COHESION @ ICRD

At the beginning of September 2017 in Bern the 4th International Conference on Research for Development (ICRD) was held. The aim of the conference was to present “visionary contributions that will enhance transformations towards sustainable development in countries of Africa, Asia, and Latin America.” (www.icrd.ch)

COHESION was of course present at this important event. COHESION co-organised two sessions on partnerships with the Council on Health Research for Development (www.cohred.org) and Commission for Research Partnerships with Developing Countries (www.kfpe.ch). Maria Amalia Pesantes from the COHESION Team in Peru was a panelist during a session on increasing equality in partnerships. These sessions on partnerships highlighted a variety of challenges in establishing partnerships, but also tools developed to help address these and the role funders can have in helping facilitate partnerships. One interesting aspect was thinking about the process of partnerships and how there are “Hard elements”, such as shared vision, setting the agenda together, fairness and sharing of process and capacity building. In parallel “Soft elements”, such as trust, respect, being open and cultural differences are equally important. Both hard and soft elements are essential to ensure success, but require different approaches to be established. It was interesting to reflect on these as COHESION as a project and a partnership evolves.

Silvana Perez Leon also from the Peru Team won a grant to present some of her work at the conference. During the session “Building transformative partnerships between health services and communities as a means to advancing the Agenda towards Sustainable Development: A pathway forward”, she presented her experience engaging with primary health care workers and community members in the COHESION project. She pointed out some of the enablers and challenges the Peru team had in building transformative partnership. Lessons from this session were that the WHO is preparing a community engagement framework that can be used for projects like COHESION. Recommendations were also that as a project we should systematically document our process of engagement which can later be used as evidence for other initiatives.

Besides COHESION’s direct contribution to the content of the conference, this was a unique opportunity to link the work being done in Mozambique, Nepal, Peru and Switzerland to the wider development agenda. A message that was mentioned frequently was the unfinished Millennium Development Goals (MDG) Agenda. Another element discussed widely was the link between economic development and health in parallel to progressing political processes and the role of communities and civil society in this.

These aspects are interesting in thinking about COHESION’s approach in dealing with diseases of poverty (NTDs) and diseases that are intimately linked to development (NCDs) by focusing attention on communities to develop interventions.

Being based in Switzerland it also emphasised the importance of Switzerland as a donor, funding such projects as the r4d scheme as well as that the Sustainable Development Goals (SDG) unlike the MDGs are for all countries and not just low income countries. This requires a change in approach from one of high income settings coming with solutions to MDG related problems to, as stated in SDG 17, partnership. The SDGs are integrated and inseparable in that many of the goals are interlinked.

The banner at the entrance of the conference had the following three words:
– Evidence
– Engagement
– Policies

Thinking about these three words and the SDGs, COHESION is increasing the evidence base in terms of burden of NCDs and NTDs at policy, health system and community level. To address these challenges, COHESION by engaging local stakeholders will develop innovative interventions to address these challenges. Based on the COHESION research to date the issue of policies is of concern in that although many aspects of NCDs and NTDs are being addressed in health systems through the delivery of care, but policies are lacking to help guide these responses and involve communities. From a COHESION perspective, a fourth element to the ICRD list would be implementation. In that evidence, engagement and policies without implementation are meaningless. As COHESION moves from formative research, engaging local stakeholders and understanding global and national policies, its next step will be to implement innovative interventions to contribute to the achievement of the SDGs.

COHESION – a challenge to Frenk and Gómez-Dantés

In The Lancet, in February 2017 (http://dx.doi.org/10.1016/ S0140-6736(16)30181-7), two leading thinkers in global health, Julio Frenk and Octavio Gómez-Dantés, challenged the status quo of many of today’s public health and healthcare delivery processes through a detailed assessment of a variety of dichotomies that exist in global health. Frenk and Gómez-Dantés’ main message was the need for integration in global health across a wide range of challenges. This interesting piece led to a thought provoking discussion within the COHESION Team where we asked ourselves: are we operating within or beyond those scenarios of dichotomies?

The first dichotomy they describe is the prevention versus treatment debate. How does COHESION address this first dichotomy? For non-communicable diseases (NCD), even if all prevention measures are successful some people will still develop some of the conditions included in this overarching group. For Neglected Tropical Diseases (NTD) the “endgame” for many of these diseases is envisionable given the existence of medicines which provide a “magic bullet” to cure people and/or break the cycle of transmission. However, for both NCDs and NTDs people have already been exposed to some of the risk factors, have biological changes (e.g. high blood pressure; infected with Cysticercosis) and therefore require care. Yet, both NCDs and NTDs share fundamental root causes that determine its existence: poverty and exclusion. We cannot address treatment solely without the broader need for prevention.

The next “clash” described is the vertical versus horizontal debate. For NCDs and NTDs this debate is mute as the main driver of vertical programmes was funding. As was seen for HIV/AIDS funds were allocated to create complete vertical systems for distribution of medicines, training of health professionals, delivery of care, etc. For both groups of diseases that COHESION focuses on this funding is lacking thus vertical solutions are not implemented. That said NTDs are more at risk of becoming “verticalised” given the higher level of funding available in comparison to the burden, the “easier” solutions of mass drug administration (for some NTDs) and the defined populations that are impacted by some diseases. COHESION through its research and development of interventions will try to ensure a horizontal approach in order to benefit not only those with NCDs and NTDs, but any one requiring health care at primary level. We are allowing ourselves to redefine the interaction of an individual with the existing healthcare system where chronicity and continuity of care are fundamental.

Number three on Frenk and Octavio Gómez-Dantés’ list is primary versus specialized care. As mentioned above the main focus of COHESION is on primary health care. Given that our emphasis is on NCDs and NTDs which are both chronic in nature this will enable a strengthening of primary health care to guarantee continuity of care. Traditionally primary health care has been successful in maternal and child health, delivery of HIV/AIDS care (with significant funding) and acute care. However, with the burden of chronic disease a shift in the role of primary health care is needed. Through its formative research and interventions COHESION will focus its efforts on developing this level of the health system. We are not denying care, but aim integrate chronic care at primary health care as well as facilitate referral to specialized care when needed.

By design COHESION lays the fourth dichotomy to rest, the noncommunicable versus communicable disease prioritisaiton. By including NCDs and NTDs together within the core of its project COHESION wanted to focus on models of delivery of care versus mode of transmission. Leprosy and Type 2 diabetes from a delivery of care perspective share many similarities despite being communicable and noncommunicable. Need for proper diagnosis and initiation of treatment; patient education and empowerment; address issues of stigma; and prevention of complications.

Finally, the latest dichotomy posed the challenge between knowledge generation versus action. Again, COHESION is in a unique position thanks to the funding mechanism developed by the Swiss National Science Foundation and Swiss Agency for Development and Cooperation. The funding COHESION has received will not only enable the generation of new knowledge on NCDs and NTDs, at policy, health system and community level, but also to use this to co-create innovative interventions working closely with local partners through.

The title of Frenk and Octavio Gómez-Dantés’ comment includes the word “integrative”. COHESION in the design of its team and project has had this word as a guiding principle. Integration of different expertise from a variety of countries, institutions and individuals; different diseases and disease groups; different methodological approaches; local partners and stakeholders in the research and intervention development. As COHESION we would add another dichotomy to the list proposed by Frenk and Octavio Gómez-Dantés that is how solutions in global health are developed. Most solutions to date have had their roots in meetings at the World Health Organization, the minds of the best and brightest academics and in the offices of Ministries of Health. Our approach proposes a bottom up approach where interventions are informed by this, but designed by beneficiaries. To date although different normative documents exist on how to tackle the burden of NCDs and NTDs success is still far away. We hope through our innovative approach to find ways of addressing NCDs and NTDs as well as contributing to breaking down the dichotomies that Frenk and Octavio Gómez-Dantés highlight.

 

Written by David Beran and Jaime Miranda for COHESION

 

 

 

 

 

 

 

COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!

COHESION PI reflects on “Meu regresso a Moçambique”

Meu regresso a Moçambique – My return to Mozambique

Mozambique is a special place for me. It was the first country I visited in sub-Saharan Africa, my first project in looking at diabetes management in a low-income country and also a country where I was able to work for close to 7 years with the Ministry of Health and Diabetes Association. Besides the professional aspect, it was also a place where I made long lasting friendships with unique people who not only shared their passion for the work we were doing together, but also imparted me with the love of their beautiful country.

So the question I got from everyone after my recent trip to Mozambique for COHESION, how was it going back? AMAZING was my answer.

Going back to Mozambique was like seeing an old friend after a long time. The link, fondness and memories were there. Both Mozambique and I had moved on since my last visit. Economic development in Mozambique, but with current economic turmoil, more projects including the launch of COHESION and my move back to Geneva on my end.

My reunion with Mozambique was also positive in that the Mozambique COHESION Team had progressed with the research, been able to involve high-level individuals in the Advisory Boards as well as gain the support for our project in the two areas where our work will take place. I had a chance to visit Xipamanine and Moamba and speak to health professionals and local members of the community. In parallel Dr. Claire Somerville (Graduate Institute and COHESION Project Lead on the Policy Analysis component) and Sarah Lachat (University of Geneva, COHESION Project Manager) had the opportunity with our colleagues to work on and carry out some interviews regarding the Policy Analysis. We were also able to meet with the Swiss Cooperation Office in Maputo. The result of all of these discussions is that COHESION has a huge role to play in Mozambique to help improve the management of Noncommunicable (NCD) and Neglected Tropical Diseases (NTD).

Being back in Mozambique not only enabled me to see progress and continuing challenges based on my previous work, but mainly the importance of the current work of the COHESION Project. There are many challenges in Mozambique with a life expectancy of 53; high prevalence of HIV/AIDS and malaria; high maternal mortality, etc. NCDs and NTDs have been neglected by policy makers and donors. This results in a lack of capacity at the level of the health system to respond, leading to challenges for individuals and communities. The interventions that our project will develop will hopefully address these and help improve the conditions for people with NCDs and NTDs.

Até a proxima (until next time) Moçambique,

Dr. David H. Beran, Principal Investigator of COHESION

Swiss team goes to Mozambique

The COHESION team meets in Mozambique. Three members of the Swiss team (Dr. David Beran, Dr. Claire Somerville and Mrs. Sarah Lachat) join the Mozambique team this week at Eduardo Mondlane University.

Policy Analysis and gender are at the top of the agenda, but the team will not miss the opportunity to advance the community and health system assessments and reporting.

The team is grateful to be able to profit from face to face time in the country.

Household Survey in Nepal

For the first time, in the rural area, Baniyani VDC, Jhapa district, South-western Nepal, a major household survey on several health issues was conducted by the Nepalese COHESION team during the last week of November 2016. The aim of the survey was to collect baseline information needed to assess the level of NCDs and NTD prevalence and related health care in one of the two selected site for COHESION intervention in Nepal.

The Household survey was conducted in the framework of the Interdisciplinary “Community Diagnosis Program” organized by School of Public Health and Community Medicine which comprises of two weeks of residential posting in rural setting for 1st Year MBBS, BDS and B.Sc. Nursing students. More than 200 students took part to the survey, supervised by 30 postgraduates and teachers, to collect data of more than 1200 households.

The questionnaires used are an innovative mixture of closed and open-ended questions concerning the socio-demographic profile of the community, reported health problems, health seeking behaviour and access to health facility and services at PHC level from a consumer perspective.

An orientation program was first organized at the B. P. Koirala Institute of Health Sciences (BPKIHS) to deliver lectures for the students on the different methods to be used. A meeting with local authorities including VDC heads, health worker, leaders, school teachers, Female Community Health Volunteers and others was also organized the week before field work, to inform the community of Baniyani VDC about the program and its aim.

The total of 201 medical graduate and nursing students under the supervision of 26 supervisors, including MD/MPH/MSc. nursing students were grouped in nine groups in accordance with the total number of wards of Baniyani VDC and performed house to house visits during 7 full days and collected more than 1200 households using semi-structured questionnaires regarding the above mentioned issues.

All households of the VDC were visited. The local communities were very cooperative in general. However, some resisted for the interview which could be due to mistrust towards health institutions or business. Others could not be assessed because of locked houses, probably due to the harvesting season or migration for work. Some members of household questioned about benefits of the survey: the fact that we were holding a health camp in parallel (day program of on the spot consultations offered by the MDs/faculties from B. P. Koirala Institute) helped a lot in this regard. At the end of the data collection exercise preliminary findings were shared with the community representatives, which also fostered mobilization of the villagers.

A challenge of the survey was to visit the place of study from the place of residence with such a huge group of students. We had to travel for more than an hour by bus. We all were very busy during the data collection with regard to visiting different households by walking. In every evening, attendance of students and briefing of status of data collection was organized.

In general, this survey was a success. Not only data were collected, but because all students had the opportunity to gain a lot of valuable experience.

r4d Mixed Methods Research Workshop

The Swiss Programme for Research on Global Issues for Development organized an r4d Skills Mixed Methods Research Workshop with Alicia O’Cathain, on integration and quality assessment. The full-day workshop took place in Bern on 28 October 2016 and congregated project leaders, project coordinators and Ph.D. students of r4d projects funded by the Programme, including COHESION.

Alicia O’Cathain is a Professor of Health Service Research, University of Sheffield, UK; and has published widely on mixed methods, mixed teams and randomized control trials. During the workshop, Dr. O’Cathain engaged participants in sessions covering definitions, rationales, designs, reporting, integration of qualitative and quantitative data, and assessing quality.

Four members of the COHESION team (Jorge Correia, Nathaly Aya Pastrana, Olivia Heller, Sarah Lachat) and one member of the project Advisory Board (Dr. Sigiriya Aebischer-Perone) participated in the workshop. Team members discussed and reflected on how to integrate and disseminate the findings of   data to be collected by the Project, balancing the insights obtained from qualitative methods with those from quantitative methods. Dr. Aebischer-Perone will share the reflections during the first Swiss COHESION Advisory Board meeting in Geneva on 21 November 2016.

To find more information about the workshop click here

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Selecting the NTD in Peru

“Selecting the NTD in Peru:
Engaging stakeholders in the difficult decision of selecting what underserved disease to prioritize”

The COHESION Project aims to address the double burden of disease that face health systems and communities by improving capacities at the national, local and community levels in three countries (Mozambique, Nepal and Peru). To assess the barriers that underserved communities face when accessing Primary Health Care (PHC) each country team selected a Neglected Tropical Disease (NTD) and two Non-communicable Diseases (NCDs) (diabetes and hypertension). These three diseases would be used as “tracer” conditions to understand the challenges of local health systems to effectively manage these diseases at the PHC level.

Why tracers? Because individuals with one or both, NTD or NCD, have the unique scenario of requiring chronic, engaging, meaningful, respectful and effective care. Both of these tracers, NTDs and NCDs, allow us a second chance to get it right, to redefine the user experience with our healthcare system.

In Mozambique, the selected NTD was Schistosomiasis, while the Nepalese team chose Leprosy. In Peru, we had initially selected Chagas but we felt we needed more information about the various NTDs with chronic sequels affecting people in Peru before making a final decision.

After several discussions with experts and internal conversations about the appropriateness of Chagas and other NTDs including Leprosy, Hydatidosis and Neurocysticercosis, we decided on Neurocysticercosis.

In this post, we share the reasons that lead us to this decision.

We first contacted an expert in Leprosy. We learned that it has not been fully eradicated in some regions in Peru, although the national prevalence rate is lower than 1 case x 10 000 inhabitants (Burstein, 2014). Leprosy still affects some small localities of the Amazon regions, where several geographical barriers and a dispersion settlement pattern predominate (Burstein, 2014). Addressing Leprosy is a challenge given the under diagnosis and other problems related with the epidemiological information systems for reporting of new cases.

Chagas disease affects over 8 million people in the Americas and about 190,000 persons with this disease live in Peru (Bayer et al., 2009). After different national and regional efforts in the nineties for the elimination of the Chagas vector (Triatoma infestans), the incidence of this disease was reduced. The main region affected in Peru is Arequipa, in the Southern Andes. As a result of efforts from different public and private institutions the vectorborne transmission of the disease has been significantly reduced and is now located in peri-urban shantytowns near the city of Arequipa as a response of urbanization processes and migration (Delgado et al., 2011). There is still work to do to eradicate Chagas, starting with the approval of a standardized protocol for the management of the disease and intensification of efforts in diagnosing people plus more thorough surveillance activities with special focus in shantytowns (Bayer et al., 2009). One reason that leads us to reconsider Chagas as the selected NTD is that symptoms may take about 20 years to develop and only few persons who have lesions show a recovery after pharmacological treatment. Additionally, the migration of the disease to peri-urban zone would leave us without the opportunity to explore the response of PHC for patients with NTD in rural area and to develop strategies to enhance the user experience with services provided by the PHC.

When exploring Hydatidosis and Cysticercosis, we learned that “controlling the parasitic infection in animals is crucial to reduce the incidence of human disease” (Otero-Abad & Torgerson, 2013). Both diseases are closely related with human behavior, for example with education about the transmission of the diseases and the prevention with hygiene actions. Currently, there is no vector control program for Hydatidosis in Peru. There was an effort for developing a program that included radio programs with educational messages and the empowerment of school teachers as providers of health and sanitary messages. However, control programs and educative activities were discontinued. Moreover, this disease is not notifiable in Peru, which makes it harder to know its current prevalence.

Finally, we looked into Neurocysticercosis (NCC), which is an “infection of the nervous system by the cystic larvae of Taenia solium” (Garcia, Nash, & Del Brutto, 2014) that frequently causes seizures and epilepsy. Worldwide, over 5 million cases of epilepsy are caused by Neurocysticercosis (Nash, Mahanty, & Garcia, 2013). Neurocysticercosis is especially endemic in areas characterized by poor water and sanitation systems and where pigs are not corralling with access to human feces (García, Gonzalez, Evans, & Gilman, 2003). In Peru, Neurocysticercosis affected approximately 35% of persons with active epilepsy, which is a very high rate comparable with Honduras and India. Only one out of every four patients with active epilepsy receive pharmacological treatment, but in sub-therapeutic doses (Moyano et al., 2014). It has been demonstrated that the transmission of Taenia solium was eliminated in 105 of 107 villages in Tumbes (region located in the north of the country) after an “attack phase” during one year that comprises people and pigs, and this result persisted over 1 year (Garcia et al., 2016; Maurice, 2014). However, there are still cases of NCC in the intervened region after several years of the implementation of the control program and there are other endemic regions affected by this disease in Peru.

The aforementioned efforts for the different NTDs and the pending actions for reaching the control of the diseases were the main topics discussed with different experts in the field. We were impressed with their high motivation, solidarity and expertise gained through the years. For example, there are strong research teams for the study of Chagas and Cysticercosis that have made relevant contributions like the risk mapping of the zones to inform surveillance system for Chagas or the massive intervention in persons and pigs from rural villages of northern Peru for blocking transmission of cysticercosis.

All experts agreed that whatever NTD we chose, we would be making a difference because they affect the most vulnerable.

Our decision about the selection of Neurocysticercosis for the purpose of the COHESION project was made considering to prioritize an NTD that generates a chronic condition that requires long-term treatment like epilepsy and affecting the poor of the poorest population in rural area, where PHC response is more relevant as the first point of entry for care. In so doing, by choosing NCC, together with an understanding of other major prevalent NCD conditions like diabetes and hypertension, will provide us with a second chance to get it right, to redefine the user experience within our healthcare system.

Acknowledgments: We thank César Náquira, Ricardo Castillo, Valerie Paz-Soldán, Aldo Lucchetti, Luz María Moyano, Ricardo Gamboa and H. Hugo García for their valuable time and insights about NTDs for the purpose of the COHESION project.

References:

Bayer, A. M., Hunter, G. C., Gilman, R. H., Carpio, J. G. C. del, Naquira, C., Bern, C., & Levy, M. Z. (2009). Chagas Disease, Migration and Community Settlement Patterns in Arequipa, Peru. PLOS Negl Trop Dis, 3(12), e567. http://doi.org/10.1371/journal.pntd.0000567

Burstein, Z. (2014). Critical appraisal about control programs and elimination of leprosy in Peru, and its consequences for Peru and America. Revista Peruana de Medicina Experimental Y Salud Pública, 31(2), 336–342.

Delgado, S., Neyra, R. C., Machaca, V. R. Q., Juárez, J. A., Chu, L. C., Verastegui, M. R., … Levy, M. Z. (2011). A History of Chagas Disease Transmission, Control, and Re-Emergence in Peri-Rural La Joya, Peru. PLOS Negl Trop Dis, 5(2), e970. http://doi.org/10.1371/journal.pntd.0000970

García, H. H., Gonzalez, A. E., Evans, C. A. W., & Gilman, R. H. (2003). Taenia solium cysticercosis. Lancet, 362(9383), 547–556. http://doi.org/10.1016/S0140-6736(03)14117-7

Garcia, H. H., Gonzalez, A. E., Tsang, V. C. W., O’Neal, S. E., Llanos-Zavalaga, F., Gonzalvez, G., … Gilman, R. H. (2016). Elimination of Taenia solium Transmission in Northern Peru. New England Journal of Medicine, 374(24), 2335–2344. http://doi.org/10.1056/NEJMoa1515520

Garcia, H. H., Nash, T. E., & Del Brutto, O. H. (2014). Clinical symptoms, diagnosis, and treatment of neurocysticercosis. The Lancet Neurology, 13(12), 1202–1215. http://doi.org/10.1016/S1474-4422(14)70094-8

Maurice, J. (2014). Of pigs and people—WHO prepares to battle cysticercosis. The Lancet, 384(9943), 571–572. http://doi.org/10.1016/S0140-6736(14)61353-2

Moyano, L. M., Saito, M., Montano, S. M., Gonzalvez, G., Olaya, S., Ayvar, V., … Peru, for T. C. W. G. in. (2014). Neurocysticercosis as a Cause of Epilepsy and Seizures in Two Community-Based Studies in a Cysticercosis-Endemic Region in Peru. PLOS Negl Trop Dis, 8(2), e2692. http://doi.org/10.1371/journal.pntd.0002692

Nash, T. E., Mahanty, S., & Garcia, H. H. (2013). Neurocysticercosis—More Than a Neglected Disease. PLOS Negl Trop Dis, 7(4), e1964. http://doi.org/10.1371/journal.pntd.0001964

Otero-Abad, B., & Torgerson, P. R. (2013). A Systematic Review of the Epidemiology of Echinococcosis in Domestic and Wild Animals. PLOS Negl Trop Dis, 7(6), e2249. http://doi.org/10.1371/journal.pntd.0002249

 

COHESION in the The Lancet Diabetes & Endocrinology

The Lancet Diabetes & Endocrinology has just published a commentary from the COHESION investigators on “The need to focus on primary health care for chronic diseases“.

DOI: http://dx.doi.org/10.1016/S2213-8587(16)30148-6

Beran, D., Chappuis, F., Cattacin, S., Damasceno, A., Jha, N., Somerville, C., Suggs, L.S., Miranda, J. J., for the COHESION Project (2016, July 15). The need to focus on primary health care for chronic diseases. The Lancet Diabetes & Endocrinology. http://doi.org/10.1016/S2213-8587(16)30148-6

Views from the World Cardiology Congress

COHESION at the heart of the matter: Views from the World Cardiology Congress
by COHESION Principal Investigator, Dr. David Beran

I was invited to give a talk at the World Cardiology Congress on lessons from diabetes and health systems that might be of use for cardiology. An interesting opportunity and when I found out that my co-Investigators Albertino Damasceno and Jaime Miranda would also be there I saw it as an added advantage to be able to see them and catch up on COHESION.

On my flight to Mexico, the Congress was in Mexico City, the person sitting next to me on the flight asked if I was going to Mexico on holiday and I said no that I was going to a Congress. They asked which Congress and I said a cardiology congress. “Ah so you are a cardiologist?”, my neighbour asked. “No” was my answer. “Then what kind of doctor are you?”, was his retort. “Actually, I am not a doctor, I work in public health and health systems”, I replied and started describing what I actually do. Luckily the bewilderment of my fellow rowmate was interrupted by the all too important question by the flight attendant͞, “Chicken or pasta?” At which point we wished each other a pleasant meal and that was the end of our interaction.

That brief contact with my fellow traveller highlighted many things. One, the view of health as that of a doctor’s domain. Secondly, that public health is a misunderstood concept and people outside the health arena do not really understand what it means. Another issue is that for many people when they hear a disease, e.g. cardiology, they see this as something that doctors and medicine can fix, versus a large societal health issue that requires multiple actors to address within and outside the health system. Finally, that I need to find a better way of explaining what I do…

These issues are essential to highlight based on this somewhat trivial interaction in that at the World Cardiology Congress many of the sessions were geared towards issues that could not have been further away from what my travel companion imagined what cardiology and a cardiology congress entailed. I attended interesting discussions on tobacco, alcohol, health systems and specificities of heart disease in different parts of the world, e.g. Africa versus Latin America. All of the presentations had one thing in common, that the COHESION project is well and truly at the heart of the matter.

To give you an example why I say that. The sessions discussing tobacco, alcohol or obesity or those discussing hypertension management highlighted that these phenomena once thought of as being only found in high-income countries have now become global issues impacting all strata of populations within and between countries. In parallel certain countries face this burden as well as the burden of cardiovascular disease linked to infectious agents such as Rheumatic Heart Disease. For an excellent review of the challenges of cardiovascular disease in poor populations see http://www.ncbi.nlm.nih.gov/pubmed/27297348 which Jaime Miranda contributed to. These examples highlight the double burden of disease as a challenge, but very few of the presentations or discussion highlighted what could be done. Many described possible avenue for improvement: strengthening health systems, better health promotion and prevention activities, the need for policy interventions, better training of health professionals, task shifting, use of “m” and “e” health, etc. None of the presentations I attended mentioned two of the cornerstones of the COHESION project namely Primary Health Care or the community.

This made me realise the importance of the COHESION project in not only addressing the specific NCDs and NTDs we are working on, but also wider health system issues. Also seeing my two co-Investigators discuss the work they do in parallel to COHESION highlighted the quality of the individuals we have and how they truly are at the forefront of their fields. Hopefully, in the future, the COHESION team will be able to present its results in such a forum highlighting lessons learnt from NCDs and NTDs in improving PHC for other conditions.

Cardiology congress_mexico 2016

Jaime Miranda, David Beran, Albertino Damasceno