It might seem surprising to many that surgery is a very common event, even in the poorest countries in the world. It is estimated that roughly 234 million surgical events take place every year – more than the number of child births. It has also estimated that surgical conditions – conditions that can be treated by surgery – account for over 10% of the total burden of disease – more than most attention grabbing conditions that have made their way into the MDGs. Yet despite this, surgery has more or less been ignored by the public health community – seen as an evil “tertiary” procedure. But surgery provides lifesaving treatment to millions of people worldwide.

Part of the reason the area is so neglected, is there are not standardized metrics to monitor surgery related service delivery. Data is rarely collected in facilities, therefore the importance of the procedures rarely enters in policy makers minds. A new publication in this week’s surgery themed edition of the Lancet calls for greater attention for the use of standardized surgery metrics.

Here are some of the metrics that the authors propose and evaluate the feasibility of measuring:

* Number of operating rooms

* Number of accredited surgeons and number of accredited anaesthesia professionals

* Number of surgical procedures done in an operating room per year

* Day-of-surgery death ratio

* Postoperative in-hospital death ratio

I really applaud such efforts. The value of such information would be tremendous for many countries, would provide stronger rationale for further investments into medical education, and would go a long way to improving population health – even in the poorest countries in the world.

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The hunt for an HIV/AIDS vaccine has been ongoing for about as long as we have known that HIV, a retrovirus, causes the syndrome of conditions collectively known as AIDS. There was some logical evidence that inducing protective immunity against this virus should be possible – the existence of some people who were apparently immune from the disorder, others that progressed slowly – but despite billions invested to date, the trials of lead candidate vaccines have all failed.

Yesterday, however, researchers have announced the qualified success of an HIV trial conducted over 6 years in Thailand. The vaccine, known as RV 144 – a combination of two vaccines which were deemed failures when administered on their own – appears to have provided some protection – it reduced the infection rate by about one third. One third reduction is obviously far from the kind of protection we are more accustomed to with other vaccines, but it is a start. These findings represent more of a proof of concept – HIV vaccination is possible – than a breakthroughs that will lead to commercial production of a vaccine anytime soon. Lots of questions remain – like why these vaccines failed on their own but seemed to work together – but it is a start.

You can read more about the trial from IAVI here.

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Little is known about how health workers are paid in developing countries, in particular how wages compare across countries and regions and how governments fund the public sector “wage bill”. Therefore the new book “Working in Health: Financing and Managing the Public Sector Health Workforce” by Marko Vujicic, Kelechi Ohiri, and Susan Sparks at the World Bank makes a substantial contribution to our knowledge base. The book can be downloaded for free from the World Bank website.

Here are some insights from the book:

1. The share of government health expenditure devoted to paying health
workers varies considerably across countries, ranging from below 10 percent
to above 80 percent.

2. There is a weak positive relationship between the share of government
health expenditure going to the wage bill and health spending and a weak
positive relationship also exists between the share of expenditure going
to the wage bill and the gross domestic product. Richer countries pay devote a larger share of their total government expenditures to health worker wages.

3. The share of government health expenditure devoted to the wage bill
varies considerably by region, and this is a strong predictor of the variation across countries. It seems that customs persist within regions, which I think is a very interesting finding and begs some really interesting questions.

4. A weak negative relationship exists between the share of government
health expenditure devoted to the wage bill and the level of donor assistance. Of course it is hard to paint a causal story here, but it does says that countries that receive a lot of aid devote less money to health workers, which is potentially troubling.

There are also some interesting outliers, and the book explores some of these outliers in interesting case studies. Ghana, for example, now spends about 90 percent of government health expenditure on wages.

I look forward to reading the whole book, and you should too.

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Photo credit, NYTimes

Earlier this year, when news that a new strain of the flu – H1N1 – was circulating and that the virus might be of Swine origin, the Government of Egypt announced a cull of all pigs in Egypt to protect against the spread of the disease. Although almost every public health official warned against the plan – arguing that it would do nothing to prevent the spread of the disease – the government moved forward anyway – entirely for political reasons.

Well it turns out there is one more reason why this plan was a horrible idea all along: the said pigs were excellent consumers of organic waste and their absence has created a new public health problem – piles of garbage throughout Cairo.

Drastic measures like these, especially when they are not supported by any public health evidence, are rarely good ideas. This is one more example of how bad politics can lead to bad public health outcomes.

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I think this is pretty cool: As of yesterday, all Public Library of Science (PLoS) journals have links to article-level metrics of online utilization. Now instead of just being able to know how many times your article has been cited, you can get information on a whole set of metrics related to the usage of the article, including how many times it has been viewed online, how many times it has been downloaded, bookmarked on social networks, and been covered in the blogosphere.

I have published two articles in the PLoS Neglected Tropical Disease Journal, so of course I was curious to find out more about how they have been used:

One article (Grépin KA, Reich MR (2008) Conceptualizing Integration: A Framework for Analysis Applied to Neglected Tropical Disease Control Partnerships. PLoS Negl Trop Dis 2(4): e174.) was viewed 660 times (thanks Mom!) and was downloaded 143 times. Not bad.

The other (Hodgkin C, Molyneux DH, Abiose A, Philippon B, Reich MR, et al. (2007) The Future of Onchocerciasis Control in Africa. PLoS Negl Trop Dis 1(1): e74. – I am an et al.) has been viewed a whopping 1664 times and has been downloaded over 300 times.

Neither have apparently had much coverage on blogs. I may have to remedy that….(see above).

As academic research is increasingly disseminated through new media channels, I think this is a very important improvement in measuring the impact of work. Old metrics, such as just the number of citations, may miss the importance of many academic publications. Here’s to hoping that more journals begin to report such data.

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Is there an oversupply of global health programs?

On September 15, 2009, in education, global health, by Karen Grepin

This week marks the inaugural meeting of the Consortium of Universities in Global Health in Bethesda, Maryland. Far from a meeting of stogy old academics, this is a a high profile meeting that has attracted academics, heads of institutions and foundations, Presidents of Universities, and lots of global health celebrities.

The popularity of this meeting is a large part due to the popularity of new global health programs that have sprung up at Universities across the United States, Canada, and certainly elsewhere. Global Health is in with students and Universities everywhere are stepping up to meet this demand. In fact, there has been a doubling of students enrolled in global health programs in recent years, which is truly remarkable.

Alanna Shaikh on her new Global Health Basic’s blog (she has moved from Change.org, so you may wish to update your RSS subscriptions) had what I thought was a very thoughtful piece today expressing concern about this surge in students. She argues that the increase in supply of new graduates is unlikely to be met by the demand for graduates and that more people walking around with fancy degrees from fancy American Universities is not going to to much to improve global health. While, I generally agree with this view, I thought I would share some of my own thoughts as someone who teaches global health on this issue.

First, I do think it makes a difference if we are talking about undergraduate programs or graduate programs. My undergraduate degree was in Immunology – a far stretch from what I now teach and research (global health policy, international health economics). But I have no regrets about having done what I did, except that I wish I had more exposure to my disciplines. I did not actually take a course in economics until I was in graduate school.

My undergraduate studies taught me a lot, and although most of the details of what I learned have are lost on me today (I vaguely remember what a cytokine is) it provided me with a really great foundation for my subsequent work and studies. I hardly think that an oversupply of undergraduates with a multidisciplinary training in health studies, as opposed to say any other social science (or dare I say a humanity?), would be a bad thing. Undergraduate degrees rarely qualify anyone to do anything these days, but is useful to open your eyes to the world around you.

Second, if it is at the professional degree level, I do think we need to exercise some caution. I get lots of emails from students with questions about where to study if they have interests in global health and I generally say the same thing – go to a good university and get the best possible degree that will help you secure a job.

Programs that fit the bill in my mind are those from top universities, graduates of which always seem to do a bit better than others, universities where the faculty are actively engaged in research and work with international organizations (jobs ultimately come this way), and one where you can take courses not just in your narrow field of interest but also courses that build practical skills ideally from across the University, and hopefully from other professional schools. Schools that allow you to cross register and take classes a business schools, schools of public policy, and law schools score high points from me.

I also think it is worth pointing out, that it is worth considering a more general degree in public policy or public administration with a specialization in health or global health, as opposed to the classic masters in public health degree option. Where I teach at NYU-Wagner, this is how our programs are run. Students essentially get a masters in public administration but then can tailor a program for themselves. Through course selection, internships, and school projects, I think students can come out looking very competitive in the global health market. But if you change your mind about global health, or even health in general, you still have a really great practical degree that is easy to spin.

Years from now we will probably look back on the last 5 years as the sort of “golden years” in global health. The increased in demand for graduates from global health programs from organizations funded by the Bill and Melinda Gates Foundation, PEPFAR, and other big donors made global health one of the parts of the economy that was growing fast with tons of new job opportunities. Some of this will continue, but I suspect that we will not see the growth that we have witnessed in the past few years again. But producing more people who care genuinely about the health of the planet, in my mind, is not a bad thing.

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Photo Credit: Moises Saman for The New York Times

Yesterday UNICEF announced new data that shows that child mortality has continued to decline globally. For the first time in a long time, the number of children who die every year has dropped to less than 9 million. Using the same data, which is based on a new estimation method, UNICEF estimates that in 1990 – the starting time period for the Millennium Development Goals – 12.5 million children died every year. They estimate that the we have seen a 28% decline in the child mortality rate in roughly 18 years, or about 1.8% a year. This, I think, is a notable achievement. But of course, it is no where near the levels required to achieve MDG4 (a two-thirds reduction in child mortality).

So what should we make of this announcement? I think most people would probably say that this is good news, which I do think it is. But of course, we could also think of this as big disappointment: we are not going to meet the MDG4.

My initial thought after reading Celia Dugger’s piece yesterday in the NYTimes was to be suspicious. The announcement was that there has been a decline in the number – or level – of child deaths, which I thought was an unusual metric to report. The number of deaths is a function of the number of women, the number of births per woman, and proportion of children that die. When I think child mortality, I think just the last of these components. Fertility has been on the decline and it could very well be that we now have less deaths because there are just less births. But as it turns out, this is not what happened because of a nifty little phenomenon that demographers like to call “population momentum“. Since there are more women alive, we still have more births even with lower fertility. We have actually seen a nearly proportional decline in the actual under 5 mortality rate (deaths per live birth). Reporting numbers was probably just to make sense to the general public.

The declines, however, have not been evenly distributed over time, nor have they be equally distributed around the world. Sub-Saharan Africa was the region with the highest child mortality rates saw the least declines, whereas the regions with the lowest child mortality rates saw the highest proportional declines, which is the exact opposite of what you would want and what we would expect if we want to give a lot of credit to these declines to the collective action from the international community to target child death in the poorest countries.

But there appears to be an acceleration of the mortality declines since 2000, which does support a story that stepped up efforts are working. During the 1990s, the average annual rate of decline was 1.4% globally, and it increased to 2.3% during the 2000s.

So what explains the declines? There is next to no mention of it in the UNICEF release, nor is the data yet available for me to try to figure this out. But in the Dugger article she argues:

The child mortality rate has declined by more than a quarter in the last two decades — to 65 per 1,000 live births last year from 90 in 1990 — in large part because of the widening distribution of relatively inexpensive technologies, like measles vaccines and anti-malaria mosquito nets.

Perhaps. I certainly buy the measles story – my guess is that measles vaccination alone might be responsible for half a million fewer deaths a year since the early 1990s, if not more. However, because the data used is based on data collected over a 3-5 year time period, UNICEF cautions against attributing too much of these declines to relatively new interventions that have only taken off during the last few years, which is where I would include malaria efforts. I suspect the declines have had more to do with expanded coverage of additional vaccines, improvements in nutrition and sanitation, and likely to an increase proportion of births that are supervised and take place in facilities, in particular in Asia (neonatal mortality is the biggest cause of death).

So how do we ensure continued progress? As I have argued recently, I do not think real progress can be made without specifically addressing some of the major killers of children, specifically neonatal mortality, pneumonia, and diarrhea. I worry, however, that these concerns are currently being overshadowed by other health concerns. As the following graph shows, even if we did completely wide out malaria and HIV, we would hardly make a dent in child mortality globally. This is not to say that I don’t think that addressing these issues is important – I think it is crucial – I just hope we give more attention to some of these other concerns. Vaccines are coming online for pneumonia and diarrhea, but neonatal mortality is less likely to be addressed in any big way – and needs to be.

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Here is a round-up of interesting tid-bits on the web on other blogs this week:

1. I find Owen Barder’s blog “Owen Abroad” a real delight to read. I liked this posting to a poster showing the size of Africa relative to other areas in the world and his commentary on why we could use more aid innovations like the AMC program for vaccines.

2. It is hard to believe, but Ouagadougou, the capital of Burkina Faso and one of the hottest and driest capitals in the world is currently experiencing severe flooding. The BBC recently released these photos of the flooding. Tens of thousands, if not more, of this “small city of a million people” have been left homeless. Tragic.

3. The Making Pregnancy Safer unit of the WHO has released these case studies of maternal and child health indicators in many developing countries. Looks promising.

4. The Lancet group has launched a new global health journal called “International Health“. I myself have frequently struggled for a good home for some of my work – which is not really medical journal worthy but that is what the Lancet is. I am hopeful but was not terribly excited by the first edition. But fingers crossed.

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The first global health job I ever had a job at the International Trachoma Initiative conducting a comparison of trachoma control with other mass drug administration (MDA) based disease control programs (e.g. onchocerciasis, lymphatic filiariasis). This work led to some later work trying to figure out how to best integrate multiple MDA programs.

Through this work I discovered that while many communities were apprehensive about accepting some of the medicines that were administered (due to side effects), almost all of the communities were thrilled to get Zithromax – or azythromyacin – the drug donated by Pfizer for trachoma control. They could not get enough of it. People would report that after the distributions all kinds of infections and ailments would disappear.

Well, as it turns out, these people were on to something…something big it seems. A ground breaking study by the Carter Center was just released in JAMA yesterday which reports that not only did the administration of azithromyacin reduce the burden of trachoma it also had a large and significant effect on childhood mortality. Among children ages 1-9, the mortality rate was essentially halved. The thinking is that the administration of a powerful broad spectrum antibiotic like azithromyacin reduced the incidence and severity of diarrhea and pneumonia, two large contributors to child mortality.

It is great when the unintended consequences of a global health initiative turn out to be really good ones for a change. I am sure that this finding will give a big boost to trachoma control programs, which they surely can use. It seems the mantra of the neglected tropical disease control community was correct after all, addressing the NTDs will have benefits far beyond the elimination of just these diseases.

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I am putting the final touches on my syllabus for my new class “Introduction to Global Health Policy”, which I will be teaching this fall at NYU-Wagner. One of the first readings I want my students to read is a paper entitled “Where and why are 10 million children dying every year?” by Robert Black, Saul Morris, and Jennifer Bryce in the Lancet in 2003 (361: 2226-34). It is a good, short summary of the magnitude and causes of child mortality in developing countries.

I’ve included this reading because I think it really sets the stage for discussions about global health priorities. Despite everything that has been done over the past decades of international cooperation, health system development, and the scale up of foreign assistance, approximately 10 million children still die every year, most in developing countries (the data is a little out of date, but not much). In most of these regions, at least 1 in 10 children still do not make it to their 5th birthdays and in some countries it is even higher than this.

Deaths among children are actually quite concentrated in just a few causes. Between a third to a half of deaths happen during the neonatal period (the first month of life from birth asphyxia, low birth weight, etc.) and then diarrhea and pneumonia are the next biggies, each responsible for about a fifth of total deaths. Malaria, AIDS, measles and everything else are therefore responsible for less than 15-25% of total deaths. Of course these figures are skewed towards Asian disease profiles due to numbers (India and China alone are responsible for over a quarter of childhood deaths). But at the global level, progress towards MDG4 will not be made unless we are able to make a dent into one of these biggies.

If I had to select one of these biggies where significant progress will likely be made, I would choose pneumonia. The disease causes about 2 million deaths a year and the major causative agent – streptococcus pneumoniae – is vaccine preventable. Roll out of the vaccine, for a number of reasons, has been slow, but I am really, really happy to hear that progress is being made.

Last week the vaccine was introduced in the Gambia – one of the countries with the highest proportional burden of the disease. Gambia is now the second developing country, following Rwanda, to have introduced the vaccine.

The introduction appears to be due to the successful efforts of a number of groups, most notably the GAVI alliance, UNICEF, PneumoAdip, the WHO, and the private sector – Wyeth contributed more than 3 million doses of Prevenar, the first ever blockbuster vaccine. It is hoped that a pneumococcal vaccine will be made available in as many as 60 countries by 2015. Many countries will not benefit from the existing vaccine, but instead will benefit from a newer formulation that will likely be the product of the first ever Advance Market Commitment program, wherein donors have already pledged US $1.5 billion to develop the next generation of vaccine, one which will be better tailored to developing countries.

This development makes me really excited because a clinical trial in Gambia of the older generation vaccine showed that an older vaccine reduced childhood mortality by 16 % – a huge deal and likely a lower bound when newer generation vaccines come online. It also makes me happy to see that when partners work together, big progress can be made. If only all partnerships could appear to work so well.

Update: Since I wrote this post, I saw this excellent related posting on the HuffPo by Seth Berkly from IAVI, on the topic, so I am linking to it here.

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