The Dean’s Blog

If You Had $100 Million for Global Health

David Vlahov

Recently, I participated in a well-attended panel discussion on the challenge of global population growth, sponsored by a consortium of academic global health programs in the San Francisco Bay Area. The discussion ranged from the pressing problems of inadequate and diminishing access to water and food to the megatrend of unremitting urbanization and the need to shift development dollars to where people are and will be.

As the session moved to audience questions, one participant asked, “If you had $100 million and were not allowed to divide it between priorities, how would you spend it?”

A hundred million dollars may seem like a large sum of money, yet it really is not when you consider the range and size of needs in global health; in 2012, the World Health Organization (WHO) reported that global spending on health exceeded $6 trillion annually. Thus, considering what the top priority should be if we had only $100 million to spend is an important exercise in triage because, sad to say, resources will always have limits.

Certainly, the possibilities are overwhelming. Some point to the need for research and development of vaccines and enhancing the availability of existing medications and treatments. Others focus on social determinants of health, which include water, sanitation and transportation infrastructure; or on the promise of shared governance, such as expanding the Latin American model of participatory budgeting, which has led to improvements in infant mortality and life expectancy. Still others propose investing more in the WHO’s urban health observatory, which carefully monitors populations and evaluates programs and policies in areas where most people live around the world; this could be extended to more countries where city growth is rapid, especially in the slums. 

Another area with the potential for a large return on investment is primary education that consciously includes women. The case for this is especially strong in low- and middle-income countries, because education builds human capital, and the inclusion of women enables countries to mobilize the entirety of their human resources.

Perhaps it’s not surprising, though, that I would argue another important direction for progress in global health is investing in the education of nurses. Doing so complements existing structures and resources such as medical schools and tertiary care hospitals for specialty care. Expanding the nursing workforce in community and public health supports essential population health initiatives in prevention, surveillance, primary care delivery and referral. More nursing education also is the fastest way to bring skilled health care workers to the front lines of all forms of health promotion, primary care and midwifery. And more nurses creates a larger workforce of community-level clinicians and leadership-trained community health workers, thus raising the collective knowledge of health and increasing the presence of quality health services for a greater proportion of any country’s population. That would be a pretty good return on a $100 million investment.

Nursing at the Front Lines of Ebola – and Beyond

David Vlahov

This month we learned about yet another case of Ebola in the US, where a second Dallas nurse became infected after treating a patient who flew here from Liberia.

We can only imagine what these infected nurses are experiencing. Our thoughts and prayers go out to them and to the others infected in the US, Europe and West Africa. We feel the caution, anxiety and fear of the nurses and other workers who are at the front lines. From a distance we sense the rising level of alarm. Yet as a profession, as colleagues in arms, we can take steps to address this threat.

The first is to put the threat into proper perspective and to not mince words: Ebola is a very dangerous virus. The Centers for Disease Control and Prevention (CDC) and the US Department of Agriculture classify possible infectious agents into levels of threat. Those agents in the highest level (Category A) can result in high mortality rates, might cause public panic and social disruption and require special action for public health preparedness. Category A includes viral hemorrhagic fevers, one of which is the Ebola virus. Given its high rate of mortality (around 50 percent; mortality rates of past outbreaks have varied from 25 percent to 90 percent), it is handled only in the most secure, Biosafety Level-4 laboratory settings. (A note: While the categorization framework was developed for planning around bioterrorism, there is no suggestion or hint of that here. What we are witnessing is an outbreak turned into an epidemic, with the potential to spread through global travel.)

With no vaccine yet and treatment limited to supportive care, step two involves health care workers making sure we can protect ourselves, so we can not just help contain the epidemic, but also address the accompanying public panic and social disruption. Guidelines for prevention are available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.

Next, as nurses, we have a role that begins with professional screening, identification and care of the individual patient, family and co-workers, but we must go beyond that. We have a crucial role in educating the communities where we live and the wider community throughout the country and the world. Preventing public panic and minimizing social disruption depends on individuals and communities having information and a sense of support, rather than stigmatization. This will be especially important as the fever and headaches of flu season kick into gear, and as people interact with friends, neighbors and family members who have come from overseas – even those who arrived here long ago. Even as I write this morning, there was a report of a community college in Texas that refused to admit a student from Nigeria.

The first law of epidemics is that whatever goes up must come down. We can make the number of cases and the anxiety surrounding them come down faster if we stick to our training and work together. By conducting objective assessments, making appropriate referrals, providing care with appropriate precautions, and calming others even in the worst of circumstances – this will be yet another time when nursing will be absolutely central to an effective public health response.

Comments

The couple of cases in Dallas are hardly the "front lines" of Ebola. Of course it's difficult to imagine what infected US nurses might be feeling, but how about we consider what the nations of West Africa might be feeling, given the 8000 cases and 4000 deaths?
I think it would be a good idea to institute a standard for video surveillance over the staff donning and doffing areas in the care of ebola patients. This could help to identify any untoward exposure that even the buddy system might miss and also be valuable in making any needed changes. Laura McIntosh, MS, RN (UCSF Alumni)
I believe the best way to prepare for this outbreak is to treat it as we do our isolation cases- TB etc . We are required to have yearly FIT testing to make sure we have the necessary equipment and demonstrate how to use it. The CDC is our experts and we need to take their advice on preparing a packet of necessary PPE that is ready and available in adequate numbers. Each and every employee needs to don/doff this equipment to be familiar with its handling. Several days ago, we had a drill for ICU/ ER to work through how they would handle the Ebola patient who walked in our door. Sonia Smith. RN ANP UCSF alumni. Berkeley.
Thank you! You could not have provided a more realistic approach for nurses to put this disease into perspective. I fear we are ignoring our much larger enemy of Influenza that seems to be ignored due to all of the national attention Ebola has created.
With Ebola starting with flu-like symptoms, influenza immunization may improve specificity for detection; yet another reason for getting immunized.

Global Disaster Nursing

David Vlahov

If ever there was a time to open a discussion about the need for global disaster training in nursing, that time is now.

As the epidemic of Ebola virus infections continues, organizations and individuals around the world are calling for the assistance of health care workers, including nurses. The USAID (United States Agency for International Development) website has information on who is needed and how to volunteer. The most urgent need is for those with training and experience in disaster response, but programs for advanced practice nurses in disaster preparedness and response are few and far between. We believe that needs to change.

Hiroko Minami (DNSc ’82, UC San Francisco School of Nursing), president of the University of Kochi, has been a leading proponent of disaster nursing, having initiated it as a specialty in her school’s PhD program. The vision for that program emerged after the 1995 Kobe earthquake and became especially resonant after the 2011 Tōhoku earthquake and tsunami, which led to the Fukushima Daiichi nuclear disaster and radiation exposure.

UCSF, Kochi and other nursing programs in the so-called Pacific Ring of Fire – home to many earthquakes and volcanic eruptions – have completed memoranda of understanding aimed at promoting programs for education and research in disaster nursing. A few schools in the United States have even developed certificate programs, although a number of those are limited to online education.

Now, however, the response to the Ebola virus epidemic has made clear that other than programs that emerged in direct response to the HIV pandemic, few prepare clinical specialists in infectious disease and population infection control. We believe we can build on existing programs to quickly create full-fledged disaster nursing curricula that include didactics, simulation and experience in epidemiology, and emergency preparedness and response for a wide range of possible events.

Doing so will fill a critical need, as natural and man-made disasters – be they hurricanes, tornadoes, earthquakes, floods, fires, chemical spills, radiation events or terrorist attacks – occur with disturbing frequency. One need only look at this map, which is updated regularly, to understand the urgency.

A key to surviving disaster is to prepare for it. That’s why now is the time to create a cadre of expert nurses who can not only help communities around the world prepare for and respond to population events, but also pursue and promote the much-needed education and research.

 

Comments

I absolutely agree. As a graduate of UCSF and a former MEPN, I would find a program like this VERY appealing. Now I work in rural Alaska, so a program that allowed for distance/low-residency would be ideal for me. Please keep that in mind!
I concur. I too am a graduate of UCSF and practice as an Emergency Clinical Nurse Specialist in the Bay Area. I am very involved in organization disaster preparedness and response as well as the Vice Commander for the San Bernardino County Medical Reserve Corp. An advanced practice curriculum that focused on preparedness, response, working with volunteers, and publice health is urgently needed.

Ebola Virus Disease and the Nursing Workforce

David Vlahov

The World Health Organization reported that as of August 11, 2014, the number of cases attributed to Ebola virus disease (EVD) in four West African countries stood at 1,848, with 1,013 deaths. More than 145 health care workers who have provided care to Ebola patients have also become infected, with 80 deaths so far.

Concern has spread to the United States, as two American health care workers who contracted the disease were flown here and are under care. Tom Frieden, director of the Centers for Disease Control and Prevention, has assured the public that the probability of EVD spreading within the US is remote. Nevertheless, both here and around the world, the virulence of the disease, some misunderstanding of how it is transmitted and a failure to have proper protections in place in some health care settings have caused alarm among those charged with treating EVD’s victims.

Those fears recall memories of when I was an infection control nurse in Baltimore, caring for patients with AIDS early in the HIV epidemic. I remember seeing an AIDS patient placed into full isolation, with nurses and physicians congregated outside the room expressing anxiety about whether they should go in at all. As the Health Resources and Services Administration’s Ryan White HIV/AIDS Program history project noted, some physicians and nursing staffs even refused to provide treatment to those with AIDS symptoms. As people died, stigma and willful ignorance kept many funeral homes from accepting bodies for burial. In 1987, the New York Times published an article titled “When Doctors Refuse to Treat AIDS.” As the country faced a new and highly fatal disease, fear was palpable.

With today’s Ebola outbreak – just as with HIV and other viral outbreaks, such as SARS (severe acute respiratory syndrome) and H1N1 influenza (swine flu) – some health care workers have volunteered to be at the front lines, but others have been reluctant. Such reluctance is understandably highest in the earliest days, especially if the routes of transmission are not well understood, health care workers don’t know how best to protect themselves – and don’t trust their employers to provide them with all of the appropriate protections. That appears to be what’s behind reports of nurses going on strike in the affected West African nations.

Given the dire need for treating EVD patients and containing future outbreaks of the disease, we must:

  • Strengthen the global nursing workforce with increased clinical and public health training.
  • Establish an adequate inventory of equipment and supplies.
  • Provide a public health infrastructure for rapid and effective monitoring and response to emerging events.
  • Train governments to lead efforts in public health preparedness and response.

This is what we eventually did with HIV/AIDS and did more quickly with SARS and H1N1. Such preparedness builds a reservoir of trust and confidence that otherwise can be tested and undermined during emergencies such as the one we are currently witnessing.

Nurses play a crucial role in establishing that trust – not just by our presence at the bedside, but through use of our public health expertise to develop policies and lead and organize our communities. By addressing understandable concerns for our own safety and that of our colleagues and communities, we can help ensure patients receive the care they so desperately need.

 

Comments

Once again UCSF School of Nursing, this time Dean Vlahov, is on the front line to address a major health problem, i.e., ebola. Thank you.
Yes, good for UCSF with this timely message...I too recall the fear generated in the hearts of some nurses when it came to the early days of hospitalized HIV/AIDS patients...one staff nurse went so far as to sit on the floor, repeatedly pounding her feet/legs up and down as she cried out her refusal to take on a care assignment of an AIDS person. Let us hope your message goes beyond the UCSF connection for I hear a lot of misinformation over the radio and TV in regard to EBOLA...Thanks for the message...I shall forward it...
Thank you for sharing your experiences during the HIV early days. I was a young ICU nurse, witnessing one of the first cases of AIDs in our SF hospital late 1970s, early 1980s. Thankfully, for us, we had 2 tremendously informed and educated Infectious Disease Physicians who helped us set up a protected treatment plan of care. Yet, I also witnessed others who refused to care for patients because of their fears and lack of knowledge. Florence Nightingale was probably shaking her finger then and now at us for forgetting about the grass roots of Nursing. We are the compassionate workforce, which we should not forget these roots. Yet, we need to be informed about highly infectious disease and the best protection to avoid putting ourselves in harms way. When we do this, we should not walk away from those who are suffering and need the care we can deliver.
What are the appropriate safeguards and how is it transmitted?
The Centers for Disease Control and Prevention (CDC) is an excellent resource: http://www.cdc.gov/vhf/ebola/prevention/

Reducing the Impact of the Doctor Shortage in a Year

David Vlahov

With startling regularity, stories continue to appear in publication after publication in which the authors fret about how to respond to the growing demand for health care, particularly primary care, and the accompanying shortage of doctors. Typically, the writers call for more medical schools, more money for medical students to lower debt, and incentives for medical students to go into primary care.

As we have noted many times before – and in many settings – such measures are important, but they will not be enough and they will not get solutions in place as quickly as is necessary. Meanwhile, there is a more immediate, research-based solution right in front of us – if only state legislatures would listen objectively to the evidence.

Nurse practitioners (NPs) are RNs with at least a master’s degree who are nationally certified for a particular specialty area, such as family health care, midwifery or adult-geriatric care. Compared with physicians, NPs take less time to train, the programs are less expensive to run and the amount of student debt is less. Equally important, studies that the Institute of Medicine has characterized as valid have shown that NPs can safely and effectively deliver 90 percent of pediatric primary care services and 75 percent of general primary care services. Other studies have shown that each discipline sends patients to specialists when needed. Moreover, NPs are more likely than physicians to practice in underserved areas, both urban and rural, where the shortages are most severe.

Despite such findings, we still find articles in national publications in which the authors or their sources espouse relegating NPs to “performing vaccinations and strep tests.” That is a woeful underutilization of highly skilled practitioners. It reflects limited scope-of-practice rules and a narrow vision for addressing the desperate need for more high-quality primary care, which nearly every expert agrees is critical to improving people’s health – and reducing the exorbitant cost of care in this country.

The Bay Area Council Economic Institute recently issued a white paper that, among other things, noted that allowing nurse practitioners in California to practice to the full extent of their education and training could save the state $1.8 billion on preventative care visits alone over 10 years while increasing the number of those visits by 2 million per year. The lead author of the report notes: “While no single policy change will be a panacea for the critical cost and access issues facing California, this reform [allowing nurse practitioners to provide the health care services they were trained and licensed for] could be an important first step to bring down some of the barriers that are keeping healthcare costs artificially high.”

To be clear: having nurse practitioners practice to the full extent of their education and experience does not remove the need for more schools, more funding for the health professions and incentives to draw more professionals into primary care.

But those are longer-term concerns. To meet the shorter-term health needs of individuals and populations, there is a solution available now. It is time for legislatures to stop being distracted by false arguments and expensive lobbying efforts. They should act immediately to free nurse practitioners to practice to the full extent of their education, so NPs can help address the health care needs of the people our legislators serve. 

Comments

All Advanced Practice Nurses should be allowed to practice to the full extent of their education. In many States all over our country Clinical Nurse Specialists as well as NP's are allowed to practice to the full extent of their education. UCSF should lead the fight for this cause in California, not just for NP's but for all Advanced Practice Nurses especially because they train so many.

Featured Articles

November 2014
The Unbroken Chain: Three Decades of HIV/AIDS Nursing – From the earliest days of the HIV/AIDS epidemic through today, UCSF nurses and faculty and alumni from UC San Francisco School of Nursing – along with partners in multiple clinical settings – have been instrumental in changing the course of the epidemic and improving the lives of people affected by it.
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Finding the Right Clinical Training and Experience – Two recent graduates bring their skills and education to the country’s only HIV/AIDS consultation call center for health care providers and receive valuable hands-on experience in return.
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In the Sim Lab – UC San Francisco School of Nursing MEPN students take advantage of a top-notch simulation lab to get their initial exposure to patient care.