Thursday, 31 October 2013
Overseas Development Institute (ODI) newsletter 31 October 2013
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Wednesday, 30 October 2013
TUBERCULOSIS: Pros and cons of high-tech TB testing
The problem with the traditional TB tests is that they need trained lab technicians and tend to be either inconclusive or extremely slow. Some cases of TB can be spotted simply by inspecting a sputum sample under a microscope, but not all; chest X-rays can also be a guide as to whether the disease may be present. But to be sure, the samples have to be cultured in a laboratory, and the process takes around eight weeks to produce a result. By then a patient may have wandered off and disappeared, and even if he does then start treatment, he has had two more months to infect other people.
The GeneXpert system looks for TB's DNA markers and can give a result within two hours, with a high degree of accuracy. The system is automated; all the necessary chemicals are contained in a cartridge, which just has to be slotted into the machine, a fresh cartridge for each test. So it is very easy to use. It can also be used to look for the DNA markers which show whether the particular strain of TB is resistant to Rifampicin, one of the most commonly used drugs.
Impressed by its capabilities, the World Health Organization (WHO) has backed its introduction and the Global Fund to Fight AIDS, Tuberculosis and Malaria is helping pay for it. But it is still expensive, even at discounted prices for developing countries - US$17,000 for the machine and $10 for each cartridge. And critics point out that it needs a reliable power supply and the kind of clean, cool environment not available in many rural clinics.
Now researchers from Cape Town University have looked at what actually happened when the system was installed in primary health care TB clinics in South Africa, Zimbabwe, Zambia and Tanzania. It was operated by nurses who had been given just one day's training, and patients presenting at the clinics with TB-like symptoms were randomly assigned to either conventional testing or to testing with the GeneXpert machines. Their results have now been publishedin the London-based medical journal, the Lancet.
Encouraging results
The results in many ways were encouraging. The nurses were capable of operating the equipment and confident about their ability to do so. More of the GeneXpert group were able to start treatment on the first day they came to the clinic, 23 percent as opposed to 15 percent of those diagnosed by smear microscopy. If you look at those treated within three days, the gap had started to close, with 32 percent of the GeneXpert group having started treatment, as opposed to 27 percent of those relying on traditional diagnosis. After eight weeks, when the culture test results were available, there was only a 1 percent difference between the groups - but as the study remarks, "This issue is important for tuberculosis control, because these patients would have continued to transmit tuberculosis if left untreated."
"A major advantage of Xpert MTB/RIF is that it can identify people with drug-resistant TB very rapidly"
So it looks as if most patients who needed treatment got it in the end, regardless of how they were diagnosed, and when they followed up the patients six months later to see how well they were doing, they could not detect any difference in death rates, or in their state of health. (They measured morbidity using the Karnofsky performance status index, which scores patients from 100 percvent = in perfect health to 0 percent = dead). One reason, they suggest, is that these clinics did not actually wait eight weeks for the results of the lab tests to start treating their patients if, despite a negative initial smear, they were pretty sure they had TB. They took chest X-rays as well as sputum samples, assessed their symptoms, and were prepared to go ahead on empirical evidence. But they could not know which cases were drug-resistant until they got the full test results. Of course, these were good clinics, with X-ray facilities available and a lot of experience in diagnosing tuberculosis. But less well-equipped clinics would be likely to struggle with more basic aspects of the new technology.
In a comment in the Lancet, Christian Wejse, of Aarhus University in Denmark, writes: "Considering (these) findings. the substantial financial burden of Xpert MTB/RIF rollout needs to be reassessed to see if it provides value for the cost. Placing very expensive equipment in health-care facilities in rural Africa that might have no electricity and poorly trained, underpaid staff is going to be a difficult undertaking. Are the incremental gains in same-day diagnosis and treatment initiation, as well as reduced loss to follow-up, enough to justify this investment?"
A more targeted role?
But Professor Alison Grant of the London School of Hygiene and Tropical Medicine, who herself works on improving TB diagnosis and treatment in southern Africa, thinks this technology does have a role, although not for universal use. She told IRIN: "Policymakers need to know how best to invest money to improve TB control. This may differ between countries. In this study, similar to others, not all patients with a positive test result started TB treatment (8 percent with Xpert versus 15 percent with smear microscopy), and systems need to be strengthened to minimize these losses, regardless of what test is used.
"A major advantage of Xpert MTB/RIF is that it can identify people with drug-resistant TB very rapidly. In this study the proportion of people with drug-resistant TB was low, and there might be a much greater benefit from using Xpert in settings where drug-resistant TB is more common, providing that people identified as having drug-resistant TB start on the correct treatment promptly."
eb/cb
POVERTY: The heavy-lifting 'mule women' of Melilla
29 October 2013 Last updated at 20:41 ET
Continue reading the main story
Maria still works, despite her injured leg
They are known as the mule women of Melilla. Every day they carry heavy loads across the border between the Spanish enclave and Morocco. Melilla is an important entry point for goods in to North Africa - and if the women can carry them, they can be imported in to Morocco duty-free.
In the early morning sunlight, a cloud of dust hovers close to the 6m-high fence that separates Melilla from Morocco. The dust is kicked up by frenetic activity as traders prepare goods to cross the border. There are second-hand clothes, bolts of fabric, toiletries and household items, all of it destined for markets in Morocco and beyond. Thousands of people are here and the noise is deafening - a cacophony of revving engines and raised voices.
Massive bales are everywhere, all wrapped in cardboard, cloth and sacking and fastened with tape and rope. And under the immense bales, obscured and bent double by the size of their loads, are Moroccan women. They are the mule women of Melilla, known locally as porteadoras.
This commerce takes place daily at Barrio Chino - a border crossing from Melilla to Morocco for pedestrians only. As long as a porteadora can physically carry her load, it is classed as personal luggage, so Morocco lets it in duty-free. The women have the right to visit Melilla because they live in the Moroccan province of Nador. But they are not allowed to reside in the Spanish territory.
Latifa claims her place in one of the rowdy queues made up of hundreds of women, and drops her load of 60kg (132lb) of used clothes. She has been doing this work for 24 years and will be paid three euros ($4.10 or £2.60) for transporting her bale across to Morocco. It is not work she chooses to do.
And then as the queue surges forward, Latifa disappears in a sea of merchandise.
Many of the women who work as porteadoras are divorced or separated like Latifa, single mothers providing for their families. Life is difficult for them in Morocco's traditional society, and often this is the only work they can get. Some of them make three or four trips a day from Barrio Chino, carrying up to 80kg.
Rates of pay vary and the women complain they must give bribes to the Moroccan guards.
In Melilla, there is debate about whether this trade should be allowed to continue in its current form.
"These are women who are risking their lives - there have been deaths as a consequence of this physical labour. It's carried out in conditions of semi-slavery," says Emilio Guerra, from the Union Progreso y Democracia political party. "What we would like is that they work under a concrete set of rules in conditions that aren't precarious."
Ultimately, he believes Melilla must change its economic model, and become less reliant on trade. Melilla's business advisor for the local government, Jose Maria Lopez, disagrees.
"There are very positive outcomes of this commercial activity. For some of the porteadoras it's the only chance they have of making a living. Sure, it's really hard work, but some of them get an income that's larger than the average income of workers in Morocco."
And the benefits of the trade to thousands more Moroccans and their families - those who sell the goods in their shops, or export it again to countries further south - are huge.
Lopez estimates that this informal trade is worth about 300m euros to Melilla, and calls it "atypical". Others call it smuggling, and believe it is worth perhaps twice that.
Back at Barrio Chino, there is a pervading atmosphere of semi-hysteria. The gates close at midday so the pressure is on to get across to Morocco and return for the next consignment.
"It's a little bit quieter today," says Arturo Ortega, an officer with the Guardia Civil in charge of maintaining order and preventing human avalanches that risk serious injury to the porteadoras.
"If you come here every day you begin to think that what you see is normal. But it isn't normal."
Hasna is leaning against a barrier, without a bundle of anything. In front of her is a mob of young men, all of them loaded up.
"The men are taking our places," she complains. Traditionally, the porters here have been women. Now they face competition from unemployed Moroccan men, and Hasna is having difficulty getting through the crowd to pick up her bale. She has one child and a sick husband. And she is six months pregnant. That does not deter her.
"If I do one trip today, I'll be paid five or six euros," she says. "If I could find another job cleaning houses or cooking, I wouldn't do this. But at the moment, there's no other work."
Also watching the men is Maria. She stands out because she is leaning heavily on a crutch.
Maria still works, despite her injured leg
Unusually for the porteadoras, Maria speaks a bit of Spanish. She explains that she injured her leg when she fell in the queue - she has also had a breast tumour. Maria has been here all morning, but confronted with the chaos at Barrio Chino, she does not feel well enough to work. Today she will return home without earning any money.
Maria lives just the other side of the border from Melilla in Beni Enzar. She has two rooms that she shares with her three daughters. There is no running water - a neighbour lets her use a tap at his house. Maria used to be married and worked as a waitress. But four years ago her life began to unravel. After being diagnosed with cancer, her husband left. Maria was pregnant at the time with her smallest daughter, Malak.
"The doctor said I would lose the baby with the treatment. But she was born alive. That's why I called her Malak - it means angel."
While Maria talks, her two oldest girls listen. Neither is in school - they stay at home and look after their little sister while their mother is at Barrio Chino. They worry about their mother.
"This is not the first time she has injured her leg and the doctor says she shouldn't carry anything heavy," says 16-year-old Ikram. "She only works as a porteadora so that we can eat."
Maria is incensed by the idea that her daughters might be forced to become porteadoras too. "It would be better for them to get married," she says. "It's dangerous work and there's no dignity in it. I hate the job but I need it."
And then Sanaa, who is 13, puts a small skateboard on the table. Maria smiles. It will help her shift merchandise more easily on her journeys across the border from Barrio Chino.
Follow @BBCNewsMagazine on Twitter and on Facebook
Hear more from Linda Pressly in Melilla on BBC World Se
Tuesday, 29 October 2013
MALNUTRITION: Fruit for thought in Tanzania nutrition fight
The government is waging an uphill struggle against malnutrition, urging residents to eat more fruit. | ||
Tanzania faces the strange contradiction of high food production and high malnutrition [Chika Oduah/Al Jazeera]
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| Selemani Hussaini never thought much about eating fruit in the past. The 46-year-old Tanzanian farmer mainly eats ugali, a thick maize-based porridge. Toss in a few cooked beans, tea or instant coffee and this completes a typical meal. "This is how we are raised to eat," says Hussaini. "No one really talked about fruit." Hussaini lives in Tanzania’s second-largest region, Morogoro. He is part of the nearly 75 percent of the national population living in rural areas. Here, long-held food customs often neglect the value of fresh fruit consumption and local attitudes show evidence of a widespread lack of awareness on basic nutritional information. "Due to traditional reasons, fruits were never considered as part of the main meal," says nutrition specialist Alex Nalitolela, Nalitolela works with Mwanzo Bora, a five-year regional nutrition project led by Africare and supported by the USAID’s Feed The Future initiative. The project, launched in 2011, addresses malnutrition by integrating nutrition and agricultural strategies. One of those strategies involves setting up Farmer Field Schools and demonstration garden plots to teach local communities about diet diversification and conduct trainings on home gardening to grow fruits and vegetables. "Our aim is to make sure community members get a diverse food diet in their homes," Nalitolela says. Mwanzo Bora has established 20 demonstration plots throughout the regions where it operates: Dodoma, Morogoro, Manyara and Zanzibar. A major part of Mwanzo Bora’s strategy is changing local ideas and behaviours surrounding food. The project organizes peer support groups for neighbors to help each other incorporate the changes they are learning through Mwanzo Bora. So far, more than 6,000 people have been mobilised into these networks to support pro-nutrition behaviors, according to the latest report. Local farmers participating in Mwanzo Bora had to learn to keep some of the fruits and vegetables from their new gardens for home consumption rather than completely selling them at the local market. Many of them, like Daria Amre, have adapted to this change by maintaining a larger farm to harvest produce for sale alongside a smaller home garden to keep the goods for the household. Behind her mud brick home on the fertile slopes of the Uluguru Mountains, Amre grows lettuce, cabbage, spinach, leeks, potatoes and she eats the ripe fruits, such as jackfruit, from nearby trees. She says her three children, whose ages range from almost two to ten years old, do not experience as many illnesses since she incorporated the practical nutritional knowledge she has learned from Mwanzo Bora. Promoting nutrition
"You can find a large contradiction," says Obey Assery, a director in the office of the Prime Minister. "We have high food production and high malnutrition." Assery is a spokesperson for the government’s nationwide agenda to address malnutrition. "It’s more about social behavior change. That is our strategy," he explains, noting that local communities do not lack food, but lack knowledge. The efforts are part of a robust national campaign, involving nine ministries, to integrate nutrition and prioritise economic development through agriculture. Agriculture accounts for more than 25 percent of the gross domestic product and the sector employs nearly 75 percent of the work force. The government implemented two landmark initiatives, Kilimo Kwanza and the Southern Agricultural Growth Corridor of Tanzania Centre (SAGCOT), to foster agricultural commercialisation and malnutrition reduction. Since its implementation in 2008, Kilimo Kwanza, which means "agriculture first" in Kiswahili, has paved the way for private sector investors to work with small-scale farmers on securing agriculture productivity and boosting profit yields. The 2011 SAGCOT strategy concentrates and evaluates development in the country’s food-producing regions. A parliamentary group solely dedicated to nutrition advocacy is pushing policies to ensure cross-sector participation. For example, in May the government rolled out a food fortification program partially funded by the UK-government to mandate local food processing factories to comply with maize flour fortification regulations. The aim is to reduce micronutrient deficiencies. Community-based engagement But beyond the policies and government initiatives, nutritionists like Nalitolela say it comes down to the grassroots level-- teaching farmers, mothers, fathers and children how to eat right and change local perceptions about food, particularly fruit.
"So far, urban residents seem to be more positive to accept the role of fruits on human health than rural people do," he says. He continues to recommend eating an orange a day, a mango a day, or even just a slice of papaya regularly. His recommendations are working for Hussaini, who admits that his eating habits have changed since engaging with Mwanzo Bora. "I was not use to eating the fruits and vegetables but now I must eat it everyday," he says. On his one-hectare farm, he not only grows the staple, maize, but he also produces carrots. He says now his favorite fruits are avocado, banana and passion fruit. He points to his son and says he and wife are teaching their five children to enjoy eating fruits. Follow Chika Oduah her on twitter @chikaodua |
TUBERCULOSIS: Funding for TB research falls for first time in eight years
The 2013 Report on Tuberculosis Research Funding Trends, 2005–2012 found that funding for tuberculosis (TB) research and development (R&D) dropped by US$30.4 million in 2012 compared to 2011, the first time funding has fallen since Treatment Action Group (TAG) began tracking investments in 2005.
The report, published by TAG and the Stop TB Partnership shows annual investments by the world’s leading donors to TB R&D, and compares current spending levels with R&D funding targets outlined in the Stop TB Partnership’s Global Plan to Stop TB 2011–2015.
Total funding of US$627.4 million for TB R&D in 2012 means that there is a gap of some US$1.39 billion compared to the US$2 billion funding target called for by the Global Plan. Reported funding fails to meet targets in all five key research areas tracked by the TAG report: basic science, diagnostics, drugs, vaccines, and operational research.
“Pharmaceutical companies spent 22 percent less on TB R&D in 2012 than they did in 2011,” said TAG’s Executive Director, Mark Harrington. “Big Pharma has always trailed far behind the public sector in funding TB research, and now their wavering support is placing greater pressure on public institutions in the U.S. and Europe.”
The report follows warnings from the World Health Organization on October 23 that fragile progress in the fight against TB is under threat from drug resistance and millions of missed patients.
“Stopping TB requires new tools, and new tools require more research investment,” said Dr Lucica Ditiu, Executive Secretary of the Stop TB Partnership. “This report’s findings show the opposite. Investments in research today will pay for themselves many times over in years to come, but any delay now means pushing the opportunity to end TB further and further away.”
Funding for TB drug research declined for the first time since TAG began reporting TB R&D investments in 2005, falling 6.7% to US$237.8 million. Spending in drug research needs to increase by US$502.2 million to meet the Global Plan funding target in this category. Diagnostics research funding fell 23.4% to US$42.4 million creating a funding shortfall of US$297.6 million. Funding for TB vaccine development dropped 9.3% to US$86.6 million, leaving a gap of US$293.4 million.
After exceeding the Global Plan funding target in 2011, operational research spending fell back below the target level in 2012. Funding for basic science increased by a modest 6.5% to US$129.6 million, but still falls US$290.4 million short of necessary spending.
For the first time ever, TAG analyzed investments in pediatric TB R&D and found them inadequate at just US$10.3 million—less than two percent of total TB R&D funding. “Spending on pediatric TB R&D saw a steep decline of nearly 12 percent from 2011 to 2012. New investments from UNITAID and USAID to formulate TB drugs for children may help to reverse this trend in 2013, but further contributions for new tools to prevent, diagnose, and treat TB among children are imperative,” said Erica Lessem, assistant director of TAG’s TB/HIV Project. Every year, TB kills at least 70,000 children, but they remain underrepresented in TB research, the report says.
“The small, unsteady gains in funding we saw from 2005 to 2011 have now sputtered and reversed,” said Mark Harrington. “Without dramatically increased funding, promising new tools will languish in clinical development, and other new technologies will never even enter it. We can only achieve zero TB deaths, new infections, and suffering with robust R&D and the reinvigorated financial commitments required to support this lifesaving research.”
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