Obi Nnedu MD, MPH is an Infectious Disease Fellow at the University of Washington and has received a scholarship as a NIH Fogarty International Clinical Research Fellow to work in Kenya. He recently attended the MIM conference in Nairobi and shares some of his impressions here.

The 5^th Multilateral Initiative on Malaria (MIM) Pan-African conference was recently held in Nairobi. The world’s leading malaria scientists converged on the Kenyan capital to discuss strategies to eradicate malaria. Topics discussed were broad and ranged from treatment to drug resistance, from bed net use to malaria in pregnancy.  Perhaps one of the most discussed topics was malaria immunology and vaccines.

For several years, vaccines have been touted as being a great strategy for controlling and possibly eradicating malaria. Despite decades of research, an effective malaria vaccine has still not been identified.  The biggest challenge has been our lack of understanding of the correlates of immunity associated with malaria.  We are yet to understand why adults in malaria endemic areas are protected from death and severe disease associated to malaria.  At the conference there was no shortage of presentations on malaria immunology and vaccine candidates.

The most advanced malaria vaccine candidate is the RTS,S.  This vaccine was invented by Dr. Joe Cohen, vice president of Glaxo-SmithKline biologicals.  During the conference, Dr. Cohen addressed a team of journalists about the recently commenced Phase III clinical trials involving this vaccine.  16,000 children will be recruited in 7 countries namely Kenya, Tanzania, Gabon, Ghana, Burkina Faso, Malawi and Mozambique.  Dr. Cohen stressed the importance of various partners including PATH, the Bill and Melinda Gates Foundation and local in-country partners in the successful start of this vaccine trial.

The RTS,S vaccine is a combination of a malaria antigen, Circumsporozoite protein and a Hepatitis B antigen.  The proteins are combined and suspended in a liquid adjuvant system called AS01.  The combination of protein and adjuvant system, often referred to as RTS,S/AS01 will be evaluated in this Phase III trial.   RTS,S is the culmination of about 20 years of research according to Dr. Cohen.  This research started in the laboratory and is now at an advanced stage of field testing.  Dr. Cohen outlined the various steps the vaccine had undertaken to get to this current state, from phase I trials that proved the vaccine was safe to phase II trials that not only confirmed the safety of the vaccine but also showed that the vaccine had some efficacy.  In phase II trials vaccine efficacy against clinical malaria was found to be 35% to 53% and vaccine efficacy against severe malaria was 50%.  The phase III trial hopes to determine the true efficacy and safety of this vaccine by using a much larger study population.

There is great anticipation for the results of the ongoing phase III trial.  However, while the RTS,S vaccine is very promising, there are still a number of hurdles to be overcome if we are to develop a very effective vaccine.  A vaccine efficacy of around 50% as was reported in phase II trials is a step in the right direction, but a much more effective vaccine will be needed to stem the scourge of Malaria. Our inability to understand what constitutes an effective immune response to malaria means that we still don’t know how RTS,S works and what immunologic correlates can be measured to determine vaccine efficacy.  Priority areas of research include understanding malaria immunology better and identifying new malaria antigens that can be studied as vaccine candidates.  Hence, while there has been great progress, we are still years away from a truly effective malaria vaccine.

The Global Forum for Health Research “Forum 2009: Innovating for the Health of All” takes place this week in Havana, Cuba from 16-20 November. This is the third of a series of posts from the conference.

The conference organized afternoon site visits to Cuban institutions on Monday, Wednesday, and Friday this week. The hot ticket was a visit to any of the institutions comprising the West Havana Biotechnology Park (”Polo Científico del Oeste de La Habana”), a cluster of 53 institutions such as the Finlay Institute, the Center of Molecular Immunology, and the Center of Genetics Engineering and Biotechnology.

Monday’s visits were cancelled and I leave Friday morning, so Wednesday was my only opportunity. I stress the word opportunity – it seems that international journalists, even though invited to the conference, are not allowed on the site visits. On Tuesday I ran into Thulsi – Thulasiraj Ravilla, Executive Director of Aravind Eye Care System – at the conference. [Aman, Mahad, and I worked closely with Thulsi when conducting organizational research with Aravind and Aurolab in 2004.] Thulsi mentioned that he’d like to visit an eye hospital, so with some essential help from the Ministry of Public Health and a few other Cubans, I tracked down the Marcelino Rios, director of Cuba’s flagship eye hospital at the conference that afternoon. He invited us for a tour of the facility on Wednesday.

After a slight detour to the Pediatric Hospital, we made it to the three-building campus that is Pando Ferrer (Ramón Pando Ferrer Cuban Institute of Ophthalmology) early Wednesday afternoon. There we met with hospital leadership and were provided a comprehensive tour of the facilities. They were very open, allowing us to take any photos that we wanted, but I won’t be able to share the photos we took because of continuing Internet issues.

Observations from the visit:

The Global Forum for Health Research “Forum 2009: Innovating for the Health of All” takes place this week in Havana, Cuba from 16-20 November. This is the second of a series of posts from the conference.

From Tuesday’s sessions, there were two parallel concepts related to developing countries assisting developing countries: governmental South-South cooperation and social entrepreneurs who have scaled their own models, a different form of South-South cooperation.

In the morning, key ideas about governments helping each other:

1. New and old partnerships. Cuba-Africa (see last post), China Africa (10 ag centers recently announced), Brazil-Cuba (health technology), India Africa (pan-African e-network).
2. Focus on capacity-building. Brought up by two panelists from Fiocruz in Brazil. A new priority in the history of SSC (South-South cooperation).
3. Moving beyond traditional partners. Brazil has largely restricted many of its efforts to Portuguese-speaking countries of the world: East Timor, Sao Tome & Principe, Mozambique, Angola, Cape Verde. I’m not certain if this is because of language or solidarity, but I expect it’s both. But now, through Unasur – a entity resembling the EU – they are working more within South America. And they are also exploring cooperation with Nigeria, Mali, Burkina Faso, and Tanzania. All this work out of Fiocruz’s Africa office.

In the afternoon, social entrepreneurs in developing countries – including IDCs or transitional countries, as Carlos Morel would have it – developing successful models and scaling the models themselves:

1. Riders for Health. Nigerian technicians training the Gambian technicians for the Riders for Health program to provide affordable, reliable health transport to rural communities. [To fund the Gambian program, which covers the entire country, Riders for Health took a loan for US$3.5 million from a Nigerian bank, underwritten by the Skoll Foundation. Now, as the government pays Riders for each km of usage in the system, Riders is paying back Skoll. This is an example of what Lakshmi Karan from Skoll called "innovating financing".]
2. Aravind Eye Care System. AECS supporting four “managed hospitals” outside Tamil Nadu, within India and providing technical assistance to countries such as Congo and Bangladesh. All based on their hospital management innovations.
3. Renascer (now Salud Criaça). Exporting the Renascer model from the favelas of Rio de Janeiro to multiple states within Brazil. A program for comprehensive support for families with high-risk children, everything from rebuilding leaky roofs to food assistance to medicines to supporting micro-enterprise.

It seems we shouldn’t forget the contribution of non-governmental players in South-South cooperation and that we should examine systems that successfully scale /within/ large and diverse (Brazil, Mexico, Nigeria) or massive and diverse (India, China) countries.

The Global Forum for Health Research “Forum 2009: Innovating for the Health of All” takes place this week in Havana, Cuba from 16-20 November. This is the first of a series of posts from the conference. Because of challenges to getting and staying online here, posts will be in dispatch format. That means delayed, linkless, medialess, error-prone, and far from comprehensive.

The meeting opened Monday with a plenary featuring:

• Gill Samuels, Chair of the Foundation Council, Global Forum for Health Research
• José Ramón Balaguer Cabrera, Minister of Public Health, Republic of Cuba
• José Ramón Fernández Álvarez, Vice President of the Council of Ministers of the Republic of Cuba

Dr. Samuels stated that a goal of planning this meeting was to better involve the private sector, specifically biotechnology and pharmaceutical companies from low-, middle-, and high-income countries. The goal was based on a sentiment that the private sector was “poorly represented” at last year’s meeting, coinciding with the Global Ministerial Forum on Health, in Bamako.

I believe conference venues are selected well in advance of conference themes, but much of the discussions have centered around tying the theme (innovation) to the place (the Cuban health system). That doesn’t really include private sector, but it does include the Cuban biotech industry.

Observations on Cuban innovations presented by the Cubans in the plenary session, most from Minister Balaguer’s “brief” one hour history of the Cuban public health system:

1. Social determinants of health. Balaguer began with a story about Comrade Fidel carrying out an attack on barracks. While this seems unrelated, he said, it is in fact very relevant because of the “social situation”. Throughout his speech, he emphasized the social determinants of health and the Cuban’s holistic response.
2. Quoting Fidel. Not really an innovation, but I have to mention this. Balaguer continued by reading a passage from Fidel Castro’s “History Will Absolve Me”, relevant to health through a discussion of child malnutrition in the context of poverty, unemployment, and corruption. Common to all Cuban presentations – I’ve seen eight at this conference, so I’m making an inference – is the practice of quoting Fidel Castro. In one case José Martí. And in another case Margaret Chan and Fidel both quoted on the same slide.
3. Human solidarity. In describing the successes of Cuba, and noting “we are not a wealthy country”, Balaguer talked of the “deepness of human solidarity” as a key factor. A gentleman from the BMJ at a later session asked a panel of Cuban health leaders if they thought the successes of the health system were transferrable or if they were tied to the political system. The question was averted, the answer was acknowledged as averted by the same, and the eventual response was no. The same issue came up in a Tuesday session on social entrepreneurship. Thulasiraj (Thulsi) Ravilla, Executive Director of the Aravind Eye Care System, spoke of how compassion led to “owning the problem”. This also helped explain the sacrifices the founders made in starting up and growing the system without donor funding.
4. Healthcare for all. They have aimed to provide care that is universal, accessible, and affordable. Cuba is known for universal provision of education and healthcare. He emphasized, as did other Cuban colleagues later, that there is no discrimination based on gender, race, religion, or political affiliation. I assume that where this happens the processes tend to be implicit (structural).
5. Shifting to practical training. In 1976, the Cubans undertook a change in the system of training physicians to be more aligned with the realities of their eventual work. They introduced more practical experience earlier in the educational process. The old system, common around the world, involved two years of class/lab work before practical training. Based on this experience, the Ministry of Higher Education learned that such practical experience would be good for engineers and architects, too. Perhaps some additional lessons for engineering education.
6. African brain drain. In response to the massive brain drain in the African health sector, Fernandez described, Cuba has helped build nine medical schools in Africa, though some have disappeared due to conflict.
7. Investing in health in tough times. As with the republics of the former Soviet Union, the Eastern Bloc, and a small handful of other countries like Mongolia, the fall of the Soviet Union was a big blow to Cuba. Still, they maintained health spending, and invested heavily in the development of the biotech sector.
8. South-South assistance. Aside from building medical schools, Cuba has engaged in many other health assistance activities, most involving the deployment of physicians to other countries. According to a speaker from Tuesday, there are Cuban doctors serving in 76 countries around the world right now.

In spite of heavy rains that slowed traffic to a crawl in Nairobi Monday morning, the 5th Multilateral Initiative on Malaria Pan-African Malaria Conference got off to a strong start. Wide ranging topics – everything from genetic mapping to eradication strategies to socioeconomic inequities of private insurance coverage for malaria treatment – have been discussed. The MIM website has a wealth of information on the conference proceedings. Detailed summaries and presentation links are available under “Session Reports“.

My particular interest was on healthcare policy and delivery strategies, which were discussed during the “Socioeconomic Aspects” of Scientific session 6. I hope to have more on an innovative bednet distribution program in Tanzania that subsidizes patient demand using a nationally distributed voucher. With national public sector campaigns to periodically give free bednets being planned, it will be interesting to see what happens to the private bednet distributors who have been able so far to meet the daily bednet needs of many low-income Tanzanians.

There is a lot going on at the conference. To give you a sample, check the daily press releases below.

Meeting news

5 Nov 2009

Transmission-blocking vaccines push towards eradication

New vaccine candidates now aim to stop transmission 
Source: TropIKA
Read…

4 Nov 2009

“YES WE CAN…Stop AIDS, TB, and Malaria!”

Kenyans Rally outside of MIM with a message for Obama 
Source: TropIKA
Read…

3 Nov 2009

Why ACTs aren’t reaching those most in need

The high cost of ACTs is proving a barrier to access, and the spread of dangerous monotherapies continues 
Source: TropIKA
Read…

2 Nov 2009

Opening Ceremony

Greetings from Nairobi, where the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference is now officially underway. 
Source: TropIKA
Read…

Fantastic presentation, cross posted from Nomadologies:

“I’ve put together a rather long presentation that has an introduction to social media for public health and then moves to a series of examples of different types of platforms used for collaboration and innovation in the social sector, government 2.0, public health. The presentation highlights the growing challenges that we face in public health with complex, multi-sectoral problems and the changing way(s) we’re seeing organizations think about the problems. I’ve decided to include everything from mapping tools and data visualizations, open innovation platforms, mobile and urban computing, sensors, etc. The presentation highlights a number of technologies but the real gist of the story is that we need to rethink organizational structures and networks, governance, the politics of data, emergent forms of technological and biological citizenship and not just think in terms of technologies, but rather socio-technological change and how we’re going to engage with these changes. The tools are already here—it requires a shift in how we think, and that is where we need to innovate. “

I want to welcome a new blogger and a very welcome addition to the team. I have included Rohan’s bio on the “About Us” page. It is also great to have a clinician perspective which is a major gap on other sites and blogs:

Rohan completed an MPH and MS from the University of California Berkeley/San Francisco Joint Medical Program and is on a gap year from his final year of medical school before continuing residency training in Family and Community Medicine. He is currently in India for a year as a Rotary Ambassadorial Scholar conducting public health research and working on health journalism and storytelling. Read more at his blog: www.rohanrad.blogspot.com In the past Rohan has worked as a Fulbright Scholar on indigenous health disparities in rural Ecuador, as the assistant to the United Nations Liaison for Médecins Sans Frontières in New York, as a Human Rights Fellow in Northern Uganda on the health effects of displacement, and as a humanitarian health consultant on child protection and shelter for UNICEF and the Norwegian Refugee Council. He is a student organizer for health reform and an avid believer in rights-based approaches. His current interests include technology and creativity driven advocacy, health systems, cost-effectiveness, and translational research. He is based in the SF Bay Area but is currently in India until June 2010.

An impressive coalition of 25 US based global health organizations has promulgated their policy recommendations for Obama last week.

Learn more and read the full report at http://www.theglobalhealthinitiative.org/policyforum.html

Here is their executive summary:
The United States, through a Global Health Initiative, should:
• Double U.S. aid for global health to approximately $16 billion per year in 2011 and challenge other donors to similarly scale up their investments;
• Establish bold U.S. targets for improved health outcomes in each of the six GHI areas and contribute our fair share to reach the healthrelated Millenium Development Goals; and
• Ensure that as we invest in programs to scale up health for all, we build on successful programs and fulfill existing commitments.

The Global Health Initiative
President Obama’s Global Health Initiative (GHI) represents an historic opportunity to achieve bold and ambitious targets in the fight against the most daunting global health challenges of our generation. Alongside related efforts to reform U.S. foreign assistance and to coordinate various initiatives that populate the global health landscape, the GHI is an important signal of the intention of the U.S. government to expand its leadership on global health. At a moment of global economic downturn, we recall the Institute of Medicine’s statement from earlier this year that global health programs “play a crucial role in the broader mission of U.S. foreign policy to reduce poverty, build stronger economies, promote peace, and enhance the U.S. image in the world today.”

Currently the GHI consists only of a limited number of known elements; fundamental aspects such as scope, targets, timelines, and specific costing data have yet to be finalized. The language of a broad and realistic vision of what the U.S. can accomplish, however, is encouraging. This report strongly supports the President’s focus on the six areas identified: HIV; tuberculosis; malaria; reproductive, maternal, newborn and child health; health systems and health workforce; and neglected tropical diseases.

TOWARD A BOLD & EFFECTIVE GLOBAL HEALTH INITIATIVE

“We cannot fix every problem. But we have a responsibility to protect the health of our people, while saving lives, reducing suffering, and supporting the health and dignity of people everywhere. America can make a significant difference in meeting these challenges, and that is why my Administration is committed to act.” –-President Barack Obama, May 5, 2009

To substantively tackle these areas, success will depend upon key decisions:
• First, funding targets must be sufficient to meet current estimates of the U.S. share of funding required to reach internationally agreed upon goals in the six priority areas of the GHI. The nation’s highest scientific body— the National Academies of Sciences, Institute of Medicine—eloquently articulated the U.S. interest in investing significantly more in global health. Initial figures for GHI—$63 billion over six years – will not be sufficient.

• Second, investing in each of these key areas could yield major synergies for people’s health—with an exponential benefit in lives saved. Yet an expanded response to certain health priorities at the expense of planned scale up in other areas would miss this opportunity. To help achieve these key elements of what the GHI can be, a coalition of civil society organizations with expertise in the six GHI priority areas has developed an analysis of the appropriate U.S. program and funding targets that should define the GHI. Our analysis also includes recommendations for policy changes necessary to facilitate the success of the GHI.

Ingredients for A Bold & Effective Initiative
The U.S. government can and should be a leader in global health on a larger scale—moving the world toward realization of the human right to health through smart, aggressive scale up of key health services that improve not only the health of people but also the economies of nations.

This requires continued expansion of what is working and scale up of other priority efforts to levels sufficient to reap the synergies possible—ensuring systems of health that can care for people long term. We cannot address maternal and child health in Southern Africa, for example, without aggressively scaling up AIDS treatment to address the largest cause of deaths of mothers and, often, their nurses and midwives as well. Simultaneously, with smart, integrated and additional programming we can ensure that their communities are stronger because these same women do not die in child birth, their children do not die of pneumonia, and everyone receives core preventative care. As the GHI announcement highlights, a cross-cutting commitment to strengthening country health systems is essential for this to happen—and this will require increased investment in the health workforce to address bottlenecks that have impeded effective health programs for decades. In order to reflect a bold, innovative new approach to global health a GHI is needed which:
1• Supports bold, people-centered, outcome-oriented services reaching toward universal access to health. A focus on a selective set of the cheapest interventions has been the hallmark of weak and ineffective responses that have undermined progress in reaching global health commitments. The GHI should not support rationing of services based on a narrow and restrictive concept of cost effectiveness.
2• Supports direct health service delivery as the core of U.S. global health programs. Major scale up in the purchase of commodities and provision of services to people should be central where it is not currently.
3• Continues promised growth of HIV/AIDS, TB, and malaria programs and uses these as a platform for expanded services. As the greatest killers of people living in impoverished nations, infectious diseases must continue to be a major priority. U.S.-supported HIV programs have been used to expand community health care coverage; these innovative models for delivering integrated community care should be expanded as best practices. This will require full funding of the Lantos-Hyde Act.
4• Sets bold U.S. targets based on global need to urgently scale-up sexual, reproductive, maternal, and child health and neglected disease response. Despite decades of promises to address these priorities, far too little progress has been made, and scandalous rates of preventable sickness, death and disability must spur the U.S. to bold action.
5• Strengthens health systems by focusing on recruiting, training, and retaining health workers. None of the U.S. priorities described here will be reached without sufficient midwives, doctors, nurses, and community health workers.

Prizes, innovation, creativity, south to north information  exchange, and web 2.0 where almost anyone can participate, perhaps a budding social entrepreneur, cool story. Is this an example of Clay Shirky’s Here Comes Everybody?

NEW DELHI: Think out of the box. It pays. This is what 15-year-old Sarojini Mahajan is happy to realise after her idea of using human pulse to charge a cellphone was picked up by Stanford University on Wednesday. Sarojini had sent her idea as an entry to IGNITE 2009 — a nationwide contest of innovative ideas. Though she won a consolation prize in the contest , Stanford University will now work on her idea.

Anil Gupta, vice-chairperson , National Innovation Foundation (NIF), which conducts IGNITE every year, Stanford University has already given a token amount of $1,000 to develop a prototype if feasible. ‘‘ The girl has provided the idea. But we need technical assistance to make it work. Stanford University has come forward to try out if human pulse can be used to charge an e-book they have developed.’’

‘‘ I can’t believe it’s true. I had thought of this idea last year but never told anyone till Neena ma’m once asked for crazy ideas in the class. It was just an idea which has become so big now.’’ Sarojini recalled that she was just sitting once when she thought of watches that run on the human pulse. ‘‘ I wondered if mobiles could be charged using the pulse too.’’

Sarojini teamed up with her teacher to develop her idea further who had by then decided to send her entry to IGNITE this year. They both worked for nearly four months and conceived a charging system in which sensors would be placed on the cellphone. Holding it in hand in a particular way would charge it using the heat of the palm. Sarojini’s recognition has got other students thinking too.

‘‘ Students have a lot of ideas some of which are absolutely crazy. Many of them will be motivated to share them now. I have already started getting new ideas from students,’’ said Punj. Agreed principal Anjali Agarwal. ‘‘ The fact that a 15-year-old student’s idea is being taken up by Stanford University will definitely inspire other students.

Full article here.

For others living in the DC area, this lecture looks well worth going to.
Thursday, Oct 22nd 630-8p.
Koshland Science Museum / costs $7:

From the Announcement:

The H1N1 virus is circling the globe as the newest pandemic. Before H1N1, people were concerned about SARS and avian influenza. Have you ever wondered how close these diseases are to your neighborhood right now or how health officials are tracking these diseases in remote areas of the globe? Join Amy Sonricker from HealthMap and Pamela Johnson, Co-Founder and Chief Health Officer at Voxiva, for a hands-on exploration of how computers, the internet, and phones are providing the new hi-tech and low cost tools of the future to track and prevent infectious disease outbreaks. Before you begin containing a global outbreak, you need to know where the outbreak is or could be occurring. Come meet a scientist and an entrepreneur who are using 21st century tools to predict and track emerging diseases around the world. Hear about the challenges they face and the impacts they have made or hope to make.