The Global Pulse Journal Blog

With heavy flooding covering much of the country and leaving millions of people homeless in Pakistan, concerns over the potential for a major outbreak of cholera are growing. With continuing rains throughout the region, Dr. Michael Merson, the founding director of the Duke Global Health Institute believes that ”Basically there is no question” there’s a major risk of an outbreak. With a lack of adequate aid to the area to ensure a consistent, clean water supply, the risk of this diarrheal illness is immense. While the flood has already killed over 1,500 people thus far, even more are at risk from a potential cholera outbreak with 3.5 million people in Pakistan lacking access to clean water. In the past year, cholera epidemics in Zimbabwe killed over 4,000 people with over 350 killed by the disease in Nigeria over the last three months, demonstrating the deadliness of this disease. Without adequate rehydration therapy, victims can die within a day or two from overwhelming dehydration secondary to extreme diarrhea with up to a liter of stool output every hour. But with adequate rehydration therapy to replace fluids and restore electrolytes, death rates can be lowered to less than one percent.

The World Bank and USAID are hosting a series of debates exploring emerging issues in global responses to HIV/AIDS and worldwide evolving approaches to development aid, .  The debates attempt to lay out the best evidence and information available to assist world governments, civil society organizations, and other development organizations in interpreting and responding to the shifting dynamics of the epidemic and our collective responses to the challenges it presents.

This global discussion series began this past May with a debate entitled “Test and Treat: Can We Treat Our Way Out of the HIV Epidemic?” which looked at testing and treating strategies with a focus on their role in Africa.

In June, a debate on “Behavior Change in HIV Prevention” took place looking at dynamics involved in behavior change approaches and their past ineffectiveness.

Check out these past debates and the ones still to come including theis week’s August 26th debate on “Discordant Couples and HIV Transmission” and continue to follow this debate series for future conversations.

Recently members of several major corporations including Nike, EBay and the Modernizing Foreign Assistance Network (MFAN) presented an open letter calling on the US government and President Obama to take an innovative approach to carrying out the goals and visions committed to at the recent G8 summit and to develop a US global development strategy. They call on US leaders and Congress to develop a rewritten US development Act to replace the outdated 1961 Foreign Assistance Act. They discuss an approach to modernize foreign assistance in the global arena.

80,000 – the number of manufactured chemicals in use in the US.

62,000 – chemicals that were “grandfathered” in by the 1976 Toxic Substances Control Act (TSCA) and therefore unstudied as to their health and environmental safety.

200 – chemicals tested for their safety under TSCA.

1,000,000+ tons – amount of Bisphenol A (BPA) consumed in the US in 2004, before widespread recognition of its multiple adverse health impacts.

The US public, and now the outsourced manufacturing hubs in China, India and other places worldwide, are essentially participating in a giant experimental trial with the chemicals in our foods, our clothes, our cleaners, plastics, and virtually everything we use.  H.R. 5820 the Toxic Chemical Safety Act, currently under consideration in Congress would begin the process of re-assessing the safety of these chemicals on the loose and replace the ineffective Toxic Substances Control Act.

The new legislation marks a shift in the regulatory philosophy towards new chemicals. Historically, the US favored self-regulation of the industry and allowed the industry to innovate without much concern for long-term effects. This new legislation follows the lead of the Precautionary Principle by beginning to assess the safety of products before they are released into the market.

Perhaps most troubling from a health perspective, aside from the fact that many of these molecules have not been tested for their long term chronic exposure safety, but that even with those that have been tested, few, if any, have had their safety assessed in the context of the myriad of other chemicals that we use on a daily basis. While it has shortcomings, HR 5820 is a step in the right direction.

For more info and perspectives see:

House Panel Tackles Chemical Legislation | EHS Today.

http://www.huffingtonpost.com/rev-fletcher-harper/choose-life-the-religious_b_662234.html

http://www.opencongress.org/bill/111-h5820/show

http://blogs.edf.org/nanotechnology/2010/07/30/not-playing-nice-the-american-chemistry-council-solidifies-its-claim-to-being-the-industry-of-no/

http://mollyannaapproach.blogspot.com/2010/07/house-members-witnesses-clash-over.html

A recently released working paper by Joel Cohen of Rockefeller University reviews important demographic trends expected to occur between 2010 and 2050. In this report, based on a lecture that was part of CGD’s Demographics and Development in the 21st Century initiative, the author explores the role of population in development and indicates some of their implications for economic and global development. Additionally, he suggests some possible policies to respond to these trends and their implications.

With the highest recorded global population growth rate and the most enormous demographic shift ever between the more developed and less developed regions, the century from 1950 to 2050 saw dramatic changes in global development. It is still unforeseen whether this pattern of human development will remain sustainable. This paper explores the ways in which policy could respond to unmet human needs, many of which have arisen from human choices rather than biophysical necessities.

Today’s post continues to explore the debate over U.S. contribution to funding for combating global AIDS. It features contributions by Anand Reddi, author of the article highlighted earlier (United States global health policy: HIV/AIDS, maternal and child health, and The President’s Emergency Plan for AIDS Relief).  A former Fulbright Scholar, Anand serves on the board of directors of the AIDS Healthcare Foundation, and is a student at the University of Colorado School of Medicine.

In a recent article on Huffington Post, Dr. Ezekiel J. Emanuel, special advisor for health policy in the OMB, defends the Obama Administration’s decision to shift some of the funding away from successful AIDS treatment efforts:

This comprehensive and integrated approach is what the President’s Global Health Initiative is all about. It recognizes that we can’t treat our way out of the HIV-AIDS epidemic. The key to ending it is to reduce the number of those who become HIV-positive in the long-term – and that takes improving their overall health and the health systems around them. After all, patients don’t come to doctors with one disease or condition, and our response shouldn’t focus on one as well.

Dr. Emanuel writes in response to widespread criticism of the Obama Administration during the International AIDS Conference in Vienna, as well as to the July 20^th New York Times op-ed by Archbishop Desmond Tutu, who writes:

During my life, I’ve witnessed amazing advances in medical science. New treatments turn H.I.V. infection from a death sentence to a manageable illness. The cost of treating it is a small fraction of what it was 10 years ago. Meanwhile, more and more African nations have invested in the public health infrastructure needed to distribute AIDS drugs. I appreciate that tough financial times require the United States government to cut spending. But scaling back America’s financial commitments to AIDS programs could wipe away decades of progress in Africa.

Anand Reddi responds on Huffington Post and specifically counters the argument that “we can’t treat our way out” of the epidemic:

Results by Dr. Julio Montaner published in The Lancet demonstrated that provision of antiretroviral therapy in British Columbia halved the rate of new infections. The Economist writes the study by Montaner is “the strongest confirmation yet that treatment and prevention are two sides of the same coin.”  Treating our way out is indeed possible.  In our recent article in AIDS, Sarah Leeper and I demonstrated the unique dynamic-reciprocal relationship that HIV/AIDS, TB, and Malaria have on maternal and child health and vice-versa in the resource limited setting. I salute Dr. Emanuel for forwarding the dialogue on global health and advocating for comprehensive, integrated, cost-effective models of care that advance not just HIV/AIDS but other important health priorities including maternal and child health. Given that the provision of antiretroviral treatment can actually lead to prevention, eradication of new HIV infections is possible if the world community remains fully committed to funding cost-effective antiretroviral treatment initiatives.

Further reading:

• Anand Reddi’s previous article about AIDS funding on Huffington Post.
• The CID journal article by Rochelle Walensky and Daniel Kuritzkes, from the Center for AIDS Research at Harvard Medical School, that Archbishop Tutu references in his letter.

A  new survey from the Centers for Disease Control and Prevention (CDC) suggests that  heterosexuals living in impoverished communities are as much as five times more likely to be HIV-positive than the general U.S. population, regardless of race or ethnicity. In the US, the overall HIV prevalence rate for African Americans is eight times the rate for whites, and the rate for Latinos is three times the rate for whites. Yet in very-low income areas this CDC study found that these disparities do not exist. The study examined 9,000 people in 23 cities, finding that 2.1% of heterosexuals living in high-poverty urban areas were infected with the HIV virus, including 2.4% of those living below the poverty line and 1.2% of those living above it. This is in comparison to the 0.45% rate of HIV infection in the general US population. The authors hypothesize that the findings could account for many of the ethnic and racial disparities in HIV infections in this country, since African Americans are 4.5 times as likely and Latinos four times as likely as whites to live in poverty.

In today’s guest post, recent medical graduate Laura Janneck, MD, MPH reflects on an elective course in social medicine she took in Uganda. Dr. Janneck is an AMSA alum, and now a resident in Emergency Medicine at Brigham & Women’s Hospital, Boston. For further information about the course, see details below.

Over the course of my involvement in global health during medical school, I began to narrow my interests toward humanitarian assistance and global health delivery in post-conflict settings. Last year, during my fourth year of medical school, I participated in a new course on social medicine being taught in Gulu, northern Uganda, a region that is recently recovering from a 20 year civil conflict. This course, called Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness was very well organized, with didactics on a range of topics from the health consequences of internal displacement, to the portrayal of Africans in the Western media. We also were able to spend time on the wards seeing patients with a range of diseases and syndromes common in the region. The keystone of this course, however, is the international student body. Half of the medical students study at Gulu University and hailed from around Uganda. The other half were American and European. This enabled fantastic discussions with different perspectives on the issues we were studying, and planted the seeds of long-term friendships between colleagues from around the world. I enjoyed my time there so much that I went back to Gulu for another clinical rotation later that semester.

If you have any questions about the course or are interested in applying, please email the course directors at: social.medicine@yahoo.com. Applications are due July 30, 2010.

Is funding for global HIV/AIDS programs too “vertical”?  Faced with funding shortfalls, should donor countries put the brakes on AIDS funding in favor of other  initiatives, ones that propose to address a broader range of health problems?  This proposal has drawn the anger of AIDS activists the world over, and is now the subject of passionate debate in Vienna. Back home, two medical students examine the Obama Administration’s plan to let PEPFAR funding flatline while promoting a new Maternal and Child Health (MCH) initiative.  In a commentary published in AIDS, Sarah C. Leeper (Warren Alpert Medical School of Brown University) and Anand Reddi (University of Colorado School of Medicine) take on the claim one argument at a time:

The architects of the Obama administration’s Global Health Initiative recommend funding the Mother and Child Campaign at the expense of future funding increases for PEPFAR. The idea that differing global health initiativesmust compete with each other lacks not only ethical legitimacy but also scientific merit. Confronting illness in isolation – whether by funding PEPFAR at the expense of programs that targetMCH or vice versa – cannot be our way forward. Policies that de-emphasize PEPFAR threaten to undermine,rather than support, MCH in countries with high HIV/AIDS prevalence [PubMed; full-text].

The strongest scientific-journal rebuttal yet to the Obama Administration’s proposal to shift resources to maternal and child health at the expense of HIV/AIDS treatment scale up comes from two medical students, who in a commentary just published in AIDS make a clear and convincing case that such a move would actually undermine the health of women and children around the globe, not improve it.

UNAIDS estimates that the cost needed to continue global HIV treatment in 2009 will be about US$9 billion.

Related reading:

• Denny CC and Emanuel EJ. “US Health Aid Beyond PEPFAR: The Mother & Child Campaign.” (JAMA,  11/2008.)
• “At Front Lines, AIDS War Is Falling Apart” (NYTimes, 05/05/2010)
• “Donor AIDS” (The Lancet Student, 05/14/2010)
• Jennifer Weinberg’s post on the Administration’s effort to address global maternal, newborn, and child health needs (GP Blog, 06/17/2010)
• “Obama ‘hurt’ by AIDS funding criticism” (The Guardian, 06/21/2010)

The International AIDS Society in partnership with the Kaiser Family Foundation is providing online access to various developments taking place at the XVIII International AIDS Conference (AIDS 2010),  in Vienna, Austria.

Selected sessions are webcast live each day with past sessions also available for viewing. Find the complete guide-to-coverage as well as the webcasts already available for viewing including the Opening Session, Monday’s plenary with former President Bill Clinton, and Tuesday’s session on the study which found Microbicides containing HIV drugs lower the infection risk in women.

Today’s schedule includes: