Title:Health on the Move

Understanding people—and disease—in transit

One hundred years ago, the world faced a relentless and devastating foe. It marched across the globe, claiming the lives of 50 to 100 million people.

It was the 1918 Spanish Influenza—one of the deadliest and costliest pandemics in human history.

Today, the flu still tops a growing list of global pandemic threats—infectious diseases that wreak havoc on people, health systems, and economies. The number of known emerging infectious disease outbreaks has increased four-fold in the past 60 years, and recent examples of new or resurgent diseases abound: SARS in 2003; H5N1 in 2007; H1N1 in 2009; MERS in 2012; Ebola in West Africa in 2014; Zika in 2015; and the re-emergence of yellow fever in 2016.

On the one hand, we are better off than we were a century ago. We know more about how diseases spread, our diagnostic tools are sophisticated, and the internet and social media have proven useful as early detectors of outbreaks in remote pockets of the globe. In addition, the global health community has made great strides in shoring up countries’ public health infrastructure, capacity, and emergency management systems.

On the other hand, there are new variables to contend with that make us more vulnerable to the spread of disease. Consider trends such as a highly globalized and interconnected global economy, ease of travel, urbanization, migration, and displacement.

People, organizations, and goods are increasingly on the move—and with them go diseases and other health considerations. Across Georgetown, a community of researchers, educators, clinician-scientists, and students are thinking about the ways in which individuals and populations are moving—and how diseases and chronic public health concerns are moving with them.

A Moving Target

If the world has learned one thing from the past century, it is that pathogens do not recognize borders—and they spread more quickly than ever. It’s now a common refrain that an infectious disease that emerges in one remote village can spread to urban centers on every continent within 36 hours.

“Right now we have the largest number of people on the move throughout the world since World War II,” says Rebecca Katz, PhD, MPH, who directs the Center for Global Health Science and Security at Georgetown University Medical Center. “There are many implications of this movement, geopolitically and from a policy standpoint. But from a disease perspective, it brings a whole new set of complex challenges.”

Katz is in good company in looking at these issues.

The Georgetown Global Health Initiative (GHI) is a university-wide platform for collaboration—linking people across schools including the Medical Center, the Law Center, the School of Foreign Service, and the McCourt School of Public Policy—to study the world’s most pressing global health challenges. By its very nature, global health demands a multidisciplinary approach—the ability to examine longstanding and emerging challenges alike through the lenses of health, science, law, ethics, business, economics, diplomacy, and anthropology.

Adding to this complexity is the fact that, while global health transcends borders, it also is highly context-specific. An intervention that works well in one community or country may not work at all elsewhere—for a variety of systemic, political, or cultural reasons.

And for people like refugees who are on the move, it may not be evident where responsibility for their health lies.

“How do we conduct effective disease surveillance in a population that is hard to keep track of, and when it is unclear who governs them? There are international legal obligations for disease reporting and response, but it is not clear in a refugee camp who is responsible for these activities or how surveillance and response can be operationalized,” Katz says.

Katz works on global health security challenges like the emerging Ebola outbreak in the DRC.

‘Hidden’ Populations

Whether they are relocating from a rural area to a city, being forcibly displaced from their homes, or seeking new economic opportunity, migrants and refugees present enormous challenges for global health security experts.

One prominent example of the relationship between migration and pandemic preparedness is China’s Guangdong province, a hub for international trade and commerce.

A group of researchers led by Jennifer Huang Bouey, PhD, MPH—an associate professor of epidemiology in the Department of International Health at Georgetown’s School of Nursing & Health Studies—is collaborating with Chinese colleagues to analyze this fascinating and complex case study.

Known as the U.S.-China Global Health Working Group, the multidisciplinary effort is co-led by Bouey and Cheng Feng, a professor at Tsinghua University in Beijing, with participation from an array of U.S. and Chinese researchers, including Katz and Michael Stoto, PhD, professor of health systems administration and population health at NHS.

After Guangdong gained notoriety in 2002 for being home to the first reported cases of severe acute respiratory syndrome, or SARS, the Chinese government began to invest heavily in surveillance, emergency preparedness, and public health system restructures to address what many criticized as a fundamental lack of readiness and transparency.

Despite these measures, one major vulnerability remains in China’s pandemic preparedness, according to Bouey. Guangdong is increasingly a draw for international migrants seeking work, particularly from Africa and Southeast Asia, who remain unaccounted for by official systems and therefore “hidden” from policy.

There is no formal mechanism to track international migrant laborers in China, including who is entering the country for factory work, how long they are staying, and where they go once they enter, Bouey says.

“As public health researchers, we see risk factors of disease transmission in migration patterns and how people move from place to place,” she says. “The fact that the international migrants go underground and become marginalized poses a threat to the public health system—there is a significant barrier to reach these people through traditional surveillance or response channels, and it is hard to provide the necessary basic health care services for those in need.”

Caring for migrants and tracking disease patterns in this population is difficult for local public health officials, Bouey says. “We know it’s a ticking bomb.”

Mobility Upward

While people often migrate out of economic necessity or because they are forced to relocate, movement can also reflect economic progress—progress that is tied to better health outcomes.

Rates of extreme poverty have fallen in the last 40 years, “mostly in China and India, but increasingly in many other parts of the world too,” said development economist James Habyarimana, PhD, the Provost’s Distinguished Associate Professor at Georgetown’s McCourt School of Public Policy.

Habyarimana contends that market forces are heavily tied to movement, which in turn is tied to public health. As markets for certain goods and services expand and change, people migrate in pursuit of new opportunities—and for every action, there are multiple reactions.

For example, he notes, expansions in transportation infrastructure in developing countries have led to improved integration between rural and urban areas, promoting both greater traffic flow as well as the growth of major capital cities such as Nigeria’s Lagos, Kinshasa in Democratic Republic of Congo, and Dhaka in Bangladesh. Meanwhile, the increased demand for elder care in the developed world has led to considerable migration of nurses and other health professionals from the developing world.

“Progress is intricately tied to connections between people and places—and to people moving to opportunity,” Habyarimana says. “And the types of things that kill people when they are poor are very different from the types when they get richer—the so-called epidemiological transition describes the shift in primary health challenges from infectious to noncommunicable diseases as societies become richer.”

These noncommunicable diseases—such as hypertension, diabetes, cancer, and mental health disorders—can be associated with economic growth, exposure to more congestion in cities, and lifestyle changes including diet and level of activity. These chronic health conditions are also increasingly observed among low- and middle-income populations, who tend to be disproportionately affected by economic shifts linked to increased migration to cities, longer work days, and more financial stress.

Though the long-term impact on health, communities, and economies can be enormous, noncommunicable diseases receive less international attention—and thus less funding—than infectious diseases.

Policymakers and donors are much more motivated to stop the spread of a killer pathogen than they are to try to untangle the causes, comorbidities, and implications of chronic illness. The impact of heart disease in an individual or community is much harder to isolate and quantify than the impact of Ebola, for example.

Global Agendas

Scholars increasingly recognize that these two global health priorities—strengthening global health security and combatting chronic disease—are not only compatible, but fundamentally interdependent.

It comes down to resilience: how strong a population is to begin with will have great bearing on how it responds to urgent health threats such as an infectious disease epidemic. As a result, many experts view efforts to ensure populations have universal health coverage as an investment in global health security.

A working group born out of collaboration between Katz’s center, Georgetown’s O’Neill Institute for National and Global Health Law, and the University of Edinburgh Global Health Governance Programme, is exploring the question of whether these two global agendas are aligned and where they might diverge. Besides Katz, Georgetown collaborators include Lawrence O. Gostin, university professor and faculty director of the O’Neill Institute, and anthropologist Emily Mendenhall, MPH, PhD, associate professor of global health in the Walsh School of Foreign Service.

As the group studies how chronic disease prevention relates to global health security, one connecting thread is clear: the importance of funding.

Follow the Money

In today’s uncertain global health funding climate, making the most of every dollar is key. That is why, besides studying the flow of people, Katz and her collaborators are also looking at the flow of funds. They have developed a new tool, called the Global Health Security Funding Tracking Dashboard, to track direct foreign investments and private foundation funding globally with the aim of surfacing gaps and eliminating redundancies.

Mapping the flow of funding against the burden of disease is complicated, and it’s an incomplete picture at best without considering the flow of power and influence.

“It is never as simple as countries investing in other countries with the highest disease burden. Foreign investment results

from a combination of disease burden, diplomacy, trade, and the ability of a country to effectively use aid—all are factors that influence relationship-building and soft power,” Katz says.

In other words, geopolitics can be the 800-pound gorilla in the room when talking about global health security. It is why political transitions, ruptures in diplomatic relationships, and shifting regional alliances can upend years of global health policy.

“So much of foreign aid is relationship-based,” adds Katz.

Economic progress and public health depend on the safe and efficient flow of goods and people, says Habyarimana.

People at the Center

What is largely missing in these conversations around global agendas and funding is “people’s lived experiences,” according to Mendenhall, a medical anthropologist. She studies a concept known as syndemics, a combination of “synergy” and “epidemic,” that looks at how diseases cluster together, the biological or social interactions that cause them, and the large-scale social forces that underpin pandemic diseases.

“At the heart of all this is real people’s lives. Yet their stories are fundamentally overshadowed by the discussion of global agendas,” Mendenhall says.

People on the move carry highly complex health conditions or illnesses with them that are not only multimorbid, but also can be born of or exacerbated by social conditions. A person’s metabolic system, for example, is affected by stress and chronic financial and food insecurity.

It is impossible to separate life events and circumstances from physical well-being, according to Mendenhall.

“Historical trauma, subjugation based on gender, race, or class—these cause extreme stress in people’s lives,” she notes. “Some people call these ‘life lesions,’ and they manifest in your body. They are something you carry with you across the border.”

To talk about the implications of movement on health, one must also consider the conditions that prompted that movement. The trauma of war, abuse, extreme poverty can show up right away, or it could take years to materialize as mental and physical illness. Either way, as people move, the health manifestations of these events move with them.

Occupational risks are another vital piece of the puzzle. For many, migration offers the promise of a better economic outlook or social standing, even if they have to take low-wage, high-risk jobs to make ends meet.

As such, economic migrants who come to the United States—particularly those who are undocumented—face extraordinary occupational hazards in high-risk industries such as construction and agriculture. Moreover, many who work in these fields may not report injuries for fear of losing their jobs; the power dynamic is heavily skewed towards the employer.

“The big issues that overwhelm everything else are people’s fear of job loss and their fear of being deported,” says Rosemary Sokas, MD, professor of human science and family medicine at NHS. “Between these two things, workers will likely end up putting up with almost everything, are unlikely to report when things do go wrong, and feel powerless to try and change anything,”

Sokas, an expert in occupational and environmental health, sits on the Board of Directors of the Migrants Clinicians Network, a nonprofit organization that works to train and support health centers, health outreach workers, clinicians, and other care providers who work primarily with migrant workers or other mobile, underserved populations.

She has collaborated with them on research to identify and address barriers to the recognition, management, and prevention of work-related illness or injury among migrant populations.

Sokas cites as an example the case of a 30-year-old immigrant construction worker with diabetes. He had bought himself a pair of new work boots, which caused blisters, but he continued to work. Because of his diabetes, he developed osteomyelitis, a rare but serious bone infection. He ultimately needed intravenous drug therapy and nearly lost his foot.

“It was one of those examples where he couldn’t take time off from work, and he powered through because he needed the income. There is no replacement for that income, no sick leave, and you can see how this all has terrible consequences for an individual in these circumstances,” Sokas said.

Care of the Whole Person

An examination of people and disease on the move requires both a macro and micro lens. It demands a high-level policy perspective grounded in an understanding of social and economic determinants of health. It is at once top-down and bottom-up.

This seeming polarity exemplifies the Jesuit value of cura personalis, care of the whole person. This means considering a person’s entire being, including where they live, where and how they move, how they impact their community, and how their community impacts them.

It is what excites researchers like Mendenhall, who was inspired to study medical anthropology through reading about liberation theology from renowned Jesuits such as Gustavo Gutiérrez and Oscar Romero.

“People’s health is always based in historical, social, and economic contexts. We must think about people’s health as being inextricably tied to their life and their existence,” Mendenhall says. “Health is fundamental to living a good life.”

The interdisciplinary approach needed to grapple with these challenges has found a fertile home at Georgetown through efforts like the Global Health Initiative, which earlier this year launched the Great Influenza Centenary Project. Spanning campuses and a variety of disciplines, the project draws on reflections from the 1918 pandemic to inform response to current pandemic challenges.

This comprehensive approach is not just beneficial for the study of today’s thorniest global health challenges—it is essential.

“These issues are so complex, so multi-dimensional,” says Katz. “You need all types of people with all types of expertise and interests to dive in—it’s how at an institution like Georgetown we can be at the forefront of shaping these conversations.”