HIV prevention smackdown

On June 27, 2010, in global health, HIV/AIDS, politics, by Karen Grepin

Global health folks are too nice. Even though there is frequently disagreement among people regarding what is the best course of action, rarely is there much direct debate. We’ll send letters to the editor, we may post comments on blogs, but rarely do people really go at it one-on-one. Even when people on a panel disagree with one another they generally begin thanking the other panelists, the hosts, all of the attendees, the donors and everyone else before they even begin to be critical.

The last time I saw anyone really duke it out was a debate between Richard Cash and Jim Yong Kim circa 2003 on “prevention vs. treatment” – it was fun. I think we could use a little bit more lively debate in our profession.

I have not attended one before, but Daniel Halperin recently made me aware of a debate series organized by the World Bank on controversial topics on “Emerging Issues in Today’s HIV Response”.

The next debate will be held this Tuesday, June 29, 2010.  The topic will be “Behavior change in generalized epidemics has not reduced new HIV infections and is an unwise use of HIV prevention resources.”  The topic is controversial and the line up looks good – so maybe it might turn into a real debate!

The Moderator will be Willard Cates, President of Research, Family Health International and the Panelists will be:

  • Myron Cohen, MD, Associate Vice Chancellor; J. Herbert Bate Distinguished Professor, Medicine, Microbiology and Immunology, and Public Health; Director, UNC Institute of Global Health and Infectious Disease; Chief, Division of Clinical Infectious Diseases,
  • Daniel Low-Beer, PhD, Unit Director for Performance, Effectiveness and Impact, The Global Fund to Fight AIDS, Tuberculosis and Malaria,
  • James Shelton, MD, MPH, Science Advisor, Bureau for Global Health, USAID,
  • Francois Venter, FCP (SA), Senior Director, HIV Management Cluster, Reproductive Health and HIV Research Unit; Associate Professor, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
Luckily for those of us who don’t live in DC, this event will be live webcasted from 9:00 to 11:00 am, Eastern Daylight Time, at the following webaddress:  Supposedly there also live videoconference sites throughout the world (Email to find out the various sites in Africa.)  I’ll be tuning in.
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This weekend leaders of the G8 group of countries will gather in Muskoka in my home country to ponder their relevance in the world and to agree to a set of collective actions to help make the world a better place.  For those who are not familiar with it, Muskoka is kind of like the Hamptons except colder, with a lot less sand and a lot more black flies – a true Canadian paradise.  On the agenda, and of greatest interest to those in the global health community, will be discussion of “the Muskoka Initaitve” on maternal health.  Over the past few months there has been a lot said about what works in reducing maternal mortality – providing access to family planning, ensuring access to skilled assistance at delivery, and other solutions – but this is not the first time the international community has come together to address this issue and the solutions that are now being advocated are largely the same that have been advocated in the past.

So why is it that we still have seen so little progress?  As someone who tends to see the glass half empty, I thought I would leave what works to the experts and instead come up of my list of things that I believe do not work in reducing maternal mortality in hopes that such missteps are not repeated again.

1.  Making it all about abortion:  Few issues in global health generate as much debate as discussions of reproductive health, in particular whether family planning does or should include abortion.  While I believe that addressing the needs of women with unintentional or unwanted pregnancies is important to discussions of maternal mortality – whether through abortion or not – it is far from the most important issue.  I believe that when politicians in rich countries – all of which provide access to safe and legal abortion to their citizens – get in a room and fight about the appropriateness of safe and legal abortion abroad it distracts from other issues and it does little to advance the cause of poor women in developing countries.  Debates of this manner have happened in the past and have likely been part of the reason why progress on maternal mortality has stalled.  National forums are more appropriate venues for such discussions.  I doubt any rich nation country would want the G8 to convene a meeting to discuss whether or not they should be providing abortions in their respective countries.

2.  Looking for a magic bullet:  As I have recently discovered, bringing a new person into the world is a long, painful, and messy process that has more or less remained exactly the same for our entire existence as a species.  It is physical.  It involves lots of blood and strange bodily fluids.  It involves pushing a big thing through a much smaller thing.  There is not going to be a magic pill or pixie dust that will make this an easy and risk free process.  The interventions that are needed are going to be multifaceted and far more complicated than simply delivering a pill.

3.  Advocating for “low-cost” solutions only:  This is a another perennial favorite of the global health community.  I had seen the use of this language in earlier drafts of the G8 documents on maternal mortality, but I do not believe that it can be addressed without addressing health systems and this is not going to come cheap.  There are simply too few health care professionals available and the infrastructure needs are enormous in countries where maternal mortality has remained high.  However, “low-cost” should not be confused with “cost-effective” as there are likely to be many interventions that are potentially cost-effective, in particular when other non-targeted health outcomes are factored into the equation.

4.  Confounding addressing maternal health and child health issues: I suspect I will get criticized for this one by many readers, but I personally believe that the way in which maternal health issues have been lumped together with child health programs – aka MCH programs – has distracted attention away from maternal health programs.  Clearly these two health needs are related, but sometimes addressing the needs of women requires completely different kinds of programs, resources and relies on very different assumptions than addressing the needs of children.   What is good for the child is not always good for the mom.  Plus, it is easier to address the needs of children which may lead to those programs being prioritized over others.

5.  Setting grand and completely unrealistic targets:  Arguably the Millennium Development Goal 5 on maternal mortality was the most unrealistic goal among all of the MDGs.  To achieve such a reduction in maternal mortality it would have required record breaking annual declines every year from 1990-2015.  In my opinion, the only value from having set such an unrealistic goal is that it can now validly be argued that it is the goal towards which the least progress has been achieved.  Adequately scaling up the workforce, which will be essential to reduce maternal mortality, may take decades: training centers must be established, health care professionals must be trained, public sector workforce policies must be radically transformed.  Goals that are established must realistically reflect these needs.

So I will be watching with great enthusiasm this weekend as the G8 summit unfolds, and hope that something good comes out of it that will benefit the roughly 100 million women who give birth in the world every year.

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I did it – it took me 4 days – but I did it:  I read a whole economics research paper, looked at the tables, and even understood (most of) it.  My baby brain is apparently starting to heal…

What was it that finally brought me out of my maternal stupor?  It was the title of a new NBER working paper recently released by Nava Ashraf (HBS), Gunther Fink (HSPH) and David Weil (Brown) entitled “Evaluating the Effects of Large Scale Health Interventions in Developing Countries: The Zambian Malaria Initiative“.  Wow – an economic evaluation of the health impacts of a national health program!?!  But the more I read, the more I realized that the article was not going to provide the kind of findings I craved – precise estimates of the health impact of such programs or insights into which health interventions were more effective than others in controlling malaria.  Instead, the paper was one of the more interesting pieces I have read that outlines the challenges of undertaking such evaluations in the real world.

In 2003, the government of Zambia launched one of the most ambitious malaria control programs launched in a modern day developing country.  Donors had invested heavily in Zambia because it was believed that malaria control programs were likely to succeed in this country.  Typical to such initiatives, it seems, evaluation was an afterthought and as such mechanisms were not put in place to ensure adequate data availability to evaluate the impact of the programs.  Although there was a national health management information system (HMIS) as well as standard demographic and health surveys (DHS) – it took a bunch of economist, and a bunch of someone else’s money – to get enough of the right people to collect and clean existing data sufficiently to even attempt such an evaluation.

To give you some sense of what the authors were up against, their discussion of the data in the working paper – something many economists only give minimum attention to – stretches out almost 10 pages – that is a lot.  The challenges were multifold: missing and incomplete reporting from health facilities, inconsistent reporting structures over time, lack of systematic verification processes, major inconsistencies in reported data, inconsistent metrics, and so on.  But also a number of additional challenges: how did the rollout of diagnostic tests alter the diagnosis of malaria (before everything was fever and now cases were being distinguished), how did the roll out of other health programs affect malaria outcomes, and also how did a major user fee policy change affect the utilization of health services?  These are major challenges, some of which the authors tried to address while others were almost impossible to fully address.

Their noble effort provides some evidence that there is an association between the rollout of the malaria programs and improvements in under 5 mortality, with the bed nets association being more robust than those for the other malaria interventions (although one should not make too much of this relative finding given that they were looking at very different things in different areas).  However, it is very difficult to attribute too much of these health improvements to the malaria interventions alone – the authors were unable to control for the rollout of the many other important health improvement efforts which likely were correlated with the rollout and uptake of these other health interventions either because some areas in a country are frequently prioritized over others, good health management at the subnational level could lead to some areas excelling along many dimensions, and because Zambia was one the the countries that has most effectively experimented with integrated delivery of health services such as ITNs and measles (for example see here).

I think the authors should be commended for their valiant efforts to make use of existing data systems, including national HMIS datasets, to conduct such an evaluation.  I suspect most people would have given up when they had seen how bad the data were and moved on to the next question.  Alternatively, others would have tried to set up their own parallel data systems rather than investing and using existing data sources.  While I think the evaluation does provide some evidence that the malaria programs  have contributed to declines in mortality in some way, the real value of the working paper is how it shows how challenging it will be to ever be able to disentangle the causal mechanism behind any of the health impact of many dozens of large scale national health programs currently underway.  I think others interested in looking into such questions should see this paper as a warning that it may not be easy, but that it is worth investigating existing data systems to see what is available already.

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I’ve let my blog lapse these past few weeks. However, I think I have a good excuse: a few weeks ago my husband and I welcomed into the world our son Nicolas Charles Grépin. It has taken a while but I am starting to have interest in the outside world again and it has now given me enough time to reflect upon my own personal experience of the medical care that both Nicolas and I received during my pregnancy, during the delivery, and in the subsequent weeks. More importantly, the ability to string more than a few words together into a sentence has returned and I have learned how to think again during his extremely adorable naps.

I think by most people’s standards, I had an uncomplicated pregnancy. I had no morning sickness (probably the longest stretch I have ever gone without getting sick). I ate just about everything (except chicken, which was so repulsive I once had to leave the room when it was served). I drank coffee (to the chagrin of the local baristas who at times refused to serve me). I traveled (if airlines awarded air miles to fetuses, my son would already have qualified for elite status on 2 airlines). That is until I hit 34 weeks – at which point things fell apart.

First it was insomnia. Then it was my stomach. Then the contractions began. Then it was tendonitis. Then it was the swelling in my legs and hands. Then it was high blood pressure. Finally, at 36 weeks, despite the findings of previous examinations, I learned that my baby was breeched (positioned the wrong way). Throughout my entire pregnancy I had been adamant about avoiding a c-section, and then I discovered I had one of the indications for which there was nearly universal agreement of the need for a c-section. I was devastated.

In the subsequent weeks, my life was consumed with trying to turn the baby. I tried everything. I had nearly daily treatments of moxibustion and acupuncture. I sat around with bags of ice on the top of my belly. I lay upside down on an incline for as long as I could. I bounced on an exercise ball. I even subjected myself and Nicolas to a barbaric procedure known as an external cephalic version where 2 doctors tried to physically turn the baby in the operating room with an epidural. But nothing worked. So at 39 weeks, in the early hours of the morning, my husband and I hailed a cab and arrived at NYU medical for a scheduled c-section. The epidural was inserted at 8:59 a.m. and by 9:11 a.m. we had a happy and healthy baby boy.

Despite all of my issues, in the grand scheme of things my problems were relatively minor. I don’t think any point either myself or my baby were at any real risk. In the back of my mind, however, I kept asking myself: what if I lived in a poor country, was a poor woman, and knew little about the medicine I was receiving. How would we have fared then?

A few things really struck me about this whole experience. First, I went from having a completely uneventful pregnancy to one with so many issues in a very short time period. In total, I probably had about 12 antenatal care visits – if women in poor countries get antenatal care most get far, far fewer than this – would they get the help they need? Second, would the antenatal care have caught the breech position? A manual evaluation at 34 weeks concluded that my baby had been in the right position, but I realize now that he never was. Most women in developing counties do not have access to the ultrasound technology that I had. Finally, while yes, the c-section was a relatively straight forward operation, I really wondered how such procedures can be delivered in resource poor settings. We hear talk about midwives and other lower skilled professionals providing such services – I had a small army of medical professionals in the room during mine – how feasible is this and is it better than the alternative?

Next week, health professionals, policy makers, government officials, celebrities and a pile of regular folks as well are converging on Washington, DC to discuss these issues at the Women Deliver Conference. I hope the discussion does get beyond a focus on the statistics or whether abortion is a part of family planning or not and get to what really matters: how can we ensure that pregnant women do not die needlessly when they deliver their babies. The solutions are not likely to be easy, not likely to be “scaled-up” quickly, nor are they likely to be “low cost”, but they are essential and they are achievable.

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