Treatment as prevention – Vancouver Style?

On February 9, 2011, in HIV/AIDS, public health, by Karen Grepin

I spent a summer while in high school at UBC in Vancouver. The scenery was breathtakingly beautiful and the proximity to the beaches more than made up for the relentless drizzle that is summer in Vancouver. Strangely, one of my most vivid memories of this trip was finding half a dozen used syringes in the city parks and the syringe disposal kits that the city had installed throughout these parks – similar to the poopy bag disposal centers that New York City parks have installed. Clearly, Vancouver had a huge drug problem.

Fifteen years later, it is interesting to read about how Vancouver has been addressing this public health problem in a recent article in the New York Times. This article describes how the city has actually set up a center where drug addicts can come in and shoot up under the watchful supervision of nurses and other health professionals. The logic is not that this institutional arrangement condones and thus promotes the use of drugs but rather that by providing a safe location for drug users to inject drugs their risky behavior, such as re-using needles and using contaminated products, be minimized and if drug overdoses occur – as they do – that fatalities can be greatly reduced.

While the value of this clinic on its own is very interesting, the author of the article Donald McNeil goes on to argue that the existence of such a site is actually part of Vancouver’s strategy to reduce HIV, and a contributor to the success that the city has had at reducing prevalence rates. But he also argues that Vancouver has been applying a test-and-treat strategy and also claims that this is driving down the epidemic.

By offering clean needles and aggressively testing and treating those who may be infected with H.I.V., Vancouver is offering proof that an idea that was once controversial actually works: Widespread treatment, while expensive, protects not just individuals but the whole community.

There was not enough information in the article for me to try to evaluate these claims, but it is an interesting and compelling idea. Is what is going on in Vancouver evidence that the “test-and-treat” strategy actually works? And if it is true, to what extent can we generalize the Vancouver experience – a city that offers free health care, syringe disposal kits, supervised drug injection sites, and public nude beaches – to any other city in the world? If I had time, I would love to get into the evaluations of the Vancouver experience, but if anyone out there knows it already, I would love to hear from you.

That said, happy to hear that a Canadian city is at the forefront of such efforts. Thanks to Jack for forwarding the link.

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The Politics of Public Restrooms

On February 8, 2011, in politics, public health, sanitation, by Karen Grepin

Public Restrooms are not exactly something that most of us spend a lot of time thinking about – but if you think about it, their existence has been crucially important to the development of our current lifestyles. But of course making people do their “private business” in public has never been easy.

It turns out some people have spent a lot of time thinking about public restrooms. NYU professors Harvey Molotch and Laura Norén have recently published a new book “Toilet: Public Restrooms and the Politics of Sharing“, which I must admit looks absolutely fascinating and is now on top of my reading list.

In this month’s Atlantic, there is also a great slideshow of Public Restrooms around this the world, which I highly encourage you to view. I think I will need to buy one of those nifty baby hooks – what a great invention:

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Cholera: a really long-running (and runny) mess

On February 8, 2011, in cholera, diarrhea, by Karen Grepin

Over the weekend, CNN and others reported that 3 cases of cholera were confirmed in New York City. Although such cases occur at a rate of about one a year, and usually in travelers returning from far-flung countries where cholera is endemic, such cases are relatively rare in most developed countries. But few diseases conjure up as many images of filth and old-worldliness as cholera. It was one of the first diseases to have spread globally at epidemic proportions. The famed John Snow basically invented epidemiology as a result of an outbreak of the disease in London. And it is hard to think about the disease without thinking of sewage, excrement, and refuse. Surely in this day and age that is a disease that is on its way out, right?

Wrong. It turns out that cholera is once again spreading around the world at “epidemic proportions”. I did not realize this myself until recently – perhaps because this “epidemic” has in fact been underway for over four decades! Cholera is on the rise, even here in the United States, and has attracted some media of attention of late *thanks* to the outbreaks that have occurred in Haiti and Zimbabwe. Despite the relative ease at which cholera can be treated with relatively simple, inexpensive, and accessible remedies, it remains one of the most acutely lethal pathogens in the world. Cholera’s killing power comes from how quickly it can kills otherwise seemingly healthy individuals: it regularly kills its victims within 12-24 hours of the onset of symptoms. People die before effective treatments can be delivered. Roughly 200,000 people are stricken every year from the disease of which there are usually about 5,000 deaths (Haiti alone has bumped up the numbers for 2010).

Although not a major contributor to the overall burden of disease, one could argue that this long-running epidemic should really be seen as a failure of global health: we know how to prevent it, we have effective vaccines to prevent its transmission, and we have effective treatments available to treat it. Yet it remains. This fact has led others to wonder if we are really doing enough to address this really long-running (and runny) mess. The basic strategy to date has been the promotion of oral rehydration solution (ORS) and education to help raise the awareness of its symptoms. Despite the fact this strategy has probably help saved dozens of millions of lives, it may not be enough, and it has a number of experts asking whether or not we are really doing enough. Is it time for a new global strategy for cholera?

Given that effective vaccines exist, should we considering immunizing more people against cholera? A good example of where such stepped up immunization programs might be warranted would be during an outbreak, such as the one observed recently in Haiti. The arguments against such programs has always been that since the vaccines take a while to become effective and given the difficulties associated with implementing these programs (typically during a period of chaos) these programs are unlikely to be effective. However, model based estimates have recently shown that such programs might in fact still be effective even under relatively slow response scenarios. Also, another recent article has shown that the use of such vaccines after an outbreak in Hanoi were also highly effective.

Of course, the cost-effectiveness of vaccinations vs. alternative approaches should be considered, prevention and treatment should not be considered substitutes, and long-term thinking will ultimately be what is needed to address this scourge but it does raise some interesting and vitally important questions (it also makes me think a lot about efforts to eradicate polio). In this case, 50 years into the epidemic, at what point can we say that we are not doing enough?

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Applications now open for the Global Health Corps!

On February 8, 2011, in fellowships, by Karen Grepin

I frequently get asked about exciting opportunities in global health for recent undergraduate grads and lately I have encouraged everyone who has asked this question to look into the Global Health Corps. The program, which offers paid year-long internships, aims to help train the next generation of global health leaders. Fellow are selected from both developed and developing countries and are paired and placed with partner organizations around the world to gain real-world experience in global health. The fellows are involved in everything from communications to monitoring and evaluation.

The first deadlines are approaching rapidly at the end of February, so prepare your applications now!

For more information, following the following link.

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Buried amidst gripping accounts of the events in Egypt, there was a well written piece in last Sunday’s New York Times about Seguro Popular, the Mexican Universal Health Insurance Scheme. The plan, which was introduced in 2003, had as the explicit goal from the outset to provide universal coverage to the millions of low and middle income Mexicans who lacked health insurance.

Coming off a years where there was so much focus on efforts to expand access to health insurance globally, I thought the piece providing some good food for thought about the real challenges – and this in a country that would be considered relatively well compared to many countries which are currently trying to address this issue.

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On Monday, I had the pleasure of attending an event hosted by the Gates Foundation called “Polio Eradication and the Power of Vaccines” hosted by Bill Gates at the newly restored Roosevelt House here in New York. At the event, Bill Gates released his 2011 Annual Letter from the Gates Foundation. The main focus of his letter – and of this event – was on polio eradication. Also present at the event were historian cum-author David Oshinsky, representatives from the Sabin Institute, the WHO, and – oddly – a very uninformed Diane Sawyer, who hosted the panel discussion during the event.

The story about polio eradication is a long complicated one. Launched in the late 1980s, buoyed by the successful smallpox eradication program, the international effort had as a goal to eradicate the disease globally. Eradication, as opposed to eliminate or control, means to eliminate it everywhere in the world. It is worth pointing out that eradication is an extremely difficult undertaking and just because one disease has been successfully eradicated, it does not mean that others will be as well. Epidemiologists have argued that some diseases, including some diseases for which global eradication efforts have been launched in the past, are not biologically eradicable (if that is even a word). For example, if there are non-human reservoirs of the infectious agent the agent could easily be reintroduced making eradication nearly impossible. This appears to be true for both malaria, yellow fever, and yaws – all three of which have been targets of failed global eradication efforts. Eradication efforts against these agents are unlikely to be successful if one takes true eradication as the goal.

Fortunately polio is biologically eradicable – in fact one strain of the virus has already been eradicated. Plus, also like smallpox, there are effective vaccines available to target polio, which was the reason why smallpox could have been eradicated. But although we have a vaccine against polio it is not as effective as the smallpox vaccine. In general, we need to give 3 doses of the vaccine and even then we don’t get full protection. There are different strains of the virus circulating and not all vaccines are equally effective against all of the vaccines. Plus, in rare cases, the use of the live version of the vaccine can also cause a mutated and virulent form of the virus – using the live polio virus has been described by some as using fire to fight fire.

Perhaps more importantly, however, is the fact that polio is a largely invisible disease. Most people who get polio are largely asymptomatic. They might have flu like symptoms but for the most part it is impossible to know when someone is infected or not – smallpox victims were easily detected from the rash and poxes that appeared on their body. Only a small fraction of those infected with polio develop paralysis or more severe symptoms. So for every reported case of polio there are literally hundreds or thousands of undetectable infections. By the time we can respond using supplementary immunization – the disease has likely spread.

Does that mean that polio should not be targeted for eradication? There has been a lot of chatter about this this past week, including some comments from experts like Donald Henderson’s whose opinion on this matter I take very seriously. The truth is we don’t know – no one, no matter how much of an expert you are on this matter knows for sure. It is feasible from a biological standpoint, but challenging due largely to issues related to poor health infrastructure in endemic countries, weak institutions, and conflict – stuff public health has not done a great job addressing in the past. Polio has been eliminated in a number of geographic regions around the world but that does not mean it can be eliminated everywhere. But the simple truth is polio will never be eradicated if we don’t try. Plus, given the progress that has been made to date, there may never be a better time than now to try.

Polio eradication is the perfect example of what economists call a public good – while most of us will benefit from polio eradication in some way, the truth is that the benefits to most people will be very small. As such, very few of us have the incentive to pay for this and so we won’t. This is a big reason why I disagree with what author David Oshinsky proposed during his talk on Monday – let’s replicate the March of Dimes efforts from 50 years ago in the United States to raise money for polio eradication. People don’t see polio anymore and as such there is very little constituency to support such efforts. Instead, I believe, it is up to governments, and fortunately for us, rich computer geeks to pay for this effort. We should be thankful, and not be too critical of Bill Gates on this issue. Polio eradication efforts were floundering a few years ago. It is because of him, and his tireless efforts that we are even talking about polio eradication today.

It has been estimated that it will cost about $1 billion a year for the next few years to move ahead with the polio eradication efforts. Some have argued that this is not a lot of money because, for example, Americans spend $18 billion a year on dog food. But that is not the right way to look at this issue. It is a lot of money. The IHME estimated that in 2010 the world allocated about $25 billion a year for development assistance for health, what will ultimately finance most of the eradication efforts. So it is a lot of money in that perspective. Some have argued that this cannot be justified on the basis of disease burden, but again this is not the right comparator. Eradication needs to be considered in a dynamic sense, investments today may lead to cost savings in the long run (actually, I believe all development assistance efforts should also consider the long-run). Investments in polio eradication are a risky investments that may or may not pay dividends in the future. We don’t know if it will be successful, we don’t know if and when we might actually be able to cease polio vaccinations – where most of the savings will come (in fact, we already know that we will likely need to switch from OPV to IPV in the near future and that may need to continue to vaccine for a long time due to that fact that some people continue to shed polio virus and will for years to come).

Bill Gates comes from a different world – he is not a public health person at heart – he is an entrepreneur. He became the worlds richest man not by playing it safe – but by taking risks. This approach has carried over to his work at the Foundation. His donations are like an investor’s portfolio with a balance of safe and risky investments. Polio eradication is certainly one of the risky investments but the high-risk-high-reward model has paid off for him in the past, and it might play out here as well. Of course, we should not just let the mission of one individual highjack the global public health apparatus but I truly believe that this is one program where it might be worth taking the risk.

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