We need a secretary of food…

On December 11, 2008, in health policy, public health, by Karen Grepin

…or so says Nick Kristof in this morning’s NYTimes. He argues that the current department of agriculture needs to be renamed and refocused because it no longer makes sense, as he writes:

“A Department of Agriculture made sense 100 years ago when 35 percent of Americans engaged in farming. But today, fewer than 2 percent are farmers. In contrast, 100 percent of Americans eat.”

Yesterday we bailed out the automakers, to the tune of many billions of dollars, but this is not new practice. The agricultural industry has been bailed-out for decades. According to Michael Pollen, quoted in the Op Ed piece:

“We’re subsidizing the least healthy calories in the supermarket — high fructose corn syrup and hydrogenated soy oil, and we’re doing very little for farmers trying to grow real food”

What this says to me is that not only is the choice of the next secretary of agriculture and important choice for the US economy, it is also an important choice for public health. How we subsidize the agriculture industry influences how we eat – and how people around the world make a living off of agriculture and get their calories.

I count myself among those 100% of “Americans” who eat (I am not American, just a resident) – pretty regularly in fact – and I think it is about time we see some real change with regards to food policy in the US.

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I have previously blogged about the tremendous success of the Global Programme to Eliminate Lymphatic Filariasis. This week’s BMJ has even more evidence to support this view.

In just over a decade, the GPELF has now successfully eliminated LF in 16 countries. Many of the countries are those pretty to easy to conquer island nations of the South Pacific, but some African countries have made the list, including Togo – a small country – but a country I can attest first hand comes with its own set of challenges.

You can read more about these successes here.

Kudos need to go out to the partnership, but I think especially to the pharmaceutical companies that have made this possible: GlaxoSmithKline, which provides albendazole, and Merck, which provides ivermectin. Both companies have been long-term partners to global health, both have made long-term commitments, and both have given their products completely free of charge.

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A big threat to global security is currently brewing in the bowels of Southern Africa (pun intended). Due to deteriorating social, economic, and political conditions in Zimbabwe, cholera is quickly spreading throughout Southern Africa. Although this disease pops up ever now and again throughout the continent, the fact that the epicenter – or its ground zero – of this current epidemic is in Zimbabwe means that there is little holding it back. Hundreds have already died and many thousands more are likely to get sick in the coming weeks.

My choice of words above were purposeful. I think it is about time we treat this as one of the greatest threats to security throughout Southern Africa and we should respond appropriately. Like the attacks in Mumbai a few weeks back have been called “India’s 9/11″, this could be Southern Africa’s.

Happily, someone with a lot more experience in this territory also agrees with me:

“The fact is there was a sham election, there has been a sham process of power-sharing talks and now we are seeing not only political and economic total devastation … but a humanitarian toll of the cholera epidemic.”

“If this is not evidence to the international community that it’s time to stand up for what is right I don’t know what will be.”

“And Robert Mugabe is simply trying to cover the fact that he’s taken a country, which was once one of the jewels of Africa, made it into a center of starvation and now of rampant disease that threatens its neighbors.”

“We ought to call it as we see it.”

Those are quotes made by outgoing Secretary of State Condoleeza Rice during the past week at various public appearances. Despite the fact that she sees this as a reason for the international community to intervene, so far no country has. Part of it is that I think the US government has been so burned in the past in Africa they are hoping the African Union will step up and fix the problems. But so far, the AU has not been terribly effective at responding. So then what?

Given that the Bush administration in on the way out and the Obama administration in on the way in, and given the global economic crisis, it will probably be months before this issue will surface on US foreign policy agendas. By then tens or even hundreds of thousands may have fallen victim to this disease.

I agree that we ought to call it as we see it, but “WHO” is we?

To read more, check out the rest of my blog.

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All eyes on Ghana

On December 8, 2008, in Ghana, politics, by Karen Grepin

Yesterday was election day in Ghana. Before heading to bed last night, I checked the latest on the polls, which seemed to suggest that the opposition NDC party had an early lead. This morning when I awoke, there was still no official results, but it was then being suggested that the ruling NPP party was in the early lead. So frustrating! I have not been this excited about an election since…well…at least November 4 (OK, bad example).

All eyes are currently on Ghana to see how this election will turn out. From most indications, the elections will go smoothly with no major violence or conflict. President Kuffuor, the current president, already respected term limits and stepped aside for the current election. As of this evening, it appears as though the election will be too close for any one party to get the majority and a run off election will be held in a few weeks.

The stakes are high in this election, not just for the future of Ghana (including deciding how future oil revenues will be spent), but for much of Africa. The outcome of this election could give hope for future elections in the rest of Africa.

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There is some really promising results published this week’s NEJM that suggest that we might be one step closer to an effective malaria vaccine…for real!

There has been a long history of attempts to come up with an effective malaria vaccine, but all of those efforts have so far failed. There are many reasons for this, but unlike many diseases for which we had vaccines early on, there are much more complicated biological processes that mediate infection and disease progression in malaria making the quest for a vaccine much more difficult.

The first important finding was a trial that looked at whether or not the vaccine candidate under investigation was protective against clinical malaria end points in young children in Kenya and Tanzania. Although the trial was small, they found that the vaccine was roughly 60% efficacious in reducing clinical cases of malaria.

Perhaps as important, the second study showed that the malaria appears to work when combined with standard EPI vaccines, suggesting that this vaccine, should it ever get the green light, could likely be combined into current vaccination programs.

I’ve been meaning to get around to write a more detailed posting on the truly remarkable progress that appears to be happening across Africa on reducing malaria incidence using physical protection strategies such as bed nets and indoor residual spraying, and I will shortly. Some of the drops appear to be really dramatic, which could lead one to ask the question of whether our efforts are better spent on these types of interventions.

I don’t think so. I think this is one of those cases where the two interventions together – vaccination and physical protection – can really work off one another to control transmission. Neither intervention will likely be entirely effective so we may need more than one intervention. Plus, spillover effects may mean that these interventions are highly complimentary.

I can’t wait to hear more about these results…I am really exciting about these new findings.

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The Institute for Health Metrics and Evaluation at the University of Washington is now accepting applications for its Post-Bachelor Fellowship program. The program is designed to give recent undergraduate graduates an opportunity to gain some real experience conducting global health research. The institute has some of the greatest scholars in this area on staff. The research is quantitatively focused, so they are looking for some evidence of that in your background.

A few years back this program used to be run out of Harvard University and I had the chance to get to know many of the PBF – as they were called. They were a great bunch of students and most of them went on to top graduate schools for medicine, public health, and doctoral studies in related fields. I can say that I think this is an amazing opportunity for anyone interested in global health work and I would highly recommend that you apply.

For more information on the program, click here. Details on how to apply are also on this website.

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Last evening, I had the great pleasure and opportunity to attend a really interesting session at the Harvard Kennedy School’s Institute of Politics. The HKS is currently hosting a week long “crash course” for all newly elected members of congress. The session I attended brought together leading experts on global health issues to speak to them about global health and its relevance to them as new members of the United States congress.

Why should they care about global health issues? How much do they even know about global health issues? What would you tell them about global health?

The speakers, most from the Harvard School of Public Health but also from the Gates Foundation, spoke mainly about the US government’s moral or ethical obligation to contribute to global health and also about the idea that protecting global health is a global public good and benefits the economy and well being of all nations on the planet.

The world is moving into a global recession, and the US will most certainly face a major economic downturn in the coming years. Add on top of that a strong mandate to improve health insurance coverage within the US, and you have a situation where it may be really hard for these new members to prioritize health issues overseas.

I thought the most practical suggestion came in response to a question from the audience where one of the speakers suggested that one big change in the new administration could be to coordinate and learn more from other major global health initiatives. I agree strongly with this idea, and it is the kind of change that does not even cost any more money.

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Analysts at the CGD, in a memo to Barack Obama, argue that just by releasing data on how PEPFAR funding data is actually spent would go a long way to make the money more effective.

All I can say is that I 10000% think this is a good idea – if not more. What a way to get things off to a fresh start with some real “Change”?

Click here to read the memo and to see the entire posting on the CGD blog.

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Can we treat away the HIV/AIDS epidemic?

On December 1, 2008, in HIV/AIDS, research, by Karen Grepin

Today is World AIDS Day. I therefore thought it appropriate to post about something HIV/AIDS related today. In the upcoming Lancet, there is going to be a very interesting article that is likely to generate a lot of discussion. The the paper, the authors (Reuben M Granich, Charles F Gilks, Christopher Dye, Kevin M De Cock, and Brian G Williams) build a mathematical model to estimate whether or not the spread of the epidemic can be stopped by treatment alone, even in countries in Africa.

Basically, they assume that they can test everyone for HIV and then put everyone who tests positive immediately on ARV therapy. They find that this approach can effectively eliminate incidence of the disease within about 10 years and reduce prevalence in another 40 or so (basically until those who have it die). I guess nothing in this should be surprising, intuitively if we assume that treatment does greatly reduce transmission and everyone who is infected is getting treated, then of course, it should follow that transmission will drop dramatically.

The real question, however, is whether or not such a approach would even be possible in the first place? If this strategy were to be true in high infection countries, then it should also be true in low infection rates, so might this be a sensible approach for higher income countries as well? Would any of this ever be feasible?

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Increasing transparency for essential medicines

On December 1, 2008, in pharmaceuticals, by Karen Grepin

Despite the fact that medicines account for 20–60% of health spending in developing and transitional countries, there is little transparency about prices paid or the availability of these medicines in most non-OECD countries. It is therefore great news that our understanding just got a bit better.

In an upcoming Lancet, Cameron et al. describes the early results of an analysis of data collected in partnership with the WHO and Health Action International. The partnership developed a standardized methodology to collect internationally comparable data on prices paid for medicines in the public sector and by end-users as well as surveys to test for the availability of medicines and carried out these surveys in dozens of low income and middle income countries. What do they find? Among other things:

Medicines were available, on average, at best half the time in public sectors.

There was great variability across countries and regions with regards to how much above the international reference price governments paid for medicines. It ranged from 0·09 to 5·37 times international reference prices.

Private sector patients paid 9–25 times international reference prices for lowest-priced generic products.

Data from the surveys is available on the HAI website.

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