Month: November 2014

THE NEED TO KEEP EBOLA ON THE FRONT PAGES

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I had already started to pen this weeks article when a few headlines/comments/articles caught my eye, forcing me to push it onto the back burner, as I feel this issue is more pertinent and pressing.

A tweet from Laurie Garrett had me concerned. She tweeted; Google News no longer ranks #Ebola in top 20 search items, and even within the health category, only in the Italian and USA news-feeds. This was then followed by a press release from the UN (United Nations’ Ebola Emergency Response Mission – UNMEER) stating that they will miss their December the 1st containment target, due to escalating numbers of cases in Sierra Leone.

The kicker, that then really got me switching my thought train was a press release from the the nonprofit ONE.org (http://www.one.org/us/ebola-tracker/). The Ebola Response Tracker follows the money and shows us the money; i.e.: how much that has been pledged, has made it onto the ground in West Africa to fight the good fight. While the Office for the Coordination of Humanitarian Affairs (OCHA), the UN, and the World Bank have data on the dollar figures associated with each pledge, no one had taken the time to figure out how much of those resources have actually made it to the ground in West Africa.

Erin Hohlfelder, global health policy director at ONE and the brains behind the tracker, says the tracker shows the importance in transparency (and the follow through on ones commitment). “It’s one thing to make a great pledge and commit to doing that, but in the meantime, every day that goes by without these resources is a missed opportunity.”

While progress has been made in the months since these pledges, there is still much work to be done. The USA leads the pack with the highest pledge and disbursement; $572 million of which 72% has made it to the ground in West Africa. Here is a sampling of a few other countries, foundations and institutions: (in no particular order)

Google/Larry Page Family Foundation pledged $25 million – none disbursed yet

Bill & Melinda Gates Foundation $50 million – 27% disbursed

African Development Bank $220 million – 20% disbursed

Paul G. Allen Family Foundation – $100 million 3% disbursed

Silicon Valley Community Foundation $25 million – none disbursed yet

EU $468 million – 17.5% disbursed

China $123 million – 8% disbursed

Australia $36 million – 38% disbursed

Visit their website to check out other countries and follow them on twitter and facebook.

At a press conference last week, Liberian President Ellen Johnson Sirleaf said that the progress her country has made may be damaging. “Our government remains concerned that progress in this battle will lead to complacency on the part of the international community. We must not interpret gains as an outright victory—nothing could be more dangerous.” Complacency must not be allowed to seep in, we need to keep the issues on the front pages. Margaret Chan, director of the World Health Organization, agrees on the complacency front; “We must not forget—Ebola virus is a formidable enemy. Yes, we are seeing some early signals of hope. Cases are stabilizing, we are also seeing some new areas where they are reporting new cases. We must maintain our vigilance. Complacency would be our enemy. And in order to get it to zero, we have been successful in bending the curve a bit, but we need to continue to do more to get to zero.”

The fight is still in the early stages, we must aggressively push to keep Ebola in the news and for more action on the ground. The international response is being outpaced by this epidemic, If more help doesn’t arrive soon, the worst may not be over. Ebola hasn’t simply overwhelmed these health-care systems, it has decimated them. Women in need of support for childbirth have been turned away, leading to an increase in infant morality rates in a region with the some of the highest numbers in the world. Children suffering from malaria or extreme diarrhea are now too often left without medical care, leading to an increase in deaths from dehydration. Life-saving vaccines for those illnesses and others are lying unused in clinics and warehouses, as there are not enough (or any) medical workers to disburse them. Crops are not being planted, food is not making it to the market places!

UNMEER was set up to provide coordination, policy and logistics rather than to treat patients. It needs more resources to halt Ebola as quickly as possible, at present the emphasis is on allocating existing resources in the smartest way, possibly because they are still waiting for more resources/pledges/manpower to make it to the ground in West Africa.

According to October estimates from the World Bank, the epidemic could cost the West African countries affected upward of $32 billion in the next 24 months. What are we waiting for! Every day spent without pledges being delivered on, manpower to hit the ground and the process of rebuilding shattered healthcare services and networks; more people die. Containing Ebola is a constant battle and already we are seeing it cropping up in Mali, where to next?

I will let Anthony Banbury from UNMEER end this weeks blog:

Containing the epidemic still calls for a tremendous increase in resources on the ground. We are far, far away from ending this crisis, there is a long battle ahead of us.

MEDICAL RESEARCH – AN EVIDENCE BASED APPROACH TO GLOBAL HEALTH

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A question posed by Jessica Taaffe on twitter, who is a TWIGH panelist, is my inspiration for this weeks blog. The question posed was: If you were to list three major research gaps for access to medicines what would they be? I posted 2 comments to that statement, the 140 characters per tweet, was not enough to fully weigh into the matter, so I am using this weeks post as a soapbox to expand further.

Firstly you might be asking what does this have to do with global health? In a nutshell, it has a huge impact, access to medicines, is dependent on the research that underpins it, it is the foundation on which medicine that we use stands. How firmly it stands depends on the strength of the research. If the road travelled to arrive at the end product is not evidence based (we will discuss the vagaries of this shortly), we then run the risk of having a flawed product, or even in some cases a product that never sees the light of day, (see my blog on Politics and Medicine).

The two comments I posted to twitter stated that evidence based medicine must be driven by independent clinicians, scientists and medical policy makers. Furthermore I stated that Levels of Evidence A (LOE – A) must be the benchmark. We cannot just be led by the large multinationals (Pharma and Medical Device Industries), they can most certainly push money into research, but the parameters of that research must be in the hands of independent clinicians, shared decision making can and must play a key role. This is a huge challenge but must be addressed, we need to claim back the labs and work alongside the drug and medical device industries

So what is evidence based medicine , why is it important and why do I say the we need to adhere to LOE -A?

Evidence based medicine grew out of critical appraisal, when Gordon Guyatt took over as the director of the internal medicine registry programme at McMaster University. He wanted to change the program so that physicians managed patients based not on what authorities told them to do but on what the evidence showed worked. It then appeared in an article in “The Rational Clinical Examination” series in Journal of the American Medical Association (JAMA) in 1992.

The strength of evidence is assessed by a specific grading system which, in fact, is quite simple. It combines a description of the existence and types of studies supporting a certain recommendation.

-Level of evidence A: recommendation based on evidence from multiple randomized trials or meta-analyses

-Level of evidence B: recommendation based on evidence from a single randomized trial or non-randomized studies

-Level of evidence C: recommendation based on expert opinion, case studies, or standards of care.

So the highest standard to attain is LOE – A, is this always the case? In 2009, a very interesting paper was published in JAMA, assessing the strength of evidence underlying the American College of Cardiology (ACC) and the American Heart Association (AHA) practice guidelines. They were reviewing recommendations to see if they were based on strong levels of evidence (LOE – A) and how much is based on “expert” opinion.

In only 11% of the guidelines published was LOE – A the benchmark, and most of the current guidelines included more than 50% of LOE – C as the standard! The authors correctly concluded that “expert opinion remains a dominant driver of clinical practice, particularly in certain topic areas, highlighting the need for clinical research in these fields”. I am sure if we had to review other areas of medical research we will be in a similar ballpark.

I can cite numerous examples from my own area of speciality where we have used certain drugs for years, with no studies definitely stating that they were beneficial to the patient, but there use was continued because of expert opinion, what drove that expert opinion is open to debate.

The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of “unfiltered” data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.

This is where the Cochrane Review stands the test of time, as it enable the practice of evidence-based health care, where health care decisions can be made based on the best available research, which is systematically assessed and summarised in a Cochrane Review. Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.

In closing then, to come back to the original question; what three major research gaps for access to medicines:

  1. Research must be evidence based with LOE-A as the gold standard

  2. Research must be driven by independent clinicians, scientists and medical policy makers

  3. Research needs to be taken back to the labs and institutions who will research what is needed globally.

We would need large NGO’s such as the WHO and the European Research Council (amongst others) to monitor and guide where research needs to be focussed. We need to thank all scientists, inventors, and researchers who are motivated by the need to know, the thrill of discovery,and the desire to make a positive contribution to mankind as a whole and acknowledge the right of people to the common ownership of medicines/vaccines etc. which are basic to their common and individual well being, as to life itself.

As the cognitive linguist George Lakoff puts it, “Empathy is at the heart of real rationality, because it goes to the heart of our values, which are the basis of our sense of justice. Empathy is the reason we have the principles of freedom and fairness, which are necessary components of justice.”

MALNOURISHMENT – A GROWING CONCERN – Food as a Weapon

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The number of hungry people has fallen by over 200-million since 1992, so says the 2014 Hunger Map and a report titled “The State of Food Insecurity in the World: Strengthening the Enabling Environment for Food Security and Nutrition” jointly prepared by World Food Programme (WFP), the Food and Agriculture Organisation (FAO) and the International Fund for Agricultural Development (IFAD).

They go on to say that 805 million people, or one in nine of the world’s population, go to bed hungry each night. But in Sub-Saharan Africa, this is even worse, with one in four people suffering from undernourishment. The report says that sub-Saharan Africa faces the most severe challenges in securing its food; mainly due to sluggish income growth, high poverty rates and poor infrastructure, which hampers physical and distributional access.

It states: “In general, in Africa, there has been insufficient progress towards international hunger targets, especially in the sub-Saharan region,”

The report also says limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities, while the region continues to face challenges in improving dietary quality and diversity, particularly for the poor. I did some work in the Southern DRC (based out of Lubumbashi in 2006) and we noted then that dehydration, was the leading cause of death in children under the age of 5. Dehydration as the result of diarrhoea, caused by unsanitary drinking water. For those who survive they are then in turn faced with stunted growth, which is made worse by poor food nourishment.

This report just published confirms that the situation has not changed in the past 8 years, limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities. In fact the report notes, that progress has been so poor, that the WFP target of halving the number of undernourished people by 2015, will not be realised.

The report highlights the following to move forward:

1. Sustained political commitment at the highest level
2. Placing food security and nutrition at the top of the political agenda
3. Creating an enabling environment for improving food security and nutrition through adequate investments
4. Better policies, legal frameworks and stakeholder participation
5. Institutional reforms are also needed to promote and sustain progress.

Plus an integrated plan focussing on:

1. Public and private investments to raise agricultural productivity
2. Better access to inputs, land, services, technologies and markets
3. Measures to promote rural development
4. Social protection for the most vulnerable (persons and countries)
5. Including strengthening their resilience to conflicts and natural disasters
6. Specific nutrition programmes, especially to address micro-nutrient deficiencies in mothers and children under five.
As reports go it is a very good piece of work tackling many complex issues and outlining clear broad action plans. As with most reports though, I take issue with their expected outcomes, to broad, not specific and in my opinion, to broad. Its like position papers from government departments or even aid agencies. It does not tackle the problem head stating what is at fault and what needs to be done in clear action plans; to do that will require stepping on toes or worse – maybe even naming names!

Regional conflicts, greedy power hungry warlords all demanding access to food, how it is priced and distributed. This can affect when and if crops are planted, and who gets the produce, and they who sells it. Food can be and is used as a weapon, to control people or even to get votes, Zimbabwe and South Africa are cases in point.

The cost of food is then another key factor, Lester Brown wrote in 2011’s “Food Issue” of the Foreign Policy magazine:

Americans generally spend less than 10% of their income on food, but there are 2 billion people who live in poverty around the globe who spend 50 to 70 percent of their income on food.

A slight increase in the cost of food for these persons could be life or death, and the costs when they do escalate, are beyond the control of the consumer, at times manipulated by external forces, for their own (political or economic) gain.

On a sad and macabre note, Saudi Arabia, South Korea and China ventured beyond their borders in 2008 to grow grain in cheaper regions, such as Ethiopia and Sudan, where, of course, people where starving and did not get any of the planted grain.

So where to from here; I think if we cast our eyes to Burkina Faso, we might see a way out, People Power. The people need to speak and speak loudly in the only way the politicians and regional leaders will listen.