January 10, 2011

Dear Friends and Colleagues,

A happy 2011 to all. The year here in New York City has opened with snow, snow, and more snow.

Amid the bitter temperatures and ice-propelling winds on and off over the last six weeks, New

Yorkers have also experienced two waves of viruses, yet to be officially characterized. The first was

what is commonly referred to as ―stomach flu,‖ though it was not an actual influenza. And the second

was a ―cold,‖ though we have not learned whether it was a coronavirus, rhinovirus, or something else.

On a purely speculative basis it is interesting to note the increase in severe weather events (possibly

related to climate change), and emergence of highly contagious viruses.

We open the New Year with an update covering:

Recent and upcoming activities in the Global Health Program at the Council on Foreign Relations

Spectacular health successes in New York City

Haiti, nearly a year after the earthquake

The new U.S. Congress and the future of foreign assistance

Malaria and vaccine successes and challenges

H5N1 returns for yet another winter

HIV prevention, the Pope, and PrEP

Soaring food prices

A few random thoughts to bring us into 2011…

Recent and Upcoming Activities in the Global Health Program

at the Council on Foreign Relations

In early December the Global Health Program hosted Chris Murray, of the International Health

Metrics and Evaluation program at the University of Washington, and Alex Preker, of the World

Bank. The discussion of the real impact of the world financial crisis on global health programs has

been transcribed and can be viewed on the CFR website.

The key documents discussed in the December 2010 meeting included the IHME‘s new report on

trends in global health funding and an interesting analysis of HIV support compiled by the American

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Foundation for AIDS Research (AmFAR) entitled, ―Rolling Back Funding to FY 2008 Levels: Impact

on the Domestic and Global AIDS Epidemic.‖

Long time update readers will recall that the Global Health Program convened meetings and

published concept papers, starting in 2005, on a scheme we called ―Doc-in-a-Box.‖ Liz Sheehan and

her Boston-based Containers 2 Clinics ran with the concept, and have now opened a pilot clinic in

Port-au-Prince, Haiti, attached to Grace Children‘s Hospital. C2C is collaborating with AmeriCares to

implement primary care from the converted shipping container. This Haitian effort is the latest in a

series of ―Doc-in-a-Box‖ twists, including the East African Health Program executed by a Minnesota-

based organization.

The new issue of the on line journal Global Health Governance is a special one, guest edited by

UNAIDS Executive Director Michel Sidibé and focused on HIV/AIDS efforts. The issue is filled with

strong insights into the governance of health and HIV programs. Among them is a piece entitled

―Global Health Governance in a G-20 World‖ by myself and El‘Haum Alavian, a former research

associate in the Global Health Program.

On December 1 the UNAIDS High-Level Commission on HIV Prevention released its Declaration

and Statement on how best to slow the spread of HIV worldwide. Combined, the documents provide

innovative thinking about the relationship between accurate measurement of HIV transmission trends

and best approaches to prevention. The documents were prepared for the commission by a scientific

panel, chaired by myself.

The Global Health Program is now preparing a January 31 major meeting on governance of food and

drug safety, in conjunction with the U.S. Food and Drug Administration. The meeting will grant

priority access to CFR members, but queries of strong interest may be directed to Research Associate

Dan Barker (dbarker@cfr.org) who will be compiling a list of non-members wishing to attend. The

issue at hand is that globalization has blurred all boundaries regarding the production, distribution

and sale of raw and packaged food and drugs, but regulation of safety remains a national function. No

nation—including the United States—can now guarantee the safety and reliability of all food sold in

eateries and groceries, or drugs sold and used in home and medical settings. The job of inspection and

regulation is simply too great—especially for countries like the United States that now import most of

the food and raw materials for drugs and pharmaceuticals. The challenge ahead, amid rising drug

counterfeiting, food contamination, and raw material monopolization, is creation of a globally shared

concern for health and safety, and resultant shared burden of inspection and regulation. This goes to

the core of global governance of health.

Spectacular Health Successes in New York City With the New Year the New York City Department of Health and Mental Hygiene released its annual

analysis of demographic and epidemiologic trends in the metropolis, and this year marks record-

breaking achievements. According to the department‘s annual report, ―New York City‘s death rate

and infant mortality rate fell to all-time lows in 2009, the Health Department reported today in its

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year-end summary of vital statistics. Nearly six thousand eight hundred fewer New Yorkers died in

2009 than in 2002, despite a larger population, as the citywide death rate fell to 6.3 deaths per one

thousand people. Cardiovascular disease and other smoking-attributable illnesses claimed fewer lives

last year than in 2008, and the city‘s infant mortality rate reached an all-time low of 5.3 deaths per one

thousand live births.‖

Source: http://www.nyc.gov/html/doh/html/pr2010/pr063-10.shtml

According to the Health Department‘s Annual Summary of Vital Statistics New Yorkers‘ average life

expectancy ―Held steady at 79.4 years in 2008, the most recent year for which data are available. That

figure—the longest ever recorded in New York City—represents a gain of 19 months since 2001. It

exceeds the national average by more than a year.‖

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Leading Causes of Death (All Ages)

Rank Cause 2009 Deaths

2008 Deaths

1 Heart Disease 20,086 21,192 2 Cancer 13,180 13,047 3 Influenza and Pneumonia 2,278 2,300 4 Diabetes 1,690 1,643 5 Chronic Lower Respiratory Diseases 1,529 1,605

Leading Causes of Premature Death (Under 65)

Rank Cause 2009 Deaths

2008 Deaths

1 Cancer 4,479 4,552 2 Heart Disease 3,342 3,406 3 HIV Disease 847 996 4 Psychoactive Substances 680 707 5 Accidents 589 618

Among the City‘s key achievements are drastic reductions over the last decade in the number of

cigarette smokers, successful HIV prevention and treatment programs, elimination of many sources of

saturated fatty foods, and aggressive influenza vaccination and treatment efforts. Deaths associated

with violent crimes have also plummeted to levels seen in the 1940s. Statistically, New York City is

now among the safest and healthiest places in North America.

Haiti, Nearly a Year After the Earthquake

Nearly one hundred thousand New Yorkers are, however, from one of the least healthy and least safe

places in this hemisphere, the island nation of Haiti. In 2008 Haiti ranked 149 (out of 182 countries)

on the World Bank‘s Human Development Index, a position that can only have worsened since the

January 12, 2010, earthquake. Striking with an epicenter just sixteen miles from the capital city of

Port-au-Prince at a Richter force of 7.0

shortly before five p.m., the earthquake

claimed two hundred and thirty thousand

lives, caused serious injury to three hundred

thousand people, and left more than one

million people homeless, according to Haitian

government estimates.

(Photo: AFP/GETTY IMAGES 3:35PM GMT 17 Nov 2010)

As the one-year anniversary of this tragedy

approaches, much media scrutiny will focus

on the sorry achievements to date in reconstruction of Haiti‘s public buildings, private residences,

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economy, and infrastructure. The picture painted will be a depressing one, and no doubt a fair amount

of finger-pointing will be directed at all players, including NGOs, the U.S. and Haitian governments,

the United Nations peacekeepers and agencies, and a long list of private actors. Most of the homeless

remain homeless, unless one counts a tent pitched on a roadside as a home. Most public buildings and

infrastructure remain in shambles, few Port-au-Prince residents have genuine employment, human

rights are in a shambles (especially for women and girls), and general reconstruction is deeply

disappointing, according to two recently released assessments from Oxfam and Amnesty

International. According to Oxfam, ―close to one million people are reportedly still displaced. Less

than 5 percent of the rubble has been cleared, only 15 percent of the temporary housing that is needed

has been built and relatively few permanent water and sanitation facilities have been constructed,‖ and

less than half the money pledged last year for Haitian relief has actually been disbursed. ―Nobody can

pretend that this has been a hugely successful humanitarian response,‖ said Paul Conneally, a

spokesperson for the International Federation of Red Cross and Red Crescent Societies. ―If anything,

it demonstrates the limitations of humanitarian action.‖

UNICEF acknowledges that three hundred and eighty thousand children are living in squalid tent

camps in Port-au-Prince and adjacent communities. The Miami Herald asks how such little progress

could have been made in a year if, as the UN claims, $1.28 billion of donor funds have been disbursed,

or roughly one thousand per Haitian (Last week the office of the UN special envoy to Haiti insisted

that 63.6 percent of funds had been distributed in Haiti). ―More than 200 nonprofit groups and

governments around the world rushed to Haiti‘s aid after the Jan. 12 quake. But the absence of

construction cranes and stalled progress on major projects such as hospitals and schools has many

people wondering: Where did all the money go? The short answer: Keeping people alive. It went to

employing Haitians in short-term low-paying jobs, providing tents and tarps, and supplying food for

four months. It paid for amputations, vaccinations of millions of people and rubble removal. But

Haitians, watchdog groups and other critics complain that much of the money raised went toward

foreigners‘ salaries, expensive vehicles or sits in the bank waiting for projects to get moving,‖ the

newspaper reports in a story examining why some are criticizing aid spending since the quake.

For public health advocates, the most egregious post-earthquake occurrence has been the emergence

of cholera in October and its unrelenting spread and death toll, now causing disease and claiming lives

in every part of the country, neighboring Dominican Republic, and Florida. The first identified case

was a twenty-year-old man from the village of Meille, treated on October 14 by Cuban physicians. In a

matter of days the vibrio spread from the northern Artibonite River region southward, toward Port-

au-Prince. Within ten days, according to the U.S. Centers for Disease Control and Prevention (CDC),

4,722 cholera cases were reported, with 303 deaths. Haiti‘s National Laboratory of Public Health

identified the vibrio as 01 serotype Ogawa, biotype El Tor–a form of cholera never previously seen on

the Hispaniola island, where no cholera of any form had surfaced in more than a century.

Given the sickening state of Haiti‘s water systems before the earthquake (when only 12 percent of the

population had piped water) and post-quake damage to the pipes and pumping stations of Port-au-

Prince, it seemed axiomatic that in the absence of heroic public health efforts the vibrio would claim an

enormous death toll and become endemic to the Haitian ecology. Indeed, the cholera crisis has

deepened, and local health authorities reported shortly before Christmas that the official death toll

had eclipsed two thousand five hundred, with one hundred and fifteen thousand cases of the disease

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identified nationwide. At its peak in late November the epidemic was claiming eighty lives a day; by

December 19 that toll was down to fifty-five daily, raising hope that the outbreak might be waning.

That hope was dashed following Christmas, however, when a record number of deaths in a single day

were recorded (one hundred), pushing the January 1, 2011 cumulative total of fatal cases to 3,651.

UN officials told reporters in mid-December that the official counts of cases and deaths likely

underestimate the true scale of the epidemic, which is likely twice as large as indicated. Moreover, the

UN reckons that by May cholera will have caused six hundred and fifty thousand illnesses in the

country and a commensurate increase in deaths.

The mortality rate is very high in Haiti, at about 6 percent of identified cases (as compared to 0.2

percent in Bangladesh with the same strain), sparking speculation that unique conditions in the

country may foster worse disease. As bad as the Haitian situation is, it cannot be much worse than the

human and ecological setting of cholera‘s origins in Bangladesh. A December 10 study in the New

England Journal of Medicine, ―The Origin of the Haitian Cholera Outbreak Strain‖, offers powerful

genetic evidence that the particular strain afflicting Haiti did indeed originate in Bangladesh sometime

between 2001 and 2008. The authors offer these sobering insights:

―The apparent introduction of cholera into Haiti through human activity emphasizes

the concept that predicting outbreaks of infectious diseases requires a global rather

than a local assessment of risk factors. The accidental introduction of South Asian

variant V. cholerae El Tor into Haiti may have consequences beyond Haiti. The

United Nations estimates of the steady growth in cholera cases and deaths, 2010.

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apparently higher relative fitness, and increased antibiotic resistance of the South

Asian strains and the ability of those strains to cause severe cholera suggest that the

South Asian variant V. cholerae El Tor that is now in Haiti could displace the resident

El Tor O1 seventh-pandemic strains in Latin America. It is likely that the Caribbean

ecosystem may now be host to a set of genes, including classical biotype-like cholera

toxin genes and the STX integrative and conjugative element, that were previously

absent from this region. Clearly, the provision of adequate sanitation and clean water

is essential for preventing the further spread of the Haitian cholera epidemic.

Vaccination would also help to prevent the spread of disease, although cholera

vaccines are in short supply.‖

The message is clear: it‘s the bacterium, stupid.

Knowing Haiti has been hit with a partially drug-resistant and virulent form of the vibrio, and that the

populace has absolutely no natural immunity having lived cholera-free for generations, many

observers are now calling for mass vaccination. In a recent Newsweek article Dr. Paul Farmer and Jean-

Renold Rejouit of Partners in Health argue in favor of such a scheme. On December 17 the Pan

American Health Organization (PAHO) cholera expert panel voted in favor of mass vaccination in

Haiti, though finding and packaging supplies of the two-dose oral vaccine will probably take three or

four months. Only two manufacturers are currently in the cholera vaccine business: Sanofi Aventis,

which makes vaccine at its subcontractor factory run by Shantha in India, and Crucell, which makes a

vaccine in the Netherlands. Until supplies are available public health workers have time to consider

how they will administer two doses of vaccine to some segment of the Haitian population of ten

million.

Field trials of oral cholera vaccines (whole-cell and B-subunit forms) conducted in Bangladesh during

the 1990s demonstrated 50 to 85 percent rates of protection against the El Tor strain. But perhaps the

most relevant study, conducted by WHO in a northern Uganda refugee camp in 1997, yielded

decidedly mixed results with a two-dose mass vaccination effort. Though the WHO team did not

measure the efficacy of the vaccine, in

terms of protection against cholera, they

did assess the logistic and cost

requirements for a mass campaign among

one hundred thousand refugees—in

conditions akin to those seen in Port-au-

Prince‘s tent cities. About a third of the

population accepted vaccination, with

second dose uptake considerably lower

than first. Significant personnel and

logistics were required to track and

administer the vaccines. In addition, costs were incurred in transport and cold-chain storage. Clean

water supplies had to be mobilized for people to swallow their vaccine, at considerable expense. In the

end total costs came to about three dollars per vaccine dose plus ten dollars per dose in logistic and

personnel costs—a hefty sum given the population was confined in a refugee camp. Worse, in this

(Photo: http://www.eurocharity.gr/en/story/7213)

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specific case many costs were offset by donated services, such as the storage and refrigeration of the

actual vaccines.

Extrapolating from the WHO refugee experience, vaccinating the entire Haitian population could cost

three hundred million to five hundred million dollars.

Farmer and Rejouit argued in Newsweek that some costs could be offset by giving Haitians both doses

of vaccine, with instructions regarding when and how to take the second dose, on their own. But they

fail to explain how Haitians will safely store their second dose, which requires refrigeration, or where

safe water will be found to swallow down the vaccine. These are precisely the sorts of issues Haitian

officials, PAHO, and NGOs ought to be working out at this time.

If money and vaccine supplies can‘t be mustered until late April, as PAHO now projects, what can be

done to save lives in the interim? The major responder at present is the U.S. government, through

USAID and a host of supported NGOs. To date the United States has committed twenty-eight million

dollars to a three-pronged effort:

1. Clean water promotion involving thirty metric tons of chlorine for urban water purification

and fifteen million Aquatabs for individual water purification use;

2. Sanitation and hygiene education, involving seven thousand five hundred trained community

health workers deployed in rural areas;

3. Oral rehydration salt therapy, featuring a December shipment of five thousand ORT packs.

Global experience with cholera outbreaks shows that case fatality rates above 4 percent, coupled with

a burst of rapid spread of the vibrio, are the norm. Case fatality rates come down to 1 percent or less

when local medical workers become familiar with methods of rapid identification and hospitalization

of acutely ill individuals, and rehydration treatment. It is dehydration that kills cholera victims, and

rehydration that saves lives. A single dose of the very inexpensive antibiotic doxycycline can both

shorten the length of illness and decrease vibrio shedding, thereby reducing the amount of bacteria in

local water supplies. But antibiotics do not save lives. Only rehydration (with cholera-free fluids) can

slow the case fatality rate.

Haiti cannot bring that case fatality rate down without considerable help from the outside. The

country has suffered three catastrophes in twelve months: an earthquake, flooding caused by

Hurricane Tomas, and now cholera. Most of the professional and middle class population of Haiti left

the country after the earthquake and has not returned, leaving an already skills-challenged nation

depleted of medical and professional talent. About 80 percent of the medical facilities in Port-au-

Prince were destroyed or severely damaged in the earthquake, and cholera patients are undergoing IV

drip rehydration treatment in tents and street-side makeshift clinics. In the Christmas issue of the

Lancet Paul Farmer and colleagues from Harvard and Haiti offer a 5-step plan for controlling the

cholera outbreak:

1. Aggressive case-finding and oral rehydration therapy;

2. A national vaccination campaign;

3. Prevention efforts focused on safe water, hygiene education, and hand washing;

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4. Encouraging all vertical health programs (HIV/AIDS, maternal health, vaccination, etc.) to

also work to strengthen the Haitian health system;

5. Confrontation of the ―social web‖ (including customs delays and global trade) that impedes

rapid and scaled response in Haiti.

The more protracted the epidemic, the greater the probability that the vibrio will become endemic to

waterways not only throughout Haiti but also in the neighboring Dominican Republic. It is not

alarmist to assume a high probability that the El Tor vibrio could still haunt Haiti and neighboring

Dominican Republic a decade from now. That fear has already prompted a secondary food crisis,

according to the United Nations‘ Food and Agriculture Organization, as frightened rice farmers are

refusing to plant their watery fields. CDC investigators reported on December 24 that just three of

the then identified cholera cases in the Dominican Republic involved individuals that had acquired

their infections in Haiti. Clusters found in impoverished parts of the Dominican Republic, such as the

El Dique slum of Santo Domingo and the Navarre district, are linked to now-contaminated local water

sources.

El Tor cholera offers disturbing historical warnings. It first appeared in Bangladesh more than seventy

years ago, and remains endemic in that country, despite hundreds of millions of dollars‘ worth of

public health efforts over the decades. In 1991 the El Tor surfaced in Lima, Peru (dumped via Asian

bilge water into the local Latin harbor), in January: in less than twelve months‘ time it spread across

the entire Latin American continent, causing more than three hundred and ninety thousand identified

cases of the disease and four thousand deaths. That outbreak lasted a full decade.

Safe Water = Infrastructure; Infrastructure = Governance; and Haiti has little that could be

characterized as ―governance.‖ The State Department cables released recently by WikiLeaks include

2009 unflattering assessments of Haitian President René Préval, who is characterized as stubborn and

corrupt. Haiti‘s national elections found Préval‘s hand-picked successor, Jude Celestin, the winner, but

it is widely believed throughout the country that Preval used his influence to rig the elections. A

second runoff election is pending. Without a genuinely accepted and duly elected leader Haiti will be

hard pressed to execute the necessary governance to end its cholera epidemic, much less rebuild the

ravaged country.

The volatile mix of decades of bad governance, poverty, poor public education, and suspicion of the

intentions of outsiders exploded into riots in November targeting UN peacekeepers, whom many

Haitians blame for bringing cholera to their country. On January 6, UN Secretary-General Ban Ki-

moon announced that Alejandro Cravioto will chair an independent commission tasked with

determining how cholera got into the Haitian ecology. Cravioto, a Mexican scientist working with the

International Center for Diarrheal Disease Research in Bangladesh, will work with Peru‘s Claudio

Lanata, U.S. scientist Daniele Lantagne, and India‘s Balakrish Nair. The special commission will report

to the Haitian government–not to the UN.

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The New U.S. Congress and the Future of Foreign Assistance

The most important take-home message from Chris Murray‘s IHME analysis of the impact of the

financial crisis on global health support is that while there has been no net decrease in global health

funding, an enormous shift in donor sources has transpired. In 2008 a single U.S. foundation (the Bill

and Melinda Gates Foundation) was responsible for 68 percent of all private funds disbursed for

global health, and a single government (the U.S. government) was responsible for 52 percent of all

global health funding. While the net impact of the crisis may not appear to be as bad as many had

feared, the political impact is potentially quite dangerous. UNAIDS, WHO, GAVI, the Global Fund,

and millions of small programs and NGOs the world over are highly dependent on U.S.-derived

money. A policy burp in either Washington (DC or Seattle) could cause a tsunami in Geneva,

Lilongwe, Hanoi, or Lima. Put another way, in the late 1970s then president Julius Nyerere told me,

―When you in Washington catch a cold, we in Dar es Salaam die of pneumonia.‖

From the point of view of foreign assistance policy and funding, a good deal more than the sniffles is

unfolding in Washington. The new Congress was sworn in this month, and its GOP leaders are

already making it clear that all foreign assistance must be cut. Nothing is sacred. For example, Bradley

A. Blakeman, who served as deputy assistant to President George W. Bush from 2001 to 2004, and is

currently a frequent contributor to the Fox News Opinion, has suggested elimination of HIV/AIDS

funding in Africa, along with wholesale cuts in most overseas humanitarian and development

programs. ―America is facing the toughest economic challenges in our nation‘s history. Now is the

time to put America first and curtail our foreign aid,‖ he wrote on December 20. ―Now is the time for

other nations to pick up the slack, step up to the plate and be as helpful as we have been. It is about

time that the world‘s communities help more and look to the U.S. less. The United States has done

more than its fair share for others since our birth as a nation.‖

Among the programs Blakeman specifically implies ought to be cut are all development and disease-

oriented efforts in Kenya and South Africa.

More significant will be incoming House Foreign Affairs chairwoman Ileana Ros-Lehtinen, a

Republican from Florida‘s eighteenth district. Born in Cuba, Ros-Lehtinen sees U.S. foreign policy

through a decidedly anti-communist, anti-Castro, and anti-abortion lens. Ros-Lehtinen‘s views reflect

those of moneyed supporters in her district. She supports the Falun Gong religious movement in

China, has doubts about all treaty arrangements with Russia, and has stated clearly that foreign

assistance should be ―directed at bringing down despots,‖ and to ―playing hardball with rogue

regimes.‖

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Ros-Lehtinen showed the hand she

intends to play this year in a striking

political maneuver days before

Christmas. As detailed in Foreign

Policy, the Florida representative

successfully blocked passage of the

―International Protecting Girls by

Preventing Child Marriage Act of

2010,‖ a bill that sought ―to prevent

the incidence of child marriage in

developing countries through the

promotion of educational, health,

economic, social, and legal

empowerment of girls and women,‖

according to the bill‘s draft language.

The bill authorized spending just $67 million over four years to develop strategic education campaigns

in countries where girls under eighteen years of age are sold into marriages with significantly older

men and are at high risk of dying in their first pregnancy because their bodies have not fully developed

into womanhood. Though Congress voted 241 to 166 in favor of the bill, Ros-Lehtinen was able to

block it using a legislative caveat too Byzantine to detail with here, though the linked Foreign Policy

piece provides a full run-down.

Ros-Lehtinen‘s opposition to the bill was two-fold. First the $67 million price tag was too much, as

any spending overseas in a time of U.S. fiscal austerity is, she insists, excessive. And secondly, she

wrote, ―There are also concerns that funding will be directed to NGOs that promote and perform

abortion and efforts to combat child marriage could be usurped as a way to overturn pro-life laws.‖

This claim cannot be supported, as the 1973 Helms Amendment specifically makes such actions by

recipients of U.S. foreign aid illegal. Last month, following her selection by the Republican leadership

to chair the House Foreign Affairs Committee, Ros-Lehtinen told reporters that she wants to cut all

U.S. support for the UN Human Rights Council, stop American engagement with Palestinian leaders,

and isolate the new wave of leftist Latin American leaders, including Venezuela‘s Hugo Chavez and

Bolivia‘s Evo Morales.

Ros-Lehtinen promises to convene hearings immediately regarding elimination of much of the

foreign assistance Account 150 budget, arguing it is vital to U.S. economic health: ―I know no State

Department official or anyone involved in international affairs wants to hear that, but that's the sad

reality of our economic state,‖ she said in a December 8 interview with McClatchy Newspapers.

―We're tightening our belts domestically, and we must do so internationally as well.'‖

In a blog post, Ros-Lehtinen vowed to ―restore fiscal discipline to foreign affairs, reform troubled

programs and organizations, exercise vigorous oversight to identify waste, fraud, and abuse,‖ and

generally shift the entire focus of foreign aid away from development of desperately poor countries, in

favor of efforts to undermine ―rogue states and violent extremists.‖

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Republican Texan Kay Granger will actually

control the purse strings for foreign affairs, as

the new chair of the House Appropriations

State and Foreign Operations Subcommittee.

Granger has long opposed giving financial

support to the United Nations, particularly the

Human Rights Council, and demands real

evidence of reform of all UN institutions.

Granger‘s north Texas district includes the city

of Ft. Worth, and is conservative territory.

Granger is wildly popular at home for having

coauthored legislation that, in her words, ―add, an amendment to the Constitution requiring that the

federal government to, balance the budget. It would prohibit Congress from spending more money

than it takes for a fiscal year.‖

The key challenge for global health advocates in the United States in 2011 will be to separate such

GOP concerns for fiscal austerity from specific ideological targeting. Foreign assistance advocates will

need to face the reality that the GOP swept into power largely on the basis of their promise to the

American people to reduce government spending across the board. But the American people did not

vote in favor of eliminating HIV treatment in Africa, malaria prevention in India, cholera control in

Haiti, or safe motherhood campaigns in Latin America. Indeed, McLaughlin & Associates polled

voters in the national midterm elections in November, finding that 66 percent agreed that ―the U.S.

should take the lead in achieving international goals to reduce hunger, poverty, and disease.‖

In addition to direct cuts in foreign assistance spending, there will likely be moderate to severe budget

shrinkage for basic science research and numerous agencies that execute overseas programs, such as

the National Institutes of Health, CDC, and the Fogarty Institute. Science is already feeling the budget

crunch throughout Europe, as countries all over the world have responded to the financial crisis by

hacking at support for research and development. Recently, EMBO reports detailed the impact cuts

are having for scientific research in biology, medicine, and the life sciences. While cuts, so far, in the

United States have been nonexistent, the impact in Asia and Europe has been nothing short of

devastating, leading to the conclusion in EMBO that the cuts are, ―the national equivalent of a farmer

eating his ‗seed corn,‘ and will lead to developing nation status within a generation.‖

Many private companies have similarly responded to bad economic times by reducing their research

and development spending, including inside the pharmaceutical industry. As with global health

funding, writ large, basic research and development for new tools applicable to such issues as HIV

secondary treatment, tuberculosis drug resistance, rapid diagnosis of antibiotic resistance patterns,

and affordable treatment of acute mental illness is increasingly overly dependent on just two sources:

the Gates Foundation and the U.S. government. And, again, that puts policy and the future of these

efforts precariously in U. S. control at a time of U.S. austerity.

As with the coming battle over foreign assistance funding, basic research and science advocates would

do well to separate ideology and arguments in defense of their efforts from the general battle of the

budgets. Among the tens of thousands of State Department documents released recently by

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WikiLeaks was ―09 State 15113, Request for Information: Critical Foreign Dependencies (Critical

Infrastructure and Key Resources Located Abroad). The document lists hundreds of mines,

companies, laboratories, telecommunications systems, and other resources around the world that are

vital to U.S. infrastructure. For example, companies in the UK that maintain and operate the

underwater cable system that carries non-satellite communications from Europe to North America

are considered vital to the U.S. infrastructure and should be protected from terrorist targeting. A

careful read of the somewhat cryptic document reveals that about a fifth of the listings are biomedical,

featuring pharmaceutical manufacturing sites, stockpiles of vaccines, sources of insulin and botulin

anti-toxin, and so on.

The Global Health Program pulled from here, searching for health-related aspects of the

infrastructure:

Mayne Pharma (fill/finish) (Australia)

Austria: Immune Globulin Intravenous (IGIV) Octapharma

Pharmazeutika, Vienna, Austria: Immune Globulin

Intravenous (IGIV)

Immune Globulin Intravenous (IGIV) Glaxo Smith Kline, Rixensart,

Belgium

Acellular Pertussis Vaccine Component GlaxoSmithKline Biologicals

SA, Wavre, Belgium

Acellular Pertussis Vaccine Component Port of Antwerp

Smallpox Vaccine Novo Nordisk Pharmaceuticals, Inc. Bagsvaerd,

Denmark

Numerous formulations of insulin Novo Nordisk Insulin

Manufacturer: Global insulin supplies Statens Serum Institut,

Copenhagen, Denmark

DTaP (including D and T components) pediatric version France

France Sanofi-Aventis Insulin Manufacturer

Global insulin supplies Foot and Mouth Disease Vaccine finishing Alstrom, France

Cyanokit Injection GlaxoSmithKline, Inc. Evreux, France: Influenza neurominidase inhibitor RELENZA

(Zanamivir) Diagast, Cedex, France: Olympus (impacts blood typing ability) Genzyme Polyclonals SAS

(bulk), Lyon, France

Thymoglobulin Sanofi Pasteur SA, Lyon, France

Rabies virus vaccine Georgia

Sanofi Aventis Frankfurt am Main, Germany

Lantus Injection (insulin) Heyl Chemish-pharmazeutische Fabrik GmbH, Germany

Radiogardase (Prussian blue) Hameln Pharmaceuticals, Hameln, Germany

Pentetate Calcium Trisodium (Ca DTPA) and Pentetate Zinc Trisodium (Zn DTPA) for contamination

with plutonium, americium, and curium IDT Biologika GmbH, Dessau Rossiau, Germany

BN Small Pox Vaccine, AG Germany

Biotest AG, Dreiech, Germany: Supplier for TANGO (impacts automated blood typing ability) CSL

Behring GmbH, Marburg, Germany

Antihemophilic factor/von Willebrand factor Novartis Vaccines and Diagnostics GmbH, Marburg,

Germany

Rabies virus vaccine Vetter Pharma Fertigung GmbH & Co KG, Ravensburg, Germany

Ireland Genzyme Ireland Ltd. (filling), Waterford, Ireland: Thymoglobulin

Glaxo Smith Kline SpA (fill/finish), Parma, Italy: Digibind (used to treat snake bites)

Strait of Gibraltar Instituto Grifols, SA, Barcelona, Spain: Immune Globulin Intravenous (IGIV)

Switzerland: Hoffman-LaRoche, Inc. Basel,Tamiflu (oseltamivir)

Berna Biotech, Berne, Switzerland: Typhoid vaccine

CSL Behring AG, Berne, Switzerland: Immune Globulin Intravenous (IGIV)

14

Sweden: Thyrosafe (potassium iodine)

Bude, United Kingdom Foot and Mouth Disease Vaccine

Generamedix Gujurat, India: Chemotherapy agents, including florouracil and methotrexate

If the biomedical infrastructure worldwide is so critical to U.S. interests, does it not follow that the

basic research and development that supports the training and ongoing efforts of hundreds of

thousands of people employed in these ventures is also critical to U.S. national security?

A final note about the finance of the global health arena: innovative financing. Loyal readers will recall

that prior Global Health Updates have reviewed a variety of innovative models for funding global

health, food, and anti-poverty programs. A month ago we noted that currency exchange levies had

received the thumbs-down from key players. Now the Global Fund to Fight AIDS, Tuberculosis, and

Malaria is planning to register a series of targeted investments with the Dow Jones Index. The first

posting will be the Dow Jones Global Fund 50 index. The index would list the top fifty corporate

donors to the Global Fund, offering quarterly-updated float factors, shares, and weights. How much

money such a scheme might raise is unknown.

And our last overall health and foreign policy mentions

concern recent appointments. Steven Radelet has been

named chief economist for USAID. Radelet, long with the

Center for Global Development, joined Hillary Clinton‘s

team at the State Department last January, serving as the

Secretary‘s top political adviser and key architect of the

QDDR (Quadrennial Diplomacy and Development

Review), the Department‘s master plan for execution of

global health, development, food and anti-poverty

programs worldwide.

On December 20 the White House announced that Dr. Nils Daulaire will serve as representative of

the United States of America on the executive board of the World Health Organization. Daulaire, who

runs the Office of Global Health Affairs in the U.S. Department of Health and Human Services, has

forty years of on-the-ground experience with health in poor countries, and previously ran the Global

Health Council.

15

Malaria and Vaccine Successes and Challenges

Advocates for global health can point to some genuine success stories, proving the case that strong

funding can make a difference. Chief among them apparently is malaria. According to the December

13 World Health Organization‘s World Malaria Report 2010,

the incidence of malaria infection was cut in half in forty-three

countries between 2008 and 2010, thanks to a 1.8 billion dollar

global campaign. In 2000 some 233 million people were

infected with malaria, and 985,000 died of the disease,

according to the WHO. By 2009 those numbers fell to 225

million infections and 781,000 deaths, despite population

increases in all of the relevant countries.

One key to malaria control has been mass distribution of

insecticide-treated bed nets, designed to protect children from

biting mosquitoes. The other, artemisinin containing

combination drug treatment or prophylaxis, has proven

dramatically effective.

(Photo: http://www.freewebs.com/netsforanewtomorrow/)

But the achievements are, in the words of WHO director-general Margaret Chan, ―very fragile.‖

Support and the global effort must be sustained or drug resistant parasites emerge, the bed net

insecticides wear off, the nets tear, and the entire campaign can fall to tatters. There have been other

great malaria eradication campaigns over the past one hundred years, and all of them have made

important strides, yet ultimately failed. Two key factors have played a role in dooming efforts:

Cessation of funding, and parasitic drug resistance.

Last week the WHO and Roll Back Malaria launched a campaign to limit drug resistance, the Global

Plan for Artemisinin Resistance Containment. Artemisinins are the only new class of anti-malarial

drugs, and their effectiveness both for prophylaxis and treatment is spectacular. But as loyal readers

have learned from several prior Global Health Updates, drug-resistant malaria has emerged in the

Thai/Cambodia/Burma region, and some manufacturers are, against the strong protest of WHO,

releasing monotherapy forms of the drugs, virtually ensuring further resistance will emerge. If the

artemisinins are lost, there is little in the drug research and development pipeline to replace the

currently available drugs.

Nevertheless, the battle against malaria has demonstrated that great things can be achieved with the

proper financial and political mobilization. Even die-hard skeptics are beginning to believe the Malaria

Millennium Development Goals for 2015 are attainable. But it may prove impossible to convince the

world that malaria infection rates have been reduced by half or by 75 percent because the baseline data

(how many people were acquiring malaria annually before the campaign commenced) is so terrible. A

November report in the Lancet demonstrates that 86 percent of child deaths to malaria in rural India as

recently as 2005 were never in health facilities and were not recorded in official mortality data for

India. The Indian data is so unreliable that the researchers conclude the actual number of malaria

16

deaths in the country annually, officially pegged at two hundred thousand, could actually be as few as

125,000 or as many as 289,000.

Success, nevertheless, is real in the malaria fight. A new meningitis vaccine campaign under way in

western Africa holds out the possibility that waves of epidemics in the region might also be controlled.

Last month some twelve million people in Burkina Faso alone received the new meningitis vaccine,

which costs just fifty cents per dose and was developed by the Bill and Melinda Gates Foundation and

the Seattle-based Path Organization. Also in the works are dengue vaccines that could radically reduce

the incidence of dengue haemorrhagic fever worldwide.

Enthusiasm, however, should be tempered. Despite the availability of polio vaccines and eight billion

dollars in global commitments to eradication of the viral disease, health officials are struggling to

control it. When the global campaign against polio, heavily funded by the Rotary Clubs International,

got under way in earnest in 1988, the world witnessed three hundred and fifty thousand cases of child

paralysis caused by the virus annually, and polio was endemic in 125 countries. In 2009 a total of

1,604 polio cases were confirmed in the world, concentrated in a handful of Asian and African

countries. But in 2010 a quarter of that number was reported in a single month in the Congo River

region, alone, killing 179. Polio is stymying eradication efforts in Congo, Angola, the Democratic

Republic of the Congo, and India. The Democratic Republic of the Congo suffered more than sixteen

hundred polio paralysis cases in 2010 with fifty deaths. In addition, the WHO believes that the case

fatality rates in Africa as a whole are climbing, sparking concern that the virus is gaining virulence.

Polio is making a comeback in Pakistan as well. In 2007 Pakistan was on the edge of eradication, with

just thirty two cases of the disease reported. But this year, following the worst monsoon in recent

history and massive flooding across an area larger than New England, 139 paralytic cases have been

reported.

The Gates Foundation is, despite such setbacks, banking on vaccines as the key to the future of global

health. In 2010 the foundation announced ―The Decade of Vaccines,‖ committing ten billion dollars to

the effort. The foundation has aggressively reached out to pharmaceutical companies and other

private entities such as the International AIDS Vaccine Initiative to mobilize an even more massive

effort. But skeptics charge inadequate attention is aimed at the key impediments to effective

immunization: vaccine cost and public health implementation. The remarkably cheap meningitis

vaccine is possible because it was developed outside of the traditional pharmaceutical sector and the

technology was transferred to an Indian manufacturer. More advanced vaccines tend to also be more

expensive, and require multiple doses and refrigeration, tough challenges for public health

vaccinators.

17

H5N1 Returns for yet Another Winter

The H5N1 bird flu is back this winter, causing major alarms in South Korea and Japan, though the

burden of reported human fatality is falling on Egypt. Panic runs so high in South Korea right now,

amid outbreaks in wild birds and chickens, that Dr. Margaret Chan was compelled last week to issue a

―calm down everybody‖ statement from her WHO director-general‘s office. On December 30 the

South Korean government announced that H5N1 had been found in two large commercial chicken

flocks, located in different parts of the country, and Korean TV viewers watched one thousand birds

get destroyed. The commercial bird outbreaks, located in Cheonan and Iksan, represent the first

H5N1 findings in the country since the spring of 2008.

South Korean officials speculate that unusual weather

conditions have resulted in a decline in food for wild

birds, pushing more of the starving animals to land on

domestic farms, where they may pass on H5N1 to

chickens and ducks. At the end of last week South

Korean officials spotted a third outbreak in

commercial ducks, located in a farm district a

considerable distance from the previous two

outbreaks. The current domestic bird epidemic,

officially confirmed last week, was preceded in

December by discovery of dead wild teals and cranes.

Japan is in an official state of alert since H5N1 was found in several species of wild aquatic birds,

including cranes, swans, and ducks, in various regions of the country. Both wild and commercial bird

deaths due to H5N1 were recorded in Hong Kong in December.

In late November the Indonesian government reported its 171st case of human H5N1 since 2005, 141

of which have been fatal, for a death rate of 83 percent. Few viruses are as lethal to human beings.

As of January 6, Egypt has reported 119 cases of human H5N1 disease; forty having been fatal. Nearly

all Egyptian cases involve young adults (twenty to forty years old), and few can be directly correlated

with exposure to infected birds. Those cases that have been linked to infected birds inevitably involve

family-owned chickens.

Since 2006 Egyptian health authorities have struggled in vain to control H5N1, in a country where

most families have small flocks, even in urban areas, and are reluctant to report ailing birds to

authorities. Authorities closed Cairo‘s chicken slaughterhouses in December, hoping to halt the virus‘

spread. The move is largely redundant to decree seventy, passed in 2009, which outlaws the sale of live

chickens throughout Egypt.

18

Soaring Food Prices

Here we go again. Actually, not again; here we go to record-breaking, unprecedented food inflation.

Prices are soaring all over the world, sparking great concern about food riots, famine, and the general

trend, now four years in a row, of seemingly unending cost increases for the most basic of foods.

Last week the Rome-based Food and Agriculture Organization (FAO) declared that food prices had

hit ―a record high.‖ Based on tracking fifty-five food commodities, the FAO index found prices had

eclipsed the June 2008 high of 213.5 points, reaching 214.7 points in December, and prices rose 4.2

percent in the month of November alone. Fortunately, rice prices have been stable, so far, minimizing

concerns that there may be a repeat of the 2008 rice riots in Asia.

But FAO economist Abdolreza Abbassian warned that unusually bad 2010 weather events threatened

cereal and grain commodities all over the world, and expected hikes in retail costs in coming months

―will affect millions of people, particularly where basic foodstuffs such as cereals are concerned.‖

Some of the world‘s largest retail food producers have already significantly raised prices of many of

their products, including Kraft, Nestle, General Mills,

Unilever, and McDonalds. So grave is the concern

that G20 finance ministers are holding emergency

talks to determine how to control prices for basic

foodstuffs, and head off the sort of rampant

commodity speculation that drove the 2008 food

situation out of control.

The price spikes mean that this year the total amount

that countries pay for imported food will exceed a

trillion dollars for only the second time in history,

according to the UN. The 2010 bill is up nearly 15

percent from last year and 2011 is on track to be worse still. ―We are in a dangerous zone,‖ FAO‘s

chief, Jacques Diouf, recently told reporters. ―Unless countries manage the situation carefully, we

could end up in another crisis.‖

Rhee Chang-yong, who represents South Korea at the G20, told Reuters this week that ―France [host

of the 2011 G20] is emphasizing food security. As a former host country of G20, we would like to

deal with the price volatility problem thoroughly. French President Nicolas Sarkozy has asked the

World Bank to conduct urgent research on the impact of food prices ahead of G20 meetings.‖

African Union Chair Bingu wa Mutharika last week called on Africa‘s governments to prepare for the

worst by setting aside ten percent of their national budgets for agricultural development and food

subsidies. Most African countries are already feeling the pinch. Chapatti flatbread sold on the streets

of Nairobi this week for eighty shillings, an enormous price jump over last year‘s fifteen shillings.

Household purchasing of maize, milk, flour, and chicken in Kenya has witnessed an average 30

percent cost increase over the past nine months. A combination of global price trends and local

political unrest is driving up food prices in Cote D‘Ivoire, where the price of a kilo of sugar or meat has

19

doubled in three months, and rice has inflated by 25 percent. Even oil-rich Abu Dhabi last month set

up an emergency food crisis center.

Why are prices soaring? There are so many factors at play that finding ways to head off disaster in

2011 will be challenging. Among them:

Rising middle class appetites and spending power are fueling inflation in China and to a lesser

degree India;

Massive forest fires in Russia and Ukraine burned much of the wheat and sparked the

governments to cap exports;

Commodity speculation is now practiced widely as a hedge against real estate and stock

volatility;

In 2007 and 2008 many nations banned exports of rice to hold down domestic prices; today

more than thirty countries have some form of export ban in place on rice and/or other basic

foods;

Oil price inflation makes all aspects of planting and distribution cost more, including fertilizers,

pesticides, mechanized plowing and harvesting, refrigeration, and processing.

Some key concerns for 2011 include bleak harvests in Afghanistan, Pakistan, and India, largely due to

record monsoons and other weather conditions. In Afghanistan humanitarian groups say 7.3 million

people face food insecurity this year, and helicopter drops of such basics as rice and flour are all that is

staving off starvation. Relief groups say the rising prices in food translate directly into fewer mouths

to be fed, unless an additional four hundred million dollars

in aid can be raised in the next three or four months.

Heat waves and drought across Argentina and neighboring

nations has driven up corn and soybean prices. The region is

in the grips of a La Niña climate event, due to decreased

surface temperatures in the Pacific. This in turn drives hard

rains along the Pacific Coast, especially the California

produce region. Commodity investment analysts predict

soybean prices could eclipse all prior records in 2011.

On January 7 the Indian government issued alarm, noting that the weeks of December saw sharp food

price inflation. An 18.32 percent spike the final week of the month was exceeded by a 19.1 percent

spike at the opening of the month. The only higher spike in recent history occurred during the

monsoon, when food costs inflated about 20 percent weekly. Inefficiencies in transport and

stockpiling of food are partially responsible, but the expanding middle class of India is driving

inflation across the board, for all consumer products, services, energy, and clothing. The situation is

pushing up the value of the rupee, driving down Indian bonds, and making consumers crazy. Political

leaders, worried about instability, this week flooded markets with subsidized rice and grains from

government stockpiles, but one wonders what tactic Delhi will use when the silos are empty.

20

Food inflation across the border in Pakistan is partially the result of the country‘s monsoon and partly

due to farmers selling their goods to India, therefore depleting domestic supplies. December food

prices in Indonesia jumped 7 percent, which was modest compared to the 12.5 percent in Estonia.

Middle-class demand, coupled with bad weather, has forced cabbage prices up in Asia sending grocery

purchasers from Beijing to Seoul into rages. NPR reports that the price of a head of cabbage in Beijing

has doubled in a year, rice soared 30 percent in December alone, and chili peppers last month cost on

1,000 percent more on December 31 than on December 1. The government has responded by

imposing harsh price caps on many industries, in hopes of holding inflation down by forcing

producers to limit their profits. Market analysts say that China‘s general inflation rate is now running

at 5.5 percent, but food is averaging twelve percent.

In the U.S. last week, according to Marketwatch:

A pound of bacon costs 44 percent more than this time last year

A slice of ham costs 11 percent more

A dozen eggs will cost you 3 percent more

A pound of coffee has skyrocketed 22 percent

A pound of sugar is up 19 percent

Summarizing the situation for Reuters on December 29 business analyst John Foley concluded ―Food

riots in 2011 are possible, but not inevitable. Granted, the world will have to get used to more food

scares as the population expands and the diets of the poor get richer. But the moment when humanity

outgrows the earth is thankfully not yet here. Cool-headed policies can still prevent a crisis.‖

So pray for cool heads.

HIV Prevention, the Pope, and PrEP

Miracles apparently do happen. The Vatican has reversed its

position on condom use to prevent transmission of HIV, nearly

thirty years into the pandemic. In November Pope Benedict XVI

issued a book, Light of the World, in which he stated that condom

use to prevent HIV infection was permissible for ―homosexuals

and transsexuals,‖ but made no comment regarding use within

heterosexual couples. The latter could, of course, violate long-

standing Vatican bans on contraception. In later clarifications,

issued by Vatican spokesmen in November and December, the use

of condoms was couched as a matter of respect and responsibility.

Vatican spokesman Frederico Lombardi told reporters in Rome

that the Pope considered condom use ―the first step of taking

responsibility, of taking into consideration the risk of the life of

another with whom you have a relationship.‖

21

As Christmas approached, a firestorm of debate was exploding inside the church, as conservative

theologians decried the Pope‘s statements. On December 21, the Pope issued further clarifications,

making it abundantly clear that the Catholic church still opposes all forms of birth control, as well as

prostitution. But ―the Church teaches that prostitution is immoral and should be shunned. However,

those involved in prostitution who are HIV positive and who seek to diminish the risk of contagion by

the use of a condom may be taking the first step in respecting the life of another -- even if the evil of

prostitution remains in all its gravity. This understanding is in full conformity with the moral

theological tradition of the Church.‖

For conservative members of the Church, Humanae Vitae (Paragraph 15), the 1968 papal encyclical

barring Catholics from using artificial contraception, is the primary and perhaps only statement that

matters. It places primary value on life, itself, making it clear that life begins at conception and cannot

be justifiably terminated. Pope Benedict XVI has not challenged that position. According to his

Vatican spokesmen, the pope has simply asserted that individuals have a moral responsibility to

protect the lives of others, which would include using condoms if they are HIV positive in order to

prevent passing the virus to their partners.

The papal sanction of condom use to prevent HIV is one of a series of events and discoveries over the

past twelve months that make it possible to imagine a dramatic worldwide reduction in the numbers of

people newly infected with the virus. The CAPRISA microbicide trial in South Africa demonstrated

that Gilead‘s Tenofovir antiretroviral product could be formulated as a vaginal gel that lowered the

risk of sexual transmission to women by 39 percent to more than 50 percent, depending on the

regularity of use.

A new study using a novel combination microbicide gel containing zinc acetate and micromolar doses

of the still-experimental non-nucleoside reverse transcriptase inhibitor MIV-150 for up to twenty-

four hours after application, has shown remarkable results in macaque monkeys. The NIH researchers

say they attained 100 percent protection against the simian form of HIV in twenty-one of twenty-one

experimental animals. The Population Council and NIH now hope to take the gel into human clinical

trials.

This latest microbicide finding comes just weeks after a joint NIH and Gates Foundation funded

multi-site study showed that daily oral Tenofovir intake can protect gay men from acquiring HIV from

infected partners. The preexposure prophylaxis, or PrEP, concept was tested in nearly two thousand

five hundred gay men, lowering their risk of acquiring HIV by 44 percent with full compliance with

daily use regimes.

In addition to these technological tools and the papal theological breakthrough, political will has

emerged in many countries. Ethiopia, for example, just launched a five-year plan that aims to halve its

HIV prevalence and quadruple condom distribution. The country currently has an estimated 1.2

million infected individuals and a national prevalence of 2.4 percent.

The Ugandan government launched a free male circumcision program in September as a new feature

of its national anti-HIV effort. In its year-end report the Ministry of Health reports enthusiastic

22

acceptance of the service, with some two thousand men having undergone circumcision in three

months.

Cost savings are coming to the treatment side of the AIDS pandemic, as well. Indian manufacturers

just announced their intention to produce generic versions of second-line antiretrovirals, despite

patent disputes with American and European pharmaceutical companies. A team of scientists from

the United Kingdom and United States has come up with a dirt-cheap method for testing CD4 levels

in patients, both to determine if they are candidates for receipt of drugs and to monitor the

effectiveness of their treatment.

Despite these advances, the challenge of scaling up both prevention and treatment to meet genuine

needs levels in countries with prevalence levels above 10 percent remains daunting. South Africa,

which has more infected citizens than any other country, is reeling under the cost burden of trying to

find and treat the estimated 5.7 million HIV positive people in that country. A recent analysis from

Results for Development reckons Pretoria will need to conjure one hundred and two billion dollars

over the next twenty years to handle its epidemic. Currently some four hundred thousand South

Africans are newly infected annually—a staggering toll that must be radically reduced lest treatment

bankrupt the nation.

Similarly, a team of Stanford University scientists estimates that universal treatment of 4.8 million

HIV positive patients in thirteen African countries would cost 14.8 billion dollars per year, assuming

prices for medicines do not increase. Currently, first-line treatment with generic medicines costs

about ninety six dollars per year. But when patients require second-line drugs, due either to side

effects encountered with the first of emergence of drug-resistant HIV, costs soar to about three

hundred dollars per year per patient. The researchers estimate that total donor global spending on

HIV hit fifteen billion dollars in 2008 for all AIDS-related services and prevention.

Finally, a Few Random Thoughts to Bring Us into 2011…

Chinese addiction to IV drips: In 2009 Chinese doctors prescribed a whopping 10.4 billion bottles of

IV drip medicines—about eight bottles on statistical average per Chinese citizen. That is well over the

average of 3.3 bottles per hospitalized patient in Europe or Japan. The overuse of intravenous drugs

poses many hazards to both individual and public health, including potential spread of hepatitis B and

hepatitis C—in a country where about 10 percent of adults are already infected with one or both of the

viruses. Why such flagrant overuse? The government has artificially fixed IV medicine prices quite

low, so there is no cost disincentive to use, and patients and doctors share the belief that IV drugs are

more effective than swallowed ones.

According to the U.S. Government Accountability Office, al-Qaeda has contemplated poisoning the

American food supply. The GAO report was made public days before Christmas. It asserts that al-

Qaeda operatives in the Arabian Peninsula or Yemen plotted to hide stashes of ricin and cyanide in

various locations around America, for eventual use in a mass poisoning event. The Department of

23

Homeland Security responded to the GAO report with a prepared statement: ―We are not going to

comment on reports of specific terrorist planning. However, the counterterrorism and homeland

security communities have engaged in extensive efforts for many years to guard against all types of

terrorist attacks, including unconventional attacks using chemical, biological, radiological, and nuclear

materials. Indeed, (al Qaeda) has publicly stated its intention to try to carry out unconventional attacks

for well over a decade, and AQAP propaganda in the past year has made similar reference. Finally, we

get reports about the different kinds of attacks terrorists would like to carry out that frequently are

beyond their assessed capability.‖

Last week mass bird die-offs were reported in Arkansas, Louisiana, and

Sweden. In each case the incidents were very sudden, featuring thousands

of birds suddenly falling dead out of the skies. And in each incident

officials have ruled out infectious diseases and poisoning, in favor of

―trauma‖ as an explanation.

Lastly, Yale University Press just

published Atlas of the Transatlantic Slave

Trade by historians David Eltis and

David Richardson. The book is a

masterful piece of scholarship, full of

astounding surprises and offering clues

to the spread of pandemics during the

first great period of globalization.

Among the most extraordinary

discoveries made by Eltis and

Richardson in this twelve year study of

slave trade records, dating from 1501 to

1867, is how tightly the commerce in

12.5 million African human beings was

linked into a general Atlantic trade cycle. Ships departed Europe (especially England) loaded with

goods and military supplies that were sold to colonial outposts along the West African coast. Those

same ships were then filled with kidnapped human beings that were carried primarily to Brazil,

secondarily to the Caribbean, and on a surprisingly smaller scale to the American colonies. Sold at

ports in the American Hemisphere, the slaves garnered the traders‘ funds to then purchase rum, sugar,

tobacco, and corn, which earned the traders great profits on their return to

Europe. The database accumulated for this extraordinary piece of

scholarship is on line at www.slavevoyages.org.

We cannot begin to express how astounding it is to read this book and

study its very illuminating graphics. From nearly every page facts and

images leap that defy preconceptions. The next obvious project would be

matching the shifting trends over centuries in both from whence Africans

were kidnapped and to what ports they were delivered, with records of

―new disease‖ outbreaks. Surely the slave trade was the single greatest

driver of microbial globalization in human history, bringing smallpox,

24

yellow fever, syphilis, gonorrhea, measles, influenza, pertussis, and a long list of other epidemic

diseases to the Americas. The opening of the Atlantic, and the spread of microbes that vanquished

some 90 percent of the indigenous Amerindian population of the Americas, was driven by slavery.

We wish all our readers moments of joy in 2011, fresh and innovative insights, and success in your

health-related endeavors.

Sincerely,

Laurie Garrett

Senior Fellow for Global Health