MSF Video: Could Antibiotic Resistance Threaten Public Health?

Thursday, June 25, 2015

This short video by Doctors Without Borders/Médecins Sans Frontières (MSF) examines antibiotic resistance and how it could threaten global public health. While most of their videos spotlight their own work in various countries or conflicts, they occasionally create pieces like this one that are more generally informative, which I like.

China bans Ramadan observances in Xinjiang region

Thursday, June 18, 2015

In a move that should surprise no one, China has once again declared its annual ban on observances of Ramadan, the Islamic holy month during which the faithful are called to fast during daylight hours and encouraged to pray and recite the Qur'an. Remaining true to its troubled history with religion in general, and Islam in particular (due to the perpetual unrest in the mostly Muslim Xinjiang province), the Chinese government has banned the observance of the lunar month in schools and by government employees, with particular emphasis on fasting:
Most Muslims are required to fast from dawn to dusk during the holy month, which began on Thursday, but China's ruling Communist party is officially atheist and for years has restricted the practice in Xinjiang, home to the mostly Muslim Uighur minority.

"Food service workplaces will operate normal hours during Ramadan," said a notice posted last week on the website of the state Food and Drug Administration in Xinjiang's Jinghe county.

Officials in the region's Bole county were told: "During Ramadan do not engage in fasting, vigils or other religious activities," according to a local government website report of a meeting this week.
As in previous years, school children were included in directives limiting Ramadan fasting and other religious observances.

The education bureau of Tarbaghatay city, known as Tacheng in Chinese, this month ordered schools to communicate to students that "during Ramadan, ethnic minority students do not fast, do not enter mosques ... and do not attend religious activities".
As with most government suppression, however, people find ways to quietly defy the ban:
Yet, Abdul Razzak and other Uighurs said the attempt to clamp down on religious expression has backfired in Kashgar, with more and more locals flaunting the restrictions.

Nearly every business in Kashgar's old city is closed during the hottest part of the afternoon when Al Jazeera visited this week during Ramadan. In the evening, throngs of young women in headscarves or full face veils pass signs posted at Kashgar's main hospital reminding them veiled women cannot enter.
"Sure, it's against the law to bring kids to the masjid [mosque], but we do it anyway," said Ghulam Abbas, a middle-aged Uighur man who makes a living selling fried fish on the main boulevard in the old city.
Asked if Uighurs are forgetting how to recite the Quran as a result, Abbas called his eight-year-old son over and, after some coaxing, convinced him to recite a chapter from memory. "They want to cut our children off from Islam," Abbas said. "We are not allowed to teach them the Quran, but we do, at home - secretly."

It is not the only restriction that is being ignored by the Uighurs in Kashgar.

"The Chinese don't want us to have kids, but we just pay fines or bribe people," says Abdul Razzak, who has five children - three more than allowed by law. His three extra children, two sons and a daughter, have cost him around 60,000 yuan ($9,670) in fines.

Sad Infographic of the Day: Violence against Children in Africa

Friday, June 5, 2015

I came across this infographic by the Economist yesterday afternoon. It visualizes recorded incidents of harm against children under age 16 from 2005 to present, color-coded according to the type of perpetrator. You can view all points together on the map or select a class of perpetrator to view just those data points. I have included a screen shot here.

The Economist describes the map as follows:
Some 353 separate attacks resulting in the death or physical harm of one or more under-16-year-olds have been recorded over the past decade, by the ACLED (Armed Conflict Location & Event Data) project. Incidents are concentrated around central Africa. Political militias, like Boko Haram in Nigeria or Anti-Balaka in the Central African Republic, have been responsible for the majority of attacks in each year since 2005, totalling 197 overall. Rebel forces, such as the Lord’s Resistance Army in central Africa, and ethnic militias have harmed or killed children in 57 and 45 separate incidents respectively. It is not only extralegal groups doing damage, however; in Egypt, Sudan and South Sudan government and mutinous forces—both military and police—are responsible for a large share of the violence against children.
This subject matter is too depressing for my usual "nifty infographic of the day" feature, so I went with sad ("horrible didn't seem right, either, since it's a decent-quality graphic).

New Lancet Paper Examines Scale-Up of #HIV Services for Bangkok #MSM

A paper in Lancet HIV on scaling up HIV testing and linkage to care among MSM in Bangkok grabbed the attention of the HIV and global health communities after it was published at the end of March. The study, funded by the World Bank and the Australian National Health and Medical Research Council, used HIV surveillance and service capacity data to model the costs of scaling up HIV services in Bangkok to achieve universal ART coverage. From the abstract:
An additional $55·3 million investment would link an extra 46 700 (30 300–63 200) MSM to HIV testing and 12 600 (8800–16 600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600–6700) HIV-related deaths and 3700 (2600–4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10 809 (9071–13 274) for each HIV-related death, $14 783 (12 389–17 960) per new infection averted, and $351 (290–424) per disability-adjusted life-year averted.
While I do not usually take an interest in cost forecasting studies (though I probably should), the study struck me because it pointed out how little Thailand spends on HIV prevention in MSM, despite the fact that they have a relatively high share of the HIV risk burden - and it is growing:
Although intervention programmes have effectively targeted female sex workers and people who inject drugs, the Thai national response to HIV in MSM has been largely neglected and, consequently, HIV prevalence in MSM was 20–30% in 2011, and has been increasing. Transmission by unprotected anal intercourse in MSM accounts for about 60% of 43 040 new HIV infections predicted in Thailand from 2012 to 2016...Despite this prediction, investment in prevention for MSM accounted for only 1·3% of the total budget in the 10th National HIV Plan.
I suspect that a large part of that is the relative political unpalatability of interventions targeting MSM - while it is easy to get stakeholder and donors to pitch in to "save" sex workers (e.g., through anti-trafficking initiatives), many are hesitant to get behind programs that reduce risk to MSM. However, MSM are consistently one of the groups at highest risk for contracting HIV - particularly in light of the heavy stigma they face for both their sexual orientation and (for positives) their HIV status.

Indeed, the study notes that "[i]f stigma and discrimination barriers can be reduced such that available infrastructure is used, then capacity is available to service all need." The infrastructure is already there! It is stigma and discrimination that present barriers to those at high risk from accessing services:
More importantly, because of persistent social stigma, MSM are often afraid of being seen by peers and discriminated against by health-care workers when receiving HIV tests. Stigma and discrimination are the most important barriers to the scale-up of services for MSM. Inconvenient operating hours of testing sites, concerns about confi dentiality, and non-friendliness of medical personnel are characteristic of the barriers to HIV testing.
Thailand certainly has a long way to go to service its populations at high risk for HIV, but it is certainly not unique in its challenges. Studies like this that provide a kind of "funding roadmap" are certainly helpful and encouraging. The one thing I was disappointed to see in the limitations section was the fact that the study did not distinguish between MSM who identify as men and transgender individuals (rather, it grouped them all together) - hopefully this can be an area of further research.

Nifty Infographic of the Day: The Internet is Replacing Print Media

Thursday, June 4, 2015

This infographic, courtesy of Statista, basically visualizes what we already knew: around the world, internet usage is on the rise at the expense of traditional (particularly print) media:
According to data published by ZenithOptimedia this week, people around the world now spend more than eight hours a day consuming media, with the Internet taking up an increasingly large chunk of total media consumption.

In 2014, people spent 110 minutes a day online, up from just 60 minutes in 2010. Meanwhile traditional media usage, i.e. TV, newspapers, magazines, radio and cinema declined from 402 to 376 minutes a day.

While television consumption fell by just 6% between 2010 and 2014, the print industry is suffering most from the new digital competition. Newspaper and magazine consumption dropped by 26% and 19%, respectively, since 2010 and is expected to see further declines in the next few years.
Infographic: The Internet Is Gradually Replacing Traditional Media | Statista

Another related infographic from Statistica earlier this year shows that the media being consumed (at least among Millenials) appears to be primarily entertainment - mostly because news is free and comes through your Facebook feed anyway:
It’s not that they don’t value information, according to the report it’s very important for them to stay informed, it’s the way they consume news that has changed fundamentally. While previous generations had to rely on newspapers and magazines to stay on top of current events, Millennials have a plethora of news sources at their disposal, many of them free and available at the touch of a finger. 82 percent of Millennials get most of their news from online sources with social media playing an increasingly important role. Facebook in particular is a popular tool to stay informed throughout the day, although dedicated news media remain the primary source for “hard” news topics such as the economy, foreign affairs and national politics.
Infographic: Millennials More Inclined to Pay for Entertainment Than for News | Statista

Insights from #IODC Last Week from @SunFoundation

Unfortunately, I was not in attendance, but I still followed last week's International Open Data Conference with some interest. (It helped that I was out of work at the University of Texas's Summer Statistics Institute, and I could be on my laptop during classes.) I spoke to one professor here on campus who described it as "preaching to the choir"; indeed, several attendees seem to have walked away with that impression.

This piece from the Sunlight Foundation came across my social media feed and struck me as particularly astute:
Openness of government is a value that NGOs, civic hackers, journalists and policymakers within this field want to work toward...However, we still haven’t gotten to the core of how we can use data to shake unjust power structures and make governments more effective and accountable. Skeptics have coined the term “open-washing” as attempts for governments to be perceived as open, while keeping all important decisions and actions closed. And, alongside many others, we commonly complain that “openness” always seems to end at high-value datasets by which governments may feel threatened.
It’s much easier to show the impact of a tool in terms of how many people used it than to show how open data has made citizens’ lives better and transformed government in the long term — and demonstrating value is something that both civil society organizations and governments are under constant pressure to do. Unfortunately, though, the impact of this work will not suddenly become visible overnight, especially given the problems we are trying to solve. At the core of it, we’re trying to use data to solve an age-old problem: How can government serve its citizen better?

When M&E falls short (and can even hinder): Scale-up dilutes impact of #HIV intervention among #sexworkers in India

Tuesday, June 2, 2015

My husband has taken an interest in ethnographic research after taking an Asian Ethnographies class last spring. As a data analyst and a quant-oriented person in general, I tend not to warm to qualitative research (particularly of the social sciences variety), but there are undoubtedly places where it is valuable. In some cases it can fill in the gaps that monitoring and evaluation cannot reach - and even highlight areas where standard M&E approaches fail and, sometimes, do more harm than good.

Last week, NAM aidsmap highlighted two such studies in India, one in Andhra Pradesh and one in Mumbai:
Two qualitative studies, investigating the implementation of a massive programme of HIV prevention through community mobilisation in India, have identified challenges to the rapid scale-up and roll-out of a programme in which grassroots action was meant to be central. While the programme was intended to empower sex workers to tackle the social conditions which made them more vulnerable to HIV, a more narrow focus on condoms and clinical services took over. This discouraged sex workers from getting involved in the programme.

Implemented in six Indian states with a high HIV burden, Avahan was one of the largest HIV prevention programmes ever delivered. It aimed to slow the transmission of HIV in the general population by raising the coverage of prevention interventions in high-risk groups such as female sex workers and men who have sex with men. Funded by the Bill & Melinda Gates Foundation, there was a strong emphasis on efficient delivery and scale-up of a defined package of interventions, in order to achieve saturation coverage. Monitoring and evaluation showed that this was achieved.
The Avahan programme aimed to replicate this success. But what happened in practice? Separate qualitative studies of the delivery of Avahan’s sex worker programmes in Andhra Pradesh and Mumbai have recently been published in Global Public Health and PLOS One respectively.
The original focus of the program was on community mobilization. Women who were well-connected and active in the community were engaged as peer workers who "not only distributed condoms, brought sex workers to clinics and provided sexual health information, but acted as community organisers to change conditions which produce HIV risk. They challenged police violence and harassment" and other conditions that contributed to HIV risk. They organized into community-based organizations and held rallies. However, when the program was transferred from the Gates Foundation to the Indian government and scaled up, these elements of the program were lost at the expense of more easily measured outcomes such as condoms distributed and clinic visits:
Less attention was given to community mobilisation, collectivisation and the formation of community-based organisations. While responding to incidents of police violence had been retained as a programme activity, the nature of the response changed. Rather than sex workers mounting a collective response, they were encouraged to approach existing public institutions such as the legal aid authority. In the end, sex workers faced with police or partner violence stopped involving the community-based organisations that Avahan had helped set up.

Whereas meetings had previously helped sex workers forge a sense of collective identity, there were now fewer structured opportunities for peer workers to meet with other sex workers or peer workers. Previously, sex workers had been interested in engaging with the community-based organisations, but the organisations’ new narrower health-focused remit felt less relevant.
These studies underscore why successful programs are holistic in nature. While "measurable" outcomes are important and necessary to demonstrate that a program is working (or not), a disproportionate emphasis on them can actually harm a program - in this case, implementers focused on them at the expense of the elements of the intervention that had real value to the target population. Qualitative and quantitative approaches must complement each other.