DevPolitics

chronic malnutrition and NGO action

I attended a conference held on Malnutrition at Columbia Thursday night. MSF, David Rieff, and Barbara Cooper represented the views regarding Niger and India. My capstone has to do with malnutrition in India, so naturally I had to ask specifics about the work being done. What fascinates me about (and draws me to)  MSF is their constant rule-breaking nature--all in the name of the people, of course. It's admirable, in my eyes. There was a brief mention of the role of advocacy and how it will change the way MSF operates, and frankly I do worry that it will change things. David Rieff brought up OxFam as an example--their incredible field work has been put aside for advocacy...which is a shame, really. Where is the balance? Is there? David Rieff was an interesting character--he actually said that he was there under false pretenses and honestly stated that he did not believe humanitarian work belonged in areas of chronic malnutrition (ie India...or historically, the majority of the malnourished populations). This argument was cut short, but it is interesting to see things from that perspective. Again, where is the balance when it comes to human lives? Malnutrition is generally accepted to have historical connotations. When emergency relief is provided in chronic situations, the services that are generally regarded to be the responsibility of the local government are now receiving support. The root cause (policy, corruption, what have you) is not being addressed, and a problem receives a bandaid in the form of aid and relief. As the roles of organizations start to blend together, I have to wonder when (if, ever??) chronic issues, such as malnutrition, will be addressed.

Pharmaceutical Responsibility

http://www.oxfam.org/en/policy/bp109_investing_for_life_0711

According to the 2008 Fortune 1000 Report, the group of Pharmaceutical companies made a profit of $40.1 billion, despite the low economic climate. Meanwhile, the majority of the world’s population does not have access to essential medicines.

I understand that the process of developing a drug, medication, or vaccine requires large amounts of money and resources. What I don’t understand, are the priorities of the companies. The amount of money spent on instilling the fear of H1N1 into the global population could have been going to finding a cure for cholera. The resources used to develop a flu vaccine each year could go to saving generations from easily curable diseases. I, for one, would much rather get the flu than trypanosomiasis—but I have been receiving emails and phone-calls urging me to get a flu vaccine based on my history of asthma. I don’t have people calling me to get the typhoid vaccine based on my history of travel.

I’m not an expert of pharmaceutical development, but I am almost positive that $40 billion is more than enough to research and develop an essential medicine for developing populations.  Even if this is not the case, $40 billion is certainly enough to warrant a subsidy on expensive medications for poor populations.  The regulations regarding patents have limited the ability to manufacture affordable versions of the drugs, further preventing the work of health workers to gain headway.

Tracy Kidder described the efforts of Paul Farmer in her book, Mountains Beyond Mountains. An essential part of Paul Farmer-philosophy is that if a medication exists, all people deserve to benefit from it, no matter the cost. Farmer also systematically “borrowed” from Harvard University’s supplies in order to get the expensive medications to the populations in need. While Farmer’s methods may be debateable, I whole-heartedly agree with his thought process: just because a person cannot pay for a drug does not mean they should have access to it.  I was under the impression that research and development of medicines were to help people and benefit the world. When did that become attached to a clause of “if the person can afford to pay?”

Another facet of the problem is the pharmaceutical company’s pointed argument of their investment in medicines for malaria, TB, and HIV/AIDs. What they don’t acknowledge is the fact that many of these drugs have been deemed too old and inefficient for use (the most recent drug for TB was developed 30 years ago!). As with any treatment, constant monitoring and development of more effective and efficient forms must be performed to combat drug resistance. This research is not being performed, and global health issues are culminating into multi-drug resistant havens. I was on Larium in 2008 and still got malaria. When I was in India, I caught Chikungunya. These are illnesses people have to live with on a daily basis—a cure, for which, just requires investment in research.

Based on the input from 12 pharmaceutical companies, the World Health Organization, Medicins Sans Frontieres, Voluntary Service Overseas, Save the Children, and other key international health players, OXFAM published a report entitled “Invest in Life.” This 2007 report was a call to action assigning responsibility to pharmaceutical companies to invest in the research and development of common ailments afflicting the developing world. The claims the pharmaceutical companies have made to claim investment in the poor were rectified: barely any research is being done on low-profile or non-communicable, existing drugs go through shameful “ever-greening” practices, donations are largely expired or near expiry, and patent-demands have prevented millions from the medicines they deserve. The twenty-year patents have created a monopoly on many valuable medications, preventing access to treatment for millions based on affordability. Despite the harsh criticism, Oxfam does acknowledge the progress the pharmaceutical companies have made since a report published in 2002 entitled, “Beyond Philanthropy.” Six pharmaceutical companies responded, largely defending the efforts they had contributed.

And yet there is still a $40 billion profit.

In this world of technological advancement and innovation, I see no reason that there have not been cures and/or vaccinations for common ailments such as dengue fever or chikungunya virus. Leprosy and polio are still major problems. Childhood diseases that we westerners were vaccinated for in our youth are still killing millions. When the medical solution exists, why is it not being used to its full potential? The practice of “donating” expired or almost expired medicines is appalling. Pharmaceutical companies are smart enough (or have teams of people that are) to figure out true demand at inflated prices to judge demand for unexpired donations. Just because a person is poor does not mean that they deserve inadequate and inefficient medical “donations.”

            When it comes to access to medicine, I completely support the efforts of Medicins Sans Frontieres. Their Access to Essential Medicines campaign has been a call to action for pharmaceutical companies and a wake up call for any informed consumer. MSF’s campaign urges the pooling of patents in order to create affordable methods of treatment, medical innovation for needs versus market priorities, and the creation of sustainable solutions for the worlds poor.  In typical MSF fashion, an eloquent yet systematic attack is placed on the institutions with the capacity to help the cause to actually help.  As an aside with regards to patent defence, the force with which Nutriset is defending its patent shocks me—I was under the impression that Plumy’nut was developed to help malnourished children, not to create a monopoly on a life-saving medicine.

I believe the work of Oxfam and MSF will eventually be successful—too many consumers are becoming aware of the situation in order to allow it to continue. The question is when. When will the poor be able to access medicines? When will the world be able to eradicate diseases such as polio and smallpox? When will children stop dying from pneumonia? It is already too late for so many…I hope that we don’t waste more lives waiting. Many pharmaceutical companies have the funds and resources necessary to provide medical innovation for people in developing countries. Market demand should be based on need, not financial profitability. I firmly stand by the belief that pharmaceutical companies should be held accountable on more than just ethic and moral terms—this involves fighting sleeping sickness instead of female sexual dysfunction. Public awareness of the disparity between medicinal access for the rich and poor is an essential component—without being held accountable by the public financing operations, how can one expect the pharmaceutical companies to change? The question is, then, how does one go about informing the general public and getting them to care? That’s a battle in itself.

AIDs vaccine--thoughts?

The health sector is going nuts over "promising" results in the clinical trial of the AIDs vaccine.

I have my skepticism, which I recently posted on facebook. With a mixed batch of friends, I naturally got a mixed batch of responses. I'd like to know what people in this class think about it.

My brief thoughts:

• It was tested in Thailand, where 8,000 people received the test and 8,000 people received a placebo. Are there too many underlying conditions in Thailand to deem a difference of ~20 people a success? How ethical is it to conduct a test involving HIV on human subjects, regardless of race or socioeconomic status, anyway?
• If an HIV/AIDs vaccine is successful, how will this affect the work that has been done on prevention and education? Will all of the progress that has been made with access to knowledge and education go down the tube? Will people become more careless?
• The clinical trial can not explain reasons for the difference in rates of infection--the infected people who received the vaccine did not have any less of a viral load than the control group. Generally in partially successful trials, the viral load would have decreased in the test group.
• If a vaccine is found to be successful, how will this change the stigma against HIV/AIDs? Will people start to see it in the same light of smallpox and typhoid?
• In my work, HIV/AIDs research on access to communities and education has led to breakthroughs in a plethora of other sectors--how will this affect "development" work in the future?

I'm curious to know what people think about this.

Blogging the Global Health Conference

Fresh from the Unite for Sight Global Health Conference at Yale which drew a stellar lineup including Jeffrey Sachs and Nicholas Kristof this weekend I thought I would share a few reflections, as many of the issues raised relate directly to the discussions we have had in class. The theme of the conference was innovations in global health. Oddly enough, it turns out that innovation in global health is not about new ideas and originality. Rather the cutting edge of global health is about the return of old ideas, continuing debates and process.

 

Innovation = 1978?

The Declaration of Alma Ata  circa 1978 made a triumphant return and was sprinkled throughout the discourse. The Declaration proclaimed “health for all,” established the “health as a human right” frame and called for primary care and attention for health systems. Speaker after speaker, from Jeffrey Sachs to Unite for Sight volunteers emphasized the fundamental right to health as driving global health initiatives. Despite the eminent commentary it still remains unclear as to who has the responsibility to provide access to this right. Further panels and talks only muddied the situation more. Everyone including western governments, corporations, donors, local NGOs, community health workers, all level of poor country governments were called upon to act and make contributions to the fulfillment of this right. While I see the value in the rights frame, especially in terms of capabilities as Sen defines it, in practice we need to have a bit more clarity. 

A related issue is the tension between focused disease specific approaches and more holistic systems initiatives. Representatives from PAHO to Unite for Sight spoke about their narrow programs to eliminate blindness, vaccinate against measles and rubella and combat HIV/AIDS. They called for these initiatives to be scaled up, while others emphasized the role of community health workers, primary care and women’s health. Jeffrey Sachs even suggested that the Global Fund add “Health Systems” to its fight against HIV/AIDS, TB and Malaria. Some believe that targeted technical programs are the most effective citing the success of polio, smallpox and measles campaigns while others argued conditions like HIV, TB and malaria are unlike these conditions and require behavioral interventions and holistic care that addresses co-infections and provides education. It seems that this divide and concern over this issue will only grow as financial constraints force trade offs between these divergent approaches. 

Evaluation is the watchword

Perhaps spurred by the Easterly school of development and cynicism about aid, evaluation was a common topic for discussion. Evaluation and monitoring are certainly not new is discussion in the field, however much of the talk obscured some of the tensions and challenges. For instance emphasis on results seems to favor simpler more measurable interventions like vaccines, bed nets, and vitamins as it requires more effort to measure empowerment, health and community participation. The outcomes of health systems efforts are also difficult to monitor. Finding novel ways to monitor and evaluate these broader projects may be where the true need for creativity lies. We should also remember, as Nicolas Kristof remarked, aid and development work does have a very good results record in one area - making the donors feel good and offering meaning to their lives. 

Health Care Reform

Serendipitous and interesting piece in the New Yorker this week on health care reform.  It gives a nice synopsis of the evolution of Britain's National Health Service that Sen references at the end of Chapter 2.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande 

Western nations lure Africa health workers away--is that a crime?

There's an interesting discussion in the latest Lancet over whether or not the incentives offered by developed nations to lure African doctors and nurses to jobs in their health systems should be considered a crime.  The NYT picked it up this morning.  You can read the full piece in the Lancet here (free registration required).

The article states:

There is no doubt that this situation is a very important violation of the human rights of people in Africa. In recent years, international law has developed the notion of international crime to strengthen the accountability of individuals for serious violations. One indication of the gravity of acts and that they deserve treatment as international crimes that has been developed by the International Criminal Court is that they create social alarm.25

Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm: the practice should, therefore, be viewed as an international crime.

Pretty strong words.  You have to wonder about the inverse of this: could you also see it as a crime if highly trained people were prevented from leaving countries in the midst of serious turmoil, food shortages, corruption, military juntas, etc?  The authors go on to state that of course trained personnel should have the right to leave if they want, but multinational corporations and health systems should not be actively recruiting people away and really what is needed is stronger systems within developing countries to encourage people to stay.  I think we might have known that part already, the question is how??

One interesting tactic might be to encourage medical programs in developed nations to partner with medical programs in developing ones.  This might mean requiring students to serve part of a semester in a clinic or hospital of a developing nation, while giving doctors running those centers access to the research and some funding resources of the developed country school. 

I'm not an expert in public health; I have little to no idea of if this has been tried already with dismal results.  I think, though, that this would be a far more constructive criticism if there were some novel approaches suggested.  As I think we've seen in many other cases, criminalization of something hardly ends its practice! 

Epstein on the ABCs of HIV/AIDS

Having worked in the HIV/AIDS field for a couple of years, I was interested in what Helen Epstein's new perspective on the epidemic was, particularly in the hardest hit area of the world, Africa.  At her talk last week, she presented her findings on the analysis of the patterns that drive the epidemic in various parts of the world, comparing the prevalence of concurrent sexual relationships in Africa to that of serial monogamous ones in the west.  Her conclusion was that while the overall number of sexual partners in both types of relationships did not differ, the ability of the HIV virus to spread was significantly pronounced in concurrent relationships.

What I found most interesting though was her analysis of the success of Uganda in turning the epidemic around using the ABC (Abstinence - Be faithful - Condomise) approach.  Dr Epstein felt that both the condom and abstinence side of the debate in the US had gotten things very wrong.  For Africa, the focus needed to be on the issue of concurrent relationships.  I found this interpretation of the Ugandan data a little worrying.  Her data on Uganda showed that while condom use was not significant, over 30% of study participants had modified their sexual behavior by abstaining or delaying their first sexual experience.  In a country of double digit infection rates, getting 30% of young people to abstain or delay their first sexual intercourse is nothing to be sniffed at.

 

For biological and socio-economic reasons, the most vulnerable to HIV infection are 15-24 year old females .  Granted, the bulk of behavioral change came from those who chose to limit their partners, but then, that’s the rationale behind the ABC approach to begin with.  I believe the ABC method has been successful because it provides a public health message with an inherent grading on the level of protection.  If you abstain, chances are you won’t get the virus.  In failing to do that, stick with one partner.  If you fail at that too, use a condom at your own risk.

The abstinence and condom issue has become so mired in political rhetoric in the states that the message is in danger of being completely lost.  In the last decade, the "just use a condom" banner has been flying all around the world with very little attention paid to the fact that there are six steps required for effective condom use and most people will not achieve all six consistently, a deadly consequence for many no doubt.  1 in 5 (ie 20%) of Americans have an incurable STD ( That is the herpes, HPVs etc) and STDs are on an alarming rise in the UK.   It is not hard to imagine a STD transmitted by a mutant virus that cannot be prevented by condoms in the not too distant future.  After all, the herpes virus which is prevalent in the US now cannot be prevented by condoms and is incurable.  Just over a year ago, a mutated HIV virus that responded to no known treatment made a short-lived but frightening appearance in NYC. 

Thus when it comes to sexually transmitted diseases, we need to go beyond the easy to disemminate but inadequate messages of condoms. It is futile to attempt to battle STDs without addressing the need for behavioral modificiation.  Saying that, the HIV/AIDS epidemic does not have a one size fits all solution and I hope we do not attempt to use Epstein's concurrent relationships data in this manner.  While scientific data is objective, its interpretation is not necessarily so.  Its about time we move past the mud slinging and start to look at the issues objectively with a meaningful exploration of all the means available to stop the deadly HIV virus in its tracks.

PEPFAR Reauthorization: Looking Forward

PEPFAR Reauthorization: Looking Forward
(note – this blog entry requires a basic familiarity with PEPFAR – for information on PEPFAR refer to www.pepfar.gov or www.pepfarwatch.org

On 5/3/2007 Center for Strategic and International Studies hosted a discussion on the reauthorization of the Presidents Emergency Plan for AIDS Relief  (PEPFAR).

Panelists included moderator Helene Gayle, President and CEO, CARE USA;
Sen. John Sununu (R-NH.);Sen. Russ Feingold (D-Wis.); and the Committee for Evaluation for the Institute of Medicine, Helen Smits, Former Faculty of Medicine, Eduardo Mondlane University, Mozambique; Stefano Bertozzi, Director of Health Economics, National Institutes of Health, Mexico; and Michael Merson, Founding Director, Global Health Institute, Duke University

Key recommendations by the IOM panel:

•     Expand workforce and efforts on prevention
•     Eliminate dual review of approved drugs – FDA and WHO (other countries only require WHO approval and in other treatment areas, the US only requires WHO)
•     Remove budget allocations/earmarks that dictate what percentage of dollars are spent on prevention, treatment and care respectively
•     Focus on community based, well-integrated operationalization vs siloed approaches to prevention, care, treatment (i.e. “I don’t know what’s happening in prevention - I’m only funded for treatment”)
•     Sustainability vs “emergency” response
•     Increase the supply of doctors and nurses through training
•     Provide the flexibility and authority to localize responses based on needs and epidemiological patterns.
•     Move to outcomes based approach – i.e away from “# of people treated” and towards how it’s extending the lives of those treated
•     Performance targets vs allocations – tied to the previous recommendation

I think there is some very good news in these recommendations. 

The focus on prevention (and potentially, more money available for prevention) is much needed and in concert with the recommendations to remove specific allocations for prevention, treatment and care (e.g. 33% towards ‘abstinence only’).  This release of constraints could enable local PEPFAR partners and organizations to tailor programmatic implementation according to local population patterns and needs.  It also indirectly addresses the estimates that new infections are outpacing treatment 6 to 1 (6 new infections for each person gaining access to treatment). If we are truly going to reverse this epidemic, until a vaccine is available, prevention must play a much bigger role in stemming new infections across the globe.   

The ideological argument over abstinence was acknowledged and recommendations, if implemented, could overcome the very contentious ‘abstinence-only’ part of the prevention programs. The prostitution oath however, was not acknowledged.  Sex workers in countries like Brazil and Thailand have been key to changing epidemiological patterns and transmission and we should at a minimum, not be excluding a population that a) needs prevention and treatment options and b) can be primary stakeholders in prevention efforts. 

The requirement for drugs to be reviewed by the FDA as well as the WHO has slowed down approval and access for people in need of treatment.  In other areas, such as malaria, the US does not require both FDA and WHO approval for drugs – thus the administration has been accused of pandering to big pharma under the guise of quality control.  The panel’s recommendation can make effective drugs available to those who need them more quickly. 

Key Shortcomings in the recommendations:
A key area overlooked by the panel (and the program as a whole since it’s inception) is that of nutrition.  ARVs cannot be properly metabolized or absorbed by the body without proper, consistent nutrition.  There are specific guidelines by the FAO http://www.fao.org/DOCREP/005/Y4168E/Y4168E00.HTM on the needs of people living with HIV/AIDS.  However, “Emergency Plan funds may pay for the procurement of food only as a last resort” (original emphasis) and for ARV patients with “evidence of severe malnutrition.” 

ARVs without proper nutrition can amplify the many side-affects of ARVs (diarrhea, nausea among the least of them) and can contribute to non-adherence.  Further, there are some studies that suggest ARVs without proper nutrition can actually make the individual more ill and that some patients should reach certain nutritional thresholds before starting ARVs.   With the panels’ recommendation towards outcomes and away from straight coverage (i.e. # of people on ARVs) but towards impact (i.e. # of lives extended by ARVs), food is a critical underpinning and should be considered, not as a last resort, but as a compulsory component based on the condition of the patient.  Certainly this will give rise to debates around cost-effectiveness and trade-offs (i.e. food with ARVs will mean fewer people on ARVs given a fixed budget), however, as the panel recommended – we should not be simply measuring the number of people getting the drugs but the effect on their livelihood (both positive and negative) so nimble and life-extending adjustments can be made to treatment responses.

While the panel acknowledged the problem of gender, there were no specific recommendations to address this problem.  Of all HIV positive persons in sub-Saharan Africa, approximately 67% are women.  In some areas, for the age range 15-19, 6 or 7 girls are infected for every boy.  This is a huge missed opportunity for the panel to make specific recommendations to squarely confront the needs of young women in the face of the epidemic.  The issue of gender and HIV is hardly a new topic and the lack of a specific recommendation is hard to comprehend.   The continued disproportion of infection has knock-on effects for families and entire communities. Illness and death of young women at such a disproportionate rate impacts rearing and socialization of children, the number of orphans and vulnerable children (covered in PEPFAR), economic household stability as well as community roles and norms.  There are some 60+ microbicide trials ongoing that may eventually give women an individual option for safer sex but until that time, intensified education and prevention efforts specifically targeted at men are one way PEPFAR could potentially address the gender imbalance.

The PEPFAR Reauthorization is a landmark event in that it is projected to be renewed at increased levels of financial commitment.  There is no doubt that PEPFAR programmes have positively impacted millions of people and is the biggest single programme to date in the fight against AIDS.  Despite all the ideological disagreements and political contests, PEPFAR has done immense good.

In the reauthorization, the Administration has an opportunity to make changes to the program, based on the IOM panel and other evaluations, that can enable PEPFAR to quickly evolve to a more effective catalyst for community driven prevention, care and treatment versus a top-down, autocratic implementation.   

PEPFAR is up for reauthorization in 2008.

Providing AIDS care and fresh vegetables

     I wanted share with you this article from the front page of the Wall Street Journal titled, “In Kenya, AIDS Therapy Includes Fresh Vegetables”. 

http://online.wsj.com/article_print/SB117502793580250798.html

     This article is of particular importance to me because it speaks directly to the work of the NGO that I work for, Doctors of the World-USA (DOW).  It also touches on some of the things that we spoke about in class, specifically Farmer's broad view of development, and health projects that actually meet the needs of communities.  In this case, providing effective AIDS care, as well as food support.

     As you will read, the Academic Model for Prevention and Treatment of HIV/AIDS, or AMPATH, was born out of a unique partnership between Indiana University and Kenya’s Moi University School of Medicine.  This model was one of the first AIDS programs to provide AIDS services, as well as a large-scale farming component.

     DOW was its first NGO partner in replicating and scaling up the AMPATH model, expanding local capacity, applying proven methods to new populations, and bringing HIV/AIDS-related services to the underserved West Pokot District in Kenya.  In addition to enrollment, monitoring, and treatment of patients with HIV, DOW is implementing complementary initiatives to increase food security and nutrition, as well as community-based care for AIDS orphans, and possibly a new micro-finance program. 

     I think this project is a good example of how governments, local institutions, NGO's, funders (in this case largely PEPFAR), and academics can work together to develop projects that actually work in developing countries.

Lugar Leads Push for U.S. to Join Advanced Market Committment for Vaccines

In February five countries--Britain, Canada, Italy, Norway and Russia--committed  $1.5 billion to support the first Advanced Market Commitment (AMC) for pneumococcal disease, the leading cause of childhood pneumonia deaths, and the second leading cause of childhood meningitis deaths worldwide. The Bush Administration was AWOL from the launch. But Senator Lugar (R-IN), ranking member of the Senate Foreign Relations Committee, has introduced the "Vaccines for the Future Act of 2007" (pdf), which would accelerate the development of vaccines for HIV/AIDS, tuberculosis, malaria and other infectious diseases that disproportionately affect populations in developing countries.