Almost back…rebuilding, upgrading, and preparing

On January 30, 2011, in administrative, by Karen Grepin

I arrived back in New York City earlier this week after a relaxing holiday only to find that my work office had been severely damaged in a frozen-pipe incident. I spent a big chunk of the week scooping up and disposing of the remains of important documents into large blue trash bins. Luckily, most of my graduate school notes have been spared, but it has still been a major setback and disruption to my life. I’ll also be homeless for a while until I get relocated to a new space elsewhere in the Puck Building.

But you may have noticed that while I was offline, I migrated my blog from blogspot to wordpress and am testing out a new blog design and format. If you notice anything wonky, please let me know. I’d also appreciate any (constructive) feedback you might have.

Also, I wanted to let you know that on Monday morning, I will be traveling up to the beautifully newly restored Roosevelt House at Hunter College to hear Bill Gates give his annual letter – a very fitting place to host this event. I’ll be live tweeting from the event. The thrust of his speech will have to do with Polio, so I’ve been preparing reading and re-reading lots of old classics on the topic. I am looking forward to the event.

So more substance soon…just need a few more days to rebuild, upgrade, and prepare for the new year.

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Going offline

On January 17, 2011, in Uncategorized, by Karen Grepin

I am finally taking a real vacation, which to my husband and me means somewhere where cell phones don’t work and where we can’t get email as we’ll be sailing around on a boat to places like Jost Van Dyke (pictured below) so I probably won’t be posting for the next week.  If anyone needs me, I’ll be under the third palm tree to the left:

A vacation also means getting a chance to read some non-academic books.  On my list?  I am currently reading a bunch of global health related books, including:

  1. The Emperor of All Maladies – a so far engrossing biography of Cancer.  I am more than half way in, and I can’t wait to get through the rest of this one.
  2. Cutting for Stone – A fictional (gasp!) story of a doctor working abroad – or so I have been told, I don’t know much more about it yet.
Back soon!
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A tax I like paying

On January 13, 2011, in Ghana, health insurance, by Karen Grepin

I have been spending the week in Accra, Ghana where I am preparing for a new course “Health Systems and Health Reform in Ghana“, which I will be teaching here at the NYU-Accra site this summer.  I have been travelling to Ghana since 2004 and I am always amazed how much this country changes on every new visit.  I have a friend here who likes to say that sometimes he leaves home in the morning and by the time he comes home from work a new building has been put up along his drive. He is only half joking.

Lots has also changed here with regards to its health system, most notably the National Health Insurance Scheme, which has been operation for about 5 years now.  The scheme is largely financed through a combination of a 2.5% VAT tax (called the National Health Insurance Levy) and premiums, however it is believed that the premiums represent only a minor share of the total revenue for the program.

One of the things that I have noticed on this trip is the way in which nearly every restaurant and business now prominently displays the amount of money collected as part of the health insurance levy.  At the bottom of every receipt I can now see exactly how much I have contributed towards the National Health Insurance Scheme.     It is funny – but somehow seeing it always makes me smile.  I figure I’ll end up contributing nearly $25 towards to National Health Insurance Fund this week but paying this tax actually makes me feel good!  A tax only a health economist could love, I suppose.

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Protecting public health from private guns

On January 10, 2011, in injury, public health, by Karen Grepin

This past weekend, an unspeakable act of violence was committed against a group of innocent Americans at a grocery store in Tucson, AZ.  The incident has sparked off another series of debates regarding gun control and finger-pointing about who is to blame for this particular incident.  While this act of terrorism deserves all of the media attention it is currently receiving, it is important to realize that firearms are responsible for tens of thousands of deaths every year in the United States, most of which do not make national headlines.  Firearm injuries are an important public health problem in the United States and therefore this incident should also be viewed as our failure to implement the best evidence-based policies that we know can help save lives.

My advisor during my masters at the Harvard School of Public Health, David Hemenway, is perhaps the world’s leading expert on the public health approach to reducing mortality and morbidity from firearms.  He has authored an excellent book on this topic “Private Guns, Public Health” – which I would encourage anyone interested in public health to read, not just those interested in firearm injury prevention.

I quote from the preface to this book:

“…motor vehicles and firearms are the leading agents of injury death in the United States, with vehicles first and guns a close second. But while motor vehicles are used by almost everyone, every day, throughout the country and are crucial for our standard of living, the same is not true of firearms.”

Firearms are nearly as lethal are motor vehicles, yet unlike the automotive industry – which we are constantly regulating to become safer and safer (e.g. speed limits, seat belts, side impact air bags, and  rear object detection sensors) and limiting who can drive a car (e.g. minimum driving regulations, license refusals for DUIs) and how (e.g. under the influence, while texting) – government has not nearly done as good of a job applying these public health principles to the firearm industry.  This past weekend, we learned (again?) why these policies are important.

Also from David Hemenway’s book preface:

“It is shameful that tens of thousands of Americans die needlessly from guns each year while our gun policy is driven more by rhetoric than scientific information.”

Hear, hear.  Let’s not wait for the next shooting spree before we wake up to the importance of firearm injury prevention policies to protect the public health.

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“Exchanging sex for money, goods, or services is a way of life for many poor women in developing countries, yet little is understood about the way that the transactional sex market functions.”

So begins a new research paper, out this month in the American Economic Journal: Applied Economics by Jonathan Robinson (UC Santa Cruz) and Ethan Yeh (World Bank) for what is likely to be an important, but poorly understood, driver of the HIV epidemic in parts of sub-Saharan Africa and elsewhere: transactional sex.   In this paper the authors identify a group of formal and informal sex workers in Western Kenya, basically women who frequently or occasionally supply sex in exchange for money but perhaps who do not identify themselves as “commercial sex workers”.  They may have another job and a family but engage in these risky sexual behaviors to help make ends meet.  Using diaries, the authors were able to track the sexual practices as well other aspects of their lives over time.

They find:

“We find compelling evidence that women increase their supply of risky, better compensated sex in response to short-term health shocks at home. Women are 3.1 percent more likely to see a client, 21.2 percent more likely to have anal sex, and 19.1 percent more likely to engage in unprotected sex on days in which another household member (typically a child) falls ill.”

When the women or someone else within their family falls ill, women increase their supply of transactional sex and engage in riskier sex in order to earn additional income, presumably to pay for medical treatments associated with these illnesses.  I found this line the most chilling:

“Women do this in order to capture the roughly 42 Kenyan shilling (US $0.60) premium for unprotected sex and the 77 shilling (US $1.10) premium for anal sex.”

Why would such women resort to such a risky activity in order to make up for – in the grand scheme of things – are relatively small income shortfalls?  It does seem kind of surprising, but the authors argue that this is due to the lack of alternative income coping mechanisms to offset these sudden and unexpected income shortfalls.  It also seems to be relatively consistent with finding that have come from other papers that have investigated similar shocks in similar settings.  But it is depressing just the same.

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The concept of “Health Systems Strengthening” has received a great deal of attention yet not everyone knows what is meant by the term – let alone how to do it.  In last month’s PLoS Medicine a group of researchers have attempted to pull together a list of 10 guiding principles “necessary for effective HSS”.

From their article, the 10 principles are:

  1. HOLISM:  Consider all systems components, processes, and relationships simultaneously.  Include all health systems strengthening principles listed below.
  2. CONTEXT: Consider global, national, regional, and local culture and politics.
  3. SOCIAL MOBILIZATION: Mobilize and advocate for social and political change to strengthen health systems and address the social determinants of health.
  4. COLLABORATION: Develop long-term, equal, and respectful partnerships between donors and recipients within the health sector and among other sectors.  Develop and commit to a shared vision among partners by challenging underlying beliefs and assumptions.  Ensure frequent communication among actors.
  5. CAPACITY ENHANCEMENT: Enhance capacity and ownership at all levels, from individuals and households to ministries of health, including leadership, management, institutional strengthening, and problem solving.
  6. EFFICIENCY: Train and supervise the most appropriate personnel to meet health needs. Utilize appropriate technology. Coordinate external aid and activities. Minimize waste. Allocate funds where they are needed most.
  7. EVIDENCE-INFORMED ACTION: Strengthen structure, systems, and processes to gather, analyze, and apply data locally. Make decisions, whenever possible, based on evidence. Monitor progress of programs, and adjust accordingly. Ensure transparency and accountability.
  8. EQUITY: Target those who are disenfranchised. Plan for equity by empowering the disenfranchised, with a particular emphasis on gender. Disaggregate indicators to track disenfranchised groups.
  9. FINANCIAL PROTECTION: Ensure that funding streams are predictable. Consider insurance schemes to protect from financial catastrophes.
  10. SATISFACTION: Respond to needs and concerns of all stakeholders. Demonstrate accountability to constituents. Implement and respond to feedback mechanisms measuring quality and provider/client relationships.
Lots of buzzwords here – but lists and frameworks can be helpful and it appears to be based on a great deal of analysis, so I think this might prove to be a useful tool for others as they embark on HSS activities in the coming years.
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The Best and Worst in Global Health in 2010

On January 3, 2011, in global health, by Karen Grepin

Today is the first day that I have managed to have a few minutes to sit down in my office to get caught up in emails and my blog.  One of the worst things about being a professor is that while the Christmas period is a holiday for most people, it is actually one of my busiest times of the year as I have to cram in a pile of grading, international travel (this year Amsterdam, Boston, Accra, and the Caribbean), and course preparation into a few short weeks.

Although my blogging has slowed a bit this year, mostly due to the arrival of my new son who has been demanding a great deal of my time and energy, my readership has continue to climb.  As others have done, I thought it was appropriate to step back and reflect on 2010 in global health by going through my blog archives for the year.  Both Alanna Shaikh and Tom Paulson have put out lists on best of in global health, so I thought I would as well.  Here is mine – including the Best and the Worst in Global Health in 2010- organized by categories:


Life-Saving Vaccines: When I was in college (or as we say in Canada, in undergrad) studying immunology, one of my professors argued that the low hanging fruit in terms of diseases that could be targeted by vaccines had all been plucked, suggesting that we were not likely to see any new and major breakthroughs in vaccines in the future, but 2010 dispelled this view with the launch of a number of new and important vaccines and new research showing new potential for existing vaccines (here and here).  It was a good year for vaccine development.

A cell phone you can pee on to learn your HIV status…OK – you don’t actually have to pee on your phone, but you could and that just seems wrong.


Integration: it’s back.  Lots of big wigs – from Hilary Clinton to Rajiv Shah and others – have started to throw this word around a lot in the context of HIV programming.  I like this word, although I have argued before that it means too many things to too many people, and I am happy to see real discussions about how recent vertical programs will need to be integrated into existing health systems.  It is just too bad that it took this long.

Universal Health Coverage: As others have argued, I find this term lacks meaning – coverage itself should not be the end goal as it is the outcomes that matter.  Despite that, this word got a lot of play in 2010 including figuring prominently at the Montreux Symposium on Health Systems Research.

Best…Controversy or Debate

Maternal mortality declines: Earlier this year there was a lot of debate regarding new estimates of maternal mortality that were released from the Institute for Health Metrics and Evaluation that sparked a major debate about the way in which these new estimates were produced and it was even suggested that some groups had asked for the new data to be suppressed.  But I think this is one example of where the public debate raised a lot of new awareness for this important issue.

Worst…Controversy or Debate
The Canadian Government inability to decide on the meaning of family planning and whether or not it includes abortion or not. I personally felt that this debate greatly detracted from the key issues in reducing maternal mortality and may have led to less commitment from some donors, which is truly sad.

Best…Conference or Event

I think I am going to have to declare a tie on this one: Women Deliver and the Montreux Global Health Systems Research Conference.  I missed the first – due to the fact that I was a woman who delivered just a few weeks before – but was lucky enough to attend the second.  It was exciting to see so much energy and enthusiasm for important global health topics that rarely get so much attention.

Worst…Conference or Event
Global Fund replenishment meeting: although I think it is fair to say the Global Fund board might have been a bit too optimistic in their funding demands from donors it might also be fair to say that donors came up short.

Best…YouTube Video

Hans Rosling’s 200 Countries, 200 Years, 4 Minutes: Our favorite Swedish geek gets fancy‬ on the BBC‪…

Worst…YouTube Video
Barack Obama being heckled by AIDS protestors:  I know, free speech and all, but I really feel like Obama is not the enemy here and treating him like it does not help.

Best…Health Priority

Tough call on this one, but I am going to go with surgery.  What was the runner up?  Non-Communicable diseases – but I suspect it will actually be the big winner in 2011.

Worst…Health Priority
Cholera: Hey cholera aren’t you supposed to be on your way out?  Not this year as we saw major breakouts in Kenya, the DRC, and of course Haiti – among other countries.  Clearly treating this disease needs to become a bigger priority for countries around the world.

Best…News Item

Despite the financial crises, international donors appear to have not cut back on development assistance for health with it projected to increase through the end of 2010.

Worst…News Item
More countries are caught stealing from the Global Fund to fight AIDS, TB, and Malaria (as I like to jokingly call it the GF “ATM”) – including most recently (that I know of anyway) Mali.


All of the things that were turned red on World AIDS day, including the Empire State Building (picture taken from my apartment).

Worst…Advocacy (aka Badvocacy)
Dying on Twitter: Alicia Keys and friends “died” on twitter to raise awareness for World AIDS day.  Here is Texas in Africa on what was bad about this idea.

Best…Donor Activity

Cash-on-Delivery AID: An idea that has been developed by the wonks at the Center for Global Development is finally starting to see some air play.  Bill Savedoff, Mead Over, and others have specifically been investigating how this new initiative might affect the health sector.  It is still an idea that needs to be proven, but it certainly stands as one of the most innovative new approaches to development assistance.

Worst…Donor Activity
Cutting back funding to GAVI.  Just as things were getting really exciting (see note above on drug development) we are starting to see donors cut back on funding specifically to this organization that has done so much. Boo-urns.


The Pope saying condoms *might* be *OK* under *some* conditions for *some* populations.  You got to start somewhere.

Ban Ki Moon’s declaration that African countries should allocate 15% of their national budgets to HIV…not just health but HIV.  C’mon be realistic….


4:53 p.m. on January 12: Haiti Earthquake.  It was one of the most deadly minutes in the history of the world and one from which that impoverished country is still trying to recover from.

9:11 a.m. on May 6: The moment my son Nicolas was born.  OK, so perhaps this is not the most exciting moment in global health, but it was the most exciting moment of my year!


I am looking forward to another year of blogging and hearing from you all in 2011!

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Inspired by topnaman’s graphical display of the waning attention that has been given to malaria over the decades as well as one I saw recently presented at a conference in Amsterdam on AIDS, I thought I would also use a new and nifty feature on google – ngrams – to display what I think has been one of the most significant trends in global health during the past decade – namely the way in which we describe the field.   Ngrams capture the number of times a given term gets used in books.

I frequently get asked what is the difference between the terms “international health” and “global health”.  My general answer is that global health is the study and practice of health issues that transcend international borders (a line I suspect I stole from HSPH Dean Julio Frenk at some point) vs. international health which is the study of health issues that affect people living in the developing world.  Global health is a newer terms that has incorporated numerous perspectives and has moved the field away from what was once a mostly clinical or basic science field.  It also reflects the more “globalized” world in which we now live.  I’ve argued that international health is outdated, although not everyone agrees.

The above is an ngram from 1900 to 2010 showing the way in which international health was once the dominant term used to described the field but that it has now been overshadowed by the term global health, which has really only been in use for a few decades.  Great!  Now I have a good graph to prove my point.

By the way, the AIDS/HIV graph that was presented at a conference in Amsterdam is also super fascinating, so I’ve uploaded it as well.  Read what you want into it.

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