Archive for March, 2011

"The Most Important Medical Discovery of the 20th Century"

Just a reminder — it wasn’t open heart surgery or sequencing the human genome:

A massive cholera outbreak in refugee camps on the border of India and Bangladesh in the 1970s exposed the limitations of intravenous treatment and paved the way for a radically different approach to treating dehydration.

In 1971, the war for independence in what is now Bangladesh prompted 10 million refugees to %ee to the border of West Bengal, India. !e unsanitary conditions in the overcrowded refugee camps fueled a deadly cholera outbreak characterized by fatality rates approaching 30 percent.’ Health officials from the Indian and West Bengal governments and relief agencies faced a daunting task: Conditions were squalid and chaotic, intravenous fluid was in scarce supply, treatment facilities and transportation were inadequate, and trained personnel were limited.’ Mass treatment with intravenous therapy alone would not halt the impending crisis.

Dr. Dilip Mahalanabis, a cholera expert at the Johns Hopkins Centre for Medical Research and Training in Calcutta and head of a health center at one of the refugee camps, proposed an alternative to the intravenous treatment. He suggested the camp use a new method of oral replacement of fluid, known as oral rehydration therapy, that had been developed in the 1960s in Bangladesh and Calcutta.

The science was as ingenious as it was simple: A solution of water, salt, and sugar was found to be as effective in halting dehydration as intravenous therapy. Dr. Mahalanabis’ team recognized the many advantages of oral therapy over the intravenous rehydration: It is immensely cheaper, at just a few cents per dose; safer and easier to administer; and more practical for mass treatment. ORT, however, had still not been tested in an uncontrolled setting, and skeptical health specialists cautioned that only health professionals and doctors should administer the new therapy.)

Mahalanabis’ team moved quickly to introduce the treatment to the 350,000 residents of the camp. Packets of table salt, baking soda, and glucose were prepared in Calcutta at the diminutive cost of one penny per liter of fluid.’ The solution was widely distributed, with instructions about how to dissolve it in water. Despite the shortage of trained health personnel, large numbers of patients were treated, with mothers, friends, and patients themselves administering the solution.

The results were extraordinary: At the height of the outbreak, cholera fatalities in the camp using ORT dropped to less than 4 percent, compared with 20 percent to 30 percent in camps treated with intravenous therapy.

From Millions Saved, case study 8: diarrhea in Egypt. Just re-reading it for a class.

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03 2011

Michael Lewis retrospective

I’ve been a fan of Michael Lewis’ writing ever since Ashby Monk (author of the best niche blog on sovereign wealth funds) pointed me towards Liar’s Poker. Some recent and not so recent fare:

Lewis’s article in Manhattan, Inc. magazine is a terrific yarn and a remarkable artifact–mainly because of how wrong Lewis turned out to be…. The imaginary scenario Lewis crafts, of a massive Tokyo earthquake crushing the global economy, reflects a time when Japan was an ascendant economic force widely believed on the cusp of ending U.S. pre-eminence. In that world, Lewis’s imagined chain of events goes something like this: Large swaths of Tokyo will be destroyed by a magnitude 7.9 earthquake. Stock markets collapse, in part as Japanese companies and investors sell foreign assets, including U.S. Treasury bonds and commodities, to finance the country’s rebuilding. Japanese banks and companies pull money and halt their loans outside the country, sapping  a big source of the fuel for economic growth world-wide. Global interest rates soar to 5%, meaning Americans can’t afford loans to buy cars or homes. The U.S. economy skids to a halt, though Japan manages just fine….

Not always right, but always interesting.

29

03 2011

Progress on Polio in Africa?

From the latest CDC Morbidity and Mortality Weekly Report: “Progress Toward Interrupting Wild Poliovirus Circulation in Countries with Reestablished Transmission — Africa, 2009-2010”

There are only four countries where polio is still “endemic” — Afghanistan, Pakistan, India, and Nigeria. Combined the four endemic countries have about 23% of the world’s population, though to be fair polio is only endemic in some portion of each country.

But the actual definition of “endemic” may not match with lay assumptions about that term. For polio, endemic countries are defined as those where transmission has never been broken. So a country where polio has been reintroduced — and is now spreading on its own, without the need for additional introductions — is by definition still not endemic. Thus, there’s essentially a three-tiered system: a) endemic countries, b) countries with reestablished transmission, and c) countries without established transmission, which may have sporadic outbreaks from imported cases or from vaccine-derived polio.

The CDC report linked above provides an overview of polio in African countries. Between 2002 and 2009 several dozen previously polio-free countries had outbreaks of polio from strains imported from India or Nigeria. (The strain of polio in each outbreak is genetically typed, which means we can determine which known strain the new one is closest too, and thus from whence the outbreak came.) Of those countries, four–Angola, Chad, Democratic Republic of the Congo (DRC), and Sudan–had persistent transmission (more than one year) after re-importation of polio that occurred before 2009. One of the milestone of the Global Polio Eradication Initiative (GPEI) was that polio transmission would be interrupted in those four countries by the end of 2010. The conclusion of the MMWR report is that it has been stopped in Sudan, but not Angola, Chad, or DRC.

28

03 2011

Truth and reconciliation in Bangladesh?

Doesn’t look like it:

The chances that the trials will win international recognition appear slim. Initial enthusiasm for them among foreign governments has worn off. Many Western diplomats think the government has taken to using the courts to pursue rivals and enemies—as many say it did when it insisted recently that Muhammad Yunus, a Nobel laureate, should retire as head of Grameen Bank, a microcredit institution. The war-crimes process was supposed to produce a measure of truth and reconciliation. It has taken an inauspicious turn.

26

03 2011

Libya

I saw this anti-war poster next to the Hopkins shuttle stop in Baltimore:

A mixture of probably true and not-so-true rhetoric about Libya. It’s about oil! Well, partly — but a single intervention can have multiple motivations, both humanitarian and otherwise. And then: “Attacking LIBYA is Attacking AFRICA!” which is helpfully illustrated with a map of Libya showing that it’s, well, in Africa. This is a fascinating reimagination of the “all Africa is the same” meme. Another interesting observation: the poster is all about the Pentagon, with no mention of President Obama.

On the other hand, I think anti-war voices are healthy and helpful, even if the rhetoric is misguided. I’m torn on the Libyan intervention — I believe it’s justified, but I’m deeply worried about what happens next. Sometimes there are no good options, and the best possible option (intervening) can still lead to terrible outcomes.

Kristof provides this powerful justification that I can’t get away from:

I’ve seen war up close, and I detest it. But there are things I’ve seen that are even worse — such as the systematic slaughter of civilians as the world turns a blind eye. Thank God that isn’t happening this time.

But another valuable voice is Alex de Waal, who doesn’t have quite the audience of Kristof. De Waal shares these troubling thoughts:

Much of Libya is now ungoverned. That is particularly true of southern Libya. There has been little attention to the towns of the south, such as Sebha and Kufra, with no international correspondents there. These places are matters of great concern to neighbouring governments such as Niger, Chad and Sudan, because these towns have served as the rear base for armed rebellions in their countries, and rebel leaders still reside there. Gaddafi’s opening of the Libyan arsenals to anyone ready to fight for the regime, and the collapse of authority in other places, means that such rebels have been able to acquire arms and vehicles with ease. [….]

I spoke with one African military officer who welcomed the NATO action in Libya, saying “nothing could be worse than Gaddafi.” I suggested that he wait and see.

Update: Andrew Sullivan links to Daniel Larison’s critique of Kristof’s view that the intervention averted civilian slaughter:

Saying that the war has averted a humanitarian catastrophe is an extremely useful claim, and there’s no obvious way to disprove it. Outside governments intervened, and a humanitarian catastrophe hasn’t happened, and supporters of the war take it for granted that one would have happened otherwise. Of course, this is why they supported the war, but this points to the dilemma that humanitarian interventionists have. If they intervene in a timely fashion and don’t make the situation drastically worse in the process, there is nothing concrete they can point to that vindicates the decision.

25

03 2011

How much can farming improve people's health?

The Economist opines on agriculture and micronutrient deficiencies:

Farming ought to be especially good for nutrition. If farmers provide a varied diet to local markets, people seem more likely to eat well. Agricultural growth is one of the best ways to generate income for the poorest, who need the most help buying nutritious food. And in many countries women do most of the farm work. They also have most influence on children’s health. Profitable farming, women’s income and child nutrition should therefore go together. In theory a rise in farm output should boost nutrition by more than a comparable rise in general economic well-being, measured by GDP.

In practice it is another story. A paper* written for the Delhi meeting shows that an increase in agricultural value-added per worker from $200 to $500 a year is associated with a fall in the share of the undernourished population from about 35% to just over 20%. That is not bad. But it is no better than what happens when GDP per head grows by the same amount. So agriculture seems no better at cutting malnutrition than growth in general.

Another paper† confirms this. Agricultural growth reduces the proportion of underweight children, whereas non-agricultural growth does not. But when it comes to stunting (children who do not grow as tall as they should), it is the other way round: GDP growth produces the benefit; agriculture does not. As a way to cut malnutrition, farming seems nothing special.

Why not? Partly because many people in poor countries buy, not grow, their food—especially the higher-value, more nutritious kinds, such as meat and vegetables. So extra income is what counts. Agriculture helps, but not, it seems, by enough.

25

03 2011

How to talk about countries

Brendan Rigby, writing at WhyDev.org, has these useful tips for how to talk about countries and poverty and whatnot while avoiding terms like “Western” and “developing”:

  • Qualify what you mean
  • Avoid generalisations althogther (highly recommended)
  • Use more discrete and established categories, such as Least Developed Countries (LDCs), or Low Income & Middle Income Countries, which have set criteria
  • Reference legitimate and recognised benchmarks such as the UNDP’s Human Development Index or the World Bank’s poverty benchmark (These have there own methodology problems)
  • Examine development issues and challenges of individual communities, countries in the context of regional geography, history and relations rather than losing countries within references to regions and continents. There is a big different between ‘poverty in Africa’ and ‘poverty in Angola’ or ‘poverty in South Africa’.

Good rules to follow. I’m generally OK with using “low and middle income countries,” except that I’m not sure “income” should be the standard by which everything is defined. I wish there were a benchmark that took into account human development, but was uncontroversial (ha!) and thus accepted by all, and then we could easily classify nations (and these naming conventions are, after all, useful shorthands) by that index without worrying about accuracy or offense. Until we get to that point, I think using clearly defined measures of income and qualifying what we mean is the best way forward when generalizing — when that’s necessary or helpful at all. Which is at least sometimes, and maybe often.

24

03 2011

"Small Changes, Big Results"

The Boston Review has a whole new set of articles on the movement of development economics towards randomized trials. The main article is Small Changes, Big Results: Behavioral Economics at Work in Poor Countries and the companion and criticism articles are here. They’re all worth reading, of course. I found them through Chris Blattman’s new post “Behavioral Economics and Randomized Trials: Trumpeted, Attacked, and Parried.”

I want to re-state a point I made in the comments there, because I think it’s worth re-wording to get it right. It’s this: I often see the new randomized trials in economics compared to clinical trials in the medical literature. There are many parallels to be sure, but the medical literature is huge, and there’s really one subset of it that offers better parallels.

Within global health research there are a slew of large (and not so large), randomized (and other rigorous designs), controlled (placebo or not) trials that are done in “field” or “community” settings. The distinction is that clinical trials usually draw their study populations from a hospital or other clinical setting and their results are thus only generalizable to the broader population (external validity) to the extent that the clinical population is representative of the whole population; while community trials are designed to draw from everyone in a given community.

Because these trials draw their subjects from whole communities — and they’re often cluster-randomized so that whole villages or clinic catchment areas are the unit that’s randomized, rather than individuals — they are typically larger, more expensive, more complicated and pose distinctive analytical and ethical problems. There’s also often room for nesting smaller studies within the big trials, because the big trials are already recruiting large numbers of people meeting certain criteria and there are always other questions that can be answered using a subset of that same population. [All this is fresh on my mind since I just finished a class called “Design and Conduct of Community Trials,” which is taught by several Hopkins faculty who run very large field trials in Nepal, India, and Bangladesh.]

Blattman is right to argue for registration of experimental trials in economics research, as is done with medical studies. (For nerdy kicks, you can browse registered trials at ISRCTN.) But many of the problems he quotes Eran Bendavid describing in economics trials–“Our interventions and populations vary with every trial, often in obscure and undocumented ways”–can also be true of community trials in health.

Likewise, these trials — which often take years and hundreds of thousands of dollars to run — often yield a lot of knowledge about the process of how things are done. Essential elements include doing good preliminary studies (such as validating your instruments), having continuous qualitative feedback on how the study is going, and gathering extra data on “process” questions so you’ll know why something worked or not, and not just whether it did (a lot of this is addressed in Blattman’s “Impact Evaluation 2.0” talk). I think the best parallels for what that research should look like in practice will be found in the big community trials of health interventions in the developing world, rather than in clinical trials in US and European hospitals.

On community health workers

Sometimes I start writing a post and it ends up somewhere completely different than I had originally imagined it. My last post, on why there might be less good global health blogging out there than you’d expect, was actually originally going to be a simple link and quote from what I think is a very good post.

A global health blogger named Emma notes some recent coverage of community health worker programs in the NYTimes (Villages Without Doctors). Then Emma writes:

There’s nothing more valuable than a good community health worker. […Some reasons they’re good….] When this happens, it’s a beautiful model.

When it doesn’t—and it doesn’t far more often than anyone would like to admit—community health workers are at best a drain on expenses with little to show for it and at worst a THREAT to community health instead of an asset.  They can lure organizations and communities into complacency and miss opportunities for training higher level health care workers, breed antibiotic resistance strains of diseases by misuse of antibiotics, or give a false sense of security to people who actually need higher levels of care, among other things.  If you think about CHWs usually are—rural, uneducated and as often as not illiterate or semi-literate people pulled from their communities and given tremendous responsibility with short training courses—this isn’t terribly surprising.

Emma also highlights a companion NYT piece called What Makes Community Health Care Work?

The article talks about really important things—make the program sustainable enough so that it can last after the donor leaves!  Teach the CHWs to teach so even if the CHW doesn’t last some of their lessons will! Provide support for newly trained CHWs so they don’t feel stranded and alone!  Expand in ways that make sense for the specific setting and situation!  Get the country’s government on board!  But…

There’s always a but.  These things are HARD.  Really hard.  Of COURSE we want to do supportive supervision for the CHW, to watch how they practice and build their skills one-on-one based on each CHWs specific strengths and weaknesses. Of COURSE we want to design a program that can last long after we don’t have money from a donor anymore (emergency grants are usually 1-2 years at most).  Of COURSE we want the CHWs to teach their communities how live healthier lives.  But supportive supervision involves enough organization employees to conduct regular visits to remote and widely dispersed sites, and a security situation that allows these workers to safely go out into communities, and enough vehicles to get out to remote sites (and donors are often reluctant to fund vehicles and the fuel and insurance they take).

Read the rest here.

22

03 2011

A formula for informed global health commentary

Here’s a formula for intelligent conversation on pretty much anything in public health:

[Method/Project/Tactic/Strategy X] is an awesome idea, and we need more of [X], but it can be challenging to do well because of problems with education / technology / resources, etc.

Now you know the secret. When you hear about Technology Y or Strategy Z, you can sound like a global health expert too.

I think this problem is one reason why there are fewer really good global health blogs than there are in some other fields. There are good ones — Karen Grepin and Alanna Shaikh for starters — and I can’t quantify the shortfall, but there do seem to be more good blogs on economic development and aid work in general than global health in particular. (There are a lot of organizational blogs, of course, but they tend to be more self-promotional, and thus less interesting to a more critical reader.)

One possible reason is that the arguments in global health tend to be about the best way to do things, such as the best mix of resources or the right tactic for fighting a particular disease like malaria, rather than what we should be doing in the first place.

The truth is that a lot of the things we want to do in global health are inherently good. Vaccinating more children = good. Stopping disease outbreaks = good. More trained health care workers = good. More funding for [insert favorite disease] = good. And so on. Disagreements typically arise because advocates of these different approaches are sometimes pulling from the same pot of resources, but it’s hard to argue that any single tactic or disease or organization should be getting less money.

Contrast that with the broader debates in development. Bill Easterly recently argued that “We don’t know how to solve global poverty and that’s a good thing.” There’s just so much still up for debate. Which leaves a lot more room for interesting commentary and argument that amongst global health experts. As a final example, I’ll offer this Lancet article by several of my professors: “Can the world afford to save the lives of 6 million children each year?” (for the record, they answer “yes”). From their abstract:

“the lives of 6 million children could be saved each year if 23 proven interventions were universally available in the 42 countries responsible for 90% of child deaths in 2000.”

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03 2011