An advisory panel for the U.S. Federal Drug Administration (F.D.A.) voted 19-3 to recommend the use of Truvada, a combination antiretroviral drug, for the prevention of HIV among people at high risk of infection. Although this is not a full F.D.A. approval, it paves the way for a decision in mid-June. The endorsement follows a groundbreaking study in 2010 that found a 44 percent reduction of infection risk among men who have sex with men who took Truvada and a 92 percent risk reduction of infection risk for those who took the pill every day (only about 10 percent of the men in the study adhered to the daily regimen). Reuters writes that the panel’s recommendation “has raised hopes that the United States could stem the growth of a national HIV epidemic that has stubbornly generated 50,000 new infection cases a year for the past two decades.”

The panel only endorsed the use of Truvada for the most at risk populations–men who have sex with men, serodiscordant couples (where one partner is positive and the other negative), and sex workers, for example. Doctors have already been prescribing Truvada for HIV prevention off-label, which is legal in the United States as long as a drug has been F.D.A.-approved. There are concerns, however, about the use of powerful antiretroviral drugs, the risk of drug-resistant strains due to non-adherence to the daily dose, and higher risk activities, such as forgoing condoms, if the drug is officially approved. The New York Times has more.

Arguments that people at risk of HIV infection will take bigger chances with their health if given a preventative measure is as nonsensical as arguing that teaching teens about condom use will lead to greater instances of pregnancy and sexually-transmitted infections: one study found that American teenagers who received comprehensive sex educations had a 50 percent lower risk of teen pregnancy than those who had abstinence-only education. Of course, cost is another issue–an annual course of preventative pills would cost about US$11,000-14,000–and the implications of driving up demand for such drugs when there are millions of people around the world without access to to Truvada and other ARVs to treat HIV, as Business Week points out. That’s on Gilead, the company that manufactures Truvada, and speaks to a larger problem about patents, generic drugs, and Big Pharma that I won’t get into today.

On the other hand, as the BBC notes, adherence could be a real challenge. As Karen Haughey, a nurse, told the advisory panel: “In my eight years, not one patient that I’ve cared for has been 100% adherent.” Although there is truth in her statement, it has been heard many times before, such as the argument that antiretrovirals should not be dispensed in sub-Saharan Africa: I doubt there are few people who make that assertion now. Drug resistance due to inability or choice of not adhering to complex regimens of expensive drugs with difficult side effects has been a challenging issue since the introduction of antiretroviral drugs, but it has not been the definitive experience of treating and managing HIV. Patients are not always going to take every single pill every day–for a wide variety of diseases or preventative therapies–but even without full adherence, there is a risk reduction. Education and support will be key to adherence (and to practicing safe sex).

Overall, the F.D.A.’s approval of Truvada as a prophylaxis against HIV infection would be just one more small victory in the fight against HIV/AIDS within the United States. Global prevention, diagnosis, and treatment of HIV/AIDS is a complex, multi-armed effort, and aggressive education programs, family and institutional support, behavioral and cultural change, better health clinics and health care workers, more and cheaper drugs, increased funding, and a host of other things will be needed to turn the tide. We’ve seen great progress in the last decade. This is not a panacea, but it is one step closer and one that the F.D.A. should take.

Header photo by Fillmore Photography, via Flickr, CC BY 2.0.

There were many factors that piled up on the plus side of the ledger, but most of the reasons grew out of tough choices that the Board made last year. A back-to-basics approach, focusing on the core business of managing grants, with common sense management, has created a situation where good things happen. Many of our friends noticed. Some got more generous. Others found they could speed up existing plans to make a donation. Still others jumped in for the first time.

Reuters reports that a portion of the new funding available comes from countries like China covering needs in their own country, releasing funds to be used elsewhere.

And, as reported by the WSJ, among donors delivering contributions earlier is the US, which has weathered the Global Fund storm with continued support.  The US is advancing $226 million to the Fund and continues to be the Fund’s largest contributor.

Now the question is, how will the new funds be used?  The Fund has stated that it will consult countries and partners to determine the allocation of the funding, so the decision will likely take some time.  Since the shake-up earlier this year, the Fund has halted new funding until 2014, so the option to bring that date forward is now on the table.

Perhaps we’ll know more today - Jaramillo was set to report to the Global Fund’s board yesterday.

According to IPPF, the resolution was adopted “late” on Friday, April 27, at the session in New York City. The CPD resolution affirms the right of young people to make their own decisions related to their reproductive health and sexuality free from violence and discrimination. It also calls for increased access to reproductive health services and comprehensive sex ed. RH Reality Check has a bit more on the implications of the resolution and the dissension in the room between pro-choice and anti-choice parties. Unsurprisingly, the wording on access to abortion is reportedly not very strong. Although this is only a statement in the right direction, the CPD’s action will spur further global discussion on one of the largest barriers to health facing adolescents today: comprehensive reproductive health education and services.

Reproductive health and sexuality are, of course, huge lightning rods in global discussions. Cultural differences abound, but cultural relativism is no excuse for the lack of access to services and education that will allow adolescents around the world to make decisions about their own bodies. Obviously, varying approaches will be required in different countries. Education on reproductive health and family planning is key to better maternal health outcomes for girls and women (and better infant health outcomes, of course) and could begin to change cultural norms about reproductive choice: If men (and women) around the world had a better understanding of the importance of adequate spacing between children or waiting to marry off their daughters until they are developed enough to handle pregnancy and birth, for example, we would see a dramatic decrease in maternal mortality. According to UNICEF, around 95 percent of adolescent births occur in low- and middle-income countries. The United States is the only industrialized country in the top ten highest numbers of adolescent births.  Whereas in the United States there is not generally a social push for teen pregnancies, in many low- and middle-income countries, this is not the case. Both of these figures illustrate the dire need for improved, widespread, and comprehensive education on reproductive health. The UN resolution is  small step in the right direction, but it will require buy-in from a number of countries, politicians, and religious figures who seem unwilling to put the health and happiness of young citizens first.

Header photo by vxla, via Flickr, CC BY 2.0.

There is no doubt that recent declines in global health funding will force programs and organizations to shut their doors.  But to reduce the lessons learned from the GHC closure to the global funding crisis would be a missed opportunity.

The organization has stated publicly that its closure is due to the fact that the global health agenda is now fragmented into single health issues.  On its website, it states that “Funding that once existed to promote a broad-based health agenda is now focused on specific health issues.”  However, some speculate that the GHC couldn’t survive the departure of its former CEO, Nils Daulaire, who was replaced by Jeffrey Sturchio in 2009.

My guess is that the closure is due to something much more simple: an unsustainable shift in its business, and specifically its revenue, model.

The GHC was founded with grants from the US government, but this practice shifted in the 90s when Daulaire became president.  Daulaire envisioned an organization that had a more independent voice and made efforts to diversify the funding base as a matter of principal.  However, this policy shifted yet again when Sturchio joined in 2009.  Jaclyn Schiff at Devex notes that the source of funding for the GHC had shifted dramatically from membership dues to donor funding (specifically the Gates Foundation) in recent years.  She also noted that Daulaire attributed the closure to a “loss of internal capacity”, specifically membership staff.

An organization which relies heavily on membership dues and caters to its members is a much different business model than an organization that relies on large foundation grants.  If, as Daulaire intimates, the staffing of the GHC shifted to reduce its membership staff, it is plausible that the focus on membership services declined simultaneously.  A heavy focus on funding from a few grantmakers would have created a revenue model much different than the one that sustained it through two decades.  When Gates made it clear that funding would not last beyond it’s 3-year mandate, the GHC could not pivot back to its original membership focus quickly enough.

Organizations must choose business models that fit with their missions.  A membership organization such as the GHC – whose mission was to be a “neutral convener and information source” for the global health community - could likely have been better able to shift to meet its members’ changing needs had it stayed loyal to its membership revenue model.

A series published in The Lancet last Wednesday found that adolescents today face greater risks to their physical and mental health than in the past.  The success of childhood survival programs and a greater focus on children’s health means that more youths are entering adolescence.  Although this is clearly outstanding news, it means that the programmatic and policy focus must broaden to include the specific challenges faced by adolescents.  The Lancet series argues “that it is now time to put the young person, not the specific issue, centre stage” and to elevate the “marginalised subspeciality” of adolescent health.

With the advent of globalization, youths are more likely to choose lifestyles that put them at greater risk for non-communicable diseases. Furthermore, risky behaviors, unprotected sex, alcohol and drugs, violence, mental illness, and traffic accidents remain major barriers to adolescent health and well-being.  UNICEF released a concurrent report card on adolescents that gives a global breakdown of adolescent health, education, and social norms.  As The Lancet pointed out, the “worst adolescent health profiles” come from the sub-Saharan Africa region.  In this region, diseases such as HIV and malaria, societal norms such as early marriages and pregnancies, and behaviors that can lead to non-communicable diseases have converged.  In fact, despite the hullabaloo in the American press about childhood and teen obesity (which is still a major issue), adolescents from low- and middle-income countries are the most likely to engage in behavior that puts them at risk for non-communicable diseases.  However, adolescents everywhere  need more support, and more must be done in the global health sector to prevent risky behavior, understand mental health vulnerabilities, and address harmful social norms at such a formative time in the lives of between one and two billion people.

Adolescence is a tumultuous time.  Between childhood and adolescence, teens around the world are asked to take on greater responsibilities, often before they’re ready mentally or physically.  For example, more than one in 10 girls in developing countries is married before she is 15.  Neuropsychiatric disorders (including substance abuse) and unintentional injuries are the leading causes of disability among teenagers.  Social pressure from parents and the community and from peers can lead to risky choices.  Overall, adolescence tends to set the stage for life: smoking, diet, mental health, education, exercise, pregnancy, STIs, and so on, will all dictate good health and well-being in the future, and furthermore, how a person will be able to engage with and contribute to society.  We’ve made great strides to ensure that children are growing up to be teenagers. Although we should not lose our focus on child survival, we must broaden our vision to include adolescents so that we can also ensure that those teenagers grow up to be adults.

Header photo of a teen grilling corn in Côte d’Ivoire.  By the Gates Foundation, via Flickr, CC BY-NC-ND 2.0.

A report released last month discussed the rising profile of BRICS countries–Brazil, Russia, India, China, and South Africa–in health and development assistance and called upon the group to further their cooperation for better global health in the developing world.  ”Shifting Paradigm: How the BRICS are Shaping Global Health and Development” (PDF), written by the NGO Global Health Strategies Initiative (GHSi) to coincide with the 2012 BRICS Summit in India, found that BRICS have vastly expanded their foreign assistance spending, their aid budget growth (though not dollar amounts) outstripping G7 countries by ten percent over the past five years.  With rapidly growing economies as well as the experience of major public health issues of their own, BRICS are in a unique position to influence the global health landscape–if they can band together.

Emerging economies Brazil, Russia, India, and China founded BRIC in 2006 at the United Nations General Assembly meeting and added South Africa in 2011, indicating the country’s prominence on the African continent despite its much lower gross domestic product (GDP).  The World Bank ranks four of the five BRICS countries in the top 15 world economies, with China at number two, Brazil at seven, India at nine, Russia at 11, and South Africa at 28 as of 2010.  According to the BRICS (PDF), they account for 40 percent of the world’s population and grew from contributing to 16 percent of the global GDP in 2000 to 25 percent in 2010.

BRICS’ global economic, political, and policy clout should be nearly boundless.  As a recent New York Times article points out, however, “the new BRIC[S] era has yet to arrive,” as country-specific agendas and rivalries have prevented the alliance from realizing its potential.  The article describes China’s outsize influence in BRICS, Indian-Chinese tensions, and differences of opinion on geopolitical issues and modes of government as hindering factors.  Despite their divergences, however, BRICS are a strong voice for a shift away from the West’s dominance in international economic, political, and development strategies.

GHSi’s report is a clear call for BRICS to step up their role in the global health and development agendas.  The United States and European Union have shrunk their global health budgets, opening a gap that desperately needs to be filled.  BRICS’ focus on South-South collaboration and their valuable experiences with development and global health within their own borders could shift the way in which aid is distributed and global health and development challenges are met in a good way.  As the GHSi report writes, this “equips them with unique perspective [sic] on improving health outcomes in developing countries.”  The report profiles the five countries and their contributions to global health, from India’s robust pharmaceutical manufacturing sector, which has provided low-cost drugs and vaccines to much of the developing world, to South Africa’s emerging TB diagnostics research, to Brazil’s groundbreaking commitment in 1996 to free, universal access to antiretroviral drugs for people living with HIV.  The report indicates that BRICS are a “potentially transformative source of new resources and innovation for global health and development” and argues that the alliance must increase its coordination and cooperation to transform the global health environment.

The BRICS Summit came and went, and the resulting Delhi Declaration was just a step above toothless.  The summit was punctuated by anti-China, pro-Tibet protests and the Indian government’s crackdown on dissent, as FPA blogger David J. Karl detailed, which does little to assuage concerns about China’s dominance of BRICS.  The declaration also mentioned India’s pet project, a BRICS Development Bank (which FPA blogger Richard Basas discusses here), although it indicates no concrete actions beyond convening BRICS’ finance ministers.  The forty-second point of the declaration directed BRICS country health ministers to continue meeting on global health strategies, which is heartening in that health was mentioned at all.  A good portion of the rhetoric in the declaration focused on criticizing Western countries’ economic models and political stances toward existing and potential conflicts in the Middle East.  Although much of this had just cause, it cemented the opinion that BRICS is a “photo op” for “the idea that the West is no longer or should no longer be viewed as the only center of gravity,” as MIT Professor of global economics and management Yasheng Huang told the New York Times in the article linked above.

BRICS represents the enormous potential of emerging economies to change the current geopolitical landscape, especially in the realm of global health.  As countries that once relied on aid and that have faced, though not surmounted, complex and damaging public health problems, BRICS can and should shape the development agenda, informed by their experiences.  Unfortunately, cooperation and coordination among BRICS countries is still sparse, and the danger of putting self-interest before the greater good is omnipresent.  Isobel Coleman of the Council on Foreign Relations points out that most of BRICS’ aid “is tied to specific business outcomes–such as access to natural resources for the donor country, or contracts for donor-country companies,” with a focus on what BRICS as donors can extract from developing countries.  In this light, health will naturally take a back seat to infrastructural and economic investments, even though good health is central to economic and political development.  Furthermore, countries like China have proved time and again that they will put profits over people and the environment almost every time.  It would be a shame to have the pro-business, short-sighted policies of Western donor governments replaced by the pro-business, short-sighted policies of BRICS and emerging economies.  It is accepted fact that BRICS will influence the global agenda going forward.  It remains to be seen whether they will also commit to supporting developing countries in their own struggles for greater economic development and improved public health.

Header photo: BRICS heads of state at the 2012  Summit in New Delhi.  From left to right, President Dilma Rousseff of Brazil, President Dmitry Medvedev of Russia, Prime Minister Manmohan Singh of India, President Hu Jintao of China, and President Jacob Zuma of South Africa.  Photo by Roberto Stuckert Filho – Presidency of the Republic of Brazil (Agência Brasil).  Via Wikimedia Commons, CC BY 3.0.

At a TEDxChange webcast event last week, Melinda Gates announced that she would dedicate the next 30 years of her life to advocate for and support family planning.  Asserting that birth control should not be a controversial issue, Gates discussed the implications of the dearth of family planning programs and services in the developing world–particularly sub-Saharan Africa and parts of Southeast Asia.  Without access to or an acceptance of modern contraceptives and family planning services, rates of maternal and child mortality and poverty are higher and education levels are lower.  Beyond hundreds of thousands of needless deaths–Gates put the number of women dying in childbirth from unwanted pregnancies at 100,000 and babies in the first year of life at 600,000–there are long-lasting development repercussions to inadequate family planning.  Gates pointed out the discrepancies in contraceptive use globally, saying: “A billion people use birth control without hesitation…But for an idea that is broadly accepted in private, birth control generates a lot of opposition in public…As a result, birth control has almost disappeared from the global health agenda. The victims of this paralysis are the people of sub-Saharan Africa and the poorest parts of South Asia.”

 Led by U.S. right-wing political pressure that has resulted in development funding policies like the Global Gag Rule and the evisceration of health budgets, funders have soured on family planning programs.  Gates took these funders to task (gently) at an event that obliquely confronted the United States and its power in shaping the global agenda.  Gates insisted on the common sense of family planning services and deplored the conflation of family planning and contraception with abortion, saying: “We need to be clear about our agenda. It is not abortion. It is not population control. We are talking about giving women the power to save their own lives and their children’s lives—and to give their families the best possible future.”  Of course, safe and legal abortion services should also be available globally, but given the vitriol in the United States and elsewhere around abortion, this was a savvy move on Gates’s part.  Her speech came across as a measured, prudent argument for universal access to family planning and birth control.  With the surfeit of mud-slinging inaccuracies (if not outright deceptions) around family planning in the political sphere, it is a welcome change to hear a powerful voice lent to a woefully neglected cause.

You can watch Melinda Gates’s talk here, or below:

Header photo of Melinda Gates at TEDx. By Gates Foundation, via Flickr, CC BY-NC-ND 2.0.

The big shake-up has shifted the vast majority of the jobs (61%) into grant management, a direct response to the findings of the financial audits last year that revealed fraud amongst grant recipients.  An additional 14% will be focused on Strategy, Investment and Impact (SIID) and the remaining 25% will be focused on support, resource mobilisation and control.

The Fund has published a presentation on its website that outlines the key priorities of the transformation.  The presentation outlines three “workstreams” that will be the focus of 2012, including (1) organizing to deliver; (2) quality and timeliness in proposal development and grantmaking; and (3) simplification of in-country monitoring of grants and risk.  (Clearly Jaramillo has got his management consultants working overtime :))

The new Secretariat structure looks like this:

Resource Mobilisation and Donor Relations is headed up by Christoph Benn, an MD with specialist training in tropical medicine; Grant Management by Mark Edington, a relative newcomer to the Fund who joined earlier last year from Save the Children; and SIID by Debrework Zewdie, a former World Bank-er with a doctorate in immunology.

Why is all of this so important?  After an age of largesse in global health funding, the financial crisis has caused funding increases to come to a screaching halt.  EU sources have all but dried up, the new US budget proposal signals a decrease in PEPFAR (long the largest source of HIV/AIDS funding globally) and private foundations are following suit.  Despite commitments that far outstretch current revenues, the Global Fund is still the most viable multilateral providing funding for global health.  National governments have signalled their hope in the Fund by re-upping their commitments.  Significantly, Obama’s new budget calls for an increase to Global Fund contributions (but a decrease in PEPFAR).

Global health has long been the poster child for success in development funding.  Slowing down the pace of progress at this critical juncture will have implications that reverberate far beyond the realm of current programs.

Earlier this year, the global health community watched with bated breath as The Global Fund to Fight AIDS, Tuberculosis and Malaria stood at a precipice.

The chain of events was like a series of dominoes falling.  Earlier, in October 2011, cash-strapped donor countries with austerity budgets said “no” when the Fund asked for $20 billion in replenishment funding.  Faced with commitments far outstretching reserves, the Fund cancelled any further grantmaking until 2014.  Poor country governments with looming treatment budgets and minimal health budgets howled while NGOs serving patients made pleas supported by scary statistics.  Meanwhile, audits of the Fund turned up significant issues of fraud.

But the Fund wasn’t just facing a financial crisis; it was caught up in election year politics as well (read Laurie Garrett’s account).  Both French and US electoral politics put Executive Director Michel Kazatchkine in a bind: to consent to restructuring meant admitting the failings of the past (which French president, Nicolas Sarkozy, did not want), but was placing the future of the Fund in great peril (as US Secretary of State, Hillary Clinton, spoke out against).  Kazatchkine, unable to stem the tide, submitted his resignation letter.  The Fund, long-lauded as a rare success story in the search for the holy grail of multilateral funding, seemed doomed.

In recent weeks, however, the global community has rallied, confirming that the Global Fund is indeed “too big to fail”.  Bill Gates put up a “promissory note” for $750 million and donor countries set about putting conditions on future funding.  Most recently, a new General Manager, Gabriel Jaramillo, has taken Kazatchkine’s place – and, as a sign of the times – he is a former banker with 35 years of experience in the finance industry (Kazatchkine is a medical doctor).

In his most recent interview with El Mundo, Jaramillo outlines his mandate as having three objectives: (1) improving the management processes of the Fund to be rigorous and disciplined; (2) ensuring that the Fund is focused on programs that have a high return on investment; and (3) raising funds from “traditional” countries as well as new countries who have “graduated”.

According to Jaramillo, for the fund to lose momentumm is “not an option.  The Fund is too important to let that happen.”

Over the next few weeks, I’ll be taking a close look at the change in leadership at the Global Fund and the implications for global health funding generally.  The changes at the Global Fund are reflective of a seachange in global health funding, both politically and philosophically.  For practitioners in the field of global health, this shift is critical; for citizens in a global world, the shift will impact generations.

A few weeks ago, the Sabin Vaccine Institute, in collaboration with the Pan American Health Organization (PAHO), Johns Hopkins’ International Vaccine Access Center (IVAC), and the CDC, announced the preliminary findings from a study on meningococcal meningitis in the Latin American-Caribbean region (LAC).   The study examines the prevalence of the disease and the cost of prevention and of controlling outbreaks in the LAC region.  The Executive Vice President of the Sabin Vaccine Institute, Ciro de Quadros, M.D., M.P.H., revealed the findings at the Regional Meningococcal Symposium in Buenos Aires at the end of last month.  The symposium was convened by the Sabin Vaccine Institute and PAHO.  Last week, Dr. de Quadros answered my questions about meningococcal meningitis and the implications of the Sabin study.

 Q: Although incidence rates vary around the world, meningococcal meningitis can be found almost anywhere, from the U.S. and Europe to South America, Asia, and sub-Saharan Africa.  Why does this disease receive so little attention from the public, governments, and even the medical/scientific community?

U.S. Funding for Neglected Tropical Diseases May Decrease

This week, the Regional Executive Director-North America for the Drugs for Neglected Diseases Initiative (DNDi), Rachel Cohen, made an impassioned case for more funding for neglected tropical diseases from the U.S. government.  President Obama’s budget request for 2013 cuts nearly 25% from USAID’s Neglected Tropical Diseases (NTD) Program, lowering funding from $89 million this year to $67 million.  Ms. Cohen charges that “this isn’t trimming the fat–it’s cutting into muscle” and that the decreased funding “will have direct consequences in terms of lives lost.”  She argues that the NTD Program should be given a budget of $100 million: the amount that President Obama initially requested (and was denied) for 2012.  Ms. Cohen also points out that unlike for other “disease-specific programs,” the NTD Program does not fund research for new drugs, diagnostics, and other treatment tools.  Furthermore the USAID program only focuses on five of the 17 WHO-identified NTDs and excludes three of the most fatal: Chagas disease, sleeping sickness, and visceral leishmaniasis (more on NTDs here).

Appearing before the House Subcommittee on State, Foreign Operations and Related Programs (within the House Appropriations Committee), Dr. Raj Shah, the USAID Administrator, testified that the Obama administration budget request “enables USAID to meet the development challenges of our time…[and] allows us to transform the way we do development.”  Using language that fits into the efficiency/country ownership/tightened belts themes that we’ve seen from donors recently, Dr. Shah specifically pointed to the NTD Program in his testimony without indicating that the request would slash its budget by a quarter.  Unfortunately, President Obama probably has little wiggle room, given the current American political climate, but Ms. Cohen is right: it’s time to take the “neglected” out of NTDs.  One in six people on the planet has one.  Without investment in research, prevention, treatment, and the development of new tools to fight NTDs, a billion people will continue to suffer from diseases that sap energy and cause disability and death.

Life in a Serodiscordant Relationship

Freelance writer John Fram wrote an article for The Atlantic this month that gives an unflinching, personal account of being half of a serodiscordant couple in the US: while Mr. Fram is negative, his partner is living with HIV.  He writes of navigating the American health care system, including long waits for doctor’s visits, applying for welfare benefits, unresponsive social workers, and filling prescriptions for anti-retrovirals.  Mr. Fram mentions brief feelings of stigma and discrimination, such as when Texan pharmacists seem to shy away: “I still can’t tell if the techs’ (and even some of the pharmacists’) apprehension in talking to us is based on busyness or a fear of getting something on them.”  Overall, however, Mr. Fram depicts caring, supportive, no-nonsense health and social workers.  He’s open about the difficulties and logistics of being in a serodiscordant relationship and the worry (and lack of worry) that comes with being at risk for infection and with caring for someone with an illness that is, luckily, becoming increasingly a chronic, as opposed to fatal, condition.   Studies released in 2011 found that HIV-negative people who took antiretroviral prophylaxis reduced their risk of infection by up to 73%, and even more strikingly, that people living with HIV who adhered to their antiretroviral therapy dropped the risk of infecting a negative partner by 96%.  This has led to calls in the HIV/AIDS sector to see treatment as prevention, but such findings also have obvious implications for people in monogamous, serodiscordant relationships.  Mr. Fram’s story of serodiscordancy is only one of many, but he gives a glimpse into the experiences of people living with HIV and those of their partners and families.  It’s well worth a read.

Malaria Prevention Efforts May Save Millions

A study published this week found that the “unprecedented effort” to prevent and curb malaria over the last decade has saved the lives of 843,000 children in 43 countries in sub-Saharan Africa (full study here, as a PDF).  Since 2000, there has been an 8.2% decrease in child deaths due to malaria, with the greatest reduction in 2010, which saw a 24.4% decrease in mortality.  The authors argued that the mass influx of insecticide-treated nets in sub-Saharan Africa “has clearly been a sound investment in health.” Between 2006 and 2009, $1.3 billion was spent on bed nets.  The authors acknowledged that their estimates were conservative, since they only examined the effects of distributing insecticide-treated nets and preventative interventions among pregnant women.  Due to lack of accurate data, they chose not to analyze the impact of effective anti-malarial artemisinin combination drugs, which are now widely available in sub-Saharan Africa and are the first-line treatment in most malaria-endemic countries.  Therefore, it’s very likely that many more children (not to mention adults) have been saved by malaria control programs.  Despite this conservative analysis, increased malaria control efforts have saved at least 230 children every day for the past ten years.  The study estimates that if universal coverage of insecticide-treated nets (i.e., every household with children or pregnant women in a malaria endemic zone has a bed net) is achieved by 2015, another 2.27 million children’s lives could be saved.  That sounds like an effort worth investing in.

New Global Fund Manager Speaks

The Global Fund’s new General Manager, Gabriel Jaramillo, spoke to Spanish newspaper El Mundo this week about the Fund (English translation provided by the Global Fund here, as a PDF).  He focused on the successes of the Global Fund and discussed the reorganization and future direction it would take under his leadership.  Mr. Jaramillo mentioned his banking credentials several times, explaining that having a financial expert at the helm would help increase efficiencies and mitigate risk.  He said: “The investments we make must yield very high returns and we can obtain those returns by using the right interventions, the newest and most effective drugs, and also methods that offer the best return of lives saved for the money invested.”  This language is very much in line with that of government and foundation donors, notably the U.S., which has changed during the global economic crisis to focus on the highest returns on smaller investments and the ability of programs to prove impact.  Mr. Jaramillo seemed sanguine about the controls and requirements put on the Global Fund by donor countries like France, Spain, and the U.S. since allegations of fraud in 2011.  Mr. Jaramillo also clarified that much of the alleged improprieties were rather about missing documentation and not necessarily embezzlement, though his commentary echoed that of Bill Gates, who said when announcing a $750 million “promissory note” to the Global Fund a few months ago  that “some losses” were the cost of doing business in the developing world.  Finally, Mr. Jaramillo argued that “it is difficult…to find investments that produce higher returns than those made in health.  There are no roads, airports or infrastructure capable of delivering greater benefits than the control of a disease in a region.”  Although I’ve disagreed with such a position in the past, Mr. Jaramillo is right.  When people are well, they are more able to work, go to school, and contribute to the economic, infrastructural, social, and political needs of a community, country, continent, or planet.  I’ll be keeping an eye on how Mr. Jaramillo fares in the next year: perhaps we’ll see some interesting changes in global health and aid.

Header photo of aedes aegypti mosquito by US Department of Agriculture, public domain, via Wikimedia Commons.

In the Rose Garden of the White House this morning, President Obama asserted: “Despite its name, the World Bank is more than just a bank.  It’s one of the most powerful tools we have to reduce poverty and raise standards of living in some of the poorest countries on the planet.”  These remarks are a clear argument for his unconventional choice.  President Obama also cited the focus on public health, particularly HIV/AIDS, in his administration’s development policies.  He explained that “the leader of the World Bank should have a deep understanding of the role development plays in the world and the importance of creating conditions where assistance is no longer needed,” going on to say: “healthy populations enable growth and prosperity.  And I’m pleased that Jim brings this particular expertise with him to his new job.”

The New York Times reported that Dr. Kim was “not among those bandied about” since the current president of the World Bank, Robert Zoellnick, announced his intention to step down on June 30 of this year.  Since the establishment of the World Bank and International Monetary Fund in 1944, a “gentlemen’s agreement” between the US and Europe has dictated that the former nominate the head of the World Bank and the latter the head of the IMF.  Unsurprisingly, this has come under fire from the developing world, especially from emerging economies, who want a fairer process.  Angola, South Africa, and Nigeria have officially nominated Ngozi Okonjo-Iweala to head the World Bank.  She is the Nigerian finance minister and a former World Bank managing director.  Former Colombian finance minister and UN official José Antonio Ocampo has also been suggested for the job.  Jeffrey Sachs, development economist, nominated himself this month but has since withdrawn, putting his support behind Dr. Kim.  Yesterday, The New Yorker’s John Cassidy discussed the possible selection of economist and former Obama advisor Lawrence Summers, whom he wrote would be a difficult but conservative choice.  Cassidy also pointed to US Ambassador to the United Nations Susan Rice and PepsiCo CEO Indyra Nooyi as contenders.

Cassidy’s analysis crystallizes many of the reasons why President Obama would make an unorthodox choice in Dr. Kim over, for example, the more economically-experienced Summers, who is tied to Wall Street and traditional centers of financial and political power, close to the Obama administration, and a strong believer “that the United States has much to teach the world.”  In contrast, Dr. Kim is firmly planted within the global health and development communities, which have been critics of the World Bank and IMF policies in the past, and has ties to and experience in the developing world.  He’s an outsider.  All of this could bolster him in the face of mounting pressure from other nations to appoint  someone who is not American to the World Bank.  PIH, predictably, was overjoyed with the selection.  Co-Founder Paul Farmer said: “I can think of no one more able to help families, communities, and entire nations break out of poverty, which is the stated goal of the World Bank.”  His sentiments were echoed by former US President Bill Clinton and current Rwandan President Paul Kagame.  Not everyone, however, is happy with President Obama’s move.  As Susan Adams of Forbes reported, Harvard Professor Lant Pritchett called the nomination “an embarrassment to the US,” charging that Dr. Kim “has no experience in banking, policy making, economics or development.”  Pritchett held up Ms. Ojonko-Iweala or “colleague and friend” Lawrence Summers as more appropriate choices, arguing: “Development is about countries becoming prosperous, democratic and capable, like being able to deliver the mail, having police forces that work and kids who get educated.  Charity work is helping people cope with the fact that they live in places where they don’t have those things.”  Pritchett also said: “I wouldn’t nominate Mother Teresa to head the World Bank if she were still alive.”

Although Pritchett’s words are a bit intemperate, he does have a point: Dr. Kim is not the traditional choice to lead the World Bank.  In my opinion, that’s a good thing for developing nations and for global health.  As a co-founder of PIH, Dr. Kim helped forward the notion that the poor not only deserve but have a right to the highest standards of health care and treatment (see PIH’s vision here).  At the WHO he oversaw the 3×5 initiative, which sought to put 3 million people living with HIV on antiretroviral treatment by 2005, and at PIH, he contributed to the development of a treatment program for multi-drug resistant tuberculosis and fought successfully to lower the cost of TB drugs (see this Wall Street Journal article).  During his time at Harvard Medical School as chair of the global health and social medicine department, he co-founded the Global Health Delivery Project, which works to improve health care and systems in the developing world.  While Dartmouth’s president, he remained committed to global health issues, galvanizing the student body to raise $1 million following the earthquake in Haiti, among other actions.  Jena McGregor of The Washington Post pointed out that if confirmed by the World Bank’s Board of Executive Directors, Dr. Kim would be the first World Bank president in history “who has devoted his career to helping the poor.”  President Obama stated this morning that “it’s time for a development professional to lead the world’s largest development agency,” and I could not agree more.  The World Bank and IMF’s devastating structural adjustment programs of the 1980s had a terrible effect on global health, worsening child nutrition, increasing infectious disease incidence, and heightening maternal and infant mortality rates.  Traditional financial institutions, players, and policies contributed to the negligence that caused the current global recession, which has led to draconian cuts to global health funding and put years’ worth of progress in jeopardy.  Dr. Kim is a welcome and very much needed change.  His track record of compassion for the world’s underprivileged and his pursuit of effective, scientifically-backed strategies to improve global health and development should hearten anyone who expects more out of its global bodies.  I welcome the appointment of Dr. Kim to the World Bank.  May we see great changes in the years ahead.

With special thanks to Hannah Burnett for inspiration for this piece.

Image: Jonathan Ernst / Reuters via Time.

Current treatment and prevention options for many NTDs require a single, preventative dose yearly (or every six months), such as that for lymphatic filariasis, commonly known as elephantiasis, or massive swelling of the limbs and/or genitals, and onchocerciasis, also known as river blindness.  As the Global Network for NTDs points out, many of the required drugs cost less than 50 cents per person per year: I was surprised to learn that Big Pharma donates a lot of drugs for NTDs, which keeps costs down (see page 15 of the WHO roadmap linked above).  In many cases, however, the treatment options are scarce, ineffective, or even toxic.  As The Guardian reported, the Gates Foundation met with 13 pharmaceutical companies, donor governments, multilateral officials, the Global Network for NTDs, and governments of affected countries to discuss NTDs at a summit in London last month.  The pharma companies agreed to donate additional meds and work on new ones, with an emphasis on public-private partnerships, to eradicate ten targeted NTDs by 2020, including Chagas and river blindness.  This is a good first step.  Additionally, vaccines are few and far between.  The Infectious Disease Research Institute (IDRI) announced this week that it had begun Phase I trials for a vaccine for visceral leishmaniasis, which is known as the “parasitic version of HIV/AIDS” and has a 90% mortality rate.

It is heartening to hear that researchers and pharmaceuticals are paying some attention to NTDs, but of course, it’s never quite enough.  As the WHO points out in its 2012 Roadmap (PDF),  NTD prevention, eradication, and control require efforts far beyond the distribution of pills, vaccines, and other “traditional” global health activities: vast development-related improvements, such as updated sanitation, clean water, and better living conditions, are key.  Changes like these are slow and expensive, especially when 900 million people do not have access to safe water and 2.5 billion do not have adequate sanitation (WHO, above).  As Peter Hotez of the Sabin Vaccine Institute details, NTDs are a “poverty trap,” lessening one’s ability to go to school or work.  Hookworm, which affects at least 600 million people, “stunts physical growth and dramatically reduces intelligence and memory in children, reducing future wages by almost 50 percent.”  NTDs have economic consequences beyond the personal (which would be bad enough): imagine how much stronger developing economies could be if those 600-million-plus-people were learning and working at the top of their abilities (unemployment and inadequate educational opportunities aside).  The causes and effects of NTDs go far beyond health and healthcare.

Unfortunately, the London Declaration goals seem overly sanguine, given the current economic climate and donor fatigue, and clinical trials take a very long time.  Worryingly, as IDRI points out in its announcement for Stage I leishmaniasis trials, “the geographical range for leishmaniasis is expanding. Spurred on by global warming, mass migration and rapid urbanization, cases are being reported in previously unaffected areas.”  This applies to other neglected tropical diseases as well: our world grows smaller every day, it seems–and warmer.  That, perhaps, is one very cynical silver lining: as the footprint of NTDs expands with globalization and global warming, affecting wealthier countries, we may see an increased demand for the development of new treatments and vaccines and more aggressive preventative measures.  Until that happens, we’ll have to keep our fingers crossed that scientists, pharmaceuticals, host and donor countries, and global health and development non-profits can keep rolling back NTDs, slowly but surely.

Header photo is of the freshwater snail oncomelania hupensis, which carries and transmits the parasite that causes schistosomiasis.  By Fred A. Lewis, Yung-san Liang, Nithya Raghavan & Matty Knight, CC-BY-2.5, via Wikimedia Commons.

This week, the WHO upheld its current guidelines in relation to use of hormonal contraception and women living with HIV.  President Obama released his administration’s budget request for 2013, with some surprising news for US global heath policy.  Finally, polio eradication efforts in Pakistan have been hamstrung by government health care and regulatory incompetency and the CIA’s fake vaccination program.

WHO Upholds Hormonal Contraceptive Use Recommendations for HIV

Last year, I wrote about a new medical study that found that the use of hormonal contraceptives could double the risk of HIV infection and transmission.  This month, the WHO convened a technical consulting group to discuss the findings from this study and others that examined the relationship between hormonal contraceptive use and HIV acquisition by HIV-negative women, the transmission of HIV from women to HIV-negative men, and disease progression in HIV-positive women.  In a technical statement (PDF), the WHO concluded that the current studies did not provide strong enough evidence and that  it would not alter its current guidelines.  The UN body did add a “strong clarification” to its guidelines, however, emphasizing the importance of condom use (the only contraceptive method that provides high protection against unintended pregnancy, HIV, and most STIs).

According to UNAIDS’ corresponding press release, 11% of women of childbearing age (15-49) worldwide have unmet family planning needs.  In sub-Saharan Africa, that unmet need jumps to 25%.  In many low- and middle-income countries, there is a deadly convergence of high HIV prevalence, low uptake of contraception and other family planning methods, and high maternal and infant mortality.  Even if hormonal contraceptives carried such a risk, they have a very positive effect on to lowered maternal mortality rates, poverty, and other factors.  In global health, decisions about treatment and prevention measures must be carefully weighed.  For example, mothers living with HIV in high income settings are recommended, if not required, to use replacement feeding options (formula) because of the risk of HIV transmission during breastfeeding.  In low- and middle-income settings where lack of access to water and convenient kitchens, stigma and discrimination, and the cost of formula are barriers to safe replacement feeding options, the WHO recommends that women living with HIV exclusively breastfeed their infants, while adhering to ARVs (as AVERT outlines here).  Although the WHO cites inconclusive evidence as the reason for upholding its current guidelines, I’d wager that they would not amend them unless the evidence were incontrovertible that the use of hormonal contraceptives carried an extremely high risk of HIV acquisition or transmission.  The other health and development considerations are as vast and as dire.

Obama Administration’s 2013  Budget Request and Global Health

President Obama released his administration’s budget request for 2013 (for the US government, the fiscal year begins in the previous October, and barring any more nasty Congressional fights, a version of this proposal would take effect on October 1, 2012).  Reactions to the request, which must pass Congressional approval, are mixed.  According to a US Department of State fact sheet, President Obama has requested $7.9 billion for his Global Health Initiative, of which $5.4 billion would be allocated to the President’s Emergency Plan for AIDS Relief (PEPFAR), as part of the administration’s commitment to put 6 million people on antiretroviral treatment by the end of 2013.

What the fact sheet does not mention (and is the highlight for many in the global health sector), is that the request also asks for $1.65 billion for the Global Fund, as Ambassador Eric Goosby, the US Global AIDS Coordinator, writes in a post for the State Department’s DipNote blog.  He notes that this request puts Obama on track to fulfill his pledge of seeking $4 billion in US funding for the Global Fund over the next three years and argues that support for the Global Fund will increase the effectiveness of PEPFAR and inspire other donor countries to support the beleaguered multilateral organization.  The Kaiser Family Foundation has a good break down of the requests for global-health related funding and their relative increase or decrease from 2012–it’s worth noting that PEPFAR’s overall budget would decrease slightly from the deep cut made in 2012 (following negotiations with Congress).  Amanda Glassman and Denizhan Duran of the Center for Global Development are optimistic about the shift towards multilateral funding, using facts and figures to argue that multilateral organizations like the Global Fund are more efficient.  Christine Lubinski of Science Speaks is less pleased with the 2013 budget proposal, writing: “Slashing the PEPFAR program to increase funding for the Global Fund would seem to undermine the promise of treatment scale up.”  Lubinski also quotes Matt Kavanaugh of Health GAP, who called this aspect of the budget request “a bait and switch worthy of Wall Street.”

Of course, hand wringing now is putting the cart before the horse: given that this is an election year, I anticipate a floor fight or another near-government-shutdown crisis.  With politics in the US as acrimonious as they have been, it can only get worse when political power is on the line.  I’m happy to see that President Obama is focusing on the Global Fund (and domestic HIV/AIDS programs as well!), and I hope that the draw down in Iraq will give him a little more wiggle room on spending while decreasing the deficit.  Of course, the Obama administration could always do more, but I am less worried about his goals and intentions for global health than I am about those of Congress.  This appears to be a shrewd political move that could have positive effects on the global health and development fronts.  We’ll just have to wait for the Congressional response.

Pakistan’s Polio Problem

In the past, I’ve written about the massive gains the global community has made against polio, with a 99% reduction in cases reported in 2011.  It’s not all been successful, however, and one of the main backsliders is Pakistan.  The BBC reported this week that Indian health officials are vaccinating all Pakistani children who cross the border.  According to the BBC, India has remained polio-free for at least a year and wishes to remain so, while Pakistan has reported 175 cases–hence the vaccination efforts.  According to IPS (who writes that India has had one case and Pakistan 197 in the last year), Pakistanis are rejecting polio vaccines due to distrust of the Pakistani public health system.  In Lahore this year, 125 cardiac patients at a government-run hospital died after being administered a cardiac drug contaminated with high doses of an anti-malarial.  Fears over government healthcare and regulatory incompetencies are driving parents away from polio vaccinations.  Clearly, more must be done to improve the current health system and shore up weak regulatory safeguards.  When governments do not or cannot commit to their health programs, this is the kind of result that we will see, as I discussed with the possible outbreak of totally-drug-resistant tuberculosis in India.

Furthermore, Pakistanis are refusing to vaccinate their children following the revelation that the US Central Intelligence Agency launched a fake polio vaccine program as part of efforts to find Osama Bin Laden, which I covered last July.  As I wrote then, the CIA’s program was reprehensible because it damaged the trust that ordinary people must place in their health care providers.  Very unfortunately, this seems to have had an adverse effect on not only polio eradication efforts within Pakistan’s borders, but potentially in Afghanistan and India as well.  Disease outbreaks do not exist in a vacuum, especially in a world where one has the ability to cross the world in a day.  Shame on the CIA and the US and Pakistani governments.

Header photo here, by Spec-ta-cles, CC BY 2.0.