The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. I was in Jamaica the week following the conference and completely offline. Now that I’m back in the U.S., I’m planning at least two more posts about Forum 2009. This is the fourth in a series of posts from the conference.

In early 2009, Oxfam released a report Blind Optimism critical of the private sector’s role in healthcare in poor countries. It drew attention to the cause of those who believe that any private involvement in healthcare in these countries is harmful. The arguments, evidence, and position of the report were flawed in numerous ways; sound responses to the report were provided by April Harding and the World Bank:

• Oxfam — This Is Not How to Help the Poor
• World Bank responds to new Oxfam health report

The reasonable conclusion one would come to from working in the field and from studying health systems is that a mix of private and public approaches will be most effective – and that the need for different approaches should be dictated by local context. Ideological extremism – pro-private or pro-public – doesn’t serve anyone, most especially the people who need access to health.

At Forum 2009, there was much stronger representation of the private sector than at the previous meetings. In addition to pharma and biotech, there were several sessions and plenary speakers dedicated to talking social entrepreneurship. One of these speakers was Al Hammond, Senior Entrepreneur-in-Residence at Ashoka. Al spoke during Wednesday’s plenary - Enhancing national environment for innovation: perspectives on low- and middle-income countries (TropIKA.net post about the session) – about Ashoka’s Healthcare for All pilot Punjab, India.

During Q&A Claudio Schuftan of the People’s Health Movement criticized Dr. Hammond and Ashok [sic] for: (1) bringing electronics to people where there is no electricity or way to repair devices, (2) supporting the interests of multinational corporations, and (3) making people dependent on products. Dr. Hammond began his response by saying, “We are aware that there is hostility towards private sector approaches”. He explained that they use market approaches to achieve efficiency and that all the programs he presented are social enterprises started by NGOs. Based on the success of the three pilots so far, the Punjabi government has requested 600 additional units. “Take what you will from that”, he ended.

Dr. Schuftan’s comments are well-aligned with the Blind Optimism ideology. Such comments attempt to polarize policymakers, donors, and implementers. In doing so, they actually keep us from thinking critically about the private sector and social entrepreneurship. Fortunately, this was not the overall tone of the meeting.

At the end of a session examining the role of governmental policy in supporting social entrepreneurship, Julius Mugwagwa of the Open University (UK) asked a question about the “backlash” that might occur if something went very wrong with one of these social entrepreneurial models. This is the type of balanced discussion we really need.

“What I really want to know is: are things getting better or are they getting worse?” – Laurie Anderson

Driving back from the Lesotho border, my eye caught the last brilliant light of the day on a young man carrying wood he had gathered for the fire. I thought back to the teenagers who guard cows all day, of the women waiting, waiting by the side of the road, sitting in the tall grass for hours with small children in the hot sun, waiting for a lift.

And in a world where anything is possible for some of us, is that really true for all of us?

Yes, we can now have video night in Kathmandu, but television only allows you to receive. The real catalyst is the internet, where you become a global citizen – you can learn and participate and create.

You can always just read the news to fall headlong into THINGS THAT ARE GETTING WORSE: “Dubai Debt Woes Raise Fear of Wider Problem”, “Traumatized Russians View Their Dead After Train Bombing”, “Afghans Detail Detention in ‘Black Jail’ at U.S. Base”.

But what the soul needs to live is hope, and dreams.

Innovation Journalism brings us ideas that can change the world by reporting on people, processes and practices of innovators, as well as risks and opportunities. It is a ‘horizontal’ beat, reaching across politics, technology, health et al to report on how innovations arise, and helps shape our future by giving us new language to talk about new ideas.

Crowdsourcing is harnessed brilliantly by Innocentive, the innovation marketplace, where Seekers pose challenges they are having difficulty solving on the internet. A stunning 50% of these questions are successfully solved, and Innocentive has just publicized a study on how successful Solvers tackle problems – which can help us all problem solve better!

But what if you live in rural Uganda, and the roots of your cassavas are rotting? Question Box to the rescue! You can ask a question in your own language that can be answered by someone with access to research, the internet and a question archive informed by local knowledge. If you want to sell those cassavas in Ghana you can text TradeNet (and in Zambia, too) to get the current market prices, so you don’t sell yourself short.

In Mozambique, Village Reach decided to extend services to the last mile.. all people should have access to essential medicines, and they decided to bring in energy sources to preserve the vaccine cold chain. By creating an energy market, now fishermen could refrigerate their catch, and the entire local economy improved.

But how to create social change? We can improve the essentials of life, but to start movements, we must collaborate. Witness the effect of Twitter on the Iranian elections. My cousin’s post on Facebook alerted me to Open Access Week, which encourages the immediate sharing of published research results with everyone, everywhere, for the advancement of science and society. But social change must also come from the grassroots, like City Year, which brings young people together for a year of citizen service, to find their place in the world, and to break down the barriers of race, class and education to change our future. Nelson Mandela saw the potential of these young leaders when he visited Seattle, and asked City Year to come to South Africa to help heal the country. But it shouldn’t be up to one person to spread the word.

Ideas this good shouldn’t be kept to ourselves, they should be shared. And then we can say, “Yes, things ARE getting better.”

Ashoka: Innovators for the Public are hosting Tech 4 Society, a conference exploring technology, invention and social change, in Hyderabad, India, in February 2009. Find out more about the conference here. This blog post is an entry in their competition to find the official blogger to travel to and cover the event.

Veronica Ades MD, MPH is a Fellow in Reproductive Infectious Disease at the University of California, San Francisco and is spending a year coordinating clinical research in Tororo, Uganda. She attended the International Conference on Family Planning in Kampala November 15th-18th and shared some highlights earlier this week.

The International Conference on Family Planning is taking place in Kampala, Uganda this week. Supported by The Bill and Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins University, the Johns Hopkins Bloomberg School of Public Health, and Makerere University, the conference is focused on research and best practices in family planning.

After a keynote address on Sunday by the first lady of Uganda, the conference had many interesting sessions on the intersection of family planning and other related areas, such as the MDGs, vulnerable populations, integration with HIV care, maternal-child health and adolescent health.  In addition, there were sessions on community distribution, effective service delivery, and franchising of services.

A particularly well-attended session entitled “Men and Family Planning” included a number of good ideas on how to integrate men into family planning service delivery, and initiated a heated but stimulating Q&A.  A presentation about acceptability and feasibility of vasectomy was questioned about the adverse effects of vasectomy, and clarified that vasectomy is not castration, and that provision of a vasectomy should still go hand-in-hand with frank discussions about responsible sexual behavior and prevention of STIs.  Another presentation reported results of a randomized intervention study from Nigeria that showed remarkably increased uptake of family planning by women whose husbands accompanied them through the entire labor and delivery process.  The presenter theorized that the increased uptake of contraception came from both the men’s presence at postpartum counseling sessions, but also their presence during the delivery and seeing all that women go through in labor.

Evening sessions have included workshops on applying for funding, training on family planning methods, translating research into policy and costing for program scale up.  A Technology Café by the Implementing Best Practices Initiative provides an opportunity for conference attendees to gain hands-on experience using electronic tools being offered by various organizations.  A cocktail hour hosted by Marie Stopes introduced a new calculator for measuring the impact of family planning programs, and a session this evening by Venture Strategies will discuss Menstrual Regulation (M.R.) – the practice of bringing on a woman’s late menstrual period without knowing whether or not she is pregnant.

CORRECTION: The original post indicated that The Bill and Melinda Gates Foundation for Population and Reproductive Health was a sponsor of the conference; however, the Gates Foundation itself was not a sponsor. As has been corrected above, The Bill and Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins University was a sponsor. -Jaspal, 30-Nov-2009

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 Lions Aravind Institute for Community Ophthalmology – 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.