Drug Resistant Malaria

The New York Times reports today on the growing resistance to first line antimalarial drug artemisinin in fighting malaria, especially in and around Cambodia:

Combination treatments using artemisinin, an antimalaria drug extracted from a plant used in traditional Chinese medicine, have been hailed in recent years as the biggest hope for eradicating malaria from Africa, where more than 2,000 children die from the disease each day.

Now a series of studies, including one recently published in The New England Journal of Medicine and one due out soon, have cemented a consensus among researchers that artemisinin is losing its potency here and that increased efforts are needed to prevent the drug-resistant malaria from leaving here and spreading across the globe.

Luckily, the Bill and Melinda Gates Foundation is making innovation in malaria vaccines and treatment a priority as reported in Gates’ First Annual Letter:

Today a number of new tools are being developed—better bed nets, better drugs, better insecticides, and a number of vaccine candidates. One of the vaccines will go into the last phase of human trials this year and could be ready for wide use by 2014. None of these tools is perfect. To understand how we should combine them, we brought in an expert in mathematical modeling who is applying a technique called Monte Carlo Simulations. This modeling work, which will show where we can eliminate malaria and where we can just reduce the disease burden, is a wonderful use of advanced mathematics to save lives, and if it goes as well as I expect, we will apply it to other diseases.

Definitely, advances in epidemiological science, vaccine technology, and pharmeceuticals will be crutial to controlling this disease. But, I also think that it is telling that:

The mosquito responsible for transmission of malaria is still endemic in the United States. But modern housing, better access to health care and the use of insecticides have virtually eradicated the disease in wealthier countries.

Once again, poverty is the main structural force shaping the risk of acquiring and dying from malaria. Shouldn’t we address the root cause – inequity – before pumping out technologies? Or, should it be a parallel process?

Kristof on Gates

Nicholas Kristof’s (recent nominee of the prestigious Natsios Award) most recent NYT op-ed discusses his interview with Bill Gates. Money quote:

I think the Gates Foundation has missed the chance to leverage the revolution in social entrepreneurship, hasn’t been as effective in advocacy as it has been in research, and has missed an opportunity to ignite a broad social movement behind its issues.

But if Mr. Gates manages to accomplish as much in the world of vaccines, health and food production as he thinks he can, then the consequences will be staggering. Squared. In that case, the first few paragraphs of Mr. Gates’s obituary will be all about overcoming diseases and poverty, barely mentioning his earlier career in the software industry.

I actually agree with Kristof here. It really is too bad that they didn’t invest more in social entrepreneurs with the drive and passion to improve the communities in which they live. Can you imagine Ashoka with the kind of resources at Gates’ disposal? However, I’m not convinced that by simply creating a vaccine for HIV or malaria, the world will magically become a more just and equitable place. Vaccines and technology are not enough. A broad social movement building solidarity and value for fundamental human rights is absolutely necessary. Lets get to work.

Bye bye global gag rule

An important step for global health equity, Obama has repealed the Mexico City Policy (also known as the Global Gag Rule) that had prevented federally funded NGOs from performing and even counseling women on abortions.

Here’s part of Obama’s statement on whitehouse.gov:

For too long, international family planning assistance has been used as a political wedge issue, the subject of a back and forth debate that has served only to divide us.  I have no desire to continue this stale and fruitless debate.

It is time that we end the politicization of this issue.  In the coming weeks, my Administration will initiate a fresh conversation on family planning, working to find areas of common ground to best meet the needs of women and families at home and around the world.

What a ladies’ man.

Photo of the day

A customer of a micro finance institution strings beads into necklaces at a workshop in a slum area in Mumbai February 17, 2007. (REUTERS/Prashanth Vishwanathan)

Ch-ch-changes

Received this email from a friend yesterday about Mark Dybul, the US Global AIDS Coordinator, and the head honcho behind PEPFAR:

…we have received confirmation that Ambassador Mark Dybul has been asked to resign, effective immediately. We understand that the office will be run by career staff until a new Coordinator is named.

Rumors are swirling about who will be named by the Obama Administration.  Names that keep coming up seem to be Nils Daulaire, former CEO of the Global Health Council, and Jim Yong Kim, Chief of the Division of Global Health Equity at the Brigham and Women’s Hospital, co-founder of Partners In Health, and other fancy titles.

Of the two (and virtually any other candidate as well), my vote is for Jim Kim.  He brings a pragmatic and passionate understanding of current on the ground realities from his time with PIH.  His grasp of global health policy (especially around HIV and TB) is hard to rival.  And, above all, he is strongly rooted in ideas of equity, human rights, and a preferential option for the poor.

While Daulaire has been a strong advocate for global health in DC, he has deep ties with big pharma and has been largely quiet in condemning the profit-driven industry.

Anxious to see where this goes.  As we have seen, the position has a serious amount of clout to influence global HIV/AIDS treatment throughout the world.

War and mental health

The impact of the destruction in Gaza will extend far beyond the time taken to rebuild public infrastructure, hospitals, universities, and apartment buildings.  Some are predicting that more than half of the children in Gaza will suffer from posttraumatic-stress disorder.  A revealing excerpt from a Newsweek piece:

Our host Hassan says all his three children now climb in bed with their parents, which they hadn’t done in years. His son Abdullah, 14, came to him half way through all this and handed him a letter, which he had carefully and beautifully written out. In it the boy pleas formally with his father to “remember me when I am dead, and promise to bury me near Grandmother and Grandfather, and please visit my grave every week.” The father wept for half an hour after reading it, he says. Abdullah, his 10-year-old son, one long night when the bombing was particularly bad, held his mother and said “please watch my eyes and make sure I don’t go to sleep, mama,” as Hassan related it. “He was afraid he would die and not wake up.”

War has a devastating, long-lasting impact on people’s health, whether they be innocent civilians or soldiers.  War recovery plans must prioritize the treatment of PTSD amongst the efforts to treat the rehabilitate the wounded and rebuild public health infrastructure.  So far, we are failing – both as a country and as a global community.

Natsios Award Nominee

Nicholas Kristof in his recent column, Where Sweatshops Are a Dream:

..the central challenge in the poorest countries is not that sweatshops exploit too many people, but that they don’t exploit enough.

He continues:

The best way to help people in the poorest countries isn’t to campaign against sweatshops but to promote manufacturing there.

In this January 14 column in the NYT, Kristof makes an argument for the importance of sweatshops as a key part of poverty-alleviation.  In the presence of jobs like rickshaw pulling, he states that sweatshops ain’t that bad relative to the alternatives that one might depend on for one’s income.  Kristof rails against poltical groups that push for greater labor standards claiming (perhaps accurately) that these types of standards often push manufacturers out of the poorest countries and into better off countries, leaving a significant portion of the population jobless.

While Kristof’s basic premise that an increase in labor is a key form of poverty-alleviation, his acceptance and encouragement of sweatshops is ludicrous without condemning the all too frequent use of unfair wages, union-busting tactics, and dangerous working conditions.  To give a thumbs up to sweathshops, simply based on the argument that they are a lesser evil than other available jobs (or no job at all) is both deconstructive and unacceptable in a push for a truly better living standard for the poor in developing countries.

This type of argument is akin to similar ones that have plagued the push for global health equity for too long.  Arguments like early WHO policy on MDR-TB treatment that opted for the “lesser of two evils” solutions, declaring treatment too expensive and even stating that it “distracts attention and resources” away from other diseases.  Little progress comes from arguments like these that have pushed for sub-standard care as a solution to sub-sub-standard care.  Just as in the case of MDR-TB treatment, progress comes from those individuals or groups that rise up, demand the status quo inequitable and unjust, and advocate and act for a better option for the poor.

Sweatshops do provide important labor for many people throughout the developing world.  But, simply providing a job to the jobless does not make it just nor does it warrant celebration.  According to a 2004 IPS report titled Wal-Mart’s Pay Gap, a Bangladeshi woman in a factory producing goods for Wal-Mart gets paid 17 cents/hour.  Such a low wage drives these workers to demand on health, food, and housing aid.  In contrast, the Wal-Mart CEO, H. Lee Scott, Jr., was paid $8,434.49/hour in 2004.  I feel its safe to assume that H. Lee is able to provide the highest quality health care, food, and housing for himself and his family, and perhaps even live exorbitantly on the side.

What are the implications for a continuation of the current use of sweatshops throughout the developing world?  While I am without an economic Ph. D., B.S. or anything of the sort, common sense tells me that such extremely low wages in the developing world in the presence of absurdly high salaries of Wal-Marts senior staff will not lead to a more equal world.  Money will  continue in the direction of the the rich Westerners and away from the hardworking laborers of the developing world.  The rising rates of inequality will continue along on their current trend.  Writing absurdities like those in Kristof’s column will allow for the continuation of people living without basic rights and will deter a push for more radical change rooted in equity and justice for the world’s poor.

Public health needs the private sector?

In response to the news of the Bill and Melinda Gates Foundations massive investment in the eradication of polio this week, Terry Kosdrosky at the University of Michigan Ross School of Business wrote an interesting piece about the important role that private corporations can have in investing in health as a public good. Kosdrosky quotes Dr. Tachi Yamada, the president of the Bill and Melinda Gates Foundation Global Health Program:

“If we can’t think of this problem in terms of a moral tragedy, we can think of self-interest,” Yamada said. “From a commercial standpoint, the emerging world is the emerging market. Real opportunity for industries, stable industries throughout the world, is in the developing world — south Asia, Africa.”

Kosdrosky goes on:

“From an economic perspective, not solving these problems will deprive businesses of a huge market, now and in the future, as mature markets see slower growth.

…there are limits to what even well-funded government programs can do. For example, Yamada recently visited a clinic in a remote part of Ghana. It was well-staffed, the professionals were well-educated, and it was fully equipped with medicine. The county has a national health insurance plan. But the clinic was only seeing about 150 people a month, or five a day.

A visit to a nearby village showed him why. The people there said very few of them went to the clinic for several reasons. For one, it took a long time to be seen because of red tape associated with the national health insurance program. If you pay cash, you can be seen right away, but the cost is prohibitive. Second, a medicine seller came by the village every so often. People would report their symptoms and he’d sell them medicine at low prices.

It tells you the public sector by itself can’t do it,” Yamada said. “It’s necessary, but not sufficient, to deliver care… The delivery channels for care are there for the private sector in a way they’re not available to the public sector.”

Of course, coming from a business school,  Terry Kosdrosky emphasizes using market forces to drive the creation of efficient health systems. I have no doubt that engaging the private sector and leveraging massive corporate resources will be essential to building true global health equity. But, I think that the fundamental position that patient = customer, or that we are all consumers of health care as a product, is fundamentally flawed. In my mind it conflicts directly with the notion that health is a fundamental human right.

How can we use market forces to drive the efficiency and quality of health systems without erroding our ultimate goal of equity?

Gates and Rotary Pair for Polio Eradication

Recently, the Bill and Melinda Gates Foundation announced that it would be donating $630 million towards finally eradicating the polio virus. They will be working primarily with Rotary International, a service organization with chapters in nearly every country in the world and over 1.2 million members as well as the UK and German governments. Together, they represent an amazing example of how the public and private sectors can effectively work together to achieve shared goals.

The effort to eradicate polio began in the 1980′s and has been largely successful, save a few trouble spots such as Afghanistan and Nigeria. Unfortunately, due to many factors such as cultural resistance to western intervention, these polio hot spots have persisted over the past two decades. The danger now is that the virus could spread out of these trouble spots and begin to enter populations who have not been vaccinated. By driving home the eradication of polio, not only will a major scourge be removed from the earth, but also the costs associated with  polio vaccination can be diverted to more pressing health issues.

Change has come

Kenyans who gathered at the grounds of the University of Nairobi to watch in giant screens the inauguration ceremony where Obama was sworn in as the 44th President of the United States of America celebrate the ocassion on January 20, 2008. Barrack Obama's father was born in Kenya. (via Boston Globe)

From Obama’s inauguration speech:

To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds.

And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to the suffering outside our borders, nor can we consume the world’s resources without regard to effect. For the world has changed, and we must change with it.

Now it is our responsibility to hold him to these words.