I left Ghana earlier today Rabat, Morocco where I will be for the next three days attending an international forum on “Promoting Maternal Survival : sharing experience and sustaining progress”. I am really looking forward to the discussion among countries about what has worked for them and what the big challenges are ahead.

I’ve been to Morocco before, but never to Rabat, and so I figured I might as well go out and get lost in the souks here as well. Eventually I ended up at this great cafe in the Kasbah overlooking where the Bou Regreg meets the Atlantic Ocean. Not one to turn down a local speciality, I had what everyone else was having: a glass of Moroccan tea (read: a bit of green tea mixed with 1/2 c white sugar, some fantastic mint, and hot water) and a snack (read: three almond and honey drenched cookies) and topped if off with a glass of freshly squeezed orange juice from a street vendor. By the time I got home, I was nearly in a diabetic coma.

Which is why it is not particularly surprising to me that rates of diabetes have been rising rapidly around the world, including in much of the developing world. Prevalence is increasing, but it is not just because people are getting older, age-specific rates of the disease also appear to be rising. Nearly 10% of the world’s adult population is now estimated to have diabetes.

While I was in Ghana, my collaborator Kim Yi Dionne and I were doing some prep work for a research survey we plan to launch later this year. We had the chance to talk to regular people about what health issues were important to them. But in at least one of these discussions, people seemed to be confused when we mentioned diabetes. On guy asked what it was while another asked “is that the sugar disease?”.

My waiter tonight at the cafe – who was probably about my age – barely had any teeth left…presumably rotted away from his regular tea drinking, which is a huge part of the culture here. I personally don’t love it when people describe the rising rates of non-communicable diseases as spreading at “epidemic proportions” because to me that term tends to describe something unexpected or something that is just passing through a population, as opposed to the problem that confronts us today. Decades of bad habits, many of which we have known for a long time are bad for us, are starting to catch up on us and we are woefully ill prepared to battle this opponent. It is going to be a long and drawn out fight.

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Recently the British Medical Journal reignited an old debate about the role of traditional birth attendants in terms of whether or not they actually help more than they hurt by essentially giving women false hope and preventing them from seeking out other care. This debate has played out elsewhere including the Maternal Health Taskforce Blog.

I am actually not sure how I feel about the issue, mostly because I have not seen very good studies of the issue, and believe that there is actually a lot of heterogeneity in the term traditional birth attendant so it is hard to generalize. But it is true that there is a lot of misunderstandings and lack of consensus on this topic.

An article in today’s Graphic here in Ghana reminded me of this confusion:

News clipping from Graphic, June 23, 2011

Talk about giving a confusing message.

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Summer Travels: Ghana and Morocco

On June 20, 2011, in Uncategorized, by Karen Grepin

I am minutes from taking off for a few weeks of research and work in Africa. First up, I am going to Ghana where I am working on a survey with Kim Yi Dionne from Texas A&M University to understand the importance of different health concerns to regular Ghanaians and to those involved in the health system and what factors might help to explain what they prioritize.

Then, I am off to Rabat, Morocco for a conference on maternal mortality. Morocco is one of those countries that has been a real outlier – the good kind – with regards to maternal mortality. I am really looking forward to engaging with the country officials who have been involved with this work.

I’ll be blogging and tweeting, while on the road when it is possible but I like to send out these notes in case any of you are also in those places and want to connect.

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Where to begin? It is well known that non-communicable diseases (NCDs) receive much less global health funding than other conditions, despite the fact that collectively they remain the largest killers of humans on the planets. If you are reading this, then they will likely kill you. For this and many other reasons, people are starting to wonder why the global health community does not care enough about addressing these issues. One big reason: Addressing the NCDs ain’t going to be cheap.

The Global Health Delivery online community for the endemic non-communicable diseases is currently convening a discussion among a number of panelists about how to fund these challenges. The panelists include Rachel Nugent, now of the University of Washington, Miriam Rabkin, from ICAP and Columbia, Sumi Mehta, from the Global Alliance for Clean Cookstoves, Brian Bilchik, the Director of ProCor, Charlanne Burke and Robert Marten, from the Rockefeller Foundation and others. If you are not a member of this online community, you can sign up at the above link and join the discussion.

The questions they have been posed include:

• What are some of the financial challenges for governments and international institutions in addressing NCDs?

• What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?

• How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs?

• Can you share examples of integrated service delivery, health insurance schemes, or innovative partnerships that offer lessons for NCD program and funding development?

These are tough questions with no easy answers. Donors may play a role but at this point I personally don’t think it is realistic to believe that they are going to be able to dramatically scale up funding to any large degree for these programs – and I am not entirely convinced that they should. Health systems in resource-limited settings are skewed to basic primary care and addressing acute illness so infrastructure investments are going to need to be dramatic. So I am looking forward what these experts have to say.

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I don’t usually blog about specific job opportunities, rather I instead maintain a jobs list to which anyone can subscribe and I usually pass along any relevant job postings that I see there. While I am on it, if you are currently looking for a job, I would also recommend you subscribe the jobs list on the excellent Global Health Hub.

But I am going to make an exception. Two of my former classmates, Manoj Mohanan and Grant Miller, have recently formed a research consortium to conduct rigorous behavioral research and impact evaluations in the Indian Health Sector India called Cohesive India. They are currently hiring a project manager as well as a field research assistant both of which are to be located in India and both are needed as soon as possible. If this is of interest to you, see the Cohesive India website for more information.

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When the lights go out

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

Yesterday afternoon I was siting at my desk at my place in CT when suddenly a very mean looking storm came over the valley. An hour later and after one of the most spectacular lightening storms I have ever experienced, our little town was in chaos: downed trees had closed off most of the major roads and many of the little ones and about a quarter of the homes had lost power. As of this morning I still did not have power and finally decided to leave the area to seek out internet and a shower.

My troubles are minor compared to the problems that many have experienced this year in the United States due to the unusual weather activity that has been affecting the country. I heard on NPR a few weeks ago that so far over 500 people have been killed in the USA from tornados, and that was before the twister that touched down a few dozen miles from us in Springfield, MA.

It made me think of this excellent post by Johns Hopkins graduate student Brett Keller on Tornado Epidemiology. It also made me think of this paper from Alfredo Burlando, an Assistant Professor at the University of Oregon, who has a paper that investigates the impact of a major power outage in Zanzibar on the health effects. He finds rather substantial impact on the probability that a child is born low birthweight at birth.

Nature is a powerful force and it continues to have major impact on both rich and poor communities around the world.

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I read this morning that Peter Hotez, currently the chair of the Department of Microbiology, Immunology and Tropical Medicine at George Washington University will be moving to Baylor where he will become the inaugural Dean for the new National School of Tropical Medicine to be founded there. That is right…I said the National School of Tropical Medicine…this will be the only school in the United States fully dedicated to tropical medicine, so I guess that does make it the national school!

Last summer, Peter published an editorial in PLoS Neglected Tropical Diseases (NTDs) calling for the creation of such a school. Over the years I have come across a few of these schools in London, Amsterdam, Antwerp, Basel, and Liverpool, all of which were founded about a decade ago around the time that the world was opening up to more and more global travel and trade and the European Colonial powers had strong presences in “the tropics”.

When I decided to do my Masters in public health I applied to 4 schools: Harvard SPH, Columbia SPH, Hopkins SPH and the London School of Hygiene and Tropical Medicine (which rejected my application). In Peter’s editorial, I learned that once upon the time the final exam at the London School of Hygiene and Tropical Medicine was once:

Students were asked to describe the methods for demonstrating the Widal Reaction in typhoid and Mediterranean fever and for purifying water on the march; to distinguish between the Anopheles and the Culex mosquito and the different filarial embryos; to diagnose leprosy, syphilis, lupus and malaria; and to describe the recommended treatments for cholera and Dhobi itch. The laboratory practicum tested for competence and little more. Students were asked to describe the steps to identify an unknown broth in a test tube, to stain blood samples for revealing the malarial parasite, and to identify abnormalities and determine the stage of infection based on microscopic specimens.

Clearly the 2 years that I spent at the Harvard SPH were focused on very different things than the curriculum of that school a decade ago: I have never heard of the Dhobi itch…let alone know how to treat it. I do vaguely remember how to identify a broth from my microbiology days but that would be it. I suspect the graduates of that school today would also not be able to do any of these things, which is a testament to how much the world has changed and how we think about health care issues in the developing world today. But clearly a lot more can be done when it comes to tackling the NTDs – they remain a challenge even today.

Peter also wrote:

…I believe there remains a strong need to have a centralized facility in North America for training in tropical medicine, i.e., one that embraces whole-organism biology of key NTD pathogens, new and appropriate health technologies and their introduction into global public health practice, and clinical tropical medicine.

To that I would also add a strong need for an understanding of the socio-economic factors that are associated with the infection and control of the NTDs and also a focus on the ways in which health systems are able to tackle these scourges.

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Are we too soft on alcohol?

On June 9, 2011, in alcohol, by Karen Grepin

A recent editorial in PLoS medicine asks:

If medical journals and public health advocates are concerned with corporate conflicts of interest, inappropriate marketing to children, impotent self-regulation, and general flouting of the rules, why are we ignoring the alcohol industry?

Good question. But I think the answer is pretty easy to answer: most of us like to drink. Plus, we have convinced ourselves that it is even a very good thing for our health – a little bit of red wine after all is associated with lower cardiovascular disease (even those who are so hell bent on needing experimental evidence to support any fact seem content to accept this correlation). But the data show that the picture is not always so rosy:

But the independent statistics defy this rosy view: the Global Burden of Disease study places alcohol-related morbidity second only to tobacco in the developed world [5], teenage drinking problems have been shown to have long term effects on individuals and communities [6], and a recent European-wide study [7] found that 10% of cancers in men and 3% in women were linked to alcohol consumption.

It reminds me about the bias that the public heath and medical community had against the perception that smoking was health hazard because again a large portion of physicians and other health officials smoked. In reading the Emperor of All Maladies I learned that at least once of the authors of the original case control study that showed the associated the overwhelming association between smoking and cancer had initially agreed to do the study with the original goal of “putting to bed” any concerns that in fact the linkage was real. He apparently quit smoking soon after his study results were published.

It does seem strange that we – as the global public health community – have taken a much harder stand against the tobacco industry and worry a great deal about risk factors that cause much less of the global burden of disease than alcohol. Is it time that we sober up and take a take a closer look? Is a global framework convention on alcohol the next step?

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