Peter Hotez is at it again. He is the master at tricking us to care about diseases that normally we would prefer to ignore. He and his co-authors caused a bit of a stir again this week when they proposed a 32 cent “solution” for HIV prevention: treating schistosomiasis with praziquantel. Josh Ruxin called this idea “revolutionary” in a recent editorial on the Huffington Post. While I don’t agree that this is a particularly new or revolutionary idea, I do believe that there are good reasons to believe it, and that it is just too good of an idea to let fade into obscurity. So here are my two cents on the thirty two cent idea.

Schistosomiasis is a classic neglected tropical disease (or NTD as Hotez and others have rebranded them for marketing purposes). It affects millions of people, causes a massive burden of disease, and can be treated cheaply and easily. But because it does not kill people or perhaps because it does not have a huge celebrity following it gets very little attention from Ministries of Health, donors, and policy makers (I should say here that the NTDs have one celebrity: Alyssa Milano is an NTD Ambassador). Heck, even people infected with schisto and visibly pee blood due to infection neglect the disease. It contributes to the burden of disease through anaemia, kidney problems, stunted growth, learning problems. Tons of really bad stuff, and as such we should really care about it, but we don’t. Classic.

The association between schistosomiasis and HIV vulnerabilty has been speculated for some time. In a cross-section of women in Zimbabwe it has been shown that schistosomiasis infection is correlated with HIV. Of course, everyone knows that correlation does not imply causation. They could have higher schistosomiasis because of HIV or because of some unobserved confounder (e.g. lifestyle or job). That said, there are lots of good clinical arguments that could be made as to why have open sores and bleeding in your genital track could make you more susceptible to HIV, so the idea is very plausible. Eileen Stillwaggon, an economist from Gettysburg College has been talking about the “ecology of poverty” in Africa, including parasite infection, as one explanation of why prevalence is so much higher in Africa for many years.

What we do know and what cannot be refuted is that we can treat this stuff really easily and cheaply. The Schistosomiasis Control Initiative, led by one of the other authors of this paper, thanks to all of the increased funding that has been given to it by Gates and the US government, has shown that whole countries can be blanketed with treatment for a few cents a treatment and guess what: it works. The success of countries like Burkina Faso are being replicated elsewhere even while the programs are challenging themselves to do even more by delivering other NTD treatments in an integrated package.

I personally believe that the NTD control programs should be further strengthened because I think treating the NTDs to relieve the suffering of billions infected with these scourges is the right thing to do and will probably do more to alleviate poverty and promote development in poor countries. But if we need to sugar coat it and say we are doing it to prevent a disease we do care about, than I guess I am OK with that as well.

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Best readings in global health

On May 25, 2009, in global health, links, by Karen Grepin

A few years ago I served as a teaching assistant for a global health course at Harvard. As part of admission into the course, students had to write an essay on what inspired them to take the course. I separated the applications into two piles, those that stated that Mountains beyond Mountains was their inspiration, and those that did not (roughly 1/3 vs. 2/3 split). I seem to recall that those that showed more original thinking did better than others, but I would have to re-run the numbers. While many would say that this is the book that inspired them to become interested in Global Health, I will argue that there is much better stuff out there.

In preparation for summer reading, I thought I would cast my two cents in terms of recommended readings for those interesting in global health in case you were looking for books to pack for your long trips overseas or your trips to the beach. Here would be my short list:

1. Better by Atul Gawande: While most of this book focuses on lessons from developed country settings, I think this book does more than any other I have read in recent years to push the idea of how health care can be improved. It even has a chapter in India. I love, love, love this book. Almost made me want to be a surgeon, then I remembered how much I hate gross stuff like touching other people. Ick. I’ll stick to my datasets, thank you very much.

2. Read back to back An End to Poverty (Sachs) and White Man’s Burden (Easterly): Lots of debate out there on the value of aid. I would recommend reading both of these books back to back as I did a few summers ago. I am personally biased as to which one I think is better. But, if you liked those, and for those with more of a research background, I would also recommend Reinventing Foreign Aid (ed. Easterly) from the Center for Global Development.

3. The Making of a Tropical Disease: A short history of malaria. If I ever get really bored and want to do more education (it could happen), I think I would do a doctorate in history. This book is part of a series called the biographies of disease, which I think is totally cool. This book taught me more about malaria than anything I have ever read.

4. Mosquito by Andrew Spielman: The late, and great, Andy Spielman, perhaps one of the greatest entomologist that has worked on malaria left behind this great work. Hard to explain, but basically a book about how mosquitos think.

5. Weak Links the Chain Parts I and II: Every few months I sit down and re-read these two papers by Filmer, Hammer, and Pritchett. These papers, perhaps more than anything else, have shaped my views on how health systems work (or don’t work) and the options available to improve them.

6. The battle against Hunger by Devi Sridhar. Last December I had the opportunity to attend a conference with Devi. I since read her book, which is an anthropological take on the World Bank’s feeding programs in history backed up with lots of data, making it hard for economists to dismiss (as we usually do with anthropological research). An amazing read, but spoiler alert: you will never want to work at the World Bank again if you read this book.

7. Finally, I think it is worth mentioning one more time on this blog: Access: How do good health technologies get to poor people in poor countries should also be on your list if you have not read it yet. This one is even free.

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Where to eat in Accra?

On May 24, 2009, in Ghana, by Karen Grepin

(Photo credit from Flickr/mtl2tky)

Normally I try to keep my posts here related to health related topics rather than boring you with other aspects of my life, which are rarely interesting to anyone other than myself. However, it is that time of the year where dozens of people that I know are heading off for field research and people are always asking me for tips on where to eat in Accra (I am a failed food blogger). So I have decided to put this all here. Feel free to send this along to anyone who would be interested. Also, do send along any tips or comments and I would be happy to update this with your ideas. Happy eating!

Best Local Food:

1. Asanka Local: One of the challenges in getting good Ghanaian food is that when you go to a restaurant you are presented with a long menu, but rarely do they actually have anything other than “chicken” or “fish”. This place never has that problem. Perhaps the largest of the chop bars in town, it has a build-your-own approach that really works. Choose your protein (ranges from chicken to fish to snails to grass cutter), choose your sauce, and then choose your starch (fufu vs. plaintain vs. kenke). It is all here and it even has live music and dancing sometimes. Sundays they do the Omo Tuo or rice balls. It is located in Osu on a side street off Oxford Street. Ask around.

2. Tilapia: I think grilled fish is my all time favorite African dish. I originally fell in love with in when I lived in Burkina Faso and there were these great restaurants up by the reservoir where one could order grilled “Capitaine” with fresh tomatoes and onions. It is even better here in Accra where the fish has some reasonable chance of being fresh. Old timers swear by a place called Blue Gate – where I have never been – but I have heard that the woman who used to cook there is now at my favorite place – Duncan’s. For either 6 or 8 cedis you get an amazing grilled tilapia with fresh tomotoes and onion. Delish. To get there, take a taxi to Frankie’s in Osu and then Duncan’s is off the side street immediately on the ocean side of Frankie’s.

Best High End Eats:

1. Osteria: This place is truly amazing. As soon as I get to Ghana I start dreaming of this place and then wait until I am really, really craving good food and treat myself. Run by an Italian man who is very passionate about food, this place is an oasis in Accra. The owner grows his own arugula and spices to ensure supply and flies in clams and other ingredients from Italy. Amazing pasta and salads are available here, as well as a full italian wine list. Not cheap, but it is worth it. It is located in Airport Residential Area close to the Galaxy International Area. Tell a taxi to take you towards this area and then look for the signs to CDD-Ghana. This place is right across the street.

2. Chaumiere: Remarkably good french food can be had at this restaurant located across the street from the Shangri-La hotel. The soup au poisson is great, as is the steak au whatever. Over air conditioned, though, so be ready for a blast.

3. Monsoon: Located above the Osu food court is a swanky place called Monsoon. Here you can get sushi or eat off of their Southern African menu, which includes things like warthog. It all sounds very exotic, but the food tends to be a bit more straightforward than it sounds (the warthog looks and tastes exactly like pork chop). But it is decent, and it is fun to try this place for no other excuse than to be seen.

Best Destination Eats:

1. Waterfront dining: Despite the fact that Accra is a coastal city, it is harder than you think to eat out on the ocean. There are at least a few good options in the immediate downtown area (excluding going out to La Palm or further). The first is called Tribes, which is located at the Afia Beach Hotel, the second is called the Osekan Bar, and the third I forget what it is called but it down the road from the La Polyclinic. The Osekan bar actually has terrible food, but the view is perhaps the best in town, so go for drinks or fried chicken and enjoy the sights, especially as the sun goes down.

2. Osu night market: The night market in the old part of Osu is a lively experience. You can wander around and try local foods. Sometimes hard to see what you are eating, but lots of fun just the same.

3. The mall: The biggest change to the Accra food scene has to be the opening of the food court at the Accra Mall. You could be anywhere in this place. Grab a movie in the new 6 theatre movie complex, shop for books, CDs, and new fashions, and then grab dinner at the open air food court. Great chicken, high end restaurants, cafes, and pizza all under one roof.

Best Ethnic Food:

1. Haveli: I ate at this restaurant the first time in 2004, and have probably eaten here about half a dozen times since then. I love this little Indian restaurant tucked in a lovely setting just off of Oxford Street in Osu. The food is really tasty, not too pricey, and is always satisfying. I love the salted lassis.

2. Lebanese: There is good Lebanese food around town, which can be a nice break from more standard fast food. I enjoy the food at Venus, which is located behind the gas station near the round about at the top of Oxford Street. However, I do find that the smoking policy inside the restaurant detracts from the food. So eat outside if you go.


1. Cafes with real coffee: After a few weeks of Ivoirian nescafe I begin to really crave a good cup of coffee. Cuppa Cappuccino in airport residential area (across from the WHO or the lavender lodge) is my little heaven in Accra. I am usually found here every Saturday when I am in town. They serve coffee, lattes, cappuccinos and some might tasty shakes (I really like chocolate banana). They also have lovely sandwiches with ham, avocado, tomato, and other good stuff. Melting Moments in Labone is also a really good cafe.

2. Local honey: Last June I stayed in a Guest House in North Dworzulu (pronounced something like Jolu). There is a man who lives up that way who runs a meditation center and selves bio-organic locally produced honey, which honestly, is very tasty and is a great gift for people to bring home that supports the local economy. Look for his stand at the light (usually not working) in front of the Fiesta Royal hotel on the motorway.

3. Fried chicken: Fried chicken has become immensely popular in Ghana with fast food shops popping up everywhere. I also love it as it is cheap, safe to eat, and almost always available wherever I am. I really like one of the original joints: Papaye’s on Oxford Street in Osu. I love the garlic sauce, which is kind of like tzatziki sauce. So, so good. The portions may be partly responsible for the rise in obesity ongoing in the country. My friend Mary and I once celebrated Canadian Thanksgiving at this place.

4. Shakes: I always find it weird that is sometimes really hard to get good fresh fruit in Africa, despite the fact that being hit in the head by a mango is a real threat. A new place recently opened up on Oxford Street called NourishLabs where you can get fresh fruit smoothies and free internet.

5. Dried apricots: I have only seen these a few times around town, but always buy them whenever I do see them. There is a local producer in town that is now selling locally produced dried apricots for retail sales. For about 4 cedis you get a whole tray. They are delish and great snacks to keep on hand.

Here is my best attempt to put it all on one map.

Here is a link to another great blog posting on eating in Ghana.

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Denise Grady has an excellent piece this morning in the NYTimes on the problems that lead to high maternal mortality rates in Tanzania. While the article is excellent, the photo collection that accompanies it is even better.

The article highlights a number of key challenges to reducing the burden of maternal mortality: insufficient human resources, poor quality of medical services, lack of physical access to facilities, the high costs of medical services, and preferences for home births.

The article pointed to small scale efforts that were being tested in parts of Tanzania including use lower level of health workers, such as district medical officers, to perform surgical procedures such as caesarean sections, and building facilities near hospitals for pregnant women to stay in as they wait to give birth. These solutions will probably help, but will not likely be enough. Bringing emergency obstetric services to the people, when and where they are needed, will be necessary. Until then, women will face the terribly high risks of death in childbirth.

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The Malaria No More blog recently linked to a report by Gallup on the state of perceptions of malaria in sub-Saharan Africa. I had been aware of public opinion surveys by the AFROBAROMETER group, but had been unaware that Gallup was also conducting public opinion surveys about global health issues in the region as well. They have some interesting questions related to malaria in their survey.

The results of a second round of surveys in 23 sub-Saharan Africa suggest that there have been marked changes in the perceptions of malaria in most of the countries in the region that were surveyed. Compared to 2006, in general, households reported higher net ownership (not use) and increased use of antimalarials (conditional on having a fever). They also find that there are increased perceptions that malaria is the most common illness in their country. Gallup had theorized that decreased perception would be an indicator of progress, but in my mind, we could also take this as a measure of awareness of the disease, which is likely being influenced by information campaigns, and no necessarily changes in the incidence of the disease alone.

So overall, good signs that progress is being made, but also that a lot still needs to be done. Ownership in general was no where near targets, and ownership does not even mean use. The majority of people still report that it is the most common health problem in their country, which also suggests that this should be an even bigger priority needing an even greater response from government, households, and donors. Plus, all the usual caveats about methodology and sampling, which were not reported, also apply. However, I was really happy to see the results of the survey and look forward to more research of this nature.

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It is official: Obama, and his wife Michelle, will be making their first official trip to Africa in a few weeks. Specifically, they have decided to visit Ghana on their first official trip to the continent as the first family (Michelle and Barack visited Kenya together years ago). OMG the place is going to be crazy, I really want to go too!

Eric Goosby was recently named new head of PEPFAR. Here is your chance to hear him speak live. The Global Business Coalition on HIV/AIDS, Tuberculosis, and Malaria is hosting their annual global health annual conference in D.C. in about a month. He will be there, as will tons of other really interesting speakers. This might be just the excuse I need to visit friends in D.C.!

Finally, my future colleague Jonathan Morduch and his colleagues have recently released a book called “Portfolios of the Poor: how the poor live on $2 a day“. I have not read it yet, but it looks really interesting. Little is known about how people in poor countries actually spend their money and balance their finances. The book is based on academic research effort at the FAI that collected detailed financial data on poor households in Bangladesh and South Africa. Health care costs, surprise surprise, figure prominently. This is definitely on my reading list for the summer.

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For a number of years, there has been a great deal of talk about the use of a “polypill”, a single pill that contains low dosages of cheap generic drugs all known to play a role in reducing the risk of cardiovascular disease. The idea is that this pill would be so cheap and so safe that anyone could (and should) take it and making a big contribution in preventing cardiovascular disease. The polypill could also be used in developing world since it is considered to be a very low cost drug and requires minimal supervision from providers.

The result of a randomized trial of the use of polypill on indicators of primary prevention of cardiovascular disease in India has shown this to be the case. The authors find that patients receiving a polypill relative to those receiving just components of the polypill:

“…the Polycap is non-inferior to its individual components in lowering blood pressure and heart rate (an indicator of β blockade). It lowers LDL cholesterol and urinary 11-dehydrothromboxane B2 substantially, but to a degree that is slightly less than that with simvastatin or aspirin alone.”

So while it is not as good as each individual component, it is almost as good, and it saves the hassles of trying to figure out what everyone needs. Plus, it seems as safe as other drugs.

I am pretty excited about this concept, these kinds of programs tend to do well from a public health perspective, and they could be very useful in mass primary prevention globally. There is still a lot of work to be done, but it also means that more targeted approaches might be better in some ways, but for now, pass the polypill….

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Later this afternoon the KFF will be hosting a live, interactive webcast with a panel of experts to discuss the recently released Obama health budget. There has been a lot of debate about the new budget, with many upset that he has flatlined funding for HIV, smaller advocacy groups are thrilled to see NTDs being given as much attention (although certainly not as much money) as some of the more prominent killers, and of course those who are not included feeling left out. You can never make everyone happy all of the time.

But you can have your say, or at least join the conversation later today:

Tomorrow, Thursday, May 14 at 1 p.m. ET, the Kaiser Family Foundation will hold a live, interactive webcast from its Washington, DC studio featuring an expert panel examining the global health aspects of the President’s recently released Fiscal Year 2010 budget proposal. The panel will discuss what has been allocated to support global health efforts abroad, including programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). The panel will also address other issues relating to the U.S. funding for global health programs and what the next steps are for the budget with Congress.

Kaiser Family Foundation Vice President Jen Kates, will moderate the discussion and the panelists will take questions from viewers, which can be submitted ahead of time or during the live program to

Ezekiel Emanuel, special advisor for health policy, White House Office of Management and Budget
Tom Hart, senior director of U.S. Government Relations, ONE
Allen Moore, distinguished fellow, Stimson Center
Tim Westmoreland, visiting professor and senior scholar in Health Law, Georgetown Law and consulting counsel, House Committee on Energy and Commerce

WHEN: Thursday, May 14 at 1 p.m. ET

WHERE: Watch the live studio webcast on

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One of the best courses I ever took, was a course on empirical methods taught by Gary King in the Government Department at Harvard. That is why I think it is so great that he now does Global Health research.

Mexico has been credited as one of the countries that has done the most to expand access to health services in a “developing” country context. Starting in 2003, the government launched a series of reforms to introduce universal health insurance, which is subsidized for the poor. The program, known as Seguro Popular, aimed to provide coverage to 50 million uninsured Mexican.

Gary King and co-authors launched a randomized clustered evaluation of the program on a large sample of households. The treatment was encouragement to join insurance as well as additional funds to upgrade the facilities in the areas. They used a random phase-in of the program, which is pretty cool and something I wish more countries used, to study the program effects.

After 10 months, the authors did find evidence that the program had been successful in reducing overall catastrophic and out-of-pocket expenditures for inpatient and outpatient medical procedures, and that the findings were strongest for the poorest individuals. However, the program had no effect on medication spending, health outcomes, or utilization. This finding was not consistent with previous observational studies.

There are a lot of potential reasons for these results, which the authors discuss in depth in their article, but it seems these findings were disappointing for all those that had hoped for so much to come of the program. Some have questioned if 10 months is too soon to evaluate the program. I am not sure what I would have expected, but I think the findings of this study should be used as a careful warning to other countries that are significantly expanding access to health insurance.

While these programs will probably do more in the long-run, short term gains might be hard to achieve – or at least demonstrate. I suspect this might be the case in Ghana, which has recently implemented national health insurance, and China which as promised a doubling of health spending in the coming years.

Health reform can be long and painful process, causing lots of headaches, costing lots of money, and may not even show immediate results on health. It is a wonder that anyone is doing it these days, but I am happy that they are….even here in the U.S…because these programs wil likely pay off in the long-run.

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Home management of malaria, that is giving households drugs and allowing them to self-treat presumptive cases of malaria, has been advocated for the treatment of malaria. Malaria outcomes improve markedly when treatment is given early but only a fraction of all people with malaria symptoms seek formal care or they wait too long to seek care. There has been a big push to get drugs into households so that they can treat at the first sign of fever. Seems like a good idea.

A recent article in the Lancet suggests that this might not be the best strategy everywhere, in particular when we are talking about home management with ACTs. In a relatively small randomized trial in an urban setting in Kampala, children were randomized to receive the home management with ACTs or standard care. Over the course of a year, the treatment children received treatments many times more often but clinical outcomes between the two groups did not differ markedly. The authors conclude that home management may not be the most cost-effective treatment strategy in an urban context where physical access to facilities is good and where transmission of malaria is relatively low.

This is just one more example of how global health policies tend to be too blunt. All poor children in all poor countries tend to be treated equally and the reality is that there is a of variation. Setting targets like 80% of children should sleep under a bet net gives an incentive to cover children in urban areas first, as they are easier to reach, but means that the interventions do always go to those who would benefit the most. We know more and we should use more of what we know into our guidelines.

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