No Plan B: Obama abandons science on morning-after pill

Published in the Guardian on Tuesday, December 13, 2011. Read the original article here.

Last Wednesday, the Food and Drug Administration (FDA) recommended that emergency contraceptive Plan B One-Step, commonly known as the “morning-after pill,” be available over the counter without age restriction. The FDA researched the pill and concluded that it was safe and effective for nonprescription use and that adolescents could use it properly without intervention of a healthcare provider.

The same day, Health and Human Services (HHS) Secretary Kathleen Sebelius overruled the FDA’s recommendation.

Sebelius said she was concerned that the manufacturer had not studied whether 11-year-olds, some of whom are capable of bearing children, would fully comprehend the product’s label and appropriate use. As a result, the emergency contraceptive will continue to be sold behind the counter at pharmacies, and women under the age of 17 will continue to require a prescription to access it.

Soon following the decision, President Obama said that he supported Sebelius’ stance. “As the father of two young daughters,” he said, “I think it is important for us to make sure that we apply some common sense to various rules when it comes to over-the-counter medicine.” He said that 10-year-olds should not step into a drugstore and be able to buy, “alongside bubble gum or batteries,” a medicine that could have adverse effects if used incorrectly.

Though the health secretary has the authority to overrule the FDA, this is the first time one has ever done so. This exercise of power signals a worrisome trend in the Obama administration.

Since Obama’s election, he has stated time and again how his administration would rely on science and not ideology. When Obama overrode the Bush-era ban on stem cell research, for instance, he said, “Promoting science isn’t just about providing resources, it is also about protecting free and open inquiry…. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda and that we make scientific decisions based on facts, not ideology.”

In her statement, Sebelius used the logic of science to justify her decision. Specifically, she claimed that the data submitted by Plan B’s manufacturer did not “conclusively establish” that young adolescents could safely use the drug. However, the preponderance of evidence behind Plan B’s safety, efficacy, and comprehension suggests that the decision was determined not by science but by ideology.

Plan B primarily works by suppressing ovulation, and though some have suggested it can induce abortion, the most recent studies have shown that it is only a contraceptive. It is 89% effective in preventing pregnancy if taken within 72 hours of unprotected sex and has no serious side effects. There are important societal benefits to this: notably, increased availability of Plan B has been linked to a decrease in abortion rates (pdf).

Moreover, most women, including adolescents as young as 12, have consistently demonstrated a good understanding of how the drug is used and the occasions that warrant its use. In one qualitative study, researchers found that “neither younger nor older teens revealed an intention… to use Plan B as their primary form of contraception.” In any case, the drug’s price – a single dose costs between 30 and 50 dollars – would likely deter most sexually active adolescents from using it frequently.

Sebelius used scientific uncertainty to justify her stance on Plan B. Yet she and previous health secretaries have made countless decisions in the face of uncertainty, including some more consequential than the uncertainty of Plan B label comprehension by 11-year-olds. When the FDA approved cholesterol-lowering Lipitor for the prevention of heart attacks in 2004, the data had not conclusively determined whether it would be effective for women or people over 65. Despite these populations being significantly larger than the population of sexually active and menstruating 11-year-old girls, the FDA and health secretary still approved Lipitor.

Henry Pollack, author of Uncertain Science, Uncertain World, warns that policymakers excessively use uncertainty as an excuse to delay or reject scientific decisions. In a talk at the University of Michigan, he said, “Waiting until uncertainty is eliminated is generally impossible. When you hear a call for postponing decision making because of scientific uncertainty, it’s an implicit endorsement of the status quo.”

In this case, the decision to “maintain the status quo” appears to be based on ideas of the importance of parental oversight and the unease of adolescents having sex lives. When Obama chose to mention his role as “the father of two daughters” in a policy discussion, he essentially, in the eyes of one feminist writer, “recast the debate as an episode of ‘Father Knows Best,’ reaffirm[ing] hoary attitudes about young women and sex.” Obama aides even admitted to reporters that the decision was rooted “less in science than in a gut feeling that teenagers might not be ready to make decisions about pregnancy.”

Not surprisingly, many supporters of the decision have congratulated the administration on similarly non-scientific grounds. One editorial discussed how approving the pill for nonprescription use would have sent a “bad message” to preteens, namely that “risky sexual behavior can be undone by simply taking a pill in the next day or so.” Others have noted how allowing minors to buy the pill “would [have] undermined parental oversight and set minors up for exploitation by adult sexual predators.”

The decision to keep Plan B off drugstore shelves is an unfortunate one. Wider access to the drug would have been a safe and effective way to reduce teenage pregnancy rates, which have been on the rise. As long as the Obama administration continues to make its decisions on women’s health issues using ideology and not science, it will continue to see similar trends.

Social Enterprise Bootcamp in Seven Steps

Published on Dowser on November 29, 2011.  Read the original article here:

Directed at budding social entrepreneurs, Social Enterprise Bootcamp, a recent two day workshop organized by students at Columbia, NYU and the School of Visual Arts, offered practical advice from an impressive array of speakers. Here are a few of the key take-aways:

A social enterprise can change the world, but only a part of it.

Greg van Kirk, founder of the New Development Solutions Group and of the micro-consignment model, told participants, “Social entrepreneurship is when people tell you you’re crazy, that your idea will never take off, but you decide it’s important enough to do anyway.” With a lofty vision, deep conviction for your cause, and solid execution capability, almost anything is possible. At the same time, however, the best social enterprises know their limits. No business can change everything, van Kirk said, and businesses that attempt to do too much will inevitably fail. Instead, he advised participants to pick what they want to influence and do it well.

Expect bumps along the way.

Starting a business, especially a social enterprise, is not easy. The speakers, many of whom were social entrepreneurs themselves, had no qualms about sharing their past and current obstacles in getting their businesses off the ground. Joanna Opot of TerraCycle, for instance, discussed the challenges all businesses face as they begin to scale up, and mentioned some ways her business is currently trying to overcome them. Joyce Meng of Givology advised participants to “keep it cheap” for as long as possible, so as to survive the unavoidable growing pains. “Do you really need an office in the early stages?” she asked. Or will it make your business more likely to sink if something goes wrong?

Do what you love.

Keynote speaker Jeffrey Hollender of Seventh Generation spoke to the importance of “doing what you love.” The process of opening a social enterprise is difficult, he said, and without a deep commitment to your cause, it will be easy to find exit opportunities. He also discussed the importance of developing a strong mission and set of values. In many cases, he said, these intangibles are more important and longer lasting than the product.

Design your business around your consumer.

Design thinking, or “human-centered design,” is important for almost any social enterprise. Jeff Chapin of IDEO explained how design thinking goes far beyond the aesthetics of a product or service, and often requires re-engineering entire business models and processes to focus on the consumer. He gave the audience examples from the water and sanitation world, where design thinkers made water filters, latrines, and mobile toilet systems with the consumer’s needs and preferences in mind.

Don’t undervalue your product/service.

It is common for social entrepreneurs, especially new ones, to undervalue the novelty of their offerings, and therefore undercharge for them. To illustrate this point, Opot of TerraCycle told participants her own story. “When we started making partnerships, we found that everyone was interested in partnering with us,” she said. It’s exciting in the beginning, Opot said, but after a point, she realized the real reason for the interest was that their prices were too low. “When we hiked up our prices, nobody even blinked,” she said.

Dot your i’s and cross your t’s.

Without basic logistical details in place, even social enterprises with rock star leaders and revolutionary business models can fail. To avoid this, some workshops focused on the legal, financial, and other backend processes needed to bring businesses to success. Speakers gave advice on how to register their businesses, how to forecast financials, how to engage good lawyers, and more.

Reflect.

One session asked participants to put everything away and spend the next forty-five minutes simply reflecting on what they had learned. Some rolled their eyes and left the session (“this isn’t what I paid money for!”), smartphones in hand, but I heard very good feedback from those who sat through it. “We’ve learned so much this weekend,” one participant told me, “and we never take time to just sit and consider what it all means.”

Top five ways Big Pharma can address neglected diseases

Published in Forbes on November 22, 2011. Read the original article here

My last post discussed the reasons why neglected diseases have historically been neglected, the growing efforts to eradicate them, and why pharmaceutical companies should develop more drugs for them.

Unfortunately, the traditional economics of drug development are stacked against neglected diseases, which disproportionally affect the world’s poorest populations. Drug development is a costly and time-consuming process, and even if a pharmaceutical company did develop a viable drug for a neglected disease, they would have virtually no way of recouping their investment.

Luckily, there are many other ways the private sector can address neglected diseases (which are defined here as the seventeen neglected tropical diseases, malaria, and tuberculosis). I spent last week speaking with top officials from pharmaceutical companies, research groups, and intellectual property organizations to understand what the for-profit pharmaceutical industry can realistically do to push research forward on these diseases. All of the solutions presented below have, importantly, already been tested in the real world.

Without further ado, here are – in no particular order – the top five ways Big Pharma can address neglected diseases.

1) Create cross-sectoral research partnerships for neglected diseases
Though pharmaceutical companies have generally shied away from independently developing drugs for neglected diseases, several are open to creating drugs with partners. Just this past Thursday, Novartis and collaborators, including Scripps Research Institute and Swiss Tropical and Public Health Institute, discovered a new dual-acting class of anti-malarial compounds. “It was a multi-disciplinary, multi-continental effort,” said Paul Herrling, head of corporate research at Novartis. “Each partner brought unique knowledge and skills needed to obtain the common goal.”

Other pharmaceutical companies have also created partnerships for neglected diseases. Sanofi has, for instance, partnered with non-profit drug developer DNDi to develop medicines for up to nine NTDs. GSK has similar partnerships with foundations including Medicines for Malaria and the Global Alliance for TB Drug Development. In most cases, the partnerships are funded through a combination of sources, including the private sector, government, and other donors.

Partnerships for neglected diseases appear to be on the rise across the pharmaceutical industry. The International Federation of Pharmaceutical Manufacturers and Association (IFPMA) found that partnerships for neglected diseases have increased five-fold from 2005, and that today, 80 percent of neglected disease research efforts are done through collaborations. Mario Ottiglio, Associate Director of Public Affairs and Global Health Policy at IFPMA, said, “[Partnerships are] basically a very pragmatic solution to address market failure in neglected diseases. Pharmaceutical companies bring adequate resources, while academia and government bring the epidemiological context.”

This does not mean, of course, that every research partnership is guaranteed to succeed. Scientifically speaking, neglected diseases are quite complicated and few efforts will yield positive results. Robert Sebbag, Vice President of Access to Medicines at Sanofi, also discussed how strong relationships are crucial to the success of a partnership. “Each partner has to respect and trust each other,” he said. “They must also have a common objective.” Without those fundamentals, he said, everyone will assume the worst in each other and the fruits of collaboration will be lost.

2) Join patent pools for neglected diseases.
Patent pools are created when two or more companies agree to cross-license certain products or technologies. Recognizing the need for shared progress in neglected diseases, the World Intellectual Property Organization (WIPO) and BIO Ventures for Global Health recently created a patent pool, WIPO Re:search, for neglected diseases. In addition to maintaining a searchable database of relevant intellectual property, it will also facilitate new research partnerships.

“Most pharmaceutical companies have some form of CSR programs. They also have intellectual property. This is basically an effort to put those two things together,” said Francis Gurry, Director General of WIPO.

Since it was only created this year, the potential of a patent pool is yet to be seen. However, Gurry has high hopes. “In the best case scenario,” he said, “[WIPO Re:search] will help create partnerships between public and private entities… which over a five or ten year period will create good candidates for products.”

Many pharmaceutical companies have responded positively to the effort, and seem generally willing to share intellectual property related to these unprofitable disease areas. Sebbag from Sanofi believes it is a “very good step forward” in neglected disease research, and a GSK spokesperson said the program was “a natural evolution” of existing efforts in the field.

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How pharmaceutical companies can help take the ‘neglected’ out of neglected tropical diseases (NTDs)

Published in Forbes on November 9, 2011. Read the original article here.

What do schistosomiasis, cysticercosis, and lymphatic filariasis have in common?

Besides verging on the unpronounceable, they are all classified as neglected tropical diseases (NTDs). NTDs are a set of diseases – seventeen, by the World Health Organization’s count – that collectively affect over a billion people, but have historically received little attention. The most common NTDs, including those listed above, are caused by parasitic worms or protozoa. Others, such as leprosy and trachoma, are the result of bacterial or viral infections.

Though caused by a range of pathogens, NTDs share some important characteristics. First, many are diseases of rural poverty. Most neglected diseases affect the poor in the developing world, particularly in Africa and Asia, but some have also been found in “pockets of poverty” in the United States. For instance, hundreds of thousands of Americans, most of whom are Hispanic immigrants, suffer from Chagas disease. Second, most NTDs cause bodily impairment and disability (i.e., they have high morbidity) but are not very lethal (i.e., they have low mortality). Some result in blindness, others in unseemly swelling, and still others in impaired cognitive development. Most patients do not die, but the morbidity often hinders wage-earning capacity, thereby creating a vicious cycle of poverty.

These and other characteristics have unfortunately led to neglected tropical diseases being, well, a bit neglected. Since most policymakers live in urban centers, geographically separated from the rural areas with high NTD prevalence, there has traditionally been limited awareness of NTDs. Similarly, because NTDs cause more disability than death, they have historically flown under the radar of many public health efforts. Perhaps most importantly, the populations NTDs disproportionately affect have little money to spend on medicine, resulting in what Peter Hotez, President of the Sabin Vaccine Institute, calls “the business plan from hell.”

How can we change this status quo? What needs to happen for the pharmaceutical industry, academic researchers, and other key players begin investing more seriously in diseases that debilitate over a billion people?

To some extent, the status quo has already begun to change. It has not yet changed nearly enough, and there is ample room for the pharmaceutical industry to invest more in NTDs, but it is important to acknowledge how far the fight against neglected diseases has come.

The term “neglected tropical diseases” was only coined in 2005; before that, each unpronounceable disease fought its own uphill battle with limited success. WHO Director-General Margaret Chan explained in 2007 the benefits of having a catch-all term: “When these diseases are viewed together, we gain critical mass. We get a better grip on the scale of the economic and social consequences as well as the health burdens. Arguments for giving these diseases higher priority become more powerful, more persuasive.”

Since the term was coined, there has been considerable activity in the neglected disease space from governments, donors, pharmaceutical companies, and nonprofits alike. The US government, the UK government, and the Bill & Melinda Gates Foundation have collectively pledged or spent over $200 million on NTD prevention and treatment by 2013. Pharmaceutical companies have donated billions of doses of drugs to various NTD control programs. Some, such as GSK and Merck, have also entered “patent pools” to allow cross-licensing of NTD innovations. The Global Network for Neglected Tropical Diseases has engaged in NTD advocacy and on-the-ground coordination efforts. They also run a frequently updated blog, End the Neglect, that discusses NTD news and reminds readers that “just 50 cents” will provide a year’s worth of treatment against several NTDs.

There has also been a marked increase in NTD product development. The nonprofit pharmaceutical company OneWorld Health, which is partly funded through the Gates Foundation, conducts R&D for drugs against kala-azar (visceral leishmaniasis) and hookworm. It also ties up with for-profit pharmaceutical companies, such as Sanofi-Aventis and Anacor, to develop and manufacture some of their medicines. “Pharmaceutical companies have become more interested in NTDs than they were five to ten years ago,” said Richard Chin, CEO of OneWorld Health. “They would have sent us to their PR department before, but now they send us to their research department.”

Chin noted how their for-profit partners have invested significant time and money into the partnerships: they put their scientists on NTD projects at their expense and allowed OneWorld Health to manufacture drugs in their facilities. Many other product development partnerships (PDPs) for NTDs, such as PATH and the Sabin Vaccine Institute, seem to function along similar lines.

These developments are impressive, especially given the short time frame, but there is still a long way to go. This is perhaps most evident in the product development space. Hotez believes the pharmaceutical industry is “generally doing very well” in donating drugs, manufacturing space, and time to NTDs, but says most have invested relatively little in developing NTD drugs and vaccines themselves. Direct pharmaceutical investment has greatly helped the fight against the “big three diseases” (that is, HIV/AIDS, tuberculosis, and malaria): most recently, GSK invested in a malaria vaccine that is in final rounds of a large-scale clinical trial. Similarly, pharmaceutical companies can invest in drugs and vaccines that spur improvements in NTD morbidity rates.

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Personhood: Why Beginning Life at Conception Carries Risks, Even for Anti-Abortion Activists

Published in Huffington Post on November 1, 2011. Read the article here or below

On November 8, Mississippi voters will be faced with the following yes-or-no question regarding their state constitution: “Should the term ‘person’ be defined to include every human being from the moment of fertilization, cloning, or the functional equivalent thereof?”

If a majority votes “no” on the measure, known as Initiative 26 or the personhood amendment, reproductive rights in the nation’s most conservative state would essentially remain unchanged. Mississippi’s one abortion clinic would continue operating, women would continue having access to a suite of contraceptive measures, the state’s three doctors who do in vitro fertilization (IVF) would continue following standards generally accepted in medical circles, and unborn fetuses would continue having fewer legal rights than fully formed humans.

On the other hand, if a majority votes “yes,” as it seems poised to do, Mississippians’ reproductive rights would drastically change. It may also fuel personhood movements in several other states, including Michigan, Florida, and Ohio.

The most publicized difference is with abortion, which would be considered murder and effectively banned — without exceptions for rape, incest, or when the woman’s health is compromised but not at immediate risk of death. OB-GYN doctor and “Yes on 26” advisory board member Freda Bush said in a press conference, “Women who have borne a child conceived in rape testify that the baby is a blessing, rather than have an abortion, which essentially continues the assault. Adoption is always a loving option.”

Limiting abortions is a popular idea in Mississippi, which has a thriving anti-abortion movement and a prominent Christian majority. Perhaps as a result, much of YesOn26′s advocacy appears designed to appeal to this audience. One YesOn26 commercial reminds Mississippians, in a manner similar to many pro-life campaigns, “No matter how small, every human life has infinite value.” Another shows the audience a 24-week-old fetus named “Lyza Kate Freeman.” Local newscasters have also highlighted the abortion element of the amendment, telling viewers, “[Initiative 26] would make abortions illegal, which is what’s at the heart of this debate.”

These segments do not, however, tell the full story. The implications of personhood — that is, of granting a fertilized egg legal rights — go far beyond limiting abortion. Regardless of one’s stance on abortion, personhood is an extreme measure that pushes against many commonly accepted reproductive and human rights.

With full legal rights, destroyed eggs are essentially treated as murder victims. This is why abortion is illegal under personhood. This is also why personhood would outlaw all contraceptives that interfere with the implantation of fertilized eggs — including intrauterine devices (IUDs), some forms of the birth control pill, and the “morning-after pill,” which YesOn26 proponents call “human pesticide.” Personhood would also prohibit scientists from destroying embryos they create in laboratories, a process often necessary during in vitro fertilization and in types of scientific research.

Personhood would also change how doctors treat women undergoing difficult pregnancies. On its website, YesOn26 advocates write, “Under personhood, a doctor would be required to save both lives if possible; but in the hard cases where the baby is unviable, the doctor would save the life of the mother.” However, doctors often have to make judgment calls on when either life is in danger, and when they should begin prioritizing the mother over the unborn baby. This is particularly true in ectopic pregnancies, a complication in which the fertilized egg implants outside the womb. Under personhood, some doctors may become wary of prioritizing the mother’s health, fearing legal ramifications if they “murder” the unborn fetus in the process.

Perhaps most worryingly, personhood may begin to criminally implicate some women for having stillbirths and miscarriages. Though YesOn26 insists personhood will not prosecute women for having miscarriages, this trend has already begun in some states, including Mississippi. Rennie Gibbs, who had a stillbirth in 2006 when she was 15, was charged with “depraved-heart murder” after prosecutors discovered she had a cocaine habit. The charge carries a mandatory life sentence.

In an extreme case, personhood could be even used to justify legal measures that most would otherwise consider preposterous. For instance, according to a recent New York Times editorial, a zygote under personhood may “be eligible to inherit money or be counted when drawing voting districts by population.” Given how many laws use the terms “person” and “people,” the editorial argued, the implications of personhood could be endless.

Within Mississippi, some groups have been trying to distinguish between the pro-life movement and Initiative 26. A grassroots organization called Parents Against MS 26, which claims to take no position on elective abortion, has been spreading its belief that “there are many valid reasons for pro-life AND pro-choice Mississippians to vote No on 26.” In addition to providing FAQs on ectopic pregnancies and IVF, the site offers several personal stories and guest bloggers. For instance, Reverend Todd Owen Watson wrote, “It would be nice if the changing of one or two words in a state constitution would solve all of our concerns about life, its sanctity, and its meaning, but this ill-written and ill-advised amendment might destroy more life than it saves because of its… heavy-handed impact across all aspects of our daily existence.”

Freda Bush hopes the personhood amendment will restore a “culture of life” in the United States. “It’s unfortunate,” she said, “that for the last forty years, the pre-born person has been marginalized and made legally irrelevant.” Sadly, by granting equivalent legal rights to fertilized eggs, the personhood amendment may tip the scales and begin prioritizing the zygote over the post-born person. Personhood is not a simply change in nomenclature; its consequences are perverse, many of them reaching well beyond abortion.

Making vaccines cost-effective: Money is only part of the solution

Published in Forbes on October 13, 2011. Read the article here or below.

Last Tuesday, researchers announced that an experimental malaria vaccine called RTS,S may help reduce the risk of malaria by half. The results – which are preliminary, as the researchers have only analyzed 40% of the study’s 15,000 participants so far – are based on a study being conducted across seven countries in sub-Saharan Africa, which accounts for 90% of worldwide malaria deaths.

RTS,S is being developed jointly by GlaxoSmithKline and the PATH Malaria Vaccine Initiative, a program funded by the Bill and Melinda Gates Foundation. When the study’s preliminary results were announced last week, Bill Gates lauded the research team and said, “A vaccine is the simplest, most cost-effective way to save lives.”

Seth Berkley, CEO of the GAVI Alliance, echoed this sentiment in a recent Huffington Post op-ed. Titled, “Vaccines: The biggest bang for the buck in global health,” Berkley wrote that vaccines offer enormous return on investment because they “cut healthcare and treatment costs, reduce the number of hospital visits, and ensure healthier children, families and communities.” Given their ability to “yield real results,” he encouraged the US to allocate more of its foreign aid to vaccines.

To an extent, Gates and Berkley are right: prevention is generally cheaper than treatment, and among prevention methods, vaccines can be quite cost-effective. Lois Privor-Dumm, the Director of Alliances and Information at Johns Hopkins’ International Vaccine Access Center, also believes that more generally, preventing disease is the right thing to do. “It gives people a better quality of life,” she said, “and it allows [the country’s hospitals] to treat people who really need it.”

If vaccines are so cost-effective and so important for society, why do 20 million children still not get the immunizations they need?

In his op-ed, Berkley pointed primarily to a lack of funding for vaccines. More money, he said, would result in a “transformation in child health and survival.” This is not, however, the whole story. Additional funding would certainly help close the immunization gap, but it would not eliminate it. Even if vaccines were free, there would still be significant obstacles preventing them from being universally accessible.

First, the cost of a vaccine may not reflect its true price to a consumer. Shipping vaccines can be expensive, and many countries pose import duties and taxes on medical supplies. Some vaccines need to be refrigerated, which makes transportation even more expensive, especially in developing countries with limited electricity and cold chain infrastructure.

There are also many indirect costs associated with getting people vaccinated. Patients have to pay, both in money and time, to go to clinics whose hours of operation may not be convenient for them. This is particularly problematic for vaccines that require multiple rounds, including RTS,S. Patients can take the time to go to a clinic once, but it may be difficult to prioritize going on a regular basis.

Compounded to these are non-monetary bottlenecks to getting people vaccinated. Medical professionals are pitifully few and far between in rural areas, and each one can only see a certain number of patients a day. Some communities may have to build demand for vaccinations through time-consuming public awareness campaigns. And regardless of vaccine availability or intention, there will always be some parents who either procrastinate or simply forget to take their children to the doctor.

Surmounting these obstacles may seem daunting, especially since many are indicative of broader failures in countries’ health systems. Luckily, many can be overcome with sustained action and a bit of creativity – and in the case of vaccines, several groups are looking to do just this.

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Can the private sector drive meaningful social progress? The case of Global Handwashing Day

Published in Forbes on October 13, 2011.  Read the article here or below.

This Saturday afternoon, 100,000 Peruvian schoolchildren will collectively attempt to break a world record previously held by Bangladesh. In 25 regions of the country, in large cities and small towns alike, they will line up in their school courtyards and wait for a signal. As soon as someone yells, “En sus marcas, listos, fuera!” all 100,000 children will begin to wash their hands.

This event is one of thousands that will occur as part of Global Handwashing Day (GHD). Celebrated annually on October 15, GHD intends to educate the world about the importance of handwashing and encourage people to make it a habit. Last year, 200 million people and 700,000 schools are estimated to have participated in handwashing events around the world, in countries as diverse as Kenya, Japan, and Tajikistan.

Perhaps surprisingly, handwashing plays a vital – and often overlooked – role in disease prevention. Studies have found handwashing to cut risk of diseases like diarrhea and pneumonia by half, which otherwise kill a combined two million children a year. Soap is easy to find and affordable for most households. The real challenge is convincing people to use it on a daily basis.

Global Handwashing Day is an important effort in promoting that simple behavior change. It began in 2008 under the auspices of a public-private partnership for handwashing (PPPHW). Myriam Sidibe, Unilever-Lifebuoy’s Global Social Mission Director and co-founder of GHD, said the team essentially wanted to create a day with lots of press and a big global profile. “Having a dedicated day,” she explained, “really helps you talk about an issue and increase its visibility.”

The fascinating thing about Global Handwashing Day is the degree to which the private sector is involved. Sidibe was part of the team that created Global Handwashing Day, and other consumer goods companies, including Proctor & Gamble and Colgate-Palmolive, came on board soon afterward. “We worked hand in hand [with NGOs and multilateral organizations] for months,” said Sidibe. “We had conference calls every week. We designed the logo, picked the day, everything.”

The private sector seems to add tremendous value to this particular advocacy effort. Katie Carroll, Secretariat Coordinator of the PPPHW, said, “In the case of handwashing, the private sector brings scale, market access, and amazing marketing know-how. Donors also can’t match private sector ability to work on behavior change. Having that is really helpful to the rest of the organizations.”

The consumer goods companies’ engagement with social advocacy is a clear example of what Michael Porter and Mark Kramer deem “creating shared value.” In a recent article in the Harvard Business Review, the authors discuss how businesses and governments have for decades created false dichotomies between economic efficiency and social progress. They contend that to remain competitive, sophisticated business leaders must reconnect economic success and societal benefits. Specifically, they must consider the latter to be “not on the margin of what companies do but at the center.”

How widely applicable is this concept? Is it feasible for businesses to promote social progress as strongly as, say, Unilever has promoted handwashing?

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Can text messages be used to improve health outcomes?

Published in Forbes on October 7, 2011.  Read the article here or below.

Imagine you are trying to quit smoking. In the process, you receive a text message saying, “This is it! – QUIT DAY, throw away all your fags [cigarettes]. TODAY is the start of being QUIT forever, you can do it!” Would that text message increase the likelihood of you quitting?

Researchers in the UK believe that such text messages may in fact double the likelihood of smokers quitting. The team randomly divided 6,000 smokers into two groups, one that received intervention texts (such as the one above) and another that received texts unrelated to smoking (e.g., “Thanks for taking part!”). They periodically messaged study participants for six months, and at the end of the period, biochemically verified whether or not the participants had stopped smoking.

To the delight of mobile health proponents around the world, the researchers found that nearly 11% of smokers in the intervention group quit smoking, as compared to 5% of those in the control group. They published their findings in the Lancet this summer.

This study is part of a growing trend towards using mobile phones as platforms to encourage healthy behaviors. With over five billion mobile phone connections worldwide, it is not surprising that the public health community is looking to use them to improve health outcomes. Proponents have even created a catchy term, “mHealth,” to encompass all medical practices supported by mobile devices.

“This is the most excited I’ve seen the medical community get for the last ten years,” said Dr. Kevin Clauson, Director of the Center for Consumer Health Informatics Research, where he conducts mHealth research. “Some people think there’s too much hype around mobile health, but I won’t do anything to quell people’s enthusiasm.”

Within mHealth, text messaging seems to offer some inherent advantages. It is relatively cheap (in the US, texts cost 2-10 cents apiece, and unlimited plans make them even cheaper), fairly ubiquitous (most simple analog phones offer texting services), and allows healthcare professionals to connect with users on an ongoing basis. Texts can also be used in a variety of ways. In addition to sending motivational anti-smoking messages, they can be used to remind people to take their medicine, schedule regular doctor appointments, and check for certain abnormalities.

Dr. Thomas Brennan, who researches mobile health applications at the University of Oxford, believes text messaging is especially useful for chronic diseases. “Conditions like hypertension, diabetes, asthma, obesity, smoking – they all have to do with changing individual behavior over time. SMSes are probably the most useful way of engaging with [patients with these conditions].”

As with any technological innovation, however, there are several kinks to be ironed out before healthcare providers start sending text messages en masse. These kinks can be divided into two categories: the operational challenges and the broader business challenges.

From an operational standpoint, there is a very real risk of health text messages eventually being considered spam. Brennan believes this risk is greatest if the messages are not personalized. “If they’re just coming out of the cloud,” Brennan said, “I think they’ll have a limited impact.” To his point, he mentioned the recent creation of an SMS anti-spam system.

To counter this risk, health blogger Andre Blackman thinks health text message systems must operate with an “opt-in” approach and be very transparent with the user. This includes informing people of how often they will receive text messages and giving them an easy way to opt out if they wish.

Another operational consideration is the look and feel of the texting systems. Researchers hypothesize that text message systems work better if they are interactive rather than one-way – meaning that users should be able to ask questions and receive more targeted health information if desired. To that end, Dr. Clauson’s team is currently conducting a study to monitor the differences in diabetes outcomes with uni-directional and bi-directional texting.

Aside from nitty-gritty operational issues, there are larger questions to be addressed on sustainable business models. The cost of sending an individual text message is low, as mentioned above, but it adds up over time and over large populations. Who should bear this burden?

Brennan believes there is scope for health insurance systems to pay for texting plans, especially if researchers can prove that they improve treatment adherence or decrease the likelihood of risky behavior. If they can further demonstrate that text messages reduce complications that would otherwise result in large hospital bills, he believes this would be a “no-brainer” for many insurance companies. Unfortunately, he admits, the proof of concept may be difficult.

There may also be some private sector interest in funding these kinds of programs. Text4baby, a free text message service for pregnant women in the US, is co-sponsored by Johnson & Johnson.  Considering that Johnson & Johnson sells countless products for infants, they have a vested interest in gaining favor with the recipients of the text messages.  As such, they may consider texting services part of their marketing plans. Manufacturers of smoking cessation aids and insulin monitoring devices may have similar mindsets.

However, Clauson warns, since Text4baby was the first program of its kind, it became a “great PR opportunity for everyone involved.” He isn’t sure other texting programs would receive such immense corporate support.

Importantly, neither the operational issues nor the business model questions are insurmountable. With the right backing, and with the right systems in place, health text messaging holds great promise for chronic disease patients around the world.