A bit later in the hour, we'll be talking about bridges. But up first, what's the one thing we could do to improve the health of the poorest people in the world, people living on less than $1 a day? That's the question posed to public health experts and some poor people by editors at the journal Public Library of Science Medicine. With their current issue, the journal joins over 200 other science journals to raise awareness of the impact of poverty on health and human development.

Joining me now to talk about what public health experts had to say about improving the health of poor people is Gavin Yamey. Dr. Yamey is senior editor of the journal Public Library of Science Medicine in San Francisco.

Our number, 1-800-989-8255, if you'd like to talk with us about it. And I'd like to welcome Dr Yamey to the program.

Dr. GAVIN YAMEY (Senior Editor, Public Library of Science Medicine): Thanks for the invitation, Ira.

FLATOW: What was the idea behind asking this question?

Dr. YAMEY: Well - so, originally, Ira, I was going to ask one or two of the really big names in global health to do an in-depth analysis, you know? What do they think are the solutions to the health problems of the very poor. But then I decided that, actually, I was going to put this question to a much broader range of experts. Some of the clinicians working at the frontlines, health reporters in these low-income settings, policymakers, development experts, and also importantly, I think, because the answers were quite revealing, the poor themselves.

FLATOW: Uh-huh.

Dr. YAMEY: I wanted to get a whole range of opinion.

FLATOW: Mm-hmm. Now, you said the answers were quite revealing. Can - share some of those with us.

Dr. YAMEY: Well - so, I think one of the dominant themes that came out of these interviews was that, with one exception, almost everybody mentioned an intervention that was low-cost and low-tech. So, things like clean water, nutrition, vaccines, latrines, bed nets, which we know protect children from deathly malaria. And the only exception was that one interviewee from the International AIDS Vaccine Initiative talked about the importance of developing a vaccine. So that would come from, I guess, the cutting edge of modern science like labology(ph) and immunology. But all the other interventions from the other 29 people that I interviewed were remarkably low-cost and low-tech.


Dr. YAMEY: I think - and another thing about the difference between what the experts said and what the poor said is that the experts talked about some of this kind of biomedical interventions, like vaccines, but the poor had a very different kind of response. They talked about the importance of family and community, a sort of a social response rather than a medical one.

FLATOW: That's an interesting point, because I was going to ask about education. Many times, you hear people saying, you know, educated people tend to be better off than non-educated people.

Dr. YAMEY: I mean, that's absolutely right, Ira. And there was another theme that came out of this that was linked to education. And that was about the empowerment and education of women. I would say…

FLATOW: Mm-hmm.

Dr. YAMEY: …three, four, five of the people I interviewed said, look, educating women is central to this issue. There was a reporter in Uganda, Rosebell Kagumire, who said, that when you educate a woman, you educate the whole village. And I think what she was talking about there is that once women have been empowered in this way - educationally, politically, socially, and so on -they can then plan better for their communities and they can manage their own health better and then the health of their children. Don't forget that in many of these very low-income countries, it's just women who are responsible for the care of children and often elders.

FLATOW: Mm-hmm. So far, you know, this is just a lot of talk, isn't it? I mean, you've asked the question, you've gotten some answers. Any way to make any practical use of the knowledge?

Dr. YAMEY: Well - so, I think my response to that would be to refer to another theme, which was that the rich world are not fulfilling their obligations to the poor. And this was something that came up time and time and again when I interviewed people. But, actually, if you look back in history, back in 1970, the rich countries pledged to set aside 0.7 percent of their GDP for development assistance. And, actually, our record in the rich world on meeting that is very poor; we've reneged on that promise.

So a lot of the respondents said, look, these interventions are incredibly cheap and as a package - you know, providing water and vaccines and bed nets and basic education, latrines, and so on - this is all entirely affordable and the rich world needs to invest in this. So these are affordable, cheap interventions and we, the global community, should be investing in them for all of our sakes.

FLATOW: Hmm. One of the experts you talked to was - someone who's very familiar with poverty and what to do about it, and that's Jeffrey Sachs.

Dr. YAMEY: Right.

FLATOW: And he thinks this isn't the right question to be asking, doesn't he?

Dr. YAMEY: That's right. Actually, it was quite interesting because Jeffrey Sachs is the first person that I contacted. And I wrote to him and I got a response back in 30 seconds. And you know, this is the world's preeminent health economist, may be one of the busiest people in the planet. And when someone like Professor Sachs is e-mailing you back within 30 seconds, you know, you think, well, may be this is an interesting approach.

And his first e-mail was very clear. This is about an Africa tackling malaria, right? And he's right, malaria causes somewhere between one in three million deaths a year, most of those in sub-Saharan Africa, most in children under five and pregnant women. So, his response, his first response was, we need to supply insecticide-treated bed nets to prevent malaria, and we need to supply effective malaria drugs. These are known as ACT, artemisinin-based combination therapy.

FLATOW: Mm-hmm.

Dr. YAMEY: But interestingly, about a minute later, I got another e-mail back Jeff Sachs saying, you know what, actually, I've spent years objecting to posing this question like that, because that low-cost we could achieve major health advantages through more comprehensive approaches. And I think that Professor Sachs is right. I mean, I'm not a global health expert, I'm a medical journal editor. I'm an interested observer here, I've been very privileged to be able to ask this question of the experts around the world. But when I think about the answers that were given, basically, people were saying to me, look, we've got the knowledge, we've got the tools, we've got the money. You know, the rich world collectively has an excess of $21 trillion, what on Earth is stopping us from acting? So I think that was another message from this survey.

FLATOW: Yeah. You know, you hear all the time, when we talk about poverty, we talk about nutrition. People who deal with these issues say, well, you know, there's enough food to feed everybody if we could just get the food to the right people. I would imagine that health care must be the same way. There's probably enough health care around if you can get and pay for it, and it reaches the right people. Many times, it never gets to the right people.

Dr. YAMEY: And many of the interviewees did talk about this issue of distribution or dissemination.

FLATOW: Uh-huh.

Dr. YAMEY: I think there is certainly a realization within the global health community that we aren't doing as well as we could be doing in disseminating or diffusing these tools that we know are effective. And so, for example, Paul Farmer, the physician and anthropologist who started Partners In Health - an organization that's worked with the very poorest in places like Haiti and Peru, and now in Africa - he talked about the importance of training and compensating village health workers.

FLATOW: Mm-hmm.

Dr. YAMEY: These would be people who are the actual neighbors of patients, who could be involved in the delivery of these tools. He uses this very interesting expression about kind of going the last mile, or going the extra mile. That too often in global health, these tools that we're talking about, you know, vaccines and bed nets, and drugs for T.B. malaria and AIDS, they get hung up in the cities…

FLATOW: Right.

Dr. YAMEY: …and that we really need to go that last mile…

FLATOW: Right.

Dr. YAMEY: …to deliver them. And that idea that Paul Farmer and Kim - Jim Kim at Partners in Health pioneered, it's really gaining a lot of traction in public health. And there are many other examples of people using the community, empowering, involving the community to kind of I guess deliver health by and for the community.

FLATOW: Mm-hmm. You end your study with an interesting quote from a South African professor. Could you read that for us?

Dr. YAMEY: Yes. So, I decided to finish the piece with this particular quote because I guess one of the themes from this theme issue in PLoS Medicine and also the theme issue broadly - you know, there were 230 journals involved - is something about our kind of interconnectedness. And that we're all, if you like, you know, a global community and we have certain obligations to each other. So, I ended the quote with - I ended the piece with a quote from Soli Benatar. He's a professor of medicine and a bioethicist. He's on the editorial board of PLoS Medicine. And Soli wrote that: Only when and if the haves developed genuine empathies for the have-nots and come to acknowledge their own long-term interdependence with all other humans, will a global economy be improved to any significant advantage for the desperately poor.

FLATOW: Mm-hmm. It's the haves versus the have-nots once again.

Dr. YAMEY: Right. And Soli has actually written quite a lot about what he sees as kind of a failure of moral imagination as being one of the blockages to…

FLATOW: Mm-hmm.

Dr. YAMEY: …to improving the health of the very poorest. That we often, in the rich world, have not been able to…

FLATOW: Right.

Dr. YAMEY: …have adequate empathy to feel connected, perhaps because of the distance in our (unintelligible).

FLATOW: Is there a follow-up question that one could ask, have you asked that one?

Dr. YAMEY: Well, I guess the follow-up question would be to now figure out what is stopping this from happening. Where are the blockages? And I guess there is a burgeoning science of this, sort of, diffusion science or kind of the science of large-scale change. I guess that for me, having interviewed these 30 people, so many of the solutions seemed very clear. But now, the next question is the delivery. What is the science of delivering these?

FLATOW: Yeah. It's something that hasn't really been fleshed out at all, has it?

Dr. YAMEY: You know, I think that's right. And actually there's a fascinating group of scientists at the Institute for Healthcare Improvement here in the U.S., and they have been looking at this kind of - this science of diffusion.

FLATOW: Mm-hmm.

Dr. YAMEY: And they say that we know about a lot of these solutions. We know about some of the medicines, the innovations, and - but their adoption has been slow, it's being unreliable, these interventions are remaining hidden in, kind of, pockets. And you could argue and this, sort of, have done so actually in this week's JAMA, the Journal of the American Medical Association, they say that failure to use these technologies is a waste. It's a waste for the donors, researchers and clinicians.


Dr. YAMEY: But obviously, the greatest waste is to the communities in developing nations.

FLATOW: Dr. Yamey, I have to say goodbye. I want to thank you very much for taking time to be with us.

Dr. YAMEY: Oh, thanks for the opportunity, Ira.

FLATOW: Gavin Yamey, senior editor of the journal Public Library of Science Medicine in San Francisco.

Stay with us. We'll be right back after this short break.

I'm Ira Flatow. This is TALK OF THE NATION: SCIENCE FRIDAY from NPR News.

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