Just a minute....

2009-01-19T20:10:00.001-08:00

Online, does everything have to be bloody intentional?

A couple of days ago I wrote a piece that casually mentioned:

Online interactions are largely expected to be intentional. On purpose. Planned. People assume you did stuff for a reason.

Since then I have begun to realise this explains something that has been bugging me for a while now:

Why does much of what people say and do in online social networks sound phoney?

Dorrr... because they are doing it on purpose. They are being 'strategic friends'. Just look at many of the status updates you see posted on Facebook - they rarely tell barefaced truths or share some of the more stark realities of day-to-day lives. People love to share news about the cool things they have done, or the photos of exotic places they have been to, or the fun they had last night, but not how up tight they are feeling today or how crap their period is this month.

Sometimes I yearn to read some of the real things my friends are doing and facing. And therein lies the conundrum of platforms like Facebook. In friendship and human interaction, you just don't do things on purpose (ok, sometimes you do), you do things because you have moments of joy, openess, inspiration, fear, sadness, empathy or compassion.

When I open Facebook I am increasingly struck by the lack of balance that being 'personally strategic' with one another generates.

OK, back to real life I guess.

2009-01-19T07:37:00.000-08:00

Engaging philanthropists: Where to begin?

…I knew I wanted to spend the rest of my life giving my time, money and skills to worthwhile endeavours where I could make a difference. I didn’t know exactly what I would do, but I wanted to help save lives, solve important problems, and give more young people the chance to live their dreams (1)

Some critical tides have been quietly changing in the non-profit and development world that have increased the relative importance of personal philanthropy to many organizations' fundraising efforts:

Institutional donors have come under increasing pressure to reduce their transaction costs – preferring to administer larger grants to fewer organisations;
The current climate of economic decline and uncertainty in many countries is bringing into question the sustainability of overseas development assistance programmes of industrialised countries and undermining the capital reserves of established foundations;
Recent foreign exchange rate fluctuations have made the spending value of some secured grants unpredictable;
Corporate and personal fortunes, combined with an increasing awareness of widespread equity challenges in many nations and communities, are fuelling a new era in philanthropy.

Engaging individual or corporate philanthropists is not simply a matter of sending the same fundraising proposal to a different contact. In many instances, new family foundations and corporate giving programmes reflect a personal motivation to make a difference in the world. In addition to being more ‘business-like’ than institutional donors (e.g., requiring higher levels of clarity and accountability), individual founders are often actively involved in their foundations. This means that understanding the underlying motivation of personal giving is vital to designing a sustainable philanthropy outreach and engagement programme.

Philanthropists are often driven by more personal needs and wants to other donors. They give, at least in part, based on an exchange of values that allows them to:

Enhance their own sense of self-worth;
See themselves in the beneficiaries being served;
Do the ‘right’ thing;
Create a return (or benefit) on their investment

Loyalty and trust are key ingredients of philanthropist engagement. They are each commanded by organizations that:

Are seen as leaders in their field;
Connect with supporters emotionally;
Provide relevance and meaning;
Help supporters to make a statement about what they value;
Help supporters meet their own vision for the world;
Provide them with a sense of belonging to something greater than themselves.

Engaging philanthropists should first be about building relationships based on the assumption that they are interested in the success of your organization, and a means to mobilize resources second.

Yesterday, the most successful non-profits were those that donors knew best. Today, the most successful non-profits are those that know their donors best (2)

References:

1. Former US President Bill Clinton in his book Giving: How each of us can change the world
2. From: Hart et al (2005): Nonprofit internet strategies: Best practices for marketing, communications and fundraising

2009-01-18T00:09:00.001-08:00

In the online world, non-profits are what they do too

As we start the year of social aggregation and syndication (as 2009 has already been dubbed) web 2.0 gurus Seth Godin and Brian Solis are talking up how your ‘digital identity’ defines who you are in the online world.

Godin asserts that two major factors influence the way we perceive people through their online incarnations:

On the web, people are judged almost entirely by their actions – usually by what they write.
Online interactions are largely expected to be intentional. On purpose. Planned. People assume you did stuff for a reason.

I don’t doubt that either of those points is true. What they make me wonder though is whether non-profit organizations and international development agencies are taking too long to see that these new accountability rules apply to them too. I am convinced they are.

If you are what you do online, then the option for organizations to just rely on the reputation their logo carries is evaporating fast. Under the new rules, only organizations that are truly impartial, transparent and that provide reliable information about their work will pass the accountability test – and that does not apply to many health- and development-focused organizations at present.

The sooner individual organizations recognise this reality and enter the online space in a genuine and open way the better. Quick start entry options include:

Introduce some simple and clear organizational policies for staff at all levels participating in online discussions and social networks;
Develop guidelines encouraging senior managers in particular to start writing their own blogs;
Keep track of what is being said about you by setting up Google Alerts on your organisation, specific technical priorities and high-profile people in your team;
Set up a news/RSS feed aggregator that tracks website content from your closest partner organizations;
Find out who in your team has a real interest in web 2.0. Task them with updating the team on significant new trends/tools in social networking. If nobody fits the bill, ask for independent advice from outside. Now.

Some of the most important players are stalled on the start line. The political realities and bureaucratic control that are central to some international organizations – such as those of some UN agencies – are incompatible with the openness and freedom of the online world. The paralysis resulting from that oil-and-water practicality will, unfortunately, not stop them from being judged by their online actions along with everyone else.

The good news is that this may present a window of opportunity for some smaller organizations and their flexible, forward-looking leaders, who can make the health and development sector online space their own before the sumos eventually arrive on the scene.

2007-12-06T21:40:00.000-08:00

Go well Mildred

People don't care how much you know, until they know how much you care...about them

In 1999, I had the pleasure of working in Lusaka with a Zambian journalist called Mildred Mpundu. I recently heard that she passed away on 13th November this year. The song on the right is dedicated to Mildred, so you might like to listen to it while reading this.

My memories of Mildred had faded over time, but the message from Henry, another colleague in Zambia, brought them flooding back. It was September 1999, and we had an idea that individuals were best placed to write about the realities of HIV themselves - something so important should not be left to the big institutions who otherwise were still telling us what was going on and what should be done. We did not really know how it was going to work, but if we could just find some capable and dedicated individuals..... enter Mildred.

That year, the African AIDS conference (ICASA) was being held in Lusaka, Mildred's home town. Along with three other people, Mildred was part of the first ever 'Key Correspondent Team' we brought together for such an event. Manju Chatani from Ghana came to Lusaka to support the team with me, and the other KCs at the conference were Omololu Falobi (who went on to found Journalists Against AIDS in Nigeria), Koudaogo Ouedraogo (from the national TB programme in Burkina Faso), and Cecilia Rachier (an HIV counsellor from Nairobi, Kenya).

L2R: Manju , me, Mildred, Omolulu, Cecilia and Koudaogo

Here is how Mildred described her involvement at the time:

"As a journalist working with AF-AIDS and a daily newspaper in Zambia, the challenge that the HIV/AIDS pandemic has created in my life is immense. I have heard, seen and felt it in those far away and close to me. Hence my interest in contributing to the fight against this ugly "monster." Through pen and paper I hope I can help comfort or save a soul from this disease."

"People don't care how much you know, until they know how much you care...about them."

That left an impression then, but in light of Mildred's own subsequent life with HIV, these words mean a thousand times more to me now.

She was certainly one of the quietest KCs in that first team, and her writing during and after the conference was sharply focused on what HIV meant to individuals: One story about a young woman who thought she was infected with HIV by her teacher; another about the realities of eating well for people with HIV; even when she wrote about the Zambian government's response to the epidemic, she came at it from an angle of what they weren't doing to protect the well being of individual ministers.

When I read her work again today, I realise that they could just as well have been written yesterday as in 1999.

Mildred, through pen and paper (ok, keyboard) your voice was indeed heard loud and clear throughout Zambia, Africa and the world. You helped guide us all in those early years of HDN, and what we saw then helped hundreds of others to follow and also to speak their world.

Go well Mildred, and keep smiling.

A memorable moment from 1999: Omolulu, Manju and Mildred
are astonished that the Zimbabwean health minister would say
such a thing about Bill Clinton's sexual exploits!

2007-11-30T19:15:00.000-08:00

The case for optimism

Google.org director Larry Brilliant uses a clip from an old Frank Capra movie to show that we've known about global warming for 50 years -- yet in half a century, we've done almost nothing to solve it. He explores this and other megatrends that could inspire pessimism. But, he says, there is a more powerful case for optimism.

2007-11-15T21:48:00.000-08:00

Open letter: To HIV epidemiologists and surveillance experts

What is causing the HIV prevalence decline in Zimbabwe?

Recent reports state that ‘official’ HIV prevalence estimates in Zimbabwe have continued the decline seen in recent years: A decline was first reported in 2004, and again in 2006, and new figures indicate the downward trend has continued, with rates falling by 10 percent over the past 5 years.

What does this HIV prevalence decline really mean?

Are HIV prevention programmes working? That would be great news, of course. But with the current economic and health service situation in Zimbabwe, some people are sceptical and looking for another explanation of the drop in HIV. Are they underestimating the resilience and AIDS competence of the people of Zimbabwe?

Or is it time for us to start thinking that maybe some of the factors that influence HIV prevalence (good and bad) are not always obvious or intuitive, no matter how familiar the term now seems? I’ll give a few examples of the discussions currently heating up the HIV listservs, but really hope that some of you experts will weigh in on this to put me, and others straight.

I vaguely recall similar arguments being made by two researchers (Stoneburner and Low-Beer) in the late 90s, when they looked closely at apparent HIV prevalence declines in Uganda. So tell us, were they wrong, or just ahead of their time?

What drives HIV prevalence up?

Instinctively, we would probably say right away that HIV prevalence goes up when more people get infected with HIV (bad).

But presumably another perfectly reasonable explanation for rising HIV prevalence is better access to care and anti-HIV drugs. Think about it: Anti-retroviral treatments make people with HIV live longer, so it follows that significantly increased access to ARVs and other care services (good) should be expected to increase HIV prevalence.

What’s more, common sense tells us to anticipate this effect being most evident during the roll-out years of initial ARV programmes in particular (i.e. now in many places). Right?

What drives HIV prevalence down?

Again, instinctively you probably would say that HIV awareness and prevention programmes are working (good), people are changing their sexual behaviours (good), and as a result HIV prevalence is falling.

Another feasible explanation, presumably, is that more people with HIV are dying (bad).

If there is poor access to health care, treatments, and/or poor nutritional status among people with HIV, the delay between HIV infection and disease, and ultimately to death, is thought to be shorter (bad). If the number of people dying goes up relative to the number of new HIV infections, then HIV prevalence should be expected to down.

These factors are not mentioned much in news about of (falling) HIV prevalence, including in the recent coverage of Zimbabwe’s HIV ‘decline’. The headlines: "Youth getting the message" or "Awareness changes behaviour" leave no room for anything other than the belief that HIV prevention is working.

There is also a synergistic effect to consider that combines three factors to influence HIV prevalence – possibly in a compounded way:

1. Personal witness:

As more people with HIV find out about their HIV status, eventually get sick and pass away, more and more people are subject to the indirect impacts of the epidemic, and even more are personal witness to its ravages. They see their friends, family members, neighbours and lovers succumb to disease and die, they see children left without parents or teachers, and they see family assets stripped, food insecurity get worse and other impacts. This personal witnessing of the epidemic has to have a huge impact on people and their perceptions of risk.

Let’s just say for argument that some people are significantly affected by ‘seeing’ the HIV epidemic for themselves. This means that a proportion of people are going to voluntarily change their sexual behaviour as a result, and take themselves out of HIV’s way.

2. HIV has already ‘removed’ a proportion of people:

Remember too that in a country with sustained and high HIV prevalence, combined with less than ideal health services, a significant proportion of sexually-active people are already taken out of the HIV vulnerability ‘equation’ by sickness and death itself.

3. Out-migration

Poor income prospects and sky-rocketing inflation has also made labour out-migration from Zimbabwe for work even more frenetic. Who typically leaves for work? Young, sexually-active people.

Under the conditions currently seen in Zimbabwe (a relatively small country of 11.6 million people after all), should we expect to reach a point where the pool of uninfected, vulnerable and sexually-active people is going to get smaller and smaller?

Just like the labour shortages seen in rapidly-expanding economies, isn’t it possible that HIV just can’t ‘find’ enough young people to maintain previously high HIV prevalences?

Zimbabwe’s AIDS programme (and its international partners, incidentally) is openly celebrating the declining HIV prevalence as evidence that its HIV prevention programmes are working, but that could easily be just a part of the full picture.

There is a chance that one day soon we shall, in fact, look back and lament that ‘some’ HIV prevalence declines were evidence that specific nations or communities were witnessing the unnecessary destruction of entire generations, that people are not living with HIV as long as they could or should be, and that the socioeconomic conditions are driving young people elsewhere and to some exent at least out of HIV’s way.

Is this really that difficult a situation for experts to understand and explain? The AIDS intelligentsia must be worried how the “ARVs drives up HIV prevalence” story will be interpreted, but that’s no excuse to sit on it.

There must have been similar deliberations around how to make sure that the “circumcision prevents HIV transmission” data was not misinterpreted. Like then, Zimbabweans in particular have a right to know what declining HIV prevalence in their country really means.

With rumours flying around that the new UNAIDS Epi report (to be published today) will include ‘news’ of general declines in HIV prevalence in some countries (because of changes in the way estimates are made), there may have never been a more important time for epidemiologists to come clean and explain what they think declining HIV prevalence means under various HIV epidemic stages.

We are all ears.

2007-03-27T18:12:00.000-07:00

WHO TB Strategy out of reach for many endemic countries

(This is an editorial I co-authored with Dr Bobby John from Global Health Advocates for World TB Day on 24 March 2007)

On the occasion of World TB Day on March 24, it is important to recognise that resistance to TB drugs has assumed very serious proportions. New global data on TB, published this week by the World Health Organisation (WHO), highlights weaknesses in many national TB programmes, which raises the potential for widespread TB drug resistance. How did the world reach this precarious state?

A WHO expert would argue that increasing levels of TB drug resistance "reflects a failure to implement the WHO Stop TB Strategy". The strategy hopefully maps out the steps that national TB control programmes need to take.

By all accounts then, national TB programmes are not living up to expectations.

The bacterium that causes tuberculosis (TB), Mycobacterium tuberculosis, is naturally sensitive to antibiotic drugs used to treat the disease. The accepted truth about how TB drug resistance starts is that it is mostly 'acquired' in individual patients, because of inadequate treatment with TB drugs, which are now at least 40 years old.

Poor patient drug adherence, or the use of too few drugs leads — the story goes — to various forms of drug-resistant TB. Multidrug-resistant TB (MDR-TB) is a specific type that does not respond to the two most powerful anti-TB drugs. Latest estimates are that MDR-TB makes up about 4 per cent of all new and previously treated TB globally. Apparently, the antiquated TB drugs are not working.

Drug-resistant TB is already geographically widespread, which includes places where TB control programmes have been in place for many years. But incredibly little is known about just how much TB drug resistance there is outside of capital cities, for example, and even in some entire countries where drug resistance may be common because of historically poor TB control.

No progress can be made if TB clinics are there but patients are not. Today's standard test for TB relies on a technique (sputum microscopy) invented over a hundred years ago. It provides no information about drug resistance. Apparently TB diagnosis is also failing us.

There seem to be too many weak links. Vital TB programme components have also been ignored for years, in favour of a single jewel in the TB strategy's crown: directly-observed treatment short course, or DOTS.

In many places, a consistent lack of focus and investment has led to chronically weak TB diagnostic and laboratory services; infrequent and incomplete TB drug resistance surveillance; inadequate management of individual drug resistant TB cases; and paltry TB infection control measures, including in health care settings.

Predictably, many TB-endemic countries have indeed failed to meet the exacting standards of the WHO Stop TB Strategy. Given the circumstances in many countries where TB is rife, what is surprising is that they should be asked to pursue such a pipe dream.

DOTS was supposed to stem TB drug resistance. Because of sloppy and unimaginative implementation, it is evidently failing us. As the full extent of TB drug resistance comes to light, prioritising TB drug delivery above all other areas of TB diagnosis and care looks increasingly like WHO has been building a house, just without foundations. We cannot now claim to be surprised when a decade of overlooking the systemic challenges faced by countries with high incidence of TB brings the entire house down.

Promoting policy frameworks is no replacement for working together to achieve what needs to be done to address TB. The Global Plan to Stop TB, (2006-2015), launched by the Stop TB Partnership just over a year ago, is a road map for such a coordinated action.

WHO urgently needs to look beyond 'their' Stop TB Strategy to help promote and coordinate the comprehensive range of actions set out in the plan and to recognise the track record of over 500 global partners who put their name behind it.

When she took office just a few months ago, the new WHO director-general, Margaret Chan, identified the organisation's many partnerships as one of her immediate priorities. "Either the partnerships have to change or we have to change or both of us have to change to be more relevant", she said. "What is important to me is, are we getting the results that matter?"

In the case of controlling TB drug resistance, the answer is an unequivocal 'no'.

About the Authors:

Dr Bobby John, is the Executive Director of the Center for Sustainable Health & Development, India, and President of Global Health Advocates
Tim France, PhD is Technical and Policy Adviser at Health & Development Networks, and Chair of the Stop TB Partnership Media and Events Task Force

This article was published in:

The Japan Times (Japan) (27 March 2007)

The Times of India (23 March 2007)

The Nation (Thailand) (24 March 2007)

The Manila Times (Philippines) (24 March 2007)

The Seoul Times (South Korea) (23 March 2007)

The Daily Monitor (Uganda) (27 March 2007)

The Kathmandu Post (Nepal) (23 March 2007)

The Daily Star (Egypt) (25 March 2007)

Asian Tribune (23 March 2007)

Cape Times (South Africa) (23 March 2007)

The Zimbabwe Times (Zimbabwe) (26 March 2007)

Scoop Independent News (New Zealand) (23 March 2007)

e-Health News (South Africa) (23 March 2007)

All Africa.Com (Africa) (23 March 2007)

The Times of Zambia (26 March 2007)

The Jerusalem Post (Jerusalem) (25 March 2007)

The Yemen Times (Yemen) (26 March 2007)

World News Network

2007-02-12T00:13:00.000-08:00

More trust needed on shared global health goals

Despite unprecedented investment in international health programmes, seven specific diseases still claim one in every four deaths worldwide. There has never been a more acute need or opportunity for the World Health Organization (WHO) to do its job. To do so, the agency must achieve an extraordinary partnership among diverse stakeholders. Hasty criticisms of WHO in the past week reveal some of the challenges that working together presents.

With expectations rising about her leadership of WHO, Dr Margaret Chan’s recent unconsidered comments about compulsory licensing of essential drugs raise real concerns. But over-interpretation of her brief remarks by the media spawned a new analysis of WHO’s ‘position’ on compulsory licensing. AIDS organisations’ willing transformation of that analysis into an accepted truth appears increasingly like an unstrategic own goal with each passing episode.

Chan was in Thailand to take part in a conference on neglected diseases. Her keynote speech praised drug companies for their donations of drugs against diseases such as trypanosomiasis, lymphatic filariasis and schistosomiasis. These are medicines that are otherwise impossible to obtain for most of the people who need them. Media reports later referred to Chan as having “praised the pharmaceutical industry lavishly in her address,” without referring to the specific context of the drug donation programmes.

Earlier that same week, the military-appointed government in Thailand had exceptionally invoked three so-called ‘compulsory licenses’, giving the go-ahead for generic versions of corresponding drugs to be made – an entirely appropriate and permissible way for a country to get around the patent protection that companies hold. These mechanisms are legitimate exceptions to international agreements on trade-related intellectual property, or TRIPS, and aim to secure access to essential medicines. In the case of Thailand, two of the licenses were for HIV medicines, and the third was for a cardiac drug.

Not surprisingly given that news, during a briefing at the National Health Security Office in Bangkok, Chan referred specifically to the option of compulsory licensing: "I'd like to underline that we have to find a right balance for compulsory licensing," Chan said, adding, "We can't be naive about this. There is no perfect solution for accessing drugs in both quality and quantity." She also encouraged the Public Health Ministry to improve the public-private partnership in order to give the public better access to drugs.

The Bangkok Post interpreted this comment under the predisposed headline: “WHO raps compulsory licensing plan.” [not available on-line, download printable scan here]

Hearing her comments, activists were clearly disappointed that Chan was not taking a clearer stand in favour of TRIPS exceptions, in this their first glimpse of her view on the issue.

Ellen ‘t Hoen, from Medicins sans Frontieres in Switzerland, said at a press conference: “It is not the role of WHO to protect the interests of the pharmaceutical companies.”
“The new DG of WHO should have stood up for the poor,” added James Love, head of a US-based group lobbying for cheaper generic drugs.

The Inter Press news agency filed these and other quotes in a story titled: “WHO Chief’s stand on generic drugs slammed.”

The US’ largest HIV healthcare and prevention and education provider, the AIDS Healthcare Foundation (AHF), promptly issued a statement alleging that the new WHO Chief “Fails to Stand Up for People Living with AIDS.”

Further details were added to the story by a report from the Kaiser Family Foundation, which elaborated: “The World Health Organization on Thursday cautioned the Thai government on its decision to allow the country to produce a lower-cost version of Abbott Laboratories' antiretroviral drug Kaletra.”

A video clip posted to the Student Global AIDS Campaign web site showed former UN special envoy on AIDS in Africa, Stephen Lewis, imploring activists to take issue with WHO, which he claimed had:

“Effectively sided with the pharmaceutical industry, against the Government of Thailand and their decision to issue a compulsory licence for the creation of Kaletra at a much lower cost.”

The letter Lewis suggested they write duly arrived on Chan’s desk in Geneva on 8 February, eight days after her comments in Bangkok, bearing over 400 signatures of people living with HIV, and other organizations and advocates for treatment access from over 30 countries. It urged her to “reconsider her comments regarding the Thai government’s decision to issue a compulsory license.”

But had she “rapped” or “cautioned” the Thailand government about their decision? Had she really “sided with the pharmaceutical industry”? Did anyone take a moment to read beyond the headlines?

Chan’s comments are undeniably vague and now subject to endless interpretation. But rather than invest valuable energy and attention in responding to the possible implications of one uttered sentence, interpretation of WHO’s position should be based on their official statements on compulsory licensing and TRIPS. We should also rely more on the immeasurable advocacy that has already happened.

Surely collective energies would be better invested in openly and confidently assuring countries that the decision to issue any compulsory license is entirely theirs. There is no requirement for countries to negotiate with either the WHO or drug companies beforehand. So why create the impression that there is?

Years of activism, lobbying and nurturing of key relationships have got the TRIPS and drug patents debate to a place where countries like Thailand clearly are prepared to consider enacting – or even threatening to enact – TRIPS exceptions. Are we really ready to demean that solid foundation on the strength of one comment? And that from someone still in the first month of her new job?

If this was a shot across WHO’s bows to let them know they are subject to the scrutiny of AIDS NGOs and activists, then on that level it may have worked. So avidly and publicly doubting WHO’s position on TRIPS, however, is an implicitly weak and apprehensive position for advocates to adopt. Placing even the possibility of doubt so visibly in the spotlight may also, ironically, have helped inflate pressure for the Thailand Government to back down from using compulsory licensing. An outcome that has evidently already been reached (see Science and Development Network).

If Chan’s vague comments played into the hands of ‘big pharma’, as Lewis alleges, then their amplification by well-intentioned advocates can only have made matters worse. It certainly did not strengthen the hand of the Thailand authorities as they sat down to negotiations with Abbott Pharmaceuticals late last week.

Unquestionably, WHO should be front and centre when it comes to rigorous civil society scrutiny. To do its job properly, the organisation needs serious reconstruction work, as commentator Laurie Garrett recently suggested. “It is too soon to assess Margaret Chan's leadership, but even if it is impressive, the WHO is likely to remain an imperfect institution,” she added. “Still, it could exercise the power of the pulpit to corral well intended but often competing NGOs, donors, philanthropies, and local government agencies into following a shared strategic vision.”

If working together to promote global health is part of what we are all striving for, then some well-intentioned stakeholders need to cut Margaret Chan, and WHO, some slack.

2007-02-03T04:04:00.000-08:00

UK's Nabarro tipped for GFATM post

According to Reuters in Geneva, Briton David Nabarro is the unexpected front-runner for the job as head of the Global Fund.

The Fund’s board, made up of representatives of donor and aid-receiving governments, as well as non-governmental groups, is due to select a successor for (Sir) Richard Feachem at a meeting next Thursday (8th Feb).

The other two short-listed candidates are evidently French AIDS envoy Michel Kazatchkine and Alex Coutinho, head of Uganda's AIDS Support Organisation.

Not surprisngly, no indication was given by Reuters as to why the other six candidates: Julio Frenk (Mexico), Carol Bellamy (USA), Kunio Waki (Japan), Jack Chow (USA), Arata Kochi (Japan), Brad Herbert (not sure), were not short-listed.

A selection committee has evaluated the three remaining nominees and ranked "Nabarro first, Kazatchkine second and Cotinho third," an apparently well-placed Fund source said.

This means that next week’s board meeting is now likely to be polarised in quite a different way to the fiasco last November, which failed to select a candidate because of a split between donor and recipient delegations. With Nabarro no doubt heavily backed by the UK government, and Kazatchkine’s French patrons rumoured as still reeling from his non-selection in 2006, this now looks like a battle to see which European donor nation will prevail.

We can save the CVs for next Friday, when we know who has (hopefully) been selected. For now though, a photo of David Nabarro is provided below. You might recall seeing Dr Nabarro appearing almost daily on television as the World Health Organization spokesman following the 2004 tsunami disaster. At the time Nabarro mistakenly predicted: “"There is certainly a chance that we could have as many dying from communicable diseases as from the tsunami.”

After a distinguished career in public health and positions with the UK’s Department for International Development, Dr Nabarro now coordinates crises and disasters at WHO.

David Nabarro is 58.

2007-02-03T02:55:00.000-08:00

Disappointing anti-HIV microbicide news

The recent news that phase III clinical trial of cellulose sulfate – a potential microbicide being tested for HIV prevention in women – are to be simultaneously halted in Benin, India, Nigeria, South Africa, and Uganda, is an unexpected and disappointing setback for microbicide development efforts.

The news also surfaces on the heels of recent steps to place HIV prevention more centre stage in the AIDS response – and after trials of circumcision as a HIV prevention approach were also halted because it was more effective than anticipated – highlighting the generally difficult and unpredictable course of seemingly sound HIV prevention strategies.

Trials of the hopeful microbicide gel, also known as Ushercell, were stopped following a preliminary review of results from trials run by CONRAD (a US-based health research organization) showed that rather than protecting women from HIV, it could lead to an increased risk of HIV infection. That report prompted CONRAD and Family Health International (FHI) to immediately pull the plug on separate ongoing trials in the five countries.

No suggestion has yet surfaced as to why use of cellulose sulfate was associated with an increased risk of HIV infection in the CONRAD trial. An independent advisory group of experts overseeing the trial will conduct a detailed review of the data to better understand the findings, and help determine any implications for other microbicide studies.

Apparently, the FHI study did not confirm the finding of increased HIV risk, but the indications from the CONRAD review were sufficient to raise the alarm about their trial, which was also called to a halt.

"In Nigeria, we did not find any evidence of greater risk of HIV infection," said Dr. Vera Halpern, principal investigator of FHI's trial. "But we also found no evidence that the product was effective in preventing HIV. Given the disappointing results from CONRAD's study of the same microbicide candidate in other countries, the responsible course of action was to halt our study."

The finding that Ushercell might increase women’s vulnerability to HIV infection are reminiscent of initial trial results with an early microbicide candidate, nonoxynol-9. After a long and complicated history of testing, scientists concluded that, when used frequently, N-9 containing products may increase risk of HIV transmission by causing small disruptions in the vaginal epithelium (cell wall). Whether similar disruptions partly explain the recent cellulose sulfate results remains to be seen.

One major contrast today, however, is that according to the World Health Organization, Ushercell is just one of four hopeful microbicide candidates currently in phase III trials for prevention of HIV and other sexually transmitted infections.

Despite this setback, women’s social and biological vulnerability to HIV underscores why continued support for effectiveness trials and development of other microbicide candidates is now even more vital.

For more information about microbicide development and trials, go to:

Global Campaign for Microbicides

International Partnership for Microbicides

2007-01-23T18:30:00.000-08:00

Careless XDR-TB media coverage may tip balance on HIV stigma

We can’t say we couldn’t see it coming. One provocative PLOS Medicine opinion piece was all it took, and today an African government, TB researchers, clinicians, and mainstream international media are talking openly about the possibility of forced detention of people with extremely drug-resistant (XDR) TB. Much of what we have struggled to contain about TB- and HIV-related stigma may be about to come horribly true in South Africa.

In an atypically unbalanced story published yesterday and titled The dilemma of a deadly disease: patients may be forcibly detained, the Guardian mused about XDR-TB causing a “global pandemic if it is not controlled” in one breath, and went on to consider the human rights “dilemma” that XDR-TB poses in the next. What they overlooked was the possible impact this public debate could have on already stigmatising attitudes towards people who are particularly susceptible to XDR-TB: people living with HIV. In South Africa at least, when you talk about detaining people with XDR-TB, you are effectively talking about people with HIV.

One word that should have been more heavily emphasised by the article was “considering” – after all, the South African authorities are only considering forcibly detaining people with XDR-TB. But that’s a precarious distinction that the article chose not to stress.

Instead, the paper opted to headline the possibility of detention, and gave it further credence by adding that the government has “discussed [it] with the World Health Organisation and South Africa's leading medical organisations.” And unlike its usually conscientious coverage, the Guardian even went on to scapegoat an individual patient, who according to the paper “discharged herself from a hospital last September and probably spread the infection.”

They further fan the dread by giving interviewees plenty of air time to push the SARS/bird flu fear buttons by talking about XDR-TB possibly “swamping” South Africa and “spreading far beyond its borders.” Unfortunately, the story offered no perspective from someone with, or affected by XDR-TB. Nor did it give the World Health Organization (WHO) an opportunity to comment on the effectiveness of detention as a public health measure.

Media attention like this certainly helps to spotlight issues around TB control. But implicit messages that feed perceptions of personal vulnerability, helplessness and scapegoating also adversely impact affected populations by arousing stigma, panic and fear (see: Living on the Outside).

One reference of note would have been a document distinctive to the TB field: The Patients’ Charter for Tuberculosis Care. Initiated and developed by TB patients from around the world, the Charter specifically outlines the rights and responsibilities of people with tuberculosis. Further coverage of XDR-TB would do well to refer to it.

A specific point mentioned by one of the Guardian's interviewees, but not elaborated by the article, is that there is a good chance that most of the XDR-TB reported in South Africa appears to have been transmitted within health care settings. While it is also important to avoid an impression that health settings are dangerous places, it does mean that in order to be effective, TB infection control measures need to focus on very specific places, including clinics and health centres. And this is something that the WHO has just published revised guidelines on.

If a shift in TB- and HIV-related stigma does occur as a result of careless media coverage of XDR-TB, it will potentially affect the lives of a huge number of people. In South Africa alone, for example, there are about five million people living with HIV, and they face the major threat posed by XDR-TB.

With little evidence available about the extent to which HIV negative people are susceptible to XDR-TB acquisition, the possibility that people with XDR-TB will “leave the isolation wards and go home to die,” as the Guardian story put it, might yet turn out to be a more effective way to stem the spread of the “deadly strain of tuberculosis” than padlocking the doors of the clinic with the patients inside.

2007-01-22T06:13:00.000-08:00

Integration and chronic conditions on the WHO agenda

Is jumping in at the deep end really the best way to learn? Dr Margaret Chan should know, as less than three weeks in new job as WHO Director-General she opens her first meeting of WHO’s Executive Board today in Geneva.

In what she referred to as “optimistic times for health” she gave some clues about how her priorities might have evolved during her first 19 days in the job. Here are a few snippets I tuned in to in particular as I read her speech – you can get the full version of her address on the WHO site.

Not surprisingly, Dr Chan flagged integration of health services as high on her agenda. (Who wasn’t talking about that as a priority in 2006?) Citing the recent attainment of Measles Initiative targets, she highlighted the ability of the initiative to also deliver a “bundle” of interventions, including bed nets, vitamin A, de-worming tablets, as well as polio and tetanus vaccines.

“I view this initiative as a model of what can be achieved through integrated service delivery,” she said. “This is a value-added approach that amplifies the power of public health.”

That might work for measles and other child-related services, but it is not clear how the ‘model’ would translate into integration of TB and HIV services, for example, or the bringing together HIV and other sexual and reproductive health services.

The theme of integration also surfaced later in her address, in relation to health system strengthening, when she talked about the unprecedented number of partnerships, initiatives, and funding agencies now devoted to public health. Without referring directly to any American philanthropists cum technology giants in particular, Dr Chan emphasised the need for working together and to align with country priorities and capacities.

“Single-disease initiatives have their place, but we need to pursue every opportunity to find synergies that bring multiple results,” she said.

She added: “I further believe that when we use an integrated primary health care approach, we will find ways to inter-relate programme activities, and thus amplify our impact.”

She gave further clues of what is on her mind when she summed up the essence of one of WHO’s dilemmas, drawing attention to the ‘multiplicity of health initiatives focused on delivering outcomes’, and their common requirement for a functional health system.

“Yet strengthening health systems is not the core purpose of these initiatives,” she emphasised. “We need a common approach to service delivery.”

Possibly signalling an imminent (and long overdue) shift away from acute care paradigms that dominate much of WHO’s work and many health systems, the new DG made it clear she is fully aware that tools and strategies for taking action on chronic care prevention and management lay waiting in the wings.

“As the report on chronic diseases makes clear, we have many excellent opportunities for prevention and a broad range of interventions that are cost-effective in all our regions,” she reminded the Board. “For these diseases, prevention is by far the best option. WHO must continue to convince health leaders in all regions that chronic diseases are part of the development agenda.”

Finally, the new DG indicated that she is also on the case when it comes to WHO’s role at the interface of public health and free-market forces, and willing to consider new thinking in this area. Focusing on fixed-dose drugs for children suffering from AIDS, tuberculosis, and malaria, she recognised that such drugs are often not available because industry has no strong market incentive.

“As you know, we are developing a strategy and action plan addressing public health, innovation and intellectual property.”

The Executive Board (EB) is composed of 34 individuals technically qualified in the field of health, each one designated by a Member State elected to do so by the World Health Assembly. Member States are elected to the EB for three-year terms.

Dr Margaret Chan is from China

2007-01-21T19:31:00.000-08:00

Brazil study creates an 'algal gel' news buzz

The chances are, if you follow the internet and other HIV information sources, you've seen a story in the past few days about a new microbicide candidate from Brazil that is derived from algae. The story goes something like this…..

An algae-based gel, highly effective at controlling replication in HIV, has passed initial trials in Brazil. Designed to block sexual transmission of the virus, the gel could provide vital protection for women in poorer countries where condom use is erratic….etc etc

(This snip is taken from the sci.dev.net coverage of the story, by Helen Mendes)

Nothing appears to be especially amazing about this story, especially when you compare it to similar stories that have surfaced over the past few years about one of lead candidate microbicides, Carraguard, that is made from a seaweed extract.

What is amazing though is how this story has been amplified throughout the world since it first appeared in a Brazilian newspaper (the Folha de S.Paulo) last Monday. If you now search Google for the full title of the article:

“Brazilian Researchers Test Algae-Based Anti-HIV Gel”

you get a whacking 23,000 hits. Try it for yourself, it is probably even higher by now.

(if the original Sao Paulo author of the story, Eduardo Geraque, does not know it already, please someone tell him that he is famous).

So what is it about this story or the way it was floated that gave it such a proliferation? It’s actually quite difficult to trace the story’s tracks, but a major boost seems to have happened when it was translated into English and put on the wire services by Agence France Press on the same day it hit the streets in Brazil. From there it was picked up by just about every health news service I have checked, as well as other news services such as Breibart, and a swathe of on-line news groups such as Google Groups and YahooNews.

But there is nothing incredible there that explains the huge buzz-factor. There must be something about the story itself that makes it worthy of such a pass-on rate.

Well, it is not a result of the high-quality science contained in the original information released about the study, which is weak by any standards.

Could it be that people love a story in which a small-fry comes good against all odds? (apologies to Luiz Castello Branco, of the Oswaldo Cruz Institute, Brazil, for calling him a small-fry, but my point is that he is not exactly Glaxo or Merck). Or could it be that it originates in Brazil/Latin America, from where we see very few stories related to health science and research?

No, I don't think so. My bet is that the world is so used to hearing disappointing news about the HIV epidemic, and so desperate to hear that the virus can be stopped, that it is willing to believe and propagate a scientifically weak but tantalizing possibility. The fact that the gel is made from algae - a ubiquitous, natural and free commodity - makes it all the more appealing and new age-ish.

By the way, the original story and the AFP release did not once use the terms ‘microbicide’, ‘vaginal’, ‘rectal’, ‘sexually-transmitted diseases’ or ‘spermicidal activity’ at all. Strange that. The furthest they went was to say: “Women can use the gel without the knowledge of their partner,” and left the rest up to the readers’ imaginations.

Alliance for Microbicide Development, Global Campaign for Microbicides, International

Partnership for Microbicides, Population Council, and World Health Organization specialists take heed: For a while at least, home-grown HIV prevention tools, including microbicides, may be 2007’s hottest property when it comes to the health news ‘buzz’. But, readers and editors may prefer to keep it simple and understated when it comes to thinking about actually using them.

(By the way, in case you are wondering the algae used by the researchers (Dictyota pfaffii) is shown in the photo above)

2007-01-17T01:27:00.000-08:00

Whatever you do UNICEF, accentuate the positive

I am getting so tired of the habitual UN practice of pumping up the positive side of anything they do on AIDS, and leaving the bad news for the small print. It is so dishonest and deceitful. I have just read the latest and most staggering example I can recall.

Instead of launching your one-year stock-take of the ‘Unite for Children, Unite against AIDS’ campaign, why don’t you just admit it, UNICEF, progress on the global response to children and AIDS is appalling, and no amount of media spin will change the numbers. If this is your mandate, then you may have screwed up big time. But we're all human, right?

One year after the launch of the campaign, press releases with headlines like:

“Signs of progress and momentum in global response to children and AIDS”

do nothing to mask the fact that progress against the campaign’s four 'Ps’ are nothing short of shameful. Trying to claim otherwise to placate your donors, or whoever else it is you are stroking, is reprehensible.

Preventing mother-to-child transmission of HIV:

Despite your focus on the handful of “countries that have achieved breakthroughs in preventing HIV transmission from mothers to children,” the overall access of pregnant women with HIV to appropriate drugs is 9%. You were right to refer to that as “unconscionably low.”

The Campaign goal for this ‘P’ is: By 2010, offer appropriate services to 80 per cent of women in need

Providing paediatric treatment

How the global average of “one in ten children needing antiretroviral treatment receiving it” constitutes progress is beyond me. And indirectly claiming some of the credit for the paediatric formulation price reductions negotiated by the Clinton Foundation – which surely is something UNICEF itself should have been blazing a trail on long ago – is manipulative and conniving.

The Campaign goal for this ‘P’ is: By 2010, provide either antiretroviral treatment or cotrimoxazole, or both, to 80 per cent of children in need

Preventing infection among adolescents and young people

Again, you choose to accentuate the positive by saying: “The stocktaking report notes that prevention responses are displaying renewed attention on the need to focus strategies on adolescents and young people most at risk.” I am not even sure what that means, it is such circuitous wriggling. The 2006 AIDS Epidemic Update, published just two months ago, describes the state of this ‘P’ very clearly:

In many regions of the world, new HIV infections are heavily concentrated among young people (15–24 years of age). Among adults 15 years and older, young people accounted for 40% of new HIV infections in 2006.

The Campaign goal for this ‘P’ is: By 2010, reduce the percentage of young people living with HIV by 25 per cent globally

Protecting and supporting children affected by HIV/AIDS

The section of the release really clutches for something self-congratulatory to say, and plumps for referring to the significant reduction “in several countries” between orphans and non-orphans in access to education. In one of his last addresses as UN Special Envoy for HIV/AIDS in Africa, Stephen Lewis called the response to the needs of children affected by the epidemic “microscopic”. He also said:

It is impossible to understand how, in the year 2006, we still continue to fail to implement policies to address the torrent, the deluge of orphan children.

One of the chilling pieces of data UNICEF should be emphasizing is that only three to five per cent of orphans receive any intervention of any kind from the state.

The Campaign goal for this ‘P’ is: By 2010, reach 80 per cent of children most in need

Why is UNICEF afraid of just telling the truth? I thought that was what advocacy was about.

Thank goodness that some journalists have taken the trouble to read the report for themselves and are today conveying the considerable disappointment that UNICEF should be communicating about it:

Few pregnant African women get AIDS drugs: UNICEF
Scientific American

African moms still pass on HIV to kids
Pretoria News

UN Report: Response To Children With AIDS Insufficient
All Headline News

Spread of AIDS to children slowing, but picture bleak
Canadian Broadcasting Company

UN Says Global AIDS Effort for Children Falls Far Short
New York Times

Ann M. Veneman is UNICEF's Executive Director

2007-01-14T19:45:00.000-08:00

Support growing for new global drug R&D framework

Looser patent control maybe on the horizon

Momentum is increasing behind a proposed global framework for drug research and development (R&D) that aims to share the benefits of scientific progress in the prevention, diagnosis and treatment of diseases more fairly.

An MSF-organised meeting took place this weekend in New York among about a hundred significant stakeholders, including drug developers, clinical researchers, health professionals, policy-makers, donors, and activists (see below). The symposium focused on TB drug development and highlighted current approaches as inadequate to respond to the urgency of the global TB epidemic:

TB is the leading killer of people with HIV/AIDS and the inadequacy of tools to diagnose and treat TB are a major threat to the health and lives of HIV/TB co-infected individuals;

We have inadequate and outdated tools for rapid diagnosis, inadequate and outdated drugs to cure many adults and children with TB today, and an inadequate pipeline to ensure our ability to cure the majority of TB cases in the future;

We lack the basic biological understanding of this complex disease to anticipate the most efficient routes to prevent and treat TB;

Clinical trials for drugs and combinations that could be done today are being held back because of a lack of funding and capacity as well as regulatory barriers;

Meaningful gains in TB control will only be made when the treatment of TB, including drug-resistant TB, can be dramatically shortened and simplified.

The statement that came out of the meeting called upon governments, intergovernmental agencies, researchers, drug and diagnostic developers, nongovernmental organizations, and funders to take action in five key areas:

Accelerate drug discovery

Expand clinical trial capacity and accelerate clinical development

Support new approaches to R&D

Commit to global TB R&D leadership

Increase funding for TB R&D activities

But in the detail describing new approaches to R&D, the participants also gave their support to mechanisms that have been proposed to stimulate research around neglected and other diseases affecting developing countries. They said:

The lack of TB drug development is a result of the failure of current profit-driven drug research and development model. The TB community must engage in the World Health Organisation’s Intergovernmental Working Group on Innovation, Intellectual Property and Public Health to establish a global R&D framework to help design new ways of setting R&D priorities and financing.
With respect to TB drug development, participants of the New York symposium support current discussion at the WHO for an alternative R&D Framework that addresses the question of who pays for essential medical R&D and de-links incentives from drug prices, instead rewarding the impact of inventions according to health care outcomes.

What do these two points refer to?

In May 2006, a World Health Assembly resolution asked WHO to establish an Inter-Governmental Working Group on Innovation, Public health and Intellectual property. Their first session (in December 2006) considered ways to stimulate R&D for neglected and other diseases affecting developing countries; improve delivery systems and access; and examine sustainable financing mechanisms to ensure long-term benefits – effectively, ways to ‘de-link’ the R&D part of drug development from profit-making and drug sales. The ‘alternative R&D Framework’ is a part of the immediate remit of the group, and a plan of action that aims to find new ways to identify gaps in research on diseases that disproportionately affect developing countries.

So as well as re-stating TB drug development needs, the meeting participants also put their collective weight behind these new mechanisms, sending a clear signal to WHO to keep the momentum towards these new models going. This might not sound that significant, until you look at who was at the MSF meeting. According to a Newswise release just before the meeting, participants included:

Médecins Sans Frontières (MSF), Weill Cornell Medical College, World Health Organization, National Institute of Allergy and Infectious Diseases (NIAID) /National Institutes of Health (NIH), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), GlaxoSmithKline, Novartis AG, Johns Hopkins University Bloomberg School of Public Health, Bill and Melinda Gates Foundation, Columbia University, Rockefeller Foundation, European and Developing Countries Clinical Trials Partnership (EDCTP), Brazilian Society of Respiratory Diseases, St. George's Hospital Medical School of London, Global Alliance for TB Drug Development, University of Illinois at Chicago, Institute for Tuberculosis Research University of Illinois at Chicago, Yale Law School, Drugs for Neglected Diseases Initiative (DNDi), Tibotec, Denver Health and Hospitals, Treatment Action Group, and the Consumer Project on Technology.

In a paper describing the new R&D framework, one of the architects of the new R&D Framework – James Love, Director of the Consumer Project on Technology (CPTech) – nicely summarizes the failure of the current model for drug development and why the new framework is so vital:

Today's high drug prices are a direct consequence of a business model that uses a single payment to cover both the cost of manufacture of a drug and the cost of the research and development (R&D) carried out by manufacturers to discover it. A 20-year patent-based marketing monopoly is then granted to the drug's developers to prevent their prices being undercut by ‘generic’ copies produced by manufacturers who do not have R&D costs to recover.

At the NY meeting, Tido von Schoen-Angerer of MSF told Reuters there had been a "failure" in TB research with only seven drugs to fight the disease in clinical development, compared with 149 drugs for cardiovascular disease and one new HIV drug annually for the past 25 years:

"We have a pharmaceutical market worth $600 billion a year and there's a very clear issue," he said. "Research and development is patented and profit-driven and is not delivering to the patients that are dying."

Watch this space..... Progress of the new WHO Working Group and of the proposed framework will surely be on the agendas of the WHO Executive Board and the World Health Assembly again during 2007. This will likely move centre stage during the coming year.

The Cornell Club in Manhattan, where the MSF meeting took place this weekend.

2007-01-12T00:28:00.000-08:00

List of Global Fund head nominees leaked to media

Following the disappointing failure of the Global Fund Board to select a new Executive Director for the fund late last year, a panel has apparently narrowed the re-run for the job down to a first short-list of nine candidates.

According to a document leaked to the Boston Globe newspaper, and published this week, the one woman and eight men are:

Julio Frenk, Mexico's former health minister who was a finalist last year to be head of the World Health Organization;
Michel Kazatchkine, France's AIDS ambassador and one of two finalists for the fund's executive director post last year;
David Nabarro, a senior WHO administrator now leading United Nations efforts to fight avian flu and a possible human pandemic influenza;
Alex Coutinho, a highly successful manager of AIDS treatment programs in Uganda;
Carol Bellamy, who led UNICEF from 1995 to 2005 and now is president of World Learning, an international educational organization based in Brattleboro;
Kunio Waki , a Japanese national who leaves his post as deputy executive director of the UN Population Fund at the end of the month;
Jack Chow , a former State Department senior official who also headed WHO's AIDS programs;
Arata Kochi, head of WHO's reenergized malaria program;
Brad Herbert, former director of operations for the fund.

Surprisingly, and despite the independent ‘public-private’ nature of the Fund, over half of the contenders are former senior UN officials, or in one case a previous Fund employee. Donor countries also feature heavily in the roll: Seven of the nine applicants are from France, United Kingdom, USA [3] or Japan [2], and just the Mexican (Frenk) and Ugandan (Coutinho) nominees are from countries receiving money from the fund. Alex Coutinho, from The AIDS Support Organisation in Uganda, is the only candidate with a civil society background.

Following interviews with each of them, the Nomination Committee is scheduled to submit a shorter list of final five candidates to the full Board by January 22. The Fund Board’s Executive Committee meets in Geneva in early February to vote on the final candidates.

The outgoing Fund ED, Professor Richard Feachem, was recently knighted by the UK Queen in recognition for his role in leading the fund since its inception. It confers the title ‘Sir’ Richard Feacham. Majestic shoes, indeed, for one of the nine nominees above to fill.