How pneumonia got me interested in global health

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. Sphere: Related Content

Good for the soul, bad for the body

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. Sphere: Related Content

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

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. Sphere: Related Content

PEPFAR and country-ownership: fact or fiction?

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. Sphere: Related Content

Promising results for a new cholera vaccine

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. Sphere: Related Content

Are we missing millions of children in Africa?

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. Sphere: Related Content

Our vision is not gender blind

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. Sphere: Related Content

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

"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. Sphere: Related Content

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

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. Sphere: Related Content

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

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. Sphere: Related Content