You can access the full text of the op-ed here.

We had a great line-up starting with Professor David Bloom of the Harvard School of Public Health, one of my co-chairs on the CGD working group that looked at UNFPA on the occasion of its recent leadership transition. David presented our motivation for the report and the working group recommendations.  My other co-chair, Dr. Jotham Musinguzi, who heads the Africa regional office of Partners in Population and Development, then talked about the way UNFPA operates in countries. After all, the vast majority of its resources are in country offices, so that’s the true test of its effectiveness. Panelists Jill Sheffield, president of Women Deliver, and Jonna Jeurlink from the DFID mission to the UN talked about their perceptions of UNFPA as a partner and as a recipient of funds, respectively.

I gave a few opening thoughts about what makes the development context interesting and challenging these days, and how that is relevant to UNFPA. The current financial climate has prompted a useful examination of how aid is working and what governance arrangements and technical modalities are best suited for the future. There are many new initiatives aimed at mobilizing resources, transforming advocacy, and aligning national strategies with international commitments. Most are also trying to increase harmonization, accountability, and transparency among donors and institutions.

Conditions are in flux and the issues we raised in the report of governance, results, effectiveness and communication are timely, offering a unique opportunity to examine how UNFPA can best position itself and its objectives to be effective. Its small size and voluntary resource base can be an advantage if it can be nimble, laser-focused, while consolidating gains and emphasizing common ground. But this new context raises many questions as well.

The working group’s four recommendations for action pose and strive to answer various questions to help UNFPA make tough choices. Can UNFPA to stick to the International Conference on Population and Development (ICPD) Programme of Action and also work on sexuality? How can they put youth in the forefront and also deal with rapidly aging populations? And how should UNFPA link to the Global Strategy for Women and Children and to UN Women, while not being redundant?

Granted, UNFPA lives in a particularly more polarizing and politicized space than almost any other UN or multilateral agency, as we’ve observed recently in Washington. Although recent congressional attempts to completely defund UNFPA failed, its funding for the current year was cut by $15 million. Yet, those financial and political challenges will not disappear. The reproductive health and family planning community should embrace and study the assessments now available on the global stage, including the CGD report and the DFID findings, and use them to show friends and foes alike UNFPA’s essential role in a new era.

Over the course of working on this project for the past year, we heard from many people in many places. We heard strong and articulate views about what UNFPA is and should be, some of them very extreme (I’ll leave those to your imagination). I was particularly surprised by the disparity in views, both about what UNFPA is, and what it should be. This implies that UNFPA’s vision may have become somewhat blurred, and needs to be focused. That is the Working Group’s first recommendation.

We met a few weeks ago with UNFPA’s new executive director, Dr. Babatunde Osotimehin, and his senior staff to share the recommendations and discuss the way forward. Dr. Osotimehin is currently gathering input from inside and outside of UNFPA and will present his plans for the Fund to UNFPA’s Executive Board this fall.  We received some assurances that the working group’s recommendations would be part of their on-going strategic planning.

The next few months are a crucial time for all who wish to see UNFPA move into its fourth decade as a stronger and more effective organization. We encouraged those who gathered in New York to keep up the pressure on UNFPA to not boycott the discussion. The member states – especially Executive Board members and those diplomats and country delegations closely involved in population, reproductive health, and family planning issues – along with key civil society organizations, should study what is in the report, consider what it says and who said it, and then decide how to act to help UNFPA achieve the shared goals of greater effectiveness and alacrity in improving women’s health and well-being.

Antimicrobial resistance is not a new problem but one that is becoming more dangerous; urgent and consolidated efforts are needed to avoid regressing to the pre-antibiotic era.

The World Health Day publicity materials highlight all manner of disasters from drug resistance: people die, health care costs rise, trade and economic development are affected (I must admit that I hadn’t imagined that particular consequence), and more. But, understanding the perils of drug resistance is not a new phenomenon at WHO. Ten years ago, on the eve of September 11, WHO was preparing to roll out a global strategy to prevent and contain drug resistance which was already of great concern to public health officials. The next day, the world was too distracted to hear the important warnings and plans contained in that strategy, and attention to drug resistance languished for a decade. It has risen again. There are plenty of reasons to hope it  remains squarely in the public eye.

WHO’s declaration of drug resistance as the theme of this year’s World Health Day is not coincidence. Last year, an enzyme that confers almost complete drug resistance on bacteria it comes in contact with, called NDM-1, popped up in India and quickly spread to 20 countries. It is almost always lethal. This new bug follows the discovery and spread of a whole range of “superbugs” that have made hospitalization, and even minor cuts and scrapes, a more threatening experience than ever before. Also last year, about the time that WHO regional and headquarters officials were deciding on the theme for World Health Day, CGD was preparing to publish an expert working group report on global drug resistance policy, The Race Against Drug Resistance. The report, the related policy brief, and the accompanying video have been widely circulated and were drawn upon by WHO in preparing materials for World Health Day 2011.

We’re happy that our working group report was useful to WHO, but we’d be a lot happier to see the momentum from 2010 turn into action in 2011. Here is a quick reminder of the 4 recommendations in the CGD report, and what has happened so far on each. The organizations responsible for carrying out each recommendation are clearly identified in our report.  Here, I grade the progress on each recommendation and briefly explain my reasoning.

Recommendation 1: Build greater laboratory capacity and create a global network for drug resistance surveillance. Publish a report on global drug resistance every two years.

Grade: C      Reason: More talk than action

Many drug resistance surveillance networks exist. The best global surveillance efforts for both HIV/AIDS and TB drug resistance have just published new reports, here and here, and a recent malaria drug resistance report is available here. WHO is making plans to gather its regional drug resistance surveillance gurus together for the first time, in an effort to help them organize and utilize a more global network. Improved laboratories in Africa (where they are needed most) are also gaining traction. The new African Society for Laboratory Medicine recently held an inaugural meeting in Addis Ababa, with PEPFAR as a major sponsor, and others are investing in better lab capacity as well. But is WHO really taking seriously the need to combine drug resistance data across regions and diseases so we have a full snapshot of the problem? Our new world map documenting drug resistance shows just how piecemeal the data are. The world desperately needs a more complete picture of this threat, which kills more people everyday than died in the World Trade Center tragedy.

Recommendation 2: Establish a secure supply chain from manufacturer to customer that ensures the safety and efficacy of the drug supply in developing countries.

Grade: D      Reason: Lack of funding

The CGD report recommended that stakeholders at the global and developing country levels partner up to identify and fix weaknesses in the drug supply chain that allow good drugs to lose efficacy (for reasons such as humidity, extreme temperatures, expiration) and bad drugs to reach consumers (counterfeits and poor quality are rampant in poor country distribution systems and prescribers and dispensers are often not well trained to detect them). Who should do this? We suggest everyone along the supply chain—from manufacturers to dispensers to professional medical associations like pharmacists and doctors. But what has happened since our report came out? Very little. Despite enthusiastic and broad-based buy-in from many stakeholders to lead these partnerships at an August 2010 meeting sponsored by CGD in Upsalla, Sweden, organizations such as MSH, the Alliance for the Prudent Use of Antibiotics (APUA), and the International Pharmaceutical Federation (FIP) haven’t found funding to move forward. Times are tough in global health and expertise and good intentions are not enough to create long-term change. Multiple organizations are ready to bring their technical expertise and practical experience to the job of securing drug supply chains. Donors and funders need to do their part to help it get started.

Recommendation 3: Use regional networks to improve national drug regulatory authority capacity to safeguard drug supplies and enforce laws

Grade: F       Reason: See above (1 and 2)

National drug regulatory authorities (NDRAs) are the front line for monitoring the quality and safety of drug supply systems, but are notoriously weak or corrupt in many developing countries. It’s a tough job and one that requires a rare combination of skills, including technical, law enforcement, diplomatic, and policymaking. The most well-known drug regulator in the developing world – Dora Akunyiki of Nigeria – finally got tired of the death threats she faced after seizing contraband drugs in her country and moved over to the quieter job of Information Minister. Something is needed to improve the regulatory culture and capacity among developing country drug regulators, especially in the African countries that are beset with a “wild west” atmosphere in their drug markets. The CGD report recommended that donors provide support to existing and new regional networks of NDRAs for training, information-sharing, and other activities that will enhance their capabilities and motivation to do the job. Donors have long lists of what they would like to see from NDRAs – including much faster and more harmonized drug registration (an example is the Gates Foundation effort through the Africa NEPAD in partnership with DFID and other donors) – but so far have been both more talk than action, and reluctant to put money into an enterprise that is so out of their control.

Recommendation 4: Establish a web-based R&D marketplace to spur innovation for disease-specific technologies

Grade: B      Reason: It’s here! But can go further

The Institute for Drug Resistance (IDR) at the University of Massachusetts provides a web-based networking site for researchers to share ideas and build collaborations on drug resistance. The network is small and still pretty U.S.-centric, but the potential and desire exists to make this site the go-to place for sharing ideas about drug resistance innovation and perhaps, even spur relationships between drug resistance scientists and research and product development funders. And as an added bonus, the IDR has enthusiastically become the publisher of the Drug Resistance Newsletter, formerly published on a monthly basis by CGD. The newsletter reaches a community of over 2,500 people interested in news and research about drug resistance, and will no doubt grow under IDR’s banner.

Where do we stand then? Not far from where we stood last June when we published the CGD working group report. It’s only fair to say that a higher level of awareness (and yes, alarm) exists about the global problem of drug resistance. Was it NDM-1, the CGD report, World Health Day that did it? Or the many other efforts from research, advocacy, and public policy organizations to bring attention to drug resistance? Probably all of the above, but if those efforts don’t result in more action and money from global donors and health agencies, as well as developing countries and companies, we’ll see another decade and many more of the drugs we rely on today slip away. On a final positive note, the 1^st Global Forum on Bacterial Infections is now being planned by the fabulous team at The Center for Disease Dynamics, Economics & Policy. It will focus on drug resistance and related policy issues in low- and middle-income countries. Let’s hope it follows an example set by the World Health Day to turn talk into action.

By the way, did you remember the theme of World Health Day 2010 yet? Urbanization and Health.

As is custom at CGD, the working group staff have posted the consultation draft report online. The draft report is a work in progress and, by design, a preliminary indication of the working group’s ideas. The purpose of the document is to elicit important feedback and comments from a broad array of experts in the field.

We invite you to comment on the draft report by Tuesday, December 21. The draft report and instructions on how to provide feedback can be found here. With feedback gathered during this consultation period, along with further deliberations among working group members, we will fashion a working group consensus report which will be delivered to Dr. Osotimehin and made public early next year.

We have received very positive feedback since publishing the report in June. However, we are acutely aware that talk is cheap. Simply writing what needs to be done (much to the chagrin of my co-authors and myself!) is far easier than actually doing it. Since the report was published, we have been working with a range of organizations to advance the ideas and see them implemented.

A critical place to begin a common response to drug resistance –our report puts this first among four major recommendations – is to collect and share drug resistance information across disease networks. The working group report recommended that the many organizations that gather information about drug resistance should join forces to identify gaps in public health and clinical knowledge about where and when drugs aren’t working, and produce a biannual global drug resistance report to inform donors and public health agencies.  I’m pleased to share that a “network of drug resistance surveillance networks” seems to be within reach.

We are working with others to form a coalition of drug resistance surveillance networks and private companies that have stated their intention to share information, methods and tools for detecting and documenting drug resistance. This would mean antimicrobial resistance people would talk to malaria resistance people (for a change) and hopefully, create a rapid diagnostic test to differentiate between malaria and pneumonia, for instance before dispensing the wrong drug and waiting to see if the fever worsens. It could mean that regions with strong TB surveillance but weak information about Strep pneumonia drug resistance might find ways to build on existing infrastructure to improve health outcomes.

The working group proposed that such a network eventually produce a biannual report of global drug resistance across diseases so that policymakers, public health agencies, and clinicians understand what they are up against, identify the gaps in knowledge, and begin to turn the tide on drug resistance. The first step of bringing together the disease-specific surveillance networks is being planned. Let’s hope the interest and momentum continue to build.

Addendum: While we’re speaking about improving diagnosis … the long-awaited announcement of a new fast-acting and reliable Tuberculosis (TB) diagnostic test last month sent ripples of anticipation through the TB community. As reported in the New England Journal of Medicine, the new molecular test can reduce the time to diagnose TB from 10 days to less than two hours. This test is a huge advance from the standard sputum smear test that has been used for many decades to identify TB. Not only can it diagnose drug-sensitive TB, the Xpert test can bypass the slow process of culturing a sputum sample for drug sensitivity and determine whether a case is Rifampin drug-resistant. And the test works with 97% accuracy to detect confirmed TB cases.

The promise of this new TB diagnostic is great for several reasons. First, simple public health. Almost 40% of estimated TB cases remained undetected (2008 figures), and therefore untreated. Only about one in ten cases of drug-resistant TB is estimated to be detected, and a small fraction of those are treated properly. These figures are tragic and illustrate once again that TB has been neglected. A new technology is way overdue to detect TB. Second, this test can be used by less skilled lab workers than the standard methods of culturing currently employed. The result can be faster results from a more extensive group of facilities. Finally, I am optimistic about the potential for molecular tests – such as Xpert – to revolutionize laboratory work by de-specializing the resources and procedures needed for disease diagnosis and drug susceptibility testing. Cross-disease labs should become the norm, replacing specialized labs. All these advances are envisioned in the Working Group’s recommendation #1: improve the ability to detect and monitor resistance. New technology and human willingness to work together, combined, will make this a reality.

For more on CGD’s drug resistance work, please sign up for or visit our monthly e-newsletter.

Working with Health Subcommittee Chair Frank Pallone, the committee staff has organized three hearings on AMR, the second of which was held last week before a full hearing room. (I wrote about the first hearing here.) So far, the hearings have focused exclusively on antimicrobial resistance (commonly referred to as AMR), and the most visible ways that AMR is manifested in the U.S., including MRSA (Methicillin-resistant Staphylococcus aureus) and Acinetobacter baumannii (sometimes called “Iraqibacter” because soldiers increasingly are sent home with resistant infections of this bug.) While this political attention is encouraging, it must extend to drug resistance across all infectious diseases and move beyond a U.S. focus.

Most of the committee members at last week’s hearing seemed genuinely concerned about the two issues on the agenda: the poor pipeline for new antibiotics, and overuse and misuse of currently available antibiotics. A stream of public and private sector witnesses did not shy from using words such as “crisis” to describe the drug pipeline. During her testimony, Janet Woodcock, who is responsible for new drug approvals at the FDA, said, “The pipeline is diminished when the need could not be greater.”

It is not yet clear what kind of bill the subcommittee might try to get through Congress, or even if it will try, before the end of the current session. Congressional Quarterly recently reported on Pallone’s plans. “It’s clear that action is needed,” Pallone said after the hearing. But “the problem is we need to know what to act on.” Pallone offered no timetable for when a decision would be made, or any guarantees that legislation would be moved this year.

In the spirit of support for the efforts of the subcommittee, I offer some thoughts about what to include in new legislation. Some of these steps don’t require any new money– which should be a plus in the current environment!

Encourage USG agencies to address drug resistance globally. Antimicrobial resistance is clearly a global issue, with huge increases in drug use occurring in emerging and developing countries–including many of the same drugs relied on in the U.S. and Europe. A stronger awareness of drug resistance is needed in developing parts of the world to reduce the inappropriate use of medicines that speeds resistance.  Through existing programs at CDC and NIH, the U.S. is a world leader in disease detection and infectious disease research. We need to build on what we’re doing with greater emphasis on drug resistance surveillance–not just disease surveillance, basic science research into resistance mechanisms, and incentives for resistance-specific technology–not just new drugs.

USAID is also a global leader in building capacity in developing countries for monitoring and improving drug quality and appropriate use of medicines, but its important role in supporting global work through WHO and other partners has been hobbled by inadequate funding. USAID’s line item funding for antimicrobial resistance was zeroed out in recent years.  It needs and deserves a shot in the arm with the green medicine.

Beyond enhancing existing programs, Congress could incorporate language into the Strategies to Address Antimicrobial Resistance Act (STAAR) Act introduced by Congressman Matheson and others, or into new legislation, recognizing the global nature of drug resistance and the need for greater coordination to fight it. Congress should also appropriate funding to the EU-US Task Force on Antimicrobial Resistance and give it some useful tasks, such as producing a credible picture of drug resistance worldwide. It may seem like a small thing, but a step toward global awareness has already been achieved with a common Antimicrobial Awareness Day in the U.S. and EU on November 18 for the first time this year (actually, in the U.S. it’s an entire week.) Next goal: make it global.

Leverage U.S. donor funds to improve drug quality and resistance monitoring. Congress could also get tough in its role as a global health donor. Through Pepfar, the President’s Malaria Initiative, and contributions to the Global Fund to Fight HIV/AIDS, TB, and Malaria, the U.S. is purchasing drugs by the semi-trailer to distribute in poor countries. Congress should require that all drugs procured with U.S. taxpayer funds be monitored for quality throughout the entire supply chain, not just at the point of manufacture, thereby reducing opportunities for resistance to emerge. Drug producers that demonstrate greater responsibility for the quality of their products should be recognized and rewarded.  This is among the recommendations made in a new report from CGD to be released on Tuesday at the National Press Club.

My final thought for Congressmen Waxman, Pallone and their colleagues on Capitol Hill: don’t wait for new drugs to solve the antimicrobial resistance problem. Prioritize the steps that can prolong the usefulness of drugs we already have, and reduce drug use where it’s not needed.

Fifteen members joined the subcommittee’s chairman, Frank Pallone (D-N.J.), and ranking member, John Shimkus (R-Ill.), including Rep. Henry Waxman (D-Calif.), chairman of the full committee, Rep. John Dingell (D-Mich.), Waxman’s predecessor as chairman, and two major supporters of legislation designed to tackle problems caused by drug resistance, Reps. Jim Matheson (D-Utah) and Jan Schakowsky (D-Ill.).

This is the kind of serious, high-level attention we need to meet the challenge of drug resistance, a growing crisis that is undermining the global health community’s efforts to treat malaria, HIV, tuberculosis, and a range of other diseases in both developing countries and wealthier nations.

Reminding us that local often trumps global, nearly every member in attendance mentioned the large – and growing – number of hospital-acquired infections that are resistant to at least one common antibiotic, and many expressed concern over methicillin-resistant Staphylococcus aureus (MRSA), citing infections or deaths in their home states. Most of the legislators’ questions dealt with the use of antibiotics in feed animals and agriculture, one key aspect of drug resistance that would benefit from substantial further research. The use of antibiotics in animals has received much of the attention paid to drug resistance because it represents a deep struggle between agriculture and health interests. But, as the panel’s witnesses indicated, there are other issues that are far less controversial and politically charged.

Dr. Fauci testified that any strategy to address drug resistance must include proper surveillance of its spread as well as infection control, the rational use of antibiotics, and sufficient biomedical research. Dr. Frieden told the subcommittee that increasing resistance leads to greater death rates and higher health-care costs, and said we must improve and monitor the use of existing antibiotics while developing new drugs.

Without action, he said, we may enter a post-antibiotic world.

That’s a frightening prospect, but one that we have the ability to avoid. Next month, CGD’s expert Drug Resistance Working Group will release a report, more than two years in the making, on the steps necessary to meet this global challenge. In line with Dr. Fauci and Frieden’s statements, the Working Group strongly emphasizes the importance of improved surveillance to understand where and how resistance is spreading. Collectively, the Group’s recommendations urge coordinated international action across all infectious diseases.

It’s good to see that Congress seems ready to be part of that effort.

I’d be willing to bet that nary a H8 meeting (if you have to ask….) has included a discussion on the impact of heart disease, obesity, or diabetes in developing countries. Yet chronic diseases, particularly cardiovascular disease (CVD), have emerged as a significant—and growing—threat to those living in poor countries.

Yesterday, the U.S. Institute of Medicine released an early version of a report entitled Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. The report details governments, global health institutions, and development agencies’ lack of attention to CVD and offers recommendations to better prevent and control the disease.

As a member of the IOM committee that produced the report, I learned a great deal from the cardiologists and diabetes docs who were my colleagues on the committee. I think what they learned from me is that silver bullet solutions to CVD in poor countries remain elusive to clinicians and economists alike. While the economic impacts of CVD are alarming, changing global health priorities and funding streams is a hard task and it’s not yet clear what it will take to convince the H8 or others to play a role in attacking the problem, rather than continue to leave it to developing country governments and households on their own.

CVD is a critical health challenge in low and middle income countries, causing nearly 30 percent of deaths each year (the largest single contributor), and has particularly significant economic ramifications. CVD is increasing, while infectious diseases are dropping in almost every developing country. At the same time, almost all health institutions, governments, and development agencies have ignored CVD as a global health priority for developing countries. Two simple points make the case:

• Chronic diseases are the least funded area of donor assistance for health. Forthcoming CGD analysis shows that only 2.3 percent of the $22 billion per year in international donor assistance in health is devoted to CVD and other chronic diseases, while chronic diseases contribute 69 percent of deaths.
• There is NO global development target for chronic diseases; therefore, no donor has to feel (or look) bad if the trend of chronic disease mortality continues to rise.

The IOM report also offers plenty of reasons why official aid agencies should worry about the impact of chronic diseases on development. For one, the report finds that poverty is both a cause and a consequence of CVD. The poor are more likely to be exposed to CVD risks than their wealthier counterparts. CVD and other chronic diseases impede household productivity and savings, thereby pushing people into poverty.

Whether you live in the U.S. or in a developing country, it’s not easy to live “heart healthy”. Without more attention to chronic diseases such as CVD, developing countries will face an ever-growing health and economic burden from these (largely preventable) illnesses. Another recent news item provides some encouragement. This week PepsiCo announced that it will revamp many of its food and beverage products to reduce sugar, salt, and transfats. Perhaps official health agencies will eventually follow the leadership emanating from the private sector.

Two award-winning journalists spent the better part of 2009 taking a global tour of drug resistance. The sights they found were astonishing – and terrifying. I spoke to one of them, Margie Mason, shortly after their five-part series entitled “When Drugs Stop Working: An Emerging Threat to Global Public Health” ran in newspapers around the world—unfortunately, in my view—during the week between Christmas and New Year. CGD has been tracking Margie’s journey and providing background information to her since she set out. Margie explained,

I was surprised by some of the things we found: I had no idea antibiotics were sprayed on fruit trees, and injected into palm trees. We also found there are 700 antibacterial or antimicrobial products on the market. Do you really need antimicrobial slippers and chopsticks?

You’ve got to admire Margie, a recent recipient of a Nieman Journalism Fellowship at Harvard University, and her Pulitzer-prize winning co-author, Martha Mendoza. This topic doesn’t exactly lend itself to the 3 paragraphs, 1 column format of USA Today. It’s complex, it’s hard to find the victims since many of them don’t know they have a drug-resistant disease, and there’s no smoking gun. “Drug resistance is not immediate”, explains Margie.  “It’s a slow, silent moving problem with many different aspects…it’s a truly global problem, and one that everyone is contributing to.” She continued,

Drug resistance was a real challenge to report on. It’s such a big issue and we tried to simplify and make it interesting to read about. There have been piecemeal stories but no-one has pulled it together in a comprehensive package. Our task was how to find things that haven’t been reported.

Our star gumshoes succeeded at that. In their first article—a breaking story that had never been made public—Mason and Mendoza reveal the first case of highly drug-resistant tuberculosis (coined XXDR-TB) in the U.S. They describe 19-year old Oswaldo Juarez’s struggle with the highly contagious and aggressive disease during his visit to Florida from Peru. Although XXDR-TB had never before been seen in the U.S., Dr. David Ashkin, one of the nation’s leading experts on tuberculosis and the medical director at AG Holley, the quarantine hospital where Juarez lived for a year and a half, explains that the case of Mr. Juarez “Really is the future. XXDR tuberculosis is so rare that only a handful of other people in the world are thought to have had it.  This is the new class people are not talking about.”

The capacity for TB to evolve into more aggressive and resilient strains is, in the words of Dr. Masae Kawamura, who heads the Francis J. Curry National Tuberculosis Center in San Francisco, “a time bomb…a man-made problem that is costly, deadly, debilitating, and the biggest threat to our current TB control strategies.”

Margie’s take on it?

The story of the kid in Florida was an incredible tale from a journalistic standpoint. We were trying to find XDR-TB in the U.S. There are a handful of TB centers across the country. AG Holley [a former TB sanitarium in West Palm Beach, Florida] is like a museum with all the old equipment. There are dark corridors, now without patients lining the walls, but where you can close your eyes and imagine yourself in another century. There are incredible patients there from all over the world. We met an Indian woman who came to the AG Holley with resistant TB and was separated from her newborn for eight months.

The two reporters’ drug resistance world tour tells of similarly heart-stopping sights elsewhere with the freshness that comes from seeing the problem for the first time. Frankly, it’s a welcome change from the scientific journals that produce almost all of the available knowledge about resistance. The journalists’ labor poured out over five days in late December, starting with Oswaldo’s story.

• Day Two: The first evidence of resistance to artemisinin combination drugs for malaria in Thailand – the same corner of the world where resistance to earlier malaria drugs began, and then spread worldwide.
• Day Three: The use of antibiotics in agricultural practices – amounting to 245 million tons of antibiotics consumed by animals in the U.S. alone.
• Day Four: The emergence of drug-resistance strains of HIV in South Africa – new and more resilient strains of HIV are being detected in roughly 5 percent of new patients in Africa, with higher resistance rates found in the U.S. and Europe.
• Day Five: The link between reduced antibiotic use in hospitals and better health results in Norway – while more than 65,000 people die of hospital-acquired infections annually in the U.S. alone.

Throughout the series, Margie Mason and Martha Mendoza compile personal stories, statistics and expert opinion to describe the dangerous capacity for medicine use to go wrong and create highly-resistant strains of infectious diseases. They conclude, “Forty years ago, the world thought that it had conquered TB and any number of other diseases through the new wonder drugs: antibiotics.  Today, all the leading killer infectious diseases on the planet are mutating at an alarming rate, hitchhiking their way in and out of countries.”

Did they arrive at this conclusion because their reporter instincts lead them to invent a crisis? No, these conclusions come straight from sober scientists. Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, and a veteran of the fight against resistant TB in the U.S. asserted, “If we’re not careful with antibiotics and programs to administer them, we’re going to be in a post antibiotic era”. Margie and Martha also quote Norway’s MRSA Control Director, Dr. Petter Elstrom, who is apprehensive about the multi-drug resistant strain of Staphylococcus aureus—commonly dubbed MRSA. “So far we’ve managed to contain it, but if we lose this, it will be a huge problem. To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can’t prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics.”

Margie’s first-hand assessment is down-to-earth.

These strains are even scarier in the developing world. They can’t get treated. You can talk about these things and make plans about prevention and treatment. But when you see the setting you realize how challenging it is to make things work. These people are moving around all the time, they are poor.

Margie explained also that she was overwhelmed by the sheer scale of the problem.

I’ve been having dreams about drug resistance, waking up thinking about it. We’ve read books, interviewed hundreds of people. There’s just so much. We tried to hit on as many of the big issues as we could, but there are many others. We didn’t get into advertising or talk much about all the incentives paid to doctors to prescribe drugs. I’ve heard all kinds of anecdotes about what people get for prescribing drugs. We’re very quick to blame poor countries but in this case it’s a truly global problem, and one that everyone is contributing to.

There are, however, some glimmers of hope. In her interview with me, Margie noted the example of a Japanese doctor, who, after realizing that the nation’s seemingly ultra-modern, sterile facilities revealed MRSA levels that were among the highest in the world, changed his practices to reduce the frequent use and dissemination of antibiotics—and got positive results. Margie and Martha finish the series with a story about hospitals using amplified precautions (including universal screening programs) to reduce hospital-acquired infections in Pittsburgh. “There are ways to control this; it’s not a doomsday scenario,” Margie reports, adding that “there is more awareness now than a long time ago.”

Awareness, such as that generated by the AP series and similar articles, will be crucial in stemming the spread of once curable drug-resistant diseases across the world. To learn more, sign up for our monthly newsletter on drug resistance. It will direct you to the consultation draft report of the CGD Working Group on Drug Resistance. This is a manageable problem if only we all are willing to take the world tour with Margie and Martha.

Courtesy U.S. State Department

When it comes to Secretary of State Hillary Clinton, no sliver of the international development community is more enamored than the sexual and reproductive health and rights (SRHR) crowd (yes, that’s their self-designation). Last Friday, Hillary returned the love. In a speech (see the full text here) in the regal Benjamin Franklin reception room at the State Department, Secretary of State Clinton and many of her top staff brought the international dimension of reproductive health and family planning in from the cold. It’s been a long winter.

The occasion of the speech was the 15th anniversary of the “Cairo Conference” – officially the International Conference on Population and Development (ICPD) – in 1994, at which then-first lady Clinton was a very prominent and passionate leader of the U.S. delegation. Last Friday she said,

There is no doubt in my mind that the work that was done and the commitments that were made in Cairo are still really the bulwark of what we intend to be doing and are expected to do on behalf of women and girls.

The ICPD was particularly ill-timed. Several months later, Republicans took control in the U.S. Congress and anything having to do with sex, rights, or Hillary became a political cudgel. The conditions for advancing the Cairo Plan of Action on SRHR became worse in 2000 when George W. Bush took office, the Mexico City policy (known by some as the global gag rule) first imposed by Ronald Reagan was reinstated, U.S. funding was pulled from the UN Population Fund (UNFPA)and replaced by Nordic and other European countries and the U.S. became a pariah in international circles concerned about women and their rights.

The SRHR crowd in the U.S. went into exile. They’ve been there for almost half the time that has elapsed since Cairo. As Margaret Pollack (newly appointed Senior Advisor on Population Issues at the U.S. State Department) said at a UN Foundation luncheon to celebrate Friday’s speech, a lot of time has been lost that could have been spent achieving the Cairo Plan of Action – and not incidentally, getting much closer to achieving MDG 5, the maternal health goal.

Secretary Clinton seems to be in a hurry to make up for lost time. She used the full arsenal of her top staff and emboldened them with strong words. Eric Schwartz, assistant secretary of state responsible for population issues, opened the event saying, “We recommit to the principles of ICPD and its Plan of Action.” Ambassador-at-Large for Global Women’s Issues, Melanne Verveer, in introducing the Secretary, called her a woman who has not wavered on the issues of SRHR and applauded the focus on girls and women in the Secretary’s “groundbreaking speech on development” two days earlier at CGD. (For those who missed it, you can read the text of the prepared remarks here – note the very nice reference to Start with a Girl in her sixth point.)

Maria Otero, the undersecretary of state for democracy and global affairs, drove home the point that the Secretary is dead serious about putting the needs and condition of girls and women at the center of U.S. foreign policy. And completing the all-star line-up, USAID Administrator Raj Shah, sworn in just the day before, assured the crowd that a newly energized and excited USAID is ready to live up to the core principles of SRHR and the full vision that the Secretary articulated in last Wednesday’s speech – a speech he called “the most important statement on development by a secretary of state in decades.”

So what did Secretary Clinton deliver in her tidings of comfort and joy? (this speech was originally scheduled to happen right before Christmas but a Washington DC blizzard delayed it.) Four points that pretty much capture the essence of what’s needed:

1. Girls and Women: The Secretary not only “Started with a Girl,” but she put girls in the center and at the end of her speech as well. After reciting some of the brutal statistics that describe the sorry state of women’s and girls’ health – including a woman dying every minute of every day from pregnancy and childbirth and 70 million women and girls worldwide with their genitals carved up – she declared the situation intolerable. (For a discussion of the available statistics on girls, see Ruth Levine’s blog here.) In addition to reinforcing on-going U.S. programs to prevent maternal mortality and female genital cutting, the Secretary is asking every program in the State Department and USAID to determine what its contribution is for the well-being of girls and women. That will require some careful searching, but it is the soul-searching that will accompany it that could most change the State Department.
2. U.S. as a global leader: I felt an undercurrent of last year’s inaugural mood in the Benjamin Franklin room as the Secretary and her cadre spoke of the future. They were wiping away 8 years of U.S. blockage and manipulation of international family planning programs and policy negotiations. There was a sense of pride and almost disbelief in the audience that the reversal could be so complete. The members of the diplomatic corps that I spoke with afterwards were perhaps the most gratified. One ambassador said to me, “Now, when the U.S. speaks, people will listen again.”
3. More money: Getting down to the important details, Secretary Clinton said, “We’ve pledged new funding, new programs, and new commitments to MDG5.” The Obama Administration has already renewed funding to UNFPA and “more is on the way,” according to the Secretary. She said there will be in increase in population funding within the U.S. budget (as we’ve seen already, by almost one-third), and reproductive health and family planning , in addition to maternal and child health, will be central to the Global Health Initiative being constructed by a constellation of USG agencies in time for the President’s budget speech in February.
4. Centrality of SRHR to development: Perhaps most challenging but key to it all is the connection between SRHR and so many other development goals. Secretary Clinton gets it in spades, and so she said, “We understand there is a direct line between a woman’s reproductive health and her ability to lead a productive, fulfilling life. And therefore, we believe investing in the potential of women and girls is the best investment we can make.” And some concrete actions: “We are integrating women, adolescents and girls into our Global Health Initiative and our Food Security Initiative. We will make sure the integration of family planning happens…all health programs will be designed to take into account women and girls.”

I daresay that not just the SRHR crowd – stalwarts all—were pleased when she said off-script,

“I know it can sometimes be hard to take, we might grow weary of the ups and downs in these things that seem so self-evident to the rest of us that this must be done. But work with us, and let’s create structural and institutional change that does not get wiped away with the political winds.”

For those of us in the development community who are immersed in questions of how to achieve better health in the developing world and/or issues of the empowerment of women, the renewed attention to the health of girls and women is very welcome. At the same time, it’s hard to quiet the inner questions about how to reconcile enthusiasm for SRHR within the “international community” with the much less positive view in many of the governments of developing countries. While it is certainly the case that in some countries receiving U.S. development assistance (for example, Ethiopia and Egypt) there appears to be genuine high-level support for family planning and good reproductive health care, this is far from a universal position. At best, countries that are not actively supportive will permit family planning services to be provided when donors pay – which is why there is a dramatic ebb and flow of access to services depending on the party affiliation of the President of the United States. At worst, the policies and practices of governments with which we do development business are retrograde with respect to the health-related rights of girls and women.

This puts us in a little bit of a bind when it comes to simultaneously insisting on the value of a women-centered approach in health and the principle of “country ownership” and engagement in true partnerships – a priority for development policy that Secretary Clinton articulated in her address earlier in the week. One way to manage that conundrum is to invoke the fact that the vast majority of the world’s nations are signatories to the Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child, which include provisions that cover almost all of actions that SRHR advocates promote. Therefore, as signatories they have already endorsed access to quality health services, protection from gender-based violence, and many other important objectives. But, sadly, the bind becomes tighter if we attempt to use this rationale because the U.S. is among the very few countries that has ratified neither of those conventions – along with Iran and Sudan in the case of CEDAW, and Somalia in the case of the CRC. In this domain, we fall far short of being able to serve as a model or inspiration – and are significantly challenged even to highlight the disconnect between other countries’ rhetoric and practices.

In spite of these significant reasons for caution, we can all bask for a moment in the reflected warmth from the end of the SRHR community’s long winter in exile.