I’ve become a big fan of reading the NYTimes on my fancy-schmancy new Kindle (which also become obsolete this week after they announced the Kindle DX out this summer). The op-ed section of Sunday’s NYTimes was basically a whole section on global health.

Nick Kristof’s piece was on pneumonia, which is the largest killer of children but also a disease area that is largely neglected.

Amy Grossman had a piece on how the use of misoprostol, a generic ulcer medication, could cheaply and effectively address hemorrhage, the major contributor to maternal mortality, in low income settings.

Esther Duflo was next with an letter arguing that providing more education to girls would be the most effective strategy to reduce maternal mortality.

Lewis Wall followed immediately with a letter suggesting that there needs to be more extensive use of partoraph, another low tech tool, that has been shown to be effective at reducing maternal morbidity and mortality by being able to better inform who needs more specialized care and who does not.

Then there was a story on the need to include maternal counseling into into nutrition programs. And then there were a few other articles related to Swine Flu, which I won’t even get into….and all of this before I was finished my cup of coffee on Sunday morning.

Then I received an email this morning about a new report out this morning called “Fatal Neglect” how health systems are failing to address diarrhoea, the second biggest killer of children. The report is by WaterAid and it looks great and I plan to read it as soon as my dissertation has been safely deposited into the Harvard Depository later this week.

I have to admit, the number of advocacy pieces all claiming to represent the disease area that is the most neglected made me really wonder about our current system of addressing global health issues. It is easier to raise money for disease specific causes but will this strategy ever allow us to strengthen health systems? I am not so sure, and even wrote about this recently in a new Canadian public policy forum. There must be a better way.

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Midwives and Global Health

On May 7, 2009, in links, maternal and child health, by Karen Grepin

Earlier this week was the “International Day of the Midwife“. My best friend growing up in Canada has recently completed all of her studies to become a midwife in Hamilton, ON. In her honor, and in the honor of midwives everywhere, here are some midwive links…

1. Meet Fatoumata Dio a Traditional Birth Attendant from Mali. Read about her life as a midwife in rural Mali.

2. The International Confederation of Midwives (ICM) and World Health Organization have argued that there is a global shortage of midwives and that the number of midwives globally will need to double to reach the MDG5 goal. I am not so sure…I may need to be convinced. But I agree that this area needs much greater investments.

3. The Partnership for Maternal, Newborn and Child Health has a new strategy which can be viewed here.

4. What is the role of primary health care in promoting health? Here is one view from Barbara Starsfield, Leiyu Shi, and my future colleague James Macinko at NYU. It is a great read.

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The big global health news story of the day was Obama’s announcement of his new “Global Health Initiative”. His 6 year plan is budgeted at $63 billion dollars, which is by my calculation a bump over the already large commitments made during the most recent reauthorization of PEPFAR ($48 billion over 5 years).

In the press release, he states:

“…I also recognize that we will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that best practices drive the funding for these programs.”

I admit, I was about as excited to see the term “health systems” as I was when he used the words “data” and “science” during his inauguration speech.

He continues to say that the focus of the program will be on :

“…broader global health challenges, including child and maternal health, family planning, and neglected tropical diseases, with cost effective intervention. It also provides robust funding for HIV/AIDS. The initiative adopts a more integrated approach to fighting diseases, improving health, and strengthening health systems.”

I found a few things interesting about this budget. First, while it represents a much larger amount of total funding for global health, most of the new monies are not for PEPFAR. PEPFAR will get about 70% of the total budget, but if you look at the annual allocations, the levels are probably less than implied during the reauthorization and the levels do not increase much over time.

I also noticed that one of stated benefits of the new “comprehensive strategy” was to prevent new infections with no mentions of putting any more people on treatment. Perhaps a realization of the challenges associated with such pledges over the long run and certainly consistent with the flatlining of allocations for PEPFAR.

Was it just me or did you double take to see family planning and NTDs among the highest priorities? This could be one of the biggest changes in the way in which the administration deals with global health issues and kudos to him for recognizing them.

On the critical side, I see a lot of talk about health systems strengthening and then a lot of discussion about disease specific projects. I am personally skeptical about the feasibility of building health systems around disease specific programs, in particular when such programs are so focus on achieving short term results. I will be very curious to see how he plans to operationalize these aspects of the program.

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Did we "cry wolf" on Swine Flu

On May 5, 2009, in influenza, public opinion, by Karen Grepin

It has been about 10 days since the Swine Flu broke out onto the world stage. While still spreading, it seems as though the epidemic may be abating, at least for now, and thankfully, the disease appears to be much more mild than initially feared. There have been about a thousand confirmed cases and a few dozen deaths. I thought Janet Napolitano summed it up well in saying that we have reason to be “cautiously optimistic” about the prospects for controlling the epidemic in the coming weeks.

I must say that I have been terribly impressed at how both the Obama administration as well as the World Health Organization handled the situation. Although everyone seemed to be quite aware of the possibility of a full blown epidemic, life went on as usual. It was a well controlled panic. I flew to Detroit this past weekend. Every now and again I would pass a traveller wearing a face mask or stand next to a coughing traveller. It was certainly at the back of everyone’s mind, but it did not stop us for living our lives. Had it got worse, we would have altered our behavior.

There is an emerging view, however, that the reaction to the epidemic had been over blown. This really bothers me.

Last evening I was watching the CBC news (a treat when I am home in Canada). There was a segment that pitted two public health official off against each other, one arguing that the global response has been justified (incidentally, it was the same public health official who had fallen ill from SARS a few years back when there was a break out in Toronto) and another claiming that everything had been blown out of proportion. On top of that, the last official argued, if we always responded this way than no one would ever take public health officials seriously, that we “cried wolf”.

When the epidemic emerged last week, we had no idea what we were dealing with. The epidemic initially appeared to be highly fatal (a common bias when one observes only really sick people in clinics), spreading, and previous epidemics, including the 1918 “Spanish” influenza, suggested that we had lots to worry about. Surveillance went into high gear, localized outbreaks were quarantined, and everyone from the World Health Organization to common businesses to regular people were encouraged to plan for the worst. No one knew how bad it would be. We reacted….well, textbook well. We don’t know if we had been prepared or not, because we got lucky with the virus, but we had to react.

I would say I know have a much more positive view of, and more confidence in, the public health system in the US and globally than before, not weaker. I might even be willing to give some of the credit for this to George W. Bush, which I never do, since many of the systems that were put into effect this past week were hold overs from his investments into bioterroism preparedness. Not everyone reacted optimally, perhaps including China which has quarantined a perfectly healthy group of Canadians in North Eastern China because they were from a country with Swine Flu or the 20 countries that have banned the import of Canadian pork products, but overall I would give the response a very high grade. And no one is willing to say that it is over, this virus will not likely disappear and could come back more deadly soon, and if it does, I sure hope we will be ready to react once again.

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A shot of protection circa 1976

On May 2, 2009, in influenza, public health, by Karen Grepin

I am now part way through an article I sent along a few days back which documents the choices made by government officials in 1976 when faced with a potential Swine Flu pandemic. Eventually the decision was made to distribute a vaccine, however, the disease never spread beyond a small group of Soldiers leading many to argue that public funds were “wasted“. The epidemic had not spread, so in my mind it is hard to call this too much of a failure.

I saw a link this morning to these really great public service announcements from 1976 advertising the need to get a Swine Flu shot. “Swine Flu…hey I am too fast for it to catch me!”. They are great, so I have linked to them here. I hope such tacky videos will still be needed in the era of Twitter and Facebook as I look forward to making fun of them for years to come.

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