Tuesday, December 18, 2007

LA TIMES: "Unintended Victims of Gates Foundation Generosity"

If you read just one piece in the mainstream media this week about global health, make sure its "Unintented Victims of Gates Foundation Generosity," by Charles Piller and Doug Smith in the Los Angeles Times.

This may be exactly the wrong season to find out about what happens when charity backfires--then again, depending on how your holiday shopping is going, you may be in exactly the right mood.

"Unintended Victims of Gates Foundation Generosity" looks at the unintended consequences of putting most of your donor dollars in the AIDS basket--something that is troubling more and more public health practitioners on the ground these days. The LA Times is one of the few media organizations that has taken a consistently critical look--both pro and con--at what Bill and Melinda Gates are doing in global health.

Here's an excerpt to whet your appetite. But definitely read the whole thing:

(from the LA Times) . . . Botswana offers an example of how a special Gates initiative, narrowly applied to a specific disease, may have disrupted other healthcare.

In 2000, the Gates Foundation joined with the drug firm Merck & Co. and chose Botswana as a test case for a $100-million effort to prove that mass AIDS treatment and prevention could succeed in Africa.

Botswana is a well-governed, stable democracy with a small population and a relatively high living standard, but one of the highest HIV infection rates in the world.

By 2005, health expenditures per capita in Botswana, boosted by the Gates donations, were six times the average for Africa and 21 times the amount spent in Rwanda.

Deaths from AIDS fell sharply.

But AIDS prevention largely failed. HIV continued to spread at an alarming pace. A quarter of all adults were infected in 2003, and the rate was still that high in 2005, according to the U.N. Program on HIV/AIDS. In a 2005 survey, just one in 10 adults could say how to prevent sexual transmission of HIV, despite education programs.

Meanwhile, the rate of pregnancy-related maternal deaths nearly quadrupled and the child mortality rate rose dramatically. Despite improvements in AIDS treatment, life expectancy in Botswana rose just marginally, from 41.1 years in 2000 to 41.5 years in 2005.

Dean Jamison, a health economist who was editor of Disease Control Priorities in Developing Countries, a Gates Foundation-funded reference book, blamed the pressing needs of Botswana's AIDS patients. But he added that the Gates Foundation effort, with its tight focus on the epidemic, may have contributed to the broader health crisis by drawing the nation's top clinicians away from primary care and child health.

"They have an opportunity to double or triple their salaries by working on AIDS," Jamison said. "Maybe the health ministry replaces them, maybe not."But if so, it is usually with less competent people." . . .

Monday, December 17, 2007

Connecting the Dots on Moms, Roads and Plumpy'Nut

Most people I run across in the public health world still view blogs suspiciously as the source of a lot of heat and not very illuminating. But with a little judicious filtering (both mental and electronic), I find blogs incredibly useful in my research and reporting.

Recently, in response to my post on Peanut Butter and Patents, someone with the handle "RUTF blogger" posted a tip about the production of peanut-based nutritional supplements in Malawi for a story I'm following on the patenting of Plumpy'Nut. Obviously, the information needs to be checked out but at least I have some names and an idea of where to look.

And last Friday, I received an e-mail reply to a question I posted at The INFO Project Blog, the brainchild of the Center for Communication Programs at the Johns Hopkins School of Public Health. While researching the link between paved roads and improved maternal health, I found a blog post that related to maternal health from the folks at JHU. I asked my question and a very nice person named Rose replied both by e-mail and on the blog.

In both cases, I am learning and assessing what I need--but because the q and a are publicly available, others may benefit as well.

Thursday, December 13, 2007

Monique and the Mango Rains is a Must Read

I sometimes think public health experts have doctor-envy because they come up with such cerebral, unemotional terms--like maternal mortality--to talk about issues of life and death.

They would do better just to encourage everyone to read a book like Monique and the Mango Rains by Kris Hollowell. It's about the friendship that develops between a Peace Corps volunteer and a midwife in Mali. A quick read, very engaging, full of joy and sorrow. Makes you want to get out and do something!

Wednesday, December 12, 2007

From Maternal Health to Web2ForDev

It's all about the links. The little snippet I wrote earlier this fall about whether Richard Cash ever considered patenting oral rehydration therapy got picked up by a class on maternal and child health at Columbia University's Mailman School of Public Health. From there I learned about a conference on using Web2.0 ideas and technology for promoting development in the poorest countries of the world.

The meeting has already happened but at least there's video from some of the sessions. Why it's Explorer-only is beyond me. Wouldn't you expect a group promoting Web2.0 to be platform agnostic? at least choose Firefox?

Meanwhile, back in the real world, I spoke with Henry Jenkins of MIT this afternoon after a panel discussion on our Totally Wired Kids. He mentioned the Center for Collective Intelligence as another possible contact for my project on promoting greater coverage of global health issues.

Huckabee No Longer Believes in AIDS quarantines

What a difference a few days make. On Dec. 9, GOP Presidential hopeful Mike Huckabee told the Associated Press that he would not back off of statements he made in 1992 in favor of isolating AIDS patients. After Ryan White's mom called him on that stance, Huckabee is backpedaling as fast as he can--not always convincingly.

Tuesday, December 11, 2007

AIDS Mom Slams Huckabee

Now that Gov. Mike Huckabee's campaign for the GOP Presidential nomination is surging, he's getting more scrutiny on his previous remarks about AIDS. From the folks at the Human Rights Campaign:

Subj: RELEASE: Letter Urges Gov. Huckabee to Repudiate AIDS Remarks, Meet with Ryan White's Mother
Date: Tue Dec 11, 2007 10:22 am

Letter Urges Gov. Huckabee to Repudiate AIDS Remarks, Meet with Ryan White's Mother. Human Rights Campaign and The AIDS Institute sign letter to Gov. Huckabee asking for meeting with Jeanne White-Ginder

WASHINGTON – The Human Rights Campaign and The AIDS Institute sent a letter to Republican presidential candidate Governor Mike Huckabee today asking that he personally meet with Jeanne White-Ginder, the mother of Ryan White, who was diagnosed with AIDS on December 17, 1984, and captivated the attention of millions as he battled the disease and ultimately succumbed to it. As reported by the Associated Press, "Huckabee once advocated isolating AIDS patients from the general public, opposed increased federal funding in the search for a cure and said homosexuality could 'pose a dangerous public health risk.'" In a FOX News interview on Sunday, December 9, Huckabee stood by his remarks and said he still believes today that people living with HIV and AIDS should have been "isolated" even after it was determined the virus was not spread through casual contact.

"Have we not learned the difficult lesson of how devastating these statements based in ignorance and fear can be to American families? Has it been so long ago that we have forgotten how our neighbors had the backs of entire communities turned on them?" the letter, signed by the Human Rights Campaign and AIDS Institute, said. "Governor Huckabee, those dark moments in American history are the direct result of ignorant views that stifle discussion, hinder resources and delay action. We have a moral obligation as a nation to never allow ourselves to repeat the shameful mistakes of the past. And we cannot sit idly by when a candidate for President of the United States tries to lead us back down that path of ignorance and fear."

As a candidate for a U.S. Senate seat in 1992, Huckabee answered 229 questions submitted to him by The Associated Press. The Senate candidate wrote: "It is difficult to understand the public policy towards AIDS. It is the first time in the history of civilization in which the carriers of a genuine plague have not been isolated from the general population, and in which this deadly disease for which there is no cure is being treated as a civil rights issue instead of the true health crisis it represents."

As the Associated Press recently reported, "When Huckabee wrote his answers in 1992, it was common knowledge that AIDS could not be spread by casual contact."(Associated Press, December 8, 2007)

In the same election year that Gov. Huckabee answered the questionnaire, Mary Fisher, an HIV-positive former aide to President Gerald R. Ford and founder of the Family AIDS Network, addressed the 1992 Republican National Convention. In her groundbreaking speech, "A Whisper of AIDS," Fisher sought compassion for and understanding of people living with HIV and AIDS and received a standing ovation from a crowd that included the President and Mrs. Ford. To view her 1992 speech visit: http://www.youtube.com/watch?v=0vTKDFcRDLY

To view the FOX News interview from Sunday visit: http://youtube.com/watch?v=2cT6n-VJ1Xg

The complete letter to the governor follows:

December 10th, 2007

Dear Governor Huckabee: In 1984, a young boy living in Indiana was diagnosed with AIDS. At the time, that boy, thirteen-year-old Ryan White, had no idea that his life would become a testament of courage and bravery responsible for opening the hearts and minds of millions of people throughout our country and around the world. Six years later, in 1990, Ryan's life ended -- a dear, precious life cut short. But Ryan's death wasn't the only tragedy in this well-known story in our country's history. Ryan and his family's battle with HIV/AIDS was also a stark reminder of what happens in our country when fear and ignorance go unchecked. Governor Huckabee, the Ryan White family was ridiculed, shunned and ostracized by people who thought the answer was to "isolate" them far away from the rest of society. In 1984, this belief was purely based on ignorance. But these same beliefs, which you espoused in 1992 and have refused to recant today, as a candidate for President of the United States, a
re completely beyond comprehension. When you answered the Associated Press questionnaire in 1992, we, in fact, knew a great deal about how HIV was transmitted. Four years earlier, in 1988, the Reagan Administration's Department of Health and Human Services issued a brochure assuring the American public that "you won't get the AIDS virus through every day contact with the people around you in school, in the workplace, at parties, child care centers, or stores." To call for such an oppressive and severe policy like "isolation," when the scientific community and federal government were certain about how HIV is transmitted was then, and remains today, irresponsible. Such statements should be completely repudiated, not simply dismissed as needing to be slightly reworded.

This was not and is not an issue of "political correctness," as you state. Rather, this is an issue of valuing science-based evidence over unfounded fear or prejudice. Have we not learned the difficult lesson of how devastating these statements based in ignorance and fear can be to American families? Has it been so long ago that we have forgotten how our neighbors had the backs of entire communities turned on them? Governor Huckabee, those dark moments in American history are the direct result of ignorant views that stifle discussion, hinder resources and delay action. We have a moral obligation as a nation to never allow ourselves to repeat the shameful mistakes of the past. And we cannot sit idly by when a candidate for President of the United States tries to lead us back down that path of ignorance and fear. Governor Huckabee, if you need a reminder of how calls for "isolation" can shatter a Mother's heart, you only need to turn to Jeanne White-Ginder. Today, we respectfully as
k you to sit down with her and allow her to share with you Ryan's story. Ms. White-Ginder continues to be active in AIDS advocacy as a member of the board of The AIDS Institute. We hope that, even in 2007, Ryan's story can continue to open hearts and minds. We would be happy to facilitate a meeting between Ms. White-Ginder and yourself, or a member of your staff. Please feel free to contact Brad Luna, Communications Director for the Human Rights Campaign, at (202) 216-1514 at your convenience.


Joe Solmonese
Human Rights Campaign

A. Gene Copello
Executive Director
The AIDS Institute

The Human Rights Campaign is America's largest civil rights organization working to achieve gay, lesbian, bisexual and transgender equality. By inspiring and engaging all Americans, HRC strives to end discrimination against GLBT citizens and realize a nation that achieves fundamental fairness and equality for all.

Monday, December 3, 2007

And Just How Did You Get Those Numbers?

First there was a movement for transparency in government. But the need for transparency in data is growing stronger by the day. And by transparency in data, I mean more than just the free and easy access to authenticated figures and official statistics--transparency in data must also include publishing the methods used to derive those numbers.

Mixed messages. Late last month the UN released new statistics, saying that 33 million people worldwide are infected with HIV instead of 40 million. More recently, the CDC reported that the number of new HIV infections in the U.S. each year is probably closer to 60,000 people rather than the long-cited stat of 40,000.

The CDC says it will release its methodology very soon. But so far, we haven't heard anything from the UN about how they came by their new numbers. That's a bit of a puzzle since some epidemiologists and demographers have been very public in their criticisms of the UN's approach to counting HIV infections.

To give just one example, check out James Chin's The AIDS Pandemic: The Collision of Epidemiology with Political Correctness. Chin used to be director of the World Health Organization's Global Program on AIDS and so should know what he's talking about.

Alas, a few folks in the blogosphere have latched on to Chin's critiques as further justification for their own AIDS denialism. Their histrionics are obscuring the real story behind the numbers.

Monday, November 26, 2007

Stephen Lewis: UN "Sloppy" on AIDS Numbers

Stephen Lewis says the United Nations, where he used to work, "was stubborn and it was sloppy" in its compilation of global AIDS statistics. The result was last week's embarrassing need to restate the number of people living with HIV from 40 million to 33 million.

The tone is so blistering that one wonders if Peter Piot, head of UNAIDS, will take it as a personal attack from Lewis, the former UN Special Envoy for HIV/AIDS in Africa?

I'll have more to say in future posts, but wanted to post what Lewis, who is now co-director of something called AIDS-Free World, said as soon as possible. The speech itself has been making the e-mail rounds, but I have also received it from Lewis's executive assistant.

Here's what Lewis told the World Health Editors Network last Friday (Nov. 23) at the Imperial College in London:

"It’s fair to say that any speech designed to address leadership and AIDS must start with the events of this week: the publication of the UNAIDS Epidemic Update, 2007.

Let me get two matters out of the way at the outset. I think the new set of numbers is much closer to the truth of the pandemic, although I’m inclined to believe that they’re still too high and that another awkward revision lies ahead. Second, I don’t believe for a moment that UNAIDS inflated the figures for the purpose of extracting money. That seems to me too conspiratorial by half. If by some bizarre happenstance, Machiavelli’s apprentices were involved, they make lousy fund-raisers: we’re billions of dollars short of where we should be, old estimates or new.

I take issue with the report on different grounds. For years, knowledgeable epidemiologists have been telling the UN that the figures were too high. They didn’t whisper their criticisms: they wrote books and articles. They lobbied behind the scenes. No one paid them heed. It doesn’t take a Nobel prize statistician to guess that prevalence rates based on urban antenatal clinics should not be extrapolated to the entire country and presented as holy writ. That became compellingly clear when the spate of population-based household surveys, country after country, invariably showed lower prevalence.

But the UN chose a course of delay and dithering. It can never admit that it’s wrong. So finally, and predictably, came the moment of truth: the result is an overall prevalence rate that is lower by almost seven million than last year’s estimate.

Sure, it can be rationalized by arguing that it’s just a methodological adjustment, rooted in superior statistical-gathering techniques. And that might even be persuasive if there hadn’t been academicians and epidemiologists clamouring for revision for years. The UNAIDS explanation sounds good; the fine print has the ring of arcane scientific authority. But down here, in the mortal universe, where people aren’t easily taken in, it doesn’t wash.

The UN was stubborn and it was sloppy. In the process, it undermined public confidence in the reliability of the figures, introducing completely unnecessary levels of doubt, contention and confusion.
Where HIV/AIDS is concerned, there is no room for the jolting of confidence. The new estimates confirm a continuing apocalypse for sub-Saharan Africa: 22.5 million infections, 61% of them women, 68% of world-wide infections, 76% of all deaths, 11.4 million orphans … this is where the focus must be, this is where it should always have been; not a report cluttered by mathematical adjustments so that virtually every story that’s written begins with the news of a statistical volte-face. If the recording of data had been more scrupulous all along, we could have welcomed this report as the latest instalment in a record of declining numbers, showing some strong hints of progress, and plausibly leading to universal access for treatment, prevention and care by 2010.

Instead, all of us have to run to the trenches to remind the world that more money is still desperately needed and that the situation, in many places, remains grim, bleak, funereal.

As a matter of fact, at the risk of knocking the nail through the wall, allow me to add that I earlier used the word ‘sloppy’ advisedly. For a number of years in the 1990’s, I was the Deputy at UNICEF and oversaw a raft of publications. I would never have permitted this Update to go out as is.

Let me explain by way of example.

In one of the dense explanatory notes, there’s a statistical adjustment described that attracted little notice, but seems to me to be of enormous import. If I may attempt a straightforward simplification, the report seems to be saying that, on average, the population-based random household surveys in countries with generalized HIV epidemics produced estimates that were 20% lower than the estimates produced by antenatal surveys. Therefore, says the report, for all those countries with generalized epidemics that have not yet done random surveys, we’re applying a reduction factor of .8 … that is to say, the new figures will be 80 % of the old figures.

That’s quite a reduction! Don’t you think it might have been useful to produce a table (there were, after all, tables galore) to show what it might mean, in practice, country by affected country? No such luck.

Instead, the report notes that “Of the total difference in the estimates published in 2006 and 2007, 70% are due to changes in six countries: Angola, India, Kenya, Mozambique, Nigeria and Zimbabwe.” I was stumped by Angola because its prevalence rate is so low, it’s hard to imagine that it could make a great difference to the numbers. India everyone knows about. Kenya and Zimbabwe have oft been talked about (although the alleged decline in Zimbabwe seems to me to be complicated by the numbers of deaths, the out-migration, and the difficulty of reliable surveys in a sociological wasteland). Nigeria was clearly possible. But Mozambique was a mystery because I remembered from my last visit that the most recent data had shown an increase in prevalence.

This is no small matter. This is a report that is telling the world that the dramatic revision in the figures, and the figures themselves, are now the best that science has to offer.
Naturally, therefore, I looked at all the entries in the report dealing with Mozambique. On page 12, there is a section on “Recent HIV and sexual behaviour trends among young people” that chronicles reductions in HIV prevalence in various countries from Kenya to Malawi to Zimbabwe to rural Botswana. However the paragraph ends with these words: “There was no evidence of a decrease in HIV infection levels among young people in Mozambique …” (emphasis mine).

On page 13, there’s an elaborate table titled, in part, “2006/2007 analysis of trends among 15 to 24-year-olds in high prevalence countries: HIV prevalence among pregnant women, 2000-2006 in sentinel surveillance systems …” Mozambique is in the table. Below the list of countries, there’s an asterisk which reads: “Analyses of countries with more than three years of data based in the following number of consistent urban and rural sites …” For Mozambique there are 20 sites listed, South, North and Central. Beside Mozambique is another legend symbol which reads: “No evidence of decrease” (emphasis mine).

On page 15 we encounter the critical “Regional Overview”, leading with the section on “Southern Africa”. It indicates that this sub-region includes the eight countries with prevalence rates over 15%: Botswana, Lesotho, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. The narrative then points out, with some gratification, that in Zimbabwe there is an actual decline in national HIV prevalence, and that “the epidemics in most of the rest of the sub-region have either reached or are approaching a plateau” The next sentence reads: “Only in Mozambique latest HIV data (in 2005) have shown an increase in prevalence over the previous surveillance period.” (emphasis mine).

Finally, on page 17, Mozambique is dealt with separately, as are all the countries of the sub-region. The opening paragraph reads “In the other lusophone country of this sub-region, Mozambique, the epidemic has again started to increase in all three zones after appearing to have stabilized in the early 2000s.” (emphasis mine … the three zones are south, central and north, and the other lusophone country is of course Angola.)

If I was in the Ministry of Health in Mozambique, I would want to know why all of the narrative evidence of the report seems to contradict the assertion that Mozambique is one of the six countries in the world that has most significantly contributed to the reduced numbers, 2007 over 2006. And if the explanation is --- as it must be --- the application of the new 80% rule applied to countries, ie Mozambique, that haven’t yet done population-based surveys, then those figures should be set out conclusively. Otherwise this report does what so many other reports have done: it slides casually over critical information. It confuses where it ought to be clarifying. It’s blurred where it should be coherent.

For me, the Epidemic Update, 2007, is simply a symbol, a symbol of insufficient leadership, within the United Nations, against the pandemic of AIDS. The time has come --- we’re just a week away from another World AIDS Day --- for the new Secretary-General to throw the full weight of his office behind a campaign to subdue the pandemic, with a particular consuming focus on Africa.
The agenda lies in the UNAIDS report.
For example, one of the most startling statistics is the revelation that women now constitute 61% of the infections in Africa … close to 14 million women infected. There are no words. It’s a catastrophe rooted in gender inequality, and everyone in the highest citadels of the United Nations knows it, but virtually nothing changes.

We have a report from a High-Level Panel on UN Reform, pointing out the lamentable UN record on women, and recommending the creation of a new international agency for women. The proposal lies dormant on the order paper of the General Assembly, crying out for leadership from the Secretary General. The Deputy Secretary General has spoken, strongly and bravely although, given the inevitable and nasty internal rivalries, her words are too often given to rhetorical sleight-of-tongue.

Where is the UN Secretary General when the AIDS pandemic rages, and the women of Africa need him most? No one pretends that the women’s agency is the sole answer, but you can bet that things would not be so excruciatingly horrendous if women had an international vehicle to draw upon, with resources and voice.

So, too, women in conflict zones. My colleagues and I carefully watched the Security Council debate on Resolution 1325 just a couple of weeks ago, and have read carefully the proceedings of the Security Council debate this week on the protection of civilians in armed conflict. The speeches are getting better: more feeling, more informed, more urgent (that is particularly true of the Undersecretary General for Humanitarian Affairs; on the other hand, the Secretary General’s speech last Tuesday on the protection of civilians in armed conflict was so pro forma as to make one weep. He managed to mention Sudan, Somalia, Afghanistan, Iraq and a passing aside to Darfur. Not a syllable on the Democratic Republic of the Congo). When you have a savage war on women, as in the DRC, with huge implications for transmission of the AIDS virus, speeches are the road to hell. When will the United Nations actually take hold? There are suggestions cited of the Secretary General leading a new campaign to eliminate violence against women. I recently saw an early draft of this potential Secretary General initiative, and I can categorically say that in more than twenty years of association with multilateralism, I’ve rarely seen anything more vapid, fatuous and insubstantial. It was as if the illusion of progress, dressed up in the Byzantine underworld of United Nations processes was sufficient unto itself. Public relations for inconsolable grief.

The Epidemic Update report acknowledges that only in a few instances has behaviour change played a serious role in the reduction of the numbers. In fact it says that the differences in estimates “result largely from refinements in methodology rather than in trends in the pandemic itself.” There is no question that a small proportion of the decline stems from changes in behaviour, but there is equally no doubt that the vast majority of the difference lies in the methodological adjustment.

Now, then, is the perfect time to rally the UN community to the side of prevention, with much greater focus on high-risk groups; on the increasingly persuasive thesis of concurrent partners; on the roll-out of male circumcision (which should have been pursued vigorously much more quickly, but like so much else in the response to the pandemic got caught up in the overweaning proclivity for excessive scientific inquiry when the case is already clear, not to mention the faint hearts in the face of potential controversy); on harm reduction around which there has been inexcusable ambivalence; on the Prevention of Mother to Child Transmission, possibly the easiest preventive intervention of all, and therefore the most grievous emblem of multilateral negligence; on the absolute, resolute need to pursue, with unflinching tenacity the continued quest for a microbicide and a vaccine, regardless the setbacks. This is the time for a crescendo of United Nations voices.

The Epidemic Update is also shocking in the information that 76% of the overall deaths lie in Africa: one million, six hundred thousand adults and children. It tells you everything you didn’t want to know about the painfully slow rollout of treatment, and how vital it is that keeping people alive not get lost in some senseless, artificial tension between treatment and prevention. Nor should we ever forget where so many of the deaths come from, and how silent were the voices of the United Nations leadership while President Mbeki pursued his fatal denialism. South Africa has far and away the highest number of HIV infections in the world: five and a half million. There are eight hundred to a thousand deaths a day. No one has ever been held to account. Talk about impunity.

And as always, there’s the question of resources. It’s hard to know how the donors will react to the new numbers published by UNAIDS. They may simply yawn, and give whatever they intended. They may feel bamboozled, and want to cut back. They may see possibilities in the reduced numbers, possibilities of greater progress because fewer people are involved. Whatever the reaction, we must somehow persuade the world that we’re way behind, billions and billions of dollars behind, when it comes to funding all the components of the pandemic, from orphans to second-line drugs.

All of these elements, so many of them flowing generically from the Epidemic Update, are the stuff of the United Nations. UNAIDS, the Joint UN Programme on HIV/AIDS, oversees or coordinates ten co-sponsors: UNHCR, UNDP, UNICEF, WFP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank. That’s a compendium of multilateral aristocracy and power rivaled in influence only by the G8 and the International Financial Institutions. And yet, members of the UN family, in the face of the AIDS pandemic, have sometimes acted with a kind of catatonic passivity. There is no excuse for it.

More than twenty-five years into the pandemic, we have an epidemic update that is --- let’s face it --- horrifying in its implications. Whether it’s 40 million or 33 million, this plague continues to ravage humankind. I simply do not believe that the United Nations has done everything it can possibly do to turn the tide. And I don’t mean just the member states, I mean the agencies and the secretariat.

I’m a multilateralist to the core of my being. But that doesn’t mean that the UN is above criticism. And it most emphatically doesn’t mean acting as an apologist for those who are chosen to lead and who have failed to lead."

Friday, November 16, 2007

An Open Standard for Global Health?

Global health advocates need to pay more attention to issues of net neutrality, open-source standards and the growing movement to create a global commons.

Over the past several months at Harvard, I’ve started to delve much deeper into some fundamental questions about who owns the Internet and the information we are accumulating in the various computers sprinkled about the globe. Thanks to the ongoing exploration of these issues at the Berkman Center for Internet and Society, I now realize these issues have major implications for how we address some of the world’s pressing health and development needs as well.

Once upon a time, whenever pundits worried about a “digital divide” between rich and poor or the developed and developing worlds, they focused on the physical tools—like computers and broadband connections—for accessing the Internet. If we aren’t careful, however, an even greater divide may be written into the very backbone that makes the Internet possible, allowing powerful companies and countries a greater voice because they can pay for faster access to their websites while the rest of us languish in slow download hell. The many injustices of the real world would then be faithfully recreated in the virtual world as well.

The global health community has long argued that everyone should enjoy equal access to basic health care—regardless of income or social standing. But does that noble goal extend to access to information—in all its many forms as news, data or research results? When first-world consultants help a developing country create an electronic medical records system, for example, do they advise their clients to use a proprietary software program or an open source one? Is it possible to access international and national health and development databases, use the information gained and distribute the results without incurring monetary fees? (These are just two examples. The more you dig, the more you find.)

Why does this matter? Open source software is, of course, no panacea. But the tech support is worldwide, sustainable and typically comes at the right price. Too often, on the other hand, proprietary software leads to digital servitude and a stranglehold on innovation.

As for databases, I’ve learned quite a lot about them from reading Yochai Benkler’s The Wealth of Networks. (I found it easier to read the book but there’s also a complete version of Benkler’s tome on the web.) Apparently, since 1991 the U.S. government has not considered databases to be copyrightable. Access to them is free—although you may want to pay a subscription service to provide the information in a more user-friendly format.

By contrast, Benkler writes, the European Union passed a Database Directive in 1996, “which created a discrete and expansive right in raw data compilation.” As a result, “government agencies are required to charge what the market will bear for access to data they collect.” So where is the database industry thriving and growing faster? In the U.S., where databases are not encumbered by copyright restrictions.

Hmmm. An open standard leads to greater innovation and growth in business. Sounds like something the global health community ought to take to heart.

Sunday, October 28, 2007

Editing the CDC on Climate Change

Take a look for yourself. The original version of Dr. Julie Gerberding's testimony before Congress about the health impact of global climate change and what she was actually allowed to say are significantly different. This is not a case of minor editing.

Tuesday, October 23, 2007

What do Patents and Peanut Butter Have to do With Starving Kids?

There's been plenty of good press about Plumpy'nut, the "miracle" food that has saved countless starving children over the past few years. But not much has been written about the patent that sustains the small French company behind this humanitarian wonder.

Is Plumpy' nut another laudable example of doing well by doing good? Or will protecting the patent lead to yet another bottleneck in yet another under-served area of global health?

My interest in this topic started innocently enough with an offhand remark directed at me at a nutrition conference I attended two weeks ago.

The gist of the remark was that Nutriset, the maker of Plumpy'nut, was protecting its investment by warning other commercial enterprises, as well as humanitarian groups, not to produce their own versions of the therapeutic food. (The recipe is dead simple: so many peanuts, so much dried milk, a little oil and some vitamins and minerals. The innovation comes from realizing, among other things, that the right mix doesn't require dilution with water, which is often a problem in the developing world.)

A little search engine digging, a few e-mails and in-person conversations later, and it feels to this longtime health journalist that there is some meat in this story.

So, now I'm collecting information, original sources, suggestions for people to talk to, etc, at tightly focused web site called, straightforwardedly enough, Patents and Peanut Butter.

I'd like it to be a group effort--sort of an experiment in collaborative reporting. (I've been reading Yochai Benkler's The Wealth of Networks: How Social Production Transforms Markets and Freedom.) But am prepared to do a lot of the heavy lifting myself until things get going.

By creating a separate blog, I hope to counter some of the chaotic, hit-or-miss nature of the Web. But who knows, that may turn out to be an entirely unnecessary step. The great thing about being at Harvard for a year, is that I can try new things out while the Nieman Foundation foots the bills.

Wednesday, October 17, 2007

Can Malaria Be Eradicated?

Update: Larry Hollon, of the Methodist church and Perspectives, attended the Malaria Summit in Seattle and has a firsthand account on his blog.

I did a double take when I read that Bill and Melinda Gates have just challenged the world to eradicate malaria from the globe. I went back and looked at several news sources. Yes, they all agreed the word "eradicate," not "control" was used. Now that's a tall order, even for a pair of billionaire philanthropists. (Full disclosure, I'm at Harvard on a Nieman Fellowship in Global Health Reporting, which is funded by the Gates Foundation.)

Back in the 1960s, health experts were convinced that widespread use of DDT against mosquitoes plus treatment with chloroquine would eradicate malaria from the world. By the 1970s, however, the environmental damage caused by massive agricultural use of the pesticide caused a sharp reduction in all DDT spraying--including inside homes against mosquitoes. Malaria has been rebounding every since.

And yet, health experts I've talked to over the years have told me that even had indoor spraying continued through the 1970s, 1980s and 1990s, malaria, at best, would have been controlled, not eradicated or eliminated from the face of the earth.

What's changed since the 1970s? A promising new vaccine that appears to be partially effective in children. Insecticide-treated bed nets. New combination drug treatments for malaria. Better education campaigns. The return, in some areas, of indoor spraying with DDT and other pesticides. The realization that there is no such thing as a silver bullet in fighting malaria. You need all of the above to control this disease.

But eradicate?

"Bill and I believe that these advances in science and medicine, your promising research, and the rising concern of people around the world represent an historic opportunity not just to treat malaria or to control it -- but to chart a long-term course to eradicate it," Melinda Gates told a gathering of international scientists and policymakers in Seattle, Washington (quote as reported in Agence France-Presse).

An eradication policy is very different--and much more costly--than a control policy. Just ask anyone who is trying to eliminate polio.

Tuesday, September 25, 2007

A Business Model for Global Health

What can business teach public health experts--and everyone else--about how to improve people's health around the world? One idea that's gaining ground around Harvard (and elsewhere) is the use of case studies--and not just the gold standard of scientifically controlled clinical trials--to figure out what works and what doesn't.

Some days I wonder if I'm at the School of Public Health or the Business School. Jim Kim--champion of the 3 x 5 initiative to get more poor people on anti-AIDS therapies--is working with Mike Porter--corporate strategy guru--on developing case studies of what does and doesn't work in global health. They'll both be teaching classes that tap into this approach in January.

Peter Piot, head of UNAIDS, brought up the case-study method in a keynote speech yesterday at, of all places, a symposium on "Meeting Children's Needs in a World with HIV/AIDS." You still need controlled trials, Piot was quick to point out when several journalists spoke with him after his speech. But there may be some ways to use case studies--to learn from past experience--to figure out how best to deliver on the promise found in controlled research studies.

Case studies, for those of us who don't have MBAs, are well-researched 3 or 4 page summaries that lay out a particular real-world problem that a real-world organization faced at some point and then ask the group to put themselves in the place of the chief executive officers or others and propose strategies for going forward.

Of course, case studies aren't going to tell you if a particular antibiotic works or not. That's the realm of a scientifically controlled clinical trial. But a case study may give insight into how to introduce a new antibiotic into the developing world, or decide between a couple of different choices of antibiotics as to which works best in the poorest parts of the world, what kind of health-care infrastructure is needed, what might happen when the antibiotic gets out into the gray market, and whether, on balance, these factors sway you towards one course of action or another.

But the use of case studies is just a piece of this business approach to global health. A more critical look at the costs and benefits of borrowing the business world's tools--which often includes a decidedly anti-government bias (very convenient for academic researchers and NGOs who are not in government)--is beyond the scope of one blog post. But it's definitely something to keep an eye on.

Friday, September 21, 2007

Listening for Sound Bites

Couldn't pick between four events yesterday after classes were over, so went to all four. We'll see how long THAT lasts.

Lots of high-falutin' ideas at MIT's forum on "What is Civic Media?" about whether social networking and distributive intelligence have killed or fostered democracy's "deliberative ideal." (Update: See Ethan Zuckerman's blog post on the "civic media" forum for more detail.) And really scrumptious chocolate cake at the meeting of the pre-med committee at Lowell House as well as great appetizers at the Knight Science Journalism Fellows reception at MIT. (Free food seems to be a theme at a lot of the events I've attended lately.)

But the thought that's still rattling around in my brain this morning as I hurry off to class is something that Ira Magaziner said at last night's student forum at the Kennedy School. I'm paraphrasing here, but basically he said, that if you love what you do, then you don't notice the hours that you put into your job and, by extension, away from your family. Specifically, of course, he was talking about his passion for global health and poverty alleviation in his capacity as chair of the Clinton Foundation HIV/AIDS Initiative. They don't worry too much about individual job satisfaction at the Clinton Foundation, Magaziner said. They're too busy saving lives.

At a minimum, that sounded to me like a recipe for burnout. And the more I thought about it, the more it also seemed like the kind of attitude that lets people off the hook too easily. If you have to be a Mother Teresa to do anything about global poverty or the wide disparity around the world in basic health care, then not much is going to get done. (And lately, we've learned that even Mother Teresa wasn't the kind of saint most people thought she was--she was privately wracked with doubt about both her faith and her mission.)

The point being that there will always be people like Paul Farmer, who was also at the Kennedy School forum, and Ira Magaziner who are driven to do something, driven to the point that their passion consumes their lives. But if we leave the vision of a more just and healthy world to people like this alone, the mission will never be accomplished.

Ordinary folks, the kind who do care about job satisfaction and vacations and having time for family, have to be part of the equation as well or the job won't get done. And it's okay to make room for ordinary folks with ordinary goals.

Wednesday, September 19, 2007

Top Tips from Bangladesh's BRAC

Be realistic about what you can accomplish. Monitor your progress. Learn from your mistakes. Always think about how you're going to scale a project up (preferably to at least the country level), even when you're in the pilot phase. Those are some of the things I took away from a talk at Harvard on Monday afternoon by Fazle Hasan Abed, founder and chair of BRAC, the highly successful poverty alleviation group in Bangladesh.

Abed is not as well known as his fellow countryman Muhammad Yunus, who won the Nobel Peace Prize in 2006 for his work with the Grameen Bank. And indeed, the men are often seen as rivals in the development world. But Abed has never shown any inclination to run for political office, while Yunus recently abandoned plans to create a new political party in Bangladesh. And perhaps that's the most important message I got from Abed's talk: "Stick to your knitting."

Monday, September 17, 2007

First Impressions from Harvard

If the past three weeks are any indication, my year at Harvard as a Nieman Fellow is going to fly by. Among the things I've learned in the first few days:

1) Never bet against the economy. Despite dire predictions in the 1970s, the world's recent unprecedented growth in population has not destroyed the global economy. Effects on environment and social well-being are another story.

2) The gap between rich and poor is not just growing. It's exploding--as even a casual look at the numbers (on life expectancy, fertility, disability and education) shows.

3) We constantly underestimate the importance of things that don't happen. More people have not been born because of China's one-child family policy than died in the Great Flu Pandemic of 1918-1919.

Saturday, September 15, 2007

Kaiser Offers Global Health Mini-Fellowships

Want to cover global health issues in greater depth but can't get your boss to cough up the money to send you to China, India or Zambia or you can't afford to bankroll the trip on your own?

The Kaiser Family Foundation has just launched a new awards program of up to ten mini-fellowships--worth as much as $10,000 each--for journalists from North America or Europe interested in doing substantive reporting on topics such as AIDS, TB or malaria. The deadline for applications is November 1, 2007 and reporting needs to be completed by Dec. 31, 2008.

Sunday, September 9, 2007

Global Health News Feeds, Part Two

Global health news tends to fall between the cracks of "world news" (wars, disasters) and "consumer health news" (asthma, heart attacks). Last week, I posted instructions on how to build your own global health news feed using Yahoo Pipes. Here's another option that's a little more hands-on.

In this case, I'm using Google Reader, a news feed aggregator and its "shared item feature" to combine news items generated by RSS feeds from the traditional media with alerts and other posts that I find particularly newsworthy as I surf the Internet.

The advantage: many of these newsy bits of information--like a recent BioMed Central research paper linking diabetes and tuberculosis in India--are typically not covered by the mainstream media.

I capture the surfed items using del.icio.us, a social bookmarking website. And then I subscribe to an RSS feed of my del.icio.us bookmarks with Google Reader.

The big advantage of del.icio.us is, of course, that you can see what others have posted as their favorite items on subjects like tuberculosis, malaria, poverty etc. Many pairs of eyes are sometimes better than one.

A further refinement, I hit the "shared button" on Google Reader only for those del.icio.us items that I think might be interesting to more people than just myself.

So if you want a news feed that combines automatically generated items with some that have been tagged by human hands, then check out my shared global health news items in the Global Health mini-blog on this page at right.

If you want to see more than five items at a time, go directly to a separate web page with my shared global health news items. There's also news feed.

If you get inspired to create your own global health news feed, let me know!

Thursday, September 6, 2007

How to Build Your Own Global Health News Feed

Step-by-step instructions for creating your own RSS feed of global health news items, using Yahoo pipes. No programming knowledge required.

Global health news tends to fall between the cracks of "world news" and "health news," as defined by the traditional media. World news is usually limited to wars, conflicts and humanitarian crises while health news typically focuses on consumer-oriented pieces about losing weight, staying fit, etc. (Good topics but not what we're after in global health.)

So I've been experimenting with building my own global health news feed, using Pipes from Yahoo.

This one, described below, is my favorite so far. It's not perfect but it's simple. Feel free to use these instructions or adapt them to fit your own needs. Let me know through the comments or by e-mail at cgormanhealth[at]gmail[dot]com, if you think of any improvements.

If you want to skip all the work that follows, here's the link for the RSS feed for Christine's custom-built, global-health news feed. (Copy and paste the url into your usual news aggregator, e.g. Bloglines or Google Reader.)

Step One. Get a Yahoo account, if you don't already have one.

Step Two. Log in to pipes.yahoo.com

Step Three. Choose "Create a pipe" from the options at the top of the page. Your screen should look something like this:

Step Four. Go to the pull-down menu on the left that says "Sources." Drag the "Fetch Feed" module into the workspace on the right.

Step Five. Add your favorite RSS feeds, one after another by clicking on the (+) sign and filling in urls like http://globalhealthreport.blogspot.com/feeds/posts/default
or http://rss.news.yahoo.com/rss/aids

Your screen should look something like this:

Step Six. Open the "Operators" tab on the left and drag the "Sort" module to the workspace. Choose sort by "item.published" in "descending order" (very important) from the pulldown menus in the module.

Step Seven. Connect your first module to your second module by clicking on the round circles on the bottom and top of the modules.

Step Eight. Add a "Unique" module from the "Operators" list. Sort by "item.title"

Step Nine. Connect second to third module and third module to "Pipe out."

Step Ten. Click on the debugger link in the frame at the bottom of the page to make sure the feed works.

Step Eleven. Save your pipe (button in the upper right-hand corner) and name it. You should have something that looks like this:

Step Twelve. Click "Run Pipe," which magically appears at the top of the menu (at least on Firefox) after you've saved.

Step Thirteen. Publish your pipe if you want others to see how you created it.

Step Fourteen. Subscribe to your pipe as an RSS feed, or in your favorite newsfeed aggregator.


In my next post, I'll outline a more hands-on approach to aggregating global health news.

Wednesday, September 5, 2007

First Day of School--And Loving It

Yesterday was the first day of classes at the Harvard School of Public Health. I started off in Richard Cash's Introduction to the Practice of Global Health. Cash is one of the people who developed oral rehydration therapy (ORT) for the treatment of severe diarrhea.

ORT doesn't cure the cholera or rotavirus infections that typically cause diarrhea but still saves millions of lives by replacing the salts and fluids the body loses during bouts of these potentially fatal illnesses. And ORT is extremely inexpensive, which is very important in desperately poor parts of the world.

Later in the evening, several of us Nieman Fellows went to the Kennedy Library to hear journalists Charlayne Hunter-Gault and Gwen Ifill talk about civil rights, Africa, the state of news coverage in the U.S. and the fact they are both PKs (Preacher's Kids). I was particularly intrigued by this last point since I'm a PK, too.

"What is it about PKs and journalism?" I later asked Ifill. She said her theory is that we are used to being watched by everyone in the congregation. So we either embrace being in the public eye or flee into hiding. (I confess to a little of both.)

The other touchstone from the evening for me was Hunter-Gault's statement that sub-Saharan Africa is no longer primarily a humanitarian issue for Americans. It's now an energy issue, with a direct effect on the price of the gasoline we put in our cars--something the Chinese government clearly understands, considering its recent ramped up investment in Africa.

"This is what is going to jolt America into understanding her national interest in Africa," Hunter-Gault told a group of several hundred people at the Kennedy Library last night. "It's China. Because China gets it."

And so my Nieman year begins.

Thursday, August 30, 2007

USAID Rule Changes Postponed

An e-mail update from the Global Health Council. . .

-----Original Message-----

From: Global Health Council
[e-mail addresses redacted]
Subj: Update: USAID Proposed Rule Changes
Date: Thu Aug 30, 2007 4:48 pm

August 30, 2007
Global Health Council Opposes Implementation of USAID's Proposed Partner Vetting System

The U.S. Agency for International Development (USAID) announced Aug. 28 that it has delayed plans to implement a sweeping information-gathering and recordkeeping measure originally called the Partner Vetting System (PVS). The measure, which was to take effect on Aug. 27, has been postponed pending further comment from affected organizations and review by USAID.

The comment period has been extended until Sept. 21, 2007. Many Council members have voiced opposition to PVS and the Council recommends that communication to USAID on this issue continue. The Council strongly encourages members to contact both USAID and their members of Congress in opposition to the proposed change.

The PVS, which is now being referred to within USAID as the Anti-Terror Vetting System, would vet individuals, officers or other officials of nongovernmental organizations who apply for USAID contracts, grants, cooperative agreements or other funding, or who apply for registration with USAID as Private and Voluntary Organizations (PVOs).

If implemented, the PVS would require all organizations that apply for USAID contracts, grants and cooperative agreements to submit detailed information about directors, officers and affected employees, including full name, date and place of birth, government issued identification information, address, phone and fax numbers, country of origin and/or nationality, citizenship, gender and profession.

The rule change was issued to ensure that USAID funds are not being used to support activities or individuals "associated with terrorism." Although there is no evidence that USAID funds are supporting terrorist organizations or terrorist activities through USAID partners, the proposal was advanced, according to USAID representatives, in response to criticisms from members of Congress and US security agencies. The Global Health Council does not believe there is an adequate statutory basis for the proposed vetting system.

The Council believes that the PVS may endanger the safety of USAID partner organization staff, is overly burdensome for USAID's partners, unnecessary, and compromises privacy rights and due process. The Council will continue to work with USAID to recommend constructive and feasible measures to address legitimate concerns. Please see the Council's Statement on PVS for sample language to include in your letter to the USAID Chief Privacy Officer. View statement.

Please send your message opposing PVS as soon as possible. The deadline for comments is Sept. 21, 2007.

Please address your message to:

Mr. Philip M. Heneghan
Chief Privacy Officer
United States Agency for International Development
1300 Pennsylvania Avenue, NW
Office 2.12-003
Washington, D.C. 20523-2120
Email: privacy@usaid.gov

Please also send copies to your Member of Congress. www.senate.gov www.house.gov

This email was sent by the Global Health Council.
For more information about the Global Health Council, please visit our website.

Our postal address is
15 Railroad Row
White River Jct, Vermont 05001
United States

Web 2.0 Comes to Public Health

There's a lot about social networking and other Web 2.0 phenomena that Tom Sawyer would recognize--particularly the part about enticing other people to do your work for you. But more and more global health aficionados are taking those first baby steps to explore social networking, shared bookmarking, tagging and other interactive tools. It's still too soon to tell how much is short-lived fad and how much could truly be effective. But here are a few I've come across.

Beth Kanter reports on fund-raising for real non-profits in the virtual world of Second Life.

Emory MPH grad Aaron Wallace has a social networking/job posting site at www.swala.org

Heather and Amber have another public health job site at their worktraveleatsleep site.

Razoo.com hopes to attract more do-gooders with a prize of $10,000. Sign up 100 other like-minded people by Sept. 15 and you have a shot at the money.

Monday, August 27, 2007

ANC Goes for Broke on Madlala-Routledge

Who could believe a single, middle-aged mother of two kids could be such a threat?

Firing apparently wasn't good enough for axed deputy health minister Nozizwe Madlala-Routledge of South Africa. Neither was billing her for the airfare to Spain for an AIDS conference, including the penalty for coming back early when the permission she thought she had received was in fact revoked. The ANC government appears bent on devastating her financially.

Now the defense department is billing her for a trip it alleges was unapproved back when Madlala-Routledge was deputy minister there. Not to be outdone, the public works department is billing for her what it says was unpaid rent for her government housing, which she has since lost.

Meanwhile, in an interview published in the Sunday Argus, Madlala-Routledge likened working for Health Minister Manto Tshabalala-Msimang to the pain and anguish she (Madlala-Routledge) had faced while in detention, including solitary confinement, under apartheid. Some of Madlala-Routledge's friends and supporters have started a fund to help her fight back.

I just can't help following every twist and turn in this conflict between admitting to any sort of a health crisis and the need to maintain political cohesion and demonstrate loyalty to a political party. South Africa's President Thabo Mbeki further laid down his thinking in his weekly online newsletter last week. His latest entry states that basically anyone who criticizes the ANC, including opposition parties, is doing the work of the underground apartheid movement. More to come, I'm sure.

Wednesday, August 22, 2007

Details of USAID Proposed Rule Change

Not sure why the hyperlink didn't come through on the last post, but until I can fix it, here's the citation from the Federal Register:


Update: links in original post "USAID Rule Targets Terrorists But Hits NGOs" are now fixed.

USAID Rule Targets Terrorists But Hits NGOs

Oh dear. More friendly fire in the war on terror.

Passing along this e-mail from the Global Health Council.

See also this update on the proposed USAID rule change.

-----Original Message-----

From: Global Health Council
Subj: Urgent: USAID Proposes Rule Changes
Date: Wed Aug 22, 2007 6:23 pm

August 22, 2007 Global Health Council Opposes Implementation
of the Proposed Partner Vetting System at USAID

The U.S. Agency for International Development (USAID) proposed a sweeping information-gathering and recordkeeping measure, the Partner Vetting System (PVS), to vet individuals, officers or other officials of nongovernmental organizations who apply for USAID contracts, grants, cooperative agreements, or other funding or who apply for registration with USAID as Private and Voluntary Organizations (PVOs).

The Partner Vetting System would require all organizations that apply for USAID contracts, grants and cooperative agreements to submit detailed information about each employee including full name, date and place of birth, government issued identification information, address, phone and fax numbers, country of origin and/or nationality, citizenship, gender and profession. The proposed measure was printed in the Federal Register on July 17. Notice, Privacy Act System of Records, Federal Register, Vol. 72, No. 136, July 17, 2007, Pages 39041-39044. View specific guidelines

The rule change was issued in an effort to improve processes for making sure that USAID funds are not being used to support activities or individuals "associated with terrorism." There is no evidence that USAID funds are supporting terrorist organizations or terrorist activities through NGOs.

The Council believes that the Partner Vetting System is overly burdensome for NGO partners, unnecessary, and compromises privacy rights and due process as envisioned. Please see the Council's Statement on PVS for sample language to include in your letter to the USAID Chief Privacy Officer. View statement

Please send your message opposing the Partner Vetting System as soon as possible. The deadline for comments is Aug. 27, 2007 - the same date PVS is scheduled to take effect.

Please address your message to:

Mr. Philip M. Heneghan
Chief Privacy Officer
United States Agency for International Development
1300 Pennsylvania Avenue, NW
Office 2.12-003
Washington, D.C. 20523-2120

E-mail: privacy@usaid.gov

This email was sent by the Global Health Council.
For more information about the Global Health Council, please visit our website.

Our postal address is
15 Railroad Row
White River Jct, Vermont 05001
United States

ANC to Investigate Madlala-Routledge

The African National Congress now plans to investigate fired South African deputy health minister Nozizwe Madlala-Routledge for her implied criticisms of both President Mbeki and the ANC on AIDS and other matters.

You would think the party would let the whole thing drop instead of further fueling the media storm. All this does is stoke the anger about how Madlala-Routledge, a well-regarded government official, got the boot. But what do I know about politics?

Interesting tidbit: the person charged with investigating Madlala-Routledge also apparently advised her not to resign but instead to let herself get fired on principle.

Meanwhile, I keep reminding myself not to get too distracted by the personality clashes and drama. The key issue here--at least from a health point of view--is what happens to South Africa's National Strategic Plan on AIDS.

President Mbeki is on record as saying he still supports the NSP and that it doesn't depend on the whether or not Madlala-Routledge is in office. That's the prize we should all be keeping our eye on.

Thoughts on South Africa, the U.S. and Buses

There's nothing like going to another country to make you think more deeply about your own. My recent trip to South Africa has me pondering a lot of things here in the U.S. from a slightly different angle.

Economic disparity. While in South Africa, the biggest contrast between haves and havenots that I saw was in Cape Town. We didn't go inside any of the lovely mansions high on the hills hugging the coastline. But it was easy to imagine what they must look like inside.

Just a few miles away on the Cape Flats, at sea level, we visited Dunoon, one of the poorer neighborhoods, where the majority of families love and work and play in crowded metal shacks. They have basic sanitation--public outhouses--and electricity. But in many cases cooking food or washing clothes still occurs over open fires.

Not surprisingly, fast-spreading fires are a huge problem in these areas. As is flooding, given the location. The week after we left, Cape Town was hit by four big Atlantic storms in a row, causing a lot of devastation. Other problems include high rates of tuberculosis and other respiratory diseases, crime, the lack of economic and educational opportunities.

What do the folks living up on the hills owe, if anything, to the people on the Flats? Even the middle class have their rewards, a comfortable life, food on the table, a car or two. Do they have anything in common--other than their humanity--with the people on the Flats?

Now back to the other side of the Atlantic. You see tremendous contrasts every day in New York City, which is my home. They may not be as great as in Cape Town, but they are most assuredly there--at least until they start seeming familiar and disappear from consciousness.

And in the past few days in Cambridge, Mass., this great bastion of higher learning and privilege in the U.S., I'm struck by the contrasts.

Just one anecdote about buses to make the point. I have a whole theory about buses and what riding buses can tell you about a community, which I may expand on in another post some day.

Anyway, Harvard provides a shuttle bus from the university campus to the medical school and school of public health. The service is free to those with a Harvard ID. So yesterday, after I got my ID (I'm starting to feel more official now), I tested it out by taking the shuttle over to the school of public health.

I didn't think much of it at the time, but everyone on board looks very serious and pre-occupied, checking out their Treos, reading books, studying texts, listening to iPods. All very professional-looking.

Later in the day, I took one of Cambridge's public buses, along Massachusetts Avenue. There was a much greater mix of people and the French-speaking couple in front of me--possibly Haitian--were clearly none too sure exactly where they were going or which stop would bring them closest to their destination.

No great conclusions. It was just a flash, an impression of contrast while riding two different buses. But it made me wonder, What, if anything, would ever bring the passengers on these two vehicles--the shuttle and the public bus--together. What, if anything, do they owe each other?

Monday, August 20, 2007

Manto Drama Enters Third Week

Just when you thought the news from South Africa couldn't get any weirder. The Sunday Times published a report yesterday that categorically declares that Minister of Health Manto Tshabalala-Msimang is an active alcoholic. Furthermore, it says doctors at a Johannesburg hospital where she received a liver transplant earlier this year covered up the fact that her own liver had failed due to alcoholic liver cirrhosis. The South African newspaper goes on to say that she has been seen drunk since the transplant.

Oh yeah and Tshabalala-Msimang was convicted of stealing jewelry and other items from patients at a hospital in Botswana, where she used to work in the 1970s.

As bizarre and damaging as Tshabalala-Msimang's pronouncements on AIDS have been, I'm troubled by how much of her personal medical records are being made public in this ongoing scandal. Privacy rules should cover everyone not just our friends.

On a personal note, I picked up a rental car over the weekend, packed up some clothes and my laptop and moved in to my new digs in Cambridge. Still learning where the post office, grocery store and other important services are located. Have already started to meet some of the other Nieman Fellows. Orientation begins next week.

Friday, August 17, 2007

CARE, Utah Mine Deaths, South Africa

CARE. Three cheers for CARE, which reject $45 million worth of food aid from the U.S. government, arguing it does more harm than good.

As the BBC reports,

"CARE criticised the way US food aid is distributed, saying it harms local farmers, especially in Africa. It said wheat donated by the US government and distributed by charities introduced low prices that local farmers are unable to compete with."
Utah Mine Deaths. True to its promise to try to take up where Confined Space left off, The Pump Handle has provided lots of good behind-the-headlines coverage of the mine disaster in Utah that has trapped six miners and now killed three rescuers.

See especially Celeste Monforton's post on the need for tracking systems for trapped miners. Monforton has a masters in public health and was part of a team that investigated the Sago and Aracoma Alma coal mine disasters on behalf of West Virginia Governor Joe Manchin.

South Africa. Meanwhile in South Africa, not even the conviction of apartheid-era security officials has stemmed the anger over the firing of deputy health minister Nozizwe Madlala-Routledge. Thobile Ntola of the South African Democratic Teachers Union criticized President Mbeki's handling of the whole affair at one of the union's branch meetings.
“Tell me what kind of a president would preach gender equality and at the same time fire a woman during Women’s Month?" Ntola was quoted as saying by the Daily Dispatch. “This proves that in this African National Congress that was formed to benefit the poor, you cannot voice what you believe will serve in the interest of one Mambhele on the street.”
While Xolela Mangcu writes in Johannesburg's Business Day that "President Thabo Mvuyelwa Mbeki has become an albatross around the neck of our political culture."

"At every turn, Mbeki has tried to pass himself off as an interesting intellectual, irrespective of whether his ideas are relevant to the reality of the population," Mangcu writes. "That surely must partly explain the instinctive denial. If it does not emanate from the "private lair of his skull" then it cannot be true. It's the perpetual intellectual quest for originality gone haywire.

I am from Eastern Cape and everyone there knows that you send your relatives to public hospitals only to die," Mangcu continues. "Not long ago, the distinguished writer Phyllis Ntantala described those hospitals as morgues after her harrowing experience there."

Today, President Mbeki responded to continuing criticism of his firing of former deputy minister of health Madlala-Routledge in his weekly "Letter from the President" as follows:

Some in our country and others elsewhere in the world, including the media, have acclaimed Ms Madlala-Routledge as a great heroine, before and after her dismissal, on the basis that she seemed to demonstrate intellectual and personal "courage" by defying the obligation to speak and act as part of a collective. In this regard, in her 10 August press conference, she made a point of emphasising her obligation to be accountable to the media.

Collective responsibility

With regard to all this, I must make the point absolutely clear, without equivocation or qualification, that while the ANC serves as government, in any of the three spheres of government, freely elected by the people, it will ensure that its members respect the principle and practice of collective responsibility.

None of the members of the ANC deployed in government will be treated by our movement as heroes and heroines on the basis of "lone ranger" behaviour, so-called because of their defiance of agreed positions and procedures of our movement and government.

For more posts on Madlala-Routledge, click here.

Thursday, August 16, 2007

Working For Water; Saving Lives

The scene: Cape Town’s world-famous Table Mountain, part of the spectacular sandstone spine of the Cape Peninsula.

The guy in the green National Parks jacket: Paddy Gordon (pictured above).

The out-of-towners: six journalists from the U.S. and U.K. on a traveling seminar sponsored by the Kaiser Family Foundation.

Gordon talked to us about how eucalyptus trees and other plants that were brought to South Africa over the past 300 years have played havoc on the natural ecology of the country's majestic mountains. Eucalyptus trees, in particular, suck up lots of water from the ground robbing the life-giving liquid from native plants.

But eucalyptus trees are very hard to uproot and get rid of. Although it’s easy to teach someone how to do it, you need lots of hands to accomplish the task. Hmmm. Anyone else see the makings of a good idea?

Enter Working for Water, an initiative of the South African government, which marries the need for ecological restoration with the demand for lots of jobs for unskilled laborers in very poor comunities like Khayelitsha.

But it doesn’t stop there. Working for Water, which was launched in 1995, also teaches job skills like basic book keeping and bidding for contracts so that workers can eventually create their own businesses. In addition, the initiative conducts regular AIDS training programs as well.

Good health requires more than healthcare workers and clinics. You also need clean drinking water, jobs, basic sanitation, jobs, adequate housing, jobs, education, jobs, legal rights, and jobs. Well, you get the point.

Regular employment makes a huge difference in how healthy a community--and often even a natural environment--can be. Working for Water is helping to make that difference.

Wednesday, August 15, 2007

Having Your Say: Pandemic Flu

Stock up on face masks. Before I left the U.S. (and my computer) last month, I put up a poll question asking you to guess when a flu pandemic might strike. Now without further ado, the unscientific results: 7 out of 15 loyal respondents believe that a pandemic flu will hit in the next five years. Five voters thought it would strike in five to ten years and three opted for 10 to 50 years. No one believed flu pandemics are a thing of history.

Madlala-Routledge Stands Alone

Party discipline holds--for now. All government officials and ANC members with political ambitions are distancing themselves from South Africa's fired deputy health minister, Nozizwe Madlala, who in the matter of a few short months had distinguished herself as an honest and refreshing voice on the HIV/AIDS crisis.

At a press conference last Friday, Madlala Routledge mentioned in passing that she had talked with three different government ministers who were concerned about conditions at Frere Hospital in the Eastern Cape. On Tuesday, all three released statements declaring that they had NEVER EVER invited her to check out the problems at the troubled hospital.

Madlala-Routledge visited the hospital on her "own initiative," they said, and they had NOTHING to do with it.

Can you spell Catch-22? Two doctors at Frere hospital were also suspended. One apparently got in trouble for writing directly to President Mbeki that conditions at the hospital really were bad. (She should have gone through channels) The other was suspended for allowing conditions at the hospital to deteriorate so badly. (Yes, even though an official health ministry task force decided things were quite normal at Frere.)

Race considerations often lurk beneath the surface of South African politics. And there's no doubt that the Democratic Alliance, a mostly white opposition party, is making a lot of hay over Madlala-Routledge's firing. But South Africa's minority whites aren't the only people who are upset.

Dr. Olive Shisana, who used to be director-general of the Ministry of Health until she was axed as well, has come out in support of Madlala-Routledge as has Zwelinzima Vavi, the General Secretary of the Congress of Southern African Trade Unions--although he apologized to the families of dead ministers after making a remark about deadwood in the Cabinet. And Dr. Kgosi Letlape of the South African Medical Association called Madlala firing "regrettable."

In truth, Madlala-Routledge's departure must be seen as a power play by President Mbeki and a warning to others who don't show him loyalty ahead of the ANC's December meeting to choose a party president. Although Mbeki cannot run for a third term as president of the country, there is apparently nothing to stop him from being chosen as head of the party for a third term.

It would be the height of irony if axing the deputy health minister--which seems to be achieving the desired political results so far--strengthens the hand of a populist like Jacob Zuma, a longtime Mbeki rival, who is positioning himself to be ANC's next leader as well as the head of the government. As I learned on my recent trip to South Africa, many people in the professional classes--black, white and other--fear that Zuma could become South Africa's own Robert Mugabe. They would rather bumble along with Mbeki than risk a Zuma election.

Meanwhile, Madlala-Routledge has been busy house-hunting. She loses her government-funded home and office at the end of September and will be taking a significant cut in pay as well. (She is still a Member of Parliament.)

For related blog entries on Madlala-Routledge, click here.

Tuesday, August 14, 2007

Lead Kills Whether in Toys or Jewelry

Say what?! It's against the law to put lead in toys but the U.S. still does not ban lead in jewelry. Lead-containing trinkets are particularly dangerous if swallowed since that can lead to acute lead poisoning, resulting in seizures, brain damage and even death.

Under growing public pressure, the U.S. Consumer Product Safety Commission is now considering adopting a ban on lead in children's jewelry and has asked for comment.

Meanwhile, toy-making giant Mattel is set to announce another recall of lead-tainted products manufactured in China.

Update: complete list of toys in latest Mattel recall.

Cross-posted in The Health Media Watch.

Monday, August 13, 2007

South Africa's Health Minister Accused of Drinking in Hospital

Last week's media storm in South Africa over the firing of deputy health minister Nozizwe Madlala-Routledge shows no signs of letting up. President Thabo Mbeki took the unusual step of releasing his letter of dismissal to the media over the weekend. In it, he declared that Madlala-Routledge was let go because of her "inability to work as part of a collective, as the constitution enjoins us to."

Mbeki was responding to continuing outrage from the government's coalition partners and others that Madlala-Routledge, widely regarded as honest and competent, had been fired instead of her former boss, the often erratic Health Minister Manto Tshabalala-Msimang.

But the President's move was quickly overshadowed by an explosive report in The Sunday Times of South Africa, accusing Tshabalala-Msimang of a "booze binge" while in the hospital two years ago for shoulder surgery.

Tshabalala-Msimang has in the past denied having an alcohol problem and press reports suggested she is considering suing The Sunday Times over the allegations. The newspaper's editors say they stand behind their story, which was based on a five-month investigation as well as leaked hospital records.

Read President Mbeki's letter to Madlala-Routledge on the official South African government site.

For related blog entries on Madlala-Routledge, click here.

Friday, August 10, 2007

Madlala-Routledge on True Leadership

Update: See video of Madlala-Routledge speaking out on why she was fired.

South Africa's sacked deputy health minister shared some incredibly thoughtful and eloquent reflections on the fight against AIDS in South Africa in this post-firing interview with The Independent. I highly recommend the article, which was written by Katherine Butler, who I got to know a little while traveling in South Africa last month.

"I don't regret saying that our political leaders should show the way and undergo HIV testing, in public," Nozizwe Madlala-Routledge told The Independent. "We need at least 25 million people tested. When you are in charge of the country, you have to offer leadership." Read the rest of Madlala-Routledge's comments here.

I've searched the Internet for an audio recording of today's press conference at which Nozizwe Madlala-Routledge spoke about her firing. Although the press conference was carried live on Cape Talk Radio, I still haven't found anything other than summaries and selected quotes. (Update: here's the video of Madlala-Routledge's comments.)

But the ANC's two coalition partners in government are clearly unhappy with President Mbeki, who axed Madlala-Routledge earlier this week. The Congress of South African Trade Unions said the firing would "deepen the culture of sycophancy among government ministers and officials," while the South African Communist Party, of which Madlala-Routledge is a member, said if they had been consulted, they "would have advised otherwise."

For related entries on Madlala-Routledge, click here.

Madlala-Routledge Tells Why She Was Sacked

South Africa's popular and now former deputy health minister told a press conference in Cape Town today that she was sacked because she visited a maternity hospital and publicly declared that deplorable conditions there constituted a "national emergency."

Nozizwe Madlala-Routledge also explained that she thought she had Presidential permission to attend a meeting about AIDS vaccines in Madrid when she left, only to discover when she arrived in Spain that it had been revoked. She then returned to South Africa without attending a single session.

Both issues came up when she was called to President Thabo Mbeki's office earlier this week and asked to resign.
Madlala-Routledge refused, so Mbeki fired her.

Madlala-Routledge had won plaudits both in South Africa and internationally for her open and honest discussions about AIDS in that country and the need to bring treatment to a greater proportion of the population. Her boss, Health Minister Manto Tshabalala-Msimang, by contrast, had famously promoted ineffective remedies like beetroot and garlic for the treatment of AIDS.

It's not the first time that a politician has gotten rid of a more popular deputy. But that doesn't explain why a top doctor at the maternity hospital in question, who wrote a letter to the President supporting Madlala-Routledge's call for reform at the hospital, is also reportedly facing disciplinary hearings for her views. Still no word yet on whether Dr. Nomonde Xundu, chief director of HIV/Aids, Tuberculosis and Sexually Transmitted Infections at the Ministry of Health, has been able to renegotiate her "resignation" either.

For related entries on Madlala-Routledge, click here.

Thursday, August 9, 2007

Even the Timid Get Axed in South African Health Shake-Up

Manto Tshabalala-Msimang is definitely consolidating her hold on the South African Ministry of Health. Not only has her outspoken deputy minister been fired, but her most senior AIDS expert, Dr. Nomonde Xundu, has reportedly tendered her resignation.

Dr. Xundu never contradicted her boss in public and faithfully used the government-approved terminology of "HIV and AIDS," which sees HIV infection and AIDS as two separate conditions rather than a continuum of illness. But Xundu clearly accepted that HIV causes AIDS and that anti-retroviral treatments are necessary to save lives. A report on news24.com says Xundu is trying to negotiate an extension of her contract.

For related entries on Madlala-Routledge, click here.

Deputy Health Minister Sacked in South Africa

Disturbing news from South Africa. President Thabo Mbeki has sacked Nozizwe Madlala-Routledge, the deputy minister of health. It seems Madlala-Routledge was just too good at her job, talking about the need for better AIDS prevention and treatment programs and encouraging ANC leaders to set an example by getting HIV tests in public.

The most immediate casualty, apart from the deputy minister herself, may be South Africa’s newly developed National Strategic Plan for AIDS (2007-2011), a highly regarded and forward-thinking blueprint for tackling the crushing HIV epidemic in that country. Nozizwe Madlala-Routledge played a major role in getting the plan pulled together, which was developed with input from many health experts inside and outside of government as well as civil society leaders. Madlala-Routledge was able to take that leading role because her erstwhile boss, Minister of Health Manto Tshabalala-Msimang, was out of the picture for a while with a serious illness that eventually required a liver transplant earlier this year.

The precipitous move is another sign of increasing strain within the African National Congress, as it prepares itself for party elections in December. Today, executives of the ANC's Women's League questioned the firing of Madlala-Routledge, coming as it did on the eve of Women's Day in South Africa. No word yet on the reaction of the South African Communist Party, which is a coalition partner of the ANC and of which Madlala-Routledge is a leader. (She is also a Quaker.)

The last straw for Mbeki and Tshabalala-Msimang, who has apparently made a full recovery, was when the deputy minister of health made an unannounced visit to a maternity hospital in the Eastern Cape. There, Madlala-Routledge found that the appalling conditions described by a local newspaper report were in fact true and that mothers and babies were dying needlessly.

Madlala-Routledge’s call for reform at the hospital was treated as insubordination by the Minister of Health. The ANC newsletter attacked the press reports as "dramatic but false" even as the Minister of Health began launching many of the needed changes.

The cause given for the deputy minister's removal was a trip she had taken in June to an AIDS seminar in Madrid, allegedly without Presidential permission. A one-sided press report suggested that she left in defiance of Mbeki's decision but rumors were rife in South Africa that she had been given permission to go, which was then revoked while she was in the air. As soon as she learned about the change, she took the next available flight home, without even attending the conference.

For related entries on Madlala-Routledge, click here.