No Ifs About The Butts, No Matter How Much You Puff

One of the most powerful and cost-effective mediums to educate consumers about the hazards of smoking is the pictorial health warning on the package of tobacco products itself. It has universal reach, and the cost of package warnings is paid for by the tobacco companies, not the government. It is empirically established from the experiences of other countries that strong pictorial health warnings on tobacco products are powerful communication tools that can take the message of the health hazards of tobacco to the masses, including the illiterate. Health warnings on tobacco product packages are critical to any effective tobacco control strategy, as they deter non starters and motivate consumers to quit. Read more

Article 11 of the WHO Framework Convention on Tobacco Control (WHO FCTC – the global tobacco treaty to which India is a signatory) obligates its parties to ensure that tobacco products packages carry appropriate health warnings describing their harmful effects. According to Dr Samlee Plianbangchang, WHO Regional Director for Southeast Asia, "Tobacco is the only legally available product that kills people, and 1.2 million people die from tobacco use in our region annually. An effective tobacco control strategy is, therefore, not just a programmatic necessity but also a moral imperative."

The Cigarette and Other Tobacco Products Act, 2003, also mandates pictorial warnings on all tobacco products in India, with annual rotation of pictures/ photographs used in these graphic warnings.

Alas! The death peddling lobby of tobacco/ cigarette manufacturers seems to have a stronger hold on the Indian government, than the right to health of its millions. After many initial delays, India finally put out pictorial warnings on tobacco products from May 31, 2009. These proved to be very mild and hence ineffective. The hazy images of lungs and a scorpion's picture on gutkha and cigarette packets were ludicrously funny, and not scary, to say the least. As per its commitment to the FCTC, and its own obligations to implement domestic laws, the government agreed to replace them, with scarier pictures of cancer stricken mouths, by 1st June 2010. To the dismay of the anti-tobacco activists and all health conscious people, this date was then shifted to 1st December 2010, and now to December 2011.

Once again our democratic government has buckled under the pressure tactics of the tobacco industry. According to a news published recently (click on the link to read the news), a RTI query, filed by Voluntary Health Association of India (VHAI), has revealed that the new pictorial warnings on tobacco products were deferred due to pressure from the tobacco industry, including ITC and the Pan Shop Owners Association, which comprises retailers of cigarettes, bidis, chewing tobacco and betel leaf. The government has unashamedly 'admitted' that the new pictorial warnings on tobacco packs have been deferred because of the 'pressure' exerted by the industry and other interested parties. The RTI revealed that the tobacco lobby had also approached the Union Health and Family Welfare Minister of Government of India, Shri Ghulam Nabi Azad to delay the implementation. Union Law Minister Shri Veerappa Moily, received a letter from Paan Shops Owners Association of India dated, March 25, 2010, which said, "Due to graphic tobacco warnings, our retailers have seen a decline in the business of our members. About 60 to 70 per cent of the business of these shopkeepers comes from tobacco products, but the impact has been felt beyond just these products as customers are not visiting these outlets. We sincerely hope you will give due consideration to the voice of aam aadmi, that is to defer the introduction of the new health warnings."

The Health Ministry also admits to have received anti-pictorial warning representations from tobacco giants like the ITC and Tobacco Institute of India. One of them, from ITC and dated March 5, 2010 said: 'Rotation of designs every year is not worthwhile as any changes in the graphic elements of the tobacco packs will require substantial redesign of the packs which in turn would necessitate procuring of new printing cylinders and ancillary equipments for a large number of packs.'

Tobacco majors argued that they have large unsold stocks and must be allowed to expend these before the warnings are changed. They threatened to maintain the current halt on fresh production - a move that can impact the labour intensive industry including cultivators.

So the Cabinet not only took a decision on Dec 7 to further defer the pictorial warnings by a year, but the Ministry of Health and Family Welfare, through a Gazette notification dated 20.12.2020, amended the Cigarettes and Other Tobacco Products (Packaging and Labelling ) Rules 2008. For Rule 5 the following has been substituted --“Rotation of Specified Health Warnings—The Specified Heath Warning on tobacco packs shall be rotated every two years from the date of notification of the rules or earlier, as the case may be, as specified by the Central Government.”

It would be worth mentioning here that while Indian tobacco products warn consumers with hazy images of lungs and scorpion, other nations clearly depict the devastating impact of tobacco on a smoker’s health through graphic pictorial warnings. A picture from Uruguay shows a baby surrounded by cigarette-smoke rings, warnings from Thailand (it has implemented 9 different pictorial warnings on 50% surface area of cigarette packs) show pictures of a mutilated and cancer-affected mouth.
While Bangladesh has six different types of text warnings covering 30 percent surface area of all smoking tobacco products, Maldives has mandated five different types of textual warnings covering 30 percent surface of the cigarette package.

Even our next door neighbour Pakistan has introduced gory pictorial warnings on all tobacco packs from August 30 in a bid to deter consumers from smoking or chewing tobacco. It has made it mandatory for 40% of all tobacco packs — on both sides — to carry the image of a rotting mouth suffering from cancer along with a health warning.

On the contrary, India, where 2,500 people die daily due to use of tobacco, has put off the introduction of strong and gory pictorial warnings till December 2011. But there is a ray of hope from the judiciary, if not from the executive. Even as the government backed down under pressure, the Supreme Court recently banned plastic packaging for tobacco products. In a reference to the fight against cancer, the Apex Court said that unlike the government, it could not remain a mute spectator to the public health menace and asked the government to implement the order by March 2011, even if it "brings the entire tobacco industry to a standstill."

We can only hope (and fight) for better sense to prevail upon the rulers of our country, so that they do not barter the lives of millions for financial gains of a miniscule, yet powerful segment of society.


Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Diabetes Media Initiative (CNS-DMI).She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP.  Email: shobha@citizen-news.org, website: www.citizen-news.org)  




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SAARC Countries To Collaborate In The Field Of Health Care

The 70th Annual conference of the Association of Surgeons of India ASICON 2010, held recently in New Delhi was one of the largest medical conferences of surgeons in the world. Over 7000 national and international delegates from India, England, Scotland, USA, Egypt and SAARC nations attended the conference. Read more

Panel discussions on surgical education, live telecasts of basic and advanced surgical procedures, and sessions on innovations in surgery were some interesting highlights of ASICON 2010. Critical evaluations, discussions and debates on surgery and surgical practices took place in a very vibrant atmosphere, leading to constructive and positive outcomes from this interactive and informative meet.

The panel discussion on “Reforms in Surgical Education, Training and Practice for 21st Century India” was indeed an intense affair, with valuable inputs and suggestions from stalwarts in the medical fraternity. According to Dr.NK Pandey, President, Association of Surgeons of India, “ Some very interesting topics in medicine and surgery such as robotic cancer surgery, reconstructive surgery, management of brain tumours, laparoscopic procedures, pancreas transplantation, SILS (Single Incision laparoscopic surgery), NOTES (Natural Orifice Transluminal  Endoscopic Surgery),and many more such innovations in surgery were discussed through lectures, orations, and presentation of case studies, by various stalwarts in the world of medicine from India and across the globe.”

 Another very interesting session was” Innovations in Surgery” (or practice of what is colloquially called Jugaad in Hindi), where different innovations for modifying surgical instruments were discussed. Surgeons have modified surgical instruments to lower the cost of surgeries. Dr.R.K Karwasra, Head of Surgery & Surgical Oncology, PGIMS, Rohtak, explained close suction technique for NGA (Naso Gastric Aspiration). In this technique the harmful secretions from the stomach are removed by aspirating it through the nasal orifice, with the help of a nasogastric tube. This method does not require precious nursing time, and is more hassle –free and convenient to use.

The SAARC symposium, aptly titled Back to Basics, saw an active participation of the medical fraternity from Sri Lanka, Bangladesh, Nepal & Bhutan. It helped in ushering a deeper understanding of basic issues in surgical education, surgical training and surgical services daunting SAARC countries. It also opened the doors for more collaborative opportunities in healthcare between India and other SAARC nations. Dr.Narender Pinto of Sri Lanka hoped that such exchanges between India and other SAARC countries in the field of medical education and sharing of expertise in surgical practices among the surgeon fraternity would continue in the years to come.

 The climate of debate/discussion highlighting emerging trends in surgery, and live telecasts of basic/ advanced surgical techniques at the conference proved to be a tremendous experience even for seasoned surgeons.  The exchange of ideas at the conference is bound to enhance surgical acumen among doctors, and will go a long way in advancing the cause of surgery.

Shobha Shukla - CNS 


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Hopes rest on a new rapid diagnostic test for tuberculosis (TB)

One of the best chances of stemming the tide of tuberculosis (TB) epidemic in low- and middle- income countries is to thwart the transmission cycle – by diagnosing TB early, and treating it successfully without delay. The microscope has been around since 1882 as the key standard TB diagnostic tool, and with low sensitivity (50-60%) and other challenges in detecting TB in varying conditions and co-morbidities, it is clear that it is high time we use better, more effective and efficient tools to accurately detect TB, and neither mis-diagnose nor miss TB diagnosis in myriad settings. Read more

This was a clear thought emerging out of the 'International Symposium on Tuberculosis Diagnostics: Innovating to make an impact' (ITBS 2010), organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi, India (16-17 December 2010) with support from the Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND).

Although high-income countries have moved on to using better and modern diagnostic tools, many low- and middle- income countries still rely principally on sputum smear microscopy.

One of the diagnostic tools that the World Health Organization (WHO) recently endorsed is a fully automated Nucleic Acid Amplification Test (NAAT) - Xpert ® MTB/RIF - a new and novel rapid test for TB, especially relevant in high TB burden countries. According to the WHO, the test could revolutionize TB care and control by providing an accurate diagnosis for many patients in about 100 minutes, compared to current tests that can take up to three months to have results. This WHO endorsement of the NAAT has come after 18 months of rigorous assessment of its field effectiveness in the early diagnosis of TB, as well as multidrug-resistant TB (MDR-TB) and TB complicated by HIV infection, which are more difficult to diagnose.

THREE-FOLD INCREASE IN DIAGNOSING DRUG-RESISTANT TB POSSIBLE
According to the WHO, evidence to date indicates that implementation of this test could result in a three-fold increase in the diagnosis of patients with drug-resistant TB and a doubling in the number of HIV-associated TB cases diagnosed in areas with high rates of TB and HIV.

But this new 'while you wait' test incorporates modern DNA technology that can be used outside of conventional laboratories. It also benefits from being fully automated and therefore easy and safe to use.

WHO is now calling for the fully automated NAAT to be rolled out under clearly defined conditions and as part of national plans for TB and MDR-TB care and control. Policy and operational guidance are also being issued based on findings from a series of expert reviews and a global consultation held last week in Geneva. The consultation was attended by more than a hundred representatives from national programmes, development aid agencies and international partners.  

75% REDUCTION IN PRICE FOR COUNTRIES MOST AFFECTED BY TB
Affordability has been a key concern in the assessment process. Co-developer FIND (the Foundation for Innovative and New Diagnostics) announced recently it has negotiated with the manufacturer, Cepheid, a 75% reduction in the price for countries most affected by TB, compared to the current market price. Preferential pricing will be granted to 116 low- and middle- income countries where TB is endemic, with additional reduction in price once there is significant volume of demand.

"There has been a strong commitment to remove any obstacles, including financial barriers, that could prevent the successful roll-out of this new technology," said Dr Giorgio Roscigno, FIND's Chief Executive Officer in a WHO communique. "For the first time in TB control, we are enabling access to state-of-the-art technology simultaneously in low, middle and high income countries. The technology also allows testing of other diseases, which should further increase efficiency."

WHO is also releasing recommendations and guidance for countries to incorporate this test in their programmes. This includes testing protocols (or algorithms) to optimize the use and benefits of the new technology in those persons where it is needed most.

Though there have been major improvements in TB care and control, tuberculosis killed an estimated 1.7 million people in 2009 and 9.4 million people developed active TB last year.

Bobby Ramakant - CNS 


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Winning project pictures life with Tuberculosis

The TB Photovoice Project, the winner of the 2010 TB Survival Prize, started as a one man's way to deal with the loss of his beloved ones to tuberculosis (TB). By now, it is touching the lives of many people around the world, helping – through pictures and narratives – to empower and raise the voices of persons and communities affected by the disease. Read more

The Tuberculosis Survival Prize is given each year by the Tuberculosis Survival Project, with support from the Lilly MDR-TB Partnership. The prize, an annual award of USD 2000, is awarded in recognition of innovation in TB/MDR-TB advocacy and social mobilization by individuals, groups or NGOs working in the field of HIV/TB or TB/MDR-TB. During a ceremony at the 41st Union World Conference on Lung Health in Berlin, Germany (November 11-15) the prize this year went to TB Photovoice.

The TB Photovoice Project provides cameras to community members (survivors, caregivers, friends, family) affected by TB, who take photographs that help them identify and improve their communities. The photographs and their stories represent what is happening in the participants' lives and serve as a point for discussion about what can be done to change the present situation in regards to TB, adherence, support, stigma, education and related issues. These photographs and their accompanying narratives give a face and voice to TB. There are initiatives in among others Brazil, Mexico, Thailand and the United States. The Stop TB Survivor award enables the project to start up a TB Photovoice in Kenya too.

Romel Lacson, founder of the Amaya-Lacson TB Photovoice Project, was personally affected by the disease, losing both his wife Claudia Amaya and their newborn daughter Emma to tuberculosis meningitis in 2004. "The project was sort of my reaction to that," he said at the sidelines of the conference. "I did not have TB myself but my family and my wife's family were providing care of her throughout the time she was in hospital. We felt very isolated, very disconnected from the world. When Claudia passed away it turned my life upside down. I had to try to make sense."

Over the years, the various initiatives - in partnership with local organizations - gave different meanings to TB Photovoice. "They have a basic foundation for it but depending on the mission of the particular organization and on the coordinator who is implementing and facilitating it, it really takes a character of its own," Lacson says. Yet there are core aspects that remain, such as photography, using images, narrative storytelling, dialogue, group discussions and ethical use of the camera. "Part of the training is to instill a sense of responsibility of the photographer that they take pictures that don't invade people's privacy or are not going to hinder any kind of confidentiality of what happened."

Eva M. Moya is involved with setting up TB Photovoice projects throughout the U.S.-Mexico border and in Mexico. With resources of the Amaya-Lacson Foundation a pilot TB Photovoice (Voices and Images of Tuberculosis) Project in the United States-Mexican border region was started in 2006. "We immediately realized we had to do it in a bi-national fashion,” Moya recalls. “It is a border community where tuberculosis knows no boundaries, where it doesn't need a visa to travel north or south."

Two groups of persons affected by TB were formed and received training, setting up photo galleries within four months. Policy and decision makers were invited and witnessed the work of the participants, and were asked to make commitments. "One of the beauties of this methodology is that you can actually see commitments," Moya says. "Which you can follow through time with decision, policy makers and health authorities so that there could be improvement. Whether it is in the area of access of services, in the leveraging of resources, or in making services much more focused on the person and services that are free of stigma and discrimination."

Through a partnership with Project Concern International SOLUCION TB the TB Photovoice (Voices and Images of Tuberculosis) initiative now includes nine projects in Mexico. Galleries that continue to move between communities. It was followed by Nuestra Casa, a three-dimensional house that reflects the life and stories of people affected by TB.

TB Photovoice asks its participants to be critical of their own community and their reality. "We ask them to tell us what it is that they see, to explain what is happening in their lives, to indicate where the problems, issues and challenges are. And then to be able to work with solutions," Moya says. Eventually many participants become activists. "There is a lot of overcoming of fears, sometimes of embarrassment, of distress, of sadness, of actually even rage, because several of our participants were unfortunately misdiagnosed. And they sort of transform that into a very powerful experience and they say well, we need to let the larger community know. It is very powerful when the story comes from the person affected and is presented to decision and policymakers, because it comes actually from the perspective of having lived the experience."

Rachel C. Orduño, one of the first participants in the U.S.-Mexico border project, lived the experience. She was diagnosed with TB in 2006 after three years of many misdiagnoses. Her treatment lasted 9 months. Her (at that time) 3 year old niece also had active TB and six other family members were treated for latent TB. Orduño remembers feeling helpless, frustrated and angry because of the misdiagnosis. Participating in the TB Photovoice Project altered these emotions.

"For people who are going through treatment, TB survivors, it is really important to share with other people," Orduño stresses. "For me TB Photovoice was first and foremost a support group. We gave each other advice and support and direction. The activist and advocacy aspect of it came later, once we felt like we can do something about it: we can't just ask the medical establishment to take care of us, we can't expect the government to look after us, we need to do something."

For Orduño that motivation came from being a group, having people to share ideas and the feeling of having something to contribute. "Now I don't see the power differential of the medical expert and the patient," she says. "Now it is the medical professional who got a lot of training plus the persons affected by the TB experience, the experience that makes us the experts. And seeing how we can be partners in developing a lot more effective treatments, how to reach the public at large and the public services."

The project even helped diminish her feelings of guilt. "That is something else that people don't tell you, that sometimes you feel very guilty for transmitting the disease to your most loved ones," she says. "I learned that for every year that I was untreated and had active TB, I could have infected 15 other people. So I may have possibly caused 45 infections. However by speaking up now, by spreading the word that we can do something about it, every one of us, all of us who have been directly been affected by TB and every medical professional and everyone who knows their story, we can all contribute. We can all try and do our best to recognize the symptoms and just be aware that TB is out there everywhere in the world. Anyone that breathes is at risk so everyone has a moral obligation and it would be a public service to do your part to contain it."

Babs Verblackt - CNS 
(The author is a freelance journalist and a Fellow of CNS Writers' Bureau)

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International Symposium on TB Diagnostics: Innovating to make an impact

The "International Symposium on TB Diagnostics: Innovating to make an impact" (ITBS 2010) shall soon be held in New Delhi, India during 16-17 December 2010. It is being organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB). ITBS 2010 is being co-sponsored by Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND). Read more

"This is the fourth meeting in the International Tuberculosis (TB) Symposia (ITBS) series that has become a regular biennial event at ICGEB, New Delhi. It is heartening to note that every meeting has attracted increasingly good number of leading TB experts from across the world as well as large number of young researchers from across India and other countries. However, tuberculosis still continues to inflict one third of the global population, causing nearly nine million new cases of tuberculosis (TB) and death of nearly 1.8 millions per year. Thanks to persistent efforts of research community across the world, Mycobacterium tuberculosis is beginning to reveal its secrets, though slowly and reluctantly. Once again it is time for us to get together, pool our resources, and form networks in order to evolve more effective intervention strategies. This Symposium is an attempt to facilitate this process" said Dr Pawan Sharma, Convener of ITBS 2010.

"It is perhaps the most opportune time to address issues in TB Diagnostics. With the largest pipeline of new drugs and drug combinations in place, 'potentially effective against all forms of disease in all patients' (TB Alliance), and a similar pipeline of TB vaccines in various stages of clinical trials, it is only imperative to devise point-of-care diagnostic methods, which are not only sensitive and specific but also time-effective and cost-effective. This Symposium provides an opportunity to take stock of deliverables in the area of TB diagnostics against the backdrop of advances made in the basic biology of the disease. I hope that this meeting offers a platform for national and global policy-makers, academia, industry and funding agencies to come together and take stock of the current status of TB diagnostics and find ways for translating research results into reliable point-of-care methods for diagnosis, and to develop more robust strategies for epidemiology studies. At this juncture, India being home to the largest number of TB patients in the world, presents a challenge and an opportunity to emerge as a global leader in the area of TB diagnostics" added Dr Sharma.

The ITBS 2010 Symposium will provide a platform for these deliberations in the following scientific sessions:
- Pathophysiology of Tuberculosis and the Challenge of Diagnosis
- Trailing the Bug: TB Diagnostics Today & Tomorrow
- Changing the Landscape of TB Diagnostics in India
- Diagnostics Innovations from India: View from Industry and Clinic
- Diagnostics Innovations in India: Enablers and Barriers

Bobby Ramakant - CNS

Where there are no drugs: TB-HIV dilemma for migrants

In  late October 2010, a large group of people living in and around Mae Sot, Tak province were closing in on a terrible 'milestone' of sorts: all of them – over 60 migrant children, women and men – were living with HIV and taking antiretroviral (ARV) drugs, which they needed to stay alive. Some were also co-infected with tuberculosis (TB), the most frequent opportunistic infection (OI) experienced by people living with HIV/AIDS (PLHIV). Read more

Each group member's daily regimen of drugs – a one-year 'buffer' provided by an international non-governmental organization (INGO) pulling its operations out of the country – was about to run out, with no new supplier in sight.

"We have been unable to secure a sustainable source of ARVs for our patients," explains a staff of the Mae Tao Clinic, a clinic providing health care services to migrants and displaced people near the Thai-Burma border. "If they stop taking their medication, we face a crisis."

DRUG RESISTANCE 
--------------
Adherence to a prescribed ARV drug regimen is essential; people living with HIV and/or TB who stop taking medication for whatever reason, and even only for a few days, can develop a resistance. Drug-resistance is dangerous, because it is irreversible and the new strains of the disease can be passed on to others.

Multi-drug- and extensively drug-resistant tuberculosis (or, respectively, MDR and XDR TB) is an even greater potential threat than HIV drug resistance in terms of impact, because unlike HIV – a blood-borne disease –, TB is transmitted from person to person through the air. A rampant increase in drug resistance can thus indeed fuel a public health crisis.

The Mae Tao Clinic representative said that "from a public health perspective TB is more difficult to handle, mainly because of time-related compliance issues. People with TB have to take medication daily for six months. If they interrupt this treatment, which happens frequently with migrants who are on the move and may stop taking drugs when they feel better, then drug resistance can occur."

Another often under-estimated problem accompanying drug resistance is the subsequent need for different drugs to replace the first regimen. These second- or third-line drugs are much more expensive and difficult to procure – here in Thailand, for example, the main first-line ARV combination therapy (for example GPO-VIR S30) is locally produced and distributed, bringing down the cost; but second- or third-line drugs must be imported, tend to be much more expensive than first-line medicine and may require special handling, like refrigeration, which complicates delivery in unstable settings.

MIGRANTS MARGINALISED
--------------
Thais living with HIV have the right to, and usually receive, free ARVs through the National Access to Antiretroviral Program for People living with HIV/AIDS, or NAPHA. People without a Thai ID can buy ARVs for a minimum of 1,350 baht per month, although NAPHA set up a provisional extension programme to cover vulnerable populations who do not have access via regular channels like Thai social welfare card holders.

Access is inevitably restricted for individuals or families already subject to the most dire of circumstances: many migrants and displaced people along the Thai-Burma border live a day-to-day existence that may include a lack of food security and reliable shelter. This can, and does frequently lead to greater vulnerability to infection and illness. An HIV positive migrant in poor health is thus more likely to contract opportunistic infections (OI) like TB, or Hepatitis C, another highly problematic OI.

A representative of a community-based organization in northern Thailand shared that "along the Thai-Burma border abutting Shan State, in Chiang Mai province, we support 125 members of the Shan community living with HIV, of whom 50 currently receive free ARVs. Unfortunately, beginning in December 2010, any new patients will have to pay for treatment – so this will affect any of the 75 not yet on ARVs who might need them in the future." There are about one or two new cases every month, and some of them also have TB.

She added that they "…have a limited budget aimed at helping with general hospital costs for community members, but we've been using it to cover ARV-related costs for our PLHIV."

Given the existing obstacles to accessing adequate and appropriate treatment, it is not surprising that migrants may start with the TB six-month short course, but then, despite doctor's instructions, stop taking the drugs once they feel better. Many migrants are by nature already mobile, which further complicates consistent compliance and follow up by medical staff.

It is this population – in addition to other key populations like sex workers, injecting drug users and prisoners – that should be the main beneficiary of effective prevention efforts and increased access to a regular supply of drugs.

In a country that currently receives generous funding from the Global Fund to fight HIV/AIDS, TB and Malaria (GFATM), how is it possible we cannot manage to take care of our most vulnerable fellow humans?

SERVICES AND GAPS 
--------------
A representative of the Thai Northern Network of People Living with HIV stated that "local hospitals do provide ARVs to migrants and displaced people as part of NAPHA's extension programme, but they are bound by a quota system which always favours Thai citizens over unregistered migrants."

He admitted that "sometimes Thais who fear being stigmatized and discriminated against by colleagues will request treatment under the extension programme instead of the regular system, because this way they can remain anonymous."

Mae Tao Clinic already offers a number of relevant services for PLHIV, including voluntary counseling and testing (VCT), home-based care and peer educators. Relatively simple preventive approaches can also be applied in the context of TB-related services, such as face-masks and better ventilation in places where people go to get tested.

"A more systematic, consistent integration of HIV and TB programmes is key," claimed another Mae Tao Clinic staff; he went on to say that "since it was at this point beyond the clinic's capacity to offer TB treatment, it was essential to have one group or entity able to take full responsibility for managing a comprehensive TB programme and willing to deal with problems such as non-compliance or adherence due to mobility."

There is an international NGO currently providing TB services in Mae Sot, serving part of the area previously covered by the INGO that pulled out last year. Yet the new organisation has limited reach and cannot accept patients outside of its focal communities, including those likely to move across the border. These unfortunate ones have to look elsewhere, and more often than not, they end up at Mae Tao Clinic.

Regarding the 'stranded' HIV-positive people, clinic staff approached the closest hospitals for help, and only Propha agreed to treat 20 people under its NAPHA extension scheme. Mae Sot, Mae Sariang and Mae Ramat hospitals were not accepting any new patients.

"We are now waiting to hear whether the Regional NAPHA Extension Unit in Pitsanuloke can help coordinate the provision of ARVs directly to Mae Tao," said the first Mae Tao Clinic staff. "This is easier and more cost-effective than transporting a large group of patients back and forth each month."

WHAT NOW?
--------------
It seems that drug resistance is here to stay – at least for now – and so the best response would include not only addressing the most immediate needs to mitigate impact, but also introducing some longer-term measures.

In addition to the interventions mentioned above, anti-stigma and -discrimination campaigns targeting Thai society would help PLHIV at all levels access existing ARV providers without fear of being socially outcast.

The representative of the Northern Network of People Living with HIV wondered whether "everything could be related to national security issues and that maybe there is no real will to find a sustainable solution to these urgent cross-border issues."

Also, "there seems to be little real interest among TB service providers to collaborate more with the HIV/AIDS sector," an independent consultant supporting HIV/AIDS-related work at national and local levels in Thailand noted. "Because TB has for so long been considered 'solved' as a public health issue here, they do not have a sense of urgency…"

Well, it can't get any more urgent for those people living with HIV/AIDS and TB here, and now - and who may soon become drug resistant due to apathy and ineffective programme design and interventions. Acknowledging and fully understanding the reality of this is the first step, acting decisively and comprehensively, the second. Here, and now.

Constanze Ruprecht
(The author has worked in international development cooperation since 2000. Focusing on a broad range of areas including public health, gender, advocacy and communications, politics and the environment, she supports people and programmes in Asia, Africa and Europe.) 


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Breaking silos: Tuberculosis (TB) and poverty

Tuberculosis (TB) continues to affect society's most vulnerable - those who live in abject poverty, are marginalized or economically and socially isolated. The poor and vulnerable people are much more likely to suffer from TB due to socioeconomic factors. The poor face significant costs and delays in accessing TB services and treatment outcomes are more likely to be adverse, said Rachael Thomson from Liverpool School of Tropical Medicine (LSTM) who was nominated by the TB and poverty sub-working group of Stop TB Partnership to speak at the Biennial Conference of Irish Forum for Global Health (IFGH) held in Maynooth, Ireland (29-30 November 2010). The IFGH meet was organized by IFGH with support from Combat Diseases of Poverty Consortium (CDPC), Irish Aid and National University of Ireland Maynooth (NUIM). Read more

"In urban Malawi poorer patients face costs six times their monthly income to access a diagnosis from 'free' facilities, and in rural Malawi this cost rises to ten times" said Rachael.

New TB case detection in many countries is low because the poor people are least likely to access TB care services. The process of accessing care is impoverishing making the people accessing care even poorer, said Rachael.

The lack of adequate diagnosis, treatment and cure means the burden of TB in poorer communities continues to increase.

Not surprisingly, the poor people have higher risk of infection, higher prevalence of disease and worse outcome of disease too. Moreover the poor people have greater health care needs, said Rachael.

Social and economic determinants at individual, household and community levels affect a person's vulnerability to TB.

Special situations such as massive population movements - the displacement of people and refugee flows - and living or working in vulnerable conditions also increase the risk of a person contracting TB. In developed countries, ethnic minorities and other marginalized communities are at a greater risk of contracting the disease.

There is a need to combat TB by addressing the barriers faced due to poverty such as infrastructural, housing, employment, educational and nutritional deficiencies.

Rachael explained that poverty is more than economic poverty (living on less than USD 1.25 per day) and encompasses lack of opportunities, voice and representation, and is a major determinant of vulnerability to disease - especially TB.

One of the major steps forward in addressing poverty and TB will be to put health on the poverty agenda and poverty on the health agenda, said Rachael.

Rachael gave an overview of the TB and poverty sub-group of the Stop TB Partnership. TB and poverty is the sub-group of the DOTS Expansion Working Group (DEWG) of the Stop TB Partnership and is a network of individuals and organisations interested in the needs of poor and vulnerable populations with respect to TB. Since September 2010, the secretariat of the TB and Poverty sub-working group of the Stop TB Partnership is housed in the south-east Asia regional office of The Union in New Delhi, India.

A two-days consultative workshop of the TB and poverty sub-working group was also held in Gurgaon, India on 29-30 October 2010 which brought together the national TB programme managers from India, Nepal and Thailand, state TB officers from eight poorest states of India, and partners from various other organizations like WHO, the World Bank, World Vision, GFATM Round 9 members, media (CNS, Asia Tribune), National Partnership for TB care and control in India among others, said Rachael.

Bobby Ramakant - CNS/ member on-site IFGH Key Correspondent team 


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Private-private partnership delivers affordable eye care

An Irish non-profit, Right to Sight (RTS), partnered with a NGO – Lions Aravinda Institute of Community Ophthalmology (LAICO) and a private-for-profit company, Shalina, to deliver quality, affordable and sustainable eye care in Democratic Republic of Congo (DRC), shared Keerti Bhusan Pradhan, who was speaking at the Biennial Conference of Irish Forum for Global Health (IFGH) in Maynooth, Ireland (29-30 November 2010). This meet is being organized by IFGH with support from Irish Aid, National University of Ireland Maynooth (NUIM) and Combat Diseases of Poverty Consortium (CDPC). Read more

Right to Sight (RTS) had raised USD 200,000 to jump start this private-private partnership (PPP) model based initiative which eventually mobilized more than USD 1.5 million from a private company and a range of other contributions and expertise to make the eye care service sustainable and affordable in a long run in DRC, said Keerti during his interaction at the Health Systems and Services (HSS) parallel session at the IFGH meet.

These three private partners got together to establish an eye-care health centre in Katanga, DRC which began operations in 2007. There was a considerably small user charge for people accessing eye care services from this centre to meet operational costs and make the initiative sustainable. “By end of first year (2007-08), this eye care health centre broke-even by meeting the operational expenses,” said Keerti. More than 35,000 outpatients were seen and 2000 surgeries conducted in the first year of operations at this centre.

Another important aspect of this initiative that needs a mention is that it had built capacities and competencies of local healthcare providers in DRC to run this eye care centre. The expat-to-local human resource ratio has been 1:6 with 5 expats to 30 DRC citizens who are part of the team at this centre and considerable knowledge transfer and sharing of skills take place between them, said Keerti.

RTS worked with the Aravinda Eye Care System (AECS) which is the largest eye care provider in the world with a renowned service delivery model, a facility for manufacturing high quality ophthalmic products at low cost - Aurolab and an institute for teaching and training – Lions Aravinda Institute of Community Ophthalmology (LAICO). They brought in another partner, Shalina Laboratories, a pharmaceutical company in DRC, to support this initiative through corporate social responsibility (CSR) initiatives. And that is how the eye care health service centre was built and started functioning towards end of 2007, said Keerti.

The DRC-based private-for-profit partner of this initiative, Shalina, plans to expand this private-private partnership model of eye care delivery to 18 African countries with six centres planned in DRC as well, said Keerti.

Although not connected directly to eye-care health services, yet in terms of similarity between the partnership approaches, it will be worthwhile to mention that a participant from Irish Aid said a similar project is also taking place in Tanzania on addressing issues related to disability.

These examples of private-private partnerships give hope – particularly to countries like India and Cambodia for example - where the first clinic most of the population visits with initial symptoms is most likely to be in private sector. If people can access quality healthcare without delay it is likely to have a very positive outcome on public health. In same HSS session at IFGH meet, another speaker Una Lynch from Queen’s University, Belfast, shared how strengthening primary healthcare services in Cuba had such pronounced positive outcomes in terms of public health.

Bobby Ramakant - CNS/ Key Correspondent at IFGH 


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Children Affected With HIV/AIDS Attend Training Workshop

Today, 1st of December, is World AIDS Day—a grim reminder of this killer disease, which has devastated millions of families all over the world. In Uttar Pradesh alone, more than 35,000 AIDS patients were registered with the state AIDS Control Office till September, 2010. How many more unregistered people would there be, is anybody’s guess. Amongst the registered ones, there are 1597 male and 777 female HIV positive children. Read more


With a view to lend a helping hand, UNICEF has organized a training workshop for such children at its pavilion at the ongoing Lucknow Mahotsava—a gala, annual event, spread over 10 days.

 The first batch of child reporters and Bal Bandhus (little friends), who arrived in Lucknow on Nov 25 have already completed a very successful training in the media tools. The second batch from Lalitpur district that started their training in the five media tools of communication at UNICEF Pavilion at the Lucknow Mahotsava from Nov 30th.

This second group of children will also be joined at the UNICEF Pavilion by HIV positive affected and infected children who will be coming from six districts of Uttar Pradesh. The children will be brought in by a non-government Lucknow based organisation named  UMEED which works for the rehabilitation and welfare of children living with HIV/AIDS and is part of the workshops from Nov 30-2 Dec 2010 .

Apart from learning the five media tools from the 18 master trainers from Maharajganj who are conducting the workshop, the HIV positive children will also be celebrating the World AIDS Day today in Lucknow at the Mahotsava.

Let all of us contribute in some way or the other to keep  the spirit of these young fighters high.

Anjali Singh - CNS
(The author is a UNICEF consultant and a senior journalist. She is also the Director of Saaksham Foundation) 

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Strengthening Health Systems: Global Health Financing

A new research report "Financing Global Health 2010: Development assistance and country spending in economic uncertainty", by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, indicates that despite the worst global economic crisis in decades, public and private donors continue to donate generously to global health, though at a slower rate. The report documents the continued rise in health funding and the effects of that funding on spending for health by governments in developing countries. The commitment to health in the developing world has grown dramatically over the last twenty years, with the  developing countries' governments increasing their spending on health. Read more

 The research shows that development assistance for health has grown 375% in the last decade-- from $5.66 billion in 1990 to $26.87 billion in 2010. Thailand, for example, has seen its health assistance explode from $2.3 million in 1990 to $67.9 million in 2008-- a staggering increase of nearly 3000%. But, when we look around the region, we find countries that receive far more aid than Thailand per person, including the Philippines, Cambodia and, most strikingly, the small island nations. Micronesia, for example, receives $161 per person, while Thailand receives only $1 per person.

However, IHME’s preliminary estimates show that the growth rate is slowing. Between 2004 and 2008, assistance grew by an annual average of 13%. But between 2008 and 2010, the rate of growth was cut by more than half to 6% annually. The government and private donors in the US made up one-half of all funding in 2008. But the economic downturn has hit US-based NGOs hard, and the amount of health funding spent by them decreased by 24% from 2009 to 2010.

Most health funding has gone to the countries with the greatest need, but researchers found striking anomalies, including the fact that 11 of the 30 countries with the highest number of people suffering from disease and high mortality receive less health funding than countries with stronger economies and lower disease burdens.
Dr. Christopher Murray, Director of IHME, feels that, “Everyone in the global health community is worried about how the economic crisis is going to affect giving. Research has shown that economic downturns don’t usually have an immediate effect on charitable giving, but we were still surprised to see sustained growth through 2010.”

Spending on HIV/AIDS programs has continued to rise at a strong rate, making HIV/AIDS the most funded of all health focus areas. Dr Murray feels that this could partly be due to the fact that, "Advances in medications to combat HIV were among the main reasons that donors and NGOs started to rally together to form what we know today as the global health community. The legacy of the early fight against HIV has maintained a strong commitment to funding for HIV-related efforts, and this includes the U.S. President's Emergency Plan for AIDS Relief, the single largest amount of funding to combat HIV."

Funding for maternal, newborn, and child health received about half as much funding as HIV/AIDS as of 2008. Again, funding for non communicable diseases represents just 0.5% of all development assistance for health.

Both, malaria and tuberculosis receive far less funding than AIDS: $1.19 billion for malaria in 2008 and $0.83 billion for tuberculosis. Funding for malaria and tuberculosis also appears to go to countries that do not have large groups at risk for these diseases. For example, of the 30 countries that receive the most malaria health funding adjusted for disease burden, only three – Eritrea, Sao Tome and Principe, and Swaziland – are located in sub-Saharan Africa, where malaria is most acute. Instead, the countries that receive the most money in proportion to their malaria burden include Georgia, Sri Lanka, Azerbaijan, Uzbekistan, Nicaragua, Kyrgyzstan, Tajikistan, Honduras, and Guatemala. All of these countries received more than $2,000 per disability-adjusted life year, or DALY, between 2003 and 2008.

Why is it so? Dr Murray feels that “in part it’s because health assistance decisions are not made entirely based on need but also reflect longstanding economic and political ties between countries, some of which go back to colonial days.”

In countries whose governments receive significant donor funding, development assistance for health appears to be partially replacing domestic health spending instead of fully supplementing it. Conversely, in countries that receive health funding mainly through NGOs, government health spending appears to increase.

The researchers indicate that the intensified focus on certain health issues – such as maternal, newborn, and child health, non communicable diseases, and health sector support – is likely to magnify the competition for limited resources and exacerbate the effects of any downturn in development assistance for health.

“More than 300,000 mothers still die every year, and more than 7 million children die before the age of 5. Chronic diseases need more attention, and countries need better health care infrastructure,” Dr. Murray said. “All of these pressing health issues require funding, and it is becoming increasingly difficult to balance competing needs.”
Whatever the compulsions of funding agencies/beneficiary governments be, Dr Murray believes that 'when a program is started it should include an evaluation component so that everyone will have a detailed understanding of whether the program is improving health. This is gives developing country governments guidelines for how to best target their limited resources, which is actually the most important factor in health spending. Spending by governments on their own health programs on the whole far outweighs spending by donors.'


Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Diabetes Media Initiative (CNS-DMI). She has worked earlier with State Planning Institute, UP.  Email: shobha@citizen-news.org, website: www.citizen-news.org)  


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New Science, New Hope: Microbicides and HIV prevention

At the forthcoming Biennial Conference of the Irish Forum for Global Health (IFGH) in Maynooth, Ireland, one of the two keynote guest lectures - The John Kevany Memorial lecture - will be delivered by Dr Zeda Rosenberg, Chief Executive Officer (CEO) of the International Partnership for Microbicides (IPM) on "New Science, New Hope: Giving Women Power over HIV/AIDS." The microbicides refer to a new type of product being developed that people could use vaginally or rectally to protect themselves from HIV and possibly other sexually transmitted infections. Read more

One of the defining moments in microbicides advocacy was in July 2010 at the XVIII International AIDS Conference (IAC) in Vienna, Austria where successful results of the much awaited tenofovir microbicides clinical trials (CAPRISA 004) were announced: women who used the tenofovir microbicide gel were far less likely to become infected with HIV than women using a placebo gel. The tenofovir microbicide gel users were 39 percent less likely, overall, to become infected with HIV than women who received a placebo gel. More importantly, underlining the significance of adherence and counselling in clinical trials, women who used the tenofovir microbicide gel correctly more than 80 percent of the time, HIV infection was 54 percent less likely. Also as many advocates of new HIV prevention technologies demand – these tenofovir microbicide also showed activity against genital herpes (a sexually transmitted infection), reducing its incidence by half.

Let me put a word of caution here: this is undoubtedly welcome news, but research is not over yet. There is still a long way to go which may span over years through rigorous path of clinical trials and product development, before any microbicide can truly be available to communities.

One of the big debates around using anti-retroviral (ARV) based microbicides to prevent HIV transmission is that tenofovir is also used by people living with HIV (PLHIV) for their ARV therapy. PLHIV take oral version of tenofovir in ARVs like Viread, Truvada and Atripla.

So the worry is: will using this ARV based microbicide (tenofovir in this case) make people resistant to tenofovir and thereby negate the positive outcomes of ARV based therapy later in their lives in case they become infected with HIV and require the ARV treatment?

"There is now evidence to indicate that ARVs can prevent HIV as well as some of the non-HIV STIs. The major challenge facing the Microbicides Society of India (MSI) as well as other partner research agencies globally, would be to make  a combination of different ARVs, so that these products  become more effective, safer and user friendly for preventing the HIV and some of the non-HIV STIs as well as reproductive tract infections (RTIs). It would be an icing on the cake, if few of these microbicidal products could also provide the contraceptive protection concurrently to the users of these products" said Dr Badri N Saxena, President, Microbicides Society of India (MSI), who is a globally acclaimed researcher and an inspiring advocate for new HIV and reproductive health technologies.

"One reason for engaging ARV drugs into microbicides development is to accelerate the candidates that are ready to go into clinical trials because they come from a very rich product development profile. So now we have so many good candidates, can we provide the much needed bridge to establish biological plausibility - to find out will these things actually work in clinical trials" said Prof Robin Shattock to this correspondent at the International Microbicides Conference in Pittsburgh, USA (May 2010).

Also at the International Microbicides Conference earlier this year, two key studies were presented - one study involving a mathematical model and the other assays of cells and tissue, and both these studies arrived at the same answer to the worrying question whether drug resistance could be a problem if ARV drugs become a mainstay for HIV prevention. Resistance could happen, if people, who are unknowingly already infected with HIV, use the approach. So in other words, if HIV negative people use ARV based microbicides the risk of developing resistance is not there, but if they are already HIV positive and unaware of their status, the risk of resistance is there. These two studies underscore the importance of incorporating routine HIV testing and ongoing monitoring of infection status in any prevention program that involves the use of ARVs.

Probably the forthcoming Irish Forum for Global Health (IFGH) biennial conference might offer some answers to these concerns and give a major thrust to research and eventual development of new HIV prevention technologies. We will post the audio recording of Dr Zeda Rosenberg's lecture at Irish Forum for Global Health (IFGH) biennial conference on www.citizen-news.org! Stay tuned!

Bobby Ramakant - CNS 

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