Live from Hopkins: Secretary Clinton on the US Global Health Initiative

For those of you who are in Baltimore, Secretary of State Hillary Clinton will be paying you a visit on Monday to discuss the Obama administration’s Global Health Initiative. That the Secretary of State is giving this talk underlines the important role of aid in the US’s foreign policy and diplomacy strategy in the developing world. Recently we have seen how various groups are competing for “the hearts and mind” of the populations devastated by the floods in Pakistan by offering the desperately needed aid that, many complain, the government is incapable or unwilling to provide.

But of course, the union of aid and diplomacy is a double-edged sword. The diplomatic fringe benefits can motivate the governments of developed nations to invest more in aid, and to shift this aid towards health and education efforts that have a more direct impact on communities (as opposed to say, massive infrastructure projects that tend to create the perfect opportunity for corrupt officials and businesspeople–not that global health efforts are immune from corruption!), but if diplomacy is the primary motivation, there is a significant risk that most decisions will be based not on the best interest of the communities in need, but rather on the political interests of those in power.

Unfortunately only SAIS students and staff will be allowed to attend the event in person, but there will be a live webcast accessible at http://www.sais-jhu.edu/.

Blurb from the Center for Global Health:

Hillary Rodham Clinton, U.S. Secretary of State, will speak at the Johns Hopkins University Paul H. Nitze School of Advanced International Studies (SAIS) on Monday, August 16 at 11:30 a.m.

Secretary Clinton will speak about “The Global Health Initiative: The Next Phase of American Leadership in Health Around the World.” The Global Health Initiative is a centerpiece of the Obama Administration’s foreign policy and an expression of U.S. values and leadership in the world. Secretary Clinton will describe the Global Health Initiative’s core principles, and call on governments, organizations and individuals to join the United States in pursuing a sustainable approach for delivering essential health services to more people in more places.

International AIDS Conference

The 18th International AIDS Conference began yesterday in Vienna. A great opportunity to take a step back and reflect upon the road ahead in the context of stagnant funding and ever greater challenges in the prevention of transmission. If you can’t afford the flight, there are live webcasts on the Kaiser Family Foundation website.

Global health at the G8 and G20 summits

Host country Canada has decided to make maternal and child health a priority at this year’s G8 and G20 meetings, starting Friday June 25. Also on the list of priorities are food security and institutional reform in Africa. Here’s to hoping that Canada’s initiative leads to more effective global health policy among the world’s leading economies.
More information on the global health policies of Canada and other G8/G20 countries from the Kaiser Foundation.

Think Local, Act Global: making domestic reform work for global health

I am no expert on domestic healthcare reform and am just beginning to understand better what it involves, but I was very interested in the Affordable Care Act’s efforts to shore up the National Health Service Corps (NHSC), which recruits and supports physicians and other health professionals to work in underserved areas, and expand residency spots in primary healthcare. If done right, the US’s efforts to increase its medical workforce in underserved areas could help to reduce its dependence on foreign medical professionals in these areas, many of whom come from developing countries where there are woefully few medical professionals.

Although the impact of “brain drain” (as opposed to training capacity, for example) is debatable, it is clear that there is a global and growing shortage of HCPs, which has incited enough concern for the WHO to adopt a Global Code of Practice for the international recruitment of health personnel during the last World Health Assembly in May. The code recognizes that international migration of HCPs has several benefits (e.g. professional development, increased income) for individuals and does not purport to halt such migration, but emphasizes that it should have a net positive balance on the health systems of developing countries such that they can retain a skilled health workforce. As we all know, it is veeeeery expensive to train a medical professional, and in most countries this burden falls on states rather than on individuals; thus, the departure of an HCP represents a significant economic loss for a poor country in addition to its effects on the attrition of the health workforce. With a fourth of its physician workforce coming from other countries, the US (as well as other major recruiters of medical personnel such as the UK and Australia), should take a leading role in adopting policies that respect the ideals of the WHO’s code.

There is already some push for the US to invest in workforce development abroad: Congresswoman Barbara Lee has sponsored a Global Health Act, which would support the training of HCPs in developing countries. A former Assistant Surgeon General has also suggested the creation of a Global Service Corps, which would function somewhat like the NHSC and send US medical professionals (including foreign-trained professionals) to developing countries to help facilitate workforce development and the strengthening of health systems. Of course, sending US HCPs abroad through the GSC means that the US will need more medical graduates to replace them. It seems only fair that the US should assume the burden of training the HCPs it will need to fulfill its commitments to domestic and global healthcare to ensure that, in its efforts to provide more equitable access to care, it does not accelerate the attrition of the medical workforce in developing countries. This of course depends not only on the government but also on professional and licensing organizations (e.g., AMA, AAMC) that can help promote domestic training capacity by licensing more medical schools and encouraging existing schools to admit more students.

It is a difficult balance to strike, but hopefully the current and future reform initiatives will allow the US to continue providing opportunities for foreign medical personnel via immigration while assuming its fair share of responsibility (and costs) for the training of its medical workforce.

Hopkins and global access to medicines

For those of you who could not make it to the meeting on Thursday, here are some of the salient points that we covered.

• The impact of unequal access

An estimated 10 million people died in 2005 due to lack of access to medicines for which treatment exists

• The role of universities in drug development

Universities are a major contributor to biomedical research and drug development (e.g., Univ. of Wisconsin and warfarin); UAEM believes that as publicly funded institution they have a social responsibility to ensure that the products of their discoveries go towards helping those who need them. Most universities do not have the means to complete the full process of drug development and marketing (i.e., clinical trials and such), so they typically license out the later stages of drug development to pharmaceutical companies. When a university researcher makes a patentable discovery, the Technology Transfer Office (TTO) has the choice to take over the patent and sell/license it to outside companies that can implement the later stages of development, or to let the researcher retain the rights, in which case the patent holder must independently find partners who can further develop and market the discovery.

• The pharma side of things

There is concern about decrease in innovation but revenue loss from generic access in developing countries would be minor as these markets represent ~3% of revenues.

• What students and universities can do

Examples of previous successful actions include Yale students and researchers negotiating a decrease in the price of the antiretroviral d4T; MIT is to put patents from NTD research in a patent pool. Thus far, nearly 2 dozen institutions (including NIH) have endorsed a Statement of Principles and Strategies for the Equitable Dissemination of Medical Technologies. Although this statement is non-binding, it is a first step in reaching a critical mass of institutions that support equitable access. The more institutions sign on, the less “risk” there is that those who sign on will lose out on licensing contracts from pharma companies that do not want to be subjected to global access requirements.

• What is Hopkins doing?

The Hopkins TTO argues that Hopkins does not need a global access licensing policy as few drug discoveries come out of JHU and so they could be dealt with on a case-by-case basis but UAEM thinks that we need to have a policy in place to ensure global access for any future discoveries. The TTO should also provide support for researchers who expressly seek global access for their discoveries, which it did not do in the case of Stuart Grossman, who developed a subcutaneous implant for the delivery of opioids. Current problems that researcher are facing is that some funders like the Gates Foundation require grantees to have a plan for global access to the products of their discoveries but there is very little guidance on how to develop such a plan.

To read more, see this article from the Hopkins Newsletter about a recent UAEM protest and the university’s response.

• What do you think?

Do you think that Hopkins should do more to ensure global access to the products of discoveries that are made here? What do you think that we can do realistically as students? How can we balance concerns for global access and maintain incentive for innovation, especially for “neglected diseases”? How do we even promote NTD research given that these diseases affect almost exclusively the poorest of the poor?

Setbacks on the HIV front: A case for sustainability, capacity building, and a comprehensive approach to global health

Once touted as a shining example in the battle against HIV in Africa, Uganda was featured two days ago as the first–but not the last–example of “how the war on global AIDS is falling apart” in a New York Times series highlighting the shortfall in funding, the US’s (diminishing?) contributions, the failures of scientific efforts to develop vaccines and microbicides, and the behavioral/cultural factors that make it so difficult to control the spread of HIV.

Although Uganda had once managed to decrease its HIV incidence rates, it appears that new infections are on the rise again, caused in part by a recrudescence of unprotected sex due to enduring social patterns of transactional sex, poor education,  and a general lack of female empowerment, among other issues. This is particularly problematic at a time when funding is drying up due not only to Wall Street’s shenanigans but also to donor fatigue. As the article reports, hope soared in the last decade as efforts by MSF, the Clinton Foundation and others led to dramatic falls in the prices of drugs, presenting a tremendous opportunity for international donors to make an impact by making available  the life-extending drugs that hade been available for years in developed countries but remained out of reach for the vast majority of HIV patients.

This “golden window” is now closed; some of the funding initiatives and grants that helped to open clinics  are coming to an end, and no new money is coming in to increase the availability of treatment, at least not at the pace needed to seriously curb the epidemic. The result? HIV patients in Uganda are now being turned away from clinics. There is justified fear that this “Kampala situation” will only spread to other countries and set us back to where we were in the 90s, when so many died without any hope for treatment. This is particularly alarming in the case of the HIV epidemic, with success being heavily dependent on not only maintaining already existing treatment slots but also increasing treatment availability rapidly. The situation is alarming, but I hope that the alarm bells will lead not to panic but rather to a serious examination of the mistakes that have been made and a reformulation of how we practice global health.

“The world on a nutritional brink”–the problem of eroding food security

Today the school of public health welcomed Patrick Webb of Tufts University and the World Food Programme to discuss the food price crisis that sent a wave of (often deadly) riots across continents, from Mexico to Mauritania. Much of the talk centered around the fact that this was not a food crisis per se, but really a crisis of prices. The problem was not food production, but rather the fear that food stocks were inadequate, which led to market speculation and reactionary protectionist policies by many countries (restrictions on food exports, hoarding of imports).

What does all this have to do with health? In poor families that spend a majority of their income on food, there is very little buffer zone to respond to the kind of dramatic price increases (upwards of 100% in some places) that occurred in 2007-2008. They step from the brink into the abyss. There were a billion chronically undernourished people in the world in 2009, shamefully enough, the first time this statistic as been this high since the 1960s. After decades of decline in undernourishment, we are now seeing a rise over the past decade, and more troubling, an acceleration of that rise, with the 2008 crisis leading to 30,000 to 50,000 more infant deaths in Africa than if the crisis had not occurred. That’s a lot of dead babies, folks! Not to mention those who did not die, but suffer from the devastating consequences of wasting, stunting, and micronutrient deficiencies.