Archive for July, 2011

Avoid immunization, go to jail. Eek.

Via Foreign Policy:

In Nigeria, avoiding a shot could mean going to jail

As Bill Gates unveiled his plan this week to rid the world of polio, health officials in the northern Nigerian state of Kano announced their own assault on the disease. “The government will henceforth arrest and prosecute any parent that refuses to allow health workers to vaccinate his child against child-killer diseases, particularly polio,” said a health ministry official.

This news, which was announced at the outset of the government’s four-day vaccination campaign targeting six million children, marks a shift in government policy toward immunization programs in the north of the country. Nigeria’s polio vaccination program stalled for more than a year after Muslim leaders raised doubts over the inoculations’ safety in the summer of 2003 — resulting in bans issued by some northern state governments….

I’m not familiar with every vaccination law in the world, but this seems like a first to me. If not a first, at least an exception to the norm. I don’t like this more coercive approach. If you have enough resistance to a policy that you feel you need to threaten jail time, then actually making that threat — and following through on it — seems likely to breed more resistance.

I think governments can and should both incentivize vaccination and make it difficult to avoid without a really good reason. Any government policy should make it easier to get vaccinated against childhood diseases than avoid vaccination, because having a fully-vaccinated population is a classic public good. I like the fact that most states in the US have opt-out provisions for religious objections to vaccination, but I also think that states should not design a policy such that getting that exemption is simpler — in terms of time and money — than getting a child vaccinated, as is the case in many states.

But threatening to throw parents in jail? Way too heavy-handed to me, and too likely to backfire.

30

07 2011

Happy Hep Day

Today is the first ever WHO-sponsored World Hepatitis Day:

These successes and challenges are amplified because viral hepatitis is not a single disease. Hepatitis is caused by at least five viruses—including two spread by water or food contaminated with feces(hepatitis A and E) and three transmitted by blood and body fluids (hepatitis B, D, and C) during childbirth (from infected mother to child); through injecting drug use, needle sticks, or transfusions; or through sexual contact. Hepatitis B and C infections can cause cirrhosis of the liver and lead to liver cancer.

Today, more than 500 million persons worldwide are living with viral hepatitis and do not have adequate access to care—increasing their risk for premature death from liver cirrhosis and liver cancer. Each year, more than 1 million people die from viral hepatitis and millions of new infections add to this global burden of disease and death.

It is not, however, the first ever World Hepatitis Day – it’s just the first one recognized by WHO. Many of these international attention-raising events grow out of smaller things which pick up steam and eventually get official recognition from international organizations. It turns out that World Hepatitis Day has been going on for several years.

On a related note, did you know that Hep B is a cause of discrimination in China, and that there is a burgeoning carriers’ rights movement? I didn’t either until I started browsing the impressively worked out Wikipedia Hepatitis B page (some epidemiologist had a field day) and found that there’s an entire page for Hep B in China. An excerpt:

Discrimination

Hepatitis B sufferers in China frequently face discrimination in all aspects of life and work. For example, many Chinese employers and universities refuse to accept anyone who tests positive. Some kindergartens refuse admission to children who are carriers of the virus. The hepatitis problem is a reflection of the vast developmental gap between China’s rural and urban areas. The largest problem facing Chinese people infected with HBV is that illegal blood testing is required by most employers in China.[17] Following an incident involving a Hepatitis B carrier’s killing of an employer and other calls against discriminatory employment practices, China’s ministries of health and personnel announced that Hepatitis B carriers must not be discriminated against when seeking employment and education.[18] While the laws exist to protect the privacy of employees and job seekers, many believe that they are not enforced.

“In the Hepatitis B Camp”

“In the Hepatitis B Camp” is a popular website for hepatitis B carriers’ human rights in China. Its online forum is the world’s biggest such forum with over 300,000 members. The website was first shut down by the Chinese government in November 2007. Lu Jun, the head of the rights group, managed to reopen the website by moving it to an overseas server, but the authorities in May 2008 began blocking access to the website within China, only 10 days after government officials participated in an event for World Hepatitis Day at the Great Wall of China. An official had told the head of the rights group, Lu Jun, at the time that the closure was due to the Beijing Olympic Games.[19]

(h/t to Tom)

28

07 2011

Grad school advice from bloggers

If you want to take advice from bloggers, they’re generally happy to give it. I’ve written a bit about my own motivation in selecting programs. I think the best advice comes from people who know you, your interests, and aspirations well. That means family and friends, especially if your friends work in similar fields. It’s also invaluable to talk to both experienced mentor figures who have some perspective and recent graduates of the programs you’re interested in (programs do change over time). Over the past year I’ve come across a number of resources written by bloggers that I think are worth highlighting:

Dave Algoso, a recent graduate of the MPA program at NYU’s Wagner School, wrote a grad student’s guide to the international development blogosphere which answers these questions:

1. Why should I read blogs? I do plenty of reading for class/work already…
2. Blogs can be overwhelming. How do I manage the information flow?
3. Okay, I’m sold. What should I be reading?

From Chris Blattman (everyone’s favorite development blogger at Yale):

Dani Rodrik responds to Blattman on graduate programs in development.

From Greg Mankiw’s blog:

Let me know if you think of something I’m missing. There does seem to be more advice out there about economics programs than those in public health. Personally I’d love to see a similar set of posts from Karen Grepin, Alanna Shaikh, and Elizabeth Pisani, amongst others.

Update: Dave Algoso suggested these posts by Amanda Taub of Wronging Rights, which I missed since I never seriously considered law school:

26

07 2011

Monday Miscellany

Oxfam on the worsening situation in the Horn of Africa. Related: Edward Carr on “Drought Does Not Equal Famine” from 4 days ago,and a follow-up from yesterday on remedies for the famine.

Texas in Africa has a round-up on what’s going on in Malawi.

NPR: Vaccine Mistrust Spreads To The Developing World – this was a subject of some discussion in Orin Levine‘s Vaccine Policy Issues class at Hopkins this spring.

The Economist summarizes a likely rough patch ahead in South African politics.

On two lighter, linguistic notes: 15 wonderful words with no English equivalent and the Economist demolishes BBC’s “anti-Americanisms.”

Also, Campus Crusade for Christ has rebranded itself — now it’s just called “Cru” (from Hemant Mehta, not The Onion.)

25

07 2011

Football epidemiology

In an attempt to prove Cowen’s First Law — “there is literature on everything” — I enjoy highlighting unusual epidemiological studies (see tornado epidemiology, for one.) These studies may seem a bit odd until you start thinking like an epidemiologist: measurement is the first step to control.

The latest issue of Pediatrics has a new study by Thomas et al. on the “Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma.” Some of the methods seem a bit sketchy, but that’s kind of the authors’ point as they note,

“without a systematic and mandatory reporting system for sudden cardiac deaths in young competitive athletes, the true absolute number of these events that occur in the United States cannot be known.”

While this study is mostly concerned with the sudden deaths not caused by cardiac events, the same principle holds true: if anything, the problem is under-reported.

Thomas et al. use 30 years of data from the “US National Registry of Sudden Death in Young Athletes,” looking at 1980–2009. Deaths in the database came from a variety of sources including LexisNexis searches, news media accounts assembled by other commercial search services, web searches, reports from the US Consumer Product Safety Commission and the National Center for Catastrophic Sports Injury Research, and direct reports from schools and parents.

Of the total deaths included in the study, about 261 were caused by trauma, or around 9 deaths per year. 57% of the 261 deaths were in a single sport, football. Notably, there were about four times as many deaths due to cardiac causes as to trauma.

In football they find defensive positions have more deaths than offensive positions, “presumably because such players commonly initiate and deliver high-velocity blows while moving toward the point of contact.” While the majority of deaths were in defensive players, the single most represented position was running backs.

Why the focus on deaths in young athletes? The authors note by comparison that lightning causes about 50 deaths per year, and motor vehicle injuries case 12,000 deaths per year. (Aside: You can tell the authors don’t work in injury prevention since they say “motor vehicle accident” rather than “injury” — injury prevention researchers prefer the latter terminology because they believe “accidental” deaths sound unavoidable.) The authors explain their own focus by noting that these sudden deaths attract “considerable media attention, with great importance to the physician and lay communities, particularly given the youthful age and apparent good health of the victims.”

In related news: “The Ivy League [announced that…] in an effort to minimize head injuries among its football players, it will sharply reduce the number of allowable full-contact practices teams can hold.”

25

07 2011

The battle for hearts and minds

A major difference between the public health approach and the beliefs and strategies underlying fields such as human rights or medicine is that public health concerns the prioritization of limited resources. There is a limited pie. Even if you believe that pie can be expanded (it can, at times), it cannot be expanded infinitely, and so at some point in the policy process someone has to make a decision about how to prioritize the resources at hand.

This traditional public health approach overlaps with and gets blurred into human rights and medicine and politics such that the value judgments underlying different claims aren’t always apparent. We have a certain number of interventions that are known to work — they save lives and reduce suffering — but we don’t have enough resources to do all of those things in every place that needs them. If we choose option A, some people will be saved or helped, and some will die. If we choose option B, a different number of people will be saved or helped, and some other group of people will die. The discussion of who will be saved is often explicit, while the discussion of the opportunity cost, those who will not be saved is almost always lacking. Both groups are abstract, but the opportunity cost group is usually more abstract than the people you’re trying to help. These are generalities of course, and in reality there is uncertainty built into the claims about just how many lives could be saved or improved with any one approach.

The problem is this: pretty much everything we do in global health is good. Sure, we can argue specifics and there are glaring examples to the contrary, but for the most part we all want to save lives, prevent suffering, and improve health. No one is seriously against successful interventions when they stand alone: no one thinks people with HIV shouldn’t get antiretrovirals, or children with diarrhea shouldn’t get oral rehydration therapy. Rather, they may oppose spending money on HIV instead of on childhood diarrhea (or in reality, vice versa). Who is comfortable with making an argument against preventing childhood burns? Being against treating horrific cancers? Any takers? So we all argue for something that is good, and avoid the messy discussions of trade-offs.

Thus, much of the conflict in the global health fields is about spending money on X intervention versus intervention or approach Y. Or, better yet, traditional and known intervention A versus new and sexy and unproven-at-scale approach B. I don’t think I’d want to live in a world where all health decisions are made entirely by cost-benefit analysis, nor would I want to live in a world where all decisions on care and policy are made from a rights-based approach — both approaches result in absurdities when taken to their extremes and to the neglect of each other. My impression is that most professionals in global health draw insight from both poles, so that individuals fall somewhere on a continuum and disagree more with others who are furthest away. The tension exists not just between differing camps but within all of us who feel torn by hard choices.

So the differences between the mostly utilitarian public health old-guard and the more recent crop of rights-driven global health advocates aren’t always clear-cut, and they often talk right past each other … or they just work at different organizations, teach at different schools and attend different conferences so they won’t have to talk to each other. To some extent they’re fundraising from different audiences, but they also end up advocating that the same resources — often a slice of the US global health budget — get spent on their priorities. These tensions usually simmer under the surface or get coated in academic-speak, but sometimes they come out. Which brings me to an anecdote to leaven my generalities:

A few months ago I was having a private conversation with a professor, one who leans a bit towards the cost-benefit side of the continuum with a dose of contrarianism thrown in for good measure. Paul Farmer came up — I don’t remember how. I paraphrase:

Resource allocation is the central dilemma in public health. Period. If people don’t get that, they’re not public health. Paul Farmer? Fuck Paul Farmer. He just doesn’t get it.

You won’t hear that in a lecture or in a public speech, but it’s there. I’ve heard similar sentiments from the other side of the spectrum, those who see the number-crunching cost-benefiteers as soulless automatons who block the poor from getting the care they need.

These dilemmas are not going away any time soon. But I think being conscious of them and striving to be explicit about how our own values and biases shape our research and advocacy will help us to collectively reach a balance of heart and mind that makes more sense to everyone.

HIV/AIDS is one of the areas of global health where the raw passion of the heart most conflicts with the terrible dearth of resources we have to fight the demon. Decisions have ugly consequences either way you choose, and, rightly or wrongly, dispassionate research is often anything but. The recent news that pre-exposure prophylaxis (PrEP) can prevent HIV acquisition in sero-discordant heterosexual couples is huge in the news right now. Elizabeth Pisani (epidemiologist and author of The Wisdom of Whores) hits the nail on the head in this recent blog post. She notes that there are voices clamoring for widespread scale-up of PrEP — treating the HIV negative partner — but that PrEP prevents infection in 60% of cases while treating the HIV-positive partner cuts infection by 96%. Continuing:

That leaves us with the question: who should get PReP? Right now, there are not enough antiretrovirals to go around to treat all the sick people who need treatment. If we’re going to use them selectively for prevention, we should start with the most effective use, which appears to be early treatment of the infected partner in discordant couples. We could also give them to people who aren’t in a couple but who know that they’re likely to get around a bit and might want to stay safe without using condoms. That’s potentially a lot of people; it will stretch our purses. But more than that, it will stretch our political will.

So who is PReP for? We’ve got a better option for discordant couples. We’re not going to want to give it to randy adolescents. We know it works for gay men, but some of the countries where the trials took place would rather thump or jail gay men than protect their sexual health.[…] But I think we would be unwise to rush around talking about massive roll-out of PReP before we actually figure out who it works for in the real world.

Treating people with HIV is good. Preventing infection via treatment is good. Prevention infection via PrEP is good (assuming it doesn’t breed more drug resistant strains and make it harder to treat everyone… but that’s another story). But most voices in the debate have an agenda and are pushing for one thing above the rest. One of them — or a balance of them — is right, but you have to understand their values before that can be discerned. And I think many people in global health don’t even think explicitly about their own values, such as the mix of cost-benefit and rights-based approaches they find most appealing. Rather, we all want to promote whatever we’re working on that the moment. After all, it’s all good.

18

07 2011

Weekend meanderings: rockets, Apollo 13 and development

Outer space and rockets were what first sparked my interested in science. My 4th and 5th grade GT teacher, Wanda Holland, taught a summer model rocketry camp for 5th grade science students in my hometown in Arkansas. I went to the camp, fell in love with rockets, and built so many in the next year that Mrs. Holland invited me back as an “assistant” the next year. I kept assisting, then co-teaching the camp through 9th grade and along the way acquired an immense knowledge of mostly useless trivia about astronomy and rocket science. By the time I reached 9th grade I had a collection of hundreds of rockets — including multiple stage rockets, gliders, scale models, and onboard cameras. I even remember asking a friend once why he would spend money on clothes when he could buy another rocket kit. Needless to say, I was cool.

At some point in high school I discovered interests in travel, in playing guitar, in cars, and in girls. Rocketry slowly fell by the wayside. In 10th grade I was building a greater-than-full-scale model of the AIM-9 Sidewinder missile in the family garage (the real thing is 9 feet tall, mine would have been 14′). I had already done the composite reinforcement on the main airframe body tubes when I calculated out how much the construction supplies, avionics, and solid fuel motors would cost, and I realized it would take much more money than my part-time job as a grocery bagger would provide. Then good fortune struck: I won $500 in a regional grocery bagging competition (seriously) which would have let me complete the rocket and buy the fuel to fly it once. But by that point my priorities had shifted and I chose to use it towards a trip to Ghana. That decision is one of many small steps that led me from wanting to be a rocket scientist or astronaut to an interest in global health. The experiences I had in Ghana, and later in Zambia and South Africa, led me to my current interests, and rockets have been a sideshow ever since.

While rocketry hasn’t been my primary interest in years, I still try and keep up with my rocket blog, especially when I get around to flying one of my own projects. The old urge to be an astronaut, still strikes now and then. I was a bit bummed that I didn’t make it down to the last ever Space Shuttle launch since I always told myself I’d make it to one of them. So this weekend I indulged myself by re-watching Apollo 13, one of my all-time favorite movies.

Apollo 13 holds up surprisingly well 16 years after its release. The casting, the acting, the writing — it’s all excellent. The special effects hold up well too. The soundtrack fits the movie perfectly, especially the triumphant horn riffs during the launch sequence (which I used to watch over and over for hours when I was in junior high). The movie manages to sneak in a surprising amount of jargon, but it works because it’s a compelling human interest story focusing on the astronauts and their families. And director Ron Howard managed to infuse the movie with considerable suspense despite everyone knowing how it ends.

Since this is a blog (mostly) about international health and development, I feel it’s my duty to draw a few extremely tenuous connections between space flight, this movie, and my current interests:

  • Computers are older than I often think. I mean, they’re relatively new in the grand scheme of things, but in my head I often date the importance of the computer to the wide availability of the personal computer. The first Apple home computer I had access to in the early 90s had an operating system contained entirely on a floppy disk, and a separate drive for another floppy disk on which you could load programs and files. Computers have come a long way since then, but even that little Apple was an incredible advance over the computers of the NASA era. Still, they were good enough to take us to the moon in the 1960s. Though you do get the distinct impression that Lovell sure could have used a USB thumb drive to transfer the ‘main operating program’ from the command module to the LEM at the height of the crisis.
  • Organization as technology. Part of my summer reading is Charles Kenny’s optimistic take on global development, Getting Better. In an early section describing the history of theories of economic development, Kenny discusses how some economists have argued that institutions are as important for development as any given technology. Example institutions include specialization of labor, “double-entry bookkeeping, just-in-time management systems,” etc. There’s an early scene in Apollo 13 where Jim Lovell (Tom Hanks) is giving a tour of the massive Vehicle Assembly Building and describes astronauts as only the most visible part of a massive system. Having just read about institutions — and economists’ attempts to predict national growth rates — I couldn’t help but think of the massive specialization of labor that allowed us to go the Moon. One of the delights of being a hobby rocketeer is that you can do it all, at least the fun parts, yourself. But real NASA engineers are part of massive systems that work together to do much more than any individual could. That’s one reason that disasters like Columbia and Challenger are almost always ultimately traceable to problems in how those systems of people work together, rather than a single failure in materials or a single mistake by an individual. The question “what caused the Challenger disaster?” can be answered on as many different levels as “what sparked the recession?”
  • Why did we win the space race? Relatedly, if economists or engineers had tried to predict who would win the race to the Moon in 1950 or 1960, there would have been any number of reasons to pick the Soviets over the Americans. Both sides had natural resources, large numbers of engineers, and rocket scientists poached from the Germans after World War II. While we got the better German, the Soviets had an early lead in rocket development. Then the 60s were particularly rough for the Soviet rocket program (see the Nedelin catastrophe). Arguments abound as to why the US eventually got to the Moon first, but my impression is that US institutions, and especially the engineering systems (not just the particular technological fixes) developed by the US played a significant role.
  • Rubella. Astronaut Ken Mattingly (Gary Sinise) was supposed to be on Apollo 13, but he was exposed to a virus and bumped to the flight lest he become sick on his back to the Moon — his removal from the flight set the stage for Jack Swigert (Kevin Bacon) to take the third spot just 72 hrs before launch. In the movie they just say “measles,” but in reality it was German measles — a synonym for rubella. The other astronauts had natural immunity because they had had rubella as kids, but Mattingly hadn’t, so he got bumped. The rubella vaccine (see graph at right) wasn’t introduced until the 1960s, so Mattingly’s kids would have gotten the vaccine, but he hadn’t. Oops. Rubella is also one of the few vaccines not developed my Maurice Hilleman. OK, that’s a slight exaggeration, but Hilleman did invent vaccines for eight diseases: measles, mumps, hepatitis A, hepatitis B, chickenpox, meningitis, pneumonia and Haemophilus influenzae bacteria. Incredible.

16

07 2011

The view from my window

Andrew Sullivan’s Daily Dish is one of my favorite blogs. One feature I’ve grown to love is the daily “View from your window,” and today he featured a shot I took on Sunday looking out my apartment window here in NYC:

13

07 2011

NYC mystery of the day: trash collection

I keep hearing complaints from both New York residents and visitors alike that the city smells. You get used to it pretty fast, but it’s true — especially during the summer.

In the two other cities I’ve lived in (Washington, DC and Baltimore) I would put the trash out in a specially marked bin or garbage can for pick-up. My apartment in the East Village has a designated bin on the sidewalk, but we seem to be an exception rather than the rule. Most people just stack their trash bags on the sidewalks, like so:

This contributes to the smell, and probably to the rat problem as well. So why doesn’t New York require trash to be placed in bins like at least some other American cities?

This brief history of trash collection in NYC is fascinating, but it doesn’t really offer an answer. So I’m stumped for now, but my best guess is that sidewalk and building entryway space are at such a premium that space-consuming trash bins have never been popular. If you have another explanation I’d be happy to hear it.

12

07 2011

CIA's despicable Pakistan vaccination ploy

Via Conflict Health, The Guardian reports that the “CIA organised fake vaccination drive to get Osama bin Laden’s family DNA”:

In March health workers administered the vaccine in a poor neighborhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

Christopher Albon of Conflict Health writes:

If true, the CIA’s actions are irresponsible and utterly reprehensible. The quote above implies that the patients never received their second or third doses of the hepatitis B vaccine. And even if they did, there is absolutely no guarantee that the vaccines were real. The simple fact is that the health of the children of Abbottabad has been put at risk through a deceptive medical operations by the Central Intelligence Agency. Furthermore, the operation undermines future vaccination campaigns and Pakistani health workers by fueling conspiracy theories about their true purpose.

Albon notes that the Guardian’s source is Pakistan’s ISI… but this McClatchy story seems to confirm it via US sources:

The doctor’s role was to help American officials know with certainty that bin Laden was in the compound, according to security officials and residents here, all of whom spoke only on the condition of anonymity because they feared government retribution. U.S. officials in Washington confirmed the general outlines of the effort. They asked not to be identified because of the sensitivity of the topic.

The sensitivity of the topic? No kidding. This is absolutely terrible, and not just because the kids originally involved might not have gotten the second round of vaccine (which is bad) or because it will make the work of legitimate public health officials in Pakistan even harder (which is very bad). Vaccines are amazing innovations that save millions of lives, and they are so widely respected that combatants have gone to extraordinary lengths to allow vaccination campaigns to proceed in the midst of war. For instance, UNICEF has brokered ceasefires in Afghanistan and Pakistan for polio vaccine campaigns which are essential since those are two of the four countries where polio transmission has never been interrupted.

I hope I’m not overreacting, but I’m afraid this news may be bad for the kids of Pakistan, Afghanistan, and the rest of the world. Assuming the early reports are confirmed, this plot should be condemned by everyone. If US officials who support global vaccination efforts are going to control the damage as much as possible — though it’s likely much of it has already been done — then there need to be some very public repercussions for whoever authorized this or had any foreknowledge. What tragic stupidity: a few branches of the US government are spending millions and millions to promote vaccines, while another branch is doing this. The CIA is out of control. Sadly, I’m not optimistic that there will be any accountability, and I’m fuming that my own country breached this critical, neutral tool of peace and health. How incredibly short-sighted.

Update: In addition to the Guardian story, Conflict Health, and McClatchy stories linked above, this NYTimes article offers further confirmation and the CNN piece has some additional details. Tom Paulson at Humanosphere, Mark Leon Goldberg of UN Dispatch, Charles Kenny of CGD, and Seth Mnookin all offer commentary.

11

07 2011