Story by Chris Atack
Illustrations by Matt Forsythe
Bridging disciplines and spanning nations, the McGill Global Health Programs are working toward a common health standard for everyone, everywhere.
When it comes to many things—politics, currency, language, culture—borders can be much more than hypothetical demarcations. But as far as something like a virus is concerned, the division between countries A and B is just meaningless lines on a map. “A classic example is the H1N1 outbreak,” says Dr. Timothy Brewer, director of the McGill Global Health Programs and an associate professor in McGill’s Faculty of Medicine. “We had cases in Canada, we had cases in Mexico, we had cases all around the world. Grappling with something like pandemic influenza is a problem everyone needs to worry about—it’s not just a problem that affects a low-income country somewhere else. When it comes to health, we’re realizing there’s no such thing as ‘their problem.’ There’s only ‘our problem.’”
As its pluralized moniker suggests, the McGill Global Health Programs (MGHP) embraces multiplicities. Within the University, the MGHP database provides a central repository for global health research, education and service projects, featuring more than 70 researchers. Not surprisingly, traditional health-focused disciplines are very much on board—one of Brewer’s own research projects, in collaboration with Harvard Medical School and the International Society for Infectious Diseases, is the creation of an outbreak report database, which he hopes to use to better recognize, and therefore more quickly contain, future outbreaks—but Brewer aims to reach out to every research nook, no matter how incongruous a pairing may seem at first blush.
“We want to have engineers, musicians, lawyers, sociologists and physicians working together on global health activities,” he says. Recruiting people from other disciplines is vital because many of the problems need to be considered from a number of vantage points. “Consider the challenge of treating a person with HIV/AIDS in sub-Saharan Africa,” says Brewer. “Patients there may not have access to essential medicines because of patent restrictions. We need our colleagues in the Faculty of Law to help us find solutions.”
Intra-McGill collaboration is just the start. Crucially, the MGHP works to connect McGill researchers with people on the ground—in NGOs, in academic institutions, in government. “It’s not about sending Canadian experts to fly in, fix the problem and leave,” says Brewer. “It’s about creating partnerships capable of finding long-term, locally sustainable solutions.”
As diverse as its efforts are, all the work under the McGill Global Health Programs umbrella is united by a single goal. “We want to create a common health standard for everyone no matter where they are in the world,” says Brewer. “How can we address the divide between the haves and have-nots? There’s a lot to be done. We have big plans, because it’s a big world out there.”
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McGill researchers have forged a fruitful McGill partnership with the Ministry of Health in Panama. Parasitologist Marilyn Scott, director of the McGill School of Environment, and long-time colleague Kris Koski, director of the School of Dietetics and Human Nutrition, are currently directing research into the relationships between nutrition and health in a country that isn’t a stranger to extreme poverty.
Among the Ngöbe-Buglé indigenous peoples of western Panama, for example, households of 10 people survive on a paltry $50 US a month, or about 16 cents per person per day. More than 60 per cent of children under five—the focus of Scott’s research—are chronically malnourished, and they have a range of infectious diseases as well.
In 2002, Leslie Payne, a master’s student working with Scott and Koski, went to Panama to study whether a vitamin A supplementation program actually improved resistance to nematode parasites that impair nutrient absorption in their human hosts’ intestines. The project was the first of several studies evaluating the benefits of programs created by the Panamanian Ministry of Health. Payne found that over 80 per cent of indigenous Panamanian children were infected with intestinal nematodes (commonly known as roundworms). She also made a surprising discovery: Supplementation improved resistance in children who were growing normally, but not in the chronically malnourished. “Children whose growth is stunted lack not only vitamin A but a whole range of micro nutrients,” says Scott. “We suspect that, while the program improved their vitamin A status, other nutritional deficiencies impaired their immune systems.”
Another Panamanian government initiative offers families living in extreme poverty either a monthly cash supplement or food vouchers so long as mothers get their children vaccinated and keep them in school. Over a two-year period, PhD student Carli Halpenny compared over 225 children whose families received cash with almost 150 children from families who received vouchers. She monitored their diets to learn whether one program increased food availability more than the other. Then she tried to establish how dietary changes affected their nutritional status and their rates of infection with various diseases.
Halpenny presented her preliminary results to the government of Panama, along with representatives from the communities, at a symposium in June—it’s an important step, given how eager Panamanian officials are to translate research into practical initiatives. Scott and her colleagues therefore work very closely with the government to develop optimal policy changes. “Because so many issues are inter-related, policy development has to be done with great care,” she says. “In global health, we often need to consider a range of issues. For example, infant growth is influenced not only by infections and diet of the children but also infections and nutritional status of their mothers during pregnancy and lactation. Diet and infection are in turn influenced by social conditions, by agricultural practices and by access to water. Together, we are trying to define sustainable policies that take into account all these factors in a holistic, multidisciplinary approach.”
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Nowhere is the need for a multidisciplinary approach more evident than in the area of trauma care, which requires doctors, surgeons, nurses, pre-hospital personnel and all sorts of other medical technical staff (and, often, police) to work together. “Trauma is a huge problem in developing nations,” says Dr. Tarek Razek, director of the McGill University Health Centre Trauma Program. “Road traffic crashes involving cars, pedestrians or cyclists are all increasing, due to increased road traffic and urbanization. Workplace injuries and violence are also major factors.”
Razek and his colleagues have worked with the Canadian Network for International Surgery, the University of Dar es Salaam Muhimbili College and the Muhimbili Orthopedic Institute (MOI) in Tanzania to set up trauma databases at major hospitals. (They’ve also collaborated with partners in Uganda and other African nations.) Recently, they created a database in Dar es Salaam to collect information on all injured patients presenting to the MOI. This information includes patient demographics, injury severity, types of injuries and the type of incidents that produced the injuries.
“Having this data is important on many levels,” Razek says. “First, it’s vital to understand what the real problems are, so you can gauge policy and get the ‘biggest bang for your buck.’ Services, training and education must all be adjusted to cope with the realities of the situation. As data accumulates, you can see how the health system is doing in terms of outcomes. Finally, you can use trauma databases to develop injury prevention policies.
“For example, our database in Uganda showed a huge spike in pediatric injuries. Further investigation showed these injuries were taking place on the way to and from school. Huge numbers of kids were walking great distances pre-dawn and after dusk in an area with poor roads and no lighting or sidewalks. Knowing this, Alexandra Michailovic, a surgical trainee and PhD student in public health, was able to develop an intervention along with the local partners. The kids were given three cent reflective armbands—super-cheap and really bright when headlights hit them. Since the program started, the injury rate for pediatric pedestrian injuries has plummeted. Building databases is not just an academic pursuit. It actually translates into lives saved.”
Training and education are also key activities for Razek and his colleagues. They work with local partners, including academic centres in Ethiopia, Mali and Rwanda, using standardized educational programs to teach the skills needed to deal with emergency situations. Hundreds of people have already received training through this program. “We train whoever is most appropriate to train in the local context,” explains Dr. Razek. “We train whoever would benefit from the training who is actually doing the work. These are often medical trainees who require more training, especially in skills and overall management of injuries. But we also train nurses and other medical technical staff as there are very few actual physicians out there to do the work.”
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Not all programs in the McGill Global Health Program are directly related to physical disease or injury; sometimes health is a more holistic concept. An estimated 300,000 children, many younger than 15 years old, are actively engaged by armies or other military groups each year. (Children are deployed in almost 75 per cent of the world’s armed conflicts.) Myriam Denov, an associate professor in McGill’s School of Social Work, is working toward a better under standing of how these children are forcibly recruited, how their engagement in violence affects their post-war lives and mental health, and how they reintegrate into society, post-conflict. Her work focuses on these children’s long-term rehabilitation and community reintegration.
Denov has been studying former child soldiers recruited against their will by the Revolutionary United Front rebel militia during Sierra Leone’s brutal civil war, which ended in 2002. Working with Defense for Children International, a small local NGO, Denov has painstakingly built relationships with hundreds of former child soldiers. Most of these boys and girls were conscripted when they were between the ages of seven and 14, but some were as young as four. The children served not only as soldiers, but also in supporting roles, carrying arms and ammunition, acting as spies and messengers, and taking care of military camps by doing cooking and laundry. In addition, many girls were victims of repeated sexual violence and forced to act as “wives” to male soldiers.
Reintegration has been difficult for the majority of children in Denov’s groups. Families and communities often refuse to take back ex-soldiers because of the shame and stigma associated with their former affiliation with the rebels and wartime violence. Former girl soldiers have often been shunned by their communities for transgressing traditional gender roles, as well as having been victims of sexual violence. “While the needs of former child soldiers across Sierra Leone are extensive, we have found that girls and boys living in urban areas can be worse off than those in rural areas, as they appear to experience greater levels of poverty and have fewer available systems of support,” Denov says. “We have begun to work with a group of former child soldiers, both boys and girls, living in the slums in Freetown. This group is facing incredibly challenging conditions: most have lost their parents in the war, they are homeless, and they struggle to eat regularly. They have few prospects for education or remunerative work, and experience high levels of violence. Most survive on less than a dollar a day by carrying loads, stealing, drug dealing and engaging in prostitution.”
To empower these former child soldiers, Denov is experimenting with a community-based participatory research method known as PhotoVoice. She and her colleagues have given cameras to a small group of young people and have trained them in photography. The young people then take pictures of what is important or meaningful to them in their community, what they appreciate about their community, and what they would like to change. It is also a means by which young people can express their views and perspectives about life in the post-war context, and a way to raise public awareness of the challenges that these largely marginalized youth are facing. The research team plans to mount a large exhibition of photos, and will invite key officials from government, NGOs and community leaders and organizations to attend.
“It’s a way to let these young people speak about issues that matter to them, and for policy makers, government officials and community members to become more aware of these often invisible issues,” says Denov. “However, helping to build awareness at the local level and encouraging policy change are small steps given that these children’s needs are so great.” Many of the human rights issues that led to the war continue to persist, particularly in relation to the political, economic and social marginalization of youth in Sierra Leone. Far greater attention needs to be paid to youth empowerment and participation. Denov notes, however, that young people are not passive or powerless in relation to their own post-conflict rehabilitation or reintegration. Another group that she’s been studying is the former child soldiers turned motorbike taxi-riders living in Bo, Kenema and Makeni, who have created a new job category for them selves. Most conventional taxis were destroyed during the war, and an enterprising group of ex-combatants have pioneered the motorbike taxi industry. Cheaper than regular cabs, and able to negotiate Sierra Leone’s busy streets, the motorbike taxi is now an important staple—and the motor bikes are almost entirely driven by former child soldiers. The drivers have even organized labour unions for themselves. “Sierra Leone’s new motorbike taxi-riders provide a great example of young people who are finding alternative means to contribute to their own reintegration, creating new niches in the job market and organizing politically. Challenging stereotypes of former child soldiers as a ‘lost generation’ or being destined to a life of violence, these young people are showing that former child soldiers are actively navigating the post-war terrain and rebuilding their lives in the absence of violence. These youth are responding to post-war challenges with organized dissent and trade unions, rather than with guns.” ■