Counterfeit Medications Continued

            After our discussion in class on Monday, I thought it would be interesting to do a little more research on the topic of counterfeit drugs on a global scale. I looked on the World Health Organization website and found a lot of quality information and facts that I think you all would enjoy!

            One of the biggest issues with counterfeit drugs is once again, the fact that there is no universally adopted definition of what a counterfeit drug is. This makes it harder to see the true extent of the problem on a global scale and limits peoples' ability to understand the issue. According to the WHO, the definition of a counterfeit drug is, "deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging".

            They go on to explain the extent of the problem to the best of their ability. They know that this issue is occurring in developed and developing countries, but once again they do not know how bad the problem is due to the lack of research and studies that have been done. This was first noted as a problem in 1985 in Kenya and has been growing ever since. Between January of 1999 and October of 2000, the WHO received 46 reports relating to such drugs from 20 different countries (60% from developing countries and 40% from developed countries). Some of the drugs that were counterfeit were antibiotics, hormones, analgesics, steroids and antihistamines.

            Another thing that I found interesting was the way in which the WHO grouped counterfeit drugs. There are six different categories as follows:

• 1.     Products without active ingredients
• 2.     Products with incorrect quantities of active ingredients
• 3.     Products with wrong ingredients
• 4.     Products with correct quantities of active ingredients but with fake packaging
• 5.     Copies of an original product
• 6.     Products with high levels of impurities and contaminants

(The above are listed in order of which one is most common to which one is least common.)

            One of the biggest problems that we face in addressing the issue of counterfeit drugs is the fact that some factors actually encourage the production of these types of drugs. For one, medicines are high value items and they are always going to be in demand. Also, the substitutes that are put into medications are a lot cheaper to buy than the other active ingredients. Producing counterfeit drugs can also be done almost anywhere and there isn't a huge factory or facility that is needed to do so. This is an easy area to deceive people because of the fact that your everyday citizen won't be able to detect whether or not their drug is counterfeit. The following list describes many of the factors that encourage the production of counterfeit drugs:

• ·      Lack of political will and commitment
• ·      Lack of appropriate drug legislation
• ·      Absence of or weak drug regulation
• ·      Weak enforcement and penal sanctions
• ·      Corruption and conflict of interest
• ·      Demand exceeding supply
• ·      High prices of medicines
• ·      Insufficient cooperation between stakeholders
• ·      Lack of regulation by exporting countries and within free trade zones
• ·      Trade through several intermediaries
• ·      Impact on public health

            This clearly shows how difficult it will be to completely fix this issue. As we discussed in class, it is something that should be more recognized and that is getting more research. At the same time, it is important to develop numerous interventions and ways of stopping this from occurring in order to eliminate this problem in the future.

References:

http://www.who.int/medicines/services/counterfeit/overview/en/index2.html

The Green Revolution

Recently in my World Food Problems course, we discussed the Green Revolution. Since I have never heard of the Green Revolution before that class, I figured that some of you might not know about it either. This is what has led me to share this topic with you.

During the late 1950s to mid-1960s a concerted research effort was established to create modern or high-yielding crop varieties, beginning with rice and wheat plants in Asia and Latin America. This research effort later became titled as “The Green Revolution.”

Early modified crop varieties of wheat and rice were quickly adopted in areas with either good irrigation systems or reliable rainfall. However, adoption was much slower in sub-Saharan Africa where irrigation is limited and rainfall is unreliable. Additionally, in these areas crop variety is limited as well, increasing the difficulty for researchers to find suitable genetic alternatives.

In the early days of the Green Revolution only 2 centers were established for modern variety crop research, however currently 16 centers have been established for research purposes. These centers support 8500 scientists/staff and have an annual budget of $350 million.

Researchers, Evenson & Gollin, recently assess the impact of the Green Revolution and how the food market would have differed without this research. Evenson & Gollin report that the late Green Revolution period (1981 to 2000) has the most gains. Yield growth from modern varieties accounted for almost all of the increases in food production in developing countries. Additionally, researchers were able to model outcomes if the Green Revolution did not take place. Without international research in crops…

•      Calorie intake per capita would be 13.3-14.4% lower in the developing world
•       There would be a 6.1-7.9% increase in malnourished children in developing countries
•       Developed countries would have to increase food imports by 27-30%

While criticism exist about the sustainability of intensive cultivation, soil degradation, chemical pollution, aquifer depletion and soil salinity. Evenson & Gollin highlight the fact that developing countries don’t have many alternatives to meet population needs with low environmental impact. Further research needs to be completed on environmentally friendly technologies that developing countries can assess and adopt.

Even though criticism still exits, the Green Revolution lowered food prices worldwide.  During this period of concerted research effort productive increased and prices fell. The Green Revolution exhibits what can be accomplished when the brightest in the world come together to solve a problem. With researchers working together to address diseases and challenges from developing countries, anything can be accomplished.

Reference:

Assessing the Impact of The Green Revolution, 1960 to 2000

Science 2 May 2003: Vol. 300 no. 5620 pp. 758-762

Is Environmental Justice a Global Health Concern?

China's Hunan province has a heavy metals problem. The province has long been an important region for heavy metal production and processing. Home to over a thousand non-ferrous metal companies, it had the third highest quantity of metals produced of China's provinces, in 2011. The worth of this production is approximately $60 billion. That money will fall a bit short of offsetting the $1.6 trillion it may cost to clean up the region's soil and waterways.

The pollution created during the processing of heavy metals in Hunan has claimed human lives and huge quantities of arable land. China's Ministry of Environmental Protection's investigation indicates that in 2006, 8.3 percent of China's arable land was contaminated to levels making it unsafe for agricultural purposes. Villagers in rural areas are finding alarming rates of heavy metal poisoning deaths in their communities and once productive fields and rice paddies have become places to avoid, let alone work in intensively. The villagers are effectively victims of structural violence, facing illness and economic disadvantages at the hands of industry and being effectively ignored by local and national government institutions (1).

A chemical factory beside a rice paddy in Yixing in Jiangsu Province, where industrial polluttion has contaminated soil and food crops.
Source: Yale360

Issues of environmental injustice, situations where specific social groups bear a disproportionate share of the affects of an environmental hazard, are global issues. Arsenic from gold mines in Africa makes its way into local waterways causing chronic and acute health issues in nearby villages, minority communities in the US are vastly more likely to have operational toxic facilities near them, and many other groups with relatively low social capitol across the world face the health impacts of environmental dangers. These sources of potential harm are prevalent in their communities, because their lower socioeconomic status increases the difficulty of keeping them outside of their communities (2).

While a definitive link between environmental inequality and disparity in community health has yet to be established, limited progress has been made in doing so. In the United States, it has yet to be quantitatively proven that communities which are burdened with our environmentally undesirable enterprises are more likely to suffer from health issues. That being said, I think it could be argued that a rural farmer in Hunan is clearly more likely to suffer from cadmium, lead and arsenic poisoning than local government officials or the operators of the plants creating the heavy metal pollution.

Large scale pollution can affect communities and individuals, but no where in the United Nations

Declaration of Human Rights is anyone guaranteed a living environment free of pollution. Pollution of the largest scale, the anthropocentric forces driving climate change, is the focus of the highly publicized UN Climate Summit being held in New York. Many of the more persuasive arguments for immediate changes to international climate change policies will have a human element, emphasizing that the actions of the world's major resources consumers will have an increased impact on the world's poor as our global climate shifts over the coming century. Basically, when facing decisions regarding the state of the environment, think people not polar bears.

Despite the lack of a research-proven, quantitative link between environmental justice issues and public health, should we be including environmental justice in our discussions about global health? Dr. Maria Neira, the WHO Director of the Department of Public Health, Environmental and Social Determinants of Health, would say so. In a commentary article published on Sept. 19th, in advance of the UN Climate Summit, Dr. Neira points to localized reduction in crop yields and increased numbers of disease carrying insects after flooding as ways in which the WHO's estimate of an increase of 250,000 deaths per year could be realized. Those who will be increasingly at risk are those who already bear the burden of under-nutrition and malaria, the world's poor, young and old (3).

So what do you think? Should global health policymakers and actors be concerned with environmental justice issues, or is the pursuit of environmental justice across the world someone else's battle?

References

(1) Guangwei, He. "The Soil Pollution Crisis in China: A Cleanup Presents Daunting Challenge." Yale Environment 360. 14 July 2014. Web. 29 Sept. 2014. <http://e360.yale.edu/feature/the_soil_pollution_crisis_in_china_a_cleanup_presents_daunting_challenge/2786/>.

(2) Brulle, Robert, and David Pellow. "Environmental Justice: Human Health and Environmental Inequalities." Annual Review of Public Health 2006 27 (2005): 103-24. Annual Reviews. Annual Reviews. Web. 29 Sept. 2014. <annualreviews.org>.

(3) Neira, Dr. Maria. "Climate Change: An Opportunity for Public Health." World Health Organization: Media Centre. WHO, 19 Sept. 2014. Web. 29 Sept. 2014. <http://www.who.int/mediacentre/commentaries/climate-change/en/>.

Communication in global health

This will be a little rambling...

This weeks readings (and, most the of course readings) have me thinking about the specific role to be played by the Communication discipline in public health. To me, it seems like the traditional transmission or "magic bullet" model of health interventions is in the rear view of global health. By magic bullet, I mean that we design a health campaign aimed at changing an 1) attitude, 2) behavior, 3) value (yikes, loaded). You do your formative research, go to your audience, ask all the right questions and design an intervention in such a way that the information or message is persuasive to your population of interest. This is simplified, but I think it reflects much of the past campaign work in developing countries or global health. I loved reading Paul Farmer’s work from this week, but, again, I want to find a place for Communication people. Is it education? Engagement? Communication for me is a tool—it is the means through which I hope to change or improve public health. With global health, we see that structural violence /barriers are the pressing issues—economics, poverty, gender relations and historic negligence by the government or ruling party. This is not so much an information war/campaign as development and infrastructure. I specifically loved that Partners in Health (PIH) were able to reject the notion that lay or culturally rooted beliefs about sickness or illness are what were stopping people from getting  or seeking care. It was a surprise to me. So what can Communication scholars add to the field of global health?
            As Communication scholars, I don’t think we can completely abandon the idea of the transmission model of communication. Our strength is in our understanding of the relationship between source, message, and receiver. This model is implicit in all of the work we read about—why are Community Health Workers (CHW) so effective? In my opinion, it is source characteristics and their effect on the reception of the message. This is an area where Communication scholars should excel! A second area I think communication scholars can contribute is in the area of health literacy and risk communication. Health literacy (more on this in later posts) is:

Health literacy is the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions (Hewitt & Hernandez, 2014).

The authors go on to say that “Nearly half of all American adults—90 million people—have inadequate health literacy to navigate the health care system”. Does that surprise you? This is in America, where I bet all of you would say or assume we are better educated than any of the populations in any of the case studies. That isn’t necessarily a criticism of any of us, but I think it does point to some implicit assumptions we have about the populations and areas in the case study (a rant for another day?). Risk communication, a slippery idea with multiple definitions, can loosely be defined as “any purposeful exchange of information about health or environmental risks between interested parties” (Covello, von Winterfeldt and Slovic, 1986; as quoted in Renn and Levine, 1991). The communication of risk is importantly tied to health literacy. Risk is an “especially complex mathematical concept that the public as well as many professionals need help in understanding” (Hewitt and Hernandez, 2014). While numerous disciplines are interest in the concept of risk and risk information, it should be the role of Communication scholars to study and aid the understanding and communication of risk once identified. 

Additional reading;

This links to a huge pdf on health literacy. 

http://www.nap.edu/catalog.php?record_id=18756&utm_medium=etmail&utm_source=The%20National%20Academies%20Press&utm_campaign=NAP+mail+new+2014.09.16&utm_content=&utm_term=&utm_expid=4418042-5.krRTDpXJQISoXLpdo-1Ynw.0 

Emotions and Giving

Charitable giving by individuals is usually driven by emotion, not logic. Is this problematic? Yes and no. I recently read an article in the Health Communication journal comparing a campaign, Malaria No More, and the response to the earthquake in Haiti. This article caused me to think more about this issue, emotional driven giving. As a person who studies communication, I am always fascinated by what sort of messages elicit particular responses.

The malaria campaign, focused on providing mosquito nets to those in areas at high risk for malaria, was overall a success. They had used celebrities, like Ashton Kutcher, and a variety of social media platforms, like Twitter, Facebook, and YouTube. The celebrities involved were provided with messages to send out or tweet that would share information and statistics that were relevant to the campaign. Most aid sent for Haiti, on the other hand, was prompted by witnessing disaster footage and listening to the stories of victims on television. Both situations provided easy methods of giving: either through clicking an icon on twitter or sending a text message that would be added to the person’s cell phone bill.

What health communication scholars Turner and Robinson (2014) attribute the difference in individual’s charitable giving to is a “vicarious emotional experience.” People are more likely to give to a cause where they can see those affected telling their stories than they are when they see numbers. Perhaps giving the celebrities in the Malaria No More campaign prewritten tweets kept them on target in terms of information accuracy, but it did not allow for their expression about their emotional response to the issue. Using media platforms like Twitter and making giving easy through smartphone use is not enough to make a campaign effective. An emotional connection is needed.

So, I ask again, is this fact problematic? Yes, in the sense that giving will not necessarily be the result of true need, but pulled toward causes for which those with authority, money, or influence feel deeply. This can also cause instability in giving (when the emotional appeal is gone, the money goes too).

So how can this be a good thing? I would say that knowing emotions drive giving is a powerful thing in and of itself. If those at the top or setting the agenda (which I will get to in a later blog) are capable of rational selection of campaign goals, then emotional appeals can be used to further that campaign. Yes, there are ethical debates about the use of emotional appeals in persuasion, but I will not discuss that here. What I find most promising is that hearing the individuals affected by whatever disease or catastrophe is being targeted has a great impact. This means that it is in the campaign’s best interest to project the voices of those affected to those giving. I think encouraging this idea could have a larger effect on the global health scene than simply increasing numbers of charitable giving for individual campaigns. Provided that the stories projected are truly the ones these individuals wish to tell, it could spark a conversation about what type of things are really needed worldwide in terms of health.

Turner, J. W., & Robinson, J. D. (2014). Malaria No More: Nothing but Nets.Health communication, (ahead-of-print), 1-2.

Malaria No More's website: http://www.malarianomore.org/

U.S. versus European healthcare costs

I was very interested to delve into this topic deeper after we discussed it in class.

I studied abroad in Italy, developed Strep throat, and went to a doctor. However, instead of going to the public hospital, I was sent to a private, American doctor. I did not know any better at the time and listened to the advice of the school's headmaster.

However, when I came back to the states, people asked, "Why didn't you go to the public hospital, isn't it free?" Which made me think about public healthcare provided by the government verses private corporations.

Yes, we have learned and discussed the matter of USA spending the most compared to other countries on healthcare, with little difference in outcomes (if not poorer outcomes). I managed to find an article where the author delved into reasons why that was.

He had the following hypotheses as to why healthcare cost so much in the USA:

1. Most U.S. citizens are wealthy, so we just pay more in our economy overall
2. We have an older and sicker population
3. Americans tend to utilize more healthcare services (e.g., go to doctors, hospitals and emergency rooms more)
4. High costs comes from our use of more technology
5. We charge higher prices for the same goods and services.

When he compared the 5 hypotheses to the rest of the world, I found the answer to be surprising.

1. While most countries do spend more when they have more money, the U.S. disproportionately spends more, by about $3,000 per head on healthcare compared to other wealthy countries.
2. The proportion of the population older than age 65 is 13% in the USA. The data collected from the OECD (Organization for Economic Cooperation and Development) had a median of 16%. The USA's 13% is much lower than Japan’s 23%. Also, our population does not necessarily seem to be more ill. Among key healthcare risk factors such as smoking and drinking, Americans actually do better in most cases. Our major problem is obesity.
3. The average number of physician visits per person in the USA is 4, below the OECD median of 6.4, and far below Japan’s 13 visits per person. The average hospital stay per person is also lower in the USA at 5.4 days versus the OECD median of 5.9 days and Canada’s average of over one week (longer stay=higher costs).
4. Americans get less MRI scans per person than Japan, and have fewer hip and knee replacements and cardiac catheterizations than many European countries. In fact, the distribution of our spending (basic medical care, diagnostics, hospitals, pharmaceuticals, and nursing homes) is not very different from European countries.

This leads us to the last hypothesis: Do we charge higher prices for the same goods and services?

So the answer is, yes. More money is spent in the USA on drug and imaging, along with higher physicians’ fees and income compared to other countries in the world.

The question now becomes, if the USA really wants to cut back spending on healthcare, how?


Source:
http://epianalysis.wordpress.com/2012/07/18/usversuseurope/

New Maternal Health Issues

           A current and long-time focus of international and global health initiatives take a concentrated look into maternal and child health as a whole. One of the important ideas is that fact that by providing safe and quality sexual and reproductive health care, we are able to decrease global rates of maternal morbidity as well as maternal mortality. Another initiative is to provide access to contraceptives as well as push women to utilize facilities that are made for childbirth. Among all of these initiatives, facilities have improved their safety and sanitation and there has been an increase in financial support for this specific issue.

            One of the main topics that we discussed in class on Monday was about basic human rights and if health care was to be considered a basic human right. While looking through topics to blog about this week, I stumbled upon an initiative proposed by the World Health Organization that involves preventing and eliminating disrespect and abuse during facility based childbirths. The statement that was given by the World Health Organization stated, "Every women has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care". I thought that this topic tied nicely into our discussion from class on Monday because in that statement by the WHO, they concur that every women has the right to distinguished health care.

            There are obviously some things behind the scenes that we don't always see. Maternal and child health has always been a pretty big issue on the global health forefront, but not as much attention has been brought to this specific issue of disrespect and abuse during childbirth. According to the WHO, research has been growing on this issue and many women's experiences, not only during childbirth, but during pregnancy as well, have been quite disturbing. Researchers are finding that women across the globe have experienced these issues, not just in a generalized location. Not only does this violate trust between the women and their health-care counterparts, but this could be another huge reason why women wouldn't want to seek maternal health care services. Some of the specific treatment that has been noted has consisted of things such as physical abuse, humiliation and verbal abuse, unconsented medical procedures, lack of confidentiality, failure to get informed consent, refusal to give pain medications, refusal of admission to health facilities, neglecting women during childbirth that are suffering life-threatening complications, and even the detention of women and newborns because of the inability to pay.

            One of the issues with this new international health problem is the fact that there isn't a global consensus on how respect and abuse are measured or defined. Likewise, this issue is not a major concern because many people are unaware that it even exists. The World Health Organization suggested these five actions that should be taken in order to help bring awareness to and eliminate the problem:

1. 1.     Greater support from governments and development partners for research and action on disrespect and abuse
2. 2.     Initiate, support and sustain programs designed to improve the quality of maternal health care, with a strong focus on respectful care as an essential component of quality care
3. 3.     Emphasizing the rights of women to dignified, respectful health care throughout pregnancy and childbirth
4. 4.     Generating data related to respectful and disrespectful care practices, systems of accountability and meaningful professional support are required
5. 5.     Involve all stakeholders, including women, in efforts to improve quality of care and eliminate disrespectful and abusive practices

References

http://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/

http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.pdf?ua=1&ua=1

Comprehensive vs Selective PHCs Approach

Health services, no matter how efficient, cannot change the condition of the marginalized people unless they are helped to become self-reliant and the root problems addressed…. People who are poor and illiterate are like uncut gems hidden under the dirt and stone. Given the opportunity, they can reach their full potential and live as responsible, sensitive human beings, possessing self-reliance and the liberty to shed those old customs and traditions that impede health and development.” Arole and Arole, 1994

I like this part about sharing with the people , in a place, the decision of health care and include them in designing  health programs , I think this will maximize the effect of the program and facilitate a lots of logistics, culture, and traditional challenges that may face health worker in that area.

Medicine needs to be demystified and knowledge shared freely with people so they can attain and maintain good health…. Hierarchical attitudes have to be replaced by a team spirit and equality. The realization that knowledge not only gives power, but that sharing knowledge also increases self- esteem is important in the development of a team spirit.”Arole and Arole, 1994

Some of Challenges that facing Alma Ata and primary health care: It is too broad and idealistic with an unrealistic time table-Turning most of health attention toward GOBI-FFF (growth monitoring, oral rehydration, breastfeeding, immunizations, food supplementation, female literacy, family planning) -  Easy to monitor and evaluate - Has indicators of success and reporting. Selective disease-specific approaches are the dominant form of global funding today -  Global Fund to Fight AIDS, Tuberculosis, and Malaria -  President’s Malaria Initiative.

 But widespread agreement that more emphasis on horizontal/ integrated/systems approaches also needed. How to combine both systems?  Is a question that has to rise, and how can we get most of advantages of each system and try to minimize the drawbacks?

Comprehensive/horizontal approaches are all inclusive and integrated packages of service that are more holistic in looking at the health issues which would allow for direct community participation and ownership of the interventions (more like a bottom up approach). As good as it seems it does not have the authority to provide the policy space required, and it requires technical expertise for guidance and for the more advanced level of services.

While for the selective/vertical is more of a top down approach which are initiated and implemented targeted at a specific health issue with largely technical experts being on control. It is target driven with less control in participation of affected populations. This approach has a strong experts opinion to it based on analytical deductions and with policy support. It is mostly external intervention to the receiving population and might not be sustainable if the implementers leave and also it does not build strong community capacity.

 

Therefore to have effective and efficient re-burst functional PHCs that would meet the principles of the Alma-Ata Declaration the two approaches must be co-delivered where their respective strengths will complement their weaknesses and there will be involvement of all necessary actors in achieving the desired health care needs of the population with a two-prong approach of comprehensive/horizontal, selective/vertical interventions.