In today’s world of “Big Data”, it seems hard to believe that less than one third of all births and over two thirds of all deaths are still not recorded around the world. For all intents and purposes, births and deaths that are not recorded don’t count – and that is a big problem. In the words of Nandini Oomman and co-authors put it so eloquently in a recent commentary in the Lancet:

Functioning vital registration systems are global public goods that help with the collection, storage, retrieval, and analysis of accurate population and demographic data to support development policy and monitor health outcomes, particularly for maternal and child health. However, without strong vital registries, individuals do not have legal documentation of their own personhood, citizenship, and all associated rights; national policy makers do not have necessary data for resource allocation and planning; and the international community does not have evidence to monitor development progress against global benchmarks—eg, the Millennium Development Goals.

For far too long the excuse has been a lack of resources, but I really don’t buy this argument. Chris Murray once told me that India had a functioning vital registration system in place up until the 1920s when it was neglected and became non-functional. It seems that collecting data on people, even vitally important data, has been neglected and ignored by national and international policy makers. This study of maternal mortality declines in Sri Lanka – one of my favorite papers, ever – documented cause of deaths in the late 1940s, which was only possible due to the excellent data systems that were in place in that country nearly a century ago.

Last week a big conference on civil registration and vital statistics (CRVS) systems was held in Bangkok. It appears that momentum is building to put such systems into place around the world. But concerted efforts will be needed to be put into place to make this a reality. Donors have a big role to play. As consumers of global health data, it is not unreasonable that they should also be expected to pay for a big part of it, but not in one-off data collection systems as they do now. CGD’s proposal to build data into its cash-on-delivery scheme seems like a good way to go – but there are other good ideas out there. The power of mobile phone technology is also making it easier, more effective, and cheaper to collect data from many locations and this should be further enforced in the context of vital registration systems.

Vital registration systems are vitally important to global health. It is about time that they get the attention they deserve.

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Not only is artemisinin one of the most important drugs in our arsenal for fighting diseases globally – it is also the most interesting. A derivative of the wormwood plant, artemisinin’s anti-malarial properties were discovered thanks in part to the Vietnam war and Mao Zedong. The history of this drug reads more like an excerpt in the history of international relations rather than the history of medicine. Due to resistance that developed to quinine, artemisinin – in combination with other medicines – has become the drug of choice in most countries against malaria today.

Sweet Wormwood Plant

In particular during the early years of the scale up of big-push initiatives to address malaria, the fact that we needed to cultivate and harvest wormwood plants in order to produce artemisinin was rate limiting and an unpredictable process. Demand outstripped supply and supply could be unreliable due to factors such as the weather. In addition, the long lead time and intensity of the cultivation process continues to contribute to the relatively higher costs of ACTs today.

It seems that this is about to change. I learned that as of today, and thanks to the efforts of PATH’s OneWorld Health, Sanofi, and other partners, we now have the ability to produce synthetic versions of artemisinin which can be produced in about 3 months, can be more readily scaled, and can be produced in a much more controlled fashion. This is a remarkable milestone in the fascinating history of this drug.

I’ve heard others say that a Nobel prize should be awarded to recognize the importance of the discovery of this drug – which has done so much to improve human health. It now seems that a new chapter, and new players, might also get to share in this prize if that in fact occurs.

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It never rains but pours in global health. After a few years of lamenting that there really is no journal for a lot of good research that gets done in our discipline – whatever that is – in the next few months we will see the entry of 2 new kids on the block.

First, the Lancet, the world’s oldest medical journal, will be launching a new open-access, peer-reviewed online journal simply called The Lancet Global Health.

Second, USAID and the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs will next week launch a new journal called Global Health: Science and Practice, which will also be open-access, peer-reviewed online journal. According to its website the journal “aims to improve health practice, especially in low- and middle-income countries”. Sounds promising.

Both seem to be a big departure from the medical journal model of publishing, which is great, and emphasize things that were not well covered or hard to publish in other journals, which is also great.

On a related note, I also think that the editorial changes at Health Policy & Planning that were announced a while back have already strengthened the quality of papers coming out there, so kudos to the editors.

Now to get my papers out…

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Blowing white smoke

On March 13, 2013, in family planning, religion, by Karen Grepin

Although I was raised Protestant, through marriage I have recently become a practicing Catholic, and despite the fact that I clearly have divergent views on certain issues – contraception to name a big one – I remain loyal to my new religion. So, like many others, I was gripped to CNN the past few days waiting to see white smoke out of the Sistene Chapel. A few hours ago the white smoke blew and Jorge Mario Bergoglio of Argentina has been named the new Pope of the Catholic Church.

So what do we know about the new Pope’s view on contraception and public health? In this new piece, I learned that the new Pope believes that condoms are “permissible” to prevent the spread of infection. There has been confusion about exactly where the Church stands on the use of condoms and in which cases it is permissible or not. If the condom is used to prevent infection and inadvertently prevents conception, is that permissible?

Conincidentally, I also learned today on Humanosphere, that in the most recent round of their grant program, the Gates Foundation has recently launched a new “Grand Challenges Exploration” challenge to design the next generation condom in order to increase the use of condoms globally. Among the criteria for acceptable grant applications includes:

Application of knowledge from other fields (e.g. neurobiology, vascular biology) to new strategies for improving condom desirability.

So if by other fields they mean Theology, and by strategies they might include clarifying where the Church stands on the issue, then perhaps the new Pope might be in the running for the 100,000 prize! Welcome to the world of Global Health Pope Francis.

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Last June, then Secretary of State Hillary Clinton announced a new partnership to address the persistent burden of maternal mortality, called Saving Mothers, Giving Life. The ambitious program aimed to reduce maternal mortality by 50% in 8 districts in Zambia and Uganda in just one year. As some of you may know, I have been working with a fabulous group of researchers up at Columbia SPH this year on the external evaluation of this program. Over the past year, however, whenever I have mentioned to colleagues that I have been working on this project, I have been struck by how few people have never heard about the project.

But the program is starting to generate some interest, even outside of the maternal survival community. Over the next few months, we will also begin to learn more about the impact that this program has had on health outcomes and health systems more broadly. Janet Fleischman and some colleagues at the Center for Strategic and International Studies recently visited Zambia and put together this video which provides useful overview of the program, including some of the important challenges it has faced in trying to reach its ambitious goals.

I’ll be posting more on this soon, once our own evaluation results have been made public, but in the meantime, I encourage you to learn more about this important program. Plus, click here to watch the Saving Mothers, Giving Life Video

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The nicest houses in town

On March 4, 2013, in health human resources, Rwanada, by Karen Grepin

Butaro, Rwanda

At first I thought I was looking at a picture of a new eco-design hotel somewhere in Africa, but before I was able to pin it to my “places I want to go” board on Pinterest, I realized that that was not at all what I was looking at. No, in fact, what I was looking at was the new doctors’ residences in Butaro, Rwanda built as part of the new Partners in Health led redesign of the health delivery system in Northern Rwanda.

Attracting health workers to rural areas has always been a big challenge (not just in developing countries, but everywhere). In Sub-Saharan Africa the problem is more acute and even basic shelters are sometimes not available. The lack of housing for health workers is believed to contribute to the low density, migration, and even absenteeism of health workers.

Enter MASS, a design firm from Massachusetts who somehow got involved with the PIH project and exit these beautiful little houses that I think most people would agree constitute pretty nice digs. From an article in the Architectural Record:

The two-bedroom houses—roughly 1,300 square feet each—mimic the hospital buildings’ low-slung forms with clay-tile roofs. While they spill down a steep hill, they cluster together in plan. As Dushimimana explained by e-mail: “Courtyards and backyards are important to Rwandan houses. They are where the family and close friends gather.” The houses were constructed with reinforced-concrete frames to make them seismically sound, and with a total of 29,000 compressed stabilized earth blocks (CSEBs) made by local workers with soil from the site. The CSEB walls are covered with plaster and white paint. Some have a second layer of local volcanic stone. Inside, whitewashed walls contrast with muvura-wood roof trusses, cypress and pine furniture, and metal light fixtures—all made by local artisans. The project cost $400,000, a figure that includes the construction of a road, extensive pedestrian paths, and infrastructure to bring water and electricity to the site.

Although I am not quite sure what to make of this project, and my perpetual internal critic of aid projects is already rambling off a list of potential problems with this approach, I am going to turn all of that off for a few moments to just admire these houses. Clearly this experiment with the redesign of the health delivery system is not a standard approach nor is it something that would have ever happened had PIH not been involved, it will be interesting to see if any of it makes any difference (not that they will be able to measure it…argh, stop it critic) and if it doesn’t, well maybe it will be good for tourism. Pin.

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Beyond Index in Beijing

On January 15, 2013, in Asia, China, environmental health, by Karen Grepin

Last November, I had the great pleasure to attend the 2nd Global Symposium on Health Systems Research in Beijing, China. This was my third visit to Beijing – I had visited once in 2004 and again in 2009 to attend the International Health Economics Association biannual conference (which was in the same conference center!). Visiting this city every few years or so has allowed me to witness first hand the remarkable transformation this city has undergone over the past decade. For example, I still remember the sight of thousands of cars rolling along the side of the road in 2004 but by 2009 they had all but been replaced by cars.

The view from my hotel room in Beijing, November, 2012.

The view from my hotel room in Beijing, November, 2012.

One of the biggest changes I noticed this time around was the increase in air pollution, which I would describe as a thick toxic fog. Although visibility was terrible when I was there in 2009, this time the air literally left me feeling ill (and may have contributed to me nearly visiting the emergency room of a Chinese hospital on one of the conference days). So I was not terribly surprised, although still alarmed, when I read about reports of reports of terrible air quality being reported this week in Beijing.

Despite local Chinese reports to the contrary, air quality has been deteriorating rapidly in Beijing and across the country, as it has been in many developing countries. Two year ago, an air quality sensor on the roof of the United States Embassy in Beijing recorded an air quality reading of more than 500 on a a scale of 500 on the EPA standards. It was “Beyond Index” or simply “Crazy Bad”. This reading was 20 times beyond what the World Health Organization considers safe to breath! New York City, where I currently live, will record figures under 20. To make things worse, last weekend a reading of 758 was measured. This is not only beyond index but beyond imaginable.

How much impact can this pollution have on health? I am not expert on this stuff but based on a few papers I have seen on this, it could be a lot. A colleague, Avraham Ebenstein from Hebrew University in Israel, has a fabulous study that has looked exactly at this question in China in a still unpublished paper with a series of co-authors. Using a policy that affects one part of the country and not another, they find that increases in air pollution of about 100 μg/m3 is associated with about 3 years of lower life expectancy. In the areas that they study they find increases in air pollution of about 2 times this across their study area and the levels recorded in Beijing would be even higher suggesting very large and very real decreases in life expectancy due to air pollution. Increases in child mortality from air pollution have also been documented by economists in Mexico City, India, and even in New Jersey. An emerging finding from many of these studies is that the impact on health of very high levels of exposure might be even worse than what we would predict based on what we know about exposure in developed countries today.

And it is not just the water that appears to be causing significant poor health. Avi also has another excellent paper that looks at the impact of water pollution in digestive cancers in China. He documents a 10% increase in digestive cancers due to water pollution due to industrialization.

Is this simply the price to pay for development? Is there really anything that developing countries can do to prevent this? Well, for starters, there needs to be admission that there is in a problem. Fortunately, the international attention to the issue may have actually led to officials admitting that there is an air pollution crises in Beijing – students have even been ordered to avoid outdoor activities. Plus, even small changes can help to improve health: the India paper I cite above finds that even there stricter environmental regulations can improve health outcomes, suggesting that public policies can make a difference.

What is clear that the health impact can be enormous and if one believes that real development involves more than just increases in gross domestic product per capita, than progress towards true development will be hampered until these types of issues are properly addressed.

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In this month’s Health Policy & Planning, Tamara Hafner and Jeremy Shiffman have a new article that I think should be on everyone’s reading list (and since it is open access, it can be). Their abstract:

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

Basically their research finds that health system strengthening (HSS) became sexy due the the fact that there was a big push for disease-specific programs and addressing the MDGs and health systems were seen as a big barrier to achieving goals on other fronts. But since no one has ever really figured out what HSS is, nor how one actually strengthens a health system, it risks falling off the global health radar, especially as we take our foot off the pedal on other global health fronts. To that I would add (as suggested to me by Rob Yates on Twitter) it has been pushed out by the embrace of another related, but sometimes as nebulous, concept – Universal Health Coverage.

Don’t get me wrong, this might not be a bad thing, and current efforts might be more realistic than pushing an agenda that involves transforming so many aspects of a health system rather than focusing on what might be a more manageable piece of the puzzle. But in this time with so much up in the air in global health, it is worth asking if it is worth bringing this issue back as a central effort, in particular in the context of post-MDG discussions. Is this an idea worth saving?

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It is old news by now that while trying to capture Osama Bin Laden in Pakistan, the CIA had a Pakistan doctor infiltrate the Bin Laden compound by launching a fake vaccination campaign. What might have seem like an innocent guise has turned deadly: late last year innocent polio vaccinators in Pakistan have been attacked and a number of them have been killed. The knock-on health effect might be even greater: polio eradication efforts have been suspended in Pakistan and organizations like Save the Children have had to pull out their foreign nationals.

In what I thought was a very well written and well informed letter to the Deans of a number of American Schools of Public Health have written to President Obama condemning these actions and asking him to take action to help restore these vital public health efforts. I wanted to share the text of this letter, so it is copied below.

Can trust ever be restored in public health in Pakistan? Who knows. The Deans suggest that an executive order might be a first step in helping to restore confidence in international public health efforts. Charles Kenny at the Center for Global Development has provided some concrete suggestions how such an order can be done here.

Addendum: Brett Keller sent me a link to this petition, where you too can show your support in banning the use of public health campaigns for intelligence missions.

January 6, 2013

Dear President Obama,

In the first years of the Peace Corps, its director, Sargent Shriver, discovered that the Central Intelligence Agency (CIA) was infiltrating his efforts and programs for covert purposes. Mr. Shriver forcefully expressed the unacceptability of this to the President. His action, and the repeated vigilance and actions of future directors, has preserved the Peace Corps as a vehicle of service for our country’s most idealistic citizens. It also protects our Peace Corps volunteers from unwarranted suspicion, and provides opportunities for the Peace Corps to operate in areas of great need that otherwise would be closed off to them.

In September Save the Children was forced by the Government of Pakistan (GoP) to withdraw all foreign national staff. This action was apparently the result of CIA having used the cover of a fictional vaccination campaign to gather information about the whereabouts of Osama Bin
Laden. In fact, Save the Children never employed the Pakistani physician serving the CIA, yet in the eyes of the GoP he was associated with the organization. This past month, eight or more United Nations health workers who were vaccinating Pakistani children against polio were gunned down in unforgivable acts of terrorism. While political and security agendas may by necessity induce collateral damage, we as an open society set boundaries on these damages, and we believe this sham vaccination campaign exceeded those boundaries.

As an example of the gravity of the situation, today we are on the verge of completely eradicating polio. With your leadership, the U.S. is the largest bilateral donor to the Global Polio Eradication Initiative and has provided strong direction and technical assistance as well. Polio particularly threatens young children in the most disadvantaged communities and today has been isolated to just three countries: Afghanistan, Nigeria and Pakistan. This is only one example, and illustrates why, as a general principle, public health programs should not be used as cover for covert operations.

Independent of the Geneva Conventions of 1949, contaminating humanitarian and public health programs with covert activities threatens the present participants and future potential of much of what we undertake internationally to improve health and provide humanitarian assistance. As public health academic leaders, we hereby urge you to assure the public that this type of practice will not be repeated.

International public health work builds peace and is one of the most constructive means by which our past, present, and future public health students can pursue a life of fulfillment and service. Please do not allow that outlet of common good to be closed to them because of
political and/or security interests that ignore the type of unintended negative public health impacts we are witnessing in Pakistan.

Pierre M. Buekens, M.D., M.P.H., Ph.D.
Dean, Tulane University School of Public Health and Tropical Medicine*
John R. Finnegan Jr., Ph.D.
Professor and Dean, University of Minnesota School of Public Health* Chair of the Board, Association of Schools of Public Health*
Julio Frenk, M.D., M.P.H., Ph.D.
Dean and T&G Angelopoulos Professor of Public Health and International Development Harvard School of Public Health*
Linda P. Fried, M.D., M.P.H.
Dean, Mailman School of Public Health, Columbia University*
Howard Frumkin, M.D., Dr.P.H.
Dean, School of Public Health, University of Washington*
Lynn R. Goldman, M.D., M.P.H.
Professor and Dean, School of Public Health and Health Services, George Washington University*
Jody Heymann, M.D., M.P.P., Ph.D.
Dean, UCLA Fielding School of Public Health*
Michael J. Klag, M.D., M.P.H.
Dean, Johns Hopkins Bloomberg School of Public Health*
Martin Philbert, Ph.D.
Dean, School of Public Health, University of Michigan*
Barbara K. Rimer, Dr.P.H.
Dean and Alumni Distinguished Professor UNC Gillings School of Global Public Health*
Stephen M. Shortell, Ph.D.
Dean, School of Public Health, University of California Berkeley*

*Institutional affiliation is provided for identification only.

James W. Curran, M.D., M.P.H.
Dean, Rollins School of Public Health, Emory University*
Regina M. Benjamin, United States Surgeon General
Hillary Rodham Clinton, Secretary of State
Thomas Frieden, Director, Centers for Disease Control and Prevention Howard Koh, Assistant Secretary of Health
Michael J. Morell, Acting Director of the Central Intelligence Agency Janet Napolitano, Secretary of Homeland Security
Kathleen Sibelius, Secretary of Health and Human Services

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