Global Trade and Organ Transplants

In the game of responsibility transfer, it is always safe to blame the dead guy. It is hard for the dead guy to argue from the grave. Sure, the dead guy may have left a written record, but that record can be interpreted, reinterpreted, misinterpreted, analyzed, parsed, deconstructed, reconstructed, decontextualized, and misquoted to such an extent that the dead guy has no defense. So I think I'll start this entry blaming a guy who is so long dead that he can't possibly defend himself. Adam Smith. Back in 1778 in the Wealth of Nations he articulated the argument that became the theology of free trade believers. In a nutshell, Smith believed that if only people would stick their knitting (i.e., doing what they do best) and then trading their knitted goods for the goods of other people who do what they do best, then everyone would enjoy the fruits of highly efficient labor. With 230 years of global trade experience we see the price we pay for trying to achieve Smith's nirvana of maximum production efficiency.

As we ship untold tons of freight around the world by air and sea we are placing an unsupportable carbon load on our planet and we spew tons of other particulate pollutants and waste into the air and water. Hardly a prescription for health and quality of life.

And contrary to free trade preaching, there are winners and losers in economic markets. There is a cycle of boom and bust that occurs in communities as producers pursue low cost labor around the globe. A boom town can be established in northern Mexico to make televisions for Canada and the U.S., but that boom town can be turned into a crime and disease ridden slum with little hope for further development when the television maker finds cheaper labor in China. And what happens to the Chinese boom town when the television maker finds even cheaper labor in Vietnam?

To be sure, the boom to bust cycle is not predestined. If the low cost producers have enough time in the boom phase to invest for the future when they are no longer the lowest cost producers in world they may have a soft landing and be in a better position than before the boom. It appears that India may be on this trajectory in its low cost service sector. But when the boom phase rests on the sale of low cost labor and that labor can be easily replaced, the boom cycle to short to establish a broader economic platform from which to launch sustainable economic development.

From the environmental and economic perspectives we can trace a pretty direct line back from some global public health issues to Adam Smith. But there is an even more subtle link. Adam Smith suggested that to achieve the highest level of economic well-being, we should take advantage of the ability of some producers to produce goods more efficiently than other producers. The key phrase here is take advantage of. There is a subtle difference between the idea of taking advantage of and exploiting. In today's global economy, taking advantage of low labor costs is the same as finding people are willing to sell their labor for the least amount of money. When the labor producer is looking for unskilled labor, the lowest cost workers are frequently those who are the poorest, the closest to losing their grip on life, the most vulnerable to exploitation. Is paying destitute people the least amount of money they are willing to work for taking advantage of low cost labor or is it exploitation? This is a truly thorny issue that isn't confined strictly to the world of global trade.

Last week Philippine authorities banned kidney transplants involving foreigners in an effort to put an end to the black market in organ trading. Local media have reported on an organ market in which desperately poor people sell kidneys for small amounts of money. This is certainly not a new problem, but the fact that Philippine government felt a need to take action indicates that the black market consists of more than isolated, infrequent cases.

In December 2003 police in South Africa and in Brazil broke up an international ring trafficking in human kidneys. Donors from destitute neighborhoods in Brazil were flown to South Africa where they donated kidneys to international clients. About the same time, Lisa Ling, a National Geographic Ultimate Explorer host, visited a village in India which was known as "kidney village" because so many residents had donated kidneys. Donors received about $800 for their donation.

Taking advantage of or exploitation? This is not an easy question to answer. We ask people to do unpleasant, dangerous things everyday. And in exchange for what we ask them to do, we pay them. As long as people feel they have a reasonable choice about whether to accept the money, then we don't consider our payment to be exploitation. But what about poor people? Eat or donate a kidney? Is that a real choice? But if we were to ask people who are in that position and have made the decision to donate, would they say they have been exploited, or would they say that they were lucky to find a way to feed themselves and their families for a month, or six months, or a year? A thorny issue indeed.

Adam Smith gave us a creed of free trade based on the idea that maximizing production efficiency is the economic ideal. We have perhaps misapplied his idea to make maximizing production efficiency the absolute ideal. In the process we have forgotten that quality of life is a more important. We have also forgotten how easy it is to cross the line from taking advantage of to exploiting. Maldistribution of wealth is going to continue into the foreseeable future. We need to engage in a long, deep global discussion of the ethics surrounding organ transplants and appropriate global policy.

Professional Volunteer Opportunities

Yes, I hve been a negligent blogger the past few weeks. It isn't for lack of material, but lack of time. I'll try to do better in the future. That clock at the bottom of this page should be a reminder to all of us that preventable death and disability never take a holiday.

World Tuberculosis Day. Today is World Tuberculosis Day. It is a good time for everyone to review updated information about the current status of TB prevalence and treatment. You can take a look at the latest data on TB and TB-related topics at GlobalHealthReporting.org The maps are a wonderful way to get an instantaneous impression the worldwide distribution of TB. Perhaps the most timely reminder of the importance of keeping an eye on TB is the March 22 Pro-med Mail report of a case of XDR-TB in Scotland. TB is a truly a worldwide issue.

Professional volunteerism. Professional volunteers are needed throughout the developing world. As much as each of us might like to jump on the next plane or boat to lend a much-needed hand, there are all kinds of obstacles that stand in our way. Not the least of those obstacles is financial support. Even if we are in a situation to be able to lend our services free-of-charge, we aren't always able to fund our own travel and other expenses related to volunteering. If that is what is stopping you, here is a connection you might want to check out --- Volunteers for Prosperity Service Incentive Program (VFPServ). The US Agency for International Development (USAID), the USA Freedom Corps of the White House, and the GlobalGiving Foundation (GlobalGiving) collaborate on this project. VFPServ can connect professionals with volunteer opportunities and help provide financial support for their volunteerism.

If you are not in a position to volunteer, VFPServe offers opportunities to donate to support volunteers. The GlobalGiving Foundation web site gives potential donors the opportunity to view specific projects and donate to those that best match their philanthropic objectives.

What a better way to celebrate World TB Day than to donate professional services and/or financial support to a global health project?

Intellectual Property and Global Health

The commentator who dares wade into the murky waters of intellectual property should do so with plenty of protective gear in place. There are three really big risks here. First, never was a metaphor more appropriate than murky waters. Intellectual property law is truly arcane, especially the branch of it that is most contentious from a global health perspective; i.e., patent law. It is difficult enough to determine how patents are awarded and what constitutes patentable property within any nation. On the international level opacity is magnified by international trade agreements. These agreements create enormous ambiguities in terms of patent enforcement, licensing, ownership and patent life. Second, hidden in the murky waters are property rights sharks ready to make mincemeat of anyone who dares suggest that property rights are not sacrosanct. Third, equally hidden are human rights piranhas who are ready to feed on anyone who dares suggest that property rights deserve any consideration when human life and well-being are at stake.

Well, here goes my first tentative step into those waters. However, I'm taking that step with a white flag clearly flying. I am not taking either a pro human rights or a pro property rights position (I think I just felt a shark's tooth on my right leg and a piranha nibble on the left.). Actually, I value both and am just enough of an idealist to think that while there will always be tension between the two, there is middle riverbed ground to be found. (Now I am feeling full-fledged bites.)

In the February 22, 2008 issue of The Chronicle of Higher Education, Panjabi, Rajkumar and Kim offer an interesting perspective on the research university's role and responsibility in humanitarian technology transfer (http://chronicle.com/weekly/v54/i24/24a03201.htm). Panjabi , et al point out something that we too often overlook in the patent fracas. Much of the basic research (and it seems to this author an increasing amount of applied research) that leads to significant technological medical advances takes place in university laboratories. Punjabi, et al suggest that because universities exist to create and disseminate knowledge in the public interest, that they have a responsibility to make sure that potentially life-saving technology developed in their laboratories be shared with the public, including the public that resides in the developing world. The problem for universities is that they are not in a position to take their discoveries from the laboratory bench to the marketplace. Private industry performs that function. To make the development process work, universities transfer their technological developments to private industry through the sale and/or licensing of patents. Panjabi, et al recommend that these licensing agreements contain language that requires the humanitarian dissemination of the new technology.

Universities Allied for Essential Medicines (UAEM) works with students and faculty in universities in the U.S., Canada, and Europe to promote humanitarian technology transfer. Readers who are interested in learning more about this topic and/or in becoming involved in promoting the concept of humanitarian technology transfer by universities should review this site.

Because it holds little promise of immediate profit, technology transfer to developing countries has been and will continue to be a challenge. However, the problem is not limited to the developing world. The same pattern holds true within developed countries. Poor people may not have access to the technologies that were developed in university laboratories. Much of the research that takes place in the university is supported either directly (ex., by federal government grants) or indirectly (ex., state tax dollars) by the general public. Everyone who supports this research should have an opportunity to benefit from it. Because they are entrusted with public money given for public purposes, universities have an ethical obligation to consider how to best assure that the intellectual property they transfer will benefit the public that paid for it.

Now to paraphrase the line from Jaws, I think I need a bigger boat.

The Oft Overlooked Factor

In the world of classical economics there are three factors of production: land, labor and capital. These are the three essential ingredients that are required to make the goods and services that are traded in the marketplace to the mutual benefit of buyers and sellers. This classic model has been tweaked any number of economists (and pseudo-economists) to capture 21st century economic subtlties. Now we see concepts like entrepreneurship and knowledge being added to the mix. However, there is no denying that labor (i.e., human capital) is essential to production. In the world of global health, our attention is often focused on capital because it is the shortage of capital that constantly undermines our most promising approaches to dealing with pressing health problems. We can't pay for enough research, enough drugs, enough equipment, enough clinics and hospitals, enough transportation, etc., etc., etc. But having all of our capital needs met is not enough if we don't have sufficient numbers of qualified health professionals in place to apply medical technology and goods to providing care to people. Health care is a labor intensive industry even in the most high tech environments . So we must be as vigilant to ensure an adequate supply human resources as we are capital resources.

Kudos to The Lancet for today's issue (February 21, 2008) that focuses our attention on the problem of skilled labor depletion in developing countries. The publication of this issue serves as a preview of the discussions that will take place at the Global Forum on Human Resources for Health, an event sponsored by the Global Health Workforce Alliance (GHWA)from March 2 to March 7, 2008 in Kampala, Uganda. The GHWA faces an enormous challenge because it is dealing with a truly global problem. Although shortages are most profound in the developing world, they exist in the developed world as well. Trying to solve a piece of the problem in one place, may make the problem worse in another place. Solutions to health workforce shortages in the developing world will not be found in the developing world only.

In their Lancet article "Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?", Mills, et al present a damning picture of recruitment practices by developed world companies who recruit physicians, pharmacists and nurses from developing countries whose populations are in desperate need of these providers. These populations have much less access to health care providers than in the developed world and the authors suggest that further intentional depletion of that limited labor supply is so egregious as to merit consideration of criminalization. Criminalization of undesirable behavior is knee-jerk policy that seldom does much to solve complex, deeply rooted problems. (Need we look much further than drug abuse?) Just thinking about the difficulty of enforcing an anti-recruitment law is enough to discredit this approach. The authors themselves raise the thorny issue of individual freedom; i.e., should health care professionals be told that they may not leave their homeland because of their choice of profession?

Among the plethora of considerations that GHWA will have to consider are:

1. Citizens of poor countries contribute economically to the education of their health workforce. Foreign recruiters (and their home countries) take advantage of the relatively low cost of training (which has been paid for by relatively poor people) when they recruit these health professionals. Is there a way to manipulate the financial incentive in a way that makes it less financially attractive to take advantage of this training cost differential? Perhaps a recruiter and/or employer surcharge could be instituted that would go into the developing countries' health education programs?
2. Substitute workers. If there aren't enough physicians and nurses, what is the appropriate role of substitute workers? How should they be trained and paid? How effective are they at making a meaningful difference in health status? How do substitute workers affect the market for skilled health labor (i.e., do they make it even more difficult for professionals to earn acceptable wages?)
   
3. Conditions that lead to emigration. What can be done at the local level to make leaving less attractive? Higher wages and better working conditions at home are always an option. In addition, perhaps government-subsidized education expenses would have to be repaid prior to emigration.
   
4. Curbing demand for foreign health professionals. Health workforce shortages are long-term problems in the developed countries. In the U.S., for example, there has long been a shortage of physicians in so-called underserved areas which are primarily rural or poor urban areas. Resolving these shortage issues in the developed world would take pressure off recruitment from developing countries.
5. Search for common ground on health workforce development. If the developed world is unable to grow its health workforce at home, then what kinds of mutually beneficial partnerships could be formed between developed and developing countries? For example, would it be possible for a developed country to support expanded training programs (which would be lower cost) in a developing country with a goal that some of the increased number of graduates would emigrate and the the remainder would remain in the home country?
   
6. Motivation of developing country health workers. One of the unknown factors in health workforce emigration is the underlying motivation of individuals entering the health workforce. If a significant number of individuals enter health professions only with an eye toward emigration, then stemming flow of emigration will do little to improve at-home access to health professionals. If talented migration-driven individuals cannot emigrate through the health professions, then they would enter other professionals (perhaps science or engineering) that would provide them with better emigration opportunities.

These are complicated issues for which there are no easy solutions. Good luck to GHWA as it works toward viable policy solutions.

Certainly with shortages of professionals through the developing world, there are many opportunities for health professionals to volunteer their services. These volunteer services fill an important emergency need. Thousands of poor people are helped every year to walk, smile, use their hands, and survive cancer through the generosity of volunteers. If you have clinical skills please consider connecting with an agency that provides these important services. It will take years for policy makers to make the kind of changes that will provide for stable workforces and continuity of care. In the meantime, the services of volunteers are critical.

Political Conflict and Health - updates

Kenya update. The African Medical and Research Foundation has reported an outbreak of measles (12 suspected cases) in Kibera, a slum in Nairobi. An additional 3 cases were diagnosed last week in a refugee camp where persons displaced by post-election violence in Kibera have fled. This is one of the outcomes that could have been predicted as a result of the disruption of health services infrastructure caused by post-election violence.

Pakistan. Pamela Constable, a reporter for The Washington Post reported yesterday ion National Public Radio's Diane Rehm Show that no widespread violence has erupted after the Pakistani elections. In the aftermath of Kenya's terrible post-election experience, there has been concern that the tension leading up to the national elections in Pakistan might erupt into similar devastating violence. It will take some time for the Pakistani government and political leaders to absorb the significance of the election results, but it seems that Pakistan may be on the way to avoiding the kind of violence that has put Kenyan health at risk.

East Timor. Unfortunately, there is still no end in sight for violence-plagued East Timor. East Timor is an example of how post-election violence can devastate national health and development. The current crisis began with a election-inspired violence in 1999. The nation eventually gained independence from Indonesia in 2002, but violence has taken root. Riots broke out in April 2006 after the firing of soldiers. People died in the riots and tens of thousands were displaced from their homes. April 2007 brought new post-election violence. Last week violence erupted again with a rebel attack on government leaders.

The numbers tell the sad tale of poor health status in East Timor.

Life Expectancy - 59.7 years (2005)
Infant mortality rate - 52/1000 live births (2005)
Underweight children less than 5 years of age - 46% (1996-2005)
GDP per capita - $358 (2005)

The people of East Timor are in desperate need. Life hangs in the balance as people face critical nutritional and health services shortages. At the same time, it is crucial that a stable political undergirding be established here. There are many groups working toward creating political and economic stability. Reuters AlertNet has a list of agencies working in East Timor if you are looking for a way to make a monetary or volunteer contribution.

It's all about when you know what you don't know

For the past few days I have been too absorbed with family health issues to stay up to date with global health news or connect with my global health colleagues. However, I have had some waiting room time to think about how we go about providing health. As my mind wandered over this terrain, I was reminded of the arcane logic of Donald Rumsfeld. Maybe it was the less-than-transparent logic of the American health care system that brought Mr. Rumsfeld to mind. One of the first lessons that the global health neophyte learns is to never assume that way things are done at home is the way that things should be done elsewhere. The past couple of days have been filled with reminders.

Although they are close to home and frustrating, my experiences are not any different from those that I hear nearly everyday from colleagues and acquantences up and down the socioeconomic spectrum. Lost productivity due to missing work to keep clinic appointments, frustration because patients seem to be able to understand the concept of time and the meaning of the word "appointment" but physicians can't, incorrect information in medical records, repeatedly recounting the same information for the same physician in the same office, utter confusion on everyone's part over how much insurance will pay versus how much the patient owes, unclear pre and/or post procedure instructions. - - - these are the things I hear constantly. As a supposed expert in health care delivery I should be able to negotiate this landscape better than the average consumer, but I sometimes feel as overwhelmed as everyone else. The one thing I am confident of is that while we may have something to offer the world in terms of medical technology, we should be every so humble when it comes to how we deliver health care and refrain from giving in to any temptation to impose the way we do things on others.

News from the frontlines of infectious disease

Multi-drug resistant tuberculosis (MDR-TB). What is the most important thing about TB control? Of course the answer is complete the course of therapy! That message cannot be over emphasized. One of the reasons we have MDR-TB and its little brother XDR-TB (extensively drug resistant tuberculosis) is that courses of TB treatment are very long and difficult to maintain. Short-term exposure to antimicrobial therapy allows TB pathogens to develop immunity. In many parts of the world it is difficult to maintain therapeutic regimens over a period of six months or more. Common difficulties in therapeutic compliance include inadequate financial resources to purchase medication, unreliable medication supply chains, and inconsistent patient adherence to prescribed regimens. Even in countries where there are economic resources and a stable supply of drugs, patient adherence is still a problem.

A recent finding from South Africa, however, is a stark reminder that patient adherence is not the only challenge in TB control. Research at a small rural hospital indicated that every case of MDR-TB was the result not of poor adherence to therapy, but rather reinfection. Analysis of MDR-TB cases at the Church of Scotland hospital indicated that an XDR-TB outbreak was due to airborne infection with the drug-resistant strain, often at the hospital itself. Certainly, this finding speaks to the need for improved infection control in health care facilities where MDR-TB is found. Infection control is particularly important in hospitals where patients may be in prolonged contact in crowded conditions.

Effective TB control requires an integrated program that stops the cycle of infection at multiple points. The World Health Organization's five elements of DOTS recognizes that adherence is not enough by addressing financing, clinical laboratory support, medication supply, and system monitoring and evaluation in addition to therapeutic adherence. The recent findings from South Africa remind us that in our effort to develop ever more elegant strategies to deal with infectious disease, we cannot lose sight of the basics. Infection control in health care facilities and preventing reinfection (especially in high risk populations such as the immunocompromised) must still be at the heart of our work.

Influenza and oseltamivir resistance. Oseltamivir is the front line drug for the treatment of ordinary influenza and human bird influenza. So the news from the European Centre for Disease Control that 19 of of 148 samples of influenza A virus isolated from ten European countries showed signs of resistance to the drug is of concern. Mortality from bird flu among people who did not take oseltamivir was 90%; among people who were given the drug mortality was 50%. Keeping this drug in the frontline therapies for bird flu is very important. Officials in countries including Japan where oseltamivir is prescribed for ordinary flu, report that resistance has not been seen. Therefore, this news is not cause for global alarm. However, it demonstrates the need for continued vigilance for resistance development.