Karen Grepin's Global Health Blog

Cultural blind spots in global health

2010-02-06T19:42:00.000-08:00

"Many of the most important issues in international health are so completely taken for granted that they are never discussed. We tend especially to have cultural blind spots because we assume that our own values are the international norm and that our way of doing things is automatically right. We become aware of cross-cultural problems only when our personal assumptions are challenged by a clear conflict of values. Only rarely do we review our motivations."

The above quotation was taken from an editorial article published in 1979 by Carl Taylor, Professor Emeritus of International Health at Johns Hopkins University's School of Public Health, in the American Journal of Public Health. I came across this article recently and included it in my spring undergraduate NYU course (Global Health: Policies, Politics, and Institutions) reading list because although the article was written over 30 years ago, it is as true today.

I found out this evening (via Twitter) that Professor Taylor passed away earlier this week. I was saddened to hear that the global health community had lost one of its founding fathers. You can read more about Professor Taylor, and his work, especially on the need for local solutions in global health problems, here.

Flushing diarrhea down the drain

2010-02-03T09:19:00.001-08:00

Earlier last week, the findings from two critically important studies on the use of the Rotarix vaccine (produced by GSK-biologicals) to combat rotavirus related diarrhea in the developing world. After prenatal causes and pneumonia, diarrhea is the most important cause of child deaths in the world - accounting for an estimated 16% of under five mortality. Most of the tools to combat the disease - oral re-hydration therapy and clean water and sanitation - have not been adequate to reduce the burden of this seemingly simple condition, perhaps because the needed behavioral response is not so easy after all. The study results overall were very positive, which is really great news, but it also raised a few important caveats which may limits its overall impact in the long run.

Rotavirus is considered to be the single largest cause of diarrhea globally and alone thought to be responsible for upwards of half a million child deaths a year. Six of the seven countries with the highest mortality due to rotavirus are in Africa (can anyone guess the other one?). Vaccines against rotavirus have been introduced in the past - and one has even been withdrawn - but their use has become increasingly common in many middle and high income countries in recent years. The world had been waiting for the results from the studies released last week.

One study, conducted in South Africa, and Malawi demonstrate that when the vaccine is given properly, it reduces all forms of reported diarrhea by about 30% and reduced the incidence of rotavirus induced diarrhea by 60% although the results were much higher in South Africa. There were not major differences in severe events, suggesting that the vaccine was also safe.

But why was there such much lower efficacy in Malawi? The results from this African study suggest that the vaccine is less efficacious in Africa than in other settings where the vaccine has been tested. There is some evidence that live oral vaccine in general tend to be less effective in low income countries, perhaps because they require an in tact and effective immune system to generate a sufficient immune response to provide protective benefits. It is also possible that children in these settings are also already exposed by the time they get the vaccine, making the vaccine seem less effective when studied in trial settings.

Also, the study findings point to a story where the timing of when this vaccine appears to matter quite a bit - not just or the sake of protecting children earlier, but or the sake of avoiding age-dependent risk of developing intussusception, a rare but dangerous side effect which was part of the reason that earlier forms of the vaccines were not expanded to the developing world. There are frequently delays in vaccine timing in many developing countries, so this might represent a real challenge precisely in the countries where it is needed most.

Plus, since this is a live oral vaccine, the cold chain considerations for this vaccine are likely to be much more important than for other forms of vaccines.

The second study, conducted in Mexico, assessed the impact of rotavirus vaccine introduction in Mexico on child mortality rates. Mexico is obviously a much richer country than Malawi and South Africa, but rather sizable declines in mortality were observed. Rates of diarrhea related deaths reduced from 61.5 to 36.0 deaths per 100,000. While not all of this can be directly related to the vaccine, it is notable and incredibly good news as I would see this as a lower bound of what might be expected in poorer countries.

So overall, really promising news on the rotavirus front - there should be no reason to hold back plans to roll this vaccine out in the poorest countries as soon as possible. But lots more attention needs to be given to the additional challenges of delivery this particular vaccine. Good thing Bill Gates has doubled his commitments to childhood immunizations…I know how I would spend some of that big chunk of change.

Africa is the fastest growing market for cigarettes

2010-01-21T17:03:00.000-08:00

I would say that most people would probably be able to guess that smoking is the leading cause of preventable death in the world - directly responsible for about 5 of the 50 odd million deaths that occur in the world every year. A lot of people, in particular anyone who has ever traveled to China, could probably guess that there are more smoking related deaths in the developing world than in the developed (more people and high rates of smoking) - and that smoking rates are growing fast. But did you know that the region with the fastest growing rates of smoking is Africa? I didn't until I read this excellent report in the Lancet by Adele Baleta about Africa's struggle against smoking.

In most instances, we would generally think think that a rapidly growing economy leads to higher incomes, better social services, and thus overall better health. But smoking happens to be one of those cases where rising incomes, which brings higher purchasing power, actually leads to worse health seeking behavior as people spend more and more of their wealth cigarettes. The rapid economic growth seen in many African countries over the past decade has meant that more and more Africans are now lighting up and becoming addicted to tobacco.

While a few countries have been forward thinking on this issue and implemented some form of tobacco control legislation, overall implementation and regulation of regulations have been lagging in the region - currently 90% of Africans are unprotected by smoke-free laws. According to a report by the Global Smokefree Partnership, the biggest obstacle to implementation of stronger anti-tobacco legislation is not weak government, lack of political will, or income but rather agressive efforts from multi-national tobacco companies.

It has now been 5 years since the WHO's Framework Convention on Tobacco Control's (FCTC) went into effect and it is sad to see that progress towards implementing this landmark agreement has been so slow at this particular point in time. Kudos to the Lancet for publishing this great piece of global health reporting.

Measles vaccination: driving declines in child mortality

2010-01-20T17:10:00.000-08:00

I gave a lecture this afternoon to my undergraduate global health policy course at NYU (P11.0032 Global Health: Policies, Politics, and Institutions) in which we discussed progress towards the Millennium Development Goal 4 - a two thirds reduction in under five mortality from 1990-2015. I argued that one of the biggest sources of progress, and perhaps the one that is most easily attributable to a single intervention, were the declines seen in mortality from measles since the use of the measles vaccine become widespread.

A recent report by the CDC, reprinted in JAMA recently, provides the evidence to support such claims. Since 2000, it is estimated that deaths from measles have declined from about 733,000 deaths to 164,000 in 2008 - a whopping 78% decline in mortality in just 8 years. Success rates like that are relatively rare in global health. A recent paper by You and co-authors in the Lancet have estimated that child deaths declined from 10.4 to 8.8 million over the same time period, so roughly one third of the total declines seen over this time period can be attributed to this single intervention.

I was saddened to learn, however, that despite these successes, maintaining progress and sustaining this progress is at risk - so much so that the authors of the report even have estimated worst case scenarios of resurgence. Probably more so than most childhood vaccine preventable diseases really high sustained vaccination coverage is needed or else there is a significant risk of flare ups of the disease (this even happens in the US when parents forego vaccinating their children).

Measles vaccine funding has fallen off sharply in the past few years, and surprise surprise, national ministries of health are also having a hard time raising adequate funds. The Measles Initiative, one of the main funding agencies for measles vaccinations, has seen a decline in funding from about $150 million to $50 million. In the post-Global Fund/Gates Foundation/PEPFAR world, these levels of funding seem almost miniscule - in particular for such an amazing buy. Such a shame.

The power of assumptions - mortality projections for HIV

2010-01-18T20:24:00.000-08:00

I was struck by the following graph that appeared in a comment by John Bongaarts, François Pelletier, and Patrick Gerland in the Lancet last week. The graph compares estimates of HIV mortality made by the WHO in the early 2000s via the Global Burden of Disease Project (GBD), updated estimates GBD estimates from the WHO, UNAIDS, and recent projections put out by the UN.

By now, I hope most people reading this blog have realized that due to a number of changes, most notably the collection of population based estimates of HIV prevalence have led to significant decreases in the projected levels of HIV mortality globally. That along with updated models explains the difference between earlier HIV mortality estimates - including the earlier GBD estimates - (consistent with the top line in the graph) and the three bottom lines, which generally now incorporate the new prevalence estimates. (Side note: I recently saw a paper from David Canning who has suggested that non-random selection effects in DHS and other population based estimates are likely underestimating true prevalence by a significant amount...more when that paper goes public).

But why do the updated GBD WHO estimates decline so much faster than the recent estimates by the UN? The difference can largely be explained by assumptions about the scale up and impact of HIV treatment programs. The authors of the comment argue that the WHO estimates "can only be achieved by massive scale-up of antiretroviral treatment to lead to near universal access worldwide in 2015-30". Great progress has been made on this front, true, but how realistic of an assumption is this? In particular in this new economic climate?

Given how widely these estimates are used for global health policy, I am somewhat surprised how optimistic of an assumption the WHO is using - if anything it only weakens their advocacy argument for more funding. But this comment clearly demonstrates that even the best statistics in global health are based on some very powerful - and potentially incorrect - assumptions.

Risky living: How where you live affects your risk of dying form injury

2010-01-15T14:28:00.000-08:00

In the NYTimes this morning, op-ed columnist David Brooks makes an interesting point: In 1989, a 7.0 magnitude earthquake struck just outside San Francisco leading the loss of 63 lives. Earlier this week, an earthquake of the same magnitude struck just outside Port-au-Prince, the capital of Haiti, and although final estimates of the death toll have not been made, without hubris I can safely say that about a thousand times more lives will be lost this time around.

Wikipedia, lists the official population of the Port-au-Price metropolitan area at 1.7 million people. The International Red Cross has estimated that the death toll could exceed - perhaps by a great deal - 50,000 people. Conservatively, this means that approximately 3% of the city perished in a few minutes, a shockingly high mortality rate.

Last fall, my husband and I moved from our suburban house just outside of Boston to an apartment in Greenwich Village, in the heart of Manhattan. Public health wonk that I am, I had wondered how living in NYC might affect my probability of dying from injury and other health conditions one morning as I walked my 10 blocks from my apartment to my office. I suspected it would have declined: I had traded my daily 18 mile round-trip daily commute on the Mass Pike with a cardiovascular enhancing walk (probably calorie neutral, given the excellent choice of coffee shops I had to contend with on my walk through the Village). But, surely we would be safer from injury in NYC than in Boston.

In early December, in the wee hours of the morning, my husband hopped in a cab to go to work, Blackberry ablaze on a conference call with London. Minutes later his cab crashed into the side of a delivery truck. My husband was sent flying face first into the bullet proof glass that separated him and his driver. His front lip was split in two my his front teeth. He has been left with a permanent scar, but luckily nothing more serious happened.

The following morning on my way to work, I also came within inches of serious injury when a bicycle narrowly missed hitting me head on at top speed flying the wrong way down a one way street - although giving my outstretched arm a good clip. I fear what would have happened to me - and worse my unborn child - had I been one second further along the crosswalk (I am 5 months pregnant).

So as it turns out, my estimated risk of injury had perhaps not declined as much as I had hoped, I had simply exchanged one risk exposure for others. But the Haitian earthquake made me reflect on how where you live, can greatly affect your probability of death from injury. Haiti lies near a fault line, and has been affected by major earthquakes in the past, although none nearly this large in a few centuries. Like most impoverished nations, construction standards are no where near as high as they are in rich countries.

It would have been easy to predict that had an earthquake hit the region many buildings would have crumbled - they did in Sichuan Province in 2008, Kashmir Province in 2005, and Acheh Province in 2004. When major earthquakes strike, your chances of surviving do seem to depend on whether you live in a rich or a poor country - one more great health inequality that exists in the world.

So if these risks are so predictable, why is there not more done about it? Well, first it is expensive. Reducing the risk of injury from earthquakes would likely require rebuilding cities, which is unlikely to be cost-effective in countries where so many more cost-effective interventions are not even implemented. As well, the risks are still after all just probabilities that something will happen, and with so many other more pressing development concerns, it is no wonder that these types of concerns would take back seats other initiatives.

But does it mean nothing can be done? New building standards can be improved and existing standards can be enforced on new projects. Risk assessments can be done, disaster management plans developed, and educations campaigns could be launched against major natural disaster risks. Tsunami warning signs have sprung up all around the world in response to the Indian Ocean tsunami of 2004.

It is encouraging to see the outpouring of donations that have ensued this past week, as they did in 2004 following the Indian Ocean tsunami, but it is discouraging that these risks get so little attention before disaster strikes. Global public health should be all about the latter, and it is therefore surprising that it receives so little attention in global health dialogues. Perhaps it is time to try harder.

Only 1300 miles between Port-au-Prince and New Orleans

2010-01-13T06:49:00.000-08:00

I've been glued to the internet this a.m. waiting for news and pictures to come in from Port-au-Prince, Haiti where a powerful earthquake struck just before sunset last evening causing massive destruction and undoubtedly the loss of hundreds, and likely thousands, of innocent lives. Haiti, the poorest country in the Western Hemisphere, was already in shambles and this newest disaster is certainly not going to help. Haiti seems to go from diaster to disaster. I am praying for the citizens of this country.

When I was a student at the Harvard School of Public Health, I took a class from Professor Jennifer Leaning entitled Disaster Management. The course provided an overview of how public health professionals should think about responding when faced with disaster to minimize loss of life and morbidity. I was trying to think back to the lessons I learned in class and how they might apply to what is unfolding in Haiti: given the physical damage caused by the earthquake first responders should be mindful of obvious and non-obvious crush injuries, from broken legs to head trauma, and they should immediately begin preparations for the next phase of the response, which will likely involve significant dehydration, hunger, and food and water born illnesses from the breakdown of water, sanitation, and food supplies. I also recall being taught that the best way to manage such a response is to set up a clear centralized command and control center where the disaster response can be coordinated and managed. I suspect much of these actions are already underway.

Over the holidays, I had a chance to read the new book by Atul Gawande entitled "The Checklist Manifesto". The basic argument articulated by the articulate Dr. Gawande is that checklists have transformed the way in which many other fields and industries deal with complexity and unpredictability and that that medicine, in particular surgery, could also benefit from the use of these simple, low-cost tools. I've blogged about some of the published results of a study Dr. Gawande and his colleagues at the WHO conducted on this over the past few years, but the book provides more background and insight into the value of these lists.

I had been struck while reading the book about how much he dumped upon the centralized command-and-control model to deal with disasters. He provides a example from when Hurricane Katrina stuck New Orleans. He argues that the traditional command-and-control model had failed and rather than recognizing that when faced with extraordinary complexity, which was further complicated by the breakdown of communication lines, power needed to be pushed out of the center to where people with local knowledge and expertise could be better utilized. The knowledge that was required to respond to this crises far exceeded the knowledge of any one person. Yet he also argues that individuals cannot act completely in isolation, they needed to be coordinated in some way, and he argues that a checklist could provide this overall coordination. In the book, he also provides examples of how successful general contractors and money managers also use checklists to manage this complexity.

It has now been almost 5 years since Hurricane Katrina, and the citizens of New Orleans are still rebuilding. Physically there are only about 1300 miles that separate New Orleans and Port-au-Prince but these two cities are almost a century apart in terms of their wealth and level of development. Dr. Gawande has shown that the same checklist can be effective in saving lives in rich hospitals in Boston and poor ones in Tanzania so I believe that many of the lessons from Katrina will be able to save lives in Haiti as well. Let's hope that those in charge of this response are thinking about the past as much as the future.

The third wave of malaria activism - stopping stock-outs

2009-12-09T13:45:00.000-08:00

“We abandoned chloroquine when it failed to cure one in four patients and was available everywhere,”.....“We now have a drug that cures 100% of patients but is not available in one in four clinics.”

That is a quote taken from a recent Editorial by the Editors of the PLoS Medicine journal who are calling for what they call a "third wave" in malaria treatment advocacy.

According to the authors of this editorial, the first wave of malaria activism brought to global attention the disparity between the burden of malaria and the amount of money spent on the disease by the international community. Successes during this period include the establishment of the Global Fund and other major new fund raising mechanisms for the disease.

The second wave highlighted the fact that although money was rushing it, much of it was not being spent on the most efficacious malaria treatments, namely ACTs. We have now seen the establishment of the Affordable Medicines Facility for Malaria (AMFm) and much more attention to this issue globally.

Now the big problem, they argue, is that despite the fact that there is money available for treatments and commitment to spend them on the best drugs, the medicines are still not always making it to the patients who need them, largely due to stock-outs of medicines in facilities. They see this as perhaps the biggest barrier to expanded treatment coverage.

This finding should not be terribly surprising, big global solutions tend to start at the top and only when they realize that things are not working do they look one level down to see why the solution did not work (parallels can be drawn with HIV and health human resources). But how is this nitty gritty operational problem going to be solved? It will all depend on health systems, and solutions are likely country specific, but will need to be resolved if global targets are to be met.

A friend of mine, Jeremie Gallien, a brilliant operations researchers at MIT, who normally devotes his energy to figuring out how to get parcels from warehouses to people's doors or how to get the latest fashions on store shelves as fast as possible, is now working on this problem in Zambia, and I can't wait to find out what he has learned.

I know that there are lots of other really smart folks out there also working on this important problem, it is just too bad we always have to start at the wrong end of a problem to identify the most important barriers or to foresee them in advance. Perhaps an operations researcher would have said that all along!

Another big win for the NTDs

2009-12-08T07:36:00.000-08:00

Last evening I a lecture on the Neglected Tropical Diseases (NTDs) in my Global Health Policy course at NYU-Wagner. One of my students asked whether the many NTD control programs that had sprung up over the years to address these diseases were in fact sustainable - an excellent question. My response was "who ever said they should be?".

Later that evening I learned some excellent news on the NTD front. After nearly 20 years of tireless work, and thanks in a large part to the help of the Carter Center, Nigeria - once the country the most afflicted by Guinea Worm - is on the verge of declaring victory in the war on the scourge. Guinea Worm - a worm that enters into your body and can grow as long as 3 feet before getting bored and exiting your body in a painful and debilitating way - is among the group of helminthic NTDs and is among what I consider to be the yuckiest diseases on the planet.

The strategy to eradicate this disease is a slow but effective one - all patients infected with the worm are identified, treated, and educated in such a way so that they do not risk spreading the worm to others. The strategy works, it just takes time. Since the mid-1980s, when the Carter Center waged a war against the disease the number of people infected has fallen from a few million to a few thousand, an impressive and significant global health achievement.

Which brings me back to the question of sustainability. Guinea Worm control program, along with other NTD control programs that aim for elimination or eradication, when successful will eventually work themselves out of a job. That is the point. Some NTD programs are likely to be even more short-lived than Guinea Worm control. Therefore, it is not clear that sustainability of these programs should ever be an important goal. Not all diseases, however, share these characteristics.

Plus, some functions of NTD control, for example ongoing disease monitoring and surveillance, are likely to be needed for years after eradication or elimination are achieved and therefore these programs should be integrated into existing health system infrastructure, this is a lesson that has been learned from onchocerciasis elimination and elsewhere. But this is one example of how vertical programming, when well targeted and well implemented, can be a good thing. The NTD community is years ahead of many other disease control programs in terms of their experiences and their learning. It is great when we can learn from great successes such as this one.

For those that can stomach it, here is an excellent video from the NYTimes Science Times from a few years back, with the mandatory views of Guinea Worm extraction.

Photo credit: Vanessa Vick via the NYTimes

Non-sexual transmission of HIV in Sub-Saharan Africa

2009-12-03T13:56:00.000-08:00

Earlier this week, I attended a symposium entitled “HIV Scale-Up and Global Health Systems" hosted by Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP). During the panel moderated by Stephen Lewis, which included former US President Bill Clinton, the moderator stopped the discussion to make the point that his organization does not use the term "mother-to-child" transmission of HIV because that places to much blame on the woman. Instead, they use the term "vertical transmission" - between generations. I found his emphasis humorous, not because I don't agree with the idea of not blaming women, but because he was making such a big deal out of what I assumed was essentially the only way children acquired HIV.

Yesterday, Kim Yi Dionne on her blog haba na haba made me aware of a debate that apparently has been brewing under the radar in the HIV community for some time, one that seems to have a small number of ardent supporters, but one that is not readily accepted by the mainstream research community.

It turns out that there are many out there who believe that non-sexual transmission may account for a substantial fraction of HIV infections in some Sub-Saharan African countries, including among children. A Telegraph article suggests that up to 1/5. Given that we generally assume young children to be sexually inactive, the authors speculate that blood exposure, through needles or through other forms of contamination is to blame. A whole edition of the journal "International Journal of STDs and AIDS" was recently devoted to a review of the research on this topic.

The primary form of evidence that exists to support this view is that a number of sero-prevalence studies have found rates of HIV infection among children to be too high to be explained by vertical transmission alone (I am not quite sure what is a normal rate) as well documented cases of HIV infected children born to HIV negative mothers. There are also qualitative surveys that have asked about all exposure risks and have relatively high rates of reported blood exposures in different populations and that people living in Africa may have much greater exposure to injections and vaccinations than in other parts of the world - partially due to injections for malaria. Together, these studies have been taken together to argue that blood exposure may account for a substantial fraction of transmission in Africa and that it has not received enough attention as it deserves from the prevention community.

I read through some of the research papers and thought some of them made strong inferences from rather limited data (e.g. the 1/5 figure came from a study of children in Swaziland, of which there were only 50 in the sample, and only 11 of which reported to be sero-discordant from their parents. Other issues, such as remarriage, false positives and false negatives, small sample size, and other potential explanations were not given enough discussion) but just the same I found the idea perplexing and interesting. PEPFAR has focused a lot of attention on blood safety in many developing countries, but perhaps more emphasis also needs to be placed on other injections and needle use as well.

Anyone out there know more about this issue that they would be up for sharing?

Ignoring the most successful HIV prevention strategy

2009-11-22T16:50:00.000-08:00

In Sub-Saharan Africa the HIV epidemic has largely been spread through sexual intercourse, a complicated and messy behavior that has proven highly stubborn to intervention. Outside of Africa, the HIV epidemic, however, has also been spread through other means, including the re-use of contaminated needles. An excellent must-read piece in today's NYTimes explains:

"In Russia, 83 percent of infections in which the origin is known come from needle sharing. In Ukraine, the figure is 64 percent; Kazakhstan, 74 percent; Malaysia, 72 percent; Vietnam, 52 percent; China, 44 percent. Shared needles are also the primary transmission route for H.I.V. in parts of Asia. In the United States, needle-sharing directly accounts for more than 25 percent of AIDS cases."

Of course, as epidemic go, even if sexual behavior is primary means of transmission, the spread of the virus is amplified through other transmission channels, such as injection drug users, who subsequently spread the virus to their sexual partners.

The good news is that there is actually an intervention available to help curb the transmission of the virus (and other viruses) that has been shown to be highly effective, low-cost, and easily adopted by targeted populations: clean needle exchange programs. Free clean needles are made available for free to drug users in exchange for their old infected ones, removing the dirty needles from the streets and greatly reducing the likelihood that drug users will spread the virus to one another.

"Needle exchange is AIDS prevention that works. While no one wants to have to put on a condom, every drug user prefers injecting with a clean needle. In 2003, an academic review of 99 cities around the world found that cities with needle exchange saw their H.I.V. rates among injecting drug users drop 19 percent a year; cities without needle exchange had an 8 percent increase per year. Contrary to popular fears, needle exchange has not led to more drug use or higher crime rates. Studies have also found that drug addicts participating in needle exchanges are more likely to enter rehabilitation programs. Using needle exchange as part of a comprehensive attack on H.I.V. is endorsed by virtually every relevant United Nations and United States-government agency."

The bad news, however, is that many policy makers and politicians refuse to support such programs on the basis that supporting these programs would be the equivalent to supporting drug related behaviors and directing public subsidies to a particularly undesirable part of the populace. The US government has banned the use of federal funds to support such programs since George Bush Sr.'s time in office, and despite claims to support such programs by both Bill Clinton and Barack Obama, the ban remains in effect.

Targeting high risk groups is likely the key to effective HIV prevention - that is a lesson that has emerged from past research efforts. It is time that public health policies begin to reflect this reality. Presumably saving lives is always good politics.

What happens when you spend too much time in Seattle

2009-11-20T05:02:00.000-08:00

"Even though HIV has captivated public discourse and funding, including over $5·1 billion in development assistance for health in 2007 alone, there are only rough estimates of its disease burden."

I could not agree more. That is a quote taken from a comment in the latest Lancet by the class of Post-Bachelor Fellows at the Institute for Health Metrics and Evaluation in Seattle. I know this program well - I was the TA for the first ever class at Harvard back in 2005 - and admire it greatly - many of its alumni are now making their way through top PhD programs and medical school across the US and around the world.

It appears that spending a year or two in Seattle working with Chris Murray will make just about anyone a "skeptical optimist" about global health data. They further expand:

"Despite the instant availability of an abundance of statistics in the information age, accurate statistics about our most basic need—our health—remain elusive. Vital registration systems remain weak in much of Africa and Asia, such that many people's births or deaths are never recorded. Estimates of costs and outcomes are often modeled with weak data, yielding inconsistent estimates: estimates from WHO and the World Bank of the cost effectiveness of intermittent presumptive treatment in pregnancy for malaria differ by a factor of nearly forty."

I make this point a lot with my own students, to the extent that now just about every memo or blog they hand in has a one sentence caveat along the lines of "of course, this is all based on data that is next to meaningless". I love my students.

I have a number of columns of key word searches around global health open in TweetDeck, and it is nearly every day someone out there tweets some statement they gleaned from some newspaper article or some other source which is so far from the truth. I bite my tongue every time. My favorites? Quotes on the biggest killers or claims of increases/decreases in maternal mortality.

While I could not agree more with the statements that the PBFs make in their comment, I also would argue that I think it is not excuse to not use what data we do have when formulating policies. Some data, for example the DHS and MICS surveys, are perhaps the best sources of data in global health and are - in my opinion - greatly underutilized. They may be the greatest public good in global health.

So while yes, we need to do a lot better at collecting better data, we also need to do a better job at using the data we do have. I am happy that there are young guys out there like the PBFs doing this every day, and encouraging the rest of us to do so as well.

What is old may become new again

2009-11-17T04:53:00.000-08:00

Right now in Kampala, Uganda a group of experts are gathered to discuss a topic that has gone out of fashion of late, but a topic that might be vitally important to achieving reductions in both child and maternal mortality.

A recent high-level meeting on the topic by Minsters of Health called it "one of the most cost-effective development investments". This intervention has been singled out as a priority in dozens of international proclamations, programs of action, declarations, and even a UN convention (the 1979 Convention on the Elimination of All Forms of Discrimination Against Women) dating back over 40 years.

The intervention is considered low-tech, low-cost, and safe and has been used by billions of people, and yet almost 200 million women who want the service do not currently have access to it. What is it? Family planning.

There are a lot of reasons why promoting family planning has fallen off the radar, including a sordid history based on the aggressive implementation of family planning in a few countries (e.g. India and China) and increased focus on other health issues, and apparently our inability to focus on any one area for more than a few years.

But there is growing interest in addressing the issue again, perhaps due to the fact that too little progress has been made on certain MDGs, or perhaps due to the fact that the benefits of decreased fertility are now being seen in many countries where family planning programs have been successful. Regardless for the reasons, the increased attention is welcomed: in many countries, contraceptive prevalence rates remain low and the unmet need for contraceptives remains high. Both demand and supply factors are likely explanations for the low use, so there will be no silver bullet, but we need to do a lot more to better understand this vitally important health intervention. Let's hope this conference helps to make this old topic new, and interesting, once again.

The impact of the global financial crises on children

2009-11-10T09:43:00.000-08:00

I have just finished up at really interesting conference in London entitled "The global economic crisis - including children in the policy response". The conference was jointly hosted by UNICEF and the Overseas Development Institute (ODI). At the conference a series of papers analyzing lessons from past crises and taking an early look on the current responses were presented by academics, developing country researchers, and members of civil society. I presented a paper that looked at how aggregate income shocks were affected household health seeking behavior (still a work in progress).

I thought I would share what I think were some of the key take-aways for me from this event. First, I think the evidence from previous crises points to a story where we will likely see quite heterogeneous effects of the current financial crises, but children have shouldered a disproportionate share of the burden in past crises and will likely again this time around. Some aspects of their lives are also more likely to be affected than others, for example, there is evidence that health seems to suffer more than education when there are large economic downturns.

Second, there was a lot of talk about what are termed the 3 "F's" of the financial crisis - "Fuel, Food, and Financial". There is growing consensus that the world is beginning to emerge from the effects of the "financial" crises, however, the food and fuel crises - which have been in effect longer than the financial crises - are likely here to stay for a while to come. The crises is far from over in most developing countries where food and fuel represent large portions of total household expenditures. This point must not be lost as the world begins to turn exclusively to discussions of recovery.

Third, part of the variation in outcomes that has been observed in previous crises (e.g. the Asian Financial Crises) appears to be explainable by whether or not countries had in place social protection programs before the onset of the crises and the extent to which these programs were preserved. In addition, countries that established permanent social protection systems in response to past crises seem to be doing better this time around as opposed to those that simply implemented temporary measures. We need to understand better why some countries committed to these programs while others did not.

Fourth, another "F" might be looming on the horizon for developing countries - "Fiscal deficits". Most countries have seen reduced revenues from taxes, tariffs, and other usual sources and have been encouraged to keep public expenditures high. However, the deficits that have been created are likely to come back to haunt some countries, in particular developing countries. Deficits might put increasing pressure on existing social protection and social programs going forward.

Finally, the way in which data is current being collected in developing countries means that for the time being we have nearly no way to monitor exactly how the crises in unfolding in most countries. One of the most interesting presentations we had was from a researcher in Egypt where they conduct large household surveys a few times a year allowing ongoing and real time monitoring of how the crises has been affecting households. It is sad that in this day and age, being able to access real time basic data on households remains a huge challenge.

The effects of the global economic crises are certainly far from over, in particular in developing countries. There was a lot of talk here about how to think of not just "recovering" from these shocks but using the opportunity for an excuse to implement more "restructuring". I am happy when I leave a conference having learned something but also that our work could really help shape policies that may one day affect the lives of real people.

How pneumonia got me interested in global health

2009-11-01T08:15:00.000-08:00

I knew from an early age that I was interested in health issues but I grew up in Canada where the concept of liberal arts education really did not exist. Upon graduation from high school students have to select between a career in "Arts" (where most social sciences were housed) or "Sciences". The daughter of a mining engineer and a biologist (albeit cum lawyer) with a strong interest in health there was not doubt in my mind: I was a scientist, not an artist. So I happily enrolled in an undergraduate degree in Immunology at McGill University which was a highly intensive program with a focus on biochemistry, microbiology, and physiology and sneered at my "artists" friends - who we all knew would never find jobs.

At McGill, I spent countless lectures in large lecture theaters memorizing biological pathways and the structure of organic molecules and invested hundreds of hours pipetting, centrifuging, and culturing nasty smelling bacteria and viruses in a lab. But for some reason, it was just not for me. All of my classmates knew that they wanted to go to medical school or get a PhD in basic life sciences, but not me. Instead, I got involved in student politics and planned to go to law school.

Towards the end of my studies I took an advanced seminar on current challenges in vaccine development. In that seminar, I was assigned the topic "pneumococcus vaccine and the developing world". I had never considered the connection between what we were studying in the classroom and its broader impact on the rest of the world. Through my research for that project, I learned that a new pneumococcus vaccine was about to come onto the market targeting mostly ear infections in the developed world, despite the fact that the same infectious agent was responsible for upwards of 2-3 million childhood deaths and significant morbidity in the developing world. Yet, due to financial incentives it was unclear whether the vaccine would even be effective in places like Africa where there slightly different versions of the bacterial types included in the vaccine. This single project was perhaps the event in my life that made it clear to me that I wanted to devote my career to global health.

Fast forward to today, that vaccine did eventually go onto the market, and did become the first blockbuster vaccine product. But coverage of the vaccine is horrendously low in developing world today. During the past year, we have seen some new developments, including the introduction of a pneumococcus vaccine in the Gambia and Rwanda. We have also seen the launch of an advanced market commitment program for the development of a more tailored pneumococcus vaccine for the developing world. And just this past week, GAVI unveiled plans to distribute the vaccine to over 130 million children worldwide.

While there is lots to be happy about on this first ever World Pneumonia Day (Monday, November 2, 2009), it is clear that efforts are just underway to address the number one killer of children. It is going to take years of focused attention, commitment from donors and governments, and financial support, but this is one battle that we should be able to win. So I will be wearing my blue jeans this Monday in support of World Pneumonia Day, and I encourage you to do so as well.

All photos were taken from the interesting "Faces of Pneumonia" feature on the World Pneumonia Day website.

Good for the soul, bad for the body

2009-11-01T00:10:00.001-07:00

Swine flu has now spread so far and wide across the globe that there is perhaps little point in governments spending a lot of effort at trying to contain the spread of the virus across its borders. But one country in particular probably has real cause for concern: Saudi Arabia. In a couple of weeks, 2.5 million pilgrims from over 160 countries are expected to make the trip to Mecca, Saudi Arabia for the hajj.

This is not the first time that the annual pilgrimage to Mecca has been scrutinized by public health experts. Anytime millions of people from different areas converge on the same place there is risk of disease transmission. There have been outbreaks of meningitis linked to the hajj and, perhaps most famously, the event propagated the spread of polio a few years ago, greatly setting back the international effort to eliminate the disease and creating one of the few diseases that seems to disproportionately affect one religious group - polio is now predominantly a disease affecting Muslim countries.

A NYTimes article last week described some of the proactive steps the government of Saudi Arabia is taking to prepare for the event and to minimize its impact on public health: encouraging all pilgrims to get vaccinated against swine flu, asking more vulnerable pilgrims to stay home (e.g. pregnant women and the elderly), and setting up sites for treatment. I am greatly encouraged by the efforts.

I am also greatly encouraged by the government's additional efforts on polio: this year they are going to require all pilgrims to swallow an oral polio vaccine upon arrival, and they have entered into the world of major donor to the global polio elimination effort by donating an addition $30 million towards the cause.

Sometimes concerns for religious and cultural practices comes at odds with public health concerns and too often one side wins out over the other. It is good to see how both concerns can be addressed at the same time, it can be good for the body and the soul.

Stuff on the net: maternal mortality around the world, corruption at the World Bank, and health systems view on the HIV epidemic

2009-10-27T18:34:00.001-07:00

Here are some links to some interesting things on the net this week:

1. The BBC takes a look at maternal mortality around the world this week. Click here for more information, including a video that shows how a simple bicycle ambulance is saving lives in Malawi.

2. My colleague Bill Savedoff blogged about the book "The Gods of Lending" on the CGD website. I started reading this book a while back, and there are some shocking details in it about the way in which the World Bank operates. The author argues that 30-40% of World Bank loans are misappropriated.

3. The Journal of Acquired Immune Deficiency Syndromes, normally a very technical and clinical journal, has put out a special supplement on HIV and health systems. Remarkably good stuff in there. Have a look.

PEPFAR and country-ownership: fact or fiction?

2009-10-27T05:44:00.000-07:00

The most recent issue of the JAIDS journal has a series of interesting articles on the HIV epidemic and health system. One that caught my eye was a short commentary from Mark Dybul, former US government AIDS czar, entitled "Lessons Learned From PEPFAR".

In his abstract he argues:

"In scope, it [PEPFAR] is the first global initiative to tackle a chronic disease and was based in a new philosophical foundation centered in country ownership, a results-based accountable approach, the engagement of all sectors, and good governance."

Did he say PEPFAR was centered on the principle of country-ownership? I can buy result-based accountable approach and engagement of all sectors and might even be sold on the idea of good governance. But I am sorry, I can't swallow the idea that PEPFAR exemplifies the principles of country-ownership.

The concept of ownership is one of the main principles of the Paris Declaration for aid effectiveness. According to a definition from the OECD website, ownership can be defined as:

"Developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption."

In the context of the HIV response, this would mean that countries would be responsible for developing intervention priorities, identifying implementing agencies, and being responsible for the programs. Of course country ownership does not have to be equated with government run, as it is also crucial that many stakeholders have a say and role in shaping priorities and strategies, but it does mean that governments are at least a key partner in the process.

The Center for Global Development in its report "Follow the Funding" report highlighted the lack of government involvement in PEPFAR projects as an area of weakness in the PEPFAR model. They argue that PEPFAR should "make the government a true partner in PEPFAR programs." PEPFAR might have incorporated inputs from national plans, but it is hard to believe that it was countries themselves that developed the hallmark strategies of PEPFAR, including a heavy reliance on faith based institutions, the adoption of abstinence only messages, and strict earmarks on how monies should be spent.

Dybul points to the fact that 90% of implementing partners are local and that 80% of them are non-governmental organizations as evidence of PEPFAR's country-ownership. I have a contract with NYU which pays me for my time as a instructor, dealing with student matters, and to support my research. But in no way does this mean that I own NYU, in fact quite the contrary given that my employer also owns the building in which I live. NYU owns me.

Even Dybul's own successor, Dr. Eric Goosby, the guy with the exact same job Dybul had just under a year ago, has been quoted saying that PEPFAR has not achieved country-ownership and that in fact it may take years before it could ever be achieved.

I want to be clear, I think PEPFAR has changed the game in global health in many good ways, and has made important contribution to the lives of millions of people in HIV affected countries, but I have not always agreed with the way in which the program was implemented. Real country ownership is a lot more than contracting with local NGOs and informing the country about operational plans. Country ownership involves letting citizens and their elected representatives have a say in how programs are developed and implemented. PEPFAR is not doing that yet, so let's save the praise until that is actually achieved.

Promising results for a new cholera vaccine

2009-10-20T06:41:00.000-07:00

Photo credit: Corbis

We don't hear a lot about cholera any more, but as the cholera epidemic that broke out last year in Zimbabwe has shown us, most developing countries are still vulnerable to occasional breakouts and in places in Asia, where cholera is still endemic, it is still causing significant illness. Over 200,000 thousand cases of the disease were reported worldwide in 2006, and this is only thought to represent a small fraction (5-10%) of the actual number of cases of the disease. It is estimated that over 100,000 people die of cholera every year, roughly 1/8 the number that die from malaria, mostly children under the age of 5. Wars, natural disasters, and economic collapse (as witnessed in Zimbabwe) can mean the disease can strike anywhere, anytime.

In theory, we have a vaccine for cholera, however, in practice the vaccine that has been on the market for many years is rarely used. The current vaccine is considered too expensive, too difficult to administer, and has the potential for side effects. As such, it is rarely used in public health programs.

A funny anecdotal story about this vaccine is that years ago, there were rumors that some customs officials used to dupe tourists into paying bribes by claiming that cholera vaccination was necessary to enter the country. Since the vaccine was never given to tourists, people who did not know better would have to pay up. My travel clinic in Montreal used to just certify that we had been given it (still in my vaccine card today) when in fact we had not.

Results of a clinical trial conducted in India have shown that we might be closer to having a safe, inexpensive, and effective vaccine against cholera in the coming years. The trial showed that the vaccine was about 67% effective at reducing cases of cholera when two doses were properly given, and was also protective in children, those most at risk of cholera. The vaccine is far from perfect, and the long term protective effect of the vaccine has not been established, but it is a good and promising start.

This trial also represents an important victory for some of the new drug discovery and development models that have come on board in recent years. This is not likely to be a lucrative market for any drug company, so it had to be done in partnership. Thanks to the Gates Foundation, the Swedish International Development Corporation Agency, and others this work was all possible.

Are we missing millions of children in Africa?

2009-10-16T07:40:00.000-07:00

During the last couple of weeks some variant of the following catchy headlines have been making their way around twitter and in the media: "Not enough malaria nets for children" or "School-age children found to be least protected from malaria". The headlines suggest that bed net efforts have been suboptimal in protecting children in Africa.

The headlines were in response to a new research article in BMC Public Health published by Abdisalan Noor and co-authors which has shown that coverage of bed nets is quite high among children under the age of five and again among adults, but is lowest among children aged 5-19. The authors conclude that universal coverage of bed nets will require new strategies, not just targeting of nets through antenatal programs, which have apparently been successful at raising coverage among children under the age of 5.

Maybe I missed this…but when did Universal Coverage of all children become the accepted goal? The Abuja Declaration, which was signed by the participants of the African Summit on Roll Back Malaria in the Spring of 2000 set out as a goal to ensure that a least 60% of the most vulnerable children, specifically those under the age of 5, should sleep under an insecticide impregnated bed net. The logic for targeting children under the age of 5 is that at younger ages children are immunologically most vulnerable to infection and that is, by far, where most deaths from malaria are concentrated. While significant progress has been made to date against this goal, it has not yet been achieved.

The logic for extending coverage to children over the age of 5 could also make sense for a number of reasons: since children in that age group are also exposed to infection and do incur some mortality it could further reduce mortality and there is evidence that at really high levels of bed net coverage (probably well beyond the levels seen in most places today) bed nets can have an effect on malaria transmission in communities. But changing the focus on young children to all children would significantly affect the cost-effectiveness of the intervention and would have massive implications for the funding envelope required. The data from the study mentioned above is that there are 2-3 times the number of school aged children in Africa than children under the age of 5. Are they advocating purchasing 2-3 times as many bed nets (in lieu of perhaps most cost effective environmental modifications)?

So while I thought this study was well done and contributed to our knowledge of the rollout of bed nets in Africa, its advocacy efforts were perhaps unfounded. I am actually quite pleased to see that efforts to date have actually focused on children under the age of 5. A more appropriate conclusion could have been "bed net rollouts appear to be targeting those most in need" and left it at that.

Our vision is not gender blind

2009-10-08T18:09:00.000-07:00

The image of a young boy leading his blind elder is common to many who have lived or traveled in rural parts of Africa. It is this image that has been captured in a series of statues located around the world to celebrate the phenomenal partnership that has been developed to address onchocerciasis - or River Blindness. Thanks to this partnership, millions of people are now receiving vision saving protection through the community directed treatment with ivermectin approach. It is a tremendous achievement.

However this image, that many now associated with blindness in developing countries, is not reflective of the fact that it is women - not men - who bear the bulk of the burden of blindness around the world. There are twice as many women who are blind than men.

Today, October 8 is World Sight Day. Vision2020 has used today to help spread the world about the great gender inequality that exists in the world when it comes to blindness. There are a number of reasons for this, first the chances of developing blindness increase with age, and women tend to live longer than men. Women have less access to health services than men, so they are less likely to get care when it is needed. Finally some forms of blindness, in particular blindness caused by trachoma, are more likely to occur in women. For trachoma, children are natural reservoirs of trachoma bacteria and women spend more time with children than men.

Over 80% of the 45 million cases of blindness in the world were preventable and almost 90% of blindness cases occur in the developing world. Some people think that it will take expensive hospital based procedures to eliminate blindness but there are many community based treatments that can be applied at low cost with great results.

To read more about blindness, I will point you to the Vision2020 website.

The second photo is from a special exhibit on Blindness hosted by the Fred Hallows Foundation. For more information please click here.

When you are neglected, 50 cents is still a lot of money

2009-10-06T20:04:00.000-07:00

"Despite new information that the disease burden of schistosomiasis in Africa may be equivalent to malaria or HIV/AIDS and a simple annual anthelminthic treatment for this disease is available for less than 50 cents per person including delivery costs, we now know that fewer than 5% of the infected population is receiving coverage. To date, this situation represents one of the first great failures of the “global health decade” that began in 2000."

Well said. That is a quote from a new editorial by Peter Hotez and Alan Fenwick in the latest PLoS Neglected Tropical Diseases. A few years ago there was little attention given to any of the neglected tropical diseases, but today, thanks largely to advocacy efforts of the authors of this editorial, financial donations from the Gates Foundation and the US government, and to the efforts of some powerful drug donation partnerships (think Merck and Glaxo for onchocerciasis and lymphatic filariasis respectively) significant progress has been made at increasing coverage of at risk populations throughout the developing world.

As the authors of this editorial argue, schistosomiasis, has not fared as well as some of the other NTDs. There are many reasons for this, so there is no easy answer as to why it is has been disproportionately neglected. Praziquantel the drug used to treat this disease has been around far longer than the drugs used to treat onchocerciasis and lymphatic filarisis. As such, by the time the disease was getting attention at the global level no major drug company was around to champion its cause or put together a drug donation program (is this an example of how patents by drug companies can actually be good for global health?). In fact, the market has been through so many ups and downs over the decades that is not surprising that the availability of the drug is a problem.

In an era of calls for universal access to ARVs and country wide bed net distribution programs, it is hard to believe that we cannot come up with $100 million a year to cover most of those in need of protection from this debilitating disease. But sadly, this is the reality.

For those really interested in this topic, there is a great chapter (chapter 3) on the challenges to access to praziquantel in the Access Book by Frost and Reich, which is available here.

Have your cake and eat it, just don't admit it

2009-10-06T18:52:00.000-07:00

The two biggest food phenomena I have discovered since moving to New York City about a month ago are (1) New Yorker's obsession with sipping coconut water while strolling around town (strange given how powerful of a diuretic this stuff is…) and (2) cupcakes. Cupcake shops - standalone operations specializing in these treats - are on nearly every street in this city. New Yorkers must eat more of these things per capita than anywhere else in the world.

The other evening my friend and I decided to try out the cupcake shop across the street from my new apartment. I spotted a gooey little number with peanut butter and chocolate and was about to yell out my order when I noticed a few numbers on the bottom of the placard. 550 calories. Each. My friend and I decided to split one and yet I still felt guilty. I have not been back.

The food calorie labeling of fast food items is a unique feature to New York City. Our mayor, Michael Bloomberg, despite being a business mogul in a previous life is really a big public health wonk (he even has a school of public health named after him) and despite his own famous culinary indiscretions has been an advocate for city-wide big-brother style public health policies, including the labeling of food calories on fast food items and a ban on trans fats in restaurants across the city. There is no other city in the world where government has so much control over what put in our mouths.

But do these policies actually lead to better eating behavior, in particular among the poor where obesity is more common? A new study published today in Health Affairs by some of my colleagues here at NYU (Brian Elbel and Rogan Kersh) seems to suggest that the food labeling policy has not had much impact on the actual choices low income consumers make, those primarily targeted by these policies. The authors compared the behaviors of fast food customers in New York City and Newark, NJ before and after the introduction of the policy in New York City. They compared the proportion of respondents who said they were aware of the labeling, indicated that the policy influenced their food choice, and those who reported purchasing fewer calories. On these measures, the policy appeared to have been successful. However, when they actually compared the number of calories purchased by people (not just what they reported) - there was no change.

Ideally, a study like this should have accounted for the fact that the policy change may have changed the composition of the people presenting in the restaurants, but I would really only worry about this had they found a big change in what people were buying. The real contribution of this study is that it supports the view that changing human behavior, in particular when it comes to one of the best things about being a human - eating - is really, really hard. People were aware of the policy and even claimed it had changed their behavior, but it didn't.

Perhaps we are all a lot like Michael Bloomberg after all: we are not very good a living by our own rules.

Photo credit to the Cupcakes take the Cake blog. Yes, a whole blog about cupcakes. These t-shirts are for sale at Magnolia Bakery in NYC, where of course you can also buy lots of cupcakes.

Facemasks and handwashing: a total waste of time or useful prevention methods?

2009-10-05T18:20:00.000-07:00

The highlight of the horrendous SARS outbreak for me a few years back was undoubtedly my first glimpse at a Hello Kitty Facemask worn by an Asian woman as she was exiting Logan airport. Clearly this was a serious epidemic if health prevention efforts had also become fashionable.

Minutes after the first chatter emerged earlier this year over the spread of the H1N1 virus (aka Swine Flu) the facemasks were back in full force. I flew that weekend to Detroit, MI and was surrounded by scores of facemask clad, nervous travelers who distanced themselves from anyone who even cleared their throat in public. In addition, Purell sales shot through the roof. There were reports of stock outs of the product coast to coast. Bottles popped up nearly everywhere. People, it seemed, were willing to try anything - even things for which there was little or no evidence that they provide any protection - to avoid catching this flu.

A new study, published today in the Annals of Internal Medicine, has more or less confirmed that such interventions provide only limited protection. A study of patients presenting with the flu at Hong Kong hospitals who were randomized to receive no intervention, were instructed to wear a facemask, or were instructed to practice proper hand washing techniques found no significant reductions in the number of family members who subsequently tested positive for the virus. However, there was some evidence that those patients who adopted the practices sooner after the onset of symptoms may have been less infectious, but only under some conditions. Lots of caveats, as there always are, these were patients who were already sick enough to decide to go to the hospital and adherence rates were abysmally low, but on the whole the evidence was far from a slam dunk for the value of facemasks and hand washing.

So breath freely, and forget reaching for a squirt the next time you are in the elevator, because it seems the flu is going to get us anyway.

ART and HRH: How do the numbers add up?

2009-10-01T06:56:00.000-07:00

Yesterday UNAIDS, the WHO, and UNICEF released a particularly upbeat report on the state of HIV/AIDS prevention and control efforts globally. There were some remarkable achievements reported, including a 35% annual increase in the number of facilities providing VCTs in reporting countries, 45% coverage of PMTCT, and increased targeting of prevention services to most at risk populations. It seems as though 2008, despite the doom and gloom of the global financial crisis, was a record year for HIV efforts.

The biggest piece of news, undoubtedly, was a 1 million increase in the number of people getting access to HIV treatment globally, with the vast majority, about 80% of the gains in sub-Saharan Africa. According to the report, nearly 4 million people are now access treatment globally - 3 million in sub-Saharan African countries alone.

There has been some speculation that these numbers may represent upper bounds, or the number of people who have ever accessed treatment not those currently accessing treatment, but regardless if these numbers are anywhere close to reality, than this is a massive achievement.

But it also made me wonder about what the implications these numbers might be on human resources for health in Africa, if in fact they were correct.

Below I did a quick back of the envelope calculation of what these new treatment figures represent given best practices about human resource requirements for HIV treatment in resource poor settings. I used data from a publication by Hirschhorn et al., from what I can gather the most heavily cited figure used these days, on the numbers of doctors and nurses required to provide ART, specifically I estimated to treat 1000 people with ART it would require 2 full time doctor FTEs and 5 nurse FTEs. I then took the treatment numbers by countries from the new report and compared this to the most recent estimate of doctors in nurses in those countries from the World Health Organization and compared the numbers.

Here are my estimates for doctors:

And for nurses:

The last column in each table is my estimate of the share of the workforce that is currently being allocated to HIV treatment programs. In particular for doctors, if we believe my assumptions, we see that a massive share of the total health workforce is entirely engaged in providing ART. In some countries over 100% of the entire medical workforce would be required to treat the number of people reportedly getting access to treatment. On average, although an average here is a bit meaningless, about 25% of the doctor FTEs would be required to provide ART. The proportion for nurses is substantially lower, because Africa in general has higher numbers of nurses.

Of course assumptions like these are by nature simplifications of reality, the HRH data is a few years old, ex-pat doctors don't generally count in the WHO figures, and there are many reasons to believe that these treatment guidelines are not being implemented optimally (either up or down). But if they are in the ballpark, and I think they might be, than it does raise some important issues regarding this massive expansion of treatment programs. Can we justify using nearly the entire health workforce in some countries to treat just one disease? What is this doing to the rest of the health sector?

I would really appreciate any comments from any readers. What are your thoughts?