Two Weeks Until Malawi

My to-do lists have to-do lists. The shotgun microphone for recording interviews has arrived but not the mosquito net. Worst comes to worst, I suppose I can buy one in Lilongwe.

Two things I want to remember from a conversation I had with Pauline Peters earlier this month. The first has to do with the growing chasm between the very poor and every one else. The second has to do with the stress caused by too many visitors.

Peters is an anthropologist who teaches at Harvard’s Kennedy School. She has been following a group of 200 families in the Zomba region of southern Malawi for more than 20 years. None of the families is rich—even by Malawian standards.

When she began, the families at the top 25% of the economic ladder had three times more income than those in the bottom 25%. Ten years later, the gap had widened to an 11-fold difference. Today, she says, the gap is about 10-fold.

The gap between rich and poor is thousands of years old and is found all around the world. But the relative difference has remained fairly steady over all those generations. What has changed in our lifetimes is this extraordinary widening of the gap into a chasm—not just in Malawi but around the world.

And it’s not just economics. There’s a chasm opening up between the healthy and the unhealthy as well. There are huge differences in lifespan of folks who make it to adulthood. I suppose if you looked, you’d find that the gap between educated and uneducated groups is widening as well.

The other thing Peters talked about is how now that Malawi has been “discovered,” everyone seems to be going there. Even presumably beneficial offers of help can prove overwhelming. Government officials get mobbed by visitors. Program directors spend so much time dealing with the needs of visitors (who often have money), they have less time to spend on the program everyone supposedly cares so much about.

I took that as a word of warning—although I’m not sure Peters directed it specifically at me. I have wondered about that myself and will be mindful of my hosts while traveling in Malawi. Even though I believe reporting on the nursing crisis there will ultimately prove beneficial, I know I’m just part of the daily juggle.

Related posts:
At Work with Malawi's Nurses
How Big a Problem is the Brain Drain?

Where are the Global Health Blogs?

Tara Smith updates us from Mongolia on the new outbreak of hand-foot-and-mouth disease that has just been reported there. Tara is both an honest-to-goodness scientist and a blogger--although she hasn't been blogging as much on Aetiology this month. Her specialty is pathogens that jump to humans from other animals.

Other public health blogs by academics that I particularly like to read include Effect Measure (always provocative) and The Pump Handle (with a focus on occupational health).

But for the most part, the number of global health professionals in the blogosphere are few and far between. I am keeping an eye on Global Health Delivery, a kind of blog aborning, to see what develops there. Otherwise, the slack is being taken up by the passionate (H5N1 and THDblog) and a few journalists here and there.

Post a comment if you there are others you know and trust.

Final Prep for Malawi

Less than a month to go before I head for Malawi. Hard to know what to make from this distance about reports of a possible attempted coup.

As for the things that are somewhat under my control, I got most of my shots last week (hepatitis B, meningitis, TdaP for tetanus, diptheria and whooping cough). My typhoid and hepatitis A vaccinations from a few years ago are still good. No need for yellow fever since Malawi is not in a yellow fever zone. Filled my prescription for malarone against malaria. Ordered a mosquito net.

The CDC recommends a pre-exposure rabies vaccine as a precaution but the travel doctor I consulted here in Cambridge says there's a shortage of vaccine in the U.S. and so it's being restricted only to folks who have actually been bitten by a bat or a dog or cat, etc.

In other words, I have taken the recommended medical precautions and will hope for the best.

Considering I'll be in Malawi in their winter, the biggest threat is probably from traffic accidents.

Related posts:
At Work with Malawi's Nurses

Job Posting: Deputy Director at SciDev.net

Help wanted: SciDev.net is looking for a deputy director in London. Deadline is May 31, 2008.

I can't vouch for what it would be like to work for them, but over the past several years, I've come to rely on Scidevnet's news feeds for great, up-to-the minute science and technology reporting from an international perpsective. Their items frequently turn up in my list of shared reading material on global health.

Editorial: US Food Aid Policy Needs to Change

My friend and fellow Nieman David Kohn has an op-ed in the Baltimore Sun on how official U.S. policy makes the food crisis worse. He argues that the U.S. could help more people for the SAME AMOUNT of money it is spending now on food aid by buying food locally instead of shipping it from the U.S. as now required by law.

In fact, U.S. generosity is being undermined by its insistence on using only food produced and shipped from America. Kohn reports that "the U.S. Government Accountability Office found that between 2001 and 2006, the average amount of food sent abroad declined by more than half" due to rising fuel costs.

Even worse, as Kohn says, U.S. policy has subverted the humanitarian mission of non-governmental organizations like Save the Children and Catholic Relief Services:

. . . The government donates much of the food it buys to such groups, which then sell it in developing countries. The transactions yield millions in profits for aid groups, which in turn use the money to pay for other aid work.

It's a perverse system: In essence, aid groups become grain and soybean brokers, making money by selling food in developing countries - and then using the profits to help the poor in those same countries. Most experts say it would be far more efficient to provide direct funding to these groups, rather than giving them food to sell. And because the food is sold to brokers in the target countries, who sell it at market prices, there's no guarantee that the neediest can even afford it. . . .

That's why CARE, which is run by Helene Gayle (who used to be at the Gates Foundation and before that at the U.S. Centers for Disease Control), is opting out of the government food donation system.

I remember thinking that was the right thing to do when I read about CARE's decision last year. Until David's editorial, however, I hadn't understood that standing up for that principle was going to cost CARE $45 million in real dollars, not just in donated food. Read David's whole editorial--it will open your eyes on food aid.

Demand for Plumpy'Nut Outstrips Supply

Dissatisfaction about the availability of Plumpy'nut keeps brewing under the surface but still not much of it is out in the open.

This from an e-mail by Jeff Johnson at Birdgsong-Peanuts (used with his permission):

. . . Demand for Plumpy Nut is many times what Nutriset and their licensees can supply, yet Nutriset won't expand production. We have asked a number of times and they refuse to grant a license outside of the countries where Plumpy Nut is used. I like using local production but the problem is demand is many times what Nutriset and the local licencees can supply. . . .

Related post:
What do patents and peanut butter have to do with starving kids?

Job: Public Health Editor for Global Voices

Global Voices, which aggregates blogs from around the world, is seeking to hire a Public Health Editor. Their preference is for candidates who are outside the U.S. or Europe. The position is part-time and they say right up front that compensation is modest. Deadline is May 24, 2008.

Who Are the Health Eight (or H8)?

And why should we care?

The Nieman Global Health Fellows had lunch with Bill Hsiao last Thursday for a wide-ranging talk about global health. Our journalists' ears perked up when he said that eight big global health groups have organized themselves into something akin to the G-8 alliance of world's biggest economies. Hsiao is a favorite amongst the Global Health Fellows because he speaks forthrightly, clearly and on the record.

Here's what the Norwegian Foreign Ministry has to say about the H-8:

Health 8 (H8) is an informal group of eight health-related organisations, WHO, UNICEF, UNFPA, UNAIDS, GFATM, GAVI, Bill and Melinda Gates Foundation, and the World Bank created in mid-2007 to stimulate a global sense of urgency for reaching the health-related MDGs. It focuses on better ways of working, particularly within institutions, which can lead to the MDGs being achieved more quickly. And it has a remit to ensure systematic and robust knowledge management and learning around the MDGs, and to seize opportunities presented by renewed interest in health systems.

That last part--about health systems--turns out to be key. Hsiao says that there's an ongoing tussle in the global health community over whether to emphasize the shortage of health care workers or the need to strengthen the health systems those doctors, nurses and others should be working in. This is not merely an academic exercise, Hsiao says. It could well determine what health strategies the real G-8 takes on at their next meeting in Tokyo in July.

And as anyone who has covered global health for at least half a minute knows, once a grand strategy gets adopted, whatever money there is often gets diverted in that direction.

Related blog posts:
How Big a Problem is the Brain Drain?

Related external links:
Why Japan sees global health as a good foreign relations initiative
Preparing for the G-8 summit in Tokyo
The health experts of the G-8 meet the H-8

Rwanda: From Genocide to Malaria Progress

Congrats to Jeb Sharp, whose Rwanda series won a Sigma Delta Chi award for feature reporting from the Society for Professional Journalists. Listen to Jeb's piece about the heartbreaking aftermath of the genocide and then marvel at Rwanda's recent successes in improving the health of its citizens. The combination of bed nets and artemisinin-based anti-malaria drugs has cut the country's death rate from malaria in half, according to the World Health Organization. Now Rwanda is expanding its anti-malaria campaign to rural areas.

Oh yeah, and happy World Malaria Day.

Related posts:
Rwanda's Agnes Binagwaho on Brain Drain

Can Malaria Be Eradicated?

Agnes Binagwaho on Brain Drain

Every time I meet Agnes Binagwaho, I am struck by her lightness of spirit. There’s usually a hint of mischief in her voice—even when she’s addressing an overflow crowd at Harvard’s School of Public Health, as she did yesterday afternoon.

That’s quite a contrast with her life’s work, which is fighting HIV in Rwanda. Dr. Binagwaho is the head of Rwanda’s national AIDS program. But when she returned to the small African country in 1996, just two years after the genocide, she told us she nearly packed her bags to go back to France. The drugs to treat AIDS were too expensive. Women died in childbirth for “entirely stupid reasons” Binagwaho recalled. “The first week I was back in Rwanda was the worst year of my life,” she continued. “I saw more deaths in one week than I had seen in five years as a pediatrician in France. I nearly packed my bags to go back. There were no resources. Everyone was dying.”

I can’t imagine what would have happened if Binagwaho had turned back. Neither apparently, could a young woman in the audience, a nurse from Rwanda who is now living in the US. It was an extraordinarily poignant moment when this young woman took the microphone and thanked Binagwaho for staying in Rwanda, for helping to bring anti-retroviral medicine to that country and for helping to insure that they are distributed and used properly. Binagwaho was quick to say that she hadn’t done it alone, that many people in Rwanda have worked to make the national AIDS program a success. And that they were now tackling other health issues.

For me, though, it was another illustration of the complexity of the brain drain issue. Binagwaho returned to Rwanda—and is helping to create the conditions that will allow more doctors and nurses to stay. But there was no recrimination for the young nurse who had left. Binagwaho understood far too well why someone might feel compelled to leave.

Related post:
Lament From a Public Hospital in Malawi

Related External Link (updated):
Health Care and Economic Development in Rwanda