global health

Drinking Our Own ORS

By Alanna Shaikh | | 12 Comments |

(This is a reprint of a post I wrote for my Global Health Basics blog, which it turns out I have neither the time nor the technical prowess to maintain.)

In social media, they talk about eating your own dog food. In global health, I think the equivalent would be drinking our own Oral Rehydration Solution (ORS). We need to do a lot of that. It’s important to think about what we ask of people because it gives us a much clearer sense of why we get ignored. Here’s the starter list for how to drink your own ORS:

1. Drink an entire glass of ORS from a packet every time you get the runs, not the tastier homemade kind. Don’t take Imodium.

2. Boil and cool all your water before drinking it.

3. Never spend a single cent on a treatment or cure that hasn’t been proven to work. No vitamin C for a hangover, no Preparation H, no Neosporin on your cuts.

4. No antibiotics when they aren’t strictly necessary. That means nothing for your bronchitis or your child’s ear infection.

5. Use a condom every single time you have sex, even with your spouse, even if your spouse doesn’t want to.

6. Take your child to the doctor immediately if she is showing any of the IMCI warning signs, but don’t take her if she is less sick than that.

7. Breastfeed exclusively until six months, and continue breastfeeding until at least age 2. If you have to work, then express milk by hand into a jar and store it in a cool place. But never feed your child with a bottle. Use a cup and spoon.

8. Choose your food on the basis of what is cheapest and most nutritious, without regard for flavor or cultural tradition.

9. Don’t see the doctor you are most comfortable with; instead, see the doctor that your government recommends.

10. When caring for your sick child, don’t follow the advice of your mother or mother-in-law. Instead, follow advice from a government doctor you may only have met once.

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(No antibiotics for her! photo credit: rabble)

Arguing against innovation

By Alanna Shaikh | | 8 Comments |

Well, I didn’t win the CSIS Smart Global Health Essay Contest, possibly because I argued against innovation in a contest that was explicitly looking for new ideas. I liked my essay, though, so I am sharing it here. CSIS was asking how the US government should spend their money on global health, and specifically looking for new and exciting ideas.


An Argument Against Innovation

Now is not the time for programming innovation. Instead, we should focus the next fifteen years on expanding the programs that work. Innovation is aimed at system-changing efforts that will lead to huge success or major failure; that’s not what we need right now. US government resources are not limitless, and we have a deep body of research in what works in global health. We have highly effective programs that are begging for funding; that is where our money should go. The government is well suited for the role of supporting boring but effective health interventions.

Global health research is full of solid, evidence evidence-based interventions that have been proven to improve health. These include increasing access to contraception, increasing vaccination coverage, home visits by nurses or community health workers, and strengthening primary health care and training health care providers in Integrated Management of Childhood Illness (IMCI). These are many effective pilot projects – proven to work – that have not been broadly implemented. Three examples:

Incorporate IMCI into physician and nurse education in every developing country. IMCI prevents stunting, promotes breastfeeding, and gets mothers to support child development by talking to their children more. It provides inexpensive, effective care for children. We know how train health care works in the strategy, and we know how to include it in medical education. The only thing stopping global adoption is money.

Meet the unmet demand for contraception. Studies have shown that giving couples access to contraception reduces child mortality rates, maternal mortality rates, and deaths from unsafe abortion. Letting women control their fertility also helps to promote gender equality and improve a family’s income. And contraception can be provided by trained health workers; a physician is not needed.

Put more resources into tropical diseases. Onchocerciasis control is a demonstrated success story, but 18 million people are still infected with the nematode that causes it. The African Programme for Onchocerciasis Control seeks to control the illness through universal treatment by 2010, but it will require financial support to keep providing the necessary drugs.

If we want to innovate, we should innovate with our funding models. The United States should start a fund that is devoted to supporting pilot projects that want to expand their reach. That would be an effective counterpoint to the many funding programs that provide “venture capital” for innovative efforts. Governments, NGOs, or UN agencies could apply for funding to scale up pilot programs with a certain number of years of experience, and a certain level of proven effectiveness.

Individuals and foundations love to fund innovative ideas; exciting new programs are easily marketed to foundations and philanthropic individuals. The Gates Foundation, for example, has a clear focus on innovation. In contrast, there is an important role for the US government in supporting the interventions that have been proven to succeed.

The American government doesn’t need to sell its ideas to fickle donors or get intensive publicity for the work it does. Instead, it can commit to the slow and steady underpinnings of global health. It’s good for global health efforts to have reliable donors supporting programs that work, and it’s good for American taxpayers to know that their money is going to projects that will definitely have an impact in improving global health.

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photo credit: LaniElberts

Sixteen Ways to Tell a Health Project is Doomed

By Alanna Shaikh | | 8 Comments |

weird scary stencil of a scary guy

1. It focuses on AIDS, TB, or malaria but is not coordinating or harmonized with global fund activities in country.
2. The staff are all clinicians, with no public health people.
3. The staff are all public health people, with no clinicians.
4. There is no plan to involve local or national health authorities in the project.
5. The project director is a clinician with no management experience.
6. It is planning on developing its own training content instead of adapting existing curricula to the current situation.
7. It depends on practicing physicians to serve as trainers, but has no plan to teach them the skills they will need to become trainers.
8. There are no women on staff.
9. It ignores the role of nurses in health care.
10. The underlying conceptual model doesn’t make any sense or staff have trouble explaining it in a way that makes sense.
11. The only monitoring indicator is how many people were trained.
12. Training success is identified by pre and post tests of participant knowledge instead of testing their skills and whether they are actually using new skills in practice.

Special guest additions:
13. Local partners/beneficiaries cheerfully insist that another expat program manager is the ONLY WAY to make the next phase sustainable… (from Tales from the Hood)
14. It’s a two-year contract and the only local staff are secretaries and drivers. (from Texas in Africa)
15. You visit the public health office and they want to know why you’re taking away their public health volunteers. (from Good Intentions Are Not Enough)
16. The per diem for your capacity building event is less than that for the World Bank project just down the road. (from Ian Thorpe)

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Photo Credit: REDRUM AYS
Chosen because searching for “doom” on flickr gets scary quickly, and my initials are AYS

Local vs Imported Solutions, and Ashton Kutcher

By Alanna Shaikh | | 0 Comments |

I just put up three posts at the Global Health blog that Blood and Milk readers may be interested in. There is a two-part series on local and imported solutions to health problems, focused on plumpy’nut and ORS. I also posted a brief rant about Ashton Kutcher and bednets for malaria.

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(photo credit: cliff1066)

On process

By Alanna Shaikh | | 2 Comments |

A friend of mine recently attended a meeting that was intended to develop a process to guide the preparatory meetings for the coordination meetings with the Ministry of Health. And the thing is, when you’re in the thick of it, these meetings make sense. You do need a unified message before you talk to your host government, and without some ground rules, the prep meetings to develop that message can get genuinely ugly.

All of this led me to think about process, and its sibling, bureaucracy. I’ve always had a pretty unpopular belief in the value of bureaucracy. Bureaucracy, to me, is the core of an organization. It’s what keeps an organization functioning when its staff changes. Without the forms and the regulations, you don’t have an organization. You have a cult. The structures are what makes it about more than just whoever works there at the moment. Bureaucracy puts the “organize” into organization.

That does not mean, however that bureaucracy should rule your work. It’s supposed to help the work get done. The work does not come second. And everyone accepts that. In fact, most non-me people hate bureaucracy.

Unfortunately, this is not the case with process. Plenty of people will sing the praises of “process.” Having a well-thought-out process means that you are Doing a Good Thing. If your intervention fails – the village women don’t feed their children more beans, or the Ministry of Education refuses to adopt your snazzy new curriculum – well, at least your process was good. Everyone benefits from being part of it.

I call shenanigans. Process is a jargon word that we use to obscure what’s going on. If your process is a series of meetings (and it almost always is), say so. And a good process is a process that achieves your goals. No more and no less. Nobody benefits from your stakeholder interviews if their input never turns into anything.

Lastly, some food for thought. A project I was connected to wanted to solve a problem they were seeing in a lot of rural clinics. The clinics would just use up all of their medicines, and then request more from the central supply. Since new drugs didn’t arrive instantly, there could be stock-out periods of a week or more while they waited for the new drugs to come.

To fix this, the project wanted to implement a pharmaceutical logistics system. They brought in a consultant from Europe, who worked with a group of clinic managers and Ministry of Health staff to estimate ongoing demand from different kinds of drugs. Based on these estimates, they then set re-order points for drugs. So, if you distributed, say, 10 IUDs a week, you would reorder IUDs when you were down to 15 of them, giving you a week and a half of time until the new ones came. The consultant turned these plans and estimates into a training system, and the project went around training rural clinics to use the new method.

Nobody ever did. Despite the training, and the eminent logic of the system, nobody ever did. Rather than try to determine why, the project wrote off the exercise as a failed pilot project and carried on. (My own suspicion is that clinics ordered their drugs when they knew that central supply had them, and were afraid that if they ordered according to some system, their orders would go unfilled.)

One of the project staff, when describing the whole fiasco to me, said something I’ve always remembered. “We paid thirty thousand dollars for the consultant, the curriculum, and the trainings,” he said. “If we’d given that thirty thousand to the government in return for a promise to improve their ordering system, every clinic in the country would be using it by now.”

(photo credit: markhillary)
Chosen because that’s exactly like many of the meetings I attend.

Briefing: Tuberculosis

By Alanna Shaikh | | 4 Comments |


I recommend that before you read this entry, you go here. Right click, open it in an another window. Then come back here, and read.

Tuberculosis (TB) is mostly an illness of the poor. It is caused by a bacterium called Mycobacterium tuberculosis. It’s hard to get tuberculosis if you have a fully functioning immune system and a nutritious diet. It’s easy to get tuberculosis if you are sick, hungry, or have HIV. People who have HIV in developing countries are very likely to also get TB. There are three kinds of tuberculosis. All are equally infectious, but some are much more fatal once you are infected.

1. Regular, which can be cured with a standard regimen of drugs, most often the regimen recommended by the “directly observed therapy short-course”, or DOTS. If your get proper treatment, it is pretty easy to survive regular tuberculosis. (And training doctors to use the DOTS drugs will ensure that the largest percentage of TB patients get better.) People in the developing world are often afraid to go for treatment, but tuberculosis can be cured, and treatment is free in many countries.

2. Multi-Drug Resistant Tuberculosis (MDR TB). This is a TB infection that cannot be cured with the usual drugs. Doctors must prescribe second-line drugs to cure this form of TB. There are two ways to get MDR TB. You can get regular TB, and be prescribed the wrong combination of drugs, or fail to take your drugs. This will mean that the weak bacteria in your body are killed by antibiotics, leaving the stronger ones to breed and take over. These survivor bacteria cannot be killed by the usual drugs. You may also get tuberculosis from someone who has gone through this process and has MDR TB; your bacteria will therefore be the stronger, survivor bacteria even at the beginning of the infection.

CDC MDR TB fact sheet

Wikipedia entry on MDR TB

3. Extremely Drug-Resistant Tuberculosis. (XDR TB) This is the worst kind of TB to be infected with. It cannot be treated with the normal, first-line drugs, or the less common drugs used for MDR TB. It requires rare, third-line drugs to cure it. These drugs are more expensive, harder to store, and may have severe side effects. 50-80% of XDR TB can be treated or cured.

Medical News Today on XDR TB
The WHO on XDR TB
The Stop TB alliance on XDR TB

For a long time, drug companies didn’t bother to research and develop new antibiotics. They were cheap and didn’t make a huge profit margin, and so effective that new ones were not really necessary. When drug-resistant TB first showed up, there were no second and third-line drugs. Doctors used veterinary drugs never used for people, and old-fashioned antibiotics that had been discontinued because of dangerous side-effects.

We can stop TB by improving the availability of good TB drugs, reducing the incidence of HIV/AIDS, or making poverty less common. Your money is well spent on any of those things.

This entry was inspired by James Nachtwey, and his TED Prize wish.

(Photo Credit: Saad Akhtar)

Things I believe in #40 – Oral Rehydration Salts

By Alanna Shaikh | | 1 Comments |

Eight ounces of clean water. One pinch of salt. One teaspoon of sugar. Mix well. Give it to your child who has diarrhea. Save her life. It doesn’t cure diarrhea, but it’ll prevent fatal dehydration until the illness passes.

It’s not a perfect solution. Not everyone has access to clean water. You need to have a clean container, too, and you need to be able to measure. And it’s not the best possible fluid for rehydration; it’s merely very good.

But it’s cheap and finding the water, the container, the sugar, and the salt is something almost everyone can do. It is something a mother or a father can do at home to heal their child. You don’t need a doctor, a hospital, an expert of any kind. Oral rehydration salts will not hurt a healthy child, and they won’t make a sick child sicker, even if they don’t heal. No one goes broke providing them, or ends up dependent on an expensive foreign-made drug.

To the parents of a sick child, oral rehydration salts are nothing short of miraculous.

Put the water in the glass first. Add the salt. Stir well. It should be no saltier than tears. Add the sugar. At least a teaspoon; more is okay. Help your little girl drink it.

There. You just performed a miracle, yourself.