The European Migration Crisis and Implications for Healthcare Delivery

By Sarah Green, BA Medicine, Health, and Society & History, Expected 2020

In 2015, the term “refugee and migrant crisis” was coined to refer to the ever-increasing number of asylum seekers in Europe. The number of refugees immigrating to countries in the European Union (EU) from non-EU member states reached over two million in 2017. Geopolitical tension, violence, climate-change related natural disasters, economic inequality, and diminished freedom across Africa and the Middle East prompted this mass migration. With more immigrants comes increased pressure on EU member states to accommodate the influx of people. Nationalist leaders, who have gained footing across Europe since the start of the decade, have blocked proposed common migration policies for European countries. By analyzing healthcare policy in Europe through the lens of migration, it is easy to see where disparities exist.

According to many European laws, especially Article 12 of the International Covenant on Economic, Social, and Cultural Rights, all individuals in Europe have the right to healthcare, regardless of citizenry. However, immigrants often slip through the cracks, as many are unable to pay the fees for care beyond emergency treatment. A phenomenon called the “healthy migrant effect” (the perception that immigrants are strong and healthy) undercuts immigrants’ often traumatic journey, their pre-existing conditions, and potentially, the underfunded healthcare systems in their country of origin. Immigrants from non-EU member states might only be familiar with emergency care, as the country they left might not have had primary care institutions. Lengthy office visits and poor understandings of migrants’ experiences contribute to substantial barriers to care. A bad experience at a European health care center can even turn immigrants away from seeking healthcare at all in Europe. Furthermore, language barriers can lead to poor medication adherence and noncompliance with treatment. Mass immigration poses significant challenges to healthcare providers too— navigating different understandings of healthcare, unfamiliar disease profiles (many migrants come from countries in epidemiologic transition), and unfamiliar languages and cultures can contribute to frustration between doctors and patients, and ultimately, form barriers for immigrants to access routine health exams and treatment.

Of course, immigration is so nuanced and complex that a solution to provide equitable citizenry, and therefore healthcare, for all those in Europe will not appear overnight. However, training healthcare providers in cultural competency— how to work effectively with people across different cultures— is a starting point to ensure positive healthcare experiences for migrants that will not deter them from seeking routine care. A 2018 case study from South Africa indicated that emphasizing cultural competency in the medical curriculum with more community-based research and increased language instruction improved healthcare delivery for minority populations. These improvements are general enough to be applied more broadly. Investment in language instruction is also critical to European healthcare providers, not only to increase cultural competency, but also to increase the number of translators available and doctors who can speak multiple languages with emphasis on languages spoken outside the EU. Additionally, the establishment of community health centers focused on immigrants’ care could be beneficial to both healthcare providers and immigrants. 

In Europe, there exists a notion of a shared identity called the “European Idea,” [1] enforced by political unions such as the EU which sustain the concept of European-ness [2]. Although the European Idea emphasizes unity, independent European nations have their own notions of citizenry and nationhood. Most European countries today exercise an assimilationist model, where immigrants who pursue citizenship accept their new country’s culture as their own and automatically become just as much a citizen as anyone born in that country. However, this égalité is more of a starry-eyed ideal, because in the face of mass migration, institutions like healthcare are put under so much pressure that they cannot adapt to serve vulnerable immigrant populations, especially refugees, who, being excluded from the basic rights guaranteed to Europeans, find it difficult to assimilate into their new country’s culture. It is also important to note that between 2016 and 2017, although immigration of people from non-EU member states to EU member states was 2 million, the number of people granted EU citizenship decreased by 17 percent. In conjunction with a recent rise in European populist voices critical of the EU gaining political traction, migrants’ freedoms and rights are on the line. Only one month ago, Susanna Ceccardi, the far-right anti-immigrant mayor of Cascina, Italy, described immigrants as exploitative “invaders” at an event for her campaign to earn a seat in the EU Parliament. Ceccardi became a right-wing star in Italy, premising that immigrants take jobs from Italian youth, who are facing unemployment rates of 30%. Sentiments such as Ceccardi’s further ostracize immigrants from citizenry-based rights in Europe.

It is difficult to say what the future holds for immigrants in Europe. The anti-immigrant politicians gaining traction now might lose ground in coming years, but their increasing popularity could have serious implications for migration to EU member states. Pressing issues such as climate change will inevitably produce more refugees with each year as more frequent natural disasters destroy peoples’ homes and land. Countries like Denmark, with xenophobia so pervasive that it has been institutionalized, are already grappling with protests over immigration policy. What we do know, is that migration to Europe has no end in sight, and in order to ensure the healthcare needs of every European citizen and migrant are met, changes must be made to the current healthcare system.


[1] Thorneycroft, Peter. “The European Idea.” Foreign Affairs (pre-1986) 36.000003 (1958): 472. Web.

[2] Brubaker, Rogers. Citizenship and Nationhood in France and Germany. Cambridge, Mass: Harvard University Press, 1992. Print.

Climate Change is Taking a Toll on our Mental Health

By Corrine Liu, BA Medicine, Health, and Society & German, Expected 2019

We have 21 years to fix our problems. This is the terrifying message from the United Nations’ Intergovernmental Panel report on Climate Change released last September. It predicted that humans could witness a major environmental catastrophe as early as 2040. To visualize the gravity of this, think of the final panel of Hieronymus Bosch’s Garden of Earthly Delights: a “paradise that’s been degraded and destroyed,” with a world of worsening food shortages, wildfires, a mass die-off of coral reefs, and other cataclysmic conditions.

The prospect of a world afflicted by climate change elicits a sense of pervasive loss, devastation, and fear about catastrophes in a very near future. The Lancet Commission on Health and Climate Change concluded that climate change presents “the biggest global health threat of the 21st century.” This harsh reality may leave many of us rattled and hopeless. A recent study demonstrated that there are 467 different pathways by which human health, water, food, the economy, infrastructure, and security have already been impacted by climate hazards. For example, researchers in Central America found that extreme heat brought on by global warming is damaging outdoor workers’ kidneys.

Our environment and physical health should not be our only concern. According to a 2017 report co-authored by the American Psychological Association (APA), Climate for Health, and ecoAmerica, “climate change-induced disasters have a high potential for immediate and severe psychological trauma.” Climate change is putting pressure on our ecosystems and our infrastructure, but it’s also taking a toll on our mental health. The authors highlighted that among a sample of people living in areas affected by Hurricane Katrina in 2005, suicides and suicidal thoughts more than doubled, nearly 50% of the people developed a mood or anxiety disorder, and 1 in 6 people developed post-traumatic stress disorder. This data informs that the destruction and loss of home due to climate impacts may diminish the sense of belonging and solace that people derive from their connectedness to the land.

In areas where catastrophic natural events not only make lands uninhabitable but also destabilize society, people are forced to take shelter overseas. Since 2008, an average of 24 million people has been displaced by catastrophic weather disasters each year. As projections of climate changes, such as desert expansion and sea level rise, progress over time, 143 million people  from sub-Saharan Africa, South Asia, and Latin America could be displaced by 2050. Inevitably, they will need to cope with displacement-related stressors that influence mental health: social isolation resulting from the loss of social networks; unemployment due to a lack relevant work skills or to host-society restrictions on permission to work; poverty and a lack of access to basic resources; perceived discrimination; increased family violence; and difficulties navigating settings of resettlement. As climate change worsens storms and droughts, climate scientists and migration experts expect the number of globally displaced persons will rise. But so far there’s no international agreement on who should qualify as a climate refugee — much less a plan to manage the growing scope of predicament. For this reason, climate refugees also face stressors that include uncertainty regarding their legal status, the possibility of being deported to the country from which they fled, and for many, prolonged detention in asylum holding camps, while their asylum claims are adjudicated. The depletion of these refugees’ coping resources by continuously stressful environmental conditions leaves them more vulnerable to the traumatic effects of climate change.

Those who are lucky enough to have stayed out of the direct path of climate change may be exposed to “unrelenting day-by-day despair.” Amid abstract global temperature trends and unfathomable volumes of melted sea ice, the everyday intimacy of climate goes under-acknowledged. Psychologically, however, such interaction takes shape in “some of the most resounding chronic psychological consequences,” according to the APA report. “Gradual, long-term changes in climate can also surface a number of different emotions, including fear, anger, feelings of powerlessness, or exhaustion.” Over long periods of time, chronic stress has been shown to suppress the immune system, “leaving people more vulnerable to pathogens in the air and water,” the researchers wrote. In other words, mental health is intimately linked with physical health, and prolonged despair can lead to disease. Susan Clayton, a psychologist at the College of Wooster predicted, “as we have more natural disasters, one would expect to also have increases in [depression, anxiety, post-traumatic stress disorder, substance abuse, and domestic abuse].” As natural disasters become more commonplace, so will mental illness.

The psychological effects of climate change are affecting even the youngest, most vulnerable members of society: our children. A study conducted by the Department of Psychology at Oregon State University found an association between experiencing a natural disaster and developing anxiety, depression, and increased aggression in children as young as two to nine years old. Don Arnold, a pediatric emergency medicine doctor at Vanderbilt Children’s Hospital, likened climate change to one of this generation’s versions of the threat of nuclear war during the Cuban Missile Crisis, “Thermonuclear war was an anxiety for kids in my generation and I think climate change, along with gun violence and […] social media is probably causing anxiety in kids today.”

We’re living through an unprecedented peak in devastating natural disasters, and with the trend we’re following, things will only getting worse. A recent article in Nature warns that unless we “aggressively” reduce our emission of greenhouse gases, by 2100 some areas of the world will be simultaneously exposed to up to six severe natural disasters simultaneously. On a more positive note, research has found that people with strong social connections and networks during, and in the wake, of a natural disaster tend to have lower rates of psychological distress and a higher capacity to withstand traumatic experiences. Restoring economic and housing resources to populations affected by a natural disaster would significantly reduce the mental health burden in populations, particularly those with resource loss, after a disaster.

Actions to mitigate climate change not only offer a wealth of immediate benefits like clean air and food security but also strengthen our mental wellbeing. Public transportation, for example, helps nearby households reduce 39 to 50 percent of their energy use, promotes cognitive functions, and augments community mental health by creating opportunities and networks to increase community cohesion. These mental health concerns must inform policymaking and a system-wide societal shift in how climate change is thought about and what the potential long-term impacts might be. Consequently, we should look beyond the mental health concerns to address the core causes of our changing climate and build social, economic, and environmental resiliency.

Why China’s Environmental Policies Are Inadequate for Improving the Nation’s Health

By Corrine Liu, BA Medicine, Health, and Society & German, Expected 2019

Nearly three years ago, Chai Jing, the former CCTV (China’s state television) investigative reporter, made her last public appearance in her documentary, Under the Dome. In the film, she demonstrates the severity of China’s air pollution issues, shows how they have formed, and assigns blame to state-owned petrochemical enterprises as well as openly criticizes the Ministry of Environmental Protection for failing to act against big polluters.

Unprecedented in its scope and range, the film caused an uproar on the Chinese internet; it was soon withdrawn from China’s mainstream websites by the government, with Chai blacklisted from TV work. Nevertheless, her efforts to inform millions of people as to the extent of the country’s environmental crisis have paid off. By revealing her experience of having her unborn daughter operated on to remove a tumor, which possibly resulted from the toxic dust that she inhaled, Chai shed light on pollution’s severe implications on health (Ren et al., 2011). Corroborating studies have shown that exposure to outdoor pollution is carcinogenic to humans and that levels of particulate matter (PM) in outdoor air are associated with lung cancer mortality (Hamra et al., 2014). Among children, long-term exposure to air pollution may increase arterial blood pressure (BP), although breastfeeding may reduce the negative impact of air pollution on BP (Dong et al., 2014). Compared to normal-weight children, overweight and obese children are more susceptible to the inflammatory effects of ambient air pollutant, leading to a higher prevalence of respiratory symptoms and asthma (Dong et al., 2013). In light of Chai’s heartrending story, there is evidence suggesting an association between ambient air pollution and adverse pregnancy outcomes. In particular, exposure to pollutants during vulnerable pregnancy periods is linked to preterm birth, low birth weight, and intrauterine growth retardation. Preterm births and low birth weight remain the most important predictors of neonatal mortality (death in the first 28 days) and infant mortality (death in the first year) in both developed and developing countries, illustrating the disconcerting fact that the effects of the pollution trickle through two generations (Behrman and Butler 2007; Blencowe et al. 2012; Institute of Medicine 2009; National Institutes of Health 2013; World Health Organization 2004).

The film came out not long after the country first started measuring nationwide levels of PM 2.5, which is a particulate air pollutant that becomes a concern for people’s health when levels are elevated, and instigated draconian anti-pollution policies demanded by the infuriated public (Cui, 2016). Collectively called the Air Pollution Prevention and Control Action Plan, the policies state that their “ultimate goal is to achieve environmental, economic and social benefits,” by enacting a strictly monitored, top-down implementation model, placing outright bans on polluting activities and disciplining local governmental officials for subpar emission management. Specifically, if targets of urban PM concentration – a 10% decrease compared with 2012 – would have been met in 2017, the Action Plan was expected to prevent 89,000 premature deaths, 120,000 hospital admissions, and 9.41 million hospital outpatients and emergency room visits. The total health benefit would be approximately 86.7 billion RMB per year (Lei et al., 2015).

Yet the command-and-control measures have failed to address Chai’s, as well as most Chinese’s, concern about the pollution’s actual health impact (Huang, 2018). Despite promising health benefits and encouraging public oversight on air quality control, official reports claiming victory on the all-out war on smog show little regard for the policy’s actual impact on health. A second look at the policies easily reveals why: health benefits are translated into monetary terms that are used to complement the overall economic goals. Environmental policies are guided by the National Development and Reform Commission – China’s economic planning body. As the country’s newly awakened environmental awareness jostles with its traditional energy sectors, political force is used to maintain the dichotomy between development and environment. The goals that are set accordingly are simply inadequate to meet public health demand: Beijing authorities pride themselves on bringing the city’s PM2.5 level below 60 micrograms per cubic meter, yet the World Health Organization recommends a maximum annual mean of 10 micrograms per cubic meter.

With a health-concerned, rather than a health-centered environmental model, many aspects of the environment-health interaction are not addressed due to the haste to fulfill and even overshoot the campaign’s targets. In an effort to avoid being named and shamed by their inspecting superiors, paying fines, or losing their jobs, overzealous local officials made sure to see a reduction in PM 2.5 in major economic zones – namely, Beijing-Tianjin-Hebei, the region surrounding the country’s capital. Yet the government’s pursuit of both clean sky and wealth has shifted the pollution elsewhere. National levels of PM 2.5 were only 4.5% lower in 2017 than in 2016 compared to the reported 54% reduction in Beijing, which implies that pollution rose in southern China.

By giving instructions to stay indoors and wear N95 respirator masks during heavy-smog days, the policies shift the burden of maintaining one’s health from local government to individuals. Additionally, staying in concrete apartment buildings, as most people do to steer clear of bad air, is also associated with risks of respiratory health hazards (Dong et al., 2013). As the country undergoes rapid urbanization and enjoys an improved living standard, an increase in construction work, housing renovation, and intensive usage of various new home decorating materials poses new health threats; associations between indoor pollution and asthma are especially notable among children (Dong et al., 2013). While public interest argument for improving indoor air has been gathering strength, the relationship between household factors and health is often overlooked when regulatory policies are devised (Roxburgh, 2013).

It is not hard to imagine why China, as one of the fastest-growing countries in the world, bases its environmental policies on economic realities. When it comes to sustainability, however, a health-centered approach is needed to fundamentally change the way China interacts with the environment, because ensuring the health of millions of individuals today will pay economic dividends long into the future (International Monetary Fund, 2004).


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Umama Salamas: A case for including traditional healers in modern health systems

By Sarah Heerboth, VUSM Class of 2019 (expected)

Mama Irene confidently stepped in to coach a struggling primigravida, and Mama Regina expertly anticipated the clinician’s needs—these women were more than just the cleaning ladies. With growing suspicion, I approached them during a quiet moment to inquire about their pasts. The women, beaming with pride, stood to answer me, explaining that they had all once been traditional birth attendants (TBAs). They finished each other’s sentences as they spoke, excited to share their knowledge with someone who had independently recognized their expertise. Soon after this interaction, they draped a rubber apron over my head as if it were a championship medal, giving me their official blessing to assist in their domain.

I went on to spend much of my free time folding gauze and hanging laundry with these Umama Salamasso that I could learn about their experiences. Leah, a Community Health Worker (CHW), told me about a particular delivery that still haunts her: she knew long before the baby was born that it had died. Her bare fingers macerated the fetus during her exams, but she couldn’t tell the mother or express her sorrow—she was fearful the patient would be too distraught to continue. She explained how helpless she once felt in the face of maternal and child mortality. What she loved most about being a TBA was not delivering babies, but rather meeting new women, earning their trust, and helping them in whatever way possible. When Lwala was founded and began offering antenatal services, Leah was not at all sorry to see her former profession go. She expressed gratitude to the organization for welcoming her into a formal health system. Now, she says, she has the tools she needs to truly make a difference in her community.

Mama Elizabeth wrote for me some of her former practices that she now regrets

In low resource settings, the inclusion of lay health workers is crucial to the success of the health system. Infectious disease and childbirth are still major sources of mortality, so education and prevention are of the utmost importance. But with only a handful of clinical officers and nurses working at each health facility, it is also essential to ensure that they are spending their time working at the top of their capabilities. With some training, community members can easily fill gaps in health education and prevention initiatives, often doing so in ways even better than their formally trained counterparts. In fact, significant reductions in childhood morbidity and mortality are achieved when lay health workers are deployed as a foundational component of health care systems. They’ve also been shown to increase breastfeeding, childhood immunizations, and tuberculosis treatment completion.[i]It is not a far leap to say that lay health workers have the power to help many of the Sustainable Development Goals become reality.

Debate remains, however, on the inclusion of traditional birth attendants in the lay health worker framework. Within their communities, TBAs are respected sources of health information and possess experiential knowledge of health problems. But many TBAs are illiterate, making training and data collection more difficult, and there is fear they may be overconfident in their abilities or reluctant to abandon traditional medicine. One study examined whether outcomes improved if TBAs were given a basic training in modern practices. While the results were somewhat promising, statistically significant impacts on mortality were not achieved.[ii]Conflict and distrust between TBAs and health care professionals have been cited as reasons why other similar efforts have been unsuccessful.[iii]

When TBAs are integrated into a larger healthcare system, however, significant increases in skilled antenatal care and birth attendance are seen.[iv],[v]Mama Elizabeth, who was a TBA for 20 years before joining Lwala, told me that women still show up at her door pregnant and bleeding or in labor. She herself had brought some of those mothers into the world, but “Lady’s Delivery Home of Uriri Village”is no longer open for business. Now, when she receives these unexpected visitors, she immediately accompanies them to the health facility, leaving their side only after they have been admitted. In my literature searches, a dichotomy emerged between studies showing success and failure of TBA engagement, perhaps accentuated by the success I have witnessed at Lwala. When TBAs are ostracized or seen as a lesser member of the healthcare team, challenges outweigh results. But when efforts are made to respect, include, and learn from TBAs, maternal and child health outcomes improve.3

Elizabeth writes what she now tells women who visit her

It is my firm belief that Lwala has its TBAs to thank for much of the success they have seen in maternal and child health. This success has been impressive: 97% of women deliver in the health facility, compared to a county average of only 53%; they’ve seen a 64% reduction in childhood deaths and a 73% reduction in neonatal mortality.[vi]  By earning the trust of the TBAs and treating them with the respect that they deserve, the organization itself earned the trust and respect of the community at large. They gained an army of strong, intelligent, and dedicated women in the fight against maternal and child mortality. Other organizations would do well to follow Lwala’s lead, finding new roles for traditional healers in modern health systems.

 Flora estimates that she conducted over 2,000 deliveries before joining Lwala as a CHW. She is unable to write her name, but has a wealth of experiential knowledge and is a treasured member of both the health facility and the local community.


For more information about Lwala Community Alliance, visit:

[i]Lewin, Simon, et al. “Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.” The Cochrane Library(2010).

[ii]Sibley, Lynn M., Theresa Ann Sipe, and Danika Barry. “Traditional birth attendant training for improving health behaviours and pregnancy outcomes.” The Cochrane Library(2012).

[iii]Glenton, Claire, et al. “Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis.” Cochrane Database Syst Rev 10.10 (2013).

[iv]Byrne, Abbey, and Alison Morgan. “How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance.” International Journal of Gynecology & Obstetrics 115.2 (2011): 127-134.

[v]Hamela, Gloria, et al. “Evaluating the benefits of incorporating traditional birth attendants in HIV Prevention of Mother to Child Transmission service delivery in Lilongwe, Malawi.” African journal of reproductive health 18.1 (2014): 27-34.

[vi]“2017 Annual Report” Lwala Community Alliance. 2018

Understanding Undernutrition in Mozambique

Trying to Understand Undernutrition in Mozambique

By Elizabeth Rose

This article is a summary of an article previously published by the author in BMC Nutrition and the full article can be accessed here:

Recent increases in globalization, urbanization, and the availability of processed foods high in sugars, sodium, and fat have contributed to a shift in focus from undernutrition to overnutrition in developing countries. Despite this shift, undernutrition continues to be a major problem, particularly in rural Africa. Among low- and middle-income countries (LMICs), the prevalence of chronic malnutrition, or stunting (height-for-age z-score less than -2), was 28% in 2011. When disaggregated by region, the prevalence of stunting in sub-Saharan African countries rose to 40% and in Mozambique, a country on the southeastern coast of Africa, the prevalence was even higher at 44%.

As the period for reaching the Millennium Development Goals (MDGs) drew to a close in 2015, assessing the reasons behind why goals were or were not reached will help guide future human development efforts in LMICs. Insufficient nutrition is a cross-cutting condition that both directly and indirectly impeded progress towards three MDGs: One (eradicating extreme poverty and hunger), Two (achieving universal education), and Four (reducing child mortality). In 2012, 25% of children under five years old (or 162 million children) suffered from stunting worldwide, with an additional 15% of children (112 million) classified as underweight (weight-for-age z-score less than -2).

Maternal prenatal nutrition and poor intake of micronutrients, such as vitamin A, by the infant in the “first 1000 days” (i.e. conception to age two years) can cause irreversible developmental damage and impediments in physical and cognitive growth that last into adulthood. Thus, proper nutrition in early childhood is important and poor nutrition at this age has been correlated with lower cognitive performance in school and decreased success in the labor market as an adult, which further perpetuates the cycle of poverty and undernutrition. Undernutrition, which includes stunting, underweight, and wasting (weight-for-height z-score less than -2), is the largest preventable cause of death among children under five years and is directly or indirectly attributed to 45% of child deaths (3.1 million). Ninety-eight percent of undernourished children live in developing countries, and while the prevalence of undernutrition has decreased across almost all world regions over the past two decades, rates have been increasing in Africa, mandating a better understanding of the determinants of undernutrition in this geographical setting.

Compounding the poor nutritional indices of Mozambique described above are the salient disparities in health care, outcomes, and budgeting allocations among the country’s provinces. The centrally-located Zambézia Province has the lowest per capita budget for health and education in Mozambique. It also has the lowest access to safe water (only 26% of people had access to safe water in 2009), the highest sanitation deprivation among children (73% of children did not have access to sanitation facilities in 2008), and the highest poverty headcount (71% of the population lived in poverty in 2008). Furthermore, this province also had some of the lowest performance indicators for health outcomes in the country, including the highest under 5 mortality rate (206 per 1000 live births, 10 year average 1998-2008) and among the highest child stunting rates (46%, 2008). Zambézia Province has been labeled as a development “priority province” and as such, numerous national and international programs have been undertaken, yet undernutrition rates have remained relatively stable. Aligning with the World Health Organization (WHO) recommendations that countries place the management of undernutrition as a public health priority, we sought to study the determinants of undernutrition among children under five years of age, over a four-year period, so as to inform future interventions and health practices that aim to reduce the prevalence of undernutrition in Zambézia Province.

In order to study the determinants of undernutrition in this population, we conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August–September 2010 (Baseline) and April–May 2014 (Endline) as part of the USAID-funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6–59 months at Baseline and 912 children at Endline and classified as: “stunted,” a height-for-age z-score less than -2; “wasted,” weight-for-height z-score less than -2; and “underweight,” weight-for-age z-score less than -2.

The results of this study included the following: Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child’s age was found to be associated with stunting and Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).

The prevalence of stunting in our study was “very high prevalence” as per WHO classification and also in comparison to worldwide rates of stunting in other LMICs that range from 5% to 65%. Recorded rates of wasting and underweight, as defined by the WHO, were categorized as “poor” and “medium prevalence,” respectively. Stunting prevalence is of particular concern since it reflects long-term structural factors of undernutrition and can serve as an indicator of a population’s well-being.

In conclusion, almost half of studied children aged 6-59 months in Zambézia Province were undernourished, revealing the need for sustained efforts to ameliorate this high prevalence rate. Of particular concern is the high rate of stunting that increased from 2010 to 2014. Intensified efforts to increase rates of vitamin A supplementation should be implemented, as well as other disease prevention measures such as interventions aimed at sustaining high rates of vaccine uptake. Interventions related to breastfeeding and hand washing practices as well as decreasing the extraordinary level of food insecurity that is prevalent throughout Zambézia Province should be implemented to help to reduce the prevalence of wasting and underweight. Future studies are needed to better explore local customs related to inter-household dietary diversity patterns, specifically focused on children under five years old. This study provided evidence that a combination of factors were associated with undernutrition. As such, use of multidimensional interventions should be considered to decrease undernutrition in children under five years old.


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Using Mobile Technology to Promote HIV Self-Testing

By Dr. Nickolas Zaller 

Dr. Nickolas Zaller is an Associate Professor in the Department of Health Behavior and Health Education and Director of the Office of Global Health at the University of Arkansas for Medical Sciences. On November 7th he was in Nashville and gave a talk at the Vanderbilt Institute for Global Health weekly Grand Rounds.

Dr. Zaller’s talk focused on mHealth to promote HIV self-testing among men who have sex with men (MSM) in Hefei, Anhui Province, China. Interestingly, HIV started in China primarily with unsafe practices surrounding rural blood donations for money. Currently, HIV risk is highest among MSM in China with rates growing compared to other high-risk populations such as sex workers. This is compounded by low rates of HIV testing among MSM.

It is in this context that Dr. Zaller and his team hope to develop a mobile platform to promote self-testing among MSM as a potentially scalable model applicable in other locations. He sees this as breaking the cycle in which the stigma of even going to a testing site combined with the fear of a positive result prevent men from getting tested. By offering self-testing at home, there is no stigma associated with going to a testing location and the barrier to entry is lower.

The natural tradeoff that comes with self-testing is the inability to counsel patients during a clinic visit. Dr. Zaller hopes to preempt this with a mobile education platform to improve HIV knowledge. Taking into account local context, this platform will be built through WeChat. While not very common in the United States, WeChat is the most common messaging platform in the world, and 25% of adult Internet users report using it. It is also by far the most common in the region.

The ultimate goal is to push educational information directly to users’ phones to both promote testing and improve HIV knowledge in this high-risk group. Dr. Zaller plans to complete a randomized controlled trial among men over 18 who self-identify as MSM with some receiving the messages and others not. Testing rates as well as other metrics—such as high-risk behavior—will be compared between the two groups. Once the content has been refined, it is potentially scalable to other cities and contexts.

The group has already performed qualitative interviews with potential participants to begin getting feedback on self-testing and the learning platform. People generally thought the test was easy and reported that it afforded improved privacy over going to a testing center. Participants were concerned about the accuracy of home testing and stated there was an inherent loss of privacy in physically purchasing the test. While they acknowledged the potential to buy tests online, they had less faith in these tests because of the potential for fakes. For the learning platform, they emphasized the need for a mix of both formal educational materials and fresh content to keep people interested. They also emphasized the need for privacy when content is pushed to a person’s phone to make sure others would not see it.

In summary, Dr. Zaller and his team aim to improve testing coverage among MSM in a scalable model using a mobile learning platform and self-testing.

Electronic Medical Record for Clinic Growth in Rural Guatemala

By Benjamin Li, MD/MBA expected 2018

Purpose: Describe the Primeros Pasos clinic and provide context for its current growth strategy: developing an electronic medical record system.

In 2004, a Vanderbilt medical student founded a non-profit primary care clinic to address health disparities in his home country, Guatemala. Like many developing countries, Guatemala struggled to provide access to health care throughout many parts of the country, especially rural areas. Located outside of Quetzaltenango (the second largest city in Guatemala), the Palajunoj Valley is an agricultural community of 18,000 inhabitants. Though situated in a beautiful landscape, it struggles with no access to clean water, heavy ash from the nearby active volcano (volcán Santa María), and poor education and nutrition. The Primeros Pasos Clinic provides care for this population.

Each year, Primeros Pasos has continued to grow through the collaboration of medical students, volunteers, and professionals. In its inception, the clinic served children from local schools. It expanded to include adult services in 2007, laboratory services in 2009, dental care in 2010, and a nutrition program for health and education in 2012. It is currently staffed with a clinic coordinator, a dentist, a pathologist, two Guatemalan physicians, six to eight rotating Guatemalan medical students, and a host of international medical volunteers who come and go throughout the year, usually one to three months at a time. It has established several partners, including local businesses, Spanish schools that provide education and lodging for volunteers, and global health alliances. The clinic treats four main conditions: intestinal parasites, respiratory illnesses, skin lesions, and malnutrition.

Like many developing clinics in poor regions, Primeros Pasos provides most of its care at low or no cost, so it relies heavily on outside funding. The clinic coordinator is responsible for applying for numerous outside grants throughout the year. In addition, each international volunteer is expected to fundraise $300 for the clinic. Vanderbilt Medical School organized a “Miss America” style event called the “Dr. Vanderbilt Pageant” to fundraise $2000 for the clinic in 2016. The clinic currently hopes to use this funding to acquire a new electronic medical record system (EMRS).

The new system, OpenMRS Software, is an open source EMRS platform commonly used to improve health care delivery in the developing world. It is designed to be adaptable for different sites, languages, and types of diseases. First implemented in Kenya and Rwanda in 2006, it is now used throughout the world.

As the clinic coordinator explained, this new system would open a whole new pathway for Primeros Pasos. Currently, the clinic operates with a handwritten paper/Microsoft Excel hybrid system in which patient records are kept in color-coded folders (pink for females, blue for males) stored alphabetically in three large filing cabinets in the clinic. The new system improves difficulties that range from illegible handwriting to providing unique patient identifiers (many people in the valley share identical names), and creates an organized way to streamline care, track patients, and collect information. Improving efficiency allows the clinic to see higher volumes of patients. This will encourage patients to return to the clinic for routine healthy check-ups, instead of just when they are ill.

On a significant note, the new EMRS opens avenues for greater funding. Many large grants require data and metrics to support program efficacy. Primeros Pasos will be able to use OpenMRS to collect, centralize, and report patient data (health demographics, diseases, treatment, outcomes, and more), allowing it to access this pool of funding. Furthermore, statistical reports can be used to evaluate and improve medical program design, approach, and policies to most effectively optimize patient care and outreach.

The steps towards this growth would not have been made possible without the interest and contribution of student volunteers and Global Health programs. Though short-term visits may appear to offer limited impact, Primeros Pasos is an example of a clinic that has benefited steadily through the years with continued support. A key component to its success has been establishing a long-term vision and a diverse board of members to oversee its growth and operations. Particular credit should be given to the clinic coordinator, who has been able to track the progress of the clinic, develop partnerships, spearhead finances, and update goals and initiatives while managing its volunteers. The clinic imparts a lasting impression on its volunteers, which serves as a testament of its collaborative success.

Systems-Based Healthcare in Lwala

By Chinonso Opara

Being a Nigerian-born American, I have grown to understand that the benefit of living and working in a first world country is not necessarily lifestyle and “Western amenities”. Nor is it the people or culture. I have come to see that the benefit of living in the United States or any other developed country is the relatively available access to healthcare. You can almost bet that when a medical emergency knocks at your door, there will be services to help meet your newly acquired needs. Through a partnership between Vanderbilt and Lwala Community Alliance (Lwala), I was immersed in the Kenyan healthcare system and was able to draw comparisons between Kenyan healthcare and that in the US. I was placed at Lwala’s hospital and observed care provided in this semi-private facility as well as the care provided through government hospitals in the area. I realized more and more that Kenya, and Africa in general, are relatively young countries – only being about half-a-century old. I realized that while Kenya still has a long way to go, it has come far and has potential to grow even more in terms of improving access to adequate healthcare. I had the opportunity to be exposed to the National Health Insurance Fund. I also had the privilege of contributing to the improvement of the KenyaEMR (electronic medical record) system at Lwala, which was originally designed for the care of HIV patients.

One dismaying thing I saw about healthcare in Kenya is that it is based too much on one’s ability to pay. If you come to the emergency room with a medical emergency, such as acute appendicitis, some hospitals will require you to pay first before they touch you, even though your life is in grave danger. While Lwala provides subsidized and free care, patients that are referred to other facilities for acute conditions face cost barriers. At least in the United States, the ER will see you, even though they’ll hand you a hefty bill later.

One particular patient I remember was a young adult with a past medical history of Hepatitis B, undergoing treatment with tenofovir and lamivudine, and who developed cirrhosis of unspecified etiology complicated by a large hepatic mass seen on ultrasound. He had no other known risk factors: no hepatitis C, no smoking, no drinking, one sexual encounter 5 months prior with a condom, no known family history of abdominal disease. The next step in the workup was to refer the patient to another facility for a CT scan, which will cost his family 7 to 9 thousand shillings ($70-$90). This is a hefty price! Especially considering the median income in Kenya is a little above KSh6000/month ($60), and in village life, it is likely much less than this. They will need help from family and good friends in order to come up with the money.

On another day, we had a patient come in with bowel obstruction. She had initially been diagnosed with bowel obstruction secondary to colon cancer in one of the main government referral hospitals. However, her family could not come up with the necessary funds for further workup and therefore took her home. At home her cancer metastasized systemically and she deteriorated. She was brought by her family to Lwala. However, because she required specified diagnostic tests that Lwala’s hospital does not have, we had to tell the family that we could not do much for her. This is another example of how a family’s limited immediate financial resources hinders even the workup of a life-altering disease.

However, we had another patient during rounds who was HIV-positive with nevirapine-induced dermatitis and hepatitis, requiring further workup, including LFTs, and kidney function tests. The difference here is she had health insurance through the National Hospital Insurance Fund in Kenya, and she could therefore afford the further workup of her condition.

The National Hospital Insurance Fund, established in Kenya in 1966, was designed to make access to adequate healthcare more feasible for families, similar to health insurance companies in the US. It is the oldest such insurance scheme in Africa and the pride of the Ministry of Health. It requires a minimum income of KSh1000/month just to enroll and the individual contribution is based on one’s monthly salary. For instance, the following income brackets of KSh1000 – KSh5999 and KSh6000 – KSh7900 must contribute KSh150/month and KSh300/month, respectively. And anyone who is self-employed must contribute KSh500/month. Considering the median Kenyan income of around KSh6000 this is expensive for the most vulnerable Kenyans.

Because of the very vulnerable population Lwala serves, very few patients are enrolled in NHIF.

In fact, in my whole time in Lwala, I only saw one person who had NHIF and that was the patient described above. Even one of the clinical officers, in his whole time in Lwala has only seen three patients with NHIF in Lwala

Lwala provides free services to pregnant mothers, children under 5 and people living with HIV as well as subsidized services to the general population. However, patients needing specialized care above the services provided at Lwala, must navigate the public system.

Lwala is in the process of registering for NHIF and aims to be a full participant in the program in 2017. Once registered, Lwala will begin an ambitious campaign to enroll its population into the insurance scheme. This will mean increased sustainability of the hospital as it receives reimbursement for the free care it provides as well as fuller coverage for patients when they are referred for higher levels of care.

My hope is that the NHIF expands in Kenya to increase coverage for and access to healthcare, but that it does so in a way that retains quality, as is the hope for any health insurance program.

Highlighting VUMC Research on TB/HIV Co-infection

Tuberculosis (TB) is the leading cause of death among people living with HIV. In 2015, there were 1.2 million people living with HIV estimated to have fallen ill with TB, and 390,000 people who died from HIV-associated TB. To control TB in high HIV-prevalence settings, it is imperative to coordinate efforts for TB and HIV control. Vanderbilt collaborates with international organizations and performs studies in population-based cohorts to identify ways to reduce the burden of TB among persons living with HIV.


William Wester, M.D., M.P.H. leads a large CDC-PEPFAR-funded initiative in Mozambique entitled, “Avante Zambézia” (“Go forward” Zambézia province) where the Vanderbilt University Medical Center (VUMC)/Friends in Global Health (FGH) team provides technical assistance supporting the scale-up of comprehensive HIV and TB services, including the provision of antiretroviral therapy (ART). Currently beginning year 5 of their initial 5-year cooperative agreement plus beginning year 1 of 5 of a new grant award, the VUMC/FGH team is making great strides in the area of service expansion, as they now support ART services in 112 health facilities across 14 out of 23 districts within Zambézia province; with plans to expand into a 15th district, namely the province’s most populous district (Quelimane) beginning in January 2017.  During the recently completed year 4 of the initial grant award (9/30/15-9/20/16), 5,224 new TB patients registered in the program and 92% of eligible HIV/TB co-infected persons initiated ART. During this current funding year, the VU/FGH team plans to specifically focus on improving the timeliness of TB diagnosis via the wide-scale implementation of the Gene Xpert diagnostic test, as well as improve TB infection control via site refurbishment to improve patient flow and air flow/ventilation.



April Pettit, M.D., M.P.H. studies the epidemiology and outcomes of those co-infected with TB and HIV via datasets from large HIV cohort collaborations. Results of an International Epidemiologic Databases to Evaluate AIDS (IeDEA) study examining mortality due to non-AIDS defining events in HIV patients on ART were presented at the International Workshop on HIV Observational Databases (IWHOD) in March 2015. Another IeDEA study led by Pediatric Infectious Diseases Fellow James Carlucci, M.D., looked at TB treatment outcomes in HIV/TB co-infected children in resource limited settings, results were presented at CROI in February 2016. Additionally, Dr. Pettit is involved in clinical studies of TB infection and disease via the Tuberculosis Epidemiologic Studies Consortium and the Tuberculosis Trials Consortium, funded by the Centers for Disease Control and Prevention.


The Caribbean, Central, and South America Network (CCASAnet) for HIV epidemiology, a network of IeDEA and led by Catherine McGowan, M.D., collects and synthesizes data through the Vanderbilt Data Coordinating Center (VDCC). CCASAnet has created a shared repository of HIV patient data that has been merged from 10 sites throughout Latin America. This dataset has allowed high-quality analyses of HIV and TB. The most recent project is evaluating TB treatment intermittency in the continuation phase and associated mortality; preliminary results will be presented at CROI in February 2017.


A newly funded NIH R01 project led by Timothy Sterling, M.D. aims to optimize the treatment of HIV-related TB in a large, genetically diverse cohort in Brazil. Treatment of TB/HIV is complicated by drug-drug interactions and increased drug toxicity risk. The current guidelines recommend a standard 6-month based regimen regardless of HIV status, but recent studies suggest that TB failure and relapse is increased in HIV-infected persons. Pharmacogenomic predictors of TB failure and relapse could help optimize treatment. This project builds on the previously established Regional Prospective Observational Research on TB (RePORT)-Brazil cohort which is enrolling patients from 5 sites in Rio de Janeiro, Salvador and Manaus.


The Vanderbilt Tuberculosis Center (VTC) is a focal point for collaborative efforts in TB research that contribute to a reduction in the burden of TB/HIV globally, including Tennessee and Nashville. The VTC also provides technical assistance to local and global service programs engaged in TB control including the Metro Nashville Public Health Department and the Tennessee Department of Health.

Health counselors: A key element in the fight against HIV

By Friends in Global Health

Under the intense sun in the district of Mocubela, in Zambézia Province, Ilda Pedro receives Bethe Gabriel into her home. They kiss each other’s cheeks and smile at each other. Ilda is an HIV positive patient, and Bethe is her health counselor. Over time, their relationship has grown substantially, moving from one between provider and patient to a deep and enduring friendship. At the time of the visit, Ilda was at home with her youngest son, still an infant. Two other children were at school, and her third was at her grandmother’s house.

Ilda sorted and cleaned the beans she would prepare for dinner. “I grew these beans myself. We are great farmers.” said Ilda, proud of her work.

She confessed that her husband was battling for his survival in a remote village. When it was time to talk about her children, Ilda became more hopeful. “My sons are healthy. It was the first one who went through a lot of complications. But he’s fine now. I don’t know yet what they want to be (when they grow up), but I would like for them all to study so that one day they can take care of me,” said the mother of four children.

This climate of health and hope has not always been present in this family. “My eldest son was always sick. I would take him to the traditional healers, but he would always have relapses. When I got pregnant with my third daughter back in 2014, I was advised to take an HIV test. My result came back positive. It was at that time I was advised to have my eldest son tested for HIV. His result was also positive,” Ilda told us.

From that day onwards she started to look out for the family’s health. Today they all know their HIV status. Only Ilda, her husband, and her eldest son have HIV. They are all on combination antiretroviral treatment. The youngest has already had his first child-at-risk (CCR) clinic consultation and his HIV test result was negative.

According to Beto Omar, the FGH clinician at Mocubela, “HIV treatment markedly reduces the probability that pregnant mom’s will transmit HIV to their newborn children.”

Ilda is grateful for the “miracle” performed by the local health unit supported by FGH. “I did not think my son would be alive today. Even his hair color had changed; it used to be brownish. Today he plays and goes to school. He’s the one that asks for his medication when the time comes to take it.”

According to Bethe, Ilda’s health counselor, Ilda was reluctant to initiate antiretroviral treatment early on. She tells us “Just like the majority of people, she (Ilda) did not accept the (HIV test) results. She had to go through a couple of counseling sessions before she could accept the reality. To be successful, we the counselors need to show that we are interested in seeing the patient get healthy.”

Ilda Pedro and Bethe Gabriel, health counselor, at a counseling session.
Ilda Pedro and Bethe Gabriel, health counselor, at a counseling session.

Mauro Timana, Chefe Médico at Mocubela, emphasizes the role of health counselors in the fight against HIV. “The health counselor is the key member of the team. They are the true pillar. It is with the health counselor that patients have their first contact, on which everything else depends.” He adds that “If the health counselor’s work is not done well, all the rest is jeopardized.” Timana says Ilda and her family are monitored by their health counselor and thanks to this follow-up, the entire family is healthy and is thriving.

Ilda finishes our conversation by expressing her angst for those women that are reluctant to be treated (for HIV). “I feel (sad) for them. Before ARVs, a lot of people would lose their children. Even adults would lose their life. But this treatment is very good.”

Health counselors are stationed in key sectors within the health facilities: antenatal care, child-at-risk clinics, HIV counseling and testing, healthy child services, provider-initiated counseling and testing areas, and psychosocial support services unit, in order to receive and welcome patients and to facilitate the health facility’s workflow.

During the antenatal consultation, aside from HIV counseling and testing, the health counselors screen for STIs, TB, hypertension and diabetes. There, they also invite male partners to benefit from the same health counseling, and to receive key positive prevention messages covering sexual behavior, correct and consistent use of condoms, treatment for STIs, prevention of mother-to-child-transmission (PMTCT) of HIV, family planning, disclosing HIV+ status to a partner, adherence to treatment, risk reduction counseling (focused on the dangers of alcohol and drug use), as well as referrals to community support groups.

Ilda is one of many mothers that has benefited significantly from the services provided by the health counselors in the 14 FGH-supported districts within the Zambézia Province as of September 2016. The health counselors support is part of the U.S. government’s President’s Emergency Plan for AIDS Relief (PEPFAR) funded Avante Zambézia project through the Centers for Disease Control and Prevention (CDC). FGH is affiliated with Vanderbilt University Medical Center and provides support to Zambézia’s Provincial Health Directorate for the implementation of HIV health related services. This partnership has made it possible for FGH to have trained health counselors working in all 14 FGH-supported districts; an essential cadre of health professionals in the fight against HIV.


Friends in Global Health (FGH) is an affiliate organization of Vanderbilt University Medical Center currently operating in rural Mozambique. Working in partnership with local government and civil sector organizations, FGH aims to implement health development programs using sustainable strategies with the long-term goal of improving community well-being.)