Back to accountability on the local level

February 24, 2007 at 7:21 am (Sarah's Posts)

We had a lecture the other day from a woman from Hopkins who is working on a large-scale clinical trial in Indonesia on the effects of maternal micronutrient supplementation on infant mortality rates (IMR).  It is an area that has been looked at a lot, but with varied outcomes that have left open questions like when supplementation is the most effective and what composition of micronutrients is best.

One of the areas that she mentioned as particularly controversial was their policy of creating a certification program for all people involved in the project, including the local community facilitators (CFs).  They realized realy on that the local workers didn’t understand the larger focus of the project beyond their specific assigned tasks.  So, they started a program that evaluated everyone based on three categories: head (understanding of the project), heart (empathy and ability to communicate with the mothers), and the hands (ability to record and keep track of data).  If a CF fails three times, he is asked to leave the project.  Both the expat and the academic communities said that this wasn’t a practical, realistic or necessary expectation, but the program coordinators insisted.

When they started looking at the data, they found some interesting things.  Firstly, there was a 20% decrease in IMR with micronutrient supplementation, with the most important time being during the last trimester.  More interestingly, when they compared the IMR for women assigned to excellent CFs as compared to those who were rated as good, there was an additional 17% decrease in IMR.  Among women who were initially assigned to a CF who had to be dismissed due to failure to pass the certification, there was a 20% increase in IMR, essentially elimitating the positive effects of micronutrients.  If seems that there was a synergistic effect of having micronutrient supplementation and an excellent CF.

Sometimes in public health work here, I see the mentality that just because we’re doing good work, it means that we don’t have to do a good job.  Outcome measurements that look at numbers of people trained or number of women reached sometimes gloss over whether the project effectively trained/communicated/reached the target popultion.  Instead, these projects need foster the idea that everyone involved is going to be held accountable because they are all responsible to the community.  It is a method of empowerment, of telling CFs that their skills and understanding are valued, particularl if it becomes clear that these skills have an effect on health outcomes.

On a site note, someone brought up the point that all these programs are merely drops in the bucket, and that any given intervention-specific project is too small in scope to make any real difference.  This lecturer felt that the greatest increases in health have come from economic development, not from any health research or specific program.  How would we begin to address the question of whoether all the money that goes into health specific interventions and research could be used more effectively if directly invested in economic development of the community?


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Ethics of scarcity

February 10, 2007 at 1:40 am (Sarah's Posts)


My university is undergoing a fairly large survey (2,400 kids) in the city of Pune to determine polio vaccine coverage during the most recent national immunization day (NID). The city is broken up into wards, and each ward is covered by an immunization officer. We’re finding pretty high overall coverage rates (I don’t have the exact numbers yet, but it is somewhere around 95%), although the survey is a little self-selecting because we’re using houses as the starting points which misses out on all the migrant workers. For polio, they are the ones that are of most concern and are responsible for most disease spread. But, at the least it has been a very informative and interesting exercise that brought us to an ethical dilemma.

The chief immunization officer for the city wanted to hear about our survey and started asking questions. Now, from his point of view, he would love to have information on exactly which children haven’t been vaccinated because then he could make sure to cover them in the next NID. So, is it ethical for us to give him that information?

My first response was a Big No Way. People underwent the survey with the understanding that we are university students who are trying to determine coverage rates, not that we would send immunization officers to their houses. I think that you’d be sent packing by any ethical review board in the states based on not getting consent to give out personal information.

On the other hand, my professor felt strongly that we should give him the information. In her mind, it is unethical to waste the money of an already stretched public health system by keeping the information to ourselves, leaving children who could potentially spread the disease. To that end, I didn’t come into contact with anyone who thought that immunization was wrong or didn’t want it. People mostly just missed the NID and thought that they would get covered in the mop-up sessions where volunteers go door-to-door with the vaccine. Still, even if nobody would protest in this case, I think that it could be dangerous to set the ethical precedent that individuals don’t have a right to their personal information.

In my mind, there is a balance in this situation where we could give out the information about any wards that weren’t well covered, but that still leaves a huge number of people that need to be combed through in order to ensure high coverage. Does scarcity affect the right of the individual to their privacy when it comes at the expense of the public good?

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On Mandating Immunity

February 9, 2007 at 11:40 am (AE Beacon's Posts)

The HPV vaccine. To me this ranks along with recent developments in stem cell technology as one of the most significant medical breakthroughs of our generation. A vaccine that prevents the second leading cause of cancer in women, unbelievable. However, despite the proven life saving ability of this vaccine, I’ve still encountered quite a few people who are ambivalent about its use.

One of the chief arguments against the HPV vaccine is that it will encourage premarital or unprotected sex. First, 90% of people in the
United States engage in premarital sex, 90%. I sincerely doubt that a vaccine could in any way increase that number. Second, quite frankly I doubt that most people think about their risk of getting HPV first or even tenth when they decide to have unprotected sex (or following the decision). From AIDS to unwanted pregnancy to herpes and gonorrhea, there are a plethora of other things that come more immediately to mind (in my male biased opinion). Obviously this is unfortunate since HPV, aside from the strains that do have acute symptoms like genital warts, is one of the STIs that can kill you. Additionally, given HPV’s prevalence at upwards of 70%, it’s pretty likely that your partner will have one of the 100 strains (hopefully an innocuous version). Either way, the risks of HPV are so under appreciated that I sincerely doubt people will change their behaviors even if there’s a vaccine.

Moving on to implementation. HPV is a clear chance to save lives and save our public health infrastructure money. HPV is the cause of most cervical cancer and, through available vaccines we can prevent most types of HPV. This will definitely save lives now and in the future. Cervical cancer costs tens of thousands of dollars per person to treat whereas the HPV vaccine costs only a few hundred dollars per dose.  It is in the interest of insurers, hospitals, doctors and consumers to take advantage of the HPV vaccine.

The key words for implementation are young, national and mandatory. The vaccine is recommended for women ages 9-25 (or 26) who have not yet contracted any form of HPV. Given the prevalence of HPV, it is therefore likely that a younger age will need to be treated. Vaccinating at the younger threshold, say 9-11, not only decreases the likelihood of previous exposure but also reduces the slim chance of changing sexual behaviors since most young women aren’t sexually active yet. Second, the vaccination must occur nationally and eventually
internationally. Domestically there are about two million female nine year olds who will need to be vaccinated. Those that aren’t covered by private insurers should be covered by Medicaid. Finally, the vaccine should be mandatory. While perhaps consumers are ambivalent about whether their child should get vaccinated, savings from the eventual reductions in cervical cancer treatment costs will be passed down to them (hopefully) as costs to insurers are reduced. Oh right, and there will be vast reductions in the number of people who get cervical cancer.

A closing note on gender equity and the HPV vaccine. I’ve heard quite a few complaints, that there isn’t a vaccine for men. Right off that bat I will admit men are equally as responsible for the spread of HPV as women and ostensibly should share the responsibility of eradicating the virus. However, women bear the brunt of the disease and the strong majority of the costs. Men can get genital warts and this alone is a good reason to develop a vaccine for men but for now it only makes sense to focus our resources on getting the vaccine into the hands of women. Additionally, given the huge costs associated with developing a drug, often estimated at around $100 million, making the existing treatment cheaper seems a better investment than creating a new vaccine.  

Æ Beacon

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Economics and mental health

February 3, 2007 at 8:23 am (Sarah's Posts)

I picked up the paper yesterday to the headline, “11 farmers end lives in 48 hours,” bringing the total to 62 farmer suicides in Jan 2007.  The numbers for the last few years have been catapulting upwards—156 in 2003, 324 in 2004, 412 in 2005, and 1050 in 2006.

A study committee on the causes of the increased suicide rate cites debts and inability to pay them back under increased financial pressure as the reason for many of these suicides.  Why?  In 2005, India decided (with a significant amount of leaning from the WTO) that they were going to open their cotton market with the goal of liberalizing the economy and ending barriers, tariffs and subsidies is crucial fields.  Having to compete on the open market has left these farmers, many of whom are still paying off the land that they work, unable to pay off their loans.  One example that the BBC cited spoke of a man who had an initial loan of $200, with interest owed at an additional $300 (that he was making a loss on), which was five times his annual income. These farmers aren’t making enough money to cope with economic shocks, and many are paying off the debts of their land with profits. 

 “Distress among cotton growers in west Vidarbha has accentuated with the wrong policies of state which is bowing to the WTO norms and free trade policies of globalization.  The Bt cotton seeds promoted by the government, instead of giving better yields or disease-free crop, has added to the woes of farmers as they are inadequately trained or protected from fake seeds,” said Vidarbha Jan Adolan Samiti president Tiwari.  As a result, the cotton economy of the region has collapsed. 

I’m not enough of an economist to speak to how sound this economic policy is (although I’d love to hear what wiser folks say), but I will say that I find these stories extremely troubling, especially because the government’s stance seems to be to blame the suicides on alcoholism and family problems.  India is under such pressure to open up their economy in order to gain more power and sway on the international stage.  But, I have a (perhaps one-sided, but not entirely untrue) picture in my mind of the business technology guys sitting alongside politicians and deciding to open up the economy to bring in more businesses to give them more money while the ones who suffer without any institutional support are the field laborers.  And they make up a darn large part of the workforce here in India.  More realistically, the ones who are suffering now are the wives of these farmers who now have to deal with a farm without anyone to work it, a family, and crushing debt. 


How should the public health person help families deal with the effects of globalization?  I don’t think that it is realistic to say that it shouldn’t happen, or that it won’t.  But, there are very clearly people losing out in a big way.  To me, one of the major problems is that nobody is catching the increased suicide rates as a major warning sign that there is a problem in the community that requires some action.  In so many ways, the public health system can be surveillance for bigger political issues.  This is one of many reasons that I think the role of the public health advocate in the future will be riddled with political and economics questions, and it would behoove all of us to add some wisdom about these areas to our arsenals.

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