Getting to know the Global Health Next Generation Network

Multidisciplinary work is part of everyday life of any resident; living among Medical Doctors in training for Public Health could isolate us from the different perspectives that exist out there. One of the efforts of Euronet is to connect the residents of the member countries, but also to build bridges between other groups, teams and associations related to Public Health. One example is the Global Health Next Generation Network (GHNGN), which in a short time has created a network of working groups, some with common objectives with Euronet, such as empowering young professionals in trainee with practical tools.

“As the voice of the next generation of Global Health professionals, GHNGN focuses on bringing people together and foster discussion around Global Health through formal (conferences) and informal events (global health hangouts) as well as mentorship opportunities (Global Health Mentorships and Peer to Peer sessions).”

The network was created in Barcelona, with students of the Master of Global Health at the University of Barcelona, with the aim of having a platform so that young professionals from different cultures and backgrounds can network and exchange Global Health expertise and skills; to promote trans-disciplinary teamwork, to help each other out in the transition from academic to professional careers in global health, to initiate and foster dialogue on Global Health education and to support engagement of young professionals in Global Health initiatives and projects worldwide. Currently, there are approximately 30 people in the team, working from 15 different countries.

There have been some attempts to bridge in the last years. But it was this 2018 winter, when members of Euronet and GHNGN gathered in Barcelona and pushed forward on partnering. Some ideas flew on our first exchange of emails like ‘Social media visibility’, ‘Inviting speakers from Euronet for the Global Health Forum‘, ‘nominating a Global Health Ambassador’, ‘Writing a blog/career story about people on each organization’, ‘Exchange of expertise’, ‘Internships´, etc.

The official presentation of the GHNGN to Euronet members was made in March, at the meeting of Nancy. In the assembly there was general approval to draft an agreement for the next meeting. This beautiful story has the next date next July in Valencia, where some members of the GHNGN will visit us to make a formal presentation of their network, pitch some ideas and party with us at our meeting organize by Euronet Spain.

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References

Twitter: twitter.com/globalhealthngn
Facebook: www.facebook.com/GHstudentnetwork/
Website: http://ghnetwork.org/

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Efrain Pantoja
MRPH at Hospital Clinic de Barcelona and ‘Mr Pantoja’ at EURONET

Elena Marban
Pre doctoral fellow at ISGLOBAL and GHNGN board member

The Ethical side of Public Health

Nowadays, we still deal with the ethical side of every public health program or initiative using concepts or ideas based on Kantianism or even Utilitarism. We overlight and quote Rose’s paradox(1), as if the population and the individual interests were the only ones that mattered on the difficult path of deciding whether a public health measure, law or policy must be implemented or not. We sometimes strive to achieve a middle point between the population’s best interest and the individual freedom. None of this is unfamiliar, however, the importance of public health as a tool to ensure the compliance of human rights is still rarely discussed.

“In the absence of action, human rights are mere words on paper”(2). This, is one of the most important critics to the human rights approach (the most common approach related to human development). It states that human rights must be associated to measures that assure to genuinely safeguard human development. Nevertheless, political agendas and public health policies around the globe do not actively direct their efforts to assure human development or human rights on the grounds that if freedom is guaranteed, human rights will be guaranteed.

No more than a year ago I met an amazingly intelligent, successful, and wonderful woman that explained to me that the human rights approach is not all. That public health is not only screening, mental health, surveillance, health promotion or Antonovsky’s view for health and illness. She explained that a theoretical negative freedom does not safeguard anything; that social justice could give more answers than questions, problems or debates. She recommended me a book in order for me to get the bigger picture, to be able to see with other eyes the ethical (or unethical) part of public health, to think public health. I’ve been reading and re-reading it ever since.

The capabilities approach (2,3) offers a list of indicators of human development. We could consider 10 central capabilities that may ensure human development (but there are other perspectives of the capabilities approach(3)). Central capabilities, or capabilities in general, are meant to be understood as a common doctrine to be considered in every policy, and more specifically in every public health policy.

Lots of public health programs focus on the power of informing the population, promoting health by every kind of activity imaginable or limiting access implicitly or explicitly to products understood as harmful. Some would define this road as a form of “desired welfarism” and not as a path to achieve human health or human development. Every piece of information, every activity, is full of ethical principles that could affect people’s preferences – and these people’s preferences affect the population’s health results. The Kantian’s idea of community of equals, the Adam Smith’s theory of the impartial spectator or even the Hampton assumption of how preferences should be examined, do not reflect that people’s preferences do not consider social justice. It is not possible to identify the preferences that are the result of unfair and hierarchical circumstances without an independent ethics theory that thinks carefully about social justice.

However, it is not my role to explain to you the theory, the book, or someone’s opinion. My goal is to make us all think and re-think, read and re-read, have another view for every initiative, program or plan. Let’s envision every project with another approach. Let’s try to make something meaningful.

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References

  1. Rose G. The strategy of preventive medicine. The strategy of preventive medicine. University Press; 1992.
  2. Nussbaum MC. Creating capabilities: the human development approach. Harvard University Press. 2011. 256 p.
  3. Sen A. Development as freedom. Oxford New. 2001. 366 p.

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Laura de la Torre Pérez
Public Health Resident
Servei de Medicina Preventiva i Epidemiologia – Hospital Clínic de Barcelona

Environmental Health – climate change and impact

Climate change is not a new issue in global agenda, as well as environmental adverse effects on health. Climate consequences are not limited to low and middle-income countries, and Europe will not be spared in such global threat. It is expected that climate change will cause over 250000 additional deaths per year between 2030 and 2050. (1) Globally it is urgent to include a new ecological public health attitude, in which sustainability becomes part of daily practice. (2) Quality evidence is required to mitigate through inclusive strategies undeniable climate outcomes. One health through a cohesive concept, addresses environment and human health sinergically with animal welfare and veterinary medicine. By moderating consequences through multiple tactics, it is possible to achieve objectives in their whole dimension. (3)

Besides total environmental related deaths have been constant, in the last decades a shift from infectious diseases to non-communicable diseases was seen both in environmental fraction and burden, translating years of development in water safety and sanitation in low and middle-income countries. By estimating burden of disease that can be attributable to environmental risks, we can predict how measures can have impact on safeguarding people’s health – population attributable fraction. The acknowledgment of which factors can be amendable is crucial to support evidence in order to locate resources in actions that have a quantifiable benefit. (4) (5)

To monitor these changes, a surveillance system that include both ecological and human health impacts is essential. It is not possible to address these issues without giving health systems an essential role on moderating climate impact on populations’ health and societies. By decreasing their not minor footprint, the sector can be an example that transformations are accessible to all, even in segments as complex as health systems. Second and more appealing to managers and business associates is that these changes can have a serious impact on systems budgets and expenses.

Remarkably, health sector can improve public health and reduce costs simultaneously. (6)

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References

  1. Hales, S, et al. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva : World Health Organization, 2014. ISBN 978 92 4 150769 1.
  2. Brousselle, Astrid e Butzbach, Camille. Redesigning public health for planetary health. The Lancet Planetary Health. May 2018, Vols. 2, Issue 5 , e188 – e189.
  3. One Health Initiative. One Health Initiative. About One Health. [Online] [Citação: 3 de May de 2018.] http://www.onehealthinitiative.com/about.php.
  4. Prüss-Ustün, A, et al. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. s.l. : World Health Organization, 2016.
  5. World Health Organization. Preventing noncommunicable diseases (NCDs) by reducing environmental risk factors. Geneva : s.n., 2017 (WHO/FWC/EPE/17.1). Licence: CC BY-NC-SA 3.0 IGO.
  6. WHO’s Department of Public Health and Environment and Health Care Without Harm. Healthy Hospitals – Healthy Planet – Healthy People | Addressing climate change in health care settings – discussion draft . s.l. : World Health Organization, 2008.

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Mariana Perez Duque
Public Health Resident
Public Health Unit ACeS Porto Ocidental, ARS Norte, Portugal

“FUNI” Workshop

Thanks to our Italian members, EuroNet has been given the opportunity to organise a workshop at the Giornate degli Specializzandi in Igiene e Medicina Preventiva, which will take place on the 15th of June in the beautiful city of Catania.


Our president Alberto Mateo and E-RECT’s WG lead Špela Vidovič will lead the workshop, titled “FUNI” (Facilitating residents’ mobility, Undertaking research, Networking, Improving residency programmes). For one hour and a half, they will lead a discussion on how training programmes work across Europe; what the strengths and weaknesses of each programme are; how we can improve them and what EuroNet is already doing.
The workshop will be a fantastic opportunity to present and promote our network, as well as some of the work that we are doing, particularly in relation to the E-RECT study and the Professionalisation Working Group.
Our Italian members will be facilitating the workshop, making sure it is a success. They will also be in charge of showing the city to Alberto and Špela, as well as making sure they try some of the finest Sicilian food and wine. Pictures and report will follow the workshop. So, stay tuned!

Residency access in Italy: how did it change?

In Italy, procedures of application in medical residency have been deeply re-elaborated in the last four years. Until 2013, in order to pursue their own careers, young graduate doctors had to choose the University and the affiliated healthcare facility where they wanted to specialize, and take an entree exam there in these structures, through a local competition.

A first fundamental reform took place in 2014, when the introduction of a national competition replaced the hundreds of exams in the different Italian universities. Therefore, candidates were asked to individually choose up to six different branches of medicine, as well as to locate some preferred facilities; after the competition, the Ministry of Education, University and Research (MIUR) issued several national rankings, one for each medical specialization. The examination consisted of a multiple-choice test subdivided into a first general part identical for all, a second one based on three different macro-areas (medical area, surgical area, and area of health services), and a final ten-question test specific to different branches. In the following two years, residency access competitions remained almost unchanged.

Yet, the 2017 edition, albeit being structured along the lines of the previous ones, has been developed following a new regulation adopted by the MIUR on September 6th, with the purpose of streamlining and making the test procedures more transparent. Moreover, access to the different Schools of Specialization is now regulated by an annual national multiple-choice test. This test is the same for all students throughout the country, and it consists of 140 questions about key topics related to Medical School’s programmes, as well as some questions more specific to all the different medical branches.

A single national ranking including all the participants is then drafted based on the test’s scores. Starting from top of the list, each participant doctor who won a place as a resident is contacted in order to let him choose and declare both the preferred school of specialization and the selected city facilities. Each doctor is given the possibility of choosing up to three different kind of residencies, in order of preference. The achievement of high test scores allows to get a good ranking. The final score is calculated by summing the number of correct answers (that are worth 1 point each, while each wrong answer means losing 0.25 a point) to “extra-test” points, represented by University curriculum, which weighs definitely less than it used to in the previous tests ; in fact, now it is less than 7 points – rather than 15 – consisting of: up to 2 points for the degree grade, up to 3 points assigned after the weighted average of university exams’ grades, 0.5 a point per an experimental graduation thesis, and 1.5 points for a previous Ph.D.

Each annual edition of this new modality of residency access has to be specifically addressed by a competition notice published around the month of May.

In conclusion, this new national test was held last November, and, starting from December 4th, the awarded candidate doctors were able to choose the preferred available facilities, in a batch process depending on their score and rank position. The last residents’ allocation was held on December 22nd.

To those who have just started their training activities, all that remains for us to do is to wish you good luck, or if you prefer, buona fortuna!

More details at: MIUR, Italy – www.miur.gov.it

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Pietro Ferrara
Public Health Resident, University of Campania “L. Vanvitelli”, Naples, Italy

Viola Del Prete
Public Health Resident, University of Campania “L. Vanvitelli”, Naples, Italy

(As published in EuroNews #13)

Public Health Residency: Time for Focus and Opportunity

Last  January, I started my residency in Public Health in Oporto, at an institution responsible for all the population living or working in the oriental area of the city. I’m very pleased with my choice and I feel very welcomed by this big community. Fortunately, public health in Portugal is on the rise in the last 8 years with an increase number of all public health professionals. Even in Europe and all around the world, public health is becoming more prominent in order to have real impact in our lives and on the ones in most need. Euronet is an excellent example of the ambition and hard work of a new technological generation of public health doctors, understanding the value of a solid and robust network between different countries and cultures. One of my first goals, after choosing public health as my profession, was to find out what it is and its objectives. Besides its fundamental actions according to WHO, promoting health, preventing disease and prolonging life, and the additional ten major interventions that we can and should address on a daily basis, I read a sentence stated by Arnaldo Sampaio, a reference figure in the development of public health in Portugal, that, in my opinion, describes the range that public health can have, “If you want you can even consider the public lighting as a promoter of better Public Health, since it gives more safety to pedestrians and decreases the probability of road accidents”.

In the first residence year our program in Portugal is focused on community health. A major aim of this phase is to learn and practice epidemiological surveillance and intervention. In Oporto, we work with a population that has a big incidence of tuberculosis comparing with other regions of Portugal. It is characterized for having a low socioeconomic status and poor neighborhoods, and consequently low hygienic conditions and reduced search of healthcare treatment in due time, which are risk factors for acquiring the disease. Those conditions promote the spread of the disease between family, friends and work colleagues. Although our job’s aim is towards the identification of the source of the disease and all the contacts, there are, unfortunately, some barriers and bureaucratic restrictions that not allow us to do it properly. For example, the minimum 6 month period of treatment of tuberculosis is a huge downsize in the battle against the disease, since some cases doesn’t even complete the treatment, despite its mandatory order to do it under observation. One suggestion to fight those problems could be health institutions merely for treating tuberculosis where patients could be hospitalized during it, depending on the danger to themselves or others. We have the ability to, if not eradicate, reduce considerably the incidence of tuberculosis with new and good practices, using all the information that we have available today.

In almost two months I proudly declare that public health is exceeding my expectations, that I feel highly motivated and we all should encourage each other in order to overcome all the barriers that we might face along our path. Public health gives us all the tools to make a better, healthier and more sustainable world. Together, and perhaps with Euronet and its communication assets, we can make the difference.

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João Paulo Magalhães
MD, Public Health Resident, Portugal

(As published in EuroNews #13)

Public Health Masters in the context of Public Health Resident Training in Europe

Nowadays, large disparities are still present among the different Public Health Masters (MPH) included in the training programmes of public health residents in Spain. Moreover, the impending changes in our training programme may result in a reduction of specific public health training for public health residents from four to two years, with the likely exclusion of MPHs as part of these changes.(1)

The Spanish Association of Residents in Preventive Medicine and Public Health (ARES MPSP) is concerned about these discrepancies and their consequences within the European context. Our aim was to characterize the disparities present among the different public health resident training programmes across the European Countries. A survey was developed to this end.

All members present at the Strasbourg meeting, representing eight of the nine countries that are part of EuroNet-MPRH, participated at the survey, which consisted in a single question “Is MPH a compulsory course part of the residency programme?”. Ireland, the remaining country, received the survey via email.

All countries, except Italy and Ireland, declared to have a MPH programme as part of their residency training programme. In Ireland, MPH is optional (See figure 1). Regarding commitment and time-dedication, 33%(3/9) of the surveyed countries reported the presence of part-time MPHs, while 44% (4/9) reported full-time commitment programmes.

Figure 1

Fees are more often covered by the employer then students, except in France, where trainees must sustain the fees by themselves. In three countries costs are covered by the ministry.

All countries except Portugal and Slovenia have an official MPH title. Although Croatia has an official MPH title, they are unsure about the accreditation status. Schools in Portugal are encouraged to consider MPH programmes as the academic part of a master programme, where students pay an extra fee to present a thesis and to obtain a degree. Slovenia hopes to have one in the future (See figure 2).

The residents satisfaction with the training received during the MPH was assessed with the question “How satisfied are you with the training you have received?”. The results show a median satisfaction of 3.5 points out of 5 [IQR: 2-5] (See figure 3).  Moreover, residents were asked about what kind of changes they would like to observe inside the MPHs programmes (Table 1).

As presented, there are great disparities among different MPH programmes across Europe. It would be desirable to further unify MPH criteria in order to increase training quality and mobility.

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References

  1.  Inamo J. et al. Existe-t-il des spécificités dans la prévalence et la prise en charge de l’hypertension artérielle aux Antilles-Guyane par rapport à la France métropolitaine ? BEH thématique, 16 décembre 2008 ; 49-50. Romon I. et al. Le poids important du diabète sur la mortalité dans les départements d’outre-mer. InVS, Mars 2007.
  2. Jaries R. et al. Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border., 2017; 13:1-5
  3. Carde E. Les discriminations selon l’origine dans l’accès aux soins. Access to health care and racial discrimination. Santé publique 2007, volume 19, n° 2, pp. 99-109.

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Fátima C. Mori Gamarra
Preventive Medicine and Public Health resident at Complexo Hospitalario Universitario de Ourense, Galicia – Spain

Julio Muñoz Miguel
Preventive Medicine and Public Health resident at Hospital Clínico Malvarrosa, Valencia – Spain

Adrían Aginagalde Llorente
Preventive Medicine and Public Health resident at Hospital Universitario de Cruces – Spain

(As published in EuroNews #13)

French Guiana – Who is the stranger?

In France, as residents, we have the possibility to do a maximum of three rotations in a different place from the one where we are doing our residency. One lazy autumn evening I went through the list of the available rotations in French overseas departments, and I chose Saint-Laurent du Maroni, French Guiana. The choice was simple: a 37 years-old public health doctor had opened a whole public health department in Western French Guiana hospital 5 years before, just out of her residency, while getting a PhD with a thesis on migrants’ health. I could not ask for anything better.

French Guiana is a French overseas department, a former penal colony, wedged between Brazil and Suriname. It is a European outermost region and the only border of Europe with South American countries, it hosts a European spaceport from where Ariane rockets are launched every month and, of course, Euro is the currency.

I vaguely imagined what expected me. I read the data: the epidemiological profile of the region is similar to that of developing countries, where communicable diseases like dengue fever and leishmaniasis persist alongside a high prevalence of cardiovascular diseases and diabetes. HIV is epidemic (>1%), half of the population is less than 25 years old and the fertility rate is 3.5%.

The first thing I noticed when I arrived in Saint-Laurent, which has more than 40 thousands inhabitants and lies on the shore of the Maroni river, was the lack of public transportation. Being born and bred in cities, public transportation for me is a fundamental part of the landscape and the absence of it struck me immediately. Public transportation has practical implications, but also a symbolic meaning. It carries communities together and fights geographical isolation. In its absence, people living in the peripheries are left out of the public life. They cannot easily access services, which are historically aggregated in the city center. It did not take long to discover that isolation, lack of access to services, inequalities, structural discrimination would be key words of my experience here.

I participate in most of the activities of the public health department, whose mission spaces from prevention activities – an IST clinic, therapeutic patient education for chronic illnesses, cultural mediation, school interventions on sexual health… – to research and training, to international cooperation with neighboring Suriname, to providing medical missions to the health centers along the Maroni river. This allows me to have a glance at population needs and the difficulties to tackle them.

There is no single cause for the particular obstacles that may be encountered in health care in French Guiana. Part of the problem are practical issues: the scarcity of means – In terms of money but above all in terms of human resources – , the complexity of the territory – the road stops 50 km south of Saint-Laurent and you can only reach further towns by boat or by plane -, the distance from the capital city, where decisions are taken.  

However, it is not as straightforward as that. Working in this environment is the concrete exemplification of how determinants of health act.

Here, as professionals or laypeople, we are obliged to confront with theoretical and political questions that we do not usually think about in our day-to-day life, such as the subject of decentralization, the role and responsibilities of the State, the scars of colonialism, how societies form and develop. Questions arise about migrations and nationality3. We wonder who is a foreigner, is it the person who was born here but who does not speak French, is it the person who comes from across the river, is it the Parisian doctor, is it me, is it no one or are we all?

And the list of questions continues. How can we support sexual violence survivors, which can be count in hundreds every year? What is the best way to advocate for undocumented migrants and to provide appropriate services to mobile people? How do you tackle the complex ties between health, education, (lack of) job opportunities, social structures? What about indigenous population?

I do not have simple answers. However, I had the great opportunity to combine practice and reflection and to learn from dedicated professionals and for that I am grateful. I hope I leave you craving for more French Guiana.

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References

  1.  Inamo J. et al. Existe-t-il des spécificités dans la prévalence et la prise en charge de l’hypertension artérielle aux Antilles-Guyane par rapport à la France métropolitaine ? BEH thématique, 16 décembre 2008 ; 49-50. Romon I. et al. Le poids important du diabète sur la mortalité dans les départements d’outre-mer. InVS, Mars 2007.
  2. Jaries R. et al. Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border., 2017; 13:1-5
  3. Carde E. Les discriminations selon l’origine dans l’accès aux soins. Access to health care and racial discrimination. Santé publique 2007, volume 19, n° 2, pp. 99-109.

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Maria Francesca Manca
Public Health Resident, France

(As published in EuroNews #13)

Noncommunicable diseases in humanitarian settings

Women wheel their food rations, that have been donated by the Australian Governemnt, at a food distirbution point in Harare, Zimbabwe on the 23rd April, 2009.

In the 21st century, we live in a world regularly affected by emergencies, often with severe local and regional health consequences. In the context of climate change and corrosive political instability in many world regions, it is probable that we will see an increase in disasters or their resulting health impacts.1 By the end of 2016, 65.6 million people worldwide were forcibly displaced from their homes. The record number includes 22.5 million refugees, 2.8 million asylum seekers and 40.3 million people living in internal displacement (ID).2,3

The number of ID has nearly doubled since 2000 and has increased sharply over the last five years. For displaced populations health care has traditionally focused on maternal and child care and treatment of communicable diseases. While these traditional health priorities remain relevant, demographic and lifestyle changes are increasing the burden of noncommunicable diseases (NCD) in populations worldwide. This epidemiological shift poses new challenges for humanitarian agencies and host country governments. NCD accounted for 19% to 46% of mortality in the top 5 source countries for refugees in 2015.4

In the absence of regular care and access to medications, NCD may result in complications requiring costly specialised care and have the potential to seriously compromise both quality of life and life expectancy, since the risk of exacerbating pre-existing conditions or suffering acute complications, is two to three times higher than it was beforehand. In the initial response of an emergency management of NCDs should focus on treatment of life-threatening or severely symptomatic conditions. During the recovery phase after emergencies or during protracted emergencies such as long-term settlements, the management of NCDs should be expanded to include management of sub-acute and chronic presentations. WHO recognizes the growing problem of NCDs, and in 2013 introduced the Package of Essential Noncommunicable Disease Interventions, or WHO PEN, a set of tools to early detect and manage cardiovascular diseases, diabetes, chronic respiratory diseases and cancer in order to prevent life-threatening complications, such as myocardial infarction, stroke, kidney failure, amputations and blindness.5

There is a need to identify challenges and gaps in order to create a more holistic approach to effective planning, implementation and delivery of health care services to displaced populations with chronic NCD.

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References

  1. Demaio, A., Jamieson, J., Horn, R., de Courten, M., & Tellier, S. (2013). Non-Communicable Diseases in Emergencies: A Call to Action. PLoS Currents, 6, 5-23.
  2. UNHCR (2017). Global Trends – Forced Displacement in 2016. United Nations High Commissioner for Refugees, Geneva.
  3. IDMC (2017). Global Report on Internal Displacement. Internal Displacement Monitoring Centre, Geneva.
  4. Sethi, S., Jonsson, R., Skaff, R., & Tyler, F. (2017). Community-Based Noncommunicable Disease Care for Syrian Refugees in Lebanon. Global Health: Science and Practice, 5(3), 495–506.
  5. WHO (2010).Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. World Health Organization, Geneva

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Ana Pinto de Oliveira
2nd year Public Health Resident
ACES Arco Ribeirinho, Barreiro, Portugal

Catarina Neves Oliveira
Public Health Specialist
ACES Arco Ribeirinho, Barreiro, Portugal

(As published in EuroNews #13)