National Academy of Medicine

In recognition of the need for a national coordinated and collective response to the epidemic of opioid addiction in the U.S., the National Academy of Medicine (NAM), in partnership with the Aspen Institute, launched a public-private partnership made up of more than 35 organizations representing federal, state, and local governments, health systems, associations and provider groups, health education and accrediting institutions, pharmacies, payers, industry, nonprofits, and academia. This partnership — the NAM Action Collaborative on Countering the U.S. Opioid Epidemic — is committed to sharing knowledge, aligning ongoing initiatives, and addressing complex challenges that require a shared response from public and private actors. The collaborative will establish shared priorities, identify unmet needs, and develop and disseminate evidence-based, multi-sector solutions to reduce rates of opioid misuse and improve outcomes for individuals, families, and communities affected by addiction.

“Since it was declared a public health emergency in October 2017, so many organizations are working around the clock to reverse the opioid epidemic, yet progress has been slow,” said Victor J. Dzau, NAM president and chair of the collaborative. “The problem is clearly not absence of will, but insufficient alignment and coordination across sectors. The complex drivers of the opioid epidemic make it impossible for any single organization or professional sector to make a significant impact on its own. This one-of-a-kind public-private partnership will bring stakeholders from government, academia, the health care industry, health education, and communities impacted by addiction under the same roof to build collective solutions and accelerate the pace of progress.”

Since 1999, the number of opioid-related deaths — from both prescription opioids and illegal drugs including heroin, fentanyl, and carfentanil — has quadrupled. Driven in large part by the opioid epidemic, drug overdose is the leading cause of accidental death in the U.S., resulting in 170 deaths every day. Addiction and overdose not only destroy individual lives, but erode the health and prosperity of entire families and communities. The economic toll is significant; according to the President’s Council of Economic Advisers, the opioid crisis cost $504 billion in 2015, or 2.8 percent of gross domestic product.

The collaborative will focus on areas such as the over-prescription of opioids for treatment of pain, where progress requires the involvement of clinicians, researchers, and regulators; inadequate health provider education and training, for which improvement depends on the commitment of educators, accrediting institutions, and specialty organizations across the health professions; and under-treatment of opioid use disorders, which requires health industry innovation and collaboration with policymakers and care providers at all levels to achieve progress.

The collaborative’s steering committee includes leadership from U.S. government, health care industry, philanthropy, and the nonprofit and education sectors. In addition to Dzau and co-founding partner Ruth Katz, vice president and executive director of the Health, Medicine, and Society Program at the Aspen Institute, the initiative is co-chaired by ADM Brett Giroir, assistant secretary for health and senior advisor for mental health and opioid policy in the U.S. Department of Health and Human Services; and Jonathan Perlin, president of clinical service and chief medical officer at HCA Healthcare. Other members of the steering committee are Helen Burstin, executive vice president and chief executive officer for the Council of Medical Specialty Societies; Thomas Nasca, president and chief executive officer of the Accreditation Council for Graduate Medical Education; and Alonzo Plough, chief science officer and vice president of research-evaluation-learning at the Robert Wood Johnson Foundation.

“It is clear that no single institution nor sector can solve the opioid crisis alone,” said Giroir. “The only viable approach to addressing the opioid misuse epidemic, the most pressing public health challenge of our time, is through multi-sector collaboration and a patient-centered approach. This collaborative brings the best from academia, industry, nonprofits, and public service to identify opportunities and recommend bold action plans to yield results.”

“The Aspen Institute is honored to be partnering with the National Academy of Medicine to address this pressing public health epidemic,” said Katz. “The action collaborative builds on our previous work, bringing together all the key players to develop and support a national, coordinated response to the crisis. This is exactly the kind of focus, commitment, and engagement long needed to get the job done.”

“With the privilege of 30 million patient care episodes annually, HCA Healthcare brings broad clinical insight and commits support to the National Academy of Medicine’s critical work to galvanize the public and private sectors in effectively combating the root causes of the opioid epidemic,” said Perlin.

Included among the collaborative’s supporting organizations are: U.S. Department of Health and Human Services (Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Food and Drug Administration, National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration), Department of Veterans Affairs, Aetna, American Hospital Association, American Medical Association, Aspen Institute, Association of American Medical Colleges, Accreditation Council for Continuing Medical Education, Accreditation Council for Graduate Medical Education, Council of Medical Specialty Societies, Federation of State Medical Boards, HCA Healthcare, Milken Institute, and the Robert Wood Johnson Foundation.

Collaborative members will establish goals and working groups to develop collective strategies in priority areas identified at the first meeting on July 27, such as education and training; prescribing guidelines and evidence standards; treatment and community approaches; communication, culture, and stigma; and research and data. Future activities will include meetings and workshops, expert publications, public engagement strategies, and the development of an information hub to share knowledge and best practices, among other efforts. Visit nam.edu/opioidcollaborative for more information and to see a complete list of participating organizations.

The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.

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#OpioidCollaborative

The National Academy of Medicine (NAM) along with the U.S. Food and Drug Administration’s Center for Tobacco Products (CTP) have named the 2018-2019 class of FDA Tobacco Regulatory Science Fellows.  Six individuals were selected through a highly selective national competition based on their exceptional, diverse professional qualifications to contribute to the work of CTP.

The 12-month fellowship will begin in September at CTP headquarters in Maryland.  Each fellow will be assigned to an office within CTP.  The fellows will lead specific projects related to tobacco-product regulation, as well as actively participate in the development of CTP’s science-based public health strategies.  In addition, they will participate in structured orientation and professional development activities, including opportunities to meet with FDA, CTP, and U.S. Department of Health and Human Services leadership.  The fellows will also receive mentorship from senior staff at CTP who will guide them throughout the fellowship.  The goal of the experience is to enrich the fellows’ understanding of tobacco products, including their health consequences, and provide opportunities to learn about and contribute to the tobacco regulatory activities of a prominent public health regulatory agency.

“This fellowship offers a unique opportunity for trainees to learn directly from the nation’s top experts in tobacco product regulation and apply their diverse expertise to contribute to public health and regulatory activities,” said NAM President Victor J. Dzau.  “The NAM is pleased to work alongside the FDA Center for Tobacco Products to offer this collaborative and productive program for these six emerging leaders in tobacco regulatory science.”

 

The 2018-2019 fellows are:

  • Frank Bandiera, Ph.D., assistant professor, School of Public Health, University of Texas, Dallas
  • Megan Hicks, M.P.H., executive director, South Carolina Tobacco-Free Collaborative, Columbia
  • Catherine Kemp, M.H.A., doctoral candidate, Tobacco Center of Regulatory Science, School of Public Health, Georgia State University, Atlanta
  • Mauricio Rangel-Gomez, Ph.D., postdoctoral fellow, Tobacco Center of Regulatory Science, School of Public Health, University of Maryland, College Park
  • Samantha Reilly, Ph.D., postdoctoral scholar, Tobacco Center of Regulatory Science, department of public health sciences, Pennsylvania State University, Hershey
  • Jamie Tam, Ph.D., researcher, department of health management and policy, University of Michigan, Ann Arbor

 

“We welcome the new class of fellows and are pleased to have the opportunity to work with these bright leaders,” said Mitch Zeller, director of FDA’s Center for Tobacco Products. “CTP offers an exciting public health experience to the fellows marked by cutting-edge research, policy and regulatory authority, and the opportunity to work with a truly dynamic staff.”

Launched in 2012, the FDA Tobacco Regulatory Science Fellowship Program aims to provide an opportunity for mid-career professionals to gain experience and expertise to further define and develop the field of regulatory science as it relates to tobacco products and FDA’s authorities under the Family Smoking Prevention and Tobacco Control Act.  For more information, visit https://www.tobaccoregulatorysciencefellowship.org.

The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond.  It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community.  Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors.  The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.

 

Contacts:

Dana Korsen, Media Relations Officer

Andrew Robinson, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail news@nas.edu

national-academies.org/newsroom

Follow us on Twitter at @theNASEM and @theNAMedicine

The National Academy of Medicine (NAM) today announced the Emerging Leaders in Health and Medicine. The individuals are early- to mid-career professionals from a wide range of health-related fields, such as basic and translational science, clinical medicine, bioengineering, federal health policy and law, and ethics.  Young leaders in this program are selected by NAM leadership to engage in a variety of activities throughout the National Academies of Sciences, Engineering, and Medicine (National Academies) over a three-year term.  Activities include biannual meetings in Washington, D.C., with NAM leadership; planning an annual Emerging Leaders Forum; participating in National Academies convening activities (such as standing committees, forums and roundtables, planning committees for workshops, and report review panels); publishing NAM Perspectives; and attending the NAM’s annual meeting each October.

“These exceptional individuals were selected to the National Academy of Medicine’s Emerging Leaders in Health and Medicine program for their leadership attributes and because they are poised to shape the future of health and medicine,” said NAM President Victor J. Dzau.  “I look forward to engaging these impressive individuals, who are the next generation of scientists, health care providers, public health professionals, and policymakers, to develop a network of young leaders and catalyze innovative and cross-disciplinary activities addressing some of the most pressing challenges in health and medicine.”

The emerging leaders are:

  • Paul Christopher, Ph.D., assistant professor of psychiatry and human behavior, Brown University
  • Deidra C. Crews, M.D., Sc.M., associate professor of medicine, division of nephrology, and associate vice chair for diversity and inclusion, department of medicine, Johns Hopkins University School of Medicine
  • Adaeze Enekwechi, Ph.D., vice president, McDermott+Consulting
  • Lori Freedman, Ph.D., assistant professor, department of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco
  • Christopher Friese, Ph.D., R.N., AOCN, FAAN, Elizabeth Tone Hosmer Professor of Nursing, and director, Center for Improving Patient and Population Health, University of Michigan
  • Jordan Green, Ph.D., professor of biomedical engineering, ophthalmology, oncology, neurosurgery, and materials science and engineering, Johns Hopkins University School of Medicine
  • Marcia Haigis, Ph.D., associate professor, department of cell biology, Harvard University
  • Sandeep Kishore, M.D., Ph.D., M.Sc., associate director, the Arnhold Institute for Global Health, Icahn School of Medicine, Mount Sinai Health
  • Mark Neuman, M.D., assistant professor of anesthesiology and critical care, University of Pennsylvania
  • Minal Patel, Ph.D., M.P.H., John G. Searle Assistant Professor, health behavior and health education, University of Michigan
  • Suchi Saria, M.Sc., Ph.D., John C. Malone Assistant Professor, department of computer science, Johns Hopkins University
  • Margaret (Gretchen) L. Schwarze, M.D., M.P.P., associate professor, division vascular of surgery, University of Wisconsin
  • Julie Segre, Ph.D., chief and senior investigator, translational and functional genomics branch, National Human Genome Research Institute, National Institutes of Health
  • Jacob Sherkow, J.D., professor of law, Innovation Center for Law and Technology, New York Law School
  • Hanni Stoklosa, M.D., M.P.H., instructor in emergency medicine, Brigham and Women’s Hospital, Harvard Medical School
  • Sohail Tavazoie, M.D., Ph.D., Leon Hess Associate Professor and head, Elizabeth and Vincent Meyer Laboratory of Systems Cancer Biology, The Rockefeller University
  • Claire Wang, M.D., Sc.D., M.S., associate professor, health policy and management, Mailman School of Public Health, Columbia University
  • Jonathan Watanabe, Pharm.D., M.S., Ph.D., BCGP, associate professor of clinical pharmacy, University of California, San Diego
  • Joseph C. Wu, M.D., Ph.D., Simon H. Stertzer MD Professor of Medicine (Cardiology) and Radiology, and director, Stanford Cardiovascular Institute, Stanford School of Medicine
  • Ramnik Xavier, M.D., Ch.B., chief of gastroenterology and director the Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital; Kurt Isselbacher Professor of Medicine, Harvard Medical School; and member, Broad Institute

 

The Emerging Leaders program facilitates opportunities for mentorship, collaboration, and innovation among the participants, NAM members, and experts across sectors.  Emerging leaders provide valuable input and feedback to help shape the priorities of the NAM and sustain its impact and reputation as a national leader in advancing knowledge and accelerating progress in science, medicine, policy, and health equity.

Inaugural Emerging Leaders Forum

The emerging leaders are planning the inaugural NAM Emerging Leaders Forum, to be held in Washington, D.C., April 11-12, 2019. The forum will provide an opportunity for invited participants to share their activities and insights on cutting-edge developments in a wide range of fields through collaborative work and interdisciplinary discussions among the nation’s evolving leadership in health and medicine.

The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond.  It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community.  Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors.  The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.

Contacts:

Dana Korsen, Media Relations Officer

Andrew Robinson, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail news@nas.edu

national-academies.org/newsroom

Follow us on Twitter at @theNASEM and @theNAMedicine

 

Introduction

In eastern Uganda, a regional hospital receives a much-needed donation: an x-ray machine that appears to be in good working condition upon arrival. The hospital staff quickly puts the machine to use, only to have it fail during a procedure. With no trained biomedical technicians at the hospital, the machine sits unused for months. Eventually, an available technician is located in Kampala. He travels to the hospital and examines the machine, identifying the replacement part that is likely needed, but he cannot verify the part without the machine’s accompanying manual. The hospital finds the new part to be more costly than anticipated and must be special ordered because it is not available in the country. When balancing the costs against the other demands on its limited budget, the hospital administration regretfully decides it cannot afford to spend time and money on securing the new part. Despite the need for its services, the x-ray machine remains out of use.

Medical devices [the terms “medical device” and “medical equipment,” are used interchangeably here (see [1] for full definitions)] like the x-ray machine have been deemed essential to health care systems in the prevention, diagnosis, and treatment of illness and disease for all populations. The advances and innovation of medical devices over time have improved accuracy, efficiency, and efficacy within health care systems, allowing people to live longer, healthier lives. However, health systems in low-income countries (LICs) often have limited access to even seemingly commonplace medical devices (the authors chose to direct their discussion toward low-income countries due to the greatest need for medical device donation in these settings). As a result, these countries rely heavily on donations, with some LICs receiving donations that make up 80 percent of their supply of medical devices [2]. While most donations are given with the intent to strengthen health systems and improve the well-being of the populations being served, an estimated 40 percent of donated medical equipment in developing countries is out of service [3]. As the example from Uganda illustrates, this mismatch between intentions and usability results from breakdowns that can occur at many points in the complex system of donations.  As countries evaluate the capacity of their health systems in response to the United Nations Sustainable Development Goals [4], the lack of available appropriate medical devices and the impact on health outcomes in LICs are put into clearer focus. Health systems depend in part on a supply chain that ensures access to high-quality, safe, and reliable medical products (http://www.wpro.who.int/health_services/health_systems_framework/en). If the supply chain, which is inclusive of all activities and resources involved from acquisition to delivery, results in medical devices that are unusable or inappropriate to treat patients, then the health system is disadvantaged—impeding the delivery of the highest quality of care. In LICs, health systems are often less equipped to handle any breakdown in the supply chain. In these countries, the donation of medical devices that are inappropriate or unusable can be costly, burdensome, and potentially detrimental to the health system that it is purporting to aid.

To increase the percentage of donated medical devices that succeed in strengthening the capacity of health systems in LICs, we, the authors of this paper, have identified three key areas for further exploration and research: quality and appropriateness of the donations, sustainability after the donation is made, and visibility of the flow of donations globally.

In this paper, we aim to:

  1. Describe the major identified barriers impacting these three areas;
  2. Acknowledge existing guidance that has been developed to address them;
  3. Introduce approaches employed by donors based on existing guidance or experience, and;
  4. Recommend targeted action to improve the system of donations overall.

 

Key Barriers to Successful Donations

Several barriers preventing high-quality and appropriate donations, the sustainability of donations, and the optimization of donations have been identified.

There is often a mismatch between the types of equipment that are needed or usable and those that are received. In addition to getting donations that are faulty or nonfunctioning, hospitals may receive donations that they already carry in surplus or cannot accommodate because their facilities do not meet the initial mandatory device requirements, such as a running supply of distilled water or a supply of oxygen. Equipment may be sent with operating manuals in languages that are unfamiliar to recipients or without instructions altogether. Equipment also may be given without crucial parts or consumables that are specific to the device and are unavailable, or difficult or costly to obtain in the receiving country [5]. Sometimes hospitals receive a much-needed device as a donation, but during setup and testing, hospital staff realize that the electrical plug needed to run the device is incompatible with their country’s electrical outlets. Even more problematic are devices that do not align with the frequency or voltage capacity of recipient facilities. These types of issues may seem minor but will be an ongoing cost to the hospital in time and resources, and sometimes prevent the use of donations altogether.

Keeping a donation in use largely depends on whether the recipient’s setting can sustain the long-term operations and costs of the device. Long-term needs include maintenance and management systems to use donated equipment, sufficient financing to operate and maintain it, adequate infrastructure, supply of consumables, and trained equipment users [5]. In LICs, these needs often go unmet and consequently become significant barriers to the sustainability of donations. Another barrier to sustainability is the lack of local biomedical technician training, leading to a shortage of individuals in the health system adept at using, maintaining, or repairing equipment. Health systems that offer biomedical technician training to build a workforce skilled in medical device maintenance and repair means a greater likelihood that equipment will be in service more often and last longer. Tools and resources, such as a skilled biomedical workforce, are needed in country to sustain donations. Without this ensured sustainability, the value of donations is diminished.

Equipment that is unsustainable will remain unused and must be disposed of, but often, health systems have no established process or dedicated funding for disposal. In 2010, medical equipment was in high demand in Haiti after a disastrous earthquake hit the region. Donations of medical devices, both new and used, arrived quickly to aid hospitals in treating the flood of patients that came with the destruction. The need for medical equipment existed, and donors responded, intending to provide some relief to the country’s overextended hospitals. However, months after the earthquake, a visit to one hospital receiving donations uncovered a bleak scene. A hospital administrator opened a door to a large storage room to reveal stockpiles of abandoned medical equipment. The hospital deemed the equipment useless, sent by donors either damaged or unsupportable given the hospital’s resources. The administrator disappointedly admitted the hospital’s inability to spend spare funds to dispose of the equipment, so it remained as waste. For this hospital, the donations were an overwhelming burden, with few good donations being delivered at the cost of disposal for countless other donations. Adding to the general difficulties of disposal are environmental concerns, including those surrounding equipment containing toxic components. Those disposing of equipment must also consider patient concerns. Equipment may store a patient’s medical information and therefore must be disposed of appropriately to maintain their privacy. Issues around disposal can go beyond being burdensome to causing harm to the environment, patient, and health system.

Donors and other stakeholders have limited access to information about the global donation landscape and, as a result, are unable to maximize the health impact of their donations. The barriers mentioned above focus more on the difficulties experienced by recipient stakeholders, but there are a number of stakeholder groups involved in the medical device donations ecosystem (see Figure 1). Each of these stakeholders affects or is affected by donation issues. Stakeholders approach the donations system in various ways, setting different objectives for donations based on incentives and expertise. As a result, each encounters different challenges, including challenges in the relationships between stakeholders due to a lack of information and communication. Among the considerable challenges shared by stakeholders are the lack of understanding on the part of each stakeholder of the larger donation landscape, of each stakeholder’s roles and responsibilities, and of the role of donations at a global level. These challenges result from a general lack of information on the global supply and demand of donations, such as the identification of the most prevalent types of donations and the countries that send or receive donations. Information on the flow of donations globally grants a visibility that can assist stakeholders in focusing their efforts, allowing them to optimize the health impact of their donations.

FIGURE 1 | Medical Device Donations Ecosystem

SOURCE: Compton et al., “Access to Medical Devices in Low-Income Countries: Addressing Sustainability Challenges in Medical Device Donations,” National Academy of Medicine.   NOTE: The diagram shows the stakeholders in the medical device donations ecosystem and some of the potential interactions and flow of equipment among them. Donors, medical surplus recovery organizations, and end users are highlighted to note their importance as primary stakeholders. Development assistance agencies and funders are placed separately to note their supportive roles in the ecosystem. They may interact with a number of stakeholders at different points to aid the flow of equipment in the import or export country.

Existing Guidance and Approaches for the Donation of Medical Devices

Stakeholders may consult existing guidance on donations to develop or improve their understanding and approaches in ways that address some of the recurring barriers in the donations system. A number of guidelines, checklists, and frameworks have been developed to steer donors and recipients from procurement to donation. Guidance has primarily focused on two areas: 1) informing donors of best practices, helping them overcome established challenges when donating medical equipment to LICs and 2) empowering and equipping recipient organizations and local public-sector actors in the decision-making process of accepting or declining donations. Prominent guidance has come from the World Health Organization (WHO), the Catholic Health Association of the United States (CHA), MedSurplus Alliance (MSA), Partnership for Quality Medical Donations (PQMD), and Tropical Health Education Trust (THET).

Over a decade ago, WHO first published guidance on medical equipment donations. WHO prepared this guidance in close collaboration with a number of national and international organizations from both high- and low-resource settings. To ensure improved access, quality and use of medical devices globally WHO updated the guidance in 2011 as part of a technical series on medical device issues. The guidance now offers considerations and best practices that may be useful for both donors and solicitors of equipment donations [6]. More recently, WHO has produced guidance for countries regarding the development of regulatory standards for medical devices. The 2017 Global Model Regulatory Framework for Medical Devices recommends guiding principles and harmonized definitions, and specifies the attributes of effective and efficient legally enforceable regulation [7].

CHA surveyed stakeholders at recipient hospitals, health systems, and medical supply recovery organizations (MSROs) to gather input on best practices, determine the greatest advantages of a surplus donation program, and identify additional areas of improvement in the relationships between hospitals and MSROs. The research resulted in a framework of leading practices for use at the hospital and health system levels to increase the quality and appropriateness of medical surplus donations [8].

Using external assessments and the knowledge and experience of its membership, PQMD has provided practical advice for donors and distributing partners on managing the supply of medical product donations in a manner consistent with WHO Guidelines for Drug Donations. The PQMD guidelines focus on products donated from an original manufacturer directly to a nongovernmental organization (NGO) partner [9,1].

The MSA has developed and adopted guidelines in the form of a code of conduct and toolkit geared toward MSROs but promoted to other stakeholders as well. The code of conduct comprises voluntary standards of practice to guide the operations and decision making of MSROs. The toolkit provides supporting guidance through examples of best practices and other resources to help MSROs understand and follow the code of conduct. Additionally, an MSA accreditation program gives MSRO members the opportunity to assess their adherence to the code to improve donation practices [10].

Using prior research and case studies, THET has created a toolkit for the United Kingdom and developing countries engaged in health partnerships. The toolkit offers practical guidance on supplying and shipping medical equipment donations, ensuring donations are put into effective use, and maintaining donations for long-term use. THET aims for the toolkit to guide both donors and recipients on the donation process, but the resource has a stronger focus toward donors, given that logistics and regulations of donations vary by recipient country [5].

Guidelines, like those mentioned, offer information and best practices for various stakeholders to approach and evaluate how to send and receive usable donations. However, for the guidelines to have an impact on the donations system, each individual stakeholder will need to contextualize them for their specific organization. As stakeholders approach the donations process and apply existing guidance in different ways, perhaps lessons can be learned from how the following individual companies consider equipment donation.

Global medical technology companies such as Becton, Dickinson and Company (BD) and Medtronic are active medical equipment donors and member organizations of PQMD. (In addition to developing donation guidelines, PQMD is a membership organization. It is composed of different stakeholders in the donations ecosystem in order to facilitate collaboration among members through knowledge and experience sharing: https://www.pqmd.org/). In its mission to provide quality health care for vulnerable populations and to improve patient outcomes, BD approaches its medical equipment donations with attention to sustainability. When considering equipment or instrument donations in a particular country, BD first works with an NGO partner to conduct a needs assessment to determine suitability. During this stage, BD ensures that the necessary technical support is in place in the event the equipment will require maintenance or replacement of parts. In managing the donation process, BD treats the recipient as a customer, setting up a two-year customer service agreement for applicable donations. Building the service agreement into the donation streamlines the process for the end user in the event that a technician is needed to make equipment repairs. BD’s service agreement typically includes a requirement for it to donate the materials (e.g. reagents) necessary to operate the product for two years, mitigating any possible interruptions in the use of the product that may be due to a lack of consumables. BD’s Social Investing Department covers the cost of the equipment and the service agreement.

At Medtronic, organizations requesting product donations for delivery outside the United States must complete a form of eligibility and sign a certificate of compliance to be considered as a potential recipient. Both requirements reference product sustainability. The eligibility form asks organizations if local physicians are adequately trained to provide patient follow-up care. The certificate states that the requestor must guarantee the ongoing maintenance of any equipment received, appropriate product storage controls, and the presence of quality and safety measures on site (http://www.medtronic.com/us-en/about/corporate-governance/medtronic-charitable-donations/donation-request-forms.html). Medtronic also works closely with donation partners—Americares, Direct Relief, and MedShare—to distribute product donations to nonprofits and clinics globally (http://www.medtronic.com/covidien/en-us/support/us-customer-service/product-donations.html).

The GE Foundation, the philanthropic arm of General Electric, is also thinking critically about the sustainability of medical equipment in low-resource settings. In 2004, GE Foundation established the Developing Health Globally™ program, which works to improve access to quality health care for vulnerable populations. The program supports capacity building by upgrading equipment and infrastructure, and providing ongoing training and support in country. All equipment upgrades are carefully managed through comprehensive service contracts and training at the facility level to account for sustainability. GE Foundation partnered with Assist International, Engineering World Health, and the Developing World Healthcare Technologies Lab at Duke University to develop an evidence-based curriculum for biomedical equipment technicians that can be used in local training programs. In collaboration with ministries of health, the program has established in-country training programs in Cambodia, Ghana, Honduras, Nigeria, Ethiopia, and Rwanda, and provides ongoing resources to foster a professional community of biomedical technicians. Furthermore, the GE Foundation partnered with the AAMI (Association for the Advancement of Medical Instrumentation) Foundation to develop recommendations for a scalable, replicable, and sustainable model to train biomedical equipment technicians in low-resource settings [11]. Recently, as part of the Safe Surgery 2020 commitment [12], GE and partners coordinated with the Ethiopian Federal Ministry of Health and regional health bureaus in the Ethiopian cities of Amhara and Tigray to install ultrasound machines, anesthesia machines, and patient monitors. In considering the proper management of medical devices, program partner Assist International conducted user training with clinical care providers and biomedical equipment technicians, among others. All of the products will be monitored over a three-year period, in partnership with GE Healthcare.

A Direction Forward: Addressing Knowledge Gaps and Identifying Solutions

The capacity of health systems in LICs relies partly on the donation of medical devices to determine the level and quality of care provided to their populations. However, significant barriers to the usability and sustainability of donations persist, disadvantaging health systems. Creating an effective medical device donations system, where needs are met and failures in donated equipment are minimal, requires a whole systems approach. Applying this approach will take time and significant resources, but meanwhile, stakeholders can still work to identify interventions and solutions that can be easily developed and implemented to target parts of the health system that are ripe for improvement. For example, one often-cited barrier to the sustainability of medical device donations is the lack of technical expertise to use, maintain, and repair donated devices. Innovative solutions can be developed to target training on managing donated devices for engineers, technicians, and users. These solutions could strengthen the health system more broadly by building capacity to not only maintain donated equipment but also increase capabilities to service new technologies. Stakeholders may also identify opportunities where solutions can be integrated into other health system priorities and initiatives—for example, addressing health system infrastructure capacity such as the development of safe surgery facilities to support the use of donated equipment. Another low hanging opportunity lies in educating those stakeholders that are not directly involved in making or procuring donations, so they are aware of the extent and nature of donation issues. Increasing their understanding of the issues can help to build support for making improvements. Ultimately, recognizing key opportunities for targeted interventions and solutions could expedite improvements in the medical device donations system.

While these small-scale solutions are being piloted, the larger field of medical device donations must advance a global research initiative to improve the understanding of the donations system landscape among all stakeholders identified in Figure 1, illuminate the specific needs across countries and regions, and identify potential system-level interventions. There are several key gaps in knowledge that a global research initiative may explore to better understand and address the most prevalent barriers to the medical device donations system, including:

Evaluation of the efficacy and impact of guidance for donors and recipients at a global, country, or organizational level. Assessing the efficacy and impact of existing guidance may generate best practices that allow future donors and recipients to steer their relationship in a manner more conducive to evaluation. Such evaluation may subsequently lead to improvement in the quality and appropriateness of donations. A critical piece of this evaluation would be obtaining feedback from recipients on what devices are needed prior to donation, what donations are usable or nonfunctioning after they are received, and when donations are not wanted altogether. Recipients may not have the opportunity to provide feedback, or they may be hesitant to be forthright out of concern of losing donations altogether or fear of damaging the relationship with a donor. To offer effective feedback, recipients must first feel empowered to make decisions based on their interests, which may include declining donations. Empowering recipients to have a voice and take action to benefit the populations they serve is an important part of the process of evaluation. Empowerment and feedback are complicated issues to address, but stakeholders must begin to work through these issues to fully discern the value and suitability of guidance for different stakeholder groups. For donors, as an important first step in evaluating whether existing guidance is useful for their operations, they must critically review their donation practices against existing guidance to determine where they are meeting the standards or falling short.

Routine collection of data on the effects of donations on recipients at all levels of health care delivery. Routinely reviewing the effects of donations may have broad consequences in determining their value and health impact. Data can indicate whether a donation is put to use and its level of benefit or harm. For example, a donation may be beneficial in treating a population but may be too costly for hospital administration to maintain, decreasing the likelihood that the donation will be sustained. Data can be collected to evaluate the costs incurred in making donations, receiving donations, and disposing of donations. This data can build research around the economic impact of failed donations, which stakeholders can then use to justify improvements to their donation processes. Data may be conveyed to donors to highlight the need for increased assessment of their donations, to better ensure that the donation is high quality, appropriate, and valuable to the recipient’s setting. Donors may also use data in their donation strategies to maximize benefit and minimize cost to the recipient, ultimately increasing the prospects for sustainability. Data collection may also be used to isolate trends and identify gaps in health care. This evidence can serve to build interest at the local, regional, or country level in integrating medical equipment needs into the planning of the health system. Identifying which equipment is most valuable to the specific health needs of a setting and building the health system with that knowledge may increase the number of lives saved or improved. Obtaining recipient feedback is a critical factor in accurate data collection, alongside strengthening the capacity of hospitals or health centers in developing countries to have the systems, infrastructure, funding, or trained staff in place to monitor, collect, and transfer data.

Country-specific information on medical device donations. Understanding a country’s existing policies on donations can illuminate some of the incentives for making donations that are specific to the country, as well as the barriers that prevent effective and sustainable donations. Making country-specific information clear and available to stakeholders can result in better coordination between donors and recipients to accommodate barriers. It can also result in better coordination to develop country-specific solutions to those barriers, so the quality of donations is not compromised. Having information up front on a country’s policies and process for donations, including the types of donations that are allowed, reduces waste in country and reduces inefficiencies for the donor. This information can also push countries to address major barriers, such as difficulties with infrastructure and supply chains, inadequate health system policies on the ground, and weak procurement and regulatory systems.

Information on the global supply and demand of medical device donations. While country-specific information is needed, global visibility on where donations are needed, going to, and coming from is also imperative. This information informs donors, MSROs, and other stakeholders on the donation-making side about where to focus their efforts. Mapping the supply and demand of donations can shed light on the types of donations that are most prevalent and those that are scarce. This kind of visibility can be useful in managing and optimizing the flow of donations so that dissemination of donations is more equitable and donors can respond to equipment needs more quickly and appropriately. Greater access to this kind of information could increase coordination among multiple donors and recipients, and invite participation from new donors to fill gaps in supply. Increased transparency could also allow donors to pool resources for securing equipment that is most in demand, and for supporting the creation of a supply depot that can provide replacement parts and group trainings to fix commonly encountered issues with the most used medical devices. In the end, global visibility is needed for a whole systems approach to donations. A whole systems approach recognizes that different stakeholders manage different components of the donations system, but each component affects and influences the others. A whole systems approach requires integration and coordination among the strategies of all stakeholders identified in Figure 1, and this cannot be achieved without increased global visibility.

Ultimately, we, the authors of this paper, encourage stakeholders in the medical device donations ecosystem to take steps now to develop and implement smaller scale innovative solutions that may tackle some of the recurring challenges in making and receiving donations. While these steps are underway, we call for a broad effort to further research on the quality and appropriateness, in-country sustainability, and global visibility of all medical device donations. We call for in-depth research in these areas to improve the process and outcomes of the medical device donations system, to strengthen health systems, and, more broadly, to support the health and development of receiving LICs.

 


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Tweet this!  A surprising amount of biomedical equipment donated to low-income countries sit unused. Our most recent #NAMPerspectives discussion paper explores how to make those donations more sustainable: https://doi.org/10.31478/201807a

Tweet this!  An estimated 40% of donated medical equipment in developing countries is broken and/or inoperable. Read more on what changes can be implemented to render donations more effective: https://doi.org/10.31478/201807a #NAMPerspectives

Tweet this!  Medical equipment donations in low-income countries are often not effectively utilized. Discussing the importance of implementing strategies to better utilize these valuable contributions is an essential step toward better health for all: https://doi.org/10.31478/201807a #NAMPerspectives

Tweet this!  The continued use of medical donations “largely depends on whether the recipient’s setting can sustain the long-term device operations and costs.” Why addressing sustainability challenges is critical to ensuring access to medical devices in low-income countries: https://doi.org/10.31478/201807a #NAMPerspectives

Tweet this!  Research has shown that some medical donations made to low-income countries are burdensome and can even cause harm to the environment, patient, and health system. New #NAMPerspectives discussion paper on how we can change this fact: https://doi.org/10.31478/201807a

 

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References

  1. Partnership for Quality Medical Donations (PQMD). 2018. Guidelines for quality medical product donations 2018. Annapolis, MD. http://www.pqmd.org/wp-content/uploads/2018/05/PQMD-Guidelines-2018.pdf (accessed July 5, 2018).
  2. Howitt, P., A. Darzi, G. Z. Yang, H. Ashrafian, R. Atun, J. Barlow, A. Blakemore, A. M. Bull, J. Car, L. Conteh, G. S. Cooke, N. Ford, S. A. Gregson, K. Kerr, D. King, M. Kulendran, R. A. Malkin, A. Majeed, S. Matlin, R. Merrifield, H. A. Penfold, S. D. Reid, P. C. Smith, M. M. Stevens, M. R. Templeton, C. Vincent, and E. Wilson. 2012. Technologies for global health. Lancet 380(9840):507-535.
  3. Perry, L., and R. Malkin. 2011. Effectiveness of medical equipment donations to improve health systems: How much medical equipment is broken in the developing world? Medical and Biological Engineering and Computing 49(7):719-722.
  4. Kieny, M.P., H. Bekedam, D. Dovlo, J. Fitzgerald, J. Habicht, G. Harrison, H. Kluge, V. Lin, N. Menabde, Z. Mirza. 2017. Strengthening health systems for universal health coverage and sustainable development. Bulletin of the World Health Organization 95: 537–539. http://www.who.int/bulletin/volumes/95/7/16-187476/en/ (accessed July 5, 2018).
  5. Mullally, S. 2013. Making it work: A toolkit for medical equipment donations to low resource settings. London, UK: Tropical Health Education Trust. https://www.thet.org/wp-content/uploads/2017/07/Making-it-Work.pdf (accessed July 5, 2018).
  6. World Health Organization (WHO). 2011. Medical device donations: Considerations for solicitation and provision. Geneva, Switzerland. http://apps.who.int/iris/bitstream/handle/10665/44568/9789241501408_eng.pdf;jsessionid=EC4467468A066D4E76ECA2D49954C1B3?sequence=1 (accessed July 5, 2018).
  7. WHO. 2017. WHO global model regulatory framework for medical devices including in vitro diagnostic medical devices. Geneva, Switzerland. http://apps.who.int/medicinedocs/documents/s23213en/s23213en.pdf (accessed July 5, 2018).
  8. Catholic Health Association of the United States. 2013. Responsible redistribution of medical supplies & equipment: Leading practices for hospitals & health systems. St. Louis, MO. https://www.chausa.org/docs/default-source/international-outreach/responsible-redistribution-of-medical-supplies.pdf?sfvrsn=0 (accessed July 5, 2018).
  9. PQMD. 2017. PQMD guidelines for quality medical product donations. Annapolis, MD. http://www.pqmd.org/wp-content/uploads/2015/07/PQMD-Standard-v6-April-2017-1.pdf (accessed July 5, 2018).
  10. MedSurplus Alliance. 2013. Medical Surplus Recovery Organization code of conduct. http://www.mission-outreach.org/files/manual/57/MSRO%20CODE%20OF%20CONDUCT.pdf (accessed July 5, 2018).
  11. Eder-Van Hook, J. L., and C. Love. 2015. Stakeholder meeting summary: BMETs in low resource countries. Washington, DC: Transition Management Consulting Inc. http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Foundation/GEF-AAMIF_2015_BMET_LRC_Training_Meeting_Summary.pdf (accessed July 5, 2018).
  12. Safe Surgery 2020. Where Are We Making an Impact. http://www.safesurgery2020.org/new-page-1/. (accessed July 6, 2018).

The National Academy of Medicine (NAM) and Robert Wood Johnson Foundation (RWJF) today named the 2018-2019 class of RWJF Health Policy Fellows.  Beginning in September, eight health professionals will spend a year in Washington, D.C., working on health-related legislative and regulatory issues with members of Congress and the executive branch.  They will also engage in seminars and discussions on health policy and participate in leadership development programs.

The fellows were chosen in a national competition for highly accomplished health, behavioral, and social science professionals who have an interest in health policy. Their experiences in Washington will enrich their understanding of federal policy formation and how federal and state governments relate to the mission of their home institutions and local communities.  The fellowship program will commence with an intensive three-month orientation, followed by a nine-month assignment in a congressional office or the executive branch, where the fellows will be involved in health-related legislation and programs.  After their Washington assignment, the fellows will continue to receive support to sustain their development as health policy leaders.

“Federal government policies have a substantial impact on the health of the nation, and health care remains one of the most politically challenging issues that we face as a country,” said Gregg Margolis, director of the RWJF Health Policy Fellows Program at NAM.  “We are proud to bring these exceptional and accomplished professionals to Washington, D.C., to participate in the policy process.  Their deep and practical experience in health care, public health, and research bring ‘real life’ perspectives to federal legislative and regulatory processes.”

The 2018-2019 RWJF Health Policy Fellows are:

  • Brutrinia Cain, J.D., B.S.N., senior legislative analyst, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland
  • Michelle Dennison, Ph.D., R.D./L.D., director, Health Promotion Disease Prevention, Oklahoma City Indian Clinic, Oklahoma City, Oklahoma
  • Kirsten Johnson, M.P.H., health officer, Washington Ozaukee Public Health Department, Port Washington, Wisconsin
  • Ellen Kurtzman, Ph.D., M.P.H., R.N., FAAN, associate professor, School of Nursing, George Washington University, Washington, D.C.
  • Daniel O’Neill, M.A., M.S., former senior vice president and general manager, Medical Network, Change Healthcare Inc., San Francisco, California
  • Kristin Paulson, J.D., M.P.H., vice president of research and innovation, Center for Improving Value in Health Care, Denver, Colorado
  • Samuel Stebbins, M.D., M.P.H., public health and school health physician, Public Health Division, Arlington County Department of Health and Human Services, Arlington, Virginia
  • Carlos Williams, M.D., M.P.H., M.B.A., director, Office of Global Health Engagement, Bureau of Medicine and Surgery, U.S. Department of the Navy, Falls Church, Virginia

 

The RWJF Health Policy Fellows program is the nation’s most prestigious learning experience at the nexus of health, science, and policy in Washington, D.C.  Since 1973, this non-partisan fellowship has offered exclusive, hands-on policy experience with the most influential congressional and executive offices in the nation’s capital.  Over 260 fellows from across the nation have worked hand-in-hand with the best and brightest in federal health policy to gain an insider’s perspective of the political process, develop unmatched leadership skills, and build a professional network that lasts a lifetime.  As chancellors and deans at major academic institutions; presidents of professional societies and voluntary health organizations; leaders in local, state and federal government; and experts at think tanks and advocacy groups, fellows transform the nation’s health care policy and practice.  For more information, visit www.healthpolicyfellows.org.

For more than 45 years, the Robert Wood Johnson Foundation has worked to improve health and health care. RWJF is working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being.  For more information, visit www.rwjf.org.  Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

 

The National Academy of Medicine is also pleased to announce that Lori Trego, Ph.D., C.N.M., FAAN has been selected as the 2018-2019 Distinguished Nurse Scholar-in-Residence. The Nurse Scholar-in-Residence program, formed in 1992, provides a leadership opportunity to participate in shaping health policy for the nation. Dr. Trego hopes to utilize the program to expand her leadership skills and to work to enhance the wellness of women who serve and have served in the military. The Nurse Scholar-in-Residence program is supported by the American Academy of Nursing, the American Nurses Association, and the American Nurses Foundation.

Despite efforts to increase rates of immunization among Medicare patients, especially racial and ethnic minorities, these rates remain well below Healthy People 2020 targets [1]. It is not difficult to conclude that we need to learn more about how and why people choose to receive or not receive immunizations. In 2017, the Roundtable on Health Literacy at the National Academies of Sciences, Engineering, and Medicine commissioned a project taking a qualitative approach to this complex issue [2].

The goal of the project was to step outside the published literature and population-level data and speak to those with on-the-ground experience in promoting and administering immunizations to people over 65. We were interested in learning about the experiences of immunizers in a variety of settings and in identifying what medical, public health, and pharmaceutical health professionals considered their most successful strategies for immunizing their patients and customers. Specifically, we were interested in whether strategies were being undertaken in accordance with the principles of organizational health literacy—that is, that immunizations are convenient and accessible; that patients are given useful, easy-to-understand information; and that impact and outcomes of the strategy are reviewed. To do this, we conducted telephone interviews with 23 health care professionals in 11 states. We identified interviewees by contacting the American Pharmacists Association, the American College of Physicians, the National Association of Community Health Clinics, colleges of pharmacy and medicine, departments of public health, and nonprofits serving seniors.

Health care professionals we interviewed believed that immunization was part of their mission and that it was important to reach out, connect, and communicate with their patients. Most providers said the key to immunizing patients is genuinely caring for them, knowing current guidelines, and being confident in informing them. The health professionals also shared the view that most adults 65 and older were receptive to influenza (flu) and pneumococcal (pneumonia) immunizations. The interviewees all believed that most resistance to immunization could be overcome with clear, respectful explanations of the vaccines and how they work. With regard to population-level differences in vaccine resistance, several interviewees told us that in their view, it is a myth that African Americans are particularly resistant to receiving vaccines. Everyone we spoke with emphasized the importance of earning the trust of patients and customers and being considered members of the communities they served.

Although many of our interviewees emphasized the importance of building a personal relationship with patients and customers, they also spoke of the importance of a well-designed workflow that promotes and supports immunization. Successful strategies for pharmacies, clinics, and community agencies were driven by senior leadership and tailored to fit the needs of the site and the patients they served.  In these organizations, leadership set immunization as a priority, promoted up-to-date training on current guidelines, and viewed staff as key in recommending vaccines. The people we interviewed believed that the most effective systems provide all staff with training based on the recommendations of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Tracking progress and providing incentives were also hallmarks of successful systems, according to the providers we interviewed. Tracking and incentivizing success not only promoted teamwork but also showed the organizational leadership’s commitment to immunizations.

The providers we interviewed also spoke of many challenges. Clinics found that tracking of immunizations was often problematic if patients did not receive immunizations on-site. Commonly used tracking systems do not allow pharmacies and clinics to easily share information. All states have immunization registries, but they are not commonly used for adult vaccines, except in public health clinics. Smaller clinics struggled to keep enough vaccines in stock without over-ordering. In addition, providers who served largely low-income populations told us that even when immunizations are covered by Medicare, patients often experience barriers that prevent immunization. For example, several rural providers noted that transportation and the distance patients had to travel to reach the clinic were barriers to receiving immunizations.

This project has a number of limitations. We asked our interviewees to relate their experiences and personal views. Thus, the information we gathered is entirely anecdotal. In addition, due to time constraints, we were limited in the number of people we could interview. We tried to mitigate this by interviewing a diverse group in terms of the type of provider, organization, and geographic location. In spite of these limitations, however, we believe that this project has much to offer to others engaged in immunizing adult populations. The people whom we interviewed were dedicated and knowledgeable and shared valuable insights into their work.

This paper provides an opportunity to address the issues surrounding low immunization rates among older adults, particularly in areas where immunization rates still fall short of national goals and disparities between different groups remain. This project may help us move closer to achieving national immunization goals for seniors and to eliminating disparities. The providers interviewed saw immunizing adults over 65 as part of their mission and viewed the provision of flu and pneumonia immunizations as a process rather than a discrete task on a checklist. Successful immunizers were patient- and community-centered and had taken steps to gain the trust of people they served. Every provider we spoke with viewed trust as a key component of successful immunization efforts. They adopted a systems approach that aligned closely with the attributes of a health-literate organization. Although not all used the words “health literate” to describe their approach to immunizations, they were, in fact, following the principles of health literacy in their day-to-day work by meeting people where they are, streamlining the process within the organization, addressing concerns in everyday language, and confirming individuals’ understanding.

 


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Tweet this! In our newest NAM Perspectives Commentary, authors conducted interviews with immunization providers across the country to investigate why vaccination levels remain well below Healthy People 2020 targets: http://ow.ly/88cS30kyglL

Tweet this! Health care professionals working to ensure that America’s aging population is appropriately vaccinated must be supported by well-designed workflows and robust data-sharing systems: http://ow.ly/88cS30kyglL

Tweet this! “Successful immunizers were patient- and community-centered and had taken steps to gain the trust of people they served.” Learn more about immunization strategies based on organizational health literacy in our newest NAM Perspectives: http://ow.ly/88cS30kyglL

 

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References

  1. Williams, W. W., P. J. Lu, A. O’Halloran, D. K. Kim, L. A. Grohskopf, T. Pilishvili, T. H. Skoff, N. P. Nelson, R. Harpaz, L. E. Markowitz, A. Rodriguez-Lainz, and A. P. Fiebelkorn. 2017. Surveillance of vaccination coverage among adult populations—United States, 2015. Morbidity and Mortality Weekly Surveillance Summary 66(SS-11):1–28. https://www.cdc.gov/mmwr/volumes/66/ss/ss6611a1.htm (accessed May 9, 2018).
  2. Davis, T. C., C. Arnold, and J. A. Dillaha. 2018. Can the attributes and practices of immunization providers successfully address racial and ethnic disparities in immunization rates among Medicare patients? Lessons learned from conversations with providers. Washington, DC: Roundtable on Health Literacy, The National Academies of Sciences, Engineering, and Medicine. http://nationalacademies.org/hmd/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Commissioned%20Papers%20-Updated%202017/Davis%20et%20al%202018%20Can%20the%20Health%20Literacy%20Attributes%20and%20Practices%20of%20Immunization%20Providers%20Successfully%20Address%20Disparities.pdf (accessed May 9, 2018).

 

The young nurse returned to room seven. Finishing up her charting just a moment earlier, she glanced at her watch and knew she couldn’t postpone going into his room any longer, despite the disconcerting vibe she got each time she went in there.

Room seven was still dark and the patient was still grinning. Glasses were still cloudy and eyes were still staring. Scanning the room, the young nurse realized that she and the doctor had left the place in shambles in their rush to escape. As she started to gather the waste, she noted a capped, pink syringe, the 20-gauger from the failed attempt [at IV insertion] earlier. The young nurse inwardly groaned. Had her manager made it in there before her, she would have never heard the end of it: You left a needle within reach of an encephalopathic patient?? What were you thinking?!

Well, she certainly was thinking now. She picked up the needle and felt a stab.

Jordana Kozupsky refers to herself in the third person in this excerpt from a narrative essay, “My Infected Reality,” that she composed in a writing course for graduate nursing students in 2015. Here, the nurse returns to the room of a patient infected with HIV who had violently resisted her and a physician’s earlier attempts at inserting an IV.

Did the needle pierce the patient’s skin before penetrating her own, thus exposing her to a serious infectious disease? She can’t be sure, and Jordana’s reality becomes infected by panic, flashbacks, and nightmares, leaving her unable to take the step of getting tested. Her writing explores an unfortunately common workplace trauma for nurses—needlestick and its aftermath—by echoing its disturbing effects on her life.

In 2010 at the Hunter–Bellevue School of Nursing (HBSON) in New York, Diana Mason, PhD, RN, FAAN; Joy Jacobson, MFA; and Jim Stubenrauch, MFA, devised a curriculum designed to address the academic challenges displayed in the writing of many nursing students: plagiarism, poorly organized ideas, and inadequately sourced scholarly material [1]. Though there are various theories about how best to approach such deficits, what distinguished this course was that it sought to improve scholarly performance by encouraging reflection and engagement in writing as a process of discovery and artistic exploration. And because it has been shown that when health care workers read literary works and write reflective narratives, it enhances their interpersonal skills, increases job satisfaction and retention, and promotes empathy [2,3], the nursing curriculum was crafted with a dual focus: to build students’ resilience and improve their academic writing. The course was called Writing, Communication, and Healing.

The need for innovative approaches to burnout prevention in the health professions is immense. In one survey of ICU nurses, 85 percent said they wanted a better job, 64 percent reported insomnia, and almost half told of being “emotionally exhausted”—all risk factors for depression [4]. A February 2017 report from the Johnson Foundation’s Wingspread Center concluded that as many as half of new nurses leave the profession in their first two years of work and that all nurses are susceptible to burnout at any stage of their careers [5]. Among other recommendations, the report advises individual nurses to create a “resiliency plan” and institutions to reframe burnout as a workplace injury.

The HBSON writing course model presumes that all people are innate storytellers, even those who have little confidence as writers. This instinct can be useful in fostering resilience, usually defined as a person’s ability to recover quickly from trauma and to restore optimism in the face of adversity [6]. Although resilience in health care providers may be recognized as a necessary quality, it is rare for health care systems or medical and nursing schools to make room for the genuine reflection it requires.

In the HBSON writing course, which is still being taught, nursing students begin to tell their own stories, to experiment with voice and point of view, and to hear their own work and each others. Such writing is not always easy for nurses, but when given support and instruction, many draft resonant narratives about patients whose lives they’ve saved and those who’ve died; about workplace violence and bullying and medical error; about their personal experiences of love and divorce, pregnancy and miscarriage, immigration, intimate partner violence, illness, and death—in short, about their losses, struggles, and triumphs. (One exceptional student’s progress with this model has recently been documented [1].) Also, engagement, investment, and pride in one’s own writing are often crucial first steps in the development of writing competence [8].

Many health professions schools are now focusing initiatives on promoting a culture of wellness. George Washington University’s School of Nursing is one such example (see Box 1).

What allows any of us to acknowledge and respond to our own suffering and that of others? A writing community can guide clinicians in igniting a spark of originality—one that permits them to respond more fully to themselves, to one another, and to their patients.

Writing as Reflection, Community as Strength

Several pedagogical models have informed this writing curriculum.

Writing instructor and journalist Donald Murray wrote that teaching writing as a process of discovery requires instructors to recognize that their first task is to listen to students’ works in progress—“We are not the initiator or the motivator; we are the reader, the recipient”—challenging the received notion that it’s the instructor’s job to edit and correct student papers [8]. One-to-one conferences and guided peer-to-peer feedback strengthen students’ ability to revise their own work and to consider writing a process rather than an event.

Physician Rita Charon and fiction writer Nellie Hermann from Columbia University’s Narrative Medicine program view clinicians’ “narrative capacity”—an essential aspect of their ability to hear and attend to patients’ stories—as a quality strengthened by reflective writing: “Writing is how one reflects on one’s experience so that it can be apprehended and then comprehended” [9].

James Pennebaker and colleagues have studied the effects of expressive writing—writing for 20 minutes a day for several days about a single difficult or traumatic experience—on various populations’ ability to cope with stress and trauma. One literature review found many studies supporting positive effects of expressive writing, perhaps because it imposes structure on the chaos of emotional upheaval, demanding “a different representation of the events in the brain, in memory, and in the ways people think” [10]. Expressive writing has even been shown to speed wound healing [11].

Similarly, poet Gregory Orr examines the ways in which the reading and writing of lyric poetry “orders and dramatizes our subjectivity and externalizes it as language” [12].

Louise DeSalvo integrated Pennebaker’s method into an immersion program in writing as a method of healing from trauma, emphasizing that not all writing culminates in what she calls a “healing narrative.” Such writing, she says, possesses five characteristics [13]:

  • It portrays experience concretely, in rich detail.
  • It connects feelings to events.
  • It balances positive and negative emotion, even as it describes difficulties.
  • It provides insight and reflection.
  • It relates a full and comprehensible story.

 

“Going public” is the last crucial step in DeSalvo’s model. She goes so far as to call the sharing of personal written stories “the most important emotional, psychological, artistic, and political project of our time” [13]. In the HBSON course, in a culmination of the community fostered during the semester, nursing students read from their essays to one another in the last class.

Although this curriculum was created as an academic course, it has been adapted for use in clinical arenas as well. A writing program for working clinicians may include any or all of the following:

  • Meetings begin with “quick-writes,” in which participants write without pausing for 3 to 20 minutes in response to a prompt such as a poem.
  • Writers have the option of reading their quick-writes and more formal writings aloud, without comment from others.
  • Participants agree to write daily, in concrete ways, about their lives and work. Daily journaling is a terrific tool for strengthening reflective capacity and overall writing skill.
  • Group members write about scientific studies in online discussion groups, telling their own stories as they analyze research methods and findings. Studies showing the consequences of professional burnout have generated lively responses from nurses.
  • Participants establish writing goals, especially for longer works, including at least two drafts and significant revision.

 

Support in the form of a regularly scheduled writing group, with set goals, can enhance nurses’ confidence as writers and help them maintain momentum [14,15].

It can be very hard for busy clinicians to maintain a writing practice, but the benefits are clear. In a follow-up survey of HBSON graduate and undergraduate nursing students who took the writing course (23 anonymous responses to 114 e-mailed surveys), nearly all said that the course positively affected their ability to be empathetic with patients and families and that they better understood academic and professional writing to include revision. Perhaps most significant was that 64 percent continued to use reflective journaling at least once per week “to help me deal with the stresses of my job,” 17 percent of them daily (see Box 2).

Jordana Kozupsky is an outstanding exemplar. She has completed her coursework for her doctorate of nursing practice and now heads a peer-tutoring program in writing at her school of nursing. She has also published a piece of writing that began as an assignment in the writing class. In “Teamwork: Caring for Ourselves and Each Other,” Kozupsky reconceives the clinical work place as a community of sustenance rather than a zone of depletion.

She writes, “We all become nurses for the same reason: to help people out. And in this field, ‘people’ doesn’t only denote patients; it denotes our fellow nurses as well” [16].

 


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Tweet this! Burnout in clinicians is widespread, and innovative approaches to combating burnout are needed. Reflective writing provides clinicians with a way of understanding their own trauma in a way they may not have considered before: http://ow.ly/GxDT30ky5A5

Tweet this! Reflective writing is not only for poets. Just 20 minutes a day can help clinicians process the trauma they see when caring for patients and assist in building resilience: http://ow.ly/GxDT30ky5A5

Tweet this! Reflective writing can build confidence, support resilience, reduce burnout and create a community among clinicians. Read about successful programs in our latest NAM Perspectives paper: http://ow.ly/GxDT30ky5A5

Tweet this! Reflective writing allows clinicians the space to look directly at the trauma they have faced, understand it more deeply, and share their experiences with others amidst a culture of silence: http://ow.ly/GxDT30ky5A5

 

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References

  1. Jacobson, J. 2016. “Like a page waiting for music”: Nursing, poetry, and autonomy. In Keeping reflection fresh: A practical guide for clinical educators, edited by A. Peterkin and P. Brett-MacLean. Kent, OH: Kent State University Press.
  2. Clary, B. 2008. Program evaluation, literature and medicine program, final report. http://www.okhumanities.org/Websites/ohc/images/Programs/Literature_and_Medicine/Lit___Med_Program_Evaluation.pdf (accessed June 6, 2018).
  3. DasGupta S., and R. Charon. 2004. Personal illness narratives: Using reflective writing to teach empathy. Academic Medicine 79:351-356.
  4. Sexton, J. D., J. W. Pennebaker, C. G. Holzmueller, A. W. Wu, S. M. Berenholtz, S. M. Swoboda, P. J. Pronovost, and J. B. Sexton. 2009. Care for the caregiver: Benefits of expressive writing for nurses in the United States. Progress in Palliative Care 17(6):307-312.
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We urge the Department of Homeland Security immediately to stop separating migrant children from their families, based on the body of scientific evidence that underscores the potential for lifelong harmful consequences for these children and based on human rights considerations.

Reports from the National Academies of Sciences, Engineering, and Medicine contain an extensive body of evidence on the factors that affect the welfare of children – evidence that points to the danger of current immigration enforcement actions that separate children from their parents. Research indicates that these family separations jeopardize the short- and long-term health and well-being of the children involved. In addition, the Committee on Human Rights of the National Academies, which has a long history of addressing issues at the intersection of human rights, science, and health, stresses that the practice of separating parents from their children at the border is inconsistent with U.S. obligations under the International Covenant on Civil and Political Rights.

Parents’ impact on their children’s well-being may never be greater than during the earliest years of life, when a child’s brain is rapidly developing and when nearly all of her or his experiences are shaped by parents and the family environment  (NASEM, 2016, p. 1).  Young children who are separated from their primary caregivers may potentially suffer mental health disorders and other adverse outcomes over the course of their lives (NASEM, 2016, p. 21-22). Child development involves complex interactions among genetic, biological, psychological, and social processes (NRC and IOM, 2009, p. 74), and a disruption in any of these — such as family disruption — hinders healthy development and increases the risk for future disorders (NRC and IOM, 2009, p.102-104).  Young children are capable of deep and lasting sadness, grief, and disorganization in response to trauma and loss (NRC and IOM, 2000, p. 387).  Indeed, most mental, emotional, and behavioral disorders have their roots in childhood and adolescence (NRC and IOM, 2009, p. 1), and childhood trauma has emerged as a strong risk factor for later suicidal behavior (IOM, 2002, p. 3).

Decades of research have demonstrated that the parent-child relationship and the family environment are at the foundation of children’s well-being and healthy development. We call upon the Department of Homeland Security to stop family separations immediately based on this evidence.

Marcia McNutt
President, National Academy of Sciences

C. D. Mote, Jr. 
President, National Academy of Engineering

Victor J. Dzau
President, National Academy of Medicine

 

Introduction

Today’s public health challenges are complex and crosscutting. Antimicrobial resistance, pollution, food security, biosafety, biosecurity, and emerging and reemerging infectious diseases are associated with changes in land use, population growth, urbanization, global travel and trade, industrial activities, and climate change [1-5]. International stakeholders have made efforts to address these issues, such as the revision of the International Health Regulations (IHR) and development of Sustainable Development Goals (SDGs) and the Global Health Security Agenda [1,6,7]. However, in recent years, the proliferation of antimicrobial-resistant organisms infecting humans and animals, political and natural disaster-related food insecurity, and outbreaks of many diseases, such as Ebola, chikungunya,  Zika virus, Middle East Respiratory Syndrome, cholera, plague, and yellow fever, have highlighted our vulnerability to emerging infectious diseases among other crises [1,8-10]. In response, a transdisciplinary approach among human, animal, plant, and environmental health disciplines, described as One Health, has gained support and visibility because of its capacity to synergistically address these challenges. Greater emphasis on the One Health approach has been suggested by several voluntary peer-to-peer reviews by countries seeking to evaluate their capacities to address infectious disease threats. These Joint External Evaluations (JEEs) have been conducted under the IHR to identify urgent gaps in participating countries’ health security systems and to broadly promote capacity building [11]. In 2016, the JEE for the United States identified a major gap: inconsistent coordination across various health sectors at the federal, state, and local levels [12]. The United States was encouraged to develop a more formal One Health strategy to address these challenges. In response to this call, the Forum on Microbial Threats of the National Academies of Sciences, Engineering, and Medicine (the National Academies) formed a One Health Action Collaborative to evaluate the current status, successes, and challenges of deploying the One Health approach and to catalyze efficient and effective implementation.

An important step toward advancing such a strategy in the United States would be to apply consistent One Health core competencies in education. Lessons learned from infectious disease outbreaks in recent years have illustrated that training professionals in the One Health arena has the potential to improve epidemic and pandemic preparedness [13,14]. Furthermore, the National Academies recommended coordinating emergency preparedness and response as one of the major future roles of the United States in global health in 2017 [15]. Without a One Health approach, experts in environmental, animal, and human health will continue to address these challenges independently and in an uncoordinated fashion, missing the opportunity to maximize the benefits of shared knowledge, shared professional expertise, and available resources [16]. Beyond conceptual benefits of employing the One Health approach, such as building partnerships across institutional and disciplinary barriers for collaborative problem solving, the available evidence illustrates higher returns on health investments and technical efficiencies, such as avoiding duplicate logistic efforts through joint pathogen detection and human-animal vaccination campaigns [17-20]. It is, therefore, a top priority for the United States to train future One Health leaders through sound, competency-based education that measures the learners’ abilities to demonstrate specific skills [21].

Although the One Health approach has been championed in many academic and international organizations for decades, trends indicate an increase in the number of professional associations, scientific publications, and academic programs with a One Health theme only in recent years [22-24]. The authors of this paper have set out to understand the evolution of existing core competencies in One Health education, assess how core competencies are being applied in academic programs in the United States, and identify gaps that should be filled through formal recommendations. In this paper, we discuss the unique challenges facing the incorporation of One Health core competencies in educational programs and provide recommendations to advance their visibility and use.

Methods

Existing Core Competencies

A literature search for One Health core competencies was conducted on PubMed, as well as websites for governmental and nongovernmental organizations, academic institutions, and professional associations. Keywords for the search were “One Health core competencies” OR “One Health competencies” OR “One Health education.” Furthermore, competencies for the master of public health (MPH) program were identified through literature search and online reports.

One Health Academic Degree Programs

One Health academic programs were identified through a literature search on PubMed, recommendations by experts, and a web-based search for academic degree programs using a combination of the following keywords: “One Health” OR “EcoHealth” OR “veterinary public health” OR “planetary health” OR “geohealth” OR “medical geography” AND “program” OR “degree” OR “bachelor’s” OR “undergraduate” OR “master’s” OR “graduate” OR “doctoral” OR “PhD.” Additionally, a combination of keywords, “public AND health AND animal,” “environmental AND health AND animal,” “agriculture AND health AND human,” “agriculture AND health AND environment,” were used. “Public health” and “agriculture health” were used in combination with other keywords, because a large number of public health and agriculture health programs did not result in One Health–related programs being identified (for example, there are 186 accredited public health schools and programs, but most are not using a One Health approach, nor do they include animal and/or environmental health) [25]. Academic degree programs were included in the study if they were based in the United States and the degree name included “One Health,” were described as a One Health program, or were taught with an interdisciplinary approach linking human, animal, and environmental health disciplines or professions.

Available information on the academic institution, department, state, name of degree, time-to-degree, eligibility, and year of program establishment were extracted and recorded in a database. Course descriptions and degree requirements for each of the programs were evaluated to complete any missing information. Furthermore, all program administrators were contacted by e-mail to complete any missing information not easily accessible in the public domain. Available information for each degree program, such as the list of core competencies, course descriptions, and degree requirements, was reviewed and assessed if key areas were mentioned, included, or taught in the degree program. While acknowledging that they are strongly interconnected, inclusion of the following key areas were assessed for each curriculum: antimicrobial resistance, zoonoses, food safety/food security, geographic information systems, emerging infectious diseases, epidemiology, plant biology, law, economics, toxicology, agriculture/livestock, policy, ecology/environmental health, vector-borne diseases, conservation/wildlife, and social and behavioral sciences. Both key neglected areas, such as plant biology and food security, and areas upon which the One Health approach has previously focused, such as zoonoses and emerging infectious diseases [26], were identified through discussions among the members of the National Academies’ One Health Action Collaborative. If the key area was represented in at least 75 percent of all identified degree programs, it was defined as “well represented.” Conversely, if the key area was represented in less than 25 percent of all identified degree programs, it was defined as “underrepresented.” Furthermore, we assessed whether programs included applied practical training and communications in their curricula. Inclusion of applied practical training in an academic curriculum was defined as the requirement to participate in practical experiences, capstone projects, internships, or externships related to their study focus.

Findings

Existing One Health Core Competencies

We identified 24 manuscripts and reports related to One Health and education and closely evaluated seven in the final review. The comprehensive review by Frankson et al. (2016) summarized the development and synthesis of One Health core competencies domains [27]. There were several past initiatives, including the Bellagio working group in 2008, the Stone Mountain Training Workgroup in 2010, and the US Agency for International Development RESPOND initiative in 2011, as well as a synthesis of competency domains completed in Rome in 2012 [27-29]. In addition, a university network in Southeast Asia defined One Health core competency domains and learning objectives in 2013 [30]. Since then, One Heath core competency recommendations have not been updated and provided as a public resource. Although the three aforementioned One Health competency frameworks were developed individually, similar core competency domains were identified. Seven domains were identified in the Rome synthesis in 2012: (1) Management, (2) Communication and informatics, (3) Values and ethics, (4) Leadership, (5) Team and collaboration, (6) Roles and responsibilities, and (7) Systems thinking. Health sciences was not identified in these competency domains. Keywords such as “cross-disciplinary,” “diversity of disciplines,” and “interdependency” were used in examples provided for these competency domains.

There is currently no accrediting body for One Health degree programs, unlike public health degree programs, understandably because One Health is considered more of an approach and less of a discipline; therefore, no standardized structure or expectations exist for these programs. In 2016, the National Academies held a workshop titled “The Role of Accreditation in Enhancing Quality and Innovation in Health Professionals,” in which attendees discussed the accreditation of One Health education and associated challenges, especially given the globalization of the workforce [31]. The workshop explored the history of accreditation within veterinary medical education and acknowledged that standardized certification could be challenging when there are different societal expectations of professions working in varying cultural contexts.

Although public health is usually focused on human health, whereas One Health takes a broader view, the two have much in common. They share the goal of promoting health and well-being at the population level through interdisciplinary collaboration, and they both require practitioners with knowledge and skills that span multiple domains. Indeed, the overlap between core competencies in the One Health Rome synthesis and the accredited MPH degree includes the competency domains of “leadership,” “systems thinking,” and “communication and informatics.” Now the One Health approach is beginning to be integrated into public health education. In October 2016, One Health was added to the accreditation criteria by the Council on Education for Public Health, the accrediting body for US public health schools [32]. The One Health concept is now included in a section titled “Foundational Public Health Knowledge,” and all MPH and doctor of public health students are expected to be able to “explain an ecological perspective on the connections among human health, animal health, and ecosystem health (e.g., One Health)” at the time of program completion [32]. This core addition is to be incorporated by the end of 2018. In addition, a recent study advocated for the inclusion of One Health in medical school education, because One Health aligns with the concept of caring for patients as a whole and has gained a high level of acceptance among international organizations [33].

One Health Academic Degree Programs 

One Health education has been championed around the world by regional university networks [30,34] and academic institutions, as highlighted in a recent Western Europe review [35]. In the United States, we identified at least 45 One Health academic degree programs (see Figure 1). The majority of One Health academic degrees are new—19 out of 23 academic programs (83 percent) for which the founding year could be identified were established in or after 2002. Additionally, two new programs were launched in 2017 (see Figure 2). Among 45 programs, 27 were master’s level (60 percent), 10 were bachelor’s level (majors and minors) (22 percent), and 8 were doctoral programs (18 percent). Time-to-degree varied according to the educational level of the degree program. All bachelor’s programs were four years; master’s programs varied from one to five years, including full-time, part-time, dual degree, or online courses; and doctoral programs were largely unspecified. Master’s degrees included 18 MPH degrees, 6 master of science degrees, 1 master of preventive veterinary medicine, 1 master of health sciences, and 1 master of food and agriculture law and policy. Six degree programs (13 percent) included the words “One Health” in the official title, such as “MPH in One Health” and “Bachelor with One Health minor.” There were 35 (78 percent) academic programs in public universities and 10 (22 percent) programs in private universities. All but one degree program were housed under colleges, departments, or schools of disciplines related to health sciences, and one program was offered in a law school. It is possible that additional programs exist but were not identified because they did not meet our search criteria. Among the 45 identified programs, 14 had competencies that were publicly available online (31 percent), and another 4 programs provided a list of competencies once they were contacted directly (9 percent). The remaining 27 programs (60 percent) did not explicitly state core competencies on their website, nor did they have them available when contacted. Some reasons given for lack of specific competency listings were that they were reflected in the program descriptions or that the curriculum was fitted to individual students’ needs and interests. Therefore, how and if core competencies have been applied in these programs is unclear.

Based on the identification of core competencies, or the programs’ course descriptions and degree requirements in cases when core competencies were unavailable, it was clear that some key areas were included in the curriculum of more degree programs than others. There were two well-represented disciplines, which were identified in 75 percent or more of all degree programs, and three underrepresented disciplines, which were identified in less than 25 percent of all degree programs. Well-represented disciplines were epidemiology and environmental health/ecology. Underrepresented disciplines were plant biology, antimicrobial resistance, and law (see Figure 3). Some programs were specifically tailored to conservation (n=1), occupational health (n=3), entomology (n=3), and policy or legal issues (n=2) employing a One Health approach.

Furthermore, 31 out of 45 One Health programs (69 percent) placed emphasis on integrated training and collaborative work between academia and public health agencies in the form of practical experiences, capstone projects, internships, or externships. Communication was mentioned in descriptions or competencies in 20 out of 45 programs (44 percent).

Figure 1 | Geographic Location of One Health Programs by State | Source: Togami et al., “Core Competencies in One Health Education: What Are We Missing?,” National Academy of Medicine. NOTE: One Health academic programs were identified in the contiguous United States only.

 

Figure 2 | Founding Year of One Health Programs by Educational Level and Major Events in One Health | Source: Togami et al., “Core Competencies in One Health Education: What Are We Missing?,” National Academy of Medicine. NOTE: Founding years were available from 24 of 45 programs. If a program was founded in one year and merged with another program later, the initial year was included in the figure. Major events in One Health were adapted from publicly available resources [36-41].

[a] CDC = US Centers for Disease Control and Prevention; [b] AMA = American Medical Association; [c] AVMA = American Veterinary Medical Association; [d] USAID = United States Agency for International Development; [e] FAO = Food and Agricultural Organization of the United Nations; [f] OIE = World Organisation for Animal Health; [g] WHO = World Health Organization; [h] G20 = Group of Twenty

 

Figure 3 | Key Areas Represented in One Health Degree Programs | Source: Togami et al., “Core Competencies in One Health Education: What Are We Missing?,” National Academy of Medicine. NOTES: “Total programs” refers to the 45 One Health academic programs identified in this study. GIS = geographic information system.

 

Discussion and Recommendations

This study, identifying and characterizing 45 One Health educational programs in the United States, illustrates that the One Health approach is now employed by numerous schools and disciplines as a means to educate students. Identification of core competencies, course descriptions, and direct communication enabled us to compare key areas taught and disciplinary emphases. We support efforts by many academic institutions to launch and continue to provide education employing a One Health approach. The variety of educational levels from undergraduate to doctoral, tailoring of programs to specific areas of emphases such as policy, law, and conservation, as well as programs being administered by schools of various disciplines not limited to the veterinary field, indicate a diverse and growing pool of One Health educational programs. Academic programs showed efforts to incorporate multiple disciplines, as well as goals of exposing students to real-life work environments as part of their curricula. However, there were some gaps that could be filled to further strengthen One Health education. In light of the above, the authors of this paper suggest the following recommendations based on the findings discussed here, as well as insights from individual participants in the National Academies’ One Health Action Collaborative.

Recommendations

1.  Clearly state core competencies, including proficiency in at least one health science

Academic institutions delivering One Health programs should make voluntary commitments to apply One Health core competencies to their programs. Programs will vary in their specific curriculum, their focus, their student base, and their expected subject matter mastery; however, program administrators can draw from these recommended core competencies to craft program-specific lists appropriate to their institutional goals. A consistent application of core competencies will mitigate the issue of inconsistent skill sets in graduates across disparate departments or schools. Table 1 outlines the core competencies we recommend, adapted from the most recently established undergraduate-level degree we identified with publicly available competencies, the bachelor of science degree in global disease biology at the University of California, Davis [42]. These competencies can be reviewed and applied according to the level of mastery that is intended for students in specific academic programs.

2.  Educate future professionals in the One Health arena in disciplines that are currently well represented, as well as disciplines that are currently not well represented

Of the One Health target areas, antimicrobial resistance, law, and plant biology have received the least amount of focus in the current educational programs reviewed here and thus represent gaps in curricula. To equip future One Health professionals with a wide array of skill sets for problem solving, we recommend that academic degree programs provide students access to a multidisciplinary curriculum and faculty. As an example, we should discuss disease management in the context of various drivers of disease (for example, biological and environmental [natural, built, socioeconomic, and so on]) and explore the range of species and environments that affect disease transmission, including insects, plants, food, and water [43]. Research methods, novel diagnostic techniques, and protocols from the plant-based agricultural and food safety fields could be used as models for disease management in other types of populations; the plant biology field, for example, uses risk assessments for pathogen introduction, surrogate models, and next-generation diagnostics in developing disease control approaches [44]. One Health program faculties should include professionals not usually engaged in medical education, such as vector entomologists, food production professionals, and plant pathologists.

It is also important for programs to recognize and stress that the One Health approach has a broader application that reaches beyond addressing infectious disease threats in humans and animals.  The interconnectedness between changes in climate, land use, population dynamics, foreign policy, biosecurity, economics, trade, agriculture, and natural resources are also important issues under the One Health umbrella [45]. For example, accelerating urbanization and changes in climate underlines the importance of ensuring that the food on our tables is safe and that people have sustainable access to nutritious and healthful food [1,46]. As institutions consider revising existing curricula or developing new programs, emphasizing underrepresented areas in One Health education for programs considering curricular revision or development will help drive paradigm shifts, such as the one needed to move beyond food safety to food security. Broadening the skill base of health professionals involved in One Health education will also help to strengthen IHR core capacities, such as pandemic preparedness, and to accelerate progress toward achieving SDGs.

 

3.  Continue to focus on practical and applied training

Most One Health degree programs already emphasize practical training, where students are required to participate in practical experiences, capstone projects, internships, or externships related to their studies. One Health programs with a focus on working in a non-academic setting will allow future One Health leaders to work effectively in various agencies, ranging from local and state agencies to international organizations. In addition, training in real-life settings equips future One Health practitioners with cultural competencies, such as understanding the importance of fostering local ownership of a project, and in undertaking multisectoral and interdisciplinary collaboration when working in lower- and middle-income countries. Practical fieldwork develops these skills in a way that classroom education cannot, and it is vital to trainees’ success, both in the public and private sectors.

4. Emphasize communication in One Health education – coordination and collaboration are essential to the One Health approach

Communication is one of the seven domains in the existing competency domains, but it remains absent in many extant One Health programs (25 out of 45 programs, 56 percent). Because coordination and collaboration across disciplines is essential to the One Health approach and shortcomings in articulating the One Health agenda have been a challenge [26], training in communication should be further emphasized and applied in all One Health degree programs. Proficiency includes communicating to build and manage a transdisciplinary team,  communicating to academics and professionals across various disciplines, and communicating to policy makers and the public, as well as communicating in different cultural settings. Anticipated effects of improving communications training include clear and timely risk communications during health emergencies and increased stakeholder engagement around the One Health approach. As further evidence becomes available, professionals should be prepared to communicate solutions derived through the One Health approach, as well as the general benefits and feasibility of employing the One Health approach as global health challenges continue to emerge.

A Step-by-Step Approach to One Health Core Competencies

We encourage program directors and administrators to employ the core competencies recommended in this paper, as well as to consider other existing core competency domains and established disciplinary-based accreditation standards in their curricular development and revision, following the six steps shown in Figure 4. This approach is intended to provide a framework for administrators to become familiar with competency-based education in One Health, clearly define their program objectives, and optimize core competencies for their academic programs. Voluntary commitment to employing One Health core competencies by program administrators would lead to a stronger, competency-based education, no matter what the program focus may be.

Future Directions

It is important to define, develop, evaluate, improve, and continue to refine One Health education, not only in One Health degree programs but also in existing public health, environmental, veterinary, and medical curricula. We suggest that One Health academic degree programs be built on a foundation of core competencies and that an emphasis on practical skills is needed. In addition, it is important that new and extant initiatives with common interdisciplinary approaches, such as planetary health, geohealth, ecohealth, evolutionary medicine, and One Health, communicate and stay connected. Moving forward, we must fill gaps, as well as evaluate career trajectories, of One Health degree program graduates. An analysis of One Health professionals in the workforce and examples of One Health successes from applying core competencies could be useful, including evaluation of the willingness of funding agencies to support investments in One Health educational programs, either directly or through active recruitment of graduates into career positions. The One Health movement has gained growing support in recent years and could continue to develop and be recognized as effective through improved education, especially if graduates are shown to be valuable assets in the health workforce and a driving force in global health problem solving.

Links embedded in Figure 4:

 


Join the conversation!

Tweet this! Properly trained #OneHealth leaders are key to addressing today’s complex public health challenges. Promoting a consistent competency-based education among One Health programs is a step in the right direction: http://ow.ly/WafS30keQQr

Tweet this! While the #OneHealth approach has been embraced by a diverse and growing number of degree programs, the authors of our newest NAM Perspectives paper have 4 recommendations for a sound, competency-based One Health education: http://ow.ly/WafS30keQQr

Tweet this! As #OneHealth education evolves in the U.S. and around the world, it is critical for academic administrators to build programs on a foundation of core competencies. Our latest NAM Perspectives paper offers a step-by-step approach: http://ow.ly/WafS30keQQr

Tweet this! #OneHealth educational programs embedded with practical training are vital to providing students with nonacademic skills that will help them thrive in a variety of agencies and organizations: http://ow.ly/WafS30keQQr

Tweet this! To ensure stronger #OneHealth graduates who can drive global health problem solving, authors of the latest NAM Perspectives paper recommend core competencies in health knowledge, holistic understanding of crosscutting health issues, and professional characteristics: http://ow.ly/WafS30keQQr

 

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The National Academy of Medicine (NAM) honors the life and work of Stuart Bondurant, who passed away on May 26, 2018. Dr. Bondurant served as Acting President of the NAM (then the Institute of Medicine) in 1991 and 1992 during the search for Samuel Thier’s successor. Dr. Bondurant provided steady leadership at a pivotal moment for the NAM – a contribution for which we remain deeply grateful.

Dr. Bondurant retired as Dean Emeritus of the School of Medicine at the University of North Carolina, Chapel Hill, after a distinguished career that focused on improving medical education and advancing cardiac research. As head of the medical branch of the Artificial Heart-Myocardial Infarction Program of the National Heart Institute in 1966, he initiated the nation’s first organized research effort on heart attacks. Dr. Bondurant was devoted to improving health in his home state of North Carolina; he co-founded the North Carolina Institute of Medicine and the North Carolina Biotechnology Center and was a longtime chair of the North Carolina Governor’s Commission on the Reduction of Infant Mortality.

To read more about Stuart Bondurant, please visit his obituary in the Winston-Salem Journal.