Monday, September 29, 2008

Diabetes and Tuberculosis Link

It's well known that infection with the AIDS virus increases a person's susceptibility to tuberculosis--especially in regions where TB prevalence is already high. Now it looks like diabetes also increases a person's vulnerability to TB.

That's another sign that the double burden of infectious disease and increases in chronic illness doesn't just add to the problems faced by poor countries but actually multiplies them.


Links between diabetes mellitus and tuberculosis: ...[Trans R Soc Trop Med Hyg. 2008] - PubMed Result

Diabetes makes people more vulnerable to TB: study | Science | Reuters

Friday, September 26, 2008

Manto Out; Singing in South African Streets

One of the first acts of new South African President Kgalema Motlanthe was to remove Manto Tshabalala (a.k.a. "Dr. Beetroot") from her position as Health Minister. The new Health Minister, Barbara Hogan, was greeted with a public serenade from AIDS activists.

Tshabalala has not left the government entirely, however. She was moved to the Office of the President, where she'll be in charge of gender, youth, disabled affairs and government communications.

Thursday, September 25, 2008

McCain and Obama Promise to Target Malaria

How times have changed. Both Senators McCain and Obama have made commitments at the CGI meeting to eliminate the number of deaths due to malaria if they are elected President. Note, this is different from eradicating the disease altogether.

McCain addressed the meeting in person. Also in attendance were Cindy McCain and Sarah Palin. Obama spoke via satellite due to a previous commitment elsewhere.

Full text of McCain's speech is here and C-Span has video here. Couldn't find text of Obama's speech but the video is here.

Update: here's the text for Obama's speech.

Al Gore: "Clean Coal is a Lie"

Lots of talk yesterday at the annual meeting of the Clinton Global Initiative about whether the current financial crisis would have a negative impact on global health and development investment. Consensus was that that shouldn't be allowed to happen--no surprise there.

The plenary session was kind of a sleepy affair until Al Gore started talking. He really woke up the room with a harangue about how the coal industry has spent half a billion dollars advertising "clean coal."

"Clean coal is a lie," Gore said, his voice rising. "It's like healthy cigarettes." He argued that the current financial crisis is nothing compared to what's going to happen with the environment. "The world has several trillion dollars in sub-prime carbon assets," he said. Then he went on to call for a national "smart grid" for electricity and a carbon tax to reduce the payroll tax.

Another point that caught my attention: a worldwide smart grid would allow countries in the developing world to export electricity from renewable energy sources (like wind and the sun) to the rich world.

Tuesday, September 23, 2008

Live From New York

Starting tomorrow at 10 AM Eastern on Wednesday, Sept. 24, the Kaiser Network is providing live webcasts of the 2008 Clinton Global Initiative Annual Meeting.

Mbeki Out; Manto Stays

No silver lining. Eleven South African government ministers have resigned in solidarity with ousted President Thabo Mbeki. Alas, Health Minister Manto Tshabalala-Msimang is not among them. You'll remember she infamously advocated beet root and garlic for the treatment of HIV and engineered the removal of her widely admired deputy minister.

Global Health Corps? Karen Grespin at Harvard University in Cambridge considers the age-old debate of training locally vs. importing volunteers to beef up health care systems in developing countries.

Good intentions. Jon Shaffer at Northwestern University in Chicago has "seen the danger of irresponsible medical 'voluntourism' while working in Ghana."

Monday, September 22, 2008

Brain Drain Hits Rural Areas Hardest

Another angle on the global brain drain: Doctors are leaving the Philippines to become nurses in the US and other countries. Health care services in rural parts of the Philippines have suffered the most. Hat tip to Andrew Quinn for the pointing out the story in the Washington Post.

Don't need all the facts and figures? See the video that journalist Blaine Harden posted as well. It's an inspiration to me as I continue logging the video and audio recordings I took while in Malawi the past three months.

Moms Need More Respect

The numbers have been dismally steady at around 500,000 deaths per year but now UNICEF is urging greater focus on maternal mortality. What changed?

One of the most shocking things I learned while at Harvard’s School of Public Health is how unpopular maternal mortality is as an issue in the global health world.

Partly that's a result of politics and funding priorities--kids are cuter (and easier to fund) than moms.

Partly it's because saving a woman's life during pregnancy is not just a simple matter of vaccinations or nutritional supplements. You need basic health care, good roads, some kind of communication system (radio or cell phone) so that women who develop problems during pregnancy get referred to the right place for a C-section or treatment for dangerously high blood pressure or bleeding.

And, something that no one likes to admit, the way certain AIDS programs are designed actually makes it harder to save women's lives.

Friday, September 19, 2008

Who Knew? Public Health is Hot!

I will be covering the annual meeting of the Clinton Global Initiative in New York next week. I'm particularly interested in Thursday morning's program on "expanding the global health workforce," especially after spending three months in Malawi learning about that country's nursing crisis.

Ironic that while so many nurses, doctors and other educated folks are emigrating from developing countries, more and more young American students are flocking to international health classes and programs. Money quote from today's Washington Post on the subject: "global health is a huge growth industry."

It may also offer a brighter future than a career on Wall Street these days.

Thursday, September 18, 2008

Growing Market for Malaria Drugs

Want to dig deeper into the decision by the US Food and Drug Administration to grant priority review for Co-Artem, the incredibly effective anti-malaria drug from Novartis. Will that allow the Swiss pharmaceutical company to expand its global market share--and if so, by how much?

It's obvious Novartis is NOT looking for a big boost from the US domestic market since only 1200 people (most of them returning travellers) are treated for malaria in the US each year.

Co-Artem is already available in countries covered by the US President's Malaria Initiative, primarily through multi-million dollar contracts with UNICEF. And there's plenty more flowing through Global Fund contracts.

So what is the advantage of going for FDA approval? I am not suggesting anything nefarious. I saw Co-Artem save lives firsthand while I was in Malawi the past three months. I just want to understand the business case.

NB: For a great article explaining how difficult it is to estimate how many people suffer from from malaria each year, check out Laura Blue's piece at

Wednesday, September 17, 2008

Incident at Malawi Road Block

Every trip has its rough spots. Mine occurred on August 27 when we were detained by police for three hours after stopping at a road block in southern Malawi. It certainly felt like a shakedown—although the sergeant who flagged us down never directly asked for a bribe. And by the time it was all over, I was silently cursing both the police officer and our car rental agency—more on their involvement in a moment. I may never know what really happened, but I definitely learned a lesson about how difficult it can be to prove corruption or assign blame for it.

First some background. We were driving in a rental car from the city of Zomba, where I had interviewed several folks at the College of Health Sciences, back to Lilongwe. I was with my sister Michele and my friend Lisa, who accompanied me the last 10 days of the trip, and our driver Godfrey.

My original plan had been to do all the driving myself but after seeing how crowded the roads were with pedestrians, bikes, children, goats and chickens, I swallowed my pride and hired a driver. Although I had been told I could rent someone’s private car for much less than a rental car agency would charge, I was suspicious of breakdowns and so, after getting a recommendation, contacted Richard Phiri at the Sputnik Car Rental Agency in Lilongwe.

The car was a reconditioned Toyota Corolla. The driver a very nice guy named Godfrey. I wondered why there was no sign on the side of the automobile advertising Sputnik, but Richard assured me that was a security measure so that no one would target the car.

Ended up traveling all over Malawi in the two weeks I used the rental car. We must have passed through dozens of roadblocks—from the really permanent ones with metal barriers and guard posts to the more makeshift ones with just a pole across some barrels. Never had a problem anywhere. Mostly the officers waved us through. Occasionally they checked the insurance stickers on the windshield.

And in fact, my most sustained previous contact with a police officer had been quite pleasant, if the source of some amusement.

But half an hour or so out of Zomba, in the small town of Machinga, we came across a roadblock that had a different feel from the others. For one thing, there was only a single police officer manning it. For another, there were no vendors selling anything nearby.

After we stopped, the police officer glanced at the camera sitting in my lap and the large blue duffel we had stowed on the back seat (it didn’t fit with the other bags in the trunk). Then he asked for Godfrey’s driver’s license and asked who the car belonged to. Godfrey said “Putnik,” leaving off the “S” which I attributed to his being nervous.

Still holding Godfrey’s driver’s license, the officer—whose name I later learned was Sergeant Mbakkie—then walked over to the left side of the car to look at the insurance stickers and announced that one was missing. Then he walked back the road a bit to flag down several other vehicles.

While we waited, I called Richard Phiri at Sputnik and he immediately concluded that Mbakkie wanted a bribe. This seemed more than plausible since the newspapers had been full of stories about a charcoal seller in a Lilongwe neighborhood who was had just been shot dead by several policemen when he refused to pay them a bribe.

Richard told me not to worry, Sputnik would refund the cost of the bribe. I asked if I need to get a receipt (okay, so I was rattled) and he assured me he would trust me on the amount, which he figured would amount to a couple thousand kwacha or $13.50.

Except Sergeant Mbakkie never explicitly asked for money. He just kept talking about how we had to go to court because the car had been hired illegally, that we would need to wait our turn like everyone else, that it would probably take all day, etc. I figured he was building everything up so that we would be grateful that he would take a bribe. But I was much too chicken to offer money because, of course, bribery is against the law and I didn’t want to be caught doing something that was definitely illegal because of something that might or might not be taking place.

I will admit that I was scared enough in the first half hour that if Mbakkie had directly asked for money at that point, I would have forked it over and been happy to go on our way. But as more time passed, I calmed down and kept telling myself not to get pressured into anything.

At critical moments the conversation between Mbakkie and Godfrey turned from English into Chichewe, which of course I couldn’t follow. We had now been stopped on the side of the road for half an hour and no one came by the car to sell tomatoes or curios or practice their English—that seemed pretty telling.

After one long discussion, Godfrey said the police wanted us to pull off the road and into the police station. I refused, reasoning that the more visible we were—even if no one was coming near us—the better off we were. That also seemed odd—that we could just say no, weren’t going to move the car, without any apparent consequences.

And in fact, later, when Sergeant Mbakkie tried to hold on to my copy of the rental car contract, which I had showed him, I simply took it out of his hands and said, “That’s my property.” And he let me keep it.

Two older women walked by at one point and made some sympathetic remarks when my sister explained the situation to them but then they headed on their way.

By this point I had called my friend Kondwani Munthali, who is a journalist for The Nation, one of three big newspapers in Malawi. (Really glad I had kept my cell phone fully charged and had plenty of airtime for it.) Kondwani ended up speaking to both Sergeant Mbakkie and Richard Phiri at Sputnik. Then I spoke with them in English and then Godfrey spoke with everyone in Chichewa.

It started to feel at some point like all these conversations were taking place at cross-purposes. Sergeant Mbakkie would walk away from us with no explanation into the police station and then come back out again—all the while holding on to Godfrey’s driver’s license. But I kept thinking that it was important to make sure as many people knew about our situation as possible. And so I focused on that. I also knew it wouldn’t do any good to get angry or raise my voice.

Then Godfrey decided to go into the police station—forbidding me from coming with him and promising that things would work out—and when he came out, he announced that Sergeant Mbakkie had agreed that since I didn’t want to take care of this in Machinga, we could go to the next biggest town—Liwonde—about 30 minutes away to deal with it.

After waiting at the Liwonde road block (which turned out to be the wrong place) and then meeting up with Sergaent Mbakkie again at the Liwonde Police Station a couple of kilometers away, we were introduced to a new character in this drama—the prosecutor.

By this point both the prosecutor and Sergeant Mbakkie told me that neither I nor my fellow passengers had done anything wrong. It was Godfrey, our driver, who was being charged. That gave me the opening to ask to see the charges, which is how I learned the police officer’s name.

The prosecutor took me to his office where Godfrey and I sat on a low wooden bench. The official statement was handwritten in English and stated that Godfrey had confessed voluntarily to driving a car for hire that was not properly registered as a rental car. (So that’s what Godfrey was doing in the police station in Machinga.) In essence, the prosecutor told us, it was the equivalent of driving a stolen car and the punishment could be five years in prison.

The most tangible proof, the prosecutor said, was that our car—like most private cars—had yellow license plates with black lettering. Rental cars were supposed to have white plates with red lettering.

I asked Godfrey if he had indeed admitted to the charge and he said he had because he thought it would move things along. (So he didn’t want me there because I might have kept him from signing?)

At this point, the only thing I could hold on to was the fact that both the prosecutor and Sergeant Mbakkie had said that I and my fellow passengers had done nothing wrong. So I pushed that point with the prosecutor, asked repeatedly why we were being held—we were now coming up on three hours—if we had done nothing wrong and then called Richard Phiri at Sputnik for the umpteenth time and told him that if he had rented us an improperly registered car it was his problem and he needed to work things out with the prosecutor.

So Phiri and the prosecutor had a long talk on my cell phone and I’m not sure what they said or even if this was the conversation that turned things around but at some point I realized that we were going to get out of all this, it was just going to take a little time and there would have to be some kind of face-saving mechanism. But there would be no bribe.

In retrospect, I realize the prosecutor might have been asking for money when he said “isn’t there someone you can call to cancel all this?” but I was not swift enough to pick up on that.

I guess I had been in the prosecutor’s office long enough that Michele started to worry and came in asking if I was okay. I said yes and tried to communicate with my eyes that I thought things had turned.

At any rate, after pointing out to the prosecutor yet again by his own admission that three of us hadn’t done anything wrong, that we had been detained for the entire morning, that we wanted to be back in Lilongwe before dark due to the dangers of driving at night, the face-saving mechanism appeared.

Sergeant Mbakkie would hold on to Godfrey’s driver’s license but give him a sheet of paper allowing him to drive without a driver’s license, pending a court appearance. Godfrey would drive us the remaining four hours to Lilongwe but agree to return the next day for his court appearance.

And so we were off. We had lost three hours, our appetites and a few previously warm feelings about Malawi. We checked out all the license plates on every vehicle we passed on the way back to Lilongwe and sure enough the private vehicles all had yellow plates with black lettering, the taxis and mini-buses had white plates with red lettering and the vehicles driven by non-government organizations had white plates with blue lettering.

The hardest part for me was trying to figure out who was at fault.

There seemed no question that Sergeant Mbakkie considered three women traveling on their own to be easy marks. But it also seemed pretty likely that our rental car was in fact improperly registered. (And in fact, Michele pointed out that the insurance stickers, once we had cause to look at them, showed the car was registered to Richard Phiri and not to Sputnik.)

This suspicion seemed even more justified when Richard immediately agreed to my demand for a 10% discount on the balance of our rental car payment (guess I should have asked for more) all the while denying that there was anything wrong with the car’s registration.

Why the rental car agency would provide us with a car (and driver) without the right papers or plates is a whole other issue. The most charitable explanation is that they didn’t have enough cars in their fleet and were trying to be accommodating.

On the other hand, if they were trying to cut corners, they sure weren’t very good at it. They should have come up with a better cover story for Godfrey to tell the police officer—something like Mr. Phiri has loaned his personal car to these ladies to drive through Malawi or this is a company car—but then, of course, we would have known something was off-kilter.

I realize I am placing more responsibility on Richard than on Godfrey in this whole affair. But Richard had more authority in the matter and Godfrey seemed more caught in the middle.

At any rate, Godfrey drove back to Liwonde the next day for his court appearance and told us the charge was dropped and showed us his recovered driver’s license to prove it. Later, Richard tried to smooth things over by saying that Mbakkie had been reassigned after being reprimanded for giving trouble to tourists—but whether or not that was true, it actually made us feel worse.

In the end, Michele, Lisa and I came away thinking that neither the police officer nor the car agency was on the up and up. I also learned that blatant corruption is not the only kind you have to watch out for. And that just because you try to do the right thing—like hire a car from a legitimate car rental agency—doesn’t mean you will succeed.

But I’d be interested in learning, by your comments below, what you think, what you might have done in the same circumstances or if you’ve had a similar experience.

Tuesday, September 16, 2008

Broadband vs. Mobile Phones for Global Health

Kenyan lawyer and blogger Ory Okolloh wins a PopTech Fellowship. Another data point in the tug-of-war between broadband and mobile phone technology over which communication platform has the most relevance for reporting on global health.

Okolloh's Ushahidi platform helped mobile phone users crowd-source the location of no-go zones during post-election violence in Kenya last January through simple SMS or text messages. Ushahidi (Swahili for witness) also documented xenophobic attacks in South Africa in May.

Broadband approaches championed by outfits like MediaStorm or Flypmedia are more visually impressive but have nowhere near the penetration of SMS texting. The mobile phone approach, however, is dogged by pricing and security issues.