Issue #3 - Can We Stop Them - Global Health Magazine by Global Health Council

Can We chart malariaâ&#x20AC;&#x2122;s demise? the allure of eradication 18 Money Off the Mark for Neglected Diseases 09

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Fall 2009:

Chronic Diseases

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issue 03

contents —

In this issue:

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12 Leveraging Partnerships against Disease

14 The Allure of Eradication

COVER STORY: infectious diseases

6 Pakistan’s Newest IDPs 0 09 Can We Chart Malaria’s Demise? 18 Are We Getting Neglected Disease Funding Right? 21 The Soldier Poets of the Caribbean

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23 Google’s Disease Detectives

stories online: C Barring None: The HIV Travel

and Immigration Ban

C TB Vaccine Researchers

Find Strength in Numbers C Can Rats Detect Tuberculosis? C Rotavirus: 35 Years Post-Discovery

screenshots —

04 polio eradication process 05 where are infants not immunized? 05 women who believe it’s okay for husbands to hit them Cover Photo credit: ©CDC/James Gathany 2008

www.globalhealthmagazine.com

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Issue 03

Global Health

letter

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from the editor

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Executive Editor

Annmarie Christensen Managing Editor

Tina Flores

editorial assistant

Geoffrey Calver Web

Winnie Mutch Liza Nanni Graphic Design

Shawn Braley

infectious diseases They are our daily norms – drinking water, a mosquito bite, breathing. All seemingly innocent and unavoidable, but it takes very little to become infected with an infectious disease. The adage goes, disease respects no borders or socioeconomic status. While that is true to some extent, your address and relative wealth (at least on the global scale) determines, in large part, whether or not you will succumb to one of these diseases. If it didn’t, why do so many infectious diseases impact those in low-resource settings? Let’s face it. The neglected tropical diseases The Carter Center is fighting to eradicate would not continue to plague millions if they were rampant in Geneva or New York. Most New Yorkers probably can’t define lymphatic filariasis, much less spell it. Indeed, many infectious diseases are mere by-products of impoverished circumstances – lack of clean water, living in refugee camps, etc. Rotavirus, discovered 35 years ago, still plagues many communities. And while recent years have seen a relative boom in funding for neglected diseases, as M Moran et al. show, these resources have, in large part, gone to the “big three” – AIDS, TB and malaria. But relatively recent collaborative efforts, such as the partnerships fostered by sanofi pasteur, as well as the network for TB vaccine researchers in Africa, are expediting the progress being made in treating and preventing diseases. Innovative ideas are likewise being implemented in the disease surveillance side of infectious diseases. Rats indigenous to Africa are being used to detect TB. The Internet giant Google is tracking the spread of disease online. We hope that this issue is a catalyst for discussion offline and at www.globalhealthmagazine.com. The Editors ISSUE 03 summer 2009

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E-mail:

magazine@globalhealth.org Global Health Council Board of Directors

Susan Dentzer, chair, William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Joel Lamstein, SM Joy Phumaphi Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org This issue of GLOBAL HEALTH was sponsored in part by sanofi pasteur as a tribute to Beth Waters.

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online exclusives

go to www.globalhealthmagazine.com for further reading

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C The Blog

The Rats Who Sniff Out TB Bart Weetjens discusses the remarkable HeroRATS who are able to detect TB.

C Hot Escapes

Havana: Immerse yourself in the history and hedonism of this island nation.

C Dim Sum

A collection of book reviews, music picks, and other cultural forays.

35 Years Post Discovery Dr. Ruth F. Bishop, who led a team that identified rotavirus, calls for a greater commitment to stop the disease.

Barring Entry Lyndel Urbano and Nathan Schaefer from the Gay Men’s Health Crisis reflect on the public health and human rights implications of travel and immigration restrictions for HIV positive individuals.

C Field Notes

The Vaccine Network Researchers find strength in numbers to find the first TB vaccine in 100 years.

C Going Viral

What’s the buzz on Twitter, YouTube, Facebook, LinkedIn and other places online. www.globalhealthmagazine.com

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Global health statistics

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Polio eradication progress 1988

2007

endemic with wild polio virus certified polio-free regions not certified but non-endemic i

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Source: World Health Organization, Progress Towards Global Immunization Goals- 2007

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infants not immunized with dtp3 In Millions

american

european 1.1 eastern 0.4 mediterranean

western pacific

1.9

1.9 african Southeast asian

7.3

11.5

Source: World Health Organization: Progress Towards Global Immunization Goals - 2007

% of Women Who Believe It’s Ok For Husbands To Hit Them somalia 75.7%

vietnam 63.8%

belize 12.2%

ethiopia 81%

georgia 6.9% haiti 29%

serbia 6.2%

Honduras 15.5%

rwanda 48%

india 54.4% iraq 59.1% nepal 23.2%

i jordan 90%

lao pdr 81.2%

Source: UNICEF Childinfo: Monitoring the Situation of Children and Women

kazakhstan 10.4%

Mali 75.2% www.globalhealthmagazine.com

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Pakistan’s Refugees By ashfaq yusufazai

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Hundreds of people who fled a military offensive against the Taliban in the Swat Valley began trickling back home in midJuly after the Pakistani government announced the first stage of a three-part plan to return them. http://www.nytimes.com/2009/07/14/world/asia

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Ashfaq Yusufazai is a Pakistan-based journalist. He has written for BMJ and the Telegraph, both in the UK, among other publications.

Photo: © Marc Westhof

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Even from a distance, the Sheihk Yasin Camp on the Mardan-Charsadda Road in northern Pakistan looks bleak. The heavily armed guards at the main entrance, where visitors are subjected to a body search, to the rows of greenish-gray tents amidst the hot, dry climate, portend much illness and suffering among its inhabitants, Pakistan’s newly displaced population. Sheihk Yasin is one of 23 makeshift camps established largely by the United Nations following the April 26 military action Pakistan launched against Islamic militants in its North West Frontier Province. An estimated 2 million civilians fled to the adjacent provinces of Mardan, Swabi and Peshawar. Of these, around 80 percent live with host communities and about 500,000 displaced people live in camps. The strain of displacement has left an indelible mark among many in this population. Dr. Mian Iftikhar Hussain, a psychiatrist at one of the camps, estimates 50 percent of the women suffer from mental disorders after witnessing the deaths of their loved ones and the destruction of their properties. The relative comfort of their old lives lies amidst the rubble they left behind. “[We] traveled on foot for hours along with other women and children after failing to get a vehicle to transport us to a safer place,” says Jamila Bibi, a 39-year-old housewife who now lives in Sheikh Yasin. Dr. Hussain says Bibi is one of many women suffering from severe depression. Bibi’s 11-year-old son, Gul Jamal, was a casualty of the raid. “My son was playing outside the house when a bomb hit him and we found his charred body scattered all over the place,” she told the doctor.

More than 90% of deaths due to diarrheal diseases occur in children under 5 years of age.

Of another woman, Hussain says, “She suffers from post-traumatic stress disorder due to the loss of her son in fighting between the government’s forces and Islamic militants. Her condition will deteriorate further due to [continued] fighting in Swat.” Children, likewise, have been affected by the trauma of conflict and displacement. Abdul Hameed, president of the Pakistan Pediatric Association, says there are about 1.3 million refugee children who are at high risk of mental illness, as well as other disease. “These children could turn into monsters in the future if they aren’t rehabilitated,” he bluntly said. “The government should arrange for children’s health, shelter and educational facilities.” In a recent survey of physicians at the various camps, of the 15,000 patients visited, 50 percent suffered from depression, 28 percent from dysentery, 11 percent from scabies, many suffer from acute watery diarrhea, according to Dr. Fazal Mabood, director-general for health services in the North West Frontier Province. In the Jallozai Camp, “About 51 percent of the camp’s (residents) suffer from acute respiratory infections and

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The strain of displacement has left an indelible mark among many in this population

19 percent had acute watery diarrhea,” said Dr. Saeed Akbar Khan, operation medical officer from the World Health Organization. The camp is home to 87,000 people from volatile districts, who are exposed to a host of diseases because of scorching heat and the lack of electricity. Lack of food or potable water, inadequate sanitation and close quarters make children particularly susceptible to illness. Children are among the worst-affected, prone to malaria, typhoid and water-borne diseases because of contaminated food and water. Dr. Khan said that along with the provision of diagnostic treatment and facilities, WHO has deployed environmental engineers to test the quality of water and food. According to UNICEF’s estimates, 15 percent of children in the camps are severely malnourished. “The worst affected are those from Nowshera, Lower Dir, Mardan and Charsadda,” said Dr. Akbar. In an effort to raise awareness about nutrition, UNICEF has launched a program to train 10 people in each camp in Communitybased Management of Acute Malnutrition (CMAM). Cholera and watery diarrhea are major problems in the camps. In May, more than 5,325 children from the Mardan camp alone were hospitalized because of an outbreak of diarrhea. A shortage of beds, coupled with the steady influx of IDPs in many of the hospitals, has forced health-care workers to place two children in one bed. The Pakistan Pediatric Association established two

Photos: © William A. Ryan / UNFPA

wards dedicated to providing specialized treatment to critically ill IDP children, one at the District Headquarters Hospital in Mardan, another at the Shah Mansoor Medical Complex in Swabi. Within two weeks, 1,424 patients were examined. Of them, 995 had acute watery diarrhea, 147 had an acute respiratory infection, 121 suffered from dysentery, 104 had high temperature, 24 had malaria, three had meningitis. Though most patients were taken care of on an out-patient basis, 360 were admitted. Hundreds of local health providers working in conflict areas of Pakistan were deployed to clinics and other facilities within the camps and in other communities where refugees are living with host families. This strategy also offers the added benefit of being able to better monitor displaced TB patients on DOTS. However, lack of coordination among government agencies, multilateral institutions and private-sector partners have severely compromised health resources in the region. The logistical challenges of triaging patients have resulted in several deaths, many of whom are children. GH —

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by eliza barclay

Can We Chart the Demise of Malaria? —

The great 20th century battle against malaria, one of the most widespread and intractable infectious diseases on the planet, began in the 1940s with famously mixed results. While 100 countries, like the United States, were able to successfully eradicate it, insecticide-spraying initiatives failed or never reached many of the worst affected areas, namely sub-Saharan Africa. Today the vector-borne disease remains endemic in more than 100 countries, with some 247 million cases annually, though it is largely preventable and treatable. In 2007, the Bill & Melinda Gates Foundation helped mobilize a new funding and research effort to eradicate the disease. But many questions remain about how to do it. Among the challenges of designing public interventions to vanquish malaria once and for all is the dearth of well-organized data on which regions are at risk, and to what extent. Most countries conduct prevalence surveys on the deadliest parasite that causes malaria, Plasmodium falciparum, to estimate how to extend prevention and treatment. But there have been next to no “risk maps” showing the scope of the problem worldwide that can guide policy-makers and donors in developing regional strategies.

A study released in March 2009 in the Public Library of Science journal PLoS Medicine is a breakthrough in visualizing the geography of malaria endemicity. The study accompanies a new geostatistical modeling tool, called the World Malaria Map – the result of two years of work by a team of researchers at Oxford University and other institutions who collaborate on the Malaria Atlas

Project – that will likely help public health experts shrink malaria’s reach on the world map. Simon Hay, an infectious disease epidemiologist at the University of Oxford and the study’s lead author, and the other researchers, which include geographers, statisticians, epidemiologists, biologists and public health specialists, began by looking at the scientific literature available on malaria going back to 1985. They assembled the data and then “geo-positioned” it, giving it a point indicating its location and place in time. That process took about a year. Then the researchers followed up with individual countries and institutions, requesting additional information where available. The resulting map has 8,000 data points up to 2007, with layers of uncertainty where data is insufficient. One of the study’s most hopeful findings is that although some 2.4 billion people live in places where they risk infection, 1 billion people inhabit places where transmission of the disease is low enough that interventions already in use – like bed nets, indoor residual spraying, and drugs – could be deployed to eliminate it. “Using these techniques and future iterations, we will be able to understand in which part of the world we are making the greatest impact on the disease,” said Hay. In the Americas, for example, endemicity is around 2 percent, Southeast Asia is around 10 percent, and Africa is about 30 percent with regional variation. Hay says that this means that it would be technically feasible to eliminate malaria in the Americas in the near future.

Eliza Barclay is a freelance journalist based in Washington, D.C. whose work has appeared in The Atlantic and The New York Times.

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Other results were more surprising. According to Hay, the map unexpectedly revealed that prevalence in West Africa remains high. “It seems that this region is proving more resilient to interventions than most,” Hay said. Until the recent ramp-up in funding from donors like the Global Fund, the U.S. President’s Malaria Initiative, and the Bill & Melinda Gates Foundation, countries like Nigeria did not have efficient malaria control programs, and were not collecting adequate prevalence data. “Countries that have huge populations … add a disproportionate amount of uncertainty into global assessments of the malaria burden,” Hay noted. Mary Ann Lansang is director of the health advisory unit for the Global Fund to Fight AIDS, Malaria and Tuberculosis, a multilateral donor that has financed the distribution of some 70 million bed nets and 74 million malaria drug treatments to date. “The framework for evaluation of the impact of P. falciparum control efforts worldwide … will be crucial … in meeting the global goals for decreasing the burden of malaria cases and deaths,” Lansang said. Lansang also noted that the Millennium Development Goal on malaria – to halt by 2015 and begin to reverse the incidence of malaria – will not be successful unless malaria control programs in Africa receive more support. According to the 2008 U.N. development goals report, the distribution of insecticide-treated nets and effective malaria drug use has fallen short of global targets. Prior to the PLoS Medicine study, the most recent global map of P. falciparum endemicity was published in 1960 and lacked specific descriptions of the input data used and estimates for the uncertainty in its predictions. The statistical methods used to construct the new map make it possible to quantify the uncertainty in the results. Though the map will help public health officials better understand endemicity and risk on a regional and global scale, malaria experts say it will be less useful for small geographic areas or country-level planning. According to Richard Cibulskis, an epidemiologist with the World Health Organization’s Global Malaria Programme, the map is imprecise at the country level in part because it can’t take into account the recent scaling up of malaria programs.

But Robert Snow, a co-author of the World Malaria Map and a professor at the University of Oxford and director of the Malaria Public Health & Epidemiology Group at the Kemri-Wellcome Trust Research Programme, says that in Kenya, for example, the maps have guided the revision of the national malaria strategic plan. To improve country level data, many countries are developing their own endemicity maps, mainly supported by Global Fund grants. There are other limitations to the Malaria Atlas Project maps, depending what the user wants to get out of it. “You don’t get a clear idea around seasonality of disease and being able to represent the year-to-year variability. When you take a standard map, and if you look at Tanzania, and compare wet and dry years, it might be very different from the map you actually have,” said Madeleine Thomson, a senior research scientist who studies malaria at the International Research Institute for Climate and Society at Columbia University. “The advances [in the World Malaria Map] would be to characterize seasonality and variability where that matters.” The Oxford researchers plan to update the map annually, establishing a continuous record of malaria control and elimination efforts that can serve as a guide for funding priorities. They now have access to 17,000 surveys, more than double the number available for the 2007 map, an increase Hay says is due to the fact that many donors and nations see the value of national prevalence surveys and committing the financial and logistic resources to make them happen. Hay and the team will eventually turn this map into revised burden estimates. They’ll also map the extent and burden of the less deadly, but neglected P. vivax parasite, which also causes malaria and accounts for more than 50 percent of cases outside of Africa. But ultimately the map will need to be used by policymakers and donors, who are confronting obstacles like communication when reaching out to malaria endemic regions. “While there may be some hope in some areas to eliminate malaria, we must equally use these maps and facts to remind us that Africa remains the hardest nut to crack and needs increased financial resources to dent transmission intensity,” said Snow. With better maps, policy-makers and donors may at least lend a hand in the right places. GH —

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In Africa, malaria is a leading cause of child deaths and, among adults, lost productivity due to illness is estimated to reduce gross domestic product growth by 1.3% per year. – Roll Back Malaria. 2005. World Malaria Report

World Malaria Maps: www.map.ox.ac.uk/ Sock! Pow! Blam! â&#x20AC;&#x201D; Fighting Malaria http://crosscut.com/2009/06/30/gates-foundation/19078/

Plasmodium falciparaum malaria risk in the World and the distribution of recorded parasite rate surveys used in the creation of the 2007 endemicity map

â&#x20AC;&#x201D;

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By Wayne Pisano

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Leveraging Strategic Partnerships in the Fight against Infectious Disease Next to clean drinking water and good nutrition, vaccines have saved more lives than any other public-health intervention in modern history. Immunization programs have wiped out smallpox, eradicated polio virus in the Western Hemisphere and begun to control childhood killers, such as measles and tetanus. According to the World Health Organization (WHO) vaccines prevent 2.5 million deaths worldwide annually. As additional vaccines are introduced globally, the number of lives saved and human suffering averted will continue to grow. Despite these accomplishments, large gaps remain in the delivery of existing vaccines to people in poor countries and in the development of new vaccines to combat diseases that are more common in the developing world. Pneumonia and diarrhea, for example, kill 3.8 million children younger than five each year although both are vaccine-preventable. And no effective vaccines are available to prevent infection by some of the largest killers in poor countries. These include HIV/AIDS, malaria and tuberculosis, which together kill many millions of people a year. Experts in international health attribute the gaps to problems, or failures, in three key areas – science has yet to make needed breakthroughs against certain diseases; markets are not always able to support incentives to produce needed medicines; and public-health systems in poor countries have limited resources to deal with complex problems. There is growing recognition that tackling complicated and systemic problems in international public health are beyond the capacity of any one sector. Instead, there must be a collaborative approach. As former WHO director-general, Gro Harlem Bundtland, noted: “In a world filled with complex health problems, WHO cannot solve them alone. Governments cannot solve them alone. Nongovernmental organizations, the private sector and foundations cannot solve them alone. Only ISSUE 03 summer 2009

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through new and innovative partnerships can we make a difference.” Over the past decade, public-private partnerships (PPPs) have emerged as a potent tool to bring the benefits of modern medicine to the developing world. These collaborations bring together government, multinational corporations and civil society – including non-governmental organizations, private foundations and multilateral groups such as WHO – to address seemingly intractable health problems. Such partnerships take many different forms in terms of legal status, governance, management and operational roles, but they share the underlying assumption that each sector brings to the table particular skills and resources that, when combined, will result in innovative and effective approaches to improving the health of the poor. For the partnership to work, each participating sector should derive some potential benefit. A study conducted for the World Economic Forum by Booz Allen Hamilton found that, to be successful, corporate involvement in PPPs must extend beyond social responsibility and have economic payoffs as well. The long-term fiscal benefits may be indirect. For companies, benefits may include opening of new markets, the reduction in tax obligations on donated products and the enhancement of corporate image. For governments in developing countries, benefits include access to products, improved infrastructure and availability of expertise. For nongovernmental organizations, benefits may be increased legitimacy, an opportunity to learn from larger partners and the chance to work abroad. Although governments have long worked with civil society organizations to further their health goals, private industry is a relatively new player at the table. In the pharmaceutical industry, the changed landscape is apparent. Multinational corporations are now Wayne Pisano is president and CEO of sanofi pasteur.

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By Wayne Pisano

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‘So far in 2009, the pharmaceutical industry has been involved in more than 200 public-private partnerships in poor countries.’ working shoulder-to-shoulder with governments, nongovernment organizations, foundations and multilateral groups to alleviate human suffering and death from dozens of infectious diseases in the developing world. Sanofi pasteur is just one company that has embraced PPPs to bring life-extending and life-saving medicines to the world’s poor. So far in 2009, the pharmaceutical industry has been involved in more than 200 public-private partnerships in poor countries. In addition to making drugs and vaccines available to the developing world for free or at deep discount, pharmaceutical companies are also lending their expertise to help build medical clinics, improve distribution routes for medicines and train medical professionals. At sanofi pasteur, which is dedicated to saving lives through vaccines, we have been privileged to see first-hand the incredible successes possible with PPPs. For example, we have been the longest-standing corporate partner in the global campaign to eradicate polio virus. Begun in 1988, the effort involves WHO, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF, Rotary International, governments in low- and middle-income countries and vaccine manufacturers. Since the effort began, worldwide incidence of polio has been reduced from 350,000 cases a year to fewer than 2,000. There are more than 5 million men, women and children who are walking around today who might otherwise have been paralyzed by polio.

years of concerted effort, the virus still persisted in certain developing countries into the 21st century. In response, WHO instituted several innovative, microtargeted programs. For example, in 2005, WHO called for development of a new monovalent oral polio vaccine to combat the disease in Egypt. Sanofi pasteur responded by developing and producing the first new polio vaccine in more than a decade. Fifty million doses went to Egypt, which was declared poliofree a year later. As part of the R&D-based vaccine industry, sanofi pasteur has been a partner of the highly successful Global Alliance for Vaccines and Immunization (GAVI) since its inception. GAVI, launched in 2000, leverages public and private partnerships to accelerate access to vaccines, strengthen health and immunization systems within countries, and introduce innovative new technology (including vaccines). Developed country donors, recipient governments, research and technical institutes, civil society organizations and vaccine industries partner with international organizations, private sector philanthropists and international financiers to find ways to fund and support immunization in the world’s poorest countries.

The original goal of the polio eradication campaign was to wipe out polio virus by the year 2000. But even after 12

Sanofi pasteur is also an active participant in the Pediatric Dengue Vaccine Initiative (PDVI), a product development partnership (PDP, which is a form of PPP that aims to accelerate the development and introduction of new vaccines) established in 2001 to accelerate the development of a safe, effective and affordable vaccine against dengue

C Public-Private Partnerships in Health: The Private Sector’s Role in Public-Private Partnerships, www.webforum.org/globalhealth

C GAVI, Innovative Partnership, www.gavialliance.org/about/in_partnership/ industrialized/index.php

C International Federation of Pharmaceutical Manufacturers & Associations, Health Partnerships, www.IFPMA.com

C WHO, Impact of Dengue, www.who.int/csr/disease/dengue/impact/en/ index.html

fever. The viral disease, which is spread by mosquitoes, causes high fever, incapacitating headache, muscle pain and rash. If left untreated, illness can progress to dengue hemorrhagic fever, shock and death. There are 50 million cases of dengue fever with 500,000 cases of hemorrhagic fever each year. Without appropriate treatment in an intensive-care setting, about 2.5 percent of those who contract the disease die. Other than mosquito protection and eradication, there are currently no measures available to effectively prevent the disease. Soon the vaccine community hopes to have another success story as we pursue PPP models to combat the threat of pandemic influenza. Many organizations are already involved including the U.S. and European CDCs, the WHO and public health agencies around the world. Roche Pharmaceuticals and GlaxoSmithKline are providing antiviral drugs that are proving effective. Hospitals, businesses and health departments are readying their pandemic plans. Testing labs are identifying and typing respiratory infections. Multiple vaccine manufacturers, including sanofi pasteur, are working with the world’s health and regulatory agencies to speed development of a vaccine that will stop this new virus and save lives. In late May, we received the H1N1seed virus, allowing us to begin work on a vaccine. Through a collaborative framework, sanofi pasteur’s goal is to develop a safe, effective and affordable vaccine that will protect everyone, including those in the developing world. GH —

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In Memory of

Reflections on a Lifetime Dedicated to Public Health Advocacy Beth Waters was a communications professional committed to advancing the cause of vaccine development and delivery. Among her many achievements, she helped to create a model for improving access to HIV treatment that has been applied to scale up treatment for other diseases. A reporter in the early years of her career, Beth was a senior managing director of Ogilvy Public Relations before co-founding Cooney/Waters Group, a health-care public relations and public affairs company in New York City. Beth was indefatigable in her work on vaccine advocacy, traveling the world to lend her intensity and expertise to her clients, governmental committees and nongovernmental organizations; and promoting immunization against polio, HIV/ AIDS, avian influenza and meningococcal disease. Beth was a wise counselor, a creative problem-solver, and a relentless optimist.

by Donald R. Hopkins, md, mph

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The Allure of Eradication

She was a founding member of the advisory board of the Vaccine Education Center of the Children's Hospital of Philadelphia and a member of the HIV Vaccine Communications Steering Group of the National Institute of Allergy and Infectious Disease. Beth Waters often said that her first job in immunization advocacy was as a child of nine. She was a “polio pioneer” – one of the children who participated in the U.S. clinical trials of the vaccine that would mark the beginning of the end of the scourge of the disease that crippled or killed children and young adults throughout the 20th century. An unrelenting crusader for the prevention of infectious diseases, her involvement with global polio eradication continued right through the last decade of her life. Indeed, much of her 30 years in communications and public affairs centered on advocacy for vaccines to protect against diseases in both industrialized countries and the developing world. Every aspect of immunization intrigued her, from the intricacies of production and supply to the involvement of communities in clinical trials of candidate vaccines for mass immunization programs. Indefatigable in her efforts, she traveled the world to lend her intensity and expertise in international scientific forums and at the grassroots level, working with her client sanofi pasteur, governmental committees and non-governmental organizations. “Beth’s work exemplifies the power of communications in bringing together people and groups to advance the prevention and treatment of infectious diseases, most notably HIV/AIDS,” said Wayne Pisano, chairman and CEO of sanofi pasteur. “It was impossible to slow her down. She fought for disease prevention with an energy and enthusiasm that was often as contagious as any of the microbes she battled.”

Sponsored by sanofi pasteur

©The Carter Center/L. Gubb

©The Carter Center/E. Staub

“You have erased from the calendar of human afflictions one of its greatest. Yours is the comfortable reflection that mankind can never forget that you have lived. Future nations will know by history only that the loathsome smallpox has existed.” Thomas Jefferson to Edward Jenner

U.S. President Thomas Jefferson’s message in 1806 to the discoverer of smallpox vaccination articulated the vision and predicted the outcome and consequences of smallpox eradication, but badly misjudged how long it would take for the world to get there. Even before humankind knew what microbes were, the idea of eradicating a disease was already imagined as the Holy Grail of combating human afflictions. More than two centuries later, smallpox has been eradicated for more than 30 years and the desire to eradicate other diseases ISSUE 03 summer 2009

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is even stronger, but that achievement has not yet been matched for any other disease (campaigns to eradicate Guinea worm disease and polio are underway), although not for lack of trying. It is useful to consider why. Even before smallpox eradication was finally achieved, separate attempts to eradicate yellow fever, malaria and yaws earlier in the 20th century had already failed. The campaign against yellow fever discovered belatedly that the virus had an inexhaustible reservoir in wild monkeys from which mosquitoes could spread it to people. Hopes for malaria eradication were dashed largely by emergence of resistance to the drug used for treating the parasite and to the insecticide used for killing the mosquitoes that spread the infection to humans. In the case of yaws, a disfiguring and debilitating bacterial affliction that attacks skin and bones, it was realized when the campaign was already underway that for each obviously affected person there were many more infected persons who showed no outward sign of being infected but who could develop sores on the skin and become infectious to others later. It was impossible to stop yaws from spreading without Donald R. Hopkins, MD, MPH, is the vice president for Health Programs at The Carter Center

Plasmodium falciparaum malaria risk in the World and the distribution of recorded parasite rate surveys used in the creation of the 2007 endemicity map

Beth Waters

C C

World Malaria Maps: www.map.ox.ac.uk/

Sock! Pow! Blam! — Fighting Malaria http://crosscut.com/2009/06/30/gates-foundation/19078/

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Dr. Hopkins ©The Carter Center

detecting and treating all infected persons, whether their infections were evident or not. When it became clear that smallpox would indeed be eradicated, that impending success spurred a flurry of efforts to identify new disease candidates for eradication. The crescendo of impulsive suggestions became so distracting that the exasperated director general of the World Health Organization (WHO) felt impelled to declare in 1980: “There are many lessons to be drawn from smallpox eradication, but the idea that we should look for other diseases to eradicate is not one of them.” Subject to more rigor and experience, the concept of disease eradication has since regained respectability. And although only WHO’s governing body, the World Health Assembly, can certify and declare a disease eradicated, for many the impulse to appropriate seductive but inappropriate claims of eradication remain. The Carter Center established the International Task Force for Disease Eradication (ITFDE), a body of 12 experts (with members from the World Health Organization UNICEF, The World Bank, the Centers for Disease Control and Prevention, universities, a bilateral development agency, etc.) in 1989 to establish criteria and systematically review potential candidates for eradication. The ITFDE’s published report in 1993 was followed by major international conferences held in Berlin in 1997 and Atlanta in 1998. The ITFDE and both conferences produced similar, precise definitions of “control,” “elimination” and “eradication” as applied

The Carter Center, a not-for-profit, nongovernmental organization, has helped to improve life for people in more than 70 countries by resolving conflicts. The Carter Center was founded in 1982 by former U.S. President Jimmy Carter

©The Carter Center/L. Gubb

to infectious diseases, in an attempt to promote agreed usage of those terms (Box 1). These efforts have been partly, but not completely successful. (The two words, eradication and elimination, may not even have distinct equivalents in most other languages besides English, French and Spanish.) Crucial to the distinctions in the definitions of eradication, elimination, and control is whether control measures against the disease in question can be halted without the disease re-emerging in a population or not. Eradication and elimination should mean zero cases globally or in a defined geographic area, respectively. The siren call of the hard-won effort to eradicate smallpox still beckons would be eradicators of other afflictions. After several false starts and some local successes (and despite the embarrassing failure to eradicate malaria, which it only acknowledged belatedly in 1969), the global Smallpox Eradication Program was formally inaugurated by a resolution of the World Health Assembly in 1966. Factors that encouraged the new global campaign to eradicate smallpox were that the often fatal viral disease was easily diagnosed in all who became infected, spread directly from person to person seasonally, induced lifelong immunity in survivors, had no reservoir of infection outside of humans, and was moderately contagious, while there existed a vaccine that was effective, safe, inexpensive, easily administered, and did not require refrigeration. Two other important characteristics were that several

and his wife, Rosalynn, in partnership with Emory University, to advance peace and health worldwide. Please visit www. cartercenter.org to learn more about The Carter Center. www.globalhealthmagazine.com

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International Task Force for Disease Eradication’s Definition of Key Terms * Eradication Reduction of the worldwide incidence of a disease to zero as a result of deliberate efforts, obviating the necessity for further control measures. True eradication usually entails eliminating the microorganism itself or removing it completely from nature. Elimination Refers to cessation of transmission of a disease in a single country, continent, or other limited geographic area, rather than global eradication (e.g., polio in the Americas). It is also theoretically possible to “eliminate” a disease in humans while the microbe remains at large (e.g., neonatal tetanus). Although a disease itself may remain, a particularly undesirable clinical manifestation of it may be prevented entirely (e.g., blindness from trachoma) or new transmission interrupted (e.g., infectious yaws). Control of a disease or its manifestations to a level that it is no longer considered “a public health problem,” as an arbitrarily defined qualitative (e.g., onchocerciasis in West Africa) or quantitative (e.g., leprosy incidence below one case per 10,000 population) level of disease control. Control Reduced incidence or prevalence of a disease or condition; control measures are still required.

large areas had stopped transmission of the virus already, and that all human beings everywhere were at risk of getting smallpox unless they had already had the disease or been successfully vaccinated. No country was safe from an imported case of smallpox with its attendant deaths, terror and expense until all countries were safe. The last case of naturally occurring smallpox became ill in Somalia on Oct. 26, 1977, after a global expenditure of about $300 million. The United States, which had its last case of indigenous smallpox in 1949 and contributed about $32 million to the global campaign, was able to cease routine vaccinations and other expensive defensive measures beginning in 1971, and has subsequently recouped its investment every few weeks, in avoided costs, disease and deaths. The global benefits of smallpox eradication are comparable. Given the cachet of totally erasing a disease “from the calendar of human afflictions,” not to mention the potential consequence, in Jefferson’s words, “that mankind can never forget that you have lived,” it is little wonder that the concept of disease eradication is so attractive that it has been invoked by all and sundry, often with good intentions but equally often with scant regard for its true meaning. Disease eradication is a powerful tool that properly used, can unleash incredible dedication and effort among health workers and volunteers, generate substantial funding from donors, and attract unusual support for a program by politicians. Health workers and volunteers are motivated by the specific, measurable day-to-day goals, while donors and politicians like the clear and immutable end point. If disease eradication is

ISSUE 03 summer 2009

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permanent and its benefits infinite, why not “go for it” as often as possible? Because eradicating a disease is usually impossible, it is costly, difficult and inherently risky when it is possible, and over-promising devalues the concept. In 1993, the ITFDE published criteria for assessing the potential eradicability of diseases. The criteria explicitly acknowledge the critical and equally important roles of scientific and political/social factors in considering whether a disease can and should be considered a likely candidate for total eradication. Just as some public health enthusiasts are inclined to ignore or under-value the political/social criteria, political leaders often do not understand or are misinformed about the scientific criteria. A disease such as tetanus that has an inexhaustible reservoir of infective spores in the environment cannot be eradicated, ever. Ditto for African trypanosomiasis (sleeping sickness), with its reservoir in certain wild animals, and most other infections, for various reasons. To the extent that one or more of the above-mentioned scientific and political/social criteria are lacking, the possibility of eradication is impossible or becomes increasingly difficult. The criteria do not, however, require a prospective disease to “be like smallpox” in order to be considered eradicable (for example, Guinea worm disease is being eradicated mainly with health education despite there being no vaccine). Equally important is the need to recognize the inescapably critical role of the endemic countries themselves, and the fact that some countries

C* http://cartercenter.org/health/itfde/program_definition.html

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DISEASES IDENTIFIED AS ERADICABLE BY INTERNATIONAL TASK FORCE FOR DISEASE ERADICATION* The task force has concluded that seven diseases can be eradicated: E E E E E E E

dracunculiasis poliomyelitis mumps rubella lymphatic filariasis cysticercosis measles

will require and deserve special external assistance, especially if the disease in question is not a major problem for them. Perhaps the most controversial requirement for success in an eradication program is the unavoidable demand that an eradication program must operate with nearruthless focus. This has led to endless debates about the relative value of narrow “vertical” eradication approaches in eradication programs as compared to broad-based, primary-care “horizontal” approaches to improving the public’s health, as well as accusations, usually unfounded in my view, that vertical programs have harmed or prevented development of broader health services. In many instances, but for the so-called vertical programs and their ancillary benefits, neglected rural populations would receive little or no health services at all. Ideally, both approaches should be pursued simultaneously, with maximal coordination and synergy, but there is no escaping the fact that to succeed, any eradication program requires obsessive focus, attention to detail, and accountability at all levels to a degree that is not true for a control program. Unlike control programs, an eradication program must try to achieve near-perfect execution, everywhere the disease occurs, all the time, until transmission is stopped. I like to point out that there is still honor in disease control, even though it is different from disease eradication, that effective disease control is needed, appropriate and possible much more than is disease eradication, and that control programs and primary-care programs would do well to adapt certain aspects of eradication programs, such as measurable interim targets and specific outcome indicators of impact on diseases and conditions. The same advice applies to recent enthusiasms for “integrated disease control” and for

C* http://cartercenter.org/health/itfde/role.html

control of “Neglected Tropical Diseases,” with the caveat that integration and eradication are usually incompatible. Channel the passion directed at “vertical programs” into developing the broad-based public health services and functioning integrated disease surveillance systems that all agree are badly needed and woefully scarce. After applying the aforementioned criteria, the International Task Force for Disease Eradication concluded in 1993 that six diseases were likely targets for eradication. It has since added measles to that list (Box 2). In its original report, the ITFDE became the first international body to champion the potential global eradicability of lymphatic filariasis, a conclusion that was endorsed implicitly by a resolution of the World Health Assembly in 1997. The World Health Assembly resolution on lymphatic filariasis hedged a bit, however, calling for lymphatic filariasis to be “eliminated” globally “as a public health problem.” The meaning of “a public health problem” in this context was unspecified. Similar sophistry was and is all too common elsewhere in attempts to garner the perceived potential political and financial benefits of asserting a goal of “eradication” even when eradication, strictly speaking, is not achievable. Apart from current efforts, albeit delayed, to eradicate dracunculiasis (Guinea worm disease) and polio, more recent initiatives to eliminate onchocerciasis from the Americas and to eliminate yaws from Southeast Asia appear to be on track and properly characterized, in my opinion. In addition, since 2006 the ITFDE has promoted the very sensible and long overdue idea that a “program to eliminate both malaria and lymphatic filariasis from the island of Hispaniola is technically feasible, medically desirable and would be economically beneficial to both the Dominican Republic and Haiti.” In summary, although the term is often abused, sometimes willfully, (disease) eradication is a powerful tool that is only rarely applicable. It should be asserted and used with great care, after much thought, and ideally with broad consensus and endorsement by the World Health Assembly. GH —

www.globalhealthmagazine.com

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By M Moran, j Guzman, al Ropars, a McDonald, l Wu, b Omune, l McSherry —

Funding New Products for Neglected Diseases: Are We Getting it Right? Recent research has, for the first time, shed light on how much is being invested globally on research and development (R&D) into new products to prevent, diagnose, manage or cure neglected diseases of the developing world. These diseases, including both well-known infections such as malaria and HIV/AIDS and less well-known diseases such as onchocerciasis and helminth infections, account for more than 11 million deaths and just under 330 million disability adjusted life years (DALYs) a year in developing countries alone. Despite this high burden, these diseases have historically received less attention than they deserve, especially in regards to funding for R&D of new pharmaceutical products. Since 2000, however, several developments have changed this field dramatically, including the establishment of new Product Development Partnerships (PDPs) for neglected diseases, increased philanthropic and public funding, and renewed commitment and participation from the pharmaceutical industry. The research showed that more than $2.5 billion was invested in neglected disease R&D in 2007. This funding was invested into development of drugs, diagnostics, vaccines, microbicides, insecticides and platform technologies for 30 neglected diseases of the developing world. Although this may sound like a substantial investment, it is important to remember that the cost of developing a single pharmaceutical can range from the tens of millions more than three to five years for a new diagnostic, to hundreds of millions over 12-15 years for a new vaccine. For example, the total cost of developing a novel TB drug has been estimated at $115 million to $240

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million, while the cost of developing a vaccine has been estimated a $200 million to $500 million (both estimates include the cost of failure). Yet another estimate from Tufts University for the cost of developing a drug for Western markets comes in at $403 million, again including the cost of failure. In short, as the R&D process is lengthy, risky and costly, very substantial investments are needed for a successful product to be developed. Where does the money go? The good news is that neglected diseases are on the global agenda and that the efforts of AIDS, TB and malaria advocates have shown results. Just under $2 billion (almost 80 percent of total 2007 funding) went to the so-called ‘Big Three’ diseases – HIV/AIDS, malaria and TB. The current portfolio of potential TB and malaria products is the largest in history. It includes, for example, advanced malaria vaccine candidates such as RTS,S (developed by GSK in partnership with the PATH-Malaria Vaccine Initiative), which has just commenced Phase III trials in seven countries in Africa. The new TB vaccine candidate (AERAS-485, being developed by the OxfordEmergent TB Consortium), which has just begun Phase II trials in South Africa, is another example of advances in the field. Unfortunately, however, not all neglected diseases have received attention, with many diseases that kill and disable millions of people in developing countries still remaining underfunded. Diarrheal illnesses – identified as one of the biggest killers in the developing world – only received $32.5 million in 2007. This is far below what is needed to develop the new drugs, diagnostics and

Authors are members of the Health Policy Division, The George Institute for International Health

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total r&d funding by disease malaria 18.3%

hiv/aids 42.3%

tuberculosis 16%

other* 23.4%

other* kinetoplastids

4.9%

buruli ulcer

0.1%

diarrheal diseases

4.4%

trachoma

0.1%

dengue

3.2%

rheumatic fever

0.1%

core funding of a multi-disease r&d Org.

4.3% 0.4%

helminths (worms and flukes)

bacterial pneumonia and meningitis

1.3%

typhoid and paratyphoid fever

0.4%

platform technologies

leprosy

0.2%

unspecified disease

vaccines needed to treat and prevent the seven major diarrhoeal illnesses, such as rotavirus and cholera, which are covered by this funding. Where does the money come from? In its first year, G-FINDER surveyed 134 funders in 43 countries around the globe. The results revealed that a small number of organizations are bearing the brunt of funding R&D for neglected diseases. In 2007, 12 organisations provided around 80 percent of global funding, with the U.S. National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation collectively investing $1.5 billion or 59 percent of the global total. Particularly in these uncertain economic times, it is imperative that we spread the risk so that withdrawal or reduction of funding by any one organisation will not have a detrimental impact on neglected disease R&D. At least 1 billion people in 149 countries are infected with neglected diseases. – WHO

In terms of public spending, the U.S. government was the largest funder with an investment of $1.3 billion; representing nearly three-quarters of global public spending, while the European Commission and European governments collectively invested $384.9 million (22 percent). Also of note is the increasing role played by innovative developing countries (IDCs), with Brazil and Russia ranking as the sixth and tenth largest government funders respectively, despite their significantly lower GDPs per capita ($5,860 for Brazil and US$7,530 for Russia, compared to $46,040 for the U.S. ). The pharmaceutical industry contributed $231.9 million in 2007, or just under 10 percent of total global funding for new neglected disease products. We note that this figure is industry’s own investments and does not include funding provided by PDPs or others to industry programs. www.globalhealthmagazine.com

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How can the G-FINDER data help? The data from G-FINDER is only one element of the equation. Policy-makers and funders need to look at a range of factors in deciding where and how much to invest to maximise the health return on a given neglected disease R&D investment. Key factors in deciding which area to invest in include the severity of unmet R&D need (for instance, the burden of disease and the shortfall in existing useful products); and the severity of underfunding, with many diseases and products receiving little or no funding, as noted above. Once a decision has been made on where to invest, the size of the necessary investment will in turn be guided by a range of factors, including: • The type of product needed, e.g. a diagnostic, which may only need a few million dollars in funding, or an expensive full vaccine development; • The state of the global portfolio, i.e. are there promising leads and how advanced are they already? • The development risk, that is the likelihood that a product can be made. Scientists and companies still do not know how to make some products – a cure for the common cold being a good example – and some neglected disease products also fall into this category. Rheumatic fever offers a helpful example of how these decision-making factors interact. Rheumatic fever is a bacterial infection, most common in children aged 5-14 years. It often leads to rheumatic heart disease, with permanent damage to the heart valves and associated risk of heart failure and stroke. According to WHO figures, rheumatic fever is the seventh highest cause of mortality from neglected diseases in developing countries, with the high death toll resulting from the lack of tertiary care facilities to treat cardiac complications in much of the developing world. A preventive vaccine for this disease is vital but does not exist. It also seems unlikely that a vaccine will be created if funders continue their current investment patterns, since the G-FINDER results showed that rheumatic fever received only $1.7 million in 2007, well below the level needed to develop a new preventive vaccine within the next decade – or even in many decades. In other words, the severity of need and severity of underfunding are both high. It is clear that a rheumatic fever vaccine would be the optimal product for developing country settings, avoiding the need for patients to have access to high-tech tertiary facilities for acute and long-term cardiac care. Vaccines are, as we saw, expensive to develop. However in the case of rheumatic fever, costs are likely to be lower due to a relatively low development risk. This is because the disease and its transmission are well understood, as are

the science and technology to develop and produce an anti-bacterial vaccine. Limited funding over the years means that few vaccine leads are currently available and ready for further development; however, several multinational companies work in related bacterial fields and may already have suitable technologies or capabilities under way. Based on the high need and large funding gap, investment into a preventive vaccine for rheumatic fever should be attractive for a funder who wants to invest in a lower-risk area where their money will have a high potential impact. The future After past decades of inertia and neglect, the participation of many organizations and countries in the development of new products for neglected diseases is a commendable and welcome achievement. The G-FINDER data shows, however, that these efforts are not evenly distributed, with some of the world’s wealthiest countries missing in action from the top 10, top 20 or even top 50 funders. We also note that investment by some private philanthropic organizations and companies is now rivalling or exceeding spending by many public organisations, and indeed many G7 and OECD countries. While the work of these private groups is praiseworthy, we note that their efforts are meant to support, not replace, those of wealthy governments around the world. The predominance of research into new products for HIV/AIDS, malaria and TB is understandable – and the generosity of funding is both necessary and a credit to funders. However, all neglected diseases, including these three, should receive the attention and funding needed to achieve discovery, development and registration of new products. A broadening of funding efforts so that all who are able to contribute do so, and that all diseases receive the attention they deserve, would lead to a dramatic positive impact on the health of developing country patients afflicted with these diseases. We hope the G-FINDER results will assist funders to identify funding gaps and see where their investments can make a substantial and valuable impact by supporting the development of new tools for neglected diseases. In tough economic times, it will be more important than ever for all funders – large and small; public, philanthropic and private; Western and developing countries – to contribute what they can to ensure that the poorest of the poor do not end up paying the price. GH —

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The economic, psychosocial and physical damage sustained due to neglected diseases is the equivalent of 57 million disability-adjusted life years (DALYs) per year.— PLoS Medicine 3(No 5 e102)

Poet Soldiers Discrimination

Only hate, scorn and glaring eyes Am I a monster? All I want is love, Someone to appreciate, Demonstrate and don’t hesitate To give me what all human beings deserve, LOVE. Every night I pray That the Almighty God Would lead me not to stray. I do the same as everyone… Eat, laugh, work and play, But why am I not looked at in the same way. I try to tell them it’s not my fault, But what do they care, All they do is just hate, scorn and discriminate. Open your eyes people, I am just like you Two legs, arms, eyes and ears. But why can’t I strive, tell me why can’t I? It’s not my fault I still try to say, but what do they care, They just, hate, scorn and discriminate. – Julonna Peterson, Lance/Corporal

STOP HIV/AIDS

Who me? NO way, I could never get AIDS I am sure that’s what many people say But am here to tell you today That kind of thinking will get you no way You better change that perception I say AIDS does not discriminate It knows no color, gender, class nor race You could be rich, poor, even displaced Homosexual, bisexual and even heterosexual are all at risk Just one moment of folly Before you know you are an AIDS case Our teenagers are AIDS favorite age. Our young adults, its popular friend too. And just imagine even married folks give it to their spouses. The unborn, innocent child can get it from their mother And to make matter worse they may grow up as orphans But do you know what is worst? Our society scorns and discriminate those with HIV/AIDS Believe me that is no help, it only makes the conditions worsen They need to know they have our support They need to be loved and cared for too So they can help to spread the message to me and you. The facts are alarming, million of men, Women and children have already died And many more millions are living with the virus And can you imagine, the Caribbean, our little slice of paradise Is marred with HIV/AIDS But guess what all is not lost, it is not doom and gloom AIDS is fatal but it can be prevented As old people say “An ounce of prevention is better than a pound of cure” Educate yourselves and those around you, Abstain, practice safe sex, and do what you must do And if you think you contracted HIV, get tested Find out the facts, and act on them And let us reclaim our lives from this deadly virus. –Idelia Ferdinand, Captain

www.candlelightmemorial.org

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These are poems written and read by members of the St. Vincent and the Grenadines Cadet Force for and at an HIV/ AIDS awareness Candlelight march and rally.

A Poem on HIV/AIDS

A long time ago, 1992 yo could say, Yo could ah neva hear a thing like AIDS going around here. But now you think is so, AIDS flying round like mosquito. They say it began in Africa, But it really started from men and women all over. A lady on the TV the other night say she ha the cure, Could she be serious? This lady must be think AIDS is trush! Anyway, all I could say is, AIDS like it nah gwine way. So I’m begging all young ladies who just coming up, Mind what you doing or your life would be corrupt. No, I did not forget the young men them, They too need to help us with this problem. – Nassine Richards, Private

Are You My Friend?

Ten years we walk together, Ten years you been me friend, But five years ago, ah never tell you wha did happened then. You remember Gina? Yes Gina, de African goddess sent? Well she and me got together, And you could imagine how that went. A few weeks later she give me a call, And ah tell yo boy, ah nearly bawl. She said she had de thing – de AIDS yo know, But ah couldn’t believe that that been so. Ah check me doctor. And ah tek de test, Fo days and days, man, ah couldn’t rest. De test came back, And de worst was true, De girl been ha de thing And I got it to. Five years now it ah burden, burden me chest, Ah ha to tell somebody, And ah think you de best. So tell me now what you gwine do, Yo gwine walk way from me? Or could I count on you? – Darrien Ollivierre, Lieutenant

www.globalhealthmagazine.com

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infectious diseases

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online exclusives

By Dr. Videlis Nduba —

C Field Notes:

Developing Country TB Vaccine Researchers Find Strength in Numbers

An infectious disease specialist in Worcester, South Africa, frustrated that children were dying from preventable diseases, set up a research unit on tuberculosis (TB) vaccine clinical trials. In Uganda, a doctor who worked on preventing mother-to-child transmission of HIV began working in vaccine research to prevent patients who were living with HIV from dying of TB. I transitioned

from sexually-transmitted disease research to working on life-changing vaccines to combat TB. We are on the front lines of the war against TB, fighting to ensure that vaccine research is conducted to the highest internationally accepted scientific and ethical standards. We share a passion to fight a disease that kills nearly 2 million people each year and sickens more than 9 million. Together, we principal investigators, along with an expanding cadre of world-class TB vaccine researchers in Africa and Asia, are working tirelessly toward the development of new vaccines that could help stop

By john donnelly

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C from the

C 35 Years after Discovery,

John Donnelly, a former reporter with the Boston Globe, will be blogging with a look inside the ministry of health in Senegal. He will then report from the health ministry in Sierra Leone – not just on what’s going on inside government but how their decisions affect the level of care in hospitals and clinics.

In 1973, using electron microscopy, a “new” virus causing this illness was discovered in a child admitted to the Royal Children’s Hospital in Melbourne, Australia. Within a year of that discovery, the virus finally had a name – rotavirus – and the global health community was beginning to understand that the best way to protect children from this often deadly disease was to prevent them from getting it in the first place. It has taken more than three decades to develop safe and effective vaccines since my colleagues and I first saw this virus. The prospect for global introduction of rotavirus vaccines is finally within reach.

ministry to the clinics

Go to www. globalhealthmagazine.com to follow John’s daily blog.

ISSUE 03 summer 2009

Go to www.globalhealthmagazine.com to read the full story.

By dr. ruth bishop —

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TB. Through a consortium of TB vaccine researchers around the world called the TB Vaccine Sites Network (TBVACSIN), we share knowledge with one another so that we will be successful in conducting planned multi-center Phase III efficacy trials to license the first new vaccine against TB in 90 years. The sites that we are developing, the clinical trials that we lead, and the expanded infrastructure, professional development, and health care associated with those trials, benefit communities now and have the potential to eliminate tuberculosis forever.

the World is on the Verge of Stopping Deadly Rotavirus

So what obstacles have been overcome? Go to www.globalhealthmagazine.com to read the full story.

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by mark s. smolinski, md, mph

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Tracking the Flu

By May 11, 2009, a swine flu detected just two months earlier in an outbreak in Mexico and the United States had spread to 30 countries raising the threat level to 5 on the global flu scale.1 On June 11, 2009, the directorgeneral of the World Health Organization further elevated it to level 6: a flu pandemic. While alarming, this should not have been a complete surprise as leading scientists have, for years, been foretelling a flu pandemic was “not a matter of if, but when.” Swine flu is initially showing us its ability to spread, while fortunately, not yet baring its ‘teeth.’ Maybe it hasn’t cut teeth yet, but it does have a name: novel influenza A, or H1N1. While some may take solace in its low lethality, the speed alone in which this single virus traversed the globe is impressive. But what do we really understand about the spread of flu? We can learn a great deal from this particular moment in history and perhaps even change the story that will be told of the influenza pandemic of 2009. We live in the day of 24-hour media, Facebook and Twitter, email, texting and all that the World Wide Web has to offer. Are we doing all we can to learn from this influenza pandemic now to be better prepared for the next, perhaps more deadly, wave? The answer, in part, may lie hidden in the spinning wheels of our social constructs. Public and private efforts can be synergistic when looking to this new age of information and technology to detect the spread of flu. For example, Google Flu Trends is built on the close relationship between how many people search for flu-related topics (query counts) and how many people actually have flu symptoms. Smith, Gavin J.D. et al Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A epidemic. Nature. Vol 459; 25 June 2009; doi:10.1038/nature08182

Google engineers compared query counts with historical public health flu surveillance systems and found that many search queries tend to be popular exactly when flu season is happening. By using aggregated Google search data, Google Flu Trends can estimate how much flu is circulating in different states and countries around the world.2 In urgent response to the swine flu outbreak in Mexico, Google launched an experimental Google Flu Trends Mexico without benefit of historical flu data. Google Flu Trends Australia exemplifies the strength of public/private synergy. Google used historical influenzalike-illness (ILI) data from the Victorian Infectious Diseases Reference Laboratory (VIDRL), the state’s largest public health reference laboratory for Google Flu Trends Australia3. Public health researchers in Australia are now using Google Flu Trends Australia and Google Trends as comparison tools for their own pilot online health surveillance system to detect epidemics of influenza.4 With Google Trends and Google Insights for Search, anyone can compare the world’s interest to topics of their choosing. Google Trends analyzes a portion of Google web searches to compute how many searches have been done for the terms you enter, relative to the total number of searches done on Google over time. Google Trends also shows how frequently topics have appeared in Google News stories, and in which geographic regions people have searched for them most. Google Insights for Search provides search volume patterns across specific regions, categories, time frames and properties. Other early detection efforts were discussed in a 4

http://flutracking.net/

John S. Brownstein, Clark C. Freifeld & Lawrence C. Madoff. Digital Disease Detection—Harnessing the Web for Public Health Surveillance. The New England Journal of Medicine May 21, 2009. 5

Jeremy Ginsberg1, Matthew H. Mohebbi1, Rajan S. Patel1, Lynnette Brammer2, Mark S. Smolinski1 & Larry Brilliant1 Detecting influenza epidemics using search engine query data. Nature 457, 1012-1014 (19 February 2009) | doi:10.1038/nature07634; Received 14 August 2008; Accepted 13 November 2008; Published online 19 November 2008; Corrected 19 February 2009

http://www.vidrl.org.au/

6 Institute of Medicine of the National Academies. . Microbial Threats to Health: emergence, detection and response. Mark S. Smolinski, Margaret A. Hamburg, and Joshua Lederberg, eds. 2003, National Academy Press.

www.globalhealthmagazine.com

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Any stigma placed on a disease outbreak early in its course can drastically alter its fate. recent GLOBAL HEALTH article (Issue 2, Spring 2009) by Kumanan Wilson and John Brownstein, including HealthMap which automatically scans 20,000 news sources every hour to aggregate and disseminate information on emerging diseases on a free map on the web. The Global Public Health Intelligence Network (GPHIN) and the International Society for Infectious Disease Program for Monitoring Emerging Diseases (ProMED) have the added value of disease specialists as moderators to assist in validating early reports5. While Google Flu Trends can help predict flu activity, it cannot replace official influenza surveillance because it does not provide the critical information that public health needs: You. All public health is local. The spread of influenza is related to our social constructs and within them to our religious and cultural practices, our social networks, our public health preparedness, indeed our world. Flu can spread through communities at any gathering, in health clubs, at the movies, in the workplace and at school. Early alerts and community health recommendations are only as effective as their ability to incite protective action on the ground. Public health surveillance is about finding cases, confirming with laboratory tests, implementing control measures, and making recommendations for public health safety and security. No self-reporting or proxy illness system can ever replace the public health need to verify an outbreak. Innovative surveillance systems, however, can complement official systems and perhaps, someday, work in unison for the earliest possible threat detection. The present and future of infectious disease surveillance requires earnest engagement of the ‘public’ in public health. It means utilizing the social constructs that often spread disease to be part of the solution for monitoring its spread, demonstrating the effectiveness of community control measures, and educating each other. It may also entail leveraging the use of electronic media to enhance the public’s participation. Any stigma placed on a disease outbreak early in its course can drastically alter its fate. Bugs don’t discriminate, people do. Look no further than HIV. Thirty years later, social oppression and HIV continue to bare their teeth in new populations around the globe. Flu spreads efficiently and quickly into all elements of

society as a respiratory pathogen. The world is at risk for flu and we must proceed in unison without the fear of stigmatization, discrimination or neglect. Delays can have unforseen consequences. David Heymann, assistant director-general for health security and environment at the World Health Organization, illuminated the “window of opportunity” that we almost missed with smallpox eradication6. HIV persons would not have been able to be vaccinated for smallpox as it would have overwhelmed their weakened immune systems. Had it not been completed just prior to the HIV pandemic, we might never have eradicated smallpox. Today, we have many individuals with immune systems weakened by chronic diseases, chemotherapy and malnutrition experiencing the flu pandemic in 2009. Historians will have to tell us later whether we ‘missed the window of opportunity’ with flu when the next yet unknown infection emerges. What if another new respiratory threat emerges coincidently within this flu pandemic? SARS, after all, was just six short years ago. SARS had the potential to be a pandemic if not for the heroic efforts of public health and health care communities in the affected countries in synergy with global health partners. It is painfully ironic that greater scientific collaboration necessary to conquer an urgent threat also leads to increase sharing of dangerous pathogens in laboratories around the globe. Scientists are ‘experimenting’ with recombinations of influenza strains to advance our understanding of pathogenicity and isolating the virus to assist in diagnostic tests and vaccine development. All are necessary but require enforced biosafety and biosecurity practices. Remain diligent and vigilant. Every new emerging infectious disease adds to our collective global health burden of prevention, preparedness and control efforts for all infectious diseases. Hantavirus, Ebola, SARS, HIV, bird flu, swine flu are all ‘new’ global health burdens bearing on adults who still have many of their parents and grandparents infectious diseases. The world still suffers from polio, malaria, pneumonia, and tuberculosis despite significant advances in science and technology. And our grandparents did not have the added burden of drug resistance like today. Indeed, polio is ‘this close’ to being eradicated from the earth. Polio eradication is to global health, what landing a person on Mars is to the space program. It’s that important. But couldn’t we learn so much more, so much faster if we just asked people without discrimination “are you sick?” during this critical time of pandemic flu? In the future, perhaps one won’t even have to be asked, but we are now in the present. Are we tracking the first flu pandemic of the 21st Century, or are we watching it? History will decide. GH —

ISSUE 03 summer 2009

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Mark S. Smolinski is a public health disease surveillance and response expert at Google, a.k.a. the ‘threat detective’. Mark is currently working for Google.org in Southeast Asia.

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pandemic paradox NETWORKS

CONNECTORS & Bridges

‘LIFE BLOOD’

ELEMENTS OF SOCIAL CONSTRUCTS

Image from tree.bio.ed.ac.uk via Goolge Image search.

Networks bridged by individuals or small groups as connectors are the social constructs through which infectious diseases can spread. Within these constructs is also the lifeblood to track pandemics and signal potential emerging threats. The same constructs can channel education, prevention and control messages into villages and communities—becoming the lifeblood of global health.

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