Globalization and Health - Latest Comments

unintended consequences

david egilman — 2008-06-03T00:00:00Z

Your paper ends by warning that "The transformation of the Global Fund into a 'diagonal' and ultimately perhaps 'horizontal' financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features."

This implies that your vertical programs can just be funded willy nilly (as they have been) without much if any thought (never mind study) about unintended adverse consequences. These take many forms, only one of which you mention (health budget substitution).

An anecdote may suffice here. Haitian HIV education programs suffer since many Haitians have realized that becoming HIV positive is their best hope for survival. They then qualify for food, job training & a job and all kinds of other services.

Trickle down is not working either. In Haiti HIV rates have dropped in half while every other health indicator has gotten worse.

As Maren wrote the road to hell is paved with good intentions. Why should one potentially fatal disease be sexier than another assuming the lost years of useful life are the same?

David Egilman MD, MPH

degilman@egilman.com

www.15by2015.org calling for 15% of all aid to go horizontal

Mobile phone transcends barriers in health system -NID in India

Rajesh Sood — 2008-05-09T00:00:00Z

In health programmes with outreach components, we found mobile phone to be a useful asset in overcoming barriers and improving performance.

Supervision in National Immunisation Days is often not easy and is the weakest link. A supervisior is expected to visit ten house to house teams in a day (often in difficult terrain over sparsely populated hamlets). When the supervisor visits the hamlet, the teams may have not arrieved or have already left, thus hampering corodination and timely feedback. Waiting or huting for the team is not practicable as he/she has to move to the next hamlet and oversee the next team with a limited transport support. Moreover, even if both are present in same area they may not be able to establish contact.

During revising microplannings in one block of District Kangra,in the himalayan region of North India, we noticed this problem and included the mobile number of any of the team members and supervisors. This served as a useful tool for improving communication and contact between the grassroot workers and immediate and higher supervisors, leading to improvement in quality of work through immediate rectification of identified problems. We reccommended upscaling of the initiative.

Limitations:

The area has a high per capita income and high mobile phone ownership which enabled the venture. this may not be areplicable in settings with poverty.

Reimbursing communication costs has not been factored into health programmes and many workers amy not be motivated enough to use their personal phones/ list their personal numbers for a health programme.

As the coverage of mobile network is poor in some underserved areas, some areas will still be left uncovered.

However if mobile phones are provided to health care staff and allowance for reccuring costs, (as in Tamil Nadu, a southern state in India), the approach is highly useful.

V-1 Immunitor

Joseph Amon — 2008-05-09T00:00:00Z

Shortly following publication of this article, Dr. Aldar S. Bourinbaiar of Immunitor USA Inc sent me an article ["Low-Cost Anti-HIV Compounds: Potential Application for AIDS Therapy in Developing Countries" by Aldar S. Bourinbaiar and Vichai Jirathitikal, Current Pharmaceutical Design, 2003, 9 (18): 1419-1431] that provided additional information on the distribution of V-1 Immunitor in Thailand and the Thai government's response.

The article states that as of 2003, V-1 Immunitor had been distributed to about 65,000 HIV-infected individuals in Thailand and 50 countries around the world. Regarding the distribution of the medicine in Thailand, the article states:

"Public opinion on V1 became sharply divided in the summer of 2001 when V1 was given away free-of-charge by local charities during massive distribution rallies at stadiums, schools, police stations and Buddhist temples. Small but vocal opponent groups and some in the local medical establishment decried such handouts as unethical, despite having nothing to offer to dying AIDS patients [115]. The proponents of V1 argued that the lack of affordable and safe anti-HIV therapy in poor countries and the indignation of patients who were abandoned by their doctors was the main impetus that drove thousands of patients to voluntarily attend these events. The Thai Ministry of Public Health, which conducted a study in a random sample of 50 HIV-infected individuals, declared in August 2001 that V1 had no effect on viral load or CD4/CD8 T-cell counts - an announcement interpreted by several media outlets that V1 was "useless" [116]. However there were serious and major flaws in this study."

Kudos

Ian Blake Newman — 2008-02-20T00:00:00Z

Siegel and Narayan have really hit upon the fundamental challenges confronting the global effort (or lack thereof) to combat diabetes. My colleagues and I (Stuart A. Seale MD and Franlin House MD) have been on the road spreading a similar message about how the former "diseases of kings" are rapidly spreading through the non-Western world, thanks in part to the "McDonaldization" of diets. Dr. House has seen this for decades in Micronesia, where Type-2 diabetes was nearly unheard of two generations ago, and is now rampant, even among the young. In our opinion, the key to stopping this tsunami of diabetes is lifestyle modification, not more medicine, though of course this is easier said than done. Like our colleague T. Colin Cambpell who authored The China Study, we're gravely concerned about the influence of our American/western culture of abundance on the rest of the world. We're very glad Globalization and Health has decided to highlight this critical issue.

Ian Blake Newman

Timely and needed

Mattie Tolley — 2007-06-19T00:00:00Z

Thank you for this excellent research. As a recently retired but still active nurse educator focusing on community and global health the issues you address are so relevant and timely. However there is little evidence to back up what is clear to some of us but not to other colleagues who have a narrower view. Now if you will just continue your research and speak to nursing education directly!

Thai compulsory license (CL) not based on 31 (f) waiver

Ellen 't Hoen — 2007-06-19T00:00:00Z

The article mistakenly presents the compulsory licenses issued by the Thai governement as based on the WTO waiver of 31(f) also known as the August 30 decision or paragraph 6 solution. However the Thai government use licenses are straightforward article 31 licenses. There was no need for a waiver of the TRIPS provision that a CL is predominantly for the suply of the domestic market because the products Thailand is importing from India are not patent protected in India and can be freely shipped to a country that has issued a CL (or where patents are not in place). In the case Thailand will produce domestically it has fulfilled the requirement that a CL is predominantly for the domestic market and thus is there no need for a wauver. See for details of the Thai CLs: http://www.moph.go.th/hot/White%20Paper%20CL-EN.pdf

So far no country has ever made use of the 31(f) waiver. In the case of Taiwan it concerned domestic production in which case the waiver is irrelevant. These are common misunderstandings that unfortunately present the use of CL as more complex than the current TRIPS rules require.

Cell phones as a health care intervention in Peru: The Cell-PREVEN project

Walter H. Curioso — 2006-10-12T00:00:00Z

Dear editor,

In response to the article, “Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?” (May 23, 2006), our answer is an empirical ‘yes’.

Author Warren Kaplan wrote that “Asides from recent work in South Africa, there is almost no literature on using mobile telephones as a healthcare intervention for chronic, non-communicable diseases such as cardiovascular disease, diabetes, depression, and for chronic, communicable diseases such as HIV and TB (in developing countries). [1]”

We would like to share our experience with Cell-PREVEN [2], a real-time surveillance system using cell phones to collect data from female sex workers in Peru [3]. Cell-PREVEN is part of a large randomized trial in Peru in 20 cities called PREVEN, which seeks to lower sexually transmitted disease rates in Peru. PREVEN is a collaborative effort between the Universidad Peruana Cayetano Heredia in Lima, Imperial College in London, and the University of Washington in Seattle, in collaboration with Peru’s Ministry of Health [3].

Cell-PREVEN allowed health care workers to enter data in cell phones using an interactive voice response application in Spanish designed with the help of Voxiva Inc., a company applying technology in public health. Health care workers interviewed female sex workers in three communities of Peru regarding adverse events from metronizadole, a medication used to treat bacterial vaginosis, and the information was relayed in real-time to a database.

If there was a severe adverse event such as vomiting, a short text message would be sent to a physician by cell phone, and he or she could respond immediately.

Health care workers received an account number, personal identification number and a plastic card with simple instructions and codes for all the symptoms they need to report. Workers could also leave voice messages regarding their cases. Information was stored in a central database with access by phone or Internet.

Both health care interviewers and female sex workers were satisfied with cell phones as a method of data collection, and the system led to much earlier and more complete reports of adverse effects [4]. Voxiva has used a similar system to monitor adverse events and disease outbreaks in Peru [5], Africa, Iraq, and India [6].

While Kaplan said, “The developed world model of personal ownership of a phone may not be appropriate to the developing world in which shared mobile telephone use is important,” we believe that doesn’t hold true in every place and over time. In Peru, sales of cell phones has jumped from 2.5 million in mid-2003 to 6.8 million by June 2006. [7,8]

In the mid-1990s “cholulares,” a nickname for "cholos con celulares" or people who rent cell phones on the streets, was popular in many cities in Peru [9]. But now, more and more people are acquiring cell phones for their own since they have become more affordable [9]. The same situation is happening throughout the developing world, such as in Zambia, Kenya, and several other African countries where mobile phones are used to make cashless payments [10].

Kaplan also stated that “the cost-effectiveness of telephonic interventions (for health) is not known.” We, however, would like to point out that a cost-analysis evaluation of Alerta, a phone-based surveillance system in Peru [5], found that the Alerta system required 40% lower costs of operations than the traditional paper system, resulted in a threefold increase in reporting coverage over a paper-based system, and that the use of voice mail for communications was around 8 times less expensive than written communication [6].

Cell phones are proving themselves to be an important tool in public health in the developing world. Their utility likely will only increase over time, since cell phones leverage existing telecommunications infrastructures in developing countries, without requiring costly standalone system support. We agree with the author that increased research attention to the appropriate use of cell phone and other communication technologies will advance the evidence base.

Walter H. Curioso, MD, MPH

Universidad Peruana Cayetano Heredia, Lima, Peru

Bobbi Nodell, MA

International Training & Education Center on HIV (I-TECH). University of Washington, Seattle, Washington, USA

Ann Kurth, CNM, PhD

University of Washington, Seattle, Washington, USA

Disclaimer

The opinions and assertions made by the authors do not necessarily reflect the official position or opinion of I-TECH.

References

1. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health. 2006 May 23;2:9.

2. The Cell-PREVEN Project. Available at: <a href='http://www.cellpreven.org/'>http://www.cellpreven.org/</a> (Accessed: July13, 2006).

3. Curioso WH, Karras BT, Campos PE, Buendia C, Holmes KK, Kimball AM. Design and Implementation of Cell PREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. AMIA Annu Symp Proc 2005; 176-180. Available at: <a href='http://faculty.washington.edu/wcurioso/cellpreven.pdf'>http://faculty.washington.edu/wcurioso/cellpreven.pdf</a>

4. Curioso WH. Chapter 18. New Technologies and Public Health in Developing Countries: The Cell PREVEN Project. [Book Chapter] In: The Internet and Health Care: Theory, Research and Practice. Monica Murero and Ronald E. Rice [editors]. Lawrence Erlbaum Associates 2006.

5. Lescano A, Ortiz M, Elgegren R, Gozzer E, Saldarriaga E, Soriano I, Martos I, Mundaca C, Kishimoto G, Negrete M, Batsel TM. Alerta DISAMAR: Innovative disease surveillance in Peru. Paper presented at: Annual Meeting of the American Society of Tropical Medicine and Hygiene. Philadelphia, 2003.

6. Prahalad C. The Voxiva Story. The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits. First printing ed. New Jersey: Wharton School Publishing; 2005:361-379. Available at:

<a href='http://www.voxiva.net/resources/Prahalad.asp'>http://www.voxiva.net/resources/Prahalad.asp</a> Accessed: August 7, 2006.

7. ONGEI. Peru: The use of information and communication technologies. Available in Spanish at:

<a href='http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf'>http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf</a> (In Spanish) Accessed: August 7, 2006.

8. OSIPTEL. Telecommunications in Peru (Statistics) Available at: <a href='http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635'>http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635</a> Accessed: August 7, 2006.

9. Cell phones can call good business. La Republica [Newspaper Online edition].

Available in Spanish at: <a href='http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484'>http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484</a> Accessed: August 7, 2006.

10. Economist (2005), The Real Digital Divide: Leader, March 18. Available at: <a href='http://www.economist.com/opinion/displayStory.cfm?story_id=3742817'>http://www.economist.com/opinion/displayStory.cfm?story_id=3742817</a> Accessed: August 7, 2006.