Congratulations to Siddhartha Mukherjee who was awarded the Pulitzer Prize in general non-fiction today for his book “The Emperor of all Maladies“. I read this book a few months ago – and loved it – so I am so happy to hear that this amazing work has been awarded such a prize. I actually read most of this book in a single voracious reading session on a eleven hour flight back from Ghana – even passing on the movie….this prize is well deserved.

In this book, Dr. Mukherjee, an oncologist from Columbia University, has crafted a captivating historical account of what is perhaps the most insidious illness ever to have afflicted humankind: cancer.

It takes us from Hippocrates to Herceptin with stops along the way in World War II chemical factories, the Massachusetts General Hospital, and the upper echelons of New York City society. We meet the good guys in this war, including William Halsted, a radical surgeon who pioneered the field of surgical oncology, Sidney Farber and Einar Gustafson (aka “Jimmy”) who helped make cancer a health priority, and nobel prize winning scientists like Harold Varmus, who elucidated some of the greatest mysteries of this disease. We meet its victims, from loving mothers to some of the greatest cancer advocates. We learn about the trial and error process that was used in the development of chemotherapy and case control studies that eventually linked smoking to lung cancer. We learn about how cancer research helped to accelerate HIV research and vice versa. This book weaves together basic sciences, clinical medicine, epidemiology, and history in one volume – an impressive accomplishment.

But as engrossing as the book was to read, I also found it incredibly depressing. Throughout I was baffled by how little we know about the disease and how much of current practice is based on simply guesswork. It was so unsatisfying. Plus, as someone involved in global health research, I kept asking myself how current treatment protocols will ever be adapted health systems in developing countries, where millions of people also fall victim to this disease every year. It seems hard to imagine.

But, the book was great- a must read for anyone passionate about health issues.

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I’ve blogged in the past about the complete neglect of stillbirths in the global burden of disease. Only children who are born alive count towards our measures of infant and child mortality. If a child does not take a breath outside of the mother’s womb, than it is considered a stillbirth, and it is not counted. Technically, I understand some of the important methodologically challenges in the measurement of stillbirths, but philosophically, I find this oversight reprehensible.

Ultrasound


The Lancet has published an entire series dedicated to what I believe is the most neglected cause of death globally – stillbirths. The newest estimates published in this series suggest that there are roughly 2.6 million stillbirths every year. My guess is that even this is an underestimate, in particular given the arbitrary nature of the definition used to define a stillbirth (death after 28 weeks gestion, but not at say 27.5 weeks). Current estimates of global child mortality are roughly 9 million deaths a year, so if we were to account for stillborn deaths, than child mortality would increase substantially.

There are some really interesting research papers in this series, including an overview of the risk factors and interventions that might be effective at reducing stillborn deaths. The biggest take-home for me from reading this series is that the main set of interventions that likely reduce stillbirths are exactly the same ones that are needed to address both maternal and child health. The intrapartum period – the labor process itself – is when about one half of stillbirths, three-quarters of maternal deaths, and one-quarter of newborn deaths occur. This means that prioritizing care during this crucial and critical time period would help to reducing millions of deaths. Antenatal services might also be important, but the key is to ensure that every woman undergoes birth in the presence of a skilled health professional and has adequate access to important life saving technologies – life saving for her and her baby – at the time of delivery. Period.

This series is a very important contribution. It is about time that this important global health issue receives proper attention from the global health community. It is now time for health system planners and policy makers to take the next step and ensure health systems are organized to provide adequate maternal care – millions of lives depend on it.

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The World Bank has been making a strong push into the blogosphere lately. They – like most policy-oriented organizations – have recognized the power of social in influencing our understanding of important issues. The “Let’s Talk Development” blog is a favorite of mine. Among the contributors, most of whom are esteemed researchers at the World Bank, are some of the leading thinkers in health and health systems, so I find this blog very useful in learning more about what is going on in health around the world.

Adam Wagstaff, who is probably one of the most knowledgeable experts on health insurance reform in Asia, has been one of these contributors. When this guy publishes an article in JHE or Health economics, I drop whatever it is I am doing and read it immediately. I am therefore thrilled to get more frequent updates from this guy on this blog – what I believe is one of the beauties of academics and experts blogging. Now if only he would join Twitter.

His latest post provides an excellent example of such a contribution. In about 1000 words he summarizes the major changes that have bee occurring in the landscape of health insurance in Asia. He argues that Asian countries, despite the lack of a big body of rigorous evidence of what works and what does not, have been converging on a consensus view of the priority elements in health financing and health provision. He summarizes these changes as:

1) More general-revenue financing
2) More arms-length ‘purchasing’
3) A reduced emphasis on government provision

Adam Wagstaff Summary of Health insurance in Asia
The rest of the post is worth a read.

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Quick question: Are there more medical schools in the United States or in all of Sub-Saharan Africa?

Given how much I go on about the dire state of health services and health human resources in Africa you would probably guess that I was asking this because the answer is the United States – I would. Well, we would both be wrong…but not by much.

According to the results of the Sub-Saharan Medical School Survey (SAMSS) there are now approximately 168 medical schools in Sub-Saharan African countries. According to Wikipedia, my source of all essential knowledge, there are 159 medical schools in the United States including 29 schools of osteopathic medicine. On a population basis, though, we can still argue that the United States produces more physicians per capita than Sub-Saharan Africa (roughly 20K for 300M pop vs. 11K for 800M pop) But Africa now has more medical schools than the USA.

Another reason why I would have selected the United States is that a few years ago when I had done a review of the topic, I seem to recall learning that there were fewer medical schools in Africa than in the United States (that review eventually turned into this). But what was known then was based on a few outdated studies from the 1970s and 1980s (i.e. pre-history). According to the findings of SAMSS, a lot has changed in the landscape of medical education in SSA and it is therefore about time that we have a new study that better reflects these changes.

Sub-Saharan Africa has actually been undergoing a little “boom” in medical education: of the 168 medical studies identified in SAMSS, 58 were established since 90s and more than half of them were established in the last decade. There is nearly 50% more medical schools today than there was just a few decades ago! Plus, almost all of the schools surveyed in SAMSS reported that they have significantly increased enrollments over the past few years. So there are more schools and existing schools are producing more graduates, overall some very good trends.

But there has also been a number of more subtle changes that I did not anticipate. I had heard a bit about the development of private medical schools in SSA, but I was not fully aware of the extent of this growth. About a third of the newly established medical schools since the 1990s were private compared to essentially zero private medical schools on the continent prior to the 1990s. Earlier this week an op-ed in the Guardian sparked off a sharp rebuttal from Michael Clemens, Senior Fellow at the Center for Global Development and NYU-Wagner Visiting Scholar, about the roles of rich countries in allowing or even fostering the migration of international medical graduates from poor countries.

At the heart of this debate is whether or not the migration of a health professional, who has received medical training that has been subsidized by its home government, represents an unfair subsidy by poor countries to rich countries and therefore such migration should be limited. Michael’s research on this topic has shown that many health professionals living abroad spend many years in their home country before migrating and on top of it send home many thousands of dollars a year in remittances which likely offset these losses. Although I tend to side more on Michael’s side on this debate – as an immigrant I believe people should have the right to migrate – I think the finding about the growth of private medical training further weakens the argument against reducing international migration – if they are paying a growing share of their own education than it also means that a smaller subsidy, if you think of it as one, is actually occurring.

Of course just generating more doctors will not solve the human resource crisis in SSA – there are many other barriers including the placement of these graduates into health systems, the distributions of the workers, on-going training, and creating the right incentives for them to work near their levels of competency – but this is a very good step in the right direction.

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