Integrative Analysis
Evidence-based Approaches to public health
WHO aims to eliminate TB by at least 95% by the end of 2035. However, with at least 10% of the latent TB progressing to active TB each year, it is difficult to contain the rate of TB incidence worldwide. Although the United States is not listed in the list of high-risk countries for TB set by WHO, it is crucial to monitor the existing latent TB rate in the US to ensure that the US contributes its share of responsibility for WHO’s aim. One major public health problem in the United States is obesity. With more than half of the adult population obese in the United States, there is a high risk of chronic diseases such as cardiovascular diseases that compromise the immunity of the US population. It is evident that these diseases compromise human immunity, multiplying the effects of other infections and diseases exponentially. One’s immunity is critical in keeping mycobacterium tuberculosis dormant in the human body. However, once the immunity is compromised with major causes like obesity, the latent TB infection progresses to active TB disease. It is also evident that there is a higher cholesterol level among the obese population. Thus, this study assesses the association between total cholesterol and the risk of tuberculosis in the United States population using nationally representative NHANES data.
Tuberculosis transfers from person to person through coughs, sneezes, and other airborne mediums (CDC, 2016). The United States requires individuals entering the country to present TB-negative results upon entry to control the infection rate. However, there are estimated to be more than 2.5 million illegal entries in the United States in recent years (CBP, 2023). The prevalence of TB in these populations mostly goes unmonitored. Thus, it is very significant that the TB rate is calculated frequently. Collection of TB tests in the port-of-entry and detention center would allow tracking TB to some extent. Similarly, data collection and availability of people more vulnerable to TB would assist in a better understanding of TB incidence and prevalence. These vulnerable groups can include homeless people and incarcerated people whose immunity is compromised due to their situations and environment. Moreover, a centralized data system for healthcare providers, organizations involved in TB research and treatment, state health services, and CDC can be used for TB data sharing. This data sharing with easy access would allow more researchers to research TB among the underrepresented population while also capturing granular data. Furthermore, NHANES has collected TB data in only two survey cycles: 1999-2000 and 2011-2012. NHANES could collect TB data every survey cycle to better understand the TB trends in the United States and implement proper interventions.
United States has put in significant efforts to control TB. Several approaches are used to control TB, including National TB Surveillance System (NTSS) and Tuberculosis Trials Consortium (TBTC). Moreover, crucial research is underway to understand TB better using TB genotyping. Current approaches include contact investigations and active tracking to prevent further disease transmission. While these approaches are practical, we could also involve other public health methods to boost the process. The other potential opportunities involve monitoring TB incidence and prevalence in detention centers, prisons, and homeless populations. It can include hosting educational campaigns to educate and empower people to identify and get tested. Moreover, more conditional research could be done to target a specific population, such as alternative medicines for pregnant women with TB.
Public Health & Health Care Systems
Integrating health care and public health entities is crucial in addressing TB in the US Population. While there are individual efforts from the different sectors in the fight to end TB, a symbiotic responsibility has yet to be established in these sectors. This lack of integration leads to gaps in TB research and treatment. As individual healthcare providers, hospitals and health centers are dedicated to treating TB case by case. Their responsibility can be further categorized among secondary and tertiary prevention. On a broader level, pharmaceuticals are responsible for developing TB treatment. However, there needs to be more communication for new medicines regarding multi-drug-resistant tuberculosis (MDR). The idea of post-tuberculosis lung infection (PTLI) has recently evolved, where people treated for TB develop some infections in their lungs. Currently, there is a treatment gap for those victims, including medicines. Moreover, public health organizations and state health and human services are conducting interventions at the public level. These interventions include TB awareness programs, screening clinics, surveillance, and the supply of resources. These interventions assist people with primary, secondary, and tertiary prevention. These organizations are also dedicated to TB research that may influence policy change.
While there are multiple organizations with shared missions, a lack of collaboration among these entities slows the progress of WHO’s End TB program. There is little to no data sharing on TB research among private and public entities. This disparity is caused by a lack of a Memorandum of Understanding (MOU), budgets, or unawareness of existing research. Furthermore, there is no coalition among these groups to connect the research insights of these organizations and advance TB research, affecting all involved parties and the public.
Data sharing policy among local, regional, state-level, and federal agencies, private healthcare providers, and research institutes should be established to integrate healthcare and public health to address TB among the US population. An incident command system (ICS) under the National Management System (NMS) used by FEMA could also be used to monitor the outbreaks or incidents on each level of the agencies. Furthermore, including community gatekeepers of the target community is significant in planning targeted interventions among people with high TB incidence and transmission.
As the United States includes people of all ages, racial differences, and socio-economic statuses, the outreach programs are not reaching the target population. Some potential causes include black people with poor medical histories, like the Tuskegee and Henrietta Lacks experiments, which developed mistrust in healthcare services among black people. In addition, as TB is not considered a high-risk disease in the US, there is a lack of urgency among people to address this issue.
The outreach programs and the interventions must be targeted with cultural and historical appropriateness to mitigate the impact of such impediments. The same outreach program used in Vermont cannot be used in Alabama. Technology use must be limited to advertising the outreach programs only among the relatively younger populations. Historically affected people in healthcare should be compensated and acknowledged to regain their trust in medical research and treatment. On the other hand, the United States must focus more on emerging infectious diseases. Most diseases that have treatments available and are considered low-risk are neglected in the US, allowing the low-risk diseases to re-emerge and be infectious- thus causing outbreaks. In the case of TB, there are a lot of comorbid diseases like HIV and diabetes that affect one’s immunity, allowing latent TB infection to progress into active TB infection. Thus, focusing on immune-compromising diseases is crucial to prevent active TB transmission and incidence. Furthermore, new policies should be formulated to ensure equitable healthcare access to people from all races and socio-economic statuses.
Planning & Management to Promote Health
The United States has diverse populations with different races and cultures. Since the target population is the whole US population, it gets tricky for WHO to target all values and practices. Most of WHO and CDC’s work is supervised by regional offices and collaborators in the US. Thus, the tasks performed by those regional offices are specific to the population and cultures the communities represent. With the collaboration from local leaders and communities, WHO disperses its service such that the interventions are community appropriate. Moreover, WHO has six official languages spoken in significant parts of the world to deliver its contents. Furthermore, the job requirements in WHO are specific to those who speak the target population’s language. Furthermore, WHO understands the disparity in healthcare resources in lower- and middle-income countries. As the technology advancement reaches late, if any of these countries, the WHO orients the policy and practices based on LMIC-appropriate techniques. It includes training personnel based on poor resource settings and utilizing local resources for treatment and care. Eventually, the WHO disperses health content worldwide through its local offices and online for awareness and health promotion programs. WHO encourages healthy habits such as physical activity and food awareness in regional communities. Their campaigns are successful as they are a credible source to the population.
There are several ways to multiply the outcomes of these efforts to enhance cultural representation and consideration by WHO. First, the WHO can conduct cultural assessments of the communities while also assessing the staff within the organization. This grants more credibility and enhances trust among the served communities. In addition, WHO can also integrate cultural competency training during the onboarding process to teach cultural values and traditions in different parts of the world. While there is preparedness training for the deployed staff, the WHO can train the staff to gather what the specific community wants instead of what the WHO perceives the community wants. Moreover, the WHO can also conduct qualitative research methods to develop general themes of the served communities on its services. Through qualitative analysis of these themes, the WHO can enhance and evaluate their culturally appropriate impact on the communities they serve.
Policy in Public Health
The US population has benefitted from several efforts from WHO and USAID to prevent and control TB and many other diseases. Several policies and practices have been put in place so that TB is identified at the latent phase and that the rate of progression of latent TB infection to active TB is mitigated among the US population. One of the significant policies includes TB screenings for immigrants. Upon entering the US, the immigrants must present their negative TB report at the port of entry, such that no international strains of TB are introduced in the US. Furthermore, the US has set aside a research budget for TB to enhance pharmaceutical advances for drug-resistant TB. These research budgets by governmental organizations such as NIH and CDC and non-governmental agencies provide a space for all TB enthusiasts to work on their shared goal. The END TB program by WHO itself is an active attempt to mitigate the TB rate in the world. In addition, the US has a better healthcare system for preventative and treatment services. The Medicare and Medicaid services assist those over 65 and those in need with treatment opportunities among the high-risk population groups for lower immunity and TB.
There are policies that both address the health issue and impede the health issue among the US population. While TB screenings for immigrants are among the best approaches to prevent international strains of TB, the immigration policies are not as supportive to the immigrants already in the US. Immigrants have little to no healthcare access due to language and cultural barriers, fear of deportation, lower quality of life, and lack of work opportunities. In addition, there are hundreds of thousands of illegal immigrants entering the US annually from more than 50 countries in the world. This allows deadly diseases like TB to enter the US without any reporting. While most of the impacts go unreported for the mentioned reasons, only a few are reported, making it difficult for epidemiologists to monitor and trace contacts. Moreover, there are occupational regulations that hinder illegal immigrants from seeking healthcare services. Most immigrants work as farmworkers and construction workers, with more than five people sharing an apartment. Due to the lack of proper inspection policies and housing regulations, infectious diseases such as TB can multiply quickly.
Any diseases can be limited to lower incidence rates through preventative efforts. Thus, increasing awareness of TB and its impact on the population is wise. Policymakers and lobbyists should have access to concise and comprehensive TB data and insights to make wise decisions. In addition, high-risk communities should pressure the government to make targeted policies. Only when the communities accept they are high-risked and act on it can government inform policies. Furthermore, the US should foster international partnerships with foreign countries to fight this deadly disease collaboratively. The existing policies have both good and bad aspects, and these steps could enhance the advocacy and policy-development efforts.
Leadership
WHO has a fascinating reputation as an international organization. As of 2023, 194 countries are member states of WHO. Thus, it takes influential leaders to run the most prominent health organization in the world. They demonstrate effective leadership with motivated individuals and stakeholders. The organization is divided into many departments and sub-departments based on the nature of diseases. These branches are led by motivated individuals with the best disease and serving population expertise. Suppose these individuals are not an expert in their respective fields. In that case, it may affect the health of the whole population in the country, as most of the tasks of WHO are done in collaboration with the Ministry of Health of the respective country. In the case of TB, leaders should be aware of the etiology of TB and its progression. The leaders must understand the prevention and treatment efforts. As influential leaders, most of their findings are essential in policy-making and decisions.
While WHO has done an incredible job with the leaders, there are still some ways to enhance leadership within the organization further. WHO can focus on capacity building of the organization through the leaders that support capacity building of the communities they serve. This allows a safe transition of expertise and resources to the communities that allows sustainability. In addition, more is needed for WHO to be at total capacity if the communities they serve are lacking. Thus, the WHO must promote community involvement throughout the research and interventions. Involving Community-Based Research Practices (CBRP) can be significant for better outcomes of the interventions. Moreover, collaboration is necessary for the WHO to serve the target population better. It can involve collaboration with the Department of Health and Human Services, the Ministry of Health, CDC, or other organizations serving at national, state, regional, and local levels. This hierarchy of collaboration allows a smooth transition of commands while allowing local-level leaders to learn on a bigger scale. Furthermore, the majority of the tasks in WHO are data-driven. While data-driven decision-making is crucial to inform policy change, it is also vital for leaders to factor in the stories behind the communities. That would allow communities to embrace the support openly. Eventually, the leaders should focus on identifying new techniques to represent the community. They can analyze the evaluations of their programs to modify their interventions.
Communication
Communication is an essential job function necessary for successful missions. WHO has demonstrated an impressive communication strategy targeting demographics of all age groups, races, member countries, and cultures. In addition, WHO implements different communication strategies for staff working for TB in different fields. For TB researchers, the WHO has made all the possible data available online, including private data, with special requests. This allows the researchers to develop new insights that are further communicated throughout the country. The WHO has developed different curricula and training for healthcare providers to stay updated on diseases. Furthermore, WHO has designated its six official languages to ensure that most of the population can be served. This allows people speaking these six major languages in significant parts of the world to feel included. Moreover, WHO collaborates with the major organizations in the respective countries, like CDC and local health departments, to create outreach programs for promoting educational campaigns on TB. Digital campaigns are also one of the powerful communication strategies of WHO. These campaigns include short movies, long movies, documentaries, posters, interviews, and radio programs in the local languages that are proven to amplify the effectiveness of the programs. Eventually, at the community level, WHO eventually fosters a listening environment more than a speaking one. It assesses community needs and desires before diving into interventions based on prejudice.
WHO has been excellent in communicating with the target demographics. However, there are some potential ways to enhance population-appropriate communication further. The WHO can conduct a weekly updates session on health and diseases through the respective country's representatives in plain language. This will allow the population to remain updated while increasing their trust in the organization. In addition, WHO can encourage community engagement with interventions that allow the community to be involved and figure out the problems themselves. Furthermore, further communication can be fostered by establishing a shared platform for the community gatekeepers, healthcare providers, researchers, and students. Eventually, monitoring and evaluating the interventions can foster communication that supports sustainability in the long run.
Interprofessional Practices
WHO has 194 countries as its member state as of 2023. In the United States, WHO collaborates with the Center for Disease Control (CDC), USAID, NIH, and several other healthcare organizations to prevent outbreaks, epidemics, and pandemics while providing primary and secondary support for pre-existing diseases. With the shortage of healthcare workforce worldwide, WHO understands the significance of interprofessional collaboration. USAID takes charge of TB prevention efforts in the US in collaboration with WHO, the Department of Defense (DoD), NIH, and the Office of Global AIDS coordinator. These organizations come together for epidemiologic surveillance, clinical research and development, research on TB-HIV co-infection and laboratory diagnostic services, and operational research. The US is the largest donor of global TB efforts. Thus, the professional teams from accounting, operations, logistics, and others are crucial for properly utilizing the budgets and smooth operations. The US is also the largest donor to a global drug facility that provides grants to countries for TB drugs. Thus, these collaborations, in relation to global health efforts, allow WHO to address TB in the US.
The United States can foster the partnership through global health efforts to enhance interprofessional approaches. The US can develop US-supported TB prevention programs in weak healthcare settings with limited operating supplies. This would allow the US to take charge of its global TB efforts through interprofessional collaboration. There are several countries like Haiti and Brazil with highly drug-resistant TB bacteria. Collaborating with these countries in TB efforts can generate new insights into the US’s fight against antibacterial resistance diseases. Moreover, TB usually co-exists with HIV, diabetes, and pregnant women. Thus, the involvement of interprofessional teams from AIDS, nutrition, and maternal and child health can enhance TB research. In addition, the US is aware of the demographics of illegal immigrants entering the US each year. So, the political meeting between the US and countries that supply a high number of illegal immigrants could limit TB cases in the US. Furthermore, TB is a global problem, so the global community must enable data and resource sharing. TB is a communicable disease that can only be stopped when everyone is safe and working together on its elimination.
Systems Thinking
Systems thinking is a critical and practical framework for identifying and intervening in public health practices. As a backbone of public health assessment, systems thinking is used by WHO to understand domestic problems and develop targeted interventions such that the allocated budget and resources provide optimal outcomes in terms of prevention and treatment. In the US, as latent TB infection is higher than active TB, WHO, in collaboration with USAID, implements systems thinking approach to identify demographics for targeted LTBI testing. TB is a deadly disease, and it is vital to understand the root of the problem so that interventions can be designed accordingly. Thus, WHO identifies the comorbidities of TB, and the high-risk comorbid populations and develops digital campaigns, as well as awareness and health education programs to motivate individuals to involve in physical activity, balanced diet awareness, and health-seeking behaviors. Through the evaluations, WHO also identifies the perceived barriers and facilitators of the health-seeking behavior among people with TB and develops the required intervention. Moreover, the UN and the WHO have developed Sustainable Development Goals (SDGs) focusing on all the social determinants of health that are crucial for better health. Systems thinking, in many cases, usually directs people to focus on social determinants of health in the public health sector. Thus, WHO’s mission, values, and objectives are deeply rooted in the systems thinking approach.
WHO demonstrates the use of systems thinking approach in all of its services. However, there is a possible way to enhance the practices using a systems thinking approach. WHO can focus on developing in-person symposiums and led discussions, not just interdepartmental, but with the collaboration from USAID, NIH, DoD, and Office of Global AIDS representatives to develop a shared understanding of the problem. These local, regional, state-level, and national collaborations are crucial in understanding TB’s prevalence and incidence. Moreover, the WHO can implement systems thinking approach to weigh the potential outcomes of the interventions. Public Health considers an intervention optimal based on the number of lives the allocated budget and resources can save. Thus, an effective outcome can be achieved using a systems thinking approach. Furthermore, strategic planning is crucial for comprehensive considerations of the problem. WHO can demonstrate strategic planning on their interventions through systems thinking. They can also engage stakeholders and the community to enhance systems thinking approaches.