Here are some links to some interesting things on the net this week:

1. The BBC takes a look at maternal mortality around the world this week. Click here for more information, including a video that shows how a simple bicycle ambulance is saving lives in Malawi.

2. My colleague Bill Savedoff blogged about the book “The Gods of Lending” on the CGD website. I started reading this book a while back, and there are some shocking details in it about the way in which the World Bank operates. The author argues that 30-40% of World Bank loans are misappropriated.

3. The Journal of Acquired Immune Deficiency Syndromes, normally a very technical and clinical journal, has put out a special supplement on HIV and health systems. Remarkably good stuff in there. Have a look.

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PEPFAR and country-ownership: fact or fiction?

On October 27, 2009, in HIV/AIDS, PEPFAR, by Karen Grepin

The most recent issue of the JAIDS journal has a series of interesting articles on the HIV epidemic and health system. One that caught my eye was a short commentary from Mark Dybul, former US government AIDS czar, entitled “Lessons Learned From PEPFAR“.

In his abstract he argues:

“In scope, it [PEPFAR] is the first global initiative to tackle a chronic disease and was based in a new philosophical foundation centered in country ownership, a results-based accountable approach, the engagement of all sectors, and good governance.”

Did he say PEPFAR was centered on the principle of country-ownership? I can buy result-based accountable approach and engagement of all sectors and might even be sold on the idea of good governance. But I am sorry, I can’t swallow the idea that PEPFAR exemplifies the principles of country-ownership.

The concept of ownership is one of the main principles of the Paris Declaration for aid effectiveness. According to a definition from the OECD website, ownership can be defined as:

“Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption.”

In the context of the HIV response, this would mean that countries would be responsible for developing intervention priorities, identifying implementing agencies, and being responsible for the programs. Of course country ownership does not have to be equated with government run, as it is also crucial that many stakeholders have a say and role in shaping priorities and strategies, but it does mean that governments are at least a key partner in the process.

The Center for Global Development in its report “Follow the Funding” report highlighted the lack of government involvement in PEPFAR projects as an area of weakness in the PEPFAR model. They argue that PEPFAR should “make the government a true partner in PEPFAR programs.” PEPFAR might have incorporated inputs from national plans, but it is hard to believe that it was countries themselves that developed the hallmark strategies of PEPFAR, including a heavy reliance on faith based institutions, the adoption of abstinence only messages, and strict earmarks on how monies should be spent.

Dybul points to the fact that 90% of implementing partners are local and that 80% of them are non-governmental organizations as evidence of PEPFAR’s country-ownership. I have a contract with NYU which pays me for my time as a instructor, dealing with student matters, and to support my research. But in no way does this mean that I own NYU, in fact quite the contrary given that my employer also owns the building in which I live. NYU owns me.

Even Dybul’s own successor, Dr. Eric Goosby, the guy with the exact same job Dybul had just under a year ago, has been quoted saying that PEPFAR has not achieved country-ownership and that in fact it may take years before it could ever be achieved.

I want to be clear, I think PEPFAR has changed the game in global health in many good ways, and has made important contribution to the lives of millions of people in HIV affected countries, but I have not always agreed with the way in which the program was implemented. Real country ownership is a lot more than contracting with local NGOs and informing the country about operational plans. Country ownership involves letting citizens and their elected representatives have a say in how programs are developed and implemented. PEPFAR is not doing that yet, so let’s save the praise until that is actually achieved.

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Promising results for a new cholera vaccine

On October 20, 2009, in cholera, India, research, by Karen Grepin

Photo credit: Corbis

We don’t hear a lot about cholera any more, but as the cholera epidemic that broke out last year in Zimbabwe has shown us, most developing countries are still vulnerable to occasional breakouts and in places in Asia, where cholera is still endemic, it is still causing significant illness. Over 200,000 thousand cases of the disease were reported worldwide in 2006, and this is only thought to represent a small fraction (5-10%) of the actual number of cases of the disease. It is estimated that over 100,000 people die of cholera every year, roughly 1/8 the number that die from malaria, mostly children under the age of 5. Wars, natural disasters, and economic collapse (as witnessed in Zimbabwe) can mean the disease can strike anywhere, anytime.

In theory, we have a vaccine for cholera, however, in practice the vaccine that has been on the market for many years is rarely used. The current vaccine is considered too expensive, too difficult to administer, and has the potential for side effects. As such, it is rarely used in public health programs.

A funny anecdotal story about this vaccine is that years ago, there were rumors that some customs officials used to dupe tourists into paying bribes by claiming that cholera vaccination was necessary to enter the country. Since the vaccine was never given to tourists, people who did not know better would have to pay up. My travel clinic in Montreal used to just certify that we had been given it (still in my vaccine card today) when in fact we had not.

Results of a clinical trial conducted in India have shown that we might be closer to having a safe, inexpensive, and effective vaccine against cholera in the coming years. The trial showed that the vaccine was about 67% effective at reducing cases of cholera when two doses were properly given, and was also protective in children, those most at risk of cholera. The vaccine is far from perfect, and the long term protective effect of the vaccine has not been established, but it is a good and promising start.

This trial also represents an important victory for some of the new drug discovery and development models that have come on board in recent years. This is not likely to be a lucrative market for any drug company, so it had to be done in partnership. Thanks to the Gates Foundation, the Swedish International Development Corporation Agency, and others this work was all possible.

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Are we missing millions of children in Africa?

On October 16, 2009, in malaria, research, by Karen Grepin

During the last couple of weeks some variant of the following catchy headlines have been making their way around twitter and in the media: “Not enough malaria nets for children” or “School-age children found to be least protected from malaria“. The headlines suggest that bed net efforts have been suboptimal in protecting children in Africa.

The headlines were in response to a new research article in BMC Public Health published by Abdisalan Noor and co-authors which has shown that coverage of bed nets is quite high among children under the age of five and again among adults, but is lowest among children aged 5-19. The authors conclude that universal coverage of bed nets will require new strategies, not just targeting of nets through antenatal programs, which have apparently been successful at raising coverage among children under the age of 5.

Maybe I missed this…but when did Universal Coverage of all children become the accepted goal? The Abuja Declaration, which was signed by the participants of the African Summit on Roll Back Malaria in the Spring of 2000 set out as a goal to ensure that a least 60% of the most vulnerable children, specifically those under the age of 5, should sleep under an insecticide impregnated bed net. The logic for targeting children under the age of 5 is that at younger ages children are immunologically most vulnerable to infection and that is, by far, where most deaths from malaria are concentrated. While significant progress has been made to date against this goal, it has not yet been achieved.

The logic for extending coverage to children over the age of 5 could also make sense for a number of reasons: since children in that age group are also exposed to infection and do incur some mortality it could further reduce mortality and there is evidence that at really high levels of bed net coverage (probably well beyond the levels seen in most places today) bed nets can have an effect on malaria transmission in communities. But changing the focus on young children to all children would significantly affect the cost-effectiveness of the intervention and would have massive implications for the funding envelope required. The data from the study mentioned above is that there are 2-3 times the number of school aged children in Africa than children under the age of 5. Are they advocating purchasing 2-3 times as many bed nets (in lieu of perhaps most cost effective environmental modifications)?

So while I thought this study was well done and contributed to our knowledge of the rollout of bed nets in Africa, its advocacy efforts were perhaps unfounded. I am actually quite pleased to see that efforts to date have actually focused on children under the age of 5. A more appropriate conclusion could have been “bed net rollouts appear to be targeting those most in need” and left it at that.

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Our vision is not gender blind

On October 9, 2009, in blindness, onchocerciasis, by Karen Grepin

The image of a young boy leading his blind elder is common to many who have lived or traveled in rural parts of Africa. It is this image that has been captured in a series of statues located around the world to celebrate the phenomenal partnership that has been developed to address onchocerciasis – or River Blindness. Thanks to this partnership, millions of people are now receiving vision saving protection through the community directed treatment with ivermectin approach. It is a tremendous achievement.

However this image, that many now associated with blindness in developing countries, is not reflective of the fact that it is women – not men – who bear the bulk of the burden of blindness around the world. There are twice as many women who are blind than men.

Today, October 8 is World Sight Day. Vision2020 has used today to help spread the world about the great gender inequality that exists in the world when it comes to blindness. There are a number of reasons for this, first the chances of developing blindness increase with age, and women tend to live longer than men. Women have less access to health services than men, so they are less likely to get care when it is needed. Finally some forms of blindness, in particular blindness caused by trachoma, are more likely to occur in women. For trachoma, children are natural reservoirs of trachoma bacteria and women spend more time with children than men.

Over 80% of the 45 million cases of blindness in the world were preventable and almost 90% of blindness cases occur in the developing world. Some people think that it will take expensive hospital based procedures to eliminate blindness but there are many community based treatments that can be applied at low cost with great results.

To read more about blindness, I will point you to the Vision2020 website.

The second photo is from a special exhibit on Blindness hosted by the Fred Hallows Foundation. For more information please click here.

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“Despite new information that the disease burden of schistosomiasis in Africa may be equivalent to malaria or HIV/AIDS and a simple annual anthelminthic treatment for this disease is available for less than 50 cents per person including delivery costs, we now know that fewer than 5% of the infected population is receiving coverage. To date, this situation represents one of the first great failures of the “global health decade” that began in 2000.”

Well said. That is a quote from a new editorial by Peter Hotez and Alan Fenwick in the latest PLoS Neglected Tropical Diseases. A few years ago there was little attention given to any of the neglected tropical diseases, but today, thanks largely to advocacy efforts of the authors of this editorial, financial donations from the Gates Foundation and the US government, and to the efforts of some powerful drug donation partnerships (think Merck and Glaxo for onchocerciasis and lymphatic filariasis respectively) significant progress has been made at increasing coverage of at risk populations throughout the developing world.

As the authors of this editorial argue, schistosomiasis, has not fared as well as some of the other NTDs. There are many reasons for this, so there is no easy answer as to why it is has been disproportionately neglected. Praziquantel the drug used to treat this disease has been around far longer than the drugs used to treat onchocerciasis and lymphatic filarisis. As such, by the time the disease was getting attention at the global level no major drug company was around to champion its cause or put together a drug donation program (is this an example of how patents by drug companies can actually be good for global health?). In fact, the market has been through so many ups and downs over the decades that is not surprising that the availability of the drug is a problem.

In an era of calls for universal access to ARVs and country wide bed net distribution programs, it is hard to believe that we cannot come up with $100 million a year to cover most of those in need of protection from this debilitating disease. But sadly, this is the reality.

For those really interested in this topic, there is a great chapter (chapter 3) on the challenges to access to praziquantel in the Access Book by Frost and Reich, which is available here.

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The two biggest food phenomena I have discovered since moving to New York City about a month ago are (1) New Yorker’s obsession with sipping coconut water while strolling around town (strange given how powerful of a diuretic this stuff is…) and (2) cupcakes. Cupcake shops – standalone operations specializing in these treats – are on nearly every street in this city. New Yorkers must eat more of these things per capita than anywhere else in the world.

The other evening my friend and I decided to try out the cupcake shop across the street from my new apartment. I spotted a gooey little number with peanut butter and chocolate and was about to yell out my order when I noticed a few numbers on the bottom of the placard. 550 calories. Each. My friend and I decided to split one and yet I still felt guilty. I have not been back.

The food calorie labeling of fast food items is a unique feature to New York City. Our mayor, Michael Bloomberg, despite being a business mogul in a previous life is really a big public health wonk (he even has a school of public health named after him) and despite his own famous culinary indiscretions has been an advocate for city-wide big-brother style public health policies, including the labeling of food calories on fast food items and a ban on trans fats in restaurants across the city. There is no other city in the world where government has so much control over what put in our mouths.

But do these policies actually lead to better eating behavior, in particular among the poor where obesity is more common? A new study published today in Health Affairs by some of my colleagues here at NYU (Brian Elbel and Rogan Kersh) seems to suggest that the food labeling policy has not had much impact on the actual choices low income consumers make, those primarily targeted by these policies. The authors compared the behaviors of fast food customers in New York City and Newark, NJ before and after the introduction of the policy in New York City. They compared the proportion of respondents who said they were aware of the labeling, indicated that the policy influenced their food choice, and those who reported purchasing fewer calories. On these measures, the policy appeared to have been successful. However, when they actually compared the number of calories purchased by people (not just what they reported) – there was no change.

Ideally, a study like this should have accounted for the fact that the policy change may have changed the composition of the people presenting in the restaurants, but I would really only worry about this had they found a big change in what people were buying. The real contribution of this study is that it supports the view that changing human behavior, in particular when it comes to one of the best things about being a human – eating – is really, really hard. People were aware of the policy and even claimed it had changed their behavior, but it didn’t.

Perhaps we are all a lot like Michael Bloomberg after all: we are not very good a living by our own rules.

Photo credit to the Cupcakes take the Cake blog. Yes, a whole blog about cupcakes. These t-shirts are for sale at Magnolia Bakery in NYC, where of course you can also buy lots of cupcakes.

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The highlight of the horrendous SARS outbreak for me a few years back was undoubtedly my first glimpse at a Hello Kitty Facemask worn by an Asian woman as she was exiting Logan airport. Clearly this was a serious epidemic if health prevention efforts had also become fashionable.

Minutes after the first chatter emerged earlier this year over the spread of the H1N1 virus (aka Swine Flu) the facemasks were back in full force. I flew that weekend to Detroit, MI and was surrounded by scores of facemask clad, nervous travelers who distanced themselves from anyone who even cleared their throat in public. In addition, Purell sales shot through the roof. There were reports of stock outs of the product coast to coast. Bottles popped up nearly everywhere. People, it seemed, were willing to try anything – even things for which there was little or no evidence that they provide any protection – to avoid catching this flu.

A new study, published today in the Annals of Internal Medicine, has more or less confirmed that such interventions provide only limited protection. A study of patients presenting with the flu at Hong Kong hospitals who were randomized to receive no intervention, were instructed to wear a facemask, or were instructed to practice proper hand washing techniques found no significant reductions in the number of family members who subsequently tested positive for the virus. However, there was some evidence that those patients who adopted the practices sooner after the onset of symptoms may have been less infectious, but only under some conditions. Lots of caveats, as there always are, these were patients who were already sick enough to decide to go to the hospital and adherence rates were abysmally low, but on the whole the evidence was far from a slam dunk for the value of facemasks and hand washing.

So breath freely, and forget reaching for a squirt the next time you are in the elevator, because it seems the flu is going to get us anyway.

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Yesterday UNAIDS, the WHO, and UNICEF released a particularly upbeat report on the state of HIV/AIDS prevention and control efforts globally. There were some remarkable achievements reported, including a 35% annual increase in the number of facilities providing VCTs in reporting countries, 45% coverage of PMTCT, and increased targeting of prevention services to most at risk populations. It seems as though 2008, despite the doom and gloom of the global financial crisis, was a record year for HIV efforts.

The biggest piece of news, undoubtedly, was a 1 million increase in the number of people getting access to HIV treatment globally, with the vast majority, about 80% of the gains in sub-Saharan Africa. According to the report, nearly 4 million people are now access treatment globally – 3 million in sub-Saharan African countries alone.

There has been some speculation that these numbers may represent upper bounds, or the number of people who have ever accessed treatment not those currently accessing treatment, but regardless if these numbers are anywhere close to reality, than this is a massive achievement.

But it also made me wonder about what the implications these numbers might be on human resources for health in Africa, if in fact they were correct.

Below I did a quick back of the envelope calculation of what these new treatment figures represent given best practices about human resource requirements for HIV treatment in resource poor settings. I used data from a publication by Hirschhorn et al., from what I can gather the most heavily cited figure used these days, on the numbers of doctors and nurses required to provide ART, specifically I estimated to treat 1000 people with ART it would require 2 full time doctor FTEs and 5 nurse FTEs. I then took the treatment numbers by countries from the new report and compared this to the most recent estimate of doctors in nurses in those countries from the World Health Organization and compared the numbers.

Here are my estimates for doctors:

And for nurses:

The last column in each table is my estimate of the share of the workforce that is currently being allocated to HIV treatment programs. In particular for doctors, if we believe my assumptions, we see that a massive share of the total health workforce is entirely engaged in providing ART. In some countries over 100% of the entire medical workforce would be required to treat the number of people reportedly getting access to treatment. On average, although an average here is a bit meaningless, about 25% of the doctor FTEs would be required to provide ART. The proportion for nurses is substantially lower, because Africa in general has higher numbers of nurses.

Of course assumptions like these are by nature simplifications of reality, the HRH data is a few years old, ex-pat doctors don’t generally count in the WHO figures, and there are many reasons to believe that these treatment guidelines are not being implemented optimally (either up or down). But if they are in the ballpark, and I think they might be, than it does raise some important issues regarding this massive expansion of treatment programs. Can we justify using nearly the entire health workforce in some countries to treat just one disease? What is this doing to the rest of the health sector?

I would really appreciate any comments from any readers. What are your thoughts?

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