AA&D report highlights pioneering efforts, imagines path toward comprehensive global care delivery for tuberculosis and diabetes


With the enormous burden across the world of both infectious diseases and non-communicable diseases (NCDs), health delivery programs need to be flexible but purposeful to address the multiple health challenges faced by individuals and communities. Despite much rhetoric about health systems strengthening and integration of health care services from national, international, and local health delivery programs, the detailed considerations in terms of policy and practice for even one area of this inquiry are many and complex.

A newly published report titled “Toward comprehensive global health care delivery: Addressing the double threat of tuberculosis and diabetes” offers examples and supporting data of settings where comprehensive programs are providing, or could provide, successful solutions to combatting multiple diseases in a way that is focused on patient care, efficiency, and strategic harmonization. This report focuses on diabetes, probably the largest public health challenge of the next several decades, and how it intersects with tuberculosis, the leading infectious killer of adults in the world.

With support from the Lilly Foundation, AA&D led a team of health delivery experts, academic faculty, and graduate researchers from Duke University Sanford School of Public Policy, University of North Carolina Eshelman School of Pharmacy, Partners In Health Russia, Harvard T.H. Chan School of Public Health, and Harvard Medical School Department of Global Health & Social Medicine in the writing and preparation of this report.

The authors focused on TB and diabetes, two disease areas in the top ten killers globally, to illustrate how even in a single overlapping and crucial area of global health care, the need for service integration, community-based solutions, inter-departmental and interdisciplinary cooperation, and quality improvement are pervasive and interconnected. They argue that a comprehensive platform is urgently needed to address global health challenges in coordinated fashion, rather than in administrative, academic, and institutional isolation.

“This deadly synergy manifests in programs, health systems, and patients’ bodies in many dangerous and challenging ways,” noted Tom Nicholson, lead author of the analysis.  “This report considers how a coordinated, patient-centered approach might function practically in several high burden countries in the immediate future. Tuberculosis and diabetes in these settings are often considered either too difficult or too expensive to deal with on a population level by health care authorities, but a glance at the near-term implications of inaction in institutional, financial, and mostly importantly human terms, shows that inaction is simply not an option.”

The hope is that reports such as this help strengthen responses in each of the countries profiled with high burdens of both diseases—specifically Peru, Russia, South Africa, and India. For example, contributing authors to the report attended the first national tuberculosis-diabetes conference “International Symposium on TB-DM comorbidity: challenges and opportunities” in Lima, Peru, in May. The event was organized by the Instituto de Medicina Tropical Alexander von Humboldt & CRONICAS from Universidad Peruana Cayetano Heredia, TANDEM,  and the London School of Hygiene and Tropical Medicine, with the support from the World Diabetes Foundation. AA&D Specialist and Contributing author Dr. Kei Alegria-Flores noted that “the Symposium highlighted academic and practical presentations on how TB and DM intersect across institutional lines; it was a long-awaited platform to start moving the needle on meaningful health systems strengthening across diseases in Peru.”

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Cuban health leaders discuss care delivery strategy


Over a two-day workshop held April 26-27 at Duke Univeristy, senior level health officials from Cuba met with Duke Center for International Development (DCID) faculty, staff and students, along with representatives from Advance Access & Delivery (AA&D) – a nonprofit public health NGO headquartered in Durham, the Indiana Recovery Alliance – a harm reduction organization based in southern Indiana, UNC-Chapel Hill and Harvard University to discuss potential future work and collaboration related to health delivery and service provision in different settings.

The discussions focused on strengthening health care delivery for vulnerable and marginalized populations through the lens of the tuberculosis (TB), opioid epidemics, and social services for immigrant communities. Guests and speakers included Dr. Lourdes Suarez-Alvarez, head of the Cuban National TB Program; Dr. Raul Diaz-Rodriguez, head of Cuba’s National Reference Laboratory of TB; Dr. Jorge Pérez, adviser to the Cuban Ministry of Health and former head of Pedro Kourí Tropical Medicine Institute (IPK); Tom Nicholson MIDP'14, AA&D executive director and associate in research at DCID; Dr. Salmaan Keshavjee, director of the Harvard Medical School Center for Global Health Delivery-Dubai and vice president and senior clinical lead at AA&D; Phyllis Pomerantz, professor of the practice in the Sanford School of Public Policy; Jon Abels, DCID executive director; and Christopher Abert, founder of the Indiana Recovery Alliance.

“This is an opportunity to learn from the global south, where most innovations are coming from,” said Pomerantz, who kicked off the discussions. “There are countries where proposed solutions have been tried but were not successful. In Cuba, we see there has been success and other countries can learn from their solutions.”

Urgent public health challenges
This event highlighted two touchstone issues that underline the difficult work of social and health services reaching marginalized and vulnerable people. Every day, roughly 4,900 people die from tuberculosis (TB), or a total of 1.8 million deaths each year. In 2015, there were an estimated 10.4 million new TB cases (incidence). Though the disease has been nearly eliminated in the United States and other western countries, TB is now the leading infectious killer of adults worldwide.

Meanwhile, in the United States, opioid use and overdose is fueling the worst drug epidemic in the country’s history. Opioid overdose is now the leading cause of accidental deaths in the U.S., with more than 33,000 people losing their lives in 2015 alone.

These drivers of early death and disease disproportionately affect vulnerable and marginalized people across the world. Both issues are fraught with stigma and often make it more difficult for patients to seek appropriate care, and both face public policy headwinds that can undercut elimination efforts.

Cuba’s success in driving down TB
Cuba has some of the lowest TB rates — both for incidence and mortality — among any country in the world. According to Cuba’s Ministry of Health, the country had a TB incidence rate of 6 per 100,000 people, and a mortality rate of .4 per 100,000 people in 2016. As a comparison, the World Health Organization (WHO) reported that U.S. rates in 2015 were 3.2 and .18 respectively, and global rates were 142 and 19 respectively. 

Members of the Cuban delegation attributed its success to the country’s comprehensive epidemiological control strategy for diagnosing, treating and preventing TB. Additionally, they pointed to Cuba’s commitment to providing holistic, community-based care where doctors and nurses are closely involved in the lives of patients as a key driver for improving TB and general health outcomes. These practices make it a strong example that others could follow in the fight against this deadly infectious disease, attendees agreed. The case to emulate Cuba’s strategies is made stronger by the fact that the small island nation has achieved this despite periods of intense resource scarcity, particularly during the 1990s when Soviet aid was discontinued and TB rates tripled.

“The Cuban case shows that a community based health system that focuses on prevention and social support is particularly well positioned to end TB as a public health menace, even in challenging conditions,” said Nicholson. “Certainly, more money will need to be spent around the world to achieve this, but by using this approach the benefits will clearly extend far beyond any single disease.”

Eliminating TB through a comprehensive strategy
Many participants from both Harvard, UNC, AA&D, and DCID are affiliated with the  Zero TB Initiative and Zero TB Cities Project, which were founded to help create ‘islands of elimination’ of TB through a comprehensive epidemic control strategy known as the Search, Treat, Prevent Approach. Through the initiative, cities, regions, or even islands fight TB by actively searching for people with the disease, providing preventive therapy to people infected with TB and those belonging to high-risk groups, controlling TB transmission by routinely using the right tools for early and accurate diagnosis, providing immediate and appropriate therapy, and ensuring supportive programs are in place to help keep patients on therapy.

"For a long time, we in the public health community have ignored tried and tested epidemic control strategies, largely because of cost,” said Keshavjee. “Cuba is proving what can be achieved when there is real commitment and follow through in using a comprehensive strategy for controlling and eliminating TB.”

The initiative works to help communities move toward elimination in their own way and support is provided as needed through founding partner organizations, including AA&D, Harvard Medical School Center for Global Health Delivery-Dubai, Interactive Research & Developments and The Stop TB Partnership. It works to assist programs and encourage exchange between cities like Karachi, Pakistan; Chennai, India; Lima, Peru; Kisumu, Kenya; and others.

Delivering high-quality care
Throughout the two days, participants discussed strategies for improving access to high quality health care and medicines, particularly for economically and socially marginalized groups. Both the Cuban delegation and U.S.-based members agreed that future collaboration on TB and other diseases would be mutually beneficial and committed to further engagement.

“Events like this help to strengthen new platforms for south-south collaboration, while also informing wealthier health systems facing huge challenges of their own,” said Nicholson. “This is a very exciting first step."


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