The Global Pulse Journal Blog

In January 2010 PLoS Medicine published a very interesting four-part weekly series on this subject.  I have posted a few excerpts below:

The study had three aims; (1) to advance current understanding of the interplay of actors in the system; (2) to evaluate its performance; and (3) to identify opportunities for improvement.

Read the rest of this entry →

For the past seven years, the United States has supported and expanded its program to fight HIV/AIDS in developing nations, underwriting almost half of the world’s AIDS relief. But some are concerned by recent setbacks in the global campaign to fight disease in the developing world. At a time when the numbers of people infected with HIV is beginning to increase after stabilizing in countries like Uganda and the number of people in need of treatment is rapidly expanding, the US funding has not kept pace. With updated World Health Organization guidelines, the number of HIV-infected people eligible for treatment has expanded to 14 million, a large increase from the only 4 million people current in treatment.

In the face of this expanding pool of people in need, US government funding seems to be staying stable. For example, at the same time that the Obama administration has announced plans to expand HIV treatment to at least 4 million by 2013, they have also signaled no increases in funding budgets through fiscal 2011. Defending the administrations commitment to fight the global pandemic, Eric Goosby, the President’s AIDS czar, stated that “our commitment to universal coverage hasn’t wavered.”

For more on the global fight on AIDS and particularly the fight in Uganda, check out the Wall Street Journal’s January 30th article and slideshow.

It has long been established that high adherence to antriretroviral therapy is associated with slowed progression of HIV infection and increased survival, but a recent study by researchers at the Johns Hopkins Bloomberg School of Public Health suggest that high antiretroviral therapy adherence is also associated with lower health care costs. Their study suggests that improved health outcomes associated with high adherence to HIV therapy results in an overall median monthly health care cost savings of $85 per patient in a cohort of 6,833 HIV-infected adults in South Africa. A large component of this cost savings resulted from a decreased need for hospitalization in patients with high adherence to antiretroviral therapy. These results suggest that effective, practical strategies are needed to encourage and actively monitor antiretroviral therapy adherance in order to improve patient outcomes and, in the process, save much need health care resources.

More details on the study can be found in the January 5, 2010 issue of Annals of Internal Medicine.

The Kaiser Family Foundation has released its latest global health survey, Views on the U.S. Role in Global Health Update. This report explores opinions of the American public on US efforts and policies aimed at improving the health of people in developing nations. The poll found that the majority of Americans support continuing current US spending to improve the health of resource-limited nations, with 32% of the public supporting maintaining spending and 34% supporting increasing spending. A quarter of respondents were leery of the economic conditions of the times and felt that the country was spending too much on health abroad. 58% of respondents felt that efforts should focus on building health infrastructure compared to 36% who felt that it is important to emphasize efforts towards eliminating specific diseases like malaria and HIV.  Reflecting our globalized world, 55% felt that money spent to improve the health of developing nations also impacts the health of Americans in the US. When asked whether US global health funding should be administered directly by the US or via coordinated international efforts, 45% believe that it is best for the US to directly provide aid on its own while 43% felt that international efforts through organizations like the Global Fund are more effective. Additional findings and data as well as information on US Global Health Policy is available from the Kaiser Family Foundation.

On October 30, 2009 President Obama announced the end of a 22-year ban on travel to the United States by people infected with the HIV virus. The President made good on an earlier promise, acting to eliminate a restriction he said was “rooted in fear rather than fact.” The new rule will take effect after a routine 60-day waiting period, ending the US’s position as one of only about a dozen countries that bar people who are infected with HIV. Read the rest of this entry →

There is an old saying that is passed down through the generations.  It is typically sung to the effect: everything in moderation.  Various individuals attribute the wisdom to various past figures, but no matter the source, the saying has some bite. Read the rest of this entry →

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 Global Health Policy Center stated that the proposal is “worse than we had feared.” On the other hand, musician Bono, representing his advocacy group ONE, praised the funding increase stating that President Obama’s “strategic leadership on these issues is protecting the long-term interests of the people in his own country as well as saving vulnerable lives overseas.”

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.

On Monday April 27, 2009, President Obama named Eric Goosby, MD as the new global AIDS coordinator and administrator for the President’s Emergency Plan for AIDS Relief. Dr Gossby is a professor of clinical medicine at the University of California San Francisco and the current chief medical officer of Pangaea Global AIDS Foundation, a non-profit consulting organization which works to address the global HIV/AIDS pandemic. He previously served as deputy director of the White House National AIDS Policy Office and as director of HHS’ Office of HIV/AIDS Policy during the Clinton administration when he managed a $2.5 billion HIV/AIDS care and prevention budget.

Dr. Goosby began his career treating patients at San Francisco General Hospital during the early emergence of AIDS as a health and policy issue. He became the associate medical director of San Francisco General’s AIDS Clinic in 1986 and worked toward establishing new strategies for entry and retention of HIV-infected patients and acted as principal investigator for several AIDS Clinical Trial Group Studies. Dr. Goosby also has extensive experience in developing international treatment guidelines and implementing clinican training and local models of care for addressing HIV/AIDS. Dr. Goosby has held many positions in the federal government, where he has acted to advance HIV/AIDS care and prevention. In 1991 he became the Director of HIV Services at the US Public Health Service/ Health Resources and Services Administration where he administered the Ryan White CARE Act to provide funding for people living with AIDS to access care and treatment. He later became director of the Office of HIV/AIDS Policy in the Department of Health and Human Services in 1994 where he advocated for responsible government HIV/AIDS policy, working with Congress on AIDS-related issues. In 1995 Dr. Goosby created the DHHS Panel on Clinical Practices for the Treatment of HIV Infections, a group which worked to define the proper use of antiretrovirals and address standards of care for their use in pediatric patients and pregnant women. Dr. Goosby acted as interim director of the National AIDS Policy Office at the White House serving as President Clinton’s senior adviser on HIV-related issues. He has continued to work toward expanding funding for and access to care for people living with HIV/AIDS through treatment, prevention and sensitive policy development.

See the White House press release and New York Times report (Macfarquhar, New York Times, 4/27) for more on this story.

On the 17th of April, the Obama administration proclaimed the new doctrine that carbon dioxide is bad for our health and circumstance.  Not much of a revelation for many in the fields of public health, but certainly a bold move politically.  With this announcement, and the Clean Air Act already in play, the EPA can step in and begin regulating emissions with the blessing of the Supreme Court and Executive branch.  The Financial Times writers, Andrew Ward and Sarah O’Connor, offer a brief synopsis of it in their article “US declares carbon dioxide a danger to human health”.

I find the maneuver encouraging, but we are still at least one large step from doing much of anything tangible to curb emissions…and a chasm away from doing it right.

Does the Obama administration really want the EPA to handle CO2 admissions?  I doubt it.  In fact, the real bite of this new axiom and emboldened EPA has already been noted by much of Congress: it’s twisting the screw to get them to pass some legislation.  It is always more pleasant for an elected official to vote for the obvious than vote for the confrontational.  Naturally, some of them are quite uncomfortable with the Obama camp turning up the heat on potential environmental legislation (perhaps that will make them more empathetic to the scientific community’s discomfort with the world’s rising temperature).  Notwithstanding some Congressional pleas that Obama isn’t playing fair, the legislative branch will now have to take a long, serious look at the current cap-and-trade proposal.  Before, it was just a matter of voting down something they (and some lobbyists) didn’t want any part of.  Now, it means forfeiting a market-based system of regulation for an executive agency book of mandates (you can almost hear the far-right teeth grinding…environmental protection, bigger government…they haven’t experienced such agony since the 70s).

But will cap-and-trade do it?  Maybe, but I’ve got my doubts.  I should moderate my demur with a caveat: it probably will do something, it just might not be much.  Briefly, this system aims to declare a national ceiling on emissions, slice the total up like a pie and distribute them to every corporation that pollutes.  Those that need more permits (slices of pie) will have to buy them from others, who have permits to spare.  Ideally, it keeps the total emissions at an agreed upon level and encourages innovation (i.e. do what you can to need as few permits as possible and sell the left-overs).  Not so bad thus far, but the tricky part comes next.  PRICING.

The conundrum of this particular proposal is putting the right price tag on the permits.  Aim to low, and they become so cheap that nobody changes behavior and we’ll merely have a bunch of permits laying around on the ground like unwanted grocery store coupons (EU demonstrated this one).  Price them too high, and you can significantly alter your export industries and engender a whirlwind of business backlash (that will be there regardless, so it’s the first point that matters).  I think this is an especially important consideration in the wake of our financial armageddon.  To curtail America’s prodigal ways, it needs to reconcile its trade deficit (i.e. export a little more and import a little less).  Some careful mathematics and a stroll down a fine line is in order if we hold to cap-and-trade.

To get away from the precarious efforts to price permits, I think we should just implement a carbon tax.  Get a few smart people in a room, initiate a circumspect approximation of the negative externalities intrinsic to each unit of CO2 emissions, and charge the polluter accordingly.  Take the new revenue and invest it in environmental protection interventions and subsidize new technology (help businesses pollute less, make solar and wind power implementable, etc.).  Don’t want to pay more taxes?  Then stop polluting…that changes behavior, right?  Additionally, the price is stable (just like a sales tax), so any business can calculate its upcoming fiscal year liabilities based on expected emissions multiplied by per unit tax.  No black magic or unexpected outcomes (like rock-bottom permit prices).  And last but not least, the carbon tax has a social appeal: it gives Rush Limbaugh and his delusional acquaintances an excuse to get together again over a cup of tea.

Ask your senators, via email and phone, to include the option of public health insurance in the Health Care Reform Bill. This would offer more choice, as the public plan would not cross off existing private insurers. Read Mary-Carol’s legislative action statement below:

Dear AMSA,  

The Senate just returned from recess on Monday and square on the agenda is a big Health Care Reform bill that has yet to be fully written.  One of the more important aspects of this reform process is over the inclusion of a “public health insurance option”.  This is what it says, a plan run by the federal government (much like Medicare), that people have the option of buying much as they would buy a private insurance plan.   

This public plan would, as our Legislators are describing it, exist alongside the private plans like Aetna and Blue Cross/Blue Shield.  The legislation is on the Congressional drawing board right now and the public plan option is the contentious issue - many opponents are saying it should be on the Congressional chopping block.  AMSA supports the creation of a single, country-wide risk pool of patients, funded from one budget, but right now, we’re not going to have any say at all unless we weigh in as this Nation’s future physician workforce with our support of the public insurance option at a minimum.We need your help to let your Senators know that you want your future patients to have the choice of a public health insurance option. Join AMSA members across the country today, Thursday April 23, to contact both of your Senators.

- Mary Carol

Will the public health insurance option take us a step closer to single payer? Perhaps so. But, the first thing congress and people at large must agree upon is the underlying principle that health is a human right. Without agreeing on this unshakeable foundation, health will still remain a commodity.