Yesterday I attended the first day of a three-day conference on IR. Coming from a political science background, I spent most of the day trying not to equate that with “international relations” in my mind. In fact, this conference was all about a different kind of IR – implementation research.
Implementation research is, to put it simply, “research to inform how to make the right thing to do the easy thing to do.” I take that to mean it’s less about theory, less about specificities and obscura, and more about practicality, making things happen in real life. Exactly the type of research you want for global health.
Put simply again: it’s important that someone, somewhere understands the intimate details of black fly breeding grounds. In the field, that knowledge is only really important insofar as its ability to translate into action: as in effective breeding-ground disruption strategies to prevent the spread of river blindness.
This theory is very important to TDR, as our current modus operandi can be summed under the headline “Research that makes a difference.” This hasn’t always been the case. As I learned yesterday, TDR can be summed up into four different phases since its creation in 1975:
Phase I (1975-1986): “Heroic Goals.” The era of dreaming big, pioneering social sciences research, and getting people excited.
Phase II (1987-1997): This decade brought in innovations in research and also ensured that the “gender dimension” became increasingly considered and accepted as important.
Phase III (1998-2007): “The Partnership Decade.” As global health problems have become increasingly better known and as a result more silo-ized, partnerships to ensure shared knowledge and coordinated strategy became more and more important.
Phase IV (2007 – Present): “Research That Makes a Difference.” More focused on downstream research, this era brought about the current three different departments of TDR: Implementation and Intervention Research; Vector, Environment, and Society; and Research Capacity Strengthening.
A brief overview of the key concepts of implementation research follows:
I. Assessing quality gaps. Quality gaps can be calculated by the following equations:
% = # receiving EB care / total service recipients, and
% = # needing care / total service recipients
II. Evidence-based interventions, or interventions that are “better.” This may seem like common sense, but often there are actually interventions in place that don’t actually work as well as they could – or work at all.
III. Theories, frameworks, and models. There are 109 different models of implementation research – how do you choose one? (don’t look at me for that answer…)
IV. Implementation strategies -> How do we move research into care? Interventions must be discrete, multifaceted, and blended.
V. Implementation outcomes. These must measure acceptability, appropriateness, fidelity, adoption, feasibility, and perhaps most importantly – sustainability.
VII. Partnerships. These include research-practice and research-team partnerships. Partnering with local communities is often the key to designing an intervention that is effective and sustainable.
VIII. Research designs and measures. Here, our lecturer asked that we keep in mind that poorly-designed plans are most likely to be rolled out during emergencies. One must balance timeliness with efficacy – and that can be an amazingly huge challenge.
Our lecturers provided two great examples of the need for implementation research in global health. The first was the example of guinea worm, which is on the cusp of becoming the second disease eradicated by humans and the first parasitic disease to be eradicated. For example Nigeria has gone from 1 million cases of guinea worm per year to zero in just 20 years. However, very recently scientists have discovered dogs and fish in Chad and the occasional baboon in Ethiopia that have become infected with guinea worm. This is classic evolution – if what you’re doing isn’t working, you need to change. For the guinea worm, dogs suddenly became much more appealing hosts than those meddling humans so intent on eradicating them.
This, in turn, poses a risk for a resurgence of the disease in humans, and massive implementation research is needed to address questions such as:
1) Is there actually a paratenic host in fish?
2) Should we start culling dogs in Chad?
3) Do we try to contain the dogs, and offer a reward or incentive for compliance?
4) Can heart guard (ivermectin) be used as a prophylaxis?
5) How do we go about aggressive vector control before this spreads?
Onchoceriasis, or river blindness, offers another excellent example of the importance of implementation research. Oncho is caused by the O. volvulus virus, which is transmitted via black flies who breed in river rapids in Africa. As you can guess from the nickname, this disease often causes blindness. In some towns, nearly 40% of residents have been blinded by this infection. This causes a huge burden on other residents, resulting in loss of productivity and mental health, and has also caused huge swatches of arable land to be abandoned – a great example of how health and economics can be related.
Back in the 1970s, vector control was the only option to contain the disease, because current medicines were too dangerous to actually use. Despite aggressive vector control, 85% of the area at risk for river blindness went uncontrolled.
The big breakthrough came in 1987, with the invention of ivermectin. Taken once a year, this medication is highly effective on microflaricides and moderately effective on adult worms. Even more amazing – this medication is being donated by Merck for as long as needed.
Now came the time to design a program to actually get this medicine where it was needed. Implementation research posed questions such as:
Why do we need to treat this? Is Oncho even a public health problem in forest areas?
Where? What is the geographic distribution of Oncho? Where is it an inconvenience, and where is it a public health problem?
What? What strategy is best to do this?
How? How the heck do we do it?
Let me remind you that Oncho was once known as “The disease at the end of the road” – it affected very remote, rural populations. As in, you couldn’t just go out with a clipboard and pass around a quick survey to answer your questions.
Researchers eventually found something that changed their whole image of the disease. While 8.4 million people living in the savannah areas of Africa suffered blindness as a result of Oncho, an additional 8.9 million living in forested areas of Africa suffered an entirely different disease pattern – lesions, depigmentation, and extreme itching, to the point where many sufferers contemplated suicide.
They knew blindness was a problem. This other pattern was an entirely new, but possibly equally as debilitating condition.
Researchers took this revelation as a cue to start listening to communities more, and eventually realized that a Community Directed Treatment plan (ComDT) would be the most effective way of going about preventing Oncho. In this model, the community decides if, how, and when to distribute the ivermectin, selects individuals responsible for dispensing it, and creates their own timetable and system. NGOs are there to help with monitoring and training, but this puts the power and the capacity in the hands of the community.
Has it worked? Well, using this method 101 million people are treated annually with ivermectin to prevent Oncho – and in fact it’s expanded to include an additional 53 million people receiving treatment through ComDT for other diseases. For about 60 million residents of Africa, Oncho has been completely eliminated.
Let me leave you with one last example – this time, I want you to figure it out. At yesterday’s conference I learned something entirely disturbing – schistosomiasis, a neglected tropical disease transmitted by snails, is now endemic in Europe. I know right, WTF? This is something completely unexpected but clearly needs addressing. Do some poking around online, and tell me, Where would you start?
Goodies included a whole Toblerone bar and a fancy schmancy notebook!
The Rolex Center (very cool/crazy library and student center at the university) had a display of circa 1750s illustrated science manuals. The building is supposedly meant to look like the inside of a Rolex watch and be an architectural master piece, but in actuality it looks quite a bit like a piece of Swiss cheese…
Under the Rolex Center, my new favorite cheese-shaped building
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