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.
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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.
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.
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.
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.
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.
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.
Probing Health Ministries
John Donnelly
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).
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
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.
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."
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).
Cholera and watery diarrhea are major problems in the camps. In May, more than 5,325 children from the Mardan camp alone were hospitalized because of an outbreak of diarrhea.
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.
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.
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.
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.
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
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.
AIDS Hotline for Ethiopian Health-Care Workers
Kathryn Utan
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.”
As of September 2009, CARE will halt the controversial practice of monetization, which is estimated to create a $45 million loss in U.S. funding each year.
Nellie Bristol is a freelance journalist specializing in health policy.
