Sunday, the World Health Organization's Executive Board announced a package of proposed reforms in response to criticism that it was slow in responding to the Ebola outbreak.   The full announcement can be found here. It includes a variety of reasonable additions and changes to WHO management of public health emergencies, such as the creation of a new position focused on coordination outbreak response, and the development of "emergency stand-by capactities".  Among the most notable is the proposed creation of a $100 million contingency fund intended to improve the WHO's ability to respond rapidly and independently to disease outbreaks and other public health emergencies.   

Although the announcement is and interesting read, there are few surprises among the proposed reforms.  However, there were two things that stood out to me.  First, although the contingency fund and other proposals seem reasonable, I question the actual viability of such reforms. These are proposed reforms, suggested by the the Executive Board, but in need of approval by the World Health Assembly (WHA).  Even if approved by the WHA, the implementation of these proposals will be determined by the availability of funds.  The WHO's budget has been in decline for years.  The budget for 2012-2013 was 20% less than the previous budget.  The current budget (which was approved in 2013) is $3.97 billion dollars.  In it, the funds for responding to health crises was reduced by half of its previous level.  

In addition to the decline of the WHO's already small budget --- consider that the budget for Department of State Health Service in Texas  in $3.3 billion --- the WHO also maintains very little discretion over its funds.  In 2013, 30% of the WHO budget was comprised of core contributions from member states.  Core contributions are unearmarked and allocated according to the WHO financing decisions.  The remaining 70% of the budget was comprised of voluntary contributions --- two thirds of which came from member states and the remaining third came from donations provided by foundations, like the Bill and Melinda Gates Foundation, philanthropic groups, and other large organizations.  Because 70% of the budget comes from voluntary contributions, actual funds available do not always meet proposed program budgets.  For example, in 2010, the WHO's proposed budget exceeded total funds by 20%.  In addition, voluntary contributions can be and generally are earmarked by donors for specific projects --- like HIV/AIDS.  This mean that even if the WHA approves the suggested reforms, and these reforms are incorporated into the next budget, and that budget is approved, the implementation of such programs is highly dependent upon funding decisions by individual donors.

The second aspect of the announcement that stood out to me, was the rhetoric about the necessity of strengthening the International Health Regulations (IHR) and health systems in developing countries.  The IHR are binding regulations that structure countries' responses to disease outbreaks.  Specifically, the IHR establish states' responsibility in monitoring, reporting, and responding to health emergencies while also limiting those responses to avoid interference with international trade.  Specifically, the IHR establish core capacities necessary to detect, assess, report and respond to public health crises at the national and international levels.  

Although the IHR are the one of the primary mechanisms through which state cooperate to control infectious disease, state level capacities generally condition the effectiveness of disease control efforts.  The WHO's announcement correctly identifies struggling health systems in developing countries and the lack of core capacities as a major obstacle detecting, assessing, reporting, and responding to outbreaks in a rapid and effective manner.  Domestic level health systems are the first line of defense in disease control.  The IHR require addition capacities, which the WHO strives to help states develop.  Yet, the function and disfunction of the health system as a whole is often neglected in favor of focusing on core capacities.  When discussing global public health, a weak health system in a developing country cannot and should not be ignored.  The Executive Board's statement clearly outlines the necessity of improving core capacities and health systems in general:
                                    
                                      "As events since the start of this century have shown, outbreaks rarely have only local or regional
                                      consequences in our highly interconnected and interdependent world.

                                     The International Health Regulations need more teeth. They provide the principal line of collective defence 
                                     against the threat from emerging and epidemic-prone diseases. The world will never reach true health security 
                                     until more countries, and eventually all countries, have core capacities in place.

                                     We need a far more rigorous methodology for evaluating these capacities than self-assessments in a 
                                     questionnaire. And we need to treat the importance of getting these capacities in place like the emergency that 
                                     it is.
                                  
                                     We need to stop thinking about core capacities as something that should be tacked onto a country's health
                                     systems, like an extra arm."

This is the message that has gotten lost in much of the developed world.  Not only must we be willing to fund the WHO --- and a wide range of its priorities --- in order to improve global health, but we must also view failing health systems in developing countries as more than unfortunate products of circumstance and poverty. We cannot just add additional capacities specifically for monitoring and reporting.  We must view the shortfalls of health systems in developing countries as threats in need and deserving of real attention.

This rhetoric stood out to me because of both its accuracy and its irrelevance.  Developing country level capacities for surveillance, reporting, and response, and building more effective health systems are arguably two of the most important challenges in global health.  The concurrent influences of poverty and poor health --- where poverty threatens health and health undermines prosperity --- make developing countries fertile ground for outbreaks.  In addition to the devastation of these outbreaks to the local population, the inability to control outbreaks increases the likelihood of spread.  

Yet the accuracy of this statement does not prevent it from being largely irrelevant. Among development scholars and practicioners, the need to strengthen local systems is an obvious and constant recommendation.  Yet, despite decades of development efforts and the coming conclusion of the Millennium Development Goals, improving basic health systems and core capacities has been a slow and difficult journey --- in large measure due to the apparent irrelevance of disease and death in developing countries to those in developing countries.  One need only look at the current Ebola crisis to be convinced of both realities.

This part of the announcement stood out to me because it is an acknowledgement of the reality and necessity of strengthening health systems in developing countries, in an announcement of reforms that will likely be disregarded, defunded, and dismissed by those most capable of doing so.  

Last week, The Carter Center announced that only 126 cases of guinea worm were reported in 2014.  You can read the full press release here.  After nearly three decades of intervention, guinea worm --- which once affecting nearly 3.5 million people each year --- remains endemic in only 30 villages worldwide.  The continued decline in the number of cases, puts guinea worm in line to be only the second infectious disease eradicated in human history --- behind smallpox, which was declared eradicated in 1980.  It is high time for another such victory.

Efforts to control guinea worm are notable for several reasons.  First, guinea worm eradication is not vaccine based.  Most of other diseases that have been targeted for eradication (and that can actually be eradicated) have resulted in extensive immunization programs --- smallpox, measles, & polio.  In contrast, there is no vaccination for guinea worm.  Instead, eradication efforts have focused on breaking the cycle of infection.  

One becomes infected by drinking water that contains water fleas infected with guinea worm larvae.  Once the fleas are ingested, the worms mature and mate in the human body.   After mating, the male worm dies and the female worm makes its way down the patient's leg and forms blisters on foot.  When the blister ruptures, the end of the worm emerges.  If worm comes in contact with water, it releases eggs into the water, where they infect water fleas and the cycle begins again.  

Because humans are the only known host for the post-larval stages of guinea worm --- unlike malaria --- preventing humans from ingesting infected water fleas has been the primary focus of eradication efforts.  This has included the distribution of drinking straws with a small filter, as well as the distribution of filteration systems and community education on how to properly filter water.  

In addition, programs have also been developed to "treat" patients with guinea worm infections.  Although the filtration systems are the primary tool, it is also necessary to prevent the release of additional guinea worm eggs into the water supply.  Thus, it is necessary to provide care to patients that will prevent them from entering the water.  I use quotation marks around "treat" here because there is no treatment for guinea worm in the western meaning of the word.  Treatment involves pulling the exposed worm out of the patients foot or leg little by little and wrapping the end around a stick between "pullings".  Although this treatment does little to ease the immediate pain of the patient, it has proven an effective intervention for preventing re-contamination of water supplies.

Efforts to control guinea worm are also notable because of how the efforts have been coordinated.  Because only one disease has been eradicated, we only have one model for how international cooperation for eradication is developed and completes its mission.  In the case of smallpox, the global eradication effort began with the World Health Organization.  Initially, the WHO's role was to mobilize around the goal, but coordination efforts were left to individual countries.  When this approach seemed to be failing, the WHO (backed by the US and Russia) took a greater leadership role.  The Smallpox Eradication Fund and the Smallpox Eradication Unit were created in the WHO, leading to a more centralized approach.  Attempts to replicate the smallpox model have had mixed results, as seen in the cases of polio and measles.

In contrast, the guinea worm eradication effort began in 1980 as an initiative of the US Center for Disease Control and Prevention (CDC) and was later adopted as a goal of the United Nations International Drinking Water Supply and Sanitation Decade.  Despite the international recognition of the goal, the Carter Center --- a non-profit organization founded by former US President Jimmy Carter --- has played a key role in eradication efforts.  The Carter Center works with ministries of health in endemic countries and assists with program development and implementation.  In addition, the Carter Center is also one of the few implementing agents for aid from donor countries and international organizations alike.  

It will be interesting to see what lessons the policy practitioners will take from this case when guinea worm is finally eradicated.  I suspect, some will call for a greater role for non-governmental organizations.  In contrast, I would argue that this case is an excellent example of why we must understand not only the biology of a disease, but the social, economic, and political dimensions as well.  

A non-profit has been successful in this case in part due to the small number of non-profits addressing guinea worm.  Eradication requires coordination and some minimal degree of centralization.  The Carter Center has proven to be a strong coordinating agent, but its effectiveness could be threatened if there were many non-profits with no clear coordination --- consider HIV/AIDS.  

In addition, there is little disagreement about how to effectively combat guinea worm --- break the cycle of infection through filtration and "treatment".  Other infectious diseases do not share this concensus, often to their detriment.  From anti-vaccination movements to treatment vs. prevention debates, it is well observed that when disease control strategies are politicized, disease control is compromised.  There are, no doubt, many lessons to be learned from the success of guinea worm eradication efforts.  However, without considering the case as a whole --- biology, public health, social, economic and political --- we may be in danger of drawing incorrect conclusions.  

In the meantime, I look forward to celebrating another global public health victory in the (hopefully) not too distant future.

For those who are unfamiliar with guinea worm, here is a short video from the Carter Center --- but be warned, it does show the extraction procedure.

A family member recently sent me an email with a link to an oped from the Washington Post --- "This year, I resolve to ban laptops from my classroom" --- and a message that read "Can you believe how mean this professor is?  I hope you don't do this to your students".  It made me laugh a little.  As a professor, I have spent a fair amount of time thinking about what role technology should play in the classroom.  I have surveyed colleagues about how they limit students' use of phones and computers in the classroom and composed detailed policies intended to discourage such distractions in my classes.  

While phones seem to be a pretty obvious item to ban (and are banned in my class), I am more conflicted about laptops.  Without question, laptops introduce the potential for added distractions.  Email, social media, games, and even videos often prove too tempting a distraction for some students.  (In an extreme example, one friend told me that she was interrupted during a 150-person lecture by the sterotypical and all too obvious sounds of pornography coming from a laptop that the user forgot to mute.) Yet, despite the potential for distraction, I have often reasoned that there are benefits to having laptops in the classroom.  Many of my students claim that they can't read their own handwriting, thus typing notes solves a variety of problems.  Several have noted that typed notes are easier to organize after class.  Others note that they can type faster than writing by hand. For my part, I appreciate that having laptops can enable activities in class that would be difficult without reserving a computer lab --- such as asking students to seek out data on a specific issue.  Also, I remember how expensive it was to print out journal articles for each of my classes when I was a student.  Being able to read and bring digital copies of articles to class is one less expense for students already struggling to finance a university education.  

The author of the op-ed points out a growing literature on why the problem of laptops in the classrom is not just about distractions.  A growing volume of literature suggests that laptop use diminishes students'  understanding, praticipation, and retention.  In addition, when students are able to take down more notes, they often become less selective about identifying the important points and instead take down everything.  Being able to evaluate the relevance and importance of pieces of information is a key skill that students need to effectively prepare for exams and that will serve them well after they have graduated.

I have tried to alter how I teach to minimize some of these problems.  For example, I have moved away from using Powerpoint whenever possible.  Instead I write on the board.  Not only does this slow me down in my presentation of information, it also decreases the amount of text I present and gives students more time to take notes and think about what they are writing down.  In addition, at the beginning of each semester, I inform students of the findings in research such as that identified by the author of the oped and encourage them to ditch the laptops in class as much as possible.  

The main question for me is should I be a benevolent dictator. My students are all adults.  I'm not yet convinced that it is my right and/or responsibility to decide how they should engage in their education.  In addition, I wonder if it is too late for some of my students.  Many students here at Tech enter undergraduate education without a variety of skills --- including, but not limited to, readable handwriting, organization of notes, paraphrasing, simplifying, and winnowing information during notetaking, etc --- for which laptops help them compensate.  Banning laptops might force them to improve these skills, but if I'm not willing to expend class time or slow class down to help teach them these skills, is it fair to kick their crutch out from under them at this point in their education?  And if I did, would the benefits to them outweigh the costs?  

 I haven't banned laptops in my classes yet --- but I consider it every year.  Maybe next year I'll join the ranks of  "mean" professors.