At Christine Gorman‘s suggestion, today a number of global health and health bloggers around the world will simultaneously post on their blogs something broadly related to the general theme of the “Prevention vs. Treatment” debate. Although the prevention debate has more or less been silenced with regards to the HIV/AIDS debate (wow, I can’t believe I have been at anything long enough to want to say stuff like “back in the day”), I thought the recent announcement of Mark Dybul’s “resignation“, the recent reported increase in HIV incidence in Uganda, as well some of my own research made me think that this debate was perhaps worth revisiting.

In reality while the debate of “prevention vs. treatment” in the context of HIV/AIDS has been more or less quiet in recent years, it was never fully resolved. While both treatment and prevention efforts have been scaled up remarkably in many developing countries, it has been much easier to quantify or measure the impact of treatment programs, and much more difficult to measure the impact around prevention. There is not even agreement that prevention efforts have worked, and a lot of skepticism if they have worked at all. Plus, prevention efforts of some donors (those that shall not be named) have so politicized the debate around prevention, that it has become much easier to focus on the benefits of treatment rather than the benefits of prevention. Perhaps, even, at the expense of prevention.

I am going to argue, that I think the focus (warranted or not) on treatment seen in recent years, has actually prevented more rigorous debate and evaluation of prevention efforts for HIV/AIDS. Whereas treatment is a much easier intervention to conceive, with more or less guidelines easy to guidelines and protocols (although admittedly still hard to implement), prevention interventions are multifaceted, multidimensional, and target hard to measure and quantify things like behavior and culture. End-points are difficult to define, let alone get a sense of how they have changed.

I tried to do a detailed search on what we know works in prevention, and came up with only a handful of well controlled studies of the topic. It is not clear how well information campaigns work, whether it is better to eliminate risk or just reduce it, or what types of human beliefs drive the types of behaviors we are interested in. The only thing that seems to have gained any sense of consensus (from my naive outsider view) is that circumcision works and should be rolled out at a larger scale (again, a highly medical easy to standardized intervention). Everything else seems to be advocated – or not advocated – based on very limited sense of what really works.

I think the debate whether or should do either prevention or treatment is a false debate, because clearly we should do both. I also think that the relative ease of measuring treatment outcomes rather than prevention programs, in particular from donors, has prevented more experimentation and evaluation of what works for prevention. If I could say anything to whoever is coming in to become the new global HIV/AIDS Czar in the Obama administration is: please don’t assume we have much of a clue how to do prevention. We don’t have to choose between prevention OR treatment. There is more than enough money to go around. We need to do a better job evaluating both.

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Despite calls from such groups as the Physicians for Human Rights, the cholera situation in Zimbabwe appears to be continuing to spiral out of control. An allAfrica.com news article reports that upwards of 3000 people have now died of the (totally curable) disease and upwards of 50,000 cases of the disease have been reported, and many thousands more are at risk of the disease. To make matters worse, the Red Cross may need to pull out due to the fact that is running out of funding for its mission.

I have a personal suspicion that that arrest of Laurent Nkunda by the Rwandan government during the same week of Obama’s inauguration was no coincidence. Could this be a sign of new American influence on the continent? If so, what could the new Obama administration due for those suffering from Cholera in Southern Africa? Whatever it is, I urge them to act fast. Thousands of lives are at stake.

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Experimenting with access

On January 27, 2009, in global health, pharmaceuticals, by Karen Grepin


A confluence of factors has got me thinking a great deal about questions of access this morning. The first is that I attended the book launch party last evening for Michael Reich and Laura Frost’s new book on access to health technologies. The second was Jessica Pickett‘s response to Alanna Shaikh‘s posting on the appropriateness of donated medicines for global health issues. The third was Bill Gates’ comments in his annual letter about his renewed commitment to the development an effective microbicide despite the failure to develop one so far. Finally, Bill Brieger had an interesting posting this morning about a cherry-flavored version of Coartem that has been developed by Novartis for pediatric use in Africa.

Michael and Laura use the following definition of access in their book:

“And end-user’s abiltiy to consistently obtain and appropriately use good quality health technologies when they are needed.”

Compare that with the comment made by Novartis Chief Executive Daniel L. Vasella in the WSJ article that was referenced in Bill Brieger’s posting:

“In the end the only drug that matters is the drug that is swallowed.”

While these quotes are saying slightly different things, I think what both of these quotes are getting at is the idea that just having a drug does not mean that it will be used. Of course, this is simply concluding the obvious, but it does raise the question of where should efforts be concentrated to improve access.

I think that it will all depend on the context: what drug, what disease, what country, what end user? There needs to be the ability for more exploration and experimentation to figure out what works and in what context. Bill Gates and Novartis has been innovators with regards to the development of new products. Will making Coartem cherry flavor really improve access, in particular in a part of the world where children probably have never even tasted cherries? APOC has been an innovator with regards to delivery mechanisms. Would the community-directed delivery strategy be effective for delivering other commodities such as bed nets (by the way, early operation research supported by APOC suggests that it might)?

It is this experimentation process that is what is going to lead to improved access. It may be a process of trial and error, but we are so far from knowing what works, that there needs to be the ability to allow new things, to study why things succeed or fail, and to learn from these mistakes.

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It has been an exciting week around my house: earlier this week Lance Armstrong made his return to professional cycling in the Tour Down Under – Australia’s premiere cycling event. We don’t watch a lot of baseball or football or other major professional sports in our house, but we subscribe to fancy cable for the sole purpose of getting Versus, the only channel that covers the Tour de France and other major cycling events. We watch the various cycling events religiously. I was thrilled that Versus covered the Tour du Faso, a professional cycling race through the pot holed and decrepit highways of my beloved Burkina Faso. We are contemplating a trip to San Francisco in February to see him in the Tour of California and to France in July for the big show.

Why would anyone who has battled cancer, led the most successful cycling career in history, and has dated a steady stream of fashion designers, rock stars, and A-list hollywood actresses since retiring want to get back on a bike and compete in perhaps one of the physically most demanding sporting events in history? Partly because Lance wants to raise awareness of cancer. I was happy to learn through this awareness that he has recently launched a campaign to raise the awareness of cancer around the world. From a press release:

“The LIVESTRONG Global Cancer Campaign will be focused on supporting the 28 million people living with cancer worldwide, dispelling the misconceptions surrounding the disease and urging world leaders to make cancer control a greater priority.”

“We have an ambitious, yet achievable goal in making cancer a global health priority.”

I think it is wonderful that his efforts may raise the profile of cancer around the world and will make it a greater priority on the international health agenda. Go Lance!

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Now that he works full time at his namesake Foundation, Bill Gates has a lot more time to devote to its day to day operations and also for keeping us informed about what is going on inside his philanthropic empire. Earlier today, taking a queue from his friend Warren Buffet, Bill Gates released his first annual letter. In it he outlined his assessment of the progress made by the Foundation to date and outlined his vision for the coming years.

The letter was full of ambition, in particular with regards to global health goals:

“I believe that within six years we will have enough distribution to have cut the number of rotavirus deaths in half. This is an ambitious goal, but it’s one of the key steps to cutting the overall number of childhood deaths from 10 million to 5 million.”

But also acknowledged some of the criticisms that have been made of the Foundation’s focus on the science and technical aspects of technologies, rather than also some of the human and social factors that influence the adoption of such technologies:

“Some people criticize this approach, saying either that the problems can’t be solved with technology, or that the technology only works if it reaches the people who need it. There is some validity to both of these points….Technology is only useful if it helps people improve their lives, not as an end in itself.”

Bill acknowledged that the Foundation’s assets decreased in value by about 20% in 2008 (fair to say a pretty good outcome…considering). Historically, the Foundation has been spending about 5% of its assets annually, roughly the minimum required by law, presumably while the Foundation was earning returns far above 5% a year. This year, despite their set back, they have decided to increase the actual amount of money given by the Foundation – to roughly $3.8 billion – which actually translates into 7% of the value of its assets.

“..the goal of our foundation is to make investments whose payback to society is very high rather than to pay out the minimum to make the endowment last as long as possible.

I consider this to be a very noble gesture, consistent with his long term commitment. Gates is clearly Keynesian at heart (he even quotes him during his letter).

I enjoyed this opportunity to see how Bill Gates thinks and what drives him to devote so much of his time and resources to his Foundation. He talked about how he learned about important problems affecting poor people in the world, spent some time further researching this topic, and from his research he asked new questions and learned about how technology may help solve the problem. He is an engineer and a scientist at heart, and this background shows in his approach to important social issues.

I think it is also important for people to continue to think big – for example, he believes that we can once again halve the number (not just the proportion) of children who die before the age of 5 in the coming years. He seems fully committed to helping to develop the strategies needed to ensure this happens.

I also liked how he wants to bring in more partners to his causes. When thinking about what the Foundation could do for polio eradication efforts, they were happy to put forward money, but made is a condition that other donors also put forward millions of new funds as well.

Perhaps one of the most remarkable parts about this letter, is there were actually very few references to the actual achievements of the Foundation, other than to talk generally about the activities the Foundation has been involved with. I guess it hard to tout one’s own horn too loudly, but I think he could have done a bit more tooting.

I enjoyed this piece of introspection on Bill Gates part and am happy to learn that this will become a regular feature for the Foundation. The Foundation is clearly evolving: learning from its mistakes and thoroughly evaluating its achievements. I am just happy to know that we will be well informed of this evolution going forward.

If you want to read the letter yourself, click here.

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Earlier this week, I blogged about an upcoming seminar that will feature the authors of a new book on access to pharmaceuticals. The book, is now available for (free) download on the book’s website.

The book explores what it is about some products that leads them to be adopted and properly used by some people while others are not. They explore a number of interesting case studies: from praziquantel to the female condom.

Happy reading!

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Adding to the list of programs that make China the most developed developing country, yesterday it was announced that the Chinese government will commit massive subsidies of about $123 billion dollars to achieve universal health insurance for all 1.6 billion Chinese citizens by 2011.

“…take measures within three years to provide basic medical security to all Chinese in urban and rural areas, improve the quality of medical services and make medical services more accessible and affordable for ordinary people.”

What this program will actually look like is not clear, but it does represent a major step forward for health in China. It also means that the government takes seriously the link between a healthy population and a healthy economy.

“荣誉” – which according to Babel Fish translation means “Kudos” in Chinese. For all I know, it could say flabby worm or anything else. But that is what I mean.

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30 years ago more than 125 countries in the world were polio-endemic and more than 350,000 children were paralyzed by the disease each year. At the time, this was a major achievement in its own right, widespread immunization with a polio vaccine, which began nearly 30 years earlier, had nearly eliminated polio from the developed world. The success of the vaccine and of the smallpox eradication program led the WHO, UNICEF, and Rotary launched a global eradication effort to wipe out the disease in the rest of the world was launched in 1988. Since then there has been great progress – last year only 2000 cases of the disease were recorded annually. Thousands of volunteers have been mobilized, billions of dollars have been raised, and countless campaigns have been launched. Despite all of these achievements – including a 99% reduction in cases globally – the battle is far from over…

Yesterday, the Gates Foundation, Rotary, the UK, and Germany announced $630 million new funds over the next 3 years to make a big push further towards eradication. The announcement could not have come at a better time, polio risks spreading out of control in the coming years, in particular as the current financial crisis may mean governments in most affected regions may face budget cut backs and increased emphasis on other diseases. Polio resurgence needs to be given proper attention if it is to be conquered and a focused effort, with a fresh infusion of funds and energy, may just be what is needed.

You can read more about the announcement, here.

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“Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.”

In this eloquent piece in the New Yorker, Atul Gawande, who I just blogged about a day ago, argues that successful health care reforms build upon what already exists. While many would call these types of reforms “incremental” or “piecemeal”, Gawande argues that it does not mean that these types of reforms necessarily need to be unambitious.

“So accepting the path-dependent nature of our health-care system—recognizing that we had better build on what we’ve got—doesn’t mean that we have to curtail our ambitions.”

On the eve of President Obama’s inauguration, I don’t think this article could have been better timed – or better argued. The health insurance systems in place in Canada, the UK, France, and Switzerland were all responses to the second world war. The individual circumstances of each country during the war – evacuation of London, Americans fighting overseas, Swiss neutrality – to some extent explains the systems now in place in each country. Could the current economic crisis be enough to spur such reforms here in the US?

“Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.”

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I thought Jessica Pickett’s post on change.org’s global health site this morning was excellent, so instead of trying to paraphrase it, I will leave it for you to read for yourselves.

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