Sunday, December 28, 2014

Uncertain Health in an Insecure World – 16

“Open Access, or The Highway?”

The first known scientific journal, Philosophical Transactions of the Royal Society, was published 350 years ago in 1665. As noted on the frontispiece below, its pages gave an “account of the ingenious in the many considerable parts of the world”.

The 15-year old Bill and Melinda Gates Foundation’s current endowment is $43 billion. Their money funds ingenious educational and health care research. Its official blog is called Impatient Optimists because Bill and Melinda, once na├»ve (by their own admission) to the ways of the world of giving, have come to understand that deep pockets & big ideas alone are insufficient conditions for global game change.

Even geniuses must learn as they go. 

Effective January 2015, the Gates Foundation will require that its funded researchers submit their results to open access online journals, like the OMICS Group and the Public Library of Science PLOS ONE. By 2017, all of the research funded by the Gates Foundation must be initially published in open access journals, without the typical constraints to information sharing associated with big publishing house costs and embargoes.

In addition, the Gates Foundation has stipulated that articles funded by their grants have a Creative Commons Attribution 4.0 Generic License (CC BY 4.0), allowing published content reproduction for both scientific and commercial uses.

So from now on, it’s full, free and immediate information access, or ‘The Highway’, for researchers planning to accept prestigious Gates Foundation money.

These publishing strings are spun from Bill and Melinda’s personal values web. They want health care workers in poor countries and emerging economies to have early access to credible research results, without expensive journal subscriptions & article reproduction fees, or other information dissemination barriers.

Fair enough! After all, it is the Gates’ money, so they can dictate the funding terms as they see fit.

The Gates Foundation’s open access online-in-the-sand looks like a game changer for lucrative multinational scientific publishing conglomerates, like The Elsevier Group. Through its data warehousing subsidiaries like Research Intelligence, Elsevier tracks impact factors for individual scientists and research journals alike, tied to the frequency that their peer reviewed publications are cited by others working in the field.

Ironically, impact factor information is highly influential within the research community for one very important reason - it is grounded in a rigorous peer review process. Impact factors can also parallel and even predict the future commercial value of an idea or patent – so-called intellectual property.

High impact scientific journals like Nature and Science do not support the Gates Foundation’s CC BY 4.0 stipulation, arguing that readily reproduced research materials can be altered or misrepresented for commercial interests, to the detriment of a researcher’s and/or a journal’s reputations.

Neither camp’s position is without merit. 

But what would the Gates say if a less robust piece of research, released without major publishing house expert review into the open access architecture, harmed patients?

And what is The Lancet’s explanation for its failed peer review of the 1998 Dr. Andrew Wakefield MMR vaccination-autism link paper, retracted in disgrace in 2010?

So, “Who is right?”

Can a global medical profession sworn to “Primum Non Nocere” (First, Do No Harm) make the compromises necessary to attain the best of both worlds for the underserved, when neither is perfect?

And if “perfection is the enemy of good” in the developing world, then aren’t pricey developed world publishing house practices simply colonialism under another book’s cover?

For us in The Square, the more germane question to both camps may be “What is wrong?”

Monday, December 22, 2014

Uncertain Health in an Insecure World – 15

“Planning for World Domination”

Human attempts at world domination come in many forms.

Kaiser Wilhelm II (1859-1941) led Germany into World War I in support of Austria-Hungary. While he was both King of Prussia and German Emperor, the Kaiser's domestic policies were vacuous and his wartime leadership ineffectual. He lost The Great War and his crown on November 11, 1918, living out his life in exile in the Netherlands.

Henry Kaiser (1888-1967), an American World War II shipbuilding magnate, assured that his employees & their families received health care at a 10-bed Kaiser Field Hospital opened in Richmond, CA in August 1942. The first Kaiser Permanente Hospital was established by his foundation in Oakland, CA in August 1944, where the company still maintains its head offices.

Today, Kaiser Permanente (KP) operates a largely western U.S.-anchored niche market health care plan.  For more than seventy years, KP has relentlessly pursued its successful integrated care and insurance coverage business model, which is now closely linked to an aggressive disease prevention program. Within the ~9,500,000 KP plan membership group, chronic disease avoidance through illness prevention has been shown to be highly cost-effective.

The key unanswered question: Can the KP ‘Total Health’ best-in-class chronic disease prevention model be exported into other countries?

Total Health remains an unproven global commodity outside KP’s U.S. markets.

KP International (KPI) is working hard to share what it has learned in sunny California with the rest of the world. My Global Health Leadership Forum (GHLF) colleague, Molly Porter, is an unreserved proselytizer for the Total Health mantra. Tyler Norris, KP vice-president for Total Health Partnerships, believes too, telling me recently that, “Total Health is a state of complete physical, mental and social well-being for all people… to address the whole person… and apply every lever we have – from paying living wages to implementing local and sustainable purchasing practices”.

I’m totally inspired!

But as of today, KP lacks evidence to support the dominating impact of Total Health around the globe. On behalf of KP, Tyler Norris has thrown down a proper organizational gauntlet: “Any community or national health system can do this, if they make the leadership commitment”.

Beyond developing motivated leadership, just what are the major barriers to Total Health adoption in the less developed countries of the world?

Care integration – communicating collective organizational goals; aligning and coordinating patient-related efforts to help achieve shared goals.

Complexity – managing the interdependence of sequential tasks, and the reciprocal effects of chronic diseases within systems of care.

Organizational direction – motivating employees & enrollees about what to think (i.e. mindset), mutual respect, and knowledge on how acquiring new skills fosters innovation.

Change – connecting today with tomorrow; getting ahead in a strategic way that is problem-focused, avoiding crises management.

Boundaries – moving beyond the health care sector, crossing into the social services sector including education, housing, childcare, etc.

KPI's Answer: the very same factors that determine Total Health's success in the U.S. will predict its successful adoption globally.

By value process mapping, pinpointing opportunities, keeping pace and coordinating relationships, KP has positioned itself to move offshore and morph its Total Health platform to meet other countries’ chronic disease mitigation needs.  

Not unlike Kaiser Wilhelm II's vain attempt to dominate early 20th century Europe, this is not going to be easy. The dis-integrated health care systems of politically fractious developing countries, where generally unhealthy populations abide, are more of a challenge than wartime industrialist Henry Kaiser ever imagined.

But KP is totally committed to spreading the gospel of Total Health internationally, and confident that it can overcome these real-world adversaries.

It's Kaisers we're talking about, so stay tuned!

The Square salutes those who take up a grand campaign.

Sunday, December 7, 2014

Uncertain Health in an Insecure World - 14


Sir Bertrand Russell, British philosopher, ethicist and social critic said, “Everything is vague to a degree you do not realize until you have tried to make it precise” (The Philosophy of Logical Atomism, 1919).

Definitions of widely used terms vary widely.

Excessive definition variability causes a pathological inflammation of essential organ systems – a.k.a. “definition-itis”.

International medical and public health communities are increasingly interested in global health. Unfortunately, these actors have widely differing and overly complex definitions for global health.

Global health is defined as research and practices that prioritize improving health and achieving health equity for all people in the world. Because these issues transcend national boundaries and domestic governmental capabilities, they are often the purview of non-governmental organizations (NGO’s) like the World Health Organization (WHO), the United Nations (U.N.), the World Bank, etc. High income countries with well-established public health institutions are home to these global health NGO’s (WHO Geneva, Switzerland, U.N. New York City & World Bank Washington, DC). 

Other definitions of global health call communities to action around the planet to collaborate effectively to make global health promotion research & evidence-based actions a trans-national policy priority. The 2007 Oslo Declaration identified global health as "a pressing foreign policy issue of our time'". 

Still others suggest that public health is actually global health for the public good (c.f. the 1978 Alma Ata Declaration of “health for all”).

International health, including tropical medicine, is not global health. It emphasizes public health solutions for infectious diseases and maternal-child health issues in low and middle-income countries. National governments often embed international NGO’s within their ministries of health in order to more effectively channel medical aid and humanitarian assistance.  The U.N. Children’s Fund (UNICEF) has 190 country programs and national committees. UNICEF country offices facilitate foreign aid efforts by developed countries, exerting a public health benefit through field work inside developing countries.

What could be wrong with the lack of a shared definition for global health?

This space has become muddy, and definitions get bent out of shape to suit the actors' purposes. If these related terms really have different meanings, then why isn’t there an effort to make that clear? Are there common core ideas that  help to explain the continuing overlap? 

Is there anything wrong with defending the use of two related terms?

It has been asserted that a common definition of global health is essential to shaping national strategic direction, which can then inform actions by the global health community. In 2009, an expert panel led by Jeffrey Koplan reached a consensus on a common definition for global health through natural language processing of the extensive published literature. Among other G-8 countries, Canada was an early adopter of this definition as a to guide their national global health strategy in 2011.


If the core relevance of global health is being widely misunderstood, then related research and actions may end up being less potent, despite the best intentions of the actors.

So let's be perfectly clear.

The global health Square is not located in Babel.

Help stamp out "definion-itis"!

Tuesday, December 2, 2014

Uncertain Health in an Insecure World - 13

“The Vaccination Games: Mockingjay”

Some of my best friends are vaccine scientists – call them ‘Capitals’. They'd likely follow Capital President Snow.

They devote their professional lives to developing vaccines to prevent a variety of potentially lethal infections. Whether these colleagues work in open labs or one of the world’s fifteen secure biosafety level (BSL)-4 containment facilities, their discoveries are converted into useful medicines at a higher rate than any other type of research. They believe in the Center for Disease Control (CDC) Vaccine Advisory Committee, despite some member ties to vaccine makers. 

Some of my best friends think that vaccinating children is harmful – call them ‘Mockingjays’. They'd follow District 13 President Coin.

Despite the seriously flawed 1998 Lancet study linking measles-mumps-rubella (MMR) vaccine to autism, which was retracted in 2000, they worry. They’re convinced that there is a link between diphtheria-pertussis-tetanus (DPT) vaccination and sudden infant death syndrome (SIDS). They ignore news of rubella outbreaks in MMR-unvaccinated enclaves of Europe and North America. They just don’t trust vaccination, or the system.

A twenty-something colleague was just diagnosed with whooping cough (pertussis), after hacking her lungs out for three weeks. She saw multiple doctors before one finally made the connection to this childhood disease. Her DPT-induced immunity had simply flagged over the years. Some believe in the “leave it to nature” approach, touting better survival through disease-induced immunity. But the alternative to vaccination is a risk of dying from measles encephalitis or H. Flu meningitis, before the body can mount an effective immune response.

Rebellion is not without its consequences – District 12 was destroyed by the Capital’s bombs!

The 2011-2020 World Health Organization (WHO) Global Vaccine Action Plan (GVAP) has been endorsed by 194 member states as a strategy to prevent millions of deaths through equitable access to vaccinations. Whether through village-centered or nation-wide vaccination programs, millions will reap a health benefit, individually and through so-called ‘herd’ immunity, which is achieved when >95% of a community has been vaccinated.

Many rebel fighters believe that herd immunity is a myth.

Outbreaks of Group A meningococcal meningitis occur every 7-14 years in the so-called 'meningitis belt' of Africa, between the sub-Saharan Senegal to Ethiopia. According to WHO, the 2009 epidemic killed 5,352 people.

That’s more deaths than from the 2014 Ebola outbreak!

Once a disease largely confined to military barracks in developed countries, Group B meningococcal meningitis is flaring up in college dorms. The U.S. FDA and CDC monitor the safety of all routinely used vaccines, and recently approved the use of a Group B meningococcal vaccine after serious outbreaks at Princeton and the University of California Santa Barbara.

But my college freshman won’t get infected.

There are over 100 human papilloma virus (HPV) sub-types; the most commonly used HPV vaccine (Gardasil) is active against HPV-6, 11, 16 and 18.  The National Health Service (NHS) estimates that 40% of annual U.K. HPV cervical cancer deaths would be prevented by routine vaccination of 9-13 year old girls who might becoming infected after sexual intercourse. Vaccination is now recommended for boys & young men aged 9-26 years who may have sex with other men, to prevent genital warts.

Of course, my teenager won't become sexually active.

Until your child is selected to represent their district in the Hunger Games, parents can’t imagine it. But unlike Katniss Everdeen's record, only one tribute survives.

So to the Capitals and the Mockingjays, you have 3 survival options: watch helplessly while viruses kill youths for sport, rebel against the system, or vaccinate your children.

And to all those walking in The Square, I say, “If they burn, we burn with them”.