The WHO has launched a new initiative on increasing awareness of STIs in developing countries. I thought the following fact was rather fascinating:

In pregnancy, untreated early syphilis is responsible for 1 in 4 stillbirths and 14% of neonatal (newborn) deaths. About 4% to 15% of pregnant women in Africa test positive for syphilis. Interventions to more effectively screen pregnant women for syphilis and prevent mother-to-child transmission of the disease could prevent an estimated 492 000 stillbirths per year in Africa alone.

Syphilis, wow – can’t we treat this stuff really easily? Since it leads to stillbirths, this is not generally picked up in our measures of infant and child mortality (although in practice I think to some extent it is hard to exclude) but clearly this is an important issue. To read more about the top 10 facts on STIs, click here.

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Paging Dr. Gupta…

On October 20, 2008, in global health, HIV/AIDS, United States, by Karen Grepin

People who know me well, know that I love to make fun of Dr. Sanjay Gupta. I find his stuff a bit over the top – like when he gets emotional and gives his North Face puffy jacket to a boy in Pakistan following the earthquake (groan!). But he does do good journalism, and he does know his stuff.

His recent coverage of the presidential nominee’s stance on HIV/AIDS is really good. He makes some really important points: the US spends 10 times as much on HIV/AIDS abroad as it does at home, while the US requires recipient countries to have a national HIV/AIDS strategy yet it does not have one itself, and that HIV prevalence rates in Washington is probably higher than the capital cities of many of the countries we send money to…Have a look.

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Progress on the Polio front

On October 20, 2008, in global health, polio, research, vaccination, by Karen Grepin

Perhaps one of the greatest disappointments in global health in recent years has been the failure of the global health community to make progress towards eradication of polio. Largely due to lack of acceptance of vaccination in parts of Nigeria and the increased movement of people around the world, polio suffered some serious set backs in recent years.

It is therefore extremely exciting to read about some good news on the polio front. In last week’s NEJM, there was an editorial and two research articles of two clinical studies that suggests that a newly developed monovalent (targets one type of virus) vaccine has much higher efficacy against the type 1 strain and since only a single dose of the vaccine is needed, could lead to much higher gains in coverage, at least in the short-term against that particular strain.

The use of monovalent versions was largely abandoned in favor of triple valent versions (there are many kinds of strains of the virus in circulation) but I this approach was adopted largely through logical reasoning (why not give three instead of one?) rather than being based on some real world study of the comparative efficacy of the vaccines or the implications of efficacy for effectiveness. What the studies above show is that if you can use a vaccine that does a much better job at protecting against type 1 virus, and that this vaccine allows you to only give it once, you might be much better off giving the monovalent vaccines individually than together. Clearly a monovalent vaccine against the other major strain (namely 3) would also be needed, but that it may be better to give it separately.

The series is available free from the NEJM.

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Last week the CDC released the most recent data on infant mortality in the United States. The good news is that infant mortality in the US has declined, the bad news is that it has not declined nearly as much here as it has in many other countries, and the US is now 29th in the world – tied with Poland and Slovakia:

What I find so surprising about this is less that the US is declining in its relative ranking, but who now tops the list. Singapore, Hong Kong, and Japan are now on top, followed by the Scandinavian countries. Canada and the UK are actually doing not much better than the US.

The reasons for the success of these countries in recent years is really interesting to think about and remains one of the great big areas that we know very little about.

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Bertozzi and Prevention

On October 20, 2008, in global health, HIV/AIDS, prevention, by Karen Grepin

The short-listing of Stefano Bertozzi by the committee appointed to select the next head of the UNAIDS, made me go back and re-read the article he and his colleagues put out earlier this year in the Lancet (Lancet 2008; 372: 831–44) summarizing the current state of HIV/AIDS prevention programs. Since significantly more attention has been given to treatment programs, the debate between treatment and prevention programs has largely fallen silent. Plus, the apparent success of efforts to scale up treatment programs, and the apparent failure of prevention efforts to make much difference (or at least show a difference), has led to the growing consensus that prevention just does not work. So I was thankful for this series in the Lancet on prevention. As the authors state:

Even after 25 years of experience, HIV prevention programming remains largely deficient.

The authors, however, argue not the prevention programs do not work, but rather prevention efforts thus far have largely been misallocated. Prevention can work, in theory, if the implementation of these programs is improved.

The failure has been the result of the fact that we fail to tailor prevention programs to country-specific level of and trends in the epidemic. Such country-specific responses are not likely to occur largely because we have not made the investments to generate adequate surveillance data to adequately plan for these programs. Ah…a man after my own heart…let’s blame it on bad data. Specifically:

…because the response to the epidemic for 25 years has been myopic, short-term, using an emergency approach to the epidemic, both nationally and globally, we have not invested appropriately in development of new methods or in generating data about the effectiveness of current methods.

I could not agree with this statement any more. It is amazing how little has been invested in gathering more data on the HIV/AIDS epidemic. How can entire billion dollar responses be built up on data largely collected periodically from pregnant women, presenting at non-random health facilities, a sample we know to be biased and incomplete (for example, what would this data tell us about men who have sex with men?)? You cannot manage what you cannot measure.

I must admit, I am not sure what to think about the effectiveness of prevention programs. I tend to be skeptical of most stuff I read, perhaps to a fault. But, I do not yet have a good handle on how effective these programs are, or even if they are at all effective. The existing literature has been far from compelling in either direction. Sadly, HIV will be around for decades to come, and even at this stage in the game, we have a lot to learn about more effective prevention programs. I agree with the authors, bring on the data!

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How do you measure who is hungry?

On October 17, 2008, in Uncategorized, by Karen Grepin

While news in the US is mostly about the financial crisis these days, much of the news in the developing world is about another crisis: that of the global food crisis. Here in Ghana I try to eat lunch most days with my colleagues at the Center for Democratic Development. Lunch is normally GH$1.50 (~1.30 USD) but due to rising food prices it just jumped to GH$2.00, a pretty significant jump.

An article in this week’s Lancet discusses the lack of consensus on appropriate and effective measures of poverty. Basically three measures are in common use.

The most commonly used is the Food and Agriculture Organization’s proportion of the population undernourished, but this measure comes from balance sheets and is basically a measure of calories per capita, which does not allow identify who is actually undernourished or provide some sense of the inequality of food security.

Next is the proportion of the prevalence of underweight children under the age of five. The biggest problems with this measure is that it is not responsive to short term changes in nutrition, it could also be measuring other factors which affect nutrition, and also ignore important behavioral effects.

Finally, the proportion of the population below the national poverty line for food is also used, but this measure, which intuitively seems to be the most compelling, is not available for most countries, and is not the same across countries (which could also be a good thing).

I am kind of happy to know that it is seems to be about as hard to measure how hungry people are to how healthy they are…however, it is too bad that we have to rely on such shoddy data for such important issues.

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Back to Basics at the WHO

On October 15, 2008, in global health, primary health care, by Karen Grepin

The World Health Organization released the annual World Health Report yesterday. To celebrate the 30th anniversary of the Alma-Ata declaration, the report was actually released from Almaty, now in the present day Kazakhstan. Like most of the previous reports, the report highlights some of the great health inequalities and inequities that exist in the world:

Differences in life expectancy between the richest and poorest countries now exceed 40 years. Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants

What does the WHO recommend to end these massive differences? The WHO recommends a refocus on primary health care to steer health systems towards better performance, to make more efficient use of limited resources, and to reduce these inequalities. In addition, while the focus on primary health care the first time around was primarily on maternal and child health programs as well as infectious disease control, the WHO also notes that”

Primary health care also offers the best way of coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization, and the ageing of populations. These trends contribute to a rise in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, that create new demands for long-term care and strong community support. A multisectoral approach is central to prevention, as the main risk factors for these diseases lie outside the health sector.

Is primary care really the panacea prescription for health systems? While I absolutely agree in principle that a refocus on primary health system is a good thing for most developing countries, in particular Africa, I wonder about two things. First, how does one really operationalize a refocus on primary health care, in particular in the present context where private sectors has been relatively unregulated in many countries for so many years, and the current focus of global health policy on scale up of large vertical programs? Second, I am also curious about this last claim. How appropriate are models of primary care at addressing chronic diseases (any ideas?)?

I eagerly await to read the whole report, if only my internet connection here in Accra here was a bit faster….

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Abuse of programs in Malawi

On October 14, 2008, in Uncategorized, by Karen Grepin

Chris Blattman covered a news item today that is related to something that I have been thinking about a lot lately. In Malawi, the government had been providing $35 a month to HIV infected civil servants to help improve their nutrition. Not terribly surprisingly, a remarkable share of people in the civil came forward claiming to be infected in order to benefit from the supplement. Due to the abuse, the program was suspended.

Numerous national HIV/AIDS programs have begun to include certain benefits or entitlements for HIV positive individuals, such as additional allowances for food, vouchers to send their kids to school, and other items intended to improve the welfare of these disadvantaged people. While the intention is certainly good, and potentially it helps to reduce stigma, it does create somewhat perverse incentives.

I attended a lecture by Vinh-Kim Nguyen last fall who presented some of his anthropological work in Cote D’Ivoire that discussed how the entire identities of people were now being shaped by their association with AIDS programs.

I was actually thinking about it this morning on my drive back from the Korle-Bu medical area in Accra. In Accra there are literally hundreds of people with very obvious handicaps in the downtown area on the streets begging. These people get nothing or very little from the government or the ministry, despite being so terribly disadvantaged.

When will they figure out that they too may benefit if they could associate with the HIV/AIDS programs? Terrible thing to think, but I am sure many of them have thought about it as well. Membership has its privileges.

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Since 1997, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) has been facilitating the scale up of mass drug administration programs in LF endemic countries. I thought about trying to include some pictures on this post of people suffering from LF, especially advanced hydroceles, but then thought better of it. This stuff really makes my stomach turn. I have never that the chance to see really advanced stage disease in person, but have seen moderates cases of swollen limbs on a recent trip to Tanzania. It is no wonder it is given the name elephantiasis.

Eric Ottensen and colleagues have recently released estimates of how much of the global burden has been averted due to the scale up of these programs in roughly half of the global LF endemic countries. The result:

More than 6 million cases of hydrocele and 4 million cases of lymphoedema prevented, translating into more than 32 million DALYs averted

What is even more remarkable, is that this is just an estimate of the direct impact of the program, and excludes the likely enormous deworming effect of these same drugs on the treated population on other helminthic infections, such as hookworms, which they do not attempt to estimate but are likely to be sizable.

And the price tag for all of this work? They estimate to be roughly $200 million, excluding the price of drugs which have largely been donated by GlaxoSmithKline (but should include in country-costs). Roughly $6 per daly averted. Not a bad deal.

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The war photographer battles XDR-TB

On October 10, 2008, in global health, photography, tuberculosis, by Karen Grepin

James Nachtway, the famous war photographer, has recently released some very powerful pictures profile the struggle against XDR-TB in the developing world.

They must be seen.

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