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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Pinterest and Global Health

On September 11, 2012, in Uncategorized, by Karen Grepin

I try to keep up – or even ahead – with trends in technology and social media. I own almost every product Apple has ever made, including a Mac laptop that dates before the MacBook (and that still works by the way). I’ve been on Facebook for almost 6 years, blogging for over 4 years, and on Twitter for almost the same amount of time. Although I sometimes need my 2 year old son to turn on the TV for me, I might appear technologically savvy…to some people.

So when I started hearing the buzz about another social media platform – Pinterest – I tried to figure what it was all about. I really tried, but honestly, I didn’t get it. But this summer, while on maternity leave, I gave it another try. It turns out perusing pictures of the cutest dresses and most beautiful recipes at 3 in the morning is exactly what my baby brain was looking for. So I guess I can now say that I am officially on Pinterest.

In the back of my head, though, I have been trying hard to figure out how to use this with my work as I do with Twitter and other forms of social media. Advocacy immediately jumped to mind, but despite my searches (by the way, I think the Pinterest search engines are terrible) I have not actually found much global health advocacy efforts on Pinterest yet.

Global Health Media guru Jaclyn Schiff alerted me this morning to one organization that is giving it a go. UNICEF has recently launched a ficitional profile of a young girl from Sierra Leone, Ami Musa, who has been putting things on her board of things she really wants. So while I am lusting over the new non-traditional Ramen shop in Carroll Gardens, she is lusting over clean water and a bowl of rice for dinner. A bit of badvocacy, perhaps, but perhaps this might prove to be a useful medium for many social causes to get the message out.

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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

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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