How to Promote Global Health

April 25, 2007 at 12:37 pm (Morgan's Posts)

The Challenge of Global Health

How to Promote Global Health

Hi Everyone! I’m Morgan Chessia, Brown University ’05. I’m new to the blog. I’m uploading the articles “The Challenge of Global Health,” by Laurie Garrett. It came out a couple months ago in Foreign Affairs, and I think that it is really worth reading. It addresses an essential question: how best to use foreign aid to improve health outcomes. Almost more interesting than the article, are the responses to it, “How to Promote Global Health,” from folks like Paul Farmer and Jeffrey Sachs, which I have also uploaded.

One of the major points in this article is the need to focus on improving general public health measures like maternal and child survival instead of targeting specific diseases like Malaria, TB, and HIV/AIDS. In general, I agree with Garrett that there needs to be more resources targeted towards improving public health in general. However, I think her assertion that disease-specific programs could worsen health on the ground is unsubstantiated. Garrett writes: “As in Haiti, even as money has poured into Ghana for HIV/AIDS and malaria programs, the country has moved backward on other health markers.” The overall health situation in Haiti has undoubtedly declined in the last decade, but I don’t think you can attribute it to an increase in funding to treat HIV/AIDS and Malaria. In most parts of the country people still don’t have even the most basic health care, let alone an HIV/AIDS program. If you were to desegregate the data and just look at the catchment areas of specific HIV/AIDS projects in Haiti like Hospital Albert Schweitzer, GHESKIO, and Zamni Lasante, you would probably find improvements in general measures of population health in the context of disease-specific programs.

Working in Haiti over the past few years I have frequently seen funding for disease-specific programs like HIV/AIDS strengthen the ability of institutions to provide general care. It pays staff like nurses and social workers who treat other patients at the health facility in addition to those with HIV/AIDS; renovates clinics, labs, and operating rooms; buys trucks and diagnostic equipment; and increases the profile of these institutions making it easier for them to access additional funds and private donations. One reason that this happens is that funding goes to established clinics and hospitals that are already providing care to patients. The directors of these institutions have a vested interest in keeping their program afloat so they figure out ways to cover general expenses through their AIDS budget.

Furthermore, patients with HIV/AIDS need comprehensive care—counseling, nutritional aid, treatment for OIs, surgical procedures, lab tests, etc.—in addition to disease-specific treatment, therefore the facilities must be established to offer these services. Any disease-specific program that denies this fact will not be successful at treating their patients.

To really improve population health we need more resources that are devoted to community-based primary health care—that means community organizing, training and local health workers, and increasing community access to essential medicines and supplies. As Garret states: “Virtually no provisions exist to allow the world’s poor to say what they want, decide which projects serve their needs, or adopt local innovations.” I would like to see this change also, but don’t think that disease-specific interventions are to blame. One of the faults lies in the way that programs are designed. A disease-specific program be it Malaria,TB, or HIV/AIDS with local management, community involvement, and training for community health workers can be a venue for empowerment. A disease-specific program so designed then offers a platform that more general public health interventions can build on. The same workers offering DOT to TB patients can quickly learn to weigh babies, administer vaccines, and check for danger signs in pregnant women.

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Another interesting microfinance article

April 24, 2007 at 9:56 am (Sarah's Posts)

http://hbswk.hbs.edu/item/5559.html

I’ll just throw this one out there and see if anyone wants ot bite.

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Patent protection and economic development

April 24, 2007 at 9:55 am (Sarah's Posts)

How Do Patents and Economic Policies Affect Access To Essential Medicines In Developing Countries?

I’ve been working on a project about patent law in India and I stumbled on this article.

It is interesting to me because it goes against the main two positions on patent protection. Big pharma says that IP protection is necessary in order for them to live and activists say that IP protection is preventing people from getting access to essential and life saving medications. This person’s conclusion was that, if you look at the data, patents are granted to so few of the WHO-classified essential drugs that neither side can be right.

That is probably said better in this paragraph:

“These data allow the reexamination of some settled assumptions. There is a belief n the activist community that patents are “a barrier in many [developing countries] to accessing affordable medicines” and, balancing it, a belief in the pharmaceutical industry that it is “necessary to protect intellectual property rights on a global scale” to assure future research and development activities and the industry’s commercial viability. Both of these views are greatly exaggerated. Patents cannot cause essential medicines to be inaccessible in “many” developing countries because they do not exist 98.6 percent of the time; similarly, patents cannot be a “global” necessity of pharmaceutical business because companies forgo them 69 percent of the time. A limited number of exceptions reduce each figure to somewhat below 100 percent, but as an empirical reality those exceptions—and therefore the contentious round dividing these opposing views—are few.”

There are two things that I was thinking (that are partially addressed in the article.) One is that these trends don’t mean that there aren’t specific cases of drugs that need to be examined and their patent status changed. Especially because HIV/AIDS drugs are likely candidates to be on that list as new and novel drugs.

Secondly, this article makes the point (once again) that lack of access to medications is more dependent on economic policy and poverty than on specific obstacles that are blocking access. None of these things are a magic bullet solution.

I just had semi-related thought, on the topic of patents and copyrights. When I/we post articles that are from journals that require a log-in or payment to access, is that technically illegal and breaking copyright?

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Funding for sexual education

April 13, 2007 at 9:25 am (Sarah's Posts)

http://www.latimes.com/news/education/la-na-abstinence8apr08,1,4821225.story

I saw this article today after hearing an NPR segment to the same effect yesterday.  The buzz is about how the federal program for sex education (which is linked to federal funding for health education) limits the scope of what is taught from A, B and C (abstinence, being faithful, condom use) to only A.  This is an issue that most of us have heard about before in the context of HIV or any other STI, but it is back in the US news because five states (Wisconsin, Connecticut, Rhode Island, Montana and New Jersey) have dropped the federal funding in favor of being able to teach kids a more encompassing curriculum.

This issue makes me rather irrationally angry, so I’m trying to be sane about it here at least.  This paragraph from the article highlights what makes me the most angry: “Smith said: “The question state leaders are starting to ask is, ‘How much of this is really about teaching kids, and how much of this is simply pushing forward a social policy favored by President Bush and the conservative right?’ ” ”

I understand somewhere in my head that those who do not want children to learn about ways to protect themselves if they are sexually active believe that they are doing something that is good for children.  But the paternalistic and arrogant attitude that young people should not even have information so that they can decide for themselves makes me bonkers.  I believe that, if even one teenager has decided to have sex, they have the right to know information that will protect them.

Nothing terribly innovative, but I saw this article and got hot and bothered.

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Universal blood created

April 6, 2007 at 6:10 pm (Sarah's Posts)

I’m attaching an article for what I thought was a nifty new technology–universal blood.  It seems that they’ve found enzymes that can convert the sugar molecules that identify red blood cells as A and/or B to O.  Which means that blood in the blood supply could be converted to type O, which can be universally given to any patient without worry about the immune system attacking foreign blood.

This particular article doesn’t mention anything about the affordability of this treatment (probably not very affordable), but it could be an interesting solution to some of the mis-regulation that goes on in blood supplies in the world.  Although this isn’t a solution to all the communicable diseases that can be passed through the blood supply, it could help minimize the deaths that are caused from transfusing the wrong type of blood or from a lack of the right type of blood available when there is a need.

Has anybody heard more about this?

Universal Blood

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Buy (Less). Give More.

March 27, 2007 at 5:53 pm (Sarah's Posts)

Sorry for my absence… I’ll be back and posting soon.

In the meantime, I came across this website that emphasizes how consumerism/corporate greenwashing isn’t the answer to solving the world’s problems, even if it raises money.  They plug into a concept that we’ve kicked around before about whether encouraging consumption as a way to raise money is ethical.

http://www.buylesscrap.org/

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Google Acquires Public Health-Oriented Statistics Tool

March 22, 2007 at 11:37 am (Links, Michael's Posts)

The story: some Swedish folks, with the health of the globe in mind, designed a cool tool for gathering statistics so as to make the plight of the poor in the world more powerfully factual in hopes of raising awareness and building strength in the discourse. Google recently bought that tool.
Is this a good or a bad thing?
Good: increased exposure and power is imbued in the tool via association with the WebGiant Google.
Bad: corporatization and the subsequent dulling of the social justice side of the tool.
Another health blog, Public Health Matters, has posted an article that I read and found interesting.
A call for action may be in the works.

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More on Racial Disparity in the USA

March 21, 2007 at 12:26 pm (Michael's Posts)

Below is an article I found in the New York Times Health Section a couple weeks ago. My reading of it points to the deep and hidden racism in America. If doctors are singling out Black and Latino patients for alcohol abuse, it’s a sign of their internal biases about the habits of their patients. Especially in light of the statement that the article makes about the lack of evidence to support such an assumption. This is most disturbing in light of the fact that minority patients are screened less for biological illnesses.

One of the issues I take with the researcher’s stance is with their statement that the increased alcohol screening rate could be due to theincome level of the patients being screened. Of all the patients I see at County, very few of them drink much. Granted, many are diabetic and many are older. However, the poor folks I see who are in their late 40s and mid 50s and not diabetic are often not drinkers. To top it off, the few really serious alcoholics I’ve seen have been white. Now, my patient exposure has not been enormous, but I’ve been working in this clinic for 6 months and I’ve seen enough to start making a few assertions.

Like I said before, by working on racism and pointing it out and watching ourselves and our colleagues, we can raise the quality of health in our country.

Disparities: Singling Out Minorities for Alcohol Counseling

By ERIC NAGOURNEY
Published: March 6, 2007

At last researchers can point to an area of medicine in which African-American and Hispanic patients get more attention than white ones do.

Whether that is a good thing is another matter. The care in question is counseling from doctors about alcohol abuse. And given that there is no evidence that blacks and Hispanics drink more than whites, the researchers ask why they seem to be singled out for the advice.

“Our results raise questions about whether physicians apply preventive screening practices systematically, and whether they inaccurately tie race to problem drinking,” wrote the author of the study, Dr. Kenneth J. Mukamal of Harvard. The report appears in the March issue of Alcoholism: Clinical and Experimental Research.

As a general rule, numerous studies have found, minority patients are less well served than whites by the medical system. They receive less screening, for instance, for cancer and other illnesses.

The new study drew on information gathered in a federal survey of more than 15,000 people about their health. Among other questions, those surveyed were asked how much they drank and if they had been counseled by a doctor about alcohol.

The study found that blacks and Hispanics were about twice as likely as whites to report having been counseled about alcohol. But when it came to counseling about diet, the differences largely disappeared.

Part of the explanation, the study said, may lie in the fact that minorities tend to see doctors whose practices focus on low-income populations. So it might be less a matter of an individual doctor treating black and white patients differently than how minority communities over all are served.

In any case, the study says, given how effective alcohol counseling has been found to be, the answer is not to give less of it to minority patients but to give more of it to all patients.

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Entitlement and the Poor

March 15, 2007 at 10:59 am (Michael's Posts)

I was shadowing one of the very senior attendings in the department of medicine at Cook County Hosptial a week ago. His reputation is well-established as a thorn in the side of those who would rather turn a blind eye to the bureaucratic waste and BS that the poor who utilize the Big Public Hospital have to put up with. He fights for them in every way he can every day. Because of his fierce advocacy, he has been passed over for promotions that he absolutely deserves. He’s not popular with the higher-ups. But the work he’s been doing for the last 30 years is indispensable. Truly an inspiration.

As we were coming out of one patient’s room, Dr Schiff commented that he was a “Classic County patient. Never worked a day in his life. Just sitting around waiting for a handout.” Now listen for a minute to this guy’s story. And imagine that everyone we talked to had a similar one.

When Dr Schiff asked this man what he had done for work in his life (he was 81 and built like a horse except his heart was fluttering like a drunk butterfly), the man looked at him with a weary smile and said, “Everything.” He worked construction during the week, bartended at night, drove a cab on the weekends, did upkeep work for various churches, etc, etc. He put FIVE of his eight kids through college. In short, he lived a busy, stressful, and very productive life.

Dr Schiff was obviously kidding when he said what he did. And with a lot of bitterness in his voice. He made me realize consciously what I knew about the people I saw in the outpatient clinic: all of these people worked hard and they’re still poor.

This idea we Americans have about “Bootstraps” and the ability to pull oneself up by them is maybe partially true but is way more conditional than we’d like to think. It depends on what you have to fight against to get upward motion. It depends on if you even have bootstraps to pull on. Think about our 80 year old friend who, with the most dignity I can imagine, submits to the whims of an inefficient bureaucracy whose higher-ups could care less about him for his medical care. Think of his grandchildren whose lives he made better. How can we treat him the way we do?

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On Deconstructing the Discourse

March 9, 2007 at 9:54 am (AE Beacon's Posts)

“Can one divide human reality, as indeed human reality seems to be genuinely divided, into clearly different cultures, histories, traditions, societies, even races, and survive the consequences humanely? … For such divisions are generalities whose use historically and actually have been to press the importance of the distinction between some men and some other men, usually towards not especially admirable ends.”

-Edward Said in Orientalism  

 

The central mission of Global and International Health is to improve health conditions for people facing the highest burden of disease and suffering. This lot typically falls to those living in Africa, Asia and South America. However, is the discourse of this benevolent mission categorically reinforcing the social order it seeks to alleviate?

What is the utility of the phrase “developing country”? The original conception of developing versus developed countries was created as an economic method of stratifying nations by economic output. Despite having limited correlations to health status, this terminology has been subsequently adopted by health workers to define areas of supposed greater disease burden and suffering.

This transliteration fails to achieve several of its objectives. First, lumping countries into developing or developed ignores the spectrum of need between nations. Second, nation based classifications of health fail to accurately represent the internal needs of political groups such as immigrants or internally displaced persons and social groups such as religious and ethnic factions or women and children. Finally, some developing countries such as Cuba, despite having the resources and political structure that would otherwise suggest poor health, have managed to produce impressive health outcomes. Thus, the concept of developing country does not accurately evaluate how well a region or nation can deal with its health issues.

The segregation of developing and developed nations does succeed in accomplishing several things. First, it insists on the immaturity of developing countries. Inherent to this distinction is the idea that developed countries have achieved a universally attainable state of happiness and prosperity, a socio political nirvana if you will, through integrity, hard work and ingenuity. Implicitly, that developing countries have failed to reach this standard reflects more on their inadequacy than on divisive social and economic structures that keep them in poverty and disarray.

Second, this construct asserts that the methodologies of my society, capitalism and cultural exportation, are requisites of domestic success.  Despite the considerably dependence of my economy on cheap goods from elsewhere, we have maintained an equal opportunity rhetoric that doesn’t suffice to describe our domestic state let alone global economic and political involvement. Finally, the concept of “developing” demeans the intelligence, talent and efforts of (health) professionals abroad. Stripped of the comprehensive diagnostic testing equipment, auxiliary support staff and myriad pharmacological interventions would our physicians be more capable? I won’t posit an answer but only suggest that poor outcomes reflect more than the physician’s capability.

So what can we change? How can we (I) more accurately delineate differences in health outcomes without disparaging those in need?

Æ Beacon

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