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Global Medicine

6

April 2009 – official IFMSA-NL magazine on

global health – distributed free of charge – www.globalmedicine.nl

Global Medicine

Why polio is eliminated and malaria eradication failed 6 Cholera in Zimbabwe Symptoms of Zimbabwe's sick economy and sick politics 24 IAVI The struggle of developing an HIV vaccine 28 Eradication & elimination


Global Medicine 6 6

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Eradication and elimination

Global Medicine regulars gm news

column

Sudan expells NGOs

Female Husband

Leishmaniasis 4

14

Editorial

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Sick of pesticides

The Global Medicine Weekends have already become a tradition. We retreat for two days, first the editors, a few weeks later the layout team. A local network and as many laptops as team members present form the centre of action. We create a huge page flow on an empty wall that, throughout the weekend, fills up with coloured papers, comments, ideas, tasks lists and shiny Christmas decorations. We lose ourselves in defining the difference between conditions and criteria (page 6) or discussing the attractiveness of warm black versus cold black (page 18-19). Increasing excitement compensates for tiredness. We’re creating a magazine! Suddenly, one of us gasps. Is life expectancy in Zimbabwe really that


Global Medicine is the official IFMSA-NL magazine and is published three times a year. Contact us at editor@globalmedicine.nl. Full references for all articles available online at www.globalmedicine.nl. Find the small print on page 35.

Should we mind the gap?

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Cholera in Zimbabwe

24

Development of an HIV vaccine

28

studying medicine in..

gm photo gallery Nutrition and health

Skopje, Macedonia

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low? Zimbabwe used to have one of the better health care systems in Southern Africa. Life expectancy at birth declined from 60 years in 1990 to the lowest in the world in 2006. The reason? A complex combination of political, social, economical, medical and other factors. Jolanda Naafs explores some of them in an Opinion article that triggered discussion already before publication (page 24). Welcome to Global Medicine 6. Glance through it, read, get excited, and gasp. Share your opinion on Zimbabwe or any other article through the Readers’ Responses page on www.globalmedicine.nl. We look forward to hearing from you. Emmaline Brouwer, editor in chief


GMNews

people living with tuberculosis

14 052 000

150 000

deaths occur in low-income countries each year due to climate change

Research Does substance abuse induce TB? In a large study in the United States, almost 20% of tuberculosis patients reported drug or alcohol abuse. The disease was more contagious in substance abusers and remained contagious for a longer period than in non abusers. One third of the world population is infected with the bacterium that causes TB. Only a small proportion of them ever develop the disease. But the effect of substance abuse on the body may raise the chances that the latent infection turns into active disease. Substance abusers have less access to routine medical care, therefore may be less likely to be screened for TB and to obtain and finish treatment. The researchers conclude that substance abusers form an important but complex target population in TB control programmes. JS

MORE dengue DUE TO CLIMATE CHANGE

Malaria vaccine: promising developments

Increased temperature and rainfall are associated with increased dengue transmission. This was demonstrated in Puerto Rico in a study using 20 years of data about seasonal variability and occurrence of dengue fever. The Aedes aegypti mosquito is proven sensitive to changes in environment. This relationship is consistent with laboratory studies of the impacts of climate factors on vector survival and viral replication, but was never studied in real-life situations. The results predict increased incidence and spreading of dengue fever by global warming in the next decades. JS

A recent publication in the New England Journal of Medicine revealed that the world’s most advanced malaria vaccine candidate gives children significant protection against malaria. Two separate randomized double-blind phase II trials, conducted in Kenya and Tanzania, showed that in children aged 5 to 17 months, the candidate vaccine RTS,S/AS01 reduced the risk of clinical episodes of malaria with 53% over an eight month follow-up period. The data have shown that the vaccine candidate can be administered as part of existing national immunization programmes. These studies open the promising way to a large scale phase III efficacy trial involving 16 000 children in 11 centres in Africa, now awaiting approval by national regulatory agencies. Research & Development of these and other malaria vaccine candidates are supported by the PATH Malaria Vaccine Initiative (MVI), a global programme established through an initial grant from the Bill & Melinda Gates Foundation. JS Read more on global vaccine initiatives in our IAVI series, starting this issue from page 28.

The Neglected Disease instalment in Global Medicine 5 (December 2008) covered Dengue. Read it at www.globalmedicine.nl.


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1 in 22

international staff of MSF were abducted in Darfur, Sudan

women in Sub-Saharan Africa will die because of pregnancy related causes

Health policy

5

UNICEF: REPORT ON THE STATE OF the WORLD'S CHILDREN

Sudan expels NGOs

Ireland where the risk was one in 47 600. The UN has called for a 75% reduction in the maternal and child mortality rate by 2015 as part the Millennium Development Goals. Since 1990, progress has been made in reducing child mortality, but the number of maternal deaths has remained largely unchanged. UNICEF says many of the deaths could be reduced by improving family planning and post-natal care and ensuring that trained medical personnel were on hand for deliveries. Conflicts and political crises, however, have made it more difficult to tackle the problem. JS

References   Tuberculosis: CDC Journal, Archives of Internal Medicine, January 2009   Malaria vaccine: N Engl Med, Biovalley Basel, January 2009   Climate change: Johansson MA et al., Local and Global Effects of Climate on Dengue Transmission in Puerto Rico. PLoS Negl Trop Dis 3(2) 2009   NGOs in Sudan: http://www.globalhealth.org/news/article/10849   UNICEF, The state of the world’s children, January 2009

Global Medicine 6 – April 2009

In response to the International Criminal Court’s issuance of an arrest warrant for Sudan’s president on 4 March, 2009, the Sudanese government has expelled 13 international organizations conducting critical work to address the critical health and humanitarian needs in Sudan. The warrant calls for the arrest of President Omar al-Bashir, depicted above, on charges of war crimes and crimes against humanity in Sudan’s Darfur region. The organizations ordered out of the country include CARE International, Save the Children, the French and Dutch branches of Doctors without Borders, Oxfam GB and others. UN officials have said that about 76 international groups had been operating in Darfur. UN Secretary-General Ban Ki-moon has urged the Sudanese government to reverse the decision. EB

A global effort to reduce deaths during pregnancy and childbirth is likely to fail unless action is taken to improve health care in the developing world, the United Nations Children's Fund concluded in their recently released report, The State of the World's Children 2009. More than half a million expectant and new mothers die each year, most in Africa and Asia where obstetrical and post-natal care is often unavailable and many pregnancies are complicated by HIV. According to ­UNICEF, the riskiest place to give birth in 2008 was Niger, where the lifetime chance to die in labour is one in seven. The safest place was


Elimination and eradication of diseases What can be learned from previous eradication and elimination programmes? Marjolijn Paauwe Introduction Elimination and eradication have been an important subject of public health research, projects and initiatives for more than a century. Although eradication of malaria, yaws and yellow fever in early years failed, the results of these campaigns contributed greatly to a better understanding of the social, biological, political and economic factors concerning disease control. Previous programmes led to a list of determinants of success or failure for upcoming disease eradication and elimination programmes. At the moment, smallpox has been eradicated and programmes to eradicate poliomyelitis and dracunculiasis (guinea worm disease) are be-

ing developed. Five diseases are proposed for eradication by the International Task Force for Disease Eradication and several other diseases have already been eliminated from parts of the world or are currently being targeted for regional or sub-regional elimination.

Eradication In theory, if the right tools were available, all infectious diseases would be eradicable. However, there are several biological features of infectious diseases and technical factors that strongly limit their potential eradication. Three criteria are considered to be essential for eradication:

$/ Ghana

23 008 000 inhabitants

$ 1 240

income per year

1. A n effective intervention must be available to interrupt transmission of the ­disease. 2. Practical diagnostic tools with sufficient sensitivity and specificity must be available to detect levels of infection that can lead to transmission. 3. Humans must be the only host of the agent. Animal reservoirs significantly complicate the eradication process. Considering the biological criteria is only one step in the decision to embark upon an elimination or eradication programme. Health resources are limited, so an evaluation of the costs and benefits of eradication is required. It is crucial to create societal and

$ ♂ 56yrs ♀ 58yrs life expectancy

6.2%

of GDP for health

/ 0.2

doctors/1000 people


Smallpox political commitment to the eradication of the disease. Therefore, besides economic considerations, social and political circumstances should be taken into account. Finally, the intervention should be technically feasible and an eradication strategy should be identified.

Smallpox was one of the most devastating diseases known to humanity. Before an effective treatment was developed, the disease killed as many as 30% of those infected. Between 65 and 80% of the survivors were marked with deep pitted scars (pockmarks), most prominent on the face. An important discovery was made by Edward Jenner in 1798, who demonstrated that inoculation with cowpox could protect against smallpox. The eradication programme that followed was very successful and smallpox was pushed back to the horn of Africa and then to a single last natural case in Somalia, 1977.

ďƒź

SUCCESSFULLY ERADICATED

Lessons from the past The eradication campaigns of yaws and malaria failed at the same time. Both campaigns began around 1955 and were terminated around 1970. It was the introduction of a new technology that triggered the launch of both programmes. For the treatment of yaws, this was a single-dose injection of long-acting penicillin and for malaria it involved the availability of large quantities of the inexpensive insecticide DDT. Surprisingly, neither campaign was based on pilot programmes to demonstrate the feasibility of eradication, given the tools and resources available. If they had, probably none of the programmes would have been started.

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The strategy of the yaws eradication programme was based on the screening of patients with clinical disease and treatment with penicillin. Besides having failed to validate the strategy in pilot studies, the programme had two evident deficiencies. First, there was no surveillance, so it has never become clear what was actually happening. Secondly, there was no research programme, which might have demonstrated the futility of this programme far earlier. Of these two programmes, the attempt to eradicate malaria was the most important

Elimination versus eradication

The malaria eradication programme failed. Lessons learnt from the programme, however, were very important in designing the smallpox eradication strategy. This programme

Global Medicine 6 – April 2009

Eradication entails the permanent reduction of the worldwide prevalence of a disease to zero. Smallpox is the only example of an eradicated disease. In this case, intervention measures are no longer needed. Eradication is sometimes confused with elimination, which is defined as the reduction of prevalence of a disease in a defined area to zero or the reduction of global prevalence to a negligible amount. Poliomyelitis and measles are examples of eliminated infections. To prevent re-establishment of transmission, continued measures are required.

and expensive. During its 15 years of existence, it accounted for more than one-third of the World Health Organization’s total expenditures and dominated the international health agenda worldwide. Three main points that contributed to the failure of the malaria programme can be recognized. First, the malaria service functioned as an independent, autonomous entity with its own personnel and its own pay scales. The community was not involved in the programme. Second, the programme was conceived and executed as a military operation to be conducted in an identical way whatever the battlefield. All programmes were obliged to adhere rigidly to a highly detailed manual, without adapting to local circumstances. Finally, research was considered unnecessary and was rigorously erased from the original programme.


Poliomyelitis ERADICATION EXPECTED

Poliomyelitis (polio) is a highly infectious disease caused by a virus. It invades the nervous system and leads to irreversible paralysis in one in two hundred infections, usually in the legs. Polio mainly affects children under the age of three. Humans become infected by faecal-oral contamination. Eradication started in 1988, when the WHO voted to launch a global target to eradicate polio. At that moment, wild poliovirus was endemic in more than 125 countries on five continents, paralyzing more than 1 000 children every day. As a result of the Global Polio Eradication Initiative, by the end of 2006, only four countries remained endemic (Nigeria, India, Pakistan and Afghanistan) and less than 2 000 cases are reported globally each year.

had to be organized differently. It was not politically acceptable nor financially possible to let the programme function as an independent, autonomous entity. The programme necessarily had to run within existing health services. This proved advantageous! With proper direction and motivation, health personnel performed well. Besides that, research initiatives were encouraged at every level. In this way, the programme was under constant evaluation to enhance its effectiveness and efficiency. Without all these research initiatives, it is unlikely that eradication of smallpox would have succeeded.

Determinants of success or failure Based on lessons from the past, the US Centres for Disease Control and prevention (CDC) formulated a list of factors that determine success or failure of an eradication programme.

The major issues are listed below.    A good surveillance system and a sensitive response mechanism are essential to monitor progress, detect epidemics and programme deficiencies, and take remedial action.    Research in advance is needed to provide the scientific basis upon which to make programme adjustments.    Both political will and commitment are essential.    Basic training and continuing education at all levels are crucial, and supervision

Endemic countries Countries with imported poliomyelitis Distribution of polio viruses in November 2008. Data adapted from WHO.

should be seen as a part of the educational process.    Community participation and coordinated national and international action are required to avoid duplication of effort and to maximize impact.

In the future… The International Task Force for Disease Eradication considers the following diseases as suitable for eradication: poliomyelitis, dracunculiasis, lymphatic filariasis, measles, mumps, rubella and taeniasis (also known as

Ashanti Duinmaijer is currently living in Taha (village in the Northern Region of Ghana) and working for the Guinea Worm Eradication programme by the Ghana Health Service

My experience with guinea worm eradication is that changing people's behaviour and attitude is very difficult. A woman, suspected from carrying guinea worm disease, in my village Taha went to get water despite telling her multiple times that it was absolutely prohibited to enter the water! But what else can be expected of a woman who can not see or feel a worm and who desperately needs water in her household?!


Guinea worm disease Dracunculiasis or guinea worm disease is a disease caused by the parasitic worm Dracunculus medinensis. The parasite causes dreadful suffering and disability among the world’s most deprived people. Currently there are no drugs available to cure or heal this infection. However, dracunculiasis is relatively easy to combat because of the exclusive relation with unsafe drinking water. Eradication efforts have been based on making drinking water supplies safer and on educating people on safe drinking water practices. These strategies proved successful: in 1986 the global incidence was approximately 3.5 million which has reduced to 9 838 cases in 2007. Only five countries – Sudan, Ghana, Mali, Nigeria and Niger – are still endemic.

To assess if diseases are eradicable it is important to research the biological, economic, social and political characteristics. Before starting a new eradication or elimination programme, it is very important to analyze previous programmes. Lessons from the past can help us make eradication or elimination of diseases successful.

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About the author cysticercosis or pork tapeworm). This task force also formulated a list of diseases of which some aspects could be eliminated, for example the vector-borne transmission of American trypanosomiasis (Chagas disease). Examples of diseases that are not eradicable at all are African trypanosomiasis, buruli ulcer, amebiasis and bartonellosis.

Conclusion Eradication of yaws, malaria and yellow fever failed. Smallpox has been eradicated since 1980. Eradication of poliomyelitis and dracunculiasis is expected soon. According to the International Task Force for Disease Eradication, lymphatic filariasis, measles, mumps, rubella and taeniasis are candidates for eradication as well.

Yaws

Further reading   Morbidity and Mortality Report (MMWR), December 31, 1999 / Vol. 48 / Supplement, Centers of Disease Control and Prevention (CDC).   International Task Force for Disease Eradication, The Carter Center, Disease candidates for eradication and elimination.

ERADICATION FAILED

Global Medicine 6 – April 2009

Yaws is a chronic infection that mainly affects the skin, bone and cartilage. The disease is rarely fatal but can lead to chronic disfigurement and disability. A single lesion develops at the point of entry of the bacterium Treponema pertenue and without treatment will lead to multiple lesions all over the body. Yaws is transmitted through direct skin contact with an infected person and can be treated with a single injection of the long-acting Benzathine penicillin. Despite the eradication programme between 1950 and 1970, the prevalence was estimated to be 2.5 million in 1990. Unfortunately, the prevalence today is not known because there is no official notification of the disease globally. There are unconfirmed reports that yaws is still present in some countries: new cases are reported and it looks as if the disease starts to come back.

Marjolijn Paauwe is a fifth year medical student from Amsterdam. She is currently enrolled in a course on International Development Studies.


Leishmaniasis A neglected disease

Rik Viergever, Katrina Perehudoff, Maaike Esselink, Dorota Sienkiewicz, Bindiya Mohabier Panday On 23 September, 2005 the Dutch secretary of Defence reports to Parliament: Early this September the skin disease cutaneous leishmaniasis was diagnosed at the Amsterdam Medical Centre among four soldiers of the battalion that was stationed in Mazar-e-Sharif in Afghanistan. In the past two weeks, about ninety Dutch soldiers who were involved in the establishment of the compound or who provided support for Parliament elections in Afghanistan, as well as several journalists that visited Mazar-e-Sharif, have been diagnosed with this disease. This Global Medicine’s Neglected Disease is leishmaniasis, also known as Orient boil, kala-azar or sandfly disease. It is a tropical disease, caused by intracellular protozoan parasites transmitted by the sandfly, often resulting in horrible disfigurements or even death. Leishmaniasis typology There are three types of leishmaniasis. The first and the most common type is cutaneous leishmaniasis that creates an open sore and subsequent skin lesion at the site of the sandfly bite. Patients recover spontaneously from the lesion. However, an unsightly scar

remains at the site of infection and people often suffer from psychologically destructive stigma. Mucocutaneous leishmaniasis is characterized by partial or complete destructive, irreversible lesions of the mouth, nose, and throat cavities. Although the disease is serious, less

$/ Afghanistan

26 088 000 inhabitants

$ 800

income per year

than 5% of cases are fatal. The third type is visceral leishmaniasis or ­kala-azar (black fever). This is the most serious type, in which internal organs are infected and over time fever, diarrhoea, lower immune status, severe bleeding, inflamed and enlarged liver and spleen or anaemia occur.

$ ♂ 42yrs ♀ 43yrs life expectancy

5.2%

of GDP for health

/ 0.2

doctors/1000 people


In the medical field, visceral leishmaniasis is one of the notorious causes of markedly enlarged spleen, which may become larger even than the liver. Untreated visceral leishmaniasis results in death within two years after initial infection. There are more than 20 species of Leishmania parasites that infect humans. Different species are endemic in different regions of the world. Also, the species determines which symptoms a patient will present with. Immunity for that species is often acquired after infection with a species of Leishmania.

Transmission

Epidemiology Poverty, famine and mass population movement have led to a tremendous increase in leishmaniasis incidences in the last decennia. The majority of new cases are unreported or undiagnosed and thus the magnitude of leishmaniasis is greatly underestimated. Official data only report 600 000 annual infections. However, the World Health Organization (WHO) estimates 2 million new cases annually, which adds to the world wide prevalence of 12 million cases. Leishmaniasis has been reported in 88 countries worldwide. Figures on the next page present the global distribution of cutaneous and visceral leishmaniasis.

lymph node aspirates. Other diagnostic tools such as PCR, ELISA or immunoblotting can be used, but are usually unavailable in most endemic areas. Finally, a leishmaniasis skin test (Montenegro test) comparable to the Mantoux test for tuberculosis, is available. It becomes positive three months after initial infection and remains positive for life.

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Treatment Reasonably effective cures are available for the treatment of leishmaniasis. Cutaneous leishmaniasis is often self-limiting. Treatment is indicated to prevent scarring and progression to mucocutaneous infection. When risk for mucosal spread is low, topical treatment (antimony compounds or paromomycin) can be used.

Diagnosis In the case of cutaneous and mucocutaneous leishmaniasis, diagnosis is usually based on the appearance of the lesion(s). Microscopy of the parasite in Giemsa stain may reveal the parasites in up to 70% of patients. Culture is also an option, but problematic due to the scantness of organisms. Diagnosis for visceral leishmaniasis is made by observing the parasites in a Giemsa stain or growing culture of bone marrow, splenic, hepatic, or

Global Medicine presents Neglected Diseases About one billion people in the world are affected by one or more neglected tropical diseases (NTDs). Neglected, because these diseases persist exclusively in the poorest and the most marginalized communities, and have been largely eliminated and thus forgotten in wealthier places. www.who.int/neglected_diseases This is the second article in a series on neglected diseases. For more information, check www.globalmedicine.nl.

Global Medicine 6 – April 2009

The Leishmania parasite is transmitted by the bite of a tiny insect (so small it can fly right through malaria preventing bed nets): the sandfly. If a female feeds on an infected host, the parasite is ingested with the blood. The parasite enters a human or other mammalian host through the consecutive bite of the sandfly. Inside the host, the parasite invades the host’s macrophages, multiplies and eventually kills the host cells. Leishmaniasis symptoms manifest from this cell loss as epidermal skin damage, damaged red blood cells leading to anaemia, and destroyed T-cells resulting in lowered immune status. There are only a few Leishmania species for which humans can function as a reservoir.

Pet dogs are the most common and problematic reservoir in developing countries.


informing the host about disease symptoms and about how to avoid transmission. Something as simple as sleeping in beds at least one meter above the ground is a promising strategy to reduce night-time sandfly bites.

Cutaneous leishmaniasis

Distribution of cutaneous and visceral leishmaniasis

Visceral leishmaniasis

Leishmaniasis is mainly prevalent in Latin America, Northern Africa, the Middle East, and Southern parts of Europe. Data adapted from WHO: www.who.int/leishmaniasis

With more invasive lesions or mucosal involvement, as well as for visceral leishmaniasis, systemic therapy is indicated. Two recently developed drugs, miltefosine and paromomycin, show promising results. As an appurtenant benefit they are both relatively inexpensive.

Risk factors and prevention Several factors contribute to the current spread of leishmaniasis. Here below, the most important ones are mentioned as well as concomitant possibilities for prevention. Poverty Lack of money for appropriate diagnosis or treatment greatly contributes to the burden

of disease in developing countries. Poverty also relates to all other risk factors mentioned below, therefore it is a large contributor to the causes of the disease. Impaired host health Malnutrition is a well-known risk factor for leishmaniasis. Impaired host health due to for example disasters and mass population movement increases susceptibility. Co-infection with HIV is also common. Education Knowledge to identify symptoms and prevent transmission is lacking, especially in illiterate populations. Educational interventions prevent leishmaniasis infections by

Environment Rural areas with lack of proper sanitation and with widespread deforestation provide the sandfly with an ideal breeding ground. Nowadays however, urban outbreaks of leishmaniasis are also common. Large numbers of individuals are at risk of infection because they live in densely populated urban areas and are in close contact with rural migrants carrying the causative parasite. Environmental interventions include the elimination of random garbage and animal burrows which greatly reduce the sandfly population. Also, sandflies feed on plants. The paper flower damages the Leishmania protozoa in the sandfly’s gut. This permanently impairs the transmission of leishmaniasis from sandfly to human or other hosts. Immediately after taking a blood meal, sandflies cannot fly away and rest on house walls. Insecticides sprayed on the interior and exterior walls of houses reduce the number of sandflies and subsequent infection rates. In addition, even though the sandfly flies right through malaria preventing mosquito nets, insecticide-impregnated bed nets may reduce transmission.


Animal reservoirs As dogs are the most common and most problematic reservoir, animals with apparent leishmaniasis infection should be culled. Dogs that do not show any visible signs of infection might be fitted with an insecticideimpregnated dog collar to deter future sandfly bites.

Conclusions Leishmaniasis symptoms range from selflimiting single cutaneous laesions to potentially horrible disfigurements and possible death. Treatment and accurate diagnosis is possible, but often not available. Many factors, almost all related to underdevelopment, contribute to the heavy burden of disease of leishmaniasis.

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About the author All authors are enrolled in the Master of Science programme on International Public Health at the Vrije Universiteit Amsterdam.

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Further reading:   WHO (2007). Leishmaniasis: Burden of disease, magnitude of the problem.   WHO (2007). Parasitic and Neglected Diseases: The PAHO Regional Program.   Emedicine: Leishmaniasis, by Renee Y Hsia, MD, MSc. Last Updated: Mar 31, 2008.

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Column

Female husband Loes Magnin I’m on my way to visit a traditional shrine in Ghana, WestAfrica. The village I arrive at is a bustling African hotspot. Women in brightly coloured dresses balance enormous bowls of food on their heads; men are playing checkers; people are sitting on the streets, talking, negotiating, cooking or doing nothing. There's loud music on every side of the street. I can smell the familiar mix of charcoal and sweat which reaches my nose by a hot breeze, while the daylight is its typical African yellowish-blue. I mean: how could I not love this? My Ghanaian friend Alice calls me from the other side of the street. She’s sitting on the pavement with a couple of her friends, and they are involved in a very serious game of… Ludo. They are extremely fanatic about this game. (Okay. I admit. When the ladies invited me to play with them I soon became as fanatic as they were. I clapped high fives in the air when I beat somebody; theatrically cried when somebody beat me; we bursted out laughing when somebody was playing tactics. Yes. I am still talking about a game of Ludo.)

I love this about travelling; wherever you go: girltalk is girltalk! One of the women heard that in Holland it is possible for a man and woman to live together as a couple without being married. For a little dramatic effect, I tell the girls that since a few years women can even marry women and men can marry men in Holland. Dramatic effect: 100%. They are absolutely shocked.

The ladies are hungry so we invite one of the women with an enormous bowl of snotty cooked okra (yuk!) on her head to sell us some. Our conversation quickly moves towards boysand-girls.

Loes Magnin studied Communication and Literature in Amsterdam and wrote her thesis on development aid dilemmas in Southern Africa. She worked as a travel guide and took dance classes in different African countries.

One of the girls is a shy, silent, young Ghanaian, who so far hasn't said much to me. But when hearing about this novelty – marrying a woman! – she reacts very pleasantly surprised; she says it would feel like paradise to her not to have to sleep with a man any more. My stomach hurts when I hear her say that. There is still a lot to do in Ghana for women’s sexual freedom. After our snotty-okra-diner we continue our game of fanatic Ludo, but the shy girl is absent minded. As the other ladies tell her off for not playing properly she looks at me with a very serious gaze: Lucy, she says, next time you come to Ghana, will you bring me back one of those female husbands?


Sick of pesticides S. Katrina Perehudoff & Genon Jensen, Health & Environment Alliance (HEAL) An estimated 26 million Europeans are diagnosed with cancer each year. A recent Impact Assessment commissioned by the European Parliament estimates that one percent – annually 26 000 cases – could be attributed to pesticides in our environment. And for some cancers this percentage could be even higher. Pesticides are also a leading culprit in other diseases including Parkinson’s disease. The association is so common that Parkinson’s

disease is now recognized as an occupational disease by a French health insurance agency. Fortunately, many pesticides are non-essential components of our current farming practices and food production schemes. Alternatives to the implicated chemicals do exist. European Parliamentarians voted on 13 January, 2009 to tighten rules on pesticides and phase-out those associated with cancer,

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reproductive problems and other health disorders. The newly approved European Union pesticides reform also includes a severe restriction of pesticide use in public areas.

More than 50% of food products in Europe contain pesticide residues

Global Medicine 6 – April 2009


The Health & Environment Alliance (HEAL), an international non-governmental organization based in Brussels, has launched a Sick of Pesticides campaign Europe-wide to raise awareness for pesticide hazards and the action needed at national level to safeguard health. It aims to involve both health professionals and the wider health community in the pesticides debate. It focuses on pesticides reform as an opportunity to achieve healthier food supplies, safer occupational health and protected public places, particularly for children.

our internal regulatory systems, disrupt normal development and reproductive process and may produce related cancers. Children’s and pregnant women’s exposure to pesticides has been positively associated with cancers both in childhood and in adult life.

Healthier food supply

Safer occupational health

Currently, more than 50% of food products in Europe contain pesticide residues, and 5% of these residues exceed the acceptable safe limit. As a result, children eating a conventional diet are found to have pesticides in their bodies exceeding acceptable levels. Pesticides can accumulate in our bodies over time and act in concert with other chemicals or conditions to play a role in many diseases. The ingredients of some pesticides can mimic the hormones in our bodies that naturally signal human development, such as the onset of puberty. These endocrine disruptors hijack

Much of Europe’s landscape is dominated by agriculture. As a result, many Europeans live and work in close proximity to farms or agroindustrial developments placing these people in routine contact with pesticides. Numerous epidemiological studies show that farmers, agricultural workers and their children are at higher risk of incurring health problems due to long-term exposure to pesticides. These health problems include leukaemia, multiple myeloma, brain tumours, prostate cancer and impaired immune system function.

The new EU pesticides legislation includes a ban on pesticides that are known to cause cancer, genetic mutations or to be toxic to reproduction. By removing these harmful chemicals from food production, one common route of human exposure is eliminated.

$/ European Union

500 000 000 inhabitants

$ 29 900

income per year

Up to one in six children grow up with a developmental disorder that can be attributed to industrial chemicals

A number of studies have found the risk of childhood cancers to be higher among the children of workers in agriculture and children living on farms, with a strong association for childhood brain tumours. Moreover, studies of children diagnosed with autism found a significant association between their mother’s residential distance from sites of agricultural pesticide application and the stage of gestation at the time of pesticide use. The new EU pesticide legislation prohibits aerial crop-spraying except in exceptional circumstances and thereby has the potential to protect both farm workers and nearby residents, if applied correctly at national level. The EU phase-out of dangerous pesticides means that agricultural workers and pesticide producers across Europe reduce their contact with toxic substances on the job, and thus, their exposure.

$ ♂ 75yrs ♀ 81yrs life expectancy

9.2%

of GDP for health

/ 3.18

doctors/1000 people


HEAL's www.pesticidescancer.eu provides current updates on the initiative, information on how to join, and resources on pesticide-related diseases. A Facebook group Sick of Pesticides disseminates the latest news and comments, including videos from involved citizens and expert scientists. By respond-

Hanneke van der Wijngaart, president of the European Medical Students' Association:

I had no idea about the scale of the problem. The statistics in this article are quite shocking. But as we have seen many times before, a new law does not imply instant change; it requires a lot of effort and goodwill from 27 national governments and millions of individuals!

ing to a one-question poll, visitors can make their voice heard on pesticides and health.

be free from toxic contaminants and safe for young and old community members alike.

HEAL

Protected public spaces

With new pesticide rules in place, pesticide use near schools, parks or hospitals would be banned or restricted. Public spaces would

Conclusion In view of growing evidence identifying pesticides’ dangers, the European Parliament demonstrated its support for tighter legislation on pesticides. If the new legislation is implemented correctly, Europeans can enjoy a healthier food supply, safer occupational health and protected public spaces thanks

to new criteria for the exclusion of the most hazardous pesticides in place. Ultimately, we can look forward to better human health outcomes across all 27 countries in the European Union.

About the author Katrina is Canadian and came to the ­Netherlands on a one-year Rotary Ambassadorial Scholarship. During this time, she completed a graduate programme in International Public Health at the VU Amsterdam.

Further reading   The European Parliament’s Committee on Environment, Public Health and Food Safety. Impact Assessment: The benefits of strict cut-off criteria on human health in relation to the proposal for a Regulation concerning plant protection products. 2008.   Pesticide Action Network Europe. An analysis of the Commission’s proposals for ‘cut off criteria’ and candidates for substitution. 2008.

Global Medicine 6 – April 2009

The European public is in close, daily contact with pesticide-laden public spaces. Cosmetic pesticides sprayed in our community green spaces contaminate the areas where children spend most of their time: parks, playgrounds and schools. Pesticide insults can be particularly dangerous to the developing brain during foetal development and early childhood. Up to one in six children grow up with a developmental disorder, including learning disabilities, attention deficit disorder and mental retardation, that can be attributed to exposure to industrial chemicals, including some pesticides.

To bring this legislation into practice, the 27 member states of the European Union will have to develop National Action Plans for reduction in using pesticides in consultation with stakeholders. HEAL will work to encourage the participation of the health community in order to realize the goals of the European pesticides policy. The HEAL Sick of Pesticides campaign aims to achieve an informal network of people and groups who are concerned and ready to act to reduce the impact pesticides have on cancer incidence.

17


Global Medicine Photo gallery

Nutrition and health Nutrition is essential for health and development. Better nutrition means stronger immune systems, less illness and better health. Healthy children learn better. Healthy people are stronger, more productive and therefore able to gradually break the cycles of both poverty and hunger. Better nutrition is a prime entry point to ending poverty and a milestone to achieving better quality of life. These pages show the winning photos in our theme contest.

The theme for Global Medicine’s next photo contest will be water and health. Your photo on this page? We welcome your contribution at editor@globalmedicine.nl. More details available on our website www.globalmedicine.nl.

Market in Mopti, Mali Merchants arrive by boat and sell their produce directly at the daily market. Marjolijn Paauwe, summer 2008


Youth Friendly Centre in Mundri, Southern Sudan Florence was trained to become a workshop facilitator and now introduces the concept of a balanced diet in her community. Robbert Duvivier, 2007


More money allocated to research on medication against baldne


Should we mind the gap?

21

The disequilibrium within health research Julia Spierings In the past decades, more money was allocated to research on medication against baldness than to serious and life threatening diseases in developing countries. 1 393 new drugs were approved between 1975 and 1999; only one percent was specifically indicated for tropical diseases. In 1986, the global expenses for health related research were­­­­­ $­­30 billion. Less than 10% of this money served the health problems of developing countries, where over 90% of the world’s population lives. The Global Forum on Health Research described this statistical finding as the 10/90 gap. Pharmaceutical companies were blamed for their lack of research on tropical diseases.

Is the gap getting smaller?

ess than to life threatening diseases in developing countries

Global Medicine 6 – April 2009

In the last ten years, the situation has changed, which makes it difficult to define the current dimensions of the gap. In 2003, the global expenditure on health research was $ 125 billion, four times higher than in 1986. The investments on research on tropical diseases have increased as well. However, the exact share for developing countries is not easy to estimate because more people and associations are involved in the funding for research than before.

Also, there is a shift in epidemiology of diseases as developing countries experience an increase in non-communicable diseases, such as cardiovascular diseases and cancer which now make up 60% of the total disease burden. This unbalances the 10/90 division, because research in developed countries on prevention and treatment of diseases of affluence could benefit developing countries as well. However, these studies do not take into account the differences in genetic components and the specific risk factors related to environmental and social conditions. Very little research focussed on non-communicable diseases in developing countries. One could question the importance of more research on several underdevelopment related illnesses. In fact 80 to 100% of the childhood diseases (e.g. diarrhoea, malaria, measles and tetanus) can be prevented and cured with existing methods and medications. Prevention programmes and a more effective distribution of medication and vaccinations in areas in need are more helpful than more research, as they can save 3 million children each year. Diseases for which there is no treatment available, such as dengue fever, contribute to a far smaller proportion of low-income country mortality rates than the abovementioned diseases.


billion US dollar

Global investment in health research & development

1986

1992

1998

2001

2003

2005

Data adapted from the Global Forum for Health Research

Redefining the gap As it remains difficult to allocate health research investments according to regional disease burden, poorer countries still find themselves on the less endowed side. Pharmaceutical companies keep being blamed for neglecting the diseases that are only endemic in third world countries. In reaction to public and political campaigns, these pharmaceuticals have indeed invested more in the development of medication against these diseases. Still, they are blamed for limiting the access to essential medicines as well as access to information and resources through patents and intellectual property rights. Other interfering factors are formed by policy makers and governments. Although cures are available, expenses on health, distribution and especially prevention programmes do not obtain sufficient priority. Thus the factors that cause the gap have shifted from a lack of research to disallocation of resources.

How to close the gap? To narrow the 10/90 gap, we should target the factors that are keeping it open. Concerning the role pharmaceutical companies have, we

might impose higher taxes on profits from these companies and limit intellectual property rights. However, implementing these proposals might discourage pharmaceutical companies to invest in research on tropical diseases or on non-communicable diseases on a population specific level. Furthermore, governments should invest in their health care systems, support organizations to start prevention programmes and stop taxation on medication. However, it is as important to ensure long-term research capacities and adequate coordination and planning in developing countries. The few currently existing research institutions lack resources, education, national investments and health research policies. There are no functional ethical and scientific review committees and there is a huge need for researchers and doctors. Therefore, policy making directed towards these goals, adequate project management and the acquirement of biochemical, socio-economic and political resources are needed. In conclusion, closing the 10/90 gap is not enough to resolve the burden of disease in third world countries. The gap has changed, estimated numbers are old, epidemiology has shifted and mortality could be reduced by efficient use of existing prevention and treatment strategies. Still, the gap describes the lack of research specifically focussed on this population.

About the author Julia Spierings is a fifth year medical student with a special interest in research on tropical and neglected diseases.

Further reading   International Policy Network, Philip Stevens. Diseases of poverty and the 10/90 Gap. November 2004   www.globalforumhealth.org   WHO (2001). Macroeconomics and Health: Investing in Health For Economic Development. Geneva


IFMSA-NL

Think Globally Act Locally

International Federation of Medical Students’ Associations Our Projects... the Netherlands

About us...

Global Medicine is a publication of IFMSA-NL; the International Federation of Medical Students’ Associations – the Netherlands. IFMSA is a worldwide student organization that strives to improve Global Health. We run global, national and local activities, varying from internships in countries all over the world, to awareness projects on, for example, the dangers of nuclear weapons. More information about the projects organized by IFMSA-NL is available in the opposite Our Projects section and on our website. IFMSA-NL has more than 400 active students spread across all 8 Dutch medical faculties. Medical students that feel there’s more to the world than just the Netherlands, and care about Global Health issues all over the world, are always welcome at our local offices, be it to obtain information on our projects, or maybe even to join one of our teams...

This section highlights a few of IFMSA-NL’s most interesting local projects.

IFMSA-NL Congress: Integrative Medicine Every year IFMSA-NL organizes a national congress for medical students. This year’s theme is Integrative Medicine. Alongside the lectures there will be plenty of room for your own input in workshops and the closing discussion.

Movies & Medicine If you like movies, this is the project for you. Movies & Medicine combines a global health related film with an inspiring lecture by a professional in that area of expertise. Any profit is always donated to charity!

MDG8Focus In 2000, the UN adopted the Millennium Development Goals as main challenges for global development. MDG8Focus is a joint project of Move Your World and IFMSA-NL. In approximately 8 evenings, the problems on how to achieve these goals will be discussed. Also, you will be given the possibility to air your own opinion on the subject.

Het Voorspel Wanna talk about sex? ‘Het Voorspel’ prepares you to give sexual education to highschool pupils.

Contact If you’d like to participate in one of our projects or you just want additional information, there’s a lot more info available on www.ifmsa.nl, or just send an email to info@ifmsa.nl


Cholera in Zimbabwe Kept quiet, not solved Jolanda Naafs

Zimbabwe is facing a huge health crisis: a cholera outbreak of biblical proportions. Cholera, a disease caused by the bacterium Vibrio cholerae, is treatable and preventable. The magnitude of this epidemic is one of the symptoms of a collapsed health system, caused by the political breakdown in Zimbabwe. In this article, Jolanda Naafs reflects on the extent of the cholera outbreak, the role of politics in this outbreak and how the Zimbabwean government is handling this epidemic.


The worst outbreak in years Cholera outbreaks in Zimbabwe have occurred annually since 1998, but previous ­epidemics have never reached today’s proportions, says the World Health Organization (WHO). The current cholera epidemic is the worst in years, according to Médecins Sans Frontières (MSF, Doctors Without Borders). Last year, the first cholera cases were reported in August 2008. From November, the incidence rate increased significantly and cholera spread rapidly to Zimbabwe’s provinces. According to WHO reports, the death toll of the outbreak reached 1 500 in December and surpassed 4 000 by the end of March 2009. Over 90 000 people are infected.

infected death toll

91 164 4 037

Zimbabwe has dealt with cholera outbreaks annually, so what is the reason that this outbreak could take on such enormous proportions? Numerous explanations, all interrelated, can be identified.

First of all, Zimbabwe has lingering political problems. Since 1987 Robert Mugabe has been President of Zimbabwe. He was initially complimented for his progressive actions, but his governing style soon changed and repression became the essence of his dictatorship. In the year 2000 a period of economical and political turbulence began when Mugabe chased the white farmers off their lands. This action resulted in a collapse of Zimbabwe’s agricultural sector, which up till then had been the main source of income in the country. The situation worsened ever since, but 2008 was the year in which economical, political and humanitarian conditions deteriorated. In April 2008 the leader of the opposition, Tsvangirai, claimed a victory in national elections. Mugabe openly questioned the results, and because of the little difference between him and Tsvangirai, a second round was organized that Mugabe won. Many people supportive of Tsvangirai have been abducted, tortured or murdered. In September 2008, Tsvangirai and Mugabe finally reached an agreement to share power. Despite this deal, Mugabe still did not consult the opposition

Zimbabwe

13 228 000 inhabitants

$ 507

income per year

Besides the abovementioned circumstances, ignorance further contributes to the spread of the disease. Cholera spreads via contaminated food or water and can be prevented by good sanitation and easily treated with rehydration. The people of Zimbabwe, especially those in rural areas, are ignorant and have little means for prevention and treatment.

$ ♂ 37yrs ♀ 34yrs life expectancy

25

8.9%

of GDP for health

/ 0.16

doctors/1000 people

Global Medicine 6 – April 2009

$/

and political instability persisted. Economic problems developed parallel to the political crisis. From the year 2000 onwards the inflation rate increased and as a reaction, the government decided to print more bank notes. But as the total economy did not improve, the currency devalued. This resulted in hyperinflation that caused the country to become bankrupt and ungovernable. The financial situation led to an inability to pay decent salaries. A mass departure of health care workers, lack of management and shortage of resources caused a collapse of the health care system. Hospitals soon became ghost hospitals. The access to available health care facilities is poor because hospitals are overfull and most people are unable to pay for transport and treatment.


easier said than done. After initial threats to leave the power-sharing deal, Tsvangirai announced in January 2009 that his party was ready to join the unity government. Tsvangirai is now Prime Minister and Mugabe will remain President. Although Mugabe's government has accepted this decision, many have a vivid recollection of his 2008 claim: Only God can dethrone me.

Reflection

President Robert Mugabe denied the presence of cholera Hushing up the disease Despite warnings from the WHO and organizations like MSF, President Robert Mugabe denied the presence of cholera. They want military intervention, because of cholera. But I’m happy to say that our doctors [‌] have now arrested cholera, Mugabe said in a speech. The Herald, a state-controlled newspaper in Zimbabwe, announced on 18 December, 2008: Cholera cases on the decline and assigned this claim to the WHO. I asked Zimbabwe correspondent Bram Vermeulen why the Zimbabwean government

has chosen to hush up the disease. Cholera is a symptom of the economical crisis in Zimbabwe. There is no money for chemicals to provide the country with clean water. This makes the cholera epidemic embarrassing for the regime, he answered. International political leaders criticized President Mugabe and suggested his withdrawal. We need a fair and sustainable political solution in Zimbabwe. And we need it fast, announced Ban Ki-moon, secretary-general of the UN, at his 2008 end of the year news conference. However, getting Mugabe to step down is

In conclusion, the political instability created an environment for hyperinflation and thus for the collapse of the health care system. These and other factors allowed for the rapid spread of cholera: there has been a huge shortage of nearly everything that could have stopped the epidemic. Of one thing I am certain: the current, appalling situation must not continue. The number of deaths keeps topping itself and the amount of affected cases already surpassed the worst case scenario of the WHO estimates in 2008. Even though the situation is complex, I am surprised that political interventions are virtually nonexistent. Of course, I am aware that a lot of Zimbabwean and foreign doctors are working extremely hard, but what is being done by world leaders to eliminate the underlying causes of this


epidemic? I genuinely hope Tsvangirai will be able to truly enter the government and, with help of the international community, to get Zimbabwe out of this enormous negative spiral. I disapprove of the hushing up of the disease and the passive manner in which the current government is dealing with the epidemic. Changing the situation in Zimbabwe will be a tough process and the hardest part will be the beginning: substantially reducing the power of Mugabe.

About the author Jolanda Naafs is a first year medical student from Utrecht.

Full references available on www.globalmedicine.nl

A Dutch nutritionist with 10 year working experience in Zimbabwe I think Jolanda Naafs´ article lacks subtlety. Reality is more complicated than drafted here. Have you ever treated cholera patients? In my experience it is really tough to make (often vomiting) people drink huge amounts of fluids in conditions where safe water for drinking and cleaning is extremely scarce. Also, not everyone disapproves of Mugabe: most African Governments recognize him as a democratically elected president. With you I encourage medical doctors to look beyond the biological causes of disease. I agree, the case of cholera in Zimbabwe is a clear example to show the impact of underlying causes of this disease, and its increase in incidence in the past decade. Many cities in the country cannot afford to import the necessary chemicals to treat the water supply. A medical solution only will not tackle the spread of cholera in Zimbabwe. The cholera outbreak in Zimbabwe is a symptom of a sick economy and sick politics.

27 A Zimbabwean medical student Our media are not really reliable on the issue of cholera. Most articles discuss ZANU-PF, Zimbabwe African National Union – Patriotic Front (Mugabe’s political party) but not its failures. What hurts most now is that the biggest hospitals are in fact malfunctioning, drugs and other basic medical things are scarce and Mugabe’s party celebrates a birthday worth thousands of USD. I managed to visit one cholera camp and saw a few patients. Among the patients there was a woman who had been admitted a few days after her husband had died of cholera. People are getting infected after attending mass gatherings (usually funerals for cholera victims) and ZINWA, the water board that has just been fired, has not been purifying water adequately. It is like in every institute, there is corruption: everyone tries to make a living and ZINWA is just another institute. Basic facilities are either malfunctioning or non functional at all. The government is not doing enough for the cholera victims, they are leaving everything to the donor community to deal with this crisis.

Global Medicine 6 – April 2009

References

Two comments on this article are printed below. Others are to be found on www.globalmedicine.nl. Global Medicine encourages you to further discuss this topic through our website. Share your opinion online at the Readers’ Responses page or email us at editor@globalmedicine.nl.


IAVI: International AIDS Vaccine Initiative Hester Kuipers

More than 25 years ago, the first cases of AIDS were reported in medical literature. In 1983 the human immunodeficiency virus (HIV) was discovered as the cause of the disease. At this time, the scientific field was optimistic about the development of a safe and effective vaccine against the virus to help put a stop to AIDS. However, HIV has proven to be the most complex virus we have ever encountered. Since its discovery, HIV has caused around 25 million deaths. Globally 33 million people are currently living with HIV and the virus infects nearly 7 500 people each day. Despite significant investments, HIV continues to outpace global response, and development of an effective vaccine remains one of the greatest scientific and public health imperatives facing the world today. In the following editions, Global Medicine in collaboration with the International AIDS Vaccine Initiative (IAVI) will pay special attention to the development of an HIV/AIDS vaccine. In this first episode IAVI presents their work.


The challenges

In 1996, with the AIDS pandemic spinning out of control and little investment by the private sector to develop a vaccine against HIV, the International AIDS Vaccine Initiative (IAVI) was founded. Their goal is to ensure the development of safe, effective, preventive AIDS vaccines for use throughout the world, and make them accessible to all who need them. IAVI was the first global, non-profit publicprivate partnership for product development (PDPs). Such an organization uses resources and works with the unprofitable public and private sector. Important is the commitment of the public sector to support important, if unprofitable, causes with the expertise and resources of the private sector to combat neglected diseases. In the case of an AIDS vaccine, the public sector (especially governments) is committed to fight the pandemic, but does not have the expertise to develop vaccines. In contrast, the private sector (biotechnology and pharmaceutical companies) does have this expertise, but lacks financial incentives, and therefore does not invest in such Research & Development (R&D). It is this gap that IAVI is filling: focusing expertise and resources from the pharmaceutical and biotechnology sector

on the development of an AIDS vaccine using finances provided by the public sector.

29

Today, there are more than 20 international PDPs responsible for three quarters of all drug development projects for poverty related diseases, including vaccines against tuberculosis and malaria.

IAVI’s work IAVI’s scientific team, drawn largely from the vaccine industry, researches and develops AIDS vaccine candidates and conducts HIV clinical trials and clinical research through partnerships. The organization also advocates for R&D effort, political attention, sufficient financial resources, and for a supportive environment in countries engaged in this effort. Finally, the organization educates and trains a broad range of stakeholders involved in AIDS vaccine R&D, including scientists, health care workers, communities, politicians and the media.

Applied science IAVI designs promising new AIDS vaccine candidates that can be quickly moved to the clinic to be tested in human trials. Together with research consortia organized around unique agreements on intellectual property, a shared scientific plan and division of tasks

Global Medicine 6 – April 2009

Developing a vaccine is never easy: it took 47 years from the discovery of the poliovirus to the development of a polio vaccine. HIV was discovered in 1983, but we have only had a serious AIDS vaccine effort for about a decade. Developing a vaccine to prevent HIV/AIDS is particularly challenging. HIV targets and destroys the very immune system that a vaccine traditionally triggers, and the genetic instability of HIV is daunting. Yet, there is compelling scientific evidence that an AIDS vaccine is possible, as some people who are infected with HIV are able to control the virus for many years. Rarely, individuals resist infection despite exposure to the virus. Researchers are studying the immune responses in these people to find clues for the development of a vaccine. But the challenges are not only scientific. The pharmaceutical sector, where most vaccine development expertise resides, has been reluctant to invest in the development of an AIDS vaccine.

An innovative model to develop a vaccine


are administrated. In addition to engaging academia, IAVI also has a programme to scan the biotechnology sector, and funds the application of promising technologies to advance AIDS vaccine R&D.

Clinical research In collaboration with national research institutes and organizations, IAVI tests AIDS vaccine candidates in clinical trials. To date, the organization has taken six candidates to clinical trials in eleven countries in Africa, Europe, India and the US. An important pillar in IAVI’s strategic plan is to engage countries that need a vaccine most, in both AIDS vaccine research and product development. Significant resources were built in Eastern and Southern Africa, including laboratories and clinics and scientists, health care workers and communities were trained. Given the variability of HIV, it is essential that vaccine candidates are tested in regions across the world where different HIV subtypes circulate. However, the reason to conduct research in Africa is not only scientific. Doing AIDS vaccine research on this continent will also help to facilitate the ultimate roll-out of a vaccine and provides important benefits to communities where the research takes place.

U


Europe

Canada

AMSTERDAM Norway Sweden Finland United Kingdom Ireland The Netherlands Belgium Germany Switzerland Spain

United States US Headquarters NEW YORK CITY Canada United States Brazil

Key India

NEW DELHI

East Africa NAIROBI

Regional IAVI office Partner country

31

Japan China India

Kenya Uganda

Brazil

Southern Africa JOHANNESBURG Zambia South Africa

Ensuring political and financial ­support for a global effort

long-term and global effort. It is regarded as one of the greatest scientific challenges that we face today, and can only be achieved with worldwide commitment from all of us.

Further reading If you want to learn more about IAVI or how you can help, please visit www.iavi.org or contact IAVI at info@iavi.org. Read on global spenditure on Research & Development in the article Should we mind the gap? on page 20.

Global Medicine 6 – April 2009

A significant amount of IAVI’s work is also geared towards raising awareness of the need for a vaccine and ensuring that there is sufficient political and financial support for AIDS vaccine development. This is done in cooperation with NGOs, parliamentarians, governments, scientists, media and communities across the globe. In 2007 globally $ 961 million was spent on AIDS vaccine R&D. While this seems to be

a significant figure, it represents less than one percent of the total annual global spending on health R&D. The funds for global AIDS vaccine R&D are raised predominantly by governments (some 80%). The contribution from Europe is approximately 10% ($ 80 million in 2007), with the US being the largest funder ($ 659 million). IAVI is now an important investor receiving funding from governments of eleven countries, the EU and private and philanthropic organizations. The development of an AIDS vaccine is a


GMMix Global careers Besides the well known medical professions as physician, medical specialist or researcher, there are a lot more interesting career possibilities in (global) health care. With these short interviews we want to introduce different, interesting, sometimes unknown, professions to you. MP

Let's introduce Henk Schallig PhD is coordinator of Parasitological research at the Royal Tropical Institute in Amsterdam. He leads a research group currently comprising 15 people, who are working on parasitic diseases, mainly malaria, leishmaniasis and trypanosomiasis, both in the Netherlands and in developing countries.

Prof Louise Gunning PhD is chairman of the executive board of the Academic Medical Centre in Amsterdam and dean of the medical faculty of the University of Amsterdam.

How would you describe your career path? Not well planned in advance. I started studying to become a teacher, but became more and more interested in doing research. After receiving my PhD at the biology faculty of the Vrije Universiteit in Amsterdam on schistosomiasis, I worked at the Institute of Infectious Diseases and Immunology of Utrecht University. My main subject was vaccine development against gastro-intestinal parasites. After a short time in the industrial world, I spent my golden handshake mainly in Thailand. Back in Holland I applied for a position at the Royal Tropical Institute, where I have been working now for almost 8 years‌ a long time. Maybe time for a change, again?

I studied medicine in Groningen, but after my first degree, I went to the US and did a Masters in International Health at the Johns Hopkins School of Public health. After that I made career in health policy and epidemiological research. I became Professor of Social Medicine at the AMC and went on to my current position.


What does your schedule for a week look like? Henk Schallig No week is the same. Last week I was in Paramaribo for the kick off of our leishmaniasis research programme. Next week, I will have to catch up with a lot of paper work, discuss results obtained by my group at the lab, report some management issues and finalize the budget for the leishmaniasis project. Then I have to prepare for a trip to Burkina Faso to monitor the progress of one of our malaria projects on drug resistance.

33 Louise Gunning Every week the Board of Directors meets, we usually have two or three quarterly meetings with the divisions of the AMC, I talk to prospective professors, government representatives, students, foreign visitors, … to be honest I spend most of my week talking to people who work or study at the AMC or with whom the AMC collaborates.

What would you like to achieve in your job? We want to contribute to better health for people living in developing countries. In particular, by making tools available which allow local doctors to make the right diagnosis and give appropriate medicines.

I would like to help fulfil the ambitions of the AMC to be the leading academic medical centre in the Netherlands, with an excellent medical school, an international reputation in science and evidence based patient care with compassion.

What do you like most about your job? Working with many different people under very different circum­stances. In Mbita, a small village on the shores of Lake Victoria in Kenya, we managed to see 1 200 patients and treated around 300 for malaria in only six weeks and with limited resources. That was very rewarding.

The diversity of the people I meet. But also doing lots of different things, including international activities. I never envisioned this position, but it is a very exciting job to perform.

What would you tell a student who wants to head in this direction? Be good at the job you choose, either as a clinician, a scientist or in the field of public health, because there are many different ways that lead to this position.

Global Medicine 6 – April 2009

Students may have the impression that it contains a lot of pleasant travelling to exotic places, but it is hard work, sometimes under difficult conditions and, unfortunately, often there is not enough funding. I advise students to get enough practical experience: work in a laboratory, see as many patients with tropical diseases as possible, and, most importantly, spend time working in a disease endemic country in the tropics.


GMMix GMMix

$/ 2 061 315 inhabitants

$ 7 850

income per year

$ ♂ 71yrs ♀ 76yrs life expectancy

7.8%

of GDP for health

/ 2.6

doctors/1000 people

Studying medicine in…

Skopje Savo Trajanovik (26) is a sixth year medical student from Skopje, Macedonia.

How is university life in Skopje? We have only one medical faculty and it is in Skopje. Students from all over Macedonia study at this faculty, so studying here is a special experience. I think that student life, and studying, here is pretty different from anywhere else in the western countries. First of all because we have a different study programme, and secondly because you know most of the people. This makes is sometimes easier, sometimes harder to concentrate on your studying, because we have a diverse and very fulfilled social life here. Is it financially possible for everyone to study medicine in Macedonia? It is very expensive, concerning the economical situation in Macedonia. It costs about € 1 000 and about € 200 if the government supports you. Unfortunately, there are only a few grants. You experienced Dutch university life through an exchange programme. What do you think is the biggest difference between studying in Amsterdam and Skopje? Educationally, I think in Amsterdam there are more possibilities to enrich your medical knowledge. I think the study programme is different and maybe better. Furthermore, I think the economic and political situation allows the medical faculty to purchase more material. Socially, there are small differences between Skopje and Amsterdam, some things are better here, some are better there. I am really glad I had the chance to participate in this exchange programme. We exchanged a lot of experiences, which gave us insight in each other’s social and educational life!

Describe your life in 2020… I see myself as a young but already successful gynaecologist. I will probably live with my wife and children by that time, which would mean I am happy both at work and home. MP

I had an exceptional time with the Dutch students! There are a lot of things I miss about Amsterdam: dropjes, drinking beer with the other students, riding a bike…


Book review Colophon Global Medicine is an official IFMSA-NL publication. Editor in Chief Emmaline Brouwer Project coordinator Richard Schol Editors Naomi Begemann, Lisanne Denneman, Evi van der Linden, Marjolijn Paauwe, Julia Spierings, Rik Viergever Art Directors Patricia Hordijk, Roel Klein Wolterink, Lies Schakelaar Finance & Logistics Frederiek Bosscher Public Relations Minke van Minde Webmaster Richard Schol IFMSA-NL Liaison Job de Grefte Proof-readers Titia Begemann, Magda Maarleveld Printing Hollandia Printing, Heerhugowaard (NL) Contact editor@globalmedicine.nl Internet www.globalmedicine.nl ISSN 1474-4345 Global Medicine is being distributed free of charge among the eight medical faculties in the Netherlands and selected faculties world wide. The printed edition has a circulation of 6000 copies and is published three times a year. The magazine is also available through our website www.globalmedicine.nl. Except where otherwise noted, this work is licensed under the AttributionNon-Commercial-Share Alike 3.0 Netherlands Creative Commons licence. In summary: You are free to copy, distribute, display, and perform the work and to make derivative works, under the following conditions: Attribution / NonCommercial / Share Alike. View the full licence at www.globalmedicine.nl/ licence before (re)using any content.

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This manual aims to build the capacity of researchers in all parts of the world by guiding public health investigators through straight forward study steps, which are tried and true. It is addressed primarily to novice researchers (students or health care professionals) interested in the conduct of epidemiological research, especially in resource-poor regions of the world. The step by step explanation for conducting an epidemiological research study takes the reader through a real-life case study, based on the experience of work in Azerbaijan. It contains a kind of toolkit to help students take action, including model templates to write proposals, advice on preparing budgets, lists of academic resources, potential donors/sponsors/funding sources, key journals, a glossary, and guidance and advice on how to produce and publish research findings in international literature. NB More information and the complete manual can be found for free on the WHO Europe webpage www.euro.who.int/healthimpact/MainActs/20020730_1

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June 2009 at your faculty

   NGO’s in primary health care: a benefit or a threat?    Neglected Diseases African trypanosomiasis (sleeping sickness)    IAVI part II Progress towards an HIV vaccine Deadline for article submissions: 10 April, 2009 Deadline for photo gallery: 10 May, 2009 Send your submissions to editor@globalmedicine.nl

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Water and health Global Medicine 6 – April 2009

Statistics p4/5/10/16/26/34 adapted from WHO, Eurostat, OECD Photos & illustrations p1/3/20/26/27 © Amfion Fotoshoots (Antonette de Groot-Klootwijk), photos for Global Medicine, all rights reserved. p2/15 © HEAL, all rights reserved. p3/5/19 © Robbert Duvivier, all rights reserved. p2831 © IAVI, all rights reserved. p33 © DSM, all rights reserved. p33 KIT (Royal Tropical Institute), all rights reserved. Available under Creative Commons licences: p2 ramesh_lalwani, p2 CDC, p3 Roel Klein Wolterink, p3/9/10 Andrew Baird, p4 kevinkarnsfamily, p5 DefenseImagery.mil, p9 CDC/Dr. Peter Perine, p14/24 Julien hameis, p26 dodmedia.osd.mil, p34 Darko Hristov, p35 Marcin Chylinski. Photos released under a CC-Share Alike licence can be found on our website.

Step by step manual for novice researchers From theory to practice in environmental epidemiology: developing, conducting and disseminating health research


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Global Medicine 6