Buried amongst all the doom and gloom news of the Swine Flu (or more correctly Influenza A(H1N1)) in this morning’s NYTimes, was an interesting article highly relevant to global public health. Yesterday, Taiwanese officials announced that China had changed its policy on blocking Taiwan’s presence as an observer at the upcoming World Health Assembly, the main decision making body of the WHO. The invitation to attend the conference had been extended to Taiwan by Margaret Chan, the Director of the World Health Organization, and a key player in the avian flu outbreak in China in 2003.

I could not help to wonder about the timing of this an announcement. Although diplomatic relations have apparently been improving between Taiwan and China in recent years, I wonder how much the current Swine Flu epidemic influenced this decision. China and the surrounding area was the epicenter of the avian flu outbreak in 2003 and China had been criticized for having blocked external action to contain the disease in Taiwan. They, perhaps better than any country on the planet, understand the importance of global collective action in controlling and preventing the spread of infectious diseases. Foreign policy in China appears to be catching up with the realities of global public health.

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ARV scale up in Ethiopia

On April 30, 2009, in aid effectiveness, Ethiopia, HIV/AIDS, by Karen Grepin

In the past, I have blogged about some country-specific case studies that have been launched to evaluate the system wide effects of rapid ART scale up in developing countries. In this month’s PLoS of Medicine, a case study of the Ethiopian experience based on secondary document analysis, was published by Yibeltal Assefa, Degu Jerene, Sileshi Lulseged, Gorik Ooms, and Wim Van Damme.

In their paper, they document the rapid expansion of ART treatment in Ethiopia since about 2003. As of today, over 100,000 patients are receiving ART treatment in Ethiopia up from nearly nothing just half a decade ago. About 25% of those who have started ART in the public sector have been loss to follow-up or presumably have died.

Their work highlights some successes and some potential areas for concern. They find find no major declines in measures of health system performance and actually find that indicators such as infant and child mortality immunization coverage have improved in recent years. However, they also find that there has been a rather dramatic decline in physicians in the public health service and attribute this to internal migration of health professionals towards mainly AIDS NGOs who have “poached” these workers. However, it appears that simultaneously there have been other efforts to rapidly scale up human resource availability in the country, so that the number of other health professionals has increased over this time period offsetting these losses.

This work points to an overall positive picture in Ethiopia, perhaps because it was able to so rapidly scale up human resource availability over this time period. Ethiopia is usually considered an outlier on how it is handling its health workforce needs, so it would be interesting to think about how realistic it would be to assume similar effects in other countries. But, I am happy to see yet another case study that is adding to our knowledge of the impact of global health initiatives on health systems. I’m off to Ethiopia in a few weeks and am looking forward to seeing some of this myself first hand.

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I’ve been glued to Twitter and the news of late trying to keep up with the Swine Flu outbreak as it unfolds real time. I have not yet posted anything related to the Swine Flu myself, because honestly, I am not sure how to predict what is going to happen. I don’t think anyone really does.

The Obama administration is currently faced with some really tough decisions, and to some extent a really classic public health problem. How do you deal with the Swine Flu epidemic when you don’t know what is going to happen and you will be judged for over reacting if it turns out to be mild but under reacting if this thing really does become the next 1918. Damned if you do and damned if you don’t.

I got an email this morning with this really great historical piece authored by Richard Neustadt and Harvey Fineberg back in the late 1970s. It is funny to see Dean Fineberg listed as an Assistant Professor. But it documents the response to the Swine Flu in the late 1970s. Due to the current situation, I thought many people might want to read this so have loaded it to my website, perhaps breaking some distribution laws, but I’ll risk it.

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There is no doubt that one of the biggest buzzwords in global health discussions lately is “Health System Strengthening” (HSS). Everyone, it seems, is doing it these days…or at least trying.

But what is it exactly and are those claiming to do it actually achieving it? The term is broadly speaking used to describe the impact that donor financed global health initiatives are having on health systems in targeted countries. I’ve definitely seen different uses of the term ranging from activities aimed at improving the outcomes specifically targeted by the global health initiatives to a broader definition which includes building up health systems to deliver other types of health services as well.

In this month’s PLoS Medicine journal, there is a review of HSS definitions and an analysis of how the major global health initiatives define and implement HSS activities authored by Bruno Marchal, Anna Cavalli, and Guy Kegels.

The review finds that there is a big gap between the HSS stated goals of the major global health initiatives and the actual practice of these organizations:

Virtually all GHAs claim to support health systems, but instead they focus on disease-specific interventions or on activities targeting system functions essential for implementation of their own programmes.

They conclude that “most current HSS strategies are selective (i.e., they target a specific disease), and their effects may undermine progress towards the long-term goal of effective, high-quality, and inclusive health systems” and argue that “we urgently need a systemic approach to HSS that is contextual and that fits the countries’ agendas first”.

While I would definitely agree with the first conclusion (some of my own research has come to the same conclusion), however, I am not sure their second conclusion necessarily follows from the first. It is not clear to me that just making these global health initiatives operate through some sort of common framework would enable us to achieve broader health system goals, nor should we even want this to be the case. But I think this article makes a great contribution to the literature on this topic and should be a must read for anyone interested in this topic.

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Photo taken from the Gates Foundation website. They have a beautiful library of photos available here.

I always wonder what the appropriate greeting is on holidays that I myself do not celebrate. I learned that saying Happy Yom Kippur is not appropriate given that it is one of the most solemn days of the year in the Jewish year. So I am not sure whether to wish you all Happy World Malaria Day given that Malaria is one of the largest killers in the world, but for some reason I almost feel as though there is something to be happy about.

There is a lot of new momentum towards addressing malaria and compared to just a few short years ago, things are really starting to look up for those at risk of this disease in some of the most affected regions in the world. There is more awareness than over before (witness the massive discussion of malaria these past few weeks on Twitter of the disease), there is more focused research for new tools to fight against malaria (click here or here for a few interesting blog posts on the topic by myself and Christine Gorman), new initiatives are being launched, and the scale up of interventions is underway. The terms “elimination” and “eradication” are even being discussed.

I decided that for my contribution to mark this day, I would try to summarize where I think we are with malaria control today and where the main points of debate are in malaria policy circles. Despite my background as an immunologist, I don’t claim to know much about some of the cutting edge scientific or technical research, so my apologies in advance for not specifically addressing this important topic. I will also mainly focus on Africa, which is where I know the most.

Disease Burden

As with any disease that predominantly exists in the developing world, there is debate about the true incidence and burden of disease from malaria. A big challenge with malaria diagnosis is that partially because it is so common, it is usually not formally diagnosed by some clinical diagnostic test, rather it is diagnosed using symptoms. So our diagnosis of malaria tends to be sensitive but not very specific, meaning that we get a lot of false positives. False positives means that we end up treating a lot of people who probably don’t need treatment, which has repercussions for both the efficiency of any response, our estimates of diseases burden, and also can increase drug resistance.

The latest global estimates of malaria are from the 2008 World Malaria Report. Best guess thinking is that half of the world lives in an area where they are at risk of malaria, that there are about 250 million annual cases of malaria, resulting in approximately 881,000 deaths (or 2400 a day, 100 an hour, 1.5 a minute). So most cases are not fatal. Most of these deaths are of children. During the discussions leading up to World Malaria Day this week I have seen all kinds of figures in use, but these are probably the best and at least the ones from the best authority. I won’t fault people too much for rounding as is convenient to make their case as there are huge uncertainty bounds on all of these estimates. These estimates probably do not fully capture the immense morbidity of malaria, but it is likely tremendous.

Global Response

The World Health Assembly has set as a goal to achieve >80% coverage of four interventions: insecticide-treated bed nets for those at risk, effective drug treatments for any suspected or probable case of malaria, indoor residual spraying for at risk households, and intermittent preventive treatment for pregnant women in at risk areas. The Millennium Development Goal 6 also targets malaria through a relatively weakly worded goal to “have halted by 2015 and begun to reverse the incidence of malaria and other major diseases”. Like any good international statement in global health, these goals are not based on any concrete evidence base as to why these things should be achieved to this level or if these goals can be achieved but they set out some fixed target for policy makers to contemplate, and I guess that is how they are helpful. The MDG sub-goal for malaria, ignoring the “other major diseases”, is one of the goals most likely to be met for health.

On the financing side, there have been new initiatives set forward to fund malaria control programs in the past year. The Global Fund and the US PMI have been major players. UNITAID is posed to become a bigger player now at the AMFm facility has been launched.

But total financing for malaria is less well understood than it is for other diseases, such as HIV. External donors fund have begun to fund a great deal of programs for malaria, but the bulk of financing for malaria control is likely private financing (out of pocket mainly) and national budgets. Households bear the bulk of the cost of diagnosing and treating malaria, governments through public financing for hospitals pay for a great deal of treatment costs and bear the burden of the lower tax revenues and output from malaria. Donors have increasingly been financing prevention activities, such as distributing the ITNs, and increasingly treatments. It is not clear how much crowd out of expenditures donors comes from government response, or how much would be optimal, but this is rarely discussed.

There is good news about the prospects around having an effective malaria vaccine. A GKS-Biologicals vaccine candidate is progressing well and a new vaccine might be possible in the next few years. Exciting stuff.

National Responses

Most African countries have a de jure policy of free bed nets for children and pregnant women, ACTs as a first line treatment, and policies for IPT. Of course what is on paper is frequently nothing like the real world and bed nets are not always free, ACTs are rarely available affordably, even in public clinics, and it is not clear how just having a policy for IPT makes it happen. I think one of my favorite moments in all my years in global health activities is at a meeting in Amsterdam a few years back I witnessed an emotional outburst from a drug company executive who was accusing an Minister of Health of gouging patients but putting high mark ups on drugs sold through the public sector! Too funny. However, most of these policies are new and therefore represent a major trend towards improved national malaria policy reform.

Coverage of Services

There is good evidence (I never say this) that the scale up of coverage of interventions has been dramatic, at least in sub-Saharan Africa. I think it is also fair to say that despite this success, coverage is less than the targets (again, not clear if these were actually achievable goals given how much time has gone by) and progress has been uneven across interventions. This is one of my problems with such big international goals and declarations, we treat them as though they are all equally important, and they are not likely to be in this case.

Bed nets tend to be the most visible intervention, probably partially due to the fact that coverage is the easiest to measure. Bed net awareness appears to be high, bed net ownership is increasing and is probably somewhere in the 30-40% range in sub-Saharan Africa, but that there is also some evidence that bed net coverage has been more rapid in rural and less endemic areas, but this is not surprising. The hardest to reach areas where malaria tends to be worst, are just that, hard to reach.

Effectiveness of Response

This is where I think there has been the most debate, and while I agree that there is good reason to be very critical of most of the evidence of major declines in malaria morbidity and mortality due to weak study designs and poor data, I think the evidence taken together points to a story of where malaria efforts are working. I think the real debate is as to exactly what is driving these declines and how national and global responses should be adjusted to reflect this evidence. For example, how much of the reductions we are seeing is coming from bed nets vs. spraying?

The WMR2008 summarizes some of the declines reported from national surveillance estimates. Smaller countries and countries with better data have been the best documented cases of malaria decline, such as in Eritrea, Rwanda, Sao Tome and Principe, and Zanzibar. Are these smaller countries (and island countries) achieving better control because they are small or because smaller countries just have better data? But the declines have been really dramatic in all of these countries, with reported decreases of over 50% in disease burden. These are big figures, recorded over relatively short time periods (say less than a decade), and really big relative to most achievements in global health in particular.

Epidemiological studies have also documented declines at sub-national levels. A few examples of such studies come from Kenya, Rwanda, Ethiopia, and Gambia, although there are others. These studies have been dismissed as not being representative because they are sub-national. I am sure that those who dismiss these studies would probably also dismiss national studies because of poor data. Ah, there is a the rub.

Bottom Line

So big picture: lots of progress but much more left to be done. I think there is lots to celebrate on this World Malaria Day but I also hope that this new momentum around malaria control translates into more effective efforts going forward.

I hope that there is more emphasis on what works in this debate. Last week the AMFm facility to subsidize ACTs largely through private distributions channels was launched. It will begin with a multi-country “pilot” program costing well over a few hundred million dollars a year. By most people’s standards this would not really be considered a “pilot”, but hopefully there will be real interest in evaluating the full spectrum of outcomes during these earlier efforts.

I also think we need to be a bit more critical in our thinking around bed nets, I don’t think they are going to be enough to eliminate malaria and worry that they are getting far too much credit in this debate, but would be happy to be proven wrong.

I am also really happy to hear about new tools coming through the pipeline. On Thursday I participated with a Global Health Blogger teleconference organized by the Gates Foundation and was really excited to hear about cutting edge research that is coming through the pipelines, such as the potential use of ivermectin to reduce transmission (Christine Gorman writes about it here).

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Well done Agnes

On April 22, 2009, in maternal and child health, user fees, by Karen Grepin

In a comment to one of my previous posts, Joe left a comment about how in extreme cases many countries revert to locking women up when they are unable to pay their user fees for delivery. I have a picture documenting this from one of my last trips to Ghana.

The women in this piece were unable to pay for their delivery fees and as a result the women were held in the hospital. A wealthy woman in the area, Agnes, basically bailed them out by paying their fees. Each was somewhere under a few hundred Ghana cedis. Well done Agnes, but perhaps we should condemn the system for having done this in the first place.

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Champion of the White Ribbon Alliance

On April 22, 2009, in maternal and child health, by Karen Grepin

An interesting event is taking place this week. There is a summit of African First Ladies being held in L.A., an obvious geographic choice for such a meeting (although I am sure it help increase attendance). Sarah Brown, wife of Gordon Brown, the British Prime Minister made a very passionate speech to the audience arguing that progress on health in Africa will only come when we put reducing maternal mortality at the top of the development agenda for Africa.

A few highlights from her speech:

..I have kept asking myself whether there is one goal that could unlock all these goals [the MDGs]? One goal that without action on which we cannot realize any of our objectives. One millennium target which if pursued aggressively could help us reach all our targets.

And I have become convinced a mother’s survival is the key, for it is the key to her baby’s welfare and often that baby’s life. A mother’s survival can help prevent her family being hit by malaria. A mother’s survival can ensure that all her children, including her girls, go to school. A mother’s survival can ensure that her children receive the right nutrition, ensure they receive their immunizations that will ensure their health during their first tender years.

I don’t believe that we will make the progress on HIV/AIDS without addressing maternal mortality. We will not make the progress we want on malaria without addressing maternal mortality. We will not make progress on getting more children to school without reducing maternal mortality. But we will make progress on all these things and on nutrition, on empowerment and education, on health care, on immunization, even — I believe — on the environment, if we make progress to reduce the number of mothers dying needlessly in childbirth.

When one mother survives, a lot survives with her.

Sarah is a spokesperson for the White Ribbon Alliance, a coallition aiming to increase awareness of maternal mortality. I spent a few minutes on their site this moring and was impressed with some of their fact sheets, like this one which provides a great summary of the Safe Motherhood strategy.

Sarah’s interest in this cause is no doubt influenced by her own history. In 2001, Sarah gave birth prematurely and eventually lost her baby proving that much work is still needed, even in developed countries, to address maternal and child health.

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(Photo Credit to the Associated Press)

I read this week that a new, and improved, version of the female condom has been approved by the FDA. In addition to providing protection against conception and transmission of STIs, it is also the only “female-initiated barrier method” meaning that the woman has “control over its use”. At least in theory.

Despite the fact that the product has been on the market since the early 1990s, and despite the major hype surrounding its role in empowering women to protect themselves against HIV, the uptake of the product has been relatively low globally. Perhaps it has something to do with the brand names: Femidom, Femy, Preservativo Feminino, El Condon Femenino, and MyFemy?

Part of the problem has been price – the female condom is many more times more expensive than male condoms. But part of the problem is more complex and has to do with the acceptability of the product by the end user. Michael Reich and Laura Frost’s new book on access to technologies has a whole chapter devoted to all the things that went wrong with the introduction of the female condom. I have linked to the book (which is free to download in the spirit of access!) here. I quote from the book a passage on the condoms:

Certain technical characteristics of the female condom can give negative first impressions to some users and pose continuing barriers to end-user adoption. Some women consider the female condom to be large and bulky, aesthetically unappealing, prone to slippage and twisting during sexual intercourse, stiff in its internal rings, and difficult to insert, as well as unpleasantly noisy and smelly. Studies have shown a high frequency of misuse and low levels of acceptability on the first attempt at use. Following repeated attempts, user confidence and satisfaction increase, as do users’ skill at correct insertion and removal. Without adequate training and counseling, women may lose interest after initial failed attempts or may expose themselves to risks of STIs and unplanned conception through mishandling of the female condom.

It seems the newer version will be cheaper and less “squeaky” but will this solve its problems?

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Do bed nets save lives?

On April 20, 2009, in behavior, infant mortality, malaria, by Karen Grepin

With all of the fanfare that donating bed nets have received this past week, thanks weirdly enough to Ashton Kutcher, and the debate that has ensued in certain circles, I thought this question was worthy of a post. I believe that the answer is yes, bed nets do save lives, however, they may not be the most effective intervention in all cases, and bed nets alone are not going to eliminate malaria.

When used effectively, bed nets can save lives. The benefits of insecticide-treated bednets (ITNs) have been shown in efficacy trials, which have suggested that bed net usage can lead to about a 20% reduction in all cause mortality in children, although the effectiveness depends on the intensity of malaria in the area. Mortality of course is only one indicator that we should care about, malaria also has a tremendous morbidity burden, so a comparable reduction in morbidity would also be a really great thing. Most studies actually show an even slightly larger reduction in incidence. But, it is worth noting than when used in experimental conditions we only see about a 20% reduction in mortality among children, which is likely to be reduced when we leave the world of RCTs and move into the real world where everything is more complex. While twenty percent is a lot, but it is not 100%. This also does account for adult mortality or morbidity.

Although there is not strong agreement, there is some evidence that malaria incidence and mortality may be declining in a number of African countries. Many people attribute this to the successful scale-up of “Roll Back Malaria”-like national control programs, but this too has been debated. I actually don’t see this as the real debate: I think what we are doing with malaria is working (I just wish we had better data systems that allowed us to measure it) I think the real debate is about what aspect of these programs is working and which are the most cost effective. These are all multi-component plans, so it is hard to isolate the contribution of any one part. Research from Kenya, Rwanda, Ethiopia, and the Gambia (among others) has all pointed to declines in malaria even if these studies are not well controlled and rely on terrible data. But something is happening, that I am sure.

Once upon a time I would have probably argued in favor of the simplicity of ITNs as a strategy to improve health because of the minimal behavioral aspects of its use. Public health struggles to influence people to change behavior, which is REALLY, REALLY, REALLY hard. Compared to giving up alcohol, quitting smoking, changing sexual practices, and exercising daily, promoting sleeping under a bed net seemed simple to me. But then I realized, I rarely do it myself when I am in Africa. Rarely is there a hook I can use above my bed (where the fan is usually positioned), I am rarely willing to sacrifice that much of my carry-on space (I never check luggage), and they are really hot and stinky to sleep under. My friends in Africa, mainly young, well educated middle class professionals, frequently complain about bed nets and none of them claim to ever sleep under one. I also think we have largely ignored how individual behavior will affect the usefulness of nets and rather than just focusing on just supplying more and more nets, we need to figure out where they are most useful, and how best to make them effective.

There is an opportunity cost of doing anything when financial resources (from donors, from countries and from households) and domestic capacity to implement are limited (which they are everywhere, in particular developing countries). If bed net programs get prioritized at the expense of other interventions that are equally and potentially more effective than it becomes a problem. Western advocacy and fundraising organizations seem to promote the message that all we need are nets and malaria will go away (case in point one organization is actually called “Nothing but Nets” whose slogan is send a net, save a life). Malaria was eliminated from many parts of the world over the past century or so, largely before bed nets were in common use. Rather many of the victories of the past have been attributed to indoor spraying, vector management strategies, and environmental management. A multicomponent response will be needed in Africa as well.

So while I am pleased to see more debate and awareness over malaria control, I think we should rely more on evidence and history to guide our priorities rather than just celebrity attention.

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The HIV triple threat

On April 17, 2009, in HIV/AIDS, public opinion, by Karen Grepin

In an op-ed in the Washington Post today, Anthony Fauci clearly summarized what he sees as “three bold new approaches to controlling the HIV/AIDS pandemic“. I have heard all of the strategies he discussed to some degree here and there but thought it was good to see them all together. I also thought it was interesting to learn how seriously some of these “bold” strategies are being taken. The strategies are:

1. Pre-Exposure Prophylaxis (or PrEP): High risk individuals would be given a daily dosage of ARVs so that should they become exposed to the virus that the low dosage of medicine would prevent them from being infected. A version of this strategy is currently in use for people who become accidentally exposed to the virus, such a health workers.

2. Universal testing and treatment: basically test everyone and then treat everyone who tests positive. Mathematical modeling exercises have suggested that such a strategy could have a major impact on transmission.

3. Functional Cures: perhaps the least straightforward of the proposals but basically to come up with new treatment strategies that might make it more likely that the body would better control the disease. From my immunology days I remember a lot of people talking about really early treatment as a way to protect the immune system from ever getting depleted, this could be part of the strategy.

It is not clear how feasible any of these strategies would actually be, but it sounds like there is real interest in investing in research to learn more, which is always good news to me. Although he did not state it directly, but if we are considering such “bold” actions, it seems to be somewhat of an admission that current treatment strategies are not working, at least not if we are also trying to achieve population level goals.

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