Health Communications 101 Part Deux: Swine Flu - Separating evidence from the fear factor.

Not sure about you, but I’ve been a little bit on edge recently with all the announcements of swine flu and media sound bites using outbreak, epidemic, and pandemic. Over the last few days there has been a wide range of news coverage of the Swine flu outbreak. Responsible coverage has provided factual information regarding what is influenza and has distinguished between pandemic and seasonal (non-pandemic) flu. I would also consider part of responsible journalism to include a discussion on why in 2009 the United States and the global community is better prepared to cope with an influenza pandemic than at any time in modern history. This includes wide availability of antibiotics that are used to treat secondary infections caused by the flu virus. What can be deemed as less-responsible journalism, has unnecessarily stoked fears of a Stephen King, “The Stand”, super bug, without a scientific review of facts and safeguards in place to avoid such a scenario.

The CDC has a Q&A regarding flu. For example did you know that it is estimated that over 36,000 Americas die each year from seasonal (non-pandemic) flu? However, it is acknowledge these statistics are somewhat inaccurate and possibly under reported for several reasons: a) it is not required to be documented for persons older than 18 years of age, b) the life of the virus is short, thus detection of the virus of a primary cause of illness is not always possible, and c) many persons who many die from flu like symptoms or secondary complications are never tested for the virus.

A scientific peer reviewed article by Peter Doshi (May, 2008) in the American Journal of Public Health provides a critical review of mortality related deaths due to pandemic and non-pandemic influenza since 1900. The article provides an assessment of the topic and concludes with a section entitled “Explaining the Gap Between Evidence and fear.” Due to copy write restrictions I am prohibited from posting excerpts from the article. However it is available through Medline or other online full text journal portals at your local library for individual use.

What we have seen in recent days is an alarm over a possible pandemic. But let us not forget that due to advances in health care infrastructure and modern medicine we are better equipped to handle such responses to ensure that the public is well protected. While there are still many gaps in our public health infrastructure, lets us also be confident and not cause undue panic before we have all the appropriate facts and evidence. Precaution is good. Wash your hands frequently, especially when in public places. If prone to upper respiratory infections, especially the young or elderly, consult a doctor if you may have symptoms of the flu.

In closing, an area that is of great need is strengthening our public health infrastructure in the United States to include the uninsured. In the United States, it is estimated in a recent institute of medicine (IOM) report on the uninsured that over 45 persons are without insurance. Thus for any minor or potentially significant health aliment these persons will most likely seek care and treatment at the local emergency room. In times when a flu pandemic is feared, the weaknesses of our public health infrastructure are most exposed. This will surely translate into unnecessary costs associated with inappropriate care and treatment at emergency rooms that could have been better served in a community health clinic. 

Health Communications – Swine Influenza or Malaria. Is there a way to integrate competing health messages?

By late morning of Saturday 25th April there were some ecstatic messages by World Malaria Day advocates that said. “Malaria is number one search term on Twitter.” But that lasted a very short while. By mid afternoon the media started to pick up on a new announcement by WHO regarding an outbreak of swine flu that claimed the lives of over 80 persons in Mexico City and the possibility of spread to the United States, Europe, and Asia.

Quickly the attention of World Malaria Day was now turning towards a flash outbreak message by WHO regarding a potential new killer pandemic. One colleague described this day of competing messages as, “while I totally understand the reasons, it was a bit deflating. We worked very hard to get out the message regarding malaria and all of a sudden it seemed we were drowned out.”

In the statement released by the WHO Director General’s Office on Saturday 25, 2009 regarding Swine Influenza, there was no mentioned of World Malaria Day. This statement was picked up by major news outlets around the world in a matter of hours.

What is your opinion?

Do you believe this could have been an opportunity to educate the public about the urgency of the outbreak of Swine Influenza while also bringing the world’s attention to a disease that is reportedly responsible for the deaths of over one million adults and children a year?

Observing World Malaria day (Saturday April 25th 2009) - what would Paul do?

Thanks to herculean efforts by mainstream advocates such as Lance Laifer and his many colleagues, the generation X and post X are becoming much more aware of a deadly disease that takes the lives of over one million adults and children every year. What makes this infectious disease particularly frustrating is that experts, clinicians, and field workers agree that many of these deaths are preventable and unnecessary.

However as awareness is increased and monies are raised to eradicate malaria deaths in resource poor settings, I choose to honor my colleague Dr. Paul Ambrose, whose death on 9/11/2001 left the public health community a gaping hole and the world without one of its brightest stars. To emulate my colleague Paul’s exceptional mind and inquisitive nature I pose some questions for us to ponder on the World Malaria day:

1. Why has a disease that kills over one million persons a year been neglected? What incentives have been lacking and how can we structurally change these incentives?


2. Can old technologies such as DDT be re-formulated to maintain their effectiveness to kill malaria infected mosquitoes while avoiding harmful side effects on humans?


3. Is money the only missing ingredient to eradicate the disease? What are the other issues such as political, social, and bureaucratic that have led to problems in the field?


4. What existing versus emerging technologies are most cost effective for prevention versus treatment; bed nets, vaccines, etc.


5. Should donors focus on the local production of bed nets versus importing foreign made bed nets to sustain and build local industry?


6. What do the local African Leaders have to say about existing efforts to date for malaria control? What have the successes been, where have we failed, how do we move forward? Can we invite these leaders to the US and speak to us about the challenges they face?


7. How can new technologies such as web casts and twitter stimulate direct dialogue with field workers to help them be more effective through existing efforts?


8. What strategies can we develop specific to discovery, development, health delivery, and primary prevention that complement other existing priority global health problems without creating health worker brain drain and maximize allocation of scarce human and financial recourses.
   
   As a global community we can work together to achieve greatness. By asking the difficult questions we can provide effective solutions to eradicate this dreaded disease while also being thoughtful about other existing problems in global health.
   
   Paul, thank you. Your shining light and inquisitive mind continue to spur us to new heights.

HST939 Update – The Fight against MDR-TB. Example of Public Private Partnership Collaboration.

Dr. Gail Cassell, Vice President for Scientific Affairs and Lilly Research Scholar for Infectious Diseases, Eli Lilly and Company was our distinguished guest today in HST939. Dr. Cassell is heading up the Lilly initiative to fight the spread of multi-drug-resistant tuberculosis (MDR-TB). The genesis for this program stems from a conversation that Dr. Cassell had with Paul Farmer and Jim Kim of Partners in Health fame. To Lilly and Dr. Cassell’s credit they embarked upon a path to develop new therapeutics to treat this deadly form of TB.

MDR-TB is defined as TB that is resistant at least to the two most powerful first line anti-TB drugs. MDR-TB has been on the rise and the WHO reported in 2008 that there are nearly one half million new cases per year of the estimated 9 million total new cases of TB estimated per year. WHO further reports that extensively drug-resistant tuberculosis (XDR-TB), a virtually untreatable form of the respiratory disease, has been recorded in 45 countries.

It was recently estimated that worldwide approximately 450 million USD was devoted towards treatment, discovery and diagnosis for TB globally. To put this in perspective it is further estimated that 1 Billion USD is required to develop and bring a new product to market. Thus as with most neglected diseases, there is a great short fall in global industry and public sector monies to tackle this disease.

The MDR-TB effort at Lilly is an example of a successful public and private collaborative for neglected disease and reportedly one of the largest philanthropic industry efforts to date. However there is much more that the global community has to do. It certainly cannot be left up to the private sector to subsidize research and development for neglected diseases in the developing world. The internationally community must come together to develop policy that incentivizes private sector partners to develop products and extend IP to ensure that the most in need receive life saving medicines.

This is arguably one of the greatest opportunities and challenges our generation has to tackle in addition to global warming and poverty; the development of capital markets that incentivize private industry to serve the world’s poor. The answers are not hard to find. Combinations of tax incentives, patent protection, subsidizes to spur innovation coupled with strengthen of quality assurance and health delivery systems can help eradicate/reduce disease burden in developing countries as well as resource poor settings within the united states, Europe and Asia. Within this context it is critical to develop an overall global health investment strategy that focuses on health systems to avoid targeting simply high profile diseases.

Re-thinking incentives

In an article written by Richard Stevenson of the New York Times, a discussion of re-thinking the current predominate economic model for the US economy is presented. Mr. Stevenson points out that, “In the two decades since the fall of the Berlin Wall, the American model of capitalism, largely unchallenged by ideological alternatives and increasingly dominant around the world, drifted toward what conservatives viewed as a more pure form of economic liberty and what liberals came to view as misguided free-market fundamentalism.”

Furthermore Mr. Stevenson states, “But now, as the United States and other nations look for lessons in the wreckage from the excesses of that period, political leaders are confronting uncertainty about what economic structures and values should define capitalism’s next chapter.” This article provides some fuel for discussion not simply on the US economy, but also the global economy. For example, currently over 90% of the worlds research and development budget for medical devices and pharmaceutical products is targeted towards 10% of the world’s population. Chaos creates opportunity.

While the existing political will and policy tools might not support a board re-shaping of how the US and European countries incentivize corporations to develop life saving medicines and products for the world’s poor, it is time to start re-thinking how best to create incentives to do so.

Microfinance: Banking for the world’s poor. Separating success from faux

Micro lending or banking for the world’s poor has been made especially famous by Professor Yunus. Professor Yunus and the Grameen organization have paved the way for new lending practices to reach millions of persons living in developing countries to help break the vicious cycle of poverty.

Given the recent problems and blatant examples of corruption exposed during the recent financial crisis in the developed world, I became curious about what safeguards are in place for the multitudes of expanding micro lending programs in developing countries.

An informative beginners article on the subject entitled Delivering microfinance in developing countries: Controversies and policy perspectives (Bhatt, 2001) provides an overview of vehicles, technologies, and performance assessments for financial service delivery to the world’s poor. Bhatt points out that absolute poverty is 75% lower in villages with Grameen programs than in villages without such programs (Khandker, 1996). However as a word of caution Bhatt further mentions that performance of other programs has not been as encouraging. Other programs have been plagued with such problems as high default rates, inability to reach sufficient numbers of borrowers, and a seemingly unending dependence on subsidies.

Given the recent implosion of the financial services industry in the developed world, particular attention should be made towards safeguarding lending practices to the world’s poor. We cannot afford for a scandal to erupt in the micro lending that would discredit an industry that has helped millions of people escape poverty. This is an area ripe for opportunity for organizations such as FINCA, Grameen, BRAC, KIVA, as well as independant agencies to further develop international standards and monitoring practices to ensure maximize outcomes and reduce corruptive influences.

HST939 Update – Clinton Foundation – Tackling Drug Supply to Increase Access to Treatment for HIV and Malaria

Today was another special day for our HST939 course. Inder Singh, Director of Drug Access for the William J. Clinton Foundation was kind enough to take time out of his busy schedule and chat to our class about his teams experiences. Inder and his team at the foundation have done extraordinary work on the supply side to help reduce costs of anti-retroviral therapies (ART) for persons living with HIV/AIDS (PLWHA).




Under his leadership an interdisciplinary team of scientists, business professionals, clinical, and public health professionals have helped to reduce the cost of ART as well as combination therapy for malaria medicines. In a few short years this team has worked to remarkably increased access to life saving medicines for pediatric AIDS patients around the globe. Another very impressive accomplishment for this team has been the 50% reduction of Malaria medicines for the world’s poor which has led to a doubling of access to life saving drugs.

A key question raised was, “How does one reduce the cost of life saving medicines for developing world markets?” A short list of answers ranged from negotiated price reductions, high volume advanced market commitment agreements, support lower cost local generic manufacturing, and price subsidies. However beyond these mechanisms, scientific and discovery ideas were also discussed. These include reformulation, harmonization of raw material supplies to help reduce risk as well as prices for manufacturers.

The Clinton Foundation is a shining example of innovative business practice. Personally, I worked with the foundation in 2004 as a country director for Jamaica. So I learned up close the workings of this extraordinary organization. I learned firsthand how one can apply business skills to tackle problems in emerging and resource poor markets. This experience has carried over and provided me great confidence that by working on a focused, no nonsense agenda with stakeholders from public health practice/NGOs, industry, public and private sectors innovative solutions can be created for seemingly impossible obstacles in global health. The motto that I still carry with me that exemplifies my experience is the Harry S. Truman Quote; “It is amazing what you can accomplish if you do not care who gets the credit.”

It is my personal belief that we have only begun to scratch the surface on supply side solutions. I also believe that innovative incentive and business models for pharmaceuticals, medical devices, and diagnostics will emerge over the next 3 – 5 years. These models will support rational design for emerging and resource poor markets as well as strengthen in-country testing capabilities that are a necessity to further the discovery and design sciences that meet these unique market needs. This is an area of great personal passion and I encourage others who may read this blog to contact me directly if interested in furthering the study and implementation of these models.

Open Source Clinical Systems and Global Health– Barriers and Opportunities

Open source for global health is an area of great strategic importance in the international community. The promise of open source projects in global health is to facilitate the implementation of interoperable platforms responsible for storing and sharing electronic health information to improve quality of health care delivery. Pioneering organizations and champions in this area include the OpenMRS Team, Google and Partners in Health. These organizations and numerous others from around the globe have been championing the cause to improve the quality and access to health information systems in developing countries. The dedication of these professionals must be applauded for their selflessness to save lives and reduce human suffering through the advancement of open source electronic medical records.
Deploying medical records systems has historically been challenging even in developed countries. For example in the United Sates, less than 50% of clinicians have adopted EMRs.

Similarly, deploying medical record systems in emerging markets and developing countries has its many challenges. Issues related to limited availability of computers, sporadic internet access, inadequate storage, intermittent power and infrequent access to in-service training all can reduce the speed of adoption of clinical management systems for global health. Other issues facing adoption of medical records in developing countries include lack of proper motivation and incentives for staff to use medical records and other critical information systems for health. This is a critical issue because there are many existing legacy systems in developing countries. However these systems often do not have adequate numbers of technical support staff to provide necessary training or report writing capabilities to motivate workers at the point of care to enter quality data into the system.

In countries where there are extreme human resources for health (HRH) crises (inadequate trained medical staff, poor retention and motivation for existing staff) there is a vicious cycle; Too few staff to adequately treat clients and poor adoption of information management tools that could improve efficiencies to improve client care by the existing health work force. Yet adoption of information systems to help improve quality of care through outcomes and resource utilization reporting is critical to maximizing the potential of human and capital resources in developing country settings.

A way forward for Open Source in Global Health

Advocates of open source development have implemented an impressive distributive programming team that engages the brightest minds from around the world to lead the development of novel medical record technologies that can be applied to improve efficiencies, while reducing the rate of unnecessary medical errors. Without a doubt the implementation of novel, low cost, easily scalable and user friendly systems to improve clinical, financial, and outcomes reporting will provide a much needed tool kit to the existing human resources for health crises that faces much of the African Continent and other emerging settings. However, one must consider the limitations of deploying open source health records if they do not look to improve the existing incentives for health workers to adopt these systems. Another critical area for expansion it to promote a sustainable local business environment that can create a vibrant home grown technology sector to maintain and expand these systems. Fortunately the trend to foster local capacity is becoming more main stream and a focus of attention.

Happy Easter and Time for Reflection

Happy Easter Sunday. My wife Michelle and I sincerely hope and wish you all a wonderful and happy holiday.

Holidays are a time to reflect, appreciate the gift of life, but also the possibilities of how we can extend ourselves to helping others in need.

Today’s New York Times has an article entitled, “States Slashing Social Programs for Vulnerable” by Erik Eckholm. This article reports upon the recent slashing of budgets for programs by a majority of states that serve the most vulnerable of populations. These include the elderly and high risk sub-populations prone to child abuse.

While in the short term cutting these programs can help balance state budgets, slashing such budgets will disrupt critical preventive efforts that would save money and reduce human suffering over time.

The United States has been facing rising health care costs for many decades. Slashing of prevention programs targeted at the most vulnerable populations is politically expedient to cope with short term budget deficits. However, in the intermediate and longer term cutting these programs will adversely impact overall health care costs for state and federal programs in years to come.

A way forward would be to complete a thorough due diligence to estimate the short term budget savings while accounting for the longer term adverse impact on human health and forecasted cost burdens to the state. Only by factoring both indirect and indirect costs into a thoughtful review of proposed reductions in social programs will policy makers be able to ensure fiscal discipline that does not forsake the overall physical and financial health of our country.

My grandmother used to say to me as a little boy, “we are only as strong as our weakest link.” To cope with the current budget crisis we can surely find ways of meeting budget shortfalls that do not slash serves for our most vulnerable populations.

Tackling Malaria - Challenges and Opportunities

Recently, there has been a surge in awareness and action in recognizing the horrible toll malaria has on the developing world. From mainstream advocacy by groups such as 'madness for malaria' and less publicized day-to-day field worker initiatives, the battle to saves lives is taking place every day.

In Tanzania, malaria still accounts for the highest all cause mortality among children. Reasons for this are complex. These include cultural, political, biological, and economic.

For example there has been important progress in Zanzibar over the years in combating the disease among children and adults. Yet despite these efforts, success has been more challenging on the mainland. Some of this was due to ineffective policy that had prohibited private sector facilities from procuring preferentially priced pharmaceuticals, creating an undue tiered system that created inequities in access to life saving medicines. Other reasons include resistant strains of the malaria parasite, inadequate distribution of bed nets, and mainstream beliefs that inhibit widespread prophylaxis.

A cautionary tale is while currently there is hundreds of millions of USD invested in the search for a malaria vaccine, it is critical to appreciate that barriers to effective treatment are multi-factorial and no magic bullets exist. New microfluidic diagnostic tools will also allow for large low cost panels to screen children and adults for dozens of infectious diseases, including the malaria parasite, within minutes. But diagnosis must also be accompanied by affordable access to life saving medicines. Even with an effective vaccines and/or diagnostic tools, public health innovation must also be achieved in policy reform that streamlines procurement and distribution practices between both public and private stakeholders for eradication strategies to be effective.

Tackling Diabetes for Worlds Poor and at Home

Diabetes is increasing faster in the world's developing economies than in developed countries. Seven out of ten countries with the highest number of people living with diabetes are in the developing world. With an estimated 35 million people with diabetes, India has the world's largest diabetes population (http://www.worlddiabetesfoundation.org/).

Unfortunately, due to lack of access to proper medicines and staff trained to diagnose and treat diabetes many persons in the developing and resource poor countries die prematurely. Type I diabetes (juvenile diabetes or insulin-dependent diabetes) is often misclassified and is an immediate death sentence for many because of lack of access to Insulin. Type II diabetes (adult-onset or noninsulin-dependent) is on the rise due to changes in lifestyle, poor diet, and urbanization of populations.

But the problem of diabetes is felt very much in the United States and developed countries. For example in the US, one out of every five health care dollars is spent caring for someone with diagnosed diabetes, while one in ten health care dollars is attributed to diabetes (http://www.diabetes.org/).

With much of the world’s attention focused on common infectious diseases such as Malaria, TB, and HIV/AIDS, non communicable diseases such as Diabetes have been forsaken.

But with evolving innovative global health partnerships with private (http://www.sido.co.tz/aphta/index.html), faith based, and public leaders in health care in developing countries the challenge is starting to be addressed.

Diabetes is a perfect example of how working in setting up a development partnership to service the bottom billion can help create cost effective design and products for the developed world. What is needed are innovative financing mechanisms to stimulate industry to design diagnostic and therapeutic products for low resource poor settings. These products and services can have great impact on reducing costs for our own health care in the US, Europe, and Asia.

For individuals and organizations interested in learning more about how to partner or learn about specific projects (http://www.bienmoyo.org/), please contact us @ info@bienmoyo.org.

Importance of Development Partnerships

Recently there has been in influx of interest in the development of low cost medical devices for resource poor and developing country settings. This has spurned a great deal of passion and interest by students, faculty, and partners to develop prototypes and send teams for short stays to document future requirements as well as tweak existing designs. Examples of ingenious devices/products from the fruits of many hours of careful design and development have ranged from pill boxes to urine strips for monitoring ingestion of life saving medicines.

However, it is critical to incorporate these activities into a framework for proper testing and evaluation to ensure safety and efficacy of programs prior to human subjects testing. A challenge in developing markets is porous oversight, especially in rural communities to monitor pilot programs and report on results. Additionally, while international standards exist for good clinical practice, the cost of adhering to such standards is not tenable in many developing markets without further direct investment.

The good news is there are some world class clinical and laboratory infrastructures in place that have been developed due to large investments from organizations such as the National Institutes of Health (NIH) and center for disease control (CDC). However these structures have primarily been focused on infectious diseases, vaccine development, and surveillance activities. Rarely have these existing platforms been available to the social entrepreneur trying to innovate.

New methods for partnership and investment are required to transform the existing landscape to better serve the bottom of the pyramid. Such investment will create a platform to support the development of a well vetted pipeline of innovations in global health practice.

THE WAY FORWARD: PARTNERSHIPS AND INNOVATION - AMNH

It was a thrill to participate in the recent Spring Symposium at the American Museum of Natural History on Exploring the Dynamic Relationship Between Health and the Environment. The conference was hosted and organized by the Center for Biodiversity and Conservation's Fourteenth Annual Spring Symposium.

I have the privilege for speaking on the final panel that focused on a way forward for strengthening collaborative projects and partnerships in global health.

http://symposia.cbc.amnh.org/health/index.html

Bottom line (audio to be released shortly) is while much has been accomplished to support research and activities for infectious diseases, we are far from a comprehensive or strategic approach to integrating non-communicable diseases (NCDs). Given the existing limitations that are related to human resources in health in developing countries, it is critical to look at cross cutting health systems strengthening areas that can improve ID and NCD integration.