Thoughts on H1N1 resposne

There's a really good editorial in the latest NEJM that reviews the US response to the H1N1 virus.
The Need for Science in the Practice of Public Health
Nicole Lurie, M.D., M.S.P.H.

In short, the US response revealed several "areas for improvement", including the turn-around time for the flu vaccine production and distribution, and evidence-based analysis of decisions to shut down schools etc.

The take-home message:
"We will all have the opportunity to learn lessons from the 2009 pandemic H1N1 virus. Although we would like to believe that pandemics occur rarely and that we have plenty of time until the next one, new infectious diseases, as well as other kinds of threats, can emerge at any time. One challenge will be to continue to invest in science — whether that means basic virology; surveillance; mitigation measures; vaccine development, manufacture, and distribution; operations and logistics; or communication — so that when the next pandemic or other emerging infectious disease appears, we will have the data we need to make informed decisions about how to confront it. A second challenge will be to strengthen the nation's public health infrastructure so that we can rapidly turn scientific knowledge into action."

Global Health News

Here are some interesting bits of news:


Global Measles mortality cut dramatically in past decade



From Foreign Policy--Top 100 Global Thinkers



GHANA: Cell phones cut maternal deaths



New (pdf) PEPFAR 5 year strategy just released

Trachoma

PLoS Neglected Tropical Diseases has a review on the global burden of trachoma.


Here's the abstract:
Trachoma is the commonest infectious cause of blindness worldwide. Recurrent infection of the ocular surface by Chlamydia trachomatis, the causative agent, leads to inturning of the eyelashes (trichiasis) and blinding corneal opacification. Trachoma is endemic in more than 50 countries. It is currently estimated that there are about 1.3 million people blind from the disease and a further 8.2 million have trichiasis. Several estimates for the burden of disease from trachoma have been made, giving quite variable results. The variation is partly because different prevalence data have been used and partly because different sequelae have been included. The most recent estimate from the WHO placed it at around 1.3 million Disability-Adjusted Life Years (DALYs). A key issue in producing a reliable estimate of the global burden of trachoma is the limited amount of reliable survey data from endemic regions.

Flu....in action

This is a really great video that shows how the flu virus (or any aerosolized virus, for that matter) gets into cells, replicates, and then is released again. Check it out!
http://www.npr.org/templates/story/story.php?storyId=114075029&ft=1&f=103

Ignoring Patents in Ecuador by Sean Boley, MSII

Within the last few days, Raphael Correa, the president of Ecuador, made a statement encouraging domestic pharmaceutical companies to ignore drug patents and produce drugs that are still protected by international agreements. He said that this move was “in the name of human health.” Certainly, his thought is that by allowing local companies to manufacture drugs that are currently on patent in country, prices will decrease dramatically for sick Ecuadorians. As of now, there has been little comment from the major pharmaceutical companies, most likely because the country of thirteen and a half million people represents a small drop in the bucket of drug expenditures. Nevertheless, I would expect some generalized outrage from the companies if only because of the signal it sends to other nations considering similar moves.
At first glance, I thought that this move was generally a reasonable one. After all, our own personal experience revealed that the Ecuadorian people desperately need access to reasonably priced medicines. We saw how many sick individuals would pay for medication by the pill at the local pharmacy and quit when the symptoms subsided. Many more would not even buy the pills at all, letting the disease linger. Surely if the local pharmacies could sell locally manufactured medications at a discounted (generic) price, more people would be able to afford complete courses of treatment. Ultimately, this would lead to a healthier and more productive Ecuador.
After further consideration, I began to question such a policy. First of all, the only drugs that this would affect would be those that are on patent. Of the most commonly prescribed drugs, very few of them do not already have generics available or have generic alternatives available. In Ecuador, many of their problems are with GI or parasitic infections. Most, if not all, of the drugs to treat these conditions are already off patent. The drugs that are still on patent, are often minor adjustments to preexisting drugs marketed for the sole purpose of extending the drug companies monopoly on the medication.
Therefore, I question how much of an effect on prices and affordability this move will have. Sure, local pharmaceutical companies can begin to offer new, ‘state of the art’ drugs like losartan at reduced prices in the country, but does this significantly improve a country whose major cause of life years lost is lower respiratory infections ? Does this affect the average Ecuadorian who could use a prescription for an NSAID for his chronic back pain from working in the fields all day? More research into how much the ignoring of patents will affect the survival and morbidity of the average Ecuadorian is warranted.
If anyone is greatly affected by this, it will probably not be the average low class Ecuadorian who needs affordable access to antibiotics and antiinflammatory drugs. Rather, it is the upper class individuals in the private clinics whose problems closely mirror the medical problems in the more developed parts of the world: diabetes, hypertension, and heart disease. The medications for these ailments are the ones that still on patent because they are the ones that make the most money for the pharmaceutical industry. Therefore, I am afraid that this move by Correa, which on the surface seems to be for the health of all Ecuadorians, is really just a mechanism by which medical, social, and health inequalities in the country will be perpetuated.

By Sean Boley, MSII

Health expense projections

Here is a comment from the current president and CEO of Kaiser Family Foundation, with a bit of a startling graph:

"This week we put out our annual benchmark survey of employer health coverage and costs. Two numbers jumped off the pages.

The first number was the average cost of a family health insurance policy in 2009: $13,375. To put that number in context, if you are an employer, you can hire an employee at the minimum wage for about $15,000 per year. If you are a consumer, you can rent an average two-bedroom apartment nationwide for $11,136 per year (though it is quite a bit more here in Menlo Park, California where our Foundation is based). You can also buy a new Chevy Aveo for $12,000, and it gets 35 miles per gallon on the highway.

The other result that jumped off the page was the stark contrast between increases in health insurance premiums and overall inflation in the general economy. Premiums went up 5% and prices overall fell 0.7% (mainly driven by a big drop-off in energy prices).

The 5% increase we found in premiums is moderate by long-term historical standards. For example, two different times during the last decade premiums increased by 13% a year, in 2002 and 2003. This year's increase continues a multi-year period of relative moderation in premium increases. Still, over the last ten years premiums have increased by 131%, while wages have grown 38% and inflation has grown 28%. Consider this: If people (and businesses) are as concerned as they are now about rising health care costs in a period when they are actually moderating, how much more concerned will they be when rates of increase return to historic averages?

Let's do some very simple arithmetic. Start with a fairly conservative assumption: If we assume that premium increases over the next ten years will average what they did over the last five (about 6.1% per year), the average premium for a family policy in 2019 will be $24,180. That's a big number. On the other hand, if we assume increases revert to the average of the last ten years—an average annual increase of about 8.7% and a very plausible scenario—premiums in 2019 will average a whopping $30,803, a very scary number (Figure 1).

One obvious implication is that we need to get more serious about reaching agreement on ways to slow the rate of increase in health care costs. But consensus on measures that would put a real dent in the health cost trajectory has been hard to achieve. Even simple first steps, such as comparative effectiveness research to collect data on what works and what does not in medical practice, have proven controversial, requiring language in draft legislation disavowing that they will ever be linked to payment. And when the public can be so readily scared that these efforts will lead to rationing, it's a signal that the obstacles to reigning in health costs are more fundamental than interest group opposition and health reform politics. Our polls show that we are far from the level of public understanding needed to meaningfully take on health care costs.

Even under the most optimistic scenarios, reducing the rate of increase in health costs will take time. This is why decisions about who gets subsidies and how generous subsidies will be in the health reform legislation now being drafted on Capitol Hill are so important. These decisions will determine how many people get help with their health care costs as insurance premiums and cost sharing become ever more unaffordable for average Americans. Projecting a family premium of more than $30,000 in ten years is simple arithmetic, but the implications for people and employers are real. Low and moderate income people are going to need some help paying for health care and health insurance as we learn which delivery and payment reforms work best and cost containment efforts ramp up.

News from UNICEF: Child deaths decreasing somewhat worldwide

Worldwide deaths of children under five decline, continuing positive trend

NEW YORK, 10 September 2009 – There are fewer children than ever dying before they reach their fifth birthday, according to new figures released today by UNICEF.

H1N1 news

Over 2,800 People Worldwide Have Died From H1N1, WHO Reports

Friday, September 04, 2009

The WHO on Friday announced the H1N1 (swine) flu virus has killed at least 2,837 people – the result of an continued increase in the number of H1N1 cases worldwide, not the virulence of the virus, Reuters reports. "There is no sense that the virus has mutated or changed in any sense," WHO spokesperson Gregory Hartl said during a news conference (Nebehay/MacInnis, 9/4).

"The data mark an increase of 652 deaths from the last toll of 2,185 published a week ago," Agence France-Presse/Khajeel Times reports (9/4).

Number Of H1N1 Cases Level Off In Southern Hemisphere, Rise In U.S.

The H1N1 flu continues to "taper off along with the influenza season in the Southern Hemisphere," Reuters reports in a separate article. The results of a "U.S. government analysis of the epidemics in Australia, Argentina, Chile, New Zealand, and Uruguay showed that while H1N1 dominated the flu seasons there, it was only moderately severe," the news service writes (Fox, 9/4). According to a summary of the report, "[a]ll countries report that after mid July, disease activity in most parts of the country decreased … indicating the duration of the current influenza season in the Southern Hemisphere, in which the 2009 H1N1 virus is the predominate strain, may be similar in length to an average seasonal influenza season." The H1N1 virus also caused stress on the healthcare system, according to the report (8/26).

Despite reports of "an uptick" in the number of H1N1 flu cases in the U.S., Thomas Frieden, director of the CDC expressed optimism on Thursday that "so far everything we've seen both here and abroad shows the virus is not changing," the Wall Street Journal reports (Dooren, 9/3). A separate Wall Street Journal article examines the CDC study released Thursday. Though "most of those U.S. children who have died of the new H1N1 flu were at least five years old, and 67% had high-risk medical conditions, predominantly neurodevelopmental disorders such as epilepsy or cerebral palsy. Some otherwise healthy children who died had bacterial infections, the study found, warning doctors to be on the lookout for them so they could be treated quickly" (McKay/Fairclough, 9/4).

Bloomberg Examines Why U.S. Health Officials May Recommend Two, Not One Dose Of H1N1 Vaccine

Bloomberg examines how Americans may need two doses of the H1N1 vaccine in order to be protected from the virus, because U.S. health "officials plan to exclude ingredients used to boost immune responses in shots" called adjuvants.

"We expect that the likelihood of needing two doses of vaccine that’s not adjuvanted is higher than with an adjuvanted vaccine," Frieden said Thursday. "We don’t anticipate that we’ll be using adjuvanted vaccine in most of the scenarios that we anticipate now, though that could change" (Randall, 9/3).

Partners in Health and Rwanda

Thanks to Kashif Khan for this note. Kashif spent this past summer with PIH in Rwanda:

On the evening of September 11, tune in to NOW on PBS for a half-hour show focusing on the innovative partnership between the Rwandan government and PIH to improve health care for the rural poor. Check for the broadcast time in your area, or watch online at www.pbs.org/now/

More on Cambodia's resistant Malaria

Here's a really nice video clip from PBS on the new resistance in Malaria in Cambodia. The video includes descriptions of ways that resistance has developed.

http://www.pbs.org/newshour/bb/asia/july-dec09/cambodia_08-25.html

Migrant care in Italy

An interesting set of short articles in a recent edition of The Lancet discuss the challenges to those who provide care to migrant workers in Italy.

Interestingly, those who are illegal migrant workers are afforded free health care under the Italian Constituation.
Now, "An amendment to the law concerning
public order measures, approved
on May 14, 2009, by the Chamber
of Deputies and now to be approved
by the Senate, introduces thecrime of illegal immigration, and
consequently obliges by law all civil
servants to report undocumented
migrants. Public health workers
are civil servants. Notwithstanding
previous legislation forbidding them
to report undocumented migrants,
this new legislation risks creating
fear among migrants, preventing
them from attending health facilities
and exposing both migrants and the
whole community to higher health
hazards."

So this would create a 'right' to health-care but no access.


Here is a link sent by one of our students with some very compelling photos:
Multimedia from NYTimes.com:

A Powerful Truth


Finally, from the Kaiser Foundation, here are a number of online modules with some information related to health policy.

Obstetrical Fistula

Article from Sojourners.org


Obstetric fistula could be a curse from the book of Job, if Job were a woman: A girl or woman is in labor in rural Africa. Forced to marry when still a child, she is only 13 or 14. Or she is 18 or 20, but malnutrition has stunted her growth. Her pelvis is too small to allow the baby to pass, and she has at most a traditional birth attendant to help her; her obstructed labor lasts days. Sometime during this agony the baby dies, and, eventually, the lifeless body is delivered. The mother, exhausted and grieving, might assume the worst of her physical suffering is over. Then she discovers that the worst may have just begun.

The prolonged pressure of the baby’s head in the birth canal killed tissue, causing a hole between the vagina and bladder or rectum. Urine or feces leak constantly. The odor becomes overwhelming. The woman is likely rejected by her husband. Without medical help, she spends the rest of her life on the fringes of her community.

Precise counts aren’t available, but an estimated 2 million women have obstetric fistula worldwide. Between 50,000 and 100,000 new cases occur each year, mostly in sub-Saharan Africa and parts of Asia. Fistula is virtually nonexistent in countries with widely available emergency obstetric care. Most fistulas occur in childbirth, but others come from the use of rape as a weapon of war, as in Congo and Sierra Leone.

The root causes of fistula are extreme poverty, inadequate health care, and the low social status of women, which deny them basic rights, education, and the capacity for self-determination. For example, when girls are allowed to continue their education at least through adolescence and delay marriage until adulthood, their risk of complicated childbirth is drastically lowered.

Key to reducing fistula is the improvement of women’s health care in the poorest part of the world—creating a network of medical facilities, identifying and monitoring pregnant women susceptible to birth complications, and training surgeons to treat the many who are already injured. A relatively brief operation, costing only about $300, can repair fistula in 60 to 90 percent of cases. Facilities such as the Addis Ababa Fistula Hospital in Ethiopia, which I visited in 2006, do nothing less than give girls and women their lives back. It is featured in the award-winning documentary A Walk to Beautiful, an engaging and inspiring window into the experience of women with fistula.

Worldwide, only a few thousand women a year receive treatment for fistula. Dr. Lewis Wall, founder of the Worldwide Fistula Fund (WFF) and a professor of obstetrics and gynecology at Washington University in St. Louis, proposes a major initiative: A 13-year program creating 40 fistula treatment and prevention outreach centers throughout Africa. The estimated cost—$1.5 billion over 13 years—is equivalent to less than 4 percent of the money the U.S. government has committed to fighting HIV/AIDS over just the next five years. Wall is partnering with Michael Horowitz of the Hudson Institute to build a broad coalition reaching across right-left and religious-secular divides to support this initiative.

As Wall, who is a Christian, writes of fistula repair surgery, “The affluent world needs to understand the profound impact that $300 can have on the lives of these impoverished, suffering women. The ‘widow’s mite’ is not only noble; when used in the right way it can be world-shaking.”

A new United Methodist campaign, Operation Healing Hope, is developing faith-based resources to raise awareness and promote action on fistula among church members. And Addis Ababa Fistula Hospital, WFF, and many other organizations have joined forces with the United Nations Population Fund in the Campaign to End Fistula. Visit www.endfistula.org to see how you can help the cause.

Julie Polter is an associate editor of Sojourners.

Diarrhea: The Great Zinc Breakthrough

Time Magazine has an article on the use of Zinc to treat diarrhea. Here's a snippet:
"Exactly how zinc stops diarrhea is not entirely clear. Olivier Fontaine, a diarrhea specialist for the WHO, believes that since the mineral is an essential ingredient in about 300 enzymes, boosting zinc levels strengthens the body's immunity, thus preventing diarrhea from turning deadly. A single course apparently also staves off further bouts of diarrhea for about three months — long enough to see a community through the deadly rainy seasons."

"Scientists first hit on zinc's effectiveness in the early 1990s, when researchers from the Johns Hopkins School of Hygiene and Public Health in Baltimore, Md., gave children in New Delhi a daily dose of syrup containing 20 mg of zinc. The rate of diarrhea dropped dramatically. "Nobody believed the results," Fontaine says. "No one had an explanation why zinc worked."

"As TIME pointed out in an international cover story three years ago, celebrities don't hold concerts for diarrhea. "Compared with malaria and AIDS, we are totally underfunded," says Fontaine. "This is truly a neglected disease."

Diarrhea: The Great Zinc Breakthrough

Final Post from Laura Spece

Hello!

I returned safely back to the States on July 29th after 20+ hours of
travel. It's really good to be home, though I'm having quite the
adjustment period. My tummy isn't too fond of American food quite
yet, but thankfully jet lag has been much better than on my arrival
trip to India. Though I do currently wake up at 5 am for no reason
whatsoever. Relative to India, everything is really quiet here, there
isn't any honking, squawking crows, or cows in the streets to make all
of that noise. Everything is also really clean and really sprawled
out. I miss India greatly, though I am glad to be home and with my
family. I'm currently feeling a little out of place, like I have one
foot here and one foot there. I'm also not used to having this much
access to people: via internet, mobile phones, etc. It can be a
little overwhelming and is making me a bit socially awkward. Though
it has been nice to catch up with the people I have seen! Not to
worry, if I haven't contacted you yet, I will. I'm still trying to
clean all of the belongings I took with me (it's all covered in dust
or mud).

I had a wonderful time traveling after my experience at CRHP in the
villages of India. I spent a day in Mumbai, which I loved (Del, you
must visit Bob and Aditi). Though the humidity was unbelievable!
Kerala was beautiful. I flew into Kochi, spent a night on the
backwaters near Alleppey, took an 8 hour bus ride to Kumily in order
to visit Periyar National Park. We hiked a small mountain of the
Western Ghats, saw 2 herds of wild elephants, plenty of scat from
various Indian animals and got attacked by a million little leeches!!
Never fear, to combat the leeches, the guide gave us these hilarious
army green socks that go up to your knees and then doused your
feet/lower legs in a tobacco powder/salt mixture. It actually worked,
the little buggers just curled up and didn't bite my feet. After all
of that adventuring, I relaxed back in Kochi for a day before heading
to Delhi. In Delhi, Rohit (a public health professor at UNC) hooked
me up with a wonderful family who helped to show me around. I took a
bus ride to the Taj Mahal/Agra Fort. The temp was around 100 degrees,
so not only was I way too melted to get a good photo (a la Princess
Diana... the original goal) but I also burnt the bottoms of my feet on
the tiles. :) Totally worth it though. The Taj was spectacular. I
also went around to see the India gate, the parliament area, the Raj
Ghat where Gandhi's ashes are interned and the Lotus Temple. I loved
it all, my only regret is not knowing much Hindi. Like I've said
before, for my return to India, I will make a more concerted effort to
learn the language. Some of the best parts of my travel was being
able to chat with Rohit and his friends' family, Aditi and Bob about
my experiences in the villages of India. It was good to decompress
and hear the opinions of people who have lived in/born in India.

School starts again on August 10th. I'm excited, but I'm having a
wonderful time relaxing at home in Lancaster with the fam. :) I have
plenty to do before school starts, there are still many photos I
haven't processed yet from my trip, plenty of life things I need to
catch up on and LionCare (the student-run free clinic in Harrisburg
that I chair) is beckoning me with responsibility. I am also trying
to pull together a presentation of sorts, not only as a requirement to
the scholarships that enabled me to make this journey, but also to
help the CRHP get some moolah. It's tough. I feel all of this
momentum to get out there and "save the kids" but my mind is sort of
mushy. :)

So this will be the final edition of "Slumdog Healthcare" (for now...
next trip won't be for awhile due to school). The next edition will
probably require a new title, since I'm thinking either Nepal or
Africa. :) Anyway, I hope you enjoyed these stories and that they
were not too dense. If you want to hear more, or see all of my
pictures, please let me know! Feel free to give me a holler be it via
phone or e-mail, I'm back on the grid. :) Can't wait to see all of
you and hear how your summers went. I hope all is well!

All my best,

Laura

More resistance foundin Malaria

Here's a concerning article in today's NEJM:
Artemisinin Resistance in Plasmodium falciparum Malaria

Malaria falciparum is resistant in most of the world to Chloroquin. Now researchers in Thailand have found resistanceto the Artemisinin therapy.


"Conclusions P. falciparum has reduced in vivo susceptibility to artesunate in western Cambodia as compared with northwestern Thailand. Resistance is characterized by slow parasite clearance in vivo without corresponding reductions on conventional in vitro susceptibility testing. Containment measures are urgently needed. "

HIV and Immigration laws

This article recently appeared in the Global Health Magazine (published by the Global Health Council) and discusses the ban on HIV positive individuals entering the USA.

http://www.globalhealthmagazine.com/guest_blog/barring_none_overturning_HIV_travel_restrictions/

The current restrictions as listed in the article state:

The United States travel and immigration ban disallows the entry of HIV-positive non-citizens into the country and prohibits HIV positive non-citizens from becoming permanent legal residents.

The Department of Health and Human Services is proposing to remove HIV from the list of communicable diseases disallowing entry into the United States; however, it is uncertain when this might take place.

What do you think about the proposed change and implications on public health policy? Did you know that the United States does not allow entry of HIV positive non-citizens and prevents HIV positive individuals from becoming citizens?

Global Health Ideas

There are bunch of interesting ideas on this website:

42 Extremely Affordable Global Health Innovations

Folks are developing USB-based Ultrasound probes, low

cost and low energy usage stoves, and lots of other neat ideas.

Also, a new report on the state of Food Insecurity was just released.

"Food security in 70 developing countries is projected to deteriorate over the next decade, according to USDA’s Economic Research Service. After rising nearly 11 percent from 2007 to 2008, the number of food-insecure people in the developing countries analyzed by ERS researchers is estimated to rise to 833 million in 2009, an almost 2-percent rise from 2008 to 2009. Despite a decline in food prices in late 2008, deteriorating purchasing power and food security are expected in 2009 because of the growing financial deficits and higher inflation that have occurred in recent years. Food-insecure people are defined as those consuming less than the nutritional target of 2,100 calories per day per person."

"Search for the Afghan Girl"

Palmer Museum of Art at State College will be screening the National Geographic film, Search for the Afghan Girl. This will be showing at the Palmer Museum of Art at 1pm every Sunday this summer between July 5 and August 16.

Also be sure to check out "Face of Asia", an exhibit of photographs by Steve McCurry, June 21-August 16.

Update from India

Here's the latest from Laura Spece as she finishes her time in India. She recounts several very difficult experiences from her trip as well as describes the community health worker program she observed:

Salam! (I've just learned that Namaste is for Hindus, Salam is the
proper hello for Muslims)

Sorry it's been so long since my last update, but things have gotten a
little hectic. I just finished the public health class yesterday, and
they had plenty of work for us to do up until then. We also painted a
mural on the wall of the pediatric ward of the new hospital (info. to
follow). Plus the pre-monsoon, "slow" rains have started to become a
more frequent, daily occurrence. Which unfortunately means power
interruptions, lost internet and a ton of mud (mixed with cow dung, of
course). Sum it all together and it's made life a whole new
adventure. Monsoon must be REALLY fun here. :) Actual monsoon rains
have reportedly started in Mumbai, which means the city is flooded.
The news report out here "in the sticks" states that the water height
can be as high as your waist! But we were also warned of
exaggerations...

So I leave Jamkhed tomorrow, which is making me quite sad. I'll
travel just a bit before coming back to the States; a day in Mumbai
(thank you Del and Bob and Aditi!), 5 days in Kochin, Kerala, then 4
days in Delhi with a day trip out to Agra for the Taj Mahal. I'm
excited to see more of India, but I will greatly miss the CRHP. I
wish I had more time to stay here; to meet more of the village health
workers and to see how Drs. Arole transition into the new hospital.
But alas, school starts soon. Unless you think I could convince Dean
Simons to let me attend med school remotely for awhile (kidding, I
miss home a lot too). :)
Which brings me to what I want to discuss. I figured this e-mail
should focus a bit on the Comprehensive Rural Health Project; in what
they do, how they got started and where they're headed. Plus I'll
throw in how I feel personally about my experience along the way...

The CRHP was started in 1970 by Dr. Raj and Mabelle Arole. They
attended the Christian Medical College in Valor, and actually met
there and got married. They also completed Masters in Public Health
degrees at Johns Hopkins. They decided they wanted to work in
poverty-stricken rural India, instead of pursuing higher-paid, more
academically respected positions in the cities. They sort of fell
upon Jamkhed, in the state of Maharashtra. Jamkhed is a small "city"
that actually sought out the Aroles shortly after they arrived in the
area, hearing rumors that they wanted to start a hospital. Some land
was donated for a small clinic by the community, and more land was
added over time to accommodate the growth of the project. We saw the
original "clinic" in town the other week, it was no bigger than my
garage. From the start, the Arole's took a community approach and
focused on delivering primary health care to the villages surrounding
Jamkhed. The problems were numerous; leprosy, malnutrition, infantile
diarrhea, anemia, maternal deaths during delivery, tuberculosis,
malaria and many, many social issues. It was quickly decided that the
focus should be on nutrition, accessing proper drinking water and
community education. To do this, the Arole's first used well-educated
(by India's standards, most girls at the time barely finished 4th
grade) Auxilary Nurse Midwives. Problem is, the ANMs didn't want to
stay and live in rural Indian villages! Plus, they couldn't relate to
the villagers at all, and were more likely to abide by strict
caste-discriminatory practices. So lo and behold, the Arole's decided
to train ILLITERATE, UNTOUCHABLE, 40+ year old WOMEN!!! These 4
categories were some of the most down-trodden of all Indian society.
And how do you teach someone who can't read or write?? Well, they
brought the women to CRHP to learn by flashcards, drawings, shadowing
the Drs. Arole on rounds through the hospital and they even dissected
a goat! The VHWs use many of the same techniques to then go out and
educate the communities. Except they use more songs and skits...
instead of goats. :)

And it's worked. Over the last 30 years, infant mortality has dropped
by 20%, malnutrition rates are 30% below the Indian national baseline
and the CRHP now serves over 300 villages in Maharashtra alone. All
accomplished by education via flashcards, drilling tube wells, making
drainage pits for standing water and community empowerment. Plus the
CRHP is helping other impoverished states start similar programs as
well. They estimate their patient coverage to nearly 400,000 people!
The social ramifications have also been vast. Women have become much
more empowered, alcoholism is down, literacy rates are climbing, age
at marriage is increasing and so are the number of girls going to
school. The female Village Health Workers I have met are
unbelievable. They are so fiesty, assertive, proud and HAPPY! It's a
real treat to sit and talk with them, and even to observe them in
their weekly class. Watching classes is also beautiful because they
are all wearing their best sarees (the customary dress of married
women, where you wrap yourself in 16 feet of chiffon or silk), which
is the most colorful sight ever. I did purchase a saree here in
Jamkhed, it's a fuschia-ish color. It took me 5 tries to get it
wrapped around myself, and even then the dining hall ladies yanked me
back into the kitchen to re-wrap me. :) At least I'm entertaining.
You do wear a petticoat beneath it, with a tailor-made blouse.
Walking in it is a work-out. The effective diameter of the skirt is
pretty small, and there is a bulk of material in pleats on the front.
I was minor-ly afraid of tipping over. But never fear, I'm sure
you'll all get to see it. I plan to use it for any presentations I
make in the future...I need a good excuse to wear it. :) To read more
about the VHWs, the CRHP was featured in the National Geographic
article, "Necessary Angels" last December:

http://ngm.nationalgeographic.com/2008/12/community-doctors/rosenberg-text

But there are things that I've seen and experienced that have jarred
me a bit. First it is just awkward to be a Western female in this
area. For example, when I tried to buy a T-shirt from the
"department" store to get the CRHP logo printed on it, the gentlemen
at the counter nearly fell over when I held it up to my chest to see
if it fit. He couldn't believe the T-shirt was for me, since T-shirts
are for men only. Pants are also for men only, unless ladies wear a
kurta (a long, dress-like shirt that goes almost to your knees) to
cover the pelvic area. Ankles are usually a no-no and knees are
positively obscene. So when the temperatures hits 40 degrees Celsius,
I'm still expected to wear pants + kurta and a little scarf. NO
shorts. Ugh. Add to the fact that I'm pale with blue eyes, I've
caused quite a stir. You see, the illegal DVD-copying industry is
quite prolific in India. And since most of rural India has never seen
a white woman in real-life, the only exposure is through Western media
(think old re-runs of "Friends") and ummm, well, how do you say this?
Smutty movies. Great. Not a good image. When I was walking in town
with a few other students, one man fell off his motorcycle as he
rubber-necked to see the gaggle of super-pale foreign girls. Yikes.
In all honesty though, I haven't had much trouble at all. Jamkhed and
the villages are really getting used to foreign women coming through
for classes on an increasing basis. So I've been treated very, very
well and am probably quite spoiled, really. Things are supposedly
much different in the cities of India (Mumbai and Delhi), so I'm
interested to see it.

***This e-mail has taken me a few days to finish, so I'm actually in
Mumbai currently and it is WONDERFUL! I do feel like I sort of
"wandering out of the bush" as I left Jamkhed and went straight to the
big city. :)

The second most bothersome thing to me was the lack of secondary
(hospital-level) care, here in rural India. It's the one thing Dr.
Raj has not yet been able to accomplish, and he regrets it heavily.
(Though he also admitted to a 2nd regret later on; a lack of general
plumbing system for the villages) The hospital that was in use (until
yesterday) had only 12 beds and lacked a lot of medical necessities.
The operating theatre was an interesting experience, since there was
no air conditioning or real ventilation. While observing (I did get
to hold a retractor), the smell and heat sometimes made my knees
buckle a little. And to suture your skin back up? Cotton thread with
a regular sewing needle. No joke, the kind you'd repair your shirt
with. But the thread is maybe a little thicker. But they did have
*cat gut* (absorbable) suture for your insides. :) They had one
warming table for infants, but lacked an incubator and other life
support necessities in a small enough size. So premies were pretty
much screwed. I've observed a lot of injuries and diseases I probably
won't see too frequently in the states (think being gored by a water
buffalo, multiples traumas from motorcycle accidents, and
extra-pulmonary tuberculosis, leprosy). The most common surgery falls
into the ob/gyn category; hysterectomies, D&C, Cesareans, forceps
delivery and of course, vaginal deliveries the good old fashioned way.
Though most deliveries (at least 80%) are done at home and go well
since the VHWs are also trained as birth attendants. Prenatal care is
taking root so they've been pretty successful at figuring out if the
pregnancy is high-risk, and schedule the delivery to be done at the
hospital. For home births, the VHWs are given sterilized packets
wrapped in saree material to take to the home, including: razorblade
(for the cord), string, gauze and a suction device for the baby's
nose/mouth if needed. I did see one delivery end badly, and it
bothered me a great deal. The mother was from a village not covered
by the CRHP model and she was severely anemic upon arrival (and
probably has been for most of her life). Since she's not too
accustomed to hospitals and pretty freaked out, she refused blood and
was giving a lot of trouble when Dr. Wout wanted to examine her
cervix. Dr. Wout couldn't find a fetal heart sound, so he did an
episotomy and yanked the baby out with forceps. They do episotomies
sideways here, towards the thigh. They say American episotomies are a
joke, so to all of the docs on this list, please comment. The baby
was "extracted" in probably 15 seconds, but came out completely blue.
I never saw anything so unnatural. Dr. Wout and the staff tried very
hard to save him, but to no avail. I was (and still sort of am)
pretty disturbed. Can't help but think that things would have been
different if this women wasn't born into extreme poverty in rural
India. Plus I had no idea how to properly comfort this woman since I
don't know the language well enough, nor what is entirely culturally
acceptable in the area. It's something I'm going to consider heavily
when I decide to work globally in the future.

The problem with the CRHP hospital is, it takes money. Lots of money.
While the primary care and VHW model is really sustainable (the VHWs
work on a volunteer basis), a hospital doesn't run on volunteer
doctors. You need doctors to permanently staff it, to keep some
continuity. And if you can't even get Auxilary Nurse Midwives (a
certificate, less than an American LPN) to stay, how on earth can you
convince a physician. Let alone afford their salary if specialized.
So that's the next phase of CRHP. They built a beautiful, 50-bed
hospital with excellent operating theatres and plenty of new machinery
for their lab, X-ray and life support.

So here's where I finally ask for your help. When I get home, I want
to try to raise $$ for CRHP to send a girl (maybe more, if possible)
to a 3-year nursing school. Ravi (the Arole's son) has a connection
with a University in Pune and in Indore to accept the village girls
(who perform educationally at a much lower level than the city girls
do) and also gets a discount on tuition. So the total cost to train
one 20+ year old, Dalit (untouchable) and super-poor village girl as
the English equivalent of an RN is $4000. This figure includes both
tuition and all living expenses for 3 years. The goal is to have the
girl attend University (which is normally impossible for them) and
then have them come back and work at CRHP. I feel this would be one
of the best ways I could help CRHP achieve the sustainability they so
desperately need, and Ravi and Dr. Raj agree. I have one person who
has already pledged to donate a good chunk of the $4000 needed. So if
you've enjoyed reading my e-mails, I encourage you to donate to the
CRHP to this end. But they need tons of other stuff as well, both for
the hospital and in the villages. You can find a list of needed
goods, and the link to make your tax-deductible donation at their
website, as well as more info. on CRHP:

www.jamkhed.org

Seriously, even $5 goes ridiculously far in the village. And if you
know of any organizations, foundations, church groups or individuals
who might be interested in donating or seeing my presentation
(complete with saree and photos of village life) please let me know.
:)

I return to the States on July 29th, late in the evening. I hope to
catch up with all of you soon. Thank you so much for all of your
thoughts and prayers. It was so helpful and motivating to have all of
your support as I've trekked through these villages.

Dhanyavad,

Laura

Global Health Articles from The Lancet

A few articles to consider:

A commentary on the Gates Foundation's priorities for Global Health. The authors argue that the funds are too heavily weighted on new technologies that will take decades to produce, whereas "two-thirds of global child deaths could be prevented if existing interventions were fully implemented..." Currently over 10 million children die each year. The vast majority of these are preventible. The authors also take issue with the 'poor correlation between fudning and childhood diesease burden." Again, where the Gates Foundation has a strong focus on select diseases (malaria, TB, HIV) the majority of child deaths are due to different diseases: pneumonia, diarrhea, malnutrition. The Lancet Editorial has words of both praise and admonition. An original paper looks at how the Gates Foundation is spending its money, and who it is giving its money to, concluding: "The findings of this report raise several questions
about the foundation’s global health grant-making programme, which needs further research and assessment."


In 2004 the WHO published a handbook on Home-Management of Malaria.
"Home management of malaria is the presumptive treatment of febrile children with prepackaged antimalarial drugs that have been distributed to households by members of the community; diagnostic tests are not used." Rural areas have been targets of this intervention due to higher incidence of malaria and poorer access to health services. An original article in The Lancet looked at home management in urban Uganda. The authors concluded:
"Although home management of malaria led to prompt treatment of fever, there was little eff ect on clinical outcomes. The substantial over-treatment suggests that artemether-lumefantrine provided in the home might not be appropriate for large urban areas or settings with fairly low malaria transmission." However, a commentary disagreed.

Finally, a letter from the Director-General of WHO, Margaret Chan, argues the case for "Primary health care as a route to health security."

Why More Africans Don't Use Human Rights Language

Thanks to Kashif Khan (who is in Rwanda right now!) for this article:

Why More Africans Don't Use Human Rights Language

Shared via AddThis

Update from Laura Spece in India

Namascar! (same as Namaste, just another version of hello)


So I'm going to start this e-mail off with a bang: Cricket. That crazy British game, quasi-resembling baseball that India, Pakistan, Bhutan and other countries can not get enough of. And has been rendered nearly impossible for Americans to understand, especially the scoring. But here are a few basics:


1. There are 2 sets of 3 wickets that the batting team runs in between to score runs.
2. There are 2 batters of the same team running between the wickets at one time. Only 1 receives the pitch. They are called "batsmen"
3. The man who pitches, or rather LAUNCHES a very hard, small ball is called a "bowler."
4. The rest of the bowler's team is in the outfield.
5. The rest of the extremely complex rules do not apply to the rest of my story...


So we decide, as a class of around 12, that we should try to play a round of cricket. One of my classmates, Jayendra, is from Bhutan and therefore quite knowledgeable of the sport. We start off with Jayendra bowling, in a amateur-friendly slow pitch fashion, to one of my male classmates (Eldon from UNC). Everything's going pretty well, except Eldon soon discovers that a cricket bat is an exceedingly heavy and awkward version of an American baseball bat. So his brilliant idea? Let's let Laura give it a go. By now, we've accumulated a few spectators. The male, Indian staff of the CRHP has started to come out to see what the crazy Westerners are up to. Now I'm OK at baseball. So with Jay pitching slowly, I was pretty successful. And many of the Indian men watching have NEVER seen a female play cricket, or any other sport. So they were surprised and commented in Marathi (translated later by Dr. Arole's son, Ravi), that this white, American girl is pretty good. To top things off, I launched a long ball over the squat building they use to build artificial limbs, securing my bragging rights. However, I should also describe our "field." It's a back lot to one of the main CRHP compound buildings, that's littered with leftover bricks, tiles and other rummage aaaand a line of latrines. You can only guess what happened. When retrieving my long ball, one of the very kind, young Indian men stepped over a bunch of tiles, covering the septic tank, and landed in a pool of human sewage. Awesome. He was fine, without injury except possibly his pride. But oh wait, it gets better. I'm appalled and promptly give up the bat, banishing myself to the outfield. But after awhile, I decide to get up again to bat. I launch ANOTHER ball over the same artificial limb hut, and a *NEW* CRHP staffer runs to get it. Now my Marathi is pretty terrible... but I still attempt to shout STOP, STOP, STOP!! (Thamba, Thamba, Thamba). But to no avail. I sent two Indian men into a large pile of crap, chasing after cricket balls. Maybe I'll give cricket a rest for awhile. :)


Back to health. I think it might be interesting to talk about... Diarrhea. Especially since it melds with the cricket story. So as many of you are already aware, diarrhea is a massive cause of infant morbidity and mortality in developing countries, like India. However, it's also one of the most common reasons for hospitalizations of infants in the United States. What's the big deal, it's just diarrhea? Well, the main problem is not necessarily the infection (though Salmonella, E. Coli, rotavirus and other nasties that cause diarrhea don't help when multiplying out of control in your gut). It's rather the extremely rapid loss of water and salts that get expelled from your GI system. Compound the loss of water and salts onto the fact that the vast majority of children in developing countries are malnourished to start, and you've got a really dangerous situation. Not to mention, that here in rural India, it was sometimes thought that a ghost or other form of black magic had grabbed hold of the child presenting with diarrhea. And how to you get rid of a GI ghost? Well, the mantrik (witch doctor/healer) says you must starve the ghost and thus the child. Which of course ends poorly for the sick child. Remind me to tell you how the mantrik "cures" tuberculosis. You'll love that one. So in the end, American infants and children don't die from diarrheal illness because we are pudgy, well-fed kids. Plus our American moms and dads were educated in the importance of maintaining adequate nutrition and hydration, AND can afford Pedialite. But here, CRHP has more of an uphill battle to fight infantile diarrhea. But here are a few ingenious ways:


1. Installing tube wells for drinking water. The CRHP worked with a German NGO to ensure that the villages stopped drinking the water they were washing in. You see, most diarrhea-causing bacteria and viruses are spread through the fecal-oral route. These tube wells reach the water table ranging from 75-200 feet below the ground surface. This depth ensures the water has been naturally filtered from contaminants. But I'll have another e-mail on water... it's a huge focus here as you can imagine.


2. A Latrine campaign. Like I've mentioned before, much less than half of the village members use a toilet. Dropping trow (spelling?) in the fields or outskirts of town is the cultural norm. Furthermore, even when the CRHP teams up with the Farmer's Club in the village to build a whole bunch of latrines, most people end up using them for grain storage!! The Village Health Workers, women's groups and Farmer's Clubs of the village end up having to hold whole village meetings to stress the use of the new toilets. Also, we're not talking western toilets that flush. I'm talking little pit-like, latrine toilets. With little imprints for your feet on the sides. (see photo) But the campaign is working. People are starting to want latrines, especially after they see the upper crust members of the village with them. A rather interesting take on "Keeping up with the Jones' " One elderly village man in a turban approached us on our last visit, saying, "Please! Build me a toilet!" He thought our very obviously foreign group were engineers, were building toilets.


3. The most ingenious, and my personal favorite. Educating the adolescent girls and also the young children. The CRHP had the Village Health Workers come up with little songs about the importance of nutrition, and how to make "limbu pani." Nutrition will be it's own e-mail, but limbu pani is quite interesting. It's rural Maharashtra's Oral Rehydration Solution (ORS)!! ORS is a life-saver for developing nations, as many of you already know. It's a balanced combination of salts, sugar and water to ensure that rehydration occurs while also re-establishing electrolyte balance. The science behind it is ingenious, the glucose (sugar) is used to "carry" the other salt ions across your gut wall, into the bloodstream. The girls and kids are taught a song about the ingredients of limbu pani, which is simply homemade ORS of lime juice, sugar and salt with water. Since measuring cups are hard to come by, they are told that the mix should be no sweeter than a banana, and no saltier than your tears. They are instructed to start limbu pani at the first signs of diarrhea, and to continue feeding the child. This method has drastically reduced infant mortality. Plus, the village health workers came up with an alternate recipe for some of the new villages joining CRHP. These villages are significantly farther from Jamkhed, and limes are harder to come by. The VHWs thus substituted rice water. Brilliant! This is cheaper than manufactured ORS tablets, and much easier to access. Maybe this is something that could be useful in the states, for more impoverished areas?? The use of ORS solution would save a lot of healthcare $$ in the US, by preventing hospitalizations for IV fluid rehydration... hmmmm.


Things to ponder:


The book, Freakonomics. It's short and written by a very young, un-traditional economist. He's considered quite brilliant, yet controversial for many reasons. He became a Harvard Society fellow at the age of 26. I better get a move on, my 27th birthday is right around the corner. :)


The Bollywood movie, Lagaan. It's fantastic. Albeit, 3.5 hours long. :) But it's chock full of dancing, singing, love and cheesiness. And the villian: the BRITISH!! The subtitles are often interesting. Whenever there was a scenic interlude between dialogues, the caption read "vanilla." But no one was speaking. :) We have yet to figure out what on earth the caption writers think vanilla describes.


I've attached 3 photos. The "adolescent" is one of the many girls who swarmed me for photos while they were visiting. Many of them have never seen a white person with blue eyes before. If you notice, there is a Bic mechanical pencil tucked into her blouse. It's one of many that I dispersed of the donations I was given by the lovely ladies of the primary care office. I had to teach them how to push out and retract the lead. They were a huge hit, these "American pens." The 2nd photo is of Yamunabai, the village health worker with 2 of the girls from her village. As you can see, they have quite a bond. Yamunabai is lovely, and so kind. She is of the untouchable caste and has had an extremely hard life. She loves big hugs and tries to talk to me in Marathi... but we have a pretty good sign language, head bobble thing going to communicate. :) And the 3rd is of the infamous "Indian toilet." You can figure out for yourself what the little buckets are for...


Well that's all for now! I have to get to class. Hope all is well back home. Keep in touch! Bare yete (see you later in Marathi)!


Wish you were here,


Laura

Moving forward with maternal health and human rights

An article from The Lancet on the recent UN resolution regarding women's health:


500 000 women die each year as a result of pregnancy or
childbirth. Eff orts are being made to reduce these deaths
by three quarters by 2015—Millennium Development
Goal 5. But many countries are not making substantial
progress towards this target. Can the human-rights
community help?
Last week, the UN Human Rights Council passed a landmark
resolution that recognises preventable maternal
mortality and morbidity as a pressing human-rights issue
that violates a woman’s rights to health, life, edu cation,
dignity, and information. The move is important because
a human-rights approach to maternal health places
specifi c legal and ethical obligations on states, such as the
establishment of eff ective mechanisms of accounta bility
(ie, maternal death audits or reviews). The approach also
reinforces equity, so it insists on disaggregated data on
maternal mortality and morbidity rates to see if vulnerable
groups are benefi ting from health programmes.
The resolution signals an increasing trend by the
human-rights community to take health issues as
seriously as they have taken issues such as torture, the
death penalty, and the right to a fair trial. For example,
in May, Amnesty International—the world’s largest
international voluntary organisation dealing with human
rights—launched, for the fi rst time, a global campaign to
address maternal mortality.
These eff orts should be welcomed by the health
community. As well as increased attention and resources
for maternal health, a human-rights approach to maternal
health can strengthen policies and programmes and make
them more equitable. But this movement needs the active
support and engagement of more health professionals
to succeed. The diffi culty is that the health community
has often misunderstood human rights to be solely
about whistleblowing, lawyers, and litigation. The health
community must be willing to learn about human rights,
realise the common ground, and work with human-rights
professionals in a respectful, constructive, and practical
partnership to prevent the unacceptably high number of
maternal deaths that occur each year. ■ The Lancet

Cash Transfers and the Millennium Development Goals

This is a quick synopsis on "cash transfers" related to child health:


Accumulating evidence from large-scale programmes
is starting to show positive eff ects of cash transfer
programmes on many levels. A new report by Save the
Children, Lasting Benefi ts, highlights the importance
of regular cash transfers, such as child benefi ts or
pensions, as one crucial intervention to get Millennium
Development Goal 4—reduction of mortality in children
younger than 5 years by two-thirds—back on track.
Currently, child mortality levels are either not
decreasing or actually increasing in 27 countries. And
even in those countries that are making progress, the
poorest are left behind. National fi gures hide great
inequalities. The report argues that three complementary
approaches need to be taken to have the greatest eff ect:
strengthening and improving health care; access to
clean water and sanitation; and poverty reduction.
Child health is inextricably linked to the environment
in which children grow up. Children in poor households
are more likely to die, more likely to have irreversible
eff ects from poor nutrition, more likely to have poor or
no education, and less likely to benefi t from even a well
functioning health-care system than children from welloff
families. User fees, drug and transport costs, and loss
of parental income are often insurmountable barriers to
seek treatment or use preventive measures.
Emerging data from cash transfer programmes,
conditional or unconditional, largely dispel the counter
arguments that these programmes prevent adults from
seeking work or create a dependency culture which
perpetuates intergenerational poverty. On the contrary,
children—especially girls —from households given cash
transfers are more likely to be in education, are in school
for longer, and have higher incomes as adults. Immediate
eff ects on local trade are also positive in most cases.
Summarising the current evidence and modelling
aff ordability, the report makes a very strong case to
include child and maternal cash transfers, especially
for young children, into the package of interventions
to reduce neonatal and child mortality. Even more
compelling is the argument that the eff ect of lifting
households with young children out of poverty will last
for many generations to come. ■ The Lancet

Blog from Laura Spece in India!

Namaste!

It's been an interesting week, for sure. We've started to get a few pre-monsoon rains here... which is really nice. It's a short, but very spirited, shower everyday around 5 or 6 pm. It's cooled things off tremendously, but has added a bit of humidity. But overall, we are extremely thankful for their arrival. As are the farmers, of course. Having these little shower bursts help to soak the ground (perhaps maybe a better term would be ground-level dust piles) and prevent severe run off. One of the main goals of the Comprehensive Rural Health Project (CRHP) here in Jamkhed, has been attempting to teach responsible, and appropriate agriculture to that end. (They really cover so much more than medicine, here!!) And a main tenet for such a drought prone region is proper crop selection and trench placement. While we were visiting one of the model farms the other day, the evening rain began, and we piled back into the bus to head back to the compound. On the way, the roads turned in to rivers and many of the stalls/shops had a solid foot of water collected within. And that shower only lasted about 30 minutes! The official, big monsoon rains will begin the end of July/beginning of August and the rains will be constant throughout the day, lasting for weeks at a stretch. I'll be out of here by then. :)

I went on my first village visit three days ago. Six of us go in a little group with a translator. The people here speak Marathi, since they the Jamkhed project is in the state of Maharashtra. So all of the Hindi I tried to learn via YouTube isn't too helpful. :( We do have a Marathi class, and so far I've learned how to say "hello," "what is your name," please may I have some water," and "where is the toilet." That brings my language count regarding the toilet to 6 different languages. And asking where a toilet is in these villages is pretty pointless. The village I visited was Padali, with a population of around 1,700. That equates to about 200 families, with only 17 of these families having a toilet. YIKES. The rest of the village's population openly defecates in the fields or on the outskirts of town. This frustrates them greatly. When I asked the Village Health Worker (her name is Pushpa), how we can best help her village now that better healthcare has been brought by the CRHP, her response was pretty profound. The first thing she says her village needs is proper plumbing to ensure sanitation. CRHP has worked very hard to try and set up a plumbing system. But many of these people live on around 50 cents per day. To operate a toilet alone costs around 20 cents per day. There's no way a family of 6 can spend half of their income on a toilet. :/ Instead, the CRHP did help them to dig small trenches along the sides of the roads. Human waste doesn't flow through these sewage drains, just wastewater from cleaning and cooking. It does help some, especially with the rains. Pushpa blames the corrupt Indian government for the lack of public plumbing, which she is probably quite correct in doing so. They joke here that if you want $5 to actually reach the poor through the government, you'd have to give the officials $25. Ouch.

The second thing Pushpa asked for, was more universities. Currently, the closest University to the Jamkhed area is in Pune. Which is 4.5 hours away, on a good day. Plus the cost is immense for a small farmer. And it's such a shame, so many of the adolescent girls have been able to now access primary and secondary school, and they yearn for more education. When we've asked them what they want to be when they grow up, so many say teachers, doctors, pilots, and one even said prime minister. I hope one of them makes it. But the harsh reality is, most don't. Another objective of the CRHP has been to increase the age of the girl's at marriage. Currently, 36% of girls in India, aged 13-16, are married and already have one child. As you can imagine, this social practice has resulted in numerous complications. Medically, the most important is that these tiny young girls just don't have a pelvis to deliver a healthy baby, nor carry it even to full term. The nutrition of women in India is a whole other issue, which results in so many of them being very short and extremely tiny... and anemic. These women just don't get a break, but woman's rights is a whole other e-mail. So the CRHP has weekend, overnight programs for the girls to come and learn about proper nutrition, childcare, education, marriage and dowry. They sing songs, learn martial arts and just generally socialize and boost their self-esteem. Things that are not permitted back home in the villages. It's also a chance for the CRHP to feed the girls. The estimated cost for this project is 3 million rupees, around US$67,000. Expensive, but totally worth it. The age at marriage is increasing, albeit slowly. But what has been increasing rapidly, is the number of years of school the girls are attending. Most have finished the 11th standard, same as our 11th grade! As I'm sure many of you know, it's the education level of the MOTHER that is most crucial to producing well-fed, well-educated and adjusted children...

I've attached 1 photo with 3 women is of 3 Village Health Workers. The woman in the center (white and orange sari) is Sakubai Gite. Her hands are gnarled from leprosy, as you can see with the flowers. She was the woman photographed in National Geographic holding the baby. It's hard to get the women to not pose for me, and just relax. With their new self-awareness and pride from their training as a VHW, they've become more self-conscious of how they look. They love to do all sorts of posed photos, and really almost harass me to snap a quick shot And they know the cameras are all digital, so they want to see what they look like after. :) Many of them stay closed lipped because they've lost so many of their teeth. It's a shame, I wish I could tell them that they are just too beautiful. Even if they only have 2 teeth left :)

I have tons more to share, but this e-mail's already gotten pretty long, and bandwidth is at a premium. I'm trying to get a blog going, but with the new rain, has come many new internet complications. One last little funny story... In Hindi/Marati, "tomorrow" doesn't literally mean the day after today. Rather, "tomorrow" just means sometime following this moment. So when we hear, "the internet will be ready tomorrow..." we now know to expect a few days delay. :)

Things to think about:

1. Reading: the book "Three Cups of Tea" by Greg Mortenson. Greg was an American alpinist who got lost on K2 and wandered into a very small and remote Pakistani village, pretty much starved to death in 1993. The villagers, all Muslim practicing, nursed him back to health over the next year. In return, he promised to build them a school. He has since built several hundred schools across Pakistan and Afghanistan, even through 9/11. He wholeheartedly believes America can "wage the war against terror" by building such schools, to provide a balanced education to the beautiful children (both boys AND girls) in the Middle East. I tend to agree. I loved this book, and finished it in about 2 days... it's a great story and easy to read. This man will win the Nobel Prize someday

2. "Thank you" in Marathi/Hindi is "Dhanyavad." Quite a mouthful.

3. Pohoe. The name of an Indian dish made of rice flakes, tumeric, coconut, mint, and peanuts. Delicious. Apparently, it's one of their more simple dishes. But I love it.

4. Congrats to Nikki and Lucas for finishing Step 1 of the USMLE (a doctor's licensing exam)!!! Best of luck, I'm sure you rocked it!


Wish you were here,

Laura

China's Health-Care reform plan

The latest edition of The Lancet includes a letter from China's Minister of Health, Zhu Chen. The Chinese government seeks to cover 90% of its people. The Minister of Health outlines 5 elements to the 'action plan':

1. Cover more than 90% of the Chinese people with basic medical insurance
2. Develop a national essential drug sustem
3. Develop the 'three-tier network' at county, town, and village levels.
4. Promote basic public health, including the expanded immunization program.
5. Reform public hospitals.


The letter follows:


The Chinese Government recently approved guidelines
for reform of the health-care system and published an
action plan of targets for reform in 2009–11.1,2 Estimates
suggest that governmental investment (both central
and local) of CNY850 billion (about US$124 billion) will
be injected into the health-care system in the coming
3 years, doubling the average annual governmental
expenditure compared with 2008.
Since China adopted its “Reform and opening up”
policy in 1978,3 the medical care system and health
of residents has developed rapidly. Nevertheless,
because the main orientation of health-care reform
in the 1980s and 1990s was to give autonomy to
hospitals without contribution of public fi nance, the
disparity between urban and rural areas and between
diff erent regions was increased and health-care
expenditure grew too large. Facing these challenges,
the Government decided, in 2006, to prepare new
guidelines for health-care reform. The main aim was to
ensure the basic health-care service works for the good
of the public.4
By absorbing input from ten think-tanks and
integrating experiences from both at home and abroad,
the new guidelines consider reasonable distribution
of health-care resources and core issues of equity and
accessibility. The draft guidelines were available for
public comment from Oct 14, 2008, to Nov 14, 2008,5
and more than 30 000 responses were received. As a
result, major revisions were made and, in particular, the
action plan for tangible targets was developed, which
received strong public support.6
The fi ve major targets in the action plan are
fundamental. First, wide medical insurance cover will
be provided for more than 90% of Chinese people. This
initiative includes basic medical insurance for urban
employees and for residents of cities (elderly people
without previous employment, university students,
children, and migrant workers without a stable labour
contract and their relatives), the new rural cooperative
Medicare scheme for farmers, and the Medicaid system
for urban and rural poor people. The funding level will
also be raised for urban residents and farmers, with
governmental allocation increased to CNY120 per head
in 2010.
Second, a national essential drug system will be
established to meet the basic need for treatment and
prevention of diseases and to ensure safety, quality, and
supply. All drugs on the list will get a high reimbursement
rate by the distinct medical insurance systems.
Third, the medical care and public health service
system will be improved at grassroots level. In rural areas,
emphasis will be on infrastructure and human-resource
development of the three-tier network at county, town,
and village levels. In urban areas, community medicine
centres (stations) will be reinforced. This move will not
only substantially reduce workload in overcrowded
city hospitals but also allow the “health-gatekeeper”
system—ie, family doctors and nurses providing services
at community medicine7 level—to be enhanced for
disease prevention and health promotion.
Fourth is promotion of the basic public health service.
This objective will be realised through: establishment of
health archives for all citizens; provision of screening for
major diseases for elderly people, women, and children;
management of chronic non-communicable diseases;
and health education. Furthermore, major projects
will be launched, including an expanded programme
of immunisation for 15 vaccine-preventable diseases
(eg, against hepatitis B virus for children younger than
15 years), prevention and control for major infectious
diseases (HIV/AIDS and tuberculosis) and geochemical
endemic diseases, and delivery in hospital for all
pregnant women.
The fi nal aim of the action plan is to launch the
pilot reform of public hospitals. This project includes
substantial increases in public investment, restructuring
of the hospital management system, and correction of
the tendency for commercialisation.
In a country with 1·3 billion people, to achieve the goal
of health for all is by no means an easy job, particularly
at a time of global fi nancial crisis and economic
downturn. Our major challenges are to enhance the
working and living conditions of 6 million health-care
workers, to improve the doctor–patient relationship,
and to establish a platform for health records for
all. However, we are determined to transform these
challenges into opportunities. By applying the policy of
prevention fi rst, focusing on rural and grassroots level
service, and paying equal attention to both Western
medicine and traditional Chinese medicine,8 we should
be able to pave a cost-eff ective way for health-care
development.

Note from Rwanda

From Kashif Khan:


Dear Friends,

Muraho! I am in Rwanda.

I work with Partners In Health and with the Rwandan Ministry of Health,
mostly throughout the District of Burera (northern Rwanda). Butaro Hospital
in Burera District is located in an absolutely stunning place amongst lush
hills and valleys. It's been beautiful weather nearly every day. At just
under 7,000 feet, the air is crisp and there are no skeeters to speak of.
Hikes are common. What is less common is a spirited futbol match between
the hospital and the Rwandan Military. Yeah, I played. There were
approximately 700-800 people crammed around the wildly uneven playing
field. It was glorious. We lost 4-2. It's about building friendly
relations, what? (Sorry that slipped out - I'm reading some P.G.
Wodehouse).

When not performing rigorous calisthenics prior to hikes and futbol, I help
to set up and run a nutrition program in a district of 14 health centers.
This involves coordination of various programs, including financing,
procurement, storage, distribution of food packets to health centers, supply
chain management, ensuring delivery of food packets to people who fit
certain criteria for malnutrition, reporting back to various organizations,
among other things.

I am conducting a video project which will illustrate - I hope - the
motivations of, and challenges faced by, health care workers, students, and
researchers (Rwandan and expat) as they pursue the work of health care
delivery in a resource poor setting.

I am working on a couple research papers evaluating the success of certain
models of health care delivery.

And, I am gaining some clinical experience, rounding with doctors here and
observing surgical procedures - c-section and tubal ligation thus far! I am
getting a good handle on my vasovagal issues. I know, I surprised myself a
little.

It's been simply an amazing privilege to work on the difficult problems of
the creating, doing, and making that successful implementation requires as
well as evaluation of projects. Everyone has welcomed me onto the wonderful
team here. I'm eating a lot of rice and beans. And I'm learning a few
phrases in Kinyarwanda.

I hope you are well. I would love to hear how you are doing!

More to come...


Jambaho (fist bump of solidarity),

kashif

Short video on Clean Water

Here is a short and potent little video put out by ONE.org:




This past week I had opportunity to speak at a local church about my work in Pestel, Haiti. I again had to say one of the most ludicrous statements: "Even drinking dirty water is better than no water."
I will be so glad when I no longer have to talk that way about Pestel.

What is Global Health?

What does the term "Global Health" mean, and how is it different than "International" or "Public health"? A group of researchers from the Consortium of Universities for Global Health (COGH) have developed a definition of global health to encompass its multi-faceted nature which was published in the June 6, 2009 edition of The Lancet.

The authors state that:

" Without an established definition, a shorthand term such as global health might obscure important differences in philosophy, strategies, and priorities for action between physicians, researchers, funders, the media, and the general public. Perhaps most importantly, if we do not clearly define what we mean by global health, we cannot possibly reach agreement about what we are trying to achieve, the approaches we must take, the skills that are needed, and the ways that we should use resources."

The authors go on to develop a definition of global health that is dependent upon the scope of the problem, not simply the location (or geographical region) of the problem:

"What is global? Must a health crisis cross national borders to be deemed a global health issue? We should not restrict global health to health-related issues that literally cross international borders....global health should also address tobacco control, micronutrient deficiencies, obesity, injury prevention, migrant-worker health, and migration of health workers. The global in global health refers to the scope of problems, not their location."

Finally, they conclude with the following definition of global health:

" Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care."

What do you think? Do you agree with the authors' definition of global health? How does your work fit into the broader scope of global health?


Koplan, J. et al. Towards a common definition of global health. The Lancet, Vol 373, Issue 9679, Pages 1993-1995.

Small business perspective on health care

Washington DC and HIV

Based on a report just published, "The District of Columbia HIV/AIDS Epidemiology Update 2008":

Overall, 3 percent of all District residents are currently known to be living with HIV/AIDS. To put that in context, the United Nations Joint Program on HIV/AIDS (UNAIDS) and the U.S. Centers for Disease Control and Prevention (CDC) have historically defined an HIV epidemic as generalized and severe when the overall percentage of disease among residents of a specific geographic area exceeds 1 percent. The overall proportion in the District is three times higher. This calculation is based on the number of cases already diagnosed and reported and U.S. Census figures of our population. Moreover, based on new targeted studies of behavior that indicate between one-third and one-half of residents may be unaware of
their infection, we know that the true number of residents currently infected and living with HIV is certainly higher. In the District, nearly every population group and age is experiencing a substantial epidemic."


To put that in national perspective, the US prevalence of HIV is about 0.6%.
You can see a list of countries by HIV prevalence here.

Vaccine Initiative

A new funding/supply mechanism has been developed to provide vaccines to developing countries This is called "Advanced Market Commitments for vaccines".

This AMC is an intriguing and big-scale system that, if I understand it correctly, takes up-front dollars from interested developing countries to provide financial down-payments to provide lower cost, set-priced vacccines. The down-payment is subsidized by other organizations (i.e. World Bank, Donors). In this way the manufacturers receive a financial guarantee and they in turn guarantee production of a certain # of vaccines (i.e. pneumococcal) to be sold at a fixed, lower price.

The first AMC is for Pneumococcal vaccine. Here's an explanation from the website:
"The Pneumococcal AMC Structure
The Advance Market Commitment pilot engages donors (five governments and the Bill & Melinda Gates Foundation), developing country governments, and GAVI Alliance members the World Bank, the World Health Organization, UNICEF and the vaccine industry to provide millions of pneumococcal vaccines to children in the developing world, 10-15 years before these life-saving vaccines would ordinarily been made available."

The graphic shown at this link portrays the arrangement for Pneumococcal vaccine.

Interview with Dr. Paul Farmer

Thanks to Deirdre Weaver for passing this along!! Here's an interview with Dr. Paul Farmer.

"Bringing quality health care to poor populations remains a huge challenge. Hear what Paul Farmer, founder of Partners in Health and subject of Tracy Kidder's Mountains Beyond Mountains,has learned about how to do it right."

News items

A few notes of interest:

1. The Global Health Scholars are currently in San Pablo, Ecuador finishing up their community-based research. Lots of photos to come!!!

2. You can also check out a blog by two of our 1st year medical students, Riva and Sarah. They are in Bolivia collecting data. I'll post their blog on the side-bar to make it easier for you to follow their happenings.

Global Health Council Annual Conference

The 36th annual Global Health Council Annual Conference was held May 26-30, 2009 in Washington, D.C., and represented a diverse cross section of the global health community. Industry, Academia, Government, Private Sector businesses, you name it - all gathered to discuss the central theme: New Technologies + Proven Strategies = Healthy Communities.

A few highlights:
There were many seminars on how to successfully keep abreast of new technologies and fully utilize them in global health research and health systems development. Text messaging, Geographic Information Systems (GIS) and live video lectures are just a few of the technologies being implemented around the globe. Uses range from tracking outbreaks and emerging infectious diseases, maintaining immunization records, to strategically assessing and planning for community-based health centers.

One great resource for epidemiologists and infectious diseases professionals is Health Map. This website traverses several thousand internet sites and foreign language newspapers each hour, providing some of the first indications of emerging infectious diseases around the world. Users can sign up for alerts specific to their country or disease of interest.


Another great use of technology is a live webcasting series on HIV/AIDS care and treatment developed by the International Training & Education Center on HIV (I-TECH). This series is an interactive training session for healthcare providers around the world, who can dial in and directly participate in case studies and various lecture materials. The program's advantage is not only that healthcare providers can receive training from internationally renowned infectious disease specialists, but that they can ask questions, participate, and take ownership of the material.

One key point emphasized throughout the conference was the need to maintain the human dimension in the midst of the rapid development of technology. During a panel discussion on HIV/AIDS and the global financial crisis, the point was made that global health organizations should broaden the traditional definition of health systems. Often the discussion on health systems stops with the health care provider - the community worker or the doctors or nurses serving a particular location or need. However, the point of care provider is often a family member, and any resource committment needs to include family caretakers in the endpoint analysis and treatment strategy (particularly in HIV/AIDS). Recognizing the key role of family members will allow for a more efficient use of resources, as well as fully engaging the community and meeting the needs of the patient.

This conference definitely highlighted the diverse nature of the global health world. Check out this year's conference highlights, and stay tuned for 2010!

Call to Action on diarrheal disease

A "Call to Action" was released on the issue of diarrheal disease. Diarrhea remains the #2 cause of child death worldwide. It is both preventable and treatable. The solutions are inexpensive.

The Call has been endorsed by 90 reputable organizations (Partners in Health, UNICEF, PATH, Save the Children etc).

What will this Call do? Hopefully it will raise awareness which will ultimately turn into funding, policy-decisions and so forth. Here is the statement:



Over the last three decades, the global community has shown that it has the tools to dramatically reduce childhood death and illness from preventable and treatable diseases, such as diarrhea. During that time, for example, millions of children’s lives have been saved by protecting them against diarrheal disease and its consequences through proven and affordable solutions.

Yet diarrheal disease still unnecessarily takes the lives of more than 4,000 children daily, despite the fact that we hold in our hands more cost-effective and proven solutions for preventing and treating diarrhea than any other childhood illness. By increased and effective allocation of resources in a portfolio of improved treatment, nutrition, and water and sanitation interventions, we can help ensure that this common disease is no longer a leading killer of children in low-income countries.

We ask our leaders to consider the burden that diarrheal disease imposes on billions around the world and within their own countries, and to recognize that our investment in deploying solutions must be commensurate with the toll that diarrhea takes. To that end, we call upon donors, international health policymakers, national leaders, and the private sector to:
Invest the resources to ensure that funding for diarrheal disease, including both prevention and treatment interventions, is commensurate with the scope of the burden the illness places on families and communities around the world;
Redouble our commitment to reducing child mortality by 2015, as stated in the WHO/UNICEF joint statement on the Millennium Development Goals, with a focus on diarrheal disease as a strategy for clear and rapid progress towards that goal;
Invest in the research and development of new effective, appropriate and affordable prevention and treatment options for diarrheal disease;
Prioritize the implementation of an appropriate combination of diarrhea interventions, including improved water, hygiene and sanitation; optimal infant and young child feeding; increased access to and uptake of vitamin A, ORS and zinc and rotavirus vaccination;
Include diarrhea prevention and control in international, regional and country plans on sanitation, water and hygiene. Conversely, include sanitation, water and hygiene interventions in health efforts, and commit to strengthening health systems capacity to address the environmental determinants of diarrheal disease.