My new favorite website

On September 19, 2008, in global health, neglected tropical diseases, research, by Karen Grepin

I have recently come across a great new source for news and information on health issues from developing countries – – a website maintained by the Special Programme for Training and Research on Tropical Diseases (aka TDR). It is a great source of information on scientific journals, policy documents, and other general going-ons in the world of global health. It has particularly good coverage of more European driven activities.

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Ruling Women

On September 18, 2008, in Africa, politics, by Karen Grepin

As shown on Chris Blattman’s blog today, women will likely outnumber men in the Rwandan parliament. I personally had no idea that any country in the world, let alone Africa, had such high levels of female representation in their parliament. I find this remarkable….

In case anyone is in Boston and interested, the President of Rwanda, Paul Kagame is actually in Boston today speaking at MIT. It should be a good show.

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Political Economy of Interdisciplinary Research

On September 18, 2008, in research, by Karen Grepin

I thought this was hysterical. From the “Social Science Statistics Blog”:

The Midwest Political Science Association, like most academic associations, charges higher conference registration rates for nonmembers than to members. Hoping to continue to increase attendance by people outside of political science and related fields at its annual meeting, the Association will begin charging the lower (member) rate to registrants who 1) have academic appointments outside of political science or related fields (policy, public administration and political economy) and 2) do not have a PhD in political science or the same related fields.

In addition, the Association grants, on request, a substantial number of conference registration waivers for first time participants who are outside the discipline.

The organizers have assumed that researchers have a steeper elasticity for conferences outsides of their main discipline, and because they are able to discriminate among applicants, they have set up a differential pricing scheme for people outside of their discipline. All this in hopes of generating more interdisciplinary research. Brilliant. I wonder what I should submit….

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I find it interesting how people pay attention to global health statistics.

A few nights back, one of the founders of the group “Nothing but Nets”, Rick Reilly, was interviewed one of the best watched, and most trusted news reports – The Colbert Report.

He talked about how he initially got interested in addressing malaria: he was in Venice and heard a news clip on the BBC that described how nearly 3000 children die every day from malaria in Africa (translation= roughly one million deaths a year). My own husband has also asked me about this figure after seeing it on TV during an advertisement for the same organization – Nothing but Nets – during the Beijing Olympics.

The reality is that it is just an estimate, it is hard to come up a very exact estimate of malaria cases and deaths. And based on a great article this morning on, it appears that like HIV/AIDS we seem to have been relying on faulty estimates for our best-guess estimate of malaria cases for some time. The new estimates of the number of annual incident cases of malaria have been downwards revised to now *ONLY* about 250 million cases a year. Only 800,000 people likely die from malaria every year. Last fall, UNAIDS embarrassingly also had to downward revise their their estimates of HIV/AIDS globally. Oh my: only 33 million people infected?!?

The truth is, these numbers matter a lot. People do pay really close attention to them, and they do influence the decisions of donors. That said, there has been some good work done recently which suggests that is it not just disease burden that matters to donors (see for example the work of Jeremy Shiffman).

In the case of malaria, however, I think we do have the ability to do a bit better. Most of the data that comes out now is based on entomological patterns, estimates from epidemiological surveillance, and administrative records from health services. While this disease-based measure of incident cases is probably important, the truth of the matter is that the way in which malaria is diagnosed – or not diagnosed – and treated in most of the developing world is based on symptoms, not true disease. There is a wealth of household survey data that would provide us a better estimate of fever, which is an imperfect proxy for malaria. From a resource allocation perspective, given that we do treat based on symptoms, the resources required to treat this epidemic should take this into consideration.

We’ll never know exactly how many people are infected or die from most tropical diseases. We as researchers, however, should become better and emphasizing the limitations of our knowledge and our estimates. For now, they are not much more than really good guesses.

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Feces in your face!

On September 16, 2008, in Africa, Ghana, by Karen Grepin

I am happy to learn that I will shortly be once again leaving for the fourth most unsanitary country in all of Africa. In this great piece, the sanitary situation in Accra, Ghana’s capital is discussed: with graphic detail.

A few months back when I was in Ghana I had the chance to speak to a senior professor of political studies about why health in Ghana seems to lagged behind other countries in Africa with similar levels of income. I thought he would say political will, or lack of management, or something like that, but his answer had to do with the fact that people just did not care about sanitation. Maybe he was right…

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Good news on the NTD front!

On September 15, 2008, in Africa, Ghana, global health, neglected tropical diseases, by Karen Grepin

President Bush hosted President John Kufuor of Ghana this morning at the White House. Some of the good news to come out of this meeting was an announcement that the integrated neglected tropical disease (NTD) drug distribution program in Ghana is set to commence later this month. Yeah!

In case you were also interested in knowing a bit more about Kufuor, he is currently finishing construction on the new Presidential Palace in Accra (see picture). The country took out a $30 million loan to help build the thing. Shaped like an Ashanti stool and made with golden glass, it is quite the sight to be seen.

I don’t know if I should be more worried about about the palace, or the fact that my town of Newton, MA is currently spending $200 million to build a new high school shaped like a question mark (see picture below).

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From Alma-Ata to Agincourt

On September 12, 2008, in Africa, global health, health systems, mortality, South Africa, by Karen Grepin

The focus of this week’s Lancet is all about reviving the focus on primary health. The MDGs are not going to be met, HIV/AIDS has highlighted the weaknesses of health systems (in particular in Africa), and health is not getting much better in low-income countries, so lets re-evaluate Alma-Ata and its focus on primary health care.

One of the research articles presented in these series is a interesting piece by Tollman and co-authors that documents the epidemiological transition, thought to be underway in most low-income countries, in a poor African population in South Africa. The article is especially important because its focus is actually on adult mortality, which is very poorly understood. While in general we know very little about overall mortality patterns in most low-income countries, adult mortality is particularly poorly understood. In fact, for the most part it is largely just made up in most of Africa. The reasons for this are numerous, but mainly because vital registration systems don’t really operate in these areas, and also it is very difficult to collect adult mortality data from household surveys (you have to be alive to answer questions).

The authors find pretty much what you would expect: children die mainly of infectious diseases, prime age adults have seen a significant increase in mortality from HIV/AIDS, and that older adults bear a large burden from chronic diseases, which are also on the rise.

While I have a few methodological issues with this paper (for example, is it possible that the all-cause mortality rate in this area was ~ 600/100,000 in 1992? This is a rate that is almost half the rate seen in most developed countries today), and while I think this article is significant in the contributions it makes, I wonder how the authors conclude on the implications of this work. Namely, the authors state that one of the main implications of their work should be that “..integrated chronic care [should be] based on scaled-up delivery of antiretroviral therapy..”.

The authors contribution was to document the rates of different types of mortality, which is very important, but do not provide any evidence about how these burdens should be addressed. Therefore, it strikes me as a major jump to come to this type of conclusion. My fear this article will now become the major article cited by advocates advocating further reliance on HIV/AIDS funding to strengthen health systems.

In my mind, we really don’t know how this should be done and what focus or priorities should be used to build up these systems. Please look before you cite.

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Food Stamps=Bigger Babies

On September 11, 2008, in maternal and child health, nutrition, by Karen Grepin

In this new NBER working paper, the effect of the US government’s federal food stamps program (FSP rollout in the 1960s and 1970s was investigated. It is well known that the US has much higher rates of low-birth weight children and child mortality than other high-income countries, all of which spend considerably less on health care per person. The reasons for these differences are not well understood, but generally believed to be due to the lack of health insurance or income inequality.

This paper is important due to the fact that it provides convincing evidence that it probably has a lot to due with the share of the population living in relatively poor economic conditions. Using variation in the dates of the rollout of the FSP programs at the state/county levels, they find that the food stamps did improve birth outcomes, most notably by significantly reducing the share of children at low-birth weight (roughly 7-10% improvements). This paper is not able to show if the programs improved nutrition or reduced household expenditures or anything else, but does show that this program did have important downstream effects.

I think it is really interesting that even in a rich country setting, improvements in wealth or nutrition or both, can still have significant impacts on health outcomes. If this is true in the US circa 1970, than I believe it is certainly true in the developing world context as well. It is not all about accessible health care, it still has a lot to do with basic nutrition.

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Defining shades of Dead

On September 10, 2008, in ethics, public health, religion, by Karen Grepin

With all the talk of religion, abortion, and right to life brought about by McCain's choice of Sarah Palin as his Vice-Presidential running mate, I thought this news clip in the upcoming BMJ was quite appropriately timed. The Vatican has recently expressed a concern with the currently, generally accepted, definition of death as the point of brain death. However, it seems the Vatican would like to see this definition to be redefined to the point of cessation of breathing and circulation. The implication of this recommendation would be that hundreds or thousands more people each year would likely be kept "alive" on breathing machines and other equipment for long periods, almost all of whom have very little hope of recovery. Admittedly, I have actually given this topic very little thought over the years but do feel as though I find the existing guidelines to be more humane and more what I would want for myself. But it is good to think about these things every now and again…

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The Coke Coast

On September 9, 2008, in Africa, by Karen Grepin

The World Politics Review has a really interesting article that discusses how Coastal West Africa, in particular countries such as Guinea-Bissau, are quickly becoming the epicenter of narco-trafficking between South America and Europe. The sums of money are large relatively to local wealth: last year a drug bust in Guinea-Bissau netted drugs with a street value worth roughly 10% of the GDP of this country. This article predicts that this new trade will continue to undermine governments throughout the region leading to more failed states.

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