In this week’s newsletter we pay quite some attention to the polio eradication debate, aka ‘the Endgame’, among others, with an eloquent guest editorial by Seye Abimbola on a new and challenging Emerging Voices viewpoint in Plos Medicine.
A number of international days were celebrated this week – it’s difficult to keep track of them, we have to say. The World Day for Decent Work, for example, the World Mental health day, today is also the International Day of the Girl Child… With all these world days, you sometimes wonder why the world isn’t a better place. But yes, too bad Malala didn’t get the Nobel Prize.
There was encouraging global health news, though, this week, with relatively good news on a malaria vaccine (commentators disagree whether the glass is half full or empty), WHO prequalification of the first Chinese vaccine, and we also noted nice contributions to the UHC & post-2015 debate (for example an Oxfam report & a Lancet Comment by Michael Marmot arguing that UHC is necessary but not sufficient – enter the social determinants, of course). Meanwhile, Kumanan Rasathanan tweeted that the UHC movement might move on from calls for post-2015 inclusion – it will be, he said – and focus on funding, measure, targets and accountability instead.
Finally, Richard Smith wrote a blog post on the new ‘Global health 4.0’ era and another global health watcher pointed out that equity is the new buzzword, including in global health. If you want to know more, read on.
Enjoy your reading.
Kristof Decoster, An Appelmans, Peter Delobelle, Basile Keugoung & Wim Van Damme
Polio eradication and the lens of established thought
Seye Abimbola ( PhD candidate at the School of Public Health, University of Sydney, Australia, and a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria. The views of the author are solely his and not of any affiliated institution.)
In the introductory essay (pdf) to their timely collection of ethnographic papers on global health, “When People Come First: Critical Studies in Global Health” (which I think everyone working in global health should read), the editors, anthropologists João Biehl and Adriana Petryna, referred to the need to interrogate the “realities that we encounter in the [global health] field… that are too often obscured by the lens of established thought.” The phrase obscured by the lens of established thought made me think about how the global health community is responding to the challenges of polio eradication. In a Policy Forum article published in the open access journal PLOS Medicine earlier this week, “The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan and Nigeria” Asmat Malik (from Pakistan), Farooq Mansoor (from Afghanistan), and I (from Nigeria) tried to address these challenges, especially of violence, as attacks on polio workers pose a serious danger to the Global Polio Eradication Initiative. The paper was read by over 400 people, shared more than 75 times in social media and widely reported in the online news media within the first few hours of publication.
While these countries, with large Muslim populations, have obvious similarities that threaten polio eradication efforts such as militancy, political unrest, lack of trust, and insecurity, the reasons for the failure to eradicate polio, as well as potential solutions, differ from country to country. For example, attacks against polio workers in Pakistan and Nigeria are unlikely to be repeated in Afghanistan because of the Taliban’s ambition to regain its role in Afghan national politics. The cause of recent distrust in northern Nigeria is partly because polio eradication is now associated with Bill and Melinda Gates, who are also promoting contraception; people distrust this push for contraception because they don’t grasp the link between a reduction in population and improved child survival. In Pakistan, this distrust is partly due to concerns by some terrorist groups that the house-to-house movement of polio workers could be used to identify wanted persons as was the case when the USA used a fake hepatitis B vaccination campaign to hunt down Osama bin Laden.
We do need to retreat a little in our battle against polio, to remove the layers of established thought from the lenses through which the global health community views polio eradication. We need to retreat for the purpose of building trust, take a rest from international deadlines to eradicate the disease, and in the meantime focus energies and resources on strengthening routine immunisation and other primary health care services. We need to change our rhetoric to one which prioritises making polio eradication part of the routine health system rather than highlighting it as “the only” health problem and put the people first, be they health workers or communities benefiting from health interventions. Polio eradication will only be achieved with stronger health systems and bottom-up community engagement, which will likely require more time and investment than the newly designated deadline to eradicate polio in 2018 affords. For example, in Nigeria we need to start working directly with community members and their immediate leaders rather than engage only with regional or provincial religious leaders to avoid elite capture in the campaign to dispel myths about the polio vaccine.
The global nature of the push for polio eradication makes polio workers a soft target in a proxy war against the West, especially in places rife with anti-West terrorist sentiments. To preserve the life of health workers in these areas, we need to reduce the fanfare and publicity associated with polio vaccination campaigns. Until polio eradication is seen by the people as a social problem that deserves priority, it will continue to be part of a foreign agenda with no incentive for groups such as Boko Haram and al-Qaeda to protect vaccination as a means of winning people’s support. For example, polio vaccination could be integrated with other interventions that tackle problems that people rightly consider a priority such as poverty, sanitation, malnutrition, and the three big childhood killers: malaria, pneumonia, and diarrhoea. Improved access to health services by the general population and an overall increase in the coverage of health services might help build trust between governments and the people, and between health workers and communities. We must avoid the portrayal of any health intervention as a battleground between Western forces and terrorist groups.
Like Biehl and Petryna so eloquently discussed in their essay, local realities in global health are inevitably often messy, transitional, and contradictory so that our analysis and proposals in our PLOS Medicine Policy Forum are neither exhaustive nor perfectly suited to the myriad of circumstances in our countries, but could be the beginning of a conversation that is long overdue. There is a cost to every ambition; one must not only count the benefits, but also the costs. We must not allow our ambition to eradicate polio at a certain date, to blind us to what we know about terrorism, and the accumulated lessons we have learned about health systems since Alma Ata. Looking into a hopefully not too distant future, when our work on polio eradication is done, I can see insightful work on the ethnography of this our final push for polio eradication. It will make for interesting reading, in the style of the humanising renderings of on-the-ground field realities of global health interventions contained in “When People Come First: Critical Studies in Global Health”, with lessons on how to, and how not to plan and implement future eradication programmes in global health.
In this week’s PLOS Medicine, two separate articles call for a shift away from the leader-centric approach that polio eradication campaigns are currently pursuing in the three countries (Nigeria, Pakistan and Afghanistan) where the disease remains endemic.
1. Plos Medicine – The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria
Seye Abimbola, Asmat Malik, Ghulam Farooq Mansoor;
In a policy forum article, Emerging Voices (authors from Nigeria, Pakistan and Afghanistan) argue that the global health community and governments involved in polio eradication efforts need to build trust and prioritize polio eradication as part of routine health services in order to address the problem of polio. For the other key messages, we refer to Seye’s guest editorial.
2. Plos (Essay) – Why We Must Provide Better Support for Pakistan’s Female Frontline Health Workers
Svea Closser et al.;
Svea Closser and Rashid Jooma argue that achieving polio eradication and strengthening Pakistan’s health system must focus not just on international engagement but also on local partnerships with Lady Health Workers and other ground-level staff.
For the latest on polio (and its re-emergence in areas previously considered polio-free, including in Somalia, Kenya, Ethiopia), see this BMJ news article.
Harare +25 conference coming up in Dakar
In 10 days from now, more than 100 international experts will gather in Dakar, Senegal, for the Regional Conference on “Health District in Africa: Progress and Prospects 25 years after the Harare Declaration” (21-23 October). This event is co-organised by the Community of Practice Health Service Delivery, HHA, WAHO and the Be-Cause Health Platform. The event aims to take stock of what has been achieved over the last 25 years, but will also raise critical questions. There can be no UHC without strong local health systems, and it seems time for an update of the health district strategy in Africa.
If you can’t attend in Dakar, you can follow activities there via a number of online platforms: the online discussion forum of the Community of Practice (https://hhacops.org/cop-hsd-pss-bilingual/ – you have to register, though); the blog Health 4 Africa (http://www.health4africa.net/); Facebook https://www.facebook.com/hhacops; Twitter (#Harare25) , …
3. Health4Africa – Harare +50: Africa, the continent where people lead healthy lives
Jean- Louis Lamboray;
In the weeks and months ahead, Health4Africa, a newcomer in the global health blogosphere, will publish blog posts related to the Harare Declaration. In this first post, Jean- Louis Lamboray (Constellation) challenges the reductionist interpretation of community involvement which prevailed over the past 25 years and calls for citizen to manage their own health. The Harare Declaration paved the way for such an ambition. Will participants of the Dakar conference take stock and decide to engage on this more radical path?
UHC & post-2015
4. Oxfam – Universal Health Coverage – Why health insurance schemes are leaving the poor behind
A must read. For an overview of the key messages and interpretations of this new Oxfam report, see blog posts & op-eds by Anna Marriott (on Oxfam Global Health Check), Rob Yates (in the Guardian – yes, a must-read, even if you probably already know what he’s saying), a BMJ news article (which singles out the World Bank: The Bank should stop encouraging developing countries to set up social health insurance schemes in the drive to ensure universal access to healthcare, the charity says). Katie Malouf (also on Oxfam’s Global Health Check blog) is more positive about the changes taking place at the WB. She says UHC will be key to the success of the WB’s new vision (which is being presented as we speak, at the annual meetings), though.
5. Lancet (Comment) – Universal health coverage and social determinants of health
UHC is necessary, but not sufficient. Referring to what happened after Alma Ata, Marmot says: “There is a danger of going down the same route again with universal health coverage to the apparent detriment of action on social determinants of health.” He gives some options on how to avoid this scenario.
6. Lancet (Correspondence) – Global kidney disease
Brendon L. Neuen et al.;
“Although the 2011 report of the WHO General Assembly on NCDs identified chronic kidney disease as posing a major health burden, it is absent from the WHO priority NCDs: heart disease, diabetes, chronic respiratory disease, and cancer. Instead, chronic kidney disease is included within the cardiovascular disease grouping. Hence, it is often lost and not given the priority it deserves as a cause, consequence, and risk multiplier of all four priority NCDs.” Neuen and collagues point out the serious global health inequities in this area.
7. BMJ blog – Moving from global health 3.0 to global health 4.0
Richard Smith writes about the four phases of global health, first described by Peter Piot, director of the London School of Hygiene and Tropical Medicine, and discussed last week at the Royal Society. “Global health 3.0, which is still the main manifestation of global health, is about researchers from rich countries leading research programs in poor countries. But global health 4.0, increasingly the present and certainly the future, is research and other activities being led by researchers from low- and middle-income countries.” There are plenty of other differences between global health 3.0 and 4.0. (the question Richard should still answer, though, is: where will it stop? Will we see, some day, global health 13.0 or global health 32 ?)
8. New Internationalist – Moving beyond the Millennium Development Goals
The new framework for international development may be the biggest opportunity for positive global change in our lifetimes – but it could be about to become a missed opportunity, argues Sarah Edwards. “Especially worrying is the lack of concrete measures to explicitly address inequality”.
9. Atlantic – Five global health concerns
In an interview with an Atlantic editor, Laurie Garrett outlined several very real threats facing the global population. Check out especially the second one: “When 3-D printing becomes 4-D printing, Garrett argues, people will be able to send self-replicating viruses across the world in seconds.” (it seems time to find a counterpart for the Nobel Prize for Peace – a Prize for ‘the most fearsome scientific invention of the year’ – scientific innovation can only benefit from this, and we can let the macho duo Putin & Abbott preside over the annual ceremony – ideally including a demonstration of the new discovery)
10. Guardian – Malaria vaccine: Hopes rise for 2015 target after successful trials
GSK will seek marketing approval for the world’s first malaria vaccine – RTS,S – next year after trial data showed the shot significantly cut cases of the disease in African children. The vaccine was found, after 18 months of follow-up, to have almost halved the number of malaria cases in young children in the trial, and to have reduced by around a quarter the number of malaria cases in infants. Although the vaccine doesn’t appear to work as well as originally hoped, both Glaxo and the PATH Malaria Vaccine Initiative, said it could still be a useful tool against malaria (see their joint statement).
The Economist concluded: “ …These figures compare with the aspiration, set by a consortium of malaria experts in 2006, to have by 2015 a vaccine that was more than 50% protective. RTS,S has not reached that desideratum, but its effects are not negligible. The big questions, then, are whether RTS,S is effective enough to win approval from the European Medicines Agency, whether the WHO will recommend its use, and whether donors will pay for it.”
Tom Paulson (on the Humanosphere blog) also wonders whether the glass if half full or half empty (as he already did a while ago).
Access to medicine
11. WHO press release – Newly accessible Japanese encephalitis vaccine will make saving children easier in developing countries
China National Biotech Group, a Chinese vaccine manufacturer got prequalified by WHO for paediatric use of its single dose vaccine against Japanese encephalitis all over the world. It’s a first for a Chinese company with an enormous global health impact: ‘A welcome development both in the fight to protect children in developing countries and in the future availability of vaccines more generally’ as WHO Director-General Margaret Chan puts it. (gongxi, gongxi, Zhongguo!!)
See also Andrew Jack (in the FT ) on this news.
12. KFF – TPP Will Not Hinder Access To Essential Medicines, U.S. Commerce Secretary Says
The Asia-Pacific free trade agreement will not hinder access to affordable medication, the U.S. commerce secretary said on the sidelines of an APEC summit that concluded on October 8 in Bali, Indonesia. ( yeah, whatever)
13. Foreign Policy – Bad Medicine
Speaking of Americans, the title of this article sounds like a crappy Jon Bon Jovi song, but the article is actually on drugs produced in India. Bate implies India is flooding the world (and especially Africa) with tainted drugs, and is getting away with it.
14. Guardian –
Dr Berkley, chief executive of the GAVI Alliance contextualises the arguments uttered by anti-vaccine movements who blame human papillomavirus (HPV) vaccination as the common denominator after the tragic deaths of some girls in India. He argues that despite the good safety record of HPV, a handful of misconceptions spread through opponents may create fear with anxious parents. Denial of the vaccine that prevents against the major cause of cervical cancer in adults, is immoral and ‘threatens the lives of millions of children the world over’.
15. Health Policy & Planning (October issue)
HP&P offers interesting articles this month – in fact, they always do, but this month even more:) Maryam Bigdeli from WHO’s Alliance for Health Policy and Systems Research, and colleagues focus on access to medicine from a health systems perspective. Relations between medicines and system components such as health financing, human resources, health information and service delivery are often ignored. This article is a plea to embed populations’ access to medicines in a health systems perspective rather than to vertically approach it.
World Day for Decent Work
16. IHP – (Some) work makes us sick: Some reflections on the International Day for Decent Work
Peter Vermeiren, in his own words ‘a sociologist at large’, wonders why the global health community pays relatively minor attention to ‘decent work’ (with some exceptions, like the social determinants crowd (see Marmot today on the importance of ‘good employment’, for example) and parts of the NCD community). Peter offers a few interesting hypotheses, and says this ‘oversight’ should be corrected post-2015.
Starvation of children in Syria
We personally have no clear opinion on Syria – by now it’s obvious that both sides are committing horrendous atrocities, and the picture is getting murkier day by day, with all these factions and interests, including many foreign ones, present in the country. But the bottom line should be that the humanitarian horror has to stop, somehow. Public health concerns over the conflict in Syria continue, see below for a contribution sent to us by Kasturi Sen, Oxford, UK, on the starvation of children in Syria.
“As Syria completes two years of western imposed (and Arab League) sanctions (2011-2013), their dramatic health effects are now being highlighted with first reports of starvation deaths among children in the suburbs of Damascus. Whilst heavy fighting has taken place in this area, experts had predicted for some time the unworkability of sanctions for regime change (see here and here), arguing that only civilians would pay the price in a country (Syria in this case) which was once well on the way to meeting the MDG health targets. (see also here). In this as in the case of other “sanctioned” countries, it’s not just “civilians” but the most vulnerable among them – children, who are experiencing their tragic consequences.”
Global Fund & PEPFAR
There’s a new GF Observer issue, most of the articles already appeared online in previous weeks (with the exception of an article on new minimum standards for country coordinating mechanisms ). An evaluation of France’s contribution to the GF, commissioned by the French Foreign Ministry, was also carried out, check out the key results here.
17. NEJM – PEPFAR in Transition — Implications for HIV Care in South Africa
Ingrid T. Katz et al.;
“Over the past decade, PEPFAR has funded HIV–AIDS treatment for more than 5 million people in resource-limited settings in sub-Saharan Africa. Now, the U.S. government has reached a turning point in its emergency response and has decided to reduce funding to many of these countries, including South Africa, recipient of the most PEPFAR dollars. In August 2012, the U.S. government announced it would cut South Africa’s PEPFAR budget in half by 2017, making South Africa the first PEPFAR-funded country to transition to full ownership of — and financial responsibility for — its HIV program. Many observers laud the move as a step toward South African independence from global donors, but others warn that it may jeopardize the health of 1.7 million South Africans who are being treated for HIV–AIDS.” The authors conclude: “As PEPFAR changes course, two central questions remain: How can the South African government provide comparable care with fewer resources? And what is the United States’ responsibility for the nearly 2 million South African patients currently receiving treatment?”
Health Policy & Financing
18. BMJ Editorial – Climate change: the challenge for healthcare professionals
Antony Costello et al.;
Last week we reported on the Lancet’s plea to bring climate change and human development together. OECD head, Angel Gurria, head of the OECD, says this week it needs to be a global effort ( in the NY Times) and wants the issue back on the agenda.
This week’s BMJ editorial focuses on the health problems that climate change will bring, and the authors say health professionals need to use, we quote, “their ability to communicate bad news in a way that stimulates a positive response”. (we know of some medics who are so good at this that the patient actually commits suicide after receiving the bad news).
Anyway, climate change is a ‘superwicked’ problem, so this seems like a hell of a job. After all, our politicians are supposed to be the best communicators around, and if they don’t know how to convey the bad news, how will medics be able?
19. Lancet – Mapping of available health research and development data: what’s there, what’s missing, and what role is there for a global observatory?
John-Arne Røttingen et al.;
The need to align investments in health research and development (R&D) with public health demands is one of the most pressing global public health challenges. The authors aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health R&D, and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. (the article already appeared online in May)
20. IHP – Australia after the election: the lucky (and selfish?) country
Read why Australia is a selfish country – but not more so than the rest of the OECD countries, we might add, including the ones with a less masculine prime minister.
For the just released principles for Ausaid, see here (including a new objective for the aid program).
21. WHO Discussion paper – WHO’s engagement with non-State actors Discussion paper for the informal consultation with Member States and non-State actors, 17–18 October 2013
“Engagement with non-State actors is a critical aspect of WHO’s role in global health governance. Non-State actors play an essential role in helping WHO fulfill its constitutional mandate. This paper proposes ways in which engagement with nongovernmental organizations and private entities can be improved, including the strengthening of due diligence, management of risks and conflicts of interest, and increasing the transparency of engagement.”
22. KFF – U.S. Humanitarian Assistance and Global Health Policy: Opportunities and Barriers for More Effective Coordination
The Kaiser Family Foundation released an issue brief that examines the policy and financing landscape at the intersection of U.S. global health and international assistance programs.
23. Lancet – The Minamata Convention on Mercury: risk in perspective
Heidi J. Larson;
“On Oct 10, 2013, a document is to be signed in Kumamoto, Japan that will not only be historic in its ambitions, but also a memorial to local history where the first case of Minamata disease was identified in 1956.”
24. AVAC – The tipping point
“Although about a dozen countries hit hard by AIDS have reached a ‘tipping point’ that means they are winning their battles against the disease … the world as a whole — and Africa in particular — is still losing the fight,” according to a new analysis from AVAC, an organization that lobbies for AIDS prevention and treatment. The analysis compares the number of people in each country who are newly infected with HIV each year to the number of infected being put on treatment for the first time. See also the NYT.
25. Guardian – Cancer experts warn of burden on poor countries as death rates soar
An industry-led cancer fund could help developing countries combat rising impact of the disease, said oncologists during the European Cancer Congress in Amsterdam. They look to the Global Fund for inspiration. As for the money, it’s not clear.
26. Lancet (Editorial) – How to cope with an aging population
This editorial comes back on the Global AgeWatch Index 2013, which was released on Oct 1, ranking 91 countries in terms of the wellbeing of their older populations. The editors say health systems should brace themselves for the rapidly aging populations, not the least in LMICs.
27. Lancet (Editorial) – Opening eyes to prevent blindness
Oct 10 was World Sight Day 2013 (WSD13), organised by the International Agency for the Prevention of Blindness and WHO. Access to basic eye care in the world is a must.
28. Economist – The Obamacare software mess
Another must is that the Obamacare software starts working – soon. If not, the consequences could be disastrous. (disaster and the US rhymes these days, even if Republicans and the Obama administration got a little bit closer to each other, in recent days)
Global health bits & pieces
- UNITAID & Japan: Denis Broun, executive director of UNITAID, on Tuesday urged Japan to introduce a so-called ‘solidarity levy,’ such as a small tax on airline ticket purchases, to help support the organization’s goal of improving access in low-income countries to diagnostics and treatments for HIV/AIDS, malaria and tuberculosis.
29. Alliance – Implementation research in health: a practical guide
David H. Peters et al.;
The Alliance HPSR launched the’ Implementation Research in Health: A Practical Guide’. “Billions are spent on health innovations, but very little on how best to apply them in real-world settings. Despite the importance of implementation research, it continues to be a neglected field of study, partly because of a lack of understanding regarding what it is and what it offers. Intended for newcomers to the field, those already conducting implementation research, and those with responsibility for implementing programmes, this guide provides an introduction to basic implementation research concepts and briefly outlines what it involves, and describes the many exciting opportunities that it presents.”
30. Global Health Action – The mismatch between the health research and development (R&D) that is needed and the R&D that is undertaken: an overview of the problem, the causes, and solutions
Roderik F. Viergever;
One of the most pressing global health problems is that there is a mismatch between the health research and development that is needed and that which is undertaken. The dependence of health R&D on market incentives in the for-profit private sector and the lack of coordination by public and philanthropic funders on global R&D priorities have resulted in a global health R&D landscape that neglects certain products and populations and is characterised, more generally, by a distribution that is not ‘needs-driven’. This article provides an overview of the mismatch, its causes, and solutions.
31. Health Policy & Planning – Does the distribution of healthcare utilization match needs in Africa?
Igna Bonfrer et al.;
An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa. The authors examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries.
Another HP&P review article focuses on the cost of injury and trauma care in LMICs.
- The World Bank’s ‘World Development report 2014 – Risk and opportunity’ was published. For an assessment, see ODI’s Tom Mitchell.
- You find a post-2015 discussion & political meetings timeline here.
- World food security talks are taking place in Rome (see the Guardian ).