuts to their body.

Ashoura means the tenth day of the Islamic month of Muharam. It commemorates the brutal death of Imam Hussain (Muslim prophet’s grandson) in a fierce battle over 1000 years ago. Imam Hussain, his family and his followers were murdered.

This event is observed mainly within the Shiite Muslim community in different ways. The range of responses varies from donating to those in need to, at the extreme end of the scale,  Shiite Muslims showing their repentance through self-inflicting injuries using knives, spiked or bladed chains and other sharp tools.

This practice is well known as Zanjeer Zani. It is most common in Pakistan, Iran, Iraq, Bahrain, Oman, and to a lesser extent, in Afghanistan, Egypt, Lebanon and Syria. However, there have been reports of this practice emerging in Europe and the UK.

While many Islamic scholars are publicly opposing  Zangeer Zani it is impossible to control or ban this deeply rooted cultural practice. Hence a harm reduction approach is best to minimise the risks associated with this ritual.

The main public health risk is Blood Borne Viruses (BBV) and other bacterial skin infections.

Unfortunately, the risks are not well documented and there is nothing published in the literature. The ministries of health of those countries where this practice is common and the WHO-EMRO region have no protocols or guidelines in place in response to this annual practice.

Although I fully acknowledge the challenges in the EMRO region, I would like to call upon clinicians and public health professionals in the UK to raise awareness, encourage testing for BBV and promote contact tracing and Hepatitis B vaccination as interim measures to reduce the risks associated with this ceremony.

Dr Bayad Nozad, FFPH with special interest in Blood Borne Viruses

 

Last week marked the end of the fifth global World Alzheimer’s Month. It gave us all a chance to reflect on the importance of this international campaign to raise awareness and challenge the stigma that surrounds dementia.

The theme for World Alzheimer’s Month 2016 was Remember Me. Alzheimer’s Disease International asked people to get involved by sharing their favourite memories, or memories of a loved one, on social media with the hashtags #RememberMe and #WAM2016.

Alzheimer associations in more than 60 countries took part in this year’s campaign, raising awareness, and advancing action to make dementia more understood.
FPH members, as part of the leading professional body for public health specialist in the UK, provide sterling service at local and national levels, promoting effective preventative measures to reduce the risk of people developing dementia, and advocating for a more dementia friendly society.

Below is just one example of that work.

Claire Beynon, Registrar and Chair of Specialty Registrars Committee – Dementia Health

Needs Assessment for Cardiff and Vale
Dementia in Cardiff and Vale
Currently in Cardiff and Vale there are estimated to be approximately 5,500 people with dementia, about half of whom have a diagnosis.  Due to a growing and ageing population by 2025 this is expected to rise to nearly 7,000 people living with dementia.  Timely diagnosis can slow the progression of dementia and help individuals identify sources of support.
How has Cardiff and Vale promoted World Alzheimer’s month?
Cardiff and Vale have been running a campaign on social media and have produced three patient stories that have proved popular, see the website for the stories. http://www.cardiffandvaleuhb.wales.nhs.uk/caring-for-someone-with-dementia
So how does my work fit into this?
By undertaking a health needs assessment I hope to raise the profile of unmet health needs in the local area.
One in five cases of dementia may be preventable with exercise, diet, diabetes prevention, and early treatment of depression so we need to consider how we can move more focus towards prevention.  The Welsh Government recently produced a guide on how to reduce your risk in six steps.

http://gov.wales/docs/change4life/publications/150515dementiaen.pdf

Why undertake a Health Needs Assessment for Dementia now?
The Cardiff and Vale 3 Year Dementia Plan is due to end in 2016/17, and there is a need to refresh the information on which it is based and make new recommendations based on the altered circumstances.  The purpose of this Dementia Health Needs Assessment Plan is to outline the process that will be undertaken to assess the health needs of people with dementia and their carers in Cardiff and Vale.
In my role as a Specialty Registrar time I will co-ordinate the Dementia Health Needs Assessment. The needs assessment will be undertaken during the period July to December 2016.  A final report will be prepared in December 2016.

isabella-goldie

  • By Isabella Goldie

  • Director of Development and Delivery

  • Mental Health Foundation

There are times throughout all of our lives when we are likely to run into difficulty, particularly at life’s pressure points: the crucial times of transition from one life stage to another. From moving away from home for university, to having children or dealing with the loss of a loved one.

If we are to rise to the challenge of reducing the prevalence of mental health problems, we need to be stepping in at these pressure points, taking preventative measures that can support people through times of difficulty and stop mental health problems from developing in the first place.

This will require a societal shift. We will need to begin truly recognising good mental health as a universal asset to be strengthened and protected. We can no longer afford to wait for mental health problems to develop before taking action.

The effective support of people experiencing mental health problems is set to become one of the greatest public health challenges of this decade. Without action on the increasing demand for public services, it will not be possible to absorb the rising costs of providing care and support for those experiencing mental ill health in the long term. We need to act decisively as we have in the past when faced with significant risks to public health.

It is essential that we also draw our attention to preventative approaches so that illness is a rarer event.

The historical approaches to curing illness and responding in crises has left a legacy of health services designed to fix problems. While access to good quality mental health services and support must continue to improve and rapidly, it is essential that we also draw our attention to preventative approaches so that illness is a rarer event, both in recognition of the economic costs and also in the sometimes devastating personal impact resulting from poor mental health and mental health problems.

Last week the Mental Health Foundation published Mental health and prevention: taking local action for better mental health, a report produced with Public Health England which lays out a road map for bringing about a prevention revolutio

n in mental health, delivered in every local area. In addition to the strong theme of mental health across the life-course, taking every opportunity to step in early and prevent the development of mental health problems, the need to improve the mental health knowledge and literacy of the entire public service workforce is highlighted.

Integrating mental health improvement into daily work

This radically different approach encourages all health and social care staff to consider the impact of mental health inequalities and act to reduce them. Staff must react to these inequalities in line with the principles of ‘proportionate universalism’, an approach that progressively applies resources where the greatest risks lie.

In practical terms, this means integrating mental health improvement into daily work, with messages and interventions tailored to meet specific needs of those at highest risk of developing mental health problems.

We need to ensure that high-quality services are both available and easily accessible for those that need them most, while also intervening early to reduce the need for specialist support. We can achieve this by giving individuals, families and communities, the tools to protect and manage their own mental health.

This will only ever be achieved by working alongside communities, listening to people’s stories of lived experience to understand what impacts their mental health and what tools they need.