Archive for the ‘Research’ Category
It’s been more than two years since we reported on Seattle as the new Geneva, that is, as the new epicenter of global health activity. An article in this morning Journal-Sentinel (Water-engineering firms see potential, challenge in developing countries) – which includes an exclusive interview with the Acumen Fund’s chief executive Jacqueline Novogratz – suggests that Milwaukee is angling to do the same for water technology:
It’s an issue that almost certainly will preoccupy business leaders in metro Milwaukee in their strategy to brand the region as an international hub of water technology. The metro area is home to scores of water-engineering companies. Gov. Jim Doyle and the University of Wisconsin-Milwaukee this month announced plans to invest millions of dollars for UWM to become a center of freshwater research.
An 2008 article from the same newspaper (Area’s tide could turn on water technology) provides more evidence:
[F]our of the world’s 11 largest water-technology companies have a significant presence in southeastern Wisconsin, according to an analysis of data from a new Goldman Sachs report.
Wall Street has tracked automakers, railroads and retailers almost since there were stocks and bonds. But water remains a novelty. Goldman Sachs Group Inc. didn’t begin to research water treatment as a stand-alone industrial sector until late 2005.
While several large MNCs have shown an active interest in clean water in developing countries (e.g., Procter and Gamble, Vestergaard Frandsen, Dow) open questions remain as to what role large MNCs will play in providing access to safe water for the one billion people who don’t have it.
(Thanks to Dr. Jessica Granderson for sending the link)
Cross-posted from Design Research for Global Health.
Giving talks is not one of my strong suits, but it seems to be a part of the job requirement. Earlier this month, I had the opportunity (even though I’m no good, I do consider it an opportunity), to give a couple talks, one to the Interdisciplinary MPH Program at Berkeley and one to a group of undergraduate design students, also at Berkeley. Despite the difference in focus, age, and experience of the two groups, the topic was roughly the same: How do we effectively use design thinking as an approach in public health?
The first session was so-so, and I suspect that the few people who were excited about it were probably excited in spite of the talk. It started well, but about halfway through, something began to feel very wrong and that feeling didn’t go away until some time later that evening. Afterwards, I received direct feedback from the instructor and from the students in the form of an evaluation. I recommend this if it is ever presented as an option. Like any “accident”, this one was a “confluence of factors”: lack of clarity and specificity, allowing the discussion to get sidetracked, poor posture, and a tone that conveyed a lack of excitement for the topic.
It’s one thing to get feedback like this, another to act on it.
The second session went much better, gauging by the student feedback, the comments from the instructor, and my own observations. This in spite of a larger group (60 vs. 20) that would be harder to motivate (undergraduates with midterms vs. professionals working on applied problems in public health). I chalk it all up to preparation and planning. Certainly there are people that are capable of doing a great job without preparation – I just don’t think I’m one of those people.
Most of that preparation by the way was not on slides. I did use slides, but only had five for an hour session and that still proved to be too many. Most of the time that I spent on slides, I spent developing a single custom visual to convey precisely the information that was relevant to the students during this session (see image). The rest of the preparation was spent understanding the audience needs by speaking to those running the class; developing a detailed plan for the hour, focusing on how to make the session a highly interactive learning experience; designing quality handouts to support the interactive exercise; and doing my necessary homework. For this last one, I spent 20 minutes on the phone with a surgeon friend, since the session was built around a case study discussing surgical complications and design.
Three resources I found really useful:
- Why Bad Presentations Happen to Good Causes, Andy Goodman, 2006. This commissioned report was developed to help NGOs with their presentations, but I think there is value here for anyone whose work involves presentations. It is evidence-based and provides practical guidance on session design, delivery, slides (PowerPoint), and logistics. Most importantly, it is available as a free download. I was fortunate enough to pick up a used copy of the print edition for US$9 at my local bookstore, which was worth the investment for me because of the design of the physical book. It’s out-of-print now and it looks like the online used copies are quite expensive – at least 3x what I paid – so I recommend the PDF.
- Envisioning Information, Edward Tufte, 1990. I read this when I was writing my dissertation. Folks in design all know about Tufte, but I still recommend a periodic refresher. This is the sort of book that will stay on my shelf. Also potentially useful is The Visual Display of Quantitative Information. For those working in global health, don’t forget how important the display of information can be: (a) Bill Gates and the NYTimes, (b) Hans Rosling at TED.
- Software for creating quality graphics. The drawing tools built into typical office applications, though they have improved in recent years, are still limited in their capability and flexibility, especially if you’re looking at #2 above. In the past 10 days, three people in my socio-professional network have solicited advice on such standalone tools, OmniGraffle (for Mac) and Visio (Windows): a graphic designer in New York, an energy research scientist in California, and a healthcare researcher in DC. Both are great options. I use OmniGraffle these days, though I used to use Visio a few years back. If cost is an issue, there are open-source alternatives available, though I’m not at all familiar with them (e.g., the Pencil plug-in for Firefox).
Last Thursday, I had the opportunity to view a PhotoVoice exhibition at the University of California, Berkeley organized by Haath Mein Sehat (HMS), a group working to improve access to clean water and sanitation in six slums of Hubballi and Mumbai, including Dharavi.
It was exciting to see a group effectively blend the advocacy elements of PhotoVoice with the design elements of cultural probes. The difference between the two approaches is less in the methods and more in the use of the outputs. In this case, they organized the exhibition to raise awareness and break down stereotypes of slum life, and they are using the photographic corpus to guide the design of both programs and technologies related to their core mission.
What I was most interested in from a design perspective were the instructions given to community photographers and how this tied back to the mission of HMS. The results below followed from the simple prompt: “Represent your daily experience with water”.
A few days back Aman wrote a post about Google Flu Trends. Thought I’d add a few thoughts here after reading the draft manuscript that the Google-CDC team posted in advance of its publication in Nature.
By the way, here’s what Nature says: Because of the immediate public-health implications of this paper, Nature supports the Google and the CDC decision to release this information to the public in advance of a formal publication date for the research. The paper has been subjected to the usual rigor of peer review and is accepted in principle. Nature feels the public-health consideration here makes it appropriate to relax our embargo rule
Ginsberg J, Mohebbi MH, Patel RS, Brammer L, Smolinski MS, Brilliant L. Detecting influenza epidemics using search engine query data. Draft manuscript for Nature. Retrieved 14 Nov 2008.
Assuming that few folks will read the manuscript or the article, here’s some highlights. I should say I appreciated that the article was clearly written. If you need more context, check out Google Flu Trends How does this work?…
- Targets health-seeking behavior of Internet users, particularly Google users [not sure those are different anymore], in the United States for ILI (influenza-like illness)
- Compared to previous work attempting to link online activity to disease prevalence, benefits from volume: hundreds of billions of searches over 5 years
- Key result – reduced reporting lag to one day compared to CDC’s surveillance system of 1-2 weeks
- Spatial resolution based on IP address goes to nearest big city [for example my current IP maps to Oakland, California right now], but the system is right now only looking to the level of states – this is more detailed CDC’s reporting, which is based on 9 U.S. regions
- CDC data was used for model-building (linear logistic regression) as well as comparison [for stats nerds - the comparison was made with held-out data]
- Not all states publish ILI data, but they were still able to achieve a correlation of 0.85 in Utah without training the model on that state’s data
- There have attempted to look at disease outbreaks of enterics and arboviruses, but without success.
- For those familiar with GPHIN and Healthmap, two other online , the major difference is in the data being examined – Flu Trends looks at search terms while the other systems rely on news sources, website, official alerts, and the such
- There is a possibility that this will not model a flu pandemic well since the search behavior used for modeling is based on non-pandemic variety of flu
- The modeling effort was immense – “450 million different models to test each of the candidate queries”
So what does this mean for developing world applications?
Here’s what the authors say: “Though it may be possible for this approach to be applied to any country with a large population of web search users, we cannot currently provide accurate estimates for large parts of the developing world. Even within the developed world, small countries and less common languages may be challenging to accurately survey.”
The key is whether there are detectable changes in search in response to disease outbreaks. This is dependent on Internet volume, health-seeking search behavior, and language. And if there is no baseline data, like with CDC surveillance data, then what is the best strategy for model-building? How valid will models be from one country to another? That probably depends on the countries. Is it perhaps possible to have a less refined output, something like a multi-level warning system for decision makers to followup with on-the-ground resources? Or should we be focusing on news+ like GPHIN and Healthmap?
Another thought is that we could mine SMS traffic for detecting disease outbreaks. The problem becomes more complicated, since we’re now looking at data that is much more complex than search queries. And there is often segmentation due to the presence of multiple phone providers in one area. Even if the data were anonymized, this raises huge privacy concerns. Still it could be a way to tap in to areas with low Internet penetration and to provide detection based on very real-time data.
More than 12 years (let that time horizon sink in) after the first indications of success, there will be a large scale trial for a new malaria vaccine. The potential global health implications of this are obvious, read the full news article, it has some good tidbits in it:
“With the exception of Mosquirix, there’s no possibility of one coming on the market within five or six years…It took eight more years of development and testing before scientists were ready to conduct a large-scale trial of the vaccine. London-based Glaxo and its partners will begin a $100 million study of Mosquirix later this year, vaccinating 16,000 children in seven African countries. If the results are positive, the drug could be on the market as soon as 2011, making it the first vaccine against the deadly disease. “
Here’s your opportunity to influence the global health research agenda: the WHO is asking for global input on their agenda for the 2008 Global Ministerial Forum on Research for Health via meetings with stakeholders, an on-line consultative questionnaire, and will be holding a structured e-forum in Spring 2008 to discuss the agenda. The call for conference papers will be sent out in February 2008, and the Lancet will publish an issue on global health to complement the conference – article submissions for inclusion are due in June 2008. The conference will be held in Bamako, Mali from 17-19 November 2008.
PURPOSE AND MEETING IMPACT
“From Mexico to Mali: a new course for global health” in the 12 January 2008 Lancet spotlights the planning process and expected impact of this meeting. The first meeting was convened in 2004 in Mexico City, and according to Lancet’s article:
“Ministers attending the  summit committed to three key priorities: health-systems research, securing public confidence in research, and bridging the gap between knowledge and action.
These developments might have helped to stimulate the recent explosion of innovative new ideas and initiatives in global health. First, some innovative developing countries (IDCs) such as Brazil, China, India, and South Africa have become important producers of low-cost drugs and vaccines. Second, donors and developing countries have both begun, rightly, to embrace science and technology as key drivers of social and economic development. Read the rest of this entry »
This piece is cross-posted from the Uganda output-based aid (OBA) site which just got a major under-the-hood overhaul in its move to a blog format. The Uganda OBA project contracts private clinics to see qualified patients for complaints of suspected sexually transmitted infections (STIs). Patients who buy a subsidized voucher from local drug shops and pharmacies are entitled to seek care for themselves and their partner at any of the contracted clinics. Clinics are reimbursed on a negotiated fee-for-service schedule.
The following report (“VSHD, 2007, Assessment of OBA Clinic Utilization”) is an evaluation of the OBA program’s first year impact on utilization at participating clinics (July 2006 to June 2007). The study, led by Berkeley graduate students Richard Lowe and Ben Bellows, was undertaken June to August 2007 and required an extensive review of thousands of handwritten lab and outpatient entries at OBA facilities. Records were kept differently at many of the clinics and,at several clinics, data were simply not available. However, we have information from 7 of the 16 clinics and they indicate a strong patient uptake and program improvement in the first year of OBA. One of the more dramatic findings is that the total number of patient visits at contracted clinics increased 226% in the first year of OBA compared to the year before OBA.
It does not appear that patients who have attended OBA clinics simply substituted the OBA voucher for their own out-of-pocket spending. Taking all seven clinics together, the number of non-OBA patients seeking STI treatment actually increased in the first year of OBA. One likely reason is that social marketing stimulated greater demand for STI treatment beyond the voucher-using population.
Program adherence also appears to be improving over the first year of OBA as the number of fully paid claims increased from 30% of all submitted claims in July/August 2006 to 70% of all claims in June 2007. Although it should be stressed that claims quality varied significantly between providers.
There is some concern about the quality of lab testing at participating clinics. Lab technicians could benefit from better on-site follow-up and incentives for high quality diagnoses. However, the percent of positive gonorrhea tests more than doubled, indicating increased awareness of this infection in the community and at provider clinics.
The report paints a detailed picture of the participating clinics in their first year of OBA and it is hoped that findings can be used for program improvement as the expansion is planned.
Our many thanks go to both Microcare and MSI who graciously assisted with our many requests for supplemental data and assistance reaching clinic providers. Many thanks as well to the KfW Development Bank and the Bixby Program at UC Berkeley for funding the research.
BBC reports that “a study published in the Public Library of Science journal by researchers from the Harvard School of Public Health suggests the policy has saved Brazil around $1bn between 2001 and 2005.” The article itself is available freely online as a part of the open access policy of PLoS.
From the Harvard School of Public Health press release:
The results showed that, although costs for Brazil’s locally produced generic antiretroviral drugs (ARVs) increased from 2001 to 2005, the country still saved approximately $1 billion in that time period through controversial price negotiations with multinational pharmaceutical companies for patented ARVs. Since 2001, Brazil has been able to obtain lower prices for patented ARVs by threatening to produce AIDS drugs locally. Though these negotiations initially prompted major declines in AIDS drug spending, HAART costs in Brazil more than doubled from 2004 to 2005. The steep increase reflects the fact that more people living with HIV/AIDS began treatment and are living longer. The increase also reflects the challenges associated with providing complex, costly second- and third-line treatments as people develop resistance to first-line drugs, live longer and require more complex treatment regimens.
Figure 6 from the article – Impact of Alternative Price and Quantity Scenarios on Total ARV Costs, 2001–2005 – shows how the increase in spending is primarily related to increases in quantities rather than costs (Figure 6.A). This figure also shows how much would have been spent if there were no price changes (6.B) and the theoretical minimum that could have been spent by buying the lowest-priced generics on the market (6.C).
Hans Rosling has developed his first GapCast video with more on the way. This has me salivating after watching his TED speech using Gapminder software he helped develop and which was recently bought by Google (for related info to this, see our previous post on Google). Many people have seen the TED video, if you have not seen it, it is an absolute must watch (first video below). For those of you who have seen it, see him debut a new series with GapCast #1 – which is not as dramatic as the TED speech, but does demonstrate the power of his delivery and the software. We need more people to think like Hans – how can we get our message across in a different format, in a format that excites people, in a format they will not forget. The TED video is 20 minutes long, but it is worth it. Really great stuff:
Contribution by Dweep Chanana
Two interesting articles point to the future direction in the pharmaceutical industry:
BusinessWeek writes about Big pharma’s addiction for lifestyle drugs:
Try as they might to distance themselves from the lifestyle drug sector, pharmaceutical companies can’t seem to kick their addiction to these lucrative products. Even as consumers and government regulators grow more alarmed over drug safety, an examination of four popular lifestyle categories—weight loss, hair loss, sleep, and sexual dysfunction—shows that the pharmaceutical industry is by no means shying away from this controversial territory.
The Economist’s analysis of drug patents under attack in the developing world (from Thailand, to India and Brazil) is particularly illuminating:
At first sight, this row reflects an old dilemma that pits today’s patients against tomorrow’s. Compulsory licensing means that more Thais will get HIV drugs now, but it also means that drugs firms will be less keen to invest in drugs for Thailand in the future. Yet look closer and this is more than a fight between the poor-country sick and rich-world drugs companies. What makes it different is the role of two new actors: muscular middle-income countries and the rising generics industry.
What does this mean for drug development? Big pharma’s “truly innovative” drugs are being squeezed, and they can no longer count on a safe regulatory environment. And simultaneously, “lifestyle drugs” offer ample reward. Will innovation suffer – even more?
Beyond bringing to the surface that rhetorical question, the Economist does pose a useful question. The war on patents in the developing world is probably a good thing, as it pushes the envelope on what is legally possible under the Doha agreement – an agreement that has not yet been tested in international courts.
But it does create a problem. Countries such as India, Brazil and Thailand can indeed get cheaper access to certain drugs by issuing compulsory licenses. But the really poor countries cannot do the same as easily – not because they do not have local drug industries, but because they cannot resist pressure from the EU and US as effectively. As the Economist says, “a perverse result of this trend is that middle-income countries are getting cheaper drugs, whereas quieter and perhaps more deserving neighbours are not.”
It also shows how India’s own response to high drug costs will have to be more nuanced in future. India’s generics drug industry benefits from compulsory licensing. But its “R&D intensive” segment of the pharma industry – which includes Dr. Reddy’s and Ranbaxy – suffer. It was that segment that was most euphoric in embracing new TRIPS legislations. Expect them to lobby for stronger – not weaker – patent legislation. At the cost of India’s poor
I want to acknowledge my team members Melissa Ho, Mahad Ibrahim, and Sonesh Surana for co-authoring the winning proposal (PDF linked here) in the Berkeley CITRIS IT for Society Challenge calling for the integration of next generation mobile phone technologies in the scale-up of Uganda output-based aid voucher services (link to the PDF presentation).
The University of California at Berkeley has a strong record in health services research and development of innovative information technologies. The team proposes to investigate the potential for smartphones to improve health service delivery financed in the Ugandan output-based aid (OBA) model. Findings on the feasibility of using smartphones could improve the efficiency and effectiveness of health service delivery with implications for scaling in many developing regions with poor healthcare and limited information technology infrastructure. The proposed strategy will tackle a critical gap in low-income countries’ health care: improving the reporting speed and quality of clinic data between healthcare providers and centrally located managers. Responding to an existing project’s need for improved information infrastructure, the team will test the feasibility of implementing a data reporting system at private clinics treating sexually transmitted infections (STIs) in a largely rural population of southwestern Uganda.
The Berkeley CITRIS IT for Society Challenge takes place as interest continues to grow in the use of mobile computing for healthcare delivery. There have been hundreds of blogposts in the last several months on the topic. I’m reposting ours from Feb 13th just to revisit the topic and a NYT article that got a lot of play in the blogsphere. Talking with researchers since the March 5th article, it’s not clear that Rwandan healthcare providers are as connected as the NYT reported (patient-level data portability is still a difficult goal to achieve at large scale), but I’ll have to get into that in another post.
THD post Feb 13th “Phones 4 Health Partnership with PEPFAR“
NYTimes March 5th “Wireless Technology Speeds Health Services in Rwanda“
Acumen Fund March 20th “Empowering with mobile phone technology“
The International Forum on Quality and Safety in Health Care 2007 is going on now in Barcelona until April 20th. The aim of the conference is to improve health outcomes and quality of care for patients and communities. The Forum is jointly sponsored by the Institute for Healthcare Improvement (IHI) and the BMJ Publishing Group.
The topics covered range from Innovation to Reducing Medical Errors to Applying Quality Improvement methods to the Developing World.
Wednesday 18 April
07:00 GMT/08:00 BST* Donald M Berwick – Can health care ever be safe?
Thursday 19 April
07:30 GMT/08:30 BST* Richard Smith – What the quality movement can learn from other social movements
Friday 20 April
07:15 GMT/08:15 BST* Lucian Leape and Linda Kenney – When things go wrong: communicating about adverse events
11:30 GMT/12:30 BST* Carol Haraden and Allan Frankel – Building and assessing a culture of safety
13:30 GMT/14:30 BST* John Prooi and Harry Molendijk – Partnering for patient safety
The sessions will also be available to download free and on-demand after the event.
* Please note, it is now British Summer Time (BST). If you are viewing the webcast in the UK please refer to the BST time given. If you are viewing outside the UK you can find your local time on
The new combination vaccine candidate Globorix(TM) promises to help control pediatric meningitis in the “meningitis belt” of Africa. Meningitis control has historically depended on expensive last-minute outbreak immunizations, and in 2000, WHO and public health experts called for a sustainable strategy where meningitis vaccine could be administered in general immunization campaigns. Until today no combined conjugate meningococcal vaccine has been available to protect infants in Africa against the disease.
Globorix (TM) is a conjugate vaccine developed by Glaxo-Smith Kline that provides immunity against diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae type b, Neisseria meningitides serogroups A and C. In clinical trials including countries in Africa and Asia, the conjugate meningococcal vaccine has demonstrated a good safety profile and immunogenicity against meningococcal meningitis caused by Neisseria meningitidis serogroups A and C in addition to five other major childhood diseases.
The current meningitis control strategy relies on reactive mass immunization campaigns using polysaccharide vaccines. While these campaigns are estimated to have saved 70% of lives in epidemics, this older type of vaccine has significant drawbacks. Polysaccharide vaccines do not offer protection to infants and in older children and adults they only protect for 3-5 years, leaving them vulnerable to future epidemics. Polysaccharide vaccines also do not address endemic meningitis
OK, so this is a bit of a public service announcement, but I just wanted to give a shout out to anyone with a computer that may be often idle. You know you’re the one if you’ve got a slick new machine and it basically serves as a fancy web browser and text editor with occasional number crunching during the dissertation or that last field report … Consider donating that down time to the World Community Grid.
The World Community Grid has been operating in its current form since November 2005 (you can read about the 2005 launch in the KaiserNetwork archives). They run a few extremely large research efforts on fundamental health science that require extremely large amounts of computer time. You can simply visit WCG, download the secure software, and you’re done. It runs in the background when you’re not using your machine and you contribute to research on genetics, cancer, and HIV. Something to consider anyway. And here’s a link for the kids explaining the science in computational grids.
The really interesting update, as reported in the Washington Post today, that Sony’s PS3 is getting involved in networked computing.
With the next software update for the game console, PS3 owners will be given an option to click an icon for Stanford’s “Folding@home” project and download software that the university has designed to help outsource the computing power of the game consoles (which are essentially computers) needed for some of its research.
The software will run “protein folding” simulations, which help researchers understand why proteins sometimes fold incorrectly and mutate into diseases such as Alzheimer’s and Parkinson’s. Each participating PS3 will periodically download and analyze a chunk of the school’s research, and then upload the results. The software, which is due at the end of the month, will run when the PS3 system is not playing games or performing other multimedia tasks.
You might be wondering what celebrities and babies have to do with chronic diseases in devleoping countries. An article in the New England Journal of Medicine (NEJM) last week implied that sympathy for HIV+ poor babies has an impact on funding for chronic diseases in developing countries (see excerpt 1 below) and that this should be pointed out. This linkage is weak at best, more likely not linked at all, and in either case posits a false dichotomony of supporting a single response to either chronic or infectious diseases.
We may be starting to turn the corner with respect to attention paid to chronic diseases in the “Global South” and let me state up front that I think this is overdue. Health Affairs last week published an excellent piece ["Reducing the Burden of Cardiovascular Disease (CVD) in the Developing World"] and the current issue of the New England Journal of Medicine (NEJM) has two articles on chronic diseases ["Expanding Priorities - Confronting Chronic Disease in Countries with Low Income" and "Obesity and Diabetes in the Developing World"]. I would like to bring your attention to the first NEJM piece ["Expanding Priorities"] by Dr. Anderson, professor at Johns Hopkins.
Jan 18, 2007 NEJM Excerpt 1 (from Expanding Priorities -Confronting Chronic Diseases) – “Sympathy is also a powerful driver of public opinion and funding. When a celebrity holds a baby with AIDS, the heartrending photographs generate attention, compassion, and donations. A photograph of a 40-year-old man with hypertension would be far less compelling, even if we knew he was a father, husband, and primary breadwinner.” [emphasis added].
While my current research focuses largely on chronic diseases and I do understand the frustration of the authors (infectious diseases such as HIV/AIDS get all the attention) there is something critical missing from their overall point. Anderson discusses reasons why more attention is paid to infectious diseases and in my opinion makes a mistake in trying to make comparisons to chronic diseases. In the article he seems to imply that because many more people die from chronic diseases and because the associated treatment is more cost-effective and lower cost compared to HIV/AIDS, we should shift funding and attention to things like hypertension in developing countries. To Anderson’s credit, this message may have not been his intention, after all the article is entitled “Expanding Priorities”, not “Changing Priorities”. I also have to give him credit for his willingness to enter such a potentially contentious debate (if framed as such) . However, the tone, approach, comparisons made, and failure to mention critical aspects about the implications of infectious diseases leaves the article lacking.
It is one thing to call for increased attention to the burden of chronic diseases in the global health arena; however it is entirely another thing to insinuate that there are misaligned priorities (which would be a fine if backed up by a well thought out argument). The critical piece Anderson fails to mention is the tremendous impact on the basic social, cultural, and economic fabric that HIV/AIDS is having in some regions of the world. If people are dying before they get chronic diseases, what would be more prudent – a focus on chronic diseases or a focus on acute infectious diseases (even if chronic disease treatment is lower cost)?
The article on CVD in Health Affairs lays out a much more cogent argument with a different tone that appeals to the cause the authors are trying to make, it is definitely worth reading. I am surprised this article was even published in NEJM. Perhaps I am being too harsh and mis-read the article, if someone has another perspective, I would love to hear it.
Excerpt 2 – NEJM (Expanding Priorities -Confronting Chronic Diseases) “…cardiovascular disease alone accounts for nearly 30% of all deaths worldwide and 10% of all years of healthy life lost to disease…Three infectious diseases — tuberculosis, human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS), and malaria — have attracted the greatest attention from international donors, but together they are responsible for only 10% of the deaths in the world (12% in low-income countries) and 11% of the disability-adjusted life-years (13% in low-income countries). Despite the fact that a substantial burden of disease in the world’s poorer countries is caused by noncommunicable chronic diseases, most international aid agencies have focused primarily on preventing and treating infectious diseases.”
Number of Deaths in Low and Lower Middle Income Regions – NEJM Jan 18th, 2007
Sleeping sickness is estimated to cause 48,000 to 100,000 deaths a year in Sub-Saharan Africa. Effective disease control has been hampered by lack of safe oral drug treatments. Friday, Essential.org’s IPhealth listserv emailed a revised news article from SciDev.Net about a breakthrough cure. The email, prefaced by the Drugs for Neglected Diseases initiative (DNDi), stated that, although DNDi did not agree with the original SciDev.net article, the new drug combination (eflornithine and nifurtimox) appears to be efficacious against the Trypanosoma brucei parasite [Jan 10, "Calls for fast access to sleeping sickness drug"].
According to Girardo Priotto of Doctors Without Borders, “The situation is so desperate in the field that we are not happy with two more years of waiting for the final results of the current trial, so we are looking for ways of extending access to this treatment through additional studies.”…
Thousands of people each year are diagnosed with advanced-stage sleeping sickness, which is fatal if not treated. Current treatment, with the drug melarsoprol, itself causes the death of around six per cent of patients. In addition, some patients are also resistant.
No data were released in this report and it remains unclear how efficacious the new treatment regime may be. ClinicTrials.gov details the study design and collaborators.
More broadly in the neglected diseases field, there is resurgent interest in drug development: from discovery to trials to regulatory approval. OneWorldHealth is a well publicized example [see Oct 8th post "Non Profit Rx Venture"] and several others including Essential.org, DNDi, and the Tropical Disease Initiative [check out the 50 min video on Shannon's Blog], each of which specialize in some link on the drug development chain. The World Health Organization and many high profile partners are also putting more muscle into the neglected diseases fight. Check out the October Preventive Chemotherapy in Human Helminthiasis news release, quoted here:
“Preventive chemotherapy does not necessarily stop infection taking place but it can help to reduce transmission,” the Director of the UN World Health Organization, Department for the Control of Neglected Tropical Diseases, Lorenzo Savioli, said. “The benefit of preventive chemotherapy is that it immediately improves health and prevents irreversible disease in adults.”The approach contained in a newly published manual, Preventive Chemotherapy in Human Helminthiasis, focuses on using a set of low-cost or free drugs to simultaneously treat the four most common diseases caused by worms and afflicting over 1 billion people: river blindness (onchocerciasis), elephantiasis (lymphatic filariasis), chistosomiasis, and soil-transmitted helminthiasis. The cost: as low as 40 cents per person per year.
“In the same way as we protect people against a number of vaccine-preventable diseases throughout their lives, the regular and coordinated use of a few drugs can protect people against worm-induced disease, improving children’s performance at school and the economic productivity of adults,” Mr. Savioli said.
The new approach provides a critical first step in combining treatment for diseases which, although different, require common resources and delivery strategies for control or elimination. The second key component brings together for the first time dozens of agencies, non-governmental organizations (NGOs), pharmaceutical companies and others into a coordinated assault on neglected diseases.
The diseases’ impact can be measured in the impaired growth and development of children, complications during pregnancies, underweight babies, significant and sometimes disabling disfigurements, blindness, social stigma, and reduced economic productivity and household incomes.
These effects can be dramatically reduced by using highly effective drugs of proven quality and excellent safety record – the majority donated free by companies or costing less than $0.40 per person per year, including the cost of the drugs and their delivery.
Another recent development in neglected diseases drug discovery by British researchers [Guardian story, hat tip to Innovation blog] has huge potential cost-savings but, at least according to the Innovation blog, the technique “effectively amounts to a sophisticated form of reverse engineering that skirts patent laws and this is not the same as conducting original drug development.” Definitely a story to watch…
Piya Sorcar, of the Learning, Design and Technology Program at Stanford University is leading Interactive Teaching AIDS (ITA), an initiative to develop “an animation-based curriculum to teach HIV/AIDS awareness and prevention strategies.” There are currently two versions of the application in development, one for India and one “general Asian version”.
I had the opportunity to speak with Piya about her work:
Why cartoon animations?
When I started this project last year, as part of my research I interviewed dozens of people on this subject. I couldn’t understand why so much misinformation was out there about a virus which many organizations have tried to combat through strong dedication and millions of dollars. After many interviews and running an IRB-approved study in India, I realized that people averse to discussing HIV/AIDS because of the stigma associated with its connection to discussing sexual practices. The educational materials are actually quite simple, it is getting the education to the people that is hard. Fighting stigma is not easy and we know this because people are so embarrassed and frightened of asking simple questions that in the long run might save their lives. I wanted to use cartoons to make the subject less embarrassing, to enhance learner comfort. When I originally ran the IRB-approved study in India, I gauged the comfort of students in learning HIV/AIDS material with various illustrations. People were most comfortable with simple graphics and actually, the simple graphics seem to get the points across just fine. It was important to me that individuals learn about this subject while feeling comfortable. I felt that cartoons accomplished this mission.
Why emphasize the biology of HIV/AIDS?
HIV/AIDS is a difficult subject to talk about. There are schools that won’t teach the prevention strategies because of its close ties to sexual practices. What we often forget is that HIV is just a virus, and we study viruses in biology classes all the time. By bringing the subject back to the basics, we can discuss it more openly and clearly. In order to prevent the spread of the virus, it’s important to build a coherent conception of where it lives, how it works and how it is transferred. In order to fully understand this, it’s important not to merely memorize a list of safe actions but to understand why a virus spreads.
What is the underlying pedagogy of this initiative?
There are many pedagogical principles utilized, but I would say the most important is based on the cognitive theory that it is important to create a coherent conception in the mind of the individual learning the material. Since in many countries there are few, if any, requirements for students to learn about HIV/AIDS in educational institutions, they tend to learn about it from mass media campaigns through television, billboards and radio. Although there are strong efforts to disseminate HIV/AIDS information in India (among other countries), because of the nature of the aforementioned education strategies, individuals must make sense of short, out-of-context pieces of information on their own. This often leads to misunderstanding as well as the memorization of random fragmented data, which doesn’t build a clear conceptual map. Interactive Teaching AIDS provides calculated learning steps to provide scaffolding for learners, allowing them to develop a coherent conception of basic biology, bodily fluids, transfer of bodily fluids into the human body, and their application to various actions or scenarios. In addition to building on a cognitive approach, we relied on other learning techniques including the use of mnemonic devices as well as Vygotsky’s scaffolding techniques. [See also: ITA Learning Theory & Rationale]
What is the current status of the projects in India and Korea? What makes those initiatives different from one another?
The Asian version of Interactive Teaching AIDS was fully funded by the Medical Research Information Center in Korea, which is funded by the South Korean government. The storyboard, which was developed at Stanford University, was animated by a professional development team and now needs to be translated into several different languages. We plan to test the production version of the project early next year. The prototype for the Indian version is complete and we have just received funding from a couple donors to create a more industry-ready version. Once that is complete we plan to test it throughout India. We hope the testing will provide us with useful data so we can iterate and make the project more effective. Finally we hope to give it away for free to various AIDS control societies, schools and eventually port to mobile devices so the information can truly be viewed in the privacy of one’s home. We are hoping also to partner with various organizations who are interested in the same goal as us – to promote awareness and prevention methods to people all over the world.
What is the overall assessment plan?
As I mentioned earlier, we hope to test this project with many students in Asia in order to inform our design and create a more effective learning tool. We hope to compare and contrast our work to other AIDS and general health education materials.
What are the key challenges ahead? (development, deployment, adoption, behavior change)
I would love to see the educational content available on all mobile devices across Asia. Perhaps governments and mobile service providers would be interested in partnering with us in order to either make this content freely available to download online or better yet, be preinstalled on the buyers cell phone or PDA. In terms of development the challenge is, of course, to develop something that is fairly short yet still gets the message across using limited screen real-estate. Once we have tested this project widely, hopefully we will have a better idea of what works and what doesn’t work and this will inform us in designing a mobile version of the project. Secondly, since there is no universal platform for cell phones, it will be challenging (not to mention expensive) to develop the animation using various scripts. When I ran the study in India, I was appalled that so many college-educated students were misinformed. The number one question was whether there was a cure for AIDS. My goal right now is to inform masses about the virus and prevention strategies. I think we have a huge problem if the population of the country with the greatest number of HIV/AIDS cases in the world doesn’t have a general understanding of how the virus spreads. Once the goal of educating people has been met, this will hopefully lead to behavior change.
Following Forum 10 in Cairo, the Global Forum for Health Research will be holding it’s next annual meeting, Forum 11, in Beijing from 29 October – 2 November 2007. They have announced a call for abstracts with a deadline of 31 January 2007. From the website:
The Global Forum for Health Research invites you to submit an abstract for Forum 11 in any area of health research relevant to the overarching theme of Equitable Access: Research challenges for health in developing countries. Papers addressing these areas from a national, sub-national or regional perspective are particularly invited. The Global Forum welcomes submissions from all parts of the world and encourages participation from lower income countries. Submissions of abstracts from students are especially encouraged and the best papers will be specially featured in Forum 11.
The five thematic strands are: access to health, innovation, research resources, decision-making, and communication. The website suggests a particular emphasis on gender equity.