Public health in a rapidly changing world
Several months in 2013 and 2014 have been a hardly predictable time in Ukraine, and the situation is still far from being stable. This made the editorial team of TCPHEE based in Ukraine postpone publishing consecutive issues. However, while the situation still requires practical steps, many aspects including those related to public health require analysis and debate. Thus we invite opinion pieces and studies addressing all different spheres of how public health should function under changing social circumstances. There might be a wide range of such related topics.
The most obvious ones are those linked to changing living conditions. Many studies have been undertaken and published with regard to health threats to refugees, people involved in natural or technical disasters (Noji, 2005). Along with environmental health threats, there might be mental health disturbances (World Health Organization, 1992) resulting from long-term strain, losses et cetera.
Another important focus is related to changes in health services provision. Crimea, which is a former Ukrainian territory now occupied by the Russian Federation, was among those in Ukraine highly affected with HIV (Dehne, Khodakevich, Hamers, & Schwartlander, 1999). This was responded by several NGOs actively providing harm reduction services to high-risk groups along with methadone substitution therapy to opiate users and antiretroviral medicines to those HIV-infected (Curtis, 2010). However, there are news reports that Russia is going to stop provision of methadone (kommersant.ru, 2014). As opiate substitution programs have been shown an effective approach towards preventing HIV transmission among people who inject drugs (MacArthur et al., 2012), such change in public health policies might affect not only most at risk populations but their partners and population as a whole as well resulting in a rapid spread of HIV.
Yet another related topic is that of how health services can be organized at times of social upheavals. Health service of Maidan, though has already attracted much attention (Yasynska, February 7, 2014), should probably become a focus of more scrutiny as an example of volunteer labor force and resources involvement.
However, a wide range of even more difficult issues is to be addressed once life comes to some order after the power transfer to those people who were in favor of the changes. Some models have long been known and just required practical implementation - including those related to preventive medicine and primary health care, to mention just two established internationally as a must of health care several decades ago but still not fully in place in Ukraine. Nevertheless, as these models could not be properly implemented for many years in line, this might derive from the obstacles pertaining to either how health workers are educated or how the system is regulated.
Considering the best intentions of people who aimed, as opposed to the bygone authorities, to work for the benefit of their compatriots, we may assume that they would be willing to implement the ideas and technologies with proven ability to improve health and well-being of people. Yet, implementation of evidence-based approaches might be deemed slow and boring in comparison to heroic happenings and populist slogans of the power transfer. What are the tipping points to achieve changes in how people think and work in order to open doors for the best practices elaborated elsewhere along with trial-based implementation of new ideas arising on the spot? Though diffusion of innovation (Rogers, 1962) is a well-known model that describes the process, what could be made to facilitate it?
If evidence-based and benefit-aimed technologies are to be brought into deployment, obviously good surveillance systems (Klaucke et al., 1988) become inexorably needed. Yet, overall they are costly and difficult to justify in a poor country. What is an appropriate way of their step by step implementation which allows quick display of payoffs and cost-effective use with the impact on the ways people think and act?
Yet, the opposite side of the same story, those pieces of surveillance which are already in place are very unlikely to be properly used. Even those favorable trends in national statistics which showed years of declining mortality (Polischuk, Krasovsky, & Andreeva, 2009) and could be presented by ruling politicians as a sign of their successes, is neglected. This certainly does not mean that surveillance is not needed, but this is still the need to be felt and the tool to be understood and learnt.
Many models considered normal and well-developed within the public health in the West are still beyond proper understanding of most health professionals in Ukraine, and probably other countries which resemble it in some features. An important achievement of Maidan was the feeling of community, the ability to self-organize in order to solve arising issues. While 'community' was a hardly definable entity in most countries deriving from the former Soviet Union, it now becomes tangible how people can be together and act together. This gives opportunities to address issues of 'community health,' which was never perceived a realistic construct before. How communities live and act, how they might interact with health policies and health determinants at different levels, how to diagnose and understand them is still another large area that was never studied or taught in a country we come from.
Moving towards Europe, as Ukraine strives now, requires crucial changes in many spheres of life. What are the known rules for these changes to happen? What are the hypothetical predictors of these changes to be successful? What are the additional factors yet to be explored and taken into account? Your knowledge, ideas and guesses are welcome!
Curtis, M. (2010). Building integrated care services for injection drug users in Ukraine (pp. 21). Copenhagen: WHO Regional Office for Europe.
Dehne, K. L., Khodakevich, L., Hamers, F. F., & Schwartlander, B. (1999). The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making. AIDS, 13(7), 741-749.
Klaucke, D. N., Buehler, J. W., Thacker, S. B., Parrish, R. G., Trowbridge, F. L., & Berkelman, R. L. (1988). Guidelines for evaluating surveillance systems. MMWR, 37(S-5), 1-18.
kommersant.ru. (2014). Chief Narcologist of Russian Ministry of Health: methadone in the Crimea was confiscated and destroyed from http://www.kommersant.ru/doc/2484868
MacArthur, G. J., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., . . . Hickman, M. (2012). Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ, 345, e5945. doi: 10.1136/bmj.e5945
Noji, E. K. (2005). Public health in the aftermath of disasters. BMJ, 330(7504), 1379-1381. doi: 10.1136/bmj.330.7504.1379
Polischuk, M. E., Krasovsky, K. S., & Andreeva, T. I. (2009). Changes in average life expectancy in Ukraine over the last 50 years as an indicator of public health effectiveness (in Ukrainian). Ukraine. Health of the nation(4(12)), 54-61.
Rogers, E. M. (1962). Diffusion of innovations: Free Press of Glencoe.
World Health Organization. (1992). Psychosocial consequences of disasters: Prevention and management.
Yasynska, V. (February 7, 2014). Physicians at Maidan. from http://euromaidanpr.com/2014/02/07/physicians-at-maidan/
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