Public Health in the 21st Century

At the beginning of the 21st century, key public health issues and challenges have taken center stage on the global scene.  Ranging from arsenic in drinking water to asthma among children and adults; from the re-emergence of cholera, to increasing rates of various forms of cancer; from HIV and AIDS to MDR-TB, malaria; from the crises faced by displaced or refugee populations to the new challenges that have emerged for reproductive health and rights; from the experience of public health emergencies as the result of disasters such as tsunamis, and catastrophic storms to the growing specter of potential global pandemics such as those linked to H5N1.  The expansion of serious public health problems, increasingly taking shape on a global scale, has been one of the defining features of recent history.

Like most aspects of contemporary life, this range of key public health problems has been increasingly impacted by processes associated with globalization.  The issues that confront us have been, and are, being shaped by evolving processes such as the growth of inequalities between the rich and the poor, the globalization of trade and commerce, new patterns of travel and migration, as well as a significant reduction in available resources for the development and sustainability of public health infrastructures.

The social, cultural, economic and political transformations associated with globalization have increasingly intersected with the growing range of environmental threats produced by industrialization, epidemics of newly-emerging infectious diseases, and the rapid increase of chronic diseases linked to changing lifestyles.

The new public health challenges of the 21st century have taken place within the context of a rapidly changing political and institutional landscape. In recent decades the field that was initially described as international health involving sovereign states has increasingly been re-conceptualized as global health within the global system. 

This change represents far more than a simple shift in language.  It stems from a fundamental transformation in the nature of health threats and in the kinds of solutions that must be posed to them.  It recognizes that many of the most serious health threats facing the world community today reach beyond the sovereign borders of nation-states and require the attention not only of governments but also of a range of non-state institutions and actors.

The Routledge International Handbook on Global Public Health, edited by Richard Parker and Marni Sommer, addresses both the emerging issues and conceptualizations of the notion of global health, expanding upon and highlighting critical priorities in this rapidly evolving field.  This comprehensive handbook is intended to provide an overview for students, practitioners, researchers, and policy makers working in or concerned with public health around the globe.

The book includes ten sections, ranging from Structural Inequalities and Global Public Health, to Ecological Transformation and Environmental Health in the Global System, Global Access to Essential Medicines, Global Mental Health, and Health Systems, Health Capacity and the Politics of Global Health, and brings together leading authors from across the world to reflect on past, present, and future approaches to understanding and promoting global public health. 

Maintaining an Audacious Hope

I’m an undergraduate student at Columbia, who completed the Fundamentals of Global Health class offered by faculty at the Mailman School. This confirmed my interest in the field of global health and I was therefore delighted when, last semester, I had the opportunity to study abroad in Kenya.

The program, which focused on health and development, taught us a lot about East African culture and current events, and how different health and development organizations operate within that context.

One issue that struck me regularly through my time in Kenya was the disconnect between government and the day-to-day realities faced by many people. For example, Kibera, the largest slum in East Africa, is in Nairobi, the capital. In fact, Kibera may be the largest slum in Sub-Saharan Africa, but slum populations tend to be hard to count. Estimates for Kibera range from 200,000 to 500,000 people. One group estimated 1,000,000. However, the Kenyan government does not recognize Kibera as a human settlement and marks it as forest on official maps.

This leaves hundreds of thousands of people without rubbish collection, electricity, or access to clean water that the government is supposed to provide. The fact that three Kenyan officials summoned to the International Criminal Court in The Hague to face charges of crimes against humanity during the widespread violence following the last elections continued to hold positions as government ministers during my stay also jarred with me.

That being said, it was a fascinating time to be in Kenya, because things are seemingly beginning to change. A new Constitution was passed last year, paving the way for a highly functional and beneficial government when it is fully implemented. The uprisings in the Arab world are encouraging Kenyans to believe that that they too have the power to hold their government accountable, and people are beginning to find their voice and call for an end to corruption. Kenyans are also beginning to unify as a nation, instead of each identifying first as the tribe of which they are ethnically and culturally a part. Everyone seems tired of the problems and, aware of the underlying causes, are ready to work to make things better.

Change comes slowly however. Many services, especially in the health sector, remain significantly supported by bilateral funding or foreign NGOs. Though there is talk about sustainability and a time when programs will be entirely run and funded by Kenyans, most people suggested to our study abroad group that this would not be anytime soon. Problems of governance, a lack of natural resources, limited infrastructure, and high disease burden are obstacles that are not going to be easily or quickly overcome.

Buses in Kenya are often decorated, and many of them have signs on the front or back. The bus shown here was one of my favorites. Using the name of the book by then-Senator Obama, this sign is indicative of the phenomenon of Kenyan identification with our president. It is also indicative of the hope that so many Kenyans have in the face of their continuing challenges.

- Devon Welsh
Student, Columbia University

Providing pregnant women access to emergency care in northern Nigeria

Drivers demonstrating how they transport a woman
(with a scarf) in labor into their car.

Nigerian women have a 1 in 23 lifetime risk of maternal death, and the country's maternal mortality ratio is the 9th highest in the world. With roughly 50% of Nigerians living in rural areas, cost and lack of physical access are two of the major barriers to Nigerian women having access to maternal health care.

The northern region is particularly burdened. As it is more rural, with lower education rates and certain cultural practices, women in the north tend to have less access antenatal care and are less likely to give birth in health facilities than in southern regions.

A user of the Emergency Transport
System (ETS)

Loosing a mother during childbirth is a reality for many in northern Nigeria, and it doesn't just effect individual families. Maternal deaths deeply impact communities who often feel (and, in reality, are) helpless to stop them. I worked for two months with the Partnership for Reviving Routine Immunizations in Northern Nigeria – Maternal, Child and Newborn Health (PRRINN-MNCH), based in northern Nigeria, and saw firsthand how they are working with local communities to break down some of these barriers.

In the communities in Zamfara state where I was living, increasing access to maternal health is incredibly complex. Not only does it require access to cars and passable roads, but the cars must work and have fuel, families must know where to find the drivers if the need them (which may require a phone), communities must be educated on when you need to go to the health facility and why, and the health facilities must be staffed, with the drugs and tools necessary to deliver a child.

And these are just a handful of the barriers I saw.

Through a variety of access programs, PRRINN-MNCH is working to break down some of these barriers. Two years ago, it launched the Emergency Transport System (ETS) program in the 4 states where it works. Using commercial drivers who volunteer their services, ETS provides pregnant women with emergency transportation to a health facility when they need it. Many women who have used ETS thus far, if not most, were suffering from excessive bleeding or were already unconscious when the ETS driver was called.

While their children did not usually survive, without ETS these women would not have either.
Calling a commercial driver would have been out of financial reach. Commercial drivers often charge extra to transport women in emergency situations. Combined with the hospital fees, these costs can make a family choose between food and basic survival and going to the hospital. In describing what he liked about the program, one community leader stated, "We are helping ourselves."

Despite these successes, a big question remains: Without financial incentives for drivers, health facility staff and community volunteers, is ETS sustainable?

Ambulances do exist, but a functioning ambulance system in Zamfara is far off. It's clear that finding an alternative is imperative to improving maternal health outcomes, and ETS has been the best alternative in the locations where it operates. Yet, ETS drivers often use their own money for fuel and loose commercial customers when transporting a woman. Their work is inspiring and admirable and they are undeniably proud to be volunteers and ETS drivers, helping their communities. Speaking with them, most of them said they do not want anything in return for the services they provide. They are helping their communities and believe they will be thanked in the afterlife for their work.

Focus group of women who used ETS

However, even with all of this they still need to provide for their families. How long will it be until the financial burden on them is too much? At what point will mothers be left to die?


PRRINN-MNCH isn't willing to wait to find out. In a few months, a series of incentives will be piloted for ETS drivers, health facility staff and community volunteers. The goal is to understand whether they work, amidst fear that providing monetary incentives, however small, will alter the altruistic spirit of the program. If drivers are seen as gaining personally from helping women, will they lose the sense of pride they have in helping the community? If so, will the program become less effective? These answers will help improve the ETS program in northern Nigeria and provide a model to improve global maternal health outcomes.

- Laura Baringer, MPH/MPA '12, Population and Family Health

August 31, 2011

The Impact of Prenatal Exposure to Pollutants: The China Initiative

Taiyaun City

The Columbia Center for Children’s Environmental Health (CCCEH) launched its first China study in 2001. The study was conducted in Tongliang, China, where a coal-fired power plant located in the center of town was the major source of ambient air pollution. In 2004, local officials shut down the power plant, creating a unique opportunity to study the effects of energy-related air pollution on children’s health before and after the plant’s closure.

Researchers specifically documented the impact of in utero exposure to polycyclic aromatic hydrocarbon (PAHs), a carcinogenic pollutant emitted from fossil fuel burning. The study tracked two cohorts of pregnant women and their children: the first was enrolled while the plant was still operational, and the second was enrolled after government authorities shut the facility down.

The study found that prenatal exposures to coal-related air pollutants adversely affected children’s health and neurodevelopment. Analyses showed that children born in 2002 when the power plant was still operating had higher levels of exposure to combustion-related PAH (measured by PAH-DNA adducts in cord blood) compared to the later cohort. Children with higher levels of prenatal exposure to PAHs had reduced head circumference at birth and a lower growth rate in childhood.

It was also shown that children who had higher levels of prenatal exposure to PAHs scored lower on the Gesell Scales of Child Development at age 2 and had more developmental delays than children who were less exposed in utero. Children born in 2005 by contrast, just a year after the plant was closed, had significantly lower levels of PAH-DNA adducts in cord blood, and did not show significant associations between PAHs and growth and developmental effects.

Tongliang power plant.

Building on this strong foundation in Tongliang, CCCEH launched a new serial prospective cohort study in Taiyuan and Changzhi, China. Taiyuan is the capital of the coal-rich Shanxi Province and is one of the most polluted areas of the country. This unfortunate distinction has been recognized by the Chinese government and the region is beginning to implement strong new policy measures to reduce air pollution over time.

Changzhi, also located in Shanxi Province, was selected for its lower pollution levels and thus serves as the concurrent control for the study. CCCEH’s goal is to document the direct benefits of these government policies in Taiyuan in terms of air quality, biomarkers of exposure in cord blood, and health and developmental outcomes in the children. These study findings, in conjunction with the findings from the Mothers and Newborn Studies in Tongliang, Krakow and New York City, have implications for future energy and public health policies in China and other coal-dependent nations.


Deliang Tang, MD, DrPH
Department of Environmental Health Sciences
Mailman School of Public Health

Other Investigators on the China Initiative: Frederica Perera, DrPH, and Julie Herbstman, PhD.

*Columbia University’s Mailman School of Public Health is pleased to announce a new practicum opportunity for MPH students at Fudan University’s School of Public Health (FUSPH) in Shanghai. FUSPH is offering a unique 3-6 month internship for students interested in international research. Two students will be selected to participate each year. The program is headed by Dr. Zhijun Zhou, Vice Dean of FUSPH.

Community Buy-in for Sustainable Community Development in Burma Peter Muennig, MD, MPH

Dr. Peter Muennig in Burma.

Many directors of non-governmental organizations feel that they will best serve a target population by maximizing their fiscal resources. At first, we thought this to be true, too. But we learned that, in some cases, this approach not only comes at a high cost, it may ultimately be less effective than a “ground-up” approach—one in which members of the community actively contribute to the project, even if they appear to take long and winding roads.

Fortunately, while we had to learn this hard lesson, we did not have to learn it the hard way. The project directors we worked with began as outsiders, too, but they had worked long enough with the community we served that they were completely trusted. They taught us that paying members of the community to do the work would likely lead to dependence and little participation in the services that we would ultimately create. Every time we wanted to buy bricks, the managers implored us to let the members of the community find a creative solution to putting in a latrine. And, lo and behold, they built the latrine with only the cost of expensive porcelain borne by our organization. Deciding where the latrines would be located in their household cluster, what they would look like, and who would maintain them were integral to the process. The latrines also made use of construction skills they had already learned as day laborers.

Thus, from its inception, our organization, the Burmese Refugee Project, was built around the idea that social capital, not fiscal capital, was what ultimately helped our project to succeed. One goal of our organization is to engage members of the community so that they can take ownership of their health. In a severely under-resourced community, this usually involves the basics: building latrines to prevent soil and water contamination, providing vaccines to reduce the transmission of vaccine-preventable illness, assessing and intervening on nutrition, providing health education, and providing basic literacy and numeracy skills. Because most of these services were labor- rather than resource-intensive, we were able to provide these services to a community of 180 people at a cost of $3,000 per year.

Of course, the central consideration one has in starting a project surrounds the local conditions and the people the project serves. The Shan are one of the largest ethnic groups in Burma (also called Myanmar by the ruling junta). They have been engaged in a decades-long armed conflict with Burma’s military dictatorship, which has ruled the country since 1962. As a result of this conflict, over 1 million Shan Burmese civilians have been internally displaced from their homes and villages, with as many as half a million migrating into neighboring Thailand. They confront a wide range of psychosocial problems and work long hours, but they are also very concerned about their health and the health of their children. Because of their forced migration and precarious positions in Thailand, the refugees were a lot more comfortable with informal, negotiated initiatives than institutionalized, “flashy” programs that they feared might attract unwanted attention.

But all this organizing takes a lot of work. The project managers had to spend a lot of time with the community members, going hut-to-hut to communicate the importance of latrines, vaccinations, clean water, and, most importantly, of the act of organizing the community itself. This relationship-building proved essential when the BRP began to work with community members on more sensitive issues, such as substance abuse, domestic violence, chronic stress and trauma, reproductive health, and gambling.

International development is littered with failed, expensive capital projects that could have been more successful with community buy-in. Certainly, organization will not work in every village or in every cultural context. But it is critical; if we had been unsuccessful at engaging the community, we doubt that we would have been successful at implementing a public health program—at any cost.

For more information, please click Burmese Refugee Project.

Dr. Muennig is an Assistant Professor of Health Policy & Management at Columbia University's Mailman School of Public Health

The Good News and the Bad News: Decreases in Maternal Deaths, But Not for Everyone

Mother and child in Ethiopia.

Over the past year, UNFPA and The Lancet released findings that offer a clear view of the maternal health interventions that save lives. This evidence affirms the efficacy of the most widely-used systems- and treatment-level interventions in the field. It clearly demonstrates good quality, comprehensive reproductive health services, including access to emergency obstetric care, family planning and antiretroviral (ARV) therapy, is key to reducing maternal mortality. And this complement of care must be delivered in strong, fully functional health systems.

Global reductions in maternal deaths are finally appearing at the population level, for the first time during my career. This holiday season, unlike any before, we can reflect on these accomplishments with renewed pride based on hard evidence, proof that our work is creating real global change.

However, the vast gains made in some countries, while great cause for optimism, must not be allowed to mask the much slower progress—even reversals—in others, most especially those experiencing conflict and crisis. Fragile states do not have the functional health systems and the necessary trained clinicians, medicines and equipment to reduce maternal death.

Now that we have the evidence to confirm that our interventions save lives, we must continue to apply this knowledge to those most in need. Women still become pregnant and experience life-threatening complications during war and in the aftermath of floods and earthquakes. They want to prevent pregnancy in these circumstances; they still want to space or limit their births. The proven interventions to prevent maternal death must be implemented or strengthened in countries experiencing or emerging from humanitarian emergencies.

Knowing what works isn’t enough. We’ll need the collective will and financial commitment to provide reproductive health care in crisis-affected countries that, to date, have been sorely lacking.

Women have a fundamental right to good quality care and a health system that can consistently provide it, no matter the crisis going on around them. When these are prioritized, we can expect an even more dramatic decline in women’s needless suffering and death.

Therese McGinn, DrPH, Director, The Reproductive Health Access, Information, and Services in Emergencies (RAISE) Initiative. The RAISE Initiative works to catalyze change in how reproductive health is addressed by all sectors involved in emergency response, from field services to advocacy, from local aid providers to global relief movements.

It Takes a Community to Treat an Epidemic

Women and their children wait to receive maternal child health services at a health center in Tanzania. Photography by Nathan Golon.

It was a long trip from Dar es Salaam, due north then west, first on paved roads and then on dusty country paths that meandered through the fields. Few fields were planted with corn or bananas while large tracts of land were open fields with little evidence of agriculture. Clusters of thatched huts passed by quickly as we made our way to the health center. In small villages along the way, women assiduously swept the earth in front of their households as children ran around pushing a ball or playing with small sticks. Men, some old, some young, sat around in circles on low stools or tree trunks in animated conversations.

It was late in the afternoon when we finally arrived at the health center. A jubilant clinical officer came out to meet us followed by two dozen peer educators, all singing and dancing in a heartfelt welcome. I was proudly informed that this small health center had already engaged close to 300 persons with HIV in care and had close to 200 already started on HIV medicines. These are just a few of the millions who have benefited from the HIV scale-up, a historic public health achievement. While only about 100,000 individuals with HIV in low and middle income countries were able to access treatment in 2002, by the end of 2009 this number has skyrocketed to close to 4 million. Most remarkably, sub Saharan Africa is the region that has had the most dramatic increase.

How was this achieved in a region plagued with weak health systems and a multitude of health crises? Shortage of skilled health care workers, lack of continuity model of healthcare for a chronic condition like HIV, dilapidated facilities, inadequate laboratories, entrenched stigma, and poverty are just some of the challenges that faced the HIV response. As I walked around the health center, I kept pondering the question, “how was this accomplished and what does it teach us?” I visited the cramped room where the clinical officer saw all her patients, where the 44 charts of the ones she had seen that day lay on the rickety table. I opened one chart and saw the neatly filled rows of information. I followed her to the pharmacy, a tiny room where the precious medications are kept under lock and key, then passed by the laboratory where a technician proudly showed me his new equipment and his impeccably organized registers.

Dr. Wafaa El-Sadr (second from left) with ICAP Tanzania staff.

The answer to my question dawned on me when I finally sat down to talk with the staff and the peer educators, themselves living with HIV. The answer lay in the fact that they were one, one team that worked together hand in hand. No hierarchy was evident, no sense of the provider as the source of wisdom and the patient as the passive recipient. The staff described the needs of the community, the gaps in services and the innovations they had come up with to cope with impediments. The peer educators astutely asked about nutrition and poverty. They shared their need for new bicycles to be able to make home visits to check on the patients assigned to them. All were passionate about their community, all were adamant on achieving high quality of care, all were cognizant of their individual value as well as their collective power.

Many years into the future, when the history of the HIV response is written, some will credit the billions of dollars of resources for the achievements. Yet, a most important factor might be overlooked. The secret of this remarkable success may lie in the partnership that I witnessed between passionate and committed staff members with knowledgeable and empowered patients.

Wafaa El-Sadr, MD, MPH, is director of ICAP at Columbia University and director of the Center for Infectious Disease Epidemiologic Research (CIDER) at Columbia University’s Mailman School of Public Health. Dr. El-Sadr also is professor of clinical medicine and epidemiology at Columbia University.