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)

Modern slavery

(Pixabay)

Modern slavery is the illegal trade of human beings for the purpose of commercial sexual exploitation or reproductive slavery, forced labour, or a modern-day form of slavery.

British and foreign nationals can be trafficked into, around and out of the UK. Children, women and men can all be victims of modern slavery. Reasons for trafficking of individuals include sexual exploitation, domestic servitude, forced labour including in the agricultural, construction, food processing, hospitality industries and in factories, criminal activity including cannabis cultivation, street crime, forced begging and benefit fraud, and organ harvesting. It distinguishes human trafficking as a crime against an individual, and smuggling as a crime against the state where there are illegal border crossings.

There are an estimated 13,000 modern slaves in the UK. To tackle modern slavery in the UK, the Modern Slavery Act 2015 has been introduced. This is the second piece of anti-slavery legislation in 200 years. The Act gives law enforcement the tools to fight modern slavery, ensure perpetrators receive suitably severe punishments for these crimes, and enhances support and protection for victims. The UK government has a scheme of assessment and support for trafficked people, but currently only a small proportion are getting this support; approximately 20-25% of victims.

Those who present in healthcare settings may have little or no engagement with any other services. Health professionals therefore have an important role to play in identifying and caring for trafficked people and in referring them for further support and by being able to support them to report to the appropriate authorities.

As part of this, Public Health England is rolling out training to the PHE workforce on identifying and supporting victims of modern slavery, of which some of the lessons are here to further raise awareness.

The relevance to public health is multitude and includes long term multiple injuries, mental health, physical health, sexual trauma, sexually transmitted infections, late access to maternity care, unplanned pregnancies, disordered eating or poor nutrition, self-harm, dental pain, fatigue, post-traumatic stress disorder, psychiatric or psychological distress, back pain, stomach pain, skin problems, headaches, and dizzy spells.

As public health professionals and as citizens in our countries we all have a responsibility to look for the signs of modern slavery and to seek support for these vulnerable people. It is usually a combination of triggers, an inconsistent story and a pattern of symptoms that may cause you to suspect trafficking. Signs to look for in an individual include being accompanied by someone who is controlling, being withdrawn, submissive, vague, inconsistent, old and untreated injuries, no registration with a GP, nursery, or school, frequent movements of location, neglect, or poor English. Importantly, trafficked people may not self-identify as victims of modern slavery, can feel fear or shame in revealing their experiences or may be limited through language barriers. Support and advice is offered by the Salvation Army for adults and local safeguarding leads for children in the UK.

As public health professionals we have a responsibility to know the signs of modern slavery, and know where to go, and to share and inform our wider workforce and colleagues who work directly with the public.
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References

  1. Modern Slavery Act 2015. Accessed on 11/10/2017 http://www.legislation.gov.uk/ukpga/2015/30/contents/enacted
  2. Department of Health, 2015. Supporting victims of modern slavery through healthcare services. Accessed on 11/10/2017 https://www.gov.uk/government/news/supporting-victims-of-modern-slavery-through-healthcare-services
  3. Public Health England. 2017. Human trafficking: migrant health guide. Accessed on 11/10/2017 https://www.gov.uk/guidance/human-trafficking-migrant-health-guide
  4. department of Health. 2015. Identifying and supporting victims of modern slavery: guidance for health staff. Accessed on 11/10/2017 https://www.gov.uk/government/publications/identifying-and-supporting-victims-of-human-trafficking-guidance-for-health-staff/identifying-and-supporting-victims-of-modern-slavery-guidance-for-health-staff

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Karen Buckley
Public Health Specialty Registrar, UK

(As published in EuroNews #13)

Portuguese seasonal influenza 2017/2018

(U.S. Navy photo by Mass Communication Specialist Seaman Cole C. Pielop / Released)

Based on the analysis of influenza virus activity in previous seasons, every year WHO launches a recommendation on the strains to be included in the trivalent and quadrivalent influenza virus vaccine (in March for the Northern Hemisphere and September for the Southern Hemisphere). The need to update this vaccine is due to phenomena of antigenic derivation of the virus that, like the previous issue, obliges the annual study of the vaccine that will present greater coverage. Based on circulating types and subtypes, this year a viral strain A (H1N1)pdm09 identical to A/Michigan/45/2015 was recommended for the trivalent vaccine; a virus strain A (H3N2) identical to A/Hong Kong/4801/2014; and a viral strain B (Victoria strain) identical to B/Brisbane/60/2008.

The quadrivalent vaccine contains the three viruses described above, and in addition another strain of virus B/Phuket/3073/2013. (1) Evaluating sentinel sites until December 2017, there was a dominance of virus B circulating in relation to type A. Of the latter, the most prevalent subtype with about 2/3 of detected cases was A (H3N2), and the remaining third H1N1 subtype. In the same surveillance period last year, type A (H3N2) virus circulated almost exclusively, with high immunity expected; however, the presence of emerging sub-strains and variants that were not covered by this year vaccine could be possible the source of suboptimal coverage. Among B viruses, type B/Yamagata was almost exclusive with 85% and the remaining 15%, type B/Victoria. For the 4th consecutive year, the trivalent influenza vaccine does not correspond to the circulating B virus subtypes, since most of the prevalent B virus strains, Yamagata, are antigenic and genetically related to B/Phuket, which is only included in the quadrivalent vaccine. In this sense, and to increase vaccination coverage of the type B virus in the coming years, ECDC advises the use of the quadrivalent vaccine. (2) (3)

Another factor to be discussed that may be among the causes of lower vaccination coverage is due to the use of eggs in vaccines production. This substrate may interact with different groups of aminoacids present and consequently, alter proteins responsible for the antibody receptors, creating minor viral amendments that may change the effectiveness of the vaccine. (4)

Influenza virus vaccine is the most effective prophylactic measure against influenza severity. Thousands of vaccines are distributed in primary health care, completely free of charge to priority groups such as population over 65 years of age, chronic and immunosuppressed patients, pregnant women, health professionals and other caregivers. During flu season and up to the first week of 2018, approximately 478,291 influenza vaccines were administered in Portugal northern health region. Along with this measure, it is also recommended to conduct respiratory etiquette and hand hygiene, as well as the use of appropriate face masks for patients diagnosed or with symptoms suggestive of influenza. (3) (5) (6)

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References

  1. World Health Organization. Recommended composition of influenza virus vaccines for use in the 2017- 2018 northern hemisphere influenza season. http://www.who.int. [Online] Março 2, 2017. http://www.who.int/influenza/vaccines/virus/recommendations/201703_recommendation.pdf?ua=1..
  2. European Centre for Disease Prevention and Control. Risk assessment for seasonal influenza, EU/EEA. Estocolmo, Estocolmo, Suécia : s.n., Dezembro 20, 2017.
  3. Administração Regional de Saúde do Norte, Departamento de Saúde Pública. Gripe sazonal – vigilância epidemiológica – Semana 40 de 2017 a semana de 1 de 2018. ARS Norte. [Online] Outubro-Janeiro 2017-2018. www.arsnorte.min-saude.pt.
  4. Paules, Catharine I, et al. Chasing Seasonal Influenza — The Need for a Universal Influenza Vaccine. N Negl J Med. DOI: 10.1056/NEJMp1714916, 2018, Vols. 378:7-9.
  5. Centro Emergências de Saúde Pública. RONDA número 2. Lisboa : Direção Geral da Saúde, 2018.
  6. Direção Geral da Saúde. Vacinação contra a gripe – Época 2017/2018. Lisboa : s.n., Setembro 26, 2017. Orientação nº 018/2017 de 26/09/2017.

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Mariana Perez Duque
Public Health Resident
West Porto Public Health Unit, Portugal

(As published in EuroNews #13)

Make it happen: A very brief note on failure, success and strange August weather

 

“Make it happen” has been the official slogan for the city of Rotterdam since 2014. So, last August, I made it happen.

Each year, Rotterdam’s Erasmus Medical Centre (MC) and Netherlands Institute for Health Sciences (NIHES) organise the Erasmus Summer Programme (ESP) that “provides hundreds of students, researchers and health professionals with the opportunity to boost their scientific careers. It is a specialized event that offers three weeks of á la carte research training in quantitative medical and health research. The programme provides its participants with a broad range of dynamic courses, both introductory and advanced, and provides the flexibility to mix and match the courses to their own individual programme.” This introductory text does a nice job of explaining the programme and was taken from ESP’s website, which I highly recommend (https://erasmussummerprogramme.nl/), not only because you can find photos of me there.

In 2016, I applied for the Fellowship programme offered by ESP and failed spectacularly to be accepted. Then I consulted my favourite quote-guy, the late and always great F. Scott Fitzgerald for some top quality advice. “Never confuse a single defeat with a final defeat”, he said. Okay, I applied again in 2017 and made it happen this time round.

So why is this ESP thing so special? Amazing programme with a rich selection of courses and topics, able to fill each public health resident’s theoretical and methodological gaps. Smart, motivated and interesting colleagues from all around the world. Literally – Egypt, Colombia, Trinidad, Pakistan, Nigeria and Hong Kong, just to name a few. Top top top professors. Do names like John Ioannidis or Johan Mackenbach ring a bell? If not, ask Pedro Oh yeah – also an ultimately bike-friendly Rotterdam in August.

Any drawbacks? Well, the cost of the courses was an issue, to start with. Also, summer in Rotterdam is not really what I imagine when someone mentions August and weather in the same sentence.

The cost problem, I managed to solve by applying for the Fellowship programme. This took time and stubbornness. It worked out from the second attempt, as I already mentioned. The coldest_and_rainiest_August_of_my_life issue, I simply solved by embracing that it is normal to wear a fleece jacket mid-Summer and get soaking wet riding your bike on odd_date days. That’s how locals do it.

For additional stories (SUP’ing around the channels, free coffee machine, chance encounters with EuroNet’ters…) plus tips&tricks how to apply, feel free to give me a call or shoot me an email.

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Damir Ivankovic
Public Health Resident from and in Croatia

Why we need a Public Health professional journal in Slovenia and how we run it

A professional journal is a collection of articles which range from research articles, reports to practical articles applicable to a profession. What separates it from scientific journal is its emphasis on practice. Although professional journals can be a source of research, they primarily address practices with feasible implementation possibilities or practices with important implications to the current state of work.

Public Health is quite a specific field of work with many different stakeholders of diverse professional backgrounds. It is not unusual to see, for example, medical doctors, anthropologists, and economists working on the same public health topic, all employing different theoretical backgrounds, research methodologies, and professional networks to distribute their findings. Public Health is notorious for adopting theories and methods from other, more basic, sciences. Publishing practical and, also, research articles from researchers and practitioners from different fields, all working on health topics, should therefore widen the horizon of readers with interest in public health issues. That is more so the case in countries where (new) Public Health is not yet a universally acknowledged and accepted profession.

Such is the case of Slovenia. Empowered by the idea presented above, we started to work on a journal where professionals working on Public Health issues would be able to publish and read about work being done in their own country. And all of this in their mother tongue, thus maintaining and developing Slovenian Public Health terminology. Apart from research and practical articles, we decided to publish two specific types of articles. In an article type named Perspectives, professionals from different fields of science deconstruct a public health issue and write a short piece on how the issue is dealt within their scientific or professional domain. The main author of the article summarises their perspectives on the issue and reveals possible conflicts or synergies among different professional and scientific fields. The second type of an article is Methodological conversation where a researcher and a methodologist discuss various methodological issues that often arise in Public Health work. The article is written in the form of a dialogue with the purpose of making often confusing statistical and methodological discussions accessible to a wider audience. In the last issue of the journal the topic of Perspectives is alcohol use disorder and Methodological conversation is on the topic of developing a questionnaire for research purposes.

The first meeting of the editorial board of our new journal was held in November 2016. Our first issue was published in October 2017 and the second one in March 2018. As an editor-in-chief I hope our effort will advance the state of the art in Public Health in Slovenia and consequently in the wider European area.

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Matej Vinko
National Institute of Public Health, Slovenia
matej.vinko@nijz.si

As published in EuroNews 

Telemedicine and virtual healthcare in Ireland

While we wait for the new issue of the Newsletter in the making, we bring you an article from the last Euronet Newsletter, about “Telemedicine and virtual healthcare in Ireland”:

Virtual healthcare and telemedicine have burgeoned in Ireland in recent years, with many private companies offering online services including video General Practitioner  (GP) consultations, prescriptions for medications and home testing kits for sexually transmitted infections (STIs). As an example, there are now at least seven different online companies offering STIs testing to individuals in Ireland without the need to see a doctor or health worker. Some of these companies are based in Ireland, others are based in other countries such as the UK.

Health insurance companies have come on board and many now have contracts with online GP consultation services offering video consultations with one of these companies as part of their health insurance package.

So what are the implications for health and health care in Ireland from the advent of such companies? Certainly there are potential benefits to using online platforms in health and health care.

They have the potential to improve access to patients who live in rural or remote areas.  In the area of STIs testing they may increase testing and treatment of STIs particularly in young people. Telemedicine may increase the number of patients who can be seen and treated during a given period of time, important at a time when many GPs in Ireland are emigrating to other countries.

Virtual platforms have been used to improve communication and delivery of healthcare between services. In Ireland, a pilot programme between family doctors and hospital specialists involving an online forum for discussion and advice on cases has been used to reduce admissions to hospital.

However, this new and developing field raises many questions for health and healthcare. Because these are private companies, without an established relationship with patients, the loss of the central pillars of primary care that include continuity of care, the management of multi-morbidities, the doctor-patient relationship and the delivery of a holistic model of care are concerns. Testing for STIs through this system may also affect notification, contact tracing and sexual health promotion. Other questions arise; for example will rates of antibiotic prescribing increase, given that physical examination will not be possible in a video consultation for a respiratory tract infection?

There are many questions to be answered as to how the advent of such systems of delivering healthcare can affect health and healthcare in Ireland, both good and bad. It’s an opportunity for Public Health in Ireland to engage with the issue as it is likely that telemedicine and virtual healthcare will continue to expand both in Ireland and internationally.

Chantal Migone

EuroNet MRPH Ireland