The impact of traumatic brain injury on economic productivity in the Caribbean.

Introduction: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in the Caribbean as well as globally. Within the Caribbean, the prevalence of TBI is approximately 706 per 100,000 persons - one of the highest rates per capita in the world. Research question: We aim to assess the economic productivity lost due to moderate to severe TBI in the Caribbean. Material and methods: The annual cost of economic productivity lost in the Caribbean from TBI was calculated from four variables: (1) the number of people with moderate to severe TBI of working age (15-64 years), (2) the employment-to-population ratio, (3) the relative reduction in employment for people with TBI, and (4) per capita Gross Domestic Product (GDP). Sensitivity analyses were performed to evaluate whether the uncertainty of the TBI prevalence data result in substantive changes in the productivity losses. Results: Globally, there was an estimated 55 million (95% UI 53, 400, 547 to 57, 626, 214) cases of TBI in 2016 of which 322,291 (95% UI 292,210 to 359,914) were in the Caribbean. Using GDP per capita, we calculated the annual cost of potential productivity losses for the Caribbean to be $1.2 billion. Discussion and conclusion: TBI has a significant impact on economic productivity in the Caribbean. With upwards of $1.2 billion lost in economic productivity from TBI, there is an urgent need for appropriate prevention and management of this disease by upscaling neurosurgical capacity. Neurosurgical and policy interventions are necessary to ensure the success of these patients in order to maximize economic productivity.

Integrating The US Public Health And Medical Care Systems To Improve Health Crisis Response.

The operational cleavage between the US public health and medical care systems contributed to the country's difficulty in containing community spread of COVID-19 in the pandemic's first months. We provide an overview of the independent evolution of these two systems, drawing on case examples and publicly available outcome data, to demonstrate how three fundamental elements of epidemic response-case finding, mitigating transmission, and treatment-were undermined by the lack of coordination between public health and medical care and how these gaps contributed to health disparities. We propose policy initiatives to address these gaps and facilitate coordination across the two systems: build a case-finding diagnostic system to quickly identify and mitigate the emergence of health threats in communities, develop data systems that facilitate the transfer of critical health intelligence from medical institutions to public health departments, and establish referral pathways for public health practitioners to connect people with medical services. These policies are practicable because they build on existing efforts and those currently in development.

Building Perinatal Pathology Research Capacity in Sub-Saharan Africa.

Introduction: Over two million stillbirths and neonatal deaths occur in sub-Saharan Africa (sSA) annually. Despite multilateral efforts, reducing perinatal mortality has been slow. Although targeted pathologic investigation can often determine the cause of perinatal death, in resource-limited settings, stillbirths, early neonatal deaths, and placentas are rarely examined pathologically. However, the placenta is a key source of diagnostic information and is the main determinant of fetal growth and development in utero, influencing child health outcomes. Methods: In 2016, our collaborative intercontinental group began investigating infectious perinatal death and adverse child health outcomes in Uganda. We developed and initiated a 4-day combined didactic/practical curriculum to train health workers in placental collection, gross placental examination, and tissue sampling for histology. We also trained a local technician to perform immunohistochemistry staining. Results: Overall, we trained 12 health workers who performed gross placental assessment for > 1,000 placentas, obtaining > 5,000 formalin-fixed tissue samples for research diagnostic use. Median placental weights ranged from 425 to 456 g, and 33.3% of placentas were < 10th percentile in weight, corrected for gestational age. Acute chorioamnionitis (32.3%) and maternal vascular malperfusion (25.4%) were common diagnoses. Discussion: Through a targeted training program, we built capacity at a university-affiliated hospital in sSA to independently perform placental collection, gross pathologic examination, and placental tissue processing for histology and special stains. Our training model can be applied to other collaborative research endeavors in diverse resource-limited settings to improve research and clinical capacity and competency for diagnostics and management of stillbirth, neonatal death, and child health outcomes.

Partnering to Build Human Resources for Health Capacity in Africa: A Descriptive Review of the Global Health Service Partnership's Innovative Model for Health Professional Education and Training From 2013-2018.

Several Sustainable Development Goals (SDGs) (3, 16, 17) point to the need to systematically address massive shortages of human resources for health (HRH), build capacity and leverage partnerships to reduce the burden of global illness. Addressing these complex needs remain challenging, as simple increases in absolute numbers of healthcare providers trained is insufficient; substantial investment into long-term high-quality training programs is needed, as are incentives to retain qualified professionals within local systems of care delivery. We describe a novel HRH initiative, the Global Health Service Partnership (GHSP), involving collaboration between the US government (President's Emergency Plan for AIDS Relief [PEPFAR], Peace Corps), 5 African countries, and a US-based non-profit, Seed Global Health. GHSP was formed to enlist US health professionals to assist in strengthening teaching and training capacity and focused on pre-and in-service medical and nursing education in Malawi, Tanzania, Uganda, Eswatini and Liberia. From 2013-2018, GHSP sent 186 US health professionals to 27 institutions in 5 countries, helping to train 16 280 unique trainees of all levels. Qualitative impacts included cultivating a supportive classroom learning environment, providing a pedagogical bridge to clinical service, and fostering a supportive clinical learning and practice environment through role modeling, mentorship and personalized learning at the bedside. GHSP represented a novel, multilateral, public-private collaboration to help address HRH needs in Africa. It offers a plausible, structured template for engagement and partnership in the field.

Analysis of results from the Joint External Evaluation: examining its strength and assessing for trends among participating countries.

BACKGROUND: The Joint External Evaluation (JEE) is part of the World Health Organization's (WHO) new process to help countries assess their ability to prevent, detect and respond to public health threats such as infectious disease outbreaks, as specified by the International Health Regulations (IHR). How countries are faring on these evaluations is not well known and neither is there any previous assessment of the performance characteristics of the JEE process itself. METHODS: We obtained JEE data for 48 indicators collectively across 19 technical areas of preparedness for 55 countries. The indicators are scored on a 1 to 5 scale with 4 indicating demonstrated capacity. We created a standardized JEE index score representing cumulative performance across indicators using principal components analysis. We examined the state of performance across all indicators and then examined the relationship between this index score and select demographic and health variables to better understand potential drivers of performance. RESULTS: Among our study cohort, the median performance on 43 of the 48 (89.6%) indicators was less than 4, suggesting that countries were failing to meet demonstrated capacity on these measures. The two weakest indicators were related to antimicrobial resistance (median score = 1.0, interquartile range = 1.0-2.0) and biosecurity response (median score = 2.0, interquartile range = 2.0-3.0). JEE index scores correlated with various metrics of health outcomes (life expectancy, under-five year mortality rate, disability-adjusted life years lost to communicable diseases) and with standard measures of social and economic development that enable public health system performance in the total sample, but in stratified analyses, these relationships were much weaker in the AFRO region. CONCLUSIONS: We find large variations in JEE scores among countries and WHO regions with many nations still unprepared for the next disease outbreak with pandemic potential The strong correlations between JEE performance and metrics of both health outcomes and health systems' performance suggests that the JEE is likely accurately measuring the strength of IHR-specific, public health capabilities.

Have geopolitics influenced decisions on American health foreign assistance efforts during the Obama presidency?

BACKGROUND: This study sought to characterize the possible relationship between US geopolitical priorities and annual decisions on health foreign assistance among recipient nations between 2009 and 2016. METHODS: Data on total planned United States (US) foreign aid and health aid were collected for the 194 member nations of the World Health Organization (WHO) from publicly available databases. Trends in per-capita spending were examined between 2009 and 2016 across the six regions of the WHO (Africa, Americas, Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific). Data on US national security threats were obtained from the Council on Foreign Relations' annual Preventive Priorities Survey. Multivariable regression models were fitted specifying planned health aid as the dependent variable and threat level of a recipient aid nation as the primary independent variable. RESULTS: Across the aggregate 80 planned recipient countries of US health aid over the duration of the study period, cumulative planned per-capita spending was stable (US$ 0.65 in both 2009 and 2016). The number of annual planned recipients of this aid declined from 74 in 2009 to 56 in 2016 (24.3% decline), with planned allocations decreasing in the Americas, Eastern Mediterranean, and Europe; corresponding increases were observed in Africa, Southeast Asia, and the Western Pacific. Regression analyses demonstrated a dose-response, whereby higher levels of threat were associated with larger declines in planned spending (critical threat nations: b = -3.81; 95% confidence interval (CI) -5.84 to -1.78, P ≤ 0.001) and one-year lagged (critical threat nations: b = -3.91; 95% CI, -5.94 to -1.88, P ≤ 0.001) analyses. CONCLUSIONS: Higher threat levels are associated with less health aid. This is a novel finding, as prior studies have demonstrated a strong association between national security considerations and decisions on development aid.

Has development assistance for health facilitated the rise of more peaceful societies in sub-Saharan Africa?

Growing evidence suggests that health aid can serve humanitarian and diplomatic ends. This study utilised the Fragile States Index (FSI) for the 47 nations of the World Health Organizations' Africa region for the years 2005-2014 and data on health and non-health development aid spending from the United States (US) for those same years. Absolute amounts of health and non-health aid flows from the US were used as predictors of state fragility. We used time-lagged, fixed-effects multivariable regression modelling with change in FSI as the outcome of interest. The highest quartile of US health aid per capita spending (≥$4.00 per capita) was associated with a large and immediate decline in level of state fragility (b = -7.57; 95% CI, -14.6 to -0.51, P = 0.04). A dose-response effect was observed in the primary analysis, with increasing levels of spending associated with greater declines in fragility. Health per-capita expenditures were correlated with improved fragility scores across all lagged intervals and spending quartiles. The association of US health aid with immediate improvements in metrics of state stability across sub-Saharan Africa is a novel finding. This effect is possibly explained by our observations that relative to non-health aid, US health expenditures were larger and more targeted.

The Global Health Service Partnership: An Academic-Clinical Partnership to Build Nursing and Medical Capacity in Africa.

The World Health Organization estimates a global deficit of about 12.9 million skilled health professionals (midwives, nurses, and physicians) by 2035. These shortages limit the ability of countries, particularly resource-constrained countries, to deliver basic health care, to respond to emerging and more complex needs, and to teach, graduate, and retain their future health professionals-a vicious cycle that is perpetuated and has profound implications for health security. The Global Health Service Partnership (GHSP) is a unique collaboration between the Peace Corps, President's Emergency Plan for AIDS Relief, Seed and host-country institutions, which aims to strengthen the breadth and quality of medical and nursing education and care delivery in places with dire shortages of health professionals. Nurse and physician educators are seconded to host institutions to serve as visiting faculty alongside their local colleagues. They serve for 1 year with many staying longer. Educational and clinical best practices are shared, emphasis is placed on integration of theory and practice across the academic-clinical domains and the teaching and learning environment is expanded to include implementation science and dissemination of locally tailored and sustainable practice innovations. In the first 3 years (2013-2016) GHSP placed 97 nurse and physician educators in three countries (Malawi, Tanzania, and Uganda). These educators have taught 454 courses and workshops to 8,321 trainees, faculty members, and practicing health professionals across the curriculum and in myriad specialties. Mixed-methods evaluation included key stakeholder interviews with host institution faculty and students who indicate that the addition of GHSP enhanced clinical teaching (quality and breadth) resulting in improved clinical skills, confidence, and ability to connect theory to practice and critical thinking. The outputs and outcomes from four exemplars which focus on the translation of evidence to practice through implementation science are included. Findings from the first 3 years of GHSP suggest that an innovative, locally tailored and culturally appropriate multi-country academic-clinical partnership program that addresses national health priorities is feasible and generated new knowledge and best practices relevant to capacity building for nursing and medical education. This in turn has implications for improving the health of populations who suffer a disproportionate burden of global disease.

An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service.

BACKGROUND: Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care. METHODS: The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized "general medicine" was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction. RESULTS: A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm. CONCLUSIONS: A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.

Retrospective Descriptive Study of an Intensive Care Unit at a Ugandan Regional Referral Hospital.

BACKGROUND: We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population. METHODS: Retrospective observational study of ICU admissions was performed from January 2008 to December 2011. RESULTS: Of 431 admissions, 239 (55.4 %) were female, and 142 (33.2 %) were children (<18 years). The median length of stay was 2 (IQR 1-4) days, with 365 patients (85 %) staying less than 8 days. Indications for admission were surgical 49.3 % (n = 213), medical/pediatric 27.4 % (n = 118), or obstetrical/gynecological 22.3 % (n = 96). The overall mortality rate was 37.6 % (162/431) [adults 39.3 % (n = 113/287), children 33.5 % (n = 48/143), unspecified age 100 % (n = 1/1)]. Of the 162 deaths, 76 (46.9 %) occurred on the first, 20 (12.3 %) on the second, 23 (14.2 %) on the third, and 43 (26.5 %) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9 % (n = 29/91), trauma 45.5 % (n = 30/66), head trauma 59.6 % (n = 28/47), and poisoning 28.6 % (n = 10/35). The rate of mechanical ventilation was 49.7 % (n = 214/431). The mortality rate of ventilated patients was 73.5 % (n = 119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95 % CI 3.83-9.87), p < 0.0001] and for length of stay beyond seven days [aOR 0.37 (95 % CI 0.19-0.70), p = 0.0021], but not significant for decade of age [aOR 1.06 (95 % CI 0.94-1.20), p = 0.33], gender [aOR 0.61(95 % CI 0.38-0.99), p = 0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95 % CI 0. 63-1.84), medical vs. obstetric/gynecology aOR 0.73 (95 % CI 0.37-1.43), p = 0.49]. CONCLUSIONS: The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48 h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.

Politics and Universal Health Coverage--The Post-2015 Global Health Agenda.

What political, social, and economic factors allow a movement toward universal health coverage to take hold in some low- and middle-income countries? Can we use that knowledge to help other such countries achieve health care for all?

The global health service partnership: teaching for the world.

PROBLEM: In many limited resource countries, medical and nursing school faculties are small and understaffed, contributing to the sparse output of physicians and nurses to support the country's health system. The World Health Organization declared that 37 African nations suffer a "critical shortage" of health practitioners. APPROACH: The Global Health Service Partnership (GHSP) is a new program that sends U.S. physicians and nurses to serve as faculty at medical and nursing schools in low-resource countries to increase the quantity and quality of graduates, thereby strengthening local health systems. The GHSP is a collaboration between the Peace Corps and Seed Global Health, a private nongovernmental organization, and is supported by the President's Emergency Plan for AIDS Relief. OUTCOMES: In July 2013, the GHSP sent 15 physicians and 15 nurses to serve as faculty at 11 schools in Uganda, Tanzania, and Malawi. These volunteers will serve for one year, working with their African counterparts teaching and building academic capacity. The program aims to help train more physicians and nurses for patient care, some of whom will become faculty in the future. NEXT STEPS: An evaluation program will track and analyze the impact of the GHSP on the schools, the volunteers, and, over time, the impact on local health care. The authors propose a "sabbatical corps" to enable more U.S. academic medical and nursing faculty to participate in the program through the sponsorship of their home institutions. In future years, the GHSP will expand to more countries and include more health professions.

Global health training in US graduate psychiatric education.

OBJECTIVE: Global health training opportunities have figured prominently into medical students' residency program choices across a range of clinical specialties. To date, however, the national scope of global mental health education has not heretofore been systematically assessed. We therefore sought to characterize the distribution of global health training opportunities in US graduate psychiatric education. METHODS: We examined the web pages of all US psychiatry residency training programs, along with search results from a systematic Google query designed to identify global health training opportunities. RESULTS: Of the 183 accredited US psychiatry residency programs, we identified 17 programs (9.3%) offering 28 global health training opportunities in 64 countries. Ten psychiatry residency programs offered their residents opportunities to participate in one or more elective-based rotations, eight offered research activities, and six offered extended field-based training. Most global health training opportunities occurred within the context of externally administered, institution-wide initiatives generally available to residents from a range of clinical specialties, rather than within internally administered departmental initiatives specifically tailored for psychiatry residents. CONCLUSIONS: There are relatively few global health training opportunities in US graduate psychiatric education. These activities have a clear role in enhancing mastery of Accreditation Council for Graduate Medical Education core competencies, but important challenges related to program funding and evaluation remain.