Long hiatus and reading

Happy 2007! I've been busy, traveling, and obviously ignoring this blog. I have quite a lot to post dating back to late November. I hope to get it all up in the next week or so if I can get my own computer online. In the interim, here are a few links to interesting TB/Botswana/global health reads. I promise more actual writing in my own stuff.

1. Laurie Garrett's article "The Challenge of Global Health" from Foreign Affairs Jan/Feb 2007. I'll paste the paragraphs on Botswana below, but it's worth reading the whole thing. Thanks to everyone who sent it my way.

http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html

Article summary: Thanks to a recent extraordinary rise in public and private giving, today more money is being directed toward the world's poor and sick than ever before. But unless these efforts start tackling public health in general instead of narrow, disease-specific problems -- and unless the brain drain from the developing world can be stopped -- poor countries could be pushed even further into trouble, in yet another tale of well-intended foreign meddling gone awry.

Botswana excerpt:
DIAMONDS IN THE ROUGH

Arguably the best example of what is possible when forces align properly can be found in the tiny African nation of Botswana. In August 2000, the Gates Foundation, the pharmaceutical companies Merck and Bristol-Myers Squibb, and the Harvard AIDS Initiative announced the launching of an HIV/AIDS treatment program in collaboration with the government of Botswana. At the time, Botswana had the highest HIV infection rate in the world, estimated to exceed 37 percent of the population between the ages of 15 and 40. The goal of the new program was to put every single one of Botswana's infected citizens in treatment and to give ARVs to all who were at an advanced stage of the disease. Merck donated its anti-HIV drugs, Bristol-Myers Squibb discounted its, Merck and the Gates Foundation subsidized the effort to the tune of $100 million, and Harvard helped the Botswanan government design its program.

When the collaboration was announced, the target looked easily attainable, thanks to its top-level political support in Botswana, the plentiful money that would come from both the donors and the country's diamond wealth, the free medicine, and the sage guidance of Merck and Harvard. Unlike most of its neighbors, Botswana had an excellent highway system, sound general infrastructure, and a growing middle class. Furthermore, Botswana's population of 1.5 million was concentrated in the capital city of Gaborone. The national unemployment rate was 24 percent -- high by Western standards but the lowest in sub-Saharan Africa. The conditions looked so propitious, in fact, that some activists charged that the parties involved had picked an overly easy target and that the entire scheme was little more than a publicity stunt, concocted by the drug companies in the hopes of deflecting criticism over their global pricing policies for AIDS drugs.

But it soon became apparent that even comparatively wealthy Botswana lacked sufficient health-care workers or a sound enough medical infrastructure to implement the program. The country had no medical school: all its physicians were foreign trained or immigrants. And although Botswana did have a nursing school, it still suffered an acute nursing shortage because South Africa and the United Kingdom were actively recruiting its English-speaking graduates. By 2005, the country was losing 60 percent of its newly trained health-care workers annually to emigration. (In the most egregious case, in 2004 a British-based company set up shop in a fancy Gaborone hotel and, in a single day, recruited 50 nurses to work in the United Kingdom.)

By 2002, the once-starry-eyed foreigners and their counterparts in Botswana's government had realized that before they could start handing out ARVs, they would have to build laboratories and clinics, recruit doctors from abroad, and train other health-care personnel. President Festus Mogae asked the U.S. Peace Corps to send doctors and nurses. Late in the game, in 2004, the PEPFAR program got involved and started working to keep HIV out of local hospitals' blood supplies and to build a network of HIV testing sites.

After five years of preparation, in 2005 the rollout of HIV treatment commenced. By early 2006, the program had reached its goal of treating 55,000 people (out of an estimated HIV-positive population of 280,000) with ARVs. The program is now the largest such chronic-care operation -- at least per capita -- in the world. And if it works, Botswana's government will be saddled with the care of these patients for decades to come -- something that might be sustainable if the soil there continues to yield diamonds and the number of people newly infected with HIV drops dramatically.

But Kwame Ampomah, a Ghana-born official for the Joint UN Program on HIV/AIDS, based in Gaborone, now frets that prevention efforts are not having much success. As of 2005, the incidence of new cases was rising eight percent annually. Many patients on ARVs may develop liver problems and fall prey to drug-resistant HIV strains. Ndwapi Ndwapi, a U.S.-trained doctor who works at Princess Marina Hospital, in Gaborone, and handles more of the government's HIV/AIDS patients than anyone else, also frets about the lack of effective prevention efforts. In slums such as Naledi, he points out, there are more bars than churches and schools combined. The community shares latrines, water pumps, alcohol -- and HIV. Ndawpi says Botswana's future rests on its ability to fully integrate HIV/AIDS care into the general health-care system, so that it no longer draws away scarce doctors and nurses for HIV/AIDS-only care. If this cannot be accomplished, he warns, the country's entire health-care system could collapse.

Botswana is still clearly somewhat of a success story, but it is also a precariously balanced one and an effort that will be difficult to replicate elsewhere. Ampomah says that other countries might be able to achieve good results by following a similar model, but "it requires transparency, and a strong sense of nationalism by leaders, not tribalism. You need leaders who don't build palaces on the Riviera. You need a clear health system with equity that is not donor-driven. Everything is unique to Botswana: there is a sane leadership system in Gaborone. So in Kenya today maybe the elite can get ARVs with their illicit funds, but not the rest of the country. You need a complete package. If the government is corrupt, if everyone is stealing money, then it will not work. So there is a very limited number of African countries that could replicate the Botswana experience." And despite the country's HIV/AIDS achievements and the nation's diamond wealth, life expectancy for children born in Botswana today is still less than 34 years, according to CIA estimates.

2. Top 10 Most Underreported Humanitarian Stories of 2006
This report by Medecins Sans Frontieres finds that the growing number of deaths worldwide from TB was one of the top 10 most underreported news stories of 2006.

http://www.doctorswithoutborders.org/publications/reports/2007/top10_2006.htm

Excerpt: Increasing Human Toll Taken by Tuberculosis

Every year, TB kills nearly two million people while an estimated nine million develop the disease. An additional 450,000 new cases of multidrug-resistant (MDR) TB are seen every year. Kyrgyzstan, 2006 © Claude Mahoudeau/MSF

While many people in the West consider tuberculosis (TB) a disease of a bygone era, the devastating human toll taken by the disease is increasing worldwide, particularly in developing countries with high HIV prevalence. Every year, TB kills nearly 2 million people while an estimated 9 million develop the disease. An additional 450,000 new cases of multidrug-resistant (MDR) TB are seen every year. This frightening situation became even worse in 2006 when a survey among 544 TB patients in Kwazulu Natal, South Africa, found 10percent had developed XDR TB, a strain of TB that is resistant to both first-line antibiotics as well as to two classes of second-line drugs. Almost all of these patients died, and the extent of the outbreak remains unknown.

Even so, the drugs in today's standard TB treatment were developed in the 1950s and 1960s, while the most commonly used TB test — sputum microscopy — was developed in 1882 and only detects TB in half of the cases. Existing TB treatments and diagnostics are even less adapted for use in people living with HIV/AIDS, even though TB is their number one killer. The years of neglect are underscored by the fact that of the 1,556 new chemical entities marketed worldwide between 1975 and 2004, only 3 were for TB. Even though some initiatives are underway, efforts need to be significantly increased in order to respond to the disastrous impact of TB. None of the drugs currently in development, however promising, will be able to drastically improve TB treatment in the near future. "That TB destroys millions of lives around the world every year shows that the current approach is just not working," said Dr. Tido von Schoen-Angerer, Director of MSF's Campaign for the Access to Essential Medicines. "The tools we have to treat and diagnose TB are woefully inadequate and outdated, and we're not seeing the necessary urgency to tackle the disease."