The Washington Post, December 2014
Think about all the ways you used water in your daily routine this morning. You probably showered, brushed your teeth, used the toilet, washed your hands, all before making a cup of coffee with water whose safety you assumed without question. It is easy to forget that we didn’t always have such immediate access in the United States.
As we began to learn that these simple precautions kept us healthy, and in extreme cases, kept highly contagious diseases from decimating entire communities, this evidence informed our policies: today, businesses and schools require public restrooms, and urban infrastructure must meet pre-determined health standards for waste and sewage management. Prioritizing public access to safe drinking water, clean toilets, and hand washing facilities lead to laws that protect us daily, whether or not we realize it.
As a global health advocate, I believe in the power of policy. Policies can seem like pieces of paper tucked away on a shelf until we stop to consider how much they shape the fabric of our everyday lives. And I believe one of the most practical ways to promote healthy families and communities is through investment in safe drinking water, sanitation, and hygiene (WASH).
Our common need for WASH begins as soon as we are born, when sanitary conditions prevent infection in already vulnerable groups: mothers and new babies. Access to WASH is particularly vital in the first five years of a child’s life, when pneumonia and diarrhea – the leading killer diseases of children globally – pose the greatest threat to underdeveloped immune systems. In fact, if everyone had access to safe water, almost 90% of diarrhea deaths could be prevented.
WASH continues to play a protective role as a child develops. Without it, repeated bouts of diarrhea can threaten physical and cognitive development and exacerbate the effects of malnutrition. Without it, girls sacrifice education – and along with it, many future opportunities – in pursuit of water for their families. So much of a person’s – so much of a nation’s – ability to survive and thrive is contingent upon access to WASH.
In Camobodia, a village health volunteer educates mothers about basic hygiene practices.
In these ways and others, investments in WASH bolster broader global health efforts. For example, PATH’s diarrheal disease programs in Cambodia, Kenya, and elsewhere show that an integrated prevention and treatment approach yield the greatest results. In fact, the demonstrated value of incorporating WASH activities into these programs helped convince policymakers in these countries to include WASH as a key component of their national diarrheal disease policies.
Every $1 spent on WASH yields a $4 return on investment, and the Senator Paul Simon Water for the World Act represents an opportunity to stretch our dollars even further, all without spending extra money. It’s about working with what we have to improve coordination, target resources to the areas of most need, develop robust monitoring and evaluation systems to ensure sustainability, and integrate WASH with complementary programs like global health.
Staff from PATH's Washington, DC office joins the global toast to water.
I believe in policy, and I believe in the power of advocates to shape policy. Social media gives us unprecedented potential to spark change from our homes and workplaces. This month, raise a glass with PATH and others and say #cheerstoH2O in a virtual, worldwide toast to celebrate World Water Day and create momentum around the Water for the World Act.
When we toast, we say, “To your health.” And when it comes to water, I can’t think of a more appropriate sentiment.
Photo credits: PATHRead more
Pneumococcal disease prevention is a key component of the integrated effort to reduce child mortality from pneumonia and diarrhea—the two leading killers of children. The global health community is hitting these diseases from all sides with a suite of prevention and treatment interventions that leverage common resources, including immunization resources, to enhance efficiency and save more lives. Dr. Alderson sheds light below on the power of current and future pneumococcal vaccines to change the face of child health.
Pneumonia is a clever killer, responsible each year for the deaths of more than a million children under five years old, most of them in the developing world. If you want to know how serious this respiratory disease is, consider one fact: pneumonia kills more young children worldwide than any other disease.
Because pneumonia has many different causes, no one intervention is enough to outsmart it. We need a diverse set of defenses to beat pneumonia, and vaccines top the list as the most cost-effective means of prevention. If we’re to outwit pneumonia over the long term, however, the vaccines we have now must continue to evolve and improve.
Vaccination against the leading cause of pneumonia, the pneumococcus bacterium, is essential for controlling pneumonia. In fact, vaccines against pneumococcus help save thousands of children each year—children who likely would have died before these vaccines became available more than a decade ago.
Pneumococcus, however, is a complex bacterium, with more than 90 varieties that vary by region. As a result, prevention to date has required the development of complex vaccines. Pneumococcal vaccines available today use an elaborate and expensive manufacturing process that essentially combines vaccines for either 10 or 13 pneumococcal varieties into a single injection. While these vaccines are saving many lives, they do not provide universal coverage against all disease-causing pneumococcal strains. In addition, it’s hard for low-income countries to afford them.
At PATH, we’re advancing the next generation of pneumococcal vaccines to broaden protection against pneumonia—and to ensure accessibility for even the poorest children. One of these candidates, which we’ve developed in partnership with Boston Children’s Hospital, is an inactivated whole cell vaccine designed to generate immunity across virtually all pneumococcal strains. Moreover, it’s simple to manufacture, which translates to low overall costs.
Early-stage clinical evaluation in adults in the United States has already shown the whole cell vaccine to be safe and to elicit immune responses thought to be protective. Next, we’re planning to test the vaccine in adults and then children in a low-resource country. If the vaccine is eventually licensed, its affordability and broad coverage could make it a versatile option virtually anywhere in the world.
Pneumonia has killed with impunity for most of human history. But we’ve become smarter about how to fight it—especially through the use of vaccines. Adding a weapon like this new vaccine candidate to the arsenal could help us more quickly make widespread childhood pneumonia deaths a thing of the past, and help end pneumonia’s reign as the top childhood killer.Read more
Studies on the cost-effectiveness of rotavirus vaccines might sound like pretty dry pursuits. Though I find science fascinating, nothing makes my eyes glaze faster than talk of monetization and math. But when I learned about the paths that investigators tread to learn how a new vaccine will impact communities where diarrhea is a matter of life or death, I found out that cost-effectiveness has a pretty personal side.
I asked Deborah Atherly and Mercy Mvundura, both health economists at PATH, to share their experiences conducting these studies and explain why costing research is essential to vaccine advocacy and saving lives. They are currently conducting cost-of-illness studies on childhood diarrhea in Rwanda and Malawi.
What does cost-effectiveness mean in the context of new vaccine introduction?
Deborah Atherly: Cost-effectiveness analysis is a method to help decision-makers understand the true value of a vaccine; that is, what are the benefits, and how much does it cost to realize those benefits?
So a main objective is to gather data to make the case for new vaccines to policymakers.
DA: The data help them understand how important vaccination is, particularly in areas where vaccination rates are low. For example, we did a study in Senegal for Hib meningitis and found that the direct costs to families for one child’s illness literally equaled the average annual income. Yes, Hib meningitis is a more rare occurrence than childhood diarrhea—but not for the child who gets it, not for their family.
We were able to communicate this finding to the government, and they walked away saying, “Wow, we really need to make sure that people can access the Hib vaccine.” They were a bit startled by the cost.
A sad reality that we see in these studies, though, is that the people who show up to the hospital are the ones who can afford it. Who we’re missing are the kids who die because their families can’t afford care. That makes universal vaccination all the more important.
Mercy Mvundura: You see this in the studies that we’re doing, where you ask families about the sources of funds to pay for hospitalization, and you can see that even with a simple diarrhea hospitalization, they may have to sell assets, rely on support from their communities, borrow from relatives, or tap into savings—if they have them—in order to be able to pay for a hospitalization.
What are the steps to gather these data from families? Walk me through the study methods.
DA: In Rwanda and Malawi we are conducting cost-of-illness studies, working with the Ministries of Health, WHO and also in partnership with the US CDC and University of Liverpool, respectively, which are conducting disease surveillance. The CDC and Liverpool researchers identify all child diarrhea cases that come into a hospital. If their participants also consent to enroll in our study, our investigator asks caregivers a series of questions about how long a child’s been ill, where they were seen before the hospital, what costs they have incurred to date. These are clinic costs, but we also ask about transportation costs to get to the hospital.
When the child is in the hospital, we collect information from their medical record: the medications they were given, staff time in caring for them, lab tests. We try to cost out all parts of their hospital care.
MM: Afterwards, when they are discharged, we follow up with caregivers to understand how much they paid for the hospital visit and the sources of the money they used to pay. We also try and capture information around their economic status. We ask whether they missed work, how many days, what is their salary.
Finally, we collect data from the hospital billing department to bring it all together.
DA: Ideally, we want to determine, from start to finish, the average cost of treating a child for diarrheal disease. We break that down into household costs and costs borne by the government or system. Thanks to the parallel CDC and Liverpool studies, we will also know the rotavirus status, so we can stratify according to whether rotavirus or another cause is responsible for the diarrheal episode.
MM: We also can look at the length of hospital stay, to see whether it differs between children who are diagnosed with rotavirus versus other types of diarrhea.
How do you relate that back to explaining to a government how introducing rotavirus vaccine is going to offset these costs?
DA: We use this cost-of-illness data to discuss cost-effectiveness. Health and finance ministers have to consider how much a new vaccine is going to cost. But what they might not think about are the potential cost offsets. That’s the perspective that our data provide: a very quantitative estimate of the financial impact: reduced costs through introducing rotavirus vaccine.
We take the cost of vaccine minus the costs that would be offset to determine the total net cost of vaccine introduction. Then you put that into the equation against the actual benefits of the vaccine. We take our cost per hospitalization and multiply it by the number of hospitalizations averted, drawing from the surveillance data that the CDC and Liverpool are collecting. This helps us reach a financial estimate of what we think a country could save with universal, routine rotavirus vaccination.
Because Rwanda and Malawi have already introduced rotavirus vaccines, how are the data useful to them, and how are they useful to other countries?
DA: In a couple years, several countries will graduate beyond the GAVI Alliance subsidy for rotavirus vaccines and need to take on the full cost. As the bill goes up, Ministries of Finance will want to know, what is the value? Data on how many deaths can be averted speak volumes. Cost-effectiveness helps to show that. We also include information on how the demand for public health services will go down because fewer children are coming to the hospital with severe diarrhea. We make the case for keeping GAVI-funded vaccines in the public health system when the country’s investment costs increase.
In your research experiences, have there been findings that surprised you?
DA: When we ask what kind of work they are missing, many mothers say “childcare.” That is so much more real than I ever imagined. Families typically don’t just have one child. They have many children. If one is sick, then to take them to the hospital, which may not be down the street, they’re leaving their other children with someone else. Here, we think of it differently. We often can easily find care or pay someone to watch other children. These mothers have to make sacrifices we might not consider in terms of their other kids. We also find that many women won’t go to the hospital until the child is literally close to death, because it’s such a big sacrifice to leave, find care for the other children, and find the transport to get to the hospital.
MM: And our perspective is coming from a society that generally undervalues staying at home. When you start trying to quantify “productivity loss” for a primary caregiver, you may think to apply minimum wage, as opposed to someone who has a set salary.
Which most stay at home mothers would argue is not enough.
DA: Yes, exactly. That’s universal no matter where you live.Read more
What appealed to you about joining PATH?
I was a research scientist conducting large scale clinical trials mostly on vaccines. However, after the trial results were declared there was nothing more I could do in terms of advocacy, preparedness planning, and execution. As a public health person, I would like to see the introduction of the some of these critical vaccines in the national programs.
As the lead on the Multi-Country Japanese Encephalitis (JE) Project, how do you propose to shape the project? What kind of achievements are you expecting?
Since the JE vaccine has been pre-qualified (an approval issued by the World Health Organization (WHO)), there are several countries that would be willing to adopt the vaccine in their EPI program. However, most countries do not have robust surveillance system in place. Our first commitment will be to set this up in collaboration with WHO in countries like Myanmar, Indonesia, and Bhutan. For countries having proper surveillance in place, we will help them apply to GAVI to help afford the vaccines. For non-GAVI countries (like Philippines) we will need to have some innovative plans. We will also organize bi-regional meetings (via the WHO regional networks) for uniformity across the board. The final achievement will be strategies to ensure strong surveillance and introduction of the vaccines into the national program in JE endemic countries.
You are a well known expert on diarrheal diseases and cholera. Could you tell us about the GEMS research that you recently concluded?
It was a multi-country case-control study to identify the causative organisms of moderate to severe diarrhea in children less than 5 years of age. The study showed excess risk of infection (ERI) highest for rotavirus infection in all seven countries, followed by Shigella, cholera, etc. according to different age groups. The final objective of this study was prioritization of vaccine introduction in each country.
What kind of projects will you be handling in your new position at PATH?
Mostly challenging immunization issues – and supporting Indian authorities with technical help in the introduction of vaccines and formulating vaccination strategies for the national programs. These will include support in the form of manpower development, advocacy, micro- planning and related issues.
Do you think that leaders in India recognize the high toll of diarrheal disease?
Unfortunately no! Probably because it is seen as a disease of the poor and is not given enough importance. Also there is no glamour around those working with diarrheal diseases in comparison to some of the high profile health campaigns in the country.
What is needed to help everyone pay more attention to this challenge?
Proper surveillance data is needed to convince policy makers and advocacy for the available and affordable vaccines. Also scientists need to be more vocal in their approach to decision makers.
You have come from a respected Indian Government organization. What learning do you bring to PATH?
There are many issues which are beyond the capacity or purview of government organizations to resolve. This is where the role of agencies like PATH becomes so vital. PATH has to support and co-ordinate these activities with the government so that the public health services are delivered to the community efficiently and effectively.Read more
You’ve heard of shopping, of course. Clothes shopping, grocery shopping, even furniture shopping. But how many of you have ever thought about toilet shopping? Did you ever stop to wonder who picked out that light blue toilet in your neighbor’s house? Or that plain while toilet in your office building? How about the toilet in your very own home?
Until a few weekends ago, toilet shopping was not part of my repertoire. But now that my husband and I are renovating our house, I’m shopping for all sorts of interesting things – like toilets!
Luckily for us, there is a place for home renovators who need toilets – a bathroom emporium. Sinks! Toilets! Bath tubs! All there for you to test, try, and possibly make your own. While bathroom shopping at the emporium, we were able to test all sorts of toilets – high end, low end, modern, traditional.
While considering the color, shape, and model of our new toilet, I couldn’t help but think about PATH’s global health work. Part of our scope of work – like so many of our partners - includes a focus on reducing diarrhea and pneumonia morbidity and mortality, and a proven way to reduce these diseases is by improving access to sanitation and hygiene. But in the countries where we work and travel, how many people have access to improved sanitation, let alone a toilet emporium? How many toilet emporiums exist in Ethiopia? What about India? How many people can just point to a toilet and have it delivered to their home, confident that it will be connected to water and sewer and flushing in no time?
In how many countries could a woman unashamedly go toilet shopping with her husband? What I was able to do freely and without ridicule, many women would never dream. In many countries a husband or father makes decisions about family expenditures and whether or not a latrine is a valuable expense. Forget color and size, or choosing the modern model. In so many countries where we work, a standard latrine slab is the only choice. You either get one or you don’t.
I developed a new appreciation for the ease with which I can find a toilet or wash my hands – at home, at work, at a restaurant, or on a plane. Not every community needs a toilet emporium of their own, but every community does need access to clean, safe, hygienic sanitation facilities.
Next time you go to the bathroom, consider how comfortable you are. How high or low the toilet is. Whether it automatically flushes, or you have to face the grimy handle. And then consider the more than 2 billion people globally who don’t have this luxury. They’re unable to access any time of improve sanitation, let alone a self-flushing, shiny, new model. As we race towards 2015, the sanitation Millennium Development Goal looms far in the distance. What really matters are the millions of boys, girls, women, and men we need to reach with a toilet. A simple, clean, functioning toilet.
For more information:
-- PHOTOS: WaterAid in America sponsored a different kind of bathroom emporium to commemorate World Toilet Day.
-- You use the toilet every day; why not celebrate it every day? Download our Places We Go 2014 calendar.
-- PHOTOS: What if every time you flushed you could make a wish?Read more