Medics March for Climate Change Action

This is a Guest Blog by Alison Whyte, Media Adviser at Medact, and Editor of the Medact newsletter Communique.

On Saturday, the 5th December 2009, a group of health professionals joined The Wave, a massive demonstration through central London prior to the crucial UN summit on climate change in Copenhagen.

The day began with a meeting hosted by the Royal College of Nursing.  Speaker after speaker drove home the fact that time is running out to avert catastrophic climate change, but the message from them all was clear and positive – what is good for the planet is good for our health.

Professor Hugh Montgomery of the Lancet commission on climate change said:

Our carbon emissions are already exceeding the worst case scenario. Health professionals have a duty to act, both as responsible citizens, and because we are engaged in dirty work – the health service consumes a huge amount of carbon.

Climate change will have the biggest impact on the poorest, but we will all be affected. There will be changes in patterns of disease, crops will fail or be wiped out completely, rain will fall at the wrong time and in the wrong quantity, food will become a security issue.

We are already in the middle of a mass extinction, with three species being lost every hour.  It is time for action.  We don’t have decades, only (have) a few years.

He said that changing our ways will be good for our health, saving as much as 80 billion euros every year.

David Pencheon of the NHS sustainable development unit said:

As health professionals, we have a duty to care.  We are demonstrating today for people with less choice and less voice than we have. In the next few weeks we have a unique opportunity to halt the tipping point. The scientific evidence shows that climate change is already happening dangerously fast. We must above all remain positive – we can have a cleaner, safer, quieter, fairer world.

(For the facts on climate change, see The Health Practitioner’s Guide to Climate Change).

The third speaker, Sarah Walpole, a young doctor from Leeds, spoke for a new generation  of doctors who will be  at the peak of their careers in 2050, when the full effects of climate change will be felt. She said climate change is an intergenerational as well as a health issue:

We can’t wait around for politicians and institutions to do things at their own pace.  As health professionals we are in a unique position to interact with lots of different people.  We need everyone to keep up the pressure and carry on campaigning.

Pushing a hospital bed containing a ‘sick planet’ and several children, the health group progressed to Parliament Square with the crowd of blue painted activists, handing out prescriptions for a healthy planet to the public on the way.

En route we met the climate change secretary Ed Miliband (see photo below).  Several of us talked to him about the health benefits of low carbon living.  He was very interested to hear our views and asked us to send him information about the health impact of climate change.

The events were organised by a group of health campaigns: the Climate and Health Council, Medact, the Campaign for Greener Health care and Medsin. If you would like more information about the impact of climate change on health, or if you would like to get involved, email: or

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Global Pulse Interviews Ellen ‘t Hoen About Patent Pool

A few weeks back, I posted a blog called Diving Into the Patent Pool, which reported on a Berkeley Law School meeting on patent pools (defined here by Médecins Sans Frontières).  I mentioned that one of the key note speakers was Ellen ‘t Hoen, Senior IP Advisor At UNITAID, who is leading UNITAID’s effort to launch an HIV patent pool. The vision of this patent pool, she said at that meeting, is to “improve access to appropriate, affordable antiretrovirals in developing countries.”

In the new issue of Global Pulse, the open access international health journal of the American Medical Students Association, there’s a fascinating interview with ‘t Hoen, who was asked how the UNITAID patent pool differs from previous efforts to improve universal access to essential medicines.  Here’s her response.

Well, the Patent Pool proposal originated very much within the Access to Medicines movement, which first taught people to understand how new intellectual property rules can empower us to bring down the prices for essential medicines in developing countries. We learned an enormous amount about AIDS drugs pricing practices, and in particular the power of generic manufacturers to provide essential medicines of quality at much lower costs. In the movement for universal access to essential medicines, it is becoming understood that pharmaceutical “patent packaging” is becoming more and more widespread, including in those countries that traditionally served as the “pharmacies” of the developing world – and unless we do something deliberate to find a solution, we will find ourselves back in the situation from 10 years ago, where anti-retroviral drugs (ARVs) were priced very, very high, including in the poorest of countries, putting them out of reach of the vast majority of AIDS patients. This reality is at the root of the proposal by UNITAID to form an international “patent pool” for HIV/AIDS drugs. What the patent pool would do is while the pharmaceutical patent exists, it would allow generic manufacturers to nevertheless play a role in increasing the competition in the market in low-income countries, bringing the costs down. In addition, once you make these patents available to a pool, you also overcome the barriers that exist for the development of a fixed-dose combination of existing drugs, or the development of pediatric formulations. Today, if the patent owner is not interested in working on those, it can also prevent other companies form doing so. Through a patent pool, that will no longer be the case: for example, a researcher who wants to develop a fixed-dose ARV combination could do that by obtaining a license from the pool, and then pay royalties off the sales of the product to the patent owner. So it is a scheme that will work within the existing framework. Now with regard to important landmarks – I think in the last decade there have been two major processes. One, the 2001 adoption of the Doha Declaration of interest in public health at the World Trade Organization, which said that while respecting the rules on intellectual property laid down by the WTO, we have to also make sure that those are implemented with high regard for the need to protect the public’s health. Parallel to that, there has been very intense debate at the World Health Organization in the context of inter-governmental working group on public health innovation and intellectual property, where more concrete proposals were developed, including looking at patent pools for increasing both innovation and access. The UNITAID Patent Pool initiative is not taking place in isolation, but should be seen in context of those larger global debates. We began to realize that some of these rules [on intellectual property] really aren’t in the interest of people in developing countries, and that if there is no deliberate action to put some remedies in place, we would get back to quite a serious access problem.

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International Health Electives: "A Delicate Balance"

Today I had lunch with Paul Drain, physician and lead author of a new guidebook to working in global health, called “Caring for the World.”  The book is aimed primarily at medical students and residents who want to gain global health experience (“Like a guidebook for those visiting a city, especially for the first time,” said a review of the book in last week’s JAMA, “it should help those contemplating work in the field of global health avoid the pitfalls and make the best of the experience.”)

“I got the idea for the book at medical school,” Dr Drain told me.

Before becoming a medical student, he’d gained a microbiology degree, worked in sanitation and health as a Peace Corps Volunteer in the High Atlas Mountains of Morocco,  completed a Masters of Public Health (involving research in Madagascar), and worked on vaccine development and delivery at PATH, a global health NGO in Seattle.

That’s a pretty unusual resume for a medical student.  It meant that his fellow medical school students at the University of Washington would often ask him “how to get into global health.”

The book is a detailed answer to their query, compiling opportunities for medical electives, and laying out the specifics of planning a trip (there are chapters on “understanding the landscape and identifying your goals,” and “funding for global health opportunities.”)  The final chapter has advice from some big names in global health: Allan Rosenfield, Jim Kim, Richard Feachem, Evaleen Jones, and Keith Brown.

I did a medical elective in rural Guatemala in my last year at medical school, and I feel sure it sensitized me to many of the issues in global health.  At the same time, I’ve often worried about the imbalance involved in Western students gaining experience in poor countries (after all, what, if anything, does the host country gain?).

I asked Paul what he thought.

“There’s a delicate balance in these rotations,” he said.

“You want to expose students to global health–then they become engaged in the issues.  The problem comes when they want too much autonomy.”  Dr Drain believes it’s problematic when a student or resident arrives in a developing country and  immediately wants to take over on day one, operating on patients, or running clinics.

Another source of difficulty is when the elective is short-term, such as four weeks.  “That’s just enough time to get bitter and frustrated about the system, ” he said, leading students to cut short their elective and “go on safari.”

There’s also the potential for medical electives to be a burden on the host country’s health system, by taking away time from professors, teachers, and admin staff.

Dr Drain thinks the answer to these problems lies in having Northern and Southern institutions enter into twinning arrangements (e.g. Massachusetts General Hospital, where Dr Drain is heading this year for a fellowship in infectious diseases, is twinned with a hospital in South Africa).  Twinning, he feels, sets up a more “cooperative” relationship, allowing bilateral student exchanges  (North to South and South to North) as well as collaborative research arrangements.

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Diving into the patent pool

When it comes to treating HIV in low and middle income countries (LMICs), there are two crises—the first garners much attention, but the second hasn’t yet become high profile.

The first crisis is that many people with HIV in LMICs who need anti-retroviral drugs (ARVs) aren’t yet receiving them.  Despite the increased availability of ARVs in LMICs, WHO estimated in 2007 that only 27-34% of people in need of ARVs worldwide were receiving treatment.

But there’s a second crisis.  While prices of older ARVs have fallen dramatically in LMICs, due to competition from generic drug manufacturers, the cost of new first-line treatments, and of second- and third-line treatments (for those who fail first- and second-line therapy), remains prohibitively expensive.  As Dr. Selina Lo, Medical Coordinator of MSF’s  Campaign for Access to Essential Medicines, said in 2008:

Today we pay at best between US$613 and $1,033 for the newer WHO-recommended regimen for first-line AIDS treatment. This is a seven to twelve-fold increase compared to older first-line treatments which are now available for $87 for one patient’s yearly treatment.

One possible solution to the second crisis is to create patent pools, which were the focus of a meeting last week at Berkeley Law School.

What’s a patent pool?  MSF defines it as follows:

A patent pool is a mechanism whereby a number of patents held by different entities, such as companies, universities or research institutes, are made available to others for production or further development – for example of paediatric formulations or fixed-dose formulations. The patent holders receive royalties that are paid by those who use the patents. The pool manages the licences, the negotiations with patent holders and the receipt and payment of royalties.

While patents have expired on several of the older first-line ARVs, making them available cheaply from generic drug manufacturers, patents are present on most new and second- and third-line ARVs.  The TRIPS agreement, the most comprehensive multilateral agreement on intellectual property (IP), meant that these newer medicines became patentable for a minimum of 20 years.

At the Berkeley meeting, MSF’s Emi MacLean said that a patent pool would be “a response to the need to overcome patent barriers.”

In the post-TRIPS era, she said, generic competition isn’t bringing down prices for newer ARVs or for second-  or third-line treatments. “The current system threatens treatment access,” she said.

If drug companies were to place patents on newer ARVs into a patent pool, she explained, then other producers (especially generic manufacturers) would be able to make cheaper versions of these medicines under pre-determined licensing conditions.

“What molecules should be in the pool?” asked MacLean.  The pool must contain newer drugs, she said, “so they become available quickly in low income countries.”  The pool should include, she said, fixed-dose combinations, pediatric ARVs, and new classes of HIV drugs such as integrase inhibitors and entry inhibitors.

MSF has written to all the ART-manufacturing drug companies, she said, to ask them to put their patents into the pool.  “All said they’re interested.  Gilead has publicly voiced support.”  She noted that there aren’t yet any patents that have been placed into a pool.

Ellen ‘t Hoen, Senior IP Advisor At UNITAID, is leading UNITAID’s effort to launch an HIV patent pool. The vision of this patent pool, she said, is to “improve access to appropriate, affordable antiretrovirals in developing countries.” The pool aims to provide access to IP relating to fixed-dose combinations and new pediatric formulations.

MSF and Knowledge Ecology International proposed the idea of a patent pool to UNITAID in 2006, she said, which was followed in 2007 by a feasibility study, based on which UNITAID moved ahead with the idea in 2008.

‘t Hoen explained that 92% of patients who are on antiretrovirals in LMICs are on generic ARVs (mostly the triple combination D4T/3TC/nevirapine).  “The pre-TRIPS patent laws allowed this to happen,” she said, but in 2005, medicines became patentable under TRIPS. The patents on newer ARVs extend for a very long time.  The patent on  darunavir, for example, extends to 2023, said ‘t Hoen.

“Generic competition won’t kick in until these dates have passed,” she said.  “That won’t work for getting prices down.”

What are the next steps in making an HIV patent pool happen?

‘t Hoen said that, together with the WHO, UNITAID will figure out the highest priority essential ARVs, identify the relevant patents, and ask the patent owners to put their patent into the pool.  There will then need to be negotiations with the patent owners, and a licensing mechanism will need to be established.

And what are the challenges in getting the pool off the ground?

“Patent holders have strong rights,” she said, “so it depends on their willingness to participate.”

‘t Hoen acknowledged that the idea of a patent pool is “a radical proposal” but was confident that it was also “a doable proposal.”

“It could have a lot of winners.”

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Drug Companies and Patient Groups: Uneasy Bedfellows

A couple of weeks ago, I was on This American Life, a weekly show on US national public radio, talking about screening for prostate cancer.  I discussed the extraordinary reaction to an opinion piece that I co-authored with Dr Mike Wilkes in 2002 in the San Francisco Chronicle.  We argued that there was no high quality evidence (from randomized controlled trials) to support population-based screening for prostate cancer, and that there was good evidence that screening was associated with major harms.

You can read here about the hate-filled e-mails that Mike and I received in response to our piece (we were accused of being, among other things, man-hating feminist Nazis; several people wrote to our employers to demand that we be silenced).

One fascinating fact about this e-mail hate campaign was that it was orchestrated by a prostate cancer patient support group.  The investigative journalist Jeanne Lenzer discovered that the group received 95% of its funding from drug companies.  These companies benefit from promoting prostate cancer screening, since screening is associated with a higher rate of prostate cancer diagnosis and treatment.

Ever since Lenzer’s investigative report, I’ve come to realize that many patient support groups, which often claim to provide “independent” or “impartial” advice, have very deep ties with drug companies—ties that present real or perceived conflicts of interest.

So I wasn’t entirely surprised by the New York Times’ piece on the National Alliance on Mental Illness, America’s highest profile mental health advocacy group, which stated:

“A majority of the donations made to the National Alliance on Mental Illness, one of the nation’s most influential disease advocacy groups, have come from drug makers in recent years, according to Congressional investigators. The alliance, known as NAMI, has long been criticized for coordinating some of its lobbying efforts with drug makers and for pushing legislation that also benefits industry.”

What did surprise me, however, was the immense amount of money changing hands:

“The mental health alliance, which is hugely influential in many state capitols, has refused for years to disclose specifics of its fund-raising, saying the details were private. But according to investigators in Mr. Grassley’s office and documents obtained by The New York Times, drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about three-quarters of its donations.”

Wow, $23 million.  That’s an awful lot of free lunches.

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Telegraph feature on scaling up mosquito nets

Over this past summer, I took a short sabbatical after being awarded a mini-fellowship in global health reporting.  For my fellowship, I traveled in Sudan, Uganda, and Kenya, investigating the opportunities for scaling up low cost, low tech global health tools.

One of the stories that I researched focused on long lasting insecticide treated bed nets.  My news feature on this topic was recently published in The Telegraph.

The newspaper has kindly given me permission to post it on this blog, provided that I include the link to the piece in The Telegraph.  The newspaper owns the copyright (the article is not published under a Creative Commons license), and I’m posting this for educational, non-commercial purposes.   At the bottom of the piece, I’ve included one of my own photos and this photo is indeed published under the Creative Commons license.

From The Telegraph:

Malaria in Africa: The net gains of keeping mosquitoes at bay

Malaria is one of Africa’s biggest child killers. The WHO has set a target to provide mosquito nets to all those at risk by 2010. But providing the nets is just half the battle.

By Dr Gavin Yamey
Published: 7:00AM BST 05 Oct 2009

Atong Deng put on her finest clothes today and walked for two hours to receive a household item that could save her life and the lives of her four children. Mosquito nets impregnated with insecticide are being distributed for free in the remote village of Riang Aker in the state of Northern Bahr el Gazal, Southern Sudan. It will be the first time Atong Deng has ever had a bed net.

Sitting under a tree, surrounded by other women from her village, she listened to a volunteer explain how to use the net, and which family members are most at risk of contracting malaria. “I learnt that children are more vulnerable,” she said.

In Africa, children under the age of five die from malaria at an astonishing rate – around 3,000 a day, or one every 30 seconds. The disease is caused by a parasite, which is transmitted to humans when they are bitten by female Anopheles mosquitoes. Transmission occurs between dusk and dawn, when the mosquitoes feed on human blood and inject saliva containing the malaria parasite.

Malaria exerts a heavy toll in Northern Bahr el Gazal. A 2006 survey by the Government of Southern Sudan found that just over half of all children under five suffered from fever, thought to be malaria, in the two weeks before the survey.

Young children are vulnerable because they have not yet developed enough immunity to fight the infection, as are pregnant women. If patients don’t receive effective malaria drugs within 24 hours of the onset of symptoms, the disease can quickly progress and damage the kidneys, liver, lungs, and brain. Severe cases can rapidly cause coma and death.

Cheap drugs, such as chloroquine, are rarely effective across Africa because the malaria parasite has become resistant. There is an excellent life-saving drug called artemisinin-based combination therapy (ACT), made from the Chinese wormwood plant, but it is expensive and often in short supply.

If Atong Deng’s children sleep under an insecticidal net, they will cut their risk of contracting malaria in half. Their risk of dying from the disease will fall by around 20 per cent. The net works in two ways; serving as a mechanical barrier, it repels mosquitoes and prevents them from biting, and it will also kill them provided the mosquitoes are susceptible to the insecticide in the net’s fibres.

The distribution of nets was organised by the Malaria Consortium, one of Africa’s biggest malaria charities, set up in 1994 by the UK Department for International Development (DFID) as a centre of expertise on malaria control. It advised DFID on its global malaria projects, and also directly assisted countries that were struggling with the disease. It’s a “boots on the ground” operation, which works hand in hand with national ministries of health to roll out malaria control strategies and monitor their impact.

“We marry our academic and research background with real world implementation experience,” said Dr Graham Root, the charity’s managing director, a British tropical disease expert based in Kampala, Uganda. The advice they give to countries like Sudan, he said, “is grounded in the realities that the countries face.” The charity has distributed around nine million mosquito nets in Africa to date. Since two people can sleep under one net, that’s protection for 18 million people. One of its newest projects is its support for Nigeria’s campaign to distribute nets, launched in May 2009, with funding from the British and US governments, the World Bank, and UNICEF. More than a quarter of Africa’s malaria cases are found in Nigeria.

The newest type of mosquito nets last up to five years, and some experts consider these to be one of the few “magic bullets” in global health. The World Health Organization’s (WHO) malaria programme has set an ambitious target. It wants everyone at risk of malaria in Africa to sleep under a long-lasting insecticidal net by the end of 2010, which they hope will cut deaths by one half.

But while countries, such as Zambia, are moving towards universal net coverage, the continent as a whole is lagging behind. The WHO estimates that fewer than one in four children in Africa under five sleeps under a net at night.

One reason is that there just aren’t enough nets to go around, even though Western donor organisations, such as DFID, have become more generous in paying for mass distributions.

“The UK has already delivered almost 10 million nets, with more on order,” said International Development Secretary, Douglas Alexander. “This is part of the 20 million nets we are committed to delivering by 2010, and we have pledged to supply a further 30 million nets by 2013.” Yet, Kenya, for example, needs to distribute about 14 million more nets next year to reach the WHO target, requiring at least $140 million of additional funding.

In Southern Sudan and Uganda, many of the communities most affected by malaria are the least accessible. One week after the net distribution in Riang Aker, the Malaria Consortium organised the delivery of 6,000 nets to a string of fishing villages along the shores of Lake Albert in western Uganda. The country has the world’s highest recorded level of malaria transmission but the villages sit at the bottom of steep cliffs formed by the Rift Valley, which can only be accessed by plane and then boat, presenting major logistical hurdles to net distribution.

Another major threat to the WHO goal is that nets are not always used. Some people say they experience a sense of suffocation or discomfort under their net. Across East Africa, there is also a rich variety of cultural explanations for why nets go unused. In Uganda, malaria nets have been sewn together for use in fishing or turned into bridal veils. Some villages in Uganda and Kenya have been afraid to use white nets out of their belief that white is the colour of death. On the Kenyan coast, people mention “the talking nets” – some communities were convinced that their malaria nets were speaking to them. In pockets of Kenya, people believed nets were medicated with a drug that would make them infertile.

Dr Elizabeth Juma, director of Kenya’s Division of Malaria Control, Ministry of Health, believes it is hard to get people to change their behaviour. “You have to get people into the habit of hanging a net,” she said. In many Kenyan homes, there is no fixed sleeping area – a different place or room in the house might be used on subsequent nights. So people must be encouraged, she said, to carry their net with them to their next sleeping place.

Interviews with women in the village of Malou in Northern Bahr El Gazal also suggest there is substantial seasonal variation in whether nets are used. Amir Garang has three nets for her household, but she still hasn’t used them because there are few mosquitoes at this time of year. “I’m looking for sticks to hang them, and waiting for the mosquitoes,” she said. Distributors express frustration when they hear about nets sitting folded and unused in the corner of a hut while a child comes down with fever.

Dr Root believes that education is the key to improving the rate of net usage, driving home the message that nets save lives. When health workers give out nets in antenatal clinics, usage rates increase if they hang up a demonstration net in the clinic and show women how to use it.

Although net coverage and usage is on the rise, global health targets come and go, rarely being reached.

“There is a real concern about what will happen after 2010 when the jamboree ends,” said Dr Root. The 2010 target has been simplified, he said, to raise funds and explain to the world that malaria can be controlled relatively easy. “That simply isn’t true.”

The Malaria Consortium organized the delivery of bed nets in Riang Aker

The Malaria Consortium organized the delivery of bed nets in Riang Aker

Photo: Copyright: © 2009 Gavin Yamey. This is an open-access photo distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Mental health in Kenya

On Sept 8 2009 I blogged about Kenya’s science cafés, and on October 13 2009 I blogged about the launch of PLoS Medicine’s series on global health in low and middle income countries.  Now I’m bringing both themes together, because I just found out that Kenya’s next science café, held in Nairobi, will deal with the topic of mental health.

Ruth Wanjala, one of the science café organizers writes:

Mental health problems affect society as a whole, and not just a small, isolated segment.  Mental illness has however been hidden behind a curtain of stigma and discrimination for far too long. It is time to bring it out into the open.

The October Science Café will discuss issues of mental health in Kenya with a diverse range of experts including top psychiatrists, mental health advocates, users and survivors of psychiatry and trained counsellors. The cafe hopes to raise awareness about mental health in Kenya and people affected by mental illnesses who are the most marginalized and vulnerable in society due to stigma and inhumane treatment.

The Café will take place on 22nd October, 2009 at the Mug Coffee House, Kaunda Street opposite Lonrho House from 6.00- 8.00 PM. Ruth has asked those interested in this event to e-mail to confirm attendance and help her plan logistically.

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Protecting hospitals from natural disasters

Today is the UN’s International Day for Disaster Reduction.  This year the UN is dedicating the day to highlighting the need to make hospitals safe from disasters.

This “hospitals theme” was also used over the past year in a campaign involving UN agencies and the World Bank, called the 2008-09 World Disaster Reduction campaign.  The campaign has been working to help hospitals withstand floods, hurricanes, cyclones, and earthquakes

In a press release from the WHO, Margareta Wahlström, Special Representative of the UN Secretary-General for Disaster Risk Reduction, said:

“No new hospital should be built unless it can withstand the impact of natural hazards. Existing health facilities should also be assessed for their safety and action take to improve their safety and the level of their preparedness.”

I was interested to learn about the Hospital Safety Index.  The Hospitals Safe from Disasters website says that the tool is a “rapid, reliable and low-cost” and aims to “help health facilities assess their safety and avoid becoming a casualty of disasters.” The index is based on a checklist that assesses the safety level in 145 areas of the hospital, and is being used in Latin America and the Caribbean.  I did a quick PubMed search to look for published studies that have evaluated the use of this index in the field, but couldn’t find any.  If you know of such studies in the literature, do let readers know by responding to this post.

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Action on global mental health

Last Friday, I attended the launch of the Centre for Global Mental Health (CGMH), a high profile event held at the London School of Hygiene and Tropical Medicine.

I was there because PLoS Medicine recently kicked off a series on “packages of care” for six mental health problems in low and middle income countries, starting with depression.  We timed our kick off with the CGMH launch.  Both of the Guest Editors of the series, Vikram Patel and Graham Thornicroft, are involved with the new center (Vikram is one of two people leading it).

One of the many highlights of the launch was a barnstorming keynote address from Dr Benedetto Saraceno, Director of the WHO’s Department of Mental Health and Substance Dependence.

Dr Saraceno was remarkably frank about how little had been done so far to provide mental health interventions in low and middle income settings.

He acknowledged that there’s been lots of research to describe the burden of disease and to highlight the “treatment gap,” yet this work hasn’t yet translated into action.

Research to describe the global burden, for example, started with the 1995 World Health Report and spanned a twelve year period, he said, culminating in the 1997 Lancet series on global mental health (which is free to access). “We’ve been excellent in describing the burden for twelve years,” said Dr Saraceno.  “We’ve been excellent in describing the gaps.”  Those gaps, he said, include gaps in human rights:

“Systematic violation of human rights occurs in developed and developing countries and is substantially ignored by many psychiatrists.”

So why, he asked, has nothing happened despite twelve years of reports?

He said there were four barriers to action:

  • Political will and funding.  There’s a widespread and incorrect belief that mental health care is cost-ineffective.  There’s the problem of inconsistent and unclear advocacy on the part of different groups of mental health advocates (in contrast to HIV activism, where advocates have had a single clear message).  People with mental health disorders aren’t organized into powerful lobby.
  • Mental health resources are centralized in large institutions in and near big cities, and extra funding is needed to shift to community based resources.
  • There’s difficulty integrating mental health care into primary health care services.  Primary health care workers are already overburdened, and there’s a lack of supervision and support after they receive training. Many primary health care centers don’t even have a continuous supply of medications.
  • Mental health leaders often lack public health skills and experience (“Great clinicians aren’t necessarily great reformers,” he said; on the other hand, professional public health training doesn’t include mental health)

In going forward, said Dr Saraceno, “we should stop blaming donors and ministers.”

“We should stop talking about the burden and gap and start talking about solutions.  We have them. They are cost effective.”

The WHO has launched a solutions-focused project, chaired by Graham Thornicroft, called the mental health Gap Action Programme, or mhGAP.  As with the PloS Medicine series, which was intended as being complementary to mhGAP, the WHO program focuses on packages of care for major disorders.  Dr Saraceno explained that the mhGAP model has 7 phases:

  1. Assess needs and resources
  2. Enhance political commitment
  3. Facilitate policy development
  4. Mobilize financial resources
  5. Strengthen human resources
  6. Deliver the intervention packages
  7. Establish a plan for monitoring and evaluation (M&E) of the packages.

“Adapting, adopting, delivering, and M&E of the packages will be crucial,” he said.  The WHO will be partnering with CGMH in this effort, especially for M&E, and it also wants to partner with the UN health agencies, development agencies like the World Bank, NGOs, health professionals, service users, and caregivers.

From 1995 to 2007, he said, there was “a big effort, small results.”  But with the launch of CGMH, the mhGAP project, and the Movement for Global Mental Health, he hopes that from 2010 to 2014 we’ll see “big efforts and big results.”

Category: Mental Health | Tagged , , , | 1 Comment

Buying a Coke in Africa: are there lessons for malaria?

Many African countries face serious shortages of essential global health tools, such as malaria drugs and mosquito nets.  Often when these shortages are discussed, someone makes the “Coca Cola” comparison (i.e. how is that Coke reaches everywhere, but health tools don’t?).

Having just returned from a reporting fellowship in  Sudan and East Africa, I can tell you from first hand experience that it really is possible to buy a bottle of Coke in some very remote places that are suffering shortages of medicines and nets.  Sarah Boseley, health editor of The Guardian, found the same thing, and in fact the title of her recent feature on the medicines crisis in Katine, Uganda, was “In Katine, a Coke is easy to buy. Medicine isn’t.”

Coca Cola has obviously achieved a major feat in establishing these distribution channels.  Nevertheless, the Coca Cola analogy isn’t a perfect one.  For example, when there was still a debate (which is now over, thanks in part to a study in PLoS Medicine) on whether mosquito nets should be given to the poor for free, or whether they should be “socially marketed” (i.e. sold), the Coca-Cola comparison was often mentioned by the “social marketeers.”  The marketeers’ belief was that poor people would value a net more if they had paid for it.  But some malaria experts rejected the comparison.  In a compelling feature article in the New York Times in 2007, Arata Kochi, director of the WHO’s malaria program, said: “I’m not sure whether the poorest of the poor actually drink Coca-Cola.”  Yes, the soft drink has great market penetration, but the world’s poorest remain too poor to actually buy it.

Sarah Boseley’s piece provoked some fascinating responses, and the one from Coca-Cola representative, David Cox , caught my eye:

“Like Sarah Boseley, Coca-Cola is concerned about the lack of vital medicines reaching Katine and other communities throughout Africa. So we are examining if it is possible to use the success of the distribution system for our drinks, and the expertise behind it, to help tackle this challenge. It is not as easy as it may seem. The reason that Coca-Cola and our other products are so widely available in Africa is largely because of the efforts of independently-owned small businesses that make money for each case they deliver. Any initiative to distribute medicines or other essential public goods has to maintain these commercial incentives or they simply will not work.”

To me that seems like a brutally honest point: the company is a commercial outfit and the distribution chain works by using commercial incentives.  End of story.

OK, but what if the supply chains and the commercial incentives remained totally intact and the global health tools were simply added to the crates that carry the Coke bottles?  It’s an intriguing idea, and there’s a charity called Colalife which is trying to get it off the ground (I read about Colalife in this month’s Good Magazine, which gives 100% of the subscription fees to innovative non-profits).  Colalife is trying to develop an “aidpod” that fits between the bottles and carries “much needed ’social products’ such as oral rehydration salts and high-dose vitamin A tablets.”  Colalife submitted its proposal to Google’s Project 10 to the 100, a “call for ideas to change the world by helping as many people as possible,” though it didn’t make it to the final 16 (by the way, voting on the final 16 ends on Oct 8 2009).  The picture (published under a Creative Commons Attribution-Noncommercial-No Derivative Works license) shows Colalife’s founder, Simon Berry, holding a mock-up of the pod.


Simon Berry unveils “Mark II” of the aid-pod. Credit: Cafe du Monde

Colalife is an interesting take on the Coca Cola analogy.  Berry is looking for an international NGO to take the project further.  He’s also trying to get Coca Cola to sponsor it. I personally think that’s a bad idea, for two reasons.  First, it could create a real or perceived conflict of interest (for example, the company might see it as an additional marketing opportunity).  Second, the soft drinks and fast food industry in general isn’t exactly known for its public health promotion (as The Lancet editors wrote recently, in an editorial highly critical of the industry’s promotional tactics, “if the industry continues on its present trajectory, the public’s opinion of Big Food is going to follow that of Big Tobacco and decay as quickly as a Coca-Cola-drinker’s teeth”).

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