Guest Blog: Jyu-Lin Chen and Annette Carley

How Did We Get to “More Is Always Better”? and Other Essential Questions on Aging

November 2015
David Vlahov

Anthropologist Sharon Kaufman is one of the original members of the Institute for Health & Aging (IHA), which on November 9 celebrated its 30th anniversary. The event brought together scientists who had flourished in the Institute and made significant contributions to our understanding of health at the individual and societal level.

At the celebration, Kaufman drew on her recently released book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line (Duke University Press, 2015), to speak about the struggle in health care between the desire to prolong life and the desire to avoid crossing the line to “too much” care. Exploring that dilemma led her to examine the larger engines of the biomedical economy: the research and insurance industries and their impact on what we do when life is at stake.

Kaufman spoke of “the hidden chain of connections among science, politics, industry and insurance that drives the US health care system,” noting especially that clinical trials sponsored by the multibillion-dollar biomedical research engine are at the heart of our increasing reliance on evidence-based care, which can be a good thing. But it’s important to remain aware that in the past 25 years, the number of trials that private and profit-driven pharma, device and biotech companies fund has more than doubled.

As these trials generate more evidence of therapeutic value, they also generate an ever-increasing number of standard – that is, difficult to refuse – treatment options. Our prioritizing of new therapies and technologies magnifies this effect, because it influences our collective perspective on the timing of death. Today in the US, says Kaufman, we consider most deaths premature, regardless of the age of the deceased.

As evidence of the phenomenon, she spoke of the implantable cardiac defibrillator (ICD). When clinical trials showed good survival rates and Medicare began to reimburse for its use, the ICD became a therapy that shifted from unthinkable a decade or so ago to routine and standard care for older persons with moderate to severe heart disease in the US. The floodgates were open.

Here’s the catch, notes Kaufman. In treating a potentially lethal arrhythmia, the ICD prevents sudden death (the silent heart attack in the night) – precisely the kind of death many say they actually want late in life. Yet the device is difficult to refuse, because doing so seems to go against medical progress and common sense.

Kaufman’s eloquent presentation distills the essence of a societal quandary nurses, physicians, patients and families must face together. It also exemplifies the value of our Institute for Health & Aging.

The IHA has been a vital incubator – not just for investigators, but also for work that has built models for improving health and, more fundamentally, how we think about health. Past work includes that of giants such as Carroll Estes, Bob Newcomer, Dorothy Rice and Patrick Fox, all of whom produced groundbreaking work on everything from Social Security and Medicare to long-term care, Alzheimer’s disease and the societal costs of tobacco, alcohol and drug use.

Today, in addition to Kaufman and IHA Director Wendy Max, the groundbreaking work emerges from other marvelous investigators, including a few the celebration highlighted: Marsha Michie on bioethics and genomics, Julene Johnson on arts and aging or Brooke Hollister on understanding the impact of reform on Medicare and Medicaid.

In each of these cases, the Institute’s investigators ask the absolutely essential questions about how scientific and medical advances change how we age and how we die. Their role and expertise have never been more important.

 

Harm Reduction

September 2015
David Vlahov

A June 2015 report from the Trust for America’s Health and the Robert Wood Johnson Foundation found drug overdose is now the leading cause of deaths from injury in the United States. Rural Indiana recently found itself wrestling with an outbreak of HIV among drug users.

These findings and events represent human tragedies; what’s worse is that in many cases, the deaths and HIV transmissions were either preventable or, at least, ripe for mitigation. The problem is that as a country we are still trying to get comfortable with an approach to substance abuse known as “harm reduction.”

In this month’s Science of Caring, we ran a story about faculty at our School who are working to advance this strategy, which is based on minimizing risk through policies, programs and/or individual practices. It is an approach that meets people where they are rather than making judgments about where they should be in terms of their personal health or lifestyle.

Take the case of the illicit drug user who is vulnerable to or can transmit HIV infection but can’t stop his or her drug dependence. For many years, the approach to these individuals was often some combination of “just say no” and incarceration. Yet when the HIV epidemic came along, harm reduction emerged as an alternative strategy. The idea was to make drug abuse treatment accessible, but to also give illicit drug users access to sterile needles and bleach for syringe disinfection. To move in that direction, communities needed to learn and embrace what harm reduction strategies could offer, and legislators at various levels needed to change policies.

My own research and that of numerous others has found that harm reduction strategies are very effective in reducing the rate of new HIV infection among drug users. Yet before these data could be turned into policy, we needed to address politicians’ concerns. In my work, we responded to political concerns by conducting studies on the possible negative consequences of community-based access to sterile syringes. Our data from pilot projects showed that access to sterile needles in communities did not increase drug use, nor did it increase sharing of needles, reduce the rate of users going into drug treatment, leave contaminated needles on the street, encourage youth to start drug use or increase crime. That was a turning point. Communities came to see the value of harm reduction, and policies and programs changed. Outreach and education have now enabled these programs to become more widespread.

In short, harm reduction is highly effective in preventing death and containing harmful behaviors associated with using drugs. We know as well that harm reduction strategies – such as public education campaigns to safely store medications away from children, and the distribution of naloxone to police and medics to rapidly reverse the effects of opioid overdose – can be very effective in preventing drug overdose deaths.

Nevertheless, the acceptance of harm reduction remains incomplete, despite evidence of its success in many areas, including some that transcend the transmission of HIV or drug overdose. For example, to prevent automobile-related injuries and deaths, we’ve implemented multiple forms of harm reduction, from public information campaigns against drunk driving to engineering solutions such as the placement of taillights at the view level of the driver behind a braking car, crumple zones for crashes, air bags, and collapsible guardrails and streetlight poles. Such strategies have worked.

It’s likely and understandable that the reluctance to apply harm reduction strategies to illicit drug use comes from a complex social psychology tied to concerns that we are somehow sanctioning the use of these drugs. It is time, however, to recognize the evidence. We have had success in reducing needle transmission of HIV and complications related to drug overdose. We have faculty who are expanding this work, making progress on addressing challenges and creating promising strategies to reduce HIV risk related to binge drinking. It is time for health care professionals to incorporate harm reduction as an important, evidence-based public health tool that we should use whenever our clinical judgment deems it necessary.

 

Why Nursing Science Matters

May 2015
David Vlahov

When nursing is the topic of conversation, terms such as expert clinical knowledge, authentic compassion, keen observation, organized patient management, complex care coordination and passionate advocacy flow easily.

Outside of the nursing community, however, when I talk about nursing science – nursing research – I often get blank looks and questions like: Why are nurses doing research? What distinguishes nursing science from medical research?

Given our powerful, but often unsung, impact on the quality of countless patients’ lives, it disturbs me that people don’t understand what we do. So allow me to try to explain.

Put simply, nurse scientists generate questions geared toward improving how clinicians and patients administer care and manage conditions. Such questions emerge from a unique nursing lens, which is always focused on detecting, understanding and responding to signs and symptoms that our patients experience. In a health care world moving toward – and certainly benefiting from – diagnosis and treatment that relies increasingly on sophisticated technology, it’s absolutely essential we not lose sight of the patient experience. It’s what provides health care’s critical balance.

Let’s take an example. In most intensive care units, a cacophony of alarms, whooshing and clicking sounds assaults the senses of the nurses monitoring and caring for the patients. Nurses know these alarms make it difficult for patients to sleep. We witness the distress alarms cause for family and other visitors. Worse, the constant noise, some of it unnecessary, can inure the nurse so that he or she misses an important event. Known as “alarm fatigue,” this phenomenon can make intensive care an unsettling and, at times, unsafe experience.

Nurse scientists such as UCSF’s Barbara Drew have insisted that we can engineer a safer nursing care environment. She and newly recruited faculty member and bioengineer Xiao Hu are collecting millions of data points and deriving algorithms so alarms can better predict clinical events. If Drew and Hu’s early results are validated, it will help some remarkable technology achieve its original purpose of providing precisely targeted advanced warning without all the unnecessary noise.

The point is that it is nurse scientists whose experience positions them to raise such questions, assemble the team to address the need, put methods together to gather the data and bring their lens to an analysis that is most likely to uncover the right answers for both nurses and patients.

Similarly, consider symptom assessment and management, something nurses have been studying for decades – and something that has a deep and lasting effect on patients. Some of the most impressive work in this area has been on the pain, nausea and fatigue associated with cancer and chemotherapy. During the past decade, nurse scientist Chris Miaskowski and geneticist Brad Aouizerat from our faculty have gone beyond measuring self-reported symptoms to uncover genetic markers for pain associated with cancer chemotherapy. The hope is that adding genetic information to data from self-reports and physical signs can help us improve how we anticipate and effectively manage pain. While colleagues in other fields study genetic markers and mechanisms for diagnosis and treatment, nursing science focuses on symptoms because patient experience tells us that pain associated with cancer chemotherapy remains an unmet challenge.

One more example: At the University of Pennsylvania School of Nursing, Mary Naylor has clearly defined best practices for transitional care from hospitals to community. Such work is especially important today, as the health care reform movement has identified transitional care as an essential component in people maintaining and improving their health after a hospital stay. We are delighted to have Mary Naylor join us this year as a Presidential Chair, so we can learn from her work and generate our own.

There are, of course, thousands of other examples, both big and small, where nurse scientists’ unique lens helps build the science that is improving both individual and population health. So at a time when everyone in health care is trying to achieve the elusive balance between high-tech and high-touch care, it is high time for people to fully recognize nurse scientists’ critical contribution to the discussion.

Getting the Most from Nursing Research

April 2015
David Vlahov

This month, a Science of Caring article highlights research that provides important insights into the health needs of older adults living alone. Among the story’s unspoken questions is this one: How does a school of nursing decide where to focus its research efforts?

This is a more complex challenge than one might expect, as nursing research covers a wide range of topics in its efforts to improve patient care and community health, as well as shape health policy. At UC San Francisco School of Nursing, we are in the process of defining criteria that will help shape and sharpen our research themes moving forward.

This rigorous process includes consideration not just of demographic trends and public health priorities, but also of trends in science, health care delivery, health professions, human capital and resources. As we sharpen our focus, we also build in safeguards to ensure the criteria are not exclusionary. Our university has a culture of “letting a thousand flowers bloom,” and we want our faculty to follow both their hearts and their minds. That said, the criteria do provide a framework to guide our discussion as we develop a strategic plan for the School.

Aging emerged here early as a research theme. With Wendy Max and Julene Johnson from the Institute for Health & Aging and Chris Miaskowski and Meg Wallhagen from the Department of Physiological Nursing leading the way, here’s how the framework guided our interest in aging:

  • Demographic trends indicate that the percentage of the US population aged 65 and older will increase from 13 percent in 2010 to 19 percent in 2030. Worldwide, the percentage of people aged 65 or older is expected to grow from 8 percent in 2010 to 16 percent in 2050.
  • In terms of public health priorities, we can expect an increase in chronic diseases such as cancer, diabetes and dementia. The number of people age 65 and older with Alzheimer’s disease could be as high as 13.8 million by 2050, with the cost to the nation of Alzheimer’s and other dementias rising to $1.1 trillion.
  • From a care perspective, older adults have expressed a desire for independence, with satisfactory physical and cognitive functioning, in their later years. Achieving this goal requires knowledge about many factors that surround healthy aging, including self-care, a responsive system of health care, and housing and transportation design.
  • From a health professions perspective, the number of physicians entering and practicing geriatric medicine is small and declining. Nursing has and can continue to fill the gap; research plays a role in optimizing the care that our nurses can provide.
  • Trends in the conduct of science include interdisciplinary teams. For example, we have geriatric research expertise in three separate departments; a fabulous relationship with the UCSF Division of Geriatrics in the Department of Medicine; and strong partnerships with other medical centers, community agencies and community organizations, including a strong portfolio of active research programs and education for emerging investigators and leaders.

We believe the thoughtful development of research themes not only helps us achieve a critical mass of the finest research talent, but also helps us recruit world-class faculty and attract the best and brightest students. We are currently working toward other research themes – which we will share with you at a later time – that will enable us to further leverage our collaborations and achieve synergies in research, education and service both within UCSF and with our sister nursing schools around the world.

 

Accepting and Understanding the Value of Gratitude

March 2015
David Vlahov

Many years ago, while nursing in a coronary care unit, I had a patient who ran a kosher deli. Each day, his family would arrive with a heaping tray of pastrami and corned beef, the best deli treats I’d ever had. At first, I was uncomfortable with the family’s gifts; I was just doing my job. Eventually, though, I recognized both the family’s sincerity and the hurt I was inflicting by not accepting their gift. Their look of happiness when I did accept has always stayed with me.

Another time, at a busy mall, a middle-aged man approached me from a mass of shoppers and squinted intently at me. He seemed familiar, but I couldn’t place him. Then his squint evolved into elation. He waved his wife over, pointed at me and said in a possessive tone that I was his nurse. He spoke of being admitted to the coronary care unit, wondering if he would survive. After I wheeled him on a stretcher and transferred him into bed, I told him, “You got yourself in here. We’re going to get you out.” He said that he knew then he was in good hands. Yet once more I was embarrassed by the attention for merely doing my job. There was an awkward silence, and looking back, I realize I stifled his desire to give thanks.

This is a common experience for many nurses. Perhaps we take what we do for granted and find it difficult to accept our patients’ gratitude. Yet the older I get, the more I understand how important it is not just to accept their appreciation, but to use it as a way to build on the things we do well, just as constructive criticism is a way to correct our deficiencies. These situations are, in fact, opportunities to deepen our connections and grow as nurses – to speak with our patients and former patients about just how meaningful their gratitude can be.

And when the gratitude comes in the form of donations to our education, it is extraordinarily meaningful and valuable. After all, data show that better-educated nurses lead to better clinical outcomes – and schools of nursing are the only way to produce the teachers and leaders that assure quality nursing education across the country.

Now is an especially important time to support nursing education. The impending nursing shortage will be hard to address because we don’t have enough doctorally prepared teachers. The debt many who might seek such preparation would incur is a significant disincentive – and the means to get help with costs are shrinking. Government support has declined. Hospitals and clinics have tighter budgets, so they find it harder to support their nurses’ continuing education.

Thus, rather than shuffle uncomfortably when we are offered thanks, now is the time to encourage our grateful patients to support nursing education, so we can produce the next generation of highly skilled nurses, leaders and educators. That type of gratitude delivers huge returns for patients, families and society.

Launching Assistant Professors

February 2015
David Vlahov

While attending a recent meeting of nursing faculty leaders from across the country, a small group of us from research-intensive schools met informally to compare notes. One of the topics was protected time for junior faculty on the tenure track: how much to provide and for how long to new assistant professors, and senior faculty’s expectations about how to accommodate such time.

There was no single shared vision across schools, but for me it is impossible to discuss this idea of protected time without looking at its role in an entire career arc.

For tenure-track junior faculty in research-intensive universities, progression through the academic ranks typically demands active research that advances knowledge, excellence in teaching and advising, and service to the academic institution, the profession and the community. Institutions vary in the proportion of effort devoted to each part of the academic mission, as well as the metric for productivity within each part, but many provide protected research time for the first year. The assumption is that new faculty members need time to become oriented to the culture of the institution and academia, write manuscripts that provide a foundation for a program of research and prepare and submit grant proposals that will fund work that advances knowledge.

The ideal is to recruit new faculty members who are already building on their dissertation and postdoctoral research topic to establish themselves as credible candidates to steward funding that produces new knowledge. Yet even for an ideal new faculty member, solid funding for research typically takes at least one and often two or three years to arrive, so providing time – and mentoring – to get proposals started is essential.

Doctoral programs prepare students in scholarship, but in many cases, doctoral work is a more solitary experience. Successful science involves collaborations across disciplines, so protected time does not mean isolated time. New faculty need to learn how to complete academic work in a more complex setting, one with a longer list of expectations and shorter deadlines. In this context, mentors are crucial resources who encourage, guide and connect new faculty members to people and programs that stimulate energy, creativity and productivity.

Protected time also implies a responsibility to the institution beyond one’s own research track – a time to learn to teach with an experienced professor and become engaged in the academic community. Senior faculty mentor on how to manage all of these challenges to succeed in the academic community.

The end of this initial period and promotion to associate professor is often an enormous relief. Yet unless the protected time and mentoring have been employed wisely, this next phase can also come as a shock. The workload in research, teaching and service actually increases. The metric for promotion to full professor is not only productivity in each area, but also evidence of leadership that includes mentoring new faculty, taking on more students and serving on committees that plan the future of the school.

Full professorship comes with even more responsibility. The expectation is to become a role model and transmitter for the culture of academia at one’s institution.

While this discussion is about faculty in the tenure track, the needs are the same for the clinical faculty – growing junior faculty to become the leaders for tomorrow.

We need to carefully manage our investment of protected research time and mentoring for new faculty. This is not solely a period for them to write and submit manuscripts and grants. It is also a support system that enables these talented individuals to grow into full citizens and leaders in the academic community – ones who attract high-caliber colleagues, bright students and the resources needed to tackle the questions that will lead to improved science.

NPs, Expanded Scope and the Need for Team-Based Health Care

January 2015
David Vlahov

My most recent blog post – which commented on an Academic Medicine article titled “Primary Care Workforce Shortages and Career Recommendations from Practicing Clinicians” – touched a nerve with some readers. People have responded in a number of ways. Some felt that the blog was “out of touch” and “tone-deaf” to the issues of concern for primary care nurse practitioners (PCNPs), in essence abandoning our shared commitment to the preparation, profession and position of nurse practitioners.

Nothing could be further from the truth! To be clear, in my earlier blog posts (e.g., “Reducing the Impact of the Doctor Shortage in a Year,” from July 2014), published articles (e.g., “Nurse Practitioners: Implementing the Affordable Care Act,” in San Francisco Medicine, April 2013) and numerous national presentations, I have consistently made the case for PCNPs being able to practice to the full extent of their education and license. The recent blog post is most definitely not a departure from that position.

The Institute of Medicine’s 2010 report on The Future of Nursing framed the future in the context of health care reform. In essence, the country needs a larger, stronger and more integrated health care workforce to meet the nation’s health care needs. To meet the real and growing challenge of providing quality care, the IOM stressed the development of educational standards for practice; the education of doctorally prepared nurses for leadership, education and research; and the need to address the scope of practice whereby nurses can fully practice to the level of their education.

In California, we have had some disappointment in making progress toward these goals. In 2013, Senate Bill 491, which would have allowed nurse practitioners to operate without physician supervision at certain medical facilities, did not pass. Among others, I was asked to and did provide research in support of independent practice. In addition to summarizing the research base that has found nurse practitioners provide high-quality and safe care, with outcomes and patient satisfaction comparable to primary care physicians, I also presented the case that it is much more cost-effective to train nurse practitioners and that they graduate with much lower debt compared to physicians. I argued for the importance of having expanded practice restrictions eased as a means to expand the health care workforce to meet the increasing needs associated with health care reform. The early version of this bill was discussed with the deans of all the UC schools of nursing, who similarly expressed support. Additionally, a letter in support of the bill came from the University of California, Office of the President.

There can be no doubt of where I stand on the issue of independent practice for nurse practitioners. And we will continue to fight for this becoming a reality in California as it already has in some states. Hopefully, the 2013 bill will be reintroduced and will pass in the next legislative session.

All of that said, a larger workforce – even one enhanced by making full use of NPs’ unique skill set – is not enough. Coordinated, team-based care is health care’s future. Thus, we need to do better in terms of training together, working together and supporting each other. Listening to and understanding the views and concerns of our professional colleagues moves us closer to these important goals.

David Vlahov, RN, PhD, FAAN

 

In Support of Primary Care Medicine

January 2015
David Vlahov

Recently, an article in Academic Medicine described the results of a survey that found 66 percent of primary care physicians (PCPs) would recommend becoming a primary care nurse practitioner (PCNP) as a career choice, whereas only 56 percent of PCPs would recommend a career in their own profession. Conversely, 88 percent of primary care nurse practitioners would recommend their own career.

As one of many nurses who have argued long and loud that the challenges of health care reform demand that we expand the scope of practice for nurse practitioners, I might be expected to take some pleasure in such findings.

I do not; I find the survey results dispiriting. A shrinking pool of primary care physicians is unequivocal bad news for anyone who cares about creating a truly responsive and high-quality system of care.

Consider one key passage of the article:

It is possible that Primary Care Physicians’ greater willingness to recommend a career as a PCNP over a career in their own profession could reflect their pessimism about the future of primary care medicine. Dissatisfaction with factors not assessed in this survey – lower payments and incomes relative to specialists, long work hours, increasing bureaucracy and compliance oversight, devaluation of primary care among the academic medical community, the additional years of education, and high debt levels following the completion of medical education, particularly in relation to their salary as compared with physicians in other specialties – could weigh heavily enough to offset PCPs’ misgivings about PCNPs and thus explain their greater willingness to recommend that qualified students pursue careers as PCNPs.

If the authors’ speculations about the sources of primary care dissatisfaction are correct – and such thoughts are nothing new for those of us who count primary care physicians as friends and colleagues – then it is time for all of us to find ways to turn this train around. A strong primary care physician workforce is a non-negotiable necessity for quality care.

Therefore, we must build new incentives for primary care medicine into the evolving designs for health care delivery and academic medicine. We must work together with our primary care physician colleagues to create and sustain the conditions necessary to maintain and expand their vital practice. Even as PCNPs have sought a wider scope for their own practice, it has always been in the context of adding value to an essential partnership with primary care physicians and other health professionals to enhance health and well-being for all individuals.

To be clear: becoming a PCNP is a great career choice. Yet PCNPs do not exist to replace primary care physicians. We are not interchangeable. There may be overlap in our roles, but there is also important differentiation where each provides additive value to health care delivery and the health of our patients.

If nursing is dedicated to creating and being part of a comprehensive health system that meets the needs of disease prevention, management and health promotion, then we must advocate for a strong primary care physician workforce that feels truly energized about bringing its expertise and innovation to our shared mission.

Thoughts on World AIDS Day

November 2014
David Vlahov

World AIDS Day (Dec. 1) is an opportunity to renew our commitment to creating a generation without this dreaded disease. This year’s theme – Focus, Partner, Achieve: An AIDS-Free Generation – is a perfect rallying cry for a fight that, unfortunately, is not yet over. Just this week, the US Centers for Disease Control and Prevention released a study which found that more than 1 million Americans have HIV, nearly 50,000 more become infected every year, and in 2011, fewer than 3 in 10 had the disease under control.

So a renewed commitment is essential – and some of us find the strength for that commitment in the inspiration of heroes. With HIV/AIDS there is no shortage of such heroes, from patients and families to researchers, clinicians, advocacy groups and policymakers.

Inevitably, though, I think of my nursing colleagues. In the early 1980s, when the disease first emerged as a virulent and mysterious killer and I saw my first patient with HIV/AIDS – when we didn’t know how to ease the suffering, and the stigma associated with this “gay disease” was more cruelly overt than it is today – nurses often took center stage.

No place was this more true than in San Francisco. In 1983, the San Francisco Department of Public Health and UCSF created the first outpatient clinic devoted to caring for people with AIDS and, led by Cliff Morrison – a nurse and clinical faculty member at UCSF School of Nursing – the first inpatient AIDS unit in the nation at San Francisco General Hospital.

Absent any known treatment or cures, Morrison and his colleagues focused on relieving the physical and emotional suffering of early AIDS patients. Symptom management – a major clinical responsibility for nurses in any setting and a major pursuit of nurse scientists – was crucial.

Morrison and his team also understood that easing suffering meant helping patients overcome the stigma of HIV/AIDS. Their early realization led to research by nurse scientists and others that has leant understanding to stigma’s role in all disease.

Community health nurses and researchers were among the first to understand that AIDS affected other communities, such as injection drug users and sex workers. Developing community health interventions was an important factor in stemming the epidemic.

As discoveries emerged, nurse educators at UCSF and other schools adapted our curricula, developing patient education techniques that helped individuals and communities reduce the risks of contracting HIV and helped patients adhere to treatment regimens. Over the years, nurse educators here have helped create a virtual army of HIV/AIDS-trained practitioners for the Bay Area and the world.

That’s important, because as HIV/AIDS has become more chronic illness than death sentence, nurses often are the clinical leads with patients. We work with physician colleagues to develop realistic treatment plans tailored to the context of our patients’ entire lives. We point patients to community resources and help them understand it is possible to live full and rewarding lives while managing the illness.

So, today, as the HIV/AIDS community renews its commitment to this fight, I feel enormous pride in my profession. We are only one among many groups whose heroic efforts inspire us today, but our work demonstrates the very best in nursing and health care – not just the compassion and kindness with which we are often associated, but our complex and essential role in many aspects and on many levels of patient care.

Still, there is much left to do. Let’s draw our strength for the continued fight from our heroes. 

If You Had $100 Million for Global Health

November 2014
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.

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