Category Archives: Health systems

Are retail clinics dangerous?

Target, Walgreens and CVS have recently started medical clinics in their stores. Opening up these “retail clinics” seems both potentially profitable and, at first blush, somehow pushes the lines on our tradition view of where medical services should be located. Giving the concept of retail clinics some thought might reveal store-based providers to be convenient and cost-effective, or alternatively full of conflicts of interest and potential harms. Should we be worried about retail clinics turning into the Walmart of medicine?
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Farming the microbial garden, tracking child deaths, and introducing universal healthcare in poor countries

We’re piloting a new format for EpiAnalysis starting this week. Rather than writing long essays every month, we’re going to post short, weekly summaries of interesting new data or controversies relevant to the epidemiology community, offering direct links to new papers and concise analysis of emerging issues. We hope this format makes the blog more accessible and quicker to read.

This week, we’re highlighting recent discussions about the “human microbiome”, controversies about child mortality data, and the flurry of universal healthcare programs being introduced in middle-income countries like Mexico and India.

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An update on global access to medicines

Back in 2001, a major ruling took place at the World Trade Organization (WTO) to increase access–at least theoretically–to generic pharmaceuticals for patients in poor countries.  The WTO signed a pact known as “The Doha Declaration“, indicating that intellectual property rights (patents) should not stand in the way of public health; that is, expensive brand-name drugs that were still under patent could be substituted for with cheaper generic alternatives when epidemic diseases were affecting a country. But has this provision worked to improve medicine access?

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Is mHealth just another gimmick?

The use of cell phones by community health workers and other medical practitioners in low-income countries has been promoted as a potential revolution for health systems development. This “mHealth” revolution has been seen as an opportunity to develop diagnostic, treatment and surveillance networks wirelessly, to build mobile apps allowing remote nurses and doctors to provide higher-quality care to rural patients even in places without a hospital or well-functioning health clinic. Several foundations are now offering grants to build and distribute phone applications that will offer everything from prescription drug advice to epidemic surveillance tools. But is mHealth really going to improve health outcomes? Or is it just another technological bomb thrown at poverty and poor infrastructure?

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Peak oil and public health: preparing healthcare for another kind of transition…

“Three threats all arise from the Earth’s limited capacity to sustain unabated human growth and consumption,” wrote Peter Winch of the Johns Hopkins School of Public Health. “(1) Global climate change, (2) ecosystem degradation, and (3) peak oil production.”

We have to admit that, until a few weeks ago, “peak oil” was not on our bulletin board of phrases used in public health (frankly, most of us epidemiologists didn’t know what it meant). By contrast, it’s become clear that climate change may alter patterns of malaria and dengue fever transmission. And that ecosystem degradation can have long-term implications for water and food shortages. But what’s the public health effect of petroleum?

In this week’s blog post, we discuss the concept of peak oil, and summarize a series of recent studies suggesting that this term should become part of our regular public health lexicon…

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Who’s afraid of a community health worker?

When asked by the journal PLoS Medicine “which single intervention would do the most to improve the health of those living on less than $1 per day?”, the global health icon Dr. Paul Farmer answered: “Hire community health workers to serve them.”

The argument was not new—community health workers (CHWs) have been promoted since at least the 1950s—but the argument for CHWs has been controversial. The term “community health worker” has been applied to a myriad of different actors, but generally describes local people who are trained to work in their (usually rural) town on a range of health problems from education to medication delivery. CHWs often make housecalls, and have been conceptualized as “an army of one” for health, like Halo officers roving through the landscape with vaccines and bandages instead of guns and grenades:

But CHW programs have also been criticized for providing substandard, unreliable medical care; some have argued that CHWs should be volunteers, to promote community “bonding” and “empowerment”, but shouldn’t be paid because such a system would be “unsustainable”. CHW programs in Tanzania, Colombia, Jamaica, and Botswana have been recently defunded under this premise. In this week’s blog, we ask: what do we know about CHWs? Do CHW programs “work”, and should we pay for them?

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Private philanthropy and conflicts of interest in global health

Suppose an Indian businessman—a billionaire who had invested in the emerging Indian auto industry—were to donate to the Hurricane Katrina rehabilitation efforts in New Orleans. Such a donation would surely be welcomed as a grand philanthropic gesture. But if the donation carried a caveat—that to receive the funds, New Orleans’ factories would have to be redesigned to produce Tata Nano cars instead of Ford pickup trucks—the donation might produce legitimate debate.

The same situation is arising in global health politics, after the Bill & Melinda Gates Foundation established partnerships with the Coca-Cola Company.

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Advancing primary care in global health – avoiding past mistakes

The President’s Global Health Initiative (GHI) has outlined a new U.S. strategy for global health. Secretary Clinton recently described the GHI as aiming to bolster health system development and particularly primary care, tackle health problems that can be eliminated with relatively little investment (for “sustainability”), and focus on maternal and child health (MCH).

To an outsider, this all sounds pretty good; but to those who are familiar with the history of global health, the rhetoric around the GHI ominously harks back to past mistakes. In this blog entry, we discuss the history behind primary care in global health, to explain why previous attempts at “health systems development” perversely backfired in the 1970s, 80s, and 90s.

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Have health inequalities worsened in South Africa since apartheid?

We’ve all heard about the infamous apartheid-era health system in South Africa. As a middle-income country, richer than many in sub-Saharan Africa, the Republic of South Africa provided world-class care for White elites, including the world’s first heart transplant. But the majority of people were denied appropriate access to health care. Spatial segregation between populations was a prominent method to sustain inequality during apartheid, with racially-biased policies leading to the creation of ‘‘Black homelands’’ that detached the poorest areas from regions with better health care infrastructure.

What’s happened since apartheid ended? Has health care access improved for the poor in South Africa? In a recent analysis of health system data from the country, we found a surprising result: an inverse and worsening relationship between health care allocations and disease burden after apartheid.

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