Sarah, I See Your Rant and Raise You an Anguished Cry For the Poor of Chicago

January 30, 2007 at 4:21 pm (Michael's Posts)

Sarah’s question in her previous post made me think of bureaucratic reform and at work at the clinic I am surrounded by the rumblings and turmoil of budget cuts. In other words, the gutting of the health system. So, I was just thinking about this crisis in light of bad bureaucracy. One of the biggest issues that i’ve heard mentioned around the campfire is that the county healthcare administration is bad at billing medicaid and medicare. As in they only get some tiny amount of the money that there is alloted for the care they offer. And that’s only for documented medicaid/medicare folks. There are thousands who qualify but who have not applied or been approved for one reason or another. Why is it not a chief priority in the clinics and hosiptals to get people signed up for these services?

A: It costs the feds money and there’s a conspiracy to prevent people signing up.
B: There’s no good reason.

I’m a down-to-earth guy (even though I am an economic radical of sorts) and I go with answer B. At least there’s no good reason the doctors I work with can think of. So it must be a failure of a bloated, inefficient bureaucracy. And since I don’t actually get paid by them and my volunteer job is not on the line, I feel free to say that. And if it be false, please, do let me know.

So it looks to me that there’s money and we’re not using it. Instead we’re contributing to the myth that there aren’t enough resources in America to go around (read: no one wants to take responsibility for the care of the poor). And this makes it look like it’s impossibly expensive to care for everyone in this country. How will we know if we don’t use the systems we have set up? We’re just going to give up on it like that? It’s a damn shame.

See also: Bureaucratic reform. (Sarah’s post on polio)

See also: public accountability. How do we make THAT work?? How can people who are as disenfranchised as the poor hold a machine as famous as the political system in Chicago accountable when it screws them over? Especially when it screws them by not charging the federal government for the medicaid and medicare it’s owed. Absurd. And if I’m totally off base with this accusation, someone set me straight). Any ideas from political type people on how to empower the poor to hold powerful government entities accountable? I know it’s a very uphill battle.


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Polio, surveillance systems, and a bit of a rant

January 27, 2007 at 9:50 am (Sarah's Posts)

Today, I heard a lecture from the Pune Municipal Corporation Immunization Officer on his experiences trying to eradicate polio.  Afterwards, he showed me how their surveillance system for polio works.  Every time that there is a case of acute flaccid paralysis (AFP) admitted to one of his 39 reporting units or 141 informers, they call him.  AFP is the surveillance marker for polio because it is the clinical manifestation of paralytic polio, among other diseases.  Roughly 1 in 500 children who are infected with polio virus exhibit AFP and these are the children that have future disability from the infection.  Whenever there is an AFP case, the doctors in all of his centers are supposed to call him so that he can come and examine the child, taking stool samples, determine the likely cause of AFP and generally start the public health system in motion.

The patient today was a 1 ½ year old boy who was admitted to a Pune hospital after seeing three pediatricians over the last five days for AFP.  The doctor’s evaluation determined that the child was an unlikely candidate for polio infection because he had loss of muscle tone in both legs (polio is normally asymmetric), no history of fever, and no known contact with a polio case.  The fact that this child slipped through three doctor’s care without being reported is an indication to me of how cases are going undetected.

Throughout this encounter, I was watching the doctor with such a sense of refreshment.  He was dedicated, knowledgeable and knew the importance of doing things right.  There is a dearth of these people in the public health field here in India.  Sometimes, I look around and wonder where the local visionaries are because there is so many things that outsiders like me simple can’t do.

I don’t think that people in the states are necessarily more dedicated to their jobs, but they are held accountable for their work in so many more ways.  There is an infrastructure that allows for some surveillance, some assurances that things are getting done.  India’s system is running on the energy of relatively few hugely dedicated people who work because they care, but certainly not because anyone is checking what they do.  One look at my professor’s face as she talks about these issues makes it poignantly clear how draining this pressure is, how easy it is to burn these leaders out under the weight of the problems and the lack of support.

I keep coming back to the issue of how to train leaders.   It is pretty easy to understand how many kids need a vaccine in order to stop the transmission of a disease.  It is much harder to think of how to build up an infrastructure that will motivate public health workers and give them the tools they need to successful combat the bazillion potential obstacles, or at least set up monitoring systems to be sure that they meet some minimum standards.  The way that polio is being addressed in India is sucking money and energy out of the health system, leaving other programs like routine immunization underfunded and underloved.  This method simply isn’t sustainable.  However successful we are with polio, we’ll need people to deal with the next epidemic, be it heart disease, avian flu, or something entirely new.  The question is how to find and nurture those people.  So, public healthy folks.  Tell me what you think we need to do to get this rolling.  What sort of institutions/setups/trainings/groundwork do we need? 

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Thank Goodness for Journalists (and I Don’t Know WHAT to Say to the Gateses)

January 24, 2007 at 2:02 pm (Michael's Posts)

Well, maybe sometimes they open our eyes to things we’d rather not have them open to.

This set of articles appeared starting a couple weeks ago in the LA Times. They’re about the contradiction between some of the investment holdings of the Gates Foundation and their stated commitment to furthering global health. Truly shocking stuff.

To be frank, after reading the first article in the series, published January 7th, 2007 (they appear on the linked page from most recently published to first published), I was sickened and disillusioned. How could people who purport to do so much good have their hands so deep in what is black-and-white bad?

Money. It seems to be about the money. But with Gates and Buffet’s fortunes combined, how could they possibly need more money? I wanted lunch 20 minutes ago but I think I lost my appetite.

Especially after reading the most recent article (1-14-07) . The Foundation’s CEO, Patty Stonesifer, argues that it would be naive to think that one investor’s divestment from companies who do great health and social harm would impact the practices of the company.

True, Ms Stonesifer. Someone else would just buy the stock. But the Gates Foundation is not just any old investor. They’re the single most high-profile charity IN THE WORLD. A public demand from the Gates Foundation to change business practices or risk divestment could do something, could it not? Or am I being naive? And is the influence that your Foundation has really not all that powerful? I’d like to think otherwise. Please do the right thing. You have the unique opportunity to fight for justice in many arenas. Why allow this contradiction to stand? Especially in the face of such hard-hitting evidence.

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Scrabble and the UIC

January 23, 2007 at 1:28 pm (Sam's Posts)

I always wondered what the word “Qat” meant, because I had used it so many times in Scrabble games to get rid of the ‘Q’ when I didn’t have a ‘U’. As it turns out, there’s a fascinating story behind it.

Qat, or khat, is a plant with leaves that, when chewed, release cathinone, a ketone amphetamine that is classified as a Schedule I drug in the U.S (read: illegal), along with heroin, cannabis, and MDMA, among others. However, the plant loses its potency steadily after it is harvested, to the point where it becomes a Schedule IV drug (read: legal) in the U.S. after 48 hours.

Here’s where it gets interesting: There are no regulations on qat in the Horn of Africa and the Arabian Peninsula. The plant, which, I read, was originally cultivated in Ethiopia, was brought to Yemen seven centuries ago, and is now the primary contributor to Yemen’s GDP. In the past few decades, qat consumption has so pervaded society that at least one survey estimates consistent qat usage at 90% of the male population in Yemen. Again, there are no regulations on qat there, so qat farmers take advantage of recent infrastructural improvements to ship the leaves to urban Yemen, as well as to Somalia, Kenya, and Ethiopia, as fast as possible in order to maximize its potency (this means that most qat is picked in the morning, and used in the afternoon). Apparently every home in Yemen has a well-kept room devoted solely to qat sessions, which happen more or less every day after lunch. People seem to say that it gives clarity and promotes healthy dialogue, often leading to its use in business deals. But many others argue that qat is shortening the work day and drastically decreasing productivity. Many also suspect that qat is harmful to one’s health. Attempts to regulate qat in Yemen have met substantial resistance in the past; the people, and the economy, rely upon it.

Here’s what the Regional Office of the Eastern Mediterranean for WHO says, regarding Yemeni health:

“In recent years the lifestyle of Yemenis has radically changed with fast food, a sedentary lifestyle, the tension of modern city life, smoking, obesity, and  lack of physical activity. Ischaemic heart disease and hypertension have become another health problem in Yemen. Almost all male Yemenis chew khat, and khat chewing among women and school-age children has increased markedly. It is well known that khat raises blood pressure and heart rate. Cathinone, the active ingredient in khat leaves, produces severe coronary vasospasm in animal models. Khat also increases the desire to smoke, produces more nervous tension, increases sympathetic activity, and encourages a sedentary life.”

(Report on the WHO STEPwise surveillance system (for Egypt, Sudan, and the Republic of Yemen))

The qat-chewing phenomenon is fascinating in itself to me. But one more thing to consider – qat is also harvested and used in Somalia. At the very end of some news articles (Western media outlets, of course)covering Somali current events, hidden amidst AL-QAEDA! and REPRESSION!, is the fact that the Union of Islamic Courts (UIC) has, among its many stabilizing actions, banned qat from Somalia. Of course, I don’t mean to ignore whatever violations of individual rights that the UIC may have committed, and I think it’s very important to consider the qat farmers whose livelihoods were made illegal – but I am again reminded that something so vital to national, and international, stability as governmental health policy can be completely ignored in the media when it comes to the war on terror.

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Further to AE Beacon’s Post, “Perspectives on NGOs Abroad”

January 22, 2007 at 3:31 pm (Michael's Posts)

I decided to make this comment a post so we could get it back in the mainstream of the conversation. It’s an important topic that didn’t get hit enough the first time around.

Here’s a link to the original post by AE Beacon. Read it first.

Beacon and Erin (and all)-

Sorry it took me a while to get back to this. Hopefully we can get the conversation going again. I just didn’t have the wherewithal to get into this at the time it was published, but I want to. So here goes.

I think that we owe a debt to the colonized world. To be frank, Westerners screwed them out of the productive parts of their society (young men and women and capital) for centuries and part of the reason some of these countries are in the dire straits they are in is because we put them there. The centralization of wealth and prosperity, and hence “progress” and “development,” is not a mistake. It’s not a cultural difference, either; the idea that somehow there is a “work ethic” that Europeans possess that the rest of the world is bereft of is an asinine idea. The reason the Global North is wealthier is because we sucked the gold out of the Global South. Systematically. And violently. Mali was once a golden empire that stretched across the Sub-Sahara that we now know as one of the most impoverished places on earth. India had wealth that Europe could only dream of. China was also wealthy beyond Western dreams before imperial conquest came to their shores.

Finally, we have a system through which we can give back some of what we stole. It’s not White Guilt that is at the root of my comment. It’s the idea that economic justice ought to be served. Morally. NGOs are a fantastic way to channel the resources that were stolen back to those who they were stolen from in the form of a redistribution of skill and services. It is an opportunity for those of us in the “developed” world (i.e. in the context of my rather radical and pissed-off subaltern economic perspective, the “thieving world”) who are aware of inequality and sick of it to try to right some of the wrongs we see. They are potentially a powerful method of redistribution.

Also, NGOs can get close to the ground-level in a way that government agencies cannot. Bureaucracies are built of offices whose officers sit behind desks and give reports but who rarely walk the streets with their fingers on the pulse. NGOs are essentially designed to be local where bureaucracies are designed to be super-local so they have great efficacy when it comes to actually getting things done. They have been instrumental in some of the successful health campaigns in recent years (Brazil’s HIV/AIDS campaign relied heavily on NGO input and logistical capability). They can be flexible and fast in ways that government cannot and thus can supersede the government in many ways.

These are the benefits to NGOs that I am sure you are taking into consideration.

You seem to express concern about this ability. The concern is that again, Western-influenced interlopers are taking control of local situations and doing with them what they see fit. However, the motive this time is giving, not taking. Does this matter? Well, in countries whose governments are often incredibly corrupt and whose populations cannot turn to them for support because of corruption or because there simply are not resources to address needs, we have to consider the fact that even if the government wanted to take care of their citizens, they are often not able to. Why? Because we crippled these countries and have not been actively involved in working out ways to get them back on their feet (I do not count foreign aid for a number of reasons that I will not go into now). So in the light of ineffective governments (and probably/possibly ineffective due to the actions of the Global North), NGOs are the next best thing. Even if they are staffed by nationals of former colonials. And maybe that is a good thing in light of my argument above.

Ought they be staffed by locals? Yes. Absolutely. No one knows more about problems than those who live with them. Do Northerners have expertise that they can bring to the situation to improve potential outcomes? Again, yes.

Erin raises a great question, though. How much of what is meant to go back to these places of now-great-need actually goes into the pockets of corrupt organizations and individuals? A considerable amount. NGOs are a business in “developing” countries. We can only control this hemorrhage of well-meant resources by effective oversight. Givers should not give unless there is oversight and accountability that, at the same time, does not infringe on the ability of the organization to perform its local functions (a great book on this is Michael Edwards and David Hulme: “Beyond the Magic Bullet: NGO Performance and Accountability in the Post-Cold War Period.”). This is indeed a problem that needs much attention.

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Mandating pre-marital HIV testing

January 20, 2007 at 1:23 am (Sarah's Posts)

There has been a lot of debate in the papers and among public health officials in India about making pre-marital HIV testing mandatory. There are several goals, but the most talked-about is to empower women who don’t have the right to ask for an HIV test for their potential partner. I can understand the goals of this program, but there are so many social implications of mandating HIV testing. What happens when one of the couple comes up HIV positive? Does this give people a false sense of security that will make them complacent after marriage? Ideally, the issue of women’s empowerment needs to be addressed by actually empowering women, instead of blanket mandates. This is a start that could allow women (and men, of course, in the opposite case) to begin protecting themselves. But it doesn’t address the fact that a wife may not be able to ask her husband to use a condom or keep him from visiting commercial sex workers. In addition, there is the question of rights. Does the gov’t have the right to enforce that people get HIV testing? The Council of Europe has stated that “In the absence of curative treatment, and in view of the impossibility of imposing behaviour modifications and the impracticability of restrictive measures, compulsory screening [is] unethical, ineffective, unnecessarily intrusive, discriminatory and counter-productive.” There are a few caveats in that statement. If curative treatment is available, then is mandatory testing ethical? Just as the government can’t ‘force’ people to vaccinate their children, they can take away public goods (like free public education) if they opt not to. Is marriage and the rights guaranteed by it a public good that can be taken away if people don’t get tested? If so, what assurances can they give people that their privacy will be safeguarded? In my opinion, programs that don’t respect the rights of individuals are not the best ways to contain disease. Using the law to try to control disease spread needs to be done with a lot of care, lest there be a social backlash to the program and the disease. For HIV/AIDS, I can envision a program of mandatory counseling and voluntary testing. If this is to be successful, it also needs to come with programs to empower women to be able to get their sexual and reproductive health needs met before and in relationships.

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Further to Alex’s post “Circumcision cuts the risk of HIV infection”

January 19, 2007 at 5:38 am (Francelle's Posts)

Hey all,

This article has been circulating here at the IOM about circumcision decreasing the risk of HIV infection in men.  It is estimated that circumcision can reduce the risks of HIV transmission by 60%.  There are lots of important concerns, including the risk of increased Hepatitis B and C infection from inexperienced practitioners and the possibility of an increase in risky behaviors of circumcised males (and a potential spike in HIV and STI rates.)  IEC campaigns and HIV counsellors should exercise caution in promoting circumcision, by qualifying that it is not 100% effective.  Countering misguided knowledge and stressing condom use alongside circumcision will be necessary.  Take a look.



January 14, 2007
A Real-World AIDS Vaccine?
Last month, scientists invented the AIDS vaccine. Missed it? Perhaps that’s because you were still seeking the vaccine fantasy: the magic bullet, the impenetrable shield that finally pitches this disease into the trash bin, the shot that will end not only the AIDS epidemic but our anxiety about the AIDS epidemic as well.

The vaccine thunderbolt didn’t strike – and might never. Drearily, the real AIDS vaccine is likely to be imperfect: one more tool in our arsenal, to be used along with condoms and all our other tools. It will most likely avert millions of infections and save millions of lives. But it will not end the Age of AIDS.

The vaccine that arrived last month was not actually a vaccine. It was, instead, a confirmation of what scientists had long suspected: circumcision helps protect men from AIDS infection. For years, AIDS researchers have observed that many African tribes that circumcise boys or young men had lower AIDS rates than those that don’t, and that Africa’s Muslim nations, where circumcision is near universal, had far fewer AIDS cases than predominantly Christian ones. The first research proof came in 2005, when a study in
South Africa was stopped early in the face of evidence that the men who had been randomly assigned to be circumcised were getting 60 percent fewer H.I.V. infections than the men assigned to the control group. Last month, ethics boards halted two similar studies, in Uganda and
Kenya, when they found similar results. In both, the circumcised men caught the AIDS virus half as often as the uncircumcised control group.

Circumcision would be given more weight if the world recognized that it is, in fact, the real-world equivalent of an AIDS vaccine. In some ways, it is closer to the fantasy than a real vaccine might be. Vaccine research began in the early 1980s but with little financing or urgency and went nowhere. In 1996, the effort was revived with the creation of the International AIDS Vaccine Initiative, and financing has soared in the last five years. But a vaccine has proved elusive. Most vaccines work by mimicking infection, which stimulates the body to make antibodies that kill the disease. But H.I.V. infection generally does not produce those kinds of antibodies. H.I.V. also mutates constantly and comes in many different varieties, factors that further complicate the search for a vaccine.

Many vaccines provide nearly 100 percent protection – after my daughters finish their two doses of the measles, mumps and rubella vaccine, for example, they won’t have to think about those diseases again. But that’s not on the horizon for AIDS. “Fifty to 60 percent efficacy is what people would feel really good about,” says Frances Priddy, the director of efficacy trials with the AIDS vaccine initiative. The best candidates in the vaccine pipeline right now – which won’t be ready until 2013 at the earliest – wouldn’t keep you from getting H.I.V. They instead would seek to change your body’s response to the virus so that if you did get infected, the disease would progress more slowly – or not at all – and you would be less infectious to others.

An efficacy rate of 50 to 60 percent is actually a lot better than it sounds, because of herd immunity. We get AIDS from one another. Every time a person is rendered less infectious, the chance of an uninfected person catching H.I.V. from each sexual contact drops, and in a virtuous circle, the whole community becomes progressively safer. A vaccine of 50 to 60 percent efficacy might come close to wiping out the epidemic in places with low AIDS rates. In high-prevalence areas, it could reduce the epidemic and save millions of lives.

In contrast to a vaccine, circumcision’s origins are about as far from the laboratory as you can get; carvings depicting circumcisions have been found in ancient Egyptian temples. But the effects may be very similar to those of a vaccine. So far, we have proof only that circumcision protects the circumcised men. But there are strong indications that it also protects their sexual partners. A trial in
Uganda is now testing whether H.I.V.-positive men are less likely to infect their wives if they are circumcised than if they are not.
Together, circumcision and an imperfect vaccine might be enough to stop AIDS. But they will need help from behavior change, microbicides, fighting malaria, treating genital herpes and other interventions we don’t even know about yet. That is unsatisfying. The danger does exist that circumcised men will feel invulnerable and throw sexual caution to the winds, a risk that would also exist with an imperfect vaccine. But so far, there is not much evidence of a problem. In the Uganda and
Kenya studies, the sexual behavior of the circumcised men was no more risky than that of the others. In the
South Africa study, circumcised men did report 25 percent more sexual activity. But the circumcised group as a whole still had 60 percent fewer infections. Certainly one reason that risky behavior did not jump is that the men got counseling as part of the clinical trials. Counseling goes naturally with circumcision; counseling would be harder to include in a vaccine campaign, since one of a vaccine’s great advantages is that it can be given assembly-line-style in seconds.

Circumcision is a surgical procedure, however, and in the hands of traditional ritual circumcisers, it has a high rate of infection and mishap. The solution is to train these circumcisers and give them decent tools, and at the same time encourage men to come to clinics. Since men in studies say that cost is the biggest reason they are not circumcised, the operation must be free. Countries will also have to equip these clinics and train counselors and medical circumcisers, who don’t have to be doctors.

Research on an AIDS vaccine is more crucial than ever. But we must not let our hope for a thunderbolt prevent us from racing ahead with circumcision now. For the biggest difference between circumcision and a vaccine is this: only one of them exists.

Tina Rosenberg, a former editorial writer for The Times, is now a contributing writer for the magazine.
Copyright 2007  The New York Times Company 

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Some Implications of President Clinton’s Visit to Cambodia

January 14, 2007 at 8:05 am (Lee's Posts, Uncategorized)

President Clinton visited Phnom Penh, Cambodia, on December 4, 2006. It was a momentous and significant occasion—it was the first time that any American president (current or former) had ever visited the country. Before that, the most famous American to have ever visited Cambodia was Angelina Jolie. Some still consider her to be #1. Jacqueline Kennedy visited in 1965 to commemorate the completion of a USAID-built road between Phnom Penh and Sihanoukville (which was later destroyed by the Khmer Rouge and recently restored by private corporations—it’s a toll road now). But in my mind, President Clinton easily wins the title for “most important American to visit Cambodia.”

Anyway, President Clinton’s visit was a true success on five fronts:

1) It brought worldwide attention to the Cambodian government’s successful HIV/AIDS treatment program. Back in 1997, Cambodia had the highest HIV prevalence rate in Asia, and it was expected to keep growing quickly. But through successful and targeted prevention and treatment campaigns in a multisectoral response to the epidemic, the government health sector, together with the hard work of many local and international NGOs and international organizations, curbed the prevalence rate to 1.9% in 2003. It is thought to be at 1.6% today. Furthermore, the treatment program and national laboratory system have been streamlined (through large technical and financial contributions by the Clinton Foundation and others) and now boasts over 18,000 people on treatment, including more than 1500 HIV+ children. Cambodia has the highest percentage of people living with HIV/AIDS (PLHAs) who are able to access treatment of any country in Asia, and has the third or fourth most total number of PLHAs on treatment of any country in the world.

All of this had remained relatively unknown to much of the international community, but the President’s visit highlighted the accomplishments of the National Center for HIV/AIDS (NCHADS), a success story within what is usually considered an ineffective and corrupt government.

2) The positive attention and recognition described above, as well as the symbolic importance of a visit from a well-regarded former US President, was an incredibly positive step for Cambodian diplomacy and Cambodian self-confidence. Putting Cambodia on center stage in such a positive light will help to shed some of the massive cultural baggage and self-deprecation that has carried over from the Khmer Rouge. This self-understanding, an almost depressed nationalism, is ubiquitous in the population and can be sensed just below the surface.

3) The Presidential visit highlighted one of the Clinton Foundation HIV/AIDS Initiative’s (CHAI) most successful programs. The partnership between CHAI and NCHADS is seen as a model of seamless and productive collaboration that other programs seek to emulate. CHAI’s accomplishments in assisting NCHADS with massive reductions in the prices of antiretroviral (ARV) drugs, as well as increasing the availability of ARVs within the country, are impressive. CHAI has also helped to restructure NCHADS’ national laboratory system for HIV testing and its logistics management system, thereby improving efficiency in the government’s procurement, storage, and distribution of ARV medicines, lab reagents, and other consumables.

4) President Clinton and Cambodian Prime Minister Hun Sen signed a Memorandum of Understanding (MOU) that allows Cambodia to access UNITAID donations. UNITAID is a newly established drug procurement and donation mechanism, housed within the UN and funded principally by France, Norway, Brazil, and a few other countries. CHAI was asked to and accepted the role of organizer and distributor of these donations.

The signing of the MOU allows the Cambodian government to access large amounts of donations of pediatric ARVs, lab reagents, and therapeutic food supplements (or RUTFs, for severe malnutrition) in 2007 (with ability to renew and increase procurement in 2008). Importantly, it will donate some pediatric fixed dose combinations (FDCs–in this case, 3 drugs in one) and offer further purchases of these ARVs at greatly reduced prices, so that Cambodia will have the means to procure pediatric FDCs for the first time.

The significance of FDCs: adherence to a drug regimen, especially for impoverished people living far from a hospital or health clinic, is one of the most difficult issues facing HIV/AIDS treatment. These drugs are only effective when taken regularly, and FDCs have been shown to improve adherence by creating a simple regimen consisting of taking only one pill, twice a day. With increased access to these pediatric ARVs, NCHADS and CHAI can push forward together towards their goal of a pediatric scale-up involving 1500 new children on ARV treatment in 2007 (doubling the current number of HIV+ children receiving treatment in Cambodia, for a total goal of 3000 by the end of 2007).

5) With photographs of President Clinton hugging, laughing with, and admiring the song-and-dance performances of healthy, active HIV+ children at Maryknoll orphanage, his visit has generated a visual understanding of what it means to have a successful pediatric AIDS treatment program. Hopefully, these images will galvanize support, both technical and financial, in order to scale-up pediatric AIDS treatment programs across the globe. The goal will be to have as many HIV+ children accessing and adhering to an ARV regimen as possible, so that all can appear as active and healthy as the Cambodian children at Maryknoll. I recognize that this statement is simplified and to some extent naïve, and does not account for many issues such as dependence on foreign aid or the additional needs of HIV+ children such as education, nutrition, and psychosocial support (among a whole host of issues). However, as a broad goal it will do.

For more info on the visit, please see my Cambodia blog–there is a link to it on the right-hand side of this page.

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Building Networks to Make Health Work, or the Big Public Hospital part 4

January 13, 2007 at 5:44 am (Michael's Posts)

One of the college professors I consider a guru (in the Indian sense of someone who is a “root teacher,” a foundational source of knowledge) is a proponent of what I call network theory.  In this idea, states and governments are subordinate to networks, be they business,  non-governmental organizations, etc.  This is due to the flexibility and border-spanning nature of networks and their ability to ignore the restrictions of states and other more “concrete” institutions.  In the comparison of what kind of power is the best and who “wins the day,” this professor comes out on the side of networks over states as the primary actors.  There is definitely truth in this if we look at interpersonal organizations like terrorist networks and corporations whose power conduits carry farther and faster than anything our state can muster.  Their power comes from who knows who and what that relationship yields in terms of help for accomplishing the goals of the group.

So.  How does this relate to health?  Well, I have been thinking about the program that I am working on at the Public Hospital.  One of my objectives in joining the program was to see how something like this could grow from the ground up in a public healthcare situation.  In thinking back on it, I was frustrated because so little of what I have participated in has been the construction of a framework or the creation of any kind of structure.  “What is this?” I asked myself.  Whence came my program?

Personal connections.  The MD who thought of this basically picked up the phone and worked his connections and I happened to show up and provide volunteer manpower to get the actual screenings going.  There was no need to build structures because they were pre-existing in his professional and personal connections with his colleagues in and near his department.  And if there was something missing, he could probe connections within the first degree of separation from his colleagues and come up with good solutions.  It’s all who you know.

If global health is going to make changes for the better, we need a network of people who are connected in some way to the conduits that carry ideas and money and power and as they get connected to them, make further connections to spread knowledge and access to power nodes.  We need to make lists of people who are doing things like consulting and law and get in touch with them when we need to know what the statutes say about a certain thing or what the best way to organize an office is.  Doctors have long been isolated from the other parts of the structures that provide healthcare.  This is changing.  We must be aware of the change towards greater interconnection and push it forward, no matter what our profession, if we are to truly bring about our goals of better health for all.

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Funding as a source of bias

January 12, 2007 at 7:45 am (Sarah's Posts)

Beverage Study

This was an interesting article that I came across that speaks to something that we implicitly understand but that is hard to measure.  This is one of the first papers that I’ve found that addresses in a systematic manner how funding can influence the outcomes of studies. 

It makes me wonder how this comes about (very few researchers would openly admit to biasing their studies, even to themselves) and how to abate the soft pressure that comes from sponsorship of research.  Where is the role of public health folks in advocating for unbiased science, particularly when it has a large impact on policy development?  This is one of the reasons that I think that a solid foundation in science is supremely important for public health people, be it in biological sciences, epidemiology or any area that gives a basis on how to evaluate the validity of scientific research.

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