Adetokunbo O. Lucas

World Report on Knowledge for Better Health: strengthening health systems

It is a painful irony that in parts of some developing countries, it is not uncommon for people to fall sick and die of diseases that can be easily prevented and treated. A simple solution of sugar, salt and water could save the lives of thousands of children who die of diarrhoeal diseases every year. Malaria kills hundreds of thousands of children who could have been protected by sleeping under insecticide-treated bednets or cured by the use of effective drugs. Lacking access to antiretroviral drugs, thousands of HIV-infected persons die prematurely. These and other examples illustrate the gap between existing knowledge and health technologies and their application. The authors of the World Report on Knowledge for Better Health have tackled the important question of how to close the gap between knowledge and its application in the health sector. The books five chapters (Learning to improve health, Towards a scientific basis for health systems, Strengthening health research systems, Linking research to action, Recommendations and action plan) present a well-argued and carefully illustrated case for the systematic use of knowledge derived from research. It draws on previous studies and reports that have addressed aspects of the problem and provides a useful synthesis of current thinking. The 1990 report of the Commission on Health Research for Development provided many of the seminal ideas and concepts on global health research. Follow-up initiatives by the Council on Health Research for Development (COHRED) and by the Global Forum for Health Research (GFHR) have extended the Commissions work. It would have been useful if the Report had highlighted the lessons that could be learned from these and other initiatives. For example, a critical review of COHREDs experience in strengthening national health research would have revealed to readers how the authors used those lessons to inform their proposed recommendations and action plan. The Report recommends a strengthening of national health research systems, with particular emphasis on strategic research, to facilitate the translation of advances in knowledge into effective intervention programmes. The authors point out that many developing countries do not provide appropriate financial support for health research. Not only does this severely limit the effectiveness of national scientists in these countries , but also more seriously, reflects a persistent failure among health officials to recognize how health research could facilitate better analysis of problems and more effective interventions. The complementary recommendations on strengthening health systems aim at ensuring …

Short textbook of public health medicine for the tropics

Health in the developing world Information for health Epidemiology Infections through the gastro-intestinal tract Infections through the skin and mucous membranes Infections through the respiratory tract Arthropod-borne infections Nutritional diseases Non-communicable diseases Policy, strategies and management of health services Family health Environmental health sanitation Health education International health collaboration.

New directions for WHO

Since its inception over 50 years ago, the World Health Organization (WHO) has earned trust and respect globally for its achievements as the lead agency for directing and coordinating international health work. Through technical cooperation and policy guidance, it promotes and coordinates international efforts to control major infectious diseases. The global eradication of smallpox and the imminent elimination of poliomyelitis are outstanding examples of its successful programmes. Less dramatic but also of great value are the Organizations activities in setting standards for vaccines and other biomedical products, and helping to define optimal strategies for disease control in various settings. In spite of significant gains in classical areas of disease control, however, some of the common infectious diseases still plague many developing countries. Furthermore, there is the constant threat of the emergence of new infections like HIV/AIDS and the recrudescence of old ones such as tuberculosis, not to mention the new danger that smallpox and other infectious agents could be used as weapons of biological warfare or terrorism. As the traditional health problems decline, WHO is taking on the growing challenge of chronic diseases--cancers, cardiovascular diseases, diabetes, etc.--which have become increasingly prominent causes of morbidity and mortality. WHO also makes significant contributions to the strengthening of health services. The Alma-Ata Conference in 1978, cosponsored with the United Nations Childrens Fund (UNICEF), generated a global consensus about primary health care as the key to health development, establishing the principle of equity as a requirement of social justice and the ethical basis of health systems. In collaboration with other development partners, WHO helps governments to improve their health services. It contributed to the analysis that led to the publication of the World Development Report in 1993, in which the World Bank raised a number of issues about health policy and planning with particular reference to cost-effectiveness and value for money. Following up the report, WHO has been refining methods for measuring the burden of disease and making financial analyses, using national health accounts. These new methods now feature in the process of health reform that many nations are currently undertaking with WHOs support. Where will the Organization go from here? It already has a full agenda, straining its limited resources, but it cannot ignore new, pressing challenges to global health. WHO will need to continue to play its role in technical cooperation for the control of specific diseases as well as providing guidance on the development and reform of health systems. The World Health Report (WHR) for 2000 clearly marks a new departure for the Organization. Going beyond the theoretical analysis of health and disease, the report confronted the controversial issue of the performance of national health systems. Using a combination of eight measures, it ranked countries on the basis of the attainment and performance of their health services. The publication generated fierce controversies, with critics challenging WHO on two main counts. Some questioned the quality of the data and the analytical methods on which WHO based its conclusions. …

Human resources for health in Africa

Better training and firm national policies might manage the brain drain A frican countries have a very low density health workforce, compounded by poor skill mix and inadequate investment.1 Yet trained healthcare staff continue to migrate from Africa to more developed countries. The World Health Organization has estimated that, to meet the ambitious targets of the millennium development goals, African health services will need to train and retain an extra one million health workers by 2010.2 It is too simplistic and misleading to define or try to resolve the crisis in human resources for health in Africa by looking only at overall numbers and density of workers, not least because these vary from country to country.3 4 Furthermore, the poor performance of health services in African countries is often compounded by shortages of drugs and other essential supplies, broken equipment, and poor …

A public-private partnership for malaria control: lessons from the Malarone Donation Programme

In 1996, Glaxo Wellcome offered to donate up to a million treatment courses annually of Malarone, a new antimalarial, with a view to reducing the global burden of malaria. The Malarone Donation Programme (MDP) was established the following year. Eight pilot sites were selected in Kenya and Uganda to develop and evaluate an effective, locally sustainable donation strategy that ensured controlled and appropriate use of Malarone. The pilot programme targeted individuals who had acute uncomplicated Plasmodium falciparum malaria that had not responded to first-line treatments with chloroquine or sulfadoxine-pyrimethamine. Of the 161 079 patients clinically diagnosed at the pilot sites as having malaria, 1101 (0.68%) met all the conditions for participation and received directly observed treatment with Malarone. MDP had a positive effect at the pilot sites by improving the diagnosis and management of malaria. However, the provision of Malarone as a second-line drug at the district hospital level was not an efficient and effective use of resources. The number of deaths among children and adults ineligible for MDP at the pilot sites suggested that high priority should be given to meeting the challenges of malaria treatment at the community level.

International collaboration in health research

There has been much interest in interna-tional collaboration in health research, especially when projects involve scien-tists from developed and developing countries. It is most valuable to replace suppositions, assumptions and anecdotal accounts that often feature in these dis-cussions with well-researched objective data such as that presented by Swingler et al. in this issue (pp. 511–517).The most successful examples of international research collaboration confer clear benefits to both contract-ing parties, and eventually to scientific progress in general. In an ideal case, the partnership produces a smooth dovetail-ing of skills and expertise. The partner from the developed country contributes expertise as well as sophisticated laborato-ry and other special resources that are not available in the less developed institution. Their peers in the developing country provide local clinical and other contextual knowledge. Contributions in kind from the host institution in the developing country complement the financial dona-tion from the developed country partner.While recognizing the potential value of such collaborative projects, there is justifiable concern about at-tendant risks and dangers. Because of the unequal power, there is the danger that the more powerful partners from the developed country could exploit the vulnerability of the developing country scientists and institutions: perhaps by focusing research on priority interests of the sponsoring foreign institutions rather than on the urgent needs of the host country. The study by Swingler et al. indicates that a high proportion of collaborative projects researched im-portant health problems in the region and that foreign sponsorship did not significantly divert scientists in African countries from their priority health problems, though the paper raises some concerns. The small number of projects

A tribute to Professor Ralph Hendrickse

The coincidence of a cluster of unrelated events made 1960 a memorable year in my personal life and professional career. It was in 1960 that I returned to Nigeria after 11 years’ sojourn in Britain; I had left home in 1949 as a teenager to study medicine at Durham University and did not return until I had graduated in medicine and completed postgraduate training in internal medicine, public health and tropical medicine. In 1960, I began my academic and professional career at University College Hospital (UCH), the teaching hospital of the Faculty of Medicine of University College, Ibadan. With the opening of the new teaching hospital, this was the first year in which medical students could complete their training in Ibadan. Before then, they had to go the United Kingdom for their training. In 1960, Nigerians shook off the shackles of colonial rule to become citizens of an independent nation. As I was reeling with the excitement of these and other events in 1960, I met Ralph Hendrickse, a brilliant paediatrician from South Africa who was also working at UCH. This was the beginning of a relationship that developed and grew over many decades. I knew Ralph Hendrickse as a highly skilled clinician, an erudite scholar and scientist, a valuable mentor, a credible role model, and, above all, a good friend. He was well respected for his great skill as a clinician, providing high-quality medical care to sick children. Under his leadership, the institution developed effective teams of paediatricians who learned from him and sought to emulate his skill and dedication to patient care. Our family was most grateful to him in the dramatic case of my niece, born prematurely weighing just under 2 pounds. Under Ralph’s skilful care, our precious niece survived and thrived. She graduated from an American university and now has four grown-up children of her own. Through his research work, Ralph made major contributions to knowledge. His studies on sickle cell disease was the subject of his MD thesis. In later years, he explored the role of aflatoxins in the pathogenesis of kwashiorkor. I had the privilege of working closely with him on a major project on malaria prophylaxis using pyrimethamine alone and in combination with sulphormethoxine or with dapsone. In this double-blind comparative trial, around 300 children were monitored over a 1-year period. Wellcome Research Laboratories used these data in the process of registering two new antimalarial drugs: Fansidar (pyrimethamine with sulphormethoxine) and Maloprim (pyrimethamine with dapsone). Noting my interest in deep mycotic infections, Ralph ensured that I was given the opportunity to see children who were admitted to the children’s wards with these infections; he also gave me permission to include these cases in my scientific publications. Ralph Hendrickse was a wise adviser. In 1962, I had to make a life-changing decision at a critical stage in my professional and academic career. I was This is based on a lecture given at a seminar held at the Liverpool School of Tropical Medicine on 5 November 2010 to commemorate the life and work of Professor Ralph G. Hendrickse who died on 6 May 2010. Ralph Hendrickse was Dean of the Liverpool School of Tropical Medicine and Professor of Tropical Paediatrics and International Child Health at the University of Liverpool. Correspondence to: A O Lucas, Department of Global Health and Population, Harvard University, Cambridge, Massachusetts, USA. Email: ADELUCAS@aol.com Ralph Hendrickse congratulating me as I received the Mary Kingsley award at The Liverpool School of Tropical Medicine

Introductory remarks: History of the Prevention of Maternal Mortality Network

I am very happy to be here today as this represents the birth of a new baby. I have been associated with the Prevention of Maternal Mortality Ž . PMM Network for almost a decade, from its conception through many years of its gestation, and now we are all here to have the results delivered to us over the next few days. I should honestly admit that I have not been an active participant in this program. The work has been done by the group at Columbia School of Public Health and the Network of centers in West Africa. My role has been that of a spectator, standing on the sidelines, watching, cheering and encouraging the teams. The spectators have their uses } or can one imagine a football match without spectators? I am happy to congratulate all the active participants on their hard work. I do not intend to give an objective, dispassionate account of PMM. I have been too close to it. Rather, I will present a personal, emotional account. Until a decade ago, my main professional