Clean water is a right

November 25, 2006 at 8:11 am (Sarah's Posts)

This is an article that I yoinked from The Economist, which intrigued me especially because of our recent talks about using economic principles to promote good public health policies. I think that the basic notion that there should be a cost for water is a bit counter-intuitive when you first approach it. But, it makes a lot of sense to me in the context of getting water available to the most people while not promoting wastefulness.

Water, sanitation and poverty: Clean Water is a Right

As a side note, I find that I often agree with the ‘socially liberal fiscally conservative’ perspective that I find in The Economist. You guys?

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Enforcing change?

November 18, 2006 at 9:59 am (Sarah's Posts)

This letter to the editor was in The Times of India yesterday.  It refers to recent controversies over laws forcing drivers of rickshaws and two wheelers to wear helmets.  In Pune, the law was passed and then had to be repealed because of widespread protests.

“Respected Sir,

Please tell to some higher officials we don’t want helmets to be made compulsory for the following reasons.

1) Bad roads and path holes

2) Traffic jams

3) Carrying helmets every wear with us like a child

4) Getting loss of hairs

5) We can’t pickup a call, due to it we should park and take out helmet and scart, by the time we do these things the call will get cut. 

First of all life is short.  By making helmets compulsory we can’t enjoy our lives because many people nowadays are loosing hairs and taking treatment. ”

 The roads and drivers in my city and in Mumbai are beyond terrible and there are a fair share of trauma cases.  So my question is this–if there is a policy that is known to save lives, how much coercion should go on to make it happen? Should auto-wallahs be forced to wear helmets for their own good?  Or is it up to any individual to decide what their own risk should be?

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The Big Public Hosptial Part 4, or Persevering with Patience

November 16, 2006 at 2:22 pm (Michael's Posts)

So this week, I have been thinking a lot about sustainability.
I think Alex Coria defined it well (in terms of what I mean by the [buzz]word) in her comment on the “On medicine abroad” post by AE Beacon:
I think in a health context, sustainable means locally sustainable without depending on non-locally produced or trade-derived resources. So basically, if all the charitable giving was taken away, being able to sustain a comparable level of health.
I wonder if my Big Public Hospital is sustainable.
If the County Board changes spending, it’s not. The Board has decided to shut down a number of the satellite clinics associated with the Hospital because of the extreme strain on funds they are experiencing. Just as in one of my past posts, I have speculated on the unsustainability of my particular program, the hospital itself is not, either. We are surviving on the good will of the County and the (possibly unconscious) good will of the taxpayers.
We are also surviving with limited resources and dense, often seemingly nonsensical, bureaucracy. Projects move slowly because the people running them are also running a number of other big things or are pulled in too many directions to give their full attention to things. It is not for lack of good will that the doctors I work with were not able to get things started for over a month. It’s just the reality that there were too many other things going on. The human resources are stretched thin.
I think this may be the case in other, non-resource-poor situations as well, but it may not be.
I did research at a private medical center in Rhode Island and whenever I needed something, I got it. Here and there, there were days that I couldn’t reach the doctor I was working with because she was very busy but by and large, I got the support from her that I needed. We sometimes had to wait a day or two to get in touch with some of the doctors at other hospitals, but never as long as at the Big Public Hospital.
When resources are scarce, patience and perseverance are the words of the day. Every day. The work we do is good. Very good. It is also something that moves slowly. In the time of fast internet and immediate gratification, this can be extremely frustrating.
I don’t have a very good idea about how quickly projects move in areas of resource wealth, but I can definitely say that where they are lacking, it’s often slower than I’d like.
Any reflections on the progress that anyone else feels they are making? And please be sure to comment on your workplace’s resource levels.

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Traditional Medicine and international standards

November 11, 2006 at 8:00 am (Sarah's Posts)

I just spent the day at the 2006 World Ayurveda Congress (www.ayurworld.org/) that was held at the University of Pune, where I am studying. It was a huge event that brought together more than 4000 people who practice or are interested in Ayurveda, traditional Indian medicine. Ayurveda, which translates to the “science of life” has had a lot of bad press in international journals like JAMA and NEJM because of some problems with heavy metals in some of the herbal medicines are regularly prescribed.

Despite the fact that many traditional medical systems are quite old and well established, it seems to me that it falls into the scope of public health to evaluate these systems for their efficacy and ability to promote health. So, the question is where we begin if we want to look at traditional medicine in a culturally appropriate way.

One of the first things that I come up against is how garbled ideas, philosophies and approaches get in the process of language translation. For better or worse, English has become an international standard, which prevents many people from being able to voice their thoughts and knowledge. In addition, many traditional medical practices are based on concepts whose translations in English are, at best, imprecise. The dominance of scientific language relegates people who do not have mastery over English to the back burners of international discourse.

I read the Dali Lama’s new book a while back, The World in a Single Atom. One of his points was that the scientific method is not an adequate tool for evaluating some disciplines because some meaning is lost in taking a third person observer perspective. So, how do we incorporate first person experiences (like the experience of meditation, the feeling of wellness, or the connection between the mind and the body) into a rational objective model for analysis?

There seems to me to be a lot of understandable resistance in traditional medical communities to the perceived arrogance of outsiders coming in to evaluate practices that have been used in communities for hundreds of years. But, I think it is imperative to look at ways to measure the safety and efficacy of these treatments because most people are not empowered or knowledgable enough to evaluate the health services available to them. Nor would we necessarily be in the US without relying on extensive health regulations and a functional judicial system to hold practitioners accountable for high standards of care.

In many communities, traditional medicine is the standard of care. Care providers know their communities and they are entrusted with the health of the people there. The question that I keep rolling around is how we can use and improve these systems to provide better care to people.

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The science of resistance

November 10, 2006 at 5:07 pm (Links, Sam's Posts)

Here is another informative perspective from the New England Journal of Medicine:

Malaria – Time to Act

It was published just a couple days ago, and it covers the viability of a possible reentry into malaria treatment protocol for chloroquinone. With only a small amount of knowledge about drug resistance in infectious disease treatment, I was previously under the impression that once a drug lost its utility, it was gone for good, and would never be helpful again. Not so.

In particular, I find it amazing that ‘chloroquine resistance presumably confers a fitness disadvantage, and stable compensatory mutations sufficient to counter these disadvantage apparently have not occurred.’ I often look at infectious disease treatment as a bacterial seige on humans, patiently mutating, waiting outside the walls until we run out of drug innovations and become defenseless. The fact that some of these stronger, mutated agents are weak enough in other ways to want to revert back to their original form once their original scourge is gone – this confers some hope. We still need long-term, all-encompassing solutions, but in the meantime, you, drug, circle around back and hop in the end of the line – your turn will come again.

-Sam

p.s. I see that the clinical trial asserting the rebound of chloroquine efficacy is also in the current issue of NEJM. In case you want to read that:

Return of Chloroquine Antimalarial Efficacy in Malawi

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On medicine abroad

November 8, 2006 at 8:50 pm (AE Beacon's Posts)

Liberal doctrine has increasingly disparaged the concept of the Western actor in developing world medical settings. Utilizing phrases like “sustainability” and “development”, the idea of an American or European physician entering an impoverished area as a first line health worker or a medical administrator has become a frowned upon concept. However, with most of the world’s medical resources and biomedical research capacity, what role should the developed world play in low resource and low access settings?

Brain drain, while one of the worst contributions of developed countries to health abroad, offers an interesting example of medical exchange. In many hospitals around the US and certainly around Europe there are doctors who immigrated from Africa, South Asia and
Latin America. These doctors undoubtedly face a variety of cultural and logistical problems upon their arrival and likely for a prolonged period thereafter. However, I find no indication that Americans (or Europeans) are particularly ambivalent about being treated by these physicians despite the supposed boundaries that we proclaim foreign medical personnel bring to clinical settings.  

I believe that health workers can successfully make people better in any setting regardless of cultural background. We have put so much emphasis on liberalized health goals like local capacity building, development initiatives and training programs that we have forgotten the brutal arithmetic of human suffering that is daily putting more patients in the hands of fewer doctors. Our enormous capacity to help through physical resources, health personnel and medical training is being handicapped by an ostensibly righteous drive to avoid (vague) concepts of medical colonization and imperialism.  This rhetoric is perpetuating inaction and diverting crucial resources to peripheral efforts. Are we so misguided that we think a sick patient in
Harare would prefer no doctor to a Western doctor?

A recent WHO report noted a deficit of 4.3 million health workers in developing countries. According to some estimates, there are almost 4 million health workers in the US and millions more in
Europe. If even a fraction of this highly trained, highly resourced workforce were to spend a few months or a year abroad, we could make a huge difference in the lives of many sick people. While perhaps they wouldn’t be able to perform many specialized procedures, simple interventions against diseases like pneumonia, diarrhea, malaria and the measles would drastically reduce the number of deaths in developing countries. In addition to contributing positively abroad, I anticipate that upon their return, these physicians would be better equipped to deal with patients from culturally disadvantaged backgrounds. Indeed a win-win situation.

Do not mistake this essay as anti-development. We are all aware of the need for local governments to arrange a successful and self sustained infrastructure. However, in the interim, we must shun our facile philosophical leaning towards inaction and don our personal and collective responsibility for making sick people healthy again.

Æ Beacon

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Consumerism as activism?

November 8, 2006 at 5:00 pm (Michael's Posts)

In light of our recent discussions about the Global Fund, I want to bring up a novel new (well, not totally new but relatively new) fundraising technique. The (PRODUCT) RED campaign is the brainchild of Bono and it is committed to helping AIDS and TB patients in Africa. They channel African products through high-end retailers and bring some charity to these countries through a piece of the profits. Partnered with Gap, Apple, and a few other retailers, the RED project brings a philanthropic slant to shopping. Especially in times when money is short for these global intiatives, it’s great to have new sources and funders.
So why is it that something about the (PRODUCT) RED campaign bugs me? Maybe it’s my anti-consumerist slant. Maybe it’s that I feel that this kind of initiative doesn’t get at the root of the imbalance in the world. It’s not revolutionary. But is it a good enough step? In a way, it seems that campaigns like this reinforce the global order. Through the consumerism that exploits the splits in the first place, we will somehow repair the disparity? I have my skepticism. But throwing it out there to be discussed.

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Holler at the Center for Global Development

November 6, 2006 at 1:29 pm (Uncategorized)

Hey hey,

I just went to and started reading a bit of the site that Alex Coria included in her post a week or so ago (A frustrating day for the global health commmunity). Good stuff! It’s a very interesting inside perspective on the issue she raised. I added the site to the blogroll column at the lower end of the right hand side of this page. Give it a look when you have time to do a little reading.

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Can I have some accountability, please?

November 5, 2006 at 5:46 am (Sarah's Posts)

When I visit Primary Health Centers around where I’m living and ask about statistics, each medical officer proudly shows off his registers. They are piles of notebooks that contain all of the health information that has been collected from the center. Hand drawn lines and figures are collected into large stacks of books. This is the response that the Indian gov’t has prescribed for data collection and accountability. These books are the final word and are the source of most health statistics coming out of the country. The medical officers that I spoke with admitted that many PHCs faked numbers or just were bad at recording data. As I looked through the columns of hand-written numbers, I was thinking about what sort of system would be better and would ensure more accountability.

 

I realize that someone who is determined to cheat can probably find ways to get around any decent accountability system. But, it seems more that it is a problem of inertia. Right now, it is easier to write a number than to get out and do the work, especially if nobody is checking that it is getting done. My professor suggested that some sort of real-time reporting would do the trick. But, few centers have computers in the first place, let alone internet access. So, I’m throwing the question out here… what sort of system would work better for reporting data? More accountability checks? Who would you ask? Community members?

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A frustrating day for the global health community

November 2, 2006 at 3:12 pm (Alex's Posts, Links)

Today, at their long-anticipated meeting in Guatemala, the Global Fund board neglected to elect a successor to Executive Director Richard Feachem. There’s been a lot written about this elsewhere, so I’ll direct people to the Center for Global Development for more info.

In the environment in which I work, this is an important issue, and an interesting one, because of the unique structure of the Global Fund board, which requires a high degree of consensus for the election of ED candidates and encompasses a wide range of stakeholders, from endemic country representatives to private pharma. And clearly, it’s ultimately important to everyone working in global health, as this organization is one of the major sources of funding for all AIDS, TB and malaria program throughout the world (along with the US, UK and Gates Foundation.)

But in the context of this community here, I find myself asking, is anyone else even paying attention? If you’re not an activist or a policymaker, will you ever even read the press release? Did you even know the name of the old Global Fund ED? I’ve found myself thinking about the different reaches and priorities of different players in the global health community in many different contexts over the past year or so, as I at once study to enter medical school and work on advocacy efforts targeted toward policymakers who may not even know what the word “falciparum” means. It’s an interesting dichotomy, and makes one wonder what the “global health community” even really refers to.

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