Take some quinine…with a side of green eggs and ham

On August 21, 2012, in history, malaria, by Karen Grepin

While Dr. Seuss may not have been a medical doctor, he did seem to have some interest in public health. The NPR’s Health Blog yesterday featured this health education poster illustrated by none other than Dr. Seuss while he was serving in World War II. The protagonist in his illustrations is a little mosquito named Ann (short for anopheles).

More great illustrations from the good doctor can also be found on the Contagion blog here.

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A Health Systems Research Bleg

On August 16, 2012, in health services, health systems, by Karen Grepin

Given that you are reading this post, there is a reasonable possibility that you might in fact be someone who engages in the field that is broadly defined as “Health Systems Research”. If that is the case, please read on.

If I were to ask you to list for me what you think are the best examples of research papers, projects or reports on health systems research, what would you say? If you do have an answer for this question, please (pretty please), email them to me at projects.karengrepin at gmail.com.

Yes, this is for research purposes. Yes, I will be forever grateful.

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When Imodium is the Enemy

On August 16, 2012, in child mortality, diarrhea, by Karen Grepin

It turns out that I am a much more adventurous eater than my Newfoundland gastrointestinal heritage has equipped me to be. This predicament has gotten me into a bit of trouble in the past: a much slower than originally anticipated hike through the Dogon Country, the *very* long flight back from Addis via Cairo, and my glamorous tour of gas stations in Togo and Eastern Ghana. You’d think I would know better than to eat raw meat in one of the countries with the lowest rankings on the human development index?? Apparently not. This problem has, however, forced me to develop a pantomime which has proven nearly universally effective to purchase Imodium in nearly a dozen of different countries. Imodium is my Friend.

But in the context of global health, Imodium is actually the Enemy. Diarrhea is the second most important killer of children under the age of five. The challenges of addressing this issue are complex:

1. Diarrhea is a common ailment that affects the vast majority of children on a regular basis so new cases rarely send parents rushing their kids off to the doctor. It is a fact of life in most developing countries.
2. Most cases are self regulating so if a parent does not treat or incorrectly treats their kid, this health seeking behavior is usually reinforced.
3. Most treatment is done at home so few cases are properly diagnosed and seeking advice from a medical professional is rare.
4. And finally, there are many cheap, readily available treatments.

While at first glance, this last challenge might not seem to be a bad thing, in the context of diarrhea it can be just that. There are many potential treatments being peddled for the treatment of diarrhea – from my trusty loperamide to the omnipresent antibiotics to my mother-in-law’s favorite: rice. When a child gets sick with a severe case of diarrhea, the World Health Organization and other agencies endorse the use of one treatment: oral rehydration therapy in combination with zinc. Some experts have list this intervention among the most cost-effective health interventions available yet I am sure many of you had not even heard about it. And the proportion of children with cases of diarrhea who are actually treated with this combination is abysmally low.

A new blog post by Oliver Sabot from the Clinton Foundations’ Health Access Initiative highlights how challenging this task can be in India, the country with the largest burden of diarrhea in the world. He writes on a the PLoS medicine blog this week:

Children are being treated for diarrhea, but they are just getting the wrong drugs. In most cases, the antibiotics and anti-diarrheal drugs that are the typical response to childhood diarrhea in India (given to roughly 60% of children with diarrhea) are at best useless and at worst actively harmful in most cases. Drugs like Loperamide work by paralyzing parts of the gastrointestinal tract, stopping everything – good or bad – from flowing out. For young children, this effect can be deadly: the drug was actively discouraged for use in children after six Pakistani children died in 1990 and a recent analysis found the drug caused severe side effects or death in around one percent of children. Yet mothers – and most health providers – here are not aware of these threats; they see only that the diarrhea decreases as they hoped and so drugs like these continue to do good business across India while less than two percent of children receive the recommended combination of zinc and ORS.

So how do we change this situation? I know Oliver and others (myself as well) have been working on developing some research projects that are aimed at trying to answer these questions. There are likely lessons to be learned from the recent experiences in trying to scale up the use of ACTs for the treatment of malaria (luckily Oliver was a big player in that process as well) but the challenges for diarrhea are also likely unique to this disease. But solving these questions has to be a much bigger priority if the world does actually hope to reduce child mortality in the developing world.

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A mangled mess

On August 13, 2012, in surgery, by Karen Grepin


I consider myself a relatively healthy person. But when I fill in a medical history form that asks for me to list all of my previous surgeries, I start to look a little worse for wear: shave biopsy left shoulder 2012, caesarean section 2012, punch biopsies to hand and right calf 2010, caesarean section 2010, lumpectomy 2009, LEEP 2005, Bankart repair to right shoulder 2004, and finally another Bankart to right shoulder 1997. I am healthy today, but only because of the way I have been cut, stitched, and singed back together by doctors with surgical training.

Until recently there has been little attention given to the need for surgical health services in low income countries. Many people consider it “too expensive” or “unnecessary” for poor people in poor countries. I think it is more than this: it is “unknown”. We have very poor information on what the need for such services might be in these settings. Health surveys, such as the DHS, mainly collect information on the health of children and women as they pertain to the rearing of children. It is hard to understand what the burden of diseases that are amendable to surgery might be in these settings. The prevalence of such conditions is unknown.

So a couple of years ago, some folks I met via Twitter (where else?) came up with the idea of developing a survey that would help shed light on the prevalence of such conditions. Their criteria was that the survey needed to provide population based estimates of a set of common conditions amenable to surgery and must be done in such a way that it could be collected quickly and inexpensively. Working with other expert they developed SOSAS: Surgeons OverSeas Assessment of Surgical Need.

On a shoe-string budget of $35K, they set out to test their survey instrument in Sierra Leone. I can tell you $35K for any substantial survey is really cheap. With it they surveyed a nationally representative sample of roughly 2000 households. Their findings are published in this week’s Lancet.


Briefly, they found that nearly a quarter of respondents had a condition that they self-identified as something that could be treated by surgery. In addition, a quarter of the reported recent deaths among household members might have been averted had surgical services been made available. This strikes me as a lot – a true mangled mess – but of course until this survey is repeated in other settings, it is hard to make a comparison to other contexts. Regardless, it seems that expanding access to surgical health services even in one of the poorest countries in the world would likely go a long way to help improve population health. All the kings horses and all the kings men could not put Humpty Dumpty together again, but perhaps all they really needed was 1 good surgeon?

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I have been in the United States now for almost a decade and have yet to eat at a Cheesecake Factory. I would like to say that the reason for this is that I have high culinary standards (no self respecting foodie would do that, right?) but in fact, it is not. My husband and I once decided to go after a day of shopping at the Prudential Center in Boston but after finding out that the wait was 1-2 hours, we opted for our favorite South End seafood joint instead. But I have always wondered whether the food and the experience really worth the wait?

Not only does Atul Gawande eat there but he somehow manages to turn an ordinary dinner out with his kids into one of the best written pieces I have read recently on what is wrong with the US health care situation (most of my dinners out with the kids these days ends up with someone vomiting or someone crying). His argument is simple, what makes the cheesecake factor so successful – scale, standardization, and a focus on process – can, and should, also be applied to the health care industry. I once attended an interesting talk by Michael Porter (the 5 forces guy) on the health care industry in which he described the health care industry as the worlds’ largest cottage industry – every hospital and every physician practice working independently and on their own.

This description has always stuck with me as it seemed so perfect. But Gawande argues that this does not have to be the case. If we were all more willing to allow the hospitals to operate more like chains we might be able to get better results (i.e. miso crusted tuna) at a lower price (all for under $15, well plus a few extra bucks for the cheesecake, of course).

Perhaps this might be fine for the high income countries, but might this also be applied to health care in low income countries? It seems that there is already at least a few cases out there where this has happened. The Aravind Eye Hospital is perhaps one of the best known chains out there in global health. It has become famous for churning out high quality and low cost eye surgeries across the developing world. There is reasons to believe that these models can work everywhere. McDonalds has more or less shown this to be true, right?

Yet while Gawande makes the connection between the rise of chains in medicine in better care and lower costs, he also makes the important point that the connection between these changes and outcomes still has not been proven.

Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them.

Part of the challenge will be reluctance from both providers and of patients to accept such changes (can we start calling health care snobs healties?). Would you want to have your eyes fixed at the Cheesecake Factory? We’ll if the benefits of such improvements are as good as people say, perhaps we might have people lining up for that too.

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