Sirens and Lights

(1) I’m still sorting out the semantics of my reaction to the Samantha Power’s resignation from the Obama campaign, and more to my general weariness/wariness towards the way this race seems to be going these days. My siblings and I had a fairly intense discussion yesterday morning regarding the Democratic primaries and the danger of so much passion with its resultant polarization. This is, of course, not a new topic, but one that took on a little more reality to me when I saw a link to a Times blog discussing Power’s slip and the consequences (You can read the article for the full story.) . She, for those of you who haven’t heard of her, is someone who is actually really inspirational on her own, with her intelligence, boldness, principles and hard-work….not to mention incredible writing skill (please please go read A Problem from Hell: America and the Age of Genocide, if you haven’t) and passion. My reaction, quite honestly, was a mixture of sadness/foreboding combined with a somewhat paradoxical sense of relief. For as much as it concerns me that these kinds of comments appear to be spreading and kind of think Power is a good enough influence that she maybe shouldn’t have resigned, I really respect Obama for wanting to keep this a clean fight, and respect that he has supporters who believe in and abide by those principles. Everyone makes mistakes, especially passionate individuals, but that there are consequences (and discouragement of others following down the path) represents more to me that most of the increasingly suspect rhetoric that makes up the campaign season these days….

(2) I wrote a post a few years ago talking about a program in Brazil intended to incentivize keeping children in school and out of the labor force. A fellow Fogarty scholar emailed out a comment from The Lancet (a medical journal) discussing this type of program, Conditional Cash Transfers (CCT), which is described as:

During the past decade, countries with transitional and middle-income economies have introduced programmes that transfer money to poor households on the condition that they comply with a set of requirements, including attendance for health care, food and nutritional supplementation, and enrolment of children in school. Conditional cash transfer (CCT), a type of social contract, is both an alternative to more traditional social assistance with handouts and a complementary strategy to the provision of health and education services.1 Because poor families usually face the greatest barriers to health interventions, CCT helps to redistribute resources and thus reduces health inequities.2 For very poor families, cash provides emergency assistance, while the conditions promote longer-term investments in human capital.

The author goes on to discuss the numerous known benefits of programs such as this one, including evidence from a “systematic review of six CCT programmes in Latin America and Africa showed a fairly consistent picture of the effects of such programmes on the use of health-care and education programmes and, to some extent, growth and health outcomes for children early in life, despite some methodological concerns.”

The accompanying concerns are not too surprising, dealing with a need for a better understanding of which aspects of programs such as these (eg, health interventions, food supplements, and cash transfer) truly affect health-outcomes and the expense of programs such as these– particularly with regards to low-income countries for whom the program may not be cost-effective, let alone feasible without appropriate health and education services.

Conditional cash transfer: a magic bullet for health?
The Lancet 2008; 371:789-791
Kenji Shibuya

To go along with the article in NEJM about the cost of medications, another recent article in BBC looked at a study published in PLoS on the savings earned through willingness/ability to negotiate with drug companies in Brasil, a middle-income country with the somewhat unique strength of being capable of producing their own drugs locally in domestic laboratories. The study found that between 2001 and 2005, the Brasilian government saved over $1 billion and were able to reduce prices on 4 out of 6 antiretrovirals used to manage HIV. Unfortunately, the price of generic drugs produced in Brasil also rose during that time. Though the reasons for that are unclear, the government did acknowledge this by issuing a compulsory license for efavirenz and importing it from another country rather than producing it for a higher cost themselves. The article mentions concern that this will affect their bargaining power over prices from drug companies for drugs without generic forms, as it demonstrates reduced capacity to produce drugs themselves….but I think that this is a good decision for the moment. Much of the respect for this program comes from its focuses on increasing as much access as possible and acknowledging that there are cheaper alternatives even accounting for importation. And hopefully, someone will be moved to explore (and fix) the reasons for these higher prices.

It’s impressive (though it shouldn’t be) that Brasil continues to offer this type of support for affected individuals in the country, even as the number of people needing coverage (and therefore cost) has risen. Brasil’s infection rate is similar to ours in the U.S., and it says a lot about their [still expanding] program and commitment to fighting this disease. This “commitment” represents 2% of the government’s total health expenditure, and covers 180,000 of the 600,000 people with HIV (I’m not sure how many of the HIV+ people need treatment). These cost findings should be motivation to countries with similar resources, and hopefully offer a potential direction to other countries. As the article notes, and as is quoted below, the results of this policy indirectly extended to savings for many around the world in remarkable ways.

Brazil’s model has affected ARV prices around the globe. First, Brazil’s model set an important precedent for price negotiations and tiered pricing schemes for other developing countries. Second, Brazil’s treatment policies have helped create a market for generic ARVs; in turn, generic competition has facilitated Brazil’s price negotiations and lowered global ARV prices. Third, other countries have also used compulsory licenses in order to import drugs and reduce drug prices….Despite declining patented ARV prices, Brazil’s total HAART costs more than doubled since 2004. Cost increases reflect, in part, the progression of Brazil’s AIDS epidemic ten years after introduction of free and universal access to HAART: more people began treatment, the standard of care evolved, and new drugs became available for both treatment-naïve and treatment-experienced patients. However, the incongruous rise in costs from 2004 to 2005 warrants further scrutiny. Brazil faces rising costs for many locally produced generic ARVs, particularly AZT/3TC. Brazil’s AIDS treatment model nevertheless resulted in sustained lower prices for four of the six ARVs consuming the largest percentage of Brazil’s HAART budget, saving Brazil over US$1 billion from 2001 to 20

Background:

The World Health Organization (WHO) estimates that globally, 2 million AIDS patients in developing countries were receiving highly active antiretroviral therapy (HAART) in December of 2006, a more than five-fold increase since 2001. However, this number is only about 26% of the estimated 7.1 million people needing HAART.

Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment Nunn AS, Fonseca EM, Bastos FI, Gruskin S, Salomon JA PLoS Medicine Vol. 4, No. 11, e305 doi:10.1371/journal.pmed.0040305

Brazil´s issuing a compulsory license for AIDS drugs…..

The PACS in Rocinha

Festa Junina! Parties held during the months of June and July celebrating Sao Joao (St. John), essentially square dancing type parties with lots of traditional foods and people dressed like country folk.

View from the PACS building in Rocinha

Photos by Andre Cypriano

“Câmara aprova quebra de patentes de remédios contra a Aids”

One part of Brasil’s legislative body has approved breaking patents for AIDS medications…it now goes to the Senate and then to President Lula…but an exciting first step.

(It’s in Portuguese, sorry to all you non-Portuguese speakers.)

There are a few other interesting things going on in Brasil this week, including a march by the Landless People’s Movement…I’ll write more later, about both that and my work for the last few weeks. It’s amazing working out here and I’m excited for the next few weeks. I wrote out stories today, and as soon as I get them typed up, I’ll share them with you all!

Um mil beijos!

i don’t know how i missed this article before (probably since i was away at the time), but i somehow did. It’s on Brasil’s Family Grants program, which provides small rewards to families for keeping their children in school and attending regular check ups. It’s really an interesting story and tells a little about the various programs to reduce poverty across Latin America. I have to admit that it also resonated with me when i think of the situation in the U.S. and the belief that making people financially responsible for their own health is the only way to encourage people to maintain their health (e.g. have regular check ups)….i spent time last month lobbying at PA’s capitol building with some of my classmates to try to prevent Medicaid cuts, and we spent quite a bit of time discussing why that won’t work. This type of program, to me, seems like a much better idea. Of course, there are lots of differences between Brasil and the U.S. (such as health care, for many, not being affordable , let alone free, in the u.s.), but you get the idea…
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To Help Poor Be Pupils, Not Wage Earners, Brazil Pays Parents
By CELIA W. DUGGER
NYTimes January 3, 2004

Vandelson Andrade, 13, often used to skip school to work 12-hour days on the small, graceful fishing boats that sail from the picturesque harbor here. His meager earnings helped pay for rice and beans for his desperately poor family.
But this year he qualified for a small monthly cash payment from the government that his mother receives on the condition that he shows up in the classroom.

”I can’t skip school anymore,” said Vandelson, whose hand-me-down pants were so big that the crotch ended at his knees and the legs bunched up around his ankles. ”If I miss one more day, my mother won’t get the money.”

This year, Vandelson will finally pass the fourth grade on his third try — a small victory in a new breed of social program that is spreading swiftly across Latin America. It is a developing-country version of American welfare reform: to break the cycle of poverty, the government gives the poor small cash payments in exchange for keeping their children in school and taking them for regular medical checkups.

”I think these programs are as close as you can come to a magic bullet in development,” said Nancy Birdsall, president of the Center for Global Development, a nonprofit research group in Washington. ”They’re creating an incentive for families to invest in their own children’s futures. Every decade or so, we see something that can really make a difference, and this is one of those things.”

President Luiz Inácio Lula da Silva, a former factory worker who took office last January as a champion of the poor, is consolidating an array of cash transfer programs, sharply expanding his version of the model, named Family Grant, and tripling the average monthly benefit, to about $24.

By 2006, Family Grant will reach 11.4 million families — more than 45 million people, about a quarter of Brazil’s population. That would be by far the world’s largest such program. Ana Fonseca, the director — who reports directly to the president and his chief of staff — called Family Grant the payment of ”an old debt the country has to its poor citizens.”

Mr. da Silva’s moves are popular with constituencies that include the poor — a bedrock of his political base — as well as the World Bank and the Inter-American Development Bank, big supporters of the model, which are putting up $3 billion in loans for the program. Its total cost over the president’s four-year term will be close to $7 billion.

Its annual cost — about a third of 1 percent of Brazil’s gross domestic product — will be more than offset by savings Mr. da Silva’s administration has squeezed out of the civil service pension system, said Joachim Von Amsberg, the World Bank’s lead economist for Brazil.

But the program has also won wide public acceptance here, surviving from government to government in large part because it is not simply a handout.

……

The spread of this approach across Latin America has been fueled by impressive results from a raft of studies — in Nicaragua, Honduras and, most influentially, Mexico, whose program now reaches more than 20 million people.

The rigorous Mexico evaluation, conducted by the Washington-based International Food Policy Research Institute, found that the children who took part were healthier and better nourished and stayed in school longer than those in a control group.

Poor Brazilians, in recent interviews, made clear that the bits of money that seem trivial by rich-country standards loom large for families living, as millions here do, on less than a dollar per person a day.

From a sprawling favela built on the sand dunes of this seaside city by the poor from the parched rural interior, people said the government money paid for beans, rice, carrots, potatoes, eggs, mangoes, cooking oil, haircuts and school supplies.

Children whose families get the grants say the fear of losing the money makes them more serious about school. Most still have jobs, too, but outside school hours.
….

(there’s more to the article, including personal stories, but i edited for lack of room)

explanations to follow later… for now, translating lots of things (which is what I’ve been doing all day even while in Rocinha, so i’m exhausted.)

A quote from a patient in Rocinha to the community health workers:

I can die by the bullet, but I will never die by TB because you come here

My research project for the summer, since some of you have been asking, concerns the role of community health workers in community and city health services in Rio de Janeiro, particularly as related to TB treatment and prevention. I’m conducting my research in two regions of Rio: (1) Rocinha, which is supposedly South America’s largest slum (favela, in Portuguese); and (2) the northern zone of the city, which has recently established its community health agents program. My work in Brasil is being funded by the Center for TB Research and by PSU Med’s Medical Student Research International Award.

Our apartment in Copacabana…. there are three of us living here for the next month, two Hopkins PhD students and me, all working for the Center for TB Research.

Oi! just wanted to say hello and that i’ve arrived :). all is going very well, and I’m currently enjoying absolutely stunning weather…

ok, off to go explore for a bit and hunt down some pao de queijo. life isn’t complete without pao de queijo :).

beijos from brasil!

where are you? what did you end up deciding about
life, dreams, everything?

I had to laugh when I got this email from a good friend from the early Watson days in Geneva. What have I decided about life, dreams, everything? I’ve had a year to think, and today marks the last day of my Watson. As of 10 pm tonight, I’ll say goodbye to Rio and to the Watson life–and as hard as it is for me to imagine being anywhere but Brasil right now, I know that reality is lurking just a short plane ride away.

If there’s one lesson I’ve learned this year, it’s been about maintaining a bit of perspective- about life, about my dreams, about my accomplishments and failures… and mostly, about accepting and embracing the uncertainty of where the days and years ahead are going to take me, and taking steps with sureness and certainty as best as I can. I realize that it was a lot to expect from this year, but I think that at some point I had unfairly thought that I would find answers for all of the questions I’ve had for my future. Despite a year of introspection and exploration, (obviously) there are many unanswered questions still swirling in my mind, and a fair share of doubts as well. I have to admit that at first I felt a bit of panic as I watched the end of the year approaching….but as the Watson year winds down, I feel like I may have found the answer that I needed most.

I began this year hoping to map out my future, to find my inspiration and motivation–who I want to be and where and how and all. At the end of 3 months in Geneva, though, I realized that my biggest fear was cutting off my options for the future, of tying myself down to one place at a high cost for the next four year; my greatest fear became about losing my freedom. As I’ve moved through this year (and especially through the hair-raising traffic in India), though, finding new mentors and ”dream lives” along the way, I think I’ve realized that no matter what I want and my worrying over finding the perfect path to my future or losing my freedom, there’s only so much of my life that I can control to begin with. The decisions I am and will be making for the next few years are important ones, but I’m realizing how much they are simply a framework for my life, not the actual substance of my world. I don’t have to set everything up perfectly–I just need to set up this structure and then let life and my experiences take me from here. In short, I’m letting go a little, to preserve my freedom, to let myself fill in the blanks as the opportunities come along….I’m more certain that ever that I’ll find my happiness better that way than I ever would on an all out mission!

And so…..I guess what I’ve decided about life, my dreams and everything is that I can’t keep thinking about them…I just need to live them and learn my lessons that way. As much as I’ve adored this year and have been really struggling with the idea of letting go of it, I know that this is where I need to be going right now, towards reality and, oddly enough, home.

(ha…and if all else fails, well, my ticket home is a return ticket to Brasil since it was cheaper :P….)

Thank you to all you who helped me through my Watson: those of you who have served as psychotherapists and guidance counsellors on the road and via email, as tour guides, friends, hosts, neighbors, surrogate parents and siblings, mentors, teachers, patients, benefactors, and, above all, as inspiration. If there’s one thing I’ve done a lot of this year, it’s been asking question. Your lives and words have provided me with so many answers this year, and as I’ve continued to come up with new questions (or am still asking some of the old ones!) I am certain that they’ll find a role in my decisions in the years to come… :-).

brasilian hip hop (went to the best concert last night!)
tender coconut water
anything passion fruit
forró
umbu, cajá, and guava juice (separately)
pão de queijo (cheese puff thing…)
portuguese expressions– fala serio, cara!
romeu e julieta–not the shakespeare, but the combination of guava jelly-type stuff and cheese!
brasilian pizza–with ketchup of course!
palmito (palm hearts)

ah, way too much more….*sigh* this is going to be a hard goodbye….
well…. it’s sunny so I’m out to spend my last day in Rio shopping and sunning on the beach before it rains!

Beijão

I’m heading home on Thursday….and before you ask, I’m just not thinking about it :-P. The last 3 weeks have been incredible…dancing forro ’til dawn in Salvador, hiking,camping and star gazing in beautiful Chapada Diamantina National Park, chilling (and more forro!) on the beach island of Morro do Sao Paulo, and being reminded to just slooooow down in the interior town of Valente (and a drag forro competition….unforgettable and completely priceless as far as memories go!)…then wandering the windy streets of Olinda before returning to Rio! Spent the last four days in the jungly beachy island of Ilha Grande, exploring colonial Paraty and partying and shopping with the last of my Watson money here in Rio… I miss you all and am looking forward to seeing you all again, but it’s weird thinking of this year ending, and my life picking up again where it left off, with the beginnings of med school and all….

See you soon.

Finally bought a plane ticket home! July 22nd, it is See you all then….

Article from the New York Times

Everytime I think that I´ve learned as much as I´m going to learn about EM in Brasil, something else surprises me. The problem with researching the development of a specialty in a country this large is that sometimes even people within a country aren´t aware of the efforts going on just a few hundred miles north of them…and so I´ve started to feel a bit like the country is made up of bits and pieces that should fit together relatively well, if only they knew where the others were, or even that they’re parts of a greater effort. After 3 months of visiting hospitals and talking to various societies involved in EM development (in Rio, Porto Alegre, Curitiba, Campinas, Sao Paulo), I finally met a doctor today who told me point blank they think that they´ll organize a specialty here within a year…. surprising after 3 months of being told that EM will take about 10 years to develop, will take forever to develop, will never develop. Technically, they´ve already gotten approval from the AMB (the Brazilian Medical Association), step one of three involved in setting up a specialty. Yet, depending on who you ask, this step is a false one– a poorly set up move done to keep EM under the guard of Internal Medicine. It´ll be interesting to see who ends up correct. In the meantime, I´ve been doing my part, collecting email addresses and phone numbers of those interested in the development of EM in Brasil and trying to put them all in touch with one another.

The research is actually going much better here than it did in any other country I´ve been to this year. I spent a decent amount of time in the trauma bays and ERs of the hospitals in Campinas and Porto Alegre, and was able to tour and observe a bit in Rio, Curitiba and Sao Paulo. In Campinas, I spent a day shadowing the SAMU ambulance service on its rounds and then spent a day with the second year med students, who were coincidentally in the middle on learning about pre-hospital services in their city. Consisted of 6 stations set up with various parts of the system– the ambulance service on the highways (www.autoban.com.br), the regular ambulance service, the firefighters (they provide first response services here in Brasil), different doctors and paramedics involved, and a really gory slideshow of the ´´best ever´´ of the Autoban rescue services. I´ve seen a lot of interesting things this year, but that may have won the award for most shocking 15 minutes of my life !

That´s the other interesting part- as doctors work on ambulances here, I wonder if there may be more room for the development of a specialty for ambulance doctors, even if it´s difficult to organize a specialty within the hospital. There is already a residency in EM here in Porto Alegre, even though there is no specialty for these physicians to work in….and I feel like there might be a home here. I´m not sure if it´s what they want, but, maybe it´ll be a start….then again, maybe there´ll be a specialty in a year. Who knows.

Anyway, off to buy a plane ticket home…eek.