A quiet revolution in global public health: The World Health Organization’s Prequalification of Medicines Programme

Journal of Public Health Policy
Volume 35, Issue 2 (May 2014)
http://www.palgrave-journals.com/jphp/journal/v35/n2/index.html

Original Article
A quiet revolution in global public health: The World Health Organization’s Prequalification of Medicines Programme
Ellen F M ‘t Hoena, Hans V Hogerzeilb, Jonathan D Quickc, and Hiiti B Sillod
aIndependent Consultant, Medicines Law and Policy, Paris, 75011, France
bUniversity of Groningen, 9713 AV Groningen, The Netherlands
cManagement Sciences for Health, Cambridge, Massachusetts 02139, USA
dTanzania Food and Drugs Authority (TFDA), P. O. Box 77150, Dar es Salaam, Tanzania
Abstract
Problems with the quality of medicines abound in countries where regulatory and legal oversight are weak, where medicines are unaffordable to most, and where the official supply often fails to reach patients. Quality is important to ensure effective treatment, to maintain patient and health-care worker confidence in treatment, and to prevent the development of resistance. In 2001, the WHO established the Prequalification of Medicines Programme in response to the need to select good-quality medicines for UN procurement. Member States of the WHO had requested its assistance in assessing the quality of low-cost generic medicines that were becoming increasingly available especially in treatments for HIV/AIDS. From a public health perspective, WHO PQP’s greatest achievement is improved quality of life-saving medicines used today by millions of people in developing countries. Prequalification has made it possible to believe that everyone in the world will have access to safe, effective, and affordable medicines. Yet despite its track record and recognized importance to health, funding for the programme remains uncertain.

The Lancet – May 10, 2014

The Lancet
May 10, 2014 Volume 383 Number 9929 p1609 – 1692
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Economic austerity, food poverty, and health
The Lancet
Preview
A century ago, the Scottish physician John Boyd-Orr saw first-hand how poverty and malnutrition lay at the heart of appalling health, especially among children in the slums of Glasgow, many of whom had rickets—the subject of a Seminar by Charlotte Elder and Nicholas Bishop in today’s Lancet, which details how this disease of the past is increasing in some parts of the UK. Later, Boyd-Orr’s vision and activism for improved population health through the delivery of equitable nutrition programmes helped establish the UK’s food policy during the austere years of World War 2 and beyond.

Human rights violations in Sri Lanka
The Lancet
Preview
5 years after the end of the 26 year long civil war, Sri Lanka has yet to secure its future stability. A World Report in this week’s issue describes torture, rape, detentions, and summary executions perpetrated by the Sri Lankan Government against people suspected of involvement in the defeated Liberation Tigers of Tamil Eelam (LTTE) and government critics. Evidence suggests a state-sanctioned campaign rather than isolated incidents and, because of a culture of impunity for the perpetrators (mainly Sri Lankan army, security forces, police officers) and fear of reporting by victims, the true scale of abuse is unknown.

Comment
Influenza vaccine in pregnancy: policy and research strategies
Preview
Mark C Steinhoff, Noni MacDonald, Dina Pfeifer, Louis J Muglia
Influenza vaccination in pregnancy reduces maternal illness, improves fetal outcomes, prevents influenza in the infant up to 6 months of age, and potentially improves long-term adult outcomes for the infant (table 1). These effects on four life stages are not widely known by policy makers, and we provide a summary with recommendations for policy and needed research.

Data, children’s rights, and the new development agenda
Preview
Tessa Wardlaw, Abid Aslam, David Anthony, Céline Little, Claudia Cappa
The coming year will mark the 25th anniversary of the Convention on the Rights of the Child1 and the culmination of the Millennium Development Goals (MDGs). As people look to the future of human wellbeing, data will play an increasingly important part in identifying inequities and in informing and evaluating interventions so these are responsive and accountable to the world’s 2•2 billion children, especially those so far excluded from the benefits of development.

Worldwide prevalence of non-partner sexual violence: a systematic review
Prof Naeemah Abrahams PhD a, Karen Devries PhD b, Prof Charlotte Watts PhD b, Christina Pallitto PhD c, Prof Max Petzold PhD d, Simukai Shamu PhD a e, Claudia García-Moreno MD c
Summary
Background
Several highly publicised rapes and murders of young women in India and South Africa have focused international attention on sexual violence. These cases are extremes of the wider phenomenon of sexual violence against women, but the true extent is poorly quantified. We did a systematic review to estimate prevalence.
Methods
We searched for articles published from Jan 1, 1998, to Dec 31, 2011, and manually search reference lists and contacted experts to identify population-based data on the prevalence of women’s reported experiences of sexual violence from age 15 years onwards, by anyone except intimate partners. We used random effects meta-regression to calculate adjusted and unadjusted prevalence for regions, which we weighted by population size to calculate the worldwide estimate.
Findings
We identified 7231 studies from which we obtained 412 estimates covering 56 countries. In 2010 7•2% (95% CI 5•2—9•1) of women worldwide had ever experienced non-partner sexual violence. The highest estimates were in sub-Saharan Africa, central (21%, 95% CI 4•5—37•5) and sub-Saharan Africa, southern (17•4%, 11•4—23•3). The lowest prevalence was for Asia, south (3•3%, 0—8•3). Limited data were available from sub-Saharan Africa, central, North Africa/Middle East, Europe, eastern, and Asia Pacific, high income.
Interpretation
Sexual violence against women is common worldwide, with endemic levels seen in some areas, although large variations between settings need to be interpreted with caution because of differences in data availability and levels of disclosure. Nevertheless, our findings indicate a pressing health and human rights concern.
Funding
South African Medical Research Council, Sigrid Rausing Trust, WHO.

Seminar
Rickets
Charlotte Jane Elder, Nicholas J Bishop
Rickets, historically referred to as “the English disease”, is common worldwide. Absence of phosphate at the growth plate and mineralising bone surfaces due to inadequate vitamin D supply either from sunlight exposure or diet is the main cause. Inherited disorders causing hypophosphataemia have shown the intricacies of phosphate metabolism. Present advice about the provision of vitamin D to young infants needs to be clarified; the existing guidance is fragmentary and contradictory, and will not help to eradicate the disease.

Viewpoint
Global Health Service Partnership: building health professional leadership
Vanessa B Kerry, Fitzhugh Mullan
Shortages of nurses, doctors, and health professionals in resource-poor countries challenge the success of many health initiatives and health-system strengthening. In many of these countries, medical and nursing schools are few and severely short of faculty, limiting their capacity to scale-up and increase the number of skilled graduates and professionals to support the health system. In an effort to address this problem, the US Peace Corps has partnered with Seed Global Health, a non-profit organisation with expertise in education for health professions, to launch an innovative new programme that sends faculty to medical and nursing schools in under-resourced settings.

Parasite Burden and Severity of Malaria in Tanzanian Children

New England Journal of Medicine
May 8, 2014 Vol. 370 No. 19
http://www.nejm.org/toc/nejm/medical-journal

Original Article
Parasite Burden and Severity of Malaria in Tanzanian Children
Bronner P. Gonçalves, M.D., Chiung-Yu Huang, Ph.D., Robert Morrison, M.Sc., Sarah Holte, Ph.D., Edward Kabyemela, M.D., Ph.D., D. Rebecca Prevots, Ph.D., Michal Fried, Ph.D., and Patrick E. Duffy, M.D.
DOI: 10.1056/NEJMoa1303944
Abstract
Background
Severe Plasmodium falciparum malaria is a major cause of death in children. The contribution of the parasite burden to the pathogenesis of severe malaria has been controversial.

Methods
We documented P. falciparum infection and disease in Tanzanian children followed from birth for an average of 2 years and for as long as 4 years.

Results
Of the 882 children in our study, 102 had severe malaria, but only 3 had more than two episodes. More than half of first episodes of severe malaria occurred after a second infection. Although parasite levels were higher on average when children had severe rather than mild disease, most children (67 of 102) had high-density infection (>2500 parasites per 200 white cells) with only mild symptoms before severe malaria, after severe malaria, or both. The incidence of severe malaria decreased considerably after infancy, whereas the incidence of high-density infection was similar among all age groups. Infections before and after episodes of severe malaria were associated with similar parasite densities. Nonuse of bed nets, placental malaria at the time of a woman’s second or subsequent delivery, high-transmission season, and absence of the sickle cell trait increased severe-malaria risk and parasite density during infections.

Conclusions
Resistance to severe malaria was not acquired after one or two mild infections. Although the parasite burden was higher on average during episodes of severe malaria, a high parasite burden was often insufficient to cause severe malaria even in children who later were susceptible. The diverging rates of severe disease and high-density infection after infancy, as well as the similar parasite burdens before and after severe malaria, indicate that naturally acquired resistance to severe malaria is not explained by improved control of parasite density. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

Glaucomics: A Call for Systems Diagnostics for 21st Century Ophthalmology and Personalized Visual Health

OMICS: A Journal of Integrative Biology
May 2014, 18(5)
http://online.liebertpub.com/toc/omi/18/5

Glaucomics: A Call for Systems Diagnostics for 21st Century Ophthalmology and Personalized Visual Health
Online Ahead of Print: April 14, 2014
Full Text PDF (168.6 KB)
Author information
Kıvanç Güngör,1 Peter J. Hotez,2,3,4 Vural Özdemir,5,6,7,8,9 and Şükrü Aynacıoğlu10
1Department of Ophthalmology, Faculty of Medicine, University Hospital, Gaziantep University, Gaziantep, Turkey.
2National School of Tropical Medicine and Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas.
3Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development, Houston, Texas.
4James A. Baker III Institute for Public Policy, Rice University, Houston, Texas.
5Office of the President, Global Technology and Innovation Policy, Gaziantep University, Gaziantep, Turkey.
6School of Journalism, Faculty of Communications, Gaziantep University, Gaziantep, Turkey.
7Department of Industrial Engineering, Faculty of Engineering, and the Technology Transfer Office (TARGET-TTO), Gaziantep University, Gaziantep, Turkey.
8School of Biotechnology, Amrita University, Amritapuri Campus, Kerala, India.
9Data-Enabled Life Sciences Alliance (DELSA Global), Seattle, Washington.
10Department of Medical Pharmacology, Faculty of Medicine, University Hospital, Gaziantep University, Gaziantep, Turkey.
ABSTRACT
This article analyzes and theorizes the current knowledge silos at the intersection of omics science, ophthalmology, personalized medicine, and global visual health. Visual disorders represent one of the largest health care expenditures in the United States, costing $139 billion per year. In middle-income and industrialized countries, glaucoma is a World Health Organization priority category eye disease, known for difficulties in its early diagnosis, chronic progressive nature, and large person-to-person differences in drug efficacy and safety. A complex disease, glaucoma is best conceptualized as a syndrome displaying an ostensibly common clinical end-point, but with vastly heterogeneous molecular underpinnings and host–environment interactions. About 12% of all global blindness is attributable to glaucoma. Glaucomics is a term that we coin here so as to introduce omics science and systems diagnostics to ophthalmology, a field that can benefit enormously from personalized medicine, and which has sadly lagged behind in systems diagnostics compared to fields such as oncology. We define glaucomics as the integrated use of multi-omics and systems science approaches towards rational discovery, development, and tandem applications of diagnostics and therapeutics, for glaucoma specifically, and for personalized visual health, more broadly. We propose that glaucoma is one of the neglected lowest hanging fruits and actionable targets for omics and systems diagnostics in 21st century ophthalmology for the salient reasons we describe here. Additionally, we offer an analysis on two of the most pertinent neglected tropical diseases (NTDs), trachoma and river blindness, which continue to plague visual health in developing countries. We conclude with a call for research on omics applications in glaucoma and personalized visual health.

A Household-based Study of Acute Viral Respiratory Illnesses in Andean Children

The Pediatric Infectious Disease Journal
May 2014 – Volume 33 – Issue 5 pp: 431-548,e121-e134
http://journals.lww.com/pidj/pages/currenttoc.aspx

A Household-based Study of Acute Viral Respiratory Illnesses in Andean Children
Budge, Philip J.; Griffin, Marie R.; Edwards, Kathryn M.; More
Abstract
Background: Few community studies have measured the incidence, severity and etiology of acute respiratory illness (ARI) among children living at high-altitude in remote rural settings.
Methods: We conducted active, household-based ARI surveillance among children aged ❤ years in rural highland communities of San Marcos, Cajamarca, Peru from May 2009 through September 2011 (RESPIRA-PERU study). ARI (defined by fever or cough) were considered lower respiratory tract infections if tachypnea, wheezing, grunting, stridor or retractions were present. Nasal swabs collected during ARI episodes were tested for respiratory viruses by real-time, reverse-transcriptase polymerase chain reaction. ARI incidence was calculated using Poisson regression.
Results: During 755.1 child-years of observation among 892 children in 58 communities, 4475 ARI were observed, yielding an adjusted incidence of 6.2 ARI/child-year (95% confidence interval: 5.9–6.5). Families sought medical care for 24% of ARI, 4% were classified as lower respiratory tract infections and 1% led to hospitalization. Of 5 deaths among cohort children, 2 were attributed to ARI. One or more respiratory viruses were detected in 67% of 3957 samples collected. Virus-specific incidence rates per 100 child-years were: rhinovirus, 236; adenovirus, 73; parainfluenza virus, 46; influenza, 37; respiratory syncytial virus, 30 and human metapneumovirus, 17. Respiratory syncytial virus, metapneumovirus and parainfluenza virus 1–3 comprised a disproportionate share of lower respiratory tract infections compared with other etiologies.
Conclusions: In this high-altitude rural setting with low-population density, ARI in young children were common, frequently severe and associated with a number of different respiratory viruses. Effective strategies for prevention and control of these infections are needed.

Natural Hazards in a Changing World: A Case for Ecosystem-Based Management

PLoS One
[Accessed 10 May 2014]
http://www.plosone.org/

Research Article
Natural Hazards in a Changing World: A Case for Ecosystem-Based Management
Jeanne L. Nel mail, David C. Le Maitre, Deon C. Nel, Belinda Reyers, Sally Archibald, Brian W. van Wilgen, Greg G. Forsyth, Andre K. Theron, Patrick J. O’Farrell, Jean-Marc Mwenge Kahinda,
Francois A. Engelbrecht, Evison Kapangaziwiri, Lara van Niekerk, Laurie Barwell
Published: May 07, 2014
DOI: 10.1371/journal.pone.0095942
Abstract
Communities worldwide are increasingly affected by natural hazards such as floods, droughts, wildfires and storm-waves. However, the causes of these increases remain underexplored, often attributed to climate changes or changes in the patterns of human exposure. This paper aims to quantify the effect of climate change, as well as land cover change, on a suite of natural hazards. Changes to four natural hazards (floods, droughts, wildfires and storm-waves) were investigated through scenario-based models using land cover and climate change drivers as inputs. Findings showed that human-induced land cover changes are likely to increase natural hazards, in some cases quite substantially. Of the drivers explored, the uncontrolled spread of invasive alien trees was estimated to halve the monthly flows experienced during extremely dry periods, and also to double fire intensities. Changes to plantation forestry management shifted the 1:100 year flood event to a 1:80 year return period in the most extreme scenario. Severe 1:100 year storm-waves were estimated to occur on an annual basis with only modest human-induced coastal hardening, predominantly from removal of coastal foredunes and infrastructure development. This study suggests that through appropriate land use management (e.g. clearing invasive alien trees, re-vegetating clear-felled forests, and restoring coastal foredunes), it would be possible to reduce the impacts of natural hazards to a large degree. It also highlights the value of intact and well-managed landscapes and their role in reducing the probabilities and impacts of extreme climate events.

Yellow Fever in Africa: Estimating the Burden of Disease and Impact of Mass Vaccination from Outbreak and Serological Data

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 10 May 2014)

Research Article
Yellow Fever in Africa: Estimating the Burden of Disease and Impact of Mass Vaccination from Outbreak and Serological Data
Tini Garske, Maria D. Van Kerkhove, Sergio Yactayo, Olivier Ronveaux, Rosamund F. Lewis, J. Erin Staples, William Perea, Neil M. Ferguson mail, for the Yellow Fever Expert Committee
Published: May 06, 2014
DOI: 10.1371/journal.pmed.1001638
Abstract
Background
Yellow fever is a vector-borne disease affecting humans and non-human primates in tropical areas of Africa and South America. While eradication is not feasible due to the wildlife reservoir, large scale vaccination activities in Africa during the 1940s to 1960s reduced yellow fever incidence for several decades. However, after a period of low vaccination coverage, yellow fever has resurged in the continent. Since 2006 there has been substantial funding for large preventive mass vaccination campaigns in the most affected countries in Africa to curb the rising burden of disease and control future outbreaks. Contemporary estimates of the yellow fever disease burden are lacking, and the present study aimed to update the previous estimates on the basis of more recent yellow fever occurrence data and improved estimation methods.
Methods and Findings
Generalised linear regression models were fitted to a dataset of the locations of yellow fever outbreaks within the last 25 years to estimate the probability of outbreak reports across the endemic zone. Environmental variables and indicators for the surveillance quality in the affected countries were used as covariates. By comparing probabilities of outbreak reports estimated in the regression with the force of infection estimated for a limited set of locations for which serological surveys were available, the detection probability per case and the force of infection were estimated across the endemic zone.
The yellow fever burden in Africa was estimated for the year 2013 as 130,000 (95% CI 51,000–380,000) cases with fever and jaundice or haemorrhage including 78,000 (95% CI 19,000–180,000) deaths, taking into account the current level of vaccination coverage. The impact of the recent mass vaccination campaigns was assessed by evaluating the difference between the estimates obtained for the current vaccination coverage and for a hypothetical scenario excluding these vaccination campaigns. Vaccination campaigns were estimated to have reduced the number of cases and deaths by 27% (95% CI 22%–31%) across the region, achieving up to an 82% reduction in countries targeted by these campaigns. A limitation of our study is the high level of uncertainty in our estimates arising from the sparseness of data available from both surveillance and serological surveys.
Conclusions
With the estimation method presented here, spatial estimates of transmission intensity can be combined with vaccination coverage levels to evaluate the impact of past or proposed vaccination campaigns, thereby helping to allocate resources efficiently for yellow fever control. This method has been used by the Global Alliance for Vaccines and Immunization (GAVI Alliance) to estimate the potential impact of future vaccination campaigns.
Please see later in the article for the Editors’ Summary

Editors’ Summary
Background
Yellow fever is a flavivirus infection that is transmitted to people and to non-human primates through the bites of infected mosquitoes. This serious viral disease affects people living in and visiting tropical regions of Africa and Central and South America. In rural areas next to forests, the virus typically causes sporadic cases or even small-scale epidemics (outbreaks) but, if it is introduced into urban areas, it can cause large explosive epidemics that are hard to control. Although many people who contract yellow fever do not develop any symptoms, some have mild flu-like symptoms, and others develop a high fever with jaundice (yellowing of the skin and eyes) or hemorrhaging (bleeding) from the mouth, nose, eyes, or stomach. Half of patients who develop these severe symptoms die. Because of this wide spectrum of symptoms, which overlap with those of other tropical diseases, it is hard to diagnose yellow fever from symptoms alone. However, serological tests that detect antibodies to the virus in the blood can help in diagnosis. There is no specific antiviral treatment for yellow fever but its symptoms can be treated.
Why Was This Study Done?
Eradication of yellow fever is not feasible because of the wildlife reservoir for the virus but there is a safe, affordable, and highly effective vaccine against the disease. Large-scale vaccination efforts during the 1940s, 1950s, and 1960s reduced the yellow fever burden for several decades but, after a period of low vaccination coverage, the number of cases rebounded. In 2005, the Yellow Fever Initiative—a collaboration between the World Health Organization (WHO) and the United Nations Children Fund supported by the Global Alliance for Vaccines and Immunization (GAVI Alliance)—was launched to create a vaccine stockpile for use in epidemics and to implement preventive mass vaccination campaigns in the 12 most affected countries in West Africa. Campaigns have now been implemented in all these countries except Nigeria. However, without an estimate of the current yellow fever burden, it is hard to determine the impact of these campaigns. Here, the researchers use recent yellow fever occurrence data, serological survey data, and improved estimation methods to update estimates of the yellow fever burden and to determine the impact of mass vaccination on this burden.
What Did the Researchers Do and Find?
The researchers developed a generalized linear statistical model and used data on the locations where yellow fever was reported between 1987 and 2011 in Africa, force of infection estimates for a limited set of locations where serological surveys were available (the force of infection is the rate at which susceptible individuals acquire a disease), data on vaccination coverage, and demographic and environmental data for their calculations. They estimate that about 130,000 yellow fever cases with fever and jaundice or hemorrhage occurred in Africa in 2013 and that about 78,000 people died from the disease. By evaluating the difference between this estimate, which takes into account the current vaccination coverage, and a hypothetical scenario that excluded the mass vaccination campaigns, the researchers estimate that these campaigns have reduced the burden of disease by 27% across Africa and by up to 82% in the countries targeted by the campaigns (an overall reduction of 57% in the 12 targeted countries).
What Do These Findings Mean?
These findings provide a contemporary estimate of the burden of yellow fever in Africa. This estimate is broadly similar to the historic estimate of 200,000 cases and 30,000 deaths annually, which was based on serological survey data obtained from children in Nigeria between 1945 and 1971. Notably, both disease burden estimates are several hundred-fold higher than the average number of yellow fever cases reported annually to WHO, which reflects the difficulties associated with the diagnosis of yellow fever. Importantly, these findings also provide an estimate of the impact of recent mass vaccination campaigns. All these findings have a high level of uncertainty, however, because of the lack of data from both surveillance and serological surveys. Other assumptions incorporated in the researchers’ model may also affect the accuracy of these findings. Nevertheless, the framework for burden estimation developed here provides essential new information about the yellow fever burden and the impact of vaccination campaigns and should help the partners of the Yellow Fever Initiative estimate the potential impact of future vaccination campaigns and ensure the efficient allocation of resources for yellow fever control.

Fecal Contamination of Drinking-Water in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 10 May 2014)

Research Article
Fecal Contamination of Drinking-Water in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis
Robert Bain mail, Ryan Cronk, Jim Wright, Hong Yang, Tom Slaymaker, Jamie Bartram mail
Published: May 06, 2014
DOI: 10.1371/journal.pmed.1001644
Abstract
Background
Access to safe drinking-water is a fundamental requirement for good health and is also a human right. Global access to safe drinking-water is monitored by WHO and UNICEF using as an indicator “use of an improved source,” which does not account for water quality measurements. Our objectives were to determine whether water from “improved” sources is less likely to contain fecal contamination than “unimproved” sources and to assess the extent to which contamination varies by source type and setting.
Methods and Findings
Studies in Chinese, English, French, Portuguese, and Spanish were identified from online databases, including PubMed and Web of Science, and grey literature. Studies in low- and middle-income countries published between 1990 and August 2013 that assessed drinking-water for the presence of Escherichia coli or thermotolerant coliforms (TTC) were included provided they associated results with a particular source type. In total 319 studies were included, reporting on 96,737 water samples. The odds of contamination within a given study were considerably lower for “improved” sources than “unimproved” sources (odds ratio [OR] = 0.15 [0.10–0.21], I2 = 80.3% [72.9–85.6]). However over a quarter of samples from improved sources contained fecal contamination in 38% of 191 studies. Water sources in low-income countries (OR = 2.37 [1.52–3.71]; p<0.001) and rural areas (OR = 2.37 [1.47–3.81] p<0.001) were more likely to be contaminated. Studies rarely reported stored water quality or sanitary risks and few achieved robust random selection. Safety may be overestimated due to infrequent water sampling and deterioration in quality prior to consumption.
Conclusion
Access to an “improved source” provides a measure of sanitary protection but does not ensure water is free of fecal contamination nor is it consistent between source types or settings. International estimates therefore greatly overstate use of safe drinking-water and do not fully reflect disparities in access. An enhanced monitoring strategy would combine indicators of sanitary protection with measures of water quality.
Please see later in the article for the Editors’ Summary

Editors’ Summary
Background
Access to clean water is fundamental to human health. The importance of water to human health and wellbeing is encapsulated in the Human Right to Water, reaffirmed by the United Nations in 2010, which entitles everyone to “sufficient, safe, acceptable and physically accessible and affordable water for personal and domestic uses.” A step towards such universal access to water is Millennium Development Goal (MDG) target 7c that aims to halve the proportion of the population without sustainable access to safe drinking-water. One of the indicators to help monitor progress towards this target used by the Joint Monitoring Project (JMP—an initiative of the World Health Organization and UNICEF) is “use of an improved source.” Improved sources include piped water into a dwelling, yard, or plot, or a standpipe, borehole, and protected dug well. Unimproved sources are those that do not protect water from outside contamination, such as unprotected wells, unprotected springs, and surface waters.
Why Was This Study Done?
While this simple categorization may reflect established principles of sanitary protection, this indicator has been criticized for not adequately reflecting safety, suggesting that reported access to safe water might be overestimated by billions of people by not accounting for microbial water safety or more fully accounting for sanitary status. So the researchers conducted a systematic review and meta-analysis to investigate whether water from improved sources is less likely to exceed health-based guidelines for microbial water quality than water from unimproved sources and to what extent microbial contamination varies between source types, between countries, and between rural and urban areas.
What Did the Researchers Do and Find?
The researchers comprehensively searched the literature to find appropriate studies that investigated fecal contamination of all types of drinking-water in low and middle-income countries. The researchers included studies that contained extractable data on Escherichia coli or thermotolerant coliform (the WHO recommended indicators of fecal contamination) collected by appropriate techniques. The authors also assessed studies for bias and quality and used a statistical method (random effects meta-regression) to investigate risk factors and settings where fecal contamination of water sources was most common.
Using these methods, the authors included 319 studies reporting on 96,737 water samples. Most studies were from sub-Saharan Africa, southern Asia, or Latin America and the Caribbean. They found that overall, the odds (chance) of contamination within a given study were considerably lower for “improved” sources than “unimproved” sources (odds ratio = 0.15). However, in 38% of 191 studies, over a quarter of samples from improved sources contained fecal contamination. In particular, protected dug wells were rarely free of fecal contamination. The researchers also found that water sources in low-income countries, and rural areas were more likely to be contaminated (both had odds ratios of 2.37).
What Do These Findings Mean?
These findings show that while water from improved sources is less likely to contain fecal contamination than unimproved sources, they are not consistently safe. This study also provides evidence that by equating “improved” with “safe,” the number of people with access to a safe water source has been greatly overstated, and suggests that a large number and proportion of the world’s population use unsafe water. As studies rarely reported stored water quality or sanitary risks, the accuracy of these findings may be limited. Nevertheless, the findings from this study suggest that the Global Burden of Disease 2010 may greatly underestimate diarrheal disease burden by assuming zero risk from improved water sources and that new indicators are needed to assess access to safe drinking water. Therefore, greater use should be made of other measures, such as sanitary inspections, to provide a complementary means of assessing safety and to help identify corrective actions to prevent water contamination.

Governance, agricultural intensification, and land sparing in tropical South America

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 10 May 2014)

Governance, agricultural intensification, and land sparing in tropical South America
Michele Graziano Ceddiaa,1, Nicholas Oliver Bardsleyb, Sergio Gomez-y-Palomac, and Sabine Sedlaceka
Author Affiliations
Edited by B. L. Turner, Arizona State University, Tempe, AZ, and approved April 11, 2014 (received for review September 23, 2013)
Abstract
Significance
Tropical South America has forest resources of global significance but exhibits a relatively high rate of deforestation. As agricultural expansion remains the most important cause of forest loss and degradation there, it is important to understand its main drivers. In this paper we address two important questions: How do the quality of governance and agricultural intensification combine to impact the spatial expansion of agriculture? Which aspects of governance are more likely to ensure that agricultural intensification allows sparing land for nature? By distinguishing between conventional and environmental dimensions of governance (which includes also the establishment of protected areas), we investigate which of these two aspects, by interacting with the process of agricultural intensification, is likely to promote land sparing.
Abstract
In this paper we address two topical questions: How do the quality of governance and agricultural intensification impact on spatial expansion of agriculture? Which aspects of governance are more likely to ensure that agricultural intensification allows sparing land for nature? Using data from the Food and Agriculture Organization, the World Bank, the World Database on Protected Areas, and the Yale Center for Environmental Law and Policy, we estimate a panel data model for six South American countries and quantify the effects of major determinants of agricultural land expansion, including various dimensions of governance, over the period 1970–2006. The results indicate that the effect of agricultural intensification on agricultural expansion is conditional on the quality and type of governance. When considering conventional aspects of governance, agricultural intensification leads to an expansion of agricultural area when governance scores are high. When looking specifically at environmental aspects of governance, intensification leads to a spatial contraction of agriculture when governance scores are high, signaling a sustainable intensification process.

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH – March 2014 Vol. 35, No. 3

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH
March 2014 Vol. 35, No. 3
http://www.paho.org/journal/index.php?option=com_content&view=article&id=141&Itemid=235&lang=en

Child malnutrition and prenatal care: evidence from three Latin American countries [Desnutrición infantil y atención prenatal: datos probatorios de tres países latinoamericanos]
Nohora Forero-Ramirez, Luis F. Gamboa, Arjun Bedi, and Robert Sparrow

“Peri-border” health care programs: the Ecuador—Peru experience [Programas de atención de salud en zonas fronterizas: la experiencia de Ecuador y Perú]
Gianluca Cafagna, Eduardo Missoni, and Rosa Luz Benites de Beingolea

The Limits of Medical Interventions for the Elimination of Preventable Blindness

Tropical Medicine and Health
Vol. 42(2014) No. 1
https://www.jstage.jst.go.jp/browse/tmh/42/1/_contents

The Limits of Medical Interventions for the Elimination of Preventable Blindness
Pablo Goldschmidt, Ellen Einterz
Released: March 18, 2014
Abstract
Background: Health authorities are working toward the global elimination of trachoma by the year 2020 with actions focused on the World Health Organization SAFE strategy (surgery of trichiasis, antibiotics, face washing and environmental changes) with emphasis on hygienist approaches for education. Objectives: The present survey was performed to assess the sustainability of the SAFE strategy 3 years after trachoma was eliminated from 6 villages. Methods: In February 2013 a rapid trachoma assessment was conducted in 6 villages of Kolofata’s district, Extreme north Region, Cameroon, where trachoma was eliminated in 2010. A total of 300 children (1–10 years) from 6 villages were examined by trained staff. Results: The prevalence of active trachoma (children aged > 1 and < 10 years) in 2013 was 15% and in at least 25% was observed absence of face washing and flies in their eyes and nose. Income level, quality of roads, hygiene, and illiteracy were similar in all the villages; they did not change between 2010 and 2013 and could not be analyzed as independent risk factors. Discussion: The heterogeneity of methods described for clinical trials makes it inappropriate to conduct meta-analysis for the present and for other SAFE-related trials. The results obtained after implementation the SAFE strategy (recurrence) reveal that the causes (infectious agents and dirtiness) and effects (illness) were not connected by illiterate people living under conditions of extreme poverty. So far, antibiotics, surgery and hygiene education are insufficient for the sustainability of trachoma elimination and highlight that hypothetic-deductive processes seem not operational after implementing the awareness campaigns. Trachoma recurrence detected in 2013 in sedentary populations of Kolofata receiving efficacious treatments against Chlamydia sp. suggest that the elimination goals will be delayed if strategies are limited to medical actions. Restricting efforts to repeated pharmacological and surgical interventions for people infected with susceptible bacteria could be understood as the hidden side of a passive attitude toward basic education actions.

From Google Scholar+ [to 10 May 2014]

From Google Scholar+ [to 10 May 2014]
Selected content from beyond the journals and sources covered above, aggregated from a range of Google Scholar monitoring algorithms and other monitoring strategies.

Refugees, Food Security, and Resilience in Host Communities: Transitioning from Humanitarian Assistance to Development in Protracted Refugee Situations
Mabiso, Athur; Maystadt, Jean-François; Vandercasteelen, Joachim; Hirvonen, Kalle
2020 Resilience Conference Paper 2 –
Building Resilience for Food and Nutrition Security – May 15-17, 2014 – Addis Ababa, Ethiopia
An emerging literature shows how the mass arrival of refugees induces both short- and long-term consequences to hosting countries. The main contribution of this paper is to conduct a selective review of this literature from a food-security and resilience perspective. First, the paper identifies a number of direct and indirect food-security consequences of hosting refugees. It provides a conceptual framework for discussing these various channels through which refugee inflows influence food security in the hosting countries. In the short run, violence, environmental degradation, and disease propagation are risks, with indirect implications for food security, while the long-run channels include changes in infrastructure, trade, and labor markets, as well as competition for resources. Second, the literature review finds that the impact of large-scale influxes of refugees on host communities and on their food security is unequally distributed among the local population. Locals with better ex ante access to resources, education, and political connections are more likely to benefit as a result of refugee inflows, while the disadvantaged become increasingly vulnerable. In the short run, humanitarian aid (for example, food aid) is the usual global response, with varying impact on the food security and resilience of host countries. Effectiveness of the humanitarian aid depends, however, on its nature and on the country context, both of which need careful consideration. In the long run, humanitarian aid should pave the way for development. In particular, investments such as improving road infrastructure and fostering trade with refugees’ countries of origin are strategies worth exploring for enhancing resilience and transitioning toward development. Finally, we stress the need for more research on the consequences of refugees and alternative polices on food security and resilience in host communities.
2020resilienceconfpaper02.pdf(1.9MB)

Brown Journal of World Affairs
Spring/Summer 2014 • volume xx, issue 1i
The Changing Face of Humanitarian Crises
FM Burkle Jr, G Martone, PG Greenough
[Initial text]
The scale and cadence of crises that demand international humanitarian response is increasing. The cumulative frequency and severity of climate change on large populations, rapid and unsustainable urbanization, decreasing biodi¬versity, and the impending realities of resource scarcities and the armed conflicts they might catalyze are only some of the challenges that loom ahead. It is ironic that while human civilization today possesses the most advanced technologies, global prosperity, and abundance, we face the greatest absolute number of people lacking access to clean water, food, shelter, and basic healthcare.1 Worldwide standards of living show that health status, life expectancy, child survival, de¬mocratization and political participation, literacy and matriculation, and gender equality are at their best while the incidence of armed conflicts is at the lowest level in human history.2 Yet despite the improvement in global standards, the shortcomings in worldwide accessibility to basic needs make the preparation of the humanitarian complex even more urgent in the face of emerging crises.
Critical masses of evidence indicate that the frequency, duration, and intensity of extreme events affecting populations are on the rise.3 These “mega-catastrophes” are attributable to a number of converging megatrends, defined here as global, sustained, and often slow to form forces that will define our future. An increasing number of droughts on every continent; rapid and unsus¬tainable urbanization plagued by insufficient public health infrastructure…

World Journal of Surgery
Volume 38, Issue 6, June 2014
http://link.springer.com/journal/268/38/6/page/1
The Extent of Soft Tissue and Musculoskeletal Injuries after Earthquakes; Describing a Role for Reconstructive Surgeons in an Emergency Response
A. J. P. Clover, B. Jemec, A. D. Redmond
Abstract
Background
Earthquakes are the leading cause of natural disaster-related mortality and morbidity. Soft tissue and musculoskeletal injuries are the predominant type of injury seen after these events and a major reason for admission to hospital. Open fractures are relatively common; however, they are resource-intense to manage. Appropriate management is important in minimising amputation rates and preserving function. This review describes the pattern of musculoskeletal and soft-tissue injuries seen after earthquakes and explores the manpower and resource implications involved in their management.
Methods
A Medline search was performed, including terms “injury pattern” and “earthquake,” “epidemiology injuries” and “earthquakes,” “plastic surgery,” “reconstructive surgery,” “limb salvage” and “earthquake.” Papers published between December 1992 and December 2012 were included, with no initial language restriction.
Results
Limb injuries are the commonest injuries seen accounting for 60 % of all injuries, with fractures in more than 50 % of those admitted to hospital, with between 8 and 13 % of these fractures open. After the first few days and once the immediate lifesaving phase is over, the management of these musculoskeletal and soft-tissue injuries are the commonest procedures required.
Conclusions
Due to the predominance of soft-tissue and musculoskeletal injuries, plastic surgeons as specialists in soft-tissue reconstruction should be mobilised in the early stages of a disaster response as part of a multidisciplinary team with a focus on limb salvage.

Nonprofit and Voluntary Sector Quarterly
April 2014; 43 (2)
http://nvs.sagepub.com/content/current
Nonprofit–Public Collaborations Understanding Governance Dynamics
Chris Cornforth1, John Paul Hayes1, Siv Vangen1
1Open University Business School, Milton Keynes, UK
Chris Cornforth, Open University Business School, Walton Hall, Milton Keynes, MK7 6AA, UK.
Abstract
As many of the challenges facing society are too complex to be addressed by single organizations working alone, nonprofit organizations are increasingly working in collaboration with public authorities. The governance of nonprofit–public collaborations is important for their effectiveness, yet it remains poorly understood. Drawing on case study research, this article examines and develops an extant conceptual model developed by Takahashi and Smutny that seeks to explain the formation and demise of nonprofit collaborations in terms of “collaborative windows” and the inability to adapt initial governance structures. The research finds that while initial governance structures are an important constraint on development, they can be adapted and changed. It also suggests that the development of collaborations is not only influenced by changes in the collaborative window but also by how key actors in the collaboration respond to important internal tensions.

UN Secretary-General Ban Ki-moon reappoints Anthony Lake Executive Director of UNICEF

UN Secretary-General Ban Ki-moon reappoints Anthony Lake Executive Director of UNICEF
[Full text]
UNITED NATIONS, 2 May 2014 – Following consultations with the UNICEF Executive Board, the Secretary-General is pleased to reappoint Mr. Anthony Lake as Executive Director of UNICEF. The Secretary-General noted his appreciation of UNICEF’s progress in effective management for results, especially for the most disadvantaged children.

UNESCO Report: Reading in the mobile era – A study of mobile reading in developing countries

UNESCO Report: Reading in the mobile era – A study of mobile reading in developing countries
UNESCO, Nokia and Worldreader
2014 86 pages pdf: http://unesdoc.unesco.org/images/0022/002274/227436e.pdf
ISBN 978-92-3-100023-2

Millions of people do not read for one reason: they do not have access to text. But today mobile phones and cellular networks are transforming a scarce resource into an abundant one.
THE CURRENT STUDY
To better understand how technology can facilitate reading, UNESCO, in partnership with Nokia and Worldreader, developed a survey to learn about the habits, preferences and attitudes of mobile readers. Specifically, the survey was designed to discover who reads on mobile phones and why; if and how mobile reading changes reading habits and attitudes towards reading; what people read and want to read on their mobile phones; what the central barriers are to mobile reading; and what factors predict people’s intentions to read and keep reading on mobile phones.

The survey was completed by over 4,000 people in seven countries (Ethiopia, Ghana, India, Kenya, Nigeria, Pakistan and Zimbabwe) and supported by qualitative interviews with numerous respondents. The depth and breadth of data collection make this study the most comprehensive investigation of mobile reading in developing countries to date.

The findings are significant. Among other conclusions, UNESCO has learned that people read more when they read on mobile devices, that they enjoy reading more, and that people commonly read books and stories to children from mobile devices. The study shows that mobile reading represents a promising, if still underutilized, pathway to text. It is not hyperbole to suggest that if every person on the planet understood that his or her mobile phone could be transformed – easily and cheaply – into a library brimming with books, access to text would cease to be such a daunting hurdle to literacy. An estimated 6.9 billion mobile subscriptions would provide a direct pipeline to digital books (GSMA, 2014).

The current study – by breaking down who reads on mobile devices and for what reasons – is a roadmap for governments, organizations and individuals who wish to help people better leverage mobile technology for reading. Knowing, for instance, that younger people are more likely to read on a mobile device than older people is instructive, as it indicates that older people will likely require significantly more guidance as they discover how to turn a device they may already own into a gateway to text. The study also exposes governments to the idea that digital libraries and mobile reading initiatives may have more impact than traditional, paper-based interventions.

In essence, the study shines light on a new strategy to bring text to the people who need it most.

It is important to qualify that access to books does not, by any means, assure or necessarily even promote literacy. Parachuting books to people – whether through mobile phones or other
mediums – is exactly that: dropping books and leaving. Deriving meaning from text is a deeply complex act that does not happen through exposure alone. People who think that literacy can be achieved by mere proximity to reading material should be reminded that it took the most talented linguists on the planet over a thousand years to decipher Egyptian hieroglyphs. The challenge wasn’t access to hieroglyphs; it was figuring out what they communicated. Humans may have a language instinct, but there is nothing natural about reading; it is a skill that needs to be taught and practiced, again and again and again. It is UNESCO’s hope that mobile reading will be integrated into broader educational systems that teach people how to use text productively – from access to comprehension, and all the stages in between.

Nevertheless, the primacy of access cannot be overstated. While it is true that books, by themselves, will not remedy the scourge of illiteracy, without them illiteracy is guaranteed.
A key conclusion from this publication is that mobile devices constitute one tool – in a repertoire of other tools – that can help people develop, sustain and enhance their literacy
skills. They can help people find good books and, gradually, cultivate a love of reading along with the myriad advantages that portends – educationally, socially and economically. This report, by explaining who reads on mobile devices and why, illuminates how mobile reading can be encouraged and spread, with a goal of making book shortages obsolete and thereby eliminating a long-time obstacle to literacy.

OECD Paper: Focus on Top Incomes and Taxation in OECD Countries: Was the crisis a game changer?

Paper: Focus on Top Incomes and Taxation in OECD Countries: Was the crisis a game changer?
OECD Directorate for Employment, Labour and Social Affairs
May 2014 8 pages
Excerpt from overview information; Editor’s text bolding

30/04/2014 – The share of the richest 1% in total pre-tax income have increased in most OECD countries over the past three decades. This rise is the result of the top 1% capturing a disproportionate share of overall income growth over that timeframe: up to 37% in Canada and 47% in the United States, according to new OECD analysis…
…But the incomes of the poorest households have not kept pace with overall income growth, with many no better off than they were in the mid-1980s. Stripping out the richest 1 percent of the population leaves income growth rates considerably lower in many countries – which is why so many people have not felt their incomes rising in line with overall economic growth.

The crisis put a temporary halt to these trends – but it did not undo the previous surge in top incomes. On average, real incomes of the top 1% increased by 4% in 2010, while the lower 90% of the population saw their real incomes stagnate…
…“Without concerted policy action, the gap between the rich and poor is likely to grow even wider in the years ahead,” said OECD Secretary-General Angel Gurría. “Therefore, it is all the more important to ensure that top earners contribute their fair share of taxes”.

The paper outlines a series of reforms governments could make to help ensure that top earners contribute their fair share of the tax burden. These include:
:: Abolishing or scaling back a wide range of those tax deductions, credits and exemptions which benefit high income recipients disproportionately;
:: Taxing as ordinary income all remuneration, including fringe benefits, carried interest arrangements, and stock options;
:: Considering shifting the tax mix towards a greater reliance on recurrent taxes on immovable property;
:: Reviewing other forms of wealth taxes such as inheritance taxes;
:: Examining ways to harmonise capital and labour income taxation;
:: Increasing transparency and international cooperation on tax rules to minimise “treaty shopping” (when high-income individuals and companies structure their finances to take account of favourable tax provisions in different countries) and tax optimisation;
:: Broadening the tax base of the income tax, so as to reduce avoidance opportunities and thereby the elasticity of taxable income;
:: Developing policies to improve transparency and tax compliance, including continued support of the international efforts, led by the OECD, to ensure the automatic exchange of information between tax authorities.

A comprehensive policy strategy is needed to tackle overall inequality
The tax policy avenues above will help ensure that wealthier individuals contribute their part towards more inclusive growth. However, in many countries, the rise in overall inequality has also been driven by low-income households falling behind in relative and, sometimes, in real terms. Therefore, a comprehensive policy strategy is needed to tackle overall inequality and promote equality of opportunities, which includes effective and well-targeted transfer policies and other social policies, as well as labour market and education policies.

More information on OECD work on inequality: www.oecd.org/social/inequality.htm

Editorial: Convergence to Common Purpose in Global Health

Editorial: Convergence to Common Purpose in Global Health
David J. Hunter, M.B., B.S., Sc.D., M.P.H., and Harvey V. Fineberg, M.D., Ph.D.
New England Journal of Medicine
May 1, 2014 Vol. 370 No. 18 p1753-1755 DOI: 10.1056/NEJMe1404077
[Full text; Editor’s text bolding]

Health and disease are, to a large extent, effects of local environmental conditions, and the work of health professionals is still largely performed one patient at a time, facilitated or constrained by local resources. So does it make sense to conceptualize “global health” on a worldwide basis rather than as a patchwork of national and local jurisdictions and responses? In examining the 17 contributions to this series (concluding with the article by Gostin and Sridhar in this issue of the Journal 1), we see five major forces and trends suggesting that as the 21st century progresses, a global perspective on public health will be increasingly critical.

First, the demographic transition from high birth and death rates to low birth and death rates in most countries, leading to a doubling of life expectancy in the 20th century and a quadrupling of the world population, is associated with the epidemiologic transition from infectious causes of death to noncommunicable diseases as the primary causes of death. In terms of morbidity, mental illness now accounts for a large proportion of years lived with a disability. Between 2010 and 2050, the proportion of the world’s population older than 65 years of age will almost double, and the proportion older than 85 will be three and a half times as large.2 This dramatic reshaping of the age structure of the world population predicts an equally dramatic reshaping of disease patterns, which will challenge health systems to adjust across the spectrum of preventive and therapeutic services. Although the transition will be completed in some countries, people in many low- or middle-income countries will face a “double burden” of disease — the “unfinished agenda” of persisting common infections, undernutrition, and maternal mortality, plus a growing burden of noncommunicable diseases.

The second major trend relates to the health consequences of globalization. The tripling of world merchandise exports since 1980, a result of economic liberalization and cheaper transport, has had manifold effects on health. Economic growth and countries’ movement from low-income to middle-income status have led to decreased poverty rates in countries such as China and India, along with an ability to invest more in health infrastructure and to plan for, or at least debate, approaches to implementation of universal health coverage. By 2030, India will probably have the world’s largest population, and China will probably be the largest economy; decisions made in New Delhi and Beijing are arguably already more important to global health than those made in Washington, Brussels, or Geneva. Jamison et al.3 have proposed that by 2035, a “grand convergence in health” is possible, as mortality patterns equilibrate in many countries.

Economic growth, however, has been accompanied by rapid urbanization, reduced physical activity, increased tobacco and alcohol consumption, and adverse changes in dietary patterns. Increases in the volume and speed of travel will enable pandemics to spread more rapidly — but there has been no corresponding acceleration in the development and manufacturing of drugs and vaccines. Diseases such as polio, which had been limited to a handful of countries and attended by hopes for worldwide eradication, can recrudesce when conditions favor the virus and a pool of unimmunized children is present. These changes in lifestyle and habitation and in the numbers of people traveling are predicted to increase, along with the consequences for human health. International disease-control regulations and other global governance mechanisms are rudimentary when compared with the size of the challenges.

Third, environmental threats are destabilizing long-standing agricultural and residential patterns and access to clean air and water, setting off unpredictable changes that affect all regions of the globe. The most obvious threat comes from climate change; related threats include the cross-border spread of air and water pollution and the export of toxic wastes. Global solutions to these problems will require unprecedented global solidarity and coordinated responses. The multilateral actions aimed at reducing atmospheric chlorofluorocarbons set a promising precedent, but the actions needed to reduce the effects of climate change are far more complex, and the delay between action and mitigation longer — all of which suggest that scaling up capacities for humanitarian response to address the increased incidence of weather-related disasters will be a necessary activity for several decades.

The fourth major trend is the internationalization of medical knowledge and the globalization of the health workforce. As little as 30 years ago, medical knowledge traveled slowly, if at all, in the pages of journals, sometimes in “airmail editions” printed on lightweight paper. Now, key articles appear online a month or two before publication in print and are available around the world instantaneously. But because drugs and devices are far from universally available and affordable, there are growing inequities in doctors’ ability to treat their patients using the latest medical knowledge. These limitations are particularly unfortunate now that medical knowledge flows in multiple directions and innovations borne of necessity in poor countries may hold the key to reducing the cost of health care in rich countries.4 New educational opportunities, such as massive open online courses, or MOOCs, hold the promise of training more health workers more quickly than can possibly be done in standard brick-and-mortar classrooms.

The globalization of the health workforce has many benefits, but rich countries’ importing of health professionals from poorer countries, a result of poor workforce planning, strips poorer countries of precious health professionals and reduces their populations’ access to care.5 We must not let the communications revolution, which should lead to more up-to-date and better-trained health professionals and more globally engaged and collegial interactions around the world, become a Trojan horse for accelerated medical migration from poorer countries. To the extent that such migration is fed by frustration with inadequate infrastructure for practicing medicine to the highest standards, those problems could be mitigated by relatively modest investments in improving health facilities.3

The final trend is the globalization of medical science. Since the report in the late 1980s of the Commission on Health Research for Development,6 the number of countries engaged in what the commission referred to as “essential national health research” has increased substantially; China, a developing country at the time, is now second in the number of articles published annually and listed in the Science Citation Index. Countries can increasingly decide for themselves what medical science they wish to pursue, instead of relying on the interests of scientists in other countries.

How we handle these five trends will do much to determine the quality of health and health services in the world in the coming decades. The environmental community uses the concept of “local to global” to remind us that individuals and communities have a role in environmental impact worldwide. Although the individual patient encounter is a local event, and global health institutions may constitute a patchwork of entities, each patient encounter takes place in a global tapestry of influences that constitute “global public health.”

Unhealthy Practice – Medical Work in Conflict Zones Is Compromised

Unhealthy Practice
Medical Work in Conflict Zones Is Compromised
By Leonard S. Rubenstein
Foreign Affairs
http://www.foreignaffairs.com/
[Excerpt; Editor’s text bolding]

For the second time in less than six months, polio vaccine workers in Pakistan have come under fire. In early April, an unidentified armed group attacked a team of Pakistani health workers administering vaccines and killed one of the police officers guarding them. The program suffered a tragic loss last December, when gunmen killed nine polio workers. Since then, the government has suspended the vaccination campaign in Pakistan’s tribal region — a major setback to public health in a country where polio remains endemic. By the end of March, almost a quarter of a million children scheduled for polio vaccinations had not received them in that region. Meanwhile, in northern Nigeria, where polio is also endemic, vaccination efforts are strained. Last February, nine vaccine workers there were killed by gunmen associated with Boko Haram, a militant Islamist group that claims polio vaccinations are part of a Western plot against Islam.

Some observers, such as the Council on Foreign Relations Senior Fellow Laurie Garrett, persuasively argue that the CIA is partially to blame for turning health workers abroad into targets. In 2011, the CIA employed a Pakistani doctor to conduct a fake vaccination campaign in an effort to track down Osama bin Laden. News of the scheme reinforced the population’s worst suspicions about the motives behind immunization campaigns. Earlier this year, deans of a dozen of the United States’ most prestigious public health schools wrote a letter to President Barack Obama demanding that public health programs never again be used as a cover for intelligence gathering operations…

…Those who attack medical personnel in conflicts should be prosecuted under international law for war crimes. As a start, the Security Council should refer the Syrian government’s killing, arrest, and torture of medical personnel for investigation by the International Criminal Court. Russia and China will no doubt resist, but their opposition is no excuse for refusing to demand criminal accountability.

The international community must recognize the fragility of health care in conflict, reaffirm the norms of protection and respect, and take vigorous action toward assuring adherence to legal obligations. Otherwise, health workers who provide care will remain at high risk and people who need care the most will be abandoned.

Transformative Scale Means “Crowding In”

Transformative Scale Means “Crowding In”
By Susan Davis
Stanford Social Innovation Review – Nonprofit Management Blog
April 28, 2014
We must develop and scale programs and ideas that harness the power of social movements.

If you’re trying to solve a problem, the scale of the proposed solution needs to match the scale of the problem itself. BRAC (formerly Bangladesh Rural Advancement Committee) began as a small relief effort in a remote part of Bangladesh after the 1972 war of liberation, but early on, we established an institutional mentality that focused on the scalability of interventions. We designed our interventions with the bigger, global problem of extreme poverty in mind. BRAC has become perhaps the world’s largest NGO—actually more like a social enterprise hybrid—touching the lives of an estimated 135 million people.

BRAC has pursued two main pathways to grow impact to a transformative scale. One is to directly multiply what works, millions of times over, balancing both scale and localism. Our organization’s disciplined program development process makes this possible. It first pilots a solution to ensure that it is effective, and then perfects the operational model to make it ultra-efficient. The result is effective, low-cost interventions in health, education, and livelihood development that are rooted in community demand and context, and that can spread to a great many other people. But such “massification” is not the only way to achieve transformative scale. The second pathway is to scale an approach with and through others. These two options are not mutually exclusive and can combine effectively.

For example, BRAC started its primary education program in 1985 in Bangladesh, responding to demands from landless parents that their children have access to the same sort of basic numeracy, literacy, and problem-solving classes BRAC was already conducting for adults. The government schools system wasn’t reaching these youth, the poorest children in the villages.
BRAC created an education program for these children, drawing teachers from the ranks of the poor themselves and focusing on teacher training. This approach supported the local economy, helped ensure teacher commitment, and kept costs very low. In selected villages, the program gave local women a standardized, two-week crash course on student-centered learning in the Freirean Pedagogy, a clean break from the drudgery and rote memorization of state schooling. On-the-job training and supervision, and monthly refreshers with a peer group followed.

The model worked. Women who hadn’t finished high school showed that they could learn and implement the basics of effective teaching. Dropout rates at BRAC schools were almost nonexistent. Moreover, parents proved willing to make financial sacrifices to give their children the chance for a better future. As a result, the final program was eminently scalable. BRAC now runs the world’s largest private, secular educational system, with 1.1 million children currently enrolled in its primary and pre-primary education program, at a cost of $36 per year per child. It has graduated more than 9 million children from its schools, and research shows that children from BRAC schools tend to perform better academically than those from government schools, despite the challenges they face growing up.

Of course, access and quality are perennial problems in education, and they intersect with health, nutrition, and livelihood issues. The complexity of these interconnected problems pushed BRAC to expand its role over time; today, it intervenes at every point along the education value chain. For example, its advocacy work and body of evidence over many years persuaded the national government to provide pre-primary school for poor children. It opened BRAC University in 2001 to expand the nation’s pipeline of talent: Today, this full-fledged higher-education institution enrolls some 6,000 students and has 22 departments, centers, and institutes. Within the university, BRAC has also created the Institute for Educational Development, which incubates new ideas and educational policies to further strengthen both government and private schools.

This education work is one example of achieving impact at scale. BRAC’s Targeting the Ultra Poor program illustrates a different pathway: achieving significant impact by enlisting others and “giving away” the program. Since 2002, BRAC has helped 1.4 million families with a tailored approach to the problem of ultra-poverty, a form of dire poverty impervious to basic microfinance. The two-year “graduation” model involves cash stipends, livelihood training, asset transfer, access to savings, and other forms of social and emotional support—all used in combination as a springboard to better life. Though this approach is not a panacea, it has been highly effective, and as a result we now believe that there may finally be an end in sight for ultra-poverty.
For this program, we didn’t just scale up directly—although direct implementation is important for knowledge and credibility. Instead, we chose to open-source the idea and give away its implementation knowledge to interested parties. Through patient participation in building a global community of practice, BRAC and BRAC University positioned the graduation idea to scale across borders and find the communities that could best benefit from it.

For example, intrigued by the powerful evidence from this program, the Ford Foundation and the Consultative Group to Assist the Poor (CGAP) launched a global experiment in 2006 to test the model in eight other countries, implemented by organizations other than BRAC. At a recent global gathering at the World Bank, we presented the research findings to policymakers, practitioners, and academics interested in ending extreme poverty. The overwhelming conclusion is that the approach works. Not only did 75 percent to 98 percent of households “graduate,” but also the vast majority stayed out of extreme poverty.

In light of these results, we’re redoubling our efforts to encourage others to “crowd in.” We are inviting policymakers, funders, microfinance institutions, NGOs, academics, media, and others into the space, because all of these groups are critical to building and sustaining the social change movements essential for tackling extreme poverty.
BRAC may be big in the nonprofit world, but extreme poverty is much bigger. Matching the scale of solutions with the scale of global problems requires that we do more than just grow institutions and programs. Disciplined program development is an important part of effective scaling, but we also need to harness the power of social movements, and encourage and support the many others who have a stake in truly transformative change.

Susan Davis (@SusanDavisBRAC) is a co-founder, and president and CEO of BRAC USA, an independent grant-making affiliate of BRAC and a member of the BRAC International board of directors.

Amref Health Africa [to 3 May 2014]

Amref Health Africa [to 3 May 2014]

International Day of the Midwife: 5 May 2014
Sub-theme: Midwives changing the world one family at a time
Preamble
On the occasion of the celebration of the International Day of the Midwife, it is noted that lack of skilled attendance at birth remains a major cause of maternal mortality. This is because countries do not have adequate numbers of midwives to provide the needed skilled care.

It is estimated that Sub-Saharan Africa needs an additional 551,000 midwives by 2015 to bridge its deficit for midwifery1. It is also estimated that at the current rate of increase in numbers of midwives, it will take 29 years to reach the WHO recommended numbers of midwives and other health professionals of 2.28 per 1000 population in Africa2.

It is notable that midwives are at the heart of deliveries in Africa. More often than not, whether in the larger hospitals, or in dispensaries, midwives play a key role in ensuring safe delivery. It is imperative to have adequate numbers of midwives in all health facilities to improve skilled attendance at birth and reduce the high maternal and perinatal mortality in most African countries.

As 2015 draws near, it is noted that countries in Africa have not been able to meet the 5th MDG. This is attributed to a number of factors. By just bridging the 510,000 deficit for midwives however, maternal mortality would fall by more than one third in Africa3. It is therefore important that health systems not only employ but also retain adequate numbers of midwives.

It is in realisation of the role that midwifery plays in saving lives of women and newborns that Amref Health Africa has prioritised training of midwives in the last few years. As such, Amref Health Africa has ongoing courses for certificate, diploma, bachelors and masters degrees offered in accordance with nursing and midwifery regulations in countries where Amref Health Africa works.

Through its three year campaign – Stand Up for African Mothers, Amref Health Africa aims to train 15000 midwives between 2013 and 2015. To date 5452 midwives have been trained through this campaign. This number will go a long way in meeting the current deficit for midwives across countries in Africa.

On this day of midwives, Amref Health Africa renews its commitment to work hand in hand with governments, development partners and civil society organisations to:
Amref Health Africa promises to:
:: Assess adequacy of the health workforce with special attention to numbers of midwives in countries and its impact on maternal and child health and develop strategies for improvement.
:: Work hand in hand with midwifery regulatory bodies and training institutions to continue building skills of practicing midwives through innovative training approaches that do not take the midwives away from their work for too long
:: Using acceptable country curricular, do basic training for midwives to add numbers of midwives to the market and reduce the deficit in Africa
:: Work closely with midwifery associations and training institutions to advocate for improved coverage, equity and quality of maternal and child health services

Amref Health Africa realises that governments are solely responsible for ensuring the right to health for their citizenry. We only support the governments to meet this objective. To that extent, Amref Health Africa urges governments as well as their development partners to meet the following obligations for improving access to midwifery care:
Amref Health Africa asks governments and development agencies supporting them to:
:: Allocate adequate resources to train more midwives to reduce the current deficit.
:: Absorb any unemployed trained midwives into the health system
:: Improve working conditions for midwives as a strategy for motivating them as well as for improving quality of maternal health services
:: Enact policies on task sharing that ensure the application of all midwifery skills as listed by the International Confederation of Midwives (ICM)
Bibliography
Alexander S. P., Richard M. S., Chris B. M., Brent D. F., Mario R. D., Estimates Of Health Care Professional Shortages In Sub-Saharan Africa By 2015, Accessed on 24th Feb. 2014 at http://content.healthaffairs.org/content/28/5/w849.full.pdf+html
Birth Rate Plus (2014), Ratios For Midwifery Workforce Planning at National, SHA and Local Level, accessed 24th Feb. 2012 at http://www.birthrateplus.co.uk/index.php?option=com_content&task=view&id=14&Itemid=1
Vincent De Brouwere and Wim Van Lerberghe (2001), Safe Motherhood Strategies, a Review of the Evidence, accessed on 24th Feb. 2014 at http://www.plan.givewell.org/files/DWDA%202009/Interventions/Maternal%20Mortality/SafeMotherhoodStrategies.pdf#page=105

Retweeted by Amref Health Africa
Sharon Rainey @RaineySharon • May 1
@AMREF_Worldwide #IDM2014 @FHWCoalition Ugandan Madudu calls 4 more support of frontline healthworkers @Capitol Hill

BRAC [to 3 May 2014]

BRAC [to 3 May 2014]

BRAC (Learning Division) signed a MOU with the Department of Women Affairs (DWA)
The Department of Women Affairs (DWA), Government of Bangladesh and BRAC has signed an MOU on 24 April 2014, aiming to sensitise DWA’s working couple groups in gender equality to create a sharing culture in their family through training. BRAC Learning Division and GJD are collaboratively working with the project, which will continue for one year from the signing date of the MOU…

MoU signing ceremony between BRAC and Ministry of Posts, Telecommunication and IT
BRAC signed a MoU with the ICT division of Ministry of Posts, Telecommunication and IT on 28 April 2014. The purpose of this partnership is to develop interactive multimedia contents for primary education on mathematics, science and social science. The content is based on NCTB primary (class 1-5) curriculum.
This will ensure conceptual clarity and better application of lessons for both students and teachers; improve the quality of education by shifting the style from teacher-centred to an interactive and engaging learner-centred. Teachers can use technology as an effective tool to deliver lessons in the classroom. The material will be developed involving relevant stakeholders and experts…

BRAC @BRACworld • Apr 29
Truly innovative #mobilemoney ideas and a rigorous selection process, BRAC’s #digital #revolution is on the roll! http://blog.brac.net/2014/04/challenge-accepted/ …

BRAC @BRACworld • Apr 28
Be sure to check out the new @SSIReview blog post by @BRACWorld’s @SusanDavisBRAC http://bspan.org/1hJz392 #TransformativeScale

Retweeted by BRAC
Rakib Mohammad Avi @RakibAvi • Apr 28
Govt of #Bangladesh and @BRACworld joining hands to develop interactive #digitalcon

tent for primary school kids

BRAC @BRACworld • Apr 27
When #mobilemoney is much more than just money transfer!! http://blog.brac.net/2014/04/bangladeshs-bkash-adoption-puzzle/ …