Sarah Arnquist

Bill Easterly says the war on AIDS is being lost. Unsurprisingly, this harsh conclusion attracted dissenters in the comments immediately below his post, Aidwatch, spurring Easterly to write a second post summarizing the debate.

“How did this enormous tragedy occur?” Easterly asks before offering an answer: “Perhaps because the global health community concentrated on AIDS treatment and neglected prevention (which they never figured out how to do). … In AIDS, virtually all of it was spent on treatment.”

This WSJ article describing how treatment clinics in Uganda and other African countries are turning people away seems to have sparked Easterly’s condemnation. The article quotes Eric Goosby, President Obama’s AIDS czar, saying that despite the global economic downturn, “Our commitment to universal coverage hasn’t wavered.”

But it seems the article’s objective was to plant substantial seeds of doubt about that feasibility of that statement. The author also addresses the failure of prevention, saying that the availability of treatment undermines prevention. “One irony is that lifesaving medicine makes the prevention message harder to deliver,” he writes.

AIDS program leaders in Brazil, where I recently traveled to learn about its HIV prevention and treatment programs,  would reject that conclusion. In 1996, the Brazilian government took the bold step of guaranteeing universal access to antiretroviral treatment, despite advice against it from global economists and health experts.

More than a decade later, more than 80% of Brazil’s AIDS program budget is spent on treatment, but leaders say separating HIV prevention and treatment discussions makes a false distinction because you cannot successfully have one without the other. (It conjures up the tune about Love and Marriage.)

Easterly says the global health community never figured out how to do prevention. A commenter points out, however, that some communities did figure out what prevention efforts work. What the global health community then has not figured out, but I believe is working hard to try and do, is how to replicate and scale-up existing successful prevention models in communities that need it most.

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My twitter feed fills daily with announcements of new electronic or mobile technology projects aimed at improving health in the developing world.

Given all this excitement around global e-health and the corresponding funding increases for new projects, it is timely that “Health Affairs” dedicated its latest issue to the topic. The journal articles address many current issues in global e-health that need more discussion, which will hopefully, lead to greater collaboration and scalability of projects.

In one of the first articles, Gerber and co-authors describe an agenda for action in Global E-health. They state seven recommendations that emerged from a 2008 conference sponsored by the Rockefeller Foundation: (1) document the impact on access to, affordability of, and quality of health services; (2) remember the ultimate goal of e-health should be to strengthen health systems and improve people’s health; (3) support collaboration and innovation across resource-constrained countries and learning between developing countries; (4) reduce donor fragmentation and harmonizing donor requirements and reporting; (5) develop the information and communications technology “business case” to increase donors’ and stakeholders’ involvement; (6) strengthen stakeholder collaboration; and (7) provide funding for pilot projects and adequate evaluation.

Those are ambitious recommendations. New projects and initiatives are emerging every day. Many are small pilot projects with just enough funding to get started and very little to evaluate their impact.

At kiwanga.net, Ken Banks, founder of FrontlineSMS, implores the e-health community to think about capturing metrics that answer the tough questions about how a product impacts someone’s health and life. Tracking the number of text messages or data exchanges is fairly simple. Tracking if patients return for follow-up care and improve their after receiving test results by SMS is much harder. But worth the effort, Banks says.

“We shouldn’t get too obsessed with the data,” he writes. “But it’s important that we don’t forget it altogether, either. We need to recognise the scale of the challenge.”

Also, related in this area is a systematic review of evaluations of e-health implementations in developing countries by GHDonline Health IT moderators Joaquin A. Blaya, Hamish S.F. Fraser, and Brian Holt.

The top half of this Harvard Business Review blog post is great … the bottom not so much. It’s a good discussion on the excess of “socially useless businesses” and the hole more constructive capitalists could fill.

Is Your Business Useless?
By Umair Haque -
Harvard Business Review
blogs.hbr.org

While out reporting a story this week, I encountered a woman caring for her nine orphaned grandchildren. When we arrived, the children were all alone while the grandma was out finding food. The oldest child was no older than 6. I did not understand how all their parents died, although some did die from AIDS.

Two of the children were HIV positive, most were malnourished. The woman had no resources to buy them food, let alone pay school fees or replace the rags they wore. Overall, I have not found my experience in Uganda to be depressing or hopeless, but situations like tear at the heart.

This hobbled old woman lived with these nine little people in a dirt-floor, two-room hut that lacked electricity and running water. Some of the children’s bellies were swollen from worms. The woman who brought me to the house said the grandmother does not always have money to buy porridge or formula for the children.

Uganda has more than 2 million orphaned children, according to UNICEF. I’ve read about the orphans in Africa, but here I saw the appalling conditions in which some of them live. And all I did was take their picture. It made me feel pathetic.

Photos of these situations are often used to drum up charity money and donations. I don’t know how I feel about that. Charity might help a few children, and undoubtedly, they will be better off. But charity can’t help them all. They need a long-term public safety-net, which the Ugandan government seems unable to provide. Can donor aid actually help strengthen the nation so it can care for these children? Or does donor aid end up lining the pockets of the politicians who somehow after lifetimes of public service are among the richest men in the country?

The global reduction in new tuberculosis cases over the last 10 years in most countries can be explained more by improved economic conditions than the scale-up of disease control programs, according to a recent study in the WHO Bulletin.

“It is remarkable that among 25 countries in central and eastern Europe, single variables, such as health expenditure per capita, can explain two-thirds (66%) of the variation in TB trends,” the authors write.

What is one to make of this finding? Would improving economic growth in poor regions do more to improve health than direct control programs?

Although, certainly no one would suggest TB control programs should end, it seems this paper lends evidence to the fact that the factors driving TB incidence lie beyond how effective the control program is.

The authors acknowledge that several additional factors need to be tested before this hypothesis can be swallowed as fact. They end with a challenge to the public health community:

“This review presents, not definitive results, but a challenge: to show that early diagnosis and treatment can have a major effect on TB transmission and incidence worldwide, overriding or reinforcing other biological, social and economic determinants of TB epidemiology.”

Oh how we take broadband Internet for granted in the U.S. The connections in Uganda are impossibly slow and many things that we automatically plan to do online at home can’t be done here, such as buying a plane ticket. For a tirp to Zanzibar, an island off the cost of Tanzania, this weekend, I had to go to the Air Uganda office and purchase my ticket in person. I can’t remember the last time I even bought a plane ticket over the phone!

Apparently, high speed internet is supposed to be just over the horizon with the arrival of an undrgound sea cable connecting East Africa to Internet lines in Europe. Everything here, however, moves slowly and must be greased with cash. It’ll be interesting to see when prices actually decreases and access increases.

Uganda’s fertility rate hovering around seven children per woman is the highest in Africa and among the highest in the world.

I plan to learn more about what is driving the high fertility rate while I am here, but I expect that the driving factors largely are the same as those that lead to high fertility rates elsewhere: poverty, high child mortality, lack of female education and employment opportunities, and poor access to contraceptives.

There might be an additional cultural factor contributing to Uganda’s high fertility because it has not seen the same drop as other African nations, despite its relatively decent rate of economic growth.

During a recent conversation with my Ugandan housekeeper about her four children, I asked her how many children women here typically want. “Maybe 10 or 7,” she said.

When I asked her why so many, she said, “Because they can help the mother, and maybe if one dies, she will still be left with four or five.”
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A campaign to reduce the spread of malaria by spraying the walls inside homes with the pesticide DDT in northern Uganda has attracted protests from local residents, Public Radio International reports.

Northern Uganda has some of the highest rates of malaria infection in the world, and the World Health Organization and U.S. government encourage use of DDT to kill the mosquitoes that transmit the disease.

Reporter Alison Hawkes interviewed government officials promoting program and journalists as well as activists protesting it to produce this nice story. Public health officials generally believe the health risks posed by DDT are far less than those posed by malaria. Mass DDT campaigns played key roles in eradicating malaria in other parts of the world, but the pesticide is now banned in the United States.

When promoting the DDT program, government officials failed to explain the comparison in risks between DDT and malaria, Hawkes reports. Perhaps, an accompanying risk communication campaign could have accompanied the pesticide program and averted the backlash.