Global Health Forum

Aid to Africa is “largely ineffective and often harmful”

camilia.kamoun — Mon, 08 Feb 2010 21:22:35 +0000

Ineffective.

Harmful.

Courtesy of KleinPictures

Those are the adjectives the Klein family uses to describe much of the aid that goes to the African continent. Their documentary What Are We Doing Here? traces the journey of three brother and a cousin who travel for 6 months from Cairo to Cape Town, talking to NGO workers to child to parents to government officials, to learn about charity in Africa. We were lucky, at Swarthmore College, to have Tim Klein present his film on January 22, 2010 to an audience of over 200 people and answer questions from the audience after the showing.

The film and the event Swarthmore’s Global Health Forum helped Americans for Informed Democracy organize were created to spark discussion about foreign aid. As the film asks, why has the situation in so many places that receive aid not improved? Wouldn’t you expect that aid should alleviate the poverty it targets? The film shows that there are various answers for why much of the aid has not helped. Moreover, it illustrates how aid is often harmful.

Here are some key and disconcerting points the film makes:

Aid to Africa is a multibillion dollar industry. The rice that serves as food aid comes from U.S. farmers, so it hurts farmers in African countries who cannot compete and who themselves become dependent. As one man says in the film, “What has been accomplished has been to effectively put many African countries on a life support system.” Much of the foreign aid does nothing to help people in the continent help themselves. That is the main problem.

When you sponsor a child, that money does not actually go to a child. Rather, the money goes to building programs and longer term initiatives that will improve children’s lives and futures. In principal, that use of money is actually more beneficial than giving the money just to one child. Why do organizations have to misled people to get money? Why isn’t it understood that true aid means helping people help themselves?

Another problem, the film argues, is that governments are not held accountable by their people. The relationship between government and people is often non-existent. People go to aid organizations directly instead of to their governments. State building where the government acts for the people is not happening. Aid organizations are not helping either, because they serve an inappropriate role as intermediaries between the government and the people. Sometimes, as in the case of the Rwandan genocide, they even give aid to people who are harming others.

Some Africans think the best thing is for other countries to leave them alone.

For me personally, watching this movie and seeing the beautiful lush land on the continent really drove home the idea that external interference has been harmful. Its not a coincidence that with so many natural resources the poverty continues.

We need to change the way aid works. To join in on these efforts, obtain the movie, or to learn more visit www.whatarewedoinghere.net.

Minus Malaria Week 2010

camilia.kamoun — Fri, 15 Jan 2010 23:57:39 +0000

The week of February 7-14, 2010 is Minus Malaria Week. Swarthmore College’s GHF is spearheading this week of college students coming together to support the eradication of the burden of malaria.

Our goals for the week:

$5,000, the equivalent of 1,000 bednets

750 letters sent through the Give a Net, Get a Vote Campaign

Students participating in Minus Malaria Week will do this in three ways: education, fundraising, and advocacy. Student organizations in support of the Minus Malaria Initiative (MMI) will host both an educational campaign and a fundraising campaign on their college campus. Through their campaigns, organizations will work to raise awareness about malaria in their communities and to advocate for malaria relief by participating in the Give a Net, Get a Vote campaign: for every $5 donated (the equivalent of one net), supporters of MMI will have the opportunity to sign a letter to Congress, expressing support for legislation that furthers the goals of MMI. All funds raised will be used to purchase bednets to be distributed in Malen chiefdom in Sierra Leone, a community where MMI has previously focused its efforts.

Interested in joining? We’ll provided extensive support to all individuals and groups interested in participating, including toolkits, help with planning, materials, event ideas, etc. Participation take the form of a small scale event that serves the two-fold purpose of fundraising and educating or it can be a week long series of events.

Contact Cariad Chester at cariad.chester@globalhealthforum.org and John McMinn at john.mcminn@globalhealthforum.org to join! Visit “For Students” section (link above right) for more information and click “Partner With Us”.

Counterfeit Malaria Drugs as a Global Health Issue

melissa.frick — Thu, 10 Dec 2009 21:23:27 +0000

This summer in Ghana an antimalarial drug came under suspicion; presumably, this medication was counterfeit. After chemical analyses, the drug sold under the name “Coartem” confirmed these doubts, lacking any active ingredient. This incident exposes a threat that is not common in the United States, but wide-spread and under-addressed in the developing world. Counterfeit drugs pose a threat to public health on an individual level as well as an international scale and often bias the poor socio-economic classes. Although there are regulatory frameworks in place, further pursuit of imitation and ineffective drugs are necessary to decrease the incidence of malaria.

Counterfeit artesunate anti-malarial tablet with fake 'X-52' stamp as seen under UV light. From www.worldvisionreport.org

Counterfeit drugs pose a major barrier in combating malaria throughout much of the underdeveloped world. The most direct reason why fakes are dangerous is those persons relying on a drug for protection against malaria presume they are safe, often ignoring other pathways for protection. To make an analogy within another spectrum of public health- it’s like protecting yourself against pregnancy without using birth control pills because you’re already using a condom… with holes in it.

Counterfeit drug makers have also learned how to thwart the system by adding minimal levels of active ingredients so that quality-screening tests reveal a false-positive. Not only are these types of counterfeits ineffective at killing the parasite infection but they also increase the likelihood of mutation and resistance. Several studies have already indicated that the prevalence of counterfeit drugs has is induced some strains of malaria to become resistant (How? Some counterfeits do have small traces of the active ingredient, but not a heavy enough dose to kill the parasite completely. The strains that survive this ineffective dose may replicate and pass on their drug-resistant genome to all following progeny. Whatever doesn’t kill them makes them stronger…).

The prevalence of counterfeit drugs has increased over the past decade. At the end of the 20th century in southeast Asia, 38% of over-the-counter counterfeit artesunate tablets containing no active ingredient; in 2004 this percentage rose to 53%. In certain countries, mainly in Africa, over a half of the available medications are fake (compare this to developed nations, like the USA, where only 1% of all medications are counterfeit) . The WHO estimates that counterfeits contribute to nearly 200,000 preventable deaths each year from malaria.

A recent study conducted a quality assessment test of available antimalarials in six urban or rural setting of southeast Nigeria. Their findings? Thirty seven percent of the tested drugs did not meet USP standards. Furthermore, this study implied that drug quality in rural settings was significantly worse than in urban settings, where 66% of quinine medications were substandard as compared to 43%, respectively. The private and low-level providers observed in this study were predominantly used by low socio-economic status (SES) individuals. This suggests that the poor SES groups often receive the lowest quality of treatment, perpetuating a cycle of poverty in endemic areas.

To understand why this large discrepancy exists in a developing country and not developed countries, we must look at how these citizens go about obtaining their drugs and how this is different than the process in the USA.

A drug dealing holding a counterfeit medication. From NYTimes.com

A majority of malaria cases in Nigeria are usually treated by private providers, purchasing drugs through shops and/or peddlers - we’ll call this the “informal private sector.” These providers do not have to hold standards or requirements (the USA has the FDA to do this); this is where counterfeits or poor drugs are often obtained. But these vendors may not have any choice but to sell faulty products. It is the drug makers who ultimately receive the most economic incentive to fudge-up their product. Medicine has relatively high production costs and when legislation (or a lack thereof) provides minimal penalties, counterfeiters are given an economic incentive to produce fakes. The providers, whether it be vendors or pharmacists, often lack awareness of the existence and/or consequence of counterfeits. The peddlers are victim to competition; they have to buy the cheapest drug marketed to them to stay in business. Public providers, such as pharmacies or retail outlets, may also have pitfalls in dispensing the correct medication. Their gaps in quality assurance result from the lack of quality control during manufacture and faulty storage environments.

There is some framework to catch these counterfeits - the U.S. Pharmacopeial (USP) Convention is a nonprofit scientific organization who develops international standards for medicine quality. They have been supported by USAID to create a Drug Quality and Information (DQI) program for developing countries to ‘verify, assure, and improve the quality of medicines intended to treat life-threatening neglected diseases.’ The recent seizure of the Ghanaian counterfeits strengthens the USP’s DQI reputation as a way to regulate fake drugs, yet the statistics prove there is a lot of ground to make up .

Other movements throughout the world are also effective in combating the market of counterfeit drugs. In China, collaboration between public health advocates, scientists, and law regulators has developed a technique called forensic palynology to track down the location of manufacture. They study the chemical makeup of the pollen contaminants in the medicine; in their studies, some of the pollen had traces of the mineral calcite which is commonly mined in southern China. This lead brought officials to a suspect in the Yunnan Province of China, eventually seizing over 24,000 doses of fake medications in 2008.

Where can we move from here? A report published in the PLoS Medicine Journal suggests ways to decrease the prevalence of counterfeit drugs. It sets out some goals; 1) the provision of effective, available, and inexpensive drugs, 2) effective drug regulatory networks, 3) openness of governments on the severity of counterfeit drug prevalence (many governments have often denied the problem), 4) cooperation between countries where counterfeit drugs are crossing borders, and 5) improved education of patients, drug sellers, and health workers. It is quite obvious from these suggestions that we cannot rely on developing nations to individually attack or pursue fraudulent manufacturers. Instead, the drug regulation and standardization process must be the responsibility of non-governmental industry manufacturers, governments, and the international community. Ultimately, if counterfeits induce drug resistance, the mutant malaria strain does not discriminate and will cross country borders whenever given the chance. By that time, the infection will be more than a local or national issue, but a looming threat to the international community.

References:

http://www.eurekalert.org/pub_releases/2009-07/up-cad072209.php

http://www.sciencedaily.com/releases/2006/06/060619005440.htm

http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx?id=3115

http://www.malariajournal.com/content/8/1/22

http://www.sciencedaily.com/releases/2008/02/080212085828.htm

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020100#s1

GMin Distribution of ITN in Sierra Leone

camilia.kamoun — Thu, 10 Dec 2009 19:25:40 +0000

As you may remember, MMI partnered with Global Minimum (GMin), a bednet distribution student group, this past spring. Here is a long overdue update on that partnership.

This summer, a group of GMin members travelled to Sierra Leone to distribute insecticide-treated bed nets (ITNs) raised through GMin and MMI. Global Health Forum’s Lois Park was also in Sierra Leone this summer, implementing a malnutrition program, which you can read about on her blog. During her trip, Lois visited the GMin team and sent us her impressions of the distribution…

August 1, 2009:

So about three weeks ago I visited the GMin team down in Sahn. It was about a 9-hour long ride from where I’m based on a poda poda (public transport) on the verge of breakdown, up and down bumpy roads (which remind you of the jerking on the Indiana Jones ride at Disneyland…). It was a good ride - the view from anywhere in Sierra Leone is breathtaking. It was also exciting because it was the first time I traveled long distances in Salone alone on public transportation.

I joined them for a full day of net distribution. Okay, so I think these guys have a little too much energy or are just very motivated. They don’t have a car (well, not that it would be completely useful because some of the areas where they do the distribution are not ”motor-able”) and the one “honda” - or motorbike that they have is used to transport the bails of nets. So what they do is walk… through the jungle and through the woods (and three pools of water) to the villages. On the day I joined them it was 4.5 miles there and 4.5 miles back. It was good exercise to say the least. Each guy on the team (on a team of 10-ish people) will have walked over 100 miles in two weeks’ time for the distribution. They’re probably walking more right now for follow-up…

I took some 400+ pics while I was with them for 2-ish days. I wasn’t able to do much video because I was busy taking pictures - but the Gmin team has a media person whose been getting tons of video footage - so no worries. And what I saw, I thought was great. When they arrive at the village the chief calls a town meeting to introduce the team to the villagers then they do a skit showing why they should use bednets then the team splits up into groups to go house to house in the village to do the net distribution. When a team goes to a house, they do a simple survey, do a walk around the house to identify how many sleeping spaces (beds and grass mats) there are and give the family enough nets to cover all sleeping spaces.

They rip the net out of its packaging (to discourage selling the nets) and hang them out on the front porch (you’re supposed to air out the nets for a few hours because if you use the net right away, you’ll have an uncomfortable tingling sensation in the morning because of the insecticide). The best part is when after the distribution the villagers come with a few chicken or a goat, thanking the team for what they’re doing. We had rice andsauce with chicken for dinner that day. Yum.

Minus-Malaria’s Campaign: Malaria, Mosquitoes, and More Bednets

admin — Tue, 13 Oct 2009 13:04:28 +0000

The Global Health Forum kicked off its “Give a Net, Get a Vote” campaign on October 4, 2010 with an incredibly successful two-part program. After raising over 120 bed nets in 2 hours with an all-you-can-eat pancake breakfast, students whetted their intellectual appetite by attending malaria-expert and historian Randall Packard’s lecture.

Swarthmore College’s Daily Gazette on October 7th, 2009 covered the event.

You can also read a blog post on Randall Packard’s talk by Swarthmore College History Professor Timothy Burke to learn about an important debate in the struggle to address the burden of malaria.

: As a GHF member wrestled with pancakes on the griddle, other students are signing letters and waiting patiently for the next batch. Photo by the Daily Gazette.

: Historian Randall Packard visited Swarthmore College to give lecture titled, “Can We Eradicate Malaria?: A Historical Perspective.”

Pictures from the Daily Gazette

Victory Junction, How Do You Feel?

melissa.frick — Tue, 01 Sep 2009 03:01:23 +0000

It isn’t spectacular that every time that question is posed, a room full of over 200 campers and volunteers responds, “We feel so good!” It isn’t even spectacular that this response comes at 7a.m. with more enthusiasm than I normally encounter at 3 in the afternoon. It’s a cheer: everyone is supposed to respond that way: eagerly and in unison. What is spectacular about this roaring response is that almost half of these cheerers are answering this question in a context with which most of us are quite familiar, when they may be more accustomed to another: that of medicine.

Although in many ways the campers at Victory Junction are very similar to those one might expect to find at any summer camp—excited, slightly nervous and always ready for what’s next—there are many things that set them apart. The same is true for the camp itself. As a whole, Victory Junction seeks everyday to empower children with serious illness and chronic medical conditions by providing them with opportunities to take on truly life-changing experiences. I spent one mere week out of my summer volunteering for Victory Junction out in rural North Carolina, and my life was changed as if I had been there a year.

One of the more describable impacts that Victory Junction had on my life was its addition of a completely new dimension to my view of illness. The majority of the work that I have done with Global Health Forum over the past year has been focused on saving and sustaining life: the illness (in this case, malaria) was something that took life, and we needed to preserve it. There are campers at Victory Junction who will pass away before the next summer, or even the end of this one, but more campers will live. For those campers, illness is a part of life, not just death. The point of camp is not to keep them alive, but rather to enrich the very distinct life that they have. Despite their various disabilities, these campers will not simply survive; they will ride horses and go swimming and play kickball. They will even make it to the top of a climbing tower and get in a hot air balloon. When they yell, “We feel so good!” they will be referring not just to their medical state, but also to their emotional enthusiasm and excitement.

Victory Junction has taught me not to approach illness with an eye reserved for the physical quality of life of it’s victims, but of their mental and emotional health as well. It is not enough simply to live—the goal should always be to love life. And while in many circumstances this goal is, as of now, unattainable, I continue to be inspired by the thought that every week, more campers at Victory Junction are able to “smile out loud.”

This article was written by Jes Downing, currently a sophomore at Swarthmore College and an Executive Board Member of the Global Health Forum.

Nigerian Polio Outbreak: When Myth Trumps Medicine

melissa.frick — Mon, 24 Aug 2009 14:40:38 +0000

This past summer the World Health Organization (WHO) announced a dire reality - polio is making a comeback. Despite the WHO’s 1988 Global Polio Eradication Initiative to eradicate poliomyelitis in the world by 2006, the northern states of Nigeria have recently experienced a relatively large polio outbreak. Polio infection rates have skyrocketed nearly 800% in 2009 when compared to the same time period in 2008.

The cause of these reinfection rates are attributable to two things: 1) a rare case of faulty vaccine and 2) local rumors. The vaccines used in Nigeria are weakened versions of the polio virus and can spread from person to person.

This isn’t necessarily that dangerous unless the infectee in not immunized. If a child has not received a vaccine, this virus can mutate into a more dangerous strain and cause a massive outbreak. This wouldn’t be so much a problem if everybody had received a vaccine - but they haven’t. And it is the presence of local misconceptions that are associated with low immunization rates.

Cited: Diplomacy and the Polio Immunization Boycott in Northern Nigeria

This is not to say the WHO has been unsuccessful in eradicating polio in other parts of the world. Back in 1988, polio was endemic in more than 125 countries and spreading at a rate of nearly 1000 infections per day. This outbreak, however, signifies that discrepancies in available medications can lead to unanticipated outbreaks in countries that cannot afford safer vaccinations.

Additionally, this current outbreak harkens back to a time in Nigeria when immunization efforts were suspended in 2003 - consequently leading to a small polio outbreak. That time, the small ‘blip’ was important because it signified that new technologies and advancements in health care were not strong enough to trump local myths and perceptions about vaccines.

In this discussion we will look at the local perceptions of vaccines in Nigeria and also broaden our scope to other unique outlooks in the non-Westernized world. We will continue to analyze why these rumors dismantle modern eradication efforts and how intervention efforts have been and can be tailored to work alongside these rumors, rather than clash with them.

Epidemiological History of Polio in Nigeria

Since the late 20th century, Nigeria has been one of the few countries to suffer from cases of polio. In 2003, the immunization program was shut down because safety questions about the polio vaccine arose. This arrest led to a new outbreak of polio. The virus reinfected polio-free areas within Nigeria, and also spread into eight polio-free countries in the surrounding area. 2004 - The Minister of Health in Nigeria publically committed to bolstering immunization initiatives in hopes to eradicate malaria by signing the Geneva Declaration for the Eradication of Poliomyelitis. Impressively, that year on July 31, polio campaigns resumed in Northern Nigeria after a 12 month hiatus. Nigeria was able to hold the infection rate relatively steady between 2004 and 2006 but since then has allowed it to grow out of control.

Nigeria, along with several other poor nations, uses an oral polio vaccine (OPV) as the standard immunization procedure because it’s more affordable, more accessible, and can protect entire villages. This OPV, though, is made from a weakened version of the polio virus which carries risk in itself. Wealthier nations can afford another version of the vaccine which is given intravenously rather than orally. This inferior version of the virus may cause polio in .000001% of immunizations or, in a worse-case-scenario, mutate into a more lethal version of polio.

Since May 2006, “Immunization Plus Days” (IPDs) have been implemented as to improve eradication efforts. These days offer substantially beneficial health interventions to increase the uptake of OPVs. Studies have shown that quality of these IPDs have made significant improvements in the uptake of OPVs over time. For example, the number of ‘missed children’ in the latest IPD in 2006 was only 12% whereas the first IPD effort was noted at 40%.

Local Perceptions

In 2003, the Nigerian government responded to community pressures by arresting all polio eradication efforts. Both socio-political and cultural beliefs lent to a unfavorable perception of the vaccine. On the most basic level, there was speculation that the polio vaccine was contaminated with antifertility drugs so that young Muslim girls would be unable to reproduce.

Politics was involved within this speculation as a result of the recent elections. In the April 2003 election, a southern Baptist General, Olusegun Obasanjo, was reelected as president and defeated a northern Muslim General, Muhammadu Buhari. In addition, the poorer quality health outcomes in the North aggravated tensions between these geographical and religious groups.

In July of 2003, a northern umbrella group of Muslim organizations called the Jama’atul Nasril Islam (JNI) called for a suspension of the use of OPVs. This suspension was fueled by a memo from one of the Muslim Emirs who said his people were concerned that the vaccine was ‘being used for the purpose of depopulating developing countries, and especially Muslim countries.’ The US ambassador at the time perceived this announcement as a reflection of overall dissatisfaction of Northern Nigeria, especially from the largely Muslim state of Kano, with the current Obsanjo government, which then attached itself to the idea that these immunizations were to blame - almost like a scapegoat.

Although UNICEF and other organizations thought this rumor would be easy to dismiss - they were proven wrong. The rumor itself was viral. At this point in time, the six remaining polio-endemic countries (Nigeria, Niger, Egypt, India, Pakistan, and Afghanistan) all harbored significant numbers of Muslims. Now it is easy to trace how this epidemic of 2003 spread so voraciously. 1) Existing health disparities in Northern Nigeria, exacerbated by a northern loss in the presidential elections spurred rumors made the northerners feel disposed and targeted 2) Rumors arose to substantiate the feeling of dissatisfaction and give a face to the blame. 3) Since the northern regions of Nigeria were majority Muslim, it therefore became a ‘Muslim’ problem and 4) the associative rule that since “I am being targeted with contaminative vaccine and I live in Northern Nigeria” and “I live in Northern Nigeria and am Muslim,” thus forth ”If I am Muslim, I could be targeted with a contaminated vaccine’ regardless of the country one lives in.

These rumors circulated through the region until the Global Polio Eradication Initiative (GPEI), the OIC secretariat and the regional director for WHO convinced religious leaders to speak out on issues of polio eradication. Fatwas, Islamic religious rulings, were issued to speak about polio vaccines in general. It wasn’t until there fatwas were issued when rumors about a Western plot to wipe out Muslims began to dispel.

Furthermore, these fears were brought to the public consciousness when a respected doctor, Dr. Datti Ahmed, claimed suspicion that the vaccine was contaminated with HIV/AIDS virus, anti fertility-substances, and other dangerous elements. These suspicions were more so caused by a cultural misperception than a political one. If local populations are given a poor understanding of the vaccine itself and the kinds of disease it prevents, then they can create unrealistic expectations of this vaccine.

For example, vague health messages can lead to local mothers to believe that “vaccines are good for the health of the child” and that “vaccines protect against serious illness.” But that’s about it. If a child were vaccinated with the polio vaccine and fell ill with malaria, the mother might be convinced that the vaccine did not do its job because the child still got sick. This misunderstanding is not necessarily the fault of the mother but a symptom of the reality of IPDs. Often, healthcare personnel are only able to give a quick explanation of the vaccine’s intentions and are not there to address concerns after the vaccination period.

With this in mind, it’s a bit easier to see how people can misattribute disease symptoms as a cause of the vaccination. In Nigeria, the HIV/AIDS infection rate is relatively sizeable and the infant mortality rate is one of the highest in the world. When the common expectation (while ill-conceived) is that vaccines protect against all diseases, including ones they are not meant to prevent - expectations are highly overinflated. Additionally, vaccines are sometime perceived to promote growth and increase a child’s weight. When a child gets sick or fails to grow, the perception is that these vaccines are ineffective and thus, rumors are spawned after crushed expectations.

One of the only ways to remediate this problem is to address the misinformation as efficiently as possible. How to do this? Raise general awareness. Sometimes this is difficult. Once immunization programs begin to take effect and infection rates are lowered, popular perceptions of the disease and their associated risks fade. With lack of general awareness, people are more prone to pick up on the adverse effects - as we’ve seen before.

Public awareness about the risk/benefits and the specific use of vaccines is imperative so that people with not misattribute outlying illness as a symptom of the vaccine. These messages need to be concise, yet accurate, correct, yet simple. Health care providers or even better, community health advocates, must be able to communicate with patients over concerns of adverse effects. They also must differentiate between direct effects of the vaccine and ailments that are not associated.

Some advocates want to bolster health education programs to introduce new information, sensitive to cultural surrounding, that complement the popular ideas of the community including a immunization education course that one needs to ‘pass’ before enrolling in school. It’s a good idea to ‘catch’ those children who have missed their vaccine but, asssumingly, not too cost-effective.

Other Examples

The northern state of Nigeria is not the first, nor the only country to experience outbreaks of disease as a consequence of bad-mouthing vaccines. Egypt has faced similar consequences after false claims were made against the polio vaccine in 2002. In Alexandra Coptic Christians (who represented 11-12% of the population) believed the vaccine was toxic. It just so happened that this ethnic group has a long history of distrust with the majority ethnic group in Egypt, the Muslims. Like the 2003 Nigerian experience, these rumors were only dispelled when religious/ethnic leaders stepped in. In Alexandria, the vaccinations were performed within churches before the people could begin trusting the safety of these vaccines.

In certain Asian countries, conspiracy theories impress the idea that foreign Christian countries are trying to convert the local population and finding a way to do so through the administration of vaccines. Here, medicine was used as an vessel of ideology and a system of beliefs (and in no way medically related).

Even earlier this year in a relatively well-educated country, vaccines were refused. A scare about adverse effects of many vaccines erupted in Ukraine and threatens to lead to disease outbreaks. In this case, the rumors appear to stem from government mismanagement and irresponsible media coverage after an extremely rare case of death in a 17-year old who had received vaccine injections for both measles and rubella. So far, the country has witnessed a 10% drop in vaccination rates. The decrease is so significant that the U.N. sponsored campaigns funded by USA dollars is being dropped.

Finally, we can look at the United States and we ourselves are guilty of allowing rumors to dissuade us from using vaccines. Yes, our own relatively well-off, well-educated, and well-cared-for population is at fault for the same reasons as Nigeria. As rumors about autism and its association with vaccines spread, many women are withholding vaccinations from their infants. This is dangerous because not only are these children infection-prone, but if they ever contract the disease, they can become vectors and infect others around them.

Where we are today

Now Nigeria is facing a similar problem that it did six years ago. Low immunization rates have put the country at an increased risk of an epidemic. And it is local rumors that often contribute to these low rates. If these rumors perpetuate, it would endanger both the Nigerian population and surrounding

19-20/12/98, Freetown, Sierra Leone, N.I.D. Photograph: Jean-Marc Giboux

countries, as it did last time. What must be done incorporates local, national, and international forces to coordinate activities so that the populace is well educated and well covered. National and international organizations must convince the smaller, more local religious and ethnic leaders to support the vaccination campaigns. The locals will trust these more personal figureheads - not the big, ‘looming’ superpowers of the world whom appear to want to domesticate all inferior countries.

Other experts urge the discontinuation of OPV use because the very minimal risk of mutant strains still causes apprehension. But this would call for the intravenous vaccines to decrease in price and increase in availability. Such efforts to lobby for lower prices may require incredible force with little result. Implementing a campaign that emphasizes education and awareness may be more cost effective and sustainable. Community health workers could be trained to dispense advice throughout the community incase a doctor or licensed health worker is not available. Such programs could also be crafted to compliment local values. Besides, even if OPVs were eliminated, the misconception about vaccine as being a panacea for all disease would still exist. Another ‘vaccine boycott’ would still be possible as long as rumors fly.

The truth of the matter is that changing the type of vaccine will not eliminate these reoccurring boycotts. And these boycotts are not just a local matter because the health of one community jeopardizes the health of the surrounding regions, as previous polio outbreaks have shown. With support and direction coming from international forces, local leaders can lead communities into an era of heightened awareness and educated decision making.

References:

http://www.polioeradication.org/content/factsheets/Nigeria_12Oct06.pdf

Hiel, Betsy. Eguypt remains committed as it closes in on becoming polio-free. Pittsburgh Tribune-Review. 3 April 2005. Accessed 18 August 2009 at http://www.pittsburghlive.com/x/pittsburghtrib/news/specialreports/unfinishedmiracle/s_319389..

Mutant polio virus spreads in Nigeria. CBS News. 14 August 2009. Accessed 19 August 2009 at http://www.cbsnews.com/stories/2009/08/14/health/main5242168.sht.

U.S. Pharmacopeia. Poliomyelitis, OPV, and Misconceptions on Vaccinations. USP Information. 9 May 2000. Accessed 19 August 2009 at http://www.usp.org/pdf/EN/dqi/polioTechnicalReportEnglish.pdf

Kaufmann JF and J Feldbaum. Diplomacy and the polio immunization boycott in Northern Nigeria. Health Affairs. 28 (4) 2009: 1091-1101.

Why some people get sick and others don’t

lucy.mcnamara — Fri, 14 Aug 2009 13:44:13 +0000

We all know that many diseases are caused by viruses, bacteria, or parasites. For instance, HIV is caused by the HIV virus; tuberculosis by the bacterium Mycobacterium tuberculosis; and malaria by the protozoan parasite Plasmodium falciparum and others of the same genus. Yet not everyone who’s exposed to a pathogen gets the associated disease. For instance, only 3 out of 1000 people who get stabbed with an HIV-contaminated needle will actually develop HIV. But why is it that some people get these diseases and others don’t? And is there any way we can use this information to protect more people?

Epidemiology 101

Welcome to the field of epidemiology, the study of the distribution and causes of disease. Commonly called the science of public health, epidemiology examines the many different factors that contribute to disease to try to find out how we can keep people healthier. There are a lot of different factors that impact health – not only exposure to pathogens, but also diet, genes, age, socioeconomic status, local water quality, population density, and others. Epidemiologists look at who gets sick, where, and when to try to figure out what factors are contributing to the illness and of those, which we can do something about.

Generally speaking, an epidemiological study looks at two groups of people: those who got sick and those who didn’t. The researchers then try to find out everything about those people – where they work, what they eat, what kind of paint they have on their house, how many pets they own – and then do statistical analyses to see if any of the factors they asked about are associated with the disease. These studies are often time-consuming and may require very large cohorts of subjects to be effective, but their results can be crucially important to the field of public health.

Epidemiology is the reason we know that smoking causes cancer and lead causes brain damage. In addition to looking at environmental toxins, many epidemiologists study chronic diseases, such as cancer and heart disease. These diseases can obviously be caused by many different factors, including exposure to various toxins, diet, genetic factors, and others. There are also a growing number of epidemiologists who study the factors that increase the likelihood of contracting an infectious disease. Some of these factors are pretty obvious too – getting a mosquito bite in a malaria-endemic country, for instance, or sharing needles with an HIV-infected person. But some of the risk factors for infectious diseases are a bit more surprising.

An example - leishmaniasis

One interesting case is that of visceral leishmaniasis in East Africa. Leishmaniasis, one of a group of diseases known as “neglected tropical diseases” due to the lack of press and funding it receives, is caused by a protozoan parasite and is transmitted by the bite of the sand fly. Visceral leishmaniasis is the most severe form of the disease, in which the parasite migrates to the vital organs, and it kills an estimated 60,000 people per year. Rates of visceral leishmaniasis have risen dramatically in East Africa over the last 20 years [1], and recent studies have attempted to figure out why.

A lesion caused by cutaneous leishmaniasis – a.k.a. leishmaniasis on your skin. Visceral leishmaniasis is like this, except on your liver.

Some of the reasons are not surprising – increased incidence of HIV, for instance, has contributed to the increased incidence of leishmaniasis just as it has contributed to an increased incidence of many other diseases [1]. But other reasons are more startling. For instance, you might think that if you owned cattle or other animals, treating them with insecticides would be a good preventative measure against leishmaniasis. The insecticides would keep the sand flies away from the cattle and thus away from you; with no sand flies to transmit the disease, no leishmaniasis. Makes sense, right?

Wrong. It turns out that treating your animals with insecticides actually increases your risk of contracting leishmaniasis [1]. The idea seems to be that if the sand flies can’t bite your animals, they’re more likely to bite you instead!

Another example – umbilical cords and mustard oil

Epidemiology also examines whether different treatments for diseases are effective or not. In southern Nepal, for instance, mustard oil is commonly applied to the cut umbilical cords of babies in an attempt to prevent infection. It turns out, however, that applying mustard oil is actually associated with an increased chance of umbilical cord infection – whereas applying mud or ash to the umbilical cord has no associated increased risk [2]. Of course, this doesn’t mean that applying ash to your baby’s umbilical cord is a good idea. Actually, in this particular study, a lot more people applied mustard oil than applied mud or ash, so it was just easier for the researchers to tell what the effect of mustard oil was [2].

Although mustard oil appeared to increase the risk of umbilical cord infections, the researchers in this study also found several techniques for decreasing the risk of infections. The more the mother and anyone else around the baby washed their hands, for instance, the lower the chance of infection [2]. In addition, the study found that keeping the baby warm, either through skin-skin contact or by giving the baby hat – also decreased the risk of infection [2]. These findings provide simple, easy-to-implement ways to keep babies safer and healthier.

Conclusion

Although some factors – such as poverty, malnutrition, and immunosuppression – are known to increase the risk of pretty much every disease, some diseases have surprising associations with factors that seem innocuous, or even with things that seem like they’d be good for you. It’s only through the careful study of the association between behaviors, exposures, and disease that we can determine what the risk factors for a given disease are. Then it’s time to move away from studies and into implementation, and use this information to devise better strategies for treating and preventing diseases.

References

1. Kolaczinski, J. H., R. Reithinger, D. T. Worku, A. Ocheng, J. Kasimiro, N. Kabatereine, and S. Brooker. 2008. Risk factors of visceral leishmaniasis in East Africa: a case-control study in Pokot territory of Kenya and Uganda. International Journal of Epidemiology 37(2): 344-52.
2. Mullany, L. C., G. L. Darmstadt, J. Katz, S. K. Khatry, S. C. LeClerq, R. K. Adhikari, and J. M. Tielsch. 2006. Risk Factors for Umbilical Cord Infection among Newborns of Southern Nepal. American Journal of Epidemiology 165(2): 203-11.

The Perfect Storm

emilia.thurber — Sat, 08 Aug 2009 02:54:31 +0000

Chester's location in Delaware County

This summer, I am participating in the Chester Community Fellows program and interning at Crozer-Chester Medical Center in the Community Health Education department. During my time as a Chester fellow, I have heard a lot about the sexual health issues facing the city, particularly those regarding STIs, HIV, and teen pregnancy. For example, the year 2007 saw an 80% increase in the number of cases of gonorrhea in Delaware County, from 513 cases in 2006 to 921 cases in 2007. Most of these cases were concentrated in and around Chester, and 55% of the cases occurred in people between the ages of 15 and 24. This spike is troubling because infection can lead to serious, long-term health problems. Gonorrhea can cause many unpleasant and uncomfortable symptoms, but some infected people, especially women, experience no symptoms at all. This can be very dangerous because, when left untreated, gonorrhea can lead to pelvic inflammatory disease and epididymitis. Also, those infected with gonorrhea have an increased susceptibility to HIV and can transmit HIV more easily to other people. This could be a serious problem for the county with the third highest rate of AIDS infection in the state.
Chester also has a very high number of teen pregnancies. According to a Chester high school teacher that I met with, Chester has the second highest rate of unplanned, unmarried pregnancies in the world. During the 2007-2008 school year alone, there were 91 pregnant students in the Chester Upland School District. This high teen pregnancy rate has severely disrupted the education of the many Chester students.

How did this happen?

The easy answer given by health officials is that the youth of Chester have been participating in “high-risk” behaviors. However, this begs the question, “Why Chester?” What situations and experiences have led these youth to be more likely to engage in high-risk behaviors? I believe that many distinct factors have all contributed to Chester’s current sexual health situation.
For starters, the city of Chester does not currently have a health commissioner. The former commissioner, Melanie Ragin, left due to “personal reasons” in November of 2008 after holding the position for little more than a year. Ragin described her work environment as hostile, and it is unclear if she was able to get much work done during her period as health commissioner. Near the end of her time working for the city, Ragin was working from home. Before Ragin took the post in 2007, Chester had been without a health commissioner for several years.
Delaware County is also lacking a health department. It is the largest county in the state of Pennsylvania without its own health department, with over half a million residents living in the area. Without an effective city health commissioner or county health department, it must be very difficult for Chester to implement the appropriate programs and initiatives to keep the city healthy.
Abstinence-only education is also likely to have contributed to the high number of STI infections and teen pregnancies in Chester. Congress has given hundreds of millions of dollars to fund state programs that promote abstinence until marriage as the only appropriate sexual behavior. The requirements for these programs often bar important information about contraception, abortion, STIs, and safe sexual practices from being presented to youth. An evaluation of these programs by Mathematica has found that they have no effect on sexual behavior when compared to a control group. In a University of Pennsylvania memo about abstinence programs in Pennsylvania, youth are described as frustrated with the unrealistic nature of the program and the lack of information given to them. The memo concludes that, “The effects of this type of education are mixed at best, and at worst leave our youth becoming sexually active without fundamental knowledge of contraception and how to protect their health.”
Despite the problems with such programs, the Bureau of Health of the City of Chester has been accepting federal funds to run such programs for many years. The project, called the Sexual Abstinence Education and Resource Project (SABER), is an after-school, abstinence-only program. As far as I know, this is the only sexual education program supported by the Chester City Health Department.
Countless other factors also contributed to this crisis. A nurse practitioner for the AIDS Care Group cites poor local economy, high drug use, and low educational attainment as reasons for the high level of HIV and STI infection in Chester. Also, the conservative political and religious nature of the city could make it difficult for programs to openly talk about safe sexual practices other than abstinence. For all these reasons, the environment in Chester has been labeled as the “perfect storm” for an STI epidemic.

Hope for the Future?

The dramatic increase in gonorrhea cases finally sparked some action in the health care arena. Due to efforts from the State Health Department, Crozer-Keystone Health System, Planned Parenthood, school districts, and other groups, the number of gonorrhea cases in 2008 has decreased to 607, down 34% from 2007*. However, this level is still higher than in 2006. How can we keep decreasing the number of gonorrhea cases and prevent another outbreak from occurring? And how can other issues, such as HIV/AIDS and teen pregnancy, be addressed?
The Chester Upland School District asked themselves the same questions and came up with the “Healthy Students, Healthy Living” policy. According to Chester Upland School District Superintendent Gregory E. Thornton, in order to have great student achievement, you must have healthy students. This policy will use sexual health education and prevention methods to hopefully improve the overall health, quality of life, and futures of the students in the district.

Health Resource Center

A main component of this policy is the opening of a Health Resource Center in Chester High School. The center is staffed with a counselor and offers pregnancy, chlamydia, and gonorrhea tests, as well as free condoms. The center also offers sexual education and counseling services.
Hopefully this new resource will allow the youth of Chester to make more informed and safe sexual decisions. So far, about 10 students a day visit the center, and Shakina McClain, the center’s coordinator and counselor, claims that “the reaction has been really good.” She also emphasizes the importance of having resources like this in community spaces, saying “Once I see them at the clinic, they usually already have the infection. Here, I can talk to them before they have the infection.” The school administration was also very careful to keep the religious and politically conservative values of many Chester residents in mind when implementing the health center by allowing parents to “opt out” of allowing their students to receive free contraceptives.
The early success of the center shows how involving community resources, such as a school, could be a very important method of implementing health education in Chester. While it is unlikely that people will just stop by a hospital or clinic to learn more about STIs, having this information available in multiple community locations may be the most effective way to carry out prevention programs in areas like Chester where health education is most needed. There is only so much doctors and state officials can do on their own; at some point, health care providers must start working with and utilizing the community to really see any sort of sustainable change.
Hopefully, the center will also make people realize that it is best to allow youth to make their own informed decisions instead of withholding important information from them. Abstinence-only programs place a moral judgment on youth by telling them that any sexual practices outside of marriage are not “the expected standard” of behavior. If students do not want to accept this standard, they are not given the tools to make safe and healthy sexual decisions. This means that abstinence programs are not only ineffective, but could cause youth to make uninformed choices that could have a lasting impact on their health. The worst part is that these poor decisions can be prevented through proper sexual health education.
Finally, although it appears the Health Resource Center has managed to succeed in its first months, a full-time city health commissioner is still needed. Every city requires someone to determine what the major health risks are for the residents and how to best create and implement programs to address these issues. It is not wise or safe for a city to keep relying on outside groups and other city officials to do these jobs. Chester needs a health commissioner.

* These are provisional numbers released from the state health department.

Sources

Brisson, Amy. “Chester searching for new health commish.” The Delaware County Daily Times. 8 April. 2009.

Brisson, Amy. “Chester Upland proposes adolescent health center.” The Delaware County Daily Times. 20 Oct. 2008.

Brisson, Amy. “Gonorrhea cases on rise in county.” The Delaware County Daily Times. 5 May 2008.

Brisson, Amy. “Gonorrhea rate drops 34% in county.” The Delaware County Daily Times. 6 Feb. 2009.

Brisson, Amy. “Health center is up and running at Chester High School.” The Delaware County Daily Times. 9 Feb. 2009.

Brisson, Amy. “Healthful resource in Chester.” The Delaware County Daily Times. 9 Feb. 2009.

Chester Upland School District. Chester Upland School District. Accessed 27 July, 2008. [www.chesteruplandsd.org].

Halt, Rosemarie O’Malley. “Make health departments mandatory in Pa.” The Delaware County Daily Times. 29 April 2009.

“Impacts of Four Title V, Section 510 Abstinence Education Programs.” Princeton, NJ: Mathematica Policy Research, Inc., April 2007, Christopher Trenholm, Barbara Devaney, Ken Fortson, Lisa Quay, Justin Wheeler, and Melissa Clark. Document No. PR07-07, 164 Pages.

Reproductive Rights Law Project (2007). Five Years of Abstinence-Only-Until-Marriage. Retrieved April 21, 2009 from http://www.law.upenn.edu/probonoprojects/reproductive-rights/Memo%20on%20state%20of%20abstinence%20ed%20in%20PA.doc

Sexually Transmitted Diseases: Gonorrhea. 20 July 2009. CDC. Accessed 27 July, 2008. [www.cdc.gov/std/gonorrhea].