My own totally biased view, of course, but I thought my talk this afternoon on global health news coverage went well. Will post my notes in a day or two. They're in my laptop but I've been blogging from my much lighter Treo.
Update: Here's the post with my remarks at the Global Health Council.
Will Gardasil and other anti-cervical cancer vaccines be as effective around the globe as they are likely to be in the U.S. and Europe? That's the question I asked myself after sitting next to a gynecologist who has been doing some work in Guyana. (These serendipitous encounters are one of the best things about attending conferences.)
Dr. Rebecca Kightlinger of the University of Virginia Health System told me that she was surprised to learn that the high prevalence of cervical cancer she found in one section of Guyana was linked to the HPV-35 subtype. Of course in the U.S., the predominant cancer-causing HPV subtyes are HPV-16 and HPV-18, which are included in Gardasil.
If the HPV subtypes that cause cervical cancer are different throughout the world, however, that means different vaccine formulations will have to be used in different parts of the globe..
It may also mean that different vaccine formulations may need to be used for different ethnic groups, who may have migrated to new regions.
Something to ponder if you're trying to reduce the enormous death toll due to cervical cancer throughout the world. (Or if you're expecting Gardasil to be a global blockbuster.)
The governments of the poorest countries have more power than they realize when talking with partners from the rich world about development programs.
Interesting point from Joy Phumaphi, who used to be the Minister of Health in Botswana and who is now at the World Bank. "What I didn't appreciate while I was in government was the power of government," Phumapi says. "Developing country governments do not appreciate the extent to which they have the authority to direct the conversation. They tend to look for complete guidance from their development partners instead of realizing they can guide the development agenda themselves."
Phumaphi suggests governments of developing countries should be more assertive in saying, as she puts it, "This is not useful to me. This is what I need." She predicts much more effective results in global health programs if governments of developing countries claimed their authority to speak out and direct planning efforts more actively, rather than just listening quietly to what donors think they want to do.
Women, Fires and Jobs. Perhaps the most dramatic point so far from this morning's panel on "Partnerships for the Well-being of Women" came from Barbara Shailor of the AFL-CIO.
Shailor compared the infamous Triangle Shirtwaist Fire of 1911, in which so many women were trapped and killed, to another fire nearly a century later in a toy factory in Bangkok. Some 200 women were killed in the toy factory fire.
The implicit message: progress is made through activism, in this case labor activism. And the real issues, the truly fundamental issues, don't change that much over the centuries.
The panelists at this afternoon's session on performance-based incentives had no trouble talking about pay for healthcare workers and even patients, under the right circumstances. That was in marked contrast to this morning's squeamishness on the topic in the brain-drain session.
Of course, the incentives being talked about in this afternoon's discussion were all for folks in the private sector, non-government organizatons and the like--and the panelists skipped any deep forays into the strengthening of public hospitals and clinics. But I guess you can't have everything.
In any event, the session was packed--standing room only, with a few participants sitting on the floor here and there. Intriguing reports about local programs in Haiti, Nicaragua and Afghanistan.
Also, it was the first time I ever heard anyone suggest making incentive payments to poor people getting treated for tuberculosis so that they will complete the full course of therapy and not just stop after two months when they feel better and decide they need to look for a job.
Update: For more information on treatment incentives for TB patients, Ruth Levine of the Center for Global Development suggests taking a look at a report one of the CGD's working groups has written on the subject. You'll find it here.
Low salaries, poor working conditions and lack of professional development opportunities keep showing up as major factors in explaining why so many doctors, nurses, pharmacists and other healthcare workers leave their homes in the poorest countries of sub-Saharan Africa to work in South Africa, Europe, Canada and the U.S.
And yet the panel for the GHC session on countering the brain drain actively avoided talking about salaries for health care providers.
Indeed, the moderator, Edward Elmendorf of the World Bank actually discouraged any talk about providing a living wage for doctors and nurses in the public sector of the poorest countries, because, goodness knows, then teachers and other civil servants will want better wages and that could lead to runaway inflation.
I would have liked to have seen more discussion on that point. What's the evidence that paying doctors, nurses, teachers and other public servants a living wage is counterprouctive? After all,the NGOs and various other research organizaions seem to be doing very well by providing their employees wit living wages. Why wouldn't such an effort in the publc sector pay dividends as well?
Certainly the panel seemed very earnest and well-meaning but I was disappointed that it was either unable or unwilling to get at the deeper issue of why the subject of salary should be off the table.
An interesting proposal bubbled up from this morning's plenary session at the annual meeting of the Global Health Council. Why not have an independent ratings agency to grade the various public-private partnerships in global health? Banks have ratings agencies. Insurance companies have ratings agencies. Even schools are rated these days.
Such an independent ratings agencies for program in global health would, for example, help businesses, foundations and governments decide which ventures to fund further, which to avoid and which could improve with help.
This idea was proposed by David de Ferranti, a senior fellow of the Brookings Institution and the United Nations Foundation.
I'm in Washington, D.C., attending the annual conference of the Global Health Council. I'll be speaking at the media luncheon tomorrow. But in the meantime, will try to post a few items based on the sessions I'm attending. (Update: here's a link to my talk on covering global health news.)
Just now, I'm headed off to a session that looks at the growing brain drain of medical personnel--doctors, nurses, etc--out of developing countries. Will post more later.
Update #1: CDC now reports the Czech Air flight number was 0104, not 410.
Update #2: Here's a list of all flights taken by the U.S. traveler, now known to be Andrew Speaker, who is infected with XDR-TB.
Did you fly from Atlanta to Paris on May 12? How about from Prague to Montreal on May 24? If so, you may well have been exposed to a fellow passenger with extensively drug-resistant tuberculosis.
The U.S. Centers for Disease Control is reporting that the infected traveller flew on Air France Fl 385 from Atlanta to Paris on May 12 and then back to North America on May 24 on Czech Air Fl. 410 [acually Fl. 0140] from Prague to Montreal, returning to the U.S. by car.
Travellers and crew on both flights are potentially at risk for developing the extremely dangerous-but-still-treatable form of TB.
Here are the salient parts of the CDC alert:
(From the CDC) Since May 25, the patient has been hospitalized in respiratory isolation and is undergoing additional medical evaluation.
CDC is collaborating with U.S. state and local health departments, international Ministries of Health,the airline industry, and the World Health Organization (WHO) regarding appropriate notification and follow up of passengers and crew potentially at risk for exposure to XDR TB. Each country involved in the investigation is determining the most appropriate guidance for its residents.
The following recommendations have been developed for U.S. residents who may have been exposed to this patient.
This patient has radiographic evidence of pulmonary TB, is culture-positive for XDR TB, but is sputum smear negative for acid fast bacilli and is relatively asymptomatic. On the basis of the patient's clinical and laboratory status, and lack of receiving adequate treatment for XDR TB, this patient was considered potentially infectious at the time of his airline travel, and meets the criteria in the WHO guidelines for initiating an airline contact investigation. http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.363_eng.pdf
In accordance with the WHO TB and Airline Travel Guidelines, to ensure appropriate follow-up and care for persons who may have been exposed to XDR TB, CDC is recommending the following for passengers and crew onboard Air France # 385 departing Atlanta on May 12 and arriving in Paris on May 13, and on Czech Air # 410 [actually Fl. # 0104] departing from Prague and arriving in Montreal on May 24: passengers seated in the same row as the index patient and those seated in the two rows ahead and the two rows behind, as well as the cabin crew members working in the same cabin should be evaluated for TB infection.
This includes initial evaluation and testing with follow up 8-10 weeks later for re-evaluation.
As there has never been an airline contact investigation for XDR TB, it is not known if the current recommendations are adequate to determine the possible range and risk of transmission of infection.
Because of the serious consequences of XDR TB and anticipated public concern, in addition to the contacts listed above, all U.S. residents and citizens on these flights should be notified and encouraged to seek TB testing and evaluation.
Persons who believe they may have been exposed to TB or XDR TB can call 1-800 CDC INFO for further information.
Where to go for information about:
Tuberculosis: http://www.cdc.gov/tb/default.htm
XDR TB: http://www.cdc.gov/tb/pubs/tbfactsheets/xdrtb.htm
TB Testing: http://www.cdc.gov/tb/pubs/tbfactsheets/skintesting.htm and http://www.cdc.gov/tb/pubs/tbfactsheets/QFT.htm
Infection control: http://www.cdc.gov/tb/pubs/tbfactsheets/ichcs.htm and http://www.cdc.gov/tb/pubs/tbfactsheets/rphcs.htm
Tuberculosis and Air Travel:
http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.363_eng.pdf
News you might have missed . . .
No room at the hospital. Doctors in South Africa send a woman home with infectious tuberculosis because they couldn't find a place for her on their isolation ward. (Cape Argus)
Noxious Weed. About 100,000 people die in China each year from the effects of passive smoking (Reuters)
Never mind. Alabama's homeland security website decides NOT to call environmentalists and activists who work for gay rights or against abortion or genetically modified foods potential terrorists, after all. (CBS News)
Christian Loucq has just been named director of the PATH Malaria Vaccine Initiative in Seattle, Washington. Loucq joined MVI to head up strategy and operations just as the Initiative's director Melinda Moree was leaving in February (coincidence?) and has previously worked in vaccine development at GlaxoSmithKline and Acambis. He'll have his hands full testing and possibly developing a half dozen potential malaria vaccines. He also needs to update his LinkedIn profile.
Update (June 5): By the way, Melinda Moree is now at Applied Strategies, a consulting and software company.
I'm pleased to report that yours truly, Christine Gorman, has just been named one of three Nieman Foundation Fellows for Global Health Reporting at Harvard University for the class of 2007-2008. The other two global health journalists are Ran An (China) from China Newsweek and Andrew Quinn (United Kingdom) from Reuters.
We'll be joining 27 other Nieman Fellows who will be exploring such wide-ranging topics as increasing friction between Muslim and Christian societies, racial implications of urban sprawl and the impact of government regulations on alternative energy technologies.
In addition to exploring basic healthcare infrastructure in developing countries, I plan to use my Nieman year to figure out ways of expanding coverage of global health news beyond traditional media outlets.
Here's the press release with more information about all 30 Nieman Foundation Fellows for 2007-2008.
Girls jumping in in Pisac, Peru
Photo credit: Robin Utrecht/APN Photo/Copyright 2007
(Headlines) News you might have missed . . .
Scaling Up. The cost of diabetes drugs likely to soar as global epidemic worsens (Reuters)
Life Happens. Being treated unfairly--independent of your income level or social status--increases your risk of suffering a heart attack, according to new results from the long-running Whitehall study (British Medical Journal)
They call it "Baghdad boil." Leishmaniasis, and other parasitic diseases, are being diagnosed more often in the U.S. as the number of troops and civilian contractors deployed overseas increases. (The Boston Globe)
And what's missing? I'm going to be part of a media luncheon on May 31 at the annual conference of Global Health Council in Washington, DC. The topic is "Reporting on Global Health: Who’s Telling the Story and Who’s Listening?" (The GHC server seems to be having problems as I write this, but hopefully that will clear up.)
I'll be talking about the big stories in global health that the media have missed. Naturally I have my own ideas, but if you'd like to add your two cents, send me an e-mail BEFORE May 28, 2007 at cgormanhealth[AT]gmail[DOT]com.
(Headlines) News you might have missed . . .
Bottom Up. Half of health cuts in Cook County (Chicago, Illinois) are doctors and nurses who serve the poor. Administrators, by contrast, take much less of a hit. (DailySouthtown.com)
Herbs to the Rescue. Edmonton, Aberta plans to stockpile ginseng in case of a flu pandemic. (CIDRAP News)
CDC 2.0. In a report to Congress, the Centers for Disease Control and Prevention backs open access to publicly funded research (Medical News Today)
Pablo Halkyard, who is pursuing his MBA at NYU, suggested that I include a few job postings in global health as I come across them. Have an opening you'd like to include? Let me know (See contact information at www.cgormanhealth.com) . . .
HIV/TB. The Gates Foundation is looking for (among many others) a Director of HIV and TB (Location: Seattle) and an Advocacy Manager for Avahan, its ever-expanding AIDS program in India (Location: New Delhi).
Journalism. Internews, a non-profit journalism site, wants to find a director of global health programs (Location: Washington, D.C.)
TB Nursing. The Pennsylvania Department of Health is seeking a community health nurse to coordinate TB services in Dauphin County (Location: Harrisburg, PA)
It's official. Tony Blair says he'll resign as British prime minister on June 27. What next? If there's an opening soon at the World Bank, would he take it?
Update: On second thought, the chances of a second Iraq-War booster would be rather small. Oh well, as The Guardian points out, there's always the Carlyle Group, where Blair can make lots of money.
Connecting the dots from public health to poverty to corruption.
Doctors treat their patients one at a time. But spend enough time chronicling the realm of medicine--as I have--and you really start to appreciate the importance of public health. (Keeping youngsters from smoking is, after all, more satisfying than telling them a few decades later that they have heart or lung disease.)
Spend enough time in the public health world, however, and you start to understand how much poverty magnifies the damage caused by germs, accidents, hunger or violence.
And so, it's no surprise that the Bill and Melinda Gates Foundation is now including poverty reduction as one of the aims of their grant work. Last week they announced a five-year, $5 million initiative to fund research into the effectiveness of micro-finance tools to alleviate extreme poverty.
But spend a couple of decades working on poverty--as Paul Farmer of Partners in Health has--and you get a strong feel for the link between poverty and corruption.
Oh, corruption. Everyone's against corruption--taking bribes and that sort of thing. We may even deplore the old Cold War habit of propping up a dictator for security reasons.
But in a speech on Tuesday, Farmer challenged students and faculty of the Wagner School of Public Service at New York University, to look beyond bribe-taking and geopolitics to the unspoken rules of academia that say it's okay to collect data and publish research papers about the poor and unhealthy without also providing for direct service to them. (A RealPlayer video of Farmer's talk should be available soon.)
After all, there's nothing intrinsic to being poor that means you must also be sick. With access to clean water, proper sanitation, well-run clinics and effective treatments, even the poor can be healthy. You don't need a study to tell you that.
I'm not sure the audience understood that Farmer was challenging them personally. He has a habit of leavening his talk with funny asides and indirect comments that allow you, at least for a while, to think he's criticizing somebody else. And then the next morning, you wake up and realize, no, he's talking about you.
Some day those Wagner students will be earning their living from "trying to help the poor." (Indeed, Wagner is one of the grantees for the new anti-poverty Gates initiative.)
The question is whether the effort will leave the poor just as poor and unhealthy--but better studied--than they were before.
(Analysis) At what point do strong patent rules strangle innovation? That's what James Surowiecki wants to know in his provocative article in the New Yorker this week on patent protections.
Definitely worth a careful read, particularly this historical note:
The great irony [Surowiecki writes] is that the U.S. economy in its early years was built in large part on a lax attitude toward intellectual-property rights and enforcement. As the historian Doron Ben-Atar shows in his book “Trade Secrets,” the Founders believed that a strict attitude toward patents and copyright would limit domestic innovation and make it harder for the U.S. to expand its industrial base. American law did not protect the rights of foreign inventors or writers, and Secretary of the Treasury Alexander Hamilton, in his famous “Report on Manufactures,” of 1791, actively advocated the theft of technology and the luring of skilled workers from foreign countries. Among the beneficiaries of this was the American textile industry, which flourished thanks to pirated technology.
(Headlines) News you might have missed . . .
Brazil set to break Merck patent on AIDS drug (Bloomberg)
New findings may lead to diagnostic test for cerebral malaria (PLoS One)
Getting ready to mark the International Year of Sanitation 2008 (UNICEF)
