Stuff on the net

On January 19, 2009, in links, stuff on the net, by Karen Grepin

In honor of inauguration day tomorrow, here are a few president related items from the net that I thought were particularly great the past few days.

1. Get your very own Mi-Obama phone. A Kenyan telecom provider has introduced an Obama branded cell phone – with his name, his colors, and even the slogan yes we can on it.

2. Thanks to my friend Andy – who shared this on facebook – Words of Wisdom to incoming president elect Obama from children across the nation. My favorite: “..tell people to not talk too much. It wastes time.”

3. And I just had to: Letterman’s top 10 favorite George W. Bush Moments. Too funny. I like to fish too.

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The results of a multi-country study on improving outcomes from surgery were recently published in the NEJM. The intervention under study is a simple and as low cost as they get – a standardized check list – but it appears to be effective in both rich and poor countries.

Surgery has become very common around the world, roughly 234 million operations are estimated to take place every year, an occurrence more frequent than childbirth. Clearly the rates of operations per population are not likely to be the same around the world, with higher income countries having more surgeries per capita than poorer countries, but the process remains an uncertain process everywhere, and nearly all surgeries are associated with some related risk of death or complications.

The current thinking is that much of these deaths and complications are preventable, suggesting that they are caused by error or other factors associated with human judgement and the results of this study certainly support this view. The check list is pretty straightforward stuff – did you confirm the patient’s name? did you confirm the reason for surgery? did you confirm the site of surgery? were antibiotics started? did anything go wrong with the equipment that should be checked before its next use? -but seems to make a big difference. Huge.

The authors rolled out the use of the same checklist to 8 sites around the world: from Tanzania to Delhi to Manila to Toronto to London. The list was associated with sizable and significant decreases in death and rates of complications in all sites: the rate of death drop from 1.5% to 0.8% (wow!) and the rate of inpatient complications dropped from 11.0% to 7.0%.

The drops were proportionally higher in lower income countries, where baseline rates of death and complications were higher, but the effects were observed in all sites. The principal investigator of the study – Atul Gawande – used the list in his own practice in Boston and was surprised at how often he and his own team ended up catching something they themselves had missed.

The implications of this study cannot be underestimated. If you believe these results are somewhat generalizable to the rest of the world, even in sites without highly motivated principal investigators like those chosen for this study, the use of such lists could translate into a few million fewer deaths per year, many fewer cases of complications, much less human suffering, and millions of dollars saved from associated medical costs. The costs of implementing the lists? Who knows, but I just downloaded it off the internet, and so could millions of other practitioners. And why stop there, such lists could easily be developed and implemented for dozens of other high risk processes and even those which are much more mundane. Some lament that this translates into boiling the “art” of medicine into some mechanized routine, but when the stakes are so high, I would argue that I would take my chances with the banal.

If you have not yet read Dr. Gawande’s books, I highly recommend that you do. Both Better and Complications are among my favorite public health books, and I am sure you will like them too.

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Yesterday I blogged about a news article in a prominent Ghanaian newspaper that suggested that the future of the National Health Insurance Scheme (NHIS) was uncertain under the newly elected government in Ghana. The news article in question prompted an immediate action from the NHIA, the implementing agency of the NHIS, to dispel any fears that the future of the program is in doubt. An editorial in today’s paper covers the response of the agency.

What is the most remarkable of this story, I believe, is that it gives a sense of how the development of democratic institutions, a relatively free press, and clearly defined chains of command for health has influenced the power dynamics in Ghana. Public opinion can now have a direct and immediate influence on health services and this is a clear manifestation of this phenomenon in action.

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Will the election in Ghana affect the NHIS?

On January 14, 2009, in Ghana, health insurance, politics, by Karen Grepin

Last year while conducting some field research on health reforms in Ghana, I conducted a series of interviews with experts on the newly implemented National Health Insurance Scheme in Ghana. One of the questions I liked to ask was the experts was their opinion on how sustainable the program was in the long-run. When I asked one senior official, he replied, “the NHIS will be sustainable until January 2009″. I paused, then I realized he meant, that he believed the program would fall apart after the presidential election.

The NHIS scheme was a key element of the social platform of the outgoing NPP party. The promise of the scheme, as well as the actual implementation of the scheme were important campaign promises during the past few elections. Despite the popularity of the scheme, it was not enough to keep the party in power this time around. It has been speculated that the NPP has been subsidizing the scheme at much higher levels than it was openly reporting in order to keep it around until the election.

A story in the Chronicle, a Ghanaian paper, suggest that there are early signs that just a few weeks after the election the scheme is starting to show some cracks. Of course, it could all be a part of regular slow downs in payments, which are certainly not new for the scheme, but it does raise some serious questions about the future of the program.

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Why is HIV incidence rising in Uganda?

On January 14, 2009, in HIV/AIDS, PEPFAR, prevention, Uganda, by Karen Grepin

Two recent news articles from Africa made me aware that it seems as though HIV incidence rates may be on the rise again in Uganda. After many years of being the poster child for HIV prevention, there is news that the incidence rates may once again be on the increase in this East African country.

Apparently – I have not read the study – a new report produced by Makerere University experts on behalf of the Uganda AIDS Committee and the UNAIDS (“The Modes of Transmission study”) showed that incidence rates are on the rise, and that the rates are rising fastest among married people aged 30-40. They argue that prevention programs tend to focus on younger populations, potentially neglecting those who are also in need of prevention messages. The article suggests that prevention programs should be expanded to include more interventions directed to older and married populations, not just younger populations.

Another news story instead blames the failure not just on a lack of targeting to a particular population, but rather on the influence of PEPFAR which has supposedly changed the emphasis of prevention activities in Uganda away from broader prevention messages to abstinence only programs.

It is not at all clear which theory is right, or even what other factors may be to blame, but it does demonstrate the fragility of prevention programs. In theory, the populations that are seeing the increased incidence rates today were the populations that were targeted by the prevention programs initiated in Uganda 10-15 years ago. Either the effect of these efforts declines over time, or maybe new messages are needed over time. Whatever is going on, it certainly means that we are far from knowing what works for prevention.

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What happens when a government presides over the dramatic reversal of its population’s access to food, clean water, basic sanitation, and healthcare? When government policies lead directly to the shuttering of hospitals and clinics, the closing of its medical school, and the beatings of health workers, are we to consider the attendant deaths and injuries as any different from those resulting from a massacre of similar proportions?

..asks the group Physicians for Human Rights in their recent report of the continuing deteriorating situation in Zimbabwe. Yesterday, they called on the UN and other international actors to stronger action against the government of Robert Mugabe and went so far to accuse him of crimes against humanity through direction actions he took that led to the near complete collapse of the health system in Zimbabwe in recent years.

The report summarizes the main findings of a emergency mission the organization made last year to assess the public health crisis in the country. In addition to the “utter” collapse of the public health system, the deterioration of the basic water and sanitation structures, and as if that was not bad enough:

The current cholera epidemic in Zimbabwe appears to have begun in August 2008. As of this writing, more than 1,700 Zimbabweans have died from the disease and another 35,000 people have been infected. The U.N. reports that cholera has spread to all of Zimbabwe’s ten provinces, and to 55 of the 62 districts (89%) and that the cumulative case fatality rate (CFR) across the country has risen to 5.0% – five times greater than what is typical in cholera outbreaks. Control has not been reached: There has been a doubling of both cases and deaths during the last three weeks of December, 2008.

WHO has reported some 200 human cases of anthrax since November 2008 with eight confirmed deaths. These cases were attributed to the ingestion of animals (cattle and goats) that had died of anthrax. Zimbabweans avoid eating animals that have died of disease – but these cases appear to occurred in starving rural people scavenging carrion.

They conclude:

The health and healthcare crisis in Zimbabwe is a direct outcome of the malfeasance of the Mugabe regime and the systematic violation of a wide range of human rights, including the right to participate in government and in free elections and egregious failure to respect, protect and fulfill the right to health.

Will anything come of these calls for more action? To an outsider the situation appears to be spiraling out of control and is getting worse from week to week. There was some mounting interest before the Christmas period, but action plans seemed to have stalled as the economy and the Obama transition appear to be consuming most of our attention. Kudos for the PHR for keeping attention on this important issue.

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All calabash-wearers will be prosecuted

On January 12, 2009, in road traffic injuries, by Karen Grepin

Earlier today, I posted a link to a picture of a man wearing a bucket on his head instead of a bike helmet in Nigeria. I posted it, because I thought it was cute, and a scene that I found to be very reminiscent of many of my trips to Africa. In Burkina, it was common for many motorcyclists to wear the blue eye masks from Air France around their noses and mouths to shield them from the dust.

I just found another link to a similar story. I gather, this was not a one off innovation, it appears as though there has been a new law passed in Nigeria requiring cyclists to wear bike helmets. Many cyclists have resorted to wearing all sorts of things on their head to get around these new laws: fruit shells, rubber tires, etc. Cyclists are complaining that the helmets are simply too expensive or other reasons for not wearing them.

Road traffic fatalities are a huge public health problem in a country like Nigeria. A BBC report of the same law reports more than 4,000 deaths a year from road traffic injuries and more than 20,000 injuries. This story highlights some of the challenges to making significant progress against this health condition. Policy responses that have worked elsewhere may be more difficult to implement in developing countries.

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Great upcoming seminar

On January 12, 2009, in events, global health, pharmaceuticals, by Karen Grepin


Rarely do I post about events happening at Harvard because I know many of you are not from around here, but I could not resist this one. If there is any chance you will be in the Boston area on Monday, January 26, I highly recommend you check out the following event from 4:30-6:00 PM at the Harvard Population Center (9 Bow Street, Cambridge):

“Access: How Do Good Health Technologies Get to Poor People in Poor Countries?”

Presented by Michael Reich, Taro Takemi Professor of International Health Policy, HSPH, and Laura J. Frost, Principal, Global Health Insights, LLC. The location is the Harvard Pop Center, 9 Bow Street, in Harvard Square. RSVPs are not required.

Michael and Laura will be discussing their soon to be released book of the same title. If you can’t attend the session, you should be able to buy the book for yourselves (or even download it?) soon.

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Next week, the Executive Board of the WHO will be voting on the “Global Code on International Recruitment of Health Personnel“, which is voluntary, non-binding legislation that will define standards for the international recruitment of health workers, generally from the poorer countries to the richer countries. While interest in such legislation has been recognized for many years, this topic has only received a lot of mainstream attention in recent years due to the increased awareness of low health worker levels in many poor countries, in particular sub-Saharan African countries.

In this week’s Lancet, a news report chronicles the plight of health worker migration from the Philippines, a country that has used the exportation of health workers as an explicit domestic strategy for increasing remittances, education, and lowering unemployment. While most takes I have seen on the Philippines model tend to present the Filipino strategy as a sort of win-win for the country, the health workers, and the receiving countries, this report raises mostly concerns about this strategy, by trying to link the export strategy with poor health care access issues in the Philippines:

“Although Filipino health workers have become one of the country’s most valuable exports, sending billions of pesos back to the Philippines as remittances and taxes, their exodus is crippling the domestic health system.”

While I don’t doubt that much of what this article argues is true, I do caution about jumping to its conclusion: it is the exodus of health workers that is causing poor health system performance in the Philippines. The real question should be: what would the health care situation be like in the Philippines without this practice? The positives from this strategy must also be considered. Other factors of the Filipino system should also receive as much scrutiny as this export strategy as a potential cause of the poor performance of the health system. For example, is the poor level of goverment expenditure hinted at in the article a cause of both the poor performance and the high levels of expressed desire of health workers to move abroad?

So is this new legislation a good thing? I had the chance to read through the text of the draft proposal that will be discussed next week. Most of it seems quite innocuous to me, and some of it even seems to make a great deal of sense. Here are a few examples:

“..migrant health personnel enjoy the same legal rights and responsibilities as the domestically trained health workforce in all terms of employment and conditions of work.” This seems like a nice thing to aspire to.

“In accordance with the principle of mutuality of benefits, both source and destination countries should derive benefits from international recruitment of health personnel.” Perhaps.

And of course, my personal favorite: “Member States should recognize that the formulation of effective policies on the health workforce requires a sound evidence base.” Yes, yes, yes.

I think the more relevant question is: will this code will have any impact at all? To what extent can voluntary, non-binding legislation have much impact? Will non-governmental entities, which frequently do a great deal of the recruitment, alter their behavior in any way? Will the basic standards be enforced when needed? Does international recruitment equal the same thing as someone who wants to migrate abroad going abroad?

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More stuff on the net

On January 12, 2009, in links, stuff on the net, by Karen Grepin

A round up of some of the more health and Africa related links over the past week:

1. Safety first. Innovations in helmet technology in Nigeria.

2. Will the genetic revolution lead to national health insurance? Probably not, but it does make for some cool self-exploration. See Steven Pinker’s article in the NYTimes magazine.

3. The rise of the Kenyan middle-class.

4. Why are American women beginning to look like a human dairy farm?

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