While I was a Peace Corps volunteer in Mozambique I had the chance to interview three women from my community who were living with HIV, but receiving treatment thanks to PEPFAR (the United State’s multi-billion dollar initiative to combat HIV). I filmed these women as part of a larger video project about preventing HIV/AIDS in Mozambique.
You can see them and hear what they have to say here: http://www.overstream.net/
Last week in Seattle, the group known as the “Health 8″ — so named in reference to constituting the “G8″ of global health finance — met among a flurry of global health conferences and talks. Sandi Doughton from the Seattle Times reports on who the Health 8 are, and whether the rest of us should care: Seattle Times article on Health 8.
Read health journalist Christine Gorman’s take on the Health 8 at the Global Health Report Blog (follow the “Related Post” link for a more detailed description of the group and what it is supposed to do).
Does the Health 8 represent the potential of high-level coordination for crafting better wide-reaching strategies? Is it fair for some philanthropic organizations to get a seat at high-level tables while others don’t even know that the table is being set? Where is there room for the voices of the people who are supposed to be the ultimate beneficiaries of global health funding? Are evidence-based models being used? What level of transparency is appropriate in such discussions? Where do we draw the line between the institutionalized anarchy of uncoordinated NGO function on one hand, and secret meetings at which the fate of billions is quite literally decided on the other? These are some questions in the air.
And so it begins….the Obama administration is ready to venture into hostile territory, the land of health care reform. To be sure, this precocious administration has already seen the likes of financial calamity and rising unemployment and even cast their environmental policy line in the face of both. They have listened to the dying engine rumbles of Detroit and continue to push progressive tax policies in the face of stern opposition. For many presidencies, all of this would have sufficed to “call it a term”, if you will, but for the Obama team, these are all mere fire-starters. Now, they feel prepared to engage the 60 Years War (this one goes back to the FDR-Truman eras). Many have encroached upon this dynamite field before, armed with reasonable valor and intentions, but none came away with much less than a sound drubbing. So, will Obama prove more tactful, more disarming, or more of the same?
As the ballooning budget is becoming evermore disconcerting to the administration, the handful of Congressmen still identifying as Republican, and the general public, the actual “reform” might undergo a metamorphosis into a series of small concessions from all major stakeholders. Perhaps not, but for your weekly dose of skepticism, pick up the recent version of “cap-and-trade”. After its dilution, the only environmental impact that legislation will have is if they manage to send the bill to the paper-recycling bin. There is a critical mass of support (going well beyond the walls of the White House) for the premier element of the Obama plan, the government managed health insurance plan. However, this is also the most contentious reform proposal. I am not fully aware of how they intend to run this scheme (manage asset, equity, and risk portfolios like private insurance companies?), or most importantly, how they plan to garner the necessary marginal support (at least a few fence dwellers will have to take the decisive step). So, in these regards, I will be watching this particular drama in anticipation along with much of the rest of the country (and likely world). But I can make a recommendation for the near-term while they wage battles for the long-term (insurance companies will never go quietly into the night).
One of the strongest criticisms of the private insurance industry is its trepidation vis-a-vis “adverse selection” (the concept that the sickest are the most likely to seek health insurance…and are also the most likely to prove costly for the insurance company and its risk pool). To hedge against these folks, they actively pursue the statistically healthy and try to screen out those with significant pre-existing health problems. Part of the Obama plan’s mission is to offer a health insurance home to these otherwise beneficiary pariahs, as well as attract any others who are looking for a better deal. Assuming the government scheme desires a risk pool, like other insurance schemes, then I suspect they are hoping that enough relatively healthy, inexpensive shoppers cross the line to dilute the intrinsic risk baggage brought with the least healthy. Could certainly work, but there are some hang-ups. For one thing, there will be immense industry push-back (but that is a foregone conclusion, so no need to dwell upon it). But there may also be some financing issues. The private companies work the hardest to attract the most healthy, least risky clientele. Therefore, it might be quite difficult to win enough of this group over, in the near-term. What may happen is the least healthy are the first to join, followed closely by those able to get insurance but just barely due to their not-so-good statistical health (with a significantly marked up premium). This does not make for such a promising risk pool and may be quite expensive in the short run.
To avoid this (again in the near-term, the long-term is for the administration and the public to decide), they may decide to operate in the facet they know best: the Payables Department. If “pre-existing conditions” keep individuals out of private insurance schemes, then make it the ticket into government sponsorship. In this way, it would now be fashionable to divulge such health problems to demonstrate absolute exclusion from private insurance and then qualify for government protection. The government can then negotiate fees for their care with given institutions and providers and pick up the tab. Conversely, if they want such individuals under a traditional insurance plan, they could accept bids from private insurance companies for this group of patients and then top off the beneficiaries’ (the patients) contributions in order to cover the otherwise unaffordable premiums. Either way, the government will write checks, which is what they will ultimately do irrespective of their scheme’s details. This is just one modality that I think could prove useful and not too expensive in the coming few years. Additionally, the insurance industry may even be amenable to it since it does not make them redundant nor coerce them into accepting their least favorite customers. Furthermore, it could help those not-so-healthy individuals with coverage but also high premiums that I mentioned before. Their premiums could actually slide down a bit and/or more of these riskier customers could be offered attractive private plans due to dilution effects: If the riskiest people in the pool are not leaving the insurance company exposed because they are shielded by the government, then the ratio of least risky to risky (but not riskiest) goes up. Meaning the risky (”not-so-healthy”) could enjoy swimming around a safer pool with lower costing flotation devices (premiums).
As I said before, I offer this only in the interest of political expedience. The administration could use something like this, or something fancier if they so choose in the immediate future while still pushing climactic reform for down the road. However, if their fortitude is not in question and their sense of adventure intact, then good luck soldiers….the war is long and the battles many….but then again, perhaps like never before, the troops are in no short supply.
A quick round-up of cool stuff in global health news:
The Global Health Magazine discusses use of technology for health in resource-poor settings.
The New England Journal of Medicine sets up an Online First page for H1N1 (a.k.a. Swine-Origin Influenza)
Doctors Without Borders / Médecins Sans Frontières release The Photographer, a graphic novel documenting their humanitarian missions in Afghanistan.
More coming soon!
In (somewhat belated) honor of Mother’s Day in the US, I would like to share the following post by Vanessa Coleman at AMPLIFY:
According to the World Health Organization (WHO) , 99% of deaths during childbirth occur in low-income countries. For example, the chance of maternal death in high income countries is 1 in 7300, where as in low income countries it is 1 in 73. As young people, this is especially important and relevant because most of the young women who are dying could very well be our friends, schoolmates and classmates had they lived in a different country (particularly if they had been fortunate enough to live in a high income country as we do). The leading cause of death in young women aged 15-19 in low-income countries is from childbirth complications.
Leading causes of maternal mortality worldwide:
Within the US, maternal mortality rates are hardly cause for complacency. The world’s foremost economic power (pending post-recession change in paradigm), we rank 28th in infant mortality, and 41st in maternal mortality:
Based on 2005 estimates, the U.N. analysis suggests that one in 4,800 women in the United States carry a lifetime risk of death from pregnancy. By contrast, among the 10 top-ranked industrialised countries, fewer than one in 16,400 are facing a similar situation. The reason? According to experts, in many European countries and Japan in the industrialised world, women are guaranteed good-quality health and family planning services that minimise their lifetime risk. Many independent experts and sympathetic legislators hold the current U.S. public health policy responsible for its dismal record because some 47 million U.S. citizens have no access to health insurance, most of them African Americans and other minorities. [IPS News]
Steep disparities in maternal health are linked to ethnicity and socioeconomic status, with African-American women being 4 times more likely to die in childbirth than white women, a point that is alternately called our “national shame”, and goes ignored.
More reading: How do socioeconomic factors affect disparities in mortality? by Deborah Maine, in the Journal of the American Medical Women’s Association, provides some nice historical context on maternal mortality in the US.
We all know the ABC’s of HIV prevention: Abstinence, Be faithful, and use a Condom (the second C is circumcision)- but should we add a D as well? Some evidence suggests that we may need to, for ‘Don’t Smoke’. Cigarette smoking has been linked as a possible independent risk factor for contracting HIV. The exact mechanism by which smoking would increase your risk for HIV is unknown, but it is thought to be by weakening your immune system. You can read about the story here. According to the study (Furber et al., Sexually Transmitted Infections, 8/21), smokers are between 60% and 300% more likely to become infected. There seems to be, however, plenty of room for confounding factors, and more research is needed to clarify the issue.
This past Tuesday, May 5, 2009, President Obama announced a $63 billion global health initiative as part of his 2010 fiscal year budget which begins October 1, 2009. Reflecting the President’s belief that, “We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health,” Obama proposed a six-year health initiative dedicating $63 billion to support programs in the world’s poorest nations. The initiative is targeted at some of the world’s largest global health challenges such as AIDS, TB and maternal health according to Deputy Secretary of State Jack Lew.
The President’s Emergency Plan for AIDS Relief (PEPFAR), a national program initiated during the Bush administration, would receive $51 billion over the six years of the initiative, aimed at AIDS, tuberculosis and malaria. Obama’s plan aims to reach beyond AIDS and dedicate the remaining $12 billion to target other tropical diseases, improve pre- and post-natal care and support child health initiatives. The President’s budget calls to increase the $366 million spent on malaria, AIDS and tuberculosis in 2009 to $7.4 billion in 2010.
The President’s proposal has drawn criticism from many activists who feel that Obama’s plan fails to fulfill his campaign promise to expand PEPFAR by $1 billion a year over the next five years (not six) with a $50 billion pledge towards HIV/AIDS worldwide by 2013. Reflecting this sentiment, the Infectious Diseases Society of America called the proposal a meager increase which would impact the health care cuts already in place by impoverished countries in light of the worldwide economic crisis. Dr. Paul Zeitz of the Washington-based Global AIDS Alliance agreed that the proposal was a betrayal of trust with its lack of increased overall funding and Christine Lubinski of the
Stay tuned, as the White House plans to release a more detailed budget proposal on Thursday, May 7, 2009. For details on the proposed global health funding for 2009 to 2014 see the White House Statement by the President on the Global Health Initiative.
As we all come down from last week’s frenzy surrounding the (now renamed for lesser offensiveness to pork-marketing sensibilities) Swine-Origin Influenza Virus (S-OIV) H1N1 , is it possible that there is a hint of disappointment in the air? Perhaps a whiff of anti-climactic letdown after the threat of feverish, lung-rending apocalypse? Are we seeing a lucky escape from a close brush with global pandemic, at mercy of mutation and chance? The product of a genuine, coordinated worldwide epidemic response? Or merely the end of one news cycle and the beginning of the next?
While you ponder those questions, I bring you what could be one of the last updates before S-OIV H1N1 becomes terminally uncool. As of Monday, April 4, the World Health Organization registered 1,085 laboratory-confirmed cases in 21 countries.1 Mexico has begun to step down its safety measures, with restaurants and other venues for public activity set to re-open on Wednesday, and U.S. public health officials will be allowing schools to remain open in spite of the continuing spread of the virus, as most new cases appear to be mild. In the business of assuaging fears, it has been confirmed by the WHO that eating pork is safe (so long as you cook it to 70°C/160°F first), and in the business of fanning fears of a different kind, U.S. conservatives are wasting no time in casting President Obama’s “overreaction” to the crisis as big-government encroachment.
For the fun flu facts reading selection this time, I introduce another global health resource: the University of Pittsburgh’s Supercourse online series on epidemiology and global health. Click on the Swine Influenza A link (or on the image below), pick your language of choice (including Spanish, Russian, Farsi, Vietnamese, and Hebrew), and click “Start” for a refresher on hemagglutinins, neuraminidases, and case definitions.
For a cool overview of influenza virus genetics, check out this article by Carl Zimmer in the New York Times:
Scientists first isolated flu viruses from pigs in 1930, and their genetic sequence suggests that they descend from the Spanish flu of 1918. Once pigs picked up the flu from humans, that so-called classic strain was the only one found in pigs for decades. But in the 1970s a swine flu strain emerged in Europe that had some genes from a bird flu strain. A different pig-bird mix arose in the United States.
In the late 1990s, American scientists discovered a triple reassortant that mixed genes from classic swine flu with genes from bird viruses and human viruses. All three viruses — the triple reassortant, and the American and European pig-bird blends — contributed genes to the latest strain.
And for possibly the best selection of flu-tracking maps you’re likely to find, this one is brought to you by Google and Rhiza Labs:
1 For the epidemiologically-minded, with a lab-confirmed death toll of 26, this makes for a Case Fatality Ratio of 2.4% and falling with every new case of lab-confirmed disease in the absence of further deaths. For comparison, your annual, garden-variety flu has a CFR of less than 0.1% in the general population, with a bimodal distribution of mortality (mostly limited to the very young and the very old). Past flu pandemics have had CFRs in the 0.1%-2.5% range, while the dreaded H5N1 avian flu virus tracked in Asia in recent years showed a CFR of 14%-60% by various estimates (Li et al., J Epidemiol Community Health. 2008 Jun;62(6):555-9). One previously reported CFR for zoonotically-acquired swine influenza was 14% (Myers et al., Clin Infect Dis. 2007 Apr 15;44(8):1084-8). As you may suspect, flu CFRs are notoriously difficult to calculate, due to the wide incidence and under-reporting of mild cases.
Good morning on this May 1st, 2009, and good bye debt! Does the burden of debt loom over your head and weigh you down more than your book-laden backpack? Do you wish that the price of going to school didn’t cost you your dreams of being a family doc? Do you want to contribute your skills as a physician and serve your local and global communities, but just can’t afford to take the time off???? Make your voice heard, and email your congressman. Let them know we’re drowning in debt, and will not take it anymore. Below is an action alert from Mary-Carol at AMSA.
Dear AMSA,
This last March, a few of our Representatives and Senators stood up to decrease the educational debt burden for future physicians by introducing a bill that would reinstate a pathway to defer loan repayment until after residency for the majority of medical residents.
This May, Congress is writing a huge piece of legislation that will reform our health care system - and impact our chosen career field for decades to come.
Your Senators and Representative need to hear from you that the cost of medical education must be addressed in this legislation.
Sound pretty good to be able to defer your loans during residency if you’re having trouble paying them? Well, don’t get used to it – as your school’s financial offices should have told you, last summer, the passage of the College Cost Reduction Act terminated this pathway for loan deferment.
As AMSA members, we have a responsibility to do everything we can to make medicine a feasible field for students from all walks of life – we need to remove the burden of intimidating student debt from the equation. Congress needs to hear from you that reinstating the economic hardship deferral pathway is a good thing, and that including comprehensive measures to decrease the cost of medical education in this month’s health reform legislation will be even better.
Thanks - let’s see this through!
– Mary Carol
Do your part to include medical school debt in the upcoming health care reform.
The Kaiser Family Foundation has a new resource for global health. While new, it features plenty of handy information for us global advocates, such as a map of cumulative cases of H1N1 influenza (the subtype of influenza A causing swine flu), convenient fact sheets on U.S. Global Health Policy, and a policy tracker in which you can follow up on the latest global health legislation.
