Global Public Health

A look at SPH collaborations in India, Africa, and Saudi Arabia

BEST TIME FOR TREATMENT
Antiretroviral treatment for people with HIV is costly, not free of toxicities, and lifelong once initiated. When to best start this therapy has been debated for years; finding an answer is critically important. To that end, the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT), led by SPH biostatistics professor Jim Neaton, is conducting a definitive randomized trial. Nearly 4,000 participants will eventually be enrolled at more than 200 sites in 33 countries, including South Africa, Uganda, Nigeria, Mali, and Morocco. In addition to helping researchers discover optimal timing for treatment, many partici­ pants in this global study have enrolled in sub­-studies specifically investigating how HIV and HIV treatments affect neuro-cognitive function, bone health, arterial elasticity, and lung function.

SUPPORT, WHERE YOU LIVE
A major challenge to worldwide efforts in scaling up HIV treatment is that patients often stop going to clinics for care. Many of those who discontinue their clinic visits either die at home or return to the clinic only after their health has significantly deteriorated. In rural southern Ethiopia, SPH epidemiology professor Alan Lifson is conducting a project to improve treatment retention by working with HIV ­infected individuals where they live. The project hired and trained community health workers from the same villages or neighborhoods as their clients. They provide education, counseling, social support, referrals, and linkage to the HIV clinic. The project, which was implemented over a year ago, is currently assessing the impact of this community­ based intervention on client retention rates, knowledge, attitudes, and health status.

TURNING THE TIDE ON MALARIA
Every year, 3.3 billion people—half of the world’s population—are at risk of contracting malaria. The disease affects poor communities most, decreasing the GNP of countries with a high malaria burden by more than 1 percent. But prevention and treatment efforts are paying off. In the past 12 years, malaria mortality rates have fallen by 25 percent globally and 33 percent in Africa. SPH doctoral student John Amuasi is leading an evaluation of a malaria treatment program in his home country Ghana. Funded by the public-­private financing group, the Global Fund, the pilot program subsidizes costly anti­-malaria drugs with the aim of improving accessibility, availability, and affordability. Not only does early treatment save lives and prevent transmission, it reduces the use of less effective treatments to which malaria parasites are becoming increasingly resistant.

GOOD HEALTH CARE EVERYWHERE
Saudi Arabia faces many of the same health care issues we do in the United States, like a growing private health insurance market and the need for efficient, cost­-effective integrated delivery systems. The SPH­ sponsored Executive Master of Healthcare Administration (MHA) program at the King Fahad Medical City in Riyadh will help senior physicians and administrative leaders meet those challenges. The program follows SPH curriculum and allows students to earn a University of Minnesota MHA degree in 25 months. Directed by health policy and management professor Dan Zismer and administrative program director Tom Gilliam, the Saudi Arabia partnership may be the first of many to come to help produce a stronger global medical community.

BANKING SAFE BLOOD
Having a safe, adequate blood supply is something few developing countries have been able to achieve. Afghanistan was one of these countries until 2010, when the Ministry of Public Health chose SPH prof­essor Bill Riley, administrator Terri Konstenius, and the Medical School’s Jeffrey McCullough to assist it in building a national blood supply, including developing screening and collection procedures and systems for recruiting donors. Later that year, this public health and medicine interdisciplinary team began a similar project in Tanzania when the Centers for Disease Control and Prevention selected the University of Minnesota to help the Tanzania/ Zanzibar National Blood Transfusion Service develop a comprehensive donor recruitment program with a goal to double the blood supply in five years.

USING THE INTERNET TO STOP THE SPREAD OF HIV
No one knows yet how well internet-­based education and intervention techniques could lower HIV transmission among high­-risk men in India—methods successful in the United States have never been tried there before. Now a University of Minnesota team has joined a California and India­ based team to collaboratively research that potential in Mumbai. Called ISH Konnect and led by SPH epidemiology research associate Michael Wilkerson, the study will investigate basic issues like internet availability, how the internet is used to connect male sex partners, and whether conducting online focus groups is feasible and culturally acceptable. An online intervention campaign in India has the potential to reach thousands of men, reduce risky beliefs and behaviors, and prevent the spread of HIV.

TOO MUCH FLUORIDE
Fluoride occurs naturally in well water, but when the water table is low, the mineral becomes concentrated. Drinking this water may lead to fluorosis, which can cause teeth enamel to erode and produce pain and damage in bones and joints. As fluorosis becomes more common around Kolar, India, SPH faculty, the Sri Devaraja Urs Medical College (SDUMC), and the Indian Institute of Science at Bangalore are collab­orating to research the issue and design preventive interventions. In the first phase of this effort, SDUMC will conduct a study to estimate fluorosis prevalence in the population. The Indian Institute of Science, because it has the necessary infrastructure, will test local water and soil for fluoride.

GOLD FIELD FALLOUT?
Phased out as a major commercial venture in 2001, the centuries­-old practice of mining gold in India’s Kolar District is suspected of leaving a legacy of occupational diseases and environmental health hazards. Despite possible risks, miners and their kin continue to strive for a revival of gold mining, their only source of employment. An SPH team including, environmental health professors Jeff Mandel, Gurumurthy Ramachandran, and Bill Toscano, has joined with Sri Devaraja Urs Medical College (SDUMC) in Kolar to investigate if mining is truly to blame for many of the region’s health issues—like lung and skin diseases, asthma, and tuberculosis—and to provide solid public health data for the people of Kolar. The long­ term goal of the SPH/SDUMC collaboration is to establish an occupational health program at the college, which has already begun biweekly health fairs where public health information is disseminated and faculty conduct health screenings.

TEACHERS AS GAME-CHANGERS
Bihar is one of India’s poorer states and has extra­ ordinarily high rates of tobacco use, even among adolescents. Epidemiology professor Harry Lando is involved with a study at government schools that focuses on tobacco abstinence among teachers. If the teachers can stop using tobacco, the hope is that they will become role models for students and others in the community, where they tend to be highly respected. After four years of the five­-year project, researchers are surprised by the high numbers of teachers who have quit using tobacco. In another part of the world, Lando is working on an NIH-­funded study to discern the capacity of Tunisia and other low­ resource countries in the region to implement Article 14 of the WHO Framework Convention on Tobacco Control, which calls for measures to reduce tobacco dependence and increase cessation.

CLEANER BURNING STOVES
Burning solid fuels in household stoves for cooking and heating harms health and contributes to carbon emissions and climate change. Environmental health professor Gurumurthy Ramachandran, University of Minnesota civil engineering faculty, and University of British Columbia researchers comprise a team that has completed phase one of a neighborhood­-scale stove replacement program in Karnataka, India. Half the households received cleaner burning stoves after the team collected data related to cardiovascular health, air pollution, and livelihood. The next phase will include collecting post-­intervention data. Team members expect the new stoves will reduce indoor air pollution and improve cardiovascular health.
At the end of the study, all participating households will receive a new stove.