India Rises, Leaving Poor Behind

Unlike in China, a leading physician activist says, India’s rising economic tide is not floating many boats to lift the poor up and out of poverty.

India’s rich and middle-class sectors are riding higher, getting richer, says Dr. Jonathan Fine, founder of the Nobel Peace Prize-winning group Physicians for Human Rights, while India’s hundreds of millions of poor people remain firmly anchored to the bottom.

Dr. Jonathan Fine

Dr. Jonathan Fine, speaking to UW students

“Things are actually getting worse in many of India’s rural villages,” Fine said on a recent visit to Seattle. The Boston physician spoke Tuesday at the UW to a student-run global health group. Fine was in Seattle to meet with — and recruit volunteers for — a local branch of an organization devoted to assisting India’s poor, Association for India’s Development.

Malnutrition rates tell the story of inequity in India, Fine said. Hundreds of millions of Indians continue to live on semi-starvation diets, he said, despite there being enough food in India to feed everyone and despite India’s overall economic progress.

According to UNICEF, China has reduced its rate of child malnutrition to 7 percent while in India today more than 40 percent of young children are malnourished – a rate worse than in many sub-Saharan African countries.

“Initiatives aimed at improving health and welfare won’t have much effect if malnutrition is not dealt with first,” Fine contended. Hungry people are more prone to illness, he said, and malnourished children don’t learn or develop properly. “The Indian government continues to largely neglect this massive problem.”

Nearly half of India's children are malnourished, photo by Mike Urban

Tapoja Chaudhuri, who teaches at the UW’s South Asia Center, and her soon-to-be-doctor husband Sunil Aggarwal (he gets his MD in a week), agreed with Fine’s comments and are, for the same reasons, planning to become more active in efforts to assist India’s poor. Both said the gap between rich and poor in India is growing.

Chaudhuri, who grew up in Calcutta, said there are terrible conflicts raging across many parts of India today due to these entrenched inequities. Though the government portrays the fight as against communist terrorists, Chaudhuri said the conflicts are fueled not so much by ideology but by the disenfranchisement of many poor communities. Government economic policies, she said, tend to focus on large-scale development projects rather than on anything that directly benefits the rural poor.

“It is not at all paradoxical to me that India’s rapid economic growth is accompanied by high rates of malnutrition,” Chaudhuri said. The way India is achieving its overall growth, she said, is by often bulldozing over – figuratively and literally — already impoverished communities.

Chaudhuri plans to work on social justice issues in India next fall while Aggarwal, who plans to someday go there as a doctor, completes his residency at Virginia Mason Medical Center.



Study: AIDS Treatment IS Prevention

For the last few years, AIDS experts have been arguing about the claim made forcefully by some Swiss scientists that giving anti-viral drugs to people with HIV also prevents transmission of the virus to others. While there had been some anecdotal  and hypothetical evidence supporting this contention, there wasn’t much hard proof.

A Seattle team of scientists has now provided some pretty solid evidence, reported in the current issue of The Lancet.

Dr. Connie Celum

“We found a 92 percent reduction in transmission among those who went on (drug therapy),” said Dr. Connie Celum, a leading AIDS prevention researcher at the University of Washington and senior author of the study.

Working in seven African countries (Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia) with nearly 3,400 couples in which one partner is HIV-infected, Celum’s team followed 349 couples for two years after the infected partner qualified to begin taking anti-HIV drugs (ARVs, anti-retrovirals).

Standard procedure for starting ARVs is based on when the blood level of an immune cell targeted by HIV, known as the CD4 cell, drops below a certain threshold. In most African countries, that threshold is a CD4 count of 200 or lower (normal being from 500 to 1,000).

It’s worth noting, however, that there’s a fierce debate going on right now about whether it makes sense to use a higher threshold (of say 350, as is often done in the U.S.) or to just put people on ARVs as soon as they are infected. San Francisco’s Department of Health recently recommended that all HIV-infected people should get ARVs no matter what their CD4 count.

Of the couples in Celum’s study, only one of the HIV-infected partners on medication transmitted the virus to her partner as compared to 103 infections transmitted by HIV-positive partners not on ARVs.

Given that the AIDS pandemic is still on the increase and millions of those infected worldwide are still not receiving these life-saving drugs, the UW team’s findings give strong support to the urgent need for expanding access to drugs as an effective means to stop the spread of AIDS. Some experts say the spread of AIDS in Africa could be contained in as little as five years if everyone infected received treatment now.

AIDS activists used to chant “Treatment is Prevention” to make the case that people must be guaranteed access to treatment in order to encourage them to be tested and engage in prevention. Now, it appears that treatment is not simply a necessary partner to prevention. Science has shown that saving the life of an infected person is also a powerful method for preventing another infection.

Connie Celum's motto

Global Health Neglects Big Killers

The field of global health has focused largely on fighting “communicable” infectious diseases such as AIDS, tuberculosis and malaria. One of the leaders in the field, Dr. Jeffrey Koplan, thinks it’s time to broaden the focus to include the other killers communicated by advertising, entertainment and social encouragement of unhealthy behaviors.

“You don’t have to cough on people to spread disease,” said Koplan, who spoke Wednesday at the University of Washington as part of the Washington Global Health Alliance’s lecture series. Koplan, a former director of the U.S. Centers for Disease Control and Prevention, is vice-president for global health at Emory University in Atlanta.

The health effects of obesity, poor nutrition, tobacco use, the “epidemic” of fast food diets and the increasingly sedentary nature of modern living, he says, are all contributing to a worldwide increase in deaths and illness from chronic diseases like hypertension, diabetes, stroke and certain cancers (e.g., lung and liver).

Taken together, the death toll from these so-called “non-communicable diseases” far outpace the toll from infectious diseases worldwide, Koplan said, yet they receive much less funding, resources and attention in the global health field.

Spending by Disease Categories, The Lancet

Referred to in public health lingo as NCDs (non-communicable diseases), Koplan suggested rechristening NCDs as “neglected communicable diseases” because they are spread throughout the world today by communications — by advertising, media and the push to find new markets for tobacco, fast food, soft drinks and other unhealthy products.

More than half the men in China smoke, he said, and American fast food chains are a growing contagion. It has been estimated that China loses about $600 billion in annual productivity from heart disease, hypertension, diabetes and other diseases caused by unhealthy behavior, he said.

Despite the toll exacted worldwide by chronic disease, Koplan said many of the leading organizations committed to global health tend to shy away from devoting resources to combating chronic diseases. This may have to do with the complexity of battling these diseases of behavior, or of going up against industry. But he said the public health community’s success in combating tobacco in the U.S. shows it can be done globally.

The first step, Koplan said, is for governments, donors and leading public health organizations to recognize that the fight against chronic disease will be just as important to achieving success in global health as the fight against infectious disease.


Microcredit guru says economic system is sick

The man who won the 2006 Nobel Peace Prize for developing the concept of microcredit loans aimed at helping poor people says the economic system is sick.

“I am back in Seattle again,” said Muhammad Yunus, who spoke Sunday at Town Hall on a tour promoting “Social Business,” his mission and the title of his latest book. “I have so many friends here.”

Muhammad Yunus and fans at Town Hall

He does indeed, as two standing ovations indicated. Yunus’ once-radical concept of microcredit has gained some powerful local devotees and spawned a number of local microcredit organizations in Seattle.

The Bangladeshi economist and founder of Grameen Bank, created in 1976 as an experiment aimed at giving the rural poor small loans to develop businesses, told the Seattle crowd that the widely held – and popularly accepted — idea that the marketplace operates best if guided only by self-interest is based on a flawed misunderstanding of economics and human nature.

Most people are self-interested, Yunus said, but most also want to help others as well. Though he didn’t cite Adam Smith, he might as well have done.

Smith, the 18th century philosopher who came up with the idea of a self-correcting free market guided by the “invisible hand” of self-interested profit-making, also expected that the human beings operating in that market would be guided by his earlier work on “The Theory of Moral Sentiments.”

Said Smith: “How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortunes of others, and render their happiness necessary to him, though he derives nothing from it, except the pleasure of seeing it.”

That’s basically what Yunus said Sunday, calling upon his audience to use the current financial crisis to push the politicians, business leaders and others to restore human balance to economics.

“All of these problems we are seeing today are expressions of a sickness in the system,” Yunus said.

Philanthropy, he said, is too often aimed at treating the symptoms of poverty rather than the root cause. The true cause of poor people suffering from disease, lack of education and many other ills of poverty, he said, comes from the distortion of economic purpose.

“Poverty is imposed upon people,” Yunus said. “It is built into the system … the same system that has created this financial crisis.”


Child survival improving worldwide, except in America

Contrary to many earlier gloomy estimates, researchers in Seattle have found substantial reductions in child mortality worldwide.

They also found the U.S. does far worse than most of the rest of the developed world, including much less wealthy countries like Croatia or Estonia.

“Previous estimates had shown child deaths falling slowly and neonatal deaths nearly at a standstill,” said Julie Knoll Rajaratnam, a global health researcher at the University of Washington’s Institute for Health Metrics and Evaluation. Rajaratnam was lead author of the study published in the current issue of The Lancet.

Change in child mortality rates 1990-2010

The Seattle team decided to take a more in-depth look at these depressing claims, analyzing more than 16,000 different kinds of records in 187 countries (census reports, birth histories, hospital records, etc.) and applying some fairly sophisticated mathematics.

They discovered more improvement than had been previously reported, with under-5 mortality in children dropping from 11.9 million deaths in 1990 to 7.7 million deaths in 2010 – a 35 percent reduction in two decades. Many poor sub-Saharan countries showed improvement.

Ethiopia cut its child mortality rate exactly in half from 202 deaths per 1,000 live births in 1990 to 101 deaths per 1,000 births in 2010. And contrary to expectations, neonatal death rates are falling even faster.

The primary purpose of the report was to examine how many countries are on target to achieve this portion of a massive international assistance project known as the Millennium Development Goals.

Though most Americans remain oblivious to this ambitious project, it has likely helped to focus the international community’s previously highly disorganized and often counterproductive attempts at assistance. Most poor countries are still far from achieving these goals aimed at reducing poverty, improving health, education and general well-being.

Some major initiatives, especially over the past decade, have made MDG Goal 4 — improving child survival — a renewed top priority in global health. The Gates Foundation’s largest funded project GAVI, which is aimed at getting basic immunizations to children, is already estimated to have prevented 3-4 million deaths in the last decade.

U.S. child mortality rates were not a primary focus of the article, but it’s worth noting this new estimate shows we haven’t improved much at keeping our kids alive. We still rank way down on the list among developed countries, 42nd place to be precise, below Croatia, Estonia and Hungary.


Thailand AIDS Vaccine Trial: Back Story Troubles

Aids virus

My report on the largest AIDS vaccine trial ever done – and, more importantly, the only such study to show effectiveness against HIV – was published Monday as part of a broader report on where we are at in the search for an effective AIDS vaccine.

The study was done in Thailand, where I went a few months ago at the request of the AIDS Vaccine Advocacy Coalition. Mitchell Warren, director of AVAC, said he wanted an independent journalist to do an assessment of this historic project. His views were featured Monday on Huffington Post explaining the broader significance of the study.

Maybe Mitchell knew ahead of time that this was a controversial story, but I didn’t. I went to Thailand believing the Thai Prime-Boost vaccine trial was just a scientific success story. It was a success, in terms of its stunning results. Science progresses by baby steps and this first demonstration of immune protection is a success even if we do not yet have a usable vaccine.

But when I got to Thailand, I learned from Thai AIDS activists about some serious problems that could have derailed the whole thing — and may, if not recognized and resolved, impede future progress in AIDS vaccine research.

Basically, the Thai government didn’t really understand that for clinical research to succeed the community has to be convinced of its value and of the need to participate in these studies.

Three young woman volunteers in Thai AIDS vaccine study

This study enrolled 16,000 people, mostly young people, who had to come in to clinics repeatedly to get multiple vaccinations, get blood drawn and subject themselves to a lot of scrutiny. I met some of them; an impressive bunch of young people who recognize the urgent need for an effective AIDS vaccine. But many threatened to drop out during the trial due to lack of adequate community engagement.

Thailand is a democracy, but officials there still have a tendency to tell people what to do. That doesn’t work in proper clinical research and the Thai government discovered this. You can read all about it in AVAC’s report.

A side note: Was this journalism? I think so. Many of my traditional journalist friends tell me that because I was paid by AVAC, this was not journalism. Yet some of these are the same people who think running someone’s blog about their love of cats on the Seattle PI’s web site is something now called “citizen journalism.” I don’t know the answer to the question. I’ll let readers judge for themselves.


Gates adds Family Planning as Top Scientific Priority

When Bill Gates started dabbling at philanthropy back in the 1990s, he initially expressed great interest in population issues. It didn’t really work out. Long story. Let’s just say this was (and is) an especially sensitive issue. People with all sorts of agendas see bogey men coming out of the shadows if anyone ever so much as mentions population control.

But the Gateses are determined people. Perhaps a subtle, indirect approach to family planning will work this time.

Few noticed that a flurry of grant awards given out this week from the Gates Foundation signaled a shift in this direction, a renewed interest in supporting this original philanthropic goal. The Gates program that awarded the grants, previously devoted to fighting disease, for the first time funded research to fight unplanned pregnancy.

Andrew Serazin, Gates Foundation Explorations

“It is a little bit different,” acknowledged Andrew Serazin, a young scientist (and Rhodes Scholar) who helped launch the overall program, known as Grand Challenges Explorations.

On Tuesday, the Seattle philanthropy announced it had awarded its fourth round of 78 grants — $100,000 apiece in “seed money” for all sorts of far-fetched ideas.

The idea behind the Explorations program, Serazin explained, is to support scientific projects that show promise but seem, well, a bit wacky and unconventional – a cell phone app to diagnose malaria; a vaccine that gets into the skin through sweat; parasite-killing lasers; the use of ultrasound as a reversible male contraceptive … to name a few.

Adding “new contraception technologies” as a goal for Explorations fits into the foundation’s broader strategic plans for global health, Serazin said, but he acknowledged it is a bit of a departure from the program’s previous focus on fighting disease. “Issues in family health, like contraception, are becoming more of a focus for the Gates Foundation.”

The Explorations program itself was a shift from the original, larger-scale strategy of the Grand Challenges in Global Health program. Yes, we’re talking about two Gates programs called Grand Challenges. Stay with me here. The original one, with lots of money and big grants for grand projects, was launched by Gates at Davos in 2003 to try to direct more scientists to work on developing world problems.

Nearly 400 Gates Grand Challenges grants worldwide

But the original Grand Challenges was criticized for allegedly favoring Western scientists with big labs at big institutions. So the Explorations program was created to make it easier for smaller labs – and developing country scientists – to get funding for new ideas. So far, Serazin said, about 10 percent of the Explorations grants go to developing country scientists. He said they hope to do better on that score but it will always be the quality of the application – the idea – that counts more than who or where the application comes from.

As of Wednesday, the Grand Challenge’s web site didn’t list the new priority – contraception technologies – under the Goals pull-down menu. But it is in there if you go deeper to this link for more info. I assume the BMGF web masters, notified of this, will have fixed the glitch by the time most folks read this post.