“We abandoned chloroquine when it failed to cure one in four patients and was available everywhere,”…..“We now have a drug that cures 100% of patients but is not available in one in four clinics.”

That is a quote taken from a recent Editorial by the Editors of the PLoS Medicine journal who are calling for what they call a “third wave” in malaria treatment advocacy.

According to the authors of this editorial, the first wave of malaria activism brought to global attention the disparity between the burden of malaria and the amount of money spent on the disease by the international community. Successes during this period include the establishment of the Global Fund and other major new fund raising mechanisms for the disease.

The second wave highlighted the fact that although money was rushing it, much of it was not being spent on the most efficacious malaria treatments, namely ACTs. We have now seen the establishment of the Affordable Medicines Facility for Malaria (AMFm) and much more attention to this issue globally.
Now the big problem, they argue, is that despite the fact that there is money available for treatments and commitment to spend them on the best drugs, the medicines are still not always making it to the patients who need them, largely due to stock-outs of medicines in facilities. They see this as perhaps the biggest barrier to expanded treatment coverage.

This finding should not be terribly surprising, big global solutions tend to start at the top and only when they realize that things are not working do they look one level down to see why the solution did not work (parallels can be drawn with HIV and health human resources). But how is this nitty gritty operational problem going to be solved? It will all depend on health systems, and solutions are likely country specific, but will need to be resolved if global targets are to be met.

A friend of mine, Jeremie Gallien, a brilliant operations researchers at MIT, who normally devotes his energy to figuring out how to get parcels from warehouses to people’s doors or how to get the latest fashions on store shelves as fast as possible, is now working on this problem in Zambia, and I can’t wait to find out what he has learned.

I know that there are lots of other really smart folks out there also working on this important problem, it is just too bad we always have to start at the wrong end of a problem to identify the most important barriers or to foresee them in advance. Perhaps an operations researcher would have said that all along!

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Another big win for the NTDs

On December 8, 2009, in neglected tropical diseases, public health, by Karen Grepin

Last evening I a lecture on the Neglected Tropical Diseases (NTDs) in my Global Health Policy course at NYU-Wagner. One of my students asked whether the many NTD control programs that had sprung up over the years to address these diseases were in fact sustainable – an excellent question. My response was “who ever said they should be?”.

Later that evening I learned some excellent news on the NTD front. After nearly 20 years of tireless work, and thanks in a large part to the help of the Carter Center, Nigeria – once the country the most afflicted by Guinea Worm – is on the verge of declaring victory in the war on the scourge. Guinea Worm – a worm that enters into your body and can grow as long as 3 feet before getting bored and exiting your body in a painful and debilitating way – is among the group of helminthic NTDs and is among what I consider to be the yuckiest diseases on the planet.

The strategy to eradicate this disease is a slow but effective one – all patients infected with the worm are identified, treated, and educated in such a way so that they do not risk spreading the worm to others. The strategy works, it just takes time. Since the mid-1980s, when the Carter Center waged a war against the disease the number of people infected has fallen from a few million to a few thousand, an impressive and significant global health achievement.

Which brings me back to the question of sustainability. Guinea Worm control program, along with other NTD control programs that aim for elimination or eradication, when successful will eventually work themselves out of a job. That is the point. Some NTD programs are likely to be even more short-lived than Guinea Worm control. Therefore, it is not clear that sustainability of these programs should ever be an important goal. Not all diseases, however, share these characteristics.

Plus, some functions of NTD control, for example ongoing disease monitoring and surveillance, are likely to be needed for years after eradication or elimination are achieved and therefore these programs should be integrated into existing health system infrastructure, this is a lesson that has been learned from onchocerciasis elimination and elsewhere. But this is one example of how vertical programming, when well targeted and well implemented, can be a good thing. The NTD community is years ahead of many other disease control programs in terms of their experiences and their learning. It is great when we can learn from great successes such as this one.
For those that can stomach it, here is an excellent video from the NYTimes Science Times from a few years back, with the mandatory views of Guinea Worm extraction.
Photo credit: Vanessa Vick via the NYTimes

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Earlier this week, I attended a symposium entitled “HIV Scale-Up and Global Health Systems” hosted by Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP). During the panel moderated by Stephen Lewis, which included former US President Bill Clinton, the moderator stopped the discussion to make the point that his organization does not use the term “mother-to-child” transmission of HIV because that places to much blame on the woman. Instead, they use the term “vertical transmission” – between generations. I found his emphasis humorous, not because I don’t agree with the idea of not blaming women, but because he was making such a big deal out of what I assumed was essentially the only way children acquired HIV.

Yesterday, Kim Yi Dionne on her blog haba na haba made me aware of a debate that apparently has been brewing under the radar in the HIV community for some time, one that seems to have a small number of ardent supporters, but one that is not readily accepted by the mainstream research community.
It turns out that there are many out there who believe that non-sexual transmission may account for a substantial fraction of HIV infections in some Sub-Saharan African countries, including among children.

A Telegraph article suggests that up to 1/5. Given that we generally assume young children to be sexually inactive, the authors speculate that blood exposure, through needles or through other forms of contamination is to blame. A whole edition of the journal “International Journal of STDs and AIDS” was recently devoted to a review of the research on this topic.

The primary form of evidence that exists to support this view is that a number of sero-prevalence studies have found rates of HIV infection among children to be too high to be explained by vertical transmission alone (I am not quite sure what is a normal rate) as well documented cases of HIV infected children born to HIV negative mothers. There are also qualitative surveys that have asked about all exposure risks and have relatively high rates of reported blood exposures in different populations and that people living in Africa may have much greater exposure to injections and vaccinations than in other parts of the world – partially due to injections for malaria. Together, these studies have been taken together to argue that blood exposure may account for a substantial fraction of transmission in Africa and that it has not received enough attention as it deserves from the prevention community.

I read through some of the research papers and thought some of them made strong inferences from rather limited data (e.g. the 1/5 figure came from a study of children in Swaziland, of which there were only 50 in the sample, and only 11 of which reported to be sero-discordant from their parents. Other issues, such as remarriage, false positives and false negatives, small sample size, and other potential explanations were not given enough discussion) but just the same I found the idea perplexing and interesting. PEPFAR has focused a lot of attention on blood safety in many developing countries, but perhaps more emphasis also needs to be placed on other injections and needle use as well.

Anyone out there know more about this issue that they would be up for sharing?

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In Sub-Saharan Africa the HIV epidemic has largely been spread through sexual intercourse, a complicated and messy behavior that has proven highly stubborn to intervention. Outside of Africa, the HIV epidemic, however, has also been spread through other means, including the re-use of contaminated needles. An excellent must-read piece in today’s NYTimes explains:

“In Russia, 83 percent of infections in which the origin is known come from needle sharing. In Ukraine, the figure is 64 percent; Kazakhstan, 74 percent; Malaysia, 72 percent; Vietnam, 52 percent; China, 44 percent. Shared needles are also the primary transmission route for H.I.V. in parts of Asia. In the United States, needle-sharing directly accounts for more than 25 percent of AIDS cases.”

Of course, as epidemic go, even if sexual behavior is primary means of transmission, the spread of the virus is amplified through other transmission channels, such as injection drug users, who subsequently spread the virus to their sexual partners.

The good news is that there is actually an intervention available to help curb the transmission of the virus (and other viruses) that has been shown to be highly effective, low-cost, and easily adopted by targeted populations: clean needle exchange programs. Free clean needles are made available for free to drug users in exchange for their old infected ones, removing the dirty needles from the streets and greatly reducing the likelihood that drug users will spread the virus to one another.

“Needle exchange is AIDS prevention that works. While no one wants to have to put on a condom, every drug user prefers injecting with a clean needle. In 2003, an academic review of 99 cities around the world found that cities with needle exchange saw their H.I.V. rates among injecting drug users drop 19 percent a year; cities without needle exchange had an 8 percent increase per year. Contrary to popular fears, needle exchange has not led to more drug use or higher crime rates. Studies have also found that drug addicts participating in needle exchanges are more likely to enter rehabilitation programs. Using needle exchange as part of a comprehensive attack on H.I.V. is endorsed by virtually every relevant United Nations and United States-government agency.”

The bad news, however, is that many policy makers and politicians refuse to support such programs on the basis that supporting these programs would be the equivalent to supporting drug related behaviors and directing public subsidies to a particularly undesirable part of the populace. The US government has banned the use of federal funds to support such programs since George Bush Sr.’s time in office, and despite claims to support such programs by both Bill Clinton and Barack Obama, the ban remains in effect.

Targeting high risk groups is likely the key to effective HIV prevention – that is a lesson that has emerged from past research efforts. It is time that public health policies begin to reflect this reality. Presumably saving lives is always good politics.

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What happens when you spend too much time in Seattle

On November 20, 2009, in global health, by Karen Grepin

“Even though HIV has captivated public discourse and funding, including over $5·1 billion in development assistance for health in 2007 alone, there are only rough estimates of its disease burden.”

I could not agree more. That is a quote taken from a comment in the latest Lancet by the class of Post-Bachelor Fellows at the Institute for Health Metrics and Evaluation in Seattle. I know this program well – I was the TA for the first ever class at Harvard back in 2005 – and admire it greatly – many of its alumni are now making their way through top PhD programs and medical school across the US and around the world.

It appears that spending a year or two in Seattle working with Chris Murray will make just about anyone a “skeptical optimist” about global health data. They further expand:

“Despite the instant availability of an abundance of statistics in the information age, accurate statistics about our most basic need—our health—remain elusive. Vital registration systems remain weak in much of Africa and Asia, such that many people’s births or deaths are never recorded. Estimates of costs and outcomes are often modeled with weak data, yielding inconsistent estimates: estimates from WHO and the World Bank of the cost effectiveness of intermittent presumptive treatment in pregnancy for malaria differ by a factor of nearly forty.”

I make this point a lot with my own students, to the extent that now just about every memo or blog they hand in has a one sentence caveat along the lines of “of course, this is all based on data that is next to meaningless”. I love my students.

I have a number of columns of key word searches around global health open in TweetDeck, and it is nearly every day someone out there tweets some statement they gleaned from some newspaper article or some other source which is so far from the truth. I bite my tongue every time. My favorites? Quotes on the biggest killers or claims of increases/decreases in maternal mortality.

While I could not agree more with the statements that the PBFs make in their comment, I also would argue that I think it is not excuse to not use what data we do have when formulating policies. Some data, for example the DHS and MICS surveys, are perhaps the best sources of data in global health and are – in my opinion – greatly underutilized. They may be the greatest public good in global health.

So while yes, we need to do a lot better at collecting better data, we also need to do a better job at using the data we do have. I am happy that there are young guys out there like the PBFs doing this every day, and encouraging the rest of us to do so as well.

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Right now in Kampala, Uganda a group of experts are gathered to discuss a topic that has gone out of fashion of late, but a topic that might be vitally important to achieving reductions in both child and maternal mortality.

A recent high-level meeting on the topic by Minsters of Health called it “one of the most cost-effective development investments”. This intervention has been singled out as a priority in dozens of international proclamations, programs of action, declarations, and even a UN convention (the 1979 Convention on the Elimination of All Forms of Discrimination Against Women) dating back over 40 years.

The intervention is considered low-tech, low-cost, and safe and has been used by billions of people, and yet almost 200 million women who want the service do not currently have access to it. What is it? Family planning.

There are a lot of reasons why promoting family planning has fallen off the radar, including a sordid history based on the aggressive implementation of family planning in a few countries (e.g. India and China) and increased focus on other health issues, and apparently our inability to focus on any one area for more than a few years.

But there is growing interest in addressing the issue again, perhaps due to the fact that too little progress has been made on certain MDGs, or perhaps due to the fact that the benefits of decreased fertility are now being seen in many countries where family planning programs have been successful.

Regardless for the reasons, the increased attention is welcomed: in many countries, contraceptive prevalence rates remain low and the unmet need for contraceptives remains high. Both demand and supply factors are likely explanations for the low use, so there will be no silver bullet, but we need to do a lot more to better understand this vitally important health intervention. Let’s hope this conference helps to make this old topic new, and interesting, once again.

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I have just finished up at really interesting conference in London entitled “The global economic crisis – including children in the policy response“. The conference was jointly hosted by UNICEF and the Overseas Development Institute (ODI). At the conference a series of papers analyzing lessons from past crises and taking an early look on the current responses were presented by academics, developing country researchers, and members of civil society. I presented a paper that looked at how aggregate income shocks were affected household health seeking behavior (still a work in progress).

I thought I would share what I think were some of the key take-aways for me from this event. First, I think the evidence from previous crises points to a story where we will likely see quite heterogeneous effects of the current financial crises, but children have shouldered a disproportionate share of the burden in past crises and will likely again this time around. Some aspects of their lives are also more likely to be affected than others, for example, there is evidence that health seems to suffer more than education when there are large economic downturns.

Second, there was a lot of talk about what are termed the 3 “F’s” of the financial crisis – “Fuel, Food, and Financial”. There is growing consensus that the world is beginning to emerge from the effects of the “financial” crises, however, the food and fuel crises – which have been in effect longer than the financial crises – are likely here to stay for a while to come. The crises is far from over in most developing countries where food and fuel represent large portions of total household expenditures. This point must not be lost as the world begins to turn exclusively to discussions of recovery.

Third, part of the variation in outcomes that has been observed in previous crises (e.g. the Asian Financial Crises) appears to be explainable by whether or not countries had in place social protection programs before the onset of the crises and the extent to which these programs were preserved. In addition, countries that established permanent social protection systems in response to past crises seem to be doing better this time around as opposed to those that simply implemented temporary measures. We need to understand better why some countries committed to these programs while others did not.

Fourth, another “F” might be looming on the horizon for developing countries – “Fiscal deficits”. Most countries have seen reduced revenues from taxes, tariffs, and other usual sources and have been encouraged to keep public expenditures high. However, the deficits that have been created are likely to come back to haunt some countries, in particular developing countries. Deficits might put increasing pressure on existing social protection and social programs going forward.

Finally, the way in which data is current being collected in developing countries means that for the time being we have nearly no way to monitor exactly how the crises in unfolding in most countries. One of the most interesting presentations we had was from a researcher in Egypt where they conduct large household surveys a few times a year allowing ongoing and real time monitoring of how the crises has been affecting households. It is sad that in this day and age, being able to access real time basic data on households remains a huge challenge.

The effects of the global economic crises are certainly far from over, in particular in developing countries. There was a lot of talk here about how to think of not just “recovering” from these shocks but using the opportunity for an excuse to implement more “restructuring”. I am happy when I leave a conference having learned something but also that our work could really help shape policies that may one day affect the lives of real people.

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I knew from an early age that I was interested in health issues but I grew up in Canada where the concept of liberal arts education really did not exist. Upon graduation from high school students have to select between a career in “Arts” (where most social sciences were housed) or “Sciences”. The daughter of a mining engineer and a biologist (albeit cum lawyer) with a strong interest in health there was not doubt in my mind: I was a scientist, not an artist. So I happily enrolled in an undergraduate degree in Immunology at McGill University which was a highly intensive program with a focus on biochemistry, microbiology, and physiology and sneered at my “artists” friends – who we all knew would never find jobs.

At McGill, I spent countless lectures in large lecture theaters memorizing biological pathways and the structure of organic molecules and invested hundreds of hours pipetting, centrifuging, and culturing nasty smelling bacteria and viruses in a lab. But for some reason, it was just not for me. All of my classmates knew that they wanted to go to medical school or get a PhD in basic life sciences, but not me. Instead, I got involved in student politics and planned to go to law school.

Towards the end of my studies I took an advanced seminar on current challenges in vaccine development. In that seminar, I was assigned the topic “pneumococcus vaccine and the developing world”. I had never considered the connection between what we were studying in the classroom and its broader impact on the rest of the world. Through my research for that project, I learned that a new pneumococcus vaccine was about to come onto the market targeting mostly ear infections in the developed world, despite the fact that the same infectious agent was responsible for upwards of 2-3 million childhood deaths and significant morbidity in the developing world. Yet, due to financial incentives it was unclear whether the vaccine would even be effective in places like Africa where there slightly different versions of the bacterial types included in the vaccine. This single project was perhaps the event in my life that made it clear to me that I wanted to devote my career to global health.

Fast forward to today, that vaccine did eventually go onto the market, and did become the first blockbuster vaccine product. But coverage of the vaccine is horrendously low in developing world today. During the past year, we have seen some new developments, including the introduction of a pneumococcus vaccine in the Gambia and Rwanda. We have also seen the launch of an advanced market commitment program for the development of a more tailored pneumococcus vaccine for the developing world. And just this past week, GAVI unveiled plans to distribute the vaccine to over 130 million children worldwide.

While there is lots to be happy about on this first ever World Pneumonia Day (Monday, November 2, 2009), it is clear that efforts are just underway to address the number one killer of children. It is going to take years of focused attention, commitment from donors and governments, and financial support, but this is one battle that we should be able to win. So I will be wearing my blue jeans this Monday in support of World Pneumonia Day, and I encourage you to do so as well.

All photos were taken from the interesting “Faces of Pneumonia” feature on the World Pneumonia Day website.

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Good for the soul, bad for the body

On November 1, 2009, in polio, politics, public health, swine flu, by Karen Grepin

Swine flu has now spread so far and wide across the globe that there is perhaps little point in governments spending a lot of effort at trying to contain the spread of the virus across its borders. But one country in particular probably has real cause for concern: Saudi Arabia. In a couple of weeks, 2.5 million pilgrims from over 160 countries are expected to make the trip to Mecca, Saudi Arabia for the hajj.

This is not the first time that the annual pilgrimage to Mecca has been scrutinized by public health experts. Anytime millions of people from different areas converge on the same place there is risk of disease transmission. There have been outbreaks of meningitis linked to the hajj and, perhaps most famously, the event propagated the spread of polio a few years ago, greatly setting back the international effort to eliminate the disease and creating one of the few diseases that seems to disproportionately affect one religious group – polio is now predominantly a disease affecting Muslim countries.

A NYTimes article last week described some of the proactive steps the government of Saudi Arabia is taking to prepare for the event and to minimize its impact on public health: encouraging all pilgrims to get vaccinated against swine flu, asking more vulnerable pilgrims to stay home (e.g. pregnant women and the elderly), and setting up sites for treatment. I am greatly encouraged by the efforts.

I am also greatly encouraged by the government’s additional efforts on polio: this year they are going to require all pilgrims to swallow an oral polio vaccine upon arrival, and they have entered into the world of major donor to the global polio elimination effort by donating an addition $30 million towards the cause.

Sometimes concerns for religious and cultural practices comes at odds with public health concerns and too often one side wins out over the other. It is good to see how both concerns can be addressed at the same time, it can be good for the body and the soul.

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Here are some links to some interesting things on the net this week:

1. The BBC takes a look at maternal mortality around the world this week. Click here for more information, including a video that shows how a simple bicycle ambulance is saving lives in Malawi.

2. My colleague Bill Savedoff blogged about the book “The Gods of Lending” on the CGD website. I started reading this book a while back, and there are some shocking details in it about the way in which the World Bank operates. The author argues that 30-40% of World Bank loans are misappropriated.

3. The Journal of Acquired Immune Deficiency Syndromes, normally a very technical and clinical journal, has put out a special supplement on HIV and health systems. Remarkably good stuff in there. Have a look.

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