Archive | February 2012

Mr. Condom Saves Thailand

Mechai_Viravaidya, affectionately known as “Mr. Condom” in his native Thailand, has been promoting condom use since the 1970’s. Everywhere he goes, he encourages the use of condoms to prevent disease and unwanted pregnancies. He is at least partially responsible for reducing Thailand’s fertility rate from 7 to 1.5 and almost completely respsonsible for reducing the number of new HIV infections by 90% between the mid 90’s and 2005. It is estimated that his campaigns have saved the lives of more than 7 million people.

Incredibly, he did it in part by giving condoms to elementary school children to take home to their parents. Given the American right’s completely backward and jaw dropping assault on reproductive freedom lately, Mechai might have found himself hanging from a tree had he attempted this in the States.

It doesn’t take a doctor to save lives. Public health activists like Mechai do it every day. In fact, people around me do it every day and receive little credit for it.

Check out Mechai’s video of a TED talk given last year.

Delivering Malaria Meds Using Coca Cola Supply Chains?

Coca Cola is walked to points of sale in unreachable areas of Africa

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.

Sweden: Could it have been a model for Michigan?

Business goes to Sweden because of its amazing metal scene

I just spent the last week in the amazing (though cold) country of Sweden. On my last day there, I was wandering lost in downtown Stockholm and stopped to ask an older gentleman for directions. He asked where I was from, I told him I was from Michigan.

“Yes, I’ve been there. It has approximately the same population as Sweden, and approximately the same GDP.”

I became instantly depressed as I realized that he was absolutely right. The similarities between Sweden and Michigan are vast. Both are cold areas surrounded by water and both are sufficiently blessed with natural and human resources to support a deep manufacturing sector.

By no coincidence at all, both areas are full of people of Swedish decent.

However, despite having similar social, natural and economic bases, the differences between Sweden and Michigan are immense. In contrast to Michigan, all Swedes have health insurance. In contrast to Michigan, all Swedes have heat. In contrast to Michigan, all Swedes have the right to political representation. Foreigners are even allowed to vote in local elections. In contrast to Michigan, the large majority of Swedes have jobs that allow them to live a healthy middle class existence.

Most importantly, in contrast to Michigan, Sweden has one of the most active, dynamic and vibrant economies on the planet. In fact, riding in from the airport, one sees the headquarters of companies one would expect to see in a place like Michigan, world class manufacturing and tech companies that are all employing Swedes. In fact, Sweden is desperate for labor to support its booming economy. If you have any type of skill, there’s a job in Sweden waiting for you.

Sweden is the most economically equal country on the planet. The Gini coefficient for Sweden in .23 vs. Michigan’s depressing .45, the same as that of Bulgaria or Guyana.

Sweden has some of the highest taxes on the planet. A full half of income can be sent to the Swedish Tax Service. Sales taxes top 25% for most items. Alcohol is taxed at 100%. Taxes make up nearly half of Sweden’s GDP.

It’s a Republican’s nightmare. High taxes, high regulation, high levels of market distorting subsidies on food and public services, heavy rules on public behavior and heavy rules on wages and working conditions. It’s Ron Paul’s worst case scenario.

Despite this, Sweden has one of the most exciting economies on the planet. It is one of the most pro-business places I’ve ever been.

Contrary to Republican logic, this is due, in large part, to guarantees of government provided guarantees of quality health care for all that relieve businesses of having to bear responsibility for creating insurance plans. If the large number of boutique vinyl shops all over Stockholm are any indication, anyone can start a small business in Sweden. In America, one has to do without health insurance to start a business, a risk that only the wealthiest can bear.

In Sweden, like health care, pensions and unemployment insurance are funded through citizen contributions. This means that private businesses don’t run into the problem of becoming bankrupt when they lack money to fund their pension plans.

The Swedes are highly educated and healthy. This means that foreign businesses wanting to set up shop in Sweden have a vast pool of highly educated and able potential workers to draw from. In fact, Sweden’s biggest problem right seems to be that it lacks UNskilled service workers.

All of this is in contrast to the disastrous situation of Michigan, where we have gutted public education to the point where we have one of the highest drop out rates in the country. We get stupider by the day. Nearly 15% of Michiganders lack access to health insurance. Michigan workers are too sick and too uneducated to meaningfully contribute to the economy. Worse yet, the recent installation of emergency financial managers has erased any potential for improvement. Nearly half (note: the poorest half) of Michigan lacks political representation in 2012, clearly a dream come true for Republicans everywhere.

Why would any business come to a place like Michigan?

Mostly, I’ve returned depressed. Michigan had its chance and it blew it. Exactly why do I live here?

An Airport Layover, ITN Wedding Veils, Science Fiction in Africa

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).

Malaria Deaths Higher Than Previously Thought: Or Not?

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
[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
[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……


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