Archive for the 'WHO' Category

Measuring malaria incidence

Why are disease burden estimates important? There are two sets of reasons: 1) technical, e.g. national priority setting etc and 2) political economy of health, e.g. advocacy and visibility, donor influence, etc. Thus, estimates are often quite contentious apart from the methodology used. The practical applications of burden estimation are on the other hand limited. Monitoring and evaluation systems can, with valid measurements of trend, help allocate regional resources, determine impact, and respond to outbreaks without necessarily measuring the magnitude of disease.

There are broadly two competing approaches for estimating malaria burden. One extrapolates from maps and surveys of population cross-sections, the other extrapolates from routinely collected surveillance data. Both have certain assumptions and biases: the former tends to overestimate, the latter generally underestimates. How should countries proceed? A new article from WHO in PloS Medicine (open access!) describes and contrasts each in a careful and informative way including actual results from 2009. While neither method is perfect, the authors present a compelling case for investing in surveillance-based approaches in the long run particularly outside of hyperendemic settings and in the context of intervention scale-up and declining transmission. Only that approach can improve the health system, and provide disaggregated and timely data amenable to frequent updates.

An accompanying editorial by Mueller, Slutsker, and Tanner broadly agrees with the author’s outlook though it includes a careful placative statement:

The two methods thus have their unique strengths and weaknesses, and rather than seeing them as competing approaches, they should be synergistically combined.

At first pass this seems a sensible assertion but on closer examination, and without other supporting text, it’s not clear what to make of it. Which distinct synergies do they envision? Should the two methods be used globally, i.e. one in countries without quality surveillance and the other elsewhere? Or should the two methods always be used in each nation? Why? Should they be used indefinitely – what about when surveillance systems mature? Are there not trade-offs both in time and space? Such discussion, drawing on the considerable program experience of the writers, would have been more helpful than conciliatory statements of questionable sincerity.

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Interview with Dr Robert Newman, WHO Global Malaria Programme

This month’s issue of the Bulletin of the WHO brings a fantastic interview with Dr Newman, director of the organization’s malaria program. A very good line:

At the centre of everything you have national malaria control programmes, which are much more sophisticated than 20 years ago.

Misdiagnosis: What Jack Chow got wrong about the WHO

Dr Jack Chow, a former WHO official with a colorful background including management consulting and investment banking, takes a bird’s eye view of the World Health Organization in Foreign Policy magazine. WHO cannot become complacent (see here) and needs to pursue serious reforms but my agreement with Dr Chow ends there.

First, the “product” of WHO is not expertise but the ability to operate as a neutral forum for cooperation between all countries. WHO is an intergovernmental agency. Period. This feature makes it unique among other health related organizations and provides unmatched credibility and mandate. In fact, it is this aspect which enables WHO to host the diverse and talented technical panels which produce the guidelines and standards that represent the agency’s expertise.

Second, strengthening country offices is an important goal but the most pressing, and admittedly difficult, reform WHO needs is in its financing structure. WHO budget comes from two sources: general UN contributions by member countries and donated funds (usually earmarked). The balance between the two sources has changed with the latter growing in proportion with time. Now, regular contributions compose only 20% of the total meaning that the vast majority of WHO budget, and consequently operations, is under donor control. Laurie Garret notes:

Yet, as Harvard University’s Christopher Murray points out, the WHO itself is dependent on donors, who give it much more for disease-specific programs than they do for its core budget. If the WHO stopped chasing such funds, Murray argues, it could go back to concentrating on its true mission of providing objective expert advice and strategic guidance.

Overall, the article belays impatience with an admirable spirit to just “get things done” but without much concern for process, sovereignty, and accountability. Dr Chow advocates for WHO to become the go-between for donors and to bypass governments to directly work with NGOs, bilateral programs, and the private-sector groups “on the ground”. Barring the question of whether this is even desirable (it undercuts state responsibility for health and represents mission creep), if WHO is underfunded, understaffed and already can’t keep up with government needs as the article notes – how will it handle those of additional players? I expected more.

For a work that carefully dissects WHO place today in the context of it’s long history see the five-part series from the unfortunately now defunct blog Effect Measure.

Has WHO eliminated artemisinin resistant parasites?

Possibly, but probably not, and certainly too early to tell. Though some would have you believe it already. The World Health Organization press release makes two claims: 1) artemisinin-resistant malaria (previously discussed here and here) has almost disappeared from areas tested in a pilot project managed by WHO and 2) the overall incidence of malaria has reduced significantly in the zone targeted by the project.

For the first claim no citation, efficacy or parasite clearance time data, or evidence of any sort are mentioned including who these researchers might be. The (presented) basis for the second claim lies in the screening of just 2,782 persons (it is unclear if this was a mass survey or several months of active case detection) in which only 2 P. falciparum cases were found. I realize this is not a scientific paper, but the ‘screening’ of a few thousand people in a border population of millions before the main malaria transmission season over the upcoming months seems little to be excited about. What was the need for this? The project just began in 2009. Why not wait another two years before making any public pronouncements? Alternatively, only provide regular updates through a somber and detailed format such as an annual project summary.

I believe in WHO. First, WHO has an unique mandate for supranational coordination. Second, WHO operates by consensus which, while time-consuming and difficult at times, allows countries large and small to have a voice at the table. And finally (related to the previous point), they maintain the trust of ministries of health in a way no other organization does – at least for now… They are losing their reputation by continuing to release shoddy statements backed by limited or poor quality data.

I’ve already complained about science and public health by press release. I understand it though from NGOs but I do not understand this trend from an organization which prides itself as a leader in developing quality health recommendations and soliciting technical excellence.

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Malaria heroes 1: Krongthong Thimasarn

Beyond the glitz and glamour of malaria advocacy on the world stage, there is a cadre of dedicated individuals that is working hard in malaria control everyday. Community volunteers, health services staff, researchers, control managers, and others may not appear in the papers, but their work is the basis for any progress achieved. I think it’s important to take some time and highlight a few people.

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My first post in this series is on Dr Krongthong Thimasarn, regional adviser for malaria at the  Southeast Asia Regional Office of the World Health Organization.

Highlights:

  • Former director of the Malaria Division at the Thai Ministry of Public Health, arguably the best malaria control program in the world
  • Founding member of ACTmalaria network – a collaborative training network for Asia
  • Medical doctor and graduate of the Thailand Field Epidemiology Training Program

In Thailand Dr Thimasarn saw Plasmodium falciparum grow resistant to chloroquine, sulphadoxine-pyrimethamine, and mefloquine in succession – what a nightmare and challenge! Her knowledge of program implementation is incredible and she understands the realities which governments often face. But more importantly, she never let those hurdles stand in the way of necessary actions or relevant evidence, no matter how difficult the changes would be or how inconvenient the data was. If you work in public health, you understand how valuable this is. Dr Thimasarn’s amazing work ethic has continued at WHO where she can often be found working as late as 8pm in the evening, including Saturdays. It is a type of dedication that is rarely matched.

If you know other malaria heroes and would like to recognize them, please email me a guest post and I will be happy to publish it.

2008 World malaria report released

The latest World Malaria Report has been released by the Global Malaria Program at the World Health Organization. More later.


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