Supplying Hydroxyurea to treat sickle cell disease in Jamaica, WI

In Jamaica, sickle cell disease is a public health issue. Approximately, 1 in 150 births are diagnosed with sickle cell disease.  In the past, Jamaica has been the focus of studies on the disease due to its population(http://www.sciencedirect.com/science/article/pii/0268960X9390001K).  The genetics of the disease, treatment and coping skills of those affected have been published.  Jamaica is a developing country and therefore all resources for the treatment of sickle cell disease is not readily available to all patients.  Though overall Jamaican patients with sickle cell disease have an better experience with the disease, they deserve to have access to all treatments (http://onlinelibrary.wiley.com/doi/10.1002/pbc.25563/epdf).  Hydroxyurea is a drug that has been significantly beneficial for sickle disease.  The drug does not cure but lessens the symptoms of disease.  Until recently, the drug was only available to those on the island that could afford it.  Currently, there has been an investment by the government to provide Hydroxyurea to all sickle cell patients who would benefit.  I would like to see continued commitment by the country to secure funds to support the treatment of sickle cell disease with Hydroxyurea.  My fear is that in a country where the US dollar is worth approximately 115 Jamaican dollars, there will be difficulty maintaining this financial support. Also, access to the medication may also be compromised due to the countries financial standing.

Stakeholders include first, the National Health Fund (http://www.nhf.org.jm/) which in 2015, contributed funds to have patients receive medication including Hydroxyurea to treat sickle cell disease (http://www.jamaicaobserver.com/news/Persons-with-sickle-cell-disease-can-now-benefit-from-NHF-_19153890).  The fund has significant interest in providing policies to assist with the care of the sickle cell population.  Second, Ministry of Health (http://moh.gov.jm/annual-reports/) in 2015, established National health fund with sickle cell disease as a priority for the island.   Third, would pharmaceutical companies which produce Hydroxyurea  be willing to supply the medication at a lower cost to this developing country?  What are benefits and burdens to those companies.  Fourth, the University of the West Indies Hospital, which is the home hospital of the Sickle Cell Trust. This is one of the teaching hospitals in Jamaica.  Fifth,  Kingston Public Hospital (http://www.serha.gov.jm/)hydroxyurea would be made available to patients at this institution as well, however, unsure of their commitment to treating sickle cell disease.  Finally, the sickle cell support foundation of Jamaica (www.sicklecellfoundationja.org/) raises awareness about the disease. Funding for patients. Among the founders are at least one with sickle cell disease and they have a positive bias to try and assist others with the disease.

I support making Hydroxyurea available to many of the patients with sickle cell disease. It is not a cure, but is less expensive with lower morbidity and mortality than the cure, bone marrow transplant.  In the long run, Hydroxyurea will save the island money that may have been used to care for these patients in the hospital either as outpatients or inpatients.  In addition, the medication could improve the experience of those with sickle cell and eventually change the stigma that surrounds the disease in Jamaica.  I would primarily appeal to the ministry of health to continue their efforts to support the supply of hydroxyurea to those with sickle cell anemia in the country.

 

Self-Determination in American Indian/Alaska Native health care

In 1975, the Indian Self Determination and Education Assistance Act (PL-93-638) was passed to allow for tribes to contract with federal agencies to govern their own services. Tribes, considered “dependent domestic nations”, have varied in how much they have taken advantage of self-determination opportunities in health care. For example, 99% of the Indian Health Service (IHS) funding in the Alaska Area is under tribal control, while very little of the Great Plains Area has been transferred to tribal control. Under treaty rights, the federal government is responsible for the “proper care and treatment” of members of recognized tribes in perpetuity. There exists some sentiment that self-determination is a way of letting the federal government out of its treaty responsibilities to Native people.  Others, like Donald Warne, MD, MPH, see so-called “638” tribally-managed health care as offering increased opportunities for third party revenue and grant funding, and increased local control versus IHS facilities, resulting in more services and better access.

AI/AN health care funds are not considered an entitlement like Medicare, Medicaid, or VA benefits, meaning that Congress must appropriate funding annually. In 2014, this was $3099  per user, which is less than that spent on federal prisoners. In comparison to the general US population, AI/AN people suffer higher age-adjusted death rates (from diabetes, chronic liver disease and cirrhosis, accidents, tuberculosis, pneumonia and influenza, suicide, homicide, and heart disease), as well as infant mortality twice the general population.  IHS is a severely underfunded and understaffed agency, which, at least in the Great Plains Area, is providing care which Senator John Barrasso (R-Wy) recently called “malpractice”.

I am calling upon the IHS to provide technical assistance, capacity development, and transfer planning for tribal control. I am also calling upon Congress to fund these efforts for the improvement of AI/AN health.

 

Decreasing Household Costs of Dengue Prevention at Low-Altitudes in Colombia: Redirecting Resources into the Hands of People Who Slap Mosquitoes Everyday

Photo by James Gathany

Colombia bears high burdens associated with dengue.  During the 2010 epidemic, disability-adjusted-life-years lost were 1178.93 (per 1 million inhabitants) versus just 88.38 averaged for 2011-2012.  Rodriguez et. al (2016) estimated economic burdens higher than $129.9 million USD each year, with most of the burden at the individual household level (46%, 62%, and 64%) for preventing/controlling mosquitos.

The Colombian Ministry of Health and Social Protection uses the 1,800m elevation mark when allocating money to low-altitude departments for dengue-related expenditures.  This suggests that only half of Colombia’s 47 million residents are at risk for dengue.  However, many people vacation at low altitudes where they risk becoming infected and bringing dengue back home.  If low-altitude residents were better equipped to control mosquitos, then both residents and visitors would be better protected.  Unfortunately, low-altitude residents shoulder a greater financial burden for mosquito prevention than the government.  Rodriquez et al. (2016) reported that almost $85 million USD was the highest household burden (for prevention alone) between 2010 and 2012, while the highest government burden was only $35 million USD (for prevention, awareness campaigns, and control combined).

If the Ministry of Health and Social Protection’s vision of equity-based protection and healthcare resources for all is to come to fruition, more money must flow into prevention and control.  Residents should not have to buy expensive sprays when they already live in poverty.  If Ministry-controlled finances were earmarked for inexpensive yet effective household supplies, such as curtains and water container covers, then less money would be required for treatment.  I advocate for reshuffling some of the dengue-related funds to reflect the prevention priority; increase amounts for household prevention and decrease treatment allocations.

Let’s not make low-altitude residents choose between buying expensive sprays or food to eat.  It’s hard enough already just to slap together supper.

Protect mothers, children and the poor from “Universal Health Coverage”

Universal Health Coverage (UHC) has been one of the top agendas in global health under Sustainable Development Goals. (Click) While having a common goal on UHC, paths to reach UHC vary across countries. (Click)

Lao PDR has had different social health protection schemes in the country such as compulsory insurance scheme for civil servants, free service scheme for mothers and children (Free MCH), and Health Equity Fund (HEF) for the poor. (Click) In addition to those schemes, in 2016, Ministry of Health (MOH) in Lao PDR has endorsed a new policy on National Health Insurance (NHI) for population in informal sector. There have been raised an issue on overlap of target population among different schemes. For example, a mother of a civil servant family could be covered both by insurance scheme for civil servant and Free MCH scheme. Ministry of Finance has raised concern that it may cause inefficient financial management. Currently, Ministry of Finance is proposing to integrate HEF and Free MCH schemes into NHI under one umbrella of Universal Health Coverage (UHC).

While we agree on improving coordination among different social health protection schemes, we insist that mothers, children and the poor, should be protected with special care in the process towards UHC through HEF and Free MCH schemes. NHI scheme is responsible for two thirds of the population, and yet covers only 4% of the target. (Figure) If we integrate HRF and Free MCH schemes before coverage of NHI is ensured to everyone, we may lose the only existing protection for mother, children and the poor.

We need to protect mothers, children and the poor through HEF and Free MCH until NHI is fully functional in the process of achieving UHC.

Playing By the Rules: How to Address Attacks on Healthcare in Combat

The last decade has seen a rise in attacks on healthcare workers in areas of conflict. Alongside increasing attacks on civilians, ambulance drivers, doctors, and healthcare support staff also find themselves unwilling targets of modern warfare. Such attacks are a clear violation of International Humanitarian Law as stated by the Geneva Conventions and threaten to destroy our concept of human rights and civility.

As the nature of warfare changes, strategies to enforce the protection of civilians and healthcare workers must be adjusted. Ensuring that innocents are protected and access to health is not hindered must always be a priority.

In May of this year the UN Security Council took the first necessary step in protecting the lives of healthcare workers by adopting Resolution 2286 condemning attacks on medical personnel and facilities. However, until the perpetrators of these heinous acts are held accountable for their actions these measures amount to nothing more than empty words.

The Unites States has an opportunity to set an example of how attacks like these should be addressed. On October 3, 2015 an airstrike hit the MSF-run Kunduz Hospital in Afghanistan killing 42 and injuring more than 30. It has since been discovered that the attack was conducted in error by a US Airforce gunship. While the US government has conducted investigations, acknowledged errors and punished those who were involved, they have been rightly criticized by many for the inherent bias in such investigations and the reluctance to call these attacks crimes against humanity.

Medical staff after the attack on Kunduz Hospital – photo courtesy of MSF

If “even wars have rules,” as stated by Secretary Ban Ki-moon, then it should follow that all member states should abide by them. Until the US attack on Kunduz Hospital is treated as a crime against humanity and a transparent and independent investigation is conducted there will be no hope for rogue nations, terrorist organizations and other actors to respect these foundations of international law. The United States needs to recognize this challenge and play by the same rules it would readily enforce upon others.

Legalizing Cannabis Sales in DC is a Matter of Public Safety and Public Health

In 2014, voters legalized the personal possession of cannabis for adults 21 years or older via ballot initiative. However, unlike the states of Colorado and Washington which legalized in 2012, the District’s ballot initiative did not include a system to legalize the sale of cannabis. This is due to a clause within the Home Rule Act, the District of Columbia’s version of a constitution, which prevents ballot initiatives from containing provisions which affect the city’s budget. In an effort to close this gap, elected officials in the District were planning on implementing a system to tax and regulate commercial sales of the plant, when the United States Congress, which has historically had legislative and fiscal authority over the District, attempted to block the District from moving forward with this plan by restricting the use of city funds to implement the law. While this is the prevailing belief of most drug policy observers, the city has methods of creating a taxation and regulation system for cannabis in spite of the attempted Congressional blockade.

As previously mentioned, the Home Rule Act establishes the legal foundation for local government in the District. It also contains a provision which establishes a special fund, which allows the Mayor of the District of Columbia to use monies saved in the fund for unforeseen, nonrecurring, needs that arise during the fiscal year, including natural disasters, unexpected obligations created by federal law, new public safety or health needs identified after the budget process has occurred, and other fiscal shortfalls arising in the District’s budgetary process. Having a law which allows for the personal possession of cannabis, but provides no means for individuals to acquire cannabis has creates a situation where black market sales have proliferated, and individuals continue to find ways to undermine other public institutions, like the United States Postal Service, in order to circumnavigate the law. More importantly, by not having a system for regulated sales, citizens of the District of Columbia lack the safe guards and quality assurance that comes from making purchases in a storefront. Clearly there are matters of public safety and public health before the elected officials of the District of Columbia, and using monies from the special fund to legalize the sale of cannabis seems most prudent.  

Advocacy organizations like the Drug Policy Alliance, DC Vote, and DC Appleseed have lobbied elected officials to take action on using special funds to establish a system to regulate cannabis in the city. The efforts have been reinforced by polling in the city which shows that approximately 80% of District residents want this change as well.

The political pressure has resulted in some action on the part of the elected officials in the city, as recently the DC Department of Health released a report calling for regulations to be established around cannabis in the city. Furthermore, the District’s Attorney General given the legal blessing to using the District’s special funds for this purpose. Currently the fund has $135.9 million, of which, only a fraction would be needed to pass this legislation. Mayor Muriel Bowser has been on record in support of creating a system for taxing and regulating cannabis in the District since as early as 2014. With all of this political, legal and fiscal support, why does she not draw down the funds to make the change happen? The public safety and public health of the citizens depend on it.

Food Security in Northern Nigeria: Is it Attainable?

Background

Malnutrition is a significant concern in parts of Africa, including Nigeria despite its rich agriculture accounting for deaths and growth stunt in 50% of children under five in the country. It has been recognized as consequence of poverty and poor nutrition education. In 2004, Nigeria launched a 1o year strategic plan (National Plan of Action) on its newly adopted food and nutrition policy, the National Policy on Food and Nutrition (2001), to address the food crisis over the next decade. It aimed to reduce poverty by 10% by 2010 and reduce starvation, chronic hunger and increase access to food among many other goals and objectives. Majority of the time, nutrition policies in Africa tends to promote food importation rather than building domestic, high-quality food capacity however this policy includes goal of increasing production in addition to its imports based on nutrition research.

Neglecting domestic production and animal stock creates a missed opportunity to address the micronutrient undernutrition children faces.

Problem

Nigeria has been supported by numerous other organizations in address its undernutrition issue. In 2011, The Working to Improve Nutrition in Northern Nigeria program, funded by Department for International Development (DFID) and implemented by the Nigerian Government, was launched to improve nutrition in over six million children under the age of 5 years in northern Nigeria. This program mainly provides treatment of malnutrition in these children, thereby reducing the stunting, wasting and underweight, and reducing childhood mortality. In just the few short years of the program’s implementation, it’s been noted that there has been increased State and Federal government’s commitment in addressing this issue, not even up to a decade yet compared to the initial policy implemented by the Nigerian government.

Based on ongoing research, it is clear that for the issue of malnutrition to be adequately addressed, preventive rather than treatment strategies must be implemented. A big challenge facing the resolution of malnutrition as well as food security in the rural parts of Nigeria is the need for continued funding and support. To truly stop this issue and make a lasting dent in the undernutrition issue in Nigeria, the nation must take ownership and leadership in providing a sustained action in the continued improvement of nutrition and health of its citizens. Specifically, Nigeria needs to recognize the value of its domestic agricultural richness and revisit its nutrition policy to build its domestic food production and enforce fortification of its food to improve micronutrient deficiency. It would be ideal if the government and other aiding organizations can invest more in securing food security for all households as set forth but the implemented policy. It’s important to note that the region of the country in question is also the region of the country that is responsible for the majority of the nation’s agricultural production. Unfortunately, in a country where corruption is so rampant and has infiltrated all ranks of the government’s structure, including its agricultural department, and also with repercussions from the recent insurgency of the notorious Boko Haram organization in the northern region of the country, perhaps attaining food security is a goal that may be best left on paper.

Intervention

The Federal government may benefit more from redirecting funds to building is agriculture in order to meet the goals of the policy. The nation’s published strategic plan does not include strategies aimed at improving its agricultural policies and food production. Doing this is not only a big step in achieving one of its set goals to attain food security in a sustainable manner but also, stimulates its economic growth that may address the poverty issue in the northern region of Nigeria, another one of the policy’s set goals.

Minority Youth, HIV and access to Pre-exposure Prophylaxis in NYC

Problem

The number of cases of HIV throughout the United States has decreased or stabilized among intravenous drug users and heterosexuals, but increased among men who have sex with men (MSM) especially minority youth and young adults. In 2014, 22% of newly diagnosed HIV cases were in youth between the ages of 13 and 24 years of age and more than 80% of those individuals were MSM/bisexual. There has also been significant increases in minority cases of HIV (87% increase in black MSM who are newly diagnosed HIV cases).  Reasons for increased HIV rates in this population include poor education (in the form of age appropriate sexual education), risk taking behaviors (low use of barrier protection, multiple sexual partners), increases in sexually transmitted disease rates, substance abuse, psychosocial issues (loneliness, fear of rejection, bullying) and poor screening habits.

In New York City, sections of the Bronx, Brooklyn and Northern Manhattan have some of the highest rates of new HIV cases and these areas are also the location of the poorest neighborhoods in the city. As with the national trends, the majority of these new cases involve minority youth and increases in new cases in these communities suggest that there are multifactorial issues that need to be addressed.

http://www.avert.org/professionals/hiv-programming/prevention/pre-exposure-prophylaxis

Prevention

One preventative that has been successful in reducing exposure to HIV is pre-exposure prophylaxis (PrEP). There is controversy regarding its use in adolescents because of concerns about bone growth and other potential side effects. When taken properly, it can reduce the risk of contracting the infection in high risk individuals by 92% making it an option that cannot be ignored.

Intervention

In NYS, minors do not have the same protections (NYS Public Health Law, Minors’ Consent Law) as those seeking reproductive health care or treatment for sexually transmitted disease. Individuals desiring this medication must have parental consent for treatment and many providers are unwilling to prescribe without some clear guidelines and protections from the state and the CDC. This requirement likely prevents minors from seeking care, making a powerful preventative unattainable to high risk youth. Amendments to the Minor Consent and Public Health Laws would set the groundwork for the introduction of PrEP to these populations in the city allowing clinicians to address this issue and hopefully see a reduction in new cases.

 

 

Addressing Canada’s Bill C14:Medical Assistance in Dying (MAID) Patient Eligibility Criteria

Canada is currently in the midst of a contentious debate regarding the validity and composition of a recently passed bill that permits suffering patients to consensually select a physician-mediated death. The bill, Bill C14: Medical Assistance in Dying (MAID), was passed during June 2016 by the Canadian Parliament and only applies to patients who suffer from a “grievous or irremediable condition” (Lancet). According to MAID, a patient must be at least 18 years old, have an incurable disease, be in an advanced state of irreversible decline and death must be reasonably foreseeable.

MAID was passed only after a narrowing of patient eligibility criteria deemed too expansive according to the Supreme Court of Canada, who stopped the original bill in 2015. It is our opinion that the current patient eligibility criteria, which does not include mature minors, patients with advanced mental disorders (ex. Dementia), or patients with advanced directives, should be expanded to include these vulnerable groups that are being unfairly excluded. We are on the side of a substantial stakeholder cohort that believes that an expanded patient eligibility criteria focusing on overall suffering and patient interpretation of their quality of life should be amended to Bill C14.

It is vital that leaders of patient advocacy groups, such as Dying with Dignity Canada, work with family members of individuals who could benefit from an expansion to raise public awareness and jointly formulate a strategy to engage influential peripheral stakeholders, such as the Canadian Medical Association (CMA). With regards to the CMA, clarification regarding patient eligibility and avenues by which physicians can refer patients, that they are uncomfortable in helping die, to another willing physician would help address barriers that the medical community have with respect to the implementation of a policy that they generally support on moral and ethical grounds (see figure 1)

(Figure 1: Graph depicting survey responses of 595 Canadian Medical Association Members,Source:Dr. Blackmer, CMA)

Raising public awareness, combining patient advocacy into one voice, and addressing the logistical issues preventing a key stakeholder from supporting a cause that they morally support are just a few suggestions that may convince the Canadian Parliament to amend bill C14. Only an amendment would allow the MAID bill to achieve the spirit of justice and mercy that underlies its’ core goal.

 

Helpful links:

1. Presentation regarding CMA physician regarding MAID:http://www.slideshare.net/CanadianMedicalAssociation/strategic-session-on-endoflife-care-in-canada-dr-blackmer/14
2. Lancet article arguing for MAID criteria expansion:http://ac.els-cdn.com/S0140673616312557/1-s2.0-S0140673616312557-main.pdf?_tid=235f7cf2-6340-11e6-ae06-00000aab0f26&acdnat=1471303960_532d675e72c06b219a268e618df47f51
3. Local stakeholders provide commentary on MAID to media: http://www.ctvnews.ca/health/key-stakeholders-react-to-assisted-dying-bill-1.2860104
4. News release by Canadian Supreme Court articulating their rejection of original bill in 2015: http://news.gc.ca/web/article-en.do?nid=1085689&tp=1

Can Children and Cricket Team Up with UNICEF for a Cleaner Odisha, India?

India has the largest prevalence of human open defecation in the world. Approximately 564 million people don’t use toilets. Consequently, as many as 1/10 of the deaths in India are caused by poor hygiene and sanitation, linked to open defecation. This issue is particularly problematic for children. Children are more vulnerable to disease by being exposed to open defecation areas near their communities and are at greater risk for childhood stunting or death from diarrhea.

In 2015, UNICEF and the International Cricket Council announced a 5-year partnership aimed at advocating on behalf of the world’s most disadvantaged children. The first public step the partnership developed was the launching of Team Swachh, a program aimed at changing experiential and instrumental attitudes and subjective norms around open defecation in India. Utilizing big name celebrities, Team Swachh teaches children the importance of practicing sanitary behaviors and using toilets.

Figure 1 http://unicef.in/CkEditor/ck_Uploaded_Images/img_1265.jpg

One quick win for Team Swachh could be in Odisha. Odisha is a rural coastal state in India that has a high incidence of poverty and disease burden. Infant mortality is 50/1000 births. Reducing death in children under age 5 is a priority for the state. Odisha is also one of the lowest performing states in latrine coverage and only fifty percent of newly constructed latrines are used. While ~ 96% of households have access to piped, pumped or well water, sanitation remains a challenge. The state government has adopted the Swachch Odisha Mission to eliminate open defecation using a community-led approach, but more can be done to address this important issue.

Capitalizing on the influence celebrities have on subjective norms, members of UNICEF Odisha partnered with Team Swachh can increase utilization of existing latrines by recruiting more “sanitation champions” in 2017 to reach the 2019 goal of eliminating open defecation. Make Odisha a priority by tweeting “Bring Team Swachh to Odisha #toilets #health @UNICEF”