The Global Pulse Journal Blog

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.

This is the start of another GP Blog series, inspired by a recent workshop in New York City addressing the implications of human trafficking and commercial sex exploitation in the clinical setting. It is my hope that this series can help increase awareness of the issue, and keep the conversation going. Read the rest of this entry →

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.

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.

Click here to send an email to your Congressperson.

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

Click here to send an email to your Congressperson.

Do your part to include medical school debt in the upcoming health care reform.

Reporting live from Manhattan…

We aren’t quite running down the streets with masks on our faces panicking yet (which, it’s not clear how good of an investment they are anyway; see Susan’s comment on masks on the previous flu post), but we did close four schools, as the number of confirmed cases in New York City rises to 51, the first US swine flu death is confirmed in a toddler in Texas, and the World Health Organization raises the pandemic alert level to Phase 5. The net worldwide case count is uncertain due to re-testing of previously identified cases in Mexico.

City health agencies are concerned about the effects of recent downsizing due to the recession on their ability to function at top form:

At a news conference on Monday, Dr. Richard E. Besser, the acting director of the federal Centers for Disease Control and Prevention, said the public health system was in “a tough situation.”

“We hear about tens of thousands of state public health workers who are going to be losing their jobs because of state budgets,” he said. “It is very important that we look at that resource because this outbreak was identified because of a lot of work going on around preparedness.”

But according to John M. Barry, author of The Great Influenza, now may be a reasonably good time to catch the bug.

For further reading while you’re holed up in your room ordering delivery and avoiding crowds:

• Link to the NYC Department of Health and Mental Hygiene swine flu info page. Hospitals and clinics are working with the DOH to keep up surveillance and testing of possible cases, and precaution measures are being used for cases of influenza-like-illness.
• Link to the New York Times swine flu tracking map (this one nicely reports suspected cases as a separate category).
• The Great Influenza by John M. Barry, Penguin, 546pp — available here on Amazon, and a good read / horror story depending on your current P.O.V. and paranoia tendencies. It has a great chapter about the beginning of both microbiology and American medical education as we know them. This is the book that first got me interested in public health history.

The CDC is collaborating with the WHO to investigate reported outbreaks of the swine flu in Mexico, California and Texas. The WHO reports that in the USA, there have been 7 confirmed cases, 5 suspected cases, and no mortalities, mostly affecting young adults (influenza usually afflicts the young, old and immunocompromised). In Mexico, Influenza-like-illness (ILI) has been under surveillance since March 18, where there have been approximately 1000 reported cases, with 59 deaths in Mexico City and 3 deaths in San Luis Potosi located in central Mexico (although Mexicans have commented that the situation is far worse than depicted by authorities).  The strains are sensitive to oseltamivir but resistant to amantadine and rimantadine.  Symptoms of the respiratory tract infection include fever, sore throat, cough, myalgia and malaise. If the cases we have seen result in Antigenic Shift (complete change in HA and NA), there is risk for h1n1 pandemic, since we have no antibodies against the virus. In 1918, a swine flu virus transferred its HA to a human strain (HSW), leading to the Spanish Flu/H1N1 pandemic which resulted in 20 million deaths across the globe. Remember: don’t give children aspirin if they present with these symptoms (Reye’s Syndrome) and follow the CDC, WHO and USA government pandemic flu site for updates.   Read the rest of this entry →

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. 

There is an interesting article at the Financial Times, “Japan unveils $154bn stimulus plan” (free registration required), and given the parallels to our current debacle, here are some thoughts.

Japan, a global economic powerhouse and the Asian leader as far as GDP per capita goes, announced a new plan to tackle some of its old problems, namely deflation. One lost decade appears to have been enough for Japan, and its government is now throwing quite a bit of money around to quell the threat of another downward spiral. This is not breath-taking news as most other developed countries have deployed similar measures. But what I have found interesting is what is present in the proposed stimulus, and most importantly, what is not.

When glancing through the litany of items, it reads nearly like a direct transcription of an Obama, Sarkozy, or Brown public address. For the medical erudite onlooker, he/she may optimistically note that there is even some money earmarked for health care spending present within the plan. However, I think the global health perspective is lost in Japan’s plan, and I think many other national stimulus packages (including the US) have knowingly or unknowingly eschewed global health as well.

Plenty of academics, pundits, and philanthropists have implored the developed countries to offer a fraction of their stimulus packages to the poorest nations in the form of aid. Yet, those calls have either fallen on deaf ears or led to any appropriations being buried deep within the stimulus package labyrinths. Although the latter may be true, I suspect not. Even small aid gestures are usually flaunted without humility, so I do not believe the rich world governments would cast their heart-felt efforts to less prominent publicity roles. So, at least for the moment, I am going to assume the handouts have been left off the table and posit that this is not in anyone’s best interest.

Briefly, developing nations will have less financial flexibility and credit worthiness to engage in similar maneuvering as Japan, the US, etc. In our current global financial calamity, this puts these nations not only between a rock and a hard place (just as most other countries, regardless of income) but also staring up at an incoming meteorite. The subsequent dominoes spell trouble for international development, geopolitics, resource procurement (even basic necessities like food), and health care systems. For many of these countries, their respective governments shoulder much of the weight when it comes to paying for and providing medical care to its citizens. If credit is frozen and money scarce, then a Ministry of Health budget can be paralyzed just the same as any other government expenditure. Intuitively, this is not good for the nations and their people (especially considering disproportionate disease burdens), but it is bad for the rest of the world too.

We have known for some time that the global population is tightly linked (and our financial mess affirms it). This bond is impetus for humanitarian endeavors and a belief in international harmony. Additionally, it means that disease, and its direct and indirect effects, does not need a passport to move about the world. If we neglect global health, then we all lose. Therefore, I think devoting some of the stimulus money from Japan, the US, and the rest is a worthwhile idea. It would be money well spent, provide for a more prosperous future, and acknowledge that we in the West are really embracing “change.”

For those that are unmoved by my internationalist perspective, they might find solace in the thought that these aid offerings could have significant economic spillover effects as well. And I am not merely referring to the good health and productivity arguments; rather, I find it plausible that money sent abroad to unfreeze credit, encourage lending, and bolster consumption in poor countries could benefit the wealthier as well. Poor countries often play vital roles in the global supply chain (and one weak link…well, you know how it goes) and they are also packed with potential consumers (much of the wealthier countries have flagged their exports and feasted on imports, and now they all scream imbalance and time for correction). So, even if you do not fancy money channeled toward poor country health care systems, you should offer your upright thumb to stimulus package aid anyway. It is in your best interest, believe it or not.

SUPPORT SYRINGE EXCHANGE! In case you didn’t know already, the globe is interconnected.  What happens here at home, affects those abroad, and vice versa. Support this domestic issue now! Call your representative and the White House to make it loud and clear to them that: 1) They must support the Community AIDS and Hepatitis Prevention Act H.R. 179 and 2) President Obama must keep campaign promises to end the ban on Federal Funding from his Fiscal Year 2010 budget.  See below for links and a letter from Mary Carol-Jennings and the AMSA AIDS Advocacy Network Steering Committee…  

Today, April 2, as part of the final budget wrap-up, we need to take a stand on domestic issues - please take just 2 minutes to call the White House and your Representative to advocate for domestic harm reduction programs.Call your Representative and the White House to ask our Nation’s leaders to support Syringe Exchange Programs and End the Federal Funding Ban!1. Urge Your Representative to Support the Community AIDS and HepatitisPrevention Act, H.R.179, introduced by Representative Serranoand2. Urge President Obama to keep his campaign promises to end the ban on Federal Funding from his Fiscal Year 2010 budgetWe made huge strides last year when Congress lifted the ban against Washington DC using its local tax dollars to support syringe exchange.Unfortunately, since 1988, there has been a Congressional ban on the use of federal funds for Syringe Exchange Programs nationwide. By allowing federal dollars to fund Syringe Exchange Programs, the Community AIDS and Hepatitis Prevention (CAHP) Act of 2009 will save thousands of lives and help reduce high-risk behavior. As future physicians and public health advocates, we must pass the Community AIDS and Hepatitis Prevention Act, H.R.179. Again, Take Action here. In solidarity, Mary Carol, your Jack Rutledge Legislative Director, and Merrian Brooks, the AMSA AIDS Advocacy Network Steering Committee   

CALL NOW! Thanks!