Is India committed to polio eradication target?

While WHO and its partners have set a target of 2012 for the end of wild polio virus transmission, India one of the four countries where polio is endemic, seems to be uncertain about whether to commit to this target. In a written reply in the Indian parliament, the Health Minister, Ghulam Nabi Azad said that it was “not possible to mention a time frame” for eradication. Is this a ministerial gaffe, or a change in strategy in India?

How severe should a pandemic be?

When the WHO eventually declares  the current pandemic to be  over, and acknowledges that the pandemic H1N1  flu virus has  become the regular seasonal flu virus, questions will still remain among sceptics about whether this was a pandemic at all, and whether a pandemic should be re-defined to include the severity of the disease.

It doesn't have to be this bad.(Credit: Office of the US Public Health Historian)

A leading flu expert, Prof Malik Peiris of Hong Kong University is in no doubt that this was a real pandemic and is also clear that severity of disease should not form part of the definition .

In this interview with the The Hindu newspaper, Malik Peiris pointed out that given the difficulties of measuring severity, attempting to define a pandemic in terms of severity would “paralyse international health policy.”

The WHO in the meanwhile seems to be indicating that it intends to sit out the Southern Hemisphere flu season, which techncially ends in September, before declaring the pandemic at an end.  In this most recent briefing note it says  “it is too early to determine if these countries have transitioned to levels and patterns expected for seasonal influenza.”

Cost effective strategies for HIV/AIDS prevention

Daniel Halperin of the Harvard School of Public health, in this commentary published by Reuters,   takes a contrarian   look  at the strategies for HIV/ AIDS prevention and treatment that are getting the most attention at the Aids Conference in Vienna.

He points out that universal testing and treatment as a method to end the epdiemic is  financially unrealistic, and suggests cost effective strategies such as male circumcision should be pursued urgently.

“While we must continue to search for new technological approaches, let’s not forget that millions of lives have already been saved through using basic prevention approaches and common-sense changes in behavior,” he writes.

Money and optimism needed

It takes boundless optimism and relentless commitment to work in the field  of HIV/AIDS. Every step forward on the road to controlling the disease reveals fresh challenges that lie ahead.

Show us the money ©IAS/Steve Forrest/Workers' Photos

There is good news coming out of the International Aids Conference in Vienna, the world’s foremost gathering of scientists, activists and public health experts working on HIV/AIDS. But the good news is more often than not overshadowed by the formidable task of actually delivering effective prevention, treatment and perhaps one day cure to the over 30 million people living with HIV and the roughly 2.5 million people who are newly infected by the virus annually.

Here’s some of the good news: The WHO estimates roughly 5.2 million are now receiving anti-retroviral treatment, compared to 4 million in 2008.  However, to put this in perspective at least 10 million more people should be receiving treatment, at a cost of roughly US$ 9 billion a year. Since the majority of those not receiving treatment are in low income countries, this will have to be paid for by increased funding from the G-8 and other developed countries.

Developed countries had pledge to do their part by spending 15 percent of  their budgets on health care. That is not happening either.

At a time when their budgets are under pressure, there is no indication that this money is going to be forthcoming. A joint report by UNAIDS and the Kaiser Family Foundation, estimates that the donor governments provided US $ 7.6 billion for AIDS relief in the developing countries, compared to US$ 7.7 billion the previous year. UNAIDS estimates that US $ 23.6 billion was required in 2009 to meet the needs of low and middle income countries.

Given the huge fiscal deficits in donor countries, there is no way that these increases in funding are going to be forthcoming in the near future.

Preventing the disease from spreading has often been seen as a alternative to expensive treatment options. But it is has increasingly become clear that the line between treatment and prevention are blurred. A recent study in the Lancet of the impact of  anti-retroviral therapy on HIV transmission in British Columbia, showed a link between increased anti-retroviral coverage and a reduction in the number of new HIV diagnoses. Pre-exposure prophylaxis, male circumcision, and possibly new microbicides could all help reduce transmission. But all of this costs money. But the alternative of not spending this money on prevention is horrific:  2 million new people every year being added every year to the numbers requiring  treatment.

Hong Kong conference looks at pandemic communication

A two day conference on pandemic communication  at the University of Hong Kong brought together communication specialists, public health experts, sociologists, historians and journalists to examine risk and health communication successes and weaknesses during the influenza pandemic, and to draw lessons for the future.

More can be found here. We will post audio files  of the sessions shortly.

The conference progamme and list of participants can be found here.

Smoke and mirrors

Is the message getting through? (Copyright WHO/Saurabh Mittal)

How effective are  the global efforts to reduce the use of tobacco?  Not very, to judge by the fact that the world’s major tobacco companies are still doing good business, finding new markets,new customers and making profits.

You would imagine that companies that make products that in the WHO’s estimates kill 5 million people worldwide every year, and are the leading cause of preventable death, would have been forced by now to wind up their business and disappear from existence.

Nothing could be further from the truth.  If you go to the slick, beautifully designed websites of  the major players in the global tobacco industry you are plunged into the a world in which tobacco and cigarettes are products like any other, competing for market share at a time of continuing global economic uncertainty, and doing reasonably well under the circumstances.

These companies speak the language of corporate social responsibility: “One of our principle goals is to be a socially responsible company. Because of this we are passionate about our social responsibility”, declares Phillip Morris International (PMI), one of the world’s tobacco giants.

British American Tobacco (BAT),  another global giants, says its vision is “to lead the tobacco industry through growth, productivity and responsibility.”

The tobacco companies acknowledge the harm that smoking causes (though in mild language that avoids words like death), and their goal is to ensure in the words of the BAT website “balanced regulation” which presumable will allow them to keep selling and marketing cigarettes as well as other tobacco products.

Philip Morris declares that it supports regulation, but not regulation that “prevents adults from buying and using tobacco products or that imposes unnecessary impediments to the operation of the legitimate tobacco market.”, or regulations that “reflect prohibitionist policies that severely restrict, if not eliminate, the ability of tobacco companies to compete.”

If tobacco control is to be effective, it has to restrict the ability of companies to function. But governments do not have the stomach for that.

In the absence of  strong efforts to curb tobacco use, the companies seem to be doing well. British American Tobacco, in its latest interim management statement for the first quarter of this year, declared that its four “ Global Driver Brands”, Dunhill, Lucky Strike, Pall Mall and Kent, “ delivered good performance and achieved overall volume growth of 6 percent, and share growth in a number of key markets.”   Selling cigarettes in the Asia Pacific region is a key source of revenue and profits, and in 2009, the company made over one billion pounds sterling in profits from the region

At a recent investor conference held in Lausanne, Andre Calantzopoulos, the Chief Operating Officer of PMI , delivered an upbeat assessment of the companies performance, and described new strategies to get young  people ( or “ Young Adult Smokers over the age of 18” as they are described) to develop a taste for that old classic Marlboro with packet and product changes.

There has been a clear failure in international efforts to combat tobacco.  Five years ago, an international treaty, the WHO Framework Convention on Tobacco Control came into force. Countries  declared they would “protect present and future generations from the devastating,  health, environmental and social consequences of tobacco consumption and exposure to tobacco smoke.”  Brave words indeed, but like many other global treaties, words that have not been matched by action from national government.

The results of a WHO study on implementing tobacco control measures make pathetic reading: only 10 percent of the world’s population is covered by even one of the major tobacco control policies. The percentage of world population covered by any of the major tobacco control meaures is shown here:

The long term costs of polio eradication

Will he need an injection after the drops? (Photo P. Virot/WHO)

A final timetable to eradicate polio by end 2012 was announced in Geneva less than a month ago at a meeting marked  by good intentions, rhetoric  and demands for additional funding.

“We must all dedicate ourselves to writing this final chapter and closing the book on polio forever. For every child” declared Anthony Lake the newly appointed head of UNICEF.

“Let’s make history. Let’s deliver on our promise to every last child, a promise with a pay-back for every future generation of children,” said the WHO’s Director General, Margaret Chan.

The this three year effort is estimated to cost US $ 2.6 billion, of which only half has been funded.  The gap is not huge, and even in these financially straitened times, donors can be persuaded to cough up the required amounts. But they will only contribute if they are convinced that this last push to eradicate polio will actually succeed. And there lies the problem.

Eradicating  polio is not as simple as it seems. An issue that is rarely mentioned in the public communication and the advocacy surrounding polio eradication is that the target that has been set for end 2012, is only to eradicate wild, or naturally occurring polio virus (WPV) transmission. But the vaccines used in oral vaccines can themselves cause rare outbreaks of disease. Disease outbreaks caused by vaccine derived polio viruses (VDPVs) are not a part of the eradication deadline, and could continue to cause disease even after polio has been officially eliminated. New forms of immunisation will be required to control  the risk of disease caused by vaccine derived viruses.

The live viruses that are used in oral polio vaccines are attenuated, and generally too mild to cause disease. However, i they have been known to  revert to a more virulent state.  Since 2000, 12 vaccine derived polio outbreaks have been  detected in different parts of the world. The potential for vaccine derived viruses to cause major outbreaks has been demonstrated recently in Nigeria, where an outbreak of circulating vaccine derived polio viruses  ( c VDPVs) caused  292 cases of polio between 2005 and 2009.

A study in the New England Journal of Medicine reported that the severity of the disease caused by the circulating vaccine derived polio virus in Nigeria was similar to that caused by wild polio virus. Because of the risk of disease caused by vaccine derived viruses, most developed countries have stopped using oral polio vaccine, and use the more expensive inactivated polio vaccine which does not use live virus, and is injected rather than orally administered.

John Modlin of the Dartmouth Medical School in a commentary on the findings in Nigeria, suggests that even after wild polio viruses are eradicated, children will have to be immunized with inactivated vaccine  in order to protect them from the risk of outbreak of disease caused by vaccine derived viruses.

This implies that the billions of dollars that have been poured into polio eradication, will have to be followed by billions of more dollars to control the viruses that have emerged from the eradication efforts. As Modlin points out “The emergence of cVDPVs forces us to accept the reality that we are fighting fire with fire.”

The additional costs will still make a world free of polio worth pursuing. But, while continuing to beat the drum for polio eradication, it is important that the WHO, UNICEF and donor bodies like the Gates Foundation, also start talking about the costs of not merely achieving, but maintaining a polio free world.  Equally, if not more important countries in the developed world, instead of being passive recipients of money and advice from donor countries and organizations, should make their own inputs into the global strategy for eradicating polio.

How safe is safe?

Nearly two years after  six infants died, and over 50,000 others were hospitalized for urinary and renal tube blockages and kidney stones after being fed infant formula adulterated with melamine in China, the international community has set down maximum levels for melamine in food and animal feed.

A sick child in Zhengzhou being brought for treatment after receiving tainted milk powder in 2008.

The United Nations’ food standards body, Codex Alimentarius Commission, meeting in Geneva this week set a maximum limit of 1 mg/ kg for powdered infant formula, and 2.5 mg/kg for foods and animal feed.

The contamination of infant formula in China was the result of deliberate mixing of melamine powder to the formula to make the protein content of the milk appear higher than it actually was.  Protein in milk is tested indirectly by measuring nitrogen, and melamine inflates nitrogen content.  Tests in China showed that the level of melamine in contaminated dairy products ranged as high as 6196 mg/kg, well above the maximum limits that Codex has stipulated.

The interesting question is how Codex set these new limits, and the interplay between the food industry and public health. Melamine finds its way into food products in a number of ways. It can pass into food and drink in minute amounts through melamine plastic ware and through use of melamine coated instruments and packaging in the manufacturing process. Certain pesticides  can also metabolize into melamine in the human body.

Codex Alimantarius, which is jointly run by the Food and Agriculture Organization ( FAO) and the World Health Organization ( WHO), is made up of representatives from the different member states of both organisations, who are under pressure to balance public health with the interests of their domestic food industries. The focus of the discussions on melamine limits, were therefore on distinguishing between wilful adulteration with melamine, as had occurred in China, and melamine that occurred “naturally” in foods because of the manufacturing process.

In an interview with Food Quality news.com, an online food industry trade publication, one of the New Zealand’s representatives at Codex, John Reeve said that the Codex committee’s work would focus on  “striking a balance between acknowledging the ‘natural’ occurrence of the compound while protecting the health of consumers and making it difficult for those willing to use unethical practices in food production.”

The problem of course is that melamine does not occur naturally: it is a by product of the manufacturing processes that the food industry uses. Countries negotiate to protect their food industries to the extent that no proven harm is caused to human health.

Thus, in the negotiations on the maximum safe limits to melamine, the European Union successfully pushed to get exceptions introduced in the 2.5 mg/kg limit on melamine in food. These exceptions relate to the use of the insecticide ( or plant protection product as it is euphemistically referred to) cyromazine. Cyromazine is a widely used insecticide, which can metabolize in the human body to melamine.  The EU also introduced exceptions for melamine in food that resulted in contact with melamine based products such as plastics , and animal feed ingredients and additives.

There is no evidence at present that the levels of melamine that result from these exceptions will cause long term harm to human health but it throws light once again to the extent to which our food has become an industrialized product: sprayed with insecticides that metabolise within our body, processed in factories and packaged in materials that once again creep into our bodies. The levels at which this happens are all judged to be “safe”.  But then, 70  years ago, tobacco was also widely judged to be “safe”, and doctors would appear in cigarette advertisements to vouch for the relaxing qualities of their favourite brands.

Parallel Universes

The centerpiece of the recent G-8 summit at Muskoka in Canada was a pledge of US$ 5 billion over the next five years to reduce maternal and child mortality. This is in addition to the US$ 4.1 billion that the G-8 already gives annually for maternal, new born and under five health. The money is welcome, as is the focus on reducing the needless tragedy of women dying unnecessarily in childbirth and young children dying because of a lack of medical attention.  But the question still needs to be asked, how is this money going to be used, where is it going to be used, and how much difference will it make?

That's maternal mortality taken care of then..

The people who should be asking these questions are those the money is intended to benefit. People like the women outside the Kangatotha dispensary in Turkana district in Kenya. As this report from IPS news service shows half of the pregnant or breastfeeding women in the district are malnourished; a majority of children also lack adequate food, many to the point of needing specialised medical care.  We have no idea how these women would want this money to be spent. We can be quite sure that they have no idea that a group of rich and powerful people have pledged all this money on their behalf.

G-8? Haven't heard of it.

We can also be quite sure that Josephine Bangali, a midwife in a village in Sierra Leone who works in a mud clinic where she often delivers babies by the flickering light of a kerosene  lamp because she has nomoney for batteries, and walks one and half kilometres to get mobile phone coverage if she needs to call an ambulance that might or might not come, is unaware of the largesse that has been pledged in Muskoka.

Those who pledge aid, and those whom the aid is mean to benefit, tend to live in parallel universes. The rich distribute billions of dollars, and NGOs and other advocacy organisations demand that they spend billions more. Women Deliver, a high powered advocacy group has declared that the international community must increase investment in maternal, newborn, and reproductive health over current funding levels by at least an estimated additional US $12 billion in 2010, increasing annually to an additional US $20 billion in 2015. Thoraya Obaid, the head of the UN Population Fund, has thrown another figure into the mix “ It would cost the world $ 23 billion a year to stop women from having unintended pregnancies and dying in child birth, and to save millions of new borns.”

These efforts and these figures are well meant, and the cause is urgent. But, unless the two parallel universes of the aid donors and the aid recipients meet, success will be far slower than it should. Global public health, and the development aid that funds it is too much of a top down process. The beneficiaries of aid are seen as passive recipients of services that others have decided they need, rather than empowered participants in the development process. It is only when the women in places like Turkana in Kenya and elsewhere all over the world start demanding better services of the global community, and letting the world know what they want and how they want it, rather than the world descending on them with services that true change will happen.

Here’s a suggestion for the next time the G-8, or other high level bodies meet to discuss the world’s poor. First, do not meet in New York, or Geneva or any of the other locations where world leaders tend to meet. Take a reality check, and meet in a poor country. Leave your security guards behind and meet the people you are supposed to help. Talk to them. Ask them what.  Listen to them.