Man Made Malaria Risk

On September 29, 2008, in malaria, research, by Karen Grepin

I think some of the most interesting research ongoing right now in global health is research focused on developing a better understanding of mosquito behavior. In the past, we have largely treated mosquitos simply as dumb vectors of malaria (and other diseases) but in fact they are complex organisms with highly variable behaviors that must be more taken into consideration in our attempts to curb the transmission of malaria. I have seen research on the preferences of mosquitos for different smells, different colors, and different water basins. Essentially research getting into the psychology and economics of mosquito behavior. My sister-in-law is trained as a veterinary for honey bees, we have friends who have dogs on anti-depressants, so will it be too long before we have mosquito psychologists?

An interesting example of research in this vein is a recent article about how deforestation (presumably from human activity) may have an impact on the transmission of malaria. This is a great example of how mosquito behavior matters and also an example of how our activities, and environmental and climate change, has a direct link with human health.

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Misfinancing global health

On September 28, 2008, in Uncategorized, by Karen Grepin

In this week’s Lancet, Devi Sridhar and Rajaie Batniji from Oxford University published an article that compares the disbursements of the major global health initiatives by disease to the burden of disease (measured in both mortality and morbidity) of that particular disease. Their analysis finds what others have found: the amount of money disbursed by donors to major global health area is not proportional to the burden of disease attributed to the disease. Their main innovation over other articles is that they use disbursements rather than commitments data, and conducted extensive leg work to come up with good measures of disbursements by donor.

In addition to burden of disease, I think that the amount of DALYs that could potentially be averted given the existing output of the health sector may be a better measure of the appropriateness of aid (some diseases have a huge burden but may not be very tractable), but without having gone through the (likely tedious) exercise of calculating these measures, I am going to guess that the answer would be more or less the same, money is probably not being directed at diseases where we could have the most bang for our buck.

So why do donors give money for health? Why do they choose particular diseases over others or particular recipient countries over others? If I knew, then I would have an amazing dissertation….

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Great sources for global health data

On September 26, 2008, in geographic data, global health, research, by Karen Grepin

A recent posting on the Bianoah blog by Tristan, made me aware of a new and useful website for data on global health from the Kaiser Family Foundation. In addition to providing the standard sets of data on global health indicators, I was surprised to also see a whole section on funding sources of aid. Very cool. While data from these sites is still considerably less useful for those doing longitudinal studies, it is certainly a great place to start.

I also wanted to let other readers know of another website that has data and an interface that makes it particularly useful – the new UNdata site.

Check them out, they may come in handy one of these days….

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It is that time of the year again when the big-wigs from around the world converge on mid-town Manhattan with such a force that even my husband, with all of his status after staying thousands of nights in luxury hotels between east 40th-60th streets, is told he must prematurely vacate his room to make way for the incoming guests. New York is crawling with dignitaries and their attachés. Secret security details are getting their workouts chasing VIPs around central park. A highlight of this fall’s meeting, at least from my perspective, is a midpoint check-in on progress towards achieving the Millennium Development Goals.

I think the consensus that will emerge from these meetings will be no surprise to anyone following these things: we are not currently on track to achieve the MDGs, and unless something extraordinary occurs, these commitments, like so many before them, will go down in history as yet another well-intentioned failure.

But might be this something extraordinary? While achieving the MDGs is a goal for the whole world, the real issue is how are we going to achieve the MDGs in Africa, where to date there has been little overall progress towards the MDGs, at least on the health measures. To many people, the MDGs have been synonymous with Africa. We are now mid way into the MDG commitment period, and not only will these goals not likely be met, I feel we don’t even yet have a good sense of how these goals can be achieved. As Paul Collier states in an op-ed in the NYTimes earlier this week:

A further weakness with the Millennium Development Goals is that they are devoid of strategy; their only remedy is more aid.

What then can we do instead? Collier argues that while he believes aid can be effective, he thinks that more structural changes will need needed, which potentially could be more effective in promoting development in Africa. Changes like that, however, are going to take forever so are there more concrete things that can be done in the interim?

I think the newly announced Global Road Map for Malaria looks promising, at least on paper. I like the focus on a global strategy for control, elimination, and research, rather than uncoordinated national strategies. How this will actually play in our real world settings, however, remains to be seen. Clearly a lot of thought and effort went into this, likely by a team of eager management consultants, but it is still not clear to me how you translate even the most effective global strategies into real world actions in communities.

Here is to hoping to the second half of the MDGs is more productive than the first.

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Anaemia is an important risk factor for maternal death and low birth weight children. In the recent report card on maternal and child health, UNICEF cites figures that estimate that aneamia is the cause of death in 4-13% of all maternal deaths in Asia and Africa. It probably also contributes as a risk factor in another important fraction of deaths, for example as a complicating factor with malaria.

Simon Brooker, Peter Hotez, and Donald Bundy recently released a systematic review of the relationship between hookworm disease and anaemia in pregnant women. The relationship between hookworm disease and anaemia has in fact already been well established, especially among children. The authors confirm that this relationship appears to be common among pregnant and women of child bearing age, suggesting that they would also benefit from deworming.

Despite the fact that deworming drugs have been shown to be cheap, easy to integrate into existing health service delivery, and safe, even among pregnant women, deworming is rarely included into antenatal care in most areas where hookworm infections are common. There was no mention of it in the UNICEF report. Iron supplementation has already been recommended for pregnant women, but the combining with deworming drugs is likely to be even more effective. Clearly more research is needed to better understand the safety of such programs, but integration of deworming into existing antenatal care packages might represent a good low hanging fruit in improving maternal outcomes.

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Giving props to sepsis

On September 23, 2008, in health care, quality, by Karen Grepin

For some unknown reason, I know a lot of people who are very passionate about sepsis. Sepsis is one of those super, super neglected diseases, because in fact is is not really a disease, rather it is a complication of many diseases. It happens all of the time, it is highly fatal, and yet it goes largely unnoticed by policy makers. Shall we start calling it an NTC? A recently published article on sepsis begins by describing sepsis as a “progressive injurious process resulting from a systemic inflammatory response to infection”. Sheesh. We need to work on marketing this thing a bit better…how about “Whole body overload”…or “eating you from the inside out”?

While case fatality from sepsis is relatively high, even in developed countries, the article described above outlines possible prevention and treatment strategies that may go a long way in saving lives. I have no idea how hard these things are to implement in practice, but some of these things seem pretty easy to a naive outsider: hydration, basic antibiotics, and popping a Zantac might help reduce morbidity and mortality from this condition. A friend of mine conducting research in Uganda on improving case management of sepsis, has suggested that training the friends and family members accompanying loved ones in the hospital, may be able to reduce morbidity and mortalty from sepsis by just telling them to call a doctor if the fluid bags in the hospital room runs low.

This article, my friend’s work, the work of others such as Atul Gawande’s work on lists for surgery, suggests that many of the improvements required to improve quality of care in developing countries can be done with very little money but will require a lot of intensive research in adopting clinical practices to real world experiences.

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I think the general perception of the human resource crisis in Africa is that there is a severe shortage of health workers. Like so many generalizations, this perception is too general to generalize to all of Africa.

In this month’s Human Resources for Health, Ummuro Adano from MSH provides a detailed description of the recent situation in Kenya and the response of the Kenya MOH and its partners to mobilize more health workers. The situation in Kenya is a good reminder that there is in fact a market for health professionals in African countries and that these markets behave in the same ways as other markets. Therefore, interventions must be designed with this in mind.

The Kenyan example highlights the importance of understanding the source of the imbalance between supply and demand. In Kenya, there is actually a relatively large pool of unemployed or underemployed heath workers (just not working as health workers). Despite this, and despite the fact that a long standing hiring freeze had limited the number of positions in the public sector, many posts remained unfilled. The cause: severe restrictions on the ability of the health sector to physically hire and pay workers. The article does not talk about whether or not the newly hired physicians received higher wages, but it appears that once these restrictions were removed there appeared to be little problem in actually hiring workers in the emergency hiring program.

As Ummuro concludes:

Most of the active roadblocks to changes in the health workforce policies and systems are ‘human’ and not technical, stemming from a lack of leadership, a problem-solving mindset and the alignment of stakeholders from several sectors.

There certainly will not be a single one size fits all solution to the human resource crisis in Africa, but general solutions will not likely work well in all countries.

Note: I helped myself to these photos from the MSH’s website.

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Mead Over and others have recently been trying to raise the profile of an idea that has been floating around in policy circles for many years, that of trying to create a US Global Health Corps as a way to increase the availability of health human resources in deprived areas, basically a Peace Corps but for medical students. A Q&A with Mead last week provides more details on a type of program that he supports. He sees this proposals as follows:

I started thinking this would be a win-win proposition. We would be helping the recipient country fill gaps in their health care system while simultaneously improving the quality of American health workers. Just like the original Peace Corps in other sectors.

In a recent posting, Mead uses a recently published article in the Washington Post to support this proposal by suggesting that there is a large demand among American students for further volunteer opportunities in global health abroad.

While I agree that it is an open question of whether or not there is sufficient demand among Americans for this type of proposal, I think that the more important question is whether or not there is sufficient demand among recipient countries for this type of proposal. Would a Global Health Corps lead to improved health outcomes in a manner that is sustainable and effective enough to justify this type of expense from US tax-payers and the costs associated with intervening into the health systems of other countries? Medical education in developing countries is actually quite inexpensive relative to training here. If we were instead willing to provide more support to the training, both pre-service and post-service, of health workers would we not be able to produce health workers for our dollars? Clearly this is an empirical question that has not been evaluated, but should be if this policy does get serious consideration.

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Last week UNICEF released a report card on the world’s performance at reducing maternal mortality. One of the Millennium Development Goals (MDGs) is to reduce maternal mortality by three-quarters from 1990 to 2015. To 2005, if we believe any of our data, maternal mortality only appears to have decreased by about 5% from 1990. This suggests that we have a ways to go, and that this indicator is unlikely to be met. Roughly, we would have to make changes to improve maternal mortality by about 5% a year, every year, between now and 2015. In Sub-Saharan African countries, the reduction in maternal mortality over the past few years has only been 0.1% a year. Basically, there has been almost no progress in Sub-Saharan Africa.

Although there was necessarily anything earth shattering in this report, I was however surprised by one quote in this report:

The causes of maternal mortality and morbidity are so clear – as are the means to combat them – that it is difficult to avoid the conclusion they have remained unaddressed for so long due to women’s disadvantaged social, political and economic status in many societies.

Although I am far from an expert on the causes of maternal mortality, I have begun to do some work in this area. I am currently looking at a policy change in Ghana to see if it had any impact on the utilization of services. What I have been searching for, and thus far have not found a very good source of information on, is some sense of why women die in these settings, and what types of interventions have actually been evaluated to reduce mortality. Given our knowledge of maternal mortality, and adult mortality in general, can we really say this is a no brainer?

The WHO, through the Safe Motherhood Initiatives, has released a series of guidelines for improving maternal and child health outcomes. My sense of a casual read through this literature, is that our understanding of exactly what incentives women face and the factors that lead to the decision to seek care are still very poorly understood. For example, in Ghana, coverage of antenatal services among pregnant women is extremely high, yet when it comes to giving birth, the rate of supervision of births by trained personnel remains low by international standards.

So while I agree with perhaps the message of this conclusion – we know that hundreds of thousands of women die needlessly in developing countries from factors associated with child birth – I still feel we don’t know nearly enough about the causes of these behaviors nor of the interventions needed to address them.

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If anyone out there reading this is a student at Harvard University, I just wanted to make sure you were all aware of the great, non-credit workshops run by the Center for Geographic Analysis at Harvard University. The sessions are stand alone sessions and are offered a few times throughout the academic year (at both the Cambridge and Longwood sides of the river). They are a great way to get started with using geographic data. The use of geographic data has become common in global health policy research as many of the new datasets, such as DHS surveys, now contain geographic identifiers. This is also a good way to integrate data from multiple surveys, including those collected for completely different reasons.

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