Freewheel Burning

The Lancet recently published the results of a longitudinal study examining resistance by malaria parasite to the latest and most effective treatment for the disease, Artemisinin Combination Therapy (ACT) along the Thai-Myanmar border.

Parasite clearance rates increased from a mean half life of 2.7 hours in 2001 to 3.6 hours in 2010, indicating that resistance is growing. Resistance was originally observed on the western side of Cambodia, but has now either spread geographically to western Thailand or emerged on its own. The latter scenario is actually the more frightening possibility. If resistant strains emerge in Sub-Saharan Africa, it could be a major setback.

Though research to develop new drugs is ongoing, ACTs are presently the most effective treatment and a major part of the arsenal with which to stop transmission and prevent early childhood death. Past treatment strategies are now largely ineffective.

Vaccines are also in development (most notably the RTSS vaccine), though I have little confidence that it will be of much use for long. It is a long series of shots and difficult to deliver in areas where medical delivery is poor or non-existent and efficacy is strain and context specific. Malaria vaccines are nice in the popular press, but impractical on the ground.

That resistance is growing in this particular end of the world, is in itself significant. Both regions are notable for poor health delivery, sporadic armed conflicts and marginalized populations. Efforts to contain the spread of resistance are likely futile. Even in the best of times, adequate delivery of care and prevention strategies are near impossible. Displacement of people due to conflict always provide ample opportunities for infectious agents, poor health and death. Tens of thousands of people languish in refugee camps along the border.

The subject of resistance in this region comes up often in meetings of malaria researchers, though I am always struck at the absence of discussion of social factors and conflict and how they create conditions favorable for the spread of resistant pathogens. It is no accident that malaria occurs in the places it does, and no accident that resistant strains of Plasmodium are able to fester and evade efforts to reign it in. It is almost as if the malaria research world believes that genetic adaptation happens at random, which it does not.

Discussion of malaria eradication cannot proceed without discussion of how to eradicate worldwide conflict, entrenched poverty and proper delivery and access to basic health care and the global forces which create these conditions. Yet it does.

Medications, vaccines and preventative interventions cannot work if there is no way to delivery them, and people cannot access them unless there is a local economy with which to support such a system. Malaria research has to address this fundamental issue or we’re just talking in the wind.

Malawi’s President Bingu, or as he was officially known “His Excellency the President Ngwazi Professor Bingu wa Mutharika” died last Thursday.

His death has left a power vacuum in Malawi. Joyce Banda, the current Vice President constitutionally is expected to take power, but members of Bingu’s Democratic Progressive Party are seeking to block her appointment. Banda, though chosen as a running mate by Bingu himself, increasingly found herself at odds with Bingu’s increasingly autocratic Presidency and ultimately left the DPP to form her own political party. Bingu sought to cancel her vice presidential seat unsuccessfully. The Malawian Supreme Court ruled that she was still entitled to the seat.

Both groups within and outside of Malawi are calling for a swift transfer of power to Banda, including the United States.

Malawi could do worse than Banda. A former educator, Banda has sponsored numerous initiatives to expand educational opportunities for children and to increase female empowerment within Malawi. Since 1990, Banda’s National Association of Business Women has provided support and training for female entrepreneurs, reaching a wide network of approximately 30,000 people. She has sponsored health initiatives in Malawi and won numerous international awards. Most impressive, she quietly sponsored a task force to determine the extent of HIV in MSM populations, a dangerous undertaking in conservative Malawi. Forbes magazine listed Banda as the third most powerful woman in Africa. In short, Banda could be the breath of fresh air that Malawi requires.

Mutharika’s Presidency, though initially lauded due to his successful seed voucher program, which he boldly implemented against the advice of the World Bank and the IMF, fell into disgrace due to widespread fuel shortages and a dearth of foreign exchange. The increasingly dire situation led to mass protests all over Malawi, a state crackdown, and the deaths of 19 people. It is questionable though, as to whether Banda can solve these problems, much of which is due to international market forces out of the control of the domestic Presidency.

Of interest to me were the circumstances of Bingu’s death. Bingu collapsed on Thursday night and was rushed immediately to Kamuzu Central Hospital, a public facility. Upon presentation at the Kamuzu, workers realized that they were lacking epinephrine and had to run to a facility run by University of North Carolina to procure it. Bingu likely died because of problems of drug stocking in Malawian facilities and substandard levels of health delivery. Bingu died due to a problem endemic to all of Malawi. Ironically, the opulent President of Malawi died needlessly like that of even the poorest of Malawians.

Readers of this blog (all 2 of you) are well familiar of the intense skepticism I hold for evangelical Christian groups operating in Africa (and everywhere else).

Forbes magazine ran a fascinating piece on Social Flow. Social Flow used their network analysis software to track connections between Twitter feeds that all had “#Kony2012″ in the text.

What they found was nothing short of illuminating. A visualization of the data can be seen at the bottom of this post.

We expect that connected Twitter users will be linked by geographic region and would expect more connections in large urban areas such as New York and LA. Far from being clustered in metropolises, people promoting Kony 2012 were located in smaller cities, such as Pittsburgh, Dayton, OH, Birmingham, AL and Noblesville, IN (wherever that is):

“The large cluster on the top right includes users from Birmingham Alabama who were some of the earliest to publicize the video. The cluster is substantially larger than the others, leading us to believe that Invisible Children had strong roots in Alabama. Additionally, the hashtag#Kony2012 initially trended in Birmingham on March 1st, a few days before the video was even placed online. Other clusters in the graph include Pittsburgh, Oklahoma City and Noblesville Indiana.” But not only were there geographical clusters, but cultural clusters as well, “This movement did not emerge from the big cities, but rather small-medium sized cities across the Unites States. It is heavily supported by Christian youth, many of whom post Biblical psalms as their profile bios.”

Amazing. Kony 2012 billed itself as a happy accident. The evidence indicates that this was a well coordinated, well funded campaign waged by a powerful religious group. “Stealth Evangelism.”

Talk To Action (thanks Jeff) is a secular watchdog organization devoted to exposing the (in my opinion) damaging and self-serving influence that the religious right has on American politics. They have recently done a series of posts on Invisible Children and the Kony 2012 campaign. The more I read about this and the more I find out about this organization, the weirder it appears to me.

Talk To Action has done some digging and found that Invisible Children receives funding from the Family and other right wing Christian sources. The Family are a powerful, though secretive US fundamentalist group and were behind Uganda’s reprehensible Parliamentary bill which called for the execution of anyone suspected of being a homosexual. Though the group denies this is the case, the evidence against them is fairly damning. It appears though, that the Family are behind much of the recent Kony 2012 craze.

Invisible Children’s founder (and creator of the Kony 2012 video) Jason Russell was heard saying the following, where he admits that IC is using the issue of suffering kids in Africa so that his batshit religious group can gain access to kids in public schools:

“Coming in January we are trying to hit as many high schools, churches, and colleges as possible with this movie. We are able to be the Trojan Horse in a sense, going into a secular realm and saying, guess what life is about orphans, and it’s about the widow. It’s about the oppressed. That’s God’s heart. And to sit in a public high school and tell them about that has been life-changing. Because they get so excited. And it’s not driven by guilt, it’s driven be an adventure and the adventure is God’s.”

This is, of course, before he got caught running around town publicly masturbating.

Apparently this animal was found in the Bui Dam project in Ghana. It is thought that this horrific beast, not shoddy construction by the Chinese contractor building the dam, was responsible for a dam collapse the same day. It is reported to have the head of a human, two claws to pull itself along and the body of a snake. Though the video doesn’t seem to confirm it, reports indicated that it is more than 100m long.

We need to be on the lookout for beasts such as this all over the globe.

It was announced to day that Barack Obama will appoint Dartmouth President and physician Jim Yong Kim to be the next head of the World Bank. This breaks a string of appointments of right wing demagogues including Paul Wolfowitz and Robert Zoellick, both part of the group which orchestrated the invasion of Iraq and the heavy handed response to 9/11 by the Bush admin. I saw Zoellick speak recently and felt kind of gross after it was over.

Jim Yong Kim has an impressive list of publications on global health, notably collaborating with Partners In Health founder and human advocate, Paul Farmer. In fact, Kim was also part of the group that founded PIH and is known for his work on “Social Medicine” (a broad signifier for social determinants of health with a focus on clinical delivery).

Kim is co-founder of The Global Health Delivery Project, a group at Harvard that seeks to improve the health and welfare of population in developing countries by focusing on issues of health care delivery.

Problems of delivery of health care in developing countries has been perhaps my number one interest as of late. In fact, I am even writing a paper on it. As researchers, we can develop effective and radical new clinical techniques and medicines, but they do no good if the systems aren’t in place to deliver them effectively. Issues of delivery will be the primary impediment to controlling and eventually eliminating devastating diseases such as malaria. It is encouraging that Kim has been selected to fill this position.

It is unsurprising that Columbia University development economist Jeff Sachs was not chosen (he has withdrawn his nomination), despite appealing to the world community to pressure the Obama admin to select him. However, it is a relief that the first choice, Larry Summers, has to forego stepping in to a leadership position at the WB. I can think of no WORSE choice. The entire world appeared to agree and it marked the first time that the international community has had a say in who heads the Bank, a welcome departure from past appointments.

Sachs himself even came out in support, likely aware of his role in having Kim picked: “Dr Jim Kim is a superb nominee for the World Bank presidency,” Sachs said in a statement. “I support his nomination 100 percent. I congratulate the administration for nominating a world-class development leader for this position.”

I am interested to learn more about Kim. He may certainly have some ideological skeletons in his closet, though his association with Farmer leads me to think not. Congratulations to the Obama admin for taking the high road on this one.

UPDATE: OK, so it appears that Kim will be the first WB President to ever be caught on film rapping and dancing at a Michael Jackson tribute:

I sat down and watched the Kony2012 video from the group “Invisible Children” which has been making the rounds in the popular press recently. Kony2012 is a group (or single individual, it’s not clear) which calls for immediate action to arrest and convict Joseph Kony, leader of the notorious Lord’s Resistance Army. The LRA, a quasi-religious rebelgroup, has been responsible for nearly 30 years of wanton violence, child abduction and rampant warfare in Northern Uganda, the DRC and South Sudan.

Filmmaker Jason Russell has put together a slick 30 minute feature on why the world should be concerned about Joseph Kony and the LRA. It is well done piece that documents Mr. Russell’s journey to Uganda and the events which led to his eventual commitment to the issue of the LRA and child soldiers. More than 60 million people have viewed the video, and has turned into a (likely temporary) viral sensation.

The intent of the film is obscure for the first ten minutes, starting out with a primer on how people in the United States spread videos of their kids on YouTube and Facebook. Soon, after several grueling and annoying minutes watching videos of Mr. Russell’s own child, we figure out what the video. All is explained in a conversation between Russell and his 4 year old son.

The video is not without critics. I am one of them. On the surface, the video is a call to action from a concerned filmmaker. Mostly, though, it is less documentary and more a shameless advertisement for the filmmaker himself. Russell even goes the extra step to try to sell the viewer Kony “Action Packs” (it sounds like something that comes out of a cereal box). For $30, you get a button and a couple of wristbands, one for yourself and one for a friend. For $30 you can feel like you did something for helpless kids in Uganda.

The trouble is, though, that Kony hasn’t been in Uganda since 2005 and Ugandan kids won’t likely see much of that money.

While Kony is a perfect evil-doer in the deeply scary continent of Africa, he is certainly not the scariest killer of children. More than one million kids senselessly die every year from malaria. Another million die even more senselessly of diarrheal diseases from drinking contaminated water. More than 30 million kids have been orphaned due to HIV. Worse yet, many millions of the kids that didn’t die after getting sick suffer from serious (though poorly researched) developmental problems. These not only pose incredible problems for the kids themselves, but are a serious impediment to the development of poor countries. If the video is any indication, Russell appears unconcerned.

Though not to discount the horror the man has committed, by comparison Kony is a small threat. The image of Kony, however, feeds into Western perceptions of Africa as being a really, really frightening place (despite the fact that people like Robert Mugabe kill more people than Kony through irrisponsible leadership). Africa is seen to be as a place of continual conflict and instability. The only way to fix it is to send in white people to protect African kids from African adults. Not only is it the only way, but we have a duty to act immediately, or more kids will die.

In the manner that it uses social media, slick production values and a sense of absolute immediacy and simplicity, it is quite similar to campaigns such as the One campaign and Product (RED). It is also similar in that it uses African crises to sell itself and its own products, while giving little to the subjects concerned. Worse yet, it gives little airtime to the numerous African led groups working day and night to solve Africa’s seemingly insurmountable problems.

To me, the real problem with groups like Invisible Children is that it presents a world where the individual, voluntary and one time actions of consumers are an easy solution to the complex problems of developing countries and global health issues. What this does is distract policy conversations from creating sustained and cooperative strategies for poverty alleviation. It allows corporate and government entities to operate with little scrutiny, despite being responsible for (and profit from) creating conditions of entrenched inequality around the world.

No doubt, Russell will have his supporters. Americans like to feel good and it makes them feel good to send in a little money, watch a video, wear a bracelet and save kids in Africa.

A new World Bank report on the state of poverty in the world suggests that the number of people living on $1.25 a day have declined over the past decade. Even raisig the bar to $2.00 a day indicates great gains in the world fight against poverty.

Much of the improvement in world poverty numbers come from Asia, specifically China, which can boast that nearly 662 million people now no longer live on less than $1.25 a day compared to 1981. In 1981, nearly 77% of people in East Asia lived in poverty. Now, only 14% do.

Though this is cause to celebrate, the world is not out of the woods yet. Africa, though slowly recovering from the disastrous structural adjustment era, which erased previous gains in poverty reduction, still provides home to large numbers of ultra poor households, particularly in rural areas. Nearly 45% of Africans live in poverty at present.

One should praise the great successes of economically emergent Sub-Saharan African countries. One should not forget to ask why Asia has been a success story and why Africa has not. Most relevant, the World Bank should at least make mention of their complicity in creating conditions of entrenched poverty in Sub-Saharan Africa.

When I saw Robert Zoellick of the World Bank last year, he only made passing mention of the programs which erased Africa’s past economic gains, dismissing the matter as a fringe concern of political freaks and over-reactionaries. The simple truth is that it is impossible to dismiss policies which have favored narrow US interests and reflected a narrow view of economics only appropriate for the most developed of countries, policies which have been implemented at the expense of the very poor.

Last year, I took a part time job in the UM Business School. At first, I was hesitant. A job in the business school? Isn’t the B-School the heart of all that is evil and wrong with the world? The desperate in me whispered that I needed the money and the academic in me reminded me that I’m intrigued by anything having to do with developing world health delivery. Moving in the circles of business might, at the very least provide insight into how the world of malaria policy works.

Though the details were hazy at first, over time, I’ve come to understand what my employers are trying to do.

In Africa, health care is a premium. What health care is offered is often difficult to access. When accessible, medicinal supplies are limited, stock outs are common, delivery ineffective and, user fees prevent the poorest of households from obtaining affordable medications.

Coca Cola on the other hand is ubiquitous. I may not be able to buy anti-malarials, get on ARTs or even a decent meal, but I can get a bottle of Coke for an affordable price just about anywhere in all of Sub-Saharan Africa, even in conflict ridden corners of the DRC. Better yet, at least for me, this is the old Coke made from cane sugar, not the new, artificial kind we get in the US.

Some folks (who pay me money to do stuff) ask the obvious question: if the multi-national Coca Cola company can get soft drinks in every corner of the globe, why can’t we effectively deliver badly needed medicines to the same people?

My colleagues then examined the nature of private supply chains that deliver Coca Cola and contrasted them with current methods of pharmaceutical delivery. Private supply chains which deliver things like Coca Cola, beer, soap, shampoo and cel phone cards are incredibly efficient.

Soft drink manufacturers, ship concentrates (to protect intellectual property) into developing countries directly to factories which bottle and prepare stocks for delivery. Stocks are then sent by truck to smaller distributors where trucks are able to pass. Distributors then sell to even smaller distributors who deliver stocks to small shops by vehicle, bicycle, or cattle driven cart, delivering to areas inaccessible due to poor roads, seasonal rains or regional insecurity. Every step of the chain is accountable to the link above it, stocks are paid for on delivery and open competition for delivery routes keeps everybody honest. Empty bottles are then returned along the same supply chain for further bottling, saving resources and keeping costs low.

It’s brilliant, really. It keeps people employed, sales generate cash that goes into communities and insures that small shops are open which can sell other types of consumer goods.

Medicines, on the other hand, are distributed through state run warehousers, which then deliver to district level storage facilities, which then are responsible for delivery to smaller clinics and dispensaries. The trouble is that 1) points of distribution are few and often inaccessible for people in rural areas 2) delivery methods often rely on vehicles which can’t pass through many of the most needy of areas, and 3) deep state control prevents competition amongst distributors and fosters corruption and a lack of accountability.

To encourage this distribution model, policy makers have begun subsidizing ACTs (an effective anti-malarial medication) to bring prices to a level where small corner shops can afford them. They are then sold to local wholesalers, who distribute the meds using the same model as that of Coca Cola, penetrating previously unreachable areas. The model works through low cost and the utilization of informal networks of delivery.

Of course, my politics tell me that bolstering an unregulated private market in essential drugs only undermines the overall quality of public health delivery. Indeed problems do exist and the program is not without its critics, but to deny that the role of private markets is essential to health delivery is short sighted and idealistic. In this case, even given potential problems and implications, the benefits far outweigh the costs.

I’m so much at a loss as to what to write and this blog has sat rusting for the past couple of weeks. I was hoping some of my friends would pick up the slack, but, alas…

So, while I sit here at the Amsterdam Shiphol Airport drinking incredibly expensive but exquisite European coffee, I will inundate you with news items that have caught my attention recently.

The Malawian judiciary is on strike. Yep, the whole judicial branch as far as I know. Incredible. Imagine if the entire federal court system of the United States decided to take a break? Fortunately, US federal judges and court workers are getting paid, unlike their counterparts in Malawi. The strike is estimated to cost in the hundreds of thousands if not millions of dollars, money Malawi simply cannot afford to lose. Rerorts are coming out that hospital workers are starting to strike, as well.

The Africa Report is late on the game and reports that insecticide treated bed nets that were distributed for free are being used for drying fish and wedding veils. While this is old news for us in the malaria world, the article continues to fan the flames of arguments against giving free stuff to poor people. No mention of whether the nets used for drying fish acutally provide benefits to the economic profile of the community, however. Maybe they are just holding back knowing that I’m working on a paper.

The same Africa Report did manage to write a cool article on African film schools. It’s not surprising that many African countries don’t have developed national cinemas, but a sad state of affairs nonetheless. With funding from European donors, a film school has been created and scholarships offered to more than 100 potential African film makers. The positioning of the school in Nigeria is dubious, however. Nigeria is know for film, but not for the kind that draws international attention. I would love to see a new generation of film makers in the tradition of Senegalese film maker Djibril Diop Mambéty or Abderrahmane Sissako, rather than the cheap throw aways that Nollywood is famous for, but we can’t have everything, can we?

In the mean time, here’s a trailer for the Galway African Film Festival of 2011, which includes clips from Kenya’s Pumzi, what is probably Africa’s only science fiction film (besides South Africa’s District 9).

In this week’s Lancet, Christopher Murray published a paper presenting evidence that deaths due to malaria are vastly higher than “official” estimates from the World Health Organization. Specifically, Murray, et al. estimate that worldwide malaria deaths, though declining over time, exceeded 1.24 million compared with the WHO’s estimate of more than 600,000.

Most notably, the Lancet paper speculates that adult deaths from malaria are far higher than previously though, contradicting accepted medical ideas that immunity increases with age, freeing adults from the risk of mortality.

Murray’s paper is not without precedent. In 2010, Dhingra, et al. also called the WHO’s estimates for malaria mortality in India into question, estimating between 125,000 and 277,000 deaths were due to malaria, far exceeding the WHO’s extremely reassuring estimate of 15,000.

That malaria deaths are down worldwide is an uncontroversial notion. The wide discrepancy between published estimates of the worldwide burden of malaria mortality is, however, highly controversial. Overestimating mortality can stream precious monetary donations, most notably from big players such as the Global Fund, needlessly toward malaria, at the expense of other health concerns such as TB and HIV. Underestimating the number of deaths from malaria, can leave countries short changed and unable to fight their own malaria related problems.

Either way, controversy as to the accuracy of reporting dishevels confidence and could provide more fuel to those who advocate for reductions in global aid to fight developing world health problems (read: all of the current Republican candidates) and distract from the creation of efficient policy.

What is needed, of course, is accurate reporting and a reliable flow of health information worldwide. Many developing world governments, however, lack the resources to efficiently provide these numbers. World aid bodies, however, have, to date, missed this essential piece and reporting methods remain antiquated in many areas.

I just visited a facility in Kenya, where records are still kept on paper, and left to mildew in an unused toilet (I kid you not). One could assume that if the records were left in a functioning toilet, the numbers might end up at the bottom of a pit latrine. With the base of the worldwide reporting system in such a shambles, how can we expect accuracy in reporting?

New estimates of malaria deaths: concern and opportunity
[The Lancet, Volume 379, Issue 9814, Page 385, 4 February 2012 doi:10.1016/S0140-6736(12)60169-X] — (English)

This week we publish surprising and, on the face of it, disturbing findings. According to Christopher Murray and colleagues at the Institute for Health Metrics and Evaluation
(IHME) at the University of Washington in Seattle, there were 1·24 million deaths (95% uncertainty interval 0·93—1·69 million) from malaria worldwide in 2010—around twice the figure of 655 000 estimated by WHO for the same year. How should the malaria community
interpret this finding? Before we answer that question, we need to look beneath the surface of this striking overall mortality figure…

Global malaria mortality between 1980 and 2010: a systematic analysis [The
Lancet, Volume 379, Issue 9814, Pages 413 - 431, 4 February 2012 doi:10.1016/S0140-6736(12)60034-8] — (English)

We systematically collected all available data for malaria mortality for the period 1980—2010, correcting for misclassification bias. We developed a range of predictive
models, including ensemble models, to estimate malaria mortality with uncertainty by age, sex, country, and year. We used key predictors of malaria mortality such as Plasmodium falciparum parasite prevalence, first-line antimalarial drug resistance, and vector
control. We used out-of-sample predictive validity to select the final model…

 

WHO Defends Its Numbers On Malaria Deaths [Voice of America (blog)] — (English) The World Health Organization is defending its numbers on global malaria deaths and disputes a new study claiming that nearly twice as many people die of malaria than previously believed……

Malaria death toll disputed [Nature] — (English) Study doubles official estimate, but scientists say its methods are flawed……

Malaria deaths higher than expected, study finds [Deutsche Welle] — (English) The latest findings show that the number of malaria-related deaths is nearly twice as high as previously thought. But other experts have doubts about the methods used to produce these estimates……

Malaria deaths hugely underestimated – Lancet study [BBC News] — (English) Worldwide malaria deaths may be almost twice as high as previously estimated, a study reports……

Malaria kills twice as many as thought: study [Reuters] — (English) Malaria kills more than 1.2 million people worldwide a year, nearly twice as many as previously thought, according to new research published on Friday that questions years of assumptions about the mosquito-borne disease……

Malaria kills more people worldwide than once thought, study says [Los Angeles Times] — (English) In an alarming statistical turn, the number of malaria deaths every year may be vastly underestimated, according to new research re-examining mortality rates from 1980 to 2010……

Malaria deaths may be double WHO estimates [Financial Times] — (English) Worldwide malaria deaths may be almost twice as high as previously estimated, according to a new study that has sharply divided scientists tackling one of the world’s most deadly diseases……

Malaria death toll possibly twice as high as experts estimated [AP via FOX News] — (English) Malaria may be killing around twice as many people as experts previously thought, and it could also be hitting older children and adults – long considered the least susceptible – a new study suggests……

Malaria death toll possibly twice as high [USA Today] — (English) Malaria may be killing around twice as many people as experts previously thought, and it could also be hitting older children and adults – long considered the least susceptible – a new study suggests……

Malaria Kills Nearly Twice as Many People Than Previously Thought, but Deaths Declining Rapidly [Science Daily] — (English) Malaria caused over 1.2 million deaths worldwide in 2010, twice the number found in the most recent comprehensive study of the disease, according to researchers at IHME and the University of Queensland……

Malaria kills more people, older people [Washington Post ] — (English) A new study found that twice as many people die of malaria every year than was previously thought and that it kills many adults as well as young children……