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200 journals join in theme issues on poverty and human development

Boston, MA - Through an international collaboration, more than 200 medical and scientific journals are publishing theme issues this week on the relationship between poverty and human development. The initiative, coordinated by the Council of Science Editors, includes presentations on seven of the journal articles which will be webcast live from the National Institutes of Health on Monday, October 22, 2007.

Two of the selected papers are by Harvard School of Public Health (HSPH) researchers.

In "Improving Child Survival Through Environmental and Nutritional Interventions," published in The Journal of the American Medical Association (JAMA), researchers at the Harvard School of Public Health (HSPH) and the University of Washington set out to determine (1) whether programs to improve child nutrition and provide clean water, sanitation and fuels, three of the United Nations Millennium Development Goals, could also impact the MDG of reducing child mortality and (2) how the benefits of those interventions varied based on how poor the targeted population of these programs were.

In "Human Resources for Treating HIV/AIDS: Needs, Capacities, and Gaps," published in AIDS, Patient Care and STDs, lead author Till Bärnighausen, doctoral candidate at HSPH and Associate Professor of Health and Population Studies, Africa Centre for Health and Population Studies, University of KwaZulu-Natal, and colleagues investigate a simulation model of the nature of the gap between needed and available healthcare personnel for scaling up HIV/AIDS antiretroviral treatment in the developing world. They conclude that universal coverage is unlikely to be achieved even if the education of healthcare personnel in developing countries is substantially increased, unless the emigration of health workers or the rate of new HIV infections is decreased at the same time.

Improving Child Survival

Reducing child mortality rates for children under five years—which in 2004 was 6.5 (per 1,000 children annually) in Latin America and the Caribbean, about 20 in South Asia and 39 in sub-Saharan Africa—is one of the United Nations Millennium Development Goals (MDGs). Those goals were established at the beginning of this decade to address the problems of global poverty, health and sustainability issues. Targets were set related to these issues, to be achieved by 2015. However, there are concerns at the midway point that the targets will not be achieved.

Researchers at the Harvard School of Public Health (HSPH) and the University of Washington set out to determine (1) whether programs to improve child nutrition and provide clean water, sanitation and fuels, three of the MDGs, could also impact the MDG of reducing child mortality and (2) how the benefits of those interventions varied based on how poor the targeted population of these programs were.

The researchers found that achieving complete coverage of interventions related to nutritional and environmental sustainability MDGs could lead to large reductions in child deaths in Latin America and the Caribbean, South Asia and sub-Saharan Africa, the three regions the researchers studied. The biggest reduction would take place in sub-Saharan Africa, where the rate might be reduced by an estimated 31%, equivalent to about 1.47 million fewer child deaths each year. In all the regions, the current regional gap toward the MDG child mortality target could be reduced by 30% to 48%.

The researchers also looked at whether giving priority to the poor in nutrition and sanitation improvements had a greater impact than distributing interventions equally among all levels of wealth. They found that prioritizing the poor did have a much greater impact, even though the better-off children were also in need of better nutrition, and cleaner water and fuel.

"Our finding that greater health gains can be achieved by prioritizing the poor provides new evidence on how policies and programs should be packaged and targeted to achieve the MDGs," said lead author Emmanuela Gakidou, formerly of the Harvard Initiative for Global Health and now with the Institute for Health Metrics and Evaluation, University of Washington, Seattle.

Gakidou, Ezzati, and colleagues analyzed data from Demographic and Health Surveys program (nationally representative household surveys in developing countries with large sample sizes), the World Health Organization's (WHO) Comparative Risk Assessment Project, and WHO Mortality Data. They also used novel methods to measure the economic status of households in the three regions and to model the benefits of nutritional and environmental programs.

Some of the key findings:

An estimated 56% of the children in the Latin America and the Caribbean, 87% in South Asia and 83% in sub-Saharan Africa were exposed to preventable risks associated with undernutrition, unsafe water, sanitation and fuels and, as a result, in need of interventions.

Child mortality declined in all regions as wealth increased. At similar levels of wealth, and especially among the poor, children in sub-Saharan Africa were worse off than those in Asia and Latin America. If the three nutritional and environmental MDGs reached all the children who needed them, it's estimated that annual child deaths would be reduced by 49,700 (14%) in Latin America and the Caribbean, 0.80 million (24%) in South Asia and 1.47 million (31%) in sub-Saharan Africa. The difference in mortality rate between poor and wealthier families would be reduced by the nutritional and environmental interventions and would be reduced further if the interventions prioritized the poor.

The researchers believe that it may be time to rethink the MDG implementation and monitoring system. "We recommend that MDG interventions be implemented and monitored as packages rather than individually," said Ezzati, given that the study found packaging multiple interventions provided very large reductions in child mortality. "We also recommend that governments and aid agencies be held accountable for how much they improve environmental MDGs among the poor," he added.

Ezzati also notes the importance of taking into account the economic status of intervention recipients, which the MDGs currently don't do. "We found that delivering the same intervention to a poor person will have greater health benefits than it would if it were given to a wealthier person in need of the same intervention. For example, it's quite likely that dealing with a whole range of health and environment issues in urban slums can save many more lives than dealing with the same issues in better-off communities," he said.

The study was sponsored by the National Science Foundation, the Grand Challenges in Global Health and the Center for International Development at Harvard.

"Improving Child Survival Through Environmental and Nutritional Interventions," Emmanuela Gakidou, Shefali Oza, Cecilia Vidal Fuertes, Amy Y. Li, Diana K.­ Lee, Angelica Sousa, Margaret C. Hogan, Stephen Vander Hoorn and Majid Ezzati, JAMA, October 24/31, 2007, Vol. 298, No. 16.

Human Resources for Treating HIV/AIDS

A second paper by Bärnighausen and colleagues David Bloom, Professor of Economics and Demography at HSPH and Salal Humair from the School of Science and Engineering at Lahore University of Management & Sciences in Pakistan, modeled the gap between needed and available human resources to quantify the challenge of achieving and sustaining universal antiretroviral treatment by 2017. In a model accounting for increased survival of treated patients and the inflow and outflow of health personnel who have had to undergo long education and training, the researchers reveal the paradox that improved outcomes for AIDS coverage generate the need for more human resources.

Outcomes vary by region: for example, sub-Saharan Africa requires 2 times; low and middle-income countries in non-sub-Saharan Africa require 1.5 times and South Africa requires more than 3 times their currently existing human resources to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further human resource increases until the system reaches a steady state.

"Our model reveals that strategies for achieving universal ART coverage can become victims of their own success," said Humair. "We may think that by increasing available human resources to meet the current coverage gap in developing countries, universal coverage can be achieved. Unfortunately the goal post keeps moving. The more coverage you provide, the more human resources you need for meeting the remaining coverage gap."

Universal coverage will require decreased outflow of human resources, substantially reduced HIV incidence, or changes in the nature or organization of care, the authors write.

"Human Resources for Treating HIV/AIDS: Needs, Capacities, and Gaps," Till Bärnighausen, David Bloom and Salal Humair, AIDS Patient Care and STDs, Volume 21, Number 11, 2007.


Contact: Robin Herman
Harvard School of Public Health

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