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Archive for the ‘Public health’ Category

Published in the Guardian on August 15, 2012 .  Read the full article here.  An excerpt is pasted below.

Men travel up to four hours by bike to get circumcised in Zambia’s Central province. Zambia has become increasingly active in fighting HIV. Photo credit: Sarika Bansal

In Zambia‘s Central province, men have started cycling long distances to undergo a traditionally stigmatised procedure: circumcision. According to Fred Mbewe, who performs circumcisions at Nangoma Mission hospital, men bear the pain – both from the surgery and the bumpy bike ride the following day – to protect themselves against HIV.

Zambia has become active in fighting HIV, largely because of the toll the disease has taken on the country, which has the sixth highest infection rate in the world, at 13.5%. It is estimated 200 Zambians become infected with the virus every day.

In addition to distributing condoms and sterile needles to prevent transmission, experts are turning to male circumcision as an HIV prevention strategy. According to some – though, importantly, not all – scientific studies, male circumcision can reduce female to male transmission by up to 60%. This means that the risk of a man contracting the disease from an HIV-positive woman decreases by more than half if he is circumcised. The procedure is relatively inexpensive, which is attractive for donors.

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Published in the New York Times on August 8, 2012 .  Read the full article here.  An excerpt is pasted below.

A two-year-old girl with a third degree burn at Kalomo District Hospital in the Southern Province of Zambia; she would have to travel more than 25 miles for her surgery. Photo credit: Sarika Bansal

LIVINGSTONE, Zambia

Late one June afternoon, Angela Chibwe was heading home on a bus on this city’s main road when she noticed an elephant on the side of the road.  This would not have normally been cause for alarm, as elephants are a common sight here.  This one, however, behaved unusually: it charged at the bus and caused it to flip upside down.

Several hours later, Angela woke up in Livingstone General Hospital.  She was the only passenger who had been badly injured.  Both of her legs were broken, and a piece of metal had cut through her forehead and left eye.  The hospital’s surgeon had been able to restore sight in her eye, though it would unfortunately remain disfigured.  When I met her, three weeks after the accident, she seemed to be in pain but grateful to be alive.

Angela was perhaps luckier than she realized.  If the accident had occurred in a distant rural area instead of the city of Livingstone, which has more than 130,000 people and a relatively sophisticated medical system, she may not have woken up in a hospital.  She may not have gotten the surgery required to restore vision in her left eye.  She may have been permanently disabled, or worse.

Across Africa, countless people die or become disabled because they cannot obtain necessary surgeries.  It is conservatively estimated that 56 million people in sub-Saharan Africa — over twice the number living with H.I.V./AIDS — need a surgery today.  Some need cesarean sections or hernia repairs, while others require cataract surgery or treatment for physical trauma.

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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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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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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.

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Published in Forbes on September 28, 2011.  Read here or below.

A small group of enthusiastic gamers on a site called Foldit recently solved the structure of a protein found in an AIDS-like monkey virus. The structure had stumped scientists for over a decade; the gamers, incredibly, cracked it in less than three weeks.

Despite using advanced crystallography technology, scientists at the University of Washington kept encountering roadblocks while trying to discern the protein’s structure. This led them, in a self-proclaimed “last ditch effort”, to begin an online protein folding competition. They offered several potential molecular structures on Foldit’s 3-D interface, and then asked players to tweak them so that, just as in real life, they emitted the lowest possible energy. Within days, a group called The Contenders submitted an answer that fit the X-ray data almost perfectly. The scientists, in an article in Nature last week,proclaimed that this was “the first instance that we are aware of in which online gamers solved a longstanding scientific problem.”

This development has huge implications for the future of crowdsourcing, or of using large groups to perform tasks typically done by individuals. In this case, gamers applied critical reasoning and spatial intelligence to a problem traditionally dominated by subject matter experts. Seth Cooper, lead designer and developer of Foldit, said in an interview on MSNBC that the players’ lack of biochemistry backgrounds may have actually worked to their advantage. Unaware of traditional rules governing biochemistry, Foldit players were able “to be really creative and come up with a lot of different interesting solutions.”

Scientists may even be able to study the gamers’ unconventional folding techniques to improve existing crystallography software. Bradford Graves, a protein crystallographer at the pharmaceutical company Hoffmann-La Roche, believes this is at least as important a contribution gamers can make to science.

Before scientists start opening a suite of unsolved mysteries to gamers, however, there are several issues to keep in mind.

First and foremost, we must consider the value being generated through these crowdsourced molecules, and how that will eventually translate in monetary terms. Who owns the intellectual property on a collaborative, crowdsourced protein structure? Ben Sawyer, co-director of theSerious Games Initiative, warns that in the worst-case scenario, these puzzles could be “exploitative” to gamers who do not fully understand the financial value of their discoveries. This question will prove especially relevant in cases where a pharmaceutical drug is developed from a Foldit discovery (that is unlikely to be the case with the AIDS-like protein). Sawyer advises both Foldit and the scientific community to think carefully about what an optimal risk-reward ratio would look like.

We should also determine the audience for which a crowdsourced protein structure would be valuable. Many scientific groups, particularly in the pharmaceutical industry but also at the university level, tend to keep their work secretive. Sawyer asks, “How do you get people to solve [protein structures] without having your competitors also see it?” In such instances, open-source software could actually prove counter-productive. Bradford Graves contends that in addition to the secrecy issue, the pharmaceutical industry may see limited value because “the structure may not get you anything in and of itself; it’s what you do with it that really counts.” Given this, Foldit may see limited application to institutions focused on basic science.

Finally, we do not yet know if this concept can scale. If we open countless scientific puzzles to the general public, Foldit will also need scientists at the back end to evaluate the answers that come in. The only way games like Foldit will work is if you have a dedicated team to parse out the good molecular structures from the bad. In an ideal scenario, the scientists should also be able to give gamers feedback, thereby educating them in the process. It is yet to be determined if Foldit can develop the capacity to do this.

These caveats aside, Foldit is in many ways a game-changing (pun intended) concept. It provides a platform for gamers to interact, and potentially solve, pressing issues in the real world. Game designer Jane McGonigal said in a 2010 TED talk that most games today are played to escape from “real world suffering,” from “everything that’s broken in the real environment.” Serious games like Foldit show us that a meaningful bridge can in fact be created between the online gaming world and the real one.

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Published in Forbes on September 22, 2011.  Read the post here or below.

Everyone reading this article has suffered from diarrhea at some point, but did you know that it kills nearly 4,000 children a day? The World Health Organization estimates that diarrhea – simple, annoying diarrhea – is the second leading cause of death in children under five, after pneumonia. It may even be responsible for taking more children’s lives than AIDS, malaria, and tuberculosis combined. Not surprisingly, nearly all diarrhea-related deaths occur in the developing world, and are especially prevalent in areas with endemic poverty and poor nutrition.

The perplexing thing about diarrheal disease is that unlike many other global health epidemics, cheap diarrhea treatments exist. Since the 1970s, the WHO has been recommending oral rehydration therapy (ORT) and continued feeding as the “gold standard” for treatment. It is very effective in helping children regain vital nutrients they lose during diarrhea, and crucially, it costs pennies. The medical journal The Lancet even once said ORT may “potentially [be] the most important medical advance of the twentieth century.” Other treatments for diarrhea, including zinc therapy and rotavirus vaccination, are also inexpensive and quite effective.

Given this, we must ask ourselves: why are 1.3 million children still dying of diarrhea every year?

I believe there are two primary reasons. First, diarrhea treatments have yet to reach everyone who needs them. In the case of ORT, only 39 percent of children with diarrhea actually receive it. Between stock-out problems in shops that sell the mixture, confusion of how and when to make the solution, andhealth workers’ mixed levels of adherence to treatment guidelines, there are several formidable barriers in getting this WHO recommended treatment to sick children.

Second, universal access to diarrhea treatment does not guarantee an end to the epidemic. Improving ORT availability is not a silver bullet; rather, stopping diarrheal deaths requires an integrated approach that addresses both treatment and prevention of disease. In this case, we must prevent children from contracting diarrhea by improving drinking water quality, hygiene standards, and childhood nutrition levels. Realistically, the epidemic will persist until and unless these broader social ills are addressed.

This does not mean, however, that markets should wait for issues like malnutrition to be “solved” before helping make treatments more readily available. While improving access to treatment will not result in an ultimate end to diarrhea, it is a vital piece of the puzzle. It is also probably the most tangible way the private sector can get involved.

Within the private sector, logistics and consumer goods companies can probably make the biggest difference to the epidemic, by helping streamline distribution of treatments to communities that need it. A recent study by Johns Hopkins University found that in sub-Saharan Africa, out-of-stock rates for ORS were as high as 38 percent – in contrast to consumer goods like mobile phone cards, which boast out-of-stock rates of 6 percent in the same geographies. Consumer goods and logistics companies could significantly help ORS manufacturers with improving their datasets, sharing knowledge of best practices, and even potentially sharing distribution infrastructure. The Johns Hopkins team believes such partnerships could be constructed not as donations or CSR activities but in ways that would benefit both parties.

Improving distribution logistics may seem like an odd and un-sexy way to stop a global health epidemic. When faced with a disease as un-sexy as diarrhea, however, it may be just what the doctor ordered.

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