JAMA: Global Health Theme Issue Topic Collection

Dimensions of Global Health , 2012

Frieden TR, Garfield RM. — Wed, 16 May 2012 00:00:00 GMT

Human health has improved more in our lifetimes than it did in the preceding thousand years. Since 1970, the number of infants who die has decreased by more than half worldwide, and maternal mortality has fallen dramatically in virtually every region of the world. Facing today's enormous global health challenges, we often lose sight of such advances. Health has improved for several reasons. First and foremost, economic growth improves people's life chances. In 1970, close to half the world's population lived in extreme poverty; now one in seven people lives in poverty. More people have access to clean water, immunizations, and basic health services because of the work of governments, charitable groups including faith-based organizations, international organizations, the private sector, and public and private development assistance. Wider dissemination of information and increasing citizen participation make it possible for many lower-income people to make better-informed decisions about their health.

Food, Micronutrients, and Birth Outcomes Food, Micronutrients, and Birth Outcomes

Christian P, Black RE. — Wed, 16 May 2012 00:00:00 GMT

In this issue of JAMA, Persson et al describe the effects of early (approximately 9 weeks) vs usual (approximately 20 weeks) food supplementation alone or in combination with multiple micronutrient supplementation (MMS) vs iron-folic acid (using 60-mg and 30-mg iron formulations) during pregnancy on outcomes of maternal anemia, birth size, gestational age, and infant mortality, using a 3×2 factorial experimental design. The main, rather complex, findings were that there was no effect of either early food supplementation or MMS interventions on birth size or gestational duration at birth. Instead, both a positive and negative interaction between food supplementation and MMS were observed related to the outcome of offspring mortality. Early food supplementation combined with MMS significantly reduced the outcomes of neonatal, infant, and under 5-year child mortality compared with the standard of care of antenatal iron (60 mg) and folic acid supplements with a food supplement starting midgestation. Neither intervention nor their combination reduced stillbirth or perinatal mortality.

PEPFAR and Maximizing the Effects of Global Health Assistance PEPFAR and the Effects of Global Health Assistance

Emanuel EJ. — Wed, 16 May 2012 00:00:00 GMT

Between 1995 and 2008, worldwide global investment in improving health in developing countries increased from $8 billion to nearly $25 billion. A main reason for this substantial increase was the creation of new institutions including the Gates Foundation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the GAVI Alliance; and, most importantly, the President's Emergency Plan for AIDS Relief (PEPFAR) program.

China's Air Quality Dilemma Reconciling Economic Growth With Environmental Protection Economic Growth vs Environmental Protection

Dominici F, Mittleman MA. — Wed, 16 May 2012 00:00:00 GMT

Before 2008, concentrations of air pollutants in the city of Beijing, China, site of the 2008 Olympic Games, far exceeded acceptable standards, which caused serious concerns in the international community about the health and performance of Olympic athletes. To ensure acceptable air quality during the Olympics (held from August 8-24) and the Paralympics (held from September 6-16), the Chinese government launched a series of aggressive measures to reduce pollutant emissions. To reduce industrial emissions, the operations of combustion facilities were restricted in smelters, cement plants, power plants, nonattainment boilers, and construction and petro-chemical industries. To reduce traffic emissions, certain vehicles and trucks were banned, 70% of government-owned vehicles were kept off the streets, and other vehicles could travel through the city only on alternating days.

The Question of Improvement

Berwick DM. — Wed, 16 May 2012 00:00:00 GMT

In this issue of JAMA, Berwanger and colleagues report a teaching-case–perfect cluster-randomized trial demonstrating the positive effects of a “multifaceted intervention” to improve the reliability of evidence-based management of acute coronary systems in general hospitals in Brazil. With a combination of reminders, a checklist, case management, and staff education, the intervention hospitals used all eligible acute therapies in the first 24 hours after admission 37% more often than control hospitals (67.9% vs 49.5%) and used all evidence-based therapies (ie, not just acute management) 67% more reliably (50.9% vs 31.9%).

Health, Economics, and the 2012 G8 Summit

Bauchner H, Frenk J. — Wed, 16 May 2012 00:00:00 GMT

Health and economics are inextricably linked. Health constitutes a vigorous sector of the economy, with effects on inflation, employment, and competitiveness. The World Health Organization estimates that health systems worldwide absorb approximately 10% of the world economy—about US $6 trillion. Differences in health expenditures, however, are huge. For instance, the United States spends more than $7000 per capita on health, whereas Eritrea spends less than US $10. For low- and middle-income countries, committing more financial resources to health is a complicated and difficult decision, because most nations face many competing priorities. Nor will improving the health of the world's population be possible unless there is global economic recovery. Enlightened ministers of finance realize that better health contributes to sustainable economic growth through its effects on improved productivity.

Changes in Prevalence of Girl Child Marriage in South Asia

Raj A, McDougal L, Rusch MA. — Wed, 16 May 2012 00:00:00 GMT

To the Editor: Girl child marriage (ie, <18 years of age) affects more than 10 million girls globally each year and is linked to maternal and infant morbidities (eg, delivery complications, low birth weight) and mortality. Half (46%) of child marriages occur in South Asia. This study assessed whether prevalence of girl child marriage has changed over the past 2 decades in 4 South Asian nations with a girl child marriage prevalence of 20% or greater.

Recent Advances in Mobile Technology Benefit Global Health, Research, and Care

Hampton T. — Wed, 16 May 2012 00:00:00 GMT

Now that more than 5 billion people worldwide have a cell phone, mobile technology sits poised to revolutionize the way medical care and health information are delivered, particularly in the developing world. A number of efforts are under way to leverage mobile technology's tools to align with pressing health priorities through a field called mobile health (mHealth).

IOM Report Lays Out a Blueprint for Improving Regulatory Systems Worldwide

Mitka M. — Wed, 16 May 2012 00:00:00 GMT

The emergence of the global economy is affecting the supply chains of food and medical products, raising public health and safety concerns throughout the world. To combat the situation, governments are looking at improving regulatory systems to ensure that medical products and foods are safe regardless of where they are produced or consumed.

Effect of a Multifaceted Intervention on Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil The BRIDGE-ACS Randomized Trial Evidence-Based Therapies in Acute Coronary Syndromes

Berwanger O, Guimarães HP, Laranjeira LN, et al. — Wed, 16 May 2012 00:00:00 GMT

Context

Studies have found that patients with acute coronary syndromes (ACS) often do not receive evidence-based therapies in community practice. This is particularly true in low- and middle-income countries.

Objective

To evaluate whether a multifaceted quality improvement (QI) intervention can improve the use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country.

Design, Setting, and Participants

The BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized (concealed allocation) trial conducted among 34 clusters (public hospitals) in Brazil and enrolling a total of 1150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012.

Intervention

Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, vs routine practice (control).

Main Outcome Measures

Primary end point was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications.

Results

Mean age of the patients enrolled was 62 (SD, 13) years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non–ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1150 [80.3%]), 67.9% in the intervention vs 49.5% in the control group received all eligible acute therapies (population average odds ratio [OR_PA], 2.64 [95% CI, 1.28-5.45]). Similarly, among eligible patients (801/1150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs 31.9%; OR_PA,_, 2.49 [95% CI, 1.08-5.74]). Overall composite adherence scores were higher in the intervention clusters (89% vs 81.4%; mean difference, 8.6% [95% CI, 2.2%-15.0%]). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group (OR_PA, 0.72 [95% CI, 0.36-1.43]); 30-day all-cause mortality was 7.0% vs 8.4% (OR_PA, 0.79 [95% CI, 0.46-1.34]).

Conclusion

Among patients with ACS treated in Brazil, a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies.

Trial Registration

clinicaltrials.gov Identifier: NCT00958958

Effects of Prenatal Micronutrient and Early Food Supplementation on Maternal Hemoglobin, Birth Weight, and Infant Mortality Among Children in Bangladesh The MINIMat Randomized Trial Prenatal Micronutrient and Early Food Supplementation

Persson L, Arifeen S, Ekström E, et al. — Wed, 16 May 2012 00:00:00 GMT

Context

Nutritional insult in fetal life and small size at birth are common in low-income countries and are associated with serious health consequences.

Objectives

To test the hypothesis that prenatal multiple micronutrient supplementation (MMS) and an early invitation to food supplementation would increase maternal hemoglobin level and birth weight and decrease infant mortality, and to assess whether a combination of these interventions would further enhance these outcomes.

Design, Setting, and Participants

A randomized trial with a factorial design in Matlab, Bangladesh, of 4436 pregnant women, recruited between November 11, 2001, and October 30, 2003, with follow-up until June 23, 2009.

Interventions

Participants were randomized into 6 groups; a double-masked supplementation with capsules of 30 mg of iron and 400 μg of folic acid, 60 mg of iron and 400 μg of folic acid, or MMS containing a daily allowance of 15 micronutrients, including 30 mg of iron and 400 μg of folic acid, was combined with food supplementation (608 kcal 6 days per week) randomized to either early invitation (9 weeks' gestation) or usual invitation (20 weeks' gestation).

Main Outcome Measures

Maternal hemoglobin level at 30 weeks' gestation, birth weight, and infant mortality. Under 5-year mortality was also assessed.

Results

Adjusted maternal hemoglobin level at 30 weeks' gestation was 115.0 g/L (95% CI, 114.4-115.5 g/L), with no significant differences among micronutrient groups. Mean maternal hemoglobin level was lower in the early vs usual invitation groups (114.5 vs 115.4 g/L; difference, −0.9 g/L; 95% CI, −1.7 to −0.1; P = .04). There were 3625 live births out of 4436 pregnancies. Mean birth weight among 3267 singletons was 2694 g (95% CI, 2680-2708 g), with no significant differences among groups. The early invitation with MMS group had an infant mortality rate of 16.8 per 1000 live births vs 44.1 per 1000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid (hazard ratio [HR], 0.38; 95% CI, 0.18-0.78). Early invitation with MMS group had an under 5-year mortality rate of 18 per 1000 live births (54 per 1000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid; HR, 0.34; 95% CI, 0.18-0.65). Usual invitation with MMS group had the highest incidence of spontaneous abortions and the highest infant mortality rate.

Conclusion

Among pregnant women in poor communities in Bangladesh, treatment with multiple micronutrients, including iron and folic acid combined with early food supplementation, vs a standard program that included treatment with iron and folic acid and usual food supplementation, resulted in decreased childhood mortality.

Trial Registration

isrctn.org Identifier: ISRCTN16581394

A Train of Hope, and a Chance to Train

Prasad C. — Wed, 16 May 2012 00:00:00 GMT

I was struck by her eyes as we appraised each other from across the crowded hall. They were big, beautiful black eyes, looking at me with a mixture of fear, curiosity, and awe. They belonged to a young girl, with a bright, lively face. I know my eyes must have mirrored hers, for I too was filled with the same emotions.

A Framework Convention on Global Health Health for All, Justice for All A Framework Convention on Global Health

Gostin LO. — Wed, 16 May 2012 00:00:00 GMT

Health inequalities represent perhaps the most consequential global health challenge and yet they persist despite increased funding and innovative programs. The United Nations is revising the Millennium Development Goals (MDGs) that will shape the world for many years to come. What would a transformative post-MDG framework for global health justice look like? A global coalition of civil society and academics—the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI)—has formed an international campaign to advocate for a Framework Convention on Global Health (FCGH). Recently endorsed by the UN Secretary-General, the FCGH would reimagine global governance for health, offering a new post-MDG vision. This Special Communication describes the key modalities of an FCGH to illustrate how it would improve health and reduce inequalities. The modalities would include defining national responsibilities for the population's health; defining international responsibilities for reliable, sustainable funding; setting global health priorities; coordinating fragmented activities; reshaping global governance for health; and providing strong global health leadership through the World Health Organization.

Policy Making With Health Equity at Its Heart Policy Making With Health Equity

Marmot MG. — Wed, 16 May 2012 00:00:00 GMT

In India, there is a cabinet minister for social justice. Would that it were catching, and spread to all government ministers. What a thought: social justice at the heart of all government policy. It would be a radical change from the current set of arrangements, in which many governments are unashamed apostles of self-interest—of their countries, of their partisan supporters or, indeed, of self-interest as a political creed. Given the link between social and economic policy and the health of populations, all ministers should see themselves as ministers of health. Putting these arguments—health and social justice—together implies that health equity should be at the heart of all policy making, national and global.

Noncommunicable Diseases A Global Health Crisis in a New World Order Noncommunicable Diseases

Marrero SL, Bloom DE, Adashi EY. — Wed, 16 May 2012 00:00:00 GMT

In September 2011, the United Nations General Assembly (UNGA) held—for the first time—a High-Level Meeting on the Prevention and Control of Non-communicable Diseases. In taking this unusual step, the UNGA, home to 193 member states and the principal decision-making organ of the United Nations (UN), has affirmed not only the global importance of the noncommunicable diseases (NCDs) but also the imperative of concerted remedial action. In this Viewpoint we discuss the outcomes of the high-level meeting (HLM) and the aftermath thereof and affirm that the heretofore unrecognized NCD epidemic has at last acquired a voice. However, the HLM, accompanied by a severe international economic downturn, exposed a new world order wherein erstwhile global health donors play a more limited role, aid recipients assume greater responsibility for developmental progress, and UN agencies increasingly integrate NCDs into their programmatic and budgetary constructs.

Primary Health Care in Low-Income Countries Building on Recent Achievements Primary Health Care in Low-Income Countries

Sachs JD. — Wed, 16 May 2012 00:00:00 GMT

Small investments in improved health of the poor have a remarkable return in reduced morbidity and mortality. While the developed economies grapple with health systems that cost several thousand dollars per person per year and often spend hundreds of thousands of dollars on a treatment to eke out an additional few months of life, outlays of just a few dozen dollars per person per year in impoverished countries can add several years to life expectancy. In the least developed countries, approximately 112 of every 1000 children die before their fifth birthday, as opposed to 8 per 1000 in the developed countries. With a concerted science-based effort, the under-5 mortality rate of the least developed countries could be reduced to less than 30 per 1000 by 2020. Such low under-5 mortality rates have already been achieved, for example, by the Dominican Republic (28 per 1000), Mexico (17 per 1000), and Thailand (13 per 1000).

Achieving Equity in Global Health So Near and Yet So Far Achieving Equity in Global Health

Bhutta ZA, Reddy K. — Wed, 16 May 2012 00:00:00 GMT

Few issues have generated as much passion and imagination over the last few decades as the challenge of global health. From major studies on the global burden of disease to the recognition of the global epidemic of human immunodeficiency virus, AIDS, and tuberculosis, health has been center stage of the global development debate. Issues, which once remained within the purview of health advocacy and policy circles, found their way into the center stage of debates in the World Economic Forum and onto agendas for G8 and G20 summit meetings. The groundbreaking reports from the Commission for Macroeconomics in Health and Social Determinants of Health highlighted the importance of appropriate resource allocations for health as well as focusing on issues that determine population health, but are frequently beyond the purview of ministries of health. Even as the world contends with a worldwide recession, there is clear recognition that health of populations everywhere must be protected and promoted, not only as a developmental commitment to equity but also as an imperative for economic growth and security.

Artemisinin-Resistant Malaria

Friedrich MJ. — Wed, 16 May 2012 00:00:00 GMT

Artemisinin resistance has increased rapidly in the malaria-causing parasite, Plasmodium falciparum, along the border of Thailand and Myanmar, according to researchers from Thailand, the United Kingdom, and the United States (Phyo AP et al. Lancet. doi:10.1016/S0140-6736(12)60484-X [published online April 5, 2012]).

Reducing Maternal Morbidity

Friedrich MJ. — Wed, 16 May 2012 00:00:00 GMT

A new report from US researchers outlines key actions to address maternal morbidity in the developing world (Hardee K et al. Global Public Health. doi:10.1080/17441692.2012.668919 [published online March 16, 2012]).

Global Burden of Hepatitis E Virus

Friedrich MJ. — Wed, 16 May 2012 00:00:00 GMT

The first estimate of the global effect of infection with the hepatitis E virus (HEV) reveals that as many as 20.1 million people were infected with HEV genotypes 1 and 2 in 2005 in 9 regions in Asia and Africa defined for the Global Burden of Diseases, Injuries, and Risk Factors Study, report researchers from the World Health Organization and the United States (Rein DB et al. Hepatology. 2012;55[4]:988-997).

Dementia Should Be a Priority

Friedrich MJ. — Wed, 16 May 2012 00:00:00 GMT

Recognizing and addressing the impact of dementia should be a public health priority around the world, according to a new report published by the World Health Organization and Alzheimer's Disease International (http://tinyurl.com/cwu7syc).

Progress Toward Global Polio Eradication—Africa, 2011

Wed, 16 May 2012 00:00:00 GMT

Morbidity and Mortality Weekly Report

Nodding Syndrome—South Sudan, 2011

Wed, 16 May 2012 00:00:00 GMT

Morbidity and Mortality Weekly Report