Monday, 31 January 2011

TUBERCULOSIS: Genetic Epidemiology of Tuberculosis Susceptibility: Impact of Study Design

Catherine M. SteinAs reviewed recently by Möller et al. [22], the body of work showing statistical associations between candidate genes and TB continues to grow. This does not include potential unpublished studies that failed to find significant associations and are not readily available due to publication bias [22]. Even in the published body of literature, however, there is a great deal of inconsistency between marker-trait associations, so we are far from reaching a consensus regarding genes involved in TB risk.

This review focused on methodological reasons for inconsistency across studies. One important factor is the diagnostic criteria for TB disease, which have differed dramatically across studies. Resources available for TB diagnosis differ by country, which is confounded when there has been conflict [72]. Differences in diagnostic criteria across studies can reflect differences in TB severity and may lead to misclassification of cases as controls; this would have a significant impact on the type I and type II error of studies. It is impossible to standardize the diagnostic definitions used across all study sites, but researchers should be mindful of such differences when interpreting their findings. We strongly recommend that researchers characterize the level of exposure to Mtb in individuals without disease, which should include TST/IGRA and careful epidemiological characterization. New studies could utilize the household contact design, which facilitates the characterization of all stages of Mtb exposure, infection, and disease [41]. When the household contact study design is not feasible, spousal controls are also ideal because of persistent and prolonged exposure.
Recall that TB follows two stages of pathogenesis, and LTBI precedes TB disease. Recent studies suggest that LTBI may have unique genetic influences [15], [28], [29]. Persons with LTBI constitute a major impediment to TB control efforts [73]. Since many ongoing vaccine development efforts will focus either preventing LTBI or progression to TB, it is important to understand host factors that influence containment of Mtb infection. However, the study of the genetics of LTBI is also not trivial. Indication of T cell memory response via positive TST and/or IGRA does not necessarily imply the presence of viable Mtb bacilli. In the US as well as other public health systems, individuals with positive TST are treated as though there are viable organisms present, adding further confusion to this phenotype. According to Parrish et al., there is a 2%–23% lifetime probability of developing TB after acquisition of Mtb infection (LTBI) [73]. This illustrates the heterogeneity in this clinical group, since the risk of progression to active TB may depend on a variety of known and unknown risk factors. Furthermore, prophylaxis of LTBI with isoniazid (INH) is the standard of care in many research settings, so that many individuals with “LTBI” based on positive TST/IGRA, genetically predisposed to develop TB, may not. One way to investigate the role of host genetics in LTBI would be to compare TST (or IGRA) positive individuals that develop incident TB to those that do not. Ideally, such a study would not include individuals on INH prophylaxis, though that is unethical in many settings. For these reasons, some may argue that it is more relevant to study TB genetics, and not LTBI, from a public health standpoint.
Thus, it is essential to take a multidisciplinary approach [74] to develop an all-encompassing picture of the natural history of Mtb infection and disease. Few studies have examined the genetics of TB immunology [15], [31], [75]–[77]. Gene expression studies using microarrays may also shed light on host responses to Mtb [78]. Proteomic studies will further elucidate host factors involved in pathogenesis. These various approaches should be analyzed together to hopefully identify more meaningful clinical groups. For example, genomic, proteomic, and immunologic data, collectively, may better capture the heterogeneity in latently infected individuals.
Additional complicating factors in comparing geographically diverse studies are potential population substructure and LD differences among populations. We recommend that future studies analyze enough SNPs to capture LD in their study population. Analyses of a few markers within a gene no longer advance the field, particularly in light of LD differences between populations. Even with advances in genotyping, many studies of “old” markers continue to be published. The choice of a reference population for tag SNP selection is not trivial [62]; thus, dense SNP mapping may be necessary, particularly in studies of African populations. If it is impossible to rigorously examine genes in this way, publishing the LD patterns in the study data [28], [45], [48], [49] is a good start. Furthermore, studies in admixed populations should attempt to examine population substructure to minimize this source of bias. Populations also differ in the Mtb strain lineage that caused TB; future studies examining host gene by Mtb gene interaction are warranted. Finally, as in all genetic epidemiological studies of complex traits, genes may act in complex ways. Genes may interact with other genes and/or epidemiological factors; these potential relationships should not be overlooked. Furthermore, too many researchers (authors and journal reviewers alike) focus too much on p-values. All p-values must be reported, even if greater than 0.05. Markers with p-values greater than 0.05 may still be important in their interaction with other markers or environmental factors. Researchers should collect sufficient data to explore these meaningful biological effects.
There are GWAS of TB forthcoming. Given the issues discussed in this review, we must interpret the findings of those GWAS cautiously. Will these studies be underpowered due to the heterogeneity among TB cases and controls? A recent summary analysis of published GWAS found the reported SNP–trait associations attaining significance (p<10−5) had a median odds ratio of 1.33, with an interquartile range of 1.20–1.61 [54]; thus, the effect sizes of SNPs identified through GWAS are relatively small. Furthermore, the proportion of heritability explained by these variants ranges between 1% and 50% [79]. TB GWAS may provide new clues into the host biology of TB pathogenesis, but the overall clinical relevance of these SNPs will be limited. In addition, GWAS of other complex traits have often merged data across ongoing research studies. Because of the dramatic heterogeneity among studies described in this review, meta-analyses of TB genetic association studies should be conducted with care.
In sum, we have barely scratched the surface in understanding the genetic determinants of TB pathogenesis. Because of the significant public health impact of TB, additional studies are necessary, and should be multidisciplinary in nature. Future studies should carefully consider phenotype definition and genetic epidemiological principles when designing, analyzing, and interpreting findings. Ideally, culture confirmation for pulmonary TB should be conducted where feasible, thorough epidemiological data should be collected in individuals without TB to better understand LTBI and risk of progression to TB, and population genetic factors should be carefully characterized and considered in the analysis.

TUBERCULOSIS: Partners In Health -- Russia

-  Laboratory in Tomsk

-  Doctor with TB patient

Partners In Health's work in Russia has a narrower medical focus over a vastly wider geographical area than any of our other projects. From a base in the region of Tomsk Oblast, Siberia, PIH has been working since 1998, in collaboration with the Russian Ministry of Health, to combat one of the world's worst epidemics of drug-resistant tuberculosis (MDR-TB). In partnership with the Division of Social Medicine and Health Inequalities (DSMHI) at the Brigham and Women’s Hospital, PIH has focused on improving clinical services for MDR-TB patients in Tomsk while undertaking training and research to catalyze change in treatment of MDR-TB across the entire Russian Federation.
Partners in Health began working with local clinicians to improve treatment of MDR-TB in Tomsk in 1998. Our joint effort got a major boost in 2004, when we assisted our partners in Tomsk in securing a five-year $10.8 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria for efforts to improve prevention, diagnosis and treatment of TB and MDR-TB. Key components of our clinical effort include improving diagnostics in order to detect cases earlier, developing a comprehensive strategy to promote adherence among patients, improving infection control in hospitals and clinics and decreasing transmission of TB to HIV-positive patients. Our work in Tomsk also encompasses health education for the public and clinical and program management training for medical personnel in Tomsk.
Even before receiving the Global Fund grant, PIH had expanded its responsibilities to provide training for healthcare professionals and to advocate for institutional change at the federal level. Drawing on financial support from the Eli Lilly and Co. Foundation, PIH’s training program for MDR-TB program managers and physicians has played an integral role in catalyzing change within the Russian TB services. To date, PIH has led training sessions for 215 physicians, representing three quarters of the territory of the Russian Federation. By 2008, PIH and DSMHI are on course to train 325 physicians and program managers, covering the entire territory of Russia, from the Baltic to the Pacific.
PIH has also organized an exchange program at the Harvard School of Public Health’s Program in Clinical Effectiveness that enrolls several promising Russian medical professionals every year. The first two students earned their Masters degrees in Public Health in 2006, and are now spreading their knowledge as lecturers at Moscow Medical Academy, where they hope to establish a permanent faculty for epidemiology and biostatistics.
Research carried out with data collected from the first two cohorts of MDR-TB patients treated in Tomsk has had a significant impact on discussions and decisions about MDR-TB treatment throughout Russia, other parts of the former Soviet Union and beyond. One study showed that very high rates of treatment success could be achieved in Russia using the WHO's pilot DOTS-Plus strategy that adds treatment for MDR-TB to the standard Directly Observed Therapy Short-course (DOTS) regiment for non-resistant TB. Another demonstrated that providing DOTS-Plus treatment for MDR-TB patients did not undermine treatment of drug-susceptible TB, as some experts had feared. In fact, the results suggested that integrating DOTS-Plus treatment for MDR-TB may strengthen the standard DOTS program. A third study showed that the greatest risk factor by far for development of MDR-TB was hospitalization, not failure to adhere to treatment. These findings are likely to lead to a reevaluation of the role of hospitalization versus community-based TB treatment in Russia.
The Tomsk research and the Russian-language edition of PIH's guide to treatment of MDR-TB treatment guide have had a significant influence on a High Level Working Group convened by WHO and the Russian Ministry of Health that has helped shape the MDR-TB portion of Russia's national TB treatment guidelines. And research findings from Tomsk also helped inform new global guidelines for treatment of MDR-TB that were released in May 2006, backed by the WHO, the US Centers for Disease Control and Prevention, PIH and other leading agencies in efforts to stop TB. The new guidelines were accompanied by a call to scale up treatment rapidly worldwide, from 16,000 patients in 2006 to more than 800,000 a decade later.

TUBERCULOSIS: Locating people most at-risk for developing tuberculosis in Siberia.


Laboratory in Strezhevoy tests for HIV and MDR-TB.

Recently, PIH-Russia (Partnwers in Health) strengthened its proactive tuberculosis program in Strezhevoy, a town of 45,000 people located about 400 miles north of PIH’s first Russian program in Tomsk City. Isolated by hundreds of miles of tundra, the town is defined by its Siberian culture, the large oil-based production companies that employ much of the city’s workforce, and one of highest incidence rate for HIV and co-infection of tuberculosis HIV and tuberculosis (TB) in that region of Russia. Making matters worse, a disproportionate number of people are developing multidrug-resistant TB (MDR-TB).
Nationwide, Russia reports 85.1 cases of TB for every 100,000 people, compared to only five per 100,000 in the United States. In Tomsk Oblast, where Strezhevoy is located, the number tops 101.5 new cases per 100,000. Additionally, about 13 percent of new TB cases are MDR-TB in Tomsk Oblast. Moreover, curbing the rate of TB in regions like Strezhevoy has been difficult, due in part a high rate of intravenous drug use and its isolation.
In order to reverse these trends, PIH-Russia refined an algorithm used to identify HIV patients who are most at risk of contracting TB. A preventive strike against TB and MDR-TB.
The team used information collected and analyzed over the past decade to create the algorithm. The formula relies on the results of the TB testing, patients’ CD4 count, their exposure to TB, and other factors.
Once identified using the formula, the patients are put on an intense anti-TB drug regimen called Latent TB Infection (LTBI) chemoprophylaxis. They will take the drugs for four months, three times a week, under the direct observation of medical staff. To encourage patients to take care of themselves while on the regimen, they receive food packages during the course of treatment.
If a patient is not able to visit the nearest treatment facility, PIH medical workers will visit the patient in their home as part of the organization’s “Hospital at Home” project.
The goal: prevent people from contracting a disease that is often painful, and for people living with HIV, deadly.
Preventing the spread of TB not only spares the patient, but also reduces the threat of transmitting the disease within the larger community.

TUBERCULOSIS: Limited diagnostic resources

In 2009, 1.7 million people died from tuberculosis (TB)—equating to 4,700 deaths a day—including 380,000 people living with HIV. TB remains the most common cause of death in people living with HIV and compared to people without HIV, people living with HIV are more than 20 times more likely to develop TB. Furthermore, TB infection may occur at any stage of HIV disease and is often the initial presentation of underlying HIV infection. Without antiretroviral treatment, up to 50% of people living with HIV who are diagnosed with TB die during the 6–8 months of TB treatment.

Although antiretroviral treatment can reduce the incidence of TB both at the individual and population level, people living with HIV on antiretroviral treatment still have higher TB incidence rates and a higher risk of dying from TB. Therefore, the World Health Organization recommends regular screening for active TB disease in all people living with HIV, so those identified as having active TB disease can be provided with appropriate treatment, and isoniazid preventive therapy (to help mitigate TB morbidity, mortality, and transmission) can be given to vulnerable individuals who do not yet have active TB.

Why Was This Study Done?
There is currently no internationally accepted evidence-based tool to screen for TB in people living with HIV—a serious gap given that the presenting signs and symptoms of TB in people living with HIV are different from those in people without HIV. Therefore, the researchers aimed to develop a simple, standardized TB screening rule for resource-constrained settings, on the basis of the best available evidence that would adequately distinguish between people living with HIV who are very unlikely to have TB from those who require further investigation for TB disease.

What Did the Researchers Do and Find?
The researchers selected 12 studies that met their strict criteria, then asked the authors of these studies for primary data so that they could map individual-level data to identify five symptoms common to most studies. Using a statistical model, the researchers devised 23 screening rules derived from these five symptoms and used meta-analysis methods (bivariate random-effects meta-analysis) and the association of study-level and individual-level correlates (hierarchical summary relative operating characteristic curves) to evaluate the sensitivity and specificity of each tool used in each individual study.
The authors of the selected studies were able to provide data for 29,523 participants, of whom 10,057 were people living with HIV. The dataset included 9,626 people living with HIV who had TB screening and sputum culture performed, of which 8,148 individuals could be evaluated on the five symptoms of interest from nine of 12 studies. TB disease was diagnosed in 5.8% of people living with HIV and the best performing rule was the presence of any one of the following: current cough (any duration), fever, night sweats, or weight loss. The overall sensitivity of the rule was 78.9% and the specificity was 49.6%. However, the sensitivity of the rule increased to 90.1% among participants selected from clinical settings and to 88.0% among those who were not previously screened for TB.

What Do These Findings Mean?
The results of this study suggest that in resource-constrained settings, the absence of current cough, fever, night sweats, and weight loss (all inclusive) can identify those people living with HIV who have a low probability of having TB disease. Furthermore, any one of these symptoms can be used in resource-constrained settings to identify people living with HIV who are in need of further diagnostic assessment for TB.
Despite the limitations of the methodology used in this study, until there are evidence-based and internationally recommended guidelines for the diagnosis and treatment of TB in people living with HIV, use of the algorithm developed and presented in this study could result in earlier TB diagnosis and treatment for people living with HIV and could help to substantially scale-up isoniazid preventive therapy

TUBERCULOSIS: Rwanda to launch free immunization campaign against TB

KIGALI, Jan. 26 (Xinhua) -- Rwanda will on Monday launch a nationwide immunization campaign against tuberculosis for 3 million children in a bid to eradicate the disease, considered as one of the leading causes of child mortality in developing nations. The campaign will focus on children ages eight months to 12, Dr Richard Sezibera of Rwanda's Ministry of Health said in a press release on Tuesday.
"Immunization against tuberculosis is necessary to prevent a high infant mortality rate in Rwanda," the statement added.
A total of 1,769 TB cases were reported in the tiny Central African nation during the second quarter of 2010, according to statistics made available by the government's Treatment and Research on HIV/AIDS Center.

TUBERCULOSIS: ‘7,000 Nigerians have drug-resistant TB’

Sade Oguntola : 27 January 2011
National Coordinator, National Tuberculosis and Leprosy Control Programme, Dr Mansur Kabir said at least 7,000 Nigerians had contracted a form of Tuberculosis (TB) that does not respond to the usual drugs for treating TB.

Dr Kabir stated this during a 2-day national training for doctors, nurses and general health workers on clinical and programmatic management of Multidrug Resistant Tuberculosis (MDR-TB), held in Ibadan.
Dr Kabir declared that many patients were discovered to have developed the MDR-TB in a survey being undertaken in the country, thus the Ministry becoming actively involved in ensuring increased access to treatment for MDR-TB.
According to him, “with the support of partners like USAID and CDC, we are working assiduously to improve our diagnostic capacity, to identify patients with MDR-TB as well as ensure the availability of required drugs for their treatment.”
Dr Kabir, disclosing that only one centre at University College Hospital (UCH), Ibadan, was treating MDR-TB cases, stated that more centres were expected to start operation in Calabar, Lagos, Zaria and Kano before the end of 2012.
He attributed the delay in commencement of treatment for MDR-TB at other zones of the country to the difficult nature of diagnosing and treating this form of TB, its expensive cost as well as the required expertise to man such facilities.
Dr Kabir, while expressing his displeasure on people selling anti-TB drugs that were meant to be free, stated that the Health Minister, Professor Onyebuchi Chukwu had written to the Inspector of police in order that punitive measures might be taken on the issue.
While declaring that Private-Public-Partnership was important in ensuring all cases of TB receive adequate care, he solicited for better documentation of TB distribution at the local government levels and health facilities to ensure adequate care is available for TB.
Dr Kabir advised persons with TB to ensure they adhere to their treatment while individuals protect themselves from contracting TB by living in well ventilated rooms, eating good diet, seeking medical care when coughing, shun smoking, maintain good hygiene as well as ensure that all babies receive the BCG vaccine to protect them from TB.
Currently, about 500,000 cases of MDR-TB cases occur yearly in the world and about 3 per cent are properly treated because diagnosis of MRD-TB is new and the required drugs are expensive.
Nigeria has the highest case of TB in Africa and it is estimated that about 450,000 new cases of TB occur yearly in Nigeria. However, only 94,000 of these TB cases were detected last year. Children and pregnant women are more vulnerable to contracting TB because of their immunity level.

TUBERCULOSIS: The variation in virulence between distinct M. tuberculosis strains

Author: Hiwa MalenGustavo De SouzaSharad PathakTina SoftelandHarald Wiker
Credits/Source: BMC Microbiology 2011, 11:18

The potential causes for variation in virulence between distinct M. tuberculosis strains are still not fully known. However, differences in protein expression are probably an important factor. In this study we used a label-free quantitative proteomic approach to estimate differences in protein abundance between two closely related M. tuberculosis strains; the virulent H37Rv strain and its attenuated counterpart H37Ra.

Results: We were able to identify more than 1700 proteins from both strains.
As expected, the majority of the identified proteins had similar relative abundance in the two strains. However, 29 membrane-associated proteins were observed with a 5 or more fold difference in their relative abundance in one strain compared to the other.
Of note, 19 membrane- and lipo-proteins had higher abundance in H37Rv, while another 10 proteins had a higher abundance in H37Ra. Interestingly, the possible protein-export membrane protein SecF (Rv2586c), and three ABC-transporter proteins (Rv0933, Rv1273c and Rv1819c) were among the more abundant proteins in M. tuberculosis H37Rv.

Conclusion: Our data suggests that the bacterial secretion system and the transmembrane transport system may be important determinants of the ability of distinct M.tuberculosis strains to cause disease.

TUBERCULOSIS: Potential cost-effectiveness of a vaccine

Chia-Lin TsengOlivia OxladeDick MenziesAnne AsplerKevin Schwartzman
BMC Public Health 2011, 11:55

The development of a successful new tuberculosis (TB) vaccine would circumvent many limitations of current diagnostic and treatment practices. However, vaccine development is complex and costly.

We aimed to assess the potential cost effectiveness of novel vaccines for TB control in a sub-Saharan African country - Zambia - relative to the existing strategy of directly observed treatment, short course (DOTS) and current level of bacille Calmette-Guerin (BCG) vaccination coverage.

Methods: We conducted a decision analysis model-based simulation from the societal perspective, with a 3% discount rate and all costs expressed in 2007 US dollars. Health outcomes and costs were projected over a 30-year period, for persons born in Zambia (population 11,478,000 in 2005) in year 1.
Initial development costs for single vaccination and prime-boost strategies were prorated to the Zambian share (0.398%) of global BCG vaccine coverage for newborns. Main outcome measures were TB-related morbidity, mortality, and costs over a range of potential scenarios for vaccine efficacy.

Results: Relative to the status quo strategy, a BCG replacement vaccine administered at birth, with 70% efficacy in preventing rapid progression to TB disease after initial infection, is estimated to avert 932 TB cases and 422 TB-related deaths (prevention of 199 cases/100,000 vaccinated, and 90 deaths/100,000 vaccinated).
This would result in estimated net savings of $3.6 million over 30 years for 468,073 Zambians born in year 1 of the simulation. The addition of a booster at age 10 results in estimated savings of $5.6 million compared to the status quo, averting 1,863 TB cases and 1,011 TB-related deaths (prevention of 398 cases/100,000 vaccinated, and of 216 deaths/100,000 vaccinated).
With vaccination at birth alone, net savings would be realized within 1 year, whereas the prime-boost strategy would require an additional 5 years to realize savings, reflecting a greater initial development cost.

Conclusions: Investment in an improved TB vaccine is predicted to result in considerable cost savings, as well as a reduction in TB morbidity and TB-related mortality, when added to existing control strategies. For a vaccine with waning efficacy, a prime-boost strategy is more cost-effective in the long term.

TUBERCULOSIS: Mozambique's new lab

Maputo — Mozambican Health Minister Alexandre Manguele on Wednesday re-inaugurated the country's main tuberculosis laboratory, remodelled and equipped with funding of over 1.5 million US dollars, provided by the United States Agency for International Development (USAID).

The National Tuberculosis Reference Laboratory is located within the grounds of Maputo Central Hospital, and is now equipped with the most recent technology for diagnosing tuberculosis, including drug resistant tuberculosis.
Speaking during the inauguration ceremony, Manguele said the laboratory will undertake specialist and reference diagnoses, and provide continual education for laboratory technicians. It will ensure quality control for microscope diagnosis, and surveillance for multi-drug resistant strains of the disease.
"Making this laboratory operational is a further determinant step for ensuring that the country's health policies are based on evidence generated nationally", he added.
Manguele warned that, in order to ensure sustainable growth in laboratory activities in Mozambique over the coming years, the country needs continual investments in human resources, equipment, up-to-date technologies, infrastructures and systems.
It was immediately necessary, he said, to strengthen the team working at the national reference laboratory, and to ensure regional tuberculosis laboratories in Beira and Nampula became operational,
The rate of prevalence of tuberculosis in Mozambique is 504 cases per 100,000 inhabitants, and Mozambique is in 19th position in the 22 countries that still have a high tuberculosis burden.
Data from 2007/2008 indicate that 3.5 per cent of new tuberculosis cases in Mozambique are caused by the multi-drug resistant strains of the bacterium. "To these statistics, which are alarming enough in themselves, we must add the fact that the tuberculosis epidemic runs in tandem with the HIV epidemic", said Manguele. "The association between HIV and tuberculosis has already become one of the major challenges for public health in southern Africa".
For his part, Todd Amani, Director of the USAID office in Mozambique, said he hoped the laboratory would contribute to improving the provision of public health services.
"Strengthening institutions such as the National Tuberculosis Reference Laboratory will help improve the prevention, diagnosis and treatment of tuberculosis, and increase the links from home care to hospital care, thus reducing the mortality and morbidity caused by tuberculosis, HIV/AIDS and other related diseases", said Amani.

Little Progress Made Against Tuberculosis : Disease challenges drug developers

Art Chimes : St. Louis, Missouri January 28, 2011
The last TB drug innovation with a completely new mechanism, was discovered almost a half-century ago.  Photo:
The last TB drug innovation with a completely new mechanism, was discovered almost a half-century ago.

Nearly 10 million new cases of tuberculosis are expected this year. The disease is more prevalent than ever, and the world's drug researchers don't seem to be making much headway.
Tuberculosis is a stubborn disease to treat. The current regimen for standard cases involves four different medicines taken over six months. More powerful medicines are needed for drug-resistant strains, and some varieties are hard to treat with any drugs.
Most recent tuberculosis drugs are variations on previous medicines. Anil Koul, a researcher with drug maker Johnson & Johnson, notes that the last TB drug with a completely new mechanism, rifampicin, was discovered almost a half-century ago. There are now just a handful of potential TB drugs in development, and some are variations of existing drugs, or scaffolds.
"With just nine drugs in the pipeline, with lots of resistance issues - some of these drugs being re-engineered scaffolds and with lots of post-approval failures in the drug industry, I think lots of work still needs to be done," he says.
Koul attributes the relatively small number of possible new tuberculosis drugs to complacency and a sense that progress was being made with existing drugs.
"The disease was in decline, people thought we eradicated it," Koul explained. "Then we stopped thinking about the disease and the innovation that was needed. This also had a knock-out effect on the funding, there was no funding available to really start any pharmaceutical projects, to really discuss innovative approaches for TB."
The United Nations has set eradication of tuberculosis by 2050 as one of its Millennium Development Goals. Koul says that would require speeding up drug development - moving from an underpowered economy sedan to a sports car is the analogy he used. But with most TB victims being among the world's poor and marginalized people, he said better drugs are only part of the answer.
"We need preventive measures. I think we also need proper access - how to bring these pharmaceuticals, which are currently in the pipeline, to these poor patients."
Those preventive measures, plus removing the social stigma of tuberculosis, says Koul.

POVERTY: Zimbabwe poverty line rises to $467 monthly for family of 5 - more than twice average govt pay

Angus Shaw
HARARE, Zimbabwe — Zimbabwean officials on Monday said it takes nearly $500 a month for families to be above the poverty line in this economically ravaged country, where most teachers and government workers earn less than half that amount.
The findings from the state statistics agency throw more weight behind the grievances of Zimbabwe's nearly 240,000 civil servants and other workers who plan to go on strike. Their average monthly incomes are around $200, well below what the agency says is now needed to support a family of five.
The former regional breadbasket is struggling to emerge from economic collapse and international isolation after President Robert Mugabe ordered the seizures of thousands of white-owned farms in 2000, disrupting the country's agriculture-based economy.
While Zimbabwe is no longer experiencing the world-record inflation of years past, the cost of living is still growing faster than most people's salaries.
In its latest bulletin, the agency Zimstat said a family of five needed a monthly income of $467 if it was to be defined as "not poor" and able to meet basic needs. That figure includes expenses for food, housing clothing, transportation, and education and health care.
The report did not account for one expense that appears to have become a necessity even for the poorest of the poor: mobile phones. Street vendors say they need phones to help them eke out a living buying and selling their wares.
A state regulatory body said more than two-thirds of the population — even beggars and street children — own 7 million mobile phones.

MALARIA: How do you solve a problem like Malaria?

January 27, 2011 by bramalingam [Big thanks to Alanna Shaikh and Bill Brieger]
Debates about malaria eradication in the aid blogosphere, along with recent scientific evidence, highlight the urgent need to improve our understanding of the complex dynamics of this terrible affliction and to use it to adapt ongoing eradication programmes.

A nearly hopeless case?
According to the WHO, one in every five childhood deaths in Africa is due to the effects of the disease and an African child has on average between 1.6 and 5.4 episodes of malaria fever each year. A child dies every 30 seconds of malaria. The latest estimate from the 2010 World Malaria Report is that in 2009 the disease killed almost 800,000 people and afflicted 225 million others. And while a 2009 global malaria risk map suggests that while risks are worst in Africa, there are clear indications of dangers in many other countries too.
Last week Chris Blattman posted a justifiably scathing response to an article in Guernica, which had suggested that attempts to eradicate malaria are ‘nearly hopeless‘, and that current global attempts to do so are doing more harm than good.
Chris put forward an eloquent and moving counter-argument which included the following points (a) disease eradication is one of the few successes of big aid (b) we can’t simply let malaria take its toll and do nothing (c) presenting malaria as a symbol of African honour – as the Guernica article does – is at best inaccurate and misleading and (d) development is the key to successful eradication.
Many (myself included) would agree wholeheartedly. Evidence suggests that the cessation of malaria control programmes can lead to severe epidemics, as in Swaziland in 1984-85, or Madagascar in 1987-88. Shortfalls in ongoing responses have also led to resurgences in Zambia and Rwanda. Much of what is presented in the Guernica article can be dismissed as bizarre, confused or just plain wrong. However, one point made is worth looking at in more detail.

Premature pronouncements and cheap mainstays
The author suggests that current approaches to malaria tend to be narrowly focused on a limited number of technical solutions, or the search for such solutions. Think bednets, drugs or the investment in the development of vaccines.
In fact, this narrowness in the focus of malaria programmes appears to have been a relatively constant feature over the last 40-50 years. In 1969, the Pearson Commission (the source of the ubiquitous 0.7% of GDP aid target for donor countries) pronounced the disease ‘virtually eliminated’. Today it is hard not to see this declaration alongside Chamberlain’s ‘peace for our time’ as one of the most premature statements ever (as well as a little disingenuous from the standpoint of developing countries).

A 2008 Lancet review cited in Malaria Matters tells us more about the failures of the first eradication effort:
[the 1960s eradication campaign] was far too monodimensional, relied too much on DDT [insecticide] spraying, and neglected the palpable problem that the delivery infrastructure was not in place in too many parts of the malarious world.”
It goes on:
The emergence of widespread mosquito resistance to DDT, and parasite resistance to the cheap mainstay of therapy compounded the difficulties.” (emphasis added)
In short, narrowness of responses allowed evolutionary dynamics to play out at various levels, changing the efficacy of those responses. This problem has not gone away. As clinical microbiologists Richard Carter and Kamini Mendis see it, for the most part, the types of tools that are available and are used for malaria control today are the same as those which were available during the ‘virtual elimination’ era.
This point does need some nuancing. There was one approved insecticide during the first eradication effort, whereas there are now a dozen. The use of treated nets – which weren’t around in the 1960s – has been responsible for large drops in some countries. But even in those countries there is growing acknowledgement of the need for a better combination of responses to make further progress. ‘Cheap mainstays’ will not do the trick. As noted on Malaria Matters:
The malaria lifecycle is complex, and health systems designed to deliver malaria interventions [are] equally complex (and challenging), which means we cannot and should not expect a magic bullet in the near future.
If we want to better understand the complexity of malaria, a good place to start would be to understand the evolutionary dynamics at play.

Exploring evolutionary dynamics
Resistance to responses – whether among mosquitoes or the parasite itself – has been identified as an evolutionary phenomenon. Biology 101 tells us that all populations of organisms display genetic variation across members which enable some to handle particular environmental stresses and opportunities better than others. Natural selection has been shown to favour the evolution of pathogen populations that can resist the drugs and insecticides in their environments.
As the Lancet article cited above notes, resistance has evolved at two distinct levels. The malaria parasite evolves, developing drug resistance. One team of researchers has found that “Drug development programs exhibit a high attrition rate and parasite resistance to… drugs exacerbate the problem. Strategies that limit the development of resistance and minimize host side-effects are therefore of major importance.”
Specific parasites also adapt at the molecular level, according to the antibodies encountered in the host’s immune system. There is also the prospect of inter-species infections, whereby – for example – parasites mainly responsible for malaria among chimpanzees find ways to adapt to new human hosts, facilitated by greater human penetration of forest environments.
Mosquitoes also evolve to adapt to changing physical environments, human behaviour and pesticides. As described by Bill Brieger on his excellent Malaria Matters blog:
…Resistance to insecticides in [a mosquito sub-species] is receiving increasing attention because it threatens the sustainability of malaria vector control programs in sub-Saharan Africa. An understanding of the molecular mechanisms conferring… resistance gives insight into the processes of evolution of adaptive traits and facilitates the development of simple monitoring tools and novel strategies to restore the efficacy of insecticides…”
There have been numerous calls for more studies into how insects exposed to pesticides undergo strong natural selection and develop various adaptive mechanisms to survive.
Of course, human populations have also have co-evolved with malaria, and developed different kinds of resistance. The protective effects of the sickle cell trait is certainly the best known example, but there are others that have been identified, including genetic variations in the populations of Thailand and New Guinea which prevent against malaria-induced miscarriages. However, humans adapt genetically less quickly than the malaria parasite or the mosquito – waiting for or relying human evolution of resistance (as the Guernica piece seems to imply) is clearly not an adequate fall-back option.
Professor Karen Day, who has studied the historical evolution of malaria, is clear about the importance of this line of inquiry:
…From Ronald Ross’s discovery that malaria is transmitted by mosquitoes came the idea that we could control malaria by impacting the life span of the mosquito. If we can better understand the evolution and diversity of malaria, we may find an Achilles heel in the parasite or new ways to thinking about control….”

Slow take-up, slow scale-up?
However, while there is some basic research attempting to bring an understanding of evolutionary dynamics to the design of better drugs, pesticides, and even vaccines, there are still questions as to whether this knowledge is ready to be applied in programmes and at the necessary scale. The overall global malaria response may still be relatively limited in terms of its repertoire of responses.
For example, a 2009 study notes that the Global Malaria Action Plan (GMAP) of the Roll Back Malaria initiative sought to spray 172 million houses annually, and distribute 730 million insecticide-impregnated bed nets. The study concluded that if this was implemented with existing insecticides, with no acknowledgement of the scope for evolutionary response, the program would create unprecedented opportunities for the development of resistance among mosquitoes, and may also create new variants of mosquitoes.
The World Malaria Report 2010 shows that global efforts to prevent malaria through bednets and sprays reduced cases from 233m in 2000 to 225m in 2009 and 985k deaths in 2000 compared to 781k deaths in 2009. However, tellingly, the statistics also show that several African countries saw a resurgence of the disease – in part because of resistance and changing contextual factors.
Researchers at Maastricht University have argued that a fundamental issue is that much malaria modelling does not take into account evolutionary dynamics. By modelling global malaria as a complex adaptive system, the researchers have been able to review the efficacy of malaria strategies, and were also able to assess the potential implications of climate change.
Overall, their conclusion was that continued changes in human behaviour (such as in agricultural methods or urbanisation, which presents its own set of challenges), as well as human impact on the environment, will mean malaria will continue to evolve and confound current interventions in areas of high prevalence. They also make a complementary point to Professor Karen Day’s – eradication and control strategies that do not take account of these complex evolutionary dynamics may well make things worse, and could ‘substantially exacerbate the significance of malaria in coming decades’.
Some of these fears may be becoming reality. An article published in Science magazine in October 2010 suggested that the mosquito strain that is responsible for most disease transmission is in the process of rapidly evolving into two genetically distinct species. The hypothesis is that the two species are evolving in different directions in reaction to differences in environment and the challenges they face. The Imperial College researchers confirmed fears that this development is likely undermine efforts to control and treat malaria – conventional strategies are unlikely to be effective against both strains.

So what?
Forty years ago, malaria eradication failed at least in part because of a lack of diversity in the mechanisms employed, and the related evolution of resistance. Although global responses are broader than before, there are still questions about whether they are diverse enough, and whether the full breadth of approaches and knowledge are being applied at scale. Narrowness in responses may, in the worst case scenarios, be making human populations more vulnerable to malaria.
This means supporters of eradication and control programmes must continue to fund research that advances an evolutionary understanding and use it to keep ahead of the disease. This makes the levelling off of aid commitments reported in World Malaria Report 2010 all the more worrying, because much hope now lies in more funding for innovative basic and applied research. At least some of this research should start with the premise that the dynamics of malaria requires a rethinking of global efforts, with a special focus on capacity of existing health systems to deliver a broader range of treatments.
In this area, like in so many other aspects of international aid, silver bullets may well be red herrings. But history and recent research suggests that this is not a battle that should be conceded easily. Rather, as Chris Blattman notes, we can take some heart and some lessons from previous eradication programmes.
Smallpox was famously wiped out in the 1970s, with the last case being in Merca, Somalia in 1977. When the eradication was announced in 1980, the campaign was described “a triumph of management, not medicine”. This was an especially unusual pronouncement given it was made by the-then Director-General of the WHO.
But what exactly did this mean? According to one major account, the DG was referring to the emergent process of adaptation and learning – the evolutionary process within the programme itself – which
…more than any other element in the campaign, [was] the key explanatory factor of the ultimate success of the program… ”
What eventually eliminated smallpox was the combined approach of top-down problem-solving—mass vaccination to reduce disease incidence to certain levels —and bottom-up emergent experimental innovations in early detection, isolation and control - to push towards complete eradication.
Of course, smallpox is a very different disease, and may have been a better candidate for eradication than malaria – exactly because of the evolutionary nature of malaria.
But there is an interesting message here: if we want to deal with the evolving problem of malaria, we also need the global response to adapt and evolve, for organisations involved to think and act ‘outside the box’.
It is not clear what this would look like yet, of course – but it is worth noting that the eventual strategy for dealing with smallpox eradication was not originally employed or even envisaged by the implementing organisations.
Whether current efforts are able and willing to take on such an adaptive management mentality remains to be seen.

MALARIA: Malaysia follows Caymans with surprise GM mosquito trial

Shiow Chin Tan: 28 January 2011

Waterfall in Bentong Flickr/CharlesFred: The mosquitoes were released in an uninhabited region of the remote district of Bentong

[KUALA LUMPUR] Malaysia became the second country in the world to release genetically modified (GM) mosquitoes into the wild in a trial whose timing has surprised international and local scientists as well as protesters.
The country's Institute for Medical Research announced this week (26 January) that around 6,000 GM male Aedes aegypti mosquitoes had been released at an uninhabited, forested site in the inland district of Bentong in Pahang state last month (21 December).
The trial passed all its regulatory hurdles last year. But the actual release took many by surprise — even the head of Malaysia's Genetic Modifications Advisory Committee, Ahmad Parveez Ghulam Kadir, admitted he was unaware that it had taken place.
In recent days local media had reported that the release had not yet occurred because of bad weather. Meanwhile the international press agency AFP had said that the release was delayed because of protests by nongovernmental organisations. It quoted a senior government official, Mohamed Mohamad Salleh, the biosafety department's director of research and evaluation, as saying that the trials had been postponed.
The trial also involved the release of 6,000 ordinary male mosquitoes and both groups were killed with insecticides in early January, with monitoring to continue for several months, said the institute in a press release.
Scientists are comparing the flying ranges and survival rates of the two groups.
Offspring of the mosquitoes die before reaching sexual maturity in the absence of the antibiotic tetracycline. It is hoped this strategy could be used to cut mosquito numbers and fight dengue fever, a disease whose incidence has risen dramatically in recent decades.
No further release can occur until post-trial monitoring is completed in accordance with the guidelines laid out by the advisory committee, with the results analysed and presented in peer-reviewed scientific journals or at meetings.
Releasing the GM mosquitoes in an inhabited area — which was part of the application the institute and its partner in the project, UK-based biotech company Oxitec, originally made — would have required the institute to gain the consensus and approval of local communities via a public forum at least two weeks before the release.
Lim Li Ching, senior biosafety researcher at the non-profit Third World Network, said: "In their interpretation of the conditions [of the approval] they did not have to organise a public forum for the release in an uninhabited area".
She said that the institute should have been more transparent about its actions considering the criticisms about excessive secrecy that surrounded trials done by Oxitec on the Caribbean island of Grand Cayman in 2009.
Ahmad Parveez emphasised that the release was small-scale (6,000 compared with Grand Cayman's three million), that the mosquitoes would all die within the monitoring period and that the goal was a modest one of data collection rather than trying to suppress the local mosquito population.
The campaigning organisation Genewatch UK recently published a report saying that the original risk assessment by the Malaysian GM Advisory Committee was incomplete and lacked full transparency because it did not list the potential hazards it had identified and its evaluations of their likelihood, consequences and estimated overall risk.

MALARIA: anopheles do not like dirt

 possible misconceptions about anopheles mosquitoes and where they generally like to breed - they do not like dirty water as culex do, yet urban sanitation proponents always cite malaria control to be a result of urban environmental sanitation campaigns

POVERTY: Social protection in Sub-Saharan Africa: Learning from experiences

Giorgia Giovannetti Marco Sanfilippo: 23 January 2011
Can developing countries afford large social-protection programmes, such as unemployment benefits or medical insurance? Summarising studies from across Africa, this column finds that such programmes are politically, fiscally, and administratively feasible – even for low-income Sub-Saharan African countries – and on a scale and scope previously thought out of reach.
Social protection is often considered as something exclusive to developed countries, even though some forms of it, often unstructured, have been in place in every society, also in developing countries. Recently, on the waves of successful implementation in Latin America, social-protection programmes have spread to Sub-Saharan Africa. Some programmes, such as pensions in Namibia and South Africa, have taken systems already in place prior to independence and expanded them to populations previously excluded or marginalised. Others, meanwhile, have been newly developed to protect targeted populations from poverty and vulnerability.
Some common and peculiar features characterise social protection in Sub-Saharan Africa (Ellis and Devereux 2009, Townsend 2009).
First, social protection continues to have limited formalisation, and its expansion is constrained by the lack of formal wage employment among the poor. Most low-income Sub-Saharan African countries have long had contribution-based social insurance schemes, often modelled on systems developed in colonial times. Their key feature is that very few people are covered by formal social insurance: not more than 5% to 10% of the workforce – principally in the form of pensions for civil servants and employees of large (formal) private enterprises (see ILO 2010).
Second, safety nets remain important, as a response to emergencies, and are widespread.
Third, there has been a considerable expansion of the number of specific targeted programmes, aimed at particularly poor and vulnerable groups, though many still remain in the pilot stage.
Fourth, in some countries, especially in southern Africa, schemes based on universality, or broadly defined target groups, are rapidly spreading.
The need and potential for expanding social protection in Sub-Saharan Africa, as well as the feasibility and the likely development outcome, have been recently examined by the European Report on Development (ERD 2010). While the programmes in Latin America have been widely described, evaluated and discussed in the economic and political literature (see, for instance, Grosh et al. 2008), there is much less on those prevailing in Sub-Saharan Africa. However, functioning social protection programmes are crucial for Sub-Saharan Africa, especially in the aftermath of the global financial crisis (see also Gerecke and Prasad 2010). The European Report on Development therefore provides a useful start, analysing the most relevant experiences of social protection in Sub-Saharan Africa, to investigate whether there are preconditions necessary for success, as well as which factors could contribute to scaling up social protection in the continent.

Some African examples on the road to social protection
In some low-middle income Sub-Saharan African countries, different examples of Social Protection are in place:
Ghana’s National Health Insurance Scheme is an intermediate form of health insurance involving social insurance financed by contributions from formal (and to a lesser extent informal) sector employees and by government coverage for those unable to contribute. This programme helped improve the efficiency of the country’s health system and reduce out-of-pocket expenditure on health;
Lesotho’s Old Age Pension is a universal non-contributory scheme including all registered citizens over 70-years-old not receiving any other form of pension benefit. There is no clear evidence on the impact of this programme on poverty, but similar schemes in South Africa had substantial effects for the elderly and their households. Furthermore, this programme has been central for its role in the political elections.
Rwanda’s Vision 2020 Umurenge Programme consists of three core initiatives to redirect social protection programmes to vulnerable populations: (1) public works; (2) the Ubudehe credit scheme; and (3) direct support through an unconditional cash transfer. Payments from the programme are used to satisfy basic consumption needs and stimulate savings. Preliminary evaluations have shown a huge reduction of extreme poor among beneficiaries (from 40.6% to 9%);
Ethiopia’s Productivity Safety Net Programme is probably the most known programme in Sub-Saharan Africa. It is a conditional transfer in cash and/or in kind based on public works. It also includes a small component of unconditional direct transfers to those unable to work. The programme reports a modest but relevant average impact, improving food security (by 11%), livestock holdings (by about 7%) and households’ ability to cope with emergency.
Kenya’s Home Grown School Feeding programme is a conditional cash transfer to schools for local purchase of food, involving half a million children of primary school age. The programme has showed a positive impact on children’s diet quality, health, learning capability and performance, school attendance. Furthermore, has had a positive impact on the economy of communities, because the food provided to the school is locally produced.
Such examples, and many others in different developing countries described in the European Report on Development (2010), allow us to identify some necessary preconditions for success, even though these programs are not necessarily suited to all countries. They also help to illustrate what is feasible in moving towards more comprehensive social protection systems in Africa.
The main message arising from the analysis of the existing cases is that it is politically, fiscally, and administratively feasible, even for low-income Sub-Saharan African countries, to put in place social protection programmes on a scale and scope previously thought out of reach.

The need for political commitment
Specific country conditions, including political commitment and prior experience, however, dictate the scope for tailored solutions. Political will is not only crucial for initially triggering the programme but also for committing to sustainable social protection schemes and to scale them up in the long term. In some cases, the government’s commitment is driven primarily by the need to address the main vulnerabilities affecting the population, in view of achieving long-term resilience. In Lesotho, the Old Age Pension was introduced to reduce the elderly burden, while indirectly supporting their households. In Ethiopia, the Productivity Safety Net Programme is aimed at overcoming dependence on emergency relief, providing predictable support to reduce chronic poverty and protect assets by promoting agriculture as the backbone of growth.
Putting social protection at the heart of the national development agenda can also affirm the social contract between the state and its citizens, thus bolstering the government’s legitimacy. In Ghana, the health insurance programme rose from an electoral promise to a rights-based entitlement, protecting the vulnerable while enforcing government accountability. The political benefits of commitment to social protection can provide significant results: in Lesotho the Old Age Pension contributed to the government’s re-election.
Such political commitment should be complemented by adequate institutional and administrative capacity. In Rwanda the Vision 2020 Umurenge Programme is embedded in a system based on subsidiarity. That is, policies are formulated at the centre, administered by sub-districts and implemented by the villages. The community-based approach – where communities take primary responsibility for identifying eligible beneficiaries – can be a valid alternative to top-down targeting that might not meet local needs, wasting resources. The Ubudehe credit scheme approach in Rwanda shows that decentralisation can contribute to the overall efficiency of interventions and avoid resources’ mismanagement. The Ghana example points in the same direction: taking advantage of the pre-existing community-based health insurance system contributed to a successful targeting and consequent extension of the scheme to the informal sector.

A starting point for social protection programmes
Affordability is often perceived as the greatest obstacle by governments. For many low-income countries in Sub-Saharan Africa, the complete package in the UN social protection floor (ILO 2008) might not be affordable, especially to the extent that revenue-raising capacity remains low and administrative costs are high. But elements of the social protection floor are fiscally affordable in most low-income Sub-Saharan African countries. Social pensions in Lesotho, with a cost of approximately 2% of domestic GDP, have been entirely covered by tax-based resources, quite high in the country (African Economic Outlook 2010). Ghana’s National Health Insurance Scheme, now covering a large part of the population, relies on different domestic sources of finance.
Hence, a good entry point for a social protection programme could be starting with non-contributory old age pensions, child grants or public works. More would be feasible in the longer run, if governments raised their tax to GDP ratios (itself desirable), reallocated resources within their budgets or obtained reliable and long-lasting external support.
Donor support can still be crucial, even when domestic political commitment and ownership of social protection are strong, since domestic resource mobilisation remains low in many Sub-Saharan Africa countries. In Ethiopia, for instance, the government provides only 8% of the total budget for the Productivity Safety Net Programme, while donors provide the rest.
In sum, political commitment, and domestic control over social protection programmes, has been the key to most, if not all, successful schemes. However, there is room for social protection to be an integral part of donors’ development policy. It is important that social protection does not crowd out markets, but forms the kind of social protection needed to enhance social cohesion.

POVERTY: Egypt and Tunisia usher in the new era of global food revolutions

Ambrose Evans-Pritchard: 31 January 2011

Political risk has returned with a vengeance. The first food revolutions of our Malthusian era have exposed the weak grip of authoritarian regimes in poor countries that import grain, whether in North Africa today or parts of Asia tomorrow.

Political risk has returned with a vengeance. The first food revolutions of our Malthusian era have exposed the weak grip of authoritarian regimes in poor countries that import grain, whether in North Africa today or parts of Asia tomorrow.
As we sit glued to Al-Jazeera watching authority crumble in the cultural and political capital of the Arab world, exhilaration can turn quickly to foreboding. Photo: REUTERS

If you insist on joining the emerging market party at this stage of the agflation blow-off, avoid countries with an accelerating gap between rich and poor. Cairo’s EGX stock index has dropped 20pc in nine trading sessions.
Events have moved briskly since a Tunisian fruit vendor with a handcart set fire to himself six weeks ago, and in doing so lit the fuse that has detonated Egypt and threatens to topple the political order of the Maghreb, Yemen, and beyond.
As we sit glued to Al-Jazeera watching authority crumble in the cultural and political capital of the Arab world, exhilaration can turn quickly to foreboding.
This is nothing like the fall of the Berlin Wall. The triumph of secular democracy was hardly in doubt in central Europe. Whatever the mix of aspirations of those on the streets of Cairo, such uprisings are easy prey for tight-knit organizations – known in the revolutionary lexicon as Leninist vanguard parties.
In Egypt this means the Muslim Brotherhood, whether or not Nobel laureate Mohammed El Baradei ever served as figleaf. The Brotherhood is of course a different kettle of fish from Iran’s Ayatollahs; and Turkey shows that an ‘Islamic leaning’ government can be part of the liberal world – though Turkish premier Recep Tayyip Erdogan once let slip that democracy was a tram “you ride until you arrive at your destination, then you step off."
It does not take a febrile imagination to guess what the Brotherhood’s ascendancy might mean for Israel, and for strategic stability in the Mid-East. Asia has as much to lose if this goes wrong as the West. China’s energy intensity per unit of GDP is double US levels, and triple the UK.
The surge in global food prices since the summer – since Ben Bernanke signalled a fresh dollar blitz, as it happens – is not the underlying cause of Arab revolt, any more than bad harvests in 1788 were the cause of the French Revolution.
Yet they are the trigger, and have set off a vicious circle. Vulnerable governments are scrambling to lock up world supplies of grain while they can. Algeria bought 800,000 tonnes of wheat last week, and Indonesia has ordered 800,000 tonnes of rice, both greatly exceeding their normal pace of purchases. Saudi Arabia, Libya, and Bangladesh, are trying to secure extra grain supplies.
The UN’s Food and Agriculture Organization (FAO) said its global food index has surpassed the all-time high of 2008, both in nominal and real terms. The cereals index has risen 39pc in the last year, the oil and fats index 55pc.
The FAO implored goverments to avoid panic responses that “aggravate the situation”. If you are Hosni Mubarak hanging on in Cairo’s presidential palace, do care about such niceties?
France’s Nicolas Sarkozy blames the commodity spike on hedge funds, speculators, and the derivatives market (largely in London). He vowed to use his G20 presidency to smash the racket, but then Mr Sarkozy has a penchant for witchhunts against easy targets.
The European Commission has been hunting for proof to support his claims, without success. Its draft report – to be released last Wednesday, but withdrawn under pressure from Paris – reached exactly the same conclusion as investigators from the IMF, and US and British regulators.
“There is little evidence that the price formation process on commodity markets has changed in recent years with the growing importance of derivatives markets”, it said.
As Jeff Currie from Goldman Sachs tirelessly points out, future contracts are neutral. For every trader making money by going long on wheat, sugar, pork bellies, zinc, or crude oil, there is a trader losing money on the other side. It is a paper transfer between financial players.
You have to buy and hoard the vast amounts of these bulk commodities to have much impact on the price, which is costly and difficult to do, though people do park crude on floating tankers sometimes, and Chinese firms allegedly stashed copper in warehouses last year.
But that is not what commodity index funds with $150bn are actually doing with food, base metals, and energy. Only governments have strategic petroleum and grain reserves big enough to make a difference.
The immediate cause of this food spike was the worst drought in Russia and the Black Sea region for 130 years, lasting long enough to damage winter planting as well as the summer harvest. Russia imposed an export ban on grains. This was compounded by late rains in Canada, Nina disruptions in Argentina, and a series of acreage downgrades in the US. The world’s stocks-to-use ratio for corn is nearing a 30-year low of 12.8pc, according to Rabobank.
The deeper causes are well-known: an annual rise in global population by 73m; the “exhaustion” of the Green Revolution as the gains in crop yields fade, to cite the World Bank; diet shifts in Asia as the rising middle class switch to animal-protein diets, requiring 3-5 kilos of grain feed for every kilo of meat produced; the biofuel mandates that have diverted a third of the US corn crop into ethanol for cars.
Add the loss of farmland to Asia’s urban sprawl, and the depletion of the non-renewable acquivers for irrigation of North China’s plains, and the geopolitics of global food supply starts to look neuralgic.
Can the world head off mass famine? Yes, with leadership. The regions of the ex-Soviet Union farm 30m hectares less today than in the Khrushchev era, and yields are half western levels.
There are tapped hinterlands in Brazil, and in Africa where land titles and access to credit could unleash a great leap forward. The global reservoir of unforested cropland is 445m hectares, compared to 1.5 billion in production. But the low-lying fruit has already gone, and the vast investment needed will not come soon enough to avoid a menacing shift in the terms of trade between the land and the urban poor.
We are on a thinner margin of food security, as North Africa is discovering painfully, and China understands all too well. Perhaps it is a little too early to write off farm-rich Europe and America.

Sunday, 30 January 2011

POVERTY: Stephen Steinberg on the "Culture of Poverty"

This article previously appeared in Boston Review.

Let's be clear: There is not and never has been such thing as a self-replicating "culture of poverty. "After 40 years of white backlash, the idea that Black poverty is a product of Black culture is on the ascent. Yet blame-the-victim ideologues claim it takes courage to be a culturalist, and that Daniel Patrick Moynihan paid dearly for blaming Black culture for the ills of the ghetto. “Against this background, the ballyhooed ‘restoration’ of culture to poverty discourse can only be one thing: an evasion of the persistent racial and economic inequalities that are a blot on American democracy.”

Poor Reason: Culture Still Doesn’t Explain Poverty
“Culturalists confuse cause and effect, arguing that lack of social mobility among black youth is a product of their culture rather than the other way around.”
“‘Culture of Poverty’ Makes a Comeback.” So read the headline of Patricia Cohen’s front-page articlein the October 17, 2010 edition of The New York Times.
The article was prompted by a recent issue of the Annals of the American Academy of Political and Social Science under the title, “Reconsidering Culture and Poverty.” In their introductory essay, the editors, Mario Luis Small, David J. Harding, and Michèle Lamont, strike a triumphant note:
“Culture is back on the poverty research agenda. Over the past decade, sociologists, demographers, and even economists have begun asking questions about the role of culture in many aspects of poverty and even explicitly explaining the behavior of the low-income population in reference to cultural factors.”

Cohen begins with a similar refrain:
“For more than 40 years, social scientists investigating the causes of poverty have tended to treat cultural explanations like Lord Voldemort: That Which Must Not Be Named. The reticence was a legacy of the ugly battles that erupted after Daniel Patrick Moynihan, then an assistant labor secretary in the Johnson administration, introduced the idea of a ‘culture of poverty’ to the public in his 1965 report on ‘The Negro Family.’“
Cohen uncritically accepts two myths woven by William Julius Wilson, the prominent Harvard sociologist, and repeated by his acolytes: first, Moynihan was clobbered for bringing to light compromising facts about black families, and second, that this torrent of criticism constrained a generation of social scientists from investigating the relation between culture and poverty, for fear that it would be pilloried for “blaming the victim.” Thus, a third, patently self-serving myth: thanks to some intrepid scholars who reject political correctness, it is now permissible to consider the role that culture plays in the production and reproduction of racial inequalities.
“The three pillars of anti-racist public policy—affirmative action, school integration, and racial districting (to prevent the dilution of the black vote)—have all been eviscerated.”
These myths add up to something—a perverse obfuscation of American racial history. They suggest that for four decades academia has abetted a censorial form of anti-racism that prevented serious research into the persistence of poverty among black Americans. If only, the mythmakers insist, we stopped worrying about offending people, we could acknowledge that there is something amiss in black culture—not, as the politically correct would have it, the politics of class—and that this explains racial inequality.
Notwithstanding the election of Barack Obama, the last 40 years have been a period of racial backlash. The three pillars of anti-racist public policy—affirmative action, school integration, and racial districting (to prevent the dilution of the black vote)—have all been eviscerated, thanks in large part to rulings of a Supreme Court packed with Republican appointees. Indeed, the comeback of the culture of poverty, albeit in new rhetorical guise, signifies a reversion to the status quo ante: to the discourses and concomitant policy agenda that existed before the black protest movement forced the nation to confront its collective guilt and responsibility for two centuries of slavery and a century of Jim Crow—racism that pervaded all major institutions of our society, North and South. Such momentous issues are brushed away as a new generation of sociologists delves into deliberately myopic examinations of a small sphere where culture makes some measurable difference—to prove that “culture matters.”

Moynihan’s Distortions
It is indisputable that the publication of Moynihan’s report on “The Negro Family”evoked a torrent of criticism and that Moynihan was thrown on the defensive. I remember seeing him on Meet the Press in late 1965, pleading for understanding:
“I was trying to show that unemployment statistics, which are so dull, and you read so many of them, and you don’t know what they may mean, and they’re hard to believe—that unemployment ended up nonetheless with orphaned children, with abandoned mothers, with men living furtive lives without even an address, that unemployment had flesh and blood and it could bleed. That’s all I was trying to do.”
Perhaps. However, it is grossly inaccurate to say, as Wilson does in the Annals, that Moynihan came under fire for bringing to light facts that “could be construed as unflattering or stigmatizing to people of color.” Or that Moynihan was prescient, in that the segment of black children born outside marriage has doubled from one-quarter in 1965 to one-half today.

“Moynihan made the fatal error of inverting cause and effect.”
The problem from the beginning was not Moynihan’s publication of what were actually well-established facts, but rather his distorted interpretation of these facts. Moynihan made the fatal error of inverting cause and effect.Although he acknowledged that past racism and unemployment undermined black families, he held that the pathology in “the Negro American family” had not only assumed a life of its own, but was also the primary determinant of the litany of problems that beset lower-class blacks. To quote Moynihan: “Once or twice removed, [the weakness of family structure] will be found to be the principal source of most of the aberrant, inadequate, or anti-social behavior that did not establish, but now serves to perpetuate the cycle of poverty and deprivation.” Moynihan followed with an even more inflated claim: “At this point the present tangle of pathology is capable of perpetuating itself without assistance from the white world.” And then the zinger: “The cycle can be broken only if these distortions are set right.”
This last statement had dire implications for public policy, especially when placed in historical context. In The Moynihan Report and the Politics of Controversy (1967), Lee Rainwater and George Yancey wrote:
“The year 1965 may be known in history as the time when the civil rights movement discovered, in the sense of becoming explicitly aware, that abolishing legal racism would not produce Negro equality.”
By 1965 the words “compensation,” “reparations,” and “preference” had already crept into political discourse, testing the limits of liberal support for the black protest movement. In Why We Can’t Wait, published in 1964, Martin Luther King observed: “Whenever this issue of compensatory or preferential treatment for the Negro is raised, some of our friends recoil in horror.” Norman Podhoretz, editor of Commentary, went further, declaring that this “radical” turn by some movement leaders had precipitated “a crisis in liberalism.” As early as 1965 Moynihan was on record as opposed to anything that smacked of “preference,” asserting, much as Wilson did 22 years later in The Truly Disadvantaged, that policy had to be universal rather than targeted specifically for blacks.
The question is not whether culture matters, but whether it is an independent and self-sustaining factor in the production and reproduction of poverty.
“The Moynihan report elicited fierce condemnation because it threatened to derail the black liberation movement in its pursuit of equality.”
With his report on “The Negro Family,” Moynihan shifted the conceptual framework that underlay policymaking. Instead of attacking racist barriers, he suggested that legislation focus on the putative defects of “the” black family. In his concluding section, “The Case for National Action,” Moynihan called for “a national effort” to strengthen the Negro family, though, as the sociologist Herbert Gans pointed out in a 1965 article in Commonweal, Moynihan offered no specific policy recommendations for accomplishing that end. Not only did he leave a vacuum that could be filled with a politics that blamed blacks for their own troubles, but he also tacked on an ominous addendum:
“After [the repair of the black family], how this group of Americans chooses to run its affairs, take advantage of its opportunities, or fail to do so, is none of the nation’s business.”
In short, the Moynihan report elicited fierce condemnation because it threatened to derail the black liberation movement in its pursuit of equality. In one palpable example of that derailment, a 1966 White House conference called “To Fulfill These Rights,” which might have been an opportunity to chart the next phase of the protest movement, instead was overshadowed by preoccupation with the Moynihan report and the ensuing controversy.

Economic Underpinnings of Nuclear Family
Far from having a chilling effect on researching and thinking about culture in relationship to poverty, the debate over the Moynihan report spawned a canon of critical scholarship. For the first time, scholars came to terms with the economic underpinnings of the nuclear family, which tends to unravel whenever male breadwinners are unemployed for long periods of time, as was true of white families during the Depression.
No longer was the nuclear family, with its patriarchal foundations, the unquestioned societal norm. The blatantly tendentious language that pervaded the Moynihan report—“broken homes” and “illegitimate births”—was purged from the professional lexicon. More important, feminist scholars forced us to reassess single parenting. In her 1973 study All Our Kin, Carol Stack showed how poor single mothers develop a domestic network consisting of that indispensable grandmother, grandfathers, uncles, aunts, cousins, and a patchwork of neighbors and friends who provide mutual assistance with childrearing and the other exigencies of life. By comparison, the prototypical nuclear family, sequestered in a suburban house, surrounded by hedges and cut off from neighbors, removed from the pulsating vitality of poor urban neighborhoods, looks rather bleak. As a black friend once commented, “I didn’t know that blacks had weak families until I got to college.”
Yet even Moynihan’s harshest critics did not deny the manifest troubles in black families. Nor did they deny that the culture of poor people is often markedly at variance with the cultural norms and practices in more privileged sectors of society. How could it be otherwise? The key point of contention was whether, under conditions of prolonged poverty, those cultural adaptations “assume a life of their own” and are passed down from parents to children through normal processes of cultural transmission. In other words, the imbroglio over the Moynihan report was never about whether culture matters, but about whether culture is or ever could be an independent and self-sustaining factor in the production and reproduction of poverty.
“It is not their culture that needs to be changed, but rather a political economy that fails to provide jobs that pay a living wage to millions of the nation’s poor.”
Many scholars have challenged the notion of culture as an independent, causal factor in generating poverty, and none more effectively than Elliot Liebow in his 1967 study, Tally’s Corner. Liebow’s subjects were men who had neither regular jobs nor stable families and took refuge on the streetcorner where they devised “a shadow system of values” to shield themselves from a profound sense of personal failure.
Liebow did not deny culture—indeed, he documented it in scrupulous detail. However, he insisted that thstreetcorner man was not a carrier of an independent cultural tradition. To be sure, there were obvious similarities between parents and children, but Liebow held that these were not the product of cultural transmission, but rather reflected the fact that “the son goes out and independently experiences the same failures, in the same areas, and for much the same reasons as his father.” Thus, it is not their culture that needs to be changed, but rather a political economy that fails to provide jobs that pay a living wage to millions of the nation’s poor, along with a system of occupational apartheid that has excluded a whole people from entire job sectors throughout American history.
Liebow is not alone. Although left scholars insist that poverty is rooted in political economy, it is preposterous to accuse them generally of eliding culture. Indeed, the anthropologist Oscar Lewis, who first used the term, was an avowed socialist, and the culture of poverty entered popular discourse through the ideas of another socialist—Michael Harrington, in his 1962 book, The Other America. Both men preferred structural explanations of poverty. They argued that the despair and coping mechanisms associated with the culture of poverty were anchored in conditions of poverty, and that the only remedy for the culture of poverty was the elimination of poverty itself.
If Moynihan’s critics were unusually vociferous, this was because they understood what was at stake. Moynihan and his supporters contended that the poor were victims of their own vices, thus shifting attention away from powerful political and economic institutions that could make a difference in their lives. If those institutions were absolved of responsibility, the poor would be left on their own.

Patently False Claims
The claim that the furor over the Moynihan report stymied research on lower-class culture for four decades is patently false. What was the massive underclass discourse of the 1980s if not old wine in new bottles—Moynihan’s culture arguments repackaged for a new generation of scholars and pundits?
As with the culture of poverty, the conception of the underclass had liberal origins. In his 1962 book Challenge to Affluence, Gunnar Myrdal borrowed a Swedish term for the lower class, underklassen, to refer to people who languished in poverty even during periods of economic growth and prosperity. This term entered popular discourse with the 1982 publication of Ken Auletta’s The Underclass, based on a series in The New Yorker.
Then, between 1986 and 1988, there was an outpouring of articles in U.S. News and World Report, The Atlantic Monthly, Fortune, Newsweek, Reader’s Digest, and Time, all providing graphic and frightening portrayals of pathology and disorder in the nation’s ghettos. The image was of poverty feeding on itself, with the implication that cultural pathology was not just a byproduct of poverty but was itself a cause of pathological behavior. This was the explicit claim of a 1987 Fortune article by Myron Magnet:
“What primarily defines [the underclass] is not so much their poverty or race as their behavior—their chronic lawlessness, drug use, out-of-wedlock births, nonwork, welfare dependency and school failure. ‘Underclass’ describes a state of mind and a way of life. It is at least as much cultural as an economic condition.”
“The image was of poverty feeding on itself, with the implication that cultural pathology was not just a byproduct of poverty but was itself a cause of pathological behavior.”
Social science lagged behind journalism, but by the late ’80s, with the backing of charitable foundations, a cottage industry of technocratic studies appeared charting the size and social constitution of the underclass. In his 1991 article “The Underclass Myth,” Adolph Reed notedthe reinstatement of the culture-of-poverty theory during the Reagan-Bush era. The pendulum had swung so far to culture that Reed was pleading for a restoration of structure:
“We should insist on returning the focus of the discussion of the production and reproduction of poverty to examination of its sources in the operations of the American political and economic system. Specifically, the discussion should focus on such phenomena as the logic of deindustrialization, models of urban redevelopment driven by real-estate speculation, the general intensification of polarization of wealth, income, and opportunity in American society, the ways in which race and gender figure into those dynamics, and, not least, the role of public policy in reproducing and legitimating them.”
Reed ended on a note of personal exasperation: “I want the record to show that I do not want to hear another word about drugs or crime without hearing in the same breath about decent jobs, adequate housing, and egalitarian education.”
Culturalists confuse cause and effect, arguing that lack of social mobility among black youth is a product of their culture rather than the other way around.
Yet here we are, two decades later, with a special issue of a prestigious journal, the Annals, launched with fanfare and a congressional briefing, bombastically claiming that “culture is back on the policy agenda,” as though it had not been there all along. Even as the editors take up this “long-abandoned topic,” however, they are careful to distance themselves from culture-of-poverty theorists who were accused of “blaming the victim,” and they scoff at the idea that the poor “might cease to be poor if they changed their culture.” Indeed, readers are assured that “none of the three editors of this volume happens to fall on the right of the political spectrum.” Alas, the culture of poverty has not made a comeback after all. The new culturalists have learned from the mistakes of the past, and only want to study culture in the context of poverty—that is, in the selective and limited ways that culture matters in the lives of the poor.
True to form, the rest of the Annals issue is a compendium of studies informed by this “more sophisticated” conception of culture. One study examines “How Black and Latino Service Workers Make Decisions about Making Referrals.” Another explores how poor men define a “good job.” Still another ventures into the perilous waters of the black family, examining the “repertoire of infidelity” among low-income men.
The problem is less with the questions asked than with the ones left unexamined. The editors and authors are careful to bracket their inquiries with appropriate obeisance to the ultimate grounding of culture in social structure. But their research objectives, methodology, data collection, and analysis are all riveted on the role of culture. Is obeisance enough? If the cultural practices under examination are merely links in a chain of causation, and are ultimately rooted in poverty and joblessness, why are these not the object of inquiry? Why aren’t we talking about the calamity of another generation of black youth who, excluded from job markets, are left to languish on the margins, until they cross the line of legality and are swept up by the criminal justice system and consigned to unconscionable years in prison where, at last, they find work, for less than a dollar an hour, if paid at all? Upon release they are “marked men,” frequently unable to find employment or to assume such quotidian roles as those of husband or father.
“Does it matter how they approach procreation, how they juggle ‘doubt, duty, and destiny’ when they are denied the jobs that are the sine qua non of parenthood?”
Enter the sociologist, to record the agony of the dispossessed. Does it really matter how they define a “good job” when they have virtually no prospect of finding one? Does it matter how they approach procreation, how they juggle “doubt, duty, and destiny” when they are denied the jobs that are the sine qua non of parenthood? Aren’t we asking the wrong questions? Do the answers bring us any closer to understanding why this nation has millions of racial outcasts who are consigned to a social death?
Obeisance is not enough. The Annals issue caps off with an article by William Julius Wilson on “Why Both Social Structure and Culture Matter in a Holistic Analysis of Inner-City Poverty.” Wilson wants to show “not only the independent contributions of social structure and culture, but also how they interact to shape different group outcomes that embody racial inequality.” At first blush this appears to be a sensible, even unassailable stance. But what is Wilson getting at with his prosaic language about the interaction of structure and culture? The answer is found several pages later: “One of the effects of living in a racially segregated, poor neighborhood is the exposure to cultural traits that may not be conducive to facilitating social mobility.” This is tantamount to blaming blacks for the racism of employers and other gatekeepers.
Like Moynihan before him, Wilson has committed the sin of inverting cause and effect. He thinks that black youth are not socially mobile because of their cultural proclivities—“sexual conquests, hanging out on the street after school, party drugs, and hip-hop music.” But a far more convincing explanation is that these youth are encircled by structural barriers and consequently resort to these cultural defenses, as Douglas Glasgow argued in his neglected 1981 book, The Black Underclass. Liebow had it right when he stripped away surface appearances and put culture in its proper social and existential context:
If, in the course of concealing his failure, or of concealing his fear of even trying, [the street-corner man] pretends—through the device of public fictions—that he does not want these things in the first place and claims he has all along been responding to a different set of rules and prizes, we do not do him or ourselves any good by accepting this claim at face value.
It makes little sense to compare—as Wilson does—the culture of a pariah class with that of mainstream youth, putting aside the fact that white suburban youth also strut around in saggy pants, listen to hip-hop music, and are far more prone to drug use than are their ghetto counterparts. Wilson’s theoretical postulates about “deconcentrating poverty” have also led him to support the demolition of public housing across the nation. Is this how cultural change takes place, with dynamite, the destruction of poor communities, and the dispersal of its residents? Or do we have to transform the ghetto itself, not by reconstructing the identities of its people, but through a wholesale commitment to eliminating poverty and joblessness?
“Wilson places all his bets on education—specifically, the Harlem Children’s Zone (HCZ), a schooling and social services organization predicated on the idea that the challenge is to 'take the ghetto out of the child,' much as earlier missionaries and educators sought to ‘take the Indian out of the child.’”
While he routinely violates his own axiom about the integral relationship between culture and social structure, Wilson injects what might be called the “culturalist caveat.” In a section on “the relative importance of structure and culture,” he concedes, “Structural factors are likely to play a far greater role than cultural factors in bringing about rapid neighborhood change.” But what structural changes does he have in mind? Despite the fact that Wilson’s signature issue for many years was jobs, jobs, jobs, since his cultural turn there has been nigh any mention of jobs. Affirmative action is apparently off the table, and there is no policy redress for the nation’s four million “disconnected youth” who are out of school and out of work.
Instead, Wilson places all his bets on education—specifically, the Harlem Children’s Zone (HCZ), a schooling and social services organization predicated on the idea that the challenge is to “take the ghetto out of the child,” much as earlier missionaries and educators sought to “take the Indian out of the child.” Wilson trumpets HCZ’s “spectacular” results, citing a study by Harvard economists Will Dobbie and Roland Fryer that purports to show that HCZ students are closing the achievement gap with students in public schools. However, these findings are based on a single class on a single test in a single year. Also, the measure of progress was scoring at “grade level” in math and reading, and as critics have pointed out, grade-level work is a weak predictor of future academic success. Furthermore, thanks to score inflation—not only prepping students for the test but also lowering the score required for achieving grade level—marks were up throughout New York on the 2007 exam, the one that Dobbie and Fryer analyzed.
Never mind; the dye is cast. With Wilson’s backing, the Obama administration has made HCZ the model for twenty “Promise Neighborhoods” across the nation. At best, however, HCZ is a showcase project that, even multiplied twenty times, is no remedy for the deep and widening income gap between blacks and others. At worst, the Obama administration is using it to camouflage its utter failure to address issues of racism and poverty.

The New Culturalists
The new culturalists can bemoan the supposed erasure of culture from poverty research in the wake of the Moynihan Report, but far more troubling is that these four decades have witnessed the erasure of racism and poverty from political discourse, both inside and outside the academy. The Annals issue makes virtually no mention of institutionalized racism. To be sure, there is much discussion of poverty, but not as a historical or structural phenomenon. Instead we are presented with reductionist manifestations of poverty that obscure its larger configuration.
Thus there is no thought of restoring the safety net. Or resurrecting affirmative action. Or once again constructing public housing as the housing of last resort. Or decriminalizing drugs and rescinding mandatory sentencing. Or enforcing anti-discrimination laws with the same vigor that police exercise in targeting black and Latino youth for marijuana possession. Or creating jobs programs for disconnected youth and for the chronically unemployed. Against this background, the ballyhooed “restoration” of culture to poverty discourse can only be one thing: an evasion of the persistent racial and economic inequalities that are a blot on American democracy.
The methodological reductionism that is the hallmark of the new culturalists is a betrayal of the sociological imagination: what C. Wright Mills described as exploring the intersection between history and biography. Instead, the new culturalists give us biography shorn of history, and culture ripped from its moorings in social structure. Against their intentions, they end up providing erudite justification for retrograde public policy, less through acts of commission than through their silences and opacities.

Stephen Steinberg,PhD, a sociologist,  can be contacted at SSteinberg1(at)