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The Global View: Lessons For Mass. Health Care From Abroad

By Dr. Jonathan D. Quick
Guest contributor

A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.

Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.

Dr. Jonathan Quick (Courtesy)

Dr. Jonathan Quick (Courtesy)

Here are four things Massachusetts could learn about health from developing countries:

1. Bring health care to the community level

Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.

CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.

2. Make it convenient

Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.

Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.

3. Generate revenue while saving lives

Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Continue reading

Exporting The Couch Potato Lifestyle (And Obesity) Via TV, Computers, Cars

(Aaron Escobar/Wikimedia Commons)

(Aaron Escobar/Wikimedia Commons)

A new study finds that the luxuries of modern life come at an extremely high cost: a greater chance of becoming obese or developing diabetes.

Researchers report that in lower-income countries, ownership of a household device — including a car, computer or TV — significantly “increased the likelihood of obesity and diabetes.”  Specifically, owning these items was “associated with decreased physical activity and increased sitting, dietary energy intake, body mass index and waist circumference.” Of the three “devices,” owning a TV had the strongest association with the bad health outcomes.

In poorer countries, such big-ticket items are clearly less prevalent than in rich countries, however they are fast becoming more ubiquitous. And so, apparently, are the ills associated with sitting around watching TV, typing on a computer and driving.

Here’s more from the news release:

The spread of obesity and type-2 diabetes could become epidemic in low-income countries, as more individuals are able to own higher priced items such as TVs, computers and cars. The findings of an international study, led by Simon Fraser University health sciences professor Scott Lear, are published today in the Canadian Medical Association Journal.

Lear headed an international research team that analyzed data on more than 150,000 adults from 17 countries, ranging from high and middle income to low-income nations.

Researchers, who questioned participants about ownership as well as physical activity and diet, found a 400 per cent increase in obesity and a 250 per cent increase in diabetes among owners of these items in low-income countries.

The study also showed that owning all three devices was associated with a 31 per cent decrease in physical activity, 21 per cent increase in sitting and a 9 cm increase in waist size compared with those who owned no devices. Continue reading

Marty Walsh’s Childhood Cancer: Curable Here, Not So Easy In Africa

By Elizabeth Mehren
Guest Contributor

Just about everyone in town knows by now that Marty Walsh is the son of Irish immigrants, a former labor organizer, a recovering alcoholic and a man who is happily unmarried to “the love of my life.” But it’s possible that few outside a rather eccentric quartet of Boston University researchers took note of one particular item in the biography of Boston’s new mayor.

Walsh is a survivor of Burkitt’s Lymphoma, a virulent variety of pediatric cancer that is rare in North America. Walsh is living proof that this fierce form of non-Hodgkin’s Lymphoma — known to be the fastest-growing human tumor — responds well to early diagnosis and chemotherapy.

But in sub-Saharan Africa, where Burkitt’s is the most widespread type of childhood cancer, the outcome is often less rosy. Burkitt’s Lymphoma represents half the number of childhood tumors treated at regional hospitals in Kenya and Uganda. Experts say the disease — first identified in 1958 — is on the rise. Diagnosis is challenging. Treatment is costly. In Africa, treatment often is difficult to obtain because so few facilities are equipped to address Burkitt’s Lymphoma.

Like most Americans, I was unaware of the fatal grip Burkitt’s Lyphoma holds on much of Africa. Then last May, I traveled to western Kenya as part of the aforementioned quirky quartet of four professors. We had joined forces to look at the intersection of public health and journalism, particularly at times of crisis and disaster.

Our goal, with funding from the Bill and Melinda Gates Foundation, was to set up a global student news network dedicated to telling the stories of foreign aid from the point of view of the recipients. And so we brought eight B.U. students together with 10 students from two Kenyan universities in Nyanza Province, Kenya’s westernmost province, and set about uncovering narratives about health, education, employment and other areas. To demonstrate our cross-cultural intentions, we named our project Pamoja Together. Pamoja is the Kiswahili word for “together,” so what we were saying was “Together, Together.”

I learned about Burkitt’s Lymphoma as we conducted research in advance of the trip, to a region that lies close to the Ugandan border, high on the banks of Lake Victoria. One of the stories that one of our Kenyan students, C.J. Ouma, reported on concerned a hospital — one of the few in Kenya that treats this difficult disease.

Chronic malaria abounds in equatorial Africa. For children, this condition can be linked to the development of Burkitt’s Lymphoma. The African strain of Burkitt’s also is closely associated with the Epstein-Barre virus, the main cause of infectious mononucleosis. Burkitt’s is especially prevalent in Kenya’s malaria-prone lake regions.

The disease often starts with swelling in the neck, groin, face or under-arm areas. In Africa, lumps on the skin can result from many causes, including insects, parasites, allergic reactions and random rashes. But Burkitt’s distinguishes itself further because these can grow rapidly, sometimes doubling in 18 hours.

Pamella Adhiambo Otieno, mother of a 2-year-old Burkitt’s Lymphoma patient, Christine Achieng, said, “The symptoms started at six months, and we assumed it was a simple growth.” Continue reading

Lancet: How To Save A Couple Of Million Small Children’s Lives A Year

(Wikimedia Commons)

(Wikimedia Commons)

We’ve made so much progress on AIDS in Africa; now it’s time to tackle the world’s biggest child-killers, pneumonia and diarrhea.

That’s the logic driving a new series of papers just out in the medical journal The Lancet. Here’s the summary, and from the press release:

Leading causes of death in children under 5 could be eliminated in 20 years

Diarrhea and pneumonia – regarded as relatively minor illnesses for most people living in high-income countries – are together the leading causes of death for children worldwide. In 2011, they were responsible for two million deaths of children under five, despite the fact that they can be treated and prevented at relatively low cost.

A new Lancet Series on childhood diarrhoea and pneumonia, from a consortium of academics and public health professionals led by Professor Zulfiqar Bhutta of Aga Khan University in Pakistan, provides the evidence for integrated global action on childhood diarrhoea and pneumonia, including which interventions can effectively treat and prevent them, and the financial cost of ending preventable deaths from childhood diarrhoea and pneumonia by 2025.

Dr. Christopher Gill of Boston University’s Center for Global Health & Development, who co-authored one of the Lancet papers, offers this (lightly edited) context for the series:

Roll back ten years. Around 2000, there was a big, passionate debate about what we should do about AIDS in Africa. The activists were saying, ‘This is a public health emergency, we’ve got to move. We can do this.’ And the skeptics and pessimists were saying, ‘This is too complicated and expensive.’ The activists won this debate, and today we can look back and say that we have made unprecedented progress on AIDS in Africa. Millions of people are in treatment, there are new drug supply chains and clinics, and the infrastructure is all built de novo. It’s spectacular.

So I look at that and say, ‘Okay, pediatric diarrhea and pneumonia kills 2 million kids a year, way more than HIV/AIDS does by many fold. The cure for pneumonia, amoxycillin, is widely available and costs nearly nothing to manufacture. For diarrhea, you need oral rehydration salts, sugar and water and zinc. Again, costs almost nothing and is wildly effective. We could cut mortality in half with interventions we’ve had available for literally decades, and we don’t do it. Why? It’s not too complicated. We’ve shown with HIV/AIDS you can take a problem that’s highly complicated and solve it in the most difficult situations possible. We have no plausible excuses why we don’t do this with diarrhea and pneumonia. We don’t need new technologies or vaccines or antibiotics to solve this. We can do it with what we have. If we’re not doing it, it’s simply because we’ve made a political decision not to, and I think that’s tragic.

So what needs to be done? Continue reading

Why Bill Gates Wants A Condom That Actually Feels Good

It’s rare to see the words “Bill Gates” “condom” and “enhance pleasure” in the same sentence but that’s precisely the gist of the latest global health challenge by the tech billionaire’s charitable foundation.

Indeed, the Gates Foundation’s latest public health quest is truly inspired: $100,000 to anyone who can invent the “next generation condom,” one that actually feels groovy and might even “enhance pleasure.” Here are the specifics, from the Foundation’s web site:
condom

Condoms have been in use for about 400 years yet they have undergone very little technological improvement in the past 50 years. The primary improvement has been the use of latex as the primary material and quality control measures which allow for quality testing of each individual condom. Material science and our understanding of neurobiology has undergone revolutionary transformation in the last decade yet that knowledge has not been applied to improve the product attributes of one of the most ubiquitous and potentially underutilized products on earth. New concept designs with new materials can be prototyped and tested quickly. Large-scale human clinical trials are not required. Manufacturing capacity, marketing, and distribution channels are already in place.

We are looking for a Next Generation Condom that significantly preserves or enhances pleasure, in order to improve uptake and regular use. Continue reading

A Health Care Success Story In An Unlikely Place

When you think about countries that might be considered health care “success” stories, Rwanda probably isn’t at the top of your list. But that’s exactly how renowned doctor and humanitarian Paul Farmer describes the African nation (once among the poorest in the world) in a recent BMJ article covered in yesterday’s New York Times.

Since the 1994 genocide in Rwanda, which claimed up to 1 million lives, “the country has become a spectacular public health success story and could provide a model for the rest of Africa,” the Times’ Don McNeil reports.

Consider these statistics cited in the news story:

In 1994, 78 percent of the population lived below the poverty line; now 45 percent do. The gross domestic product has more than trebled. Almost 99 percent of primary-school-age children go to school.

yodod/flickr

yodod/flickr

With help from Western donors, the number of people getting treatment for AIDS rose to 108,000 from near zero a decade earlier.

Many doctors fled Rwanda before the genocide, and many were killed. Even now, the country has only about 625 doctors in public hospitals for a population of almost 11 million. But it also has more than 8,000 nurses, and a new corps of 45,000 health care workers, elected by their own villages, to do primary care for malaria, pneumonia, diarrhea, family planning, prenatal care and childhood shots.

Largely because of these workers, the country has high rates of success in curing tuberculosis and keeping people with AIDS on antiretroviral drugs.

Nearly 98 percent of all Rwandans have health insurance. Continue reading

Around The World, Living Longer But Not Living Better

(Vedant Gulati/Wikimedia Commons)

(Vedant Gulati/Wikimedia Commons)

By Judy Foreman
Guest Contributor

A massive new study out today shows that around the world, people are living longer than they did 20 years ago, but there’s a catch: many of these extra years are spent in poor health — in some cases with conditions that might be preventable or treatable.

The collaborative project, published in a special issue of The Lancet and led by researchers at the University of Washington and a consortium including the Harvard School of Public Health and the Johns Hopkins Bloomberg School of Public Health, found that some of the old scourges of humankind — infectious disease and childhood illnesses — that were once the leading causes of death have decreased dramatically, even in many developing areas. Deaths among children under five used to be the biggest contributor to the world’s health burden; now it’s chronic diseases that cause severe pain, impair mobility or keep people from seeing, hearing and “thinking clearly,” as the university put it in a statement.

But as childhood deaths have decreased, there has been a troubling increase in deaths among young adults, those aged 15 to 49 – mainly because of violence and HIV/AIDS. And while malnutrition – including starvation – used to be the leading risk factor for death worldwide, now it’s the opposite that’s the big threat: poor diets and physical inactivity. In fact, dietary risk factors and physical inactivity now account for a whopping 10 percent of the world’s health burden, as excess weight and high blood sugar continue to soar.

We are living longer, but some of those “extra” years are years of pain, sickness, immobility, depression, anxiety and other forms of poor health.

As some health problems have lessened worldwide between the new study, called the Global Burden of Disease Study 2010 and its predecessor in 1990, others have soared, chief among them lower back pain and road accidents. The latest research, funded by the Bill and Melinda Gates Foundation, was a massive endeavor with 486 authors from 302 institutions and more than 30,000 survey participants in more than 100 countries. It resulted in seven scientific papers being published together.

In statistical terms, what’s happening is that although life expectancy from birth is still increasing all around the world, what might be called the “healthspan” is not keeping pace. In other words, we are living longer, but some of those “extra” years are years of pain, sickness, immobility, depression, anxiety and other forms of poor health. Continue reading

Why To Exercise Today: Everybody’s Doing It

crowded marathon runners

(geograph.org.uk)

One recent morning, when a rare surge of early energy propelled me to the gym at 6 a.m., I was shocked — shocked — at how crowded it was. There are a lot of morning larks who work out at dawn. It’s a big club. We tend to hear so much about how Americans are fat and lazy and sedentary that you might assume couch potatoes are the norm. But no.

The medical journal The Lancet tweeted this morning, “1/3 of adults are at high risk of disease from failing to do recommended amounts of physical activity” and I thought, “Only a third? That’s a glass two-thirds full.” (The stats look worse for adolescents; That Lancet tweet was: “4 out of 5 adolescents are at risk of disease from failing to do the recommended amounts of physical activity.)

All these numbers are emerging from a cornucopia of new — and open access! — research in the Lancet’s new series on physical activity. The abstract of the paper on population statistics:

Worldwide, 31·1% (95% CI 30·9—31·2) of adults are physically inactive, with proportions ranging from 17·0% (16·8—17·2) in southeast Asia to about 43% in the Americas and the eastern Mediterranean. Inactivity rises with age, is higher in women than in men, and is increased in high-income countries. The proportion of 13—15-year-olds doing fewer than 60 min of physical activity of moderate to vigorous intensity per day is 80·3% (80·1—80·5); boys are more active than are girls.

So okay, it’s just a little more than half of Americans who are dangerously inactive. Still — wouldn’t you rather vote with the majority?

What The Rich U.S. Health System Can Learn From The Poor

http://www.youtube.com/watch?v=4w4oa7PEaaE

A trio of superstar health innovators have a message for the broken U.S health care system: broaden the definition of health to include basic life necessities, bring care to where people live and study how it’s done in poor countries where you can’t always rely on expensive tests and drugs to make people better.

The persuasive new report on “re-aligning health with care” is written by Harvard doctors Paul Farmer (co-founder of the medical nonprofit Partners in Health) and Heidi Behforouz (executive director of the Prevention And Access To Care And Treatment [PACT] program) and Rebecca Onie, CEO of the nonprofit Health Leads. In it, they argue that with some rethinking, the U.S. can deliver better care at a lower price.

They lay out the central problem here:

The health care system is in crisis, driven chiefly by escalating costs, suboptimal health outcomes, scarce primary care resources, and rising poverty. At the same time…a growing number of health providers around the globe have learned to deliver high-quality health care at low cost. Now we need to align our resources in the United States to bring this knowledge fully to bear in saving dollars and lives.

Sounds great, but how to do it? The key, they write in the Summer 2012 edition of the Stanford Social Innovation Review is to change the way we view the “product” of health care, the places it’s delivered and the providers who dole out patient care. Continue reading

Jim Kim: World Bank President, Astronaut Rapper

I’ll admit it, I’m a biased, pro-Jim Kim groupie.

Ever since I sat in on a Harvard class with Kim and Paul Farmer in which they recounted stories about treating people with drug resistant tuberculosis in Peru and in Russian prisons, the historical factors driving HIV/AIDS in Haiti in those early years, the gritty mechanics of health care delivery and the deep connections between poverty and disease, I’ve been awed by their incredible dedication to the idea that health is a human right. It’s impossible not to be.

So it’s pretty cool that Kim was elected Monday as the World Bank’s next president.

But Kim does have a lighter side: See him as a rapping astronaut here on YouTube.

http://www.youtube.com/watch?v=Vi4V8FgK-nY

Here’s more on his global health accomplishments from the folks at Partners In Health, the international health non-profit Kim co-founded 25 years ago:

“I can think of no one better able than Jim to help families, communities, and entire nations break out of poverty, which is the mandate of the World Bank,” said PIH co-founder and Harvard University Professor, Dr. Paul Farmer.

As a physician and medical anthropologist, Dr. Kim’s mission to serve the poor has led him from Haiti to Peru to Lesotho and beyond for nearly three decades. He and Paul Farmer met as medical students at Harvard and joined with Ophelia Dahl, Thomas J. White, and Todd McCormack in 1987 to found Partners In Health. Continue reading