This week, the WHO upheld its current guidelines in relation to use of hormonal contraception and women living with HIV.  President Obama released his administration’s budget request for 2013, with some surprising news for US global heath policy.  Finally, polio eradication efforts in Pakistan have been hamstrung by government health care and regulatory incompetency and the CIA’s fake vaccination program.

WHO Upholds Hormonal Contraceptive Use Recommendations for HIV

Last year, I wrote about a new medical study that found that the use of hormonal contraceptives could double the risk of HIV infection and transmission.  This month, the WHO convened a technical consulting group to discuss the findings from this study and others that examined the relationship between hormonal contraceptive use and HIV acquisition by HIV-negative women, the transmission of HIV from women to HIV-negative men, and disease progression in HIV-positive women.  In a technical statement (PDF), the WHO concluded that the current studies did not provide strong enough evidence and that  it would not alter its current guidelines.  The UN body did add a “strong clarification” to its guidelines, however, emphasizing the importance of condom use (the only contraceptive method that provides high protection against unintended pregnancy, HIV, and most STIs).

According to UNAIDS’ corresponding press release, 11% of women of childbearing age (15-49) worldwide have unmet family planning needs.  In sub-Saharan Africa, that unmet need jumps to 25%.  In many low- and middle-income countries, there is a deadly convergence of high HIV prevalence, low uptake of contraception and other family planning methods, and high maternal and infant mortality.  Even if hormonal contraceptives carried such a risk, they have a very positive effect on to lowered maternal mortality rates, poverty, and other factors.  In global health, decisions about treatment and prevention measures must be carefully weighed.  For example, mothers living with HIV in high income settings are recommended, if not required, to use replacement feeding options (formula) because of the risk of HIV transmission during breastfeeding.  In low- and middle-income settings where lack of access to water and convenient kitchens, stigma and discrimination, and the cost of formula are barriers to safe replacement feeding options, the WHO recommends that women living with HIV exclusively breastfeed their infants, while adhering to ARVs (as AVERT outlines here).  Although the WHO cites inconclusive evidence as the reason for upholding its current guidelines, I’d wager that they would not amend them unless the evidence were incontrovertible that the use of hormonal contraceptives carried an extremely high risk of HIV acquisition or transmission.  The other health and development considerations are as vast and as dire.

Obama Administration’s 2013  Budget Request and Global Health

President Obama released his administration’s budget request for 2013 (for the US government, the fiscal year begins in the previous October, and barring any more nasty Congressional fights, a version of this proposal would take effect on October 1, 2012).  Reactions to the request, which must pass Congressional approval, are mixed.  According to a US Department of State fact sheet, President Obama has requested $7.9 billion for his Global Health Initiative, of which $5.4 billion would be allocated to the President’s Emergency Plan for AIDS Relief (PEPFAR), as part of the administration’s commitment to put 6 million people on antiretroviral treatment by the end of 2013.

What the fact sheet does not mention (and is the highlight for many in the global health sector), is that the request also asks for $1.65 billion for the Global Fund, as Ambassador Eric Goosby, the US Global AIDS Coordinator, writes in a post for the State Department’s DipNote blog.  He notes that this request puts Obama on track to fulfill his pledge of seeking $4 billion in US funding for the Global Fund over the next three years and argues that support for the Global Fund will increase the effectiveness of PEPFAR and inspire other donor countries to support the beleaguered multilateral organization.  The Kaiser Family Foundation has a good break down of the requests for global-health related funding and their relative increase or decrease from 2012–it’s worth noting that PEPFAR’s overall budget would decrease slightly from the deep cut made in 2012 (following negotiations with Congress).  Amanda Glassman and Denizhan Duran of the Center for Global Development are optimistic about the shift towards multilateral funding, using facts and figures to argue that multilateral organizations like the Global Fund are more efficient.  Christine Lubinski of Science Speaks is less pleased with the 2013 budget proposal, writing: “Slashing the PEPFAR program to increase funding for the Global Fund would seem to undermine the promise of treatment scale up.”  Lubinski also quotes Matt Kavanaugh of Health GAP, who called this aspect of the budget request “a bait and switch worthy of Wall Street.”

Of course, hand wringing now is putting the cart before the horse: given that this is an election year, I anticipate a floor fight or another near-government-shutdown crisis.  With politics in the US as acrimonious as they have been, it can only get worse when political power is on the line.  I’m happy to see that President Obama is focusing on the Global Fund (and domestic HIV/AIDS programs as well!), and I hope that the draw down in Iraq will give him a little more wiggle room on spending while decreasing the deficit.  Of course, the Obama administration could always do more, but I am less worried about his goals and intentions for global health than I am about those of Congress.  This appears to be a shrewd political move that could have positive effects on the global health and development fronts.  We’ll just have to wait for the Congressional response.

Pakistan’s Polio Problem

In the past, I’ve written about the massive gains the global community has made against polio, with a 99% reduction in cases reported in 2011.  It’s not all been successful, however, and one of the main backsliders is Pakistan.  The BBC reported this week that Indian health officials are vaccinating all Pakistani children who cross the border.  According to the BBC, India has remained polio-free for at least a year and wishes to remain so, while Pakistan has reported 175 cases–hence the vaccination efforts.  According to IPS (who writes that India has had one case and Pakistan 197 in the last year), Pakistanis are rejecting polio vaccines due to distrust of the Pakistani public health system.  In Lahore this year, 125 cardiac patients at a government-run hospital died after being administered a cardiac drug contaminated with high doses of an anti-malarial.  Fears over government healthcare and regulatory incompetencies are driving parents away from polio vaccinations.  Clearly, more must be done to improve the current health system and shore up weak regulatory safeguards.  When governments do not or cannot commit to their health programs, this is the kind of result that we will see, as I discussed with the possible outbreak of totally-drug-resistant tuberculosis in India.

Furthermore, Pakistanis are refusing to vaccinate their children following the revelation that the US Central Intelligence Agency launched a fake polio vaccine program as part of efforts to find Osama Bin Laden, which I covered last July.  As I wrote then, the CIA’s program was reprehensible because it damaged the trust that ordinary people must place in their health care providers.  Very unfortunately, this seems to have had an adverse effect on not only polio eradication efforts within Pakistan’s borders, but potentially in Afghanistan and India as well.  Disease outbreaks do not exist in a vacuum, especially in a world where one has the ability to cross the world in a day.  Shame on the CIA and the US and Pakistani governments.

Header photo here, by Spec-ta-cles, CC BY 2.0.

The Internet has exploded over the past couple of days with news that Susan G. Komen, the largest breast cancer organization in the US, would halt funding for Planned Parenthood, the largest provider of reproductive health services in the US.  A virtual uprising on Twitter, Facebook, and other social media platforms by Komen and Planned Parenthood supporters and opponents and high-profile media coverage has inspired a national debate.  As of this morning, Komen has reversed its decision.  Since 2005, Komen has funded Planned Parenthood’s breast health and education programs, which include screenings and referrals for mammograms and other diagnostic testing, with just under $700,000 in grants disbursed to 19 (of 83) affiliates last year.  At the heart of the controversy: the American abortion debate.

Planned Parenthood and its defenders, as well as some from Komen itself, have alleged that the organization gave in to pressure from anti-choice groups that oppose Planned Parenthood’s contraception and abortion programs.  Komen, the “marketing juggernaut that brought the world the ubiquitous pink ribbon campaign,” has maintained that its funding halt was the result of internal changes to grant-making criteria.  Komen founder and CEO, Nancy Brinker, appeared in a video, posted to the organization’s website and YouTube, charged critics with “mischaracter[ing]” the changes, which were made to increase impact and efficiency.  An investigative piece from The Atlantic’s Jeffrey Goldberg cited anonymous sources within Komen who said that the new funding guidelines were merely an excuse to stop all grants to Planned Parenthood, which finds itself continually under fire from socially conservative, often religious, groups and politicians.  The revised Komen grant rules stipulated that any grantee under investigation by a local, state, or federal authority would no longer be eligible to receive funding.  Representative Cliff Stearns, Republican of Florida, has been leading an investigation to learn whether Planned Parenthood had used US government funding for abortions, which would violate federal regulations.  Goldberg also discusses the role of Komen’s new senior vice president for public policy, Karen Handel, in pushing to end funding to Planned Parenthood.  Handel ran for governor of Georgia in 2010 and is on the record as anti-choice and against Planned Parenthood’s mission.  As Goldberg points out, Planned Parenthood and Komen both say that previous funding has been used for breast cancer programs, not abortions or other reproductive health services.

While announcing Komen’s restitution of funding to Planned Parenthood, the organization apologized to the American public, stating that it would “ensure that politics has no place in our grant process.”  Only grantees under criminal investigation would be deemed ineligible.  The executive director of a Komen branch in New Jersey attributed the reversal to the public uproar and to actions within the organization itself: “We sent official letters to the headquarters,” she said. “Komen is a grassroots organization. The displeasure and the outrage was heard and the decision was reversed. I’m thrilled.”  Planned Parenthood, which has an annual operating budget of $1.1 billion, ended up benefitting from the national attention: New York City Mayor Michael Bloomberg pledged a $250,000 matching grant, a Texas couple donated another $250,000, and 6,000 individual donors gave $400,000 in the first 24 hours after the initial Komen decision.

How, you might ask, could an almost universally-celebrated organization (almost, with emphasis) that focuses on breast cancer end up at the center of a debate about abortion?  The American political debate about a woman’s right to choose, of course, is so bitter and so divisive that it spills over to almost anything to do with women’s health.  In the past, HIV/AIDS programs and reproductive health services worldwide that were funded by US government programs were hobbled by the global gag rule.  It is an unfortunate (and ridiculous) truth that women’s health is inherently politicized.  It is also true that with or without legal protections for reproductive choice, some women will still seek out abortions, whether legal and safe or illegal and dangerous, which Foreign Policy Blogger for Children, Cassandra Clifford, discussed last week.  To quote Secretary of State Hillary Clinton, abortion should be safe, legal, and rare.  In fact, Secretary Clinton just says it all:

The Arab Spring and Occupy Wall Street protesters and the recent virtual protests against SOPA and PIPA and Komen’s decision have a vector in common: the power of the Web.  In the past, grassroots activism has been a long and slow road–such as that for HIV/AIDS awareness, ARV access, and increased investment in prevention and treatment programs.  Social media platforms have transformed into global megaphones, where people around the world can connect with each other, pass along news even before it breaks on mainstream media sources, and demand change.  This week’s events have illustrated the potential of the Internet as a grassroots platform to call for more awareness about and funding for global health.  As I’ve written too many times in the past, precarious funding situations and underfunding are the major barriers to improved health worldwide.  With the strength of online grassroots activism, global health advocates have an ideal tool to promote their messages and to secure funding.  They must hone these tactics to initiate viral awareness and fundraising campaigns across social media and other web-based platforms.  After all, it doesn’t count if it’s not on Facebook.

Header photo by WeNews, CC BY 2.0.

First, the Global Fund announced that Executive Director Michel Kazatchkine would step down in March.  He cited the recent executive-level re-organization for his decision.  A General Manager, Gabriel Jaramillo, has been appointed to manage day-to-day operations for the fund.  Following reports of financial mismanagement and alleged fraud last year, some donor countries canceled or suspended funding.

The re-organization and other internal changes have restored confidence, and coupled with the fund’s impact over the last ten years, it remains key to rolling back the deleterious effects of malaria, TB, and HIV.  In an opinion piece for Reuters, Natasha Billmoria of the Friends of the Global Fight Against Aids, Tuberculosis, and Malaria argued that more must be done to bolster the Global Fund’s coffers, writing: “We’re in a tough global economy, to be sure, but we’re also primed to beat back AIDS, tuberculosis, and malaria.”  She cited the success of the Global Fund, which has put 3.3 million people living with HIV on antiretroviral treatment, provided PMTCT services to more than one million pregnant women living with HIV, detected and treated 8.6 million cases of tuberculosis, and distributed 230 million bed nets to prevent malaria.  The fund itself estimates that it has saved 7.7 million lives in ten years.  The International HIV/AIDS Alliance released a report last week discussing the potential impact of the Global Fund’s cancellation of its funding round in November, studying the effects this lack of funding would have in five countries.  The report called for donors to provide an estimated $2 billion to fill the funding gap.

“The internal checks and balances have worked in every case…but if you’re going to do business in Africa, you’re going to have some losses.” -Bill Gates

Ask and ye shall receive, it seems.  At the World Economic Forum, Bill Gates announced that his foundation had pledged a $750 million “promissory note” to the Global Fund.  Mr. Gates said that the economic recession was “no excuse for cutting aid to the world’s poorest.”  This announcement marks a bit of a shift for the Gates Foundation, which in the past has disbursed $650 million to the Global Fund for vaccines and innovations, rather than ARV distribution and day-to-day operations.  In his annual letter on behalf of the foundation, Mr. Gates supported the Global Fund’s efforts and pointed out that despite some reports, the fund had had less than five percent of its funding misused and had instituted further internal reforms that will decrease those problems.  Mr. Gates also argued that some financial mismanagement was a cost of working in the developing world.  He was quoted by AP as saying: “The internal checks and balances have worked in every case [at the Global Fund]…but if you’re going to do business in Africa, you’re going to have some losses.”

Although $750 million is not a trifling sum, it is not the $2 billion or more needed to finance grants at the Global Fund.  With his announcement, Mr. Gates has demonstrated his confidence in the Global Fund, which might inspire bilateral donors to honor their pledges and/or restore interrupted funding.  Recent internal changes at the Global Fund may also prompt donors to donate.  We are certainly witnessing a turning point in the fight against some major diseases, such as HIVand malaria, and it is a shame that these partial successes have arrived in tandem with a global recession that shows few signs of turning around soon.  With a strong, well-financed Global Fund, we may, with hope, see  an HIV-free generation and the further curbing of malaria and TB.  Mr. Gates’ support of the Global Fund should give it the much-needed shot in the arm that will help us achieve these goals.

Header photo available here, via USACE Europe District, CC BY 2.0.

The Ministry also pointed out that the World Health Organization (WHO) does not recognize the classification of “TDR” at this time.  In an article written this month, the WHO explains that current drug susceptibility tests cannot determine with enough certainty whether a strain is XDR or TDR to make a solid conclusion.  The WHO will meet in March to discuss TB drug susceptibility diagnostics and whether, or how, to define TDR-TB.  The author of the study claiming the emergence of TDR in India, Dr. Zarir Udwadia, argued that this was not the time to parse words, saying: “Let them call it what they want.  For physician and patient, it’s not just a question of semantics–it’s a question of survival and mortality.”  In more concerning news, Business Week published an article today detailing that ten more possible cases of TDR (or XDR) TB have emerged 250 miles (400 kilometers) south of Mumbai.  Indian and WHO officials are meeting to discuss what to do, including the possibility of mandatory quarantines.

Whether or not it’s fair to use the TDR moniker, drug resistance is a serious, emerging issue that may very well define the next stage of global health.  The appearance of multi-drug resistant (MDR) and XDR TB, MRSA strains, and other drug resistant pathogens in the past couple of decades or so, has shown that despite the great strides we have made since the discovery of penicillin in the last century, life will find a way around the miracle drugs we have developed (about which I wrote in September 2011, including Dr. Fleming’s concerns in 1945).  More aggressive quarantine protocols and drug adherence strategies must be discussed, for a start.  This in itself is a fraught notion, as it raises questions about patients’ rights and freedoms, stigma of and discrimination against people diagnosed with drug resistant pathogens, and similar issues.  Better diagnostic tools must be developed and rolled out globally, with particular attention paid to developing nations, where need, disease burdens, and non-adherence are often greatest.  More efforts must be made to strengthen overburdened and underfunded health systems, particularly in the developing world, and to effectively train health care workers to diagnose, treat, and support patients with pathogens that may become, or are, drug resistant.  Finally, pharmaceutical companies must make new drugs more widely available and affordable, while stepping up development of new drugs.  These last three points, of course, have been sticking points for almost every global health issue for a long time and continue to plague disease prevention, treatment, and eradication efforts worldwide.  We are reaching a turning point, one at which some drug resistant pathogens are on the cusp of shifting from a handful of cases, an endemic, to a bigger, epidemic or even pandemic problem.  Now is the time to initiate discussions on what the global community will do to stem drug resistance.

*If you want a bit more information on TDR-TB, take a look at the WHO’s page on TDR, or check out The Los Angeles Times‘ interview with Dr. Otto Yang of the UCLA medical school.  Discussions of (and mild panic about) drug resistance, especially for TB, have been around for years–check out John Le Carré’s novel The Constant Gardener or its excellent film adaptation for a little MDR-TB/Big Pharma/international conspiracy thriller on the topic.  

Header photo of hand-stitched lung art available here, by Spec-ta-cles, CC BY 2.0.

Totally Drug Resistant Tuberculosis in India: As Wired reported yesterday, a totally drug resistant strain of tuberculosis (TDR-TB) has been found in twelve patients in one hospital in India.  This means that the infection does not respond to any of the currently available antibiotic treatment options, a step above extremely drug resistant TB (XDR-TB) and multi-drug resistant TB (MDR-TB).  Although it is not time to panic and buy out the local pharmacy’s surgical mask supply, this is exceedingly worrying, especially on top of the 15 TDR-TB cases in Iran that were (quietly) reported on in 2009 by Velayati et al.  That study also underlines the ease with which such TDR strains could be transmitted across borders and that in all likelihood, they already have been.   Maryn McKenna of Wired and Malathy Iyer of The Times of India both point out that weak health systems are at the root of drug resistant strains of TB.  Inadequate or non-existent diagnostic tools and systems, under-trained and over-burdened health care workers, and lack of adherence to drug regimens or ability to track patients with TB has worsened the epidemic and exacerbated the rise of drug resistant strains.  The largest global health issues will not go away unless these service gaps and system weaknesses are addressed.  TDR tuberculosis is just a major example of what can go wrong when health care systems are not strong and widespread.

Ban on US Funding for Needle Exchange: As part of the rancorous 2012 federal budget negotiations that ended just before (another) government shutdown in mid-December of last year, President Obama has signed into law a ban on funding for needle exchange programs within the US and abroad, as reported by The San Francisco Examiner last week.  Additionally, USAID and other health and development funding was also flatlined, essentially, into 2012, as per the excellent breakdown from the Kaiser Family Foundation.  The White House claims it is against the ban, blaming Congress for its reinstatement.  It was the Obama administration that lifted a 21-year ban in December 2009, but the winds have shifted drastically since those heady days.  Needle exchange programs are a key component of HIV prevention programs and target injecting drug users (IDUs), one of the demographics most disproportionately affected by HIV/AIDS.  The San Francisco Gate quotes Laura Thomas, SF Director of the Drug Policy Alliance, who is understandably frustrated with the ban.  She said: ”Reinstating the ban is murderous. It’s saying that people who use drugs should contract fatal and expensive diseases and die.”  Although her words may be intemperate, they do underline that when it comes to public health funding in the United States and elsewhere, the most marginalized and stigmatized populations are almost always the first to be cut out.  Needle exchange programs decrease HIV transmission rates and are a necessary component of any successful HIV prevention and treatment strategy.  It is a shame that political posturing has once again gotten in the way of rolling back the HIV/AIDS pandemic.

M-Health in Kenya: MedAfrica has released a mobile website and app (usable with a smart phone or feature phone) that offer possible a symptom checker, healthy eating tips, first aid guidelines, and a directory for doctors and hospitals in Kenya.  CEO Steve Mutinda and business development officer Mbugua Niijhia discuss their innovation in a video (with poor sound quality, my apologies) for MobileBeat.  Technology Review has more, including the ambitious plans for an Africa-wide rollout, new services, and a sustainability strategy.  Mobile health, or m-health, is exploding at the moment, as uptake of mobile phones even in the remotest parts of the developing world has seen exponential growth.  M-health offers a way for health information to be spread easily and to better inform patients of what and who is available to them, as well as of healthy behaviors.  Although MedAfrica’s efforts should be lauded, a review of their mobile site showed a few bugs and some usability issues–which should, with hope, be remedied as the platform moves out of beta.  According to Technology Review, there are 25 million phone users out of 40 million Kenyans, and there have been 25,000 downloads of the app since its launch in November.  It remains to be seen, however, how widespread such a platform can become when it requires a more expensive smart or feature phone to use.  The greatest hope for mobile health innovation is that it will increase access to health care and information, especially for those hard-to-reach patients.  As m-health platforms grow in popularity, their designers must ensure that services will benefit as many as possible and not just those who can afford smart phones.

The header photo is the author’s own.  

Thursday, December 1, was World AIDS Day.  Each year, people gather worldwide to remember those lost to or affected by HIV/AIDS and to raise awareness.  It’s also a time to reflect on what’s been accomplished and what remains to be done, and the day serves as a time for politicians, celebrities, implementers, and activists to speak out.  This year, thirty years from the official beginning of the epidemic, proved similar. As always, discussions about increasing financial support of HIV/AIDS programs were at the forefront of most speeches, articles, and press releases.  For World AIDS Day, the UN released an ambitious set of goals to reach by 2015, which they acknowledge are “aspirational.”  In this uncertain funding environment, fears of budget shortfalls, program closures, and stock-outs of vital anti-retroviral drugs are very real.  AIDS-related deaths and new infections are on the decline, something that felt almost unimaginable just a decade or so ago.  We are close to radically altering the course of the epidemic, but the global economic recession is putting progress at jeopardy.

The Atlantic put together a series of articles for World AIDS Day.  Dr. Mitch Besser of mothers2mothers (disclosure: I used to work at m2m) focuses on prevention of mother-to-child transmission of HIV (PMTCT) efforts, highlighting UNAIDS’s Global Plan for elimination of MTCT by 2015 and the importance of US foreign aid programs.  Other highlights at The Atlantic include discussions on new scientific developments, a snapshot of the HIV epidemic in the United States, and what it will take to achieve an HIV-free generation.

As per usual, Bono had a thing or two to say.  Although his opinion piece for The New York Times  was a bit slick (and tripped in the end on an image of flag planting, which was meant to parallel the moon landing but inadvertently and unfortunately evokes colonialist imagery) , there’s no denying what he has done to shape the fight against the epidemic.  The piece recalls the frustration of the early years of ART, when drugs were available in high-income countries but not elsewhere.  Bono also acknowledges the vital role the US played in funding efforts to curb the epidemic, listing the names of the politicians and other figures from both sides of the aisle who contributed to the government’s legacy on HIV/AIDS.  He concludes with a shrewd argument about “smart power”–that the effects of US foreign aid efforts contribute to national security and global diplomacy.

US President Barack Obama spoke on Thursday and reiterated and expanded his commitment to fighting HIV/AIDS domestically and around the world.

He pointed to the declining rates of new infections and deaths around the world and the paradoxical steady rate of new infections in the US and the toll of the epidemic on minority populations in particular.  President Obama, perhaps to counter activists’ claims that he has not done enough to address HIV/AIDS, pointed out his administration’s increased financial commitment to HIV/AIDS programs and the lifting of the travel ban against people living with HIV, which will allow the next International AIDS Conference to be held in the US for the first time ever.  He underlined the need to implement the new US national HIV/AIDS strategy and pledged $15 million in additional funding for the Ryan White Program (which supports HIV clinics in the US) and $35 million extra for state ARV assistance programs.  He also called on countries to fulfill their pledges to the ailing Global Fund and for countries who were once recipients of aid but are now able to create foreign assistance programs, such as China, to make pledges of their own.  President Obama also announced two goals: to provide ARVs for 1.5 million pregnant women over the next two years for PMTCT and to get 6 million people on ART by 2013, which was greeted with hoots and wild applause.  He ended with a request that Congress continue to work together, saying that the gains made under the last three presidencies show “that we can do big things when Republicans and Democrats put common humanity before politics.  We need to carry that spirit forward.”  President Obama’s remarks are heartening, and it’s good to see his administration re-focus on HIV/AIDS efforts.  Julie Pace of the Associated Press reports, however, that PEPFAR will not see an increase in funding and that decreasing the cost of treatment and making current programs more efficient will be required steps to fund the the ambitious goals set out on Thursday.

I’d like to end with Susan Sontag’s definitive piece from 1986 called “The Way We Live Now,” which The New Yorker re-released this week.  It’s a heartbreaking reminder of the earliest days of the epidemic and of how far we have come in the twenty-five years since it was published.  Here’s to making even more progress, expanding commitments, and “getting to zero.”

Photo, via Wikimedia Commons, depicts activists from South Africa’s Treatment Action Campaign in Cape Town in 2003.  The photo is from the TAC.

Although global health in 2011 was overshadowed by the economic recession and related budget cuts by donor countries, there were a few rays of hope to be found.  Much progress has been made in combating some global epidemics and more attention has been paid to others.  Innovations in global health, from simple solutions to harnessing new technologies, could potentially change the face of health systems and drive demand for services.  On the other hand, bitter budget squabbles in the US, funding shortfalls around the world, and the failure of global bodies to commit strongly to global health made up much of the narrative of 2011.  Profits and politics continued to take precedence over public health, funding for programs, and access to care.  As the year comes to a close, the overarching theme is one of uncertainty about whether funding will increase or even stay at current levels and whether we will be able to increase or merely maintain the gains that were made over the course of 2011.

First, with the good news: progress was made in ending polio, strengthening commitments for an HIV-free generation, and preventing or even eradicating malaria.  2011 saw a 99% reduction in polio cases.  This is exciting, but the achievement rests on fragile ground that will require strong commitments from countries with polio cases and more funding to push the world toward eradication of this disease.  HIV/AIDS turned 30 this year, and new scientific discoveries, such as the role of antiretroviral drugs in preventing the spread of HIV (here and here), show promise in further curbing this epidemic. Additionally, the UN High Level Meeting on HIV/AIDS in June brought strong commitments to eradicate mother-to-child transmission of HIV (MTCT) by 2015.  Scientific discoveries have potentially brought us to the brink of a malaria vaccine and a way to control mosquito populations through genetic modification of the insects, though more investigation and research is needed, and concerns persist about GMOs.  Chronic non-communicable diseases, such as diabetes, and mental illnesses were finally introduced into the global health agenda, as it has become harder to ignore that these issues affect the world as whole and not just individuals living in high-income nations. Furthermore, a more holistic view of health that includes factors such as poverty or access to green space has re-focused the debate on inequality and its effect on overall well-being.

Simple, cheap solutions and new technologies are now being applied to health issues, as lack of funding and IT developments have inspired innovative thinking for global health.  Task shifting, peer educators, and community health workers are becoming more acceptable responses to strengthen overburdened health systems and lower health care costs, such as the UN’s designation of “mentor mothers” (mothers living with HIV who educate and support mothers through prevention-of-mother-to-child transmission of HIV care) as key to eradication of MTCT efforts.  Other innovations, such as screening for cervical cancer with vinegar, also harness cheap, available resources for improved health outcomes.  Mobile health, or m-health, is becoming an increasingly trendy topic, as is “crowdsourcing” for HIV prevention, maternal health, and crisis mapping.  These tech-based solutions could be key to increasing demand for services, providing information and education related to health, and reaching patients who are unable to access treatment.  They could also draw from community-based experience and expertise, engage the disenfranchised, and inspire innovation from unlikely sources.

There were numerous setbacks in 2011, however.  The failure of the G20 summit in Cannes left one avenue for financing for global health, the financial transactions tax, out in the cold.  Although the UN High Level Meeting on HIV/AIDS resulted in strong commitments to eradicate MTCT, the unprecedented High Level Meeting on Non-Communicable Diseases produced a weak, watered-down “resolution” that provided no hard targets for curbing non-communicable, chronic illnesses like cancer and diabetes.  Profits and politics outweighed health around the world, as illustrated by stories about lead poisoning in China, high HIV prevalence in Mississippi, and maternal morbidity and mortality in South Africa.

Overall, 2011 marked a year of even further uncertainty around funding for global health.  Political in-fighting in the United States, the Euro Zone crisis, and the global recession soured the public’s support for foreign aid and shrunk already wanting program budgets even further.  Although it was the squabbling over the US budget between members of Congress and the Obama administration that caught the most attention (see here, here, and here), the lack of appetite for funding global health also affected many organizations’ efforts, including the Global Fund.  Without an increased willingness to fund global health programs, the gains made over 2011 will matter little and progress will backslide.

Most Unexpected Event

In June, the UN held its second-ever High Level Meeting on HIV/AIDS.  A Global Plan (PDF) was created around two goals: reducing childhood infections of HIV by 90% and maternal deaths related to HIV by 50% by 2015.  As opposed to other high-profile events and summits in 2011 (and in general), this meeting resulted in hard targets, a clear plan, and commitments from donors and countries, which was quite a surprise for those of us who have watched similar efforts fail or result in wishy-washy plans.  Although implementation of the plan is in its infancy and funding remains uncertain, this is an encouraging step towards an HIV-free generation.

People of the Year

There are many out on the front lines of global health that should be recognized for their efforts, but those researchers involved in the RTS,S Clinical Trials Partnership are my people of the year.  The team has developed a malaria vaccine whose preliminary results show that 47% of young children who are vaccinated are protected from severe malaria.  After more than twenty-five years of development, the clinical study will continue until 2014.  This is not a slam-dunk in the fight against malaria just yet, and most vaccines are not approved until they reach at least 90% efficacy, but the finding is one of the best discoveries of the year and a rare uplifting moment in a sector that often tells depressing stories.  Bravo to everyone involved.

Books of the Year

Although there was a dearth of titles on global health as a whole, there were a few notable books about specific health topics in 2011, especially for the diseases against which much progress has been made.  Tom Koch’s Disease Maps: Epidemics on the Ground discusses the history of epidemic mapping and the birth of epidemiology.  Now that crisis mapping and crowdsourcing are becoming popular, Koch’s book lays the foundation for current epidemiological methods and their evolution over the years.  Alex Perry’s Lifeblood: How to Change the World One Dead Mosquito at a Time sheds light on the fight against malaria and how business acumen can be applied to health and development aid to make it more efficient and effective.  With new methods for fighting malaria and other insect-borne diseases on the horizon and scrutiny increasing on the cost and impact of health and development programs, Perry’s work is timely and informative.  In the 30th year since the advent of the modern HIV/AIDS epidemic, much has been written about the tragedies and gains of the past three decades.  Jacques Pepin’s The Origins of AIDS looks further back to the conditions that brought HIV to existence, from Belgian colonialism in the Congo to the globalization of the post-World-War-II world.

Forecast for 2012

We are on the cusp of turning back and even eradicating some major epidemics–HIV, polio, and malaria, for example–but without the willingness to support funding for these efforts, a great opportunity will be missed.  Although many experts are saying that the global economic recession is starting to turn around, the Euro Zone crisis and concerns in the US about spending will likely persist into 2012.  Furthermore, with the US presidential and congressional elections looming, government spending and a balanced budget will be top points of discussion and there is little doubt that foreign aid will be back on the chopping block.  I predict that all of these factors will be bad news for major funding for global health.  Organizations will have to tighten their belts even more and will have to prove that they can provide cheaper, more efficient programs with demonstrated impact.  Simple, cost-saving solutions will be in even higher demand–and that’s not necessarily a bad thing.  However, I fear that efforts to curb major diseases may struggle.

At the same time, new health issues may gain prominence.  Non-communicable diseases, mental illnesses, and drug resistant strains of prevalent diseases have been brought increasingly into conversations about global health and are, in my mind, the next-stage problems that the sector will face.  As the US Supreme Court gears up to hear legal challenges to the “Obamacare” health care legislation, I anticipate that its ruling for or against the program will have wide-reaching implications.  Although many countries have put universal health care systems in place, the US’s immense influence on the world stage could inspire or squelch new attempts for universal care elsewhere, and a court ruling upholding the legislation could cement, at long last, that health is a human right.  I think that tech-based interventions will further crystallize in 2012 and that the somewhat nebulous m-health, crowdsourcing, and other IT innovations will gain definition and shift from trendy novelties to accepted best practices.  Ultimately, the progress that has been made over 2011 could continue, and we could see the end of polio and the reversal of many other diseases.  Although I cannot forecast this with any certainty, it is something for which I can hope.

Header photo via Dominique Godbout, CC BY 2.0.

What this progress report and World Pneumonia Day illustrate, along with every other “disease day,” is that health routinely takes a back seat to other issues that require funding and global attention, especially when the countries bearing the brunt of a disease burden are low-income or don’t hold strong international influence.  Like the prevention of polio, TB, or malaria, pneumonia requires targeted, though not necessarily expensive, interventions.  Pneumonia also suffers from lack of public awareness–HIV, for example, gets much more press coverage.  I’d wager that if polled, most people would guess that HIV and not pneumonia is the number one killer of kids in developing nations.  This is not to say that HIV treatment and prevention efforts do not require more investment; on the contrary, they are woefully underfunded, as are most global health interventions.  As I’ve written too many times before, more funding is needed, which looks unlikely in the current global climate.  One day, perhaps, the world will wake up and realize that the right to health and equitable access to health care are as vital to economic development, strong societies, and good governance as every other human right.  Advocates must carry on pressing for more funding for global health, even if such arguments proceed to fall on deaf ears.  For now, those working in global health organizations must continue to use existing funding to develop, implement, and prove the efficacy of simple, low-cost health interventions: a rapid test, a trained community health worker, or a shot in the arm.

*It’s unclear however, how certain cases of HIV and pneumonia are separated–it’s a common opportunistic infection for newborns who are HIV-positive, which is why a newborn whose mother has HIV should be administered the antibiotic Cotrimoxazole as a pneumonia prophylactic before their own serostatus has been determined.

Header photo, of aspiration pneumonia, by KGH, CC BY-SA 3.0.

This week, UNAIDS has launched a new project to work with young people for a youth-centered HIV strategy.  Scientists are moving into the next stages of deploying genetically-modified mosquitoes to combat insect-borne diseases like dengue, and concerns about the risks of bioengineering have been raised.  The G-20 Summit in Cannes could not get out from under the European Union debt crisis and worldwide economic downturn, even as proposals for a tax to support development aid  brought out the “big guns” of development and global health.

Crowdsourcing HIV/AIDS Strategies: UNAIDS has launched a new platform for crowdsourcing ideas for a youth strategy on HIV over the next two months.  Using Facebook, Twitter, and other social networks, CrowdOutAIDS hopes to bring together young people aged 15-29  to create a youth-centered approach to the disease.  I’ve written about crowdsourcing before, a theory of innovation that solicits opinions and ideas from experts and amateurs to create projects, programs, and other products.  In this instance, crowdsourcing will allow young people to have a voice in shaping HIV/AIDS policy at the UN level.  Their Western and Central Europe/North America Facebook page asks for perspectives on how the UN, NGOs, and various agencies have succeeded and failed in involving young people in their activities and strategies.  The project is in its first stage (of four), and it’s still pretty nebulous where it will go from gathering feedback to an actual plan.  The idea–giving agency to young people so that they can tailor approaches to HIV/AIDS to fit their demographic–is a good one.  Engaging youth in the forums where they most often connect also demonstrates a better understanding of how to converse with and spur innovations from young people.  This could be an important milestone on the way to increased prevention.  It will require more definition and a strong hand to do more than just generate conversation, however.  I’m awaiting further developments on CrowdOutAIDS before passing judgment, but I am excited to see that such a prominent global body does want to work with young people to combat HIV.

Concerns About Genetically Modified Mosquitoes: A few weeks ago, I wrote about scientific studies that are using genetically modified mosquitoes to curb malaria.  It turns out that bioengineering companies are moving faster on the insect front than I thought, this time to combat dengue fever, which has seen a resurgence in the US state of Florida and other tropical climes.  The New York Times has the story.  A study published last week in Nature Biotechnology discusses the first release of genetically modified mosquitoes in the Cayman Islands in 2009.  There have been wider releases in the same spot and in Brazil and Malaysia since then.  Other bioengineering projects to curb insect populations have focused on agricultural pests, such as the pink bollworm, which consumes cotton crops, and Mediterranean fruit flies.  Although the Times article does not go into specifics about the possible negative outcomes of genetic modification of a species, it does note that critics are concerned that the biotechnology company Oxitec, which is responsible for developing the dengue fever-fighting insects, has pushed into implementation without enough review or public consultation, all the while operating in countries with too little regulation.  As I wrote when discussing mosquitoes engineered to combat malaria, I am concerned that these biotech companies might move too quickly without understanding the effects genetic modification may have on an ecosystem, just as DDT was considered a harmless lightning-in-a-bottle insecticide solution (with huge profits to be had) before it was discovered that it caused massive environmental and health problems.  Genetic modification of crop-damaging and disease-carrying insects could be, as one US official in the Times article points out, “a more ecologically friendly way to control mosquitoes than spraying insecticides,” but it could also trigger problems that cannot not be anticipated without careful, controlled study.

Failure of the G-2o Summit: The Group of 20 industrialized nations met in Cannes, France, this week.  The summit, overshadowed by the Eurozone crisis, financial instability in Greece and Italy, and the economic recession, put off most action not connected to these issues until the next meeting in February.  There was some hope in the development and global health communities that this November meeting could install a financial transactions tax (FTT, or “Robin Hood” tax), a portion of which could provide a more stable funding source for global health and development initiatives.  Doctors Without Borders (MSF) published a report (PDF) and press release calling for a percentage of any FTT to be allocated for global health programs, citing the success of successful but underfunded medical interventions that are already underway.  Referring to state financial support of struggling corporations, Sharonann Lynch, the MSF Policy Advisor for HIV/AIDS, said, “It is time that global health got its bailout.”  A Voice of America article put the estimated revenue from an FTT at $75 billion per year.  Bill Gates addressed the G-20 on Thursday and also called for an FTT earmarked for development aid, to no avail.  This is a logical way to bring financial stability to development and global health efforts, but it comes at a terrible time.  Any hope that development and global health leaders may have had for this initiative was wholly unrealistic, given the sorry state of the European Union, United States, and other nations, the possibility of a resurgent economic crisis, and a widespread distaste for further increases to development and health aid.  It’s an unfortunate truth, and one that will most certainly cost lives and reverse the successes of global health interventions over the last decade.

Header photo by Abode of Chaos, CC BY 2.0

GPEI’s Independent Monitoring Board released a scathing report on Monday (PDF) that called for improvements to the GPEI program.  As Judith Kaufmann pointed out in a blog post for Health Affairs, although the GPEI has a $535 million funding gap, the Monitoring Board focused on people management as a key obstacle to eradication efforts, as well as the need for data-informed improvements and more innovation.  The report highlights the backsliding of some of the seven countries with persistent polio, such as Nigeria and Pakistan.  Others, like India and Afghanistan, were praised for their efforts.  In five of these countries, there have been more cases of polio in 2011 so far than at the same time in 2010, and unless drastic improvements are made, the GPEI will not be on track to eradicate polio by the end of 2012.  Unfortunate “surprises,” such as an outbreak in China after ten polio-free years, are also worrying.  The Monitoring Board questioned why “tired and ineffective” leaders remain in their positions at GPEI and pointed out that lack of compensation and adequate “rewards” were contributing to disinterest in front-line vaccination and surveillance work.  Lack of accountability was also a key issue within GPEI and at local government levels in countries like Nigeria.  Instability, conflict, and weak governmental structures in Chad, the DRC, Afghanistan, Pakistan, and so on, also contribute to the list of challenges.  The call, as always, did come for more funding and more engagement by countries where polio is already history.  There is some good news, however: India has had one case of polio in 2011 and may eradicate the disease by the end of the year.

In a piece for The Huffington Post, Bill Gates wrote, “The last one percent is the hardest percent.”  Polio, for many, seems like an old-fashioned disease that no longer presents much danger, and without public interest and funding, the effort to eradicate it may founder.  In places where polio has persisted, the risk of death, paralysis, and disability is omnipresent, and polio can spread quickly without efforts like the GPEI.  The GPEI has made incredible progress, but without a strong push for that last one percent of cases, polio will endure.  Achieving a 99% reduction in polio cases is one of humankind’s great achievements.  We should celebrate this milestone and then dig in deeper, work harder, and pledge just a little more money to push our 99% success rate over to a hundred.

Header photo, of polio survivor and US President Franklin D. Roosevelt, by Margaret Suckley [Public domain], via Wikimedia Commons

There are exciting new developments in the fight against malaria. More attention must be paid to mental illness around the world. Finally, a community-based program out of Senegal is stamping out female genital cutting, and the model should be developed to be scalable and replicable for areas where the practice endures.

Malaria Developments: As fellow Foreign Policy Association blogger Cassandra Clifford writes, a new malaria vaccine in phase three trials from GlaxoSmithKline has shown promising results.  The vaccine, currently named RTS,S, provides 47% protection against severe malaria in children.  Although this is not a slam-dunk, it is heartening news.  The WHO and PATH have also released a report (PDF) projecting that one-third of countries with endemic malaria will eliminate the disease within ten years.  Reuters has the short version. Of course, there is more to be done.  An editorial in The Economist points out that “eliminating malaria in a stable country is dramatically easier than doing so in a turbulent one.”  Unfortunately, endemic malaria and unstable regions sometimes go hand-in-hand.  Furthermore, the editorial reminds us that this discovery comes at a time “when global health programmes must compete fiercely for cash.”  On the bright side, anti-malaria efforts have the support of the Bill and Melinda Gates Foundation, the largest private foundation in the world.

In The Huffington Post, Ms. Gates discusses the importance of social media and new technologies in fighting malaria.  She writes that social media has helped raise awareness in donor countries about malaria and that community-based efforts have helped curb the epidemic.  Ms. Gates cites the Lalela Project’s Night Watch campaign as a positive example.  Night Watch releases 30-second nightly reminders on television, radio, and by SMS to sleep under treated bed nets in Cameroon and Senegal (with programs opening soon in Tanzania and Chad).  The reminders are read by local celebrities.  Although it seems unclear from the website how much of an effect the reminders are having (I suspect it might be difficult to measure such an impact), this is a cheap, simple, locally-based innovation that has the potential to be replicated and scaled broadly.  All-in-all, it’s nice to report on something hopeful in the global health community for once.

Global Mental Health: In 2007, The Lancet published a series of papers on global mental health.  Now, the journal has pulled together a follow-up series.  The UN’s humanitarian news agency, IRIN, has a good overview.  Although mental illness makes up almost 14% of the global disease burden (see here), in high-income countries only a third of people with mental illnesses receive treatment.  In low- and middle-income countries, that rate can be as low as one in fifty, or 2%.  The former rate is unacceptable and the large gap represented by the latter rate is unconscionable.  As Dr. Julian Eaton et al. discuss in their paper, there are significant barriers to implementing and scaling up successful mental health programs, including little reporting and baseline data, lack of political will and funding, and social stigma.  They suggest that decentralizing mental health services and decreasing the focus on institutionalization of people with mental illnesses would be better solutions than large mental health hospitals in major urban areas (which is supported by medical evidence).  They also point out that mental health professionals are scarce, but their suggestions for task-shifting and decentralization do not address the problem of overburdened and overworked health care professionals across the board in many lower-income countries.  Unfortunately, as always, the call comes for more funding.

In a commentary in the series, Giuseppe Raviola et al. suggest that the successes in HIV/AIDS care can be adapted for mental health.  Many people living with HIV/AIDS have a chronic, if now manageable, illness and have had to face social stigma, functional impairment, and lack of health knowledge.  Raviola et al. argue that people with mental illnesses confront a parallel set of issues: a chronic, impairing disease that is stigmatized and about which the public knows little.  They assert that mental health programs should borrow from successful HIV/AIDS interventions and build upon existing health structures.  This argument holds a bit more water, since it looks to enhance and strengthen efforts that are already underway, instead of constructing entirely new programs.  With hope, global mental health can find a funding champion like the Gates Foundation, and the gap in services can be remedied.

Female Genital Cutting in Senegal: The New York Times published an article last Sunday on female genital cutting (FGC) or mutilation (FGM) and efforts to abandon the practice in Senegal.  Tostan, a community education program started in Senegal and now operating in ten African countries, implements a health and human rights curriculum at the village level and relies on support from community leaders.  At the center of its efforts, Tostan encourages neighboring villages whose youth intermarry to mutually abandon FGC.  So far, over five thousand villages in Senegal have committed to ending the practice.  As the Times article details, FGC has been an ineffable subject until recently, and efforts to eradicate the practice have been underfunded.

FGC/FGM is a difficult topic.  It can be stomach-churning to read about: check out the UNFPA’s fact page if you want to learn more.  Understandable vehemence from mostly Western-based women’s rights groups have led to an underground continuance of the practice.  It is hard to argue for more measured words (the shift from “female genital mutilation” to “cutting” is a controversial one) in the face of such a practice, which is a clear human rights violation and increases risk to maternal and infant health.  Without considered, community-based approaches, however, it will be impossible to end FGC.  In my own experience living in Senegal, it was clear that while a village in which I was staying said it was not practicing FGC, the government ban (which is ten years old) was resented, and the practice continued anyway.  In the Times article, it is pointed out that the practice is “a convention parents [follow] out of love for their daughters” and due to religious stipulation.   Without women and men from local communities speaking out and parents pledging to protect their daughters, FGC will endure in spite of legislation.  Tostan’s technique is the right one.  Unfortunately, it is also expensive, costing around $21,000 per village for its 2-3 year program.  For a successful end to FGC, we will need–you guessed it–more funding and support to replicate Tostan’s program or to develop similar approaches that cost less.  For now, however, I hope that Tostan continues to do the work that is needed to eradicate FGC, one village at a time.

Header photo available here, by Pratham Books, CC BY 2.0.

Photo: UNICEF

Every day across the globe children die from preventable diseases.  One of the biggest and most preventable killers is malaria.  Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected mosquitoes.  According to the World Malaria Report 2010, there were 225 million cases of malaria and an estimated 781 000 deaths in 2009, a decrease from 233 million cases and 985 000 deaths in 2000. Most deaths occur among children living in Africa, where a child dies every 45 seconds from malaria and the disease accounts for approximately 20% of all childhood deaths.

Approximately half of the world’s population is at risk of malaria. Most malaria cases and deaths occur in sub-Saharan Africa. However, Asia, Latin America, and to a lesser extent the Middle East and parts of Europe are also affected. In 2009, malaria was present in 108 countries and territories.  Children are the most susceptible for the transmission of malaria due to their under developed protective immunity against the most severe forms of the disease.  However, pregnant women are also at high risk for transmission and  malaria brings a high rate of miscarriage (up to 60% in P. falciparum infection) and maternal death rates of 10–50% , according to the WHO.  An estimated 200,000 infants die annually as a result of malaria infection during pregnancy.

Bed nets treated with insecticide have been the biggest and most sought after form of prevention to the spread of malaria, however efforts to produce an effective malaria vaccine for children and adults have been unsuccessful due to the difficulty of producing a vaccine against a parasite.  The cost of fighting and treating malaria has been crippling on economies.  “Beyond causing disease and deaths, malaria saps many developing nations’ economies, accounting for 40 percent of medical costs, up to half of all hospitalizations and 60 percent of all visits to health clinics.”

“Our intention is to supply this vaccine at the lowest cost possible,” said Glaxo’s chief executive, Andrew Witty. “We have no intention of making a profit here.” (The Washington Post)

Global anti-malaria efforts were given a boost on Tuesday when news was released regarding an experimental vaccine that, for the first time, considerably diminished the risk of African children catching malaria. The new vaccine from GlaxoSmithKline, is administered via a shot and has been given to more than 15,000 infants in seven African countries in the past two years.  The two year trial period has shown a reduced infection risk by half and also lowered the risk of contracting a potentially fatal case of malaria by 47%.

“We are very happy with the results. We have never been closer to having a successful malaria vaccine,” said Christian Loucq, director of the PATH Malaria Vaccine Initiative (Reuters).

While the vaccine is still technically in a trial stage, it shows great hope for the future health of children across the globe, especially in Africa. However, 106 countries are affected by malaria.  More details of the study results were released in the The New England Journal of Medicine, who published the full findings online, along with this editorial.

Injectable birth control is an important contraceptive method for many women, especially those in places where women are not treated equally, maternal morbidity and mortality are high, and health systems are strained:  it is only administered every three months, does not require a doctor to provide the dose, and is discreet.  Unfortunately, there is overlap between places with gender inequality and overburdened health care and places with higher HIV rates.  The New York Times reports that 12 million women in sub-Saharan Africa use injectable contraceptives (the sample size for women using the pill was too small to draw clear conclusions).  The World Health Organization is examining the findings and discussing whether to alter its guidelines on contraceptive use.  MedPage Today has a slightly more in-depth discussion of the implications of the study.

To put it simply, this is not good news. Millions of women rely on hormonal contraceptives around the world.  Some of these women will be exposed to HIV or will expose their partners to HIV.  In cultures, communities, and countries where women have little control over when they have sex, whether they use condoms, or how many children they bear, hormonal contraceptives have been a blessing.  In many settings, uptake of any kind contraception has been limited.  This finding throws another wrench in the works.  Unfortunately, there is little to be done other than further study on the issue. One day, perhaps, we can get everyone to use condoms, have gender equality, and build strong health systems.  Unfortunately, we’re a long way away.

In more uplifting news, The New York Times recently reported on a successful Doctors Without Borders (MSF) intervention that has helped people living with HIV who are taking anti-retroviral drugs (ARVs) in a Mozambican province.  Patients are put into six-person groups, and every month, one of the group members travels to an HIV clinic to collect the group’s ARVs.  The patients pool money for transportation, and each person goes twice a year to get the drugs.  Everyone saves on transportation costs and the time it takes to reach and wait at the clinic.  For people with very low incomes who live in remote areas, this is a wonderful solution.  MSF reports that 97.5% of patients in the groups were still in care, 92% were adhering to their ATV regimen, 2% had died, and 2% were lost to follow-up after two years. These are very good numbers.  For example, almost one-third of ARV patients in sub-Saharan Africa are lost to follow-up within two years (that means they can’t be found because they’ve moved, died, or don’t want to be found).  This patient collective model also decreases the burden on health care facilities and workers, since only one patient waits for drugs and each patient goes in for a regular consultation (while getting the ARVs) every six months.  MSF reports that there was a four-fold reduction in consultations.  Even better, the model was designed in consultation with the patients.  Although this is not explicitly mentioned in the study, I’d guess that the collectives also serve as informal support groups.  Having five other people living with HIV to lean on could increase mental (as well as physical) well-being and decrease feelings of stigma and isolation.  This is an easy, low-cost solution to a host of common problems associated with HIV/AIDS, ARV adherence, hard-to-reach locations, and overburdened systems.  I hope to see it implemented more broadly, from Boston to Kampala to Bangkok, and everywhere in between.

Header photo, of Kenyans waiting to board a matatu, can be found here.  It was taken by luigig, CC BY.

In an opinion piece for The Huffington Post, Jeffrey Sachs points out the big funding black holes in US foreign aid programs, clarifies confusions around foreign aid, and proposes solutions.  Those big expenditures are in construction contracts with big companies like Halliburton, Bechtel, and so on, and in bilateral (state-to-state) funding to “crony governments,” such as Afghanistan, Pakistan, or Egypt.  In the latter case, the US knows the money is being wasted away through inefficiency and corruption but pays up anyway for diplomatic reasons.  In the former, Dr. Sachs suggests something about campaign contributions and those big corporations.  He argues that these funding dumps need to stop and that programs should be focused on specific issues, such as HIV/AIDS or hunger: funding should be invested in “practical, targeted, and scientifically-oriented programs,” such as the Global Fund or agriculture programs.  He also points out that most Americans overestimate by up to 30 times how much foreign aid the US disburses, which has something to do with fatigue over how much we’ve perceived to have spent.  Furthermore, Dr. Sachs proposes cutting military spending by $200 billion (yeah, right) and taking one-eighth of that funding–$25 billion–to double the foreign aid investment in programs for the poorest countries in the world.  Meanwhile, Mitt Romney, a front-running candidate for the Republican presidential bid, has promised to increase military spending if elected, arguing that the “most powerful” country in the world just needs a few more missiles to achieve world peace and keep dictatorships at bay.  Because being a military superpower has been incredibly successful in preventing global conflicts and promoting democracy so far.  Oh, wait.

I’m sorry to be coming off so cynically, but it’s so frustrating to see foreign aid take the hit again and again and again.  I can say from personal experience that foreign aid spending is one of the best things the US does for its diplomatic and foreign policy efforts.  Global health programs like PEPFAR (for HIV/AIDS) or the President’s Malaria Initiative (PMI) have saved millions of lives.  There are certainly reforms that must take place to make foreign aid programs more efficient and effective, such as those proposed by Dr. Sachs.  In the grand scheme of things, however, even the inefficient programs aren’t costing the American taxpayers that much, and their percentage of federal expenditures is a merely drop, and one of the good and moral ones at that, in the pork barrel bucket.

To end on a happier note, Happy Birthday to anti-Apartheid hero and Nobel Laureate Archbishop Desmond Tutu, who is 80 today.  His birthday has been a subject of controversy, however, since the South African government failed to grant a visa to the Dalai Lama.  It’s great to see he’s just as much of a firecracker as ever and just as unwavering in speaking truth to power.

Header photo via Tyne & Wear Archives and Museums, from The Commons.

The Declaration uses standard non-committal UN language–”profound concern,” “multisectoral approach,” and “advance the implementation” come to mind–and calls for voluntary targets to be set by 2012 and a progress report in 2014.  Miriam E. Tucker of Family Practice News reports that revisions just prior to the HLM “essentially [stripped] the document of specific and time-bound targets.”  These omissions included a goal to reduce preventable deaths from cancer, cardiovascular disease, diabetes, and chronic respiratory disease by 25% by 2025 and a goal to reduce salt intake to less than five grams per day per person.  In teh document, there are the beginnings of ideas that could one day lead to stronger commitments on NCD prevention and treatment, such as calling for governments to approach population-wide interventions that address NCD risk factors, integrate NCDs into health systems, and learning from infectious disease epidemics to improve responses, but the language is vague.  Furthermore, the Declaration does raise some specifics about stemming tobacco use worldwide, but Big Tobacco is the go-to villainous whipping boy of NCD prevention (with absolute reason, of course).  None of this is a shock coming from the body that did implement some responses to HIV/AIDS but only held a formal HLM on HIV/AIDS in 2001, a full twenty years after the beginning of the epidemic.

It is possible to have stronger responses to NCDs, which can be see at the local and national level.  New York City has led the way, for example.  As the UN itself reported in a press release, NYC Mayor Michael Bloomberg addressed the HLM on the final day and cited his and the previous administration’s efforts to prevent NCDs in the city.  Smoking bans in restaurants, bars, parks, and beaches, a costly tax on cigarettes, and media campaigns have contributed to a drop in smokers’ numbers, from 22% of the city’s population in 2002 to 14% in 2011, with teenage smokers dropping from 18% to 7% over the same period.  Bloomberg estimated that these municipal endeavors have saved 1,500 lives.  In 2008, NYC became the first American city to require that restaurants post calorie charts.  The city has also increased the number of “green” street carts (as opposed to the ubiquitous hot dog and pretzel vendors), banned or otherwise restricted trans fats, worked with manufacturers and grocers to reduce salt in food products, and initiated a public education campaign.  According to Bloomberg, a New Yorker’s life expectancy has risen 1.5 years from 2001-2008, above the national average, and no additional city funds were spent on the smoking bans, trans fact restrictions, and calorie postings.  Tobacco taxes went directly to the city’s coffers.  Now, I’m realistic: we’re not going to see a trans fats ban or calorie counts in spaza shops, dibiteries, or bake and shark shacks any time soon.  However, increased taxes on tobacco and alcohol that then fund public education campaigns are efforts that can start in a relatively short period of time, if the political will exists and the global community participates.

There are other medical solutions to NCD prevention and treatment that fall somewhat under the dubious “appropriate technology” category–except that they are as, if not more, effective as their higher-income counterparts.  The New York Times reported this week on the success of a screening and treatment program for cervical cancer in Thailand.  Cervical cancer used to be the number one cancer killer of women in the US, but changes in health care interventions and public awareness, such as frequent pap smears, have lowered its lethality.  250,000 women still die each year from cervical cancer, however, and many developing country health infrastructures are not equipped to screen and treat women. In Thailand, nurses brush vinegar on a woman’s cervix, and any pre-cancerous or cancerous lesions will appear white.  These are frozen off with carbon dioxide, which can be procured from, as Times  writes, the ever-present local Coca-Cola plant.  While pap smears require a lab and biopsies most often require a doctor, a nurse can be trained to do both procedures.  Freezing off the lesions (cryotherapy) is 90% effective with minimal common side-effects.  One of the pioneers of this technique, Thai gynecologist Dr. Wachara Eamratsameekool, said: “Some doctors resist.  They call it ‘poor care for poor people.’  This is a misunderstanding.  It’s the most effective use of our resources.”  Now, I’m completely for equal health care and treatment worldwide, and I do not like the “appropriate technology” argument, generally (see part 4 of my last post).  This solution, however, is working and does not result in a lower efficacy.  In fact, if I were given the choice between vinegar or a biopsy, I’d probably go with the vinegar (especially given skyrocketing health insurance costs in the US…for another day).  More health solutions like these must be discovered, developed, and implemented.  Equal access and treatment become more attainable when we can use efficient, on-hand resources that offer the same successes as more expensive, less available options.

The non-communicable disease epidemic is not going to go away, and as just about everyone says, it’s going to get a whole lot worse.  The time to act is now–before we reach a crisis point that we cannot reverse.  In those places where the food, alcohol, drug, and tobacco lobbies are keeping national governments from curbing NCDs, local governments and community leaders should step forward.  New York City did just that.  More medical and public health researchers should be looking for novel approaches to prevent, screen, and treat NCDs that take into account local conditions and needs without compromising on the quality of these interventions.  Just as the HIV/AIDS epidemic required grassroots activism to force change, so does the NCD epidemic.  It is time for individuals to act, since it is apparent that the UN and global leaders will not step up as needed now.

Header photo by Chris Erbach [GFDL, CC-BY-SA-3.0 or CC-BY-SA-2.5-2.0-1.0], via Wikimedia Commons