Polio vaccine switchover: An untold success story in global health

Syed Latif, a polio vaccinator and activist, hands out polio information at the Mansehra Polio Resource Center in Mansehra, Khyber Pakhtunkhwa Province of Pakistan. Photo: Mansehra Polion Research Center.

This was originally published on Global Health TV on November 28, 2017.

In April 2016, something extraordinary happened in global health. Thousands of community health workers in more than 120 countries — from African villages to the Himalayas to the Pacific Islands — all mobilized and synchronized their efforts to switch from one oral polio vaccine to another. Any slip-ups could have resulted in creating more “vaccine-derived” poliovirus cases at a moment when we are down to our last few cases of polio.

The fact that many children receiving such oral vaccines were living in areas of high conflict and low development (which means low levels of health infrastructure) made the accomplishment all the more remarkable.

The feat was accomplished in a single day (each country was told to pick one day within a two-week period in April 2016 to make the change).

The story of this amazing synchronized switch constitutes an untold global health success story and can be told with the backdrop of the current number of wild poliovirus type 1 cases down to only 15 — 10 in Afghanistan and 5 in Pakistan. The polio eradication community had hoped that we would be down to zero by 2017. Now they are hoping it will happen in 2018.

10 lessons we've learned from AIDS that we can apply to chronic diseases

An assistant at the Etoug-Ebe Baptist Hospital, a subsidiary of the Cameroon Baptist Convention Health Services, takes a blood sample of a patient participating in the Novartis Access program to fight non-communicable disease. Photo: Anne Mireille Nzouanekeu

This was originally published on the Huffington Post on October 30, 2017.

Communicable diseases like HIV/AIDS and malaria have taken a terrible toll on Kenya and other African countries over the last 20 years. In 2010, an estimated 51,000 Kenyans died from AIDS but that number has declined steadily, to 36,000 in 2016. Kenya is now considered an HIV success story. The same is true in many other countries.

Now there is a new epidemic of non-communicable diseases (NCDs) that is rising just as the world is starting to get a handle on communicable diseases, according to the Institute for Health Metrics and Evaluation. The Institute reports that the largest contributors to the loss of healthy life are now high blood pressure, smoking, high blood sugar and excess body weight.

But Dr. Samuel Mwenda, who knows a thing or two about both epidemics, believes there are lessons we have learned in the fight against communicable diseases that can now be applied to NCDs. Mwenda is general secretary and CEO of the Christian Health Association of Kenya (CHAK), a network of Protestant health facilities in Kenya. CHAK now supports 46,000 people living with HIV with antiretroviral therapy, representing about 9 percent of the total number of patients nationally.

In 2015, CHAK turned its attention to NCDs: With the support of Novartis Access, it began offering a portfolio of 15 products to treat cardiovascular disease, diabetes, respiratory illness and breast cancer at a price to governments, NGOs and other institutional customers not to exceed $1.00 per treatment per month. Since then, Novartis Access has also started working in Cameroon, Ethiopia, Pakistan, Rwanda and Uganda.

Initiatives to expand access to medicine on the rise, but need better evaluation

In Nairobi, Kenya, parents receive prescription medicines for their children as part of a free medical camp operated by Slums Information Development & Resources Centers. Photo: George Onyango, Courtesy of Photoshare

This was originally published on Global Health TV on August 31, 2018.

In the 1990s and 2000s, AIDS activists and other global health advocates started pressuring pharmaceutical companies to share their largesse with low- and middle-income countries (LMICs) by supplying critical medicines for free or at subsidized prices, especially for HIV/AIDS. The pressure was successful, and led to a series of access-to-medicine (AtM) initiatives.

The international community increasingly recognizes that the pharmaceutical industry must play a leading role in improving access to medicines. And apparently pharma companies themselves also acknowledge this responsibility, according to a study published in Health Affairs by a team of researchers at Boston University Department of Global Health. That study found that the number of these initiatives grew from 17 in 2000 to 102 in 2015. The researchers called this “clear evidence” that pharmaceutical companies had responded to calls to increase their commitment to improving access to medicines.

Though preventable, cervical cancer causes half million cases per year

Four volunteers of ICANSERVE Foundation exhort women to take advantage of free cervical and breast cancer screening at an event in the Philippines. Photo: ICANSERVE Foundation

This was originally published on Global Health TV on February 28, 2017.

Over 16 years ago, Sally Kwenda survived colon cancer and HIV, and then lost her husband and two children to AIDS-related illnesses.

Sally Kwenda

“Just when I thought I was done with the hurt and the pain, I was diagnosed with stage II cervical cancer,” she recalls. “Many of those I have met on this journey have either passed away or are worse off than me. Many of them got their diagnoses when it was too late to change the tide. Yet cancer does not have to be a death sentence. My experience reveals that cancer is curable.”

Cervical cancer is the most common cancer among women in Sally’s home country of Kenya as well as in 38 low- and middle-income countries, mainly in sub-Saharan Africa, according to the American Cancer Society (ACS).

The reasons for the high rates of cervical cancer in Kenya, according to Deborah Olwal-Modi, executive director of the Kenya Cancer Association, include lack of knowledge and awareness, inadequate facilities for prevention and treatment, economic barriers, and co-morbidity of cervical cancer and HIV/AIDS. For example, almost all women (97 percent) do not know that a virus causes cervical cancer, according to a new study among women in major Kenyan cities.

As infectious disease falls, chronic disease increases; possible solutions emerge

A patient in Kenya undergoes a full physical exam as part of an attempt to detect and treat non-communicable disease supported by Novartis Access. Photo: Bedad Mwangi

This was originally published on Global Health TV on January 31, 2017.

As 2017 begins, we celebrate the fact that many diseases of developing countries have been significantly weakened. The numbers of people suffering from HIV, malaria and tuberculosis are in decline. Children are healthier and living longer.

But as these communicable diseases wane, non-communicable diseases (NCDs) wax (like cancer, diabetes, cardiovascular and chronic respiratory diseases).

This was hammered home by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington which, just in the last two months, released three new reports that provide further evidence of this trend:

• Almost 20% of global deaths in 2015 were linked to elevated blood pressure, according to the latest Global Burden of Disease study. The number of people in the world with high blood pressure, including hypertension, has doubled in the past two decades, putting billions at increased risk for heart disease, stroke and kidney disease.
• Cancer is growing almost everywhere in the world but the greatest increase between 2005 and 2015 occurred in the poorest countries that are least equipped to deal with it, according to a new analysis.
• 30% of all deaths from diabetes worldwide occur in the poorest countries bringing a double burden of disease – from communicable and non-communicable disease – to many countries in Africa, according to a new IHME report. Women often bear most of the burden.

Some children overcome malaria only to confront chronic disease

A patient at a rural health camp in Mwae County, Kenya has his blood pressure checked as part of a full physical exam. If needed, non-communicable disease drugs will be made available through Novartis Access, a new program to make NCD drugs available in developing countries.

This was originally published on Global Health TV on January 13, 2017.

We have much to celebrate with the news contained in the World Malaria Report 2016, released by the World Health Organization (WHO) last month. WHO estimated that a cumulative 1.3 billion fewer malaria cases and 6.8 million fewer malaria deaths occurred between 2001 and 2015 than would have occurred had incidence and mortality remained the same. About 97% of those deaths averted were for children under five years.

Buried, and little-noticed in the report (Page 50), is the gist of what makes this news so exciting: In WHO’s Africa Region, these reduced malaria mortality rates have translated to a rise in life expectancy at birth of 1.2 years, accounting for 12% of the total increase in life expectancy of 9.4 years.

This means many more children will survive the perils of childhood in Africa and go on to lead productive lives as adults. This is one of the most exciting global health developments of several encouraging trends in recent years.

Drug companies test out new strategies for improving access to treatment in poor countries

This was originally published on Humanosphere on November 25, 2016.

When Harald Nusser first walked into the waiting room of the hospital in Addis Ababa, Ethiopia and saw so many people suffering in the late stages of cancer, without even basic palliative care, he couldn’t believe his eyes.

“Some of them had so much pain, they were hitting their heads against the walls, to balance the pain they had inside with a different type of pain,” Nusser said.

A physician who works for one of the world’s biggest drug companies, he was especially affected by the women he saw suffering from breast cancer: “It was absolutely breath-taking to look at those women and realize that 99 percent of them would be dead in a year.”

For decades, the global health community has been focused mostly on communicable diseases like AIDS and malaria. Many like Nusser say the changing disease burdens of lower-income countries require more attention to noncommunicable diseases like cancer. Yet this isn’t happening, and most health systems in poor countries are not equipped to meet the need.

“When I saw this for the first time, I said to myself, you have to do something to change this,” Nusser said. That was in 2013 and, at Novartis, he is today doing something to try to change the situation.

Controversy brewing over the greatest barriers to access to medicine

A worker selects medicine from the MEDS (Mission for Essential Drugs and Supplies) warehouse in Nairobi. MEDS is jointly owned by the Kenya Conference of Catholic Bishops and the Christian Health Association of Kenya. Photo: Bedad Mwengi

This was originally published on Global Health TV on July 16, 2016.

In comments last week at the International AIDS Conference in Durban, South Africa, UN Secretary General Ban Ki-moon said four things deserved credit for getting the AIDS pandemic under control — people living with HIV, biomedical companies, generic medicines and international finance.

But despite his gratitude to biomedical companies and generic medicines, the secretary-general is overseeing a process that threatens to undermine those companies' ability to improve access to medicine in developing countries.

The World Health Organization says an estimated 2 billion people (27% of the world’s population of 7.5 billion) lack access to essential medicine, most of them in Africa and Asia, but a full three-quarters of the world’s population (around 5.5 billion) have no access to proper pain relief treatment.

To address this staggering problem, the Secretary-General set up a High-Level Panel on Access to Medicines earlier this year. The purpose of the panel was “to review and assess proposals and recommended solutions for remedying the policy incoherence between the justifiable rights of inventors, international human rights law, trade rules and public health in the context of health technologies.”

Sounds like a great and noble idea, right? But some expert commentators say the panel is on track to do more harm than good because of its terms of reference.

Kenya starts to shift focus to chronic diseases while not relenting in HIV fight

A patient at a rural health camp in Mwae County, Kenya has his blood pressure checked as part of a full physical exam. If he needs hypertension treatment, he will get it as part of the cost of the camp. Photo: Bedad Mwangi

This was originally published on Global Health TV on June 28, 2016.

For some time, huge disparities between global health spending and the global disease burden have raised concerns that this funding was not being allocated based on the evidence. That is, money was not always going where the disease burden was greatest.

The Institute for Health Metrics and Evaluation (IHME) has pointed out that the disparities are most extreme in HIV/AIDS on the high end and non-communicable diseases (NCDs) on the low end.

As the toll from communicable diseases like AIDS and malaria decline and people live long enough to get NCDs, we need to invest more in fighting NCDs (also called “chronic diseases”) and reduce these glaring disparities between global health spending and disease burden. Countries like Botswana, Eritrea, Kenya Malawi, Mozambique, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zambia — all countries that increased their treatment coverage by more than 25% between 2010 and 2015, according to UNAIDS — now have to pivot to NCDs without taking their eyes off of HIV.

Kenya is an excellent case in point.

A Christian warrior for health takes on chronic disease after battling AIDS

Dr. Samuel Mwenda after receiving the award as the 2016 Christian International Health Champion.

This was originally published on the Huffington Post on June 21, 2016.

In Kenya, non-communicable diseases (NCDs) such as cardiovascular and respiratory disease, diabetes and cancer used to be quite rare, because communicable diseases like AIDS and malaria were more likely to kill you first. That is why life expectancy peaked in 1987, and then went down in the 1990s, as AIDS made its presence felt.

But since about 2002, as more Kenyans have gotten AIDS treatment, life expectancy has started going up again and, if current trends continue, Kenya will return to its historic peak of 60 years in 2017, according to a World Bank blog.

That’s great news. But it also means many Kenyans are surviving AIDS only to live long enough to be killed by NCDs. Annually, 28 million people die from NCDs in low- and middle-income countries like Kenya, representing nearly 75% of deaths from NCDs globally. Health programs, therefore, must turn their attention to this new pandemic without losing focus on the existing one (AIDS). This scenario is playing out not only in Kenya but also in Botswana, Eritrea, Malawi, Mozambique, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zambia. All of these countries increased their treatment coverage by more than 25% between 2010 and 2015, according to UNAIDS.

Dr. Samuel Mwenda is a seasoned veteran of campaigns against both pandemics. For 13 years, as the general secretary and CEO of the Christian Health Association of Kenya, a network of Protestant church facilities in Kenya, he has led CHAK’s comprehensive approach to HIV/AIDS prevention, care and treatment. Kenya is now considered an AIDS success story, with CHAK making a significant contribution to that success. UNAIDS says that Kenya is one of the countries “showing the most remarkable progress in expanding access to antiretroviral medicines and reducing the number of new infections.”

In Africa, gap between need and funding of mental health is huge

Adolescent boys in talk therapy group near Kampala, Uganda. Credit: StrongMinds

This was originally published on Global Health TV on June 29, 2015.

Sean Mayberry has spent his entire life surrounded by mental illness. As a child and an adult, people close to him have endured this affliction. But he had an epiphany when he happened upon a young man behind a farmhouse in Uganda, sitting in his own excrement and digging in the dirt.

“It was a turning point for me,” he recalls. “I left that young man knowing that I had to do something for the mental health of that continent.  He gave me the courage to try to make a difference for some of his mentally ill brothers and sisters.”

Pauline Muchina is dealing with mental illness in her family in Kenya. Her 50-something sister lost her job due to depression and had to come home to live with her mother. She is now on medication and attends counseling.

Muchina also has a nephew suffering from depression. While in a government hospital, he was chained to a bed for one week and his condition got worse. Now the family has found a private rehabilitation center for him. He is getting better but it is costing the family $2,500 for six months. Muchina’s family is middle-class and can pay the treatment (with difficulty), but the vast majority of Kenyans could never afford such expensive treatment.

Mental disorders and substance abuse are the third greatest contributor to the global burden of disability with 23% of the burden – greater than cardiovascular disease or cancer.

New development goal falls short of protecting those most at risk of HIV

This ISHTAR wellness center in Nairobi works to ensure that gay men have access to non-discriminatory HIV and sexual health services. Credit: Corrie Wingate for the International HIV/AIDS Alliance.

This blog was originally published by The Huffington Post on May 8, 2015.

Dominique, 26, realized he was gay in his early adolescence and now sells sex to other men to survive and to support his relatives in Kisii, in western Kenya. He goes regularly to a drop-in center outside Nairobi run by the Kenya AIDS NGO Consortium (KANCO) where he gets a holistic package of HIV and sexual and reproductive health services.  As a result, he is HIV-negative.

Dominique is a good example of why we need to support people most vulnerable to HIV. Yet the language currently proposed in the Sustainable Development Goals (SDGs) falls short of prioritizing the most marginalized and vulnerable groups (the SDGs are the new development goals replacing the Millennium Development goals which expire later this year).

Goal 3 of the SDGs is to “ensure healthy lives and promote well-being for all ages.” Target 3.8 under this goal commits to Universal Health Coverage (UHC). Unfortunately, the UHC target and indicators do not meet the specific needs of the most marginalized, stigmatized and underserved people in the world — like men who have sex with men (who are 19 times more likely to contract HIV than the general population) and transgender women (who are up to 49 times more likely to acquire HIV than all adults of reproductive age).

Three world-changers: Drones, sanitary pads and schools

This blog originally appeared on Humanosphere on April 20, 2015.

On the Pacific archipelago nation of Vanuatu, a “digital humanitarian” has been using drones to carry out a detailed assessment of the damage caused by Cyclone Pam last month.

In Rwanda, a young African woman is improving the lives of other young women by the simple act of providing them with locally made sanitary pads so they don’t miss work and school.

And in Kenya, a man who grew up in extreme poverty, without formal education, is building schools and fighting poverty and gender inequality in the worst slums of Nairobi. New York Times Columnist Nicholas Kristof says he might be the next Mandela.

All of these young people are trying to change the world in very different ways. Along with at least 50 others, they will be in Saxapahaw, North Carolina April 23-24 for the fourth annual SwitchPoint, a global gathering organized by IntraHealth International (which I need to disclose is one of my clients).

Stymied by Less Smoking in Richer Countries, Big Tobacco Shifts Focus on Developing Countries

Anti-tobacco demonstrators in Brazil demand implementation of the national Tobacco Control Law. Credit: Aliança de Controle do Tabagismo

This was originally published by Global Health TV on March 2, 2015.

Between 1990 and 2009, cigarette consumption decreased by 26% in Western Europe, but in Africa and the Middle East, it increased 57%, according to the American Cancer Society (ACS). In response, many of these developing countries are stepping up their efforts to fight tobacco with new laws and restrictions. Big Tobacco is using its deep pockets to finance creative attempts to circumvent those laws.

The problem is so daunting that ACS named rising use of tobacco in developing countries as one of it “Three Top Cancer Challenges of the 21^st Century” earlier this month when it observed World Cancer Day. Comedian John Oliver covered the issue very well in this segment from his HBO show “Last Week Tonight.”

An estimated 8 million of the 14.1 million new cancer cases diagnosed in 2012 occurred in developing countries with 82% of the world’s population, according to Global Cancer Facts & Figures, 3^rd Edition. Smoking causes at least 12 types of cancer, according to the U.S. Surgeon General, and accounts for a fifth of all global cancer deaths. Tobacco use is the cause of nearly 6 million premature deaths annually, notes the report.

We will not banish AIDS until we banish stigma

Eugene comes to a drop-in center for men who have sex with men.

This originally appeared on the ONE Campaign Blog on July 23, 2014.

Earlier this year, I met Eugene and Dominique at a drop-in center for men who have sex with men (MSM) outside Nairobi, Kenya.

Eugene, 23, comes to the center regularly to get condoms, lubricants and HIV counseling and testing, and has brought other gay men to the center. So far, he is HIV-negative.

Dominique, 26, also frequents the center. He was treated for a sexually-transmitted infection, and gets tested there every month. He, too, is HIV-negative.

In Kenya, most gay men are very much in the closet, due to the strong stigma against them. Many of these men would not have access to health services if not for the handful of drop-in centers in Nairobi, Kisumu and other urban centers for the simple reasons that most health facilities are not gay-friendly. Quite the contrary. Thus, most MSM have no access to gay-friendly services.

AIDS-free generation will not be achieved without more investment in harm reduction

Abubakar, an injecting drug user since 1989, receives a safe injecting kit in Nairobi, in a project supported by the International HIV/AIDS Alliance.

This was originally published on the Huffington Post on July 21, 2014.

NAIROBI, Kenya -- In 2010, the United Nations announced that an AIDS-free generation was achievable if we focused on the most disadvantaged communities.

Almost four years later, three leading harm reduction organizations are telling us we are not paying enough attention to one of those communities -- people who inject drugs (PWID) -- and that "an AIDS-free generation will not be possible" if the rate and pace of investment in harm reduction continues.

Harm reduction is a range of public health policies designed to reduce the harmful consequences associated with, in this case, injecting drug use.

To coincide with the 20th International AIDS Conference in Melbourne, Australia, Harm Reduction International, the International Drug Policy Consortium and the International HIV/AIDS Alliance are publishing a report that says that due to changing donor policies, HIV prevention services for PWID are not being prioritized and this failure to invest will bring an exponential rise in HIV transmission which will impose much higher costs on governments and donors.

What are the keys to family planning success in Africa?

This was originally published on the Global Health TV website on June 24, 2014.
 
In the last 20 years, Ethiopia has emerged as a family planning powerhouse. In Studies in Family Planning, I reported that, from 1990 to 2011, modern contraceptive use increased ninefold, from 2.9% to 27.3%, and the total fertility rate (the average number of children born to a woman in her lifetime) dropped from 7.0 to 4.8.

Now Ethiopia’s reputation has been further burnished by the results of a report released May 27^th by Performance Monitoring and Accountability 2020 (PMA2020) that show an increase in the use of modern contraception from 27.3% in 2011 to 33.3% in 2014 and a drop in the fertility rate from 4.8% to 4.4%.

Four Central Determinants of Success

This prompts the question: What are the factors that lead to family planning success? And what are the factors that stall such progress? Our article in Studies in Family Planning identified four determinants of success in Ethiopia. I suspect that many, if not all of these, ring true elsewhere in sub-Saharan Africa:

Kenya quietly takes public health approach with HIV most at-risk groups

Chief Rose Ayere talks to a group of injecting drug users in Nairobi.

This was originally published on Global Health TV on May 27, 2014.

NAIROBI and KISUMU, Kenya — Anti-gay legislation recently signed into law in Uganda and Nigeria has alarmed organizations implementing HIV prevention in Africa, fearing that such laws will further stigmatize and marginalize at-risk populations already hard to reach with health services.

So when I traveled to Kenya this month to interview men who have sex with men (MSM), injecting drug users (IDUs), and people working in programs trying to help them supported by the International HIV/AIDS Alliance, I wondered whether I would encounter “the next Uganda” in gay rights. I did not, but what I did find surprised me.

Years of investments put health workers on global stage

Two midwives in a low-income area of Jakarta, Indonesia that are part
of DKT's "Andalan" social franchising network.

This article was originally published in The Huffington Post on Sept. 23, 2013.

For almost 10 years, I managed health programs in Africa, Asia, and South America that harnessed social marketing techniques to produce tangible benefits for poor consumers. Our programs made low-cost products such as condoms, contraceptives, and oral rehydration salts available at reduced, affordable prices. We worked mostly through the private sector and were proud of our bottom-line health impact. We didn't think much about underlying health systems or how to improve them. And if we had, we probably would have dismissed health system strengthening as overly ambitious.

But I've been thinking more about health systems lately, as I have seen governments and their nongovernmental partners carefully and patiently nurse ailing systems to health. The payoffs are not immediate -- far from it -- but as we move away from the segmented solutions to global health that prevailed in the 2000s (such as in the cases of AIDS and malaria) and toward greater country ownership, there is a growing consensus that we need stronger health systems to make sustainable improvements in global health.

This means more, better trained, and better managed frontline health workers -- the backbone of health systems.

I've heard that mantra for the last few years but, in 2012 and 2013, I saw it play out repeatedly as I traveled to very different countries in Africa, Asia, and Latin America:

Kenyans struggle to come to terms with abortion and its impact on maternal health

This was originally published on The Huffington Post on Oct. 17, 2012.
 
NAIROBI, Kenya -- The abortion issue in Kenya is raucous, rancorous and highly emotional and political, just like in the U.S., but there is one major difference: In Kenya, abortion rights have been liberalized in certain cases in a Constitution approved in a public referendum two years ago.

I spent four weeks in Kenya this year working with the Reproductive Health and Rights Alliance, a coalition of six Kenyan organizations committed to improving maternal health, to communicate better to key groups the nature of those changes. I talked to some 40 doctors, gynecologists, nurses, lawyers, government bureaucrats and technocrats and non-governmental workers and journalists. And a few taxi drivers.

The issue of abortion is so sensitive and taboo in Kenya that it almost derailed the constitution-making process. I discovered that even though the debate was heavily covered by the Kenyan media leading up to the August 2010 referendum, there's still a lot of misinformation on what exactly the Constitution changed, or didn't change -- even among health providers. Some think the Constitution legalized abortion on demand. Others think it changed nothing and abortion remains virtually illegal. The truth lies somewhere in the middle.