Thanks to the efforts of the Onchocerciaisis Control Program (OCP), a now completed partnership of the WHO/AFRO, the World Bank, and its partners, onchocerciasis – or River Blindness as it is also known – has largely been controlled throughout West Africa. The program was based largely on a strategy of vector control – an expensive but highly effective strategy. The program has been heralded, deservedly, as one of the most effective public health programs of our time.

Since the closure of the OCP program, regular monitoring of the epidemiological and entomological situation has been recommended and been carried out by the new African Programme for Onchocerciasis Control (APOC), one of the hardest working and most impressive public health groups in Africa (in my opinion, at least). Paul Chinnock, on his excellent TropIKA website, has reported that onchocerciasis may be on the return in Cote D’Ivoire.

What I think this example show us is that there will be a continual need for ongoing monitoring and evaluation and the political power and flexibility to intervene as-needed on a case by case basis. In this case, community directed treatment with ivermectin will likely be recommended. The program needs to be prioritized immediately and put in place with no delay. These little black flies can travel long distances and could lead to the spread of the disease throughout the entire region. It also means that donors will need to ensure long-term support for this program, by long term I mean continuous.

This is largely the conclusion that an advisory group, of which I was a participant, recently recommended and was adopted by the governing bodies of the APOC program. Now let’s see some action.

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Africa's Aid Addiction and Corruption

On November 25, 2008, in Africa, aid effectiveness, corruption, by Karen Grepin

“Where I come from in West Africa, we have a saying: “A fool at 40 is a fool forever”, and most African countries have now been independent for over 40 years.”

This quote was taken from a new, and very interesting news piece from the BBC reporter Sorious Samura. The report contains a rather fascinating video in which the reporter travels to shops in Africa and asks vendors why they are selling goods, including bed nets and drugs, that were donated by donor programs. The reporter then goes on to interview government employees to find out how the products went from the the government stores to these for profit stores.

The root of Africa’s development problem, arugues the reporter, is in the interplay between Africa’s addiction to foreign aid and corruption.

“When half the government budget comes from aid, African leaders find themselves less inclined to tax their citizens. As a result, governments that are highly dependent on aid pay too much attention to donors and too little to the actual needs of their own citizens.”

“Another criticism of aid increasingly voiced by Africans, but rarely heard in the West is that it sponsors failure, but rarely rewards success.”

To what is the extent is the problem aid or to what extent is it corruption? Or is one just a symptom of the other? How much truth is there to any of these arguments? Do click on the link above and watch the video.

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Recently published research results in the NEJM suggest that early initiation of anti-retroviral therapy in newborns can have a profound effect on early mortality, even in low-income settings. In the trial, HIV infected babies were randomized to begin treatment immediately or to wait until they qualified using existing clinical guidelines. I thought this study had a few really interesting findings.

First, mortality declines for the early treated patients was substantial – a nearly 80% reduction.

Second, nearly two thirds of those who were randomized to the wait until needed approach ended up needing treatment anyway. Just missing that early treatment opportunity really makes a big difference for newborns.

I attended a conference last week on ARV treatment in Africa at HMS and I gathered from the clinical experts is that there is a big move underway to move treatment initiation up for adults as well. What will all of these changes have on the way in which national ARV treatment programs are being run?

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A strange story caught my attention this morning. A province in Indonesia is about to pass a bylaw that requires some HIV/AIDS patients to have a microchip injected into them to prevent them from passing on the virus.

“It’s a simple technology. A signal from the microchip will track their movements and this will be received by monitoring authorities,” said an official for the government.

Apart from not being able to understand how exactly knowing where people are would prevent them from passing on the virus, this law is going to attract disastrous negative attention to this government from human rights activists and patient groups. Do they really think this is a good idea?

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There has been mounting concern of late among development folks that the current economic crisis, which has now really become a global economic crisis, could have important effects on the amount of money available for development programs, including global health initiatives.

Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations, eloquently argues in a recent piece that:

“…for reasons of political influence, national security, global stability, and humanitarian concern, the United States must, at a minimum, stay the course in its commitments, meeting prior promises to double aid to global health and development, as well as basic humanitarian relief.”

The current economic crisis seems to be creating a perfect storm of factors that could lead to decreased foreign aid: rising inflation means that running aid programs will cost more, tightening donor budgets means less money will be available for development, the declining US dollar relative to foreign currencies means that money given is just off the bat worth less, and of course tightening of credit markets means that poor countries will need to increasingly have to rely on credit, which may come with lots of strings attached conditions.

Laurie provides some real examples of how the crisis is already affecting global health programs:

“The Haitian Health Foundation serves the needs of 250,000 residents of rural Haiti. The cost of fueling its ambulances has risen 50 percent during 2008; food inflation has driven some 40 percent of the target population into malnutrition; and cuts in U.S. government support have reduced funding by 40 percent.”

“A Minnesota organization assists the Tanzania Child Survival Project. Over the last twelve months, the value of the U.S. dollar against the Tanzania shilling has declined 16 percent, and the costs for fuel, transport, food, and supplies have increased. Fuel prices alone have soared more than 20 percent. Overall, the project has seen an approximately 30 percent decrease in grant value.”

So what does this all mean for the future of aid programs? We may not be able to do much about some declines in foreign aid, so my view is that hopefully this crisis will make us ask whether or not we are making the best use of funds that are available for global health. Like most of the world that is currently trying to deal with the changes in their finances it may mean that donors more carefully evaluate how they spend their money. Cutting back on things that we value less, making sure we spend our money on the things that will give us the most value for our money.

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Defecation and the MDGs

On November 21, 2008, in millennium development goals, sanitation, by Karen Grepin

Yesterday was World Toilet Day. Had I known I probably would have decorated up ours at home or something to celebrate, oh crap, I will now have to wait until next year to celebrate.

This is not actually my first posting on potty related policies. The lack of access to proper sanitation facilities remains an important challenge in many developing countries and therefore probably deserves a bit more attention. A recent article from the IDS has given me the opportunity to talk about these issues once again:

Almost 6,000 people, mainly children under five, die every day because of poor sanitation, hygiene and lack of access to clean water, making sanitation one of the most important challenges for developing countries.

The article describes a program being run by IDS to involve the community to make the interventions more effective. They describe their approach as a “revolutionary approach to sanitation”. Basically:

Community members make coloured maps on the ground that show where they live and where they shit. They walk and stand in the area where they do it. They calculate the amount generated in a day, a month and a year by a household and by the whole community. They analyse the pathways between the shit and their mouths. There is embarrassed laughter and powerful emotions of shame and disgust, as they realise that they are literally eating one another’s shit.

Nice, but I can see how this approach would be effective.

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Sad to say but my home country, Canada, rarely gets international acclaim for being the best of anything these days (we even loss to Russia in the Hockey world championships last year)…but we do have a really good African correspondent who does a very good job at covering important global health issues from the perspective of people in Africa.

I enjoyed reading Stephanie Nolan‘s newest dispatch on the apparently successful reduction in Malaria that has occurred in Kenya in the past few years.

This topic also received significant coverage in Lancet a few weeks back of the declines that have occurred in both Kenya and the Gambia.

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I have been very impressed with the way in which the current Director General of the WHO, Dr. Margaret Chan, has engaged in public discourse around important health issues while in office. Here are some excerpts from a piece she published in an African newspaper this morning expressing her opinion as to why traditional medicines are used in favor of modern medicines in many cultures:

This [the use of traditional medicines] is the reality, and this form of care unquestionably soothes, treats many ailments. This is the reality, but it is not the ideal.

The point I wish to make is straightforward. Traditional medicine has much to offer, but it cannot always substitute for access to highly effective modern drugs and emergency measures that make such a critical life-and-death difference for many millions of people.

This is not a criticism of traditional medicine. This is a failure of health systems in many countries to deliver effective interventions to those in greatest need, on an adequate scale.

This article was sent to me from Bill Brieger’s excellent all-things-malaria blog and listserv.

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Deaton's take on Sachs and Easterly

On November 16, 2008, in Africa, aid effectiveness, global health, by Karen Grepin

I was delightfully surprised to see Angus Deaton’s name on a review recently published in the Lancet. He chose this journal to publish his review of two books (1) Common Wealth, by Jeff Sachs and (2) Reinventing Foreign Aid, edited by Bill Easterly. Deaton criticizes Sachs’ characterization of poor people in poor countries as people unable to make their own decisions, without their own preferences over their lives, and constantly in need of help from the outside to improve their lives. He argues that these views are not supported by the general academic development community, the community which is the focus of Eastery’s book, as he states, “Sachs’ views are a long way outside of the very broad current mainstream”.

Deaton then goes on:

“My own view is that we should do the opposite of what Sachs recommends, and stop the mass external aid flows to the poorest countries of the world. We are most likely doing harm, not good; financial support cannot be given in exchange for good governance because financial support undermines good governance.”

“Related arguments can be made in favour of The Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President’s Emergency Plan for AIDS Relief, and other vertical health programmes, although the argument is more difficult. These programmes have no doubt worked to reduce mortality in poor countries and to speed the delivery of new medicines to people who would otherwise have to wait, often until it is too late. But these programmes also involve large financial flows and the associated negative effects, and they undercut the indigenous development of health provision by government and civil society.”

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That is how a recent article in PLoS NTDs on yaws begins. What are yaws? Beyond being one of my favorite Scrabble words, to be honest I did not really know what it was either. However, I am currently analyzing some health utilization data in Ghana and noticed it as among the conditions presenting with regular frequency in outpatient clinics throughout the country. What the heck is it?

A google image search leads to some incredibly nasty photos, which again I will be kind enough to spare you from viewing. The disease is caused by a bacterial infection, one that can easily and inexpensively treated if caught early, but when not treated can lead to severe deformities or other disabling conditions. It affects mainly children in poor rural areas, in particular in South-East Asia (Indonesia, Timor-Leste, Papua New Guinea) and Africa (Ghana, Republic of the Congo).

I was surprised to learn (or be reminded, as it does sort of ring a bell) that yaws was the second disease ever targeted for eradication by the newly formed World Health Organization back in the 1950s. The program had huge initial impact – by some estimates it was able to reduce burden of the disease by 95%. But full eradication was never achieved. The article argues it was due to a failure to see the project through to the end. Some quotes from this article:

“The failure to achieve complete eradication was due to multiple reasons, notably the premature integration of yaws control activities into the general health services and the disappearance of support for yaws control”

“Basically, the dedicated vertical programs were dismantled before the final blow could be struck, and the resources and commitment for yaws and its surveillance activities also disappeared”

“[Yaws] programs have been deficient in failing to aggressively seek and contain yaws cases and contacts after mass treatment campaigns reduced yaws prevalence to low levels,” wrote Donald Hopkins in 1976, slightly before smallpox global eradication was certified and while yaws was already resurgent.

The WHO, is bringing it back. Yaws eradication that is. New efforts are underway to eradicate the disease, although there are some clinical and biological challenges, the main challenges are seen as political and financial. It can be eradicated, they argue, it just needs attention from policy makers. India has had tremendous success in recent years, which lends to the credibility of the success of such programs, but as the author argues:

“…a second failure against this vincible enemy could cast discredit and mistrust on other ongoing and future eradication efforts, directed against more pernicious and less vulnerable pathogens.

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