Humanitas Global Development Blog

World Hepatitis Day: Reinvigorating the Discussion to Foster Action against the Epidemic

By Obaid Khan, Humanitas Global

In the backdrop of Sustainable Development Goals, a global consensus emerged on eliminating HIV/AIDS, tuberculosis, malaria and neglected tropical diseases by 2030. However, the consensus over viral hepatitis was on combating, not eliminating the disease. On World Hepatitis Day (July 28^th), it is worth asking: Is there a global sense of responsibility for 1.5 million people that die each year from Hepatitis A, B, C, D and E?

The major modes of transmission for viral hepatitis include contaminated food and water, exchange of blood or other bodily fluids, unsafe injections and/or sub-standard sterilization of medical equipment. As in any other disease, there are multiple challenges and binding constraints associated with combating the epidemic. A whole host of factors, other than the viral and immunological determinants, can be predictive of high incidence and prevalence of viral hepatitis. A CDC report attributes health disparities in viral hepatitis to social and economic determinants. Lack of awareness is a strong underlying factor for high hepatitis incidence and transmission as an estimate 95% of people with hepatitis don’t know about their infection. Transmission trends were explored more in depth in one of our previous blogs, which can be read here.

The World Health Organization  (WHO) reveals that 2 million people contract hepatitis each year due to unsafe injections and 780,000 people die each year from Hepatitis B. One must bear in mind that vaccines have been developed for Hepatitis A and B. However, no vaccines are available for Hepatitis C and E, except a few candidate vaccines. One can argue that the progress on the innovations frontier to combat and eliminate is lackluster. This gap can be attributed to the aforementioned determinants, but more importantly it is to the dearth of concerted campaigns to raise awareness about viral hepatitis in the global community. Campaigns and advocacy have yielded great results in the fight against and elimination of many diseases. The decade of 1950s was termed as an ‘Era of the Mass Disease Campaign’. The campaigns led tothe fight against yaws through mobilization of global health workers , testing of 3.5 million children for TB in mid-1950s worldwide, wide-scale treatment of trachoma through anti-bacterial ointment and DDT spraying to combat malaria.

These initiatives did not emerge in a vacuum, but were a result of advocacy campaigns grounded in the instrumental role of global concerted efforts. Publicly renowned figures can play a crucial part in advocating a reinvigorated focus on viral hepatitis as a global concern and bring its elimination as an agenda into the limelight. Celebrities, like Elton John, Sir Paul McCartney and Stephen Fry, have helped garner worldwide attention for HIV/AIDS epidemic, cancer patients and mental health respectively. The question remains: Who will champion the cause of eliminating viral hepatitis by 2030?         

Today, the World Hepatitis Alliance with a number of civil society organizations has answered that question through launch of a global movement called “NOhep” to eliminate viral hepatitis by 2030. NOhep’s objective is to raise and build awareness of the disease and the role people can play from the household level and up. This movement succeeds the recently adopted WHO Global Health Sector Strategy for Viral Hepatitis, where 194 Member States agreed to a goal of eliminating hepatitis B and hepatitis C by 2030.  NOhep will serve as a global umbrella platform for people everywhere to learn more, take action, and ensure global commitments are fulfilled and hepatitis is eliminated.

Join the movement to eliminate viral hepatitis and become a champion for good health and well-being for the global community.

Zika and Women: Where Do We Stand?

By Nicole Graham, Humanitas Global  

Since the beginning of the outbreak in Brazil, the Zika virus has spread to most other countries in Latin America. Zika disproportionately affects women; particularly women who are pregnant, women who could become pregnant, or even women engaging in sexual activity. Symptoms of the disease are mild, yet the impact of the virus on a pregnant woman is much more serious.

Courtesy of The New York Times

 

In a Center for Disease Control and Prevention (CDC) report released in April 2016, researchers announced that having the Zika virus during pregnancy results in an increased risk of having a baby with microcephaly – a condition where newborn babies are born with a small head or the head stops growing after birth. Although some women infected with the virus have delivered babies that appear to be healthy, the environment in all impacted Latin American countries is one of panic.  A sense of urgency to contain the infection has spread to the United States, as the first baby with Zika-related microcephaly in the U.S. was born in  Florida this past week.

Months ago, the CDC began examining a handful of female Zika infected patients where it was believed that sexual activity led to contraction of the virus. In all fourteen investigated cases, women had engaged in sex with men who had traveled to countries where the virus was circulating. As of last week, recent findings suggest that intimate contact may account for more Zika infections than was previously believed. These reports are disputed, but new evidence suggests that women are much more likely to be infected by Zika in Latin America than men, although all individuals are assumedly exposed to virus-carrying mosquitos the same amount. The gender difference in infections is particularly striking around the age where sexual activity begins.

As of March 2016, no research was being conducted to determine if females could reciprocally transmit the virus to their sexual partners. Scientists still do not know whether the virus is passed through semen or general sexual activity, whether it can be passed through saliva, and whether sexual transmission poses different risks for birth defects than mosquito-borne transmission. With these developments, Zika has revealed itself to be “scarier than we once thought”. The CDC has not released any recommendations for how women can protect themselves besides avoiding mosquitos, using a condom, avoiding sexual activity with a Zika-infected partner, and frequent Zika testing.

Like so many other aspects of Zika, it is undetermined whether or not breastfeeding can transmit the virus. The Lancet has introduced research that Zika does in fact appear in breastmilk, but more information is still needed. Breastfeeding is an essential practice for infant and young child health and development, especially in the developing world. The World Health Organization (WHO) recommends that infants begin breastfeeding within one hour of birth, and then are exclusively breastfed for at least six months, with appropriate and gradual introduction of complementary foods.

Regardless of the recent revelations that Zika can be transmitted outside of mosquito bites, WHO breastfeeding recommendations remain in place during the Zika context. The organization states that mothers who suspect they are infected should receive “skilled support from health care workers to initiate and sustain breastfeeding”, and that mothers should also continue to breastfeed if it is confirmed that she or her baby are infected.

Yet the research gaps that currently exist in understanding Zika infection are frightening, particularly for women and infants because the true nature of the disease remains unknown. The given recommendations by international institutions are only in place until actual solutions are developed. But unlike past outbreaks, much more research is necessary to determine how threatening Zika truly is.

A year after Brazil reported a suspicious skin rash in its northeastern states, the WHO responded with a Public Health Emergency of International Concern. Although human trials were recently approved for an experimental vaccine for Zika, it seems unlikely that a viable vaccine will be released to the public anytime soon. Uganda’s Virus Research Institute (UVRI) is examining ways to contain outbreaks though no focus is given to treatment or cures. A US bill to provide $1.1 billion to fight Zika was blocked by Senate Democrats because it involved riders related to controversial issues such as restrictions on use of funds for birth control services, further delaying needed research.

With limited understanding of Zika, family planning is an essential tool to fighting the virus’ tendency to cause birth defects. In Brazil, the country hit hardest by Zika, increased funding for education and contraception have lowered birth rates and created a more knowledgeable population and a lower birth rate. These efforts should be scaled up in the face of Zika. Because women seem hardest-hit by the virus, females should take initiative to educate themselves and others about family planning to avoid infection and curb Zika rates. Thanks to recent efforts, 88.9 percent of the female population in Brazil is literate, and 80 percent of women of reproductive age report using some form of contraception. This indication of a knowledgeable and empowered population could facilitate a decline in Zika infection if the effort was coordinated by pointed policy.

Researchers maintain that the general, non-pregnant public has little to fear from Zika. But until researchers determine how long Zika remains in the body, exactly how it is transmitted, and how at risk women and babies are, women have reason to be cautious and adopt practices to prevent infection.

Evidence-based Solutions to Poverty: Synthesizing Randomized Controlled Trials and Lessons from the Field

By Obaid Khan, Humanitas Global

In the second half of the series, we turn our attention towards harmonization of the evidence generated from RCTs and anecdotal narratives to inform development policy and practice.

Adopting intellectual humility with respect to the external validity of interventions is imperative. For example, conditional cash transfers worked well for Progresa in Mexico for improving education outcomes, but the model had to be adapted to the Colombian context for similar effectiveness. In Udaipur, monitoring participation worked to improve attendance of teachers, but not for the health staff.  The key takeaway is to utilize evidence from different settings that leads to adoption of adaptive and flexible approaches to inform development policy and practice in varying contexts.

Developmental efforts must be directed towards a synthesis of evidence and anecdotal narratives to ascertain how and why poor people, in different settings, make the decisions that they make. Economists, policy makers and practitioners can follow in the footsteps of Amartya Sen in ‘humanizing’ the field of development economics and keeping fair distance from abstract theoretical models that are out of touch with reality and human behavior.

RCTs, even at a small scale, can help guide evidence and context-based interventions and avoid the temptation of following a particular ideology. For example, a RCT for malarial bed-nets in western Kenya showed that purchase and usage of bed-nets varied considerably based on price but showed free provision of bed-nets was most effective in increasing uptake and usage. This behavioral response warrants a more pro-active longitudinal study that documents how the price elasticity of demand would change when the associated benefits of nets are realized. This can be particularly crucial to provide sustainable solutions in resource-constrained settings.   In Kenya, ‘nudging’ was used as a commitment device for prompting farmers to make prepaid payments at the time of harvest, after receiving vouchers for fertilizer before planting. Timing the required payment after harvest, when farmers had money was the active ingredient to counter the problem of failed payments or a lack of money in the future. It must be noted that micro-level interventions can only take us so far, in terms of far-reaching impact. However, the subsequent evidence generated can help governments scale-up these interventions.

A substantial gap in discourse and practice still remains about answering the critical questions regarding government, institutions and local realities. In countries with weak institutions, there are many actors with conflicting interests who are vying for economic and political power. In such countries, the incumbent governments are more prone to corruption than implementing and scaling up evidence-based interventions. Moreover, local culture, religious and political realities are important in shaping the behaviors of population. Humans respond to economic incentives, but are also driven by their cultural, religious and political affiliations. These dimensions of institutional and behavioral realities are often not adequately addressed by academics or policy makers. Anecdotal narratives can help enrich the discourse in unlocking the paths of reasoning that culminate into individual and collective decisions. 

Using RCTs and behavioral economics to determine what works in which situations is a feasible way forward in combating poverty. Despite frequent use of a one-size fits all approach to reducing poverty, a context-based approach is more effective and has the potential for large-scale poverty reduction. There is a need to amalgamate experiential learning to contextualize the quantitative findings, often used alone as evidence for interventions. Individual narratives should be viewed as complements to the broader policy directives that stem from the evidence.

Evidence-based Solutions to Poverty: The Utility of Randomized Controlled Trials in Varying Contexts

By Obaid Khan, Humanitas Global

In this two-part series on evidence-based solutions to poverty, we first focus on the stylized insights to randomized controlled trials (RCTs) for solving the poverty puzzle.

Economists are and have often been criticized for portraying people as rational profit-maximizing economic agents without empirical evidence. Using abstract economic theories that are incompatible with ground reality can translate into extreme worldviews that either propose increased aid to end poverty or going cold turkey on paternalistic aid distribution. A recent wave of economists and practitioners has suggested a paradigm shift in development policy and practice by using tools from behavioral economics and hands-on experimental research. With these tools, it is possible to examine and understand what interventions work in some settings and not in others. In a sea of evidence, books like, ‘Poor Economics’ and ‘More than Good Intentions’ aptly document evidence-based and context-oriented field research to avoid the pitfall of prescribing policies as universal solutions. Organizations like J-PAL and IPA, neatly highlight the evidence with focusing focus on the context-specific rigorous evaluations of interventions to ascertain the effectiveness of proposed poverty solutions. Academics and practitioners have made an honest attempt to better understand the heterogeneous behaviors and ground realities of the poor. The trend of ‘humanizing’ the target population can help move the discourse and practice from universal to context-specific policy prescriptions to tackle poverty.

The overarching idea reiterated in the development discourse is that evidence, not rhetoric, must inform development policy and practice to tackle poverty. In the health realm, innovative thinking and adaptive policies are needed to improve health outcomes. For example, authors Banerjee and Duflo of ‘Poor Economics’ found that free provision of chlorine tablets does not necessarily improve usage, but placing them in dispensers near water collection point does. Similarly, Karlan and Appel in their book ‘More than Good Intentions’ found that in Seva Mandir catchment area, monitoring attendance and tying incentives to teacher’s attendance improved attendance and student scores. However, similar strategy failed to improve the attendance of health officials in nearby clinics and centers.  Evidence from free versus subsidized mosquito nets in a study conducted by J-PAL and IPA, illustrates how health service utilization behaviors can change with marginal price changes. 

Community worker is teaching a woman how to use chlorine dispensers in Western Kenya. Source: Wash Funders

The complex nature of poverty makes it difficult to prescribe universal solutions without contextualizing the issue under consideration and its inter-connectedness with other factors. Most sustainable development solutions might well lie in the middle ground, between the polarizing assertions that aid is the be all and end all of development and that aid does more harm than good. The primary tools employed, in development, need to be reorient towards rigorous randomized controlled trials, evidence from behavioral economics and context-based learning approach in different settings.

Academics have come to the realization that anecdotal evidence from field experiences complement randomized control trials to ascertain the effectiveness of various poverty or development-related interventions in different settings. Lessons from behavioral economics can also be utilized to explain results and finding from the field research, some of which may be counter-intuitive in neo-classical economic frameworks or models. Varying contexts have been and should be rightly focused on across health, education and agriculture sectors. Despite the evidence generated and valuable lessons learned, widespread application of evidence-based interventions is still elusive for developmental challenges. In the next post, we will explore how and why RCTs and field evidence should be an integral part of development discourse and practice.