A new metric of surgical capacity

On September 28, 2010, in research, surgery, by Karen Grepin
Perhaps the bigger “global health winner” of the UN MDG Summit held this past week in New York City was reproductive, newborn and child health.  The UN announced a new “Global Strategy for Women’s and Children’s Health” – and backed up by $40 billion in commitments to fund the strategy.  The Bill and Melinda Gates Foundation announced a new Alliance to support Country-Led Reproductive, Newborn, and Child Health initiatives.

Key to reducing maternal mortality is to ensure that, when needed, women have access to emergency obstetric care, including the capacity to surgically deliver her baby.  This point at times get lost with the justified focus on family planning, skilled birth attendants, and facility-based births.  As I have highlighted on this blog before, the accessibility of safe surgery is poor in many developing countries and is likely limiting the availability of such life saving technologies.

In this past week’s lancet, there is another excellent study that points to the need for increased investment in surgical infrastructure.  The metrics available to measure and monitor surgical availability is poor – no surprise – but the authors of a new study have used the availability pulse oximetry as a “proxy for adequacy of operating theatre equipment supply because of this scarcity in low-income settings, and because international organisations such as the World Federation of Societies of Anaesthesiologists (WFSA) and WHO regard it as essential for safe anaesthesia and surgery.”  Sounds reasonable.

Not terribly surprisingly, they find that availability is poor in many parts of the world, specifically they find:

The estimated number of operating theatres ranged from 1·0 (95% CI 0·9–1·2) per 100 000 people in west sub-Saharan Africa to 25·1 (20·9–30·1) per 100000 in eastern Europe. High-income subregions all averaged more than 14 per 100000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100 000. Pulse oximetry data from 54 countries suggested that around 77 700 (63 195–95 533) theatres worldwide (19·2% [15·2–23·9]) were not equipped with pulse oximeters.

Obviously, making a pulse oximetry machine available is not a perfect measure of the capacity to conduct safe surgery (interestingly, it turns out one can even purchase such machines on Amazon should one ever desire one).  Surgery is complicated.  Not only to you need some basic machines, but you also need a surgeon, anesthesia, a sterile environment, functioning equipment, a reliable blood supply and other items.  But if basic equipment is not there, it suggests that the rest is also lacking.  This study highlights how challenging, and different, addressing this health priority will be relative to simpler health interventions.

Photo Credit: Alin S/Flickr
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Can we laugh at global health jokes?

On September 21, 2010, in global health, pneumonia, by Karen Grepin

I just returned from an event at the New York Times building called Pneumonia’s Last Syrah – a social event to raise awareness of the problem of pneumonia which featured food, wine, and a beautiful photo exhibit. It was a lovely evening, so I must thank Mala Persaud from +gmmb for inviting me. We academics don’t get out nearly enough.

While at this meeting, I met a woman who formerly worked for a large global health organization and who now works in stand up comedy. I asked her if she had ever considered developing a whole stand up comedy routine about global health. She asked, is there really such thing as a good global health joke? Could we really laugh at disease and disability? Is global health funny?

It turns out, the “pairing” of Syrah and Pneumonia actually grew out of a global health joke once cracked by Eric Asimov, the New York Times wine critic, who once asked:

What’s the difference between a case of Syrah and a case of pneumonia? You can get rid of the pneumonia.

As a lecturer, I sometimes compare my lectures to a comedy routine. I prepare my talks, test a few lines each year on my students, and then once I find that something works I do it over, and over, and over, again. Sad to say it, but University professors are really just very bad stand up comics.

But this got me thinking, are there really global health jokes out there? If so, what is your favorite?

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Earlier this morning, Melinda Gates and others spoke of the importance of branding and marketing to help advance global health goals at the TEDxChange conference in New York City. Amnesty International, an organization that has understood this principle for a long time unveiled the following maternal death clock in New York City this morning:

Two hundred a thirty one women have died in childbirth since I went to work this morning – two in the time it took me to write this blog post. Tragic.

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Live Blogging from TEDxChange

On September 20, 2010, in Uncategorized, by Karen Grepin

src="http://www.coveritlive.com/index2.php/option=com_altcaster/task=viewaltcast/altcast_code=46fef95a21/height=550/width=470" scrolling="no" height="550px" width="470px" frameBorder ="0" allowTransparency="true" >Live Blogging from TEDxChange

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Yes, Geneva has the World Health Organization, the Global Fund, GAVI and dozens of other global health organizations.  Sure Seattle has the Gates Foundation and now the University of Washington – a new powerhouse in Global Health.  Of course DC is where much of the power and money for US based Global Health flows.  Yes, Boston has lots of fancy Universities and Schools of Public Health.  But this week, this week New York City is the place to be if you are interested in Global Health.  And that is where I will be.

I’ll be running around town taking advantage of the fact that bloggers are now considered “media” trying to cover a number of the UN Summit on the Millenium Development Goals.  Here is where I will be:

  • On Monday, I will be blogging live from the Bill and Melinda Gates Foundation organized TedxChange event starting at 11 a.m. EST.
  • Also on Monday, I hope to be able to attend the Ministerial Roundtable on Achieving MDG4: Power of Vaccines and Partnerships To Reduce Deaths organized by the GAVI Alliance.
  • On Monday night after I lecture in my Global Health Policy Class, I’ll be rushing off to attend the second half of the Pneumonia’s Last Syrah event organized as a part of World Pneumonia Day.
  • On Tuesday, and part of the rest of the week, I’ll be attending the UN Week Digital Media Lounge, organized by the UN Foundation, Mashable and the 92 Y.
  • On Tuesday afternoon, I will also be giving a guest lecture at Weil Cornell Medical School on the role of donors and the international community in influencing Global Health priorities.  I don’t think this is open to the public.
  • Tuesday evening, I will be attending a Tweet-up called ICTinNYC.
  • Wednesday, I will be attending an MDG Side Event called “AIDS plus MDGs: Delivering Results towards Shared Commitments”, hosted by UNAIDS.
Somewhere in there I’ll be trying to do my day jobs too, good luck, huh?  But I’ll be tweeting from most of these events, and hope to get a few blog posts up there as well.  If you are in town, and plan to be at some of these events, let me know.  It would be great to say hi!
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Best global health blogs

On September 16, 2010, in global health, links, by Karen Grepin
It seems hard for me to believe, but I have now been blogging about global health at this location for over two years.  I started this blog mostly as a way for me to help sort out all of the stuff running through my head while I was finishing up my dissertation in Health Policy at Harvard.  Surprisingly, people started to read it and my readership has grown steadily over the years.  When I started blogging, there were not that many global health blogs out there, and many of the blogs that existed then are no longer around.  I personally find subscribing and reading blogs is the best way to keep up to date with current debates in global health policy and an important part of what I do every day.
On my blog, I try to provide coverage of a wide-range of global health issues.  While my primary goal is to help interpret and advertise new policy relevant research, I also try to provide coverage of events, current debates, and other issues.  The blogs that I read, and tend to enjoy reading the most, are the blogs where I can also learn a thing or two, in particular those that are also good at providing updates on research related work.  
Here are a list of some of the global health or international health blogs that I read regularly.  Admittedly, there is a bias towards more policy oriented blogs – because that I what I enjoy.  I’ve tried to organize them in such a way that people can decide which blogs are most relevant to them.  As well, I have provided some links to other web based resources that I think people interested in global health should know about.  Many of these people are also on twitter, so where possible I have included their twitter name so you can track them down there as well.  
Happy reading!
Best general global health blogs:  
1.  Center for Global Development Global Health Policy Blog: Nandini Oomman (@NandiniOomman), Mead Over, Nancy Birdsall (@nancymbirdsall), Christina Droggitis, Bill Savedoff and a few others contribute to this great policy blog.  It provides excellent coverage of topics that are related to the focus areas of the Center for Global Development’s Global Health team, including HIV/AIDS, maternal health, health systems, aid effectiveness, and other important topics.  Also see the related CGD blogs which also provide coverage of related development policy issues.
2.  The Wherever-Alanna-is-Writing-Now Blog: Alanna Shaikh (@alanna_shaikh) has been blogging about global health and other development issues for a while now on her Blood and Milk blog, the UN Dispatch health blog, and as a guest blogger elsewhere.  Never one to hold back, Alanna is a great person to read about controversial topics in global health.
3.  globalhealthpolicy.net:  Devi Sridhar (@devisridhar), a post-doctoral fellow at All Souls College at Oxford and a colleague officially launched her own global health blog a few weeks back.  Devi is an expert on Global Health Governance and she talks a great deal about related issues on her blog.  She is also one of the authors of one of the books I have recommended on my “Best Readings in Global Health” list.
4.  Humanosphere: Tom Paulson (@tompaulson) is a Seattle-based reporter and has recently launched a great global health blog covering a wide range of topics and news items, with a focus on what is going on in the Seattle area – what he describes as the ” the epicenter of a global effort to beat back poverty and illness in the poorest corners of the world”.  Perhaps.  Regardless, his blog is always informative and usually a lot of fun.  I’ve really enjoyed reading this over the past few months.
5.  Sarah Boseley’s (@sarahboseley) Global Health Blog: the health editor of the Guardian in the UK, Sarah provides great coverage of current newsworthy global health items.  She is always very good at raising some very important questions.
Specialized global health blogs:
1. End the Neglect: If the Neglected Tropical Diseases are still not receiving as much attention from the global health community than they deserve, it is not because this blog is not trying hard to raise their profile.  Instead of having one central blogger, this blog has been working hard to solicit NTD related blog posts from other bloggers and contributors.  It works.
2.  Topnamen:  What this blog lacks in quantity, it certainly makes up for it in quality.  This blog is written by Naman Shah, and MD/PhD student at the University of North Carolina and is self described as a blog about “miscellaneous malaria news and discussion” it is actually a really well researched and informative blog about what is important in the malaria world.  I’ve learned a lot by reading this blog.
3.  Maternal Health Taskforce’s blog: This blog is an excellent source of information on things maternal health.  They keep me up to date on new publications, upcoming events, and research opportunities.
4.  Malaria Matters:  Bill Brieger (@bbbrieger) is Professor in the Health Systems Program of the Department of International Health at Johns Hopkins University as well as the Senior Malaria Adviser for JHPIEGO.  Bill provides excellent coverage of issues related to malaria and health systems.  His blog played a big part in inspiring me to start my own blog.
5.  Tropika.net’s Blog:  If there is a new scientific discovery that has changed the way in which the scientific community thinks about global health, you’ll hear about it here first.  Paul Chinnock and the rest of the editorial team here spend hundreds of hours scouring the medical and biomedical journals so you don’t have to!
Web-based global health resources:
1. Kaiser Family Foundation Global Health Policy:  keeping with the tradition of being the go to place for information for domestic health policy, the Global Health Team (see @J_Schiff) KFF has done a darn good job at pulling together all the best news items in global health on a daily basis.  It also provides great coverage of upcoming global health events, in particular those in DC. 
2. Global Health Council: the Global Health Council’s website has lots of information for those interested in global health, including a great global health career site, and information on upcoming events.
3.  The Global Health Hub:  This is a new site but so far what I see I really like.  This site, which is edited by Sarah Arnquist (@sarnquist) uses nifty software to automatically pull in global health content from across the web on global health.  Material is organized by disease/topical area and also includes information on things like careers.
4.  RSS subscription to major journals including Lancet, BMJ, the PLoS journals, and others:  If you want to keep up to date with your favorite journals, why not add the TOC feeds to your RSS reader?
If you are new to the blogosphere, and don’t currently subscribe to blogs I would recommend reading this post by Owen Barder (@owenbarder) (who runs a great general development blog, and also provides frequent coverage of health issues) on how to quickly become a savvy blog reader.

I am also on Twitter (@KarenGrepin)

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How malaria ruled humanity for 500,000 years

On September 14, 2010, in books, global health, malaria, by Karen Grepin
I spent most of the summer retreating from the heat and humidity of New York City in Litchfield County, Connecticut.  It was the perfect place to hang out with my new baby, catch up on lost sleep, and recover from the difficult last few months of my pregnancy.  Compared to the city the air was cool and relaxing.  I went for long walks in the forests and fields.  I picked wild growing raspberries, blackberries, and concord grapes.  By mid-July the farmers markets were brimming with fresh local fruits, produce, and meats.  I sometimes went days without buying anything that was not grown or raised within 5 miles of my home.  It is just what my body needed.

It is therefore very surprising for me to to learn that this exact area of Connecticut was once the site of a terrible outbreak of malaria that once afflicted thousands.  In the late eighteenth century, a man by the name of Elijah Boardman, who eventually became a prominent business man in the town of New Milord (where I regularly visit the excellent Saturday morning farmers’ market), had once been a soldier in the Revolutionary War.  When he returned to his home town after the war, he brought with him more than just some bad memories – he also brought some malaria parasites that continued to stream through his veins for years. 

After this return home, the Housatonic River, which happened to run through the backyard of the now wealthy Boardman’s mansion in New Milford, was dammed to help generate energy for the expanding industrial base of the region.  Soon after the banks of the river were raised, thousands, including Boardman’s own wife and son, fell seriously ill with malaria.  The outbreak came and went for years and eventually took the lives of hundreds of people spreading throughout this area of New England.  Litchfield County and the Berkshires were no longer known as areas where people went to relax, it was known as a place to get sick from malaria.

This story is just one of the really fascinating stories author Sonia Shah describes in her new – and excellent – book “The Fever“.  In this well researched book, Shah chronicles how malaria, which is currently experiencing a resurgence of attention from the global health community, in her words “ruled humanity for 500,000 years”.

I’ve always been a big fan of historical accounts of the interplay of infectious diseases and humanity, but when I think of the diseases that have really radically shaped society through geopolitical struggles, malaria is not on the top of my list.  I tend to think first about smallpox, measles, the plague, and now HIV.  But Shah chronicles a long history of how plasmodium influenced the world, like how the development of partial immunity against malaria helped provide an advantage to the Bantu-speaking people of Africa allowing them to spread across the continent and forcing their rivals to the peripheral regions.  Or how even as recently as WWII, malaria had played a role in weakening armies which led to the Japanese army employing elderly women as “net tuckers” to tuck bed nets around soldiers on the front lines at night.

In one chapter, Shah provides a nearly comical account of the “Global” Eradication program launched by the World Health Organization in the mid 1950s.  In retrospect it is always easy to mock the failures of a program as ambitious as this program, such as the irony of trying to eradicate malaria globally without even addressing Africa, but it does make you wonder why there had been such devotion from so many players who should have known better.  It also raises some important questions as the international community begins to whole heartedly embark on another effort to eradicate this disease.  She also comes down hard on what she sees as the over zealous advocates who are over relying on bed nets to eliminate malaria.  Go big or go home, Shah argues.   I tend to agree.

In perhaps my favorite chapter of the book, titled the “Karma of Malaria”, Shah raises and attempts to answer a very important question.  Why does a disease that has the potential to kill so many people not invoke the same level of fear in people living in malarious areas that it does to us outsiders?  She argues that when one lives around malaria one develops a very different attitude to the disease, it becomes part of life, and we need to take this into consideration when developing programs to address the disease.  In one memorable story she asserts that in some areas, if a child presents with fever and receives a positive test for malaria it might actually be welcomed – it means the child is not sick with something more serious!

I liked this book – a lot – but some people might find some aspects of her book hard to accept, such as description of a malaria control manager from Panama who only tends to get excited about malaria when donors are around to impress, or her critique of the Western donor communities over reliance on bed nets.  I can’t judge the validity of all of her claims, and was frequently irked at some of the generalizations she makes, but overall I think this is an excellent book to add to your global health reading list.

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Tomorrow, Wednesday, September 15, I will be hosting Dr. Adam L. Kushner, MD, MPH, FACS, a board certified general surgeon who practices exclusively in developing countries and a founder of Surgeons OverSeas (SOS), will present an overview of surgery in the developing world – a subject Dr. Paul Farmer has called “the neglected stepchild of global health.”  His talk is entitled “International Humanitarian Surgery: Surgery for the Rest of the World”.
Based on Dr. Kushner’s experience of working in over 20 developing countries, he will provide an overview of the problems and complexities of providing quality surgical care for the billions of people who live on less than $2 a day, highlight recent research, and discuss future plans to address the massive unmet global burden of surgical disease.   I will also be making some opening remarks regarding the need for and neglect of surgical services in the developing world.
For more information, or if you have any questions, please contact: wagner.globalhealth.events@gmail.com
Event Details:
When: 9/15/2010 12:30pm-2:00pm
Where: The Puck Building, The Rudin Family Forum for Civic Dialogue, 2nd Fl., 295 Lafayette Street, New York, NY 10012-9604
Hope to see you there!
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Why just having a net is not enough

On September 4, 2010, in malaria, research, by Karen Grepin

This month’s Malaria Journal has published the findings of a survey of bednet ownership, use and quality conducted in Western Kenya (h/t to @bbbrieger for flagging it).  The results may be a depressing to those who are strong believers in the importance of insecticide treated bed nets in the fight against malaria.

The author find:

“Of the 670 households surveyed, 95% owned at least one net.”

Wow, great news.  But then they go on:

“Only 59% of household residents slept under a net during the night prior to the survey.   77% of those who slept under a net used an insecticide-treated net (ITN) or long-lasting insecticide-treated nets (LLIN).   Out of 1,627 nets in the survey households, 40% were deemed to be of poor quality because of holes. Compared to other age groups, children aged 5-14 years were most likely to have slept under nets of poor quality (odds ratio 1.41; p= 0.007).”

The large discrepancy between ownership and use has been documented elsewhere, but there has been much less documentation of the low quality of the bednets.  I am sure that sleeping under a bednet with a hole is probably still better than not sleeping under a bednet, but it does raise one more important issue that must be dealt with when so much focus has been given to bednets for the control of malaria.

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