Sarah B. Macfarlane

A scandal of invisibility: making everyone count by counting everyone

Summary Most people in Africa and Asia are born and die without leaving a trace in any legal record or official statistic. Absence of reliable data for births, deaths, and causes of death are at the root of this scandal of invisibility, which renders most of the worlds poor as unseen, uncountable, and hence uncounted. This situation has arisen because, in some countries, civil registration systems that log crucial statistics have stagnated over the past 30 years. Net of debt relief, official development assistance reached US

Iron supplementation increases prevalence and effects of malaria: Report on clinical studies in Papua New Guinea

80 billion in 2004. Yet because of the weakness in recording vital statistics, we have little authoritative evidence that these funds have their desired effects on either mortality or poverty reduction. Sound recording of vital statistics and cause of death data are public goods that enable progress towards Millennium Development Goals and other development objectives that need to be measured, not only modelled. Vital statistics are most effectively generated by comprehensive civil registration. Civil registration has a dual function, both statistical and legal; it also helps with economic development. 30 years of stagnation will not be overcome quickly, although new efforts to develop national statistical capacities offer a unique opportunity to refocus attention on civil registration. Now is the time to make the long-term goal of comprehensive civil registration in developing countries the expectation rather than the exception. The international health community can assist by sharing information and methods to ensure both the quality of vital statistics and cause of death data, and the appropriate use of complementary and interim registration systems and sources of such data. The continued cost of ignorance borne by countries without civil registration far outweighs the affordable necessity of action.

In the Name of Global Health: Trends in Academic Institutions

A placebo-controlled trial of intramuscular iron dextran prophylaxis for two-month-old infants was carried out on the north coast of Papua New Guinea where there is high transmission of malaria. The results indicate that the placebo group became relatively iron deficient whereas the iron dextran group had adequate iron stores and, in the absence of malaria, a higher mean haemoglobin. However in the iron dextran group there was a higher prevalence of malaria, as judged by parasite and spleen rates at 6- and 12-month follow-up; a lower haemoglobin associated with malaria when compared with the placebo group and a greater reticulocytosis in response to malaria infection. Within the placebo group it was noticed that the malaria rates were lower at follow-up in those infants who had had a low birth haemoglobin. In neither group was there apparent suppression of marrow activity in the presence of malaria. Malaria infection in both groups was associated with a significantly raised serum ferritin level and transferrin saturation. Over-all these data give evidence for a protective role of iron deficiency against malaria and would argue against the injudicious use of iron replacement in areas where malaria is endemic.

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey.

This paper describes accelerating development of programs in global health, particularly in North American academic institutions, and sets this phenomenon in the context of earlier programs in tropical medicine and international health that originated predominantly in Europe. Like these earlier programs, the major focus of the new global health programs is on the health needs of developing countries, and perhaps for this reason, few similar programs have emerged in academic institutions in the developing countries themselves. If global health is about the improvement of health worldwide, the reduction of disparities, and protection of societies against global threats that disregard national borders, it is essential that academic institutions reach across geographic, cultural, economic, gender, and linguistic boundaries to develop mutual understanding of the scope of global health and to create collaborative education and research programs. One indication of success would be emergence of a new generation of truly global leaders working on a shared and well-defined agenda – and doing so on equal footing.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.

Aflatoxins and kwashiorkor: a study in Sudanese children.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap

Blood and urine samples from 252 Sudanese children were investigated for their aflatoxin content by high-performance liquid chromatography. The children comprised 44 with kwashiorkor, 32 with marasmic kwashiorkor, 70 with marasmus, and 106 age-matched, normally nourished controls. Aflatoxins were detected more often and at higher concentrations in sera from children with kwashiorkor than in the other malnourished and control groups. Aflatoxicol, a metabolite of aflatoxins B1 and B2, was detected in the sera of children with kwashiorkor and marasmic kwashiorkor but not in the controls and only once in a marasmic child. The difference between children with kwashiorkor or marasmic kwashiorkor and those in the control or marasmus groups was significant. Urinary aflatoxin was most often detected in children with kwashiorkor but their mean concentration was lower than in the other groups. Aflatoxicol was not detected in urine in any group. These findings suggest either that the children with kwashiorkor have a greater exposure to aflatoxins or that their ability to transport and excrete aflatoxins is impaired by the metabolic derangements associated with kwashiorkor. The presence of aflatoxicol in the sera of children with kwashiorkor but not in the others suggests a difference in metabolism between the two groups. Further studies are needed, and measurement of aflatoxins in the food eaten by these children is already underway.

Public health in developing countries

BACKGROUND The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality. METHODS This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Africa using aggregate data from the Service Provision Assessments and Demographic and Health Surveys of five countries: Ghana, Kenya, Rwanda, Tanzania and Uganda. For hospitals and health centres, competency was assessed in six areas: basic infrastructure, equipment, medicine storage, infection control, education and quality control. Percentage of compliant facilities in each country was calculated for each of the six areas to facilitate comparison of hospitals and health centres across the five countries. RESULTS The percentage of hospitals with dependable running water and electricity ranged from 22% to 46%. In countries analysed, only 19-50% of hospitals had the ability to provide 24-hour emergency care. For storage of medication, only 18% to 41% of facilities had unexpired drugs and current inventories. Availability of supplies to control infection and safely dispose of hazardous waste was generally poor (less than 50%) across all facilities. As few as 14% of hospitals (and as high as 76%) among those surveyed had training and supervision in place. CONCLUSIONS No surveyed hospital had enough infrastructure to follow minimum standards and practices that the World Health Organization has deemed essential for the provision of emergency and surgical care. The countries where these hospitals are located may be representative of other low-income countries in sub-Saharan Africa. Thus, the results suggest that increased attention to building up the infrastructure within struggling health systems is necessary for improvements in global access to medical care.

Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries

Poverty not only excludes people from the benefits of health-care systems but also restricts them from participating in decisions that affect their health. The resulting health inequalities are well documented, and the search for greater equity attracts many concerned players and initiatives. Fundamental to the success of these efforts, however, is the need for people to be able to negotiate their own inclusion into health systems and demand adequate health care. This calls for a restatement of the centrality of people in public health and its practice. New forms of communication and cooperation are required at all levels of society, nationally, and internationally, to ensure equitable exchange of views and knowledge to formulate appropriate action to redress inequalities and improve peoples health and wellbeing.

Tanzania's health system and workforce crisis

In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.