The Case of Ebola in West Africa - Swedish Healthcare Workers' Experiences of Navigating Global Health Interventions

In this time of global health interventions, preventing borderless diseases, such as Ebola, is a question of implementing global health policies in different cultural contexts. Although these interventions are mediated by international organs, the healthcare workers on the ground are actually those who implement policies. From this starting point, this thesis investigates the extent to which Swedish healthcare workers, when combating the Ebola virus disease in West Africa, take into consideration the local context in their application of global health preventive measures. It does so by exploring healthcare workers’ experiences of navigating global health interventions, while negotiating culture. Qualitative semi-structured interviews were conducted with participants in the Swedish Civil Contingencies Agency’s medical mission, which aimed to combat Ebola in Liberia and Sierra Leone. To understand their experiences, Michael Lipsky’s ‘bottom-up’ theory and conceptualization of the street-level bureaucrat inspired this study’s theoretical foundation. Three themes were prevalent in the interview material: Navigating the field and establishing trust, Consolidating objectives and Negotiating culture. This thesis argues that constant flexibility and adjustment to the pre-existing challenges in the field are vital in the adaptation of health policies. Moreover, flexibility is dependent on the information transferred from the field. Without rapid information transferal, bureaucracies and their employees have false perceptions of the field, on which they articulate their objectives for partaking in the health interventions. It is further argued that these actors continuously have an internal negotiation of ‘Self’ in relation to ‘Other’ and the bureaucracy that they work for, while trying to navigate health interventions in a foreign context. In conclusion, the ‘one size fits all’ approach does not work and this mindset (re-)produces a dichotomy between ‘us’ and ‘them’ where a certain way of doing things is seen as predominant

State-building in Somalia: Voices from the “International community” and the “Somali diaspora”

Somalia has been a failed state since 1991, which has made it questionable whether the country would be able to rebuild its state. This thesis aims at understanding the factors affecting the state-building process in the country based on voices from interviewees belonging to the “International community” and the “Somali diaspora”. To gain an understanding of what implications the factors could have on the reconstitution of a Somali state, a Weberian inspired theoretical framework was applied. This thesis argues that three main categories i.e. political, social and economic factors can be identified as having implications on the state-building process. However, the political aspects are highlighted as the most important. Furthermore it is argued that the ideal state model, as a Eurocentric discourse, evolves to the “hegemonic powers” advantage, thus supporting their dominant position, which makes it questionable if the Somali state can adapt to such a model

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population. Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay. Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity. Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes