“Do No Harm” in Foreign Affairs


An analysis of the ‘Age of Generosity’ of global health, and the risks posed by infusing money into poor countries in the absence of strategic global thinking, appears in the current issue of Foreign Affairs. Authored by Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations, the article has garnered a very strong response and inquiries from Capitol Hill.

The article is now posted on line:

On January 18th Foreign Affairs will stage an on-line debate of the Garrett piece, in which critics will take Garrett to task. Readers are welcome to participate that day, at:
www.foreignaffairs.org

Please note:

In the January issue of Foreign Affairs, Laurie Garrett mistakenly attributed a quote to Steve Radelet of the Center for Global Development. The statement -- "foreign aid efforts suck all the air out of local innovation and entrepreneurship," was not made by Radelet. It was made by Arvind Subramanian, Division Chief, Macroeconomic Studies Division, International Monetary Fund at a May 12, 2006 panel discussion at the Council on Foreign Relations. Radelet was also on the panel, and attribution was made in error to him. Because Radelet takes a quite different view of the impact of foreign aid on local economic and entrepreneurial efforts, author Laurie Garrett wishes to apologize to Radelet, and the readers, for the error.


While we are mentioning Radelet’s Center for Global Development, we would like to direct you to:

http://blogs.cgdev.org/globalhealth/2006/12/what_2006_means.php

Ruth Levine of the CGD offers a list of the prime issues in global health in 2006.


A Universal Influenza Vaccine?


Despite predictable allegations that concern about avian influenza has been overblown (See M. Fumento, “The Chicken Littles Were Wrong,” The Weekly Standard, Dec. 25, 2006, pp. 7-9), the H5N1 virus has continued to defy agricultural and human health experts. In December 2005, only 14 nations had experienced cases of animal and/or human H5N1 infection. By the end of 2006 that number was 55 nations. And in recent weeks H5N1 has resurged in Vietnam, China, Nigeria, Egypt Indonesia and Thailand. The resurgences – particularly in the much-touted success story of Vietnam – are distressing. It is clear that in the absence of an effective, timely, safe human vaccine H5N1 will remain a threat.

With current technologies it is impossible to stockpile effective influenza vaccines in advance of a human outbreak, as the virus constantly mutates beyond the range of effective antibody response. Though innovations are on the way that would allow more rapid R&D of targeted vaccines, hopefully narrowing the gap in time between emergence of a dangerous new strain and production of effective vaccine, that avenue still faces years of work.

In the last couple of weeks the British company Acambis, and the Swiss firm Cytos have independently announced breakthroughs in development of what might be a universal anti-Influenza vaccine. The products under development would, in theory, wipe out all A-type influenza strains in the world, including H5N1. Acambis calls its product “the Holy Grail,” and Cytos plans human trials in a few months of its vaccine.

Both of the new products target a protein, dubbed M2, that is found on all Influenza A viruses. The hope is that periodic injections with an anti-M2 vaccine would protect individuals for the rest of their lives against all dangerous strains of flu.

There is one very big caveat, however: Human beings already make antibodies against M2, and as far as can be seen, said antibodies fail to protect us from infection and disease. The vaccine developers are banking on the idea that higher doses of M2 exposure will result in a stronger, effective anti-M2 response. Only large-scale human trials will reveal whether the gamble makes sense.


Margaret Chan’s first days at the helm of WHO


Dr. Margaret Chan was sworn in last week (January 4th) as the new Director-General of the World Health Organization. It is still early, of course, but initial signals are quite positive. In her first address as D-G Chan vowed primary commitment to, “two populations: women and the people of Africa.”

Chan has promised staff changes and reorganization of WHO, but, “Upheaval, no.” That will no doubt come as a relief to WHO staff, as recent years have witnessed several rounds of upheaval, chiefly in the organization’s Geneva headquarters.

Chan’s first major appointment, announced earlier this week (January 10th), named Dr. Anarfi Asamoa-Baah Deputy Director-General of WHO. This is an excellent move. Since he joined WHO six years ago, Asamoa-Baah has cut a wide swath through the institution, rising to take command of outbreak identification and response. Formerly director of medical services for Ghana, Asamoa-Baah is a solid public health expert. On a personal level Asamoa-Baah is well-liked and respected, both within WHO and outside the institution. And on the politically-critical symbolic level, having a Chinese physician in charge and an African physician second-in-campaign promises to position WHO well for leadership in global health.



New elections for leadership of the Global Fund to Fight AIDS, Tuberculosis and Malaria


We wish that we could express the same optimism about the Global Fund to Fight AIDS, Tuberculosis and Malaria, the multibillion dollar funding organization that remains unable to choose a new leader. Last fall the governing board of the Fund failed to break a voting logjam in its choice for a new Executive Director (replacing Britain’s Richard Feacham, who steps down this spring). In the lead-up to the would-be election the Center for Global Development issued a report, entitled:

Challenges and Opportunities for the New Executive Director of the Global Fund: Seven Essential Tasks


Sadly, the sorts of issues outlined by the CGD report do not appear to have been the basis of disputes over future leadership. According to the Boston Globe (J. Donnelly, “Global health organization prepares to name leader,” Boston Globe, Jan. 9, 2007) the fall leadership fight has left a trail of bitterness inside the Fund:

“The other finalist for the post last year, Michel Sidibe, has withdrawn from consideration, saying the voting process "bitterly polarized" the 20-member Global Fund board, according to a Dec. 17 e-mail he sent to Carol Jacobs, the board chair. Under its rules, two-thirds of the board from developing countries and two-thirds of the board from wealthy countries must both support the executive director; Sidibe and Kazatchkine failed to win both super-majorities.”
This week the Fund released a list of names of candidates for the leadership post, most of which are newly under serious consideration. The names arose through a process of both self-nomination and Board consideration, and rumors are rife that some of the named individuals have already withdrawn. The names include:

Julio Frenk, Mexico's former health minister

Michel Kazatchkine, France's AIDS ambassador

David Nabarro, a senior WHO administrator now leading United Nations efforts to fight avian flu

Alex Coutinho, manager of AIDS treatment programs in Uganda

Carol Bellamy, former Manhattan Borough President who led UNICEF from 1995 to 2005, now is president of World Learning

Kunio Waki , a seasoned Japanese diplomat who is now head of the UN Population Fund

Jack Chow , a former U.S. State Department senior official who also headed WHO's AIDS programs

Arata Kochi, former WHO TB czar, now head of WHO's malaria program

Brad Herbert , former director of operations for the Global Fund.

The Fund’s board plans to narrow that list down to five finalists on January 19th, and make a final selection sometime in March.

The new list is stronger than the final five the Board selected last fall. We wish one other name were on that list: Mark Malloch Brown. Britain’s Brown has proven to be one of the most outstanding political leaders to ever set foot in the UN system, having shaken up UNDP and salvaged the final years of the Kofi Annan administration. He has proven himself capable to directing complicated development and AIDS efforts. And, equally importantly, he can raise billions of dollars. We would have liked to have seen his name on the list, demonstrating the board’s recognition that the Fund needs not only to demonstrate that the money it dispenses is properly used to save hundreds of thousands of lives, but also that it can maintain – indeed accelerate – its fundraising momentum.


The Bulgarian health workers in Libyan prison


With the New Year Bulgaria officially became a member of the European Union. Addressing massive celebrations in Sofia, Prime Minister Sergey Stanishev called upon EU leaders in Brussels to fight for the freedom of five Bulgarian nurses and a Palestinian physician now sentenced to death in Libya. “We will go on fighting for the release of the nurses and we will then celebrate together with them,” Stanishev said to a roaring crowd.

Many in Bulgaria believe the EU response to Libya’s intention to execute the Benghazi Six, as they are called, has been lukewarm. Stanishev repeatedly told Bulgarians last week that fighting for freedom for the Benghazi Six will be his number one priority within the EU.

As readers of this list-serve will recall, the five nurses and physician were arrested in 1999 following an outbreak of HIV among more than 420 children who had been hospitalized at various times over the prior year in a facility in Benghazi. The foreign healthcare workers were charged with deliberately injecting HIV into the children, as part of an alleged bioterrorism scheme spawned by the U.S. CIA. Despite strong scientific evidence presented in their defense, the Benghazi Six were a few weeks ago sentenced (for a second time) to face death by firing squad.

In numerous editorials over the last year, Global Health Program Senior Fellow Laurie Garrett has urged scientists and healthcare workers to recognize the stake they, collectively and individually, have in the outcome of this case. If outbreaks of infectious diseases can be blamed on foreign healthcare workers, who are subsequently executed, there can be no guarantee of safety for international work and travel for health and science professionals. We are pleased that the editorial board of Britain’s Nature has expressed the same point of view (“Libya and Human Values,” Nature 445:10.1038/4452a, January 4, 2007).

The internet search company Google is helping draw attention to the plight of the Benghazi Six. If one types “Libya” into your search, one of the Google-sponsored links takes you to:

Free the Bulgarian nurses and the Palestinian doctor prisoners in Libya!

Sadly, Libyan leader Col. Muammar Gadaffi has in recent days lashed out against the international community, swearing the sentence against the Benghazi Six will be carried out.


The loss of a giant in the field of malaria


On December 20, 2006 the world lost one of its most wonderful citizens, and greatest experts in malaria and insect-borne disease, Andrew Spielman. Andy, who was on the faculty of the Harvard School of Public Health for 20 years, was a terrific scientist, mentor and colleague. His enthusiasm for insects was contagious. Nobody could spend time watching Andy collecting ticks off a Nantucket field, or harvesting mosquitoes from inside an African hut without feeling the unabashed joy with which he tackled the tasks. (The picture below captures it all: Andy, harvesting ticks on a cold, clear Massachusetts day, grinning all the while.)

Andy was one of the first intellectuals to grasp the significance of the reemergence of malaria-carrying mosquitoes worldwide, calling for radical changes in insect control policies. He did pivotal work on Lyme Disease, yellow fever, malaria, Dengue and a host of other vector-borne infectious diseases.

Since word of Andy’s passing has spread, tributes and obituaries have appeared all over the internet and in print. We will not, therefore, repeat his life story or many contributions.



We would like to tell you about Andy’s final project, which has yet to be completed, but is extremely promising. Andy visited the Council to brief us about his discoveries and, as always, his enthusiasm was contagious. Together with his graduate students and Harvard colleagues Andy asked a fundamental, deceptively simple question: “Why are so many people dying of malaria today in Africa when, by all historic accounts, the disease was rare in most parts of the continent before colonialism?”

Malaria is not an ancient scourge for most of Africa – data suggests the mosquitoes that carry P. falciparum circulated in river areas, deltas, and in dense rainforests. Andy and his colleagues approached their question ecologically, looking for a major change in the African environment brought by the European colonialists. They concluded that the single greatest change was the introduction of corn, which was indigenous to the Americas and had never grown in Africa. Europeans planted corn all over Africa, and it soon became the staple food of nearly every African society. Today even Africans assume that corn has always been part of their climate and culture, as few on the continent can imagine a day without mealie-meal.

In laboratory studies Andy and his colleagues discovered that the species of mosquitoes that carry malaria parasites in Africa are able to eat corn pollen. Worse, when the insects feasted on pollen, which is high in sugar, they became more aggressive, even larger. Andy theorized that the insects dined on corn between human blood feasts, partially explaining how the mosquitoes are able to traverse vast, sparsely populated distances. Further research showed that moving corn fields to the farthest reaches of villages’ lands, and bringing mosquito-inedible crops like cassavas in close to the homes, decreased the child malaria rate dramatically.

Andy’s dream was to develop transgenic corn that would be completely healthy for people, but would contain an agent that would sterilize hungry mosquitoes. He thought this would revolutionize the African malaria situation. But he ran straight into the international politics of genetically modified foods, skittish donors and malaria lobbies pushing hard for entirely different approaches to the disease’s control.

We miss you, Andy.


As always, the Global Health Program of the Council on Foreign Relations will endeavor to keep you posted on developments in the field.