According to a report to be released by UNICEF on Thursday (9/17/09), the number of children dying before the age of five has fallen below 9 million, the New York Times reports. This is the lowest that this rate has been since child mortality has been tracked, since about 1960. In 1990, 12.5 million children under the age of 5 died. In 2008, UNICEF is estimating that number to be 8.8 million.
Public health experts say that an increase in the distribution of vaccines, mosquito nets, and a rise in the number of women breast-feeding (which reduces the amount of contaminated water infants consume) has contributed to the decrease in child deaths. Malawi has experienced one of the largest drops in childhood mortality. Malawi’s success is owed in large part to their health workers. Over 10,000 high school-educated village health officials work in Malawi. With at least 10 weeks of training, they are able to diagnose illness, provide injections, and give out medicines. Not having to depend on doctors or nurses in rural villages makes a world of difference in the continued struggle to bring down child mortality rates.
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In related news, South Africa has launched an ambitious, 2-week program to vaccinate and provide vitamins to 3 million children across the country. The program, started on September 7th, was set up by Health Minister Dr. Aaron Motsoaledi. Temporary clinics have been set up and health workers are going door-to-door to visit various homes throughout the country. Dr. Motsoaledi is a welcome figure in South Africa, after years of health leaders who have denied the link between HIV and AIDS and the effectiveness of anti-AIDS drugs.
Researchers have concluded that if HIV patients start treatment earlier than the World Health Organization recommends, approximately 76,000 lives could be saved in South Africa. In addition, 66,000 cases of associated diseases could be prevented within the next five years. The study, published in the Annals of Internal Medicine and funded by the National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation, truly challenges the manner in which HIV has been traditionally treated. The appropriate time to begin treatments is determined by measuring the patient’s CD4 levels. A healthy human’s CD4 levels are between 800-1200 per cubic millimeter of blood. Developed nations traditionally administer treatment to patients when the levels fall below 350. The World Health Organization (WHO) recommends starting treatment in South Africa, and other nations, when CD4 levels fall below 200 per cubic millimeter of blood.
According to Rochelle Walensky, leader of the researchers in this study, earlier treatments should begin immediately. “Waiting five years for trial results could be costly in human terms,” she said. She also explained how starting treatment earlier would also help prevent people with HIV from spreading the disease, as the ARTs would be able to reduce the levels of the virus to such low levels, that they would be harder to pass on. The number of 76,000 saved lives was determined assuming that the current infection rates of HIV in South Africa continue and also assuming that 30% of those infected are diagnosed. Approximately 5.7 million people in South Africa have HIV, more than any other nation (South African HIV/AIDS statistics here).
At the fifth IAS Conference on HIV Pathogenesis, Treatment, and Prevention, Reuben Granich of WHO also argued that viral load is the greatest risk for HIV transmission. The use of anti-retroviral drugs (ARVs) to reduce viral load would significantly reduce the spread of the disease - to the point where Granich believes incidence would reduce from 20,000 per million to 1,000 per million and the number of people living with HIV would be lower than 1% by 2050.
Dr. Francois Venter of the Reproductive Health Research Unit in Johannesburg also spoke at the conference. He used his own experience and studies to show that the debate of when to start ARVs is moot when considering that most patients in sub-Saharan Africa begin treatment very late; the average CD4 count for patients starting treatment is around 100. Studies in South Africa are showing that when patients begin treatment with CD4 levels below 200, there is massive mortality. “Below 200″ is the current South African policy. Dr. Venter says that the majority of patients are entering the treatment system with CD4 levels between 50 and 100. Venter notes that there is a poor linkage between HIV testing and access to ARVs. Dr. Andrew Boulle of the University of Cape Town agrees, “We see the largest mortality before people are enrolled onto ARVs.” A WHO article addressing the ART studies states:
“WHO will be reviewing evidence and revising guidance on ART use, including when to start, for adults and children later this year, but there are many advocates for earlier therapy. There is little doubt that ART has preventive effects; what is uncertain is how best to apply it and combine it with other evidence-based prevention interventions for maximal synergy and benefit.”
The cost of providing ARV treatment on this scale is a looming reason for delayed treatment. But Granich says, “The initial resources would be higher, but over time, given the reduction in HIV incidence, this approach may provide cost savings.” The researchers of the study cited in the Annals of Internal Medicine estimate in their conclusion that if even 10% of people began treatment when higher levels of CD4 were in their blood, the cost of treatment would increase by $142 million over the next five years (offset in part by the reduced incidence of opportunistic disease, such as TB). If 100% began earlier treatments, the additional cost over $1.4 billion, with 221,000 cases of opportunistic disease prevented and 253,000 deaths averted.
In Ethiopia, 350 participants from 36 African nations are meeting to create strategies for utilizing non-physician clinicians (NPCs) in the fight against maternal death and disability. The conference, entitled “Human Resources for Maternal Survival: Task-Shifting to Non-Physician Clinicians”, is a collaborative effort of the Ethiopian Ministry of Health, AMDD, UNFPA, UNICEF, and WHO. It will end on July 2, 2009.
NPCs include nurses and midwives, and play a crucial role in African nations, especially in rural settings where physicians are in short supply. NPCs are often responsible for emergency obstetric care and sometimes for more highly specialized procedures, such as surgery. According to UNICEF, maternal mortality in sub-Saharan Africa is highest worldwide, while rates in North Africa follow shortly behind. Improving maternal health is the fifth goal of the Millennium Development Goals. Dr. Werner Haug, Director of the Technical Division in the United Nations Population Fund, focused on the importance of working towards reproductive health and achieving benchmarks in progress by 2015. “The challenge is to produce health professionals with the right skills and in sufficient numbers to provide family planning services in every community and basic and comprehensive emergency obstetric and newborn care in every district,” Dr. Haug stated. “This is an issue of equity, social justice and human rights.”
Private Equity Fund to Invest in Health Care
The International Finance Corporation (IFC, a member of the World Bank Group), the African Development Bank, the Bill and Melinda Gates Foundation, and a German development finance group DEG, have combined forces to create a new private equity firm that will specifically invest in the health care sector of Africa. The Health in Africa Fund will “invest in small- and medium- sized companies in sub-Saharan Africa … with the goal of helping low-income Africans gain access to affordable, high-quality health services.” [Full Article]
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UN Working to Improve Communications for Health Workers
The Economic and Social Council of the United Nations is supporting the expansion of the telecommunications available for health workers in West Africa. The World Health Organization’s program eHealth will promote communications between physicians for diagnostic purposes, while also creating ethical and legal policies surrounding the collection and storage of electronic health information. The Director General of Ghanaian health services, Dr. Elias Sory says, “If you get a doctor who is away in the village and has come across a case he or she thinks is beyond him or her, why cannot that doctor be able link up easily with a senior doctor in Korle Bu to get advice on it? So we are not there. But eHealth will get us there.” [Full Article]
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HIV/AIDS Progress
During a briefing at the World Economic Forum on Africa being held in Cape Town, U.N. Special Envoy for HIV and AIDS in Africa Elizabeth Mataka said that several African countries have successfully scaled up their HIV/AIDS prevention and treatment programs, reports The Lusaka Times. Mataka listed Zambia and Botswana as some of the countries in Africa that have cited significant gains in the fight against HIV/AIDS. [Full Article]
Emergency Yellow Fever Vaccines Set to Run Out in 2010; Recent Outbreaks in Africa and Latin America Draw 6 Million Doses - from Reuters South Africa, May 26, 2009
New South African Health Minister Aaron Motsoaledi to launch an accelerated plan for preventing mother-to-child HIV transmission in an attempt to reduce the “war-like” infant mortality statistics. - article from The Times, May 25, 2009
“Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.” - article from the NYTimes, May 23, 2009
“The U.S. Commitment to Global Health: Recommendations for the Public and Private Sectors”, from the Institute of Medicine of the National Academies Summary available here - May 20, 2009
Celebrating Relief from Fistula in the Ivory Coast
According to a recent report from The World Bank entitled “Averting a Human Crisis During the Global Downturn” (pdf available here), millions of people that are currently undergoing medical intervention for HIV/AIDS with antiretroviral treatment (ART) are faced with the risk of their medicines being interrupted. As international organizations and African governments are experiencing budget cuts due to the financial crisis, the health community fears that increasing unemployment will lead to reduced food security. The resulting loss of quality of nutrition will continue to put pressure on already weak health systems.
Specifically, the World Bank reports that continuity of treatment could be threatened for around 70% of people currently on ART in eastern and southern Africa. The report also addresses commitments that may need to be cut from international aid organizations. According to NAM, a non-profit community based HIV information provider based in the UK, Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, TB and Malaria has announced a funding shortfall of $4 billion in 2010. Organizations like the South African Treatment Action Campaign are speaking out to advocate for greater health funding during the crisis, pointing out that “…The region of sub-Saharan Africa bears the greatest burden of disease, and has 68% of the world’s HIV-positive people but only 1% of the global expenditure on health, and 2% of the global health workforce.”
This financial struggle during the global crisis highlights an already alarming problem. In April 2001, the members of the Heads of State and Government of the Organisation of African Unity, met in Abuja, Nigeria, and created the Abuja Declaration, committing to set aside 15% of their national expenditure towards health, specifically to fight HIV/AIDS. According to Paula Akugizibwe, regional advocacy coordinator of Windhoek-based AIDS and Rights Alliance for Southern Africa (ARASA) in Namibia, “”Very few countries have met this goal. The money is there. It’s all about prioritisation of resources. The situation is very frightening, because governments cut back on already insufficient HIV treatment and care programmes.” (Click here for full article and Akugizibwe’s comments.)
The World Bank’s report calls for “a combination of efficiency improvements, being selective in cutting of certain types of expenditures, and/or income support mechanisms can allow governments to maintain services that are critical to the most poor and vulnerable.” The report also lists the hazards of stopping treatment for those who are receiving it, including:
- Severe consequences for households (”children orphaned, loss of human capital, increased household poverty”), and the loss of experienced workers to the economy.
- Increased infectiousness of those who stop being treated.
- Diminished drug effectiveness, “requiring use of extremely costly second-line drugs and placing additional demands on health systems to monitor their use.”
Summary of the World Bank’s Key Policy Recommendations regarding HIV/AIDS
- A more rigorous and determined push for efficiency and cost-effectiveness helps countries better prioritize resource allocations across HIV/AIDS treatment and prevention programs.
- For countries with high reliance on external financing for AIDS programs, national authorities and their development partners should identify impending cash flow interruptions and provide bridge financing that, at the very least, prevents treatment interruptions.
- A simple early warning system can help track and minimize treatment interruptions, including better monitoring of drug supplies and use of key health services.
- For countries receiving emergency budget support, an appropriate base level of funding for HIV should be included as part of the social protection package.
The health community continues to focus on malaria (see our recent post on new malaria detection technologies), as governments, health organizations, and non-profit organizations hope to eradicate this deadly disease. Almost 1 million people die from malaria every year, and the majority of deaths occur in children living in sub-Saharan Africa. DDT is the pesticide that is commonly used to target mosquitoes, which are the vector for the parasites that cause malaria.
Scientists at the National Institute of Environmental Sciences (NIEHS) have concluded that DDT “should be used with caution, only when needed, and when no other effective, safe and affordable alternatives are locally available.” The scientists also reported that the adverse health effects associated with DDT include genital birth defects, breast cancer, and diabetes. (See full article and research here.)
IRS is a routine anti-malarial program, used by many organizations. Because of this, DDT use is on the rise in Africa and Asia. Only one study has been conducted to study the effects on individuals living in areas where IRS is employed routinely. In this study, conducted in 2007, men in South Africa who were continually exposed to DDT were found to lower sperm counts, lower semen volume, and high levels of DDT in their blood. DDT is also known to accumulate in other bodily fluids, such as breast milk.
“DDT is now used in countries where many of the people are malnourished, extremely poor and possibly suffering from immune-compromising diseases such as AIDS, which may increase their susceptibility to chemical exposures,” said panel member Jonathan Chevrier, a University of California at Berkeley post-doctoral researcher in epidemiology and in environmental health sciences.
The authors of the study from NIEHS hope that the scientific community can find a suitable, and safer, pesticide to use in the war against malaria. In the meantime, we hope that DDT will be used as more sparingly in Africa and Asia, while other methods of prevention against the spread of malaria, such as bed nets and anti-malarial drugs, will be more readily available to those who need it the most.
Sierra Leone , Comende village. Malaria has followed Amadu Sheriff through all the four years of his life. According to his mother, Amadu,Äôs recent infection is just the latest in a row. To Amadu and other children in Sierra Leone, access to medicine and bed nets are essential to prevent the disease from killing them.
As new diseases cause epidemics and public health emergencies worldwide (swine flu, avian flu, SARS), Africa continues to battle against malaria - one of the world’s oldest maladies. Symptoms of malaria were recorded in ancient Chinese medical writings dated to 2700 BC. While medicines and preventative measures are available, scientists and doctors struggle against the disease’s drug resistance. The mosquito-borne disease claims the life of over one million people worldwide. Most casualties are among young children in Africa.
The Centers for Disease Control and Prevention commemorated World Malaria Day on April 25th, directly on the heels of the announcement by researchers at the University of Glasgow that an electronic chip could serve as a new weapon in the fight against malaria. View video on chip, courtesy of the BBC
While the chip is still being discussed as a method for travelers to Africa to remain safe and disease-free, the public health implications for Africans are astounding. New pledges from US President Barack Obama to meet the United Nation’s goal to eradicate malaria by 2015 have encouraged many living in Africa, as well as public health specialists and doctors; technological advances in detection would only help in this fight.
The 15 participating First Ladies, who are participating by invitation only, are focusing on professional leadership development, education, and awareness-raising, and culminates in a Gala evening event and fundraiser. Clearly defined goals for the summit were created among the First Ladies and USDFA for months prior to this event, so that the closed-door meetings would have the greatest productivity during this innovative summit.
The goals include:
- Educate the world about the First Ladies’ philanthropic efforts across Africa.
- Focus on 1-3 of the First Ladies’ most pressing priorities, for example on maternal health, as well as girls’ education and HIV/AIDS.
- Identify actionable items on these topics, to be pursued together with global partners and in-line with the UN Millennium Development Goals.
- Engage in professional development workshops of interest for the First Ladies.
- Identify top donors to support First Ladies’ work.
- Lift visibility and international respect for First Ladies work.
In a conference to review the national food and nutrition policy in Sierra Leone in early April, Deputy Health and Sanitation Minister Mohamed Daudis Koroma announced an overall improvement in the nutritional status of children under the age of five. Koroma addressed a body of participants that included the Acting Chief Medical Officer Dr. Kisito Daoh, the UNICEF Nutrition Manager Sefano Sebele, and the Senior Permanent Secretary Ministry of Health Edward Bai Kamara. The conference was organized with support from the Ministry of Health and UNICEF.
Koroma described many causes of malnutrition in Sierra Leone, including poverty and lack of education. Koroma also stressed the need for a plan of action that would address malnutrition’s effect on infection in children. As children become more and more vulnerable to simple infections due to malnutrition, the mortality rate of children under five continues to be the highest in the world (click here for UNICEF’s State of the World’s Children report). For the three days of the conference, Koroma encouraged participants to create goals in the areas of agriculture, livestock, fisheries, forestry, and health education to fully analyze the state of nutrition in Sierra Leone.
Dr. Daoh emphasized the toll that malnutrition takes on women and young children. Dr. Daoh hoped to create a document that would outline the needs of the people of Sierra Leone. Such a document would then be used to create health policies that would address malnutrition. Sebele discussed the food and nutrition security, describing it as a “critical challenge”. Kamara went a step further, describing food as a “human right”. Kamara also noted that the Ministry plays a leading role in the process, as malnutrition belies healthy development of the country.
