Also In This Issue

By: Tina Flores

Beth Waters was a communications professional committed to advancing the cause of vaccine development and delivery. Among her many achievements, she helped to create a model for improving access to HIV treatment that has been applied to scale up treatment for other diseases.

A reporter in the early years of her career, Beth was a senior managing director of Ogilvy Public Relations before co-founding Cooney/Waters Group, a health care public relations and public affairs company in New York City. Beth was indefatigable in her work on vaccine advocacy, traveling the world to lend her intensity and expertise to her clients, governmental committees and non-governmental organizations; and promoting immunization against polio, HIV/ AIDS, avian influenza and meningococcal disease. Beth was a wise counselor, a creative problem-solver, and a relentless optimist. Beth passed away in 2006.

She was a founding member of the advisory board of the Vaccine Education Center of the Children's Hospital of Philadelphia and a member of the HIV Vaccine Communications Steering Group of the National Institute of Allergy and Infectious Disease.

Beth Waters often said that her first job in immunization advocacy was as a child of nine. She was a "polio pioneer" – one of the children who participated in the U.S. clinical trials of the vaccine that would mark the beginning of the end of the scourge of the disease that crippled or killed children and young adults throughout the 20th century. An unrelenting crusader for the prevention of infectious diseases, her involvement with global polio eradication continued right through the last decade of her life. Indeed, much of her 30 years in communications and public affairs centered on advocacy for vaccines to protect against diseases in both industrialized countries and the developing world.

Every aspect of immunization intrigued her, from the intricacies of production and supply to the involvement of communities in clinical trials of candidate vaccines for mass immunization programs. Indefatigable in her efforts, she traveled the world to lend her intensity and expertise in international scientific forums and at the grassroots level, working with her client Sanofi Pasteur, governmental committees and non-governmental organizations.

"Beth's work exemplifies the power of communications in bringing together people and groups to advance the prevention and treatment of infectious diseases, most notably HIV/AIDS," said Wayne Pisano, former chairman and CEO of Sanofi Pasteur. "It was impossible to slow her down. She fought for disease prevention with an energy and enthusiasm that was often as contagious as any of the microbes she battled."

This issue of GLOBAL HEALTH is dedicated to Beth Waters, with corporate sponsorship provided by Sanofi Pasteur.

Post a Comment( 1 )

On the Brink of a Watershed Moment for HIV Vaccine R&D

By: Margaret McGlynn and David Cook

In late 2009, researchers from Thailand’s Ministry of Health and the United States Military HIV Research Program caused quite a stir when they announced that a vaccine regimen they evaluated in a large clinical trial in Thailand was modestly effective in preventing HIV. It was the first experimental demonstration that a vaccine can protect people from HIV, but it wasn’t at all clear why the regimen tested in that trial, known as RV144, had worked. So a global team of researchers was quickly convened to find the answer.

Their efforts were not in vain. In September, the team revealed at the international AIDS Vaccine 2011 Conference in Bangkok what it had learned from its analysis of the blood samples collected in the RV144 trial. The conclusion of their analysis capped another year of extraordinary productivity in a number of areas of AIDS vaccine research. From antibody discovery to the evaluation of new methods to deliver HIV vaccine candidates, researchers have lately made remarkable headway against some of the toughest scientific challenges the virus has presented – generating unprecedented momentum and optimism in the field.

Vaccinologists know very little about how exactly an AIDS vaccine should engage the immune system to prevent infection by HIV. Of course, a truly preventive HIV vaccine will probably have to activate both a broadly effective antibody response, which stops viruses from slipping into their target cells, and the cell-mediated response, which destroys cells that have already been commandeered by the virus. But the devil, as always, is in the details – what are the particular identities and roles of the scores of molecular and cellular supporting actors essential to this response? Vaccinologists call those details the correlates of protection, and they remain in large measure a mystery even for existing vaccines. The slightest hint about what they might be for HIV would be a big help to AIDS vaccine designers.

That the global RV144 research team – led by Barton Haynes, director of the Duke Human Vaccine Institute at Duke University School of Medicine – found anything at all of value in their correlates analysis came as a pleasant surprise. The correlates analysis was hindered by the fact that it was a retrospective, case-controlled analysis and not a prospective, randomized study. Further, due to the limited number of appropriate samples available to researchers and the small number of people who contracted HIV, there was a possibility that the analysis would lack statistical power. The study design in RV144, for want of funds, had not been designed to reveal such information. Still, Haynes and his colleagues discovered that two distinct types of antibodies that bind HIV in roughly the same place corresponded with different outcomes of vaccination. Specifically, those who produced an antibody known as Immunoglobulin G (IgG) at the peak of their immune response to vaccination were 43 percent less likely to contract HIV than those vaccinated volunteers who did not produce the antibody. Conversely, those who had another type of antibody in their blood, known as IgA, that similarly targeted HIV, had a higher risk of subsequently becoming HIV-positive. This risk was roughly equal to that of unvaccinated RV144 volunteers – which is to say that vaccination did not increase the risk of HIV infection but did decrease the protection afforded by the vaccine. It isn’t clear why this was the case, but the phenomenon isn’t entirely strange. Haynes and his team point out that the presence of IgA has been known to similarly compromise the immune response to tumors.

To stress the limitations of its findings, the team referred to their markers as “correlates of risk,” rather than protection. Still, these are the first such markers to have been found in an HIV vaccine trial, and their discovery has buttressed the credibility of the trial result. Researchers are planning studies to test various hypotheses to explain the phenomenon. The discovery also will influence the design of future vaccine candidates and the clinical trials in which those candidates are evaluated. Trials slated to be conducted in Thailand and South Africa are already being planned in the hope of improving upon the results of RV144.

There have also been major successes on the vaccine design front over the past year. HIV researchers have made important breakthroughs in approaches to designing both immunogens – the active agents of vaccines – as well as vectors, the genetic vehicles in which HIV immunogens are delivered. One such approach seeks to devise vectors that are safe, yet capable of replicating like a naturally occurring virus after they are introduced into the body. All vectors currently used to make HIV vaccine candidates are, for safety reasons, engineered to be incapable of replication. The hope is that replicating vectors, by more closely mimicking a natural infection, will elicit more sophisticated and enduring immune responses to HIV immunogens.

That notion found support in the results of a study done on an animal model of HIV that was published in the journal Nature this summer. In that study, led by Louis Picker, associate director of the Oregon Health & Science University's Vaccine and Gene Therapy Institute, rhesus macaques were given an experimental vaccine based on a novel replicating viral vector bearing immunogens derived from simian immunodeficiency virus (SIV), the monkey analogue of HIV. When the macaques were later exposed to SIV, all of them went on to develop infection. But, one year later, while the unvaccinated ones had developed simian AIDS, more than half of the vaccinated primates had suppressed SIV so effectively that the virus could not be detected in their bodies. In fact, they showed no sign of ever having been infected. Picker and his colleagues are now studying ways to adapt this vector to human use.

There has been a flurry of activity in immunogen design as well. Researchers at and affiliated with IAVI and The Scripps Research Institute, as well as a separate team working at the Vaccine Research Center of the U.S. National Institutes of Health (VRC), have made notable progress in the study of antibodies that target a broad spectrum of circulating HIV variants. The hope is that these antibodies will yield clues to the design of immunogens that elicit similarly broadly neutralizing antibodies.

All of the antibodies isolated by the VRC-led team target the part of the virus that makes direct contact with its docking station on HIV’s target cell, known as the CD4-binding site. The VRC team recently published an important paper in the journal Science that parsed the genetic origins of these kinds of antibodies. Their analysis reveals that the CD4-binding broadly neutralizing antibodies, despite having been isolated from different and unrelated people, share a very similar genetic lineage. All of them also go through an exceptionally extended process of change and refinement at the genetic level as they mature into potently neutralizing antibodies. This information could someday be applied to vaccine design, allowing researchers to create immunogens that sequentially direct the generation of increasingly potent broadly neutralizing antibodies. More immediately, however, it could help vaccine developers devise methods to quickly assess whether candidate immunogens in trials are inducing the CD4-binding broadly neutralizing antibodies likely to protect people from HIV.

But the CD4-binding site isn’t the only viable target for antibodies. Indeed, researchers at the IAVI Neutralizing Antibody Center at The Scripps Research Institute, which serves as the headquarters of the Neutralizing Antibody Consortium (NAC), published in Science earlier this year a report on the isolation and characterization of 17 novel broadly neutralizing antibodies that target a variety of different sites on HIV. This brings to 20 the number isolated through a hunt for such antibodies that was launched by IAVI in 2006 in partnership with research centers in a dozen countries on four continents.

Some of the broadly neutralizing antibodies are 10 to 100 times as potent as previously isolated ones. This is of interest because, in theory, a vaccine would only need to induce relatively low levels of a similarly potent antibody to confer protection from HIV. This matters because there is no guarantee that people will produce high levels of antibody in response to an AIDS vaccine candidate. Studies of the neutralizing breadth and potency of the newly isolated antibodies also revealed information of potential value to vaccine design. Based on their analysis, the NAC team suggested that a vaccine devised to elicit broadly neutralizing antibodies will probably need to elicit multiple combinations of such antibodies to provide comprehensive protection from HIV.

That insight might be put to the test within a few years: immunogen design based on the close study of broadly neutralizing antibodies has recently begun to gather pace. Researchers at a variety of laboratories, including those of the VRC and the NAC, have made significant headway in capturing, at an atomic scale, the molecular structures targeted by some of the major broadly neutralizing antibodies. They have even made significant progress in their attempts to recreate those structures for evaluation as candidate immunogens.

The one thing that could stall this renaissance in AIDS vaccine design and development is a shortage of resources. Global funding for the effort has so far held relatively steady – $859 million was invested last year, a $9 million decline from 2009, according to the HIV Vaccines and Microbicides Resource Tracking Working Group, in which IAVI participates. But a sudden decline in funding remains a looming possibility due to the economic troubles that have beset traditional donor nations.

That would be a pity. AIDS vaccine research is advancing at a rate that would have been unimaginable just a few years ago. Success in this endeavor likely will stretch far beyond HIV, as the strategies, tools and technologies that are being developed to solve the most stubborn problems of HIV vaccine design are likely to find useful application in the prevention and treatment of a variety of human diseases. But most of all, the successful creation of a broadly preventive HIV vaccine would have a major impact on curbing the HIV pandemic, which has so far taken approximately 30 million lives and devastated communities and economies across the globe.

And that’s a goal worth supporting – through thick as well as thin.

Margaret McGlynn is president and CEO, and David Cook is COO of the International AIDS Vaccine Initiative.

Post a Comment( 1 )

Vaccination Week in the Americas Goes Global

By: Mirta Roses-Periago, MD

Hundreds of children from the border area of Bolivia and Peru receive vaccines against infectious diseases during the launch of the 9th Vaccination Week in the Americas.

On April 2012, a decade of trailblazing efforts by all the countries and territories of the Americas will make a public health dream come true as the first World Immunization Week is launched. Such a towering endeavor will provide a crowning significance to the celebration of the 10th Vaccination Week in the Americas (VWA).

Along this journey, this initiative has resulted in more than 365 million individuals vaccinated. In the beginning, what is today the largest multinational health effort in the Western Hemisphere was far more humble, but it turned a public health challenge into a great opportunity to achieve health for all. Vaccination became the most equitable collective action to make the right to health a reality.

Historically, the countries and territories of the Americas have been champions in immunizing their populations and promoting a culture of prevention. Working together, they have been on the global forefront in the eradication and elimination of vaccine-preventable diseases such as smallpox, polio, and endemic measles and rubella. Other vaccine-preventable diseases such as diphtheria, tetanus, pertussis, meningitis, as well as hepatitis A and B, have also decreased significantly.

Direct reductions in morbidity and mortality provided by strong vaccination programs have resulted in a reduced burden on families and health care systems alike. Moreover, achievements in vaccination have spilled over by strengthening health systems, rewarding health workers and volunteers, and freeing individuals from the mental and physical sequelae of vaccine-preventable diseases; thus contributing to more economically productive and inclusive societies.

Evolution of the Vaccination Week

Dr. Mirta Roses gives oral polio vaccine to a child from the Bolivia-Peru border area. The overall success of vaccination programs hides the challenges of the tremendous inequities characteristic of the Americas. Because of this, gaps in vaccination coverage at local clusters have persisted, piercing the public health protection net and placing many communities at risk.

It was this reality that sparked the idea of vaccination week. In 2001 and into 2002, the last regional outbreak of endemic measles occurred in Venezuela and spread into Colombia, resulting in a total of 2,500 cases. It also moved the Ministers of Health of the Andean Region to sign the Sucre Agreement on April 23, 2002, calling for a simultaneous Andean vaccination week in the following year.

The Pan American Health Organization (PAHO) raised this flag and over the following months carried out advocacy efforts to promote and expand the initiative to other countries in forums across the Americas. By the time the first Vaccination Week in the Americas was launched in April 2003, 19 countries had come on board. Under the slogan “Vaccination: an Act of Love,” national and local authorities with enthusiastic social participation and health volunteer engagement, rallied around the new imitative. Gathering along border areas, health care workers fanned out across the region on foot, by river and by air to reach the un-reached. Populations with non-existent or incomplete vaccination schedules living in urban fringes, rural and border areas, and in indigenous and afrodescendent communities were among the most benefited. More than 16 million individuals of all ages were vaccinated during this pioneering effort. By September 2003, Vaccination Week in the Americas was endorsed by all Ministers of Health of the Americas at PAHO’s Directing Council, with a resolution that mandated future celebrations of the initiative.

From then on, vaccine week has flourished throughout the region, with ever-expanding goals and outreach. It covers all the countries and territories in the Western Hemisphere and inspired sister initiatives in other regions of the World Health Organization. Europe (2005), the Eastern Mediterranean (2010), Africa (2011), and the Western Pacific (2011) have implemented their own vaccination weeks, designed to meet the distinctive needs of each region. South-East Asia has committed to come forward in 2012, completing the loop for the launching of the first World Immunization Week.

Key Elements to Success

An initiative born from the response to an outbreak in two countries soon covered more than 40 countries and territories in the Americas. In just a decade, it evolved to become a global effort. There are crucial elements learned to promote and implement other overarching, high achieving public health endeavors.

The vaccination weeks flourished thanks, in part, to the political visibility and support granted by Presidents, First Ladies, Ministers of Health and community leaders, including mayors and religious figures, as well as leaders of international organizations, NGOs and social service groups. The participation of internationally renowned artists and sport celebrities in events, and the intensive media coverage spotlighting the work of national immunization programs, raised public awareness and mobilized private and public corporations.

The country ownership at the core of the initiative’s design – including its flexibility to adapt to each nation’s circumstances – was another key aspect to success. Each year, countries and territories decide the specific focus and operations of vaccination weeks based on their current national health objectives. This sometimes has taken the form of large scale vaccination campaigns; others have focused on communication initiatives and health promotion efforts; and others have used Vaccination Week in the Americas as a platform for new vaccine introduction or for the integration of other preventive interventions with vaccination. While country measures differ, each April everyone is ready to party and celebrate vaccination facilitated by international communication and cooperation across borders, promoting equity and solidarity in the spirit of true Pan-Americanism.

A mother proudly displays her daughter’s vaccination card after visiting a health post in the Senkata neighborhood of El Alto, Bolivia.

Close cooperation and combined efforts between countries and international and local partners have also been a distinctive characteristic of Vaccination Week in the Americas. Countries foot the bulk of funding their activities, but the regional and national activities have also counted on the monetary and technical support of various key partners, including the U.S. Centers for Disease Control and Prevention (CDC), the Canadian International Development Agency (CIDA), the Spanish Agency for International Cooperation (AECID), multiple NGOs, service groups, private companies and local authorities, among many others.

The PAHO Revolving Fund for Vaccine Procurement has been a key instrument as well This fund – the only such mechanism in the world – allows 39 countries and territories in Latin America and the Caribbean to benefit from significant economies of scale and a timely supply of high-quality vaccines at the lowest prices. The Revolving Fund provides net savings of at least 11 percent on the cost of vaccines and syringes, serves as a catalyst for price negotiations and leads to significantly lower prices for the introduction of new vaccines. The Fund has also reduced uncertainty, allowing vaccine developers and manufacturers an effective programming of investments, by providing predictable demand and payments, a simplified mechanism of one-stop shopping, and a reduction in unnecessary losses.

The global community continues to confront many challenges in the control of vaccine-preventable diseases, among them sustaining the public trust and confidence in these miracle tools, as well as the persistence of polio transmission and the resurgence and importation of measles into free areas. The increasing number of new vaccines that are going to become available in the near future is a reminder of the need to ensure sustainable financing, strong public health systems and public opinion support. The millions of deaths averted by the appropriate use of vaccines are a powerful call to celebrate the upcoming World Immunization Week as an ACT OF LOVE.

Vaccination: an Act of Love

For more than 100 years, the Pan American Health Organization has walked the streets and sidewalks of the Americas. Together with the people of the region, PAHO has told stories of transformed lives, achievements, challenges, and lessons learned. PAHO gives recognition to a group of men and women who joined in this journey and who, with commitment and dedication, captured the images presented here through their camera lenses.

To the late Julio Vizcarra, to Carlos Gaggero, Armando Waak, David Spitz and Harold Ruiz – and to all those who anonymously have contributed to this legacy – we thank you for capturing our stories, and for believing that health is not a privilege, but the innate right of every human being.

Mirta Roses-Periago, MD is director of the Pan American Health Organization.

In April 2012, all regions of the World Health Organization will celebrate vaccine week.

Post a Comment( 1 )

Vaccines: A Top Priority for Global Health

By: Olivier Charmeil

Vaccines can easily become the “forgotten hero” for the enormous impact they have had on global health. When vaccines are successful, they prevent infectious diseases, many of which become forgotten over time. Mass vaccination programs have significantly improved global health and decreased mortality from vaccine-preventable diseases, such as smallpox, polio, pertussis and diphtheria. In high-income countries, lower respiratory infections are the only infectious diseases among the 10 leading causes of death. However, vaccine-preventable diseases remain prevalent and responsible for excessive mortality in poorer nations, particularly in children.[1] According to the World Health Organization, as many as 2.5 million children may die of vaccine-preventable diseases in a single year.[2]

Since the inception of the WHO Expanded Program on Immunization (EPI) in 1974, much progress has been made in vaccinating children around the globe against infectious diseases. The Global Alliance for Vaccines and Immunization (GAVI) recognized vaccination as a collective activity and increased the global immunization effort. The Bill & Melinda Gates Foundation’s 2010 commitment to infuse $10 billion into immunizations during the next 10 years – Decade of Vaccines – has the potential to decrease morbidity and mortality from vaccine-preventable diseases to historical lows.

Formal Analyses of the Value of Vaccines

Estimates of cost-effectiveness and cost-benefits vary depending on the specific vaccine, the locale and the delivery strategy. In nearly every analysis, vaccines emerge as a cost-effective strategy in enhancing global health, although the payback is not always immediate. Over time vaccines prevent illness and disability, save lives, free funds that would be spent on treatment of vaccine-preventable diseases, and lead to a healthier, more productive society.

A recent study calculated the economic benefits of increasing childhood vaccination rates in 72 countries to 90 percent. The specific vaccines were those against pertussis, measles, rotavirus, malaria (assuming a vaccine is available by 2015), pneumococcal and Haemophilus influenzae type b (Hib) pneumonia, and meningitis. Over the next ten years the expanded vaccination effort would prevent 426 million cases of illness, save 6.4 million lives, and avoid $6.2 billion in treatment costs. Gains from increased productivity would total $145 billion.[3]

The cost of vaccines, especially the older ones, is a mere fraction of the cost of treating the illnesses they prevent. Estimated costs per fully immunized child (that is, a child who has received the six original EPI vaccines to protect against diphtheria, pertussis, tetanus, measles, polio and tuberculosis), range between $3 and $31, depending on the location and the vaccine strategy.[4] Of course, some newer vaccines, based on technologies unavailable 50 years ago, cannot be compared with older vaccines. The takeaway message here is that all vaccines avert treatment costs and save lives.[5] For example, the vaccine to protect against Hib costs about seven times as much as the six original EPI vaccines combined. But it is so effective in preventing serious, often fatal meningitis and pneumonia that 89 countries had offered it in their infant immunization programs by 2004.[6]

Far-Reaching Societal Benefits

Individuals, families and their communities reap additional advantages that cannot be directly converted into dollars or lives saved. These gains are particularly relevant for low-income countries, where the burden of vaccine-preventable diseases is greatest.

A vaccination encounter may represent a rare opportunity for some people to come into contact with health care providers. In the course of the immunization process, a treatable medical condition may be detected before it has caused irreparable damage; health education may be introduced and promoted.

Challenges to the Expansion of Vaccine Efforts

Countries that have achieved great gains in vaccination still have unvaccinated young residents. Many of these children live in remote areas, and reaching them will take a concerted effort. Not only is it more expensive to deliver vaccines to isolated areas, but it may require new strategies or vaccines. To illustrate, a vaccine that requires continual refrigeration poses a problem in places with unstable electricity. Replacing such a vaccine with a heat-stable alternative could facilitate access to vaccines and increase coverage rates.

Costs are a major challenge to expanded vaccine efforts. Factors to consider include delivery strategies, vaccine prices and the scale of a vaccination program. One analysis found that the most expensive component is labor.[7] Therefore, strategies that minimize labor, such as administration of combination vaccines, may control costs.

Public perception is another challenge to broader vaccine coverage. After some countries became complacent and ended their campaigns against polio, the disease began to resurface. Because of – often unfounded – concerns about vaccine safety, some parents refuse to give their children recommended vaccines.

A Few Troublesome Diseases

A brief look at three diseases – pneumonia, diarrhea caused by rotavirus, and dengue – illustrates the importance of expanded vaccination efforts. The first two diseases are the biggest killers of young children throughout the world, whereas dengue represents a disease that has crossed into new territory.

Pneumonia. About 1.6 million children younger than 5-years old worldwide every year from pneumonia, making it a greater killer than AIDS, malaria, and tuberculosis combined. Among children in this age group who die, pneumonia is the cause in 18 percent of cases.[8]

Vaccines are available to protect against the two most common bacterial causes of pneumonia, Streptococcus pneumoniae and Hib. These vaccines also protect against meningitis and other serious diseases caused by these infectious agents. Yet only 44 countries were using pneumococcal vaccines by the end of 2009.[9]

If more children around the world received vaccinations to prevent pneumonia in the next 10 years, the results would be phenomenal. One estimation is that more than 56 million cases and 2,661,000 deaths from pneumonia could be prevented. This would free up nearly $68,000 million to spend for other purposes.[10] According to another calculation, the pneumococcal vaccine would still constitute a cost-effective intervention even at a cost of more than $26 a dose.[11]

Most industrialized countries routinely immunize children with the Hib vaccine, and as a result invasive disease has practically disappeared in many nations. But half of all infants live in countries that do not offer the vaccine in their routine immunization schedule, putting these children at risk for Hib pneumonia.[12]

Rotavirus diarrhea. Second only to pneumonia, diarrhea is responsible for 15 percent of deaths of children younger than 5.[13] Only 23 countries were using vaccines against rotavirus, a major cause of diarrheal disease in infants and young children, by the end of 2009.[14]

Persistence of rotavirus diarrhea in areas where water, sanitation, and personal hygiene have improved in recent years is proof that widespread vaccination also is essential to limit this disease. Because of the serious side effects of an early rotavirus vaccine, lingering, misplaced concern about safety may contribute to the minimal use of current, highly effective vaccines.

With an expanded global vaccination program over the next decade, 316,654,000 cases of rotavirus infection could be averted. A total of 1,525,000 deaths could be avoided if nearly every infant living in risk areas were vaccinated.[15]

Dengue. Once limited in scope to tropical urban areas, the mosquito-borne infection dengue has spread dramatically in recent decades: two-fifths of the world population is now at risk. While dengue fever is still primarily a tropical disease that occurs in cycles in south Asia and Central and South America, the dengue virus has dramatically increased its range over the past three decades. In the 1950s, just nine countries reported outbreaks of dengue to the WHO. Today, more than 100 countries in Africa, the Americas, the Eastern Mediterranean and the Western Pacific are considered endemic regions, with Southeast Asia and the Western Pacific being most seriously affected.

Approximately 2.5 billion people are at risk for dengue infection in tropical and subtropical regions. The disease infects an estimated 50-100 million people annually, many of them children.[16] Dengue is characterized by high fever, severe muscle and joint pain, and rash. A serious form of the infection is called dengue hemorrhagic fever, which can be fatal in up to 10 to 15 percent of cases.[17]

There is no effective treatment for dengue. Control has been the focus for many years, through environmental measures, including removal of standing water where mosquitoes breed and insecticide spraying. These measures, however, have failed to curtail the spread of dengue, pointing to the need for better preventive tactics.

Today, several vaccines are in various stages of advanced development, and preliminary data are encouraging. A balanced immune response was generated against all four subtypes of the dengue virus in a recent study among American adults using Sanofi Pasteur’s candidate vaccine. A large-scale clinical study using the Sanofi Pasteur vaccine candidate to assess efficacy in children has begun in Thailand, while other Phase 3 trials have also been initiated. If the Sanofi Pasteur trials are successful, dengue vaccine could be available as early as 2015-2016, providing a much needed public health intervention for this growing, worldwide threat.

Conclusions

Vaccines are unquestionably a cost-effective preventive intervention, although the benefits may not be immediately apparent. Over time, vaccines save lives, avert long-term disabilities, and make treatment for associated illness unnecessary.

Expansion of programs to reach more children with more vaccines will require substantial resources for vaccine development and delivery. Consequently, it is imperative for the global community to deploy a consistent and coordinated approach for developing appropriate vaccination strategies for specific countries or regions. Key considerations include introduction of new vaccines, infrastructure for disease monitoring and surveillance supported by lab-based confirmation, and immunization strategies to cultivate innovative financing mechanisms for vaccine purchase and sustainable immunization programs.

We are on the verge of realizing a new era in vaccine innovation with enormous global public health potential. Our success hinges on the global community’s ability to spearhead new ways to address these issues and ensure a stronger appreciation for the vital role vaccines play in keeping deadly infectious diseases at bay.

REFERENCES

[1] WHO. The top 10 causes of death. Available at: http://www.who.int/mediacentre/factsheets/fs310/en/index.html. Accessed July 15, 2011.

[2] WHO. Challenges in global immunization and the Global Immunization Vision and Strategy 2006-2015. Weekly Epidemiol Rec 2006;81(19):190-195.

[3] Stack ML, Ozawa S, Bishai DM, Mirelman A, Tam Y, Niessen L, et al. Estimated economic benefits during the “decade of vaccines” include treatment savings, gains in labor productivity. Health Affairs 2011;30(6):1021-1028.

[4] Brenzel L, Wolfson LJ, Fox-Rushby J, Miller M, Halsey NA. Vaccine-preventable diseases. In Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006:389-411.

[5] Brenzel L, Wolfson LJ, Fox-Rushby J, Miller M, Halsey NA. Vaccine-preventable diseases. In Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006:389-411.

[6] WHO. Haemophilus influenza type B (HiB). Available at http://www.who.int/mediacentre/factsheets/fs294/en/#.

[7] Brenzel L, Wolfson LJ, Fox-Rushby J, Miller M, Halsey NA. Vaccine-preventable diseases. In Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006: 389-411.

[8] WHO. Pneumonia. Available at: http://www.who.int.mediacentre/factsheets/fs331/en/index.html. Accessed July 25, 2011.

[9] WHO. Immunization highlights: 2010. Available at: http://www.who.int/immunization/newsroom/highlights/2010/en/index1.html. Accessed July 26, 2011.

[10] Stack ML, Ozawa S, Bishai DM, Mirelman A, Tam Y, Niessen L, et al. Estimated economic benefits during the “decade of vaccines” include treatment savings, gains in labor productivity. Health Affairs 2011;30(6):1021-1028.

[11] Vespa G, Constenla DO, Pepe C, Safadi MA, Berezin E, Cassio de Moraes J, et al. Estimating the cost-effectiveness of pneumococcal conjugate vaccination in Brazil. Pan Am J Public Health 2009;26(6):518-528.

[12] WHO. Invasive Haemophilus influenzae type B (Hib) disease prevention. Available at: http://www.who.int/nuvi/hib/en/index.html. Accessed July 26, 2011.

[13] WHO. World Health Statistics 2011. Available at: http://www.who.int/whosis/whostat/2011/en/index.html. Accessed July 15, 2011.

[14] WHO. Immunization highlights: 2010. Available at: http://www.who.int/immunization/newsroom/highlights/2010/en/index1.html. Accessed July 26, 2011.

[15] Stack ML, Ozawa S, Bishai DM, Mirelman A, Tam Y, Niessen L, et al. Estimated economic benefits during the “decade of vaccines” include treatment savings, gains in labor productivity. Health Affairs 2011;30(6):1021-1028.

[16] WHO. Dengue and dengue haemorrhagic fever. Available at: http://www.who.int/mediacentre/factsheets/fs117/en/index.html. Accessed July 27, 2011.

[17] Beatty M, Letson GW, Margolis HS. Estimating the global burden of dengue. Am J Trop Med Hygiene 2009;81(5):231.

Olivier Charmeil is president and CEO of Sanofi Pasteur.

Post a Comment

Fighting Syphilis and HIV in Women and Children: Lessons from Uganda and Zambia

By: Edward Bitarakwate, Susan Strasser, Tabitha Sripipatana and Jen Pollakusky

Syphilis is often called a silent killer, because its symptoms frequently go undetected. But combined with HIV, it can be even deadlier – especially for women and children.

Approximately 12 million new cases of syphilis occur each year worldwide[1], and nearly 10 percent of all HIV-positive people are also infected with syphilis. In sub-Saharan Africa, co-infection of syphilis[2] and HIV is a serious public health challenge, with women and young children among the most vulnerable groups.

Prevalence rates of syphilis among pregnant women can be as high as 17 percent.[3, 4, 5] With no treatment, women are in danger of passing syphilis on to their infants. If mothers are also infected with HIV, a syphilis infection actually increases the risk of HIV transmission from mother-to-child.[6] Pregnant women living with both HIV and syphilis are twice as likely to pass HIV on to their babies compared to a woman infected with HIV alone.[7]

Like HIV, syphilis is a major cause of morbidity and mortality among women and children in resource-limited settings. Untreated syphilis during pregnancy is associated with a number of negative outcomes, such as stillbirth, premature delivery, low birth weight and infant death.

Syphilis, however, is curable with an affordable and accessible antibiotic medicine – penicillin. And both HIV and syphilis in infants and young children are almost entirely preventable by stopping mother-to-child transmission of the diseases.

Unfortunately, although HIV testing has become more accessible for pregnant women in sub-Saharan Africa as part of routine antenatal care, in many countries, including Uganda and Zambia, syphilis testing must still be accessed at separate sites.

Once tested for syphilis, many women have to wait until their next antenatal appointment to receive their test results – and since many do not return to the clinic, they never learn their diagnosis. Without proper diagnosis, most women never receive the medicines they need to treat syphilis, and unknowingly may pass syphilis on to their babies.

A recent study in Uganda and Zambia conducted by the Elizabeth Glaser Pediatric AIDS Foundation found that integrating new rapid syphilis screening with HIV testing for pregnant women can have a significant effect in preventing both transmission of syphilis and HIV from mother-to-child. The study also showed that screening of pregnant women for syphilis and HIV is feasible, cost-effective and an integral part of improving maternal and child health.

In partnership with the Ministries of Health in Uganda and Zambia, and the Centre for Infectious Disease Research in Zambia (CIDRZ), the study identified high rates of syphilis and HIV co-infection in pregnant women in both countries. In Uganda, 14.3 percent of syphilis-positive pregnant women also tested positive for HIV, and the rate was 24.2 percent in Zambia.

Although policies on syphilis screening of pregnant women have been in place in Uganda and Zambia for several years, these policies have not been widely implemented. This is, in part, due to logistical challenges with current testing methods, which require electricity, refrigeration and laboratory equipment. Testing supplies are often limited and unavailable at some health clinics, and few staff are trained to administer syphilis tests.

But newly devised rapid syphilis testing has made it easier to integrate syphilis screening into services provided at antenatal clinics to prevent mother-to-child transmission (PMTCT) of HIV. These simple and affordable tests make it possible to screen pregnant women for syphilis in a variety of urban and rural settings, without the need for special laboratory equipment or refrigeration.

The new rapid syphilis tests are simple to read and can be performed by many types of health care workers, increasing the number of pregnant women that can be tested for syphilis during routine antenatal visits. Results from the new tests are available within 20 minutes, allowing women to be diagnosed almost immediately, and if they test positive, receive treatment during the same visit. In addition, by combining rapid syphilis with HIV testing, women can receive these two important tests simultaneously.

A survey of health care workers conducted in Uganda and Zambia also showed that rapid syphilis testing could be incorporated into routine antenatal care and PMTCT services without any interruption or negative impact on service delivery or quality of care.

In Uganda, prior to rapid syphilis testing, laboratory technicians would perform syphilis testing for pregnant women. After rapid testing was introduced, it could be performed by a greater variety of health care practitioners, including midwives, who oversee the majority of antenatal care in most hospitals and rural health centers in Uganda. Shifting the responsibility of syphilis testing from lab technicians to midwives and nurses improved efficiency and uptake of syphilis testing, while decreasing the number of specialized staff needed to perform tests and improving the integration of syphilis and HIV services into routine antenatal care.

In Uganda and Zambia, integrated syphilis and HIV testing has also helped increase male involvement in the prevention and treatment of syphilis. As part of the introduction of rapid syphilis testing in Uganda, male partners were encouraged to attend the clinic for syphilis and HIV testing with their partners, and letters of invitation requesting men to get tested were sent home with women attending antenatal clinics. In many traditional African settings, male involvement is critical because gender roles dictate that men make decisions about their female partners’ health care, including whether women participate in PMTCT programs.

As a result of the invitation letters, there was a small but significant increase (from 9.8 percent to 12.5 percent) in men coming to the clinic with their partners for a package of care that included syphilis and HIV counseling and testing, syphilis treatment and referral for HIV care. In Zambia, partner notification letters were sent home with women who tested positive for syphilis to track the follow-up and treatment of male partners.

As a result of rapid syphilis testing, there has been swift and direct policy change in Uganda and Zambia to further the goal of eliminating congenital syphilis and pediatric HIV and AIDS. Findings from this study were presented to the Ministries of Health in Uganda and Zambia, which are now both incorporating rapid syphilis testing into their standard package of PMTCT services and antenatal care. In Zambia, the Ministry of Health, with support from the Elizabeth Glaser Pediatric AIDS Foundation, is procuring rapid syphilis test kits and supporting national trainers as part of a national rollout plan to support rapid syphilis testing of pregnant women across the country.

Providing a total package of maternal and newborn health care, including screening and treatment for HIV and syphilis, is important to improving the health of pregnant women and their children. Diagnosing pregnant women early and providing them with the proper treatment to prevent the transmission of syphilis and HIV to their infants may significantly reduce the number of miscarriages, stillbirths, preterm and low-birth-weight infants, early infant deaths, and AIDS in children.

At a global level, the World Health Organization (WHO) has called for the elimination of mother-to-child transmission of HIV and syphilis, and the U.S. Centers for Disease Control and Prevention (CDC) has declared that the scale-up of both PMTCT and the prevention of congenital syphilis is a winnable battle. The Americas and Africa are the focus of this strong, dual initiative to end both of these diseases in children.

Today, we have an important opportunity to ensure that syphilis and HIV do not continue to plague women, children, and families around the world. With the availability of treatment to prevent transmission of HIV and syphilis from mother-to-child, ending both diseases in children can soon be a reality.

REFERENCES

[1] World Health Organization (WHO). Global prevalence and incidence of selected curable sexually transmitted infections. Overview and estimates. Geneva: WHO; 2001

[2] Kalichman S, Pellowski J, Turner C. Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention. Sex Transm Infect 2011; 87:183-190.

[3] Ratnam AV, Din SN, Hira SK, et al. Syphilis in pregnant women in Zambia. Br J Vener Dis. 1982;58:355-358.

[4] Wilkinson D, Sach M, Conolly C. Epidemiology of syphilis in pregnancy in rural South Africa: opportunities for control. Trop Med Int Health. 1997;2:57-62.

[5] Mayaud P, Uledi E, Cornelissen J, et al. Risk scores to detect cervical infections in urban antenatal clinic attenders in Mwanza, Tanzania. Sex Transm Infect. 1998:74 (suppl 1):S139-146.

[6] Lee MJ, Hallmark RJ, Frenkel LM, et al. Maternal syphilis and vertical perinatal transmission of human immunodeficiency virus type-1 infection. Int J Gynaecol Obstet. December 1998; 63(3):247-252.

[7] Mwapasa V, Rogerson SJ, Kwlek JJ, et al. Maternal syphilis infection is associated with increased risk of mother-to-child transmission of HIV in Malawi. AIDS 2006; 20(14); 1869-1877.

Edward Bitarakwate, MD is the Elizabeth Glaser Pediatric AIDS Foundation’s country director for Uganda. Jennifer Pollakusky, is the Elizabeth Glaser Pediatric AIDS Foundation’s senior public policy officer. Tabitha Sripipatana, MPH is the Elizabeth Glaser Pediatric AIDS Foundation’s senior technical officer. Susan Strasser, MPH, MSN, PhD is the Elizabeth Glaser Pediatric AIDS Foundation’s country director for Zambia

Post a Comment

Partnering for Change: The Role of the Private Sector

By: Rhona Applebaum

The global burden of non-communicable diseases (NCDs) is growing at an alarming rate. NCDs have reached every corner of the world, overtaking infectious diseases to become the leading cause of death, illness and disability, as well as a central factor in escalating health costs.

NCDs are no longer primarily identified with development and wealth. On the contrary, the impact of such ailments is far greater in low- and middle-income countries, where 80 percent of NCD-related deaths occur. Moreover, NCDs are a leading threat to social and economic development, and they exacerbate inequalities between countries and populations.

Key factors fueling this rapid growth in NCDs include increased life expectancy and the aging population, urbanization with changes in consumption patterns and lifestyle, including tobacco use, physical inactivity, drug and alcohol abuse, and unhealthy diets. Nearly 35 million people and about 3.5 million children die annually from NCDs related to micronutrient inadequacies.

NCDs are a growing threat to global health and we need focused interventions to keep non-communicable diseases from becoming an even greater burden on society. Otherwise, based on current trends, deaths from NCDs will continue to increase and cause even greater worldwide stress.

Addressing the Problems

The WHO 2010 Global Status Report on Noncommunicable Diseases demonstrated progress over the last decade. However, it also reinforced the fact that governments and civil society cannot succeed alone. Collaboration with the private sector and partnering across sectors will increase the likelihood of finding workable solutions that result in sustainable improvements.

Today, we’re entering a new era of global collaboration, driven by a shared awareness that problems such as NCDs affect all of society and that each sector has an appropriate role to play and contribution to make. Addressing the problem of NCDs requires the concerted will, effort and expertise of government, civil society and the private sector. Harnessing the power of every sector can lead to synergies to affect positive change.

The September 2011 United Nations General Assembly High-level Meeting on the Prevention and Control of Non-communicable Diseases is an historic opportunity to elevate NCDs on the global agenda and increase the worldwide urgency toward overcoming this challenge. As the world prepares for this meeting, it’s essential that we build an ongoing and robust dialogue among all stakeholders. Broad engagement will ensure a true multi-sectoral response that drives informed, effective and systemic action.

The Role of the Private Sector

Private sector organizations can play a substantive, positive role in helping to identify and advance workable solutions to NCDs. The private sector should work closely with key stakeholders – including governments, academia, health professionals and civil society – to promote active, healthy lifestyles, healthy diets and adequate physical activity.

Private sector companies should evaluate their expertise and infrastructure to identify unique advantages and areas of expertise they can lend to broaden the impact of global health programs. For example, The Coca-Cola Company is now lending its extensive distribution system to deliver medicine, health messages and vaccines to communities in Africa that previously had little or no access to these life-saving health supplies.
Then there are things every company, regardless of size or expertise can and should do, like focusing on promoting healthier lifestyles among its employees, consumers and the communities that it serves. For example, in our workplaces, we provide smoke-free facilities, annual health checks, flu vaccinations and well-being incentives to encourage a healthy and active workforce.

An Industry-Wide Effort

Just as collaboration across sectors is essential to affect real change, collaborations comprising private sector companies within industries can lead to synergistic effects.

In 2008, The Coca-Cola Company, along with seven other major international food and non-alcoholic beverage companies, made voluntary global public commitments to action in support of continuing efforts to implement the 2004 WHO Global Strategy on Diet, Physical Activity and Health.

These commitments include reformulating and introducing new products to provide consumers with options they can use in building sensible, balanced diets; providing easy-to-understand and meaningful, fact-based nutrition labelling and information; changing how and what the industry advertises to children; supporting nutrition education and physical activity programs; and participating in national and regional efforts with governments, NGOs and professional organizations to promote healthy lifestyles in the workplace and in communities.

The International Food & Beverage Alliance, a group of food and non-alcoholic beverage companies with a presence in more than 200 countries worldwide, was also formed in 2008 with a goal of helping consumers in all nations achieve balanced diets and healthy lifestyles. Over the past three years, the food and beverage industry has made significant and substantial progress in all the areas listed in the preceding paragraph and we will continue to commit time, resources and expertise to do our part. Progress is captured in an annual report.

Another collaboration, the Consumer Goods Forum – a global network of more than 650 retailers, manufacturers, service providers and other stakeholders across 70 countries – works together to address consumer health and wellness. CGF has adopted resolutions to address three primary areas: availability of products and services that support healthier diets and lifestyles; transparent, fact-based information that helps consumers make informed choices; and communication and educational programs to raise awareness and inspire healthier lifestyles.

These coordinated efforts demonstrate one industry’s commitment to contribute to efforts to the promotion of active, healthy living for all.

One Company’s Experience

At The Coca-Cola Company, we strive to make a lasting difference everywhere we engage. We are committed to refining, strengthening and expanding our role in decreasing the growth of NCDs, working toward the day that they are no longer a global threat. We firmly believe that we can do well as a global company by doing good as a responsible corporate citizen.

We don’t have all the answers, but we recognize a need to think differently, challenge ourselves constantly and form new partnerships that will help find workable solutions to some of society’s most pressing problems.

We are keenly aware that leading an active, healthy lifestyle is a complex proposition for many. Experts believe that it is important to balance the calories you take in with the calories you burn by consuming a sensible, balanced diet combined with regular physical activity. This concept of balancing calories in and out is what the experts refer to as ‘energy balance.’ That’s why our efforts focus on three areas – education, variety and physical activity, “THINK, DRINK, MOVE” – to help educate associates, consumers and communities about the importance of energy balance. We encourage active, healthy living through energy balance programs that offer physical activity and nutrition education. Examples include Moderation, Balance, Diversity, a school program in Greece and Triple Play, a program delivered through the Boys and Girls Club of America that has reached more than 4 million children in the U.S. Having the necessary information for making informed choices is essential, which is why we are committed to transparency about our products’ nutrition profile. Our global policy on front-of-pack energy labelling has been in effect since 2009.

While proper nutrition is essential, other factors play an important role in maintaining a healthy lifestyle. According to the World Health Organization, tobacco kills more than 5 million people a year. Our company, therefore, prohibits smoking inside its facilities. Physical inactivity and sedentary lifestyles have also been identified as a major underlying cause of NCDs. There is strong evidence that school, workplace and community physical activity programs can make a difference in reducing risk factors associated with NCDs. That’s why we sponsor more than 250 physical activity and nutrition education programs in more than 100 countries. By 2015, we hope to have at least one such program in every country we operate.

We also support others who are in positions to provide training and/or perform key research aimed at reducing the incidence and impact of NCDs. Our unrestricted grant to the U.S. Centers for Disease Control and Prevention (CDC) Foundation supports efforts to build global capacity for NCD prevention in low and middle income countries. With support from this grant, CDC is more effectively and concretely interacting with key global partners for NCD prevention and supporting the training of a critical future generation of researchers. We support similar efforts in other parts of the world as well as a variety of additional programs to help develop workable solutions to this very complex problem. With complex, multi-faceted problems like obesity and NCDs, the right answers aren’t always simple and the simple answers aren’t always right. Thus a multi-disciplinary approach, new thinking, and creative partnerships across all stakeholder groups are essential ingredients.

Through product innovation, we’re also seeking to address micronutrient shortages in certain countries. For instance, NutriJuice® is a fortified drink specifically focused on providing iron to iron-deficient children in the Philippines. We’re working to replicate this concept in other parts of the world.

The Time to Act is Now

Today, NCDs represent one of our most significant global challenges and should be collectively addressed by all key sector stakeholders – private and public– working together. Our goal is simple – to help harness the synergies of these different sectors to affect positive change. Our combined efforts will have far greater impact than those of one sector alone, giving us the greatest opportunity to reverse negative health trends and improve the health of society as a whole.

As a global citizen, the world’s largest beverage company and one of the largest multi-national employers, The Coca-Cola Company embraces the opportunity to help find workable solutions and we encourage our private industry colleagues and all interested stakeholders to heed the call to do what they can to support these efforts, and to consider what we have long recognized: the health of any business is interwoven with the health of its employees, its consumers and the communities in which it operates. We can indeed do well, by doing good.

Rhona Applebaum, PhD, is vice president, and chief scientific and regulatory officer for The Coca-Cola Company.

Post a Comment( 3 )

Brazil: Getting a Move on NCDs

By: Elizabeth Nussbaumer, Thea Joselow and Nalini Saligram

By 2030, non-communicable diseases (NCDs) are projected to cause nearly five times as many deaths as communicable diseases worldwide. All people, rich and poor, are affected by this epidemic, but none more so than the poorest populations in developing countries, as NCDs increase poverty, which in turn causes rising rates of disease. Changing behavior – such as getting people to exercise – is one of the hardest challenges in chronic disease prevention.

Since the 1970s, Brazil has experienced rapid economic growth, resulting in significant lifestyle changes. Unfortunately, the consequence of these shifts was considerably higher levels of non-communicable diseases. The book Sick Societies: Responding to the Global Challenge of Chronic Disease asserts that in 2004, chronic diseases accounted for 70.1 percent of all deaths in Brazil. Additionally, an estimated $49.2 billion (2.5 percent of Brazil’s GDP) has been lost due to disability or death from chronic disease. It is imperative to Brazil’s continued development that it contains and prevents NCDs.

That is why Arogya World is highlighting the Agita São Paulo initiative which increases physical activity levels for an estimated 520,000 people each year in the state of São Paulo, Brazil. The simple framework and its remarkable success in a developing country at minimal cost make the Agita method adaptable in other high-risk populations worldwide.

A Movement for Movement

In 1996, the Agita São Paulo initiative was created in response to the growing level of physical inactivity in Brazil and increasing number of deaths due to chronic disease, especially within the state of São Paulo. The word agita means to move the body, or to move the crowd, as well as changing ways of thinking and becoming more active. The initiative seeks to achieve two objectives: increasing both the public’s knowledge of physical activity’s importance and its physical activity levels. Additionally, Agita fosters partnerships with governmental and nongovernmental organizations, currently working with more than 350 partner institutions.

Fundamentally, the initiative promotes simple behavior changes to achieve 30 minutes of moderate physical activity each day. A smiling clock mascot, the “half hour man,” was created to remind citizens that little time is needed to achieve their health goals. The Agita approach is effective, especially because it focuses on moderate rather than vigorous activity, and reminds citizens that physical activity can be accumulated in manageable intervals throughout the day. By so framing the daily physical activity requirements, people found the goals to be more achievable. It especially appealed to the women of São Paulo who traditionally disliked vigorous exercise.

The initiative targets students, workers, and the elderly, reaching large groups through mega events (reaching at least one million citizens) and community-level activities with partner organizations. The Agita Galera mega event, for example, is held at 6,000 public schools each August in partnership with the Department of Education. Agita conducts classes and students take part in walks, sports and other creative activities that increase their level of physical activity and educate them on its benefits. Physical activity levels in these public schools were 33 percent higher than in non-participating private schools.

Furthermore, from 2002 to 2008, the proportion of insufficiently active people dramatically declined from 43 percent to about 11 percent, whereas moderate physical activity increased from about 50 percent to 70 percent. In 2004, the Centers for Disease Control found that Agita was not only cost-effective, but also a cost-saving intervention, and in 2006, the World Bank found that the initiative represented $310 million in savings per year in the health sector.

The Agita São Paulo model is applicable at local, national or global levels. The key is simplicity, and the following actions can help promote physical health in the community: Promote 30 minutes of physical activity per day and remember that anyone can engage in physical activity, at any age, anywhere;
Build partnerships to promote the importance of physical activity;
Adapt to the culture, beliefs, and values of your community to ensure sustainable success;
Provide scientific information on the benefits of physical activity;
Hold large events or health days to spread awareness.

Agita São Paulo’s model now includes 72 countries, and forges global alliances to promote health, creating a strong framework for implementing physical activity initiatives around the world.

However, a persistent challenge remains in the social perception of the threat of NCDs. In the words of Victor Matsudo, the head of Agita São Paulo, “Social perception of risk is equal to the relative risk times indignation. In the case of NCDs, relative risk from sedentary lifestyles is quite high, but because indignation is low, the social perception of the risk is low.”

Elizabeth Nussbaumer is a member of the Arogya World policy team. Thea Joselow is an advocacy and digital media consultant at Arogya World. Nalini Saligram is founder and CEO of Arogya World.

Post a Comment( 2 )

India: The Private Sector Takes Action on NCDs

By: Muruga Vadivale and Aparna Thomas

India is the second most populous nation in the world with nearly 1.2 billion inhabitants. The impact of chronic and infectious diseases on patients, families and society is significant. In addition to the obvious effects on quality of life, morbidity and mortality, the burden of these diseases to the country’s economy is substantial in terms of loss of productivity, loss of employment, and health care expenditures.

The scope and impact of non-communicable diseases (NCDs) such as cardiovascular disease, cancer and diabetes are so complex that all stakeholders, including governments, NGOs, academia and the private sector need to participate in developing solutions. The common challenge – and opportunity – for all stakeholders is to save millions of people from premature death and debilitating health complications, as well as promoting social and economic development.

Health care in India has shown remarkable improvement since independence in 1947. However, in 2004, out of the estimated 10.3 millions deaths, 1.1 million (11 percent) were due to injuries, 4 million (39 percent) to communicable diseases and 5.2 million (50 percent) to NCDs.

In 2005, 9.2 million years of productive life were lost in India due to heart diseases, stroke and diabetes. This translated into US$ 9 billion of lost national income. The projected 2005-2015 cumulative loss of national income for India due to these premature deaths is US$ 237 billion.

India’s total health care spending was 4.2 percent of gross domestic product (GDP) in 2008-09. Public spending on health (0.93 percent of the GDP) was among the lowest in the world, and the reason for private expenditures accounting for 78 percent of total health spending in the country.

Although India’s economy is witnessing remarkable growth, inadequate health care infrastructure continues to be a barrier to access to basic health services. For example, there are only 60 physicians per 100,000 people as compared to 140 per 100,000 globally. Likewise, India has only 130 nurses per 100,000 people whereas the global average is 280 per 100,000.

It is estimated that more than 46 percent of patients travel more than 100kms from small towns to urban facilities to seek proper medical care. Knowing that 71 percent of the population is living in rural areas, accessibility to health care infrastructure is a major issue.

Therefore, in cooperation with other stakeholders (such as doctors, hospitals, institutes and policy makers), Sanofi India is organizing a number of actions to understand the real burden of disease, raise awareness of diabetes and increase access to health care in rural areas.

Estimating the prevalence and risk factors of diabetes and hypertension

The International Diabetes Federation estimates that India has the second highest prevalence of diabetes in the world with 50.8 millions diabetes patients in 2010.
Indians with hypertension are projected to number 214 million in 2025, up nearly 100 million since 2000. Hypertension is an important worldwide public-health challenge because of its high frequency and concomitant risks of cardiovascular and kidney disease.
Reliable information about the prevalence of hypertension and diabetes is essential to the development of health policies for prevention and control of these conditions.

Therefore, in January 2009 Sanofi launched SITE (Screening India’s Twin Epidemic), a cross-sectional study to estimate the prevalence of diagnosed and undiagnosed cases of diabetes and hypertension in outpatient settings in major cities across India.

As of July 2011, SITE has enrolled 15,662 patients from 802 centers across eight states in India (Maharashtra, Delhi, West Bengal, Tamil Nadu, Andhra Pradesh, Karnataka, Gujarat, and Madhya Pradesh) and has partnered with 800 general practitioners and consulting physicians to conduct the screenings, record and report the results. The study was conducted in waves over two years, one state at a time, with 2,000 patients screened from each state over two days per wave.

“Through SITE we hope to identify gaps in treatment needs at the first point of contact for a patient,” said Dr. Shashank Joshi, a consultant endocrinologist at the Lilavati Hospital and the national coordinator of the study. “SITE will give us important insights on how we screen patients for risk factors and how well we manage them versus current guidelines.”

The results obtained in the different cities are progressively communicated at congresses. When the results of the New Delhi screenings were announced, medical researchers, public health officials and physicians were able to compare the prevalence of diabetes and hypertension in Maharashtra and New Delhi. The findings were both alarming and revealing:

The twin epidemics of diabetes and hypertensions do exist in both states, although more serious in Maharashtra where 29 percent of the patients were both diabetic and hypertensive, as compared to 21 percent in New Delhi.
Hypertension is more prevalent than diabetes in both states.
Less expected, were the regional differences: both diabetes and hypertension are more prevalent in Maharashtra (40 percent and 56 percent, respectively) than in New Delhi (33 percent and 48 percent, respectively).
As troubling were the rates of patients who had been diagnosed and treated, but whose conditions were still uncontrolled.
In Maharashtra, three-quarters of known diabetics had uncontrolled blood sugars (Hba1c levels), as compared to two-thirds in New Delhi.
Uncontrolled hypertension was also a serious problem in both states and occurred at about the same rate: 79 percent in Maharashtra and 77 percent in New Delhi.

Through partnerships with doctors, hospitals and other organizations in these eight States, SITE has already started to raise disease awareness of the risk factors, symptoms and treatment of diabetes, hypertension and other related conditions, such as cardiovascular diseases.

Celebrating Diabetes Control

According to Dr. Shailesh Ayyangar, general manager of Sanofi in India and vice president of Sanofi in South Asia, “The diabetes epidemic makes it essential to create awareness about diabetes control. The ‘I Am A Champ’ program will help patients who are in control to reach out to others with their inspiring testimonials. Treatment regimens must be complemented by a more comprehensive approach to diabetes management for the health and well-being of a patient.”

Through the program patients and caregivers are learning that a positive attitude and few lifestyle changes to support their treatment regime can empower them to improve their health and well-being.

India’s first ever Diabetes Awards Ceremony was the first step to kick start the ‘I Am A Champ’ program which is based on the model of peer-to-peer counselling. Champions from various regions in the country were assessed on various parameters such as their understanding of diabetes, awareness about diabetes complications, their fitness and diet regime, and the ‘champ’ factor. In their role as ‘Champions of Diabetes’, they will be the face and voice of this awareness program in their respective cities.

Sanofi provides the 42 (seven national and 35 regional) ‘champs’ with platforms to share their testimonials, create awareness amongst other diabetes patients in their respective cities and address their concerns on managing the disease. These individuals symbolize triumph over diabetes and are a beacon of hope for countless other diabetics who often believe that ‘life is over’ once they are diagnosed with diabetes.

Empowering Doctors in Rural India

Prayas, meaning endeavour in Sanskrit, focuses on empowering doctors in rural India with the latest developments and updates in medicine.

The government is doing extensive work through the National Rural Health Mission (NHRM) to provide effective health care to India’s rural population. Considering the magnitude of the task, NHRM has incorporated public-private partnerships in its strategic roadmap for achieving its public health goals. This was echoed by Shomita Biswas, joint secretary, Public Health, Government of Maharashtra, citing,“Two major problems that government is facing at the grass root level is lack of infrastructure and adequately trained human resources. There is also an acute need of training institutes for developing nursing and paramedic professionals at the rural level. These are some of the areas where government will look forward to getting support from the private organizations.”

Launched in 2009,Prayas is aimed at bridging the diagnosis-treatment gap through a structured continuing education program for rural doctors across India. In Prayas, specialists from semi-urban areas share latest medical knowledge, clinical experience and practical insights through structured workshops for general practitioners- from smaller towns and villages in the interiors of India - through a ‘mentor-mentee’ model.

As of July 2011, 4,700 workshops have been conducted across 14 states for more than 11,500 rural doctors. Forty-eight expert doctors and 574 mentors have so far lent their support to Prayas. The workshops cover major acute-care therapy areas like respiratory diseases, infections, allergies, gastrointestinal disorders, etc. Each course is validated and certified by reputable international medical associations such as the American College of Physicians and the American Gastroenterology Association, amongst others.

Progressively disease awareness camps were organized to improve awareness and treatment seeking behaviour of patients in these regions. These camps focus on topics like child health, anaemia and malnutrition, and diarrhea which are in line with the needs of the patients.

With plans to cover new doctors under the program on a continual basis, there should be 100,000 mentees by 2015.

To complement this knowledge-based program, the Hoechst Business Unit, a Sanofi Unit has also launched a new range of quality medicines at affordable prices in these geographical areas. The product range helps address the challenges of accessibility, affordability and availability of quality medicines to patients in remote villages. In addition, a new distribution model with emphasis on availability of drugs to the most rural interiors is being established. The next step is to adapt this model to the fight against diabetes which is also developing in rural areas.

References

1. World Health Organization, Global Health Observatory. Accessed July 17, 2011
2. World Health Organization, Global Infobase. Accessed July 17, 2011
3. World Health Organization, Chronic Disease Report, 2005. Accessed July 17, 2011
4. World Health Organization, Global Health Expenditure Database. Accessed July 26, 2011
5. World Health Organization, World Health Statistics 2010. Accessed July 17, 2011
6. Accessible Healthcare - Joining the Dots Now. White paper, TECHNOPAK Leadership Forum on Healthcare, Oct. 20, 2011, New Delhi.
7. International Diabetes Federation. 4th Atlas - 2009. Accessed July 17, 2011
8. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365: 217-23.
9. Joshi S.R. et al. SITE 1st wave results (Maharashtra). ADA June 2010. Mithal A. et al. results from Delhi (abstract 2496-PO) and Jindal S. et al. Results from Madhya Pradesh (abstract 2497-PO). ADA June 2011.
10. Marketing Whitebook (2011-12) report.

Dr. Muruga Vadivale is senior director, Medical and Regulatory Affairs, Sanofi India. Aparna Thomas is senior director, Communications and Public Affairs, Sanofi India.

Post a Comment( 6 )

NCDs in the Developing World: Looking for Solutions

By: Nellie Bristol

Diagnosing and treating non-communicable diseases (NCDs) can be a complicated and expensive proposition. Trying to do so in a low resource setting with poor health infrastructure and a dearth of doctors, particularly specialists, makes it that much more difficult. Nonetheless, according to experts, many of the most common chronic diseases like diabetes and cardiovascular disease, can be mitigated through population-wide measures including a variety of policy changes. The World Health Organization in its Global Status Report on Noncommunicable Diseases 2010, released in April, listed several “best buys” in reducing NCDs in a cost effective manner. They include banning smoking in public places and warning about the dangers of tobacco, raising taxes on alcohol and tobacco, reducing salt in food and eliminating trans-fats.

A high powered group of health experts including Partners in Health Founder Paul Farmer and Julio Frenk dean of the Harvard School of Public Health, listed a range of cancers responsive to prevention and treatment in low- and middle-income countries as part of a call to action in an August, 2010 Lancet. For example, curbing tobacco use could prevent lung, head and neck, and bladder cancers while reducing human papillomarvirus infections could cut cervical, head and neck cancer. In addition, early detection could reduce the impact of cervical, breast and colorectal cancer while several lymphomas could be curable with systemic treatment.

In the technology area, a number of groups and manufacturers are working to develop low cost ways to screen, diagnose and treat NCDs in resource poor settings. For example, PATH is working to with several partners to develop simple cost effective methods for diabetes screening. Diagnosing diabetes in developed countries is often a multi step process that requires patients to fast and to return to a health care provider several times. To work in a low resource setting, according to Bernhard Wiegl, director of PATH’s Center for Point-of-Care Diagnostics for Global Health, mechanisms must be inexpensive, quick, easy to maintain and require no preparation by the patient. Several possibilities are now being explored, including one that simply involves a patient placing an arm on device which tests for diabetes related abnormalities through the skin. Groups also are working to reduce the amount of blood sugar testing required to monitor the disease, current a time consuming and expensive undertaking.

In addition, several vaccines, if priced right and distributed adequately, could go a long way toward reducing the incidence of certain cancers. The HPV vaccine, which became widely available in the U.S. over the last five years, would actually be much more useful in the developing world where regular Pap smears are not available and 88 percent of cervical cancer deaths occur. Unfortunately, the series of vaccines can run $300 per patient in the U.S. But movement is seen there too. The GAVI Alliance announced in June that Merck will offer the group the HPV vaccine for $5 per dose, a 67 percent reduction in current the lowest public price.

While NCD detection and treatment will likely lag in the developing world for some time, new efforts and technologies could whittle down the disparity. “I’m not saying everybody’s going to get on a treatment plan any time soon, but I think diabetes treatment can certainly reach farther down the economic strata than it currently does,” Wiegl said.

Nellie Bristol is a freelance journalist specializing in health policy.

Post a Comment( 5 )

Grappling with the Tensions around NCDs

By: Sir George Alleyne, Alafia Samuels and Karen Sealey

Recent global health conferences have highlighted many of the issues that health and other sectors must address to prevent and control NCDs. This growing awareness about non-communicable diseases (NCDs), coupled with the upcoming United Nations High Level Meeting on Non-communicable Diseases mark a significant milestone in the effort to raise the political priority of NCDs. However, this has brought to the fore several tensions inherent in focusing on any particular health problem.

First, there will inevitably be challenges that arise from the nature of the diseases or health problems themselves, different constituencies attempt to promote to one or other group of diseases, and clamoring to highlight “their” category of disease or heath issue – for example, communicable diseases vs. NCDs. Further strain emerges within disease groupings, with “factions” and advocates using one or other metric to claim priority for their disease, e.g. within NCDs, cancer vs. chronic respiratory diseases. It is also salutary to note that there are also tensions within the communicable disease community as arguments arise over the attention paid to malaria versus other infectious diseases such as HIV/AIDS. Although these tensions may be decried as being unhelpful, they do exist, must be recognized and, if possible, converted into sources of creative energy for improving health.

Here we explore the nature and geneses of some of the tensions around NCDs, but in particular that between NCDs and communicable diseases, and indicate possible means of reduction or resolution. We should be clear that the discordance between groups of advocates for one or other disease exists predominantly in the developing countries and within the international community. While it is true that NCDs have not had the priority that they merit on a global level, this is not the case in wealthy nations. In these countries, with their aging populations, enormous burden of NCDs and relatively low burden of communicable diseases, little or no tension exists, and expenditure is heavily slanted toward the care of patients with non-communicable diseases.

In the international arena, there is apprehension over the attention currently being paid to NCDs and conversely, the possibility of a lessened focus on communicable diseases. The argument is that communicable diseases still contribute the majority of health problems in the poorest countries, and it is irresponsible to address NCDs before resolving existing challenges. While it is true that in sub-Saharan Africa, communicable diseases still account for the major part of the burden of illness, this is not the case in any other region of the world. Further, sub-Saharan Africa is the region in which the incidence of NCDs is rising fastest.

Indeed, in 2008, about two-thirds of the 57 million deaths globally were due to NCDs; 80 percent of those who died were in developing countries. By 2030, the burden of disease from NCDs will be three times greater than that of communicable diseases and maternal, perinatal and nutritional conditions combined. As the Secretary-General of the United Nations Ban-Ki Moon said recently, “NCDs have emerged relatively unnoticed in the developing world and are now becoming a global epidemic.”

Framing the discussion in terms of one set of diseases versus the other stems, in part, from one of the many misconceptions about the epidemiological transition and a need to raise awareness about what is important at the population level. During the epidemiological transition, as communicable diseases decline, NCDs emerge, but there is no sharp temporal division in disease profile. Thus, there will be a stage of co-existence or double burden, the NCDs and their behavioral risk factors coexisting with the communicable diseases. Some countries must continue to suffer a double burden of both communicable and non-communicable diseases for some time as the appearance of the HIV epidemic and the recent H1N1 pandemic have made it clear that all countries still have to deal with communicable diseases.

The tension is also due in part to the nature of the two groups of diseases. Communicable diseases are, in general, acute in onset with external, often dramatic manifestations, with a definitive end result – recovery, disability or death. NCDs are often imperceptible in onset, of long duration and, in the popular perception, without a cure. However, therapeutic developments are leading to cures for some NCDs, for example some cancers. Also, attention to the predominant risk factors can actually prevent the disease and appropriate treatment can extend the patient’s life.

Some tension has also arisen in the public because of the fear engendered by communicable diseases – a feeling which does not extend to the same degree to NCDs. There are no initial outward acute manifestations of NCDs and they are not contagious in the main population. In developed countries, the acute, more obvious communicable diseases are viewed as the urgent issues on which the health community and the political directorate should focus, rather than problems which are perceived to primarily affect the elderly. So it is not surprising that there is at least one publication about patients with diabetes wishing that they had HIV/AIDS because they noted the level of services and the resources available to patients with HIV/AIDS.

Other challenges lie in the fact health services remain disease- as opposed to patient-centered, with insufficient regard for holistic disease management. In some populations, HIV+ patients are being treated in single purpose, easily identified facilities, thus compromising their anonymity. If the same patient also has diabetes or heart disease (more likely, given the atherogenic effects of anti-retroviral therapy) these patients are sent to a different, often under-resourced, sub-par facility.

A significant source of international tension has been the omission of NCDs as a health or development issue in the Millennium Development Goals. Indeed, there has been resistance to even the idea of expanding the MDGs to include NCDs, even although it is now clear that there is a close relationship between non-communicable diseases and many of the MDG goals. The world will not achieve the targets set forth by the MDGs without taking NCDs into account. To give one very pertinent example, research shows low birth weight that occurs as a result of maternal nutritional deprivation is a major predicting factor for adult high blood pressure and diabetes.

Perhaps the major source of tension is in the funding of health globally. In this current constrained economic climate, there is a natural anxiety that funds may be diverted from what is described as the unfinished agenda of communicable diseases to address NCDs. There is concern that there may be a call for new funding to address the NCDs in the same way that funds were mobilized for HIV/AIDS. The tension is fuelled by the fact that many in the NCD community point out that most of the parameters that should lead to establishing NCDs as a priority for funding are present, yet funding for the NCDs remains low by any standard both at national level and among the development partners. The development agencies of the developed countries may be concerned that any effort to deviate their funding from established programs which are not yet completed, but to which long term commitments have already been made. One possible example of such a program is PEPFAR. There is also the view that because communicable diseases from the global South can threaten the health of those in the global North, the heavy funding for communicable diseases is really self-serving for those in wealthier countries.
The resolution of these tensions will come principally from the dissemination of information and communication between the different “communities” and a focus on the appropriate interventions to address all the health problems of the world’s populations. In this context, it was gratifying to see the major NCD non-governmental organizations formed the NCD Alliance to join forces, press for focus on common risk factors, and exert pressure at national and global level for greater political, technical and financial attention to NCDs. It is important to focus on the health system as the common final pathway for addressing both, since patients will present with both communicable and non-communicable diseases.

Until recently, primary care services focused on maternal and child health, and acute problems, both with finite resolution. It is now necessary to reorient health systems to provide continuing care that is patient centered, disregards the nature of the health problem or its duration, involves secondary and tertiary care facilities, and promotes community involvement and participation. The articulation of all the inputs needed for care, irrespective of the nature of the problem, should be coordinated at the primary level with continuity of oversight.

Optimistic prospects for the world’s health are based on the view that with more attention to the social determinants of health, there will be a steady decrease in communicable diseases with concomitant relative and absolute increase in the incidence of NCDs. Given the steady aging of the world’s population, there is a certain inevitability of NCDs, so the target must be to reduce avoidable mortality from NCDs. But it is equally certain that we will never be able to rid the world of the microbes which cause communicable diseases which, in some cases, because of the nature of the infection will be chronic, e.g. HIV/AIDS. The sooner we recognize the origins, nature and overlap between the two sets of problems, the sooner some of the tensions described will be resolved and the sooner will it be possible to address all the health problems of the world’s people regardless of origin.

George Alleyne is director emeritus of the Pan American Health Organization. T. Alafia Samuels is senior lecturer at the Faculty of Medical Sciences, University of the West Indies. Karen Sealey is senior adviser, UN Matters and Partnerships at the Pan American Health Organization.

Post a Comment( 1 )

Opening the Door to Global Health Talent

By Jonny Dorsey and Barbara Bush

Young people do amazing work toward building a world where everyone can access health care and live a full life. Yet all too frequently, they must claw their way into opportunities within the global health community.

Consequently, many young people who have a desire to serve turn to other careers. If we want to win the battle against today’s enormous health challenges, we must build a robust pipeline of talent for global health, and harness the wave of energy, enthusiasm and skill of the millennial generation.

Global Health Corps is a testament to the power of young people in action. Since its founding in 2009, Global Health Corps has placed 58 fellows from 10 countries in health nonprofits around the world to fill critical needs – welcoming them into a growing community of public servants while providing a stepping-stone into a career in public health. Importantly, fellows are placed in team of two: one American, and one peer from the African host country. A strong leadership pipeline must include young people from emerging and developing countries as well as their wealthier-nation peers to create meaningful change and build leadership around the world.

For example, at Partners In Health (PIH) in Rwanda, two Global Health Corps fellows – a Rwandan and an American – managed a $1.4 million procurement of medical equipment and supplies for the Burera Hospital in northern Rwanda. But they weren’t the only fellows who worked on this project; two other fellows worked as architects of the hospital. Another fellow created the operating plan for the hospital, which serves a community of 400,000 poor Rwandans. Other fellows helped plan the integration with the Rwandan government.

Following their fellowships, one individual now works as PIH’s Africa procurement and logistics coordinator, while another oversees the construction and rehabilitation of health centers across the entire country in his new position within the Rwandan Ministry of Health.

Unfortunately, most of the young talent that seeks to work in this space is turned away. In fact, one of the fellows who worked on the Burera Hospital had difficulties getting a foot into the global health community, despite performing well in school, starting a FACE AIDS Chapter, and providing hospice care in his home community. When he applied for Global Health Corps, he was bartending in Washington, D.C. to make a living. During his fellowship, he was so effective that he was hired and promoted by his placement organization – yet our sector almost missed out on his commitment, and his talent.

Huge numbers of millennials want to serve in global health, and this desire is only growing. This year Global Health Corps received more than 2,000 applications for 70 positions. Many organizations, including two we work with closely, FACE AIDS and GlobeMed, are further strengthening this pool of equity-focused student-leaders through engagement on high school and college campuses.

The private sector has focused significant resources on building talent pipelines of young people. Entire programs at business schools and large corporations focus on recruiting, training and retaining talent. While the social sector cannot always use the same strategies as multinational companies, it can still invest in emerging leaders, and in exchange, reap great results. No organization proves this as clearly as Teach for America.

Teach for America recruits more than 4,000 young teachers from the top colleges in America every year – many of whom emerge two years later not only with a dedication to continue to work in education, but also a commitment to create a world where every child has access to a good education. The young teachers receive training, mentorship, career development resources and a strong community committed to social justice. Several of the most innovative programs in education – from KIPP Charter Schools to The New Teacher Project – were founded by dedicated Teach for America alumni.

We must build a similar pipeline for global health – one that will produce thousands of leaders committed to health equity. Doing this will take significant investment. Teach for America spent $155 million in 2009. And this is just one of many efforts in education to train new leaders. In health we count on universities to do too much of the heavy lifting. Certainly, they are an important piece of the puzzle. But just as Teach for America is complementary to schools of education, and corporations’ leadership programs round out business school, we, in health, must build programs that support the rigorous academics of universities. Some foundations devote funds to building the leadership pipeline in health, but the examples are few and far between. Fortunately, some foundation leaders have shown a clear understanding of this challenge and opportunity; Bill Gates himself stated that the biggest challenge we face is getting the best and brightest to tackle our biggest problems.

We must respond to that challenge with wise investments. Success would include robust recruiting programs that harness talent of all types – from computer scientists to managers to epidemiologists. Success would also include strong training and mentoring programs for young talent, and reasonable salaries that will retain them. Most importantly, success requires helping emerging leaders develop a set of values that will inspire them to not just build careers in the health sector, but also to work toward health equity.

Though this endeavor will take many years, there are a few solutions that could be put into practice today to strengthen the global health sector’s leadership pipeline.

Pay interns. Our sector limits the talent pool we draw from when we tell inspired youth that they must go elsewhere if they seek to be paid.
Recruit more interns. Provide pathways into the field for young people with all the necessary skills in this movement – not just pre-medical students.
Provide strong mentorship. Ensure you have a structured mentoring program that develops young talent.

Our world’s ability to provide quality care to everyone will depend largely on who steps up to work and create new solutions, and what values they bring with them. The millennial generation is knocking, eager to make a difference in global health with their talents, energy and commitment. Let’s open the door, and build a movement that will succeed.

Jonny Dorsey is Co-Founder of Global Health Corps and FACE AIDS. Barbara Bush is Co-Founder and CEO of Global Health Corps.

Post a Comment( 1 )

A Malaria-Free World is Within Reach

By Awa Marie Coll-Seck

A decade ago, far from public outcry or front-page headlines, malaria was killing 3,000 people every day, mainly African women and children. Few of more than over 3 billion people at risk had access to mosquito nets or effective malaria drugs. Chloroquine, the main malaria drug, had become ineffective against malaria's deadliest strain, and the pipeline for new drugs, vaccines and other tools to control malaria was virtually empty.

Since the moment when advocacy efforts shifted malaria from a neglected disease to global health priority, the results were tangible: a 30-fold jump in international funding, increased commitment by African leaders, a rapid expansion of research and development, and the creation of new alliances addressing malaria. The Roll Back Malaria Partnership, the global framework for coordinated action created in 1998 by the WHO, UNICEF, UNDP and the World Bank, is now a worldwide movement of more than 500 public and private sector partners.

Change has been most dramatic in Africa, where enough insecticide-treated mosquito nets have been delivered to cover 76 percent of people at risk and 11 countries have reduced malaria cases and deaths by more than 50 percent. In just a decade, Africa has begun to extract itself from the grip of a disease that has held sway for millennia. The Global Fund to Fight AIDS, Tuberculosis and Malaria, now the source of two-thirds of all malaria funding, has been instrumental in realizing many of these gains together with the U.S. President's Malaria Initiative, the World Bank Booster Programme, UNITAID and other bilateral contributions.

However, these gains are as fragile as they are impressive. While countries could soon be able to distribute enough bed nets to protect everyone at risk, achieving similar traction with treatment, diagnosis and indoor spraying has proven more difficult. More critically, growing drug and insecticide resistance, left unchecked, could leave millions without effective treatment and prevention options, essentially turning the clock back to the conditions of 10 years ago.

The challenge now is to not only sustain these hard-won results, but also to make greater advances in areas where progress has eluded us most, particularly access to diagnostics and treatment. Without proper use of malaria drugs, we will never conquer resistance and eliminate malaria.

As we go forward, two ambitious objectives are before us: the Millennium Development Goal target to halt and begin to reverse the incidence of malaria, and the goals of the Global Malaria Action Plan, particularly the milestone to reduce malaria deaths to near zero by 2015. To reach these goals we will need to both maintain our present gains and intensify our efforts. This cannot be done without greater commitment, innovation and new ways of funding malaria control and elimination. We have already seen the power of public-private partnerships, which have made drugs more affordable and available, nurtured innovative sources of financing, and furthered research and development efforts to create new drugs, insecticides, rapid diagnostics tests and vaccines.

We cannot fail to meet these objectives. If we do, the price will be too high. In addition to the millions of lives which will be lost, the impact on development will be huge. Let us not forget that in countries with a large malaria burden, particularly those in Africa, the disease consumes up to a quarter of household incomes, trapping people in a cycle of poverty. About 40 percent of government health spending goes to malaria, a disease which costs Africa $12 billion in direct costs every year, and much more in lost productivity.

Countries struggling with malaria and those that have long since eliminated it both have a role to play in fighting this disease. Political leaders in countries with malaria burdens must remain firm in their commitments, from increasing health budgets to improving supply lines. Donors must meet their own pledges and help find ways to bridge the gaps in necessary funding going forward. Malaria has proven itself to be a good investment. As the most cost effective single health intervention after childhood vaccination, universal malaria prevention coverage alone can save the lives of at least 3 million African children by 2015.

The results of the last 10 years have shown us that with innovative public private partnerships and by increasing financial and political support; we can move many steps closer to controlling and eliminating malaria. The role of partners to drive success in these areas cannot be underestimated. This tremendous progress has laid the foundation for the next phase of the malaria fight. It is now clear that while creating a malaria-free world is challenging, it is possible.

This year for World Malaria Day, the Roll Back Malaria Partnership and the UN Foundation’s Nothing But Nets campaign launched a photo exhibit at UN headquarters featuring portraits of some of the “Champions” in the fight against malaria. Among those highlighted were world-leaders, faith-leaders, musicians, and a 10-year-old girl – it is truly wonderful to see the vastly different faces that are driving progress against malaria. This diversity and close partnership at every level is the secret to our success.

Going forward, I hope to see even more people join what really has become a “movement” to end malaria. It is clear that the momentum continues to build: teachers are telling their students about the disease and what they can do to help, students are telling their parents, parents are telling their government representatives, and governments are coming together with public and private organizations to take action quickly.

We have an opportunity to end deaths from a disease that has killed millions of people over thousands of years. Let’s seize this incredible opportunity to ensure a healthier future for people around the world.

Prof. Awa Marie Coll-Seck is the executive director of the Roll Back Malaria Partnership and former health minister of Senegal

Post a Comment( 5 )

Paying for a Healthier Future

By Catherine Connor, Laurel Hatt and Thierry van Bastelaer

Development assistance for health has ballooned from $5.6 billion in 1990 to $21.8 billion in 2007. Until the recent economic crisis, many developing countries were enjoying economic growth rates of five to six percent, and stepping up their commitment to health. Despite these trends, unfortunately, many developing countries still face financing gaps that must be overcome to secure a healthier tomorrow.

Given the magnitude of health issues remaining in many developing countries, there is a continuing need to accelerate investment in health over the coming decades.

Increase Investment

How much should a developing country spend on health? In 2009, the WHO set a target of $54 per capita for a basic package of essential health services in developing countries. Even under very optimistic assumptions, estimates show that governments in 28 African countries would still not reach that target by 2020.

How can the gap in financing be bridged?

Increase government budget allocations. This outcome depends on many factors, beginning with growth of the formal taxable economy – rising GDP in developing countries between 1995 and 2006 made it possible for governments to almost double the amount of resources going to health. Another factor is the capacity of governments to collect tax revenues efficiently by upgrading tax administration systems and staff capacity, and by upholding accountability and anti-corruption measures. In addition, the health sector – particularly ministries of health – must demonstrate to ministries of finance that budget allocations will be fully executed and spent efficiently. Finally, governments must resist the temptation to reduce their own budget allocations to health when donor funding for health increases.

Leverage the formal private sector. A recent report by the International Finance Corporation estimates that $11–$20 billion of new investments could be raised in Africa from private investors in the next 10 years, largely in physical infrastructure for health. In order to encourage this type of investment, and to ensure that private spending achieves desired outcomes, it will be necessary to strengthen the capacity of public and private regulatory bodies, and to enhance the ability of public entities to procure services and manage contracts with private organizations. Countries can also promote tax policies that are friendly to private sector investment in the health system, and work to increase access to local and international capital for private investors in health.

Support innovative financing mechanisms for new health technologies. Innovative financing mechanisms, such as advance market commitments for vaccines and the Affordable Medicines Facility for Malaria, provide revenue to stimulate the development and manufacture of vaccines for developing countries and to facilitate widespread financial access to malaria treatments, respectively.

Improve Equity in Risk Sharing

Formal and informal private spending on health is mostly in the form of out-of-pocket spending – the most regressive and exclusionary form of health financing, which accounts for an average of 34–50 percent of total health financing in developing countries. This contributes to the financial catastrophe that more than 135 million people suffer because of the costs of health care. In addition, the absence of financial protection against health costs generates a vicious circle: families postpone seeking care because of financial barriers, suffer worse clinical outcomes, leading to foregone income, and even higher financial vulnerability down the road.

What are some options to reduce poor households’ vulnerability?

Develop and strengthen health insurance systems. More extensive and sustainable risk pooling systems are needed to harness household spending – particularly for expensive, inpatient care – in an equitable and predictable way. These efforts can take several forms:

National or social health insurance schemes;
Community-based health insurance;
Voluntary private insurance programs targeting the poor, such as schemes managed by microfinance organizations.

Explore and develop alternative micro health financing tools. In settings where insurance is unavailable or unaffordable but microfinance services are offered, savings and loans can help spread the impact of the cost of health care over manageable periods of time. Health savings accounts can help accumulate amounts necessary to cover most outpatient expenses. Health loans allow poor households to borrow the amount necessary for most inpatient care, and repay it over several months – avoiding the necessity to sell productive assets at the time of a health crisis.

Target fee exemptions and subsidies to the most vulnerable. Although large numbers of households in developing countries are financially able to contribute a small portion of the cost of health care, even small contributions may be out of reach for the poorest and most vulnerable households. Targeted subsidies via vouchers, conditional cash transfers, and targeted user fee exemptions are a central element of equitable health financing policies that have been proven to increase use.

Increase Efficiency

Even if sufficient funding for health becomes available and even if it is generated without placing an excessive financial burden on poor households, there remains an overriding need to ensure that existing and future resources are spent as efficiently and effectively as possible. According to a conservative estimate by the WHO, 20-40 percent of health resources are being routinely wasted. Addressing this means ensuring that the most effective interventions are prioritized, efficient providers (public or private) are selected, and that providers are incentivized to perform well in terms of health outcomes and quality.

What are some options to increase the efficiency of resources devoted to health?

Implement performance-based financing systems. By aligning financial incentives with the achievement of desired results, performance-based financing seeks to change behaviors among public and private sector providers by linking their payment to health outcomes and other measurable indicators of performance. Performance-based financing gives incentives to households, providers, and local governments to find on-the-ground, practical and effective solutions to health systems challenges. In addition to its ability to increase efficiency in financing, performance-based financing offers stronger incentives to health workers to provide higher quality of care and, more broadly, a better medical experience for patients.

Engage in public-private partnerships for the provision of care. By contracting with private sector service providers to expand access to high-quality services, governments and the private sector can each focus on their respective strengths. Appropriately qualified and certified private providers can bring the benefits of more efficient management and systems to the delivery of quality care, while governments can focus their efforts on raising fiscal resources for health, or subsidizing access by the poorest or most vulnerable citizens.

Increase donor coordination and put donor spending on-budget. Improving coordination among donors so that agendas and priorities are aligned with those of recipient countries increases the efficiency of resource utilization and reduces the country's reporting burden. Donor health financing that is "on-budget" (included within the country's national budget) can help to foster sustainability, accountability and transparency.

Improve public financial management systems. Improve systems to ensure that resources are used for the right purposes (financial accountability) and produce the desired results (programmatic accountability). Financial management systems in the public sector have been a problem in most developing countries due in part to lack of staff capacity, poorly functioning accounting systems (in many cases, hand-written ledgers are still used), and corruption.

The Way Forward

Health financing challenges are real, and these solutions are not simple. The good news is that, while these approaches are beneficial in their own right, they also can reinforce one another. A number of countries – Brazil, Cambodia, China, Ghana, Mali, Mexico, Rwanda, Thailand – are demonstrating that progress is indeed possible.

Lessons from these country experiences highlight three principles of good practice in health financing. First, countries need to make choices based on sound evidence, local context and robust stakeholder input. Second, external technical support must be fully objective and sensitive to country-specific needs. Third, care should be taken to balance the urgency to respond to immediate priorities using short-term solutions with the importance of careful design of long-term health financing strategy and systems that will address both current and future health needs.

Catherine Connor is deputy director, Health Systems 20/20 project at Abt Associates. Laurel Hatt is a health economist, Health Systems 20/20 project at Abt Associates. Thierry van Bastelaer is health financing advisor, Strengthening Health Outcomes through the Private Sector (SHOPS) project, Abt Associates. This article draws on Laurel E. Hatt and Lisa K. Fleisher, Toward Solving Health Financing Challenges in Africa - A Way Forward. Health Systems 20/20 project, Abt Associates Inc., January 2009.

Post a Comment

NCD Prevention Begins in the Womb

By Priya Matzen and Nicolai Lohse

As little as 10 years ago, the prevailing wisdom held was that the major chronic diseases of Westernized societies were due to poor lifestyle choices or genetic inheritance. But recent research indicates that adverse environmental conditions in the womb – undernutrition, overnutrition or exposure to harmful toxins as a result of maternal malnutrition, obesity, stress, smoking, etc. – is an equal, if not more, significant determinant of a person’s future vulnerability to non-communicable diseases.

Diabetes during pregnancy, with its associated high blood glucose levels and link to maternal obesity, creates such an adverse environment and is a condition that poses a significant risk to both mother and child if it is not detected and managed. Diabetes often occurs for the first time during pregnancy, so-called gestational diabetes. Babies of mothers with diabetes are typically larger, which contributes to health problems like damage to shoulders during birth, low blood glucose at birth, a higher risk of breathing problems, and the need for delivery by caesarean section. Gestational diabetes is also associated with an increased risk of spontaneous abortion and pre-term delivery.

Women who suffer from gestational diabetes and their offspring are at a high risk of developing chronic diseases during their lifetime. Pregnant women who experience gestational diabetes are more than seven times more likely to develop type 2 diabetes later in life – and their children are at a four to eight times greater risk of developing the disease – than those whose pregnancies were not affected by diabetes.

In a recent Lancet series on stillbirth, screening and management of diabetes mellitus in pregnancy is recommended as part of the intervention package to reduce stillbirth prevalence in countries with moderate to low rates of stillbirth. However, the positive effects of this intervention on broader maternal and child health continue to be downplayed and underestimated, particularly in countries with high prevalence of stillbirth. Based on a conservative estimate, 5 to 10 million pregnant women of 136 million pregnancies worldwide have gestational diabetes each year. Despite scattered evidence, the global prevalence of gestational diabetes appears to be increasing, reaching 17.8 percent in urban areas in India. It varies from low rates in some countries to nearly 30 percent in others. New diagnostic criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups operate with lower thresholds and are likely to increase prevalence two to three-fold, for example from 13 percent to 38 percent in the United Arab Emirates. Thus, the exact scale of the problem is likely to be underestimated, and screening is often not available or poorly implemented.

To address some of these challenges, Novo Nordisk has set up local public-private partnerships in India, Colombia and Nicaragua, working with local health authorities as well as academic and implementing partners to train health care professionals, build capacity in the health system for gestational diabetes screening and management, and test innovative ways to change the lifestyle of mothers with gestational diabetes and their families with the aim of identifying cost-effective ways of reducing the burden of diabetes-related disease both in the short and long term.

Prevention of Non-Communicable Diseases

There is a growing recognition that the development of many non-communicable diseases may have their roots in the uterine environment and up to the age of two years. A healthy pregnancy has been primarily thought of as a key to a healthy infancy and childhood, but new evidence is showing that the effects linger well into adulthood. Therefore ensuring optimal health of women and their children early in life is critical for the prevention of non-communicable diseases and intergenerational transmission of poor health

This new evidence underlines the importance of early intervention in the prenatal and early childhood years as a cost effective means of preventing later chronic diseases. Through strengthened maternal health policy and early interventions, current initiatives could be expanded to achieve multiple goals: preventing non-communicable diseases, ending the intergenerational transfer of ill health, reducing child mortality and advancing human development.

A Multi-Sector Partnership

The challenge presented by non-communicable diseases is of such a magnitude that we need to carefully consider how the global health community can have the greatest impact over the short and long term. Early Origins of Health is an initiative aiming to design timely early interventions that can reduce the risk of developing non-communicable diseases in adult life. This initiative needs a broader focus than diabetes only, and therefore Novo Nordisk is building partnerships with Johnson & Johnson, PepsiCo, Steno Diabetes Center, the World Diabetes Federation and the United Nations Foundation who will provide their expertise in the field of health literacy, nutrition, research, access to health, and connecting people, ideas and resources. In joining this effort, partners acknowledge the need for positively influencing the women’s standing in society, including the cultural, family-related, political, and societal contexts set for maternal and child health. The development of health literacy among mothers and those influencing their health will be a key indicator for the program. Our focus will be on women living in low- and middle-income countries where the unmet needs are most prevalent and where the full impact is greatest.

Policy Implications

The Early Origins of Health initiative provides a unique platform for bringing together actors from many health agendas, thereby breaking the silo focus that is too often predominating global health thinking. The initiative will foster a multi-stakeholder policy dialogue around the specific links between MNCH, non-communicable diseases, and the MDGs. The time is ripe for such a multi-stakeholder dialogue, and the concept of early interventions to address lifelong prevention provides us with a unique opportunity to bring together stakeholders also from the infectious disease communities to address integration of services at the programmatic level for a public health goal that reaches across the lifespan and across disease areas.

A strong policy statement in the outcomes document from the UN High-level Meeting on non-communicable diseases in September 2011 on the link between early environment and prevention of non-communicable diseases will spur the much needed innovation on early interventions required to turn the tide of the NCD epidemic.

Conclusions

Pregnancy provides an opportunity to intervene that may enable us to prevent non-communicable diseases over the entire lifespan. Policy makers need to recognize that the promotion of maternal health is a central component of diabetes prevention strategies. To achieve sustainable outcomes, the private sector needs to partner with other sectors and take an active role in designing practical and scalable solutions. This will also enable us to provide a healthy start to life that is passed on to future generations.

Priya Matzen is program director, Early Origins of Health at Novo Nordisk. Nicolai Lohse, MD, PhD is program director, Changing Diabetes in Pregnancy at Novo Nordisk

Post a Comment( 3 )

The Stopgap Midwife

By Hawa Talla and Lindsey Freeze

The Stopgap Midwife: that’s what her Senegalese colleagues affectionately started calling her for her willingness to work on all fronts. Like many health workers in Africa and other regions where human resources are scarce, 47-year-old midwife Céline Nataye Sow is spread thin, working beyond traditional boundaries to fill in gaps where she can. But here, as in other countries where health systems are strained, “stopgap” means much more than the phrase might conjure.

Céline, manages the Sampathe Health Post, in Thiès, Senegal (50 miles from Dakar), which serves 16,100 people. One of only a few midwives in Senegal working as a health post manager, she usually sees 40 to 45 clients per day, while serving as a constant mentor to a busy staff of 19. And under Céline’s leadership, the post has undergone major renovations and reduced waiting times. The health post now receives twice as many clients as it did before she came in 2008.

Céline lives with her 11-year-old daughter, Mamina, the youngest of her three children, in an apartment above the Sampathe pharmacy. It is about 100 miles away from her husband who is a nurse at the Kaolack Regional Hospital, southeast of Thiès. He visits every two weeks. This living situation is not uncommon for health workers – in Senegal and elsewhere. Here’s the story of one day in Céline’s life.

6 am Céline’s day starts, like that of many mothers, rising to help her daughter get ready for school. She heats water for Mamina’s shower before school and makes snacks.

6:45 am Prayer beads in hand, Céline walks her daughter to catch the bus every morning, about a hundred feet away from the house. She worries about Mamina’s safety on the road. Although road safety in Senegal has dramatically improved in the last decade, Africa still has the highest traffic fatality rate in the world.

6:55 am Before returning to her apartment above the health post, she checks on the matron and midwifery intern in the main ward. To ease staffing shortages – a strain throughout the region – Céline relies on interns from private training institutions. On average, she mentors about 30 each year.

Almost one-quarter of the people who live in the Sampathe Post’s four-to-seven-mile vicinity are women ages 15 to 49, who will likely need a range of reproductive health services during child-bearing years from family planning, HIV- and STD-testing, to antenatal and newborn care.

7:00 am Céline goes back to her apartment to enjoy a cup of coffee and get ready for her day. Putting on make-up, she pays close attention to the noises below – chairs moving, doors opening, brooms falling, staff greeting each other – listening as the health post gets busier.

8:00 am Makes her way back downstairs to start her official work day.

8:15 am Rushing to the main ward, she is alerted by the cries of a child whose foot was run over by a car. Once the child is bandaged up, Céline urges the mother to return for a follow-up visit.

8:28 am Cleaning her desk, opening the registers, and gathering the supplies needed for morning consultations. The day quickens: Céline has 22 antenatal visits, 12 family planning clients, and four general consultations – all before lunchtime.

1:30 pm After 40 consultations, Céline passes an empty waiting room. Home for lunch, Mamina waits outside. Once upstairs, they sit at the table and watch TV; Mamina calls her father in Kaolack to let him know what she’s been up to…

3:10 pm Mid-afternoon, Céline goes to a computer class – for Excel – offered by the health committee. The classes help strengthen providers’ IT skills and improve their overall productivity. At the health post level, they generate resources which complement the funds used to pay for operating costs, including water, utilities, and stipends paid to community health workers.

4:15 pm Céline attends another meeting, this time at the district health offices for a meeting on the health post’s partnership with training institutions.

From her mentor, Anna Ngom, Céline learns that a partner is about to allocate funds to buy new equipment for the Sampathe post – now, a spacious facility that includes a consultation room, waiting room, a delivery ward, another for critically injured patients, one devoted to postpartum patients, a pharmacy, a staff room and two observation rooms (one for women and one for men). In 2009, under Céline’s watch, the health committee renovated the health post in response to problems identified during an on-the-job training approach (called tutorat, introduced by IntraHealth through the USAID-funded bilateral project in Senegal).

5:30 pm – Thiès Regional Hospital – Céline trains future health workers in obstetrics, gynecology, and contraceptive technology. In collaboration with the hospital’s gynecologist, she facilitates participatory training sessions where students are encouraged to demonstrate individual leadership.

One third of low-income women in Senegal lack access to modern family planning, contributing to the country’s high maternal and newborn mortality rates. In Senegal, nearly 400 of every 100,000 pregnancies end in the mother’s death.

On the days she doesn’t teach, Céline helps community health workers from the health post organize special events that promote child health in nearby communities. They weigh children to monitor growth and nutritional status.

7:00 pm The day nears an end. Before going home, Céline goes back to the health post to see if any new patients have arrived and ensure that the nightshift is in place and everything is running smoothly in her absence.

7:40 pm At home. She helps Mamina with her homework. They talk about school. They cook and have dinner together. For Céline, it’s the best time of the day; she finally has time for her daughter and herself.

9:00 pm Céline’s day is finally over…unless something comes up at the health post during the night.

Hawa Talla is team lead, Health Partnership and Communication, IntraHealth International, Dakar. Lindsey Freeze is an external relations officer, IntraHealth International, Chapel Hill.

Post a Comment( 1 )

Disrespectful and Abusive Treatment of Women During Childbirth

Sarah Whitmarsh, MA and Maura Gaughan, MPH, MA

Most pregnant women face motherhood with mixed emotions -excitement, joy and, understandingly, nervous anticipation. In many settings, women also face uncertainty about the level of care and services available to them. What they may not anticipate is being disrespected and abused by the very people expected to care for them during labor and delivery. Worldwide, it is a problem that has been long overlooked.

When it was time for Grace, a Kenyan woman, to deliver her baby, she arrived at a maternity hospital with several relatives, who were ordered by hospital staff to leave her. Grace had to find her own way to the maternity ward and a nurse ordered Grace to "stop pretending to be in pain." As her labor pains worsened, Grace was told she had to continue suffering since she was responsible for her own pregnancy. When she crawled to nurses for assistance, they asked if she "was exercising." Later, after giving birth, Grace sat on a wooden bench with her naked newborn for six hours as she waited to be stitched. Finally, a nurse helped Grace by providing her with water and clothing for her baby.

A senior Ministry of Health official from Sub-Saharan Africa relayed the treatment her sister-in-law had received during labor in which health workers forcefully pushed on her abdomen to try to speed the delivery. "I could see them doing this to her and I did not say anything because I was so shocked...This was the first time I was exposed to this sort of thing with someone close to me. Later, I relayed what happened to the director of the hospital and he took it very easily, like this is a normal thing here...This gave me insight to when people complain and tell me this is what is happening here."

Unfortunately, this kind of treatment has been reported across a wide range of settings. Many women have reported being beaten, slapped, yelled at, and humiliated during childbirth. Others have had unnecessary procedures performed, information about their care withheld, or simply been abandoned during delivery.

Abuse and disrespect of women in health facilities has been reported in high, middle and low income countries. Women have reported feeling coerced into caesarian sections in the United States, Peru, the Dominican Republic and Kenya. A study from five Nordic countries found a prevalence of ‘any lifetime experience of abuse' in health care facilities to be between 13 and 28% among women ages 18 to 64.

What is Disrespectful and Abusive Childbirth Care?

Disrespectful and abusive maternal care represents distinct points along a spectrum that spans dignified, patient-centered care, non-dignified care, and overtly abusive care. Non-dignified maternal care may manifest in a range of ways including: subtle and overt humiliation and discrimination based on race, ethnicity, age, language, HIV/AIDS status, traditional beliefs and preferences, economic status, and educational level. Likewise, abusive maternal care can occur in a range of ways.

"Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth," a qualitative landscape analysis by Diana Bowser and Kathleen Hill of the Translating Research into Action (TRAction) Project, reviews evidence for disrespect and abuse in facility-based childbirth and defines seven dimensions of disrespect and abuse in childbirth: physical abuse, non-dignified care, non-consented care, non-confidential care, discrimination, abandonment of care, and detention in facilities.

The landscape analysis reports that while there are many accounts of disrespect and abuse in childbirth in the published and gray literature, there is no data on the prevalence of disrespect and abuse in facility-based childbirth.

Disrespect and abuse of women during childbirth is too complex an issue to simply lay blame at the feet of health care workers. There are likely many interacting drivers that contribute to disrespect and abuse in facility-based childbirth including:

• Individuals and communities may normalize disrespect and abuse during childbirth;

• National laws and policies do not exist or are not enforced;

• Leadership and governance for respect and non-abuse are lacking;

• Standards of care and mechanisms for accountability are not available or enforced at the site of service delivery

• Providers may be demoralized due to inadequacies in their work environment (e.g. lack of adequate human resources and supplies; lack of adequate supervision and access to specialty support; low salaries and lack of professional development opportunities.)

• Providers may act out prejudices found in the larger society, contributing to discriminatory care based on the specific attributes of a woman.

Some evidence suggests that disrespectful care may act as a powerful deterrent to skilled birth care utilization, a key Millennium Development Goal (MDG) indicator, in addition to other more commonly recognized deterrents such as geographic or financial obstacles.

Tackling barriers to utilization of skilled care during childbirth is one important strategy for achieving the fifth United Nations Millennium Development Goal of reducing maternal mortality. Disrespectful and abusive care of women violates international human rights laws, which states that people have inherent rights to equality, non-discrimination, and dignity and freedom from torture and cruel, inhuman, or degrading treatment.

Research to Evaluate the Problem and Promote Dignified Childbirth Care

The landscape analysis identifies programs that have applied various approaches to promote dignified, respectful care for women in pregnancy and childbirth, including improving quality of care, promoting caring behaviors, reducing stigma, and promoting accountability mechanisms, among others.

The USAID supported Translating Research into Action (TRAction)Project has awarded the Population Council and the Columbia University Mailman School of Public Health's Averting Maternal Death and Disability (AMDD) Program two year grants to conduct separate implementation research studies on the topic of disrespect and abuse of women during childbirth at clinic-based facilities. The Population Council will perform implementation research to in five districts in Kenya and AMDD will carry out its work in two districts in the Tanga Region of Tanzania.

The research will start with a baseline assessment to examine incidence, prevalence, and primary manifestations of disrespect and abuse in facility childbirth and to explore potential contributors to the problem. Results of the baseline assessment will guide the design, implementation, and evaluation of targeted interventions to reduce disrespect and abuse and achieve dignified childbirth care.

Global Efforts to Improve Respectful Care of Women during Childbirth

The White Ribbon Alliance for Safe Motherhood (WRA) recently launched the "Respectful Care at Childbirth" campaign. WRA and its partners will form a Leadership Action Committee to Promote Respectful Care at Birth to provide global leadership in raising awareness of disrespectful and abusive care of women. The WRA will also foster country-level partnerships to affect policy change. This evidence may be used to enable the development of effective policies and approaches which could be scaled up and adapted at the national and local level.

The US Global Health Initiative principles call for a woman-and girl-centered approach to improve health outcomes by expanding access to improved, high quality, primary healthcare services. Implementation research on disrespectful and abusive care of women is a necessary approach to stop abuse and increase use of quality skilled birth care. With this strong commitment and a rigorous approach, the time is ripe to uncover, understand, and eliminate the long-veiled problem of disrespect and abuse of women in pregnancy and childbirth.

Sarah Whitmarsh, MA currently works as a specialist at University Research Co., LLC - Center for Human Services and Maura Gaughan, MPH, MA is a research analyst at URC-CHS.

Post a Comment( 6 )

Women and Girls in a Changing World Photography Contest

Tina Flores

A young girl performs a dance about standing up to violence in her community as part of International Medical Corps' recognition of International Women's Day. Since the earthquake over a year prior, she has lived in a displacement camp in Port-au-Prince, Haiti.

The winner of GLOBAL HEALTH Magazine’s photo contest, Women and Girls in a Changing World, is Chessa Latifi a program officer for International Medical Corps in Haiti. Latifi began taking photographs while visiting Kosova after the 1999 war, where much of her extended family lives. She has worked for International Medical Corps in Iraq and now in Haiti, where she oversees an emergency response program that includes four primary health clinics, several dozen water and sanitation projects, and a disaster risk reduction program as well as an emergency medicine development program at the largest hospital in the country. These pages feature a selection of Latifi’s other work from Haiti.

Q&A with Chessa Latifi

When did you start taking photographs?
My earliest pictures are from visiting Kosova after the war in 1999. At 15 years old, I was intent on documenting the destruction with a 35mm Nikon. I don’t have the negatives anymore, but I have the old prints of rubble, graffiti, bullet holes, and one portrait of my grandmother that I still cherish.

What has finding photography meant to you?
It means I can convince people that these far corners of the world – Haiti or Kurdistan, for example - are not what they believe. These places are oftentimes much more wondrous than expected.

What do you think is special and unique about the winning image?
Much of her dance was listless, just moving through the steps. And then, at the captured moment, she burst out and really expressed herself. It was beautiful.

Any advice for people looking to get into photography?
First, put your camera down and look around. You want to see your surroundings with your eyes first, not your camera lens. Then, pay attention to your composition.

What has been the most moving experience for you in the field?
It was actually the moment captured in the winning photograph. This girl really expressed herself, and it was amazing to be there to witness it, and feel like I had a small part in giving her that platform at International Medical Corps' clinic.

What does photography give to global health? Photographs provide a connection to and awareness of a subject to an audience.
In a world of growing distractions, a photograph is evidence of the true reality of others.

Post a Comment( 2 )

Young People Need Evidenced-Based Information Too

Ishita Chaudhry

I grew up in India with very little information about my sexuality, my body, or my right to health. My first memory of being taught about the human body was in primary school, when my teacher listed our body parts, “Head, face, neck, shoulders, stomach, hands, knees and toes.” I remember my friend asking the teacher, where the vagina was. We’d read the word in a book and didn’t know what it meant. We both got yelled at, with my friend being sent to the principal for “inappropriate conduct” and my class being given a lesson in how children from good families didn’t read “dirty things.” I was 10 years old at the time.

Sixteen years later, at a workshop on sexuality education with young people in Delhi, a 20 year-old female college student from a well-known university asked one of my colleagues if the clitoris is in the foot and is an organ that keeps the heart healthy. Her question is not unusual. My colleague took it in stride and provided her with accurate information.

It’s disappointing that throughout the course of our youth and adolescence, so many young people do not get even basic information about their anatomy, and even more disappointing considering that there are 1.2 billion people between the ages of 10 and 19 in the world today – the largest generation of adolescents ever. Young people, especially girls and young women, face great challenges to their well-being and their human rights. To face these challenges young people need evidence-based, accurate information about their sexual and reproductive rights and health, as well as support and skills to feel comfortable and confident about their bodies and their sexuality.

Today The YP Foundation, an organization we founded when I was 17 in 2002, has grown from three high school students working from my parent’s bedroom to a journey that has brought together 300,000 young people across India. In the last 9 years, we have created more than 250 projects in India that promote, protect and advance young people’s human rights by creating programs and influencing policies that build leadership and strengthen youth-led initiatives and movements.

Together, we created India’s first youth-led and run campaign for legalizing and supporting the implementation of sexuality education across India. Our program, “Know Your Body, Know Your Rights,” has trained more than 300 young activists from different communities across 10 states in India, using social networking, poster campaigns, national and state level meetings to bring over 4,800 young people’s voices to the fore. For the first time, young people’s voices will reach policy makers. We are speaking up to our governments on our needs, aspirations and rights to accurate, life saving information on comprehensive sexuality education that is free from stigma, fear and judgment.

We are at a historic moment: strong movements of young people are gaining momentum for their agendas centered on human rights and social justice. Young people’s lives are increasingly shaped by trends towards democracy and the rise of civil society. We must seize this opportunity and ensure that young people have the information and skills they need to navigate adulthood safely.

This is the way that it should be, and until every woman and every young person in every part of the world can lead just and healthy lives, our work is not done and we cannot go back to the comfort of our silences.

Ishita Chaudhry is founder of the YP Foundation in India.

Post a Comment

Moving Toward Gender Equitable Health Organizations

Sarah Johnson, Ummuro Adano and Willow Gerber

There have been significant investments in gender mainstreaming and training staff in health organizations to be “gender-sensitive” or to undertake “gender analysis.” However, these efforts to date have generally focused on changing attitudes and behavior of individual staff members, rather than changing the way the broader organization works. Change in the way health organizations address or remedy gender-based inequality has been minimal What’s needed is an organized approach that requires people to work together to create new ways of acting within organizational functions that will lead to gender equity.

With workforces ranging from five to 10 people to thousands of staff, local public sector institutions and NGOs delivering health services are not immune to the social differences between females and males learned throughout the life cycle and rooted in culture. Although change is occurring, hierarchical and patriarchal structures still exist; organizational culture is often more sensitive to men’s needs than women’s, work may be valued differently for women and men – either overtly or subliminally – and, at worst, flagrant gender discrimination as well as sexual harassment and abuse may exist. The net result is under appreciation and under utilization of women at different levels of the organization, which affects not only working women but also productivity and the delivery of health services.

Gender equity is not just an issue of human rights and justice; it is also a winning business formula. If women are to reach their full potential as health managers, leaders and workers, then health organizations and institutions must do more. Using existing organizational development frameworks and tools can help.

ENTRY POINTS FOR CAPACITY BUILDING

Organizational capacity building is defined as the strengthening of internal organizational structures, systems and processes, management, leadership, governance and overall staff capacity to enhance organizational, team and individual performance. Effective organizational capacity building consists of evidenced-based approaches to meet a hierarchy of needs over time and it must occur with the full support of the organization’s leadership. At a time when attention is being placed on country ownership and health systems strengthening, organizational capacity building has a key role to play in strengthening institutions. It can also help to create gender supportive organizations.

There are existing tools and approaches that can be used to promote greater equality within health institutions. The seven Gender Quality Principles offer standards to organizations and institutions by which progress can be assessed and measured.

The AIDSTAR-Two project’s organizational capacity building framework is developed around a set of core organizational functions that must be present and functioning effectively in a sustainable institution. This framework speaks to many of the gender quality principles and also illustrate different entry points for assessing and addressing gender within organizational capacity building.

ORGANIZATIONAL ASSESSMENTS

Even well managed successful organizations must constantly assess and adapt their management practices as demand and environments change. Typical organizational assessments evaluate the current capacity of management components including organizational mission and values, strategies, structure, and internal management systems. These instruments can be easily adapted to also assess current organizational capacity and performance in gender equality, for example, examining the organization’s human resource policies. Much can be borrowed from the existing literature and toolkits on gender best practices and gender integration to adapt these tools; alternatively, organizational development assessment tools can be used along-side existing gender tools.

MISSION, VALUE AND STRATEGY

It is worthwhile to review the organization’s mission as well as the presence or absence of stated organizational values on gender equity. Organizational strategies – the broad approaches used to achieve the organizational mission – are often set during a strategic planning processes. Strategic planning offers an opportunity to assess external threats and opportunities and internal strengths and weaknesses and develop overall strategic objectives and strategies to reach a defined shared organizational vision set 2-3 years in the future. Such planning processes are an appropriate time to look at strategies to address gender equity.

STRUCTURE

Structure – which encompasses the formal lines of authority of an organization, distribution of responsibilities, the way that decisions are made, and internal communication mechanisms – answers the question, are we organized in a way that facilitates what we want to do and where we want to go. Adjusting the organizational structure, assigning new roles and responsibilities to managers and staff, and improving internal communication effectiveness may help to facilitate an overall effort on gender strengthening and put women in new roles.

MANAGEMENT SYSTEMS

Senior leaders, advisory or governance bodies with the support of HR officers, must examine the composition of their workforces and the roles and positions of women.
Assessment and improvement in internal management systems, such as the human resource management system, can help assure that policies on recruitment, salaries, promotion, support and supervision are aligned with gender equity objectives. Promoting mentoring programs for women so that they have role models, and staff trainings in gender knowledge and skills and team building can also be useful. Multiple curricula on gender skills building exist. Improvements to other management systems can also contribute to overall institutional gender strengthening. For example, gender-sensitive indicators within the organization’s information and M&E systems are important for measuring progress, raising awareness of issues, improving the evidence-base for decision making, and helping to identify the exact issues that need priority attention.

PARTNERSHIPS, EXTERNAL RELATIONS AND NETWORKING

Organizations can partner on joint programming initiatives on topics such as violence against women and girls, anti-discrimination, and equal pay for equal work. Multi-stakeholder partnerships can include task forces that identify and tackle any of these and many more topical issues that enhance gender parity.

GOVERNANCE AND LEADERSHIP

Organizational leaders – men and women alike – play the single most significant role in fomenting and institutionalizing good practice in gender inside their organizations and worksites. Support and actions from senior leadership, including board of directors and advisory boards, are of fundamental importance, and might include public statements on gender equity, assessment of and changes in institutional norms, and modeling behavior.

Leadership development programs serve to strengthen leadership competencies and skills to address challenges such as internal organizational gender policies and practices and career pathways for women or lack thereof. Change management practices and processes, a part of sound organizational development, must be used across all these and other activities to build gender equity and to assure that best laid plans are actually executed and produce measurable results.

CONCLUSION

Health and equity improve when an organization commits to gender mainstreaming, institutionalizes gender equitable internal policies and procedures, improves technical competency in gender integration, and pays attention to gender differences in the design of programs and measures impact.

Speaking at a conference on gender at Radcliffe, Brigham Young University Professor Valerie Hudson reaffirmed what has been said many times and is supported by evidence, “There is no policy more effective in promoting development than the health and education of women.”

Indeed, organizational health will also be greatly improved by planning and implementing effective organizational capacity development initiatives aimed at gender equity inside health institutions. Organizational capacity building, oriented by gender equity principles and frameworks for assessment, action and measurement can play a significant role in promoting gender equitable organizations.

Sarah Johnson is the director of the AIDSTAR-Two Project, Management Sciences for Health (MSH). Ummuro Adano is the deputy director and senior capacity building advisor for AIDSTAR-Two. Willow Gerber is the knowledge management officer at AIDSTAR-Two.

Post a Comment( 2 )

Maternal and Child Undernutrition: Translating Evidence and Rhetoric into Action

Tom Arnold and David Beckmann

Will 2011 be remembered as a turning point in the global effort to combat maternal and child undernutrition? Although it’s an effort that has been the subject of much research and rhetoric in recent years, concrete action has lagged behind the indisputable data and the strong words. But in the last several months, we are starting to see real evidence of forward momentum; and in the coming months there will be new opportunities to increase this momentum. National governments, the United Nations, civil society organizations, development agencies, academia, foundations and the private sector are committing themselves with growing urgency and focus.

Adequate nutrition is critically important during the first 1,000 days (from pregnancy to 2 years of age) of a child’s life. There is conclusive evidence of the impact of undernutrition on infant and child mortality and its largely irreversible long term effects on health and on cognitive and physical development.

Globally, malnutrition is an underlying cause of one-third of all maternal and childhood deaths, in large part because young children who are malnourished are more susceptible to illness and life-threatening health conditions. Child malnutrition is further responsible for 11 percent of the global disease burden, thereby hindering progress toward the Millennium Development Goals. This evidence has underpinned a number of recent political and policy initiatives aimed at improving early childhood nutrition.

A NEW CONSENSUS

Undernutrition causes an estimated 3.5 million maternal and child deaths annually. As U.S. Secretary of State Hillary Rodham Clinton said, “These deaths are intolerable because they are preventable.” Today, 195 million children are stunted. This is a third of all children in the world who are younger than 5 years-old. Of these, 90 percent live in just 36 countries, 21 of which are in sub-Saharan Africa. In some African countries the proportion of children stunted is as high as 50 percent.

In January 2008 the Lancet issued a five-part series on nutrition which provided evidence on the impact of early childhood undernutrition. The most common form of malnutrition across the world is micronutrient deficiency, which affects 2 billion people. The four most widespread deficiencies are in vitamin A, zinc, iodine and iron, which are associated with 10 percent of all deaths in children under 5.

Malnourished children are more at risk of contracting illnesses such as diarrhea, malaria and pneumonia. They are more likely to grow up to be shorter adults. Malnourished girls are more likely to give birth to low birth-weight offspring, contributing to a multi-generational cycle of malnutrition. Impaired cognitive function leading to lower educational performance and economic productivity means child undernutrition hinders economic development. In Zimbabwe, children who were stunted at preschool age started school seven months later, lost an average of 0.7 grades of schooling and earned 12 percent less over their lifetime, a trend mirrored in many studies. Where childhood malnutrition is pervasive, the loss to GDP can be as high as 2 to 3 percent, not including the indirect costs of malnutrition such as health care and lost wages due to illness.

The barriers children, young women and mothers face in meeting their nutrition needs include poverty, a lack of education on healthy diets and infant care, a lack of access to a diverse variety of nutritious foods, a lack of access to adequate health care and sanitation, restrictive cultural practices and low social status. In countries where gender inequality is great, high rates of hunger also occur as female members of a household will ‘eat least and last.’

Low rates of exclusive breastfeeding also inhibits a child’s growth and development and ‘suboptimal’ breastfeeding results in the death of 1.4 million young children each year. Complementary foods, ideally introduced at 6 months, may also be unavailable, of poor nutritional quality or introduced too early or too late.

WHAT CAN BE DONE?

The Lancet series indentified proven, high impact and cost effective interventions focused on the “window of opportunity” from minus 9 to 24 months (i.e. the first 1,000 days) to reduce death and disease and prevent irreversible harm.
The steps that need to be taken include:

Direct nutrition-specific interventions focusing on pregnant women and children younger than 2.
Nutrition-sensitive multi-sectoral approaches such as supporting agricultural development, improving social protection and ensuring access to health care.

In 2009 the World Bank identified a package of 13 interventions for the first 1,000 days (C see table online). The World Bank estimated the total cost of the 13 interventions in the 36 highest burden countries at $11.8 billion annually, of which $1.5 billion would be absorbed by households. That package of interventions would save the lives of 1 million children annually.

A PLAN OF ACTION

In April 2010, A Framework for Action to Scale Up Nutrition (SUN) was launched to advocate a better focus on child undernutrition. It was endorsed by more than a hundred entities, including national governments, the United Nations, civil society organizations, development agencies, academia, foundations and the private sector. The Framework was followed by the development of A Road Map for Scaling Up Nutrition, which was launched at the UN General Assembly Summit for the Millennium Development Goals in September 2010. A transition team, chaired by the UN Secretary-General’s Special Representative for Food Security and Nutrition, Dr. David Nabarro, is now in place to oversee the SUN Road Map.

The SUN Road Map envisages three stages of country participation: (a) national authorities taking stock of the national nutrition situation and of existing strategies, institutions, actors and programs; (b) national authorities developing their own plans for scaling up nutrition; (c) rapid scaling up of programs with domestic and external financing.

The aim is that countries ready to scale up nutrition will start to receive intensive support from the international community by the end of 2011. To date, ‘early riser’ countries include: Bangladesh, Ethiopia, Guatemala, Malawi, Mozambique, Nepal, Niger, Peru, Senegal, Tanzania, Uganda, Mali, Rwanda, Sierra Leone, Ghana, Haiti and Zambia.

The governments of countries facing the greatest undernutrition problems must be the main investors in efforts to scale up nutrition. But they need support from the other stakeholders committed to improve nutrition. National health systems which integrate improved nutrition practices need sustained investment and trained personnel. Additional financial resources will be required, some from a re-prioritization of national resources and international aid, others from additional net resources for early childhood nutrition. The social and cultural barriers to achieving improved child nutrition, including the low status of women in many societies, must be honestly acknowledged and addressed.

The SUN transition team draws on the work of six task forces rallying for sustained support for SUN actions within participating countries. They deal with (a) national capacities and systems strengthening, (b) advocacy and communications, (c) social mobilization, (d) engagement of development agencies/donors, (e) involvement of the private sector in nutrition sensitive sustainable development and (f) monitoring and evaluation.

CALL TO ACTION

SUN is supported by the 1,000 Days advocacy initiative that focuses attention on the 1,000-day window of opportunity between pregnancy and a child’s second birthday, when adequate nutrition has the greatest impact on saving lives and on cognitive and physical development. The initiative aims to rally support for nations to improve their people’s nutritional status within 1,000 days – i.e. between the 2010 MDG Summit and June 2013.

Bread for the World and Concern Worldwide participated in the 1,000 Days launch, calling for a broad set of voices and actors to speak up about the urgency and importance of scaling up nutrition interventions, especially in the first 1,000 days.

A June 2011 summit meeting sponsored by the two organizations is one of a number of initiatives designed to organize a voice for civil society in order to maintain and build on the political momentum.

We must do all we can to sustain political commitment to address the issue of maternal and child malnutrition, bolster and reinvigorate champions of this issue and help recruit new champions. We must help develop a shared advocacy agenda and strategy for the planned follow-up event at the next UN General Assembly and the upcoming G20 Summit, including a focus on financing to mobilize the additional resources needed to scale up nutrition.

The international nutrition community has accumulated extensive evidence concerning the burden, consequences and effective interventions related to undernutrition. Countries and their partners have extensive knowledge and experience concerning the management of multi-stakeholder platforms and the capacities needed for scaling up nutrition. A global momentum is building for a renewed effort to translate these assets into large-scale improvements in the nutrition of high burden countries.

The coming years will be crucial for sustaining the commitment, the capacities and the coordination for these efforts to succeed. There are important roles in this process for members of the global health community and we look forward to building momentum to scale up nutrition interventions, especially in the first 1,000 days of a child’s life.

Tom Arnold is CEO of Concern Worldwide. David Beckmann is president of Bread for the World.

Post a Comment( 1 )

What Happens After Women Come Through the Door?

Steve Hodgins

The UN Secretary General has led an initiative to which $40 billion has been committed for maternal-child health. This has resulted in the formation of the Commission on Information and Accountability for Women’s and Children’s Health. The Commission, in turn, has formed a Working Group on Accountability for Results, chaired by Lancet editor Richard Horton, which has been tasked with recommending how results should be tracked and proposing a short list of indicators.

For maternal health, the working group has recommended tracking maternal mortality ratio and “attendance by a skilled provider.” Although not reflected in the proposed indicators, their recommendations included a strong call for attention also to be given to quality of care. This is to be commended. It is important to make the content and quality of care a priority, rather than only tracking contact with the health care system, which is really all we are measuring using the standard indicators of skilled birth attendance and antenatal care visits.

With significant new funding commitments for improving women’s and children’s health over this past year, we have a valuable opportunity to effectively focus the attention of policy makers, donors, program managers and technical assistance partners in a way to bring about substantial gains in health status.

Identifying suitable indicators is challenging; there are several important criteria to be met. First, they need to be effective for policy advocacy. That means, in the words of Stephen Harper, which Richard Horton quoted in his comment in the Lancet on Feb. 5, that we need “to strip out the complexity, boil the problem down, decide on a few priorities, choose a ‘few simple things.’” Furthermore, indicators chosen need to be measurable with some reasonable degree of validity. And finally, and this is the point I want to emphasize here, they need to communicate appropriate signals to program managers. This is important because as program managers we focus our efforts on what we are required to measure.

As global benchmark indicators, we have been relatively well served by those used for child and newborn health. Most measure use of specific technical interventions or household practices with a direct and well established causal link with mortality risk (e.g. percentage of children sleeping under an insecticide-treated mosquito net, percentage of children with diarrhea treated with oral rehydration salts, percentage of children aged 12-23 months who are fully immunized). Using indicators with such characteristics, we communicate a clear signal to policy makers, donors and program managers that they need to marshal their efforts to increase coverage of these effective interventions and practices.

For maternal health, however, we have relied heavily on skilled attendance at birth and antenatal care, both of which have been measured only as contacts with the health care system. Noticeably absent as benchmark indicators for maternal health has been the content and quality of care. This has meant sending a signal to program managers that what is important is getting women through the front doors of their health facilities.

The Working Group on Accountability for Results has recommended skilled attendance at birth as one of its very short list of recommended indicators. While this may be necessary and appropriate, I would like to make a plea to the Commission for clear language also to be included in its final recommendations on accountability that clearly draws attention to the importance of content and quality of care.

In this connection, it is relevant to note that in an increasing number of countries, use of oxytocin (or other suitable uterotonic) during the third stage of labor is now being included in national health information systems (e.g. in Senegal, Chad and several countries in Latin Ameria). Like the benchmark indicators used in child health, this indicator meaningfully measures rate of use of an intervention effective in driving down deaths due to one of the most important causes. Although most countries are not yet in a position to report on this indicator, this is almost ‘ready for prime-time.’ As we look to how best ensure accountability for results under the new maternal-child health initiative, and as we look to the challenges of achieving MDGs and how best to measure progress, an indicator like uterotonic use in the third stage of labor (which addresses the principal cause of maternal deaths in sub-Saharan African and South Asia) is a good example of the kind of measurement of content and quality of care that is needed. Use of such indicators at the highest policy level sends a clearer message to program managers that they need to give serious attention to what happens after women come through the front door.

Steve Hodgins is the global team leader of USAID’s flagship Maternal and Newborn Child Health Program MCHIP/John Snow Inc.

Post a Comment

2011 Photo Contest: Women & Girls in a Changing World

Katrina Overland

VOTE for your Favorite Photos

Thank you for participating in our photo contest, Women and Girls in a Changing World. We have more than 500 entries (although not all of them are visible to the public). To help us select the best once, we invite you to vote for your favorite photos by clicking the "Favorite" button on the top left corner above the image. The fan favorite will be featured in the spring edition GLOBAL HEALTH Magazine. Voting starts today and ends at noon, April 15. Tell us your favorites by visiting our Flickr page, Women & Girls in a Changing World. The contest ends at noon on April 15, and winner will be featured in GLOBAL HEALTH Magazine.

Images can be powerful.

GLOBAL HEALTH Magazine wants to harness that power by giving you the chance to share your images with the wider community. GLOBAL HEALTH Magazine's photography contest invites both amateurs and professionals to submit selections of their work which bring to bear the issues of global health. We are looking for photos that convey emotional depth and understanding of this year's theme, Women & Girls in a Changing World. While some global health concerns are often difficult to discuss, photography can help tell a story that be overwhelmed or obscured if told with words.

Post a Comment( 2 )

Moldova: What Happens to MDR-TB Patients?

David Rochkind

Moldova has one of the highest rates of multi-drug resistant tuberculosis (MDR-TB) anywhere in the world. This deadly strain of the disease can emerge as a result of low quality health systems, poor quality drugs, lack of accessibility to treatment, and when a patient intermittently takes his medicine or fails to complete his treatment. After the fall of the Soviet Union, Moldova faced a huge economic shortfall, which exacerbated all of these conditions. The health care system crumbled, poverty rose and the country became more vulnerable to the emerging TB crisis. It is now estimated that 44 percent of all TB patients in the country are infected with MDR-TB.

MOLDOVA: WHAT HAPPENS TO MDR-TB PATIENTS? from Global Health Council on Vimeo.

As hospitals closed down and jobs became scarce, very few social programs were put in place to help manage the myriad of problems that the country’s population was now facing. In essence, TB patients were left on their own to deal with the consequences of being infected with a contagious disease they knew very little about. Over the past 10 years the country has begun to implement new programs focusing on TB, but there is still very little education about the disease and even fewer resources to help treat and prevent it. TB seems to take a back seat to other social and health issues, evidenced by the fact that there are only four organizations in the country that work on tuberculosis. While the overall TB numbers have dropped or stayed stagnant in recent years, the number of MDR-TB patients has risen, showing that Moldova’s infrastructure is currently incapable of dealing with the complex problems that TB treatment and prevention present.

Speranta Terrei is a small NGO that works in Balti, a town in northern Moldova that has one of the country’s highest TB incidence rates. The organization is the only one in the city that works on TB; it is underfunded and staffed mostly by volunteer community health workers. Their admirable work falls short in the fight against TB not because of a lack of knowledge or will, but rather due to a lack of funding and resources. They consistently work to spread awareness about the disease, and provide patients with home health care that helps them correctly adhere to their treatment, but their staff constantly strains to reach patients on such a small budget.

Likewise, Balti’s TB hospital suffers from a lack of resources and consistently operates 10 to 20 percent above their capacity of 200 patients. In 1999 the old TB hospital in Balti was closed as the government looked to make budget cuts and, according to local doctors, determined that the size of Balti did not warrant such a large TB hospital. The new hospital is smaller, has fewer resources and faces daily struggles to meet the needs of the city’s TB patients.

Balti has more than 50 people who have a form of TB that does not respond to any medication – meaning the patients have no treatment options. What was once a treatable disease has produced lethal strains that leave some patients with no options but to try to stay comfortable while they wait for the inevitable. If proper measures are not taken, MDR-TB could spread to more of the general population in Moldova and beyond.

David Rochkind is a photojournalist whose work in Moldova was sponsored by the Pulitzer Center on Crisis Reporting.

Post a Comment( 3 )

Why We Need Men to Save Lives

Koki Agarwal

An interesting aspect of working on women's health in the developing world is that it is often the men who hold the keys to improving maternal health. In many low-resource settings, men are the primary decision-makers for the family - from determining the number of children to the timing of pregnancies, and even whether women can seek health care for themselves or their children. We have been hesitant, in many cases, to engage men in what has traditionally been seen as a women-centered issue. But to improve maternal health outcomes in developing countries, men must be considered equally important to reach as women.

Our program work shows that males can become valuable allies in addressing health issues. Time and time again we have seen maternal health programs benefit from the positive roles men play within their communities. Educating and empowering men to become more involved in maternal and health issues not only improves outcomes for the mother and baby, but can mean the difference between life and death in cases of complications, when women need immediate medical care. However, men also need to see the advantages for themselves and be key contributors to the dialogue. When equipped with the right knowledge and information, men can begin to understand the role they can play as a leader in the community, the societal benefits of a healthy family and the resulting economic growth that can be achieved. The care and support of an informed husband can go a long way, not only within his own family unit, but also within the community at large.

In Northern Nigeria, for instance, men are encouraged to take an active role in their partners' pregnancies in an effort to reduce maternal deaths. As a result, even in a region where women have little access to education, are predominantly confined to domestic activities, and have few economic opportunities, their husbands' permission to form "savings and loans clubs" has dramatically improved the handling of emergency health problems for pregnant mothers and their newborns.

Comprised of women of reproductive age and older, members of these clubs engage in group lending to support each other's needs. Members of the clubs operate and maintain two major savings portfolios every week on a regular basis. The first savings is collected for paying small interest bearing loans to their members to engage in small scale businesses and the interest charged ranges from 5 to 20 percent. The second savings is collected for emergency obstetric and newborn care and does not attract an interest because it is meant to solve emergency health problems for pregnant mothers and their newborns. Any member of the club that needed financial assistance for emergency obstetric and neonatal care made her intention known during regular meetings.

The activities of the loan clubs showed that women - with the support and encouragement of their male family members - can contribute significantly to reducing complications associated with pregnancy, labor and delivery. And much of the success of these clubs can be attributed to the use of male birth spacing motivators, who are community volunteers trained in communications, to help local men achieve their vision for a healthy community.

Men in Northern Nigeria have embraced the Mothers Savings and Loans Clubs initiative because they found that it was financially empowering their wives and indirectly reducing demands on husbands. Furthermore, because of the financial benefits derived from the program, men have not objected to the educational messages being delivered during the meetings such as recognition of danger signs in pregnancy, during and after child birth and in newborns. They also did not object to messages on healthy timing and spacing of births and family planning. In short, the clubs have served as an appropriate vehicle for getting maternal and newborn health messages across to women.

And this is not unusual: we have seen better outcomes in our programs throughout the world when we and our colleagues engage men. In other parts of Africa - such as Kenya, Tanzania and Malawi - this includes teaching women to prevent HIV transmission to their children and encouraging them to bring their male partners to clinics for follow-up treatments.

In Asia, the trend is the same. Afghanistan has projects that train community midwives with the help of the local council of male village elders, who have consented to let the women attend training and assist in births when they return to the community. And in the conservative eastern region of Bangladesh, male groups are trained to deal with the unexpected complications that can arise during pregnancy. As a result, in a setting where less than 10 percent of the women have facility births, Bangladeshi men have set aside funds for transportation to hospitals in case of maternal emergencies, something that would have been impossible without their allowance.

Engaging men means reaching out to community elders, leaders and religious groups, but there are challenges in reaching men, who are often away at work. We need to continue to work to reach them where they are - mosques or job sites, such as the mines in South Africa - knowing that a 75 percent reduction in global maternal deaths by 2015 is only possible with their involvement in the countries that need it most. We have definitely seen better outcomes in health programming when we engage men in our programs and as a result, have seen women become agents of change themselves. We must continue to do our part to recognize the importance of their role in saving the lives of women and children across the globe- and encourage our colleagues to do the same.

Koki Agarwal directs USAID's flagship Maternal, Newborn and Child Health Integrated Program.

Post a Comment( 5 )

Stigma Research to Build Better Mental Health

Rebecca G. Palpant, MS

Today, we can map the course of a seizure as it travels across the brain or pinpoint where memories exist in the inner recesses of the mind. We have medicines that are so technically advanced they target specific types of neurons. The genetic and biological causes of some mental illnesses have been identified after decades of research. Despite all of this progress and the tremendous growth in availability of cost-effective treatments, we still know so very little about how to prevent or reduce the stigma against mental illnesses, which can be as damaging to a person’s health and well-being as the illness itself.

Stigma, a mark or label that leads to discrimination, remains one of the greatest barriers to people seeking treatment worldwide. Stigma against mental illnesses is linked with heinous forms of discrimination and human rights abuses, with some of the most disturbing violations taking place in psychiatric hospitals. In both developing and wealthy nations, mental health services and institutions are chronically underfunded and understaffed, functioning largely as crumbling warehouses for the suffering rather than providers of rehabilitative care.

Mental illnesses are some of the most expensive and disabling conditions – they represent five of the top 10 leading causes of disability worldwide for men and women in their prime.¹ The disease burden, alone, is greater than that of all cancers combined. Stigma and discrimination often define the barriers that prevent so many from accessing less costly and effective early interventions critical to maintaining a productive and meaningful life. If millions of people in both developed and developing countries could access appropriate mental health treatment without fear of labeling or discrimination, and could remain as productive and contributing members of the community, the economic benefits to communities would be countless.

The Movement for Global Mental Health, BasicNeeds and The Carter Center, among many other mental health groups, are working to identify innovative ways to address the barriers to providing evidence-based treatments where mental illnesses are highly stigmatized and discrimination is pervasive. In Liberia, for example, approximately 40 percent of the population is believed to suffer from a range of mental health disorders, including post-traumatic stress disorder (PTSD), after a long and brutal civil war. The Liberian Ministry of Health and Social Welfare has committed to improving mental health in the nation, but faces many challenges, not the least of which, according to preliminary research conducted by The Carter Center, are prevailing myths on the causes of PTSD. For example, there is a belief that PTSD is caused by having committed a crime or wrong-doing during the war, and that those who suffer from it deserve such a punishment.

In developing countries, stigmatizing attitudes are more widespread across various illnesses and not necessarily associated with just mental health. But the myths and misunderstandings about mental illness are just as concerning in developed nations. In many parts of the developed world, violence and serious mental illnesses are inextricably linked, perpetuating the stereotype that people with mental illnesses are to be feared with very little evidence to support a significant relationship. In fact, data indicate that people with mental illnesses are far more likely to be violated than those without the experience of mental illness.

Great strides have been made in the field of mental illness stigma research over the past decade through the efforts of many people that have devoted their careers to this issue. But much more needs to be done. We are learning a great deal about how to increase knowledge and understanding of mental illnesses – more people now believe in the effectiveness of treatments. Progress, however, in the area of changing attitudes and behaviors has been challenging.

Finding ways to advance quantitative research in the area of stigma research could advance the field in new and bold ways. More work is needed to build outcome measures for methods to address the intractable problem of stigma and discrimination associated with mental health problems. Millions of dollars and the hard work of untold numbers of consumers and advocates continue to drive wide-reaching anti-stigma campaigns in many countries. We must do better in providing the evidence to support anti-stigma messages and initiatives, not only validate their effectiveness, but ensure that they aren’t doing more harm than good.²

Recent findings indicate that touting mental illnesses as brain diseases – “a disease like any other” – in some cases has inadvertently encouraged the belief that there is nothing one can do to prevent these diseases. The impetus behind the approach was to help people understand the physical component of mental health using general health terminology, but instead, it led people to believe that the illnesses are permanent, leading to the notion that nothing should be done to change unsupportive social and physical environments that adversely affect mental health (e.g., lack of good parenting skills; poverty; living in conflict/war-prone areas).

Table 1³

Positive Developments	Negative Developments
Increase in willingness to discuss mental illness	Increase in association with violence
Increase in willingness to seek help	Permanence implied with genetic/brain approach
Belief that meaningful lives are possible for those with the experience of mental illness	Belief that the general public is uncaring and unsympathetic

Gaps in the Research
The field of mental health stigma research is in its infancy, and only recently has research begun driving a comprehensive and well-defined agenda to improve our knowledge base on this issue. Of paramount importance is the development of consistent measures endorsed by the field. Critical to the success of these endeavors is the establishment of an outlet for information exchange of projects that select a problem, define it, determine how to measure it, create a program to address the problem, and measure the results and outcomes. The Carter Center is an affiliated organization with the journal Stigma Research and Action, set to launch in January 2011 that will help provide one of the first such formal venues to share this information.

The future directions for the field should center on a demonstration of cause and effect relationships. By changing knowledge and attitudes about mental illnesses, can behavior consequently be changed? Additionally, how might positive behaviors be enhanced instead of focusing on stopping negative ones? The most pressing question is how to address the perceived connection between mental illnesses and violence, which is one of the most significant causes of stigma and discrimination against these disorders.

The media play a key role in perpetuating these stereotypes and more work should be done on how best to inform them about inaccurate depictions as well as going further to encourage sensitivity and balance. The Rosalynn Carter Fellowships for Mental Health Journalism is an ongoing initiative to encourage journalists to explore a timely mental health topic over the course of a year and complete a major media project connected to their work. The field could benefit from the evaluation of other mental health and media initiatives to assist in guiding further development of these important programs.

Those with the lived experience of mental illness can provide critical “on the ground” information and insights that are invaluable, but not often sought by the field. This sizeable gap provides a major barrier to progress, and mental health consumers must inform future thinking and directions in the field. Their voices can be the best guides in identifying targets for stigma research as well as desired outcomes.

Future Directions
Critical to the success the field of mental illness stigma research has achieved over the past decade have been the key partnerships and coalitions formed globally. There are lessons to be learned from other stigmatized health conditions and public health campaigns, and they should be shared in a structured and consistent process. The field holds substantial professional opportunities for the next generation of bright and innovative researchers if they can be engaged and their interest cultivated.

Other areas for further exploration include an examination of the contribution of mental health professionals to perpetuating or reducing stigma, exploration of attitudes of children, and increase in evaluation research. The field could benefit from further exploration of the use of direct observation in research methodology.

The next decade of mental illness stigma research has the potential to be the guiding force in measuring and re-shaping stubborn attitudes and behaviors that have been intractable for generations. The knowledge-base has been laid, partnerships have been cultivated and developed, and key measurement tools have been identified. With these critical factors in place, it would be unconscionable if the field does not leverage the opportunity at this critical point to propel stigma research forward and ultimately to make a difference in how people with mental illnesses are perceived and treated within their communities.

Rebecca G. Palpant, MS is assistant director of the Rosalynn Carter Fellowships for Mental Health Journalism, The Carter Center Mental Health Program.

¹ WHO Report 2001 Mental Health: New Understanding, New Hope

² Pescosolido B, Martin J, et al.: “A Disease Like Any Other”? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence. American Journal of Psychiatry 2010; 167:1321–1330

³"A Meeting of International Mental Illness Stigma and Discrimination Leaders,” Final Report. The Carter Center, 2009.

Post a Comment( 3 )

Implementation Research: A Primer

David D. Nicholas

It is well known in the international health community that there are a large number of proven, evidence-based interventions that are not being implemented or scaled up in many developing countries. Often these are low resource countries with the highest maternal, newborn and child mortality rates and as a result millions of lives are being lost and MDG goals are not being achieved.

For example, the Active Management of the Third Stage of Labor (AMTSL) is an accepted intervention that can significantly reduce post-partum hemorrhage, the leading cause of maternal mortality in many developing countries. In 2006, Niger had yet to implement this intervention. However, in that year, it used a form of participatory action research, the improvement collaborative, to introduce and expand the use of AMTSL. Facility teams in 33 sites studied their labor and delivery processes and tested ways to effectively incorporate AMTSL into their practice. Within two years, AMTSL had been spread to cover 32 percent of total facility births in Niger with a reduction in post partum hemorrhage of 75 percent.

Implementation Research: A Definition
A useful definition of research is that it is the advancement of knowledge by the systematic collection of data and information to test hypotheses or solve problems. It can range from theoretical to experimental to applied research. In the health sector, translational research focuses on moving laboratory discoveries into widespread use of new drugs and treatments in everyday practice. It includes, efficacy research, which uses very controlled experimental designs to study the efficacy of these new drugs or other interventions and effectiveness research, which tests these drugs and interventions in real world situations. Implementation research focuses on studying and developing approaches to effectively and efficiently implement and scale up proven interventions. Clearly, there is some overlap in the terminology and definitions of these types of research.

Among the many things that program managers need to know to effectively and efficiently implement and scale up interventions are:

Why do programs fail/succeed?
How can we better assure success?
What are the best ways to design programs?
What are the options for program designs? Can modeling help evaluate the possible options and identify the most cost-effective design?
What epidemiologic information is needed for program design?
What policies need to be implemented or changed?
What is the best marketing approach?
What behaviors will need to change and what are the best approaches for achieving the needed behavior change?
How should health workers be compensated and motivated?
What is the most cost-effective training program for the health workers and supervisors?
How must the supply system be changed to meet the program's needs?
How must community and client participation be addressed?
How should the program's inputs, processes, outputs and impact be monitored?
How can continuous improvement of the program be assured?

Implementation research is eclectic and may use a variety of methods during the course of a study or a program roll out, including:

Effectiveness research and comparative effectiveness research
Policy analysis and prospective policy research
Marketing and behavioral research
Quality Improvement
Modeling

There are also a number of types of research designs that may be employed, including:

Operations research for problem solving
Quasi-experimental designs (including plausibility & probability designs)
Adequacy studies

Gaps in Implementation Research
In the last decade, there has been active debate about the nature and expectations of research, the value of different kinds of research, and the most effective ways to acquire knowledge to improve people's lives. There has been critical analysis of the assumptions about published experimental research and concern that effective interventions are not reaching those who need them . There has also been a greater recognition for the use of mixed methods in public health, both qualitative and quantitative, and of the need for "customization" of the research design and methods used that are most appropriate for the context in which the research will be carried out.

"Democratization of research" such as that fostered by quality management, where the research is embedded into programs, and the research is carried out by program staff and providers themselves, is needed. Outside researchers may or may not be asked to provide assistance, depending on the needs. This usually results in the identification of innovative solutions to problems, better understanding of work processes and better commitment to achieving program goals. Participatory Action Research is a well known approach to involving providers and communities in setting priorities, implementing programs and overcoming barriers. Yet, this form of research is greatly underutilized because it has not been in the mainstream of health research, skepticism of the validity of the data and results and fear that the community may change priorities.

Finally, there is increasing recognition that health systems, even at the local level, are complex adaptive systems, with multiple interdependencies and feedback loops. Introducing a new program may have many unpredicted effects. The application of Complexity Science as applied to health care and health research is in its infancy but a number of researchers are working to find out how it can be best applied to health research so that programs can better understand the systems in which they work, develop more simple work rules that function better in complex systems, and re-adjust to uncertainties and unexpected barriers and effects. If these efforts are successful, it could result in a "quantum leap" in health research and in the impact of health programs.

Because of this need to design and assure effective programs for the scale up of proven interventions and save many more lives, more resources must be devoted to implementation research. The Translating Research into Action Project (TRAction) works to close the gap between the development of effective interventions and their implementation at large scale.

Its current priority implementation research topics include:

The Integrated Community Case Management of Childhood Illness - policy, costs and financing, and embedded implementation research.
Targeting key maternal and newborn interventions to high risk populations.
The integration of maternal, neonatal and child health services.
The effect of performance based financing on access and quality of maternal, neonatal and child health services.
Improving the community recognition of neonatal illness and complications, referral and case management at facilities.
Reducing abuse and disrespect during facility childbirth.
The combined and complementary use of indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) for malaria vector control.

There is great ferment, debate and creativity in the field of research in general and of implementation research in particular. We are hopeful that this will lead to the quantum leap in knowledge that will help close the gap between what we know and what is being done.

David D. Nicholas, MD, MPH is the project director of the Translating Research into Action Project, TRAction, funded by USAID and led by University Research Co. LLC, in collaboration with the Harvard University School of Public Health.

Post a Comment( 3 )

Tragedy Brings Faces and Names to TB

TB Photovoice Participants

"Quieres cafe, mi amor?" Would you like some coffee, my love? Romel Lacson would ask this question to his wife Dr. Claudia Lacson every morning. He even asked it while she lay dying from TB meningitis in an Atlanta, GA hospital in 2004. He prayed for her to hear his voice and wake-up so they could continue their life filled with love and promise. Yet the complications from TB were too great. Claudia, along with her prematurely born daughter Emma, died in the summer of 2004.

Romel knew that Claudia's story and the stories of millions of people affected by TB needed to be shared and used in a way that would help prevent the root causes of TB. Their stories and perspectives, often reflecting stigma, isolation, poverty, as well as hope and family support, were missing from the global TB conversation.

Guided by Claudia's deep compassion for caring and advocating for others, Romel founded TB Photovoice in 2005. Using a method called photovoice, persons affected by TB document their own health realities by taking photographs of the people, places and systems that both positively and negatively affect their TB care and treatment. Through this process, participants share their local knowledge and photographs with each other in small groups. They identify themes associated with TB and craft recommendations toward improved TB diagnosis, effective and compassionate person-centered treatment, and ultimate TB elimination. TB Photovoice participants act as recorders, and potential catalysts for social action and change in their own communities.

TB Photovoice has assisted projects in Mexico, South Africa, Thailand, Philippines, Brazil and the United States.

Photovoice has been a transformative experience for participants in eight locations across Mexico and one in El Paso Texas-Ciudad Juarez border region. As a collective, they have expressed their journey through the fear of loss of a loved one, to the relief of healing.

TB Photovoice reminds us that there is a human face to TB. There are faces like Claudia's and those whose words and photos are represented here. Their voices will help to change policies that impact the root causes of TB if they are given the opportunity.

In Mexico, TB Photovoice partners with Project Concern International, Solucion TB Project, The Allliance of Border Collaboratives, Programa de Investigacion en Migracion y Salud (PIMSA), and other TB organizations and community organizations.

Post a Comment( 3 )

Reflections of a Lifetime Dedicated to Public Health Advocacy

In Memory of Beth Waters

A reporter in the early years of her career, Beth was a senior managing director of Ogilvy Public Relations before co-founding Cooney/Waters Group, a health-care public relations and public affairs company in New York City. Beth was indefatigable in her work on vaccine advocacy, traveling the world to lend her intensity and expertise to her clients, governmental committees and non-governmental organizations; and promoting immunization against polio, HIV/ AIDS, avian influenza and meningococcal disease. Beth was a wise counselor, a creative problem-solver, and a relentless optimist. Beth passed away in 2006.

Beth Waters often said that her first job in immunization advocacy was as a child of nine. She was a "polio pioneer" - one of the children who participated in the U.S. clinical trials of the vaccine that would mark the beginning of the end of the scourge of the disease that crippled or killed children and young adults throughout the 20th century. An unrelenting crusader for the prevention of infectious diseases, her involvement with global polio eradication continued right through the last decade of her life. Indeed, much of her 30 years in communications and public affairs centered on advocacy for vaccines to protect against diseases in both industrialized countries and the developing world.

Every aspect of immunization intrigued her, from the intricacies of production and supply to the involvement of communities in clinical trials of candidate vaccines for mass immunization programs. Indefatigable in her efforts, she traveled the world to lend her intensity and expertise in international scientific forums and at the grassroots level, working with her client sanofi pasteur, governmental committees and non-governmental organizations.

"Beth's work exemplifies the power of communications in bringing together people and groups to advance the prevention and treatment of infectious diseases, most notably HIV/AIDS," said Wayne Pisano, chairman and CEO of international vaccines company sanofi pasteur. "It was impossible to slow her down. She fought for disease prevention with an energy and enthusiasm that was often as contagious as any of the microbes she battled."

This issue of GLOBAL HEALTH is dedicated to Beth Waters. Corporate sponsorship provided by sanofi pasteur.

Post a Comment( 1 )

BUILDING BRIDGES, DISMANTLING WALLS

Seth Berkley

The development of a vaccine to prevent HIV infection is one of the most daunting scientific challenges of our time. Yet, for all its complexity, this field of research seeks to answer a relatively simple question: how do you get the immune system to detect and disable HIV before it has a chance to insert itself into the human genome and establish an intractable infection? Most vaccines against viruses, such as those that prevent measles and polio, do so by teaching the immune system's B cells to generate neutralizing antibodies - exquisitely targeted protein missiles that bind to invading pathogens and tag them for destruction. HIV, however, is no ordinary adversary. It has evolved multiple strategies to flummox the immune response. Not least among these is a nearly unparalleled mutability that has vexed vaccine designers for the better part of three decades.

Any vaccine devised to seriously curb the AIDS pandemic will, at a minimum, have to protect against those HIV subtypes that predominate in developing countries, where some 90 percent of new infections occur. It should also thwart multiple variants of those viruses. This poses extraordinary scientific and logistical challenges. But it also has significant implications for the policies that guide and shape AIDS vaccine research and development. First, it requires that candidate HIV vaccines be tested in developing countries, which entails the establishment of the requisite human resources and technical capacity in such places. Second, in light of the unique scientific challenges of AIDS vaccine development, funders and policymakers need to find ways to encourage innovation and the application of hitherto untapped technologies to solve the toughest problems in the field. Finally, global efforts to develop AIDS vaccines would benefit from greater participation from the private sector. The market disincentives and risks - most prominently high failure rates and opportunity costs - inherent to HIV vaccine development have traditionally discouraged industrial participation. But appropriate incentives and funding policies could do much to change that.

This is especially true today. Following the failure of two AIDS vaccine candidates over the past decade, some commentators had begun to suspect that AIDS vaccine researchers might be tilting at windmills. But significant breakthroughs in the past year have countered such doubts. Late last year, a clinical trial in Thailand demonstrated - for the first time ever in humans - that a vaccine can prevent HIV infection (though this particular vaccine candidate provided only modest protection). A few weeks prior to that, researchers at the International AIDS Vaccine Initiative (IAVI) and in the Neutralizing Antibody Consortium (NAC) it oversees reported in the journal Science that a highly collaborative effort involving some 1,800 HIV-positive volunteers in eleven countries on four continents had resulted in the isolation, from a single African volunteer, of a pair of novel antibodies capable of neutralizing a wide spectrum of HIV variants. The two broadly neutralizing antibodies (bNAbs) - PG9 and PG16 - were found to be exceptionally potent neutralizers of HIV. This discovery was closely followed by the isolation of equally potent bNAbs by the Vaccine Research Center (VRC) of the U.S. National Institutes of Health, and several others from IAVI's antibody project.

Why should these findings matter? In short, because they clear a path to solving one of the most pressing problems of AIDS vaccine development - the elicitation of sufficiently potent antibodies against many of the subtypes of HIV in circulation.

Most of the experimental AIDS vaccines that have been put into clinical trials in recent years have been devised to primarily harness cell-mediated immunity (CMI). This is the branch of the immune response that depends on the recruitment of specialized soldiers known as T lymphocytes to detect and destroy cells already infected by HIV. But most researchers believe that an effective vaccine will also need to activate a neutralizing antibody response. In this view, the ideal vaccine would first deploy antibodies to prevent HIV from infiltrating cells, and would then mobilize the CMI response to mop up any viruses that slip past that biologic barrier. One of the major difficulties with this strategy has been in designing immunogens - the active ingredients of vaccines - that can teach B cells to produce broadly and potently neutralizing antibodies.

Researchers have long known that some HIV positive people produce just such antibodies. And animal experiments suggest that these bNAbs, if elicited by a vaccine, would block HIV from establishing an infection in the first place. This is why researchers had exhaustively studied four particularly versatile - though not especially potent - bNAbs that were isolated more than a decade ago. But it was clear that more such antibodies were sorely needed to inform vaccine design.

Antibodies attach with exquisite precision to unique folds and surfaces on large molecules. These shapes are known as epitopes. The careful study of purified bNAbs, and the epitopes they target, is the first step to devising strategies to elicit similar antibodies via vaccination. One approach to the neutralizing antibody problem - known as reverse vaccinology, the driving objective of the NAC - is to study these shapes in atomic detail, recreate them in the lab (or at least find similar structures) and use the synthetic epitopes as immunogens. Of course, the more such antibodies researchers have to scrutinize, the more likely they are to find an epitope that can be replicated to make a broadly effective vaccine.

NAC researchers have found that the newly discovered bNAbs, PG9 and PG16, have several potentially valuable traits. They latch on to a relatively unchanging patch on its endlessly mutable spike - a roughly toadstool-shaped scrum of proteins on its surface that HIV uses to invade its target cells. This epitope may prove an Achilles heel on HIV, given that it appears to be relatively accessible compared to the target sites of previously isolated bNAbs. This means scientists might have an easier time devising immunogens to elicit similar antibodies. Finally, the antibodies are notable for their potency. This is of great practical significance because candidate HIV vaccines have historically failed to elicit vigorous antibody responses, and the more potent an antibody the less of it is needed to block infection.

Beyond the elegance of the science, IAVI's antibody project provides a lesson in how well-conceived policies can drive the development of drugs and vaccines that may have questionable market prospects but are of critical significance to global health. For one thing, it confirms the value of cultivating biomedical research capacity in developing countries and working in partnership with local scientists and institutions to conduct vaccine trials and HIV research. A network of clinical research centers IAVI supports in five southern African countries played an indispensible role in the antibody project. The network, along with a half-dozen other research centers worldwide, provided the NAC with well-characterized cohorts of HIV positive volunteers who could be studied for the project. And it allowed IAVI to cast a wide net in the antibody hunt: there's no guarantee that a single, small cohort of volunteers would have yielded even a single antibody of interest.

The IAVI-supported clinical trials network continues to contribute to the antibody project, especially through cohorts participating in Protocol C, an IAVI study of HIV positive volunteers that tracks how the virus and the immune response to it evolve from the earliest phases of infection. Thanks in part to their access to these cohorts, IAVI researchers recently received a major grant from the NIH to explore why it is that only some HIV-positive people make potent bNAbs.

The antibody project also illustrates how practices that promote partnerships with the private sector can advance science in the public interest. The detection and isolation of bNAbs were accomplished through close collaboration between IAVI and affiliated scientists and researchers at two biotech companies - Monogram Biosciences in San Francisco, and Theraclone Sciences in Seattle. The former adapted its existing screening technology to evaluate hundreds of blood serum samples for their ability to neutralize a panel of HIV variants selected by IAVI researchers.

Theraclone, one of four laboratories charged with isolating antibodies from IAVI's blood samples, was the first to succeed, successfully isolating PG9 and PG16. It was the recipient of a grant from the Innovation Fund, which IAVI supports in partnership with the Bill & Melinda Gates Foundation to underwrite the novel application of existing technologies to AIDS vaccine development. Until it became involved in the antibody project, the company had applied its technology primarily to discover drugs for autoimmune disorders. By participating in the project, it got to showcase the versatility and power of its technology, which is just the sort of thing a start-up needs to generate new streams of revenue. In fact, Theraclone's success with PG9 and PG16 helped it win new business from a Japanese drug company.

IAVI continues to work with Theraclone and Monogram to isolate new bNAbs from several other serum samples collected in the antibody project, and has engaged other biotechs in vaccine design through the Innovation Fund. Other policy approaches that might draw more private sector participation in AIDS vaccine development include the fashioning of better incentives, advance market commitments and even public sector support to lessen the financial risk of tackling such a formidable problem.

Finally, policies that support long-term rather than project-by-project financing for research would benefit AIDS vaccine design. The NAC, for example, funds labs that have a long track record of success and a demonstrated ability to innovate. This not only gives researchers the time they need to pursue the painstaking business of designing vaccines. It also frees them to adapt their strategies to respond to advances in the swiftly evolving fields of HIV pathogenesis and immunology. It is noteworthy that the NAC and the VRC, which takes a similar approach to funding, have both made several significant contributions to AIDS vaccine design. By providing a measure of financial and professional security, such policies also create a space for young HIV researchers to hone their skills in vaccine-related research, and ready the best of them for future scientific leadership.

Thanks to the recent renaissance in R&D, the outlook for an AIDS vaccine is more promising today than ever. The progress was achieved in laboratories and in clinical testing centers, but was made possible by policies and practices, beyond the domain of pure science, that encourage collaboration, capacity-building, innovation and private-sector engagement. Those practices must be extended and expanded if we are to reach the goal of making an AIDS vaccine a reality.

Dr. Seth Berkley is president, CEO and founder of the International AIDS Vaccine Initiative.

Post a Comment( 6 )

In Ancient Culture, New Battle Starts Against TB

John Donnelly

KATHMANDU, Nepal - The history of fighting tuberculosis has its share of disasters - piecemeal control efforts, resistant strains of TB passed stealthily from cell to cell in prisons, and national programs suddenly running out of money due to political revolutions or even just a change of administrations. And then there was a moment, in the midst of a luncheon at the four-star Bluestar Hotel in Kathmandu on Feb. 23, 1996, when Nepal's early efforts to seriously battle TB were called out as going nowhere.

In the fall of 1995, Nepal had become one of the first countries in Asia to sign onto the World Health Organization's ambitious efforts to install a DOTS strategy, which called for following a series of unbreakable rules, including that health workers should directly observe a patient swallow TB drugs every day for months.

But in that luncheon, a group of international experts presented a report that basically gave Nepal an F.

"DOTS is not being implemented properly, and very few patients are being supervised at the treatment centres," the report read. "No action is taken for patients who are late for treatment. The drug supply system is not functioning properly, and several treatment centres have suffered stock outs of drugs. ... The laboratory network is not functioning, because posts for microscopists have not been established."

What would Nepal do? Pretend it didn't hear, or attack the problem?

It attacked.

"Those experts who came in were right," said Dr. Dirgh Singh Bam, then the Director of the National Tuberculosis Centre, looking back at that moment 14 years later. "I agreed with them - the pilot programs we had started were really not that good. I said, `OK, give us six months. Let's see what we can do."'

Country Director Hits the Road

Bam, his chief assistant, Dr. Ian Smith, and several others started to travel frequently to the countryside, insisting that health workers and patients follow the DOTS protocol. "Those who refused," Bam said, "I removed them."

The Ministry of Health's strategy - it was backed by a group of about a half-dozen NGO partners who were directing the programs, donors such as the Japanese government, and WHO's technical advisers - began to produce results. It took many players, often cajoled by the near-maniacal country TB director, but Nepal built its program step by step.
"We put in place a much more robust program of supervision, recording and treatment," said Smith, who is now an adviser to WHO Director-General Margaret Chan. "Dr. Bam was constantly on the road, always out supervising people, meeting with private doctors, trying to motivate them. He was a stickler for information - he made sure people submitted the right information. From then on, there was a different picture. For the next four or five years, we had a period of rapid expansion to reach 100 percent of the country."

TB cure rates, which had hovered around 45 percent before DOTS began, soared to more than 80 percent, and would eventually reach 90 percent in 2009. The country achieved nationwide DOTS coverage in 2001, started to treat multiple-drug resistant TB in 2005, and wrote a new National Strategic Plan in 2010 that outlined strategies and goals for the next five years. The Global Fund to Fight AIDS, TB, and Malaria awarded Nepal a $56 million, five-year grant to help it meet those goals.

Nepal, a rarely told story in the expansion of global TB efforts, now is being tested again. The small mountainous country of 27 million people, wedged between India and China, is intensifying its battle against TB strains resistant to drugs, which threaten to torpedo past efforts.

Dr. Kashi Kant Jha, a TB medical specialist who worked with Bam in those early days, now leads the country program. He is confident Nepal's TB program can meet new difficulties. "If your home is strong and you are earnest, you will get support and get good results," he said.

Long List of New Challenges

But Jha said the job wouldn't be easy. Among the new challenges: health workers need more training; the lack of laboratory facilities in many parts of the country; the high number of MDR- and XDR-TB (extensively drug resistant) cases identified in the last five years; concerns of co-infection with the country's estimated 60,000 HIV-positive patients; and the lack of a TB hospital in the entire country, which means that even people with infectious drug-resistant TB remained in the community, not in an isolated setting.

The National Strategic Plan calls for 125 new microscopy centers in under-served areas; building Nepal's first chest hospital that would have 150 beds; improve the control program in urban areas; immediately identify and rent 10 hostels for MDR- and XDR-TB patients; and greatly expand an effort to intensify case finding in crowded settings, such as slums, prisons, refugee camps, and factories.

As with any TB control effort, all strategies are necessary in order to be successful. But experts here have put particular focus on the last two points - the treatment of drug-resistant TB patients and becoming more aggressive in finding cases.

In Pokhara, a city in Nepal's center that draws tourists for the magnificent views of the snow-peaked Annapurna mountain range, Dr. Prakash Mishra, director of the Regional Tuberculosis Centre who oversees treatment for dozens of TB patients, believes the two strategies go hand in hand.

"Where did we get MDR-TB from?" he said. "Either we didn't do the right thing in the past, or we compromised the treatment somewhere. If we do not find all of these cases, the exposure to people in the community continues."

MDR-TB cases now comprise about 3 percent of all new TB cases - which is not high compared to rates approaching a quarter of all cases in some Central Asia cities, but not insignificant either. The country has identified 826 cases in the last five years.

"We need to now move from a passive system of case finding to an active one," Mishra said. "We need to let people know that if they cough for a couple of weeks, they should immediately come in and get tested for TB."

‘I was a TB Patient'

Some outreach is underway. One afternoon this fall in a slum along the Manahara River in Kathmandu, health educator Jeevraj Adhikari gathered about 40 women and children in a small room to talk to them about TB. Rain poured outside - so loud on the tin roof that Adhikari couldn't be heard for more than 15 minutes. He patiently waited it out.

He asked what they knew about TB. Answers came from all corners.

Still, he warned them: "TB is everywhere, inside your home, outside your home."

He asked if any of them knew someone who had TB.

Several hands rose. He called on Devi Kunwar. She said she was a TB patient. All eyes turned to her.

"How are you doing?" Adhikari asked.

She said she was much better following six months of treatment.

"Now, I am cured," she said.

"That is great news," Adhikari said.

John Donnelly is a free-lance writer specializing on global health issues. His trip to Nepal was supported in part by the World Health Organization.

Post a Comment( 2 )

Resisting Vaccines

Eliza Barclay

In recent years the contours of the battle against vaccine-preventable diseases have changed dramatically. While immunization rates worldwide are at an all-time high largely because international health institutions are reaching thousands of new children each year, vaccines have also come under fire from parents and critics questioning their safety. Not only are skeptics in countries like the United States and United Kingdom opting out of vaccines, but the anti-vaccine movement has also recently ignited in countries like India and Ukraine.

“What has happened globally is that we are becoming more terrified of vaccines than the diseases themselves,” said John Budd, UNICEF’s chief of communication for Central and Eastern Europe and the Commonwealth of Independent States, who has witnessed active anti-vaccine communities in Ukraine, Moldova, Georgia and Romania derailing vaccination campaigns.

A sudden outbreak of polio in Tajikistan this year has also raised new questions about the exhaustiveness of routine immunization programs in countries certified as polio-free. All of these new challenges are causing vaccine advocates to reexamine their strategies and look for new ways to sustain high immunization coverage and eradication goals.

With the dedication of new funds for research and global immunization drives to beat back and eradicate several vaccine-preventable diseases, vaccines have become more effective and much more widely available. Worldwide, immunizations are at an all-time high and cases of measles, yellow fever, polio, rotavirus, and other vaccine-preventable diseases have fallen dramatically resulting in huge improvements in child mortality. Deaths from measles, for example, fell by 74 percent between 2000 and 2007. But according to a 2009 report by UNICEF, the World Bank and the World Health Organization one in five children, or 24 million infants, are not receiving routine vaccinations.

“Getting to the last 20 percent is the toughest,” said Jeffrey Rowland, spokesman for the GAVI Alliance in Geneva. “We’re talking about weak health systems, and the most remote and poorest people who have the least access to health care.”

Among the diseases that have eluded eradication is polio. Since 1988, when public health leaders committed to eliminate the disease forever, the number of polio cases has gone down by 99 percent. But the disease remains stubbornly endemic in four countries: Afghanistan, Nigeria, India and Pakistan. The campaign against polio also suffered a setback this year with a major outbreak of polio in Tajikistan, a country certified as polio-free since 2002. According to UNICEF, which procured vaccines and educated people about the disease during the outbreak, there were 26 deaths and 458 confirmed cases of polio in Tajikistan this year.

Jeff Raikes, the CEO of the Bill & Melinda Gates Foundation, wrote in September that wiping out the disease is still among the foundation’s top priorities, but that there is a funding shortfall. “Right now, there is not enough money past next summer to carry out all of the immunization activities to keep the world on track to eradicate polio,” wrote Raikes. “It’s very clear: This is make-or-break time for polio eradication.”

If less than 90 percent of a population has received a vaccine, the community at large can lose its herd immunity to a disease like polio, putting more people at risk in an outbreak. While the World Health Organization is still investigating the exact reasons for the polio outbreak in Tajikistan, experts suspect that it occurred because routine vaccination programs in Tajikistan were not as thorough as reported.

The Tajikistan outbreak also caught the eye of many vaccination experts in other polio-free countries who noted that they may be at risk of similar outbreaks because routine immunization rates have declined slightly. Paul Hébert, an epidemiologist at the University of Ottawa, told a writer for the Journal of the American Medical Association that “we seem to have let our guard down" in maintaining high vaccination rates and that the threat of polio in countries like Canada and the United State is “more than theoretical.” Several states in the U.S. have already seen an uptick in measles and pertussis cases in recent years; California, for example, had over 4,000 confirmed, probable or suspected cases of pertussis as of mid-September, the most reported since 1955.

Part of the problem is that some parents have been curbing vaccinations for their children or eschewing them altogether. Doubts about the safety of vaccines sprouted in the United Kingdom and United States in 1998 with the publication of an article in The Lancet by Dr. Andrew Wakefield on a possible link between children with developmental problems like autism and the Measles-Mumps-Rubella vaccine. The article ignited an intense debate among parents with autistic children around the question of whether vaccines were responsible for their children’s condition, and many organizations formed to denounce compulsory vaccines. Since the article’s publication – and even after The Lancet retracted it in February 2010 on – the anti-vaccine movement has become more vocal and prolific in its generation of Internet-based materials refuting the safety of vaccines. According to a 2004 study published in the journal Pedriatrics, each year 2.1 million American children aged 19 to 35 months are under-vaccinated or receive no vaccinations at all. Not all of these cases are motivated by vaccine safety suspicions, but several health departments around the U.S. report that parents are choosing ''philosophical exemptions'' from normal vaccination requirements.

To the scientists and other public health officials who have developed revolutionary vaccines and are still rolling them out around the world to children who lack access to them, these developments are disturbing. William Foege is a senior fellow with the Bill & Melinda Gates Foundation and an epidemiologist who worked in the successful campaign to eradicate smallpox. Foege’s home is on the island of Vashon in Puget Sound, which has three times more children who are not fully vaccinated than in the rest of the state, according to county health officials.

“I am concerned by parents’ refusal of immunizations because of the unintended harm they expose their own children to but also to weakening of the social contract that protects all of us collectively,” said Foege.

Budd of UNICEF says that public health community has struggled to combat the misinformation of the anti-vaccine movement. “We are big institutions, and the anti-vaccine movement is very nimble and passionate,” said Budd “They don’t subscribe to same rigid standards of science, while we have to make sure everything we say is accurate.”

But the United States is not the only country where anti-vaccine advocates have managed to convince parents not to vaccinate their children. In 2008 in Ukraine, UNICEF and WHO decided to launch a campaign to vaccinate nice million people against measles and rubella between the ages of 16 and 29. But the government decided to move the campaign forward by two weeks, which did not allow health workers enough time to educate the public on the safety and importance of the vaccine. In the interim vocal vaccine critics cast doubt on the campaign. One Ukrainian politician even went so far as to call vaccinations the “medical genocide of Ukrainians.” The campaign was initially postponed but in the face of the firestorm was eventually cancelled within a year.

“The consequence is that that cohort of young people remain incredibly vulnerable to measles and rubella,” said Budd.

David Wood, a coordinator in the department of immunization, vaccines and biologicals at the World Health Organization, saw a similar backlash to the Human Papilloma Virus in vaccine in India. A pilot project this year was stopped due to local groups’ critiques of the safety of the vaccine.

“In a globalized environment, there are advocacy groups in different parts of world who are picking up on the anti-vaccine message through the Internet to help them further their cause,” said Wood. “This is a big issue that we need address, and we have to continue to try to get information about the safety of vaccines into the pubic domain.”

Eliza Barclay is a freelance journalist based in Washington, D.C. whose work has appeared in The Atlantic and The New York Times.

Post a Comment( 4 )

A Photographer’s Encounter in Kroo Bay

Photos and Story by Dominic Chavez

Recently while working in Freetown, the capital of Sierra Leone to document maternal and infant mortality issues, the ministry of health was launching a free health-care program for pregnant women and children under five. I had planned to stay after my contract was over, in hopes of sharing more time with Sierra Leone mothers and their families and to make known the difficulties they live every day.

My plans quickly changed after meeting a wonderful family who lived underneath a small bridge in Freetown. I was surprised by the amount of raw sewage and the lack of clean water. After visiting this family a couple more times they told me there were communities in Freetown much worse.

This was when I first heard of Kroo Bay, a difficult slum filled with good families and shanty structures overrun with garbage, extreme sanitation issues, and a long list of health conditions due to the lack of clean water. Some of the biggest issues they are facing are polio, ringworm, typhoid fever and malaria, not to forget a high incidence of child malnutrition.

For little over a week, I spent as much time as possible documenting the community. These families lived in some of the worse conditions I have seen, yet they opened their makeshift homes and offered what little they had. Many homes had hard packed dirt floors, no windows, no doors and with poor roofing materials to shelter them from the heat and rain.

Within minutes of entering the community, I stood shoulder to shoulder, making pictures of children digging in heaps of trash and pools of blackened water. I walked slowly introducing myself with a soft voice and sometimes placing my hand over my heart to show my respect. As I walked deeper into the neighborhood and slowly made pictures, I was feeling overwhelmed, almost frozen. At that moment I heard a man screaming from maybe 25 feet away, I lowered my camera slowly and saw no one moving except one, he was marching towards me. He was enraged. He had open sores all along his arms and was built like a malnourished body builder. At this point I was reminded I had broken my first rule of always creating a simple exit (just in case), there was nothing I could do except to face him.

He unloaded and was venting his frustrations. After a few minutes, I interrupted him and told him, your anger is why I'm here! It silenced him for a second and then he burst loudly with laughter - he laughed with his mouth wide open pointing towards the sky.

He then asked me: you want to know the truth? We're all suffering here in Kroo Bay. He began talking about the water issues again and showing me his arms with open sores, "you see these, they move at night" - he was talking about the worms in his body. I continued listening humbly as he talked, after a few more minutes he was aware we could help one another and began introducing me to his family and friends.

My hope is never to take pictures or shoot pictures, but to share the experience and the moment with the people I'm photographing. It's important to me that they feel I am not there to take something from them.

Post a Comment( 97 )

From the Front Lines of the Global AIDS Fight

Peter Navario, PhD, MPH and Alan Whiteside, DEcon, MA

The picture of the current state of AIDS in South Africa is ambivalent. There are some notable successes in preventing mother-to-child transmission and access to antiretroviral treatment (ART), but a worrisome lack of progress in preventing new adult infections. Prospects for resourcing and financing over the next five years are equivocal at best.

Earlier this year a group of South Africa's leading HIV experts, the authors among them, gathered to reflect on progress, identify challenges, and recommend strategies and tactics for surmounting obstacles in the fight against HIV and AIDS. The Special Report on the State of HIV/AIDS in South Africa summarizes the analysis and recommendations that emerged from that meeting.

One theme was transcendent - winning the AIDS fight requires a paradigm shift on the part of all South Africans. Two strategic objectives were mooted again and again as essential to galvanize this shift: 1) The South African department of health must change the way it does business; and 2) Reversing the trend of new infections requires a mass social movement. At a glance, these objectives appear as inchoate as they do intractable, though they reflect several fundamental truths about the current state of AIDS. With five infections for every two people started on ART, HIV incidence remains too high. Extant public sector health staff, including doctors, pharmacists and laboratory technicians, cannot cope with the 3 million plus people needing ART by 2015. Finally, there is not enough money in the AIDS budget to treat everyone needing ART.

The success of prevention and treatment programs in South Africa hinges on leadership from the department of health at national and provincial levels. Management capacity within the health sector merits a great deal more attention than it currently receives. Far too few people in leadership and management positions have any management training; the drug stock outs in Free State Province and high rates of ART patients, who are lost to follow-up, are just two indicators of the current state of health system management. Fiscal management is also a major concern. The independent Budget and Expenditure Monitoring Forum reports that provincial health departments routinely incur large amounts of unplanned expenditures, fail to budget based on estimated service needs, and suffer widespread corruption.

Doctors, nurses and other key leadership staff should be incentivized to receive management training. Better management should lead to more efficient use of resources, improved supply chain efficiency and reliability, greater levels of accountability, improved working conditions, and ultimately, better patient care at lower cost. For example, given the talk of clinic overcrowding and health worker burden, it is curious that clinics across the country are empty every day by three o'clock and closed after one o'clock on Fridays and on weekends. Moreover, the public health system does a notoriously poor job of holding non-performing and/or negligent health professionals accountable, jeopardizing patient health and program efficacy.

The health department's policy options to cut costs and reduce workload and patient burden include better use of community health workers; modification of the current treatment guidelines to permit quarterly dosing for patients who are adherent and stable on treatment; and less intensive laboratory monitoring - recent research from Uganda and Zimbabwe found twice-yearly laboratory monitoring to be cost-ineffective.

Finally, data management is a shambles. Public sector data are poor quality and not used to inform program management or even future budgets, which are just carried over from year to year with small annual increases. Worse still, some provincial health departments have undermined facility-based efforts to implement their own data management systems, citing fragmentation and quality concerns. The time has come to either expedite the database selection process or publish data standards and guidelines and let the facilities select the database that best suits their needs.

Changing the course of the South African epidemic cannot be the sole responsibility of government, and a commensurate effort by individuals and communities across the country is essential. All South Africans should know their HIV status. The new testing campaign announced by President Zuma is a start, but HIV testing must become habitual for all sexually active adults and adolescents. The Botswana model of opt-out testing, where doctors and nurses automatically suggest an HIV test during consultations - and the patient may elect to decline - resulted in the highest treatment coverage in Africa.

In the absence of a "game-changing" bio-medical intervention (e.g. vaccine), it is up to all South Africans to cut the infection rate. Even under the rosiest of scenarios, 5 million are expected to contract HIV over the next 10 years. But this need not be a fait accompli. New research estimates that incidence among young women aged 15 to 24 dropped by 60 percent between 2005 and 2008, driven in part by higher rates of condom use. Significant reductions in new infections are possible through behavior change. A national social movement for behavior change, rooted in a national dialogue led by national and local leaders, churches, traditional healers, chiefs, private sector companies and others should focus on prevention in the context of epidemic drivers: intergenerational sex, multiple concurrent sex partnerships, and discordant couples. Indigenous leadership and organic, context-specific prevention initiatives are crucial: all prevention is local.

Government has two options to address the HIV program financing gap: increase investment and reduce costs. In reality, it needs to do both. The new budget allocations from the Treasury show a clear commitment to grow domestic investment in HIV. However, with the U.S. President's Plan for AIDS Relief (PEFPAR) - South Africa's biggest AIDS donor - budget essentially frozen, and the Global Fund for AIDS, TB and Malaria facing its own multi-billion dollar budget gap, the prospects for additional donor money are bleak. Cost cutting and improved efficiency is imperative, starting with HIV drugs, which typically comprise more than 50 percent of total treatment costs. Incomprehensibly, South Africa pays more for drugs than its neighbors despite having the largest ART drug market in the world. The next biggest cost driver is staff - training lower level staff to perform more of the routine aspects of HIV care should yield savings without compromising quality.

The current PEPFAR law expires at the end of 2013. Increased domestic spending shows the U.S. Congress that South Africa is serious about addressing AIDS, and should put it in a favorable position as it requests an extension of PEPFAR funds through 2015 (at which point the number of patients starting treatment should level off). The government would do well to organize an "all donors" financing meeting to secure longer-term commitments, coordinate funding streams and harmonize domestic and donor-funded programs.

The demand for HIV services in South Africa is beginning to exhaust the financial and human capacity to provide them. Tough choices need to be made to close the demand-resource gap, but it's not clear just how willing leaders and citizens alike are to engage in HIV/AIDS realpolitik. What is the government willing to pay for HIV and AIDS care? What is required of communities and individuals? The role of the private sector? And civil society?

At the January meeting in Cape Town, there was consensus that South Africa is exceptional, not just for the scale of its epidemic, but also for its ability to lead the region and the world in responding to the global AIDS crisis. Its ability to succeed requires bold leadership and an engaged populace: the paradigm shift begins now. The success of the World Cup shows this is indeed possible.

ONLINE EXCLUSIVE

Special Report on the State of HIV/AIDS in South Africa: The country's leading HIV experts weigh in on the status of treatment, prevention and resourcing at the epicenter of the pandemic

View full report here.

Peter Navario is a fellow in global health at the Council on Foreign Relations and Alan Whiteside is a professor in the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal in Durban.

Post a Comment( 4 )

Will Bugs Creep North as Climate Heats?

Onome Akpogheneta

With predictions of temperatures rising by the end of this century, what will happen to the bugs that carry disease when the world warms? Will diseases of the Southern Hemisphere become more prevalent in these countries? Will the insects carry their disease burdens to the North? For many statistical models the effect of climate change on vector-borne diseases are real causes for concern. But perhaps predictions about climate change and disease migration support actions to limit climate change rather than highlight the most likely of disease-spread scenarios.

It has been widely hypothesized that global warming will bring new permissive environments for biting insects that can carry viral, bacterial, helminth and protozoal diseases. These insects include mosquitoes, ticks, sandflies, snails and blackflies; all are sensitive to climatic changes. Mosquito-borne diseases including malaria, dengue, viral encephalitides, West Nile fever, filariasis and yellow fever are some which have caused climate change associated concerns and investigations in recent years. Fears persist that newly resident infected mosquitoes could harbour and import diseases to regions and countries from which they have been absent or eradicated. The result could be greater disease prevalence and more disease outbreaks within countries of the Global South, as well as northern migration of disease epidemics. Fears have grown that climate change disease migration could become a global health threat in the 21st century.

While fears have grown, reliable evidence to reflect long-term climate change effects on mosquito-borne diseases has not kept pace. "Detailed scientific evidence remains scanty," says Peter Byass in an 2009 article in Global Health Action magazine; he considers that "entomological studies [are] expensive [and] not seen as high priority for disease surveillance." It is precisely because of "scanty" historical and longitudinal data on vector habitats and associated disease outbreaks that climate change predictions will likely be unreliable for vector-borne diseases. Predictions for simplistic long-term correlations should be made with disclaimers; there's simply not enough data to prove cause and effect.

"We still need evidence of the [long-term] effect of climate change," says Tarekegn Abeku, senior technical specialist in disease prevention at the Malaria Consortium and a contributor to the 2007 report of the International Panel on Climate Change. Abeku says "several studies have shown malaria in highlands might be caused by changes in weather" but these were short-term changes. Short-term studies can inform long-term predictions, but in order to reach conclusions, Abeku says, "you have to have data for decades" and even then the picture is still "very complex."

So what contributes to this complexity? Surely associations could be simply made between climate change factors and disease vectors. Wouldn't more rainfall, higher humidity and higher temperatures simply mean more hospitable areas for mosquitoes? It has long been known that seasonal rains, with hot, humid conditions are frequent correlates with mosquito-borne disease epidemics and outbreaks. Short-term climatic anomalies, such as the El Nino Southern Oscillation, are also known to lead to epidemic spikes and have been associated with malaria and dengue outbreaks in Africa, Asia and South America. In addition, higher temperatures can mean shorter maturation periods for mosquito larvae, and faster blood digestion with more frequent feeding for adult females. But there is a downside for the bugs, too; warming above 34oC could have a deleterious effect on their habitats and lifespan. Higher temperatures are predicted to make arid and semi-arid areas drier, while making mid-to-high latitude areas wetter. As ecosystems change, so too will the distribution of mosquitoes; both increased and reduced rainfall could mean shifting habitats, but these generalized effects will not move in a uniform direction for all mosquitoes.

"It's almost a routine tool to model distribution of [mosquitoes] by determining their climate envelope," says Steve Lindsay, professor of public health entomology at the London School of Hygiene and Tropical Medicine, but it's "important not to over-interpret conclusions." Statistical models and exploratory analyses can provide "insight," "scenarios" and a "foundation for understanding vector-borne diseases [and disease] transmission" but for Lindsay it's crucial to "go to the field" and collect real-life data.

Hypotheses of disease importation with vector migration are unsubstantiated and often overlook evidence that mosquitoes capable of carrying disease are resident and living comfortably in many locations where particular diseases are not endemic. Within 5 years after West Nile Virus was introduced to the U.S. in 1999, the disease spread rapidly from the northeastern corner across the country. "There is little evidence that the entry and establishment of West Nile Virus in the U.S.A. was influenced by climate change," says Walter Tabachnick in the Journal of Experimental Biology this year. Tabachnick describes that the "vectors were present in the U.S.A., and entry of West Nile Virus was not contingent on climate change in North America."

Until the mid 20th century, malaria was endemic in parts of the Northern Hemisphere; in Europe, as far north as Finland, and in North America, as far as Canada. Malaria caused illness and death in these areas at rates comparable to those in some malaria-endemic parts of sub-Saharan Africa today. In England today, there are currently six species able to transmit malaria. Although these malaria-capable vectors persist, Lindsay et al comment in the Malaria Journal that "one is much more likely to be struck by lightning than to get malaria from an English mosquito."

Climate was not a factor associated with malaria eradication from the developed world. It was due to ecological changes in insect habitats, in particular effective mosquito control measures, improvements in human living conditions, and greater access to medical care that malaria was eradicated prior to the advent of man-made global warming. While malaria began to wane as a worldwide public health problem by the mid 20th century, dengue and yellow fever, which belong to the same virus family and share the same mosquito vectors, began to emerge. According to WHO surveillance data, prior to 1960, dengue cases were reported in fewer than five countries; after 1960, the disease began to emerge in all continents, with cases reported in nearly 60 countries by 2007.

The migration of mosquito vectors (and the viruses themselves) had already occurred centuries earlier with transnational shipping and commerce in the 17th and 18th centuries. By the 20th century vectors were already permanent residents in today's disease endemic and non-endemic countries. According to WHO, the re-emergence of dengue after 1960 was associated with "rapid population growth, rural-urban migration." In addition, an increase in water containers and discarded items provided urban larval habitats. It was independent of climate change that mosquito vectors for dengue and yellow fever viruses adapted efficiently to new habitats, maintained close proximity with humans, and became especially well domesticated disease vectors.

Vector-borne diseases rely on the availability of human populations as much as their vectors for disease transmission. As such, it's important to consider more widely how climate change will likely affect a host of other socio-economic and human migration factors. The effect of climate change on human migration patterns could mean movement away from or movement toward disease carrying vectors, decreasing risk for one disease while increasing risk for another, depending on which diseases are endemic where. If global warming drives human migration toward urban areas, it could mean a movement away from largely rural endemic diseases, such as malaria, and toward urban epidemics with diseases like dengue. For filariasis, however, urban-rural human migration patterns may not suggest a clear epidemic outcome; some filariasis vectors have adapted to rural habitats, while others are urban or semi-urban residents.

To make robust associations between climate change and vector-borne disease means ignoring the absence of evidence. Climate change won't cause uniform changes for all vectors and all disease. It will have direct impacts not only on vectors, but also on pathogens and human hosts. Disentangling these multiple climate change effects and proving direct, causal relationships between specific diseases and climate change will likely continue to prove problematic and complex for many decades to come.

Sources

Climate Change and Population Health in Africa: Where are the Scientists?

Challenges in Predicting Climate and Environmental Effects on Vector-Borne Disease Episystems in a Changing World

Assessing the Future Threat from Vivax Malaria in the UK Using 2 Markedly Different Modeling Approaches

World Health Organization: Impact of Dengue

Onome Akpogheneta has a PhD from the London School of Hygiene and Tropical Medicine. Her work has been published in Infection & Immunity, Parasite Immunology, The Faster Times, MalariaWorld, The Periscope Post and Livestrong.

Post a Comment( 4 )

Achieving Maternal Health

By Adrienne Germain

This month, a study published in the The Lancet reported a decline in maternal mortality. While this is cause for optimism, we cannot afford to be complacent: more than 300,000 women still die senseless deaths and suffer disabilities each year due to preventable causes related to pregnancy and childbirth, and in some countries, maternal deaths are on the rise. Many of these girls and women give birth and die at home, often alone, in fear and agony. Or, they die in substandard medical facilities ill-equipped to deal with problems that are routinely managed for women in rich countries and for rich women in their own countries. Saving women's lives in childbirth requires relatively inexpensive and known interventions at the clinical level - not fancy hospitals, new technologies or scientific breakthroughs. This decline does give us reason to be optimistic, but with political will, we can and should continue to make maternal health a global priority. And we must also make it easier for women and girls to decide to use, and actually reach, these services.

With impetus from the Millennium Development Goals (MDGs), specifically MDG 5, priorities are starting to shift and nations are beginning to pay more attention to women. Our mission, however, is not simply to reduce maternal deaths, but to achieve maternal health. Maternal health is a state of being. It cannot be achieved through a simple technical fix, nor through maternity care alone. Rather, we must also equip women with the information, skills and services to make informed decisions whether to become pregnant and to give birth. They must have access to safe, affordable contraceptives, including emergency contraception, and male and female condoms, especially where HIV and other sexually transmitted infections (STIs) are prevalent. They must also have the choice of safe abortion. And they need prevention and treatment for the myriad of STIs that jeopardize not only their own health and lives, but those of the children they choose to bear.

Maternity care, contraception, safe abortion, prevention and treatment of STIs including HIV - these four, together with comprehensive sexuality education form the core sexual and reproductive rights and health (SRRH) package, which is required to ensure that women and young people can live just and healthy lives. Each of the five main elements of the package relies on the others to reach peak effectiveness. Focusing only on one element of this package without the others in concert is not only shortsighted, but a failure to respect women's realities. As we look at the function of each element, the justification for providing the complete package is clear, not only in terms of girls' and women's needs, but in terms of efficacy.

Knowledge is power - and a key element of the SRRH package. In Nicaragua, almost 90 percent of sexually active adolescents did not use contraception the first time they had sex simply because they were unaware that they could. Early, comprehensive sexuality education for girls and boys can help fill gaps in knowledge, empower young people to make healthy decisions, prevent unwanted pregnancies, reduce the risk of STIs, and encourage equal and balanced relationships based on respect for human rights and for consent.

The second element of the package is access to contraception. More than 200 million women who want to delay or prevent pregnancies lack the information or contraceptives needed to do so; and nearly half of the 205 million pregnancies that occur each year are unplanned. By making effective contraception affordable and accessible, we can help ensure that every pregnancy is wanted and reduce the need for abortion.

Contraception helps reduce unwanted pregnancies, but will not eliminate them. More than half of the 80 million unwanted pregnancies that occur each year end in abortion - and half of those are performed in unsafe conditions. About 67,000 women die annually from complications of unsafe abortion, and thousands more are severely injured. Preventing these deaths and injuries would reduce maternal mortality by approximately 13 percent globally. Yet, even where abortion is legal, access is often limited by barriers imposed by health institutions; a shortage of skilled providers; and lack of information.

When women give birth, skilled birth attendance with ready referral to facilities that can provide good quality emergency obstetric care could reduce maternal mortality by over 50 percent. The absence of these services remains a major problem especially where populations are widely dispersed. Only two out of every three women living in the developing world today give birth with skilled assistance, and even fewer have access to essential obstetric care.

Finally, prevention and treatment of STIs, including HIV, is vital for both maternal and neonatal health. Women with pelvic inflammatory disease (PID) from untreated STIs are at higher risk of infertility and ectopic pregnancy, a condition that is fatal without skilled care. A recent study showed that HIV-positive women in South Africa were up to five times more likely to die of pregnancy-related causes than pregnant women not living with HIV. Educating women and men on preventing STIs through the use of male and female condoms and other safer sex practices, as well as diagnosis and treatment, would save lives and transform communities.

The integrated SRRH package I've just outlined is not simply a concept. It has proved to be an effective strategy for the improvement of maternal health. In Bangladesh, one of the poorest countries with high rates of maternal mortality, the success of a comprehensive SRRH initiative in the 1990s provides inspiration. Within five years of initiation, the percentage of women receiving check-ups and care prior to childbirth doubled from 26 percent to 56 percent. Use of emergency obstetric care rose by nearly 25 percent. Female life expectancy increased by two years. Maternal mortality dropped by 26 percent.

Fifteen years after the United Nations International Conference on Population and Development (ICPD), the Obama administration announced a Global Health Initiative that mirrors the ICPD SRRH approach which was adopted by Bangladesh. They, other donors, the U.N. Secretary General, and many nations are now increasing attention to MDG 5. But we must not try to play with only half the deck available. We must fully fund and implement the comprehensive sexual and reproductive health package, not only maternity care or only family planning or HIV prevention and treatment. Together, the elements of the SRRH package add up to far more than the sum of its parts. Its full implementation will not only achieve maternal health, but also secure health and human rights for generations.

Adrienne Germain is president of the International Women's Health Coalition.

Post a Comment( 11 )

A New Angle on Pediatric HIV/AIDS in Swaziland

Photos and story by Jon Hrusa

I've been taking pictures for the Elizabeth Glaser Pediatric AIDS Foundation since 2004, photographing donor trips in South Africa, Tanzania and Swaziland. I've visited many Foundation-supported health clinics, and I've always known that the Foundation's mission is to eliminate pediatric HIV and AIDS. But it wasn't until November 2009 that I fully understood how that goal can be achieved.

In recognition of World AIDS Day (Dec. 1, 2009), I wanted to tell the story of a family living with HIV in Swaziland -- the country with the highest HIV prevalence on earth. Through my relationship with the Foundation, I was introduced to Mfanzile Dlamini (28), his wife Zanele (24), and their 13-month-old daughter Phiwa. Mfanzile and Zanele are both HIV-positive, but Phiwa has thus far tested negative thanks to the Foundation-supported prevention of mother-to-child transmission (PMTCT) services that she and her mother received.

Living in South Africa, HIV/AIDS has become an accepted fact of daily life. Before I met the Dlaminis, I knew that people with HIV needed antiretroviral medications (ARVs) to stay alive. When it came to prevention, I'd heard a lot about the "ABC" campaign - Abstinence, Be faithful, Condoms. But I knew very little about preventing mother-to-child transmission of HIV. When I thought of pediatric HIV/AIDS, I usually thought about helping the children who already have it, rather than preventing them from getting it in the first place.

The reality hit me as the Dlaminis were sitting outside their one-room house, with Phiwa crawling around in the dirt: This child's parents are HIV-positive, and she is HIV-negative. The Foundation's work helped bring this about. And if every mother living with HIV had access to the same services that Zanele received, there would be no more pediatric AIDS. It was mind-blowing.

I photographed the Dlaminis for nearly three days and witnessed every aspect of their daily lives. Despite dealing with extreme poverty, life-threatening illness, and social stigma from their HIV status, the Dlaminis are a family just like any other. They work hard and their lives are difficult, but they like to eat and laugh and play with their daughter.

I was particularly struck by the relationship between Mfanzile and his little girl. In the health clinics I've visited over the years, I usually see babies with their mothers. But Phiwa gravitated to her father as well as her mother. I'll never forget the afternoon that Phiwa ran into the hut to wake Mfanzile, who slept during the day because he worked as a night watchman. I was very moved by this intimate moment between father and daughter.

My time with the Dlaminis left me feeling grateful and incredibly humbled. As a photojournalist, I tend to enter a situation, shoot it as I see it, and move on. My camera is a barrier between me and the emotions on the other side of the lens. But since the Dlaminis welcomed me into their home for several days, I had time to put my camera down. I played with Phiwa and talked with her parents. I saw them as people rather than subjects.

On my last day with the Dlaminis, I went with them to the plot of land they farm. While Mfanzile and Zanele toiled planting seeds, Phiwa played next to me in the field. Mfanzile took a moment away from work to pick up his daughter, and I was there to catch it. There's so much hope in this photo - Mfanzile looking up at Phiwa as he lifts her toward the sky. It sums up my feelings about this project and the admiration I have for the Foundation's work.

Jon Hrusa is a staff photographer for the European Pressphoto Agency, based in Johannesburg, South Africa. He has been partnering with the Elizabeth Glaser Pediatric AIDS Foundation on photography projects since 2004.

Post a Comment( 3 )

From the Ground Up

By Nellie Bristol

Haiti's new health system will guarantee access to quality services for all through a performance-based funding system and large investments in human resources, according to rebuilding plans laid out by the Haitian government. The effort will require an investment of $1.5 billion according to a Post Disaster Needs Assessment (PDNA) developed by the Haitian government and international groups. The estimate of funding "needs" in the document takes into account recovery, reconstruction and re-establishment of the Haitian government.

Stakeholders already have begun meeting to develop specific objectives and goals for the system's development, said Judith Timyan, health program coordinator for USAID's Haiti Reconstruction Task Team. Overall reconstruction initially will be overseen by a Haitian interim commission for recovery led by former U.S. President Bill Clinton in his role as UN special envoy to Haiti and by Haitian Prime Minister Jean-Max Bellerive.

Donor funding will be pooled in trust fund overseen by the World Bank. Auguste Kouame, World Bank Sector Leader for Poverty Reduction and Economic Management and Lead Economist for the Caribbean, said the Bank will serve as a fiduciary agent for the fund. The trust fund will receive and distribute money largely from major international donors, keeping with the priorities of the Haitian government. Kouame said the fund is modeled on a similar structure used to distribute international donations related to the 2004 tsunami and included strict oversight to ensure the quality of the work funded through the program. "It worked beautifully," Kouame said. "If we could replicate and adapt the Aceh model in Haiti it would be great."

The PDNA indicates that 30 out of 49 hospitals have been damaged or destroyed. On the plus side, it says, 90 percent of health centers are intact or suffered only minor damage, providing a platform to launch a community based health strategy. Priorities for a new system include services in maternal and reproductive health and to combat the spread of HIV/AIDS.

The goal is to build a system that is a vast improvement over the pre-earthquake model, which left 47 percent of citizens without access to health care. "The health system is fragmented, highly unfair (6 percent of the poorest women give birth in health-care institutions, compared with 65 percent among the most well-off) and highly inefficient, with expenditure of $32 USD per capita per year and poor health outcomes for expenditure of this level," the PDNA says. It cites fee-for-service arrangements as a major barrier to health-care access.

One of the biggest obstacles to revamping the Haitian health-care system is lack of personnel. "The earthquake has had a major impact on health-care staff, with more than 50 percent living in tents, leading to disorganized service delivery," the report says. Further, most of the country's training facilities and universities were located in the earthquake zone leaving a major gap in that sector.

While all concerned are anxious for the government to take charge of reconstruction efforts, many worry it doesn't have the resources needed. "They're going to need a lot of help," said Timyan. Lindsay Coates, vice president of policy and communication for the NGO umbrella group InterAction, agrees: "The Haitian government is very thin."

"There is a very strong desire to work with the government of Haiti in partnership," she said. "The challenges are around the government's capacity." InterAction received funding from USAID to set up a "coordination cell" that is helping NGOs connect with the UN system.

Coordination of UN activities and program implementers is being overseen by the UN Office for the Coordination of Humanitarian Affairs and representatives of the Haitian government. Souad Lakhdim, a Pan American Health Organization official helping to coordinate UN health activities, said OCHA, government representatives and NGOs are meeting regularly to exchange information and synchronize activities. Despite the effort, some say more is needed to ensure help is reaching those in greatest need and isn't duplicative, particularly as the effort moves from relief to reconstruction. "The problem in responding to the earthquake is not lack of material or coordination, but lack of complete and coherent planning that could be implemented without gaps," said Loris de Filippi, Medecins Sans Frontieres' Haiti operational coordinator.

Creating the local personnel capacity to take charge of the reconstruction and mobilize the many resources to carry it out is a top priority. In the health sector, USAID is offering technical assistance to train health personnel, particularly allied personnel such as pharmacists' assistants, nurse midwives and auxiliary nurses, Timyan said.

Many are seeing the involvement of the Haitian diaspora as a key to ensuring that as many indigenous personnel as possible are part of reconstruction, with the hope that the involvement will make new systems sustainable. The Center for Global Development (CGD) is urging development of a mechanism to support the exchange. "Dozens, even hundreds might be willing to return home for up to two years to help jumpstart and expand the school and health systems, replacing the skills of the huge number of Haitian civil servants who lost their lives," CGD President Nancy Birdsall wrote in a commentary on the group's website. She suggested that USAID could support a group like the Clinton Foundation or the Peace Corps to manage the program, screen the applicants, and to arrange modest monetary support. CGD also is urging flexibility in USAID contracting rules to ensure Haitian NGOs receive priority in contracting for work.

Haiti will need all the help it can get to repair not only earthquake damage, but to escape a history rife with instability and hardship. "It is a plan to create a ‘New Haiti,'" UN Secretary-General Ban Ki-moon said of the reconstruction. "A Haiti where the majority of people no longer live in deep poverty, where they can go to school, and enjoy better health, where they have better options than going without jobs or leaving the country all together."

Nellie Bristol is a freelance journalist, specializing in health policy.

Post a Comment

NGOs Seek Seat at Table

By Nellie Bristol

International relief and development NGOs working in Haiti are seeking a greater say in how rebuilding progresses as they tally up contributions of more than $2 billion for recovery and reconstruction. The push comes even as the groups come under criticism from some quarters for a history of side stepping the government and failing to support sustainable local systems.

Sam Worthington, president and CEO of the NGO alliance group InterAction, said U.S. NGOs had received more than a billion dollars in donations by the end of March, $500 million of which is slated for reconstruction. European Union donations totaled $880 million with an additional $150 million raised in Canada, he said. "We are committed to investing a tremendous amount of financial and human resources in Haiti, and should be recognized by nation-states as a key partner in the reconstruction effort," he added. InterAction received $330,000 from USAID to establish a "coordination cell" to help groups connect with UN system activities.

In a recent interview, Lindsay Coates, InterAction vice president for policy and communication called the amount of money raised by NGOs "astounding." She said the sum changes the relationship the groups have with donors. "We're more of a partner and less of an implementer," she said.

International NGOs are seeking a voting position on the interim commission for the reconstruction of Haiti, an entity of donors and Haitian officials established to oversee recovery efforts, and the Haitian development authority that will eventually replace the commission. "Given both the significant resources NGOs are contributing to the rebuilding effort and their role as the primary implementers of the post-earthquake recovery and reconstruction activities, NGOs should be included as voting members of these institutions," the groups argued in Principles and Recommendations for International NGO Participation in Haiti Recovery, Reconstruction and Development. The statement was developed by NGO alliances representing groups in Brazil, Canada, Chile, Europe, France, Spain and the U.S.

Foreign aid in Haiti historically has been complicated and controversial. Billions of dollars have been donated to the country over several decades with limited results. Erratic and politically motivated donor support, Haitian government corruption, and lack of coordination by development groups are often cited. With an unprecedented amount in foreign funding now pledged for the country's reconstruction, stakeholders are saying they want things done differently. "The old ways in Haiti have never been good enough in the past and they won't be good enough in the future," said Peter Bell, senior research fellow at Hauser Center for Nonprofit Organizations at Harvard University. "Everyone is going to have to change, including NGOs."

InterAction's Coates said NGOs are committed to working more cooperatively and transparently. "We need to work with the government in a partnership," she said. The groups support the development of a single country plan through which specific projects can be taken on by different donors and NGOs, she said.

NGO critics say the groups have not supported the government enough in the past. While providing most of Haiti's health care and education, NGOs "have been accountable neither to users or funders," Paul Collier, Oxford professor of economics and former UN special advisor on Haiti, wrote on ForeignPolicy.com He also cited lack of quality assurance and coordination.

Long-time Haiti health provider Paul Farmer of Partners in Health, now UN deputy special envoy to Haiti, voiced a similar message. "The fact that there are more NGOs per capita in Haiti than in any other country in this hemisphere is in part a reflection of need, but also in part a reflection of over-reliance on NGOs quite divorced from public health and public education sectors," he told a Senate panel. He added: "The aid machinery currently at work in Haiti keeps too much for overhead for its operations and still relies overmuch on NGOs or contractors who do not observe the ground rules we would need to follow to build Haiti back better.," he said. New rules should include a demand to create local jobs for Haitians, building infrastructure for sustainable economic growth, and reducing Haiti's dependence on aid, he said.

Those working on the ground reject attempts at greater government authority over their work. "We'd lose control over some very successful programs," said Jeremiah Lowney, president of the Haitian Health Foundation (HHF). The group, which started in Haiti in 1982, regularly supports 250,000. It is now providing health, education and food for an additional 50,000 people who fled earthquake-affected areas to the region where his group works. He says the school it runs now offers two shifts a day to accommodate an influx of children displaced by quake-related destruction.

While aid groups resist greater government authority, many say they crave better coordination with the government and with each other and seek out mechanisms to achieve it. "We really need a leader," said Dianne Jean-Francois, Haiti country director of the Catholic Medical Mission Board, which has been working in the country since 1912. "The Ministry of Health needs to take leadership to facilitate all of the players that are on the ground." Coordination of NGOs is being conducted through the U.N. Souad Lakhdim of the Pan American Health Organization is the U.N. contact for health groups. She said about 300 groups are registered with the system and that it helps them coordinate with other NGOs and with the government. But, she said, there are groups that don't register. "They are not aware of the rules and they just come do whatever they want," she said.

The U.S. attempted to improve NGO coordination through the USAID funded InterAction office. "Given the magnitude of the disaster, USAID saw a need for supporting critical humanitarian coordination efforts including NGO coordination activities to supplement the intentional coordination architecture in Haiti," USAID Legislative and Public Affairs special assistant, Anna Gohmann wrote in an email. "USAID support to InterAction for a NGO coordination cell was intended to provide guidance and an advocacy forum to both international and national NGOs and to facilitate access for new agencies not familiar with existing international coordination structures." InterAction worked with the Switzerland-based International Council of Voluntary Agencies in the effort to facilitate contact with groups beyond InterAction's U.S. NGO members.

Nellie Bristol is a freelance journalist, specializing in health policy.

Post a Comment( 1 )

The Making of Anatomy of a Pandemic: A PBS Documentary

By Larry Klein

When novel H1N1 was beginning its global trek toward pandemic status in late spring 2009, we approached PBS about producing a special that would attempt to look at the pandemic from the point-of-view of those on the front lines of the effort to slow infection rates and treat those already sick.

We decided on this approach because this would be a documentary requiring months to complete. We knew we could not compete with the news of the day (the networks and cable providers would certainly do that). But we could be like imbedded journalists for this war - examining the outbreak from the ground up and through the eyes of those our society entrusts with our very lives and well-being. The Corporation for Public Broadcasting funded the project and we were off ... sort of.

The main focus of the program remained our guiding principle throughout: Is the country's public health and health-care infrastructure prepared enough and capable enough to take on a major flu outbreak?

But in order for our battlefront approach to work, we would need to win the trust of local health officials and hospital authorities, who would have to consent to our filming inside the planning-and-response meetings and emergency rooms and Intensive Care Units where the real action would be taking place. This was a lot to ask as we would be shooting highly sensitive situations where the pressures on public health and medical professionals could become intense. And in the hospitals, we would need to respect patients' rights and wishes.

We, nonetheless, were able to persuade public health and hospital authorities in Seattle and Boston to let us in. We chose these cities in large part because of contrasts: older eastern city with urban poor and top flight medical community versus newer west coast city with wider affluence and another strong medical community. Since we knew the vaccine would be a hot-button topic, the fact that the Seattle area boasts a large anti-vaccine community and Boston a highly compliant one presented another attractive reason for the two choices.

By mid-September, permissions were lined up and then we waited ... and waited. The outbreak hit the south in the early fall but took weeks to appear in the communities we had prepped. As the news reports shouted about flu dorms, school closings and hospitals with tents in parking lots, we began to feel the pressure: could this outbreak pass us by? As the clock ticked, we began filming secondary targets, such as random vaccine clinics, and we produced those before the pandemic sequence in Boston. But it was now the middle of October, our Dec. 14 airdate loomed, and we had very little in the can of what we originally set out to do.

Fortunately, we held fast and the outbreak finally struck Boston. We filmed at a furious pace over the next several weeks realizing that if we truly wanted a ground-up view, we would have to jettison Seattle. There was no time left to do both cities comprehensively. Boston, like most regions, ended up handling this flu pretty well. The disease remained mild enough so the resources put in place, such as supplies of Tamiflu and the administrative efforts to deal with the surge of cases, worked. In some areas, things were stretched but not broken. Had the flu been more virulent, it was also clear that regardless of how well Boston or the even the CDC had prepared, we might not have done nearly as well. And this became the overall conclusion of the program.

We would have liked to film longer. A new flu virus can change over the course of a large outbreak - becoming more or less virulent - and the disease can also come in waves. As new infections slowed in December, some experts began declaring the outbreak over while others warned of a re-emerging outbreak. There were also reports of increased virulence in places like the Ukraine and more and more instances of Tamiflu resistance through endemic regions. And the vaccine continued to be late arriving. So we wanted to see things through to the end. But the film was tied to a December airdate. So we stopped filming in November to edit and complete the program. It felt like we were ending the story in the middle of Act Two, but hopefully we did a good job of meeting our original goals and that people understand that the U.S. and rest of the world really does need to devote far more resources to combat influenza for we may not be as lucky the next time.

There is also the fact that pandemics like this one often come in waves. So although it looks like things may be slowing down right now, the outbreak could pick up steam for another round in the late winter or even the spring. But we knew that at some point we had an airdate to meet and that we would need to report on the status of the pandemic "before" we knew all the answers. That can be a bit frustrating for documentary productions (as opposed to news). But as one of our experts said: "If anyone tells you they know what will happen with this pandemic, don't believe them."

Learn More

Anatomy of a Pandemic companion site, with experts interviews, lesson plans and H1N1

Anatomy of a Pandemic is available for purchase at ShopPBS.org

Larry Klein is the producer, director and writer of Anatomy of a Pandemic. He won an Emmy Award in 2006 for the PBS show, Rx for Survival: A Global Health Challenge.

Post a Comment

Leadership and Management

By Joseph Dwyer and Sara Wilhelmsen

A broken health system is a silent killer. People get sicker and die in disproportionate numbers just as they do during an epidemic. Yet the culprit is not lack of knowledge. Nor is it always a shortage of funds. Technically and medically, we know what to do to reduce illness and save lives. But what is sorely amiss is the dearth of knowledge and skill to manage these very complicated health systems. Dr. William H. Foege sums up the issue as "global health waits expectantly for management to match its science."

Simply put, global health initiatives must recognize the critical need for investing in the leadership and management skills of those running health systems. Doing so is a key step in getting countries back on track towards making progress on the ambitious Millennium Development Goals (MDGs). More important, it is essential if countries are to meet the health needs of their own populations and ensure the sustainability of long-term health interventions.

Linking leadership and management to results

Building the management and leadership capacity of health care managers and practitioners is an important step in improving service delivery. When leadership and management are strengthened, the rewards for the health system are high.

In Brazil, for example, the Secretariat of Health of Ceará mandates that public servants receive leadership training to apply for management positions. This process has broken the mold of just promoting people, prepared or not, to leadership positions. The improvement in health results was significant, illustrating the link between transparency, governance and health outcomes. In one municipality, infant mortality dropped from 26 to 11 deaths per 1,000, while the percentage of women receiving pre-natal care increased from just over 50 percent to 80 percent. Overall, 70 percent of the 25 municipalities that participated in the leadership development process were able to reduce their infant mortality - some by as much as 50 percent.

In order to establish a link between the strengthening of management and leadership practices and the strengthening of health systems overall, as was seen in Brazil, those working in the health sector at all levels - governmental, institutional, academic and other - must commit themselves to the monitoring and evaluation of data that validates this connection.

Although performance planning and evaluation systems and performance-based financing mechanisms are gaining popularity as ways of holding managers accountable for results, measuring the impact of leadership and management has been a major challenge. A breakthrough related to this challenge has been a change in thinking from seeing improved leadership and management as a means to an end, not an end unto itself. True measurement of leadership and management capacity can be undertaken when those working in health systems have the expertise and capabilities to clearly identify their challenges, mobilize resources, select meaningful indicators, and measure results.

When we look at health leaders and managers as a critical part of the workforce and plan for them accordingly, we will go beyond the skills of medical practitioners to the skills of planning, motivation, procurement systems, and accountability for results (including monitoring and evaluation) that are fundamental in making a health system effective.

Investing in Leadership and Management

High-level efforts by the U.S. Agency for International Development (USAID), the World Health Organization (WHO), the Rockefeller and Gates Foundations, and others have shed light on the importance of investing in leaders to strengthen global health systems. WHO's three-country study of South Africa, Togo and Uganda provides insight into the challenges faced by health managers. Fortunately, many are acknowledging the need for change and taking action. At the country level, the ministries of health in Kenya recognize that effective leaders and managers are the foundation to achieve both Kenya's National Vision 2030 and the MDGs for health. This had led to a systematic, intensified reform process and new policies requiring leadership and management development for those entering the health sector.

It is this kind of country ownership and action paired with investment by the global community that shows the potential to produce more effective health systems. Countries have a responsibility to develop and support policies that address health leadership and management at all levels and in all aspects of the health system. Donors have an accountability to ensure their approach will influence positive change and deliver results.

What does building leadership and management capacity look like?

Government mandates such as Kenya's, and regional resolutions for improving leadership and management such as the one drafted at the East, Central and Southern Africa Health Minister's Conference in 2009, are one approach to building leadership and management capacity. Integrating a focus on these areas into the earliest stage of a health worker's career - while they are still preparing to join the field - is another. Four universities in Nicaragua have been taking this pre-service approach over the past few years. Another method is offering those tasked with leadership and management responsibilities professional development opportunities, such as ADRA International's Professional Leadership Institute, which offers in-service trainings once a year to health sector workers in Africa, Asia, and Latin America.

In order to understand the benefits of building capacity through these approaches, perhaps it is best to start with what happens in the health system when people lack these skills. It has been well-documented that poor leadership and management result in low staff morale, high staff turnover, and unacceptable levels of vacancy, all of which waste financial and human resources. More recently, it has also been documented that a shortage of doctors, nurses and allied health professionals does, in turn, lead to higher maternal and child mortality.

One example of how investment in leadership and management can make a difference in even the most challenging of circumstances comes from Afghanistan. There, the ministry of public health works to strengthen the leadership and management of the central and provincial levels by making managers more aware of their role as stewards of the health system. Under a program supported by USAID, more than 1,800 health professionals throughout 13 provinces have been reached, with gratifying results. These managers have been able to increase vaccination coverage and access to family planning services, resulting in improved child and maternal health. The most significant improvements: an increase of almost 70 percent in health facility births and a 28 percent increase in family planning consultations.

These examples show how all levels of the health sector recognize the great need for leadership and management as well as illustrate that models for practical preparation do exist.

Conclusion

We potentially face billions of dollars in wasted resources if the people who drive the health system have not been prepared with the management and leadership skills to take proven medical programs and practices to scale. The evidence for the critical role of leadership and management in closing the gap between what is known about public health problems and what is done to solve them is clear. Policies that support leadership and management at every level of every initiative, organization, government agency, hospital, and university to prevent needless deaths are needed and the time is now. If we are going to make a difference in global health, we must invest in leadership and management.

Joseph Dwyer is the director of the Leadership, Management & Sustainability Program at Management Sciences for Health (MSH). Sara Wilhelmsen is a senior program officer in MSH's Center for Leadership & Management.

Post a Comment( 6 )

In-Country Supply Chains

By Prashant Yadav

Great progress has been made in recent years in developing new medicines, vaccines and other technological interventions to improve health throughout the world.

Increased financing from multilateral, bilateral and private donors has resulted in these new drugs and vaccines being available to end patients in low-incomes countries, where affordability remains a serious issue. Many global health managers now realize that promoting health and reducing the burden of disease requires action across the health system, including vast improvements in the supply chain for distribution of medicines and other health commodities.

The need for better in-country supply chains is no simple matter; the inefficiency and ineffectiveness of the in-country supply chains is often staggering.

Many large multilateral donors, such as the Global Fund to fight AIDS, TB and Malaria and GAVI, have begun to acknowledge that the overwhelming lack of supply chain infrastructure and management capacity in recipient countries poses a key challenge to their ability to spend their resources effectively.

Many innovations have occurred at the global flow architecture for products, financing and information in this supply chain (See Figure 1). For instance, donors have started to explore pooled procurement as a means to address weak in-country procurement capacity and reduce disparity in prices; pledge guarantees and market-driven bridge-financing mechanisms are being piloted to counter against uncertainties in financial flows; coordination between multiple stakeholders and better information flow from countries is leading to more accurate forecasts; and, regional distribution hubs are cutting down the time and cost of flow of products from the manufacturers to the countries.

Some argue that a key reason for poor availability of drugs at the service delivery point is on account of poor financial and operational management, which leads to delays in purchasing drugs and does not ensure that sufficient quantities are in the pipeline. However, in my opinion, the weakest link in the chain now is the in-country distribution system. The costs of ignoring this key part of the health system can be extremely high.

A key reason for the poor performance of the in-country supply distribution system is the lack of an institutional and governance framework on how to organize in-country distribution. When it comes to health-care provision, OECD countries have a varying mix from private to public with many shades in between. However, the distribution of pharmaceuticals to hospitals and retail point of dispensing is invariably carried by the private sector in almost all OECD countries. On the other hand, very few developing country governments and other global health stakeholders have begun to accept that pharmaceutical distribution is not necessarily a public sector role.

Most African governments still choose a distribution model, where a publicly run central medical store distributes drugs to clinics using a government-owned transport fleet. In such a model, the managers of government-owned central medical stores confront severe challenges in improving operational performance. They often have difficulty hiring people with business experience and skills because of poor wages and incentive systems in the public sector and often lack the ability to remove incompetent workers.

Distribution models such as decentralized medical stores, quasi-private or private drug-distribution systems offer several advantages over fully public distribution systems but are rarely implemented. A few countries, such as Zambia, have established para-statal drug distribution entities and have contracted out the operational management of such entities to private third-party companies. Some countries, such as Ghana, have decentralized their distribution by allowing districts to purchase drugs and supplies from private-sector suppliers, creating competition for the publicly run central medical store.

Admittedly, many of these models have not yielded their promised successes, but implementation weaknesses should not be seen as weaknesses in the distribution model itself. Admittedly, it is not a one-size-fits-all problem. Not all countries can outsource medicine distribution to the private sector because in many countries there is no capacity in the private sector to carry out this role. In other instances, the regulatory and contracting capacity in the government is so poor that monitoring and ensuring the quality of the distribution will be a challenge.

Within publicly owned and operated drug distribution systems, a large number of countries have a three-tiered distribution system with product flowing from a central medical store to district or regional stores and then to the clinics. The most challenging part of such distribution systems (often called "last mile logistics") is making deliveries to small clinics and health centers that are remote and have poor road access. In such instances, the clinic and health center staff themselves travel to the district or regional medical store to receive their drug supplies using their own means of transport, such as cars, motorbikes etc., in the process taking away extremely crucial health-care worker time from the primary health system. When there is a system to distribute from the districts to the clinics, there is often a shortage of staff at the health centers that are trained to carry out the tasks of stock-keeping, ordering and requisitioning. Poor last mile logistics imply lack of consumption data from the service dispending point which should be the backbone of all planning in the upstream system.

Here it is worthwhile to note that organizations, such as Coca-Cola, which are known to have high distribution reach and efficiency, use a more decentralized distribution model in Africa. In developed countries, their distribution model works on the principle of delivering large amounts of product via trucks or smaller vehicles to retail outlets. However, acknowledging the challenges of road infrastructure and smaller retail markets in Africa, they use a distribution method that relies on manual distribution, utilizing methods such as bicycles, boats and pushcarts to distribute small quantities of product to a range of small dispensing outlets. Their model is similar to community health workers travelling to small villages with drug and health commodity supplies with the difference being that owners of Coca-Cola manual distribution centers have a financial incentive to ensure timely and adequate replenishment at each of the retail points.

With the recent explosion of inexpensive information technology such as mobile phones, a range of new options to organize last mile distribution and collect information about clinic level consumption have become available. However, while mobile phone technology will clearly act as an enabler and catalyst of innovative distribution models at the last mile, it alone cannot achieve much unless the institutional and governance structure in the public sector creates the right incentives for better last mile distribution and investments are made to train field staff on better quantification and replenishment planning.

Prashant Yadav is professor of Supply Chain Management at MIT-Zaragoza International Logistics program in Spain.

Post a Comment( 5 )

Health Worker Migration: Disease or Symptom?

Michael A. Clemens

Do health workers who leave developing countries, and the organizations that hire them, cause death? Enormous concern has arisen around this issue. Many analysts assert that health worker migration from poor countries kills large numbers of people. If this is true, others reason, the international recruitment of African health workers is an atrocity, a crime against humanity.

We should take these claims seriously. If health worker migration by itself were a substantial cause of death, then stopping health worker migration - by itself - would save lives. Allowing it would have plain ethical implications. Measures that have been proposed to limit health worker migration include restrictions on the international recruitment of health workers, and promoting health worker self-sufficiency in destination countries. Such measures are coercive; they work to interrupt health workers' ability to find jobs abroad, without those workers' permission.

But migration is simply a choice about where to live. Stopping health worker migration by itself means restricting health workers' choices about where to live, against their will. That has ethical implications too, especially because many of those who advocate limiting health worker migration enjoy freedom of movement and spectacular wealth that many developing-country health workers could never hope for. We should not consider forcibly restricting the freedoms of others without overwhelming evidence that doing so directly saves many lives.

What hard evidence do we have that health worker migration is an important cause of death? The main evidence in most writings on health worker migration is that places with more health workers have lower rates of mortality. Here's an example from one report that advocates measures to limit health workers' mobility:

Source: Joint Learning Initiative, Human Resources for Health: Overcoming the Crisis, page 26.

But the fact that places with more health workers have lower death rates does not mean necessarily that the number of health workers determines a country's mortality rate. Places with more cancer patients use more chemotherapy, but that does not mean that chemotherapy causes cancer. In order to believe that health worker migration is a substantial cause of death, we need to know much more than the fact that places with lots of migration have lots of death. We need to know that if there were less migration, and if all else were equal, there would be many fewer deaths.

To believe that, you would need to believe two things.

The first thing you would need to believe is that migration is an important cause of health worker shortages. Right away there's a problem. To say that a Malawian doctor is absent from Malawi "because" she is in Britain is like saying that a bowl of soup is salty "because" you put salt in it. It's literally true, but it doesn't tell you anything you didn't already know. Most importantly, it tells you nothing about why she decided to leave.

The reasons for her decision should be the focus of our attention. We can ignore the reasons and focus on stopping migration itself if we feel comfortable changing her choice without giving her a reason to change her choice - that is, coercing her decision. But in that case, either we must claim special authority to coerce others to live in circumstances often far more difficult than our own, or we should feel comfortable with others coercing our own decisions about where we live. If neither of these is palatable, the goal of policy toward migration should be to influence the underlying reasons for migration decisions.

Those reasons are transparent. The World Health Organization surveyed more than 2,000 health professionals in six African countries in 2003, asking them if they were thinking of emigrating and why. Roughly half declared an intention to emigrate. Common, unsurprising reasons included: "better remuneration", "better living conditions", and "to save money". But in many countries a more common answer was "to gain experience" or "upgrade qualifications". Roughly as common were the responses: "lack of facilities", "poor management", "safer environment", and "violence and crime".

These are the underlying causes of migrant health workers' absence from the country they chose to leave. Changing these causes is both more effective and more ethical than focusing on stopping movement itself, via recruitment bans or "self-sufficiency". Focusing on underlying reasons is more effective because it treats the disease rather than the symptom. And it is more ethical because it gives potential migrants a reason to change their minds, rather than coercing their actions.

There is a second thing you would need to believe in order to believe that less health worker migration per se would mean substantially fewer deaths. Even if you believe that migration per se is the "cause" of health worker shortages, you would also need to believe that health worker shortages at the national level are an important cause of death relative to other causes of death.

Health outcomes are determined by a constellation of forces. Most health professionals who migrate internationally are very highly skilled clinical care professionals with several years of advanced education. But health workers like these play a limited role in determining the health outcomes that are most grave in the most afflicted countries.

Diarrhea kills a child in northern Mozambique. We could list many potential "causes" of that sad event: lack of proper sanitation, lack of a distribution network for cheap electrolytes, lack of parental education, lack of rural-service incentives for health professionals, the skill mix of the national health workforce, and a long list of others. Very far down that list would be the number of physicians who live within the national borders of Mozambique. Adding one physician within those borders by preventing his migration - adding one secondary or tertiary care worker more likely to work in the capital Maputo than in the rest of the country - would have been highly unlikely to prevent what befell that child.

That's not a call to inaction. There are many, many things that policymakers can do to build a human resource base for health and development without restricting international movement. I have discussed these options elsewhere. They include real incentives for service in underserved areas, pay that is tied to performance, innovations in how health workers' training is financed, changes in the skill-mix of the health workforce toward prevention and very basic primary care, disassembling legal barriers to effective deployment of existing health workers, supporting temporary return by émigré health workers, and supporting regional centers of excellence in care, prevention and research.

The migration of health workers is a symptom rather than a disease. The disease that causes this symptom is often the very poor working conditions that these professionals face at home, relative to the excellent conditions that their rich-country colleagues take for granted. If our interest is in building the capacity of developing-country health systems to prevent suffering and death, we should move away from thinking of migration as the problem. Seeing migration as the problem leads us to "solutions" that involve stopping migration itself, forgetting that migration is merely a choice of where to live, a choice that very few of us would accept losing without our consent.

Building up developing-country health systems means asking health workers what they would need in order to stay and what they would need to be effective, as well as reconsidering the incentives created by current public systems of health-worker training and employment. In short, it means thinking of health workers less as human resources and more as human beings.

Michael A. Clemens is a research fellow at the Center for Global Development.

Post a Comment( 13 )

Kiev Diary: TB, AIDS and Junkies

Photos and story by Michael Wang

I have been graced. In my 20-year career as a photographer, the most satisfying work has come now with PATH. I believe in their mission to improve the health of people around the world. And when I document their projects, I am a step toward a solution I could never accomplish alone.

As I travel the world, it is my hope to do justice to the men, women and children I photograph. No matter how far from home I am, even in the harshest conditions in Latin America or Africa, I always feel a bond with the people I photograph – as if they were my own family. I’ve been able to see strangers with the eyes I use for relatives. But that wasn’t the case in Ukraine, at least not at first.

I was there to turn my camera to PATH's work on HIV and tuberculosis prevention and education. Ukraine has one of the fastest-growing AIDS epidemics in the world. More than half the HIV infections are caused by IV drug use. When HIV infection weakens the immune system, TB infection can activate and become TB disease. Without treatment these two infections are fatal.

These facts can be easily understood by a layman like me, but what do they mean? I was out of my depth. Here’s a story unlike any other I’ve photographed …a story not about the struggle of a family to find health care, or of a woman finding the strength in herself to fight against adversity, or of a poor baby struggling to stay alive for lack of a simple vaccine or clean water. I was to take photographs of injection-drug users.

Their story is hard to tell through images. There are no sympathetic faces of strong mothers and vulnerable, beautiful children. Instead there’s a junkie. A man, maybe in his late 20s – but I can’t tell because of the ravages of his drug use. I find him with the help of a Ukrainian NGO called Club N.A., who give support, counseling and clean needles to injection drug users in Kiev. He's one of three men living in the projects. These men are rough, urban and anything but inspiring at first glance. But as I speak to them (or communicate as best I can with the little Ukrainian I know) my guard begins to drop.

These junkies came to me with open eyes and open faces. In one of the moments of documenting them, I shot a picture that reversed my stereotype of them. This photo (man with needle) is here for you to see, for you to decide what constitutes a sympathetic person. Totally vulnerable to my lens, cascading a light that’s Rembrandt in its mirroring… at the decisive moment of the shutter’s click I know that as much as a baby in need of vaccine, this man is in need. This man, with his faults and his self-inflicted harm, is in need of help and he deserves aid as much as the strong woman who walked 5 miles across the Andes in Bolivia to get to a health clinic. He has as much right to health care as the mother of five in Kenya. That’s the realization I have when I click the shutter. I had to see him clearly as a human in need before I could show him to you that way.

The marginalized sufferers are easy to ignore and dismiss, whether it’s because we are casting moral judgments on their actions or because it’s just too hard for us to summon empathy. But they are the ground zero, they are the nexus of many epidemics and they need and deserve the kindest eye.

Michael Wang is a project documentary photographer for PATH.

Post a Comment( 18 )

The Killers We Ignore

Nellie Bristol

Americans and other rich country denizens have been hearing the message for years: snub out the smokes, cut out the chips, crawl off the couch, and move your body. But in many low- and middle-income countries, daily lives were consumed with ensuring children lived past the age of five and getting through the days’ back breaking labor to feed the family. Now globalization, urbanization and successes in combating infectious disease are bringing the burden of “lifestyle” diseases to health systems that are still struggling to catch up with rich-country levels of vaccine coverage and sanitary standards. Experts say the trend adds another formidable argument for focusing scant resources less on specific diseases and more toward health system strengthening and public health activities.

Chronic diseases, including cardiovascular disease, chronic respiratory disease, diabetes and cancer, now account for about half of all deaths and disability in low- and middle-income countries, a figure that is expected to increase dramatically in the coming decades. The rise is occurring in compressed form, catching health systems and donors unprepared.

“It’s quite astonishing how quickly chronic diseases have overtaken infectious diseases in developing countries,” said Rachel Nugent, the Center for Global Development’s deputy director for global health. She cites figures from Bangladesh that show an 86 percent reduction in age-standardized mortality for diarrhea and dysentery, and 79 percent for respiratory infections (excluding TB). The same time period (1986-2006) shows a 3,500 percent increase in deaths from cardiovascular and cerebrovascular disease, and a 495 percent increase from cancer.

Several factors contribute to the rapid rise: successful efforts against infectious diseases, which both decreased the total disease burden and allowed more people to age to the point where chronic disease could become an issue. Also fueling the surge is the spread of smoking, which the UN Food and Agriculture Organization says is growing at a rate of 1.5 percent a year, almost exclusively in developing countries. Add to that urbanization, resulting in changes in exercise habits, providing greater access to a less healthy diet, and increasing exposure to toxic agents like air pollution and industrial waste.

The change in conditions can affect a family in as little as a generation and has been shown to have even more harmful biological effects as a result. Research indicates that fetuses and infants whose mothers are malnourished develop bodies that have adjusted to the nutritional shortfall. The adaptation has been shown to make those children of shorter stature even more susceptible to obesity and its associated metabolic effects if overnutrition becomes an issue later in life.¹ “Their lifestyles have changed dramatically in a pretty short time,” Nugent points out.

Further, chronic diseases are disabling and killing those in the developing world at a younger age since cholesterol reducing pills and screening for pre-diabetes are rarely available. The World Bank reports that more than three-quarters of chronic disease disability in low- and middle-income countries affects those between the ages of 15 and 69, prime age for economic productivity.

Keith Norris, interim president of Charles Drew University of Medicine and Science and an ambassador In Research!America’s Paul G. Rogers Society for Global Health Research, points out another factor that exacerbates conditions in the developing world. Globalization not only introduces Western World sedentary, fast food lifestyles to developing countries, but also results in the dumping of toxic technology trash in some areas. The lack of environmental pollution controls and some countries’ acceptance of contaminated waste contribute to “an exposure to environmental toxins that is going to be many fold greater than what people in developed nations may experience,” he said.

The combination could prove to be particularly lethal, Norris added. ”We’ll have numerous children who not only will be developing obesity and diabetes at higher rates than previously – they’re also going to be exposed to an additional burden of toxins and substances that are going to further accelerate the vascular complications for them,” he said.

WHO, the World Bank and others have expressed concern over this development for several years, but voices calling for greater attention are getting louder. The Institute of Medicine is working on a report with recommendations for combating cardiovascular disease in developing countries. It follows a 2007 report on cancer control in low- and middle-income countries and is expected to be released next year. Chronic disease is likely to be addressed in recommendations released in January 2010 by the Center for Strategic and International Studies’ Commission on Smart Global Health Policy.

“We wanted to signal that in many of the countries we’re working in … we often focus on the traditional infectious diseases and maternal and child health and increasingly, chronic diseases are going to be the more important on the landscape for low- and middle-income countries,” said commission co-chair Helene Gayle, president and CEO of CARE.

Greater attention both within countries and from donors is desperately needed. In numbers she is developing for a new paper, CGD’s Nugent estimates chronic disease attracts a mere 0.23 percent of donor funding compared to an Institute for Health Metrics and Evaluation estimate of 23 percent of disease-specific funding for HIV/AIDS. Meanwhile, cardiovascular disease alone kills five times as many people as HIV/AIDS in low- and middle-income countries, according to WHO.

Experts agree that the trend calls for concerted public health education efforts in developing countries. Not only is awareness of the negative health effects of their new lives limited, but resources to deal with them are scant. “I think particularly in low-income countries, when resources are low, prevention is absolutely paramount,” said Montserrat Meiro-Lorenzo, senior public health specialist for the World Bank. Relatively inexpensive measures for primary prevention include smoking cessation, increasing taxes on tobacco and alcohol, ensuring vaccination coverage, and improving water and sanitation. Overall health improvements and vaccinations, she said, will reduce exposure to agents linked with cancer, including hepatitis and the human papillomavirus.

The increase in chronic diseases also will force new thinking on the provision of screening and prevention methods. Since some of the technology required, such as mammograms, is very expensive, centralization may be required. Dissemination of new, less expensive tests, such as use of Lugol’s iodine to identify women at risk of cervical cancer, also is necessary.

“We’re going to have to think about ways of making those services available at a reasonable cost because otherwise the cost of these secondary measures is going to overwhelm the health system,” Meiro-Lorenzo said.

Retraining of health-care providers, and patients themselves, is also required. In places where many people encounter the health-care system rarely and sometimes never, providers need to ensure patients remain connected for a number of years, and probably for the rest of their lives. “Treatment [for chronic disease] requires a completely different mindset for the person that provides the health care,” Meiro-Lorenzo said.

The diseases also require a different economic approach for the family. Whereas an acute disease can require a bankruptcy-inducing cash outflow for many families, chronic diseases can have similar but more subtle consequences, requiring the family to devote substantial resources to it on a regular basis. “The burden on the family, while it may not be as catastrophic as an acute disease, it may be more progressive and it may be much more insidious,” Meiro-Lorenzo said.

This makes properly regulated risk-sharing insurance arrangements even more necessary, a solution that will need to be developed by a country’s legislators.

But getting policy-makers to give chronic disease proper attention will be difficult in countries already overwhelmed by acute diseases and a global recession. Gayle, the co-co-chair of the Commission on Smart Global Health Policy, notes, for example, that it will be difficult to convince major tobacco producer China to cut back when it counts on the industry for a substantial percentage of its net government income.

But some of the tools needed to improve detection and treatment in the developing world are simple and available. Blood pressure and diabetes screening can be incorporated into vaccination days; pharmacists can be trained to track patients; and developing world public health officials can implement the same messages in their countries that have become the mantra here.

“If pushed now [public health interventions] could have a huge impact on the health of nations in the future,” Gayle said.

Reference

1 Gluckman, PD and Hanson, MA, 2008, Developmental and Epigenetic Pathways to Obesity: an Evolutionary-Development Perspective, International Journal of Obesity, vol. 32, pgs S62-S71.

Bobbi Nodell is a freelance writer.

Post a Comment( 6 )

Cancer, Silent but Intense, Threatens Systems

John R. Seffrin et al

This article is an abbreviated version of an editorial entitled “It Is Time to Include Cancer and Other Noncommunicable Diseases in the Millennium Development Goals” that appeared in the September/October 2009 issue of CA: A Cancer Journal for Clinicians. The material has been excerpted and reprinted with permission from John Wiley & Sons and the American Cancer Society. For free access to the original and complete text of the editorial, go to cajournal.org.

In 2008, more than 7.6 million people died from cancer globally. Photo courtesy of Fundacion CIMA*B

The worthy efforts in recent years to increase attention on HIV/AIDS, tuberculosis, malaria and other communicable diseases have helped the world respond more effectively to the threat these diseases pose in low- and middle-income countries. But at the same time in these countries, a silent pandemic of cancer and other noncommunicable diseases (NCDs) has been spreading and now threatens to overwhelm health systems and undermine social structures.

NCDs, which include cancer, cardiovascular disease, diabetes and chronic obstructive lung disease, claim more than 35 million lives each year, accounting for 60 percent of all deaths worldwide. According to the World Health Organization, mortality rates are higher for noncommunicable diseases than for communicable disease among men and women age 15 to 59 in all regions of the world save Africa. Now, more than ever, the world must take steps to balance the global response to both communicable and noncommunicable diseases, especially in low- and middle-income countries where the burden of NCDs is already great and the level of unnecessary suffering profound.

Frightening Threshold

In 2008, cancer accounted for 7.6 million deaths globally, more than AIDS, malaria and tuberculosis combined. We have reached the point where cancer is set to become the leading cause of death in the world, followed by heart disease and then stroke. This threshold has been approaching for years, yet has largely gone unnoticed. Cancer and other NCDs are rarely addressed in major policy forums, such as meetings of the G8 and G7, and have only recently been incorporated into discussions at the World Economic Forum.

Perhaps most strikingly, NCDs are not specifically referenced in the United Nation’s landmark Millennium Development Goals (MDGs), which are designed to reduce “income poverty, hunger, disease, lack of adequate shelter and exclusion.” Expanding the Millennium Development Goals to specifically address cancer and other noncommunicable diseases and setting firm targets (or indicators) for controlling these diseases are important steps toward more fully addressing the world’s leading causes of death and disability.

All Income Groups, Ages Touched

The impact of NCDs can be felt throughout the world and cuts across all income groups and ages. In absolute numbers, the vast majority of NCD deaths – more than 80 percent – occur in low- and middle-income countries, where population sizes are high, access to high quality health care is often limited, and health promotion programs are rare. Cancer alone claims more than 5.3 million deaths annually in low- and middle-income counties – more than 70 percent of all cancer deaths worldwide. According to the World Health Organization, adults are especially vulnerable to NCDs. “People in these countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries.”

Link to Infectious Diseases

Although NCDs are often associated with unhealthy lifestyle behaviors, such as tobacco use and poor diet, a significant number of NCDs are closely connected to infectious agents. Cervical cancer, which is the second most common cancer among women worldwide, is caused by human papillomavirus. Despite the fact that most cases of cervical cancer could be prevented or effectively treated, approximately 273,000 women die from the disease each year. The vast majority of these deaths – more than 80 percent – are among women in low- and middle-income countries. Most women in these nations do not have access to care that can prevent the onset of this disease or detect it early.

Overall, infection-related cancers account for approximately 26 percent of all cancer cases in low- and middle-income countries compared to 8 percent in economically developed countries. These and other disparities must be addressed.

Balancing Priorities

Efforts to control noncommunicable diseases should not come at the expense of other global health initiatives. Too often calls for disease-specific interventions force decision makers into a zero-sum approach to resource allocation. In reality, a higher overall level of funding – even in hard economic times – is needed to effectively address major disease issues globally. We must identify new resources for combating NCDs and, over time, build a more balanced public health portfolio that includes health promotion and policy reform along with prevention and treatment. The cost to address noncommunicable diseases will not be insignificant, but it pales in comparison to the very real costs –economic and human – of doing nothing.

John R. Seffrin, PhD, is chief executive officer of the American Cancer Society. David Hill, PhD, is president of the International Union Against Cancer. Werner Burkart, PhD, is deputy director general of the International Atomic Energy Authority. Ian Magrath, MB, BS, FRCP, FRCPath, is president of the International Network for Cancer Treatment and Research. Rajendra A Badwe, MD, MBBS is director of the Tata Memorial Centre. Twalib Ngoma, MD, is president of the African Organisation for Research and Training in Cancer at the Ocean Road Cancer Institute. Alejandro Mohar, MD is director general of the Mexican National Cancer Institute. Nathan Grey, MPH, is the national vice president for international affairs at the American Cancer Society.

Post a Comment

Probing Health Ministries

John Donnelly

Minister Sheiku Koroma, Ministry of Health & Sanitation FREETOWN, Sierra Leone – Inside the fifth-floor conference room at the Ministry of Health and Sanitation, Minister Sheiku T. Koroma faced a team of visiting financial auditors, and laid open his troubles.

"We have a budget of nearly $11 million, and here we are in the seventh, eighth month of the year, and we've spent just $3 million," he told them. "Something is wrong. There is money. But how do we spend it? We don't know. The system is broken and we want you to help us.''

If the auditors were startled, they didn’t show it. They simply nodded and scribbled notes. They were at the meeting as part of a project by the Ministerial Leadership Initiative for Global Health (MLI), a four-year initiative funded by the Bill & Melinda Gates Foundation and the David and Lucile Packard Foundation to help strengthen the capacities of five health ministries in the developing world.

The auditors’ very presence was noteworthy. While some people in global health speak of neglected tropical diseases, a recent Rockefeller Foundation report found that health ministries themselves have been long neglected, calling them one of the most forgotten parts of government in poor countries. The report detailed a history of how donors place heavy demands and expectations on the people who run their country’s health system, but rarely help them succeed in meeting those tasks.

But signs of change are beginning to emerge – inspired from a gradual understanding that the crush of new global health initiatives will not work to potential unless health officials strengthen their systems, allowing them to absorb new funding and new programs.

Now, a few relatively small pioneering efforts have begun to start supporting leaders in the ministries. They include MLI’s $11.2 million initiative in five countries and Synergos Institute’s Gates-funded work in Namibia, along with new funding made available for health system strengthening by the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the GAVI Alliance; that system-strengthening money could potentially be put toward bolstering the capacity inside ministries. The dollars overall are not huge yet, but no longer are almost all the funds going toward programs, drug purchases, or vaccine campaigns or research.

"One reason for the low funding has been that the big international donors and most countries see the health ministry as part of a consuming sector as opposed to a growth sector that could contribute to economic development," said Jo Ivey Boufford, president of the New York Academy of Medicine who helped lead the Rockefeller study. "Another reason is that the structural adjustment patterns in the 1980s and 1990s focused on shrinking the public budget. The first thing that governments did was cut administrative expenses, and ministries of health absorbed many cuts in staff. The ministries have not been a strong political force in these countries."

Boufford and Dr. Francis Omaswa, who also helped direct the Rockefeller report, both said that ministries deserved much more direct assistance, ranging from helping them sort out their financial systems to day-to-day peer management training to building a work plan on reproductive health issues.

"They all know what their problems are," Boufford said of the leaders in health ministries. "But they generally do not have many people who can do needs assessments and policy analysis. In many of the poor countries, supporting institutions such as universities and think-tanks ought to be available to the ministries, but they, too, lack capacity to help."

Omaswa, who was director general of Uganda’s Ministry of Health from 1999 to 2005, said that international donors could help the long-range performance of their programs if they helped build a better-functioning ministry. Instead, he said, most donors focused on the short-term results from their own programs. He cited one prominent example – the U.S. global AIDS program known as PEPFAR.

"PEPFAR helped save many, many lives," he said. "It also put U.S. ambassadors in charge of the program in their country. Now the U.S. government is saying the countries have to take it over, even though PEPFAR hasn’t allowed the countries to have ownership of the programs until now. In an environment like this, which has undermined the ministries in the past, outsiders should think about ways of supporting the countries and each of its institutions – ministries, think-tanks, universities – so that they will be able to use aid as well as possible."

MLI, a program of Realizing Rights that is housed in the Aspen Institute, is working with ministries in Sierra Leone, Senegal, Mali, Ethiopia and Nepal. Each of the five countries has helped design the type of assistance it most desperately needs. MLI hasn’t focused solely on ministers – three of the five countries had a turnover in the position in 2009 – but rather has sought to help the entire senior leadership in the ministries.

MLI’s assistance has been in three policy areas: equitable health financing and resource allocation formulas to make sure money was going to reach the poorest; coordination of donor activities and projects; and working on reproduction health policy toward improving access to quality services, especially for the most vulnerable.

Rosann Wisman, MLI director, said the feedback has been positive so far. "Health systems are important to strengthen, but you’ve got to have leaders to make the systems work," she said. "The approach that is emerging for us is placing more importance on collaborative learning, peer learning, and developing trusted relationships with a range of partners, including donors, NGOs, and people inside other ministries."

In Nepal, Dr. Baburam Marasini, chief of the Health Sector Reform Unit at the Ministry of Health and Population, said MLI helped the ministry start to build a better relationship with donors. He said one of the most difficult issues for the ministry is not knowing exactly what the various non-governmental organizations are working on. He estimated that 25 percent of the money spent on health programs in Nepal – more than $50 million – came from NGO-funded programs.

"So much of what is happening in Nepal's health sector is done by donors but not coordinated by us,'' Marasini said. "Our government has to build up their capacity so that we can understand and track these programs much better.''

John Heller, senior director of Partnerships at Synergos, said that his team’s approach in Namibia has been to listen to people in the ministry tell Synergos what they need – and then to act on it.

"One of the underlying lessons for us is there’s leadership and capacity within the system, but that it is latent and hasn’t been pulled out yet," he said. "We help bring people together in the right kind of way to help unblock things. We assume they know what they are doing. But we also know they need coaching, guiding, helping and supporting ways to help remove the blockages."

Despite these new initiatives, Boufford remains concerned that donors and governments will not continue to support the ministries of health.

"The management capacities of these groups have not been valued," she said. "There has been so much more priority put on drugs, vaccines, and now workforce. But the systems and infrastructure has to be managed properly."

In Sierra Leone, Minister Koroma is grateful for the help – as are people in charge of his numerous departments, from environmental health to reproductive health.

"We need to bring many things under control – financially and with our programs," Minister Koroma said in an interview after the auditors left to begin their investigation. "We have the people in the ministry who can make things work. We need outside help to guide us, to help us do our jobs better. We have a big problem in Sierra Leone – rebuilding a health system from 11 years of civil war. But we can do it."

John Donnelly is a freelance writer based in Washington, D.C. Part of his reporting for this story was done on a trip to Senegal and Sierra Leone supported by the Ministerial Leadership Initiative for Global Health. He can be reached at (JavaScript must be enabled to view this email address).

Post a Comment( 5 )

Poet Soldiers

Poems written and read by members of the St. Vincent and the Grenadines Cadet Force for and at an HIV/AIDS candlelight memorial

Are You My Friend?

Ten years we walk together,
Ten years you been me friend,
But five years ago, ah never tell you wha did happened then.
You remember Gina?
Yes Gina, de African goddess sent?
Well she and me got together,
And you could imagine how that went.
A few weeks later she give me a call,
And ah tell yo boy, ah nearly bawl.
She said she had de thing - de AIDS yo know,
But ah couldn't believe that that been so.
Ah check me doctor.
And ah tek de test,
Fo days and days, man, ah couldn't rest.
De test came back,
And de worst was true,
De girl been ha de thing
And I got it to.
Five years now it ah burden, burden me chest,
Ah ha to tell somebody,
And ah think you de best.
So tell me now what you gwine do,
Yo gwine walk way from me?
Or could I count on you?
- Darrien Ollivierre, Lieutenant

Discrimination

Only hate, scorn and glaring eyes
Am I a monster?
All I want is love,
Someone to appreciate,
Demonstrate and don't hesitate
To give me what all human beings deserve, LOVE.
Every night I pray
That the Almighty God
Would lead me not to stray.
I do the same as everyone...
Eat, laugh, work and play,
But why am I not looked at in the same way.
I try to tell them it's not my fault,
But what do they care,
All they do is just hate, scorn and discriminate.
Open your eyes people, I am just like you
Two legs, arms, eyes and ears.
But why can't I strive, tell me why can't I?
It's not my fault I still try to say,
but what do they care,
They just, hate, scorn and discriminate.
- Julonna Peterson, Lance/Corporal

A Poem on HIV/AIDS

A long time ago, 1992 yo could say,
Yo could ah neva hear a thing like AIDS going around here.
But now you think is so, AIDS flying round like mosquito.
They say it began in Africa,
But it really started from men and women all over.
A lady on the TV the other night say she ha the cure,
Could she be serious?
This lady must be think AIDS is trush!
Anyway, all I could say is,
AIDS like it nah gwine way.
So I'm begging all young ladies who just coming up,
Mind what you doing or your life would be corrupt.
No, I did not forget the young men them,
They too need to help us with this problem.
- Nassine Richards, Private

STOP HIV/AIDS

Who me? NO way, I could never get AIDS
I am sure that's what many people say
But am here to tell you today
That kind of thinking will get you no way
You better change that perception I say
AIDS does not discriminate
It knows no color, gender, class nor race
You could be rich, poor, even displaced
Homosexual, bisexual and even heterosexual are all at risk
Just one moment of folly
Before you know you are an AIDS case
Our teenagers are AIDS favorite age.
Our young adults, its popular friend too.
And just imagine even married folks give it to their spouses.
The unborn, innocent child can get it from their mother
And to make matter worse they may grow up as orphans
But do you know what is worst?
Our society scorns and discriminate those with HIV/AIDS
Believe me that is no help, it only makes the conditions worsen
They need to know they have our support
They need to be loved and cared for too
So they can help to spread the message to me and you.
The facts are alarming, million of men,
Women and children have already died
And many more millions are living with the virus
And can you imagine, the Caribbean, our little slice of paradise
Is marred with HIV/AIDS
But guess what all is not lost, it is not doom and gloom
AIDS is fatal but it can be prevented
As old people say "An ounce of prevention is better than a pound of cure"
Educate yourselves and those around you,
Abstain, practice safe sex, and do what you must do
And if you think you contracted HIV, get tested
Find out the facts, and act on them
And let us reclaim our lives from this deadly virus.
-Idelia Ferdinand, Captain

Post a Comment( 3 )

Pakistan’s New IDPs

Ashfaq Yusufazai

Even from a distance, the Sheihk Yasin Camp on the Mardan-Charsadda Road in northern Pakistan looks bleak. The heavily armed guards at the main entrance, where visitors are subjected to a body search, to the rows of greenish-gray tents amidst the hot, dry climate, portend much illness and suffering among its inhabitants, Pakistan's newly displaced population.

Sheihk Yasin is one of 23 makeshift camps established largely by the United Nations following the April 26 military action Pakistan launched against Islamic militants in its North West Frontier Province. An estimated 3 million civilians fled to the adjacent provinces of Mardan, Swabi and Peshawar. Of these, around 80 percent live with host communities and about 500,000 displaced people live in camps.

© William A. Ryan/UNFPA The strain of displacement has left an indelible mark among many in this population. Dr. Mian Iftikhar Hussain, a psychiatrist at one of the camps, estimates 50 percent of the women suffer from mental disorders after witnessing the deaths of their loved ones and the destruction of their properties. The relative comfort of their old lives lies amidst the rubble they left behind.

"[We] traveled on foot for hours along with other women and children after failing to get a vehicle to transport us to a safer place," says Jamila Bibi, a 39-year-old housewife who now lives in Sheikh Yasin.

Dr. Hussain says Bibi is one of many women suffering from severe depression. Bibi's 11-year-old son, Gul Jamal, was a casualty of the raid. "My son was playing outside the house when a bomb hit him and we found his charred body scattered all over the place," she told the doctor.

Of another woman, Hussain says, "She suffers from post-traumatic stress disorder due to the loss of her son in fighting between the government's forces and Islamic militants. Her condition will deteriorate further due to [continued] fighting in Swat."

© William A. Ryan/UNFPA Children, likewise, have been affected by the trauma of conflict and displacement. Abdul Hameed, president of the Pakistan Pediatric Association, says there are about 1.3 million refugee children who are at high risk of mental illness, as well as other disease. "These children could turn into monsters in the future if they aren't rehabilitated," he bluntly said. "The government should arrange for children's health, shelter and educational facilities."

In a recent survey of physicians at the various camps, of the 15,000 patients visited, 50 percent suffered from depression, 28 percent from dysentery, 11 percent from scabies, many suffer from acute watery diarrhea, according to Dr. Fazal Mabood, director-general for health services in the North West Frontier Province.

In the Jallozai Camp, "About 51 percent of the camp's (residents) suffer from acute respiratory infections and 19 percent had acute watery diarrhea," said Dr. Saeed Akbar Khan, operation medical officer from the World Health Organization. The camp is home to 87,000 people from volatile districts, who are exposed to a host of diseases because of scorching heat and the lack of electricity.

Lack of food or potable water, inadequate sanitation and close quarters make children particularly susceptible to illness. Children are among the worst-affected, prone to malaria, typhoid and water-borne diseases because of contaminated food and water. Dr. Khan said that along with the provision of diagnostic treatment and facilities, WHO has deployed environmental engineers to test the quality of water and food.

According to UNICEF's estimates, 15 percent of children in the camps are severely malnourished. "The worst affected are those from Nowshera, Lower Dir, Mardan and Charsadda," said Dr. Akbar. In an effort to raise awareness about nutrition, UNICEF has launched a program to train 10 people in each camp in Community-based Management of Acute Malnutrition (CMAM).

A shortage of beds, coupled with the steady influx of IDPs in many of the hospitals, has forced health-care workers to place two children in one bed.

The Pakistan Pediatric Association established two wards dedicated to providing specialized treatment to critically ill IDP children, one at the District Headquarters Hospital in Mardan, another at the Shah Mansoor Medical Complex in Swabi. Within two weeks, 1,424 patients were examined. Of them, 995 had acute watery diarrhea, 147 had an acute respiratory infection, 121 suffered from dysentery, 104 had high temperature, 24 had malaria, three had meningitis. Though most patients were taken care of on an out-patient basis, 360 were admitted.

Hundreds of local health providers working in conflict areas of Pakistan were deployed to clinics and other facilities within the camps and in other communities where refugees are living with host families. This strategy also offers the added benefit of being able to better monitor displaced TB patients on DOTS.

However, lack of coordination among government agencies, multilateral institutions and private-sector partners have severely compromised health resources in the region. The logistical challenges of triaging patients have resulted in several deaths, many of whom are children.

Ashfaq Yusufazai is a Pakistan-based journalist. He has written for the BMJ and the Telegraph, both in the UK, among other publications.

Post a Comment( 1 )

Charting Malaria’s Demise

Eliza Barclay

The great 20th century battle against malaria, one of the most widespread and intractable infectious diseases on the planet, began in the 1940s, with famously mixed results. While 100 countries, like the United States, were able to successfully eradicate it, insecticide-spraying initiatives failed or never reached many of the worst affected areas, namely sub-Saharan Africa.

Today the vector-borne disease remains endemic in more than 100 countries, with some 247 million cases annually, though it is largely preventable and treatable. In 2007, the Bill & Melinda Gates Foundation helped mobilize a new funding and research effort to eradicate the disease. But many questions remain about how to do it. Among the challenges of designing public interventions to vanquish malaria once and for all is the dearth of well-organized data on which regions are at risk, and to what extent.

Most countries conduct prevalence surveys on the deadliest parasite that causes malaria, Plasmodium falciparum, to estimate how to extend prevention and treatment. But there have been next to no "risk maps" showing the scope of the problem worldwide that can guide policy-makers and donors in developing regional strategies.

A study released in March 2009 in the Public Library of Science journal PLoS Medicine is a breakthrough in visualizing the geography of malaria endemicity. The study accompanies a new geostatistical modeling tool, called the World Malaria Map - the result of two years of work by a team of researchers at Oxford University and other institutions who collaborate on the Malaria Atlas Project - that will likely help public health experts shrink malaria's reach on the world map.

Simon Hay, an infectious disease epidemiologist at the University of Oxford and the study's lead author, and the other researchers, which include geographers, statisticians, epidemiologists, biologists and public health specialists, began by looking at the scientific literature available on malaria going back to 1985. They assembled the data and then "geo-positioned" it, giving it a point indicating its location and place in time. That process took about a year. Then the researchers followed up with individual countries and institutions, requesting additional information where available. The resulting map has 8,000 data points up to 2007, with layers of uncertainty where data is insufficient.

One of the study's most hopeful findings is that although some 2.4 billion people live in places where they risk infection, 1 billion people inhabit places where transmission of the disease is low enough that interventions already in use - like bed nets, indoor residual spraying, and drugs - could be deployed to eliminate it.

"Using these techniques and future iterations, we will be able to understand in which part of the world we are making the greatest impact on the disease," said Hay.

In the Americas, for example, endemicity is around 2 percent, Southeast Asia is around 10 percent, and Africa is about 30 percent with regional variation. Hay says that this means that it would be technically feasible to eliminate malaria in the Americas in the near future.

Other results were more surprising. According to Hay, the map unexpectedly revealed that prevalence in West Africa remains high.

"It seems that this region is proving more resilient to interventions than most," Hay said.

Until the recent ramp-up in funding from donors like the Global Fund, the U.S. President's Malaria Initiative, and the Bill & Melinda Gates Foundation, countries like Nigeria did not have efficient malaria control programs, and were not collecting adequate prevalence data.

"Countries that have huge populations ... add a disproportionate amount of uncertainty into global assessments of the malaria burden," Hay noted.

Mary Ann Lansang is director of the health advisory unit for the Global Fund to Fight AIDS, Malaria and Tuberculosis, a multilateral donor that has financed the distribution of some 70 million bed nets and 74 million malaria drug treatments to date.

"The framework for evaluation of the impact of P. falciparum control efforts world-wide ... will be crucial ... in meeting the global goals for decreasing the burden of malaria cases and deaths," Lansang said.

Lansang also noted that the Millennium Development Goal on malaria - to halt by 2015 and began to reverse the incidence of malaria - will not be successful unless malaria control programs in Africa receive more support. According to the 2008 U.N. development goals report, the distribution of insecticide-treated nets and effective malaria drug use has fallen short of global targets.

Prior to the PLoS Medicine study, the most recent global map of P. falciparum endemicity was published in 1960 and lacked specific descriptions of the input data used and estimates for the uncertainty in its predictions. The statistical methods used to construct the new map make it possible to quantify the uncertainty in the results.

Though the map will help public health officials better understand endemicity and risk on a regional and global scale, malaria experts say it will be less useful for small geographic areas or country-level planning.

According to Richard Cibulskis, an epidemiologist with the World Health Organization's Global Malaria Programme, the map is imprecise at the country level in part because it can't take into account the recent scaling up of malaria programs.

But Robert Snow, a co-author of the World Malaria Map and a professor at the University of Oxford and director of the Malaria Public Health & Epidemiology Group at the Kemri-Wellcome Trust Research Programme, says that in Kenya, for example, the maps have guided the revision of the national malaria strategic plan.

To improve country level data, many countries are developing their own endemicity maps, mainly supported by Global Fund grants.

There are other limitations to the Malaria Atlas Project maps, depending what the user wants to get out of it.

"You don't get a clear idea around seasonality of disease and being able to represent the year-to-year variability. When you take a standard map, and if you look at Tanzania, and compare wet and dry years, it might be very different from the map you actually have," said Madeleine Thomson, a senior research scientist who studies malaria at the International Research Institute for Climate and Society at Columbia University. "The advances [in the World Malaria Map] would be to characterize seasonality and variability where that matters."

The Oxford researchers plan to update the map annually, establishing a continuous record of malaria control and elimination efforts that can serve as a guide for funding priorities. They now have access to 17,000 surveys, more than double the number available for the 2007 map, an increase Hay says is due to the fact that many donors and nations see the value of national prevalence surveys and committing the financial and logistic resources to make them happen.

Hay and the team will eventually turn this map into revised burden estimates. They'll also map the extent and burden of the less deadly, but neglected P. vivax parasite, which also causes malaria and accounts for more than 50 percent of cases outside of Africa.

But ultimately the map will need to be used by policy-makers and donors, who are confronting obstacles like communication when reaching out to malaria endemic regions.

"While there may be some hope in some areas to eliminate malaria we must equally use these maps and facts to remind us that Africa remains the hardest nut to crack and needs increased financial resources to dent transmission intensity," said Snow.

With better maps, policy-makers and donors may at least lend a hand in the right places.

Eliza Barclay is a freelance journalist based in Washington, DC whose work has appeared in The Atlantic and The New York Times.

Post a Comment( 2 )

Neglected Disease Funding Remains Off the Mark

M Moran, J Guzman, AL Ropars, A McDonald, L Wu, B Omune, L McSherry

Recent research has, for the first time, shed light on how much is being invested globally on research and development (R&D) into new products to prevent, diagnose, manage or cure neglected diseases of the developing world.

These diseases, including both well-known infections such as malaria and HIV/AIDS and less well-known diseases such as onchocerciasis and helminth infections, account for more than 11 million deaths and just under 330 million disability adjusted life years (DALYs) a year in developing countries alone. Despite this high burden, these diseases have historically received less attention than they deserve, especially in regards to funding for R&D of new pharmaceutical products. Since 2000, however, several developments have changed this field dramatically, including the establishment of new Product Development Partnerships (PDPs) for neglected diseases, increased philanthropic and public funding, and renewed commitment and participation from the pharmaceutical industry.

The research showed that more than US$2.5 billion was invested in neglected disease R&D in 2007. This funding was invested into development of drugs, diagnostics, vaccines, microbicides, insecticides and platform technologies for 30 neglected diseases of the developing world. Although this may sound like a substantial investment, it is important to remember that the cost of developing a single pharmaceutical can range from the tens of millions over 3-5 years for a new diagnostic, to hundreds of millions over 12-15 years for a new vaccine. For example, the total cost of developing a novel TB drug has been estimated at US$115 million to US$240 million , while the cost of developing a vaccine has been estimated a US$200 million to $500 million (both estimates include the cost of failure). Yet another estimate from Tufts University for the cost of developing a drug for Western markets comes in at US$403 million, again including the cost of failure. In short, as the R&D process is lengthy, risky and costly, very substantial investments are needed for a successful product to be developed.

Where does the money go?

The good news is that neglected diseases are on the global agenda and that the efforts of AIDS, TB and malaria advocates have shown results. Just under US$2 billion (almost 80 percent of total 2007 funding) went to the so-called ‘Big Three' diseases - HIV/AIDS, malaria and TB. The current portfolio of potential TB and malaria products is the largest in history. It includes, for example, advanced malaria vaccine candidates such as RTS,S (developed by GSK in partnership with the PATH-Malaria Vaccine Initiative), which has just commenced Phase III trials in seven countries in Africa. The new TB vaccine candidate (AERAS-485, being developed by the Oxford-Emergent TB Consortium), which has just begun Phase II trials in South Africa, is another example of advances in the field.

Unfortunately, however, not all neglected diseases have received attention, with many diseases that kill and disable millions of people in developing countries still remaining underfunded. Diarrhoeal illnesses - identified as one of the biggest killers in the developing world - only received US$32.5 million in 2007. This is far below what is needed to develop the new drugs, diagnostics and vaccines needed to treat and prevent the seven major diarrhoeal illnesses, such as rotavirus and cholera, which are covered by this funding.

Where does the money come from?

In its first year, G-FINDER surveyed 134 funders in 43 countries around the globe. The results revealed that a small number of organisations are bearing the brunt of funding R&D for neglected diseases. In 2007, 12 organisations provided around 80 percent of global funding, with the U.S. National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation collectively investing US$1.5 billion or 59 percent of the global total. Particularly in these uncertain economic times, it is imperative that we spread the risk so that withdrawal or reduction of funding by any one organisation will not have a detrimental impact on neglected disease R&D.

In terms of public spending, the U.S. government was the largest funder with an investment of US$1.3 billion; representing nearly three-quarters of global public spending, while the European Commission and European governments collectively invested US$384.9 million (22 percent). Also of note is the increasing role played by innovative developing countries (IDCs), with Brazil and Russia ranking as the sixth and tenth largest government funders respectively, despite their significantly lower GDPs per capita (US$5,860 for Brazil and US$7,530 for Russia, compared to US$46,040 for the US ).

The pharmaceutical industry contributed US$231.9 million in 2007, or just under 10 percent of total global funding for new neglected disease products. We note that this figure is industry's own investments and does not include funding provided by PDPs or others to industry programmes.

How can the G-FINDER data help?

The data from G-FINDER is only one element of the equation. Policy-makers and funders need to look at a range of factors in deciding where and how much to invest to maximise the health return on a given neglected disease R&D investment. Key factors in deciding which area to invest in include the severity of unmet R&D need (for instance, the burden of disease and the shortfall in existing useful products); and the severity of underfunding, with many diseases and products receiving little or no funding, as noted above.

Once a decision has been made on where to invest, the size of the necessary investment will in turn be guided by a range of factors, including:
• The type of product needed, e.g. a diagnostic, which may only need a few million dollars in funding, or an expensive full vaccine development;
• The state of the global portfolio, i.e. are there promising leads and how advanced are they already?
• The development risk, that is the likelihood that a product can be made. Scientists and companies still do not know how to make some products - a cure for the common cold being a good example - and some neglected disease products also fall into this category.

Rheumatic fever offers a helpful example of how these decision-making factors interact. Rheumatic fever is a bacterial infection, most common in children aged 5-14 years. It often leads to rheumatic heart disease, with permanent damage to the heart valves and associated risk of heart failure and stroke. According to WHO figures, rheumatic fever is the seventh highest cause of mortality from neglected diseases in developing countries, with the high death toll resulting from the lack of tertiary care facilities to treat cardiac complications in much of the developing world. A preventive vaccine for this disease is vital but does not exist. It also seems unlikely that a vaccine will be created if funders continue their current investment patterns, since the G-FINDER results showed that rheumatic fever received only US$1.7 million in 2007, well below the level needed to develop a new preventive vaccine within the next decade - or even in many decades. In other words, the severity of need and severity of underfunding are both high.

It is clear that a rheumatic fever vaccine would be the optimal product for developing country settings, avoiding the need for patients to have access to high-tech tertiary facilities for acute and long-term cardiac care. Vaccines are, as we saw, expensive to develop. However in the case of rheumatic fever, costs are likely to be lower due to a relatively low development risk. This is because the disease and its transmission are well understood, as are the science and technology to develop and produce an anti-bacterial vaccine. Limited funding over the years means that few vaccine leads are currently available and ready for further development; however, several multinational companies work in related bacterial fields and may already have suitable technologies or capabilities under way.

Based on the high need and large funding gap, investment into a preventive vaccine for rheumatic fever should be attractive for a funder who wants to invest in a lower-risk area where their money will have a high potential impact.

The Future

After past decades of inertia and neglect, the participation of many organisations and countries in the development of new products for neglected diseases is a commendable and welcome achievement.

The G-FINDER data shows, however, that these efforts are not evenly distributed, with some of the world's wealthiest countries missing in action from the top 10, top 20 or even top 50 funders. We also note that investment by some private philanthropic organisations and companies is now rivalling or exceeding spending by many public organisations, and indeed many G7 and OECD countries. While the work of these private groups is praiseworthy, we note that their efforts are meant to support, not replace, those of wealthy governments around the world.

The predominance of research into new products for HIV/AIDS, malaria and TB is understandable - and the generosity of funding is both necessary and a credit to funders. However, all neglected diseases, including these three, should receive the attention and funding needed to achieve discovery, development and registration of new products.

A broadening of funding efforts so that all who are able to contribute do so, and that all diseases receive the attention they deserve, would lead to a dramatic positive impact on the health of developing country patients afflicted with these diseases.

We hope the G-FINDER results will assist funders to identify funding gaps and see where their investments can make a substantial and valuable impact by supporting the development of new tools for neglected diseases. In tough economic times, it will be more important than ever for all funders - large and small; public, philanthropic and private; Western and developing countries - to contribute what they can to ensure that the poorest of the poor do not end up paying the price.

The full G-FINDER 2008 report is available online

HO (2008) The Global Burden of Disease: 2004 update. Geneva: World Health Organisation. pp.1-146.

Pekar N, editor (2001) The Economics of TB Drug Development. New York: Global Alliance for TB Drug Development. Accessed 16 January 2009

Serdobova I, Kieny MP (2006) Assembling a Global Vaccine Development Pipeline for Infectious Diseases in the Developing World. Am J Public Health 22 (9): 1554-1559. . Accessed 16 January 2009

DiMasi JA, Hansen RW, Grabowski HG (2003) The price of innovation: new estimates of drug development costs. J Health Econ 22:151-185. Accessed 16 January 2009

World Bank (2007) World Development Indicators Database. Revised 24 April 2009. Accessed 11 June 2009

If you or your colleagues are active in neglected disease R&D and would like to have your contribution included in the G-FINDER survey, please contact us at: (JavaScript must be enabled to view this email address)

The authors are members of the health policy division of the George Institute for International Health.

Post a Comment( 8 )

Rwanda’s Living Legacy of Violence and Healing

Story and Photos by Jonathan Torgovnik *

A WORD FROM THE PHOTOGRAPHER

April 7, 2009, marked the 15th anniversary of the Rwandan genocide. On this date in 1994, Rwandan Armed Forces and Hutu militia began one of the most intensive killing campaigns in human history with the mass slaughter of more than 800,000 Rwandan Tutsis and moderate Hutus. First forced to witness the annihilation of their families, many women were then subjected to unconscionable forms of sexual violence – gang rape, rape with sharpened objects, sexual mutilation. In the aftermath of the destruction, many female survivors learned that they had been impregnated by their captors, contracted HIV/AIDS, or both.

I first traveled to Rwanda in February 2006 on assignment for Newsweek magazine with then-health editor Geoffrey Cowley, to work on a story about HIV/AIDS on the 25th anniversary of the disease’s identification. It was then that I met Odette, a woman who had been brutally raped multiple times during the genocide. She described how her entire family had been killed and recounted the abuse she experienced, in detail. The ordeal resulted in a pregnancy – a baby boy – and HIV/AIDS. It was the most powerful and saddest interview I had ever witnessed. Odette’s horrific story led me to return to Rwanda to document her story and those of others like her.

Local nongovernmental organizations estimate 20,000 children were born from rapes committed during the genocide. Over the last three years, I returned to Rwanda several times, uncovering more details of the heinous crimes committed against the mothers of these children. The photographs and stories I collected comprise the book and exhibition, Intended Consequences: Rwandan Children Born of Rape.

Even though I knew what their stories might contain, it was impossible to prepare myself for what I was going to hear. Most of the women had not revealed their experiences to their children and communities; yet each woman shared the most intimate details of her suffering and the daily challenges that continue as a direct result of the brutality. They knew why I was there, and they wanted to tell their stories to the world. It is hard for me to understand how a mother can say, “I do not love my child.” In one of the interviews, the mother put her hand on me and said, “I know what you are asking me. I understand your question very well. I know it is terrible saying this as a mother, but this is what I feel now. Maybe, one day it will change.”

On the other hand, several mothers told me that their children are their hope, that without them they would not feel the will to survive. All of the women I photographed and interviewed demonstrated that they cared for their children. They had accepted the responsibility of motherhood despite the violent circumstances in which their children were conceived and, in many cases, despite knowing that the fathers of their children were responsible for killing their families. The mothers in this project have lived through the most severe torture any human can endure, and in the aftermath they continue to struggle against multiple levels of trauma. I admire their resilience and courage. They are undoubtedly the strongest human beings I have ever encountered.

View the Exhibition

On Sept. 2, 1998, the International Criminal Tribunal for Rwanda made history by issuing the first conviction for genocide in an international court, as well as the first conviction for sexual violence in a civil war. It also was the first time that an international court held that rape is an act of genocide when it is committed to destroying a target ethnic group.

Considering that rape was not included in the 1948 United Nations Genocide Convention, this case was a landmark decision, and an overdue revision to international law. For the first time, it was recognized that genocide could be accomplished through rape. Rwandans have continued making significant strides in healing the genocidal rape and devastation that nearly destroyed them. In 2003, the constitution was rewritten so that 30 percent of parliamentary and cabinet seats are reserved for women. In September 2008, Rwanda's parliament became the first in the world where women hold 56 percent of the seats. Although they are healing, Rwanda’s wounds are still very open and fresh, and the daily reality of the female survivors of genocidal rape is complicated as many women bore a child of rape, contracted HIV, or both. These women continue to suffer in silence 15 years post-genocide.

When I asked them how they viewed their future and that of their children, a question with which I closed all of the interviews, they would often look at me and say, “I don’t even know what’s going to happen to me tomorrow.” When pushed further and asked what future they would envision if they had the means, nearly every mother talked about education for her children and how vital it is that these children, in particular, acquire the skills to provide for themselves should their mothers not survive. More than half of the women I met are HIV positive. I was deeply moved by this repeated appeal and affected by the incredible challenges these women and children face daily.

For the first time in my career, I felt compelled to do something beyond documenting stories. Inspired to act, I co-founded a nonprofit organization, Foundation Rwanda, to improve the lives of children born of rape committed during the genocide. Foundation Rwanda provides funding for secondary school education for these children and links their mothers to existing psychological and medical services. It also helps raise awareness about the consequences of genocide and sexual violence through photography and new media. Many of the same Hutu militiamen who killed, raped and maimed in Rwanda, escaped to Congo and neighboring countries. These militiamen are continuing the cycle of violence and raping young girls and women on a massive scale in Congo today.

Many of the women we spoke to took more than a decade to start the healing process and tell their stories. For some, these interviews were the very first time they spoke about what had happened to them. Unfortunately, victims of sexual violence in Congo, Darfur and around the world are facing challenges similar to the women in Rwanda. My greatest hope is that, in reading these stories and seeing the images of the women and children in this book, people will be inspired to act and work toward ensuring that similar acts of violence never happen again and that these families can have a brighter future.

To learn more about or donate to Foundation Rwanda, go to www.foundationrwanda.org.

Purchase Intended Consequences: Rwandan Children Born of Rape the book, or listen to the podcast.

Jonathan Torgovnik is an award-winning photographer, whose work has been featured in publications such as Newsweek, The Sunday Times Magazine, Smithsonian and Paris Match, as well as in exhibitions around the U.S. and Europe. *Carl Auerbach, PhD, Denise Sandole, MS, contributed to this article.

Post a Comment( 16 )

The Million Dollar Email

Shannon Raybold

Raising $1 million with one e-mail message with stories from the field? Hard to believe, but Nothing But Nets, a grassroots campaign to save lives by preventing malaria, has raised more than $25 million by keeping it simple.

Keep it simple, find compelling ways to tell your story, give people a myriad of ways to get involved, and report back to them their success - these are key components to a successful online strategy.

The Nothing But Nets campaign grew from a Sports Illustrated column by Rick Reilly about malaria, challenging each of his readers to donate at least $10 for the purchase of anti-malaria bed nets, and the subsequent response from thousands of Americans across the country.

To date, the UN Foundation has raised more than $25 million, delivered more than 2.5 million life-saving bed nets, and created a "buzz" around malaria that has led to the involvement of faith groups, sports teams, local mayors, governors and everyday citizens in this battle to eliminate this preventable, infectious disease.

How did we do it?

We made it simple for people to understand the problem and how they can help.
The concept of the bed net is so easy, we were able to break it down to six words: Send a Net. Save a Life. This tag line is the heart of the campaign, both online and off.

This simplicity was reinforced on the website, NothingButNets.net, the true home of the Nothing But Nets campaign. It contains all the tools of the digital age - blogs, multi-media, Flash, etc. They pave the way for the actions we want people to take upon visiting the site - donate, involve their community through the Netraiser tool, and share their story with one another. No matter where they go on the website, visitors are prompted to take those three actions.

More than 1 million people have visited the site in the last two years, and the average donation is approximately $53. The site has hundreds of stories from around the country about how Americans are helping send bed nets to Africa. A common theme is that they didn't understand how easy or cheap it is to save a life - until finding Nothing But Nets.

Telling the Story

An important component of the website and the campaign is to tell the story of how malaria impacts the lives of women and children in Africa. The main section, or Flash feature, of the homepage, is used to illustrate the problem of malaria for new supporters through the life of a young refugee in Uganda. This rotating feature contains compelling photographs and short copy, explaining the current goal of the campaign.

Right now, the focus is the immediate need to send more than 275,000 bed nets to refugees in four African countries. In the "storycube," there is a compelling slide show of how malaria is affecting the refugees in each country, an explanation about the urgent need for nets, and an immediate link to the donate page. Again, it makes it simple to understand and easy for the audience to act.

Involving the Community

Courtesy of Nothing But Nets Another main feature of the website is its bustling blog, showcasing individuals and their involvement in the fight against malaria, along with touching stories from the field about those who receive the bed nets. Many organizations feel they don't have the internal resources to maintain or monitor a blog. The UN Foundation had that same concern, but the blog is worth the effort. It's not only a prominent place to acknowledge donors' work, but it also helps drive people to the website. Individuals who share their stories often share the link - and the cause -with others. This means the campaign is constantly being introduced to new audiences - for once it is posted on the homepage, the individual(s) who have written the post share the link with their friends and family.

The campaign also gives people other ways to engage their friends and family. Upon signing up for the campaign, they have the option of getting monthly text message updates. They can create their own fundraising teams online; share videos, toolkits, web banners, and links to buy Nothing But Nets gear; or play a bed net delivery game. They can also join us on the social networking sites Facebook, MySpace, YouTube and Flickr - now even more important with the new Facebook design, which has increased access to supporters' feeds and enables us to reach all their friends through status updates.

Reporting Back - The $1 Million Email

Reporting back to our community is a key part of the overall communications strategy. In 2008, the executive director of Nothing But Nets sent a message to the campaign's email list about a net distribution in Mali. It focused on thanking supporters for their contribution, encouraging more ways for them to help protect children, and continuing to educate about malaria. This email, which featured stories and pictures from the ground, raised $1 million and is the UN Foundation's single most successful email, ever.

Nothing But Nets is just one of the many initiatives the United Nations Foundation has developed to tackle global problems, but the lessons learned from this effort have informed all of its online (and overall communications) strategies. Eliminating malaria by 2015 is a daunting goal, but at the UN Foundation, we believe we've found a platform to engage individuals and get them on board with helping to solve this global challenge.

Shannon Raybold is the Internet director at the United Nations Foundation.

Post a Comment( 2 )

AIDS Hotline for Ethiopian Health-Care Workers

Kathryn Utan

Courtesy of AIHA Ethiopia is home to an estimated 980,000 people living with HIV or AIDS, including some 75,000 pregnant women. With support from large-scale international donors, there has been a dramatic increase in the number of individuals receiving life-saving care over the past five years. Currently, some 3,500 health-care workers at nearly 420 separate facilities spanning the country are providing combination antiretroviral treatment to more than 180,447 patients. The vast majority of these are receiving first-line therapy.

While the recent strides in improving access to treatment are a significant victory in Ethiopia's war against HIV/AIDS, the low ratio of experienced HIV-care providers per infected patient poses an equally significant obstacle - particularly in remote areas of the country. Physicians, nurses, pharmacists and a broad range of allied health-care workers all play an integral role in providing quality care, but many do not have the specialized knowledge and skills necessary to manage complex HIV treatment regimens.

To fill this void, the National AIDS Resource Center in Addis Ababa has established the Fitun Warmline, a toll-free telephone service designed to provide health-care professionals across Ethiopia with quick, accurate and up-to-date answers to their questions about HIV/AIDS care and treatment. Fully functional since May 2008, the Warmline helps caregivers stay current on the latest information about HIV/AIDS despite the country's limited resources, evolving communication infrastructure, and lack of time for busy health professionals to maximize continuing education opportunities.

The service was developed jointly by Ethiopia's National AIDS Resource Center, Johns Hopkins Center for Communication Programs, and Ethiopia's National HIV/AIDS Prevention and Control Office with support from PEPFAR through the U.S. Centers for Disease Control and Prevention. The American International Health Alliance's HIV/AIDS Twinning Center provides technical assistance for the project, linking the National AIDS Resource Center with similar call-in services in Uganda and at the University of California-San Francisco (UCSF).

According to Dr. Adefirs Beyene, one of the physicians who staff the Warmline, the service has three key objectives at this time: to produce rapid, evidence-based responses to a wide range of questions on HIV/AIDS-related topics; to contribute to the quality of comprehensive HIV prevention, care and support services in Ethiopia; and to develop a targeted communications strategy that will increase its number of callers.

The partnership with UCSF is helping staff meet their objectives, Beyene points out. "Working with our counterparts at UCSF is helping improve access to quality HIV care and treatment in Ethiopia by strengthening our clinical consultation skills and organizational capacity, as well as by assisting us to develop a strong continuous quality improvement program," he reports.

Courtesy of AIHA Health-care professionals can contact the Warmline by dialing 932 free of charge from any mobile phone or landline. Queries may also be submitted on its website. "When possible, we answer the questions immediately. For more complex questions, though, we conduct additional research to produce a reliable and informative answer and then return the call within two hours. When necessary, we also supply documentation to support the answer provided," Beyene said.

The Warmline is staffed by a multidisciplinary team of HIV/AIDS experts that includes two medical doctors, a pharmacist, a laboratory technologist, two nurses, a public health specialist, and a psychiatrist. "The Warmline has fielded some 16,000 calls - mostly from mobile phones -and six e-mail queries since its launch last spring. These days, we average about 400 calls a week, half of which originate in Addis Ababa. The remainder come from more remote outlying regions," according to Dr. Emebet Dendir, another staff physician, who stresses that the majority of these focus on the complex issues surrounding the provision of antiretroviral therapy.

These early numbers are impressive, particularly given the challenges staff have faced during the long start-up process. Procuring and setting up the necessary equipment and phone lines was time consuming and arduous, but obstacles faced by potential end users present problems that are even more exigent. "Many health-care providers lack telephone and Internet connectivity, which of course affects their ability to access the Warmline's services. Also, many health facilities face severe shortages of equipment, supplies and medications necessary to provide effective care and treatment for people living with HIV," Dendir said.

In 2008, the National AIDS Resource Center installed Internet connections at 53 hospitals spanning the country and plans to do the same at 50 hospitals and 200 health centers during the coming year. They will also provide phone lines to 120 hospitals and 400 health centers nationwide, which will not only help care providers tap into the Warmline's call-in services, but also allow them to access a wealth of HIV/AIDS resources and guidelines available on the organization's website.

Kathryn Utan, MA, is the editorial services and media manager at the American International Health Alliance.

Post a Comment( 1 )

Low-Tech Saves Lives

Jennifer Wilder

Like many Nigerian women, Jamila delivered her first baby at home, with the help of a traditional birth attendant. But following the birth, her uterus failed to contract and she began to bleed heavily. The birth attendant failed to recognize the severity of blood loss, and by the time Jamila reached the nearest primary health center, she was in shock and her life was in jeopardy.

Luckily, the health worker at the primary health center had been trained to use the non-pneumatic anti-shock garment to halt postpartum hemorrhage and reverse shock. Starting at the ankles, neoprene fabric is snugly tightened with Velcro straps around the legs, gradually moving up to the thighs and finally across the abdomen below the breasts, shunting blood to the heart, lungs and brain, restoring consciousness, pulse and blood pressure. Once stabilized, Jamilla was moved to the nearest district hospital, where she waited five hours for available blood replacement and a doctor.

The amazing non-pneumatic anti-shock garment is part of the continuum of care model -a comprehensive, low-tech package of interventions that addresses the causes of postpartum hemorrhage morbidity and mortality in low-resource settings. Put simply, the archetype works because it keeps the woman alive long enough to be transported and seek further treatment.

Nearly 536,000 women die annually from complications of pregnancy and childbirth. At least 25 percent of these deaths are the result of postpartum hemorrhage, which can be treated successfully by trained health-care providers using the continuum of care model.

The model was put into practice through a grant from the John D. and Catherine T. MacArthur Foundation to Pathfinder International and its partners* to address postpartum hemorrhage in India and Nigeria. Community support and well-trained providers who can implement the strategies are the crux of this model, which comprises of: management of labor, measuring blood loss, treating shock, and community education.

Active management of the third stage of labor has demonstrably reduced the number of postpartum hemorrhage cases caused by uterine atony by as much as 60 percent. To do so, three essential steps - the administration of an utertonic drug immediately following delivery, controlled cord traction, and massaging of the uterus - must be performed. Unfortunately many providers are either inadequately trained or do not implement all of the necessary procedures.

Recent studies have found misoprostal to be clinically effective as an uterotonic drug, offering a major breakthrough, as it can be administered orally and stored in poor facilities without refrigeration, a potential replacement for drugs that require injection and cold storage.

Rajni Patni/Pathfinder India Failure to recognize the severity of blood loss is another big challenge. Providers are learning better methods for visual estimation, as well as the Kanga method, which uses pre-measured absorbent cloths that, when fully saturated, signal that blood loss is excessive. In Nigeria, providers are learning to use a plastic blood collection drape that is placed under the woman's body to capture and accurately measure blood. It is easy to use and effective, though in India, stringent regulations limit use and disposal of plastics.

Shock can also compromise a woman's life. In the continuum of care model, trained, skilled providers apply the non-pneumatic anti-shock garment as a first aid tool when a woman has gone into shock, and refer her immediately to a facility capable of providing emergency obstetric care. The garment can sustain a woman for many hours, saving those who must travel long distances for care, or wait for hours for blood or a doctor's availability.

If necessary, physicians provide surgery while the garment is still in place, or the garment can sustain a woman until she receives blood and is stable enough that it can be removed. Staff must be trained to remove it gradually, as improper removal can be fatal. Systems must be in place to safely clean and store it, and to ensure its timely replacement or return to the original facility. The garment has now been made available in varied sizes to fit women of different size and build.

Some women have been sustained by the garment successfully for more than 50 hours while awaiting access to a facility, a doctor or blood.

Resistance to facility-based deliveries remains a real challenge. As part of the model, community health workers, traditional birth attendants, health officials, and community leaders are all being trained to teach women and their families why skilled care is important and how to plan for possible emergencies. Facilities have been upgraded and schedules have been changed to keep them open 24 hours a day, while families are taught how to recognize danger signs and to trust in the availability of capable providers who are caring and respectful. Communities are also organized to make emergency transportation available to any woman in crisis, and community and religious groups are beginning to promote the donation of blood.

Status Review

Dawn Shapiro In Nigeria, 31 facilities currently use non-pneumatic anti-shock garment, and of the more than 840 hemorrhage cases seen between August 2008 and January 2009, half of the women received the garment. Some women have been sustained by the garment successfully for more than 50 hours while awaiting access to a facility, a doctor or blood.

In India, project activities have started in Tamil Nadu, Maharashtra and Rajasthan, with additional work being negotiated in Bihar. In one district of Maharashtra alone, 90 facilities have been evaluated for upgrading and staff training. Because providers in most Indian primary health centers have limited capacity, Pathfinder concentrates on training and equipping secondary and tertiary facilities where most crisis cases first appear. Interest in the model is also growing among private sector doctors, who provide 30 percent of Indian deliveries.

What's Next?

Efforts are under way to scale up the continuum of care model in additional sites in Nigeria and India, and to replicate it in other countries, including Bangladesh and Peru.

The continuum of care model holds immense promise for women in developing countries, and has garnered significant interest among community members, health-care providers, and government representatives in several countries. The non-pneumatic anti-shock garment, in particular, has caught people's imagination and raised hopes; many call it a "miracle." However program staff must repeatedly remind providers and planners that the garment is only part of the solution; the first goal must be to prevent postpartum hemorrhage through the management of labor, and to ensure the availability of quality emergency obstetric care at facilities. The garment is only a miracle as long as it keeps women alive until they can receive treatment; once it is removed, the doctors must work their own miracles.

Jenny Wilder is senior technical documentation advisor at Pathfinder International. Cathy Solter, Abdelhadi Eltahir, Habib Sadauki, Rekha Masilamani, Amy Coughlin and Susan Collins contributed to this article.

*Dr. Suellen Miller of the University of California, San Francisco and Dr. Stacie Geller of the University of Illinois at Chicago.

Post a Comment( 10 )

Sustained Fixes for Nutrition?

Bobbi Nodell

Plumpy'nut, a fortified peanut butter with milk and vitamins, has been hailed as a lifesaver for starving people. But for nutritionists like Dr. Susan Shepherd, who works in nutritional emergencies for Médecins sans Frontières (Doctors Without Borders), Plumpy'nut is far from a magic bullet. Not only is it expensive, but there is simply not enough of it. She estimates just 5 percent of the acutely malnourished people, who desperately need therapeutic foods like Plumpy'nut, are getting it.

And while such nutrition-dense foods are lifesavers, they are not a long-term solution. "If you really want to focus on under-nutrition, you need to work in prevention, targeting the golden window of opportunity – conception through the first 24 months," said Katharine Kreis, a senior program officer with the Bill & Melinda Gates Foundation.

According to the Lancet nutrition series (January 2008), 178 million children under 5 suffer from nutritional deficiencies – 55 million acute and 19.3 million severely acute (wasting). Unlike many diseases, malnutrition has a cure – a balanced diet, regular consumption of fortified foods, supplements when local foods don’t have the nutrients needed, and animal-based products like milk, fish, eggs and cheese.

As Shepherd notes, "Plumpy'nut is the equivalent of a glass of milk and a multivitamin." But for millions of people, essential vitamins and minerals are a luxury they simply cannot afford.

One solution is to dramatically increase spending on nutrition. According to the Lancet nutrition series, $300 million a year is spent on nutrition while $6 billion is spent on HIV/AIDS. But increasing public funding is not sustainable, say nutritionists. Making nutrition available and affordable requires a partnership with businesses, governments and non-governmental organizations to increase both the supply and demand for affordable products.

“Nutrition can only be sustainable if people ultimately pay for it,” said Dr. Alfred Sommer, dean emeritus of the Johns Hopkins Bloomberg School of Public Health. “Nutrition could stop being a program when governments change priorities."

Today, unlike any time before however, several partnerships are galvanizing efforts to solve the nutritional crisis with sustainable solutions.

Mass Food Fortification

One of the biggest drivers in forging public-private partnerships is the Global Alliance for Improved Nutrition or GAIN, an alliance of key institutions founded in a United Nations session in 2002. GAIN now has partnerships in 18 countries as well as a project with UNICEF on iodization of salt in 13 countries. GAIN’s current main effort is in mass food fortification – the addition of micronutrients to commercially processed staple foods such as maize, rice and wheat flour, condiments like salt, sugar, fish sauce and soy sauce, and milk and oil.

“GAIN uses different program implementation approaches according to the country’s specific circumstances,” said Regina Moench-Pfanner, senior manager of the Food Fortification Program. For example, in Egypt, GAIN is working with the United Nation’s World Food Programme (WFP) in partnership with the government to fortify the wheat flour used in baladi bread, the staple food consumed by low-income populations throughout the country and subsidized by the government.

GAIN is providing $3 million to the WFP to assist the government in strengthening and upgrading the quality system of the fortification of flour and in implementing a social marketing campaign to raise awareness of the health benefits of fortification, while the Egyptian government is investing $20 million for premix, equipment, manpower and quality control over five years.

In Pakistan, where food products are not subsidized, GAIN is working with the government and millers to support fortification activities, including buying the premix.

For long-term sustainability, GAIN and its partners advocate for mandatory food fortification laws, said Moench-Pfanner.

"I really think that organizations like GAIN are making a huge difference in this field," said Dr. Martin Bloem, chief of nutrition and HIV/AIDS policy for WFP and a board member of GAIN. "Ten years ago, I would be talking only about the public sector and I would say we need more money. But that's only part of the solution."

Sprinkles

Meanwhile, in rural Tanzania, the Boston-based NGO Global Action is fighting malnutrition with Sprinkles, a micronutrient powder of essential vitamins and minerals, such as vitamin A, the B vitamins, iron, iodine and zinc. These are essential to boosting the immune system and preventing millions of childhood deaths a year.

Global Action is launching a program in Tanzania in two regions where iron anemia is 88 percent and 79 percent respectively. The packets will be distributed at community health centers when children receive their free immunizations and through community health workers to reach a larger number of children in rural villages, said Michelle Lyden, the CEO.

Dr. Stanley Zlotkin, a senior scientist with the Hospital for Sick Children in Toronto, invented Sprinkles just 10 years ago and now it’s being used in 15 countries, according to the Sprinkles Global Health Initiative.

Courtesy of Valid International The H.J. Heinz Co. and DSM are the biggest producers of micronutrient powders like Sprinkles, which they provide to NGOs for low-cost or through donations. Heinz now has manufacturing plants for Sprinkles in India and Indonesia and could open more if there was demand, said Tammy Aupperle, the director of the H.J. Heinz Company Foundation, the philanthropic arm of Pittsburgh-based Heinz. “We are completely dedicated to this project,” she said.

Demand is created in many ways. Lyden said one way is for governments to take ownership and adopt Sprinkles in the national agenda similar to vitamin A and immunization. Another model being evaluated in Kenya and India is selling Sprinkles to women so they can sell it for a small profit (a penny or two). “Mothers want to have healthy children,” said Lyden, and many can afford to pay 20 cents to 30 cents a month.

In Guyana, the government received a loan from the Inter-Development Bank to improve its micronutrient status and now is paying a local manufacturer to produce Sprinkles, said Zlotkin. He said the packets are distributed through public health clinics, which reach many of the poor but not everyone who wants it.

“One has to be creative in distribution,” Zlotkin said. “You need multiple models of distribution – public sector, government sector, NGO sector and social marketing.” Population Service International in Washington, D.C, for example, has sold Sprinkles in Bostwana , Haiti, Bangladesh and Pakistan as part of its social marketing efforts.

Other Products

Many other solutions to the world's nutritional needs are under way, such as efforts to create a lower cost version of nutrient-dense ready-to-eat products like Plumpy'nut. Valid Nutrition, an Irish-based charity for example, is active in developing local production capacities in a number of countries – Kenya, Ethiopia, Malawi and Zambia – each one based upon recipes that use locally available ingredients. And Project Peanut Butter operates a factory in Malawi dedicated to the production of a life-saving lipid/vitamin paste.

Meanwhile, new partnerships are forming between commercial food companies and microcredit companies. Jonathan Gorstein is a University of Washington associate professor whose business, Sagilo Solutions, is working together with GAIN to help forge these partnerships. In Bangladesh, he said, the Grameen Group is providing microcredit to dairy farmers so they can purchase hybrid cows, which produce significantly more milk than local cows. French-based Danone Foods then buys the milk from the farmers and makes yogurt fortified with essential vitamins and minerals. The yogurt is sold to consumers for a small profit by local women who then use the proceeds to improve their lives.

“It’s very exciting for us to have all these new products to prevent and treat malnutrition,” said Ellen Piwoz, a senior program officer with the Gates Foundation, which is backing GAIN and several other organizations. “We think of nutrition as a neglected global health problem that has a solution.”

Bobbi Nodell, a veteran journalist, is the communication specialist for the University of Washington Department of Global Health.

Post a Comment( 4 )

The African Green Revolution

Lillian Aluanga

Dinah Wetaba has always loved the sound of raindrops pattering down her iron-roofed house in Western Kenya’s Butere District. For Wetaba, a farmer and mother of five, rain completes a cycle of long days toiling on her half acre plot, tilling, planting and tending her maize, beans, sweet potato, soyabean, spinach and collard greens. Lately though, delayed and unpredictable rains have threatened the promise of harvest.

But Wetaba has other worries as well. This season she could not apply fertilizer to her crops. Since 2005, the cost of fertilizer has tripled from Sh1,600, (about US$20) to Sh4,000 (US$60) for a 50kg bag.

As the world grapples with a global crisis that has seen food prices skyrocket and production shrink, Africa is looking to a new project – the African Green Revolution – as its last hope in easing suffering from hunger and malnutrition of one-third its population.

To help millions of small-scale farmers rise out of a cycle of poverty and hunger, the Alliance for a Green Revolution in Africa (AGRA) has come up with programs to develop practical solutions that will significantly boost farm productivity and income for the continent’s farmers, while safeguarding the environment.

AGRA is an African-led partnership of farmers, scientists and the private sector, working with governments across the continent to help farmers out of poverty and hunger. It advocates policies that support its work across key aspects of the African agricultural ‘value chain’ – from seeds, soil health, water, markets and agricultural education.

So far, AGRA’s efforts to revolutionize Africa’s food production appear to be gaining ground.

At the July 2008 G8 Summit in Japan, leaders of the worlds’ wealthiest countries promised to work with organizations such as AGRA, which has in less than two years committed US$330 million in programs that address challenges across the agricultural value chain.

Among key challenges facing this chain is the spiraling cost of fertilizer, felt across the continent and on global markets.

In Kenya, the government announced plans in July to introduce subsidies for farmers through an Agricultural Development Fund that will reduce the cost of farming and includes such necessities as fertilizer and seed. Farmers will foot 60 percent of the cost while the government provides 40 percent.

Real Hope or Pipe Dream?

Skeptics have termed it another ‘white elephant’ (given similar attempts in some countries which flopped), claiming its nothing more than a scheme to enrich corporations from the West. But its proponents argue that it’s the continent’s most powerful weapon against hunger.

In the past, there have been concerns that AGRA’s “dalliance” with organizations like Monsanto, (a leading producer of genetically engineered seed), would result in genetically modified organisms being heaped onto unsuspecting farmers.

Dr. Namanga Ngongi, AGRA president, disputes claims of such partnership. “If anything,” he said, “AGRA is counteracting Monsanto as it strives towards supporting the capacity of countries to produce seed using their own natural plant genetic material.”

Kofi Annan, AGRA’s chairman and former UN Secretary General, says the revolution must incorporate the diversity of Africa’s agro-ecological environment and assure sustainable food production with improved varieties of staple food crops and improved soil fertility.

Crucial in improving food productivity is the revitalizing of soils, long weakened by poor farming practices.

“African governments must invest in fertilizer for farmers if we are to realize the concept of an African Green Revolution,” said Dr. Wilson Songa, Kenya’s secretary of agriculture. But that is not enough, he adds. “The fertilizer needs to reach farmers in a timely fashion which requires good roads and a functioning rail network.”

On both counts, the country falls far short, often leaving farmers stranded with rotting fruit and vegetables.

Given the prohibitive cost of fertilizer and desperate need for better yield, Benta Abuko, like many other farmers in her village, has turned to home-made organic manure, made from a mixture of leaves, water, crushed eggshells and cow dung. But she knows this isn’t enough to replenish the depleted soils’ nutrients and feed her family of seven.

In addition, there are questions about the effect of run-off fertilizer on already endangered water bodies. Ngongi says that AGRA recognizes the environmental concerns over pollution, but that the level of fertilizer use in Africa does not justify the claims.

“Fertilizer use per hectare in sub-Saharan Africa is the lowest in the world,” he said.

The region, Ngongi adds, uses about 9kg per hectare compared to the 300kg being used by Europe and China.

Although the soil is further weakened by poor farming practices such as mono-cropping, shrinking acreage and growing populations, farmers like Wetaba and Abuko have little choice but to plant the same crop each season to feed their families.

Frustrated by the time and effort put into farming and the meager earnings, some pyrethrum ( a plant with bright yellow flowers, whose extract is used to manufacture insecticide), maize and wheat growers in Kenya are threatening to seek out more lucrative ventures, such as running small retail businesses. To halt the trend, the government launched the National Accelerated Agricultural Input Program, which identifies and provides very poor farmers with an acre’s worth of seed and fertilizer. With a budget of Sh200m this year alone, targeting some 30,000 farmers, Songa is optimistic that the program will help farmers graduate from poverty to improved productivity and “even have surplus food for sale.”

Access to information is another cog that proponents of the African Green Revolution believe will turn the wheels of change faster. In Kenya, the ministry of agriculture has introduced mechanisms to ensure that precise market information reaches farmers. One example is a collaborative network between the Kenya Plant Health Inspectorate Services (Kephis) and a mobile phone company to provide farmers with information, for example, on approved crop varieties in their locations. This helps farmers make informed choices on what seed type to plant.

Other challenges arise, such as the difficulty of surviving in the face of civil strife, which creates an environment too unstable for people to remain on the land long enough to invest.

Ngongi also points out that proponents of the green revolution needs to think ahead and strategize on how to combat climate change and the coming shortage of water. For starters, the land under irrigation on the continent would have to increase from the current 7 percent to 40 percent and the need to produce drought resistant crops would push many countries to emphasize the growing of sweet potatoes, millet, sorghum and cassava.

Previously ignored for their inability to attract ‘good markets’ in comparison to other higher income earners like tea and coffee, there is a push to revert to the growing of improved varieties of these indigenous crops, noted for their ability to adapt to harsh weather conditions and added nutritional value.

Already the foods are making a comeback on many dinner tables in Kenyan homes and restaurants.

But AGRA’s initial appearance on the scene was not without a cold shoulder from several African countries suspicious of its objectives. The tide, according to Ngongi, is now changing.

“Ensuring support for new programs to improve agricultural production requires a good working relationship with governments,” Ngongi said. A growing appreciation among African leaders of the relationship between policy and agricultural production is crucial given its importance in accelerating food productivity on the continent.

Although the revolution has support from organizations such as the Rockefeller and Gates foundations, AGRA cites the need for African governments to ultimately sustain their own programs.

In Kenya, a partnership between AGRA, the Equity Bank, International Fund for Agricultural Development (IFAD), and the Ministry of Agriculture, dubbed ‘Kilimo Biashara,’ has seen the signing of an agreement for a loan facility of US$50M to speed up financing for about 2.5 million farmers.

For farmers like Wetaba and Abukho, the gesture may have come too late to salvage their harvest this season. But they cling onto the hope of a better tomorrow, one whose prospects appear brighter by what a green revolution on the continent promises to offer.

Lillian Aluanga is a journalist with the Standard Newspapers in Nairobi, Kenya.

Post a Comment( 2 )

How Did We Get Here?

C. Peter Timmer

Prices of basic foods have increased sharply since mid-2007. The causes and impact of higher prices are the subject of much analytical and policy debate, with little agreement except on the tragic consequences for the nutritional and health status of poor consumers. Fortunately, the price panics seen early in 2008 have reversed. But price levels remain well above long-run trends and significant micro and macro adjustments are in the works. How did we get here?

What Happened?

Two separate dynamics, with separate causes, are involved: a gradual increase in basic food prices since mid-decade, and then a rapid acceleration in price increases after mid-2007. The gradual run-up in prices was caused by three fundamental and interrelated factors:

Rapid economic growth and structural transformation, especially in China and India, put pressure on a variety of natural resources such as oil, metals, timber and fertilizers. Demand simply increased faster than supply for these commodities, and prices for non-food commodities climbed steadily after 2004.
A sustained decline in the U.S. dollar since mid-decade added to the upward price pressure on dollar-denominated commodity prices directly, and indirectly drove a search for speculative hedges against the declining dollar—often in commodity futures.
A combination of high fuel prices and legislative mandates to increase production of bio-fuels established a price link between fuel prices and ethanol/bio-diesel feed stocks—corn in the U.S. and vegetable oils in Europe. The legislative mandates in both the U.S. and Europe stem from longstanding efforts to increase agricultural prices in these rich societies to ease the pressure of rapid structural transformation on their rural economies.

The causes of the price spikes depend on commodity-specific factors, although the underlying tightness in broader commodity markets clearly contributed to market expectations that prices were headed higher. Weather and disease problems affected the wheat harvest in 2007, and soybean supplies (and production of soyoil) were reduced in the U.S. as farmers switched acreage to corn to meet demand for ethanol production. Rice is the clearest example of commodity-specific price behavior, as the price spike was triggered by a ban on exports, first in India, then in Vietnam. These export bans were intended to help contain domestic food price inflation, but also had the dramatic, if unintended, effect of sharply reducing supplies available to a very thin world rice market. Commodity markets are now global even if their impact remains country-specific.

The supply response to rapid growth in demand The pressing question is whether supply dynamics will begin to match the rapid growth in demand. In past episodes of high food prices and fears of Malthusian crises, supply responses have been vigorous, albeit with a lag, returning world food prices to the long-run downward trend that had stimulated rapid structural transformation, reduced poverty, and significantly increased life expectancy. This time, there may be little supply response left in the system, for three basic reasons:

There is little high-quality agricultural land to be opened, and climate change may be reducing productivity on existing cropped area;
The yield potential of existing agricultural technologies has been static for decades, reflecting a serious lack of investment in agricultural research for over two decades—a consequence of undervaluing the sector by markets, governments and donors; and
The costs of inputs needed to achieve higher yields are high and rising, especially for fuel, fertilizer and water. Continued high grain prices may also cause land rents and rural labor costs to rise.

In view of these difficulties, it seems unlikely that basic food prices will return to their real long-run downward trend. A more unsettling prospect is that the new link between food and fuel prices—and resulting high food prices by historical standards--could reverse the process of structural transformation, which has been the only sustainable pathway out of poverty. If so, hunger and malnutrition will rise.

Can Anything be Done about High Food Prices?

Should policy-makers try to do anything about this new equilibrium? Clearly, it was appropriate to prick the speculative price bubbles, especially for rice, even if ad hoc measures were used. It is unfortunate that the world does not have any internationally-mandated mechanism for stabilizing grain prices, or for keeping large countries from destabilizing them. But that is the world we live in.

Equally, it was also appropriate for the international community to rally resources on behalf of increased food aid to the most affected populations. Safety nets for poor consumers are essential in a world of highly unstable food prices. But no one should be fooled into thinking that such safety nets are a solution to poverty, or even high food prices, in more than a transitory way. The only long-run solution for these households is inclusive, or pro-poor, economic growth that provides reliable real incomes and stable access to food from home production or in local markets.

The appropriate policy response to high food prices, then, is to find ways to stimulate such growth. Much of the action will be in the agricultural sector, especially in investments to raise productivity of basic food crops. High food prices now seen in world markets provide plenty of incentives to make those investments. But many investments in rural health and education facilities and in agricultural research and extension would have paid off at the prices of a decade ago if donors and governments had recognized the full social value of rising agricultural productivity. That is doubly true now.

C. Peter Timmer is a fellow at the Center for Global Development and a visiting professor in the Program on Food Security and Environment at Stanford University. This article is drawn from the author's recent works: A World Without Agriculture: The Structural Transformation in Historical Perspective, Wendt Memorial Lecture (2008), American Enterprise Institute, Washington, DC., and Causes of High Food Prices, Chapter 2 in Asian Development Outlook Update, September, 2008, Asian Development Bank, Manila, Philippines.

Post a Comment( 2 )

Is the U.S. Using Money Wisely?

Nellie Bristol

While millions of struggling people worldwide benefit each year from U.S. donated food, critics of the system advocate for a more efficient, development-oriented food assistance program.

Photo courtesy of GAIN

The food price crisis is spurring food aid policy reforms at institutions as varied as the World Bank and the Gates Foundation. But the largest food donor, the United States, which provides more than half of food aid globally, is largely maintaining what many feel is an antiquated and inadequate food delivery system. With the best chance for reform, the 2008 U.S. Farm Bill, already behind them and the crisis not likely to abate, food aid advocates are wondering what it will take to force U.S. policy to be more responsive to the hungry and vulnerable.

Devised 50 years ago largely to offload farm surpluses and promote trade, U.S. food aid is delivered almost entirely in the form of grain and other commodities and transported mainly on more expensive U.S. ships. The Government Accountability Office (GAO) calculates that even in emergency situations, the shipments take four to six months to arrive in needy areas. Sometimes they arrive after the harvest has come in and the crisis has abated, which leaves shipments to flood the now functioning local market. Those pushing for reform are asking the U.S. to provide more cash for local and regional food purchases both to make aid quicker and to bolster local markets. They also are advocating for more resources to support long neglected developing world agriculture sectors.

“This is really all about a flexible approach,” said Phillip Thomas, GAO assistant director for international affairs and trade. “If you’re really about feeding hungry people in an emergency situation or in a development situation, you want to have all the tools.”

The longer the food price crisis continues, the more imperative it becomes that food is used in the most efficient form. On average, Congress appropriated $2 billion yearly for food aid since 2002. It allotted $2.5 billion a year in the recent Farm Bill and an additional $1.2 billion to address the food crisis. GAO estimates that even before the current crises, fuel and business costs reduced the total tonnage of food delivered with U.S. funds by 52 percent over five years. The stakes are high for the world’s vulnerable populations. The price of food more than doubled over the last several years in some places, causing additional stress for families and increasing political pressure for developing country leaders. The UN Food and Agriculture Organization estimates that more than 75 million people have been added to the roles of the hungry since prices began to climb in 2005. With the global financial crisis, growing markets in China and India, and added pressures from climate change, the situation is only expected to get worse. Some predict that the era of food surpluses may be over, indicating a drastic need for increased agricultural development in food insecure areas.

Food security is key to the health both of economies and individuals, especially for particular populations. Research shows that lack of essential nutrients in the first two years of life can lead to irreversible damage including shorter adult stature, lower attainment in school and reduced earning capacity. Lack of food has a range of effects for HIV/AIDS positive individuals. Infected adults need 10 percent to 30 percent more calories than the non-infected while HIV positive children can require up to 100 percent more calories than other children. Poor nutritional status can speed progression of AIDS related illness and jeopardize drug adherence, said Stuart Gillespie, director of the Regional Network on AIDS, Livelihoods and Food Security. “Some people are actually scared to take the drugs because they know their appetite will increase and they know that they won’t be able to find the food for that increased appetite,” Gillespie adds. Adequate food availability can also have a preventive effect, keeping women in particular from engaging in risky transactional sex to feed themselves or their families.

The most effective form of aid is highly context oriented and sometimes even specific to the type of person receiving the aid, said Agnes Quisumbing, senior research fellow at the International Food Policy Research Institute. While all forms of food aid show increases in weight to height, work by Quisumbing and her colleagues shows differences in aid effectiveness depending on whether the food was distributed for free or used in a food-for-work situation. It also shows variations in effectiveness depending on the gender of the recipient. Research continues on whether food or cash is more effective for long-term results. While nutritional status may improve more rapidly in the short term with direct commodity distribution, cash may encourage sustainable markets, which could improve health outcomes more in the long term, she noted. “The donors were hoping we would come up with one blanket recommendation,” for the most effective food aid, Quisumbing said, but the results were not that clear. Overall, she said, research findings argue for greater investment in long-term agricultural development over provision of emergency aid after nutritional status already has been compromised.

But emergency relief has grown in recent years and now comprises the bulk of U.S. food aid. In addition, funding for agricultural development has dropped steadily over the years from all donors. Agriculture made up 18 percent of official development assistance in 1979, but fell to 3.5 percent in 2004. Many are pushing for greater attention to increased crop yields and diversification and market improvements to reduce the number of food emergencies. “I think there’s general recognition that just focusing on the short term, we’re chasing our tail and we’re getting further and further behind,” said Thomas Melito, GAO director for international affairs and trade.

To better address short-term concerns and support longer range market issues, food aid reformers advocate a range of interventions that respond to local market and nutritional needs rather than just choosing one donation method for all situations. Cash is often quicker and more efficient but may cause more problems than straight food donation in some cases. “The problem is that cash works really well if markets work well,” said Christopher Barrett, international professor of agriculture at Cornell University and co-author of Food Aid After 50 Years: Recasting its Role. In other circumstances, “just pumping cash into the system can be purely inflationary,” he added. Food also is the better choice in situations where commodities are not available in a broad regional area.

Barrett and co-author Daniel Maxwell, associate professor at Tufts University, developed a food aid decision tree that analyzes local markets and food availability to determine whether aid should come in the form of food or cash and whether food should be purchased locally, regionally or come from abroad. They and other advocates warn against locking into any specific donation method, but urge looking at the specific situation. Food, in fact, may become the more valuable commodity if prices remain high. “In-kind food aid is suddenly in very short supply and very high demand,” Maxwell noted. While recipients had been asking for cash, “Now they are saying, ‘please, we want the food and not the cash.’”

Many also are arguing that the nutritional value of food, both that obtained locally and donated, needs to be considered more carefully. “We may need to bring in something that is trying to address the nutrition issue a bit more directly. That’s a big issue,” said Bob Bell, director of the food resources technical team for CARE.

The food crisis is arguably felt the strongest in refugee camps, such as the three Dadaab Refugee Camps in northern Kenya.

The recent Farm Bill, approved in June by Congress, calls for increased nutritional analysis of U.S. food and establishes a pilot project that provides cash for local food purchases. But many were disappointed that the bill didn’t go further. Bill sponsors rejected a Bush Administration proposal allotting 25 percent of food aid funding for local purchase instead of buying commodities in the U.S. The pilot program set aside $60 million over four years for local purchase, less than 1 percent of total U.S. food aid. An additional $50 million was added in supplemental appropriations, but advocates still find it lacking. “If you like the status quo then [the Farm Bill] is not so bad. If you’re interested in improving and reforming our food aid program, then it was a disappointment,” said Gawain Kripke, senior policy advisor on international trade issues for Oxfam America.

Pushing against more sweeping reform is what is known as the “iron triangle” of agribusiness, maritime interests and NGOs that use funding generated from selling food aid to support their programs. Those interests “all have a major stake in seeing to it that the status quo is not upset because they all stand to lose if that coalition of interests falls apart,” said Tufts’ Maxwell. Some NGOs sell U.S. food that is donated to them in low-income countries. They then use the cash to support development programs and operations in a practice known as “monetization.” GAO calls monetization “inherently inefficient” and some estimate that for every $1 used to buy the food initially, 50 cents or less actually ends up in program budgets.

The funding method is highly controversial and has divided the NGO community. One of the largest monetizers, CARE, instituted a four-year phase-out of the practice, which becomes fully effective in September 2009. “We stopped doing it because it was wasteful and because it has unintended harmful consequences,” including commercial displacement of local products and undermining local development, said David Kauck, senior program technical advisor with CARE. Bell adds, “Imported food aid is probably best when used in times of emergency or to support certain kinds of safety nets. Monetization, while important as a source of cash, was not the right use of the resource.”

While CARE’s move is described as “bold” by several observers, the group says it expects to lose as much as $45 million a year in U.S. funding as a result of the decision. While it is working to raise the funds from other donors, CARE officials said the move will affect their operations in certain countries. That money was used for precisely the types of long-term programs most needed to ensure sustainable agriculture in developing countries. While some groups have expressed support for CARE’s move, including Catholic Relief Services and Mercy Corps, none has joined it yet.

Pro-monetization forces, including World Vision, Feed the Children and Land O’Lakes, all members of the Alliance for Food Aid, argue that monetization provides important food resources in certain countries and supports key programs. “The proceeds generated from sales are used to support delivery of donated food or for projects that improve local food security, including decreasing childhood malnutrition, increasing agricultural productivity, and increasing household incomes in poor areas,” Alliance documents say. Sixteen NGOs received donated non-emergency food through the U.S. Agency for International Development’s Food for Peace program in 2007 valued at $348 million. USAID staff said about two-thirds of non-emergency food is monetized yearly.

Reform supporters say most NGOs, at least privately, admit that monetization is inefficient, but they are loath to give up the practice without a guarantee that equivalent funds would be made available to support their programs. “The challenge for NGOs is if you’re seeing investments in agriculture going down, why would you say stop food aid on an assumption that it would somehow go up?” said Sam Worthington, president and CEO of InterAction, an NGO umbrella organization. The European Union switched from a largely commodity based food aid system to a cash program, but some say the total amount of aid available has decreased. Also, they argue the current U.S. system generates political support for food aid from farm-state representatives in Congress and others and potentially generates good will for the U.S. as the needy receive bags of grain emblazoned with U.S. symbols. “There certainly are valid political reasons for why the status quo has been maintained, there’s no question about that,” Maxwell said.

As turmoil continues both in the food and financial markets, donors will be looking for ways to improve their aid efficiency. “The longer the food crisis goes on, the more flexible the U.S. is likely to become,” said Lisa Kuennan, director of the public resource group at Catholic Relief Services (CRS). She said USAID already shifting some of its contract with CRS from food to cash to mitigate the high costs of shipping.

Other proposals also are being developed. Sen. Richard Lugar, R-IN, ranking Republican on the Senate Foreign Relations Committee, introduced legislation in September that would authorize $5 billion over five years to develop an integrated U.S. global food security plan and support agricultural development in high-risk countries. It also would provide funding for local and regional purchase of food aid separate from current food aid programs.

Despite entrenched interests in current U.S. food aid policy, some are optimistic there will be a move toward greater efficiency in the future. The food price crisis, said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, “changes the whole context” of food aid policy. “It gives a whole different rationale and sense of urgency and allows us to lift the debate out of where it’s been stuck for a very long time.”

Nellie Bristol is a freelance journalist specializing in health policy.

Post a Comment

Features

Also In This Issue

Reflections of a Lifetime Dedicated to Public Health Advocacy - In Memory of Beth Waters

By: Tina Flores

On the Brink of a Watershed Moment for HIV Vaccine R&D

By: Margaret McGlynn and David Cook

Vaccination Week in the Americas Goes Global

By: Mirta Roses-Periago, MD

Evolution of the Vaccination Week

Key Elements to Success

Vaccines: A Top Priority for Global Health

By: Olivier Charmeil

Formal Analyses of the Value of Vaccines

Far-Reaching Societal Benefits

Challenges to the Expansion of Vaccine Efforts

A Few Troublesome Diseases

Conclusions

REFERENCES

Fighting Syphilis and HIV in Women and Children: Lessons from Uganda and Zambia

By: Edward Bitarakwate, Susan Strasser, Tabitha Sripipatana and Jen Pollakusky

REFERENCES

Partnering for Change: The Role of the Private Sector

By: Rhona Applebaum

Addressing the Problems

The Role of the Private Sector

An Industry-Wide Effort

One Company’s Experience

The Time to Act is Now

Brazil: Getting a Move on NCDs

By: Elizabeth Nussbaumer, Thea Joselow and Nalini Saligram

A Movement for Movement

India: The Private Sector Takes Action on NCDs

By: Muruga Vadivale and Aparna Thomas

Estimating the prevalence and risk factors of diabetes and hypertension

Celebrating Diabetes Control

Empowering Doctors in Rural India

References

NCDs in the Developing World: Looking for Solutions

By: Nellie Bristol

Grappling with the Tensions around NCDs

By: Sir George Alleyne, Alafia Samuels and Karen Sealey

Opening the Door to Global Health Talent

By Jonny Dorsey and Barbara Bush

A Malaria-Free World is Within Reach

By Awa Marie Coll-Seck

Paying for a Healthier Future

By Catherine Connor, Laurel Hatt and Thierry van Bastelaer

Increase Investment

How can the gap in financing be bridged?

Improve Equity in Risk Sharing

What are some options to reduce poor households’ vulnerability?

Increase Efficiency

What are some options to increase the efficiency of resources devoted to health?

The Way Forward

NCD Prevention Begins in the Womb

By Priya Matzen and Nicolai Lohse

Prevention of Non-Communicable Diseases

A Multi-Sector Partnership

Policy Implications

Conclusions

The Stopgap Midwife

By Hawa Talla and Lindsey Freeze

Disrespectful and Abusive Treatment of Women During Childbirth

Sarah Whitmarsh, MA and Maura Gaughan, MPH, MA

What is Disrespectful and Abusive Childbirth Care?

Research to Evaluate the Problem and Promote Dignified Childbirth Care

Global Efforts to Improve Respectful Care of Women during Childbirth

Women and Girls in a Changing World Photography Contest

Tina Flores

Q&A with Chessa Latifi

Young People Need Evidenced-Based Information Too

Ishita Chaudhry

Moving Toward Gender Equitable Health Organizations

Sarah Johnson, Ummuro Adano and Willow Gerber

ENTRY POINTS FOR CAPACITY BUILDING

ORGANIZATIONAL ASSESSMENTS

MISSION, VALUE AND STRATEGY

STRUCTURE

MANAGEMENT SYSTEMS

PARTNERSHIPS, EXTERNAL RELATIONS AND NETWORKING