NYT Mistaken on Polio Eradication Feasibility

Whether polio eradication should be pursued or whether it is central to global health are questions that should be and are asked by The New York Times in “Critics Say Gates’s Anti-Polio Push Is Misdirected.” However, the Times also contends that “Victory may have been closest in 2006…” when victory may be closer now than ever before. And the latest blast of polio funding and initiatives, described by the Times, comes not because the eradication effort is on its heels but because it’s going for the kill.

Eradication hinges less on the number of countries suffering polio cases than on knocking out the sources—or “reservoirs”—of the disease. The two largest such reservoirs are India and Nigeria. Today, both countries have historic, record low cases. The Times describes this as “doing much better.” Perhaps also underappreciated by the article, wiping out the reservoirs of polio will stop outbreaks. The Times mentions outbreaks in Nepal, Kazakhstan, Tajikistan, Turkmenistan and Russia. All originated from India.

Further, the case of India seems to demonstrate that there are no scientific or technological barriers to eliminating polio. In particular, the Indian states of Bihar and Uttar Pradesh once were the most impregnable redoubts for the poliovirus anywhere on the planet. Yet, because of the huge expense and exertions described by The New York Times, Bihar and Uttar Pradesh saw nearly zero cases even during the “high season” for polio. (See my Polio in Retreat: New Cases Nearly Eliminated Where Virus Once Flourished.)

In Africa, Nigeria has been the most intractable polio problem. No sooner is eradication on track in that nation, than new sources—Angola, Chad, Congo and Sudan—arose to continue infecting the continent. Indeed, Angola and Sudan have even reverted back into polio reservoirs, the disease spreading within and across borders. The Times properly draws attention to this indisputable, highly problematic regress. But the obstacles to eliminating polio in Angola do not compare with those of India where the degree of difficulty approached near impossibility. And Angola has gotten rid of polio before. How did it come back? Cases imported from India, a reservoir now drawn down to historic lows.

The New York Times represents a crucial exception to the influence of the Gates Foundation on global health coverage. It is important to question whether, in retrospect, polio eradication ought to have been undertaken, given all the costs. Also, whether today polio ought to be treated as the number one priority in global health is likewise a valid inquiry. And the Times is right that the Bill & Melinda Gates Foundation has doubled down on polio eradication several times before in the aftermath of setbacks to the program. However, the recent slew of polio announcements and initiatives is not in response to setbacks. It’s to unload a knock-out punch while the opponent is staggered. It might work.

Science faltering? No comment, no coverage

A National Science Foundation study cast doubt on the idea that scientific progress is accelerating--or even maintaining speed. Nearly two dozen scientists, science administrators, members of Congress and the Executive branch declined to comment. The study elicited almost no coverage.

I explain these phenomena in Columbia Journalism Review:

Science Faltering? Obama wants more R&D, but few willing to discuss research productivity


Columbia Journalism Review series on global health journalism: Part 1 of 2

The Columbia Journalism Review today republished my article, "How Ray Suarez really caught the global health bug." Part two goes up tomorrow.

As CJR's editor's note says:

This article was originally published on the author’s personal blog in July. With a few updates, we are running it as the first in a two part series exploring the implications of the Bill and Melinda Gates Foundation’s increasingly large and complex web of media partnerships. This part deals with a partnership between the PBS NewsHour and the Gates Foundation formed in 2008. Part two, running tomorrow, will examine a partnership with the Guardian, a British newspaper, announced in September, and one with ABC News announced on Wednesday.

Systems and synthetic biology: Neither models nor miracles

From my article on Ars Technica:

The 20th century broke open both the atom and the human genome. Physics deftly imposed mathematical order on the upwelling of particles. Now, in the 21st century, systems biology aims to fit equations to living matter, creating mathematical models that promise new insight into disease and cures. But, after a decade of effort and growth in computing power, models of cells and organs remain crude. Researchers are retreating from complexity towards simpler systems. And, perversely, ever-expanding data are making models more complicated instead of accurate. To an extent, systems biology, rather than climbing upwards to sparkling mathematical vistas, is stuck in a mire of its own deepening details.

Read the rest....

Polio Turns Stealthy in India

Oral polio vaccine (Photo credit: quilty2010)  

Polio eradication may be entering a new phase in India where incidence of the disease has become so faint, it’s sometimes undetectable. Yet polio is still very much there and capable of spreading. Sewage in New Delhi tested positive for poliovirus six straight weeks recently. (Polio is usually spread by oral contact with water contaminated by the feces of people infected by the virus.) But no cases of polio have been reported in the entire state of Delhi for more than a year. How can there be circulating virus and no cases?

Only about one in 200 polio infections results in paralyzing disease. But these cases must be detected to be counted and to prevent further spread. Across India, more than 20,000 people comprise the detection network, in theory at least one to every block of every district in the country.

But in the states of Uttar Pradesh and Bihar, one of the world’s largest polio redoubts, the challenges of detecting polio cases are immense. The sheer reproductive force of the region astonishes: 500,000 children are born every month in Uttar Pradesh. Poverty, illness and death are likewise extreme in degree while infrastructure is scant. And many people are highly mobile, migrating far and wide, all of which makes detecting polio cases from this oceanic flux difficult. And it is getting harder.

Frequent, massive vaccination campaigns have beaten polio down. Uttar Pradesh hasn’t seen a case since April and only six in total this year. But the disease is cropping up elsewhere. New cases were reported in the state of Jharkhand, which borders Bihar, but also in Maharashtra on the other side of the country. And a spectacular outbreak ignited in Tajikistan a few months ago. 452 people became infected with a poliovirus traced back to Bihar. A smaller outbreak occurred in Nepal, again originating in neighboring Bihar.

But even giant outbreaks don’t threaten polio eradication. Make it rain oral polio vaccine and new outbreaks can be fairly reliably extinguished, albeit at significant cost. The problem facing eradication efforts is that the gauges read “zero” when clearly the actual number of polio cases sits above zero. As the World Health Organization put it, new cases in India last week and the sewage samples in New Delhi are “evidence of ongoing, low-level [poliovirus] transmission in the country.” (Wild Poliovirus Weekly Update, 11 August 2010).

The level of transmission has dropped to where it can’t always be seen but it remains high enough to sustain the cycle of infection.  The good news is that strenuous vaccination efforts have driven cases down. The bad news is that polio is not eradicated and now might fly too low to be picked up by the existing detection network, hindering efforts to stamp the virus out for all time.

Today the Bill and Melinda Gates Foundation invited proposals to address exactly this problem. According to the foundation, “as eradication nears the signal provided by paralytic disease will be eventually lost; new methods to monitor poliovirus circulation are increasingly necessary.” The foundation identified other obstacles to eradication that need to be addressed but the overarching theme was for what it described as the “poliovirus endgame.”

How close is this endgame? The steep fall in cases evokes guarded optimism from Steve Wassilak at the Center for Disease Control, which is part of the Global Polio Eradication Initiative. In email, he said:

We, the interested parties, do need to avoid over-weighing any decline in cases as a clear path to zero, given the ups and downs in the past, particularly in India. However, we are squarely now in the high season and the total number of cases is at an historical low…

The outlook for 2010 appears good, although according to Dr. Yash Paul, a pediatrician in Jaipur, India, “In India high incidence of polio starts June onwards, so we shall know the likely polio scenario in end August” because of reporting lags. Also, one good year doesn’t automatically beget another. While 2005 saw just 66 cases, 2006 brought over 600 cases while 2007 produced more than 800.

Wassilak pointed out that the passing of the high season for polio could snap the few remaining chains of transmission. Or not. “[A]n alternative,” Wassilak hypothesized, “is can mobile populations be sustaining/contributing to transmission but cases of paralysis among these populations be missed?” The sewage tests in New Delhi, at Swaran Cinema, might support this hypothesis if the moviegoers are from neighboring Uttar Pradesh.

Other known problems obstruct eradication. Notably, the oral polio vaccine quite often fails to elicit immunity. WHO began addressing this in April. (See Polio Eradication: Harder Than it Looks.) Similarly, the Gates Foundation, in its invitation for polio eradication proposals today, included investigating why “vaccines have shown reduced efficacy in children living in certain resource-poor environments.”

A newer potential problem is re-infection among persons who were earlier protected by prior immunizing exposure. Such re-infections might be helping sustain the poliovirus cycle in areas with long-running eradication efforts—a vicious circle.

Finally, India is not the only endemic source of polio. Nigeria, Pakistan and Afghanistan also have never interrupted transmission, although a decade ago, 20 countries fell in this category. Unfortunately, transmission has become re-established in several nations in Africa and is unlikely to be stopped in those places by the end of the year, a revised goal for the eradication effort which originally was supposed to conclude in 2000.

Still, the potential is there for this be the turning point.



Gates Seeks to Close Out Polio in Nigeria (June 7, 2010)

Heavy Lifting: Raising Health Beyond Polio's Reach (May 13, 2010)

Wall Street Journal: Pulling the plug on polio eradication? (April 26, 2010)

Polio Eradication: Harder Than it Looks (April 14, 2010)

The future of spaceflight: “social welfare for nerds”

Nuclear thermal propulsion: not a new idea (Photo: Wikimedia Commons)

Tom Markusic, of Space Exploration Technologies (SpaceX), recently warned that spaceflight on its present course “will devolve into social welfare for nerds.” To escape federally funded self-indulgence, Markusic proposes developing a potentially game-changing technology: nuclear thermal propulsion.  But its nominal prospects only make his unhappy prediction for the future of spaceflight more likely.

NASA chief Charles Bolden called for new ideas after President Obama earlier this year cancelled the Constellation project, which looked much like its antecedent, the half-century old Apollo program. Nuclear thermal propulsion, which Markusic advocates for getting to Mars, also dates back to the golden age of space. Beginning in the 1950s and continuing into the ‘60s, NASA extensively investigated thermal nuclear technology which combusts hydrogen at the extreme temperatures of a nuclear reactor, providing much greater thrust than the chemical reaction used in conventional rockets.

Clearly it’s not a new idea. Rather it underlines the paucity of new, workable technologies that meaningfully enhance the prospects for human exploration of space.

Nuclear thermal does work and it delivers about twice the kick from a given amount of hydrogen compared to burning it the usual way. But it’s expensive. And it’s nuclear.  In the 1950s we looked forward to everything atomic. But no longer.

SpaceX founder Elon Musk contradicted Markusic a few days ago saying “I don’t think nuclear thermal is the way to go.” Musk, perhaps wanting to keep his company out of the nuclear fray, said the weight of the reactor would offset the benefit of greater combustion energy. However, Stanley Borowski and colleagues at NASA firmly contend that nuclear thermal rockets would roughly halve the transit time for a Mars mission from about 4.7 years to 2.5. But a not-quite-factor-of-two improvement has failed to captivate.

When Musk entered the rocket business, he was looking for a “Moore’s law of space,” exponential advances which would make humanity a spacefaring species. Markusic appears to have truer insight into the future of spaceflight.



Goodbye Mars, Hello Malaria: Bill Gates’ Imprimatur on Science and the 21st Century

 Human Space Exploration: Scaled Back to Vanishing 

Space Age entering eclipse—unnoticed

How Ray Suarez really caught the global health bug

The Gates Foundation, global health and the media

How did Ray Suarez catch the global health bug? Simple, he said in a recent talk answering  that exact question. Suarez explained: “The executive producer of the NewsHour, Linda Winslow, came into my office and asked me if I was interested in covering global health for the program and I said ‘yes.’ ”

But the actual reason is, following that conversation, Suarez wrote a proposal for the Bill & Melinda Gates Foundation resulting in $3.6 million of funding for NewsHour programming on global health. The Gates Foundation also sponsored the event at which Suarez was speaking. The moderator came from the foundation too, posing questions and selecting others from the audience, the funder interviewing a journalist whose global health education it had financed.

Suarez has heard gripes about Gates Foundation funding before. He defended the arrangement as giving an under-reported subject increased coverage while preserving “complete editorial independence.” Continued Suarez: “The foundation doesn’t hold the purse strings, encouraging some stories and discouraging others. And we don’t get approval before we embark on projects.”

But could Suarez’s own internal process for selecting stories and storylines be susceptible to influence? Certainly there are no stories thus far that seem contrary to foundation views. On the other hand, hardly every Gates-funded story examines an issue high on its agenda, obesity in China, for example. Malaria eradication does sit near the top of the foundation agenda. But NewsHour coverage of Tanzania mostly spoke of malaria elimination which targets specific regions rather than worldwide eradication which is more difficult and controversial.

Suarez went to considerable effort to avoid covering global health projects also funded by his funder. He described this as an accomplishment given “the remarkable number of pies around the world that the foundation has its fingers in…” However, the ubiquity of the Gates Foundation in global health is itself important. The malaria vaccine trial Suarez covered on his trip to Tanzania, for example, would never have taken place absent Gates Foundation support. The vaccine was shepherded forward by the Gates-funded PATH Malaria Vaccine Initiative. Both the event and its coverage are products of Gates money.

Every story has more facets than can be examined. But Gates Foundation funding discourages or even forecloses examination of certain storylines. Suarez can’t credit the foundation for making gigantic contributions to global health, for example. At the same time, the elephant in the room—the Gates Foundation—remains out of frame even as it pays for the camera.

Does that matter if the main effect of Gates funding is to increase awareness of global health? As Suarez pointed out:

A few months ago in Washington, I watched Bill & Melinda themselves give a presentation on global health research to an auditorium packed with a who’s who of Congress, the executive branch, think tanks and the media, not demanding one policy approach or another or recommending one drug protocol or another as much as hammering home the idea that public knowledge creates support for [global health] efforts…

By funding the NewsHour as well as Public Radio International, the foundation heightens general awareness of and support for global health. However, while the Gateses might not have advocated for specific programs, they and their foundation do have distinct policy preferences and require strict compliance.  Furthermore, the foundation’s policy-agnostic advocacy efforts link together with its policy-shaping efforts, again by influencing the media.

In October 2008, the same time it awarded the NewsHour funding, the Gates Foundation granted the Kaiser Family Foundation (KFF) $2 million with a remit to “inform policy making and program development and implementation” for U.S. global health policy. The Kaiser Family Foundation doesn’t specify precisely how it uses these funds and publishes no annual reports on its website. Concerning its spending and governance, the KFF website only alludes to the possibility of such funding:

With an endowment of over half a billion dollars, Kaiser has an operating budget of over $40 million per year.  The Foundation operates almost exclusively with its own resources, though we do occasionally receive funds from grant-making foundations, primarily to expand our global programs.

Prominent among these programs is KFF’s US Global Health Policy portal. The portal selects and summarizes global health news from more than 200 worldwide sources spanning mainstream media outlets to blogs. KFF sends a daily email news digest to policy makers, opinion leaders and journalists. Also, KFF offers its own original research and analysis, from cheat sheets for journalists to extensive reports on subjects such as the US global health architecture.

Gates Foundation financing of the enterprise is, arguably, hidden. KFF’s daily emails carry no boilerplate mention of Gates funding. The only disclosure on the KFF US Global Health Policy site resides under the “About” link at the bottom right of page, which says only that KFF’s work on global health and the global health gateway receives “substantial support” from the Gates Foundation.  

In other respects, however, the influence of the Gates Foundation is more apparent. Not only does KFF have the power to choose what constitutes global health news but, in summarizing the stories it selects, it can give them a construction of its choosing. In key instances, the Kaiser Family Foundation’s global health news coverage suggests bias both in story selection and preferential treatment of the Gates Foundation.

In May 2009, the Lancet ran two papers and an accompanying editorial offering multiple, sharp criticisms of the Gates Foundation. The KFF summary muted the few criticisms it repeated and dismissed the one paper it discussed as “marred by ideological assumptions.” The summary quoted the Gates Foundation as saying “We welcome the article and its findings…” although, as the Lancet editorial noted, the foundation had actually “declined our invitation to respond…” Unusually and perhaps uniquely, KFF did acknowledge in its daily email that it “receives substantial support from the Bill & Melinda Gates Foundation for the Kaiser Daily Global Health Policy Report.”

In June, USA Today ran a largely positive story on the Gates Foundation. But the article also said:

…the Gates Foundation has been painted by critics and even admirers as sometimes too heavy-handed in saying how its money is used and too prone to listening to the recommendations of experts vs. grass-roots groups when setting its strategies to battle global poverty.

In Kaiser’s rendering, this became: “The article reports on different perspectives about the Gates Foundation's influence and approach to global health and other work.” While not strictly false, such gentle treatment does appear to be reserved for the Gates Foundation.

A June 19 Lancet story entitled, “WHO heads back to the drug development drawing board” became in KFF’s version “WHO Scraps Old Drug Development Group, Creates New One” and featured quotations about “unclear methods, a lack of transparency and signs of industry interference” as well as “suspicions of impropriety.” Although the Lancet story quoted one source as saying “We think this is a landmark decision,” that more positive perspective was not included in the KFF summary.

 BMJ recently alleged improper ties between WHO H1N1 advisors and the pharmaceutical industry. KFF quoted the editor-in-chief of BMJ saying “The WHO's credibility ‘has been badly damaged.’ ” However, four days later, Nature News/Scientific American wrote:

To judge from media coverage last week, a major scandal had been exposed in the handling of the H1N1 flu pandemic by the World Health Organization (WHO). But nothing could be further from the truth.

However, after this debunking, KFF only reported that “the authors of the BMJ piece agreed the timeline they presented in the article was off.”

KFF lets hard knocks for some organizations through, but cushions blows for the Gates Foundation and sometimes ducks them entirely. The Los Angeles Times ran a series of stories in January 2007, beginning with “Dark cloud over good works of Gates Foundation.” The Times contended that the foundation’s endowment investments worked against its global health objectives:

The Gates Foundation has poured $218 million into polio and measles immunization and research worldwide, including in the Niger Delta. At the same time that the foundation is funding inoculations to protect health, The Times found, it has invested $423 million in Eni, Royal Dutch Shell, Exxon Mobil Corp., Chevron Corp. and Total of France — the companies responsible for most of the flares blanketing the delta with pollution, beyond anything permitted in the United States or Europe.

The Kaiser Daily Global Health Policy Report never mentioned the series.

KFF frequently mentions coverage of the Gates Foundation appearing in the Seattle Times. But the Times' recent, June 15 story, “Gates Foundation gets low marks in relations with non-profits” went ignored. The foundation actually surveyed not just non-profits but all 1,544 of its grantees from a recent one-year period. There was good news, according to the foundation: “strong ratings for our work in grantees’ fields,” and “a positive impact on knowledge, policy, and practice in our strategy areas.” However, the Gates Foundation received “lower than typical ratings on many other aspects of the grantee experience,” such as communication and clarity with respect to goals and strategy.

The foundation paid out roughly $3 billion to its grantees over the timeframe examined yet the obvious potential story about the effectiveness of foundation spending received neither mention nor exploration, an omission true of all media organizations, not just the Kaiser Family Foundation. Concerns about transparency, raised by KFF in different circumstances, here go dormant.

The lens of KFF’s portal gives particular shape to reader perception of the world’s coverage of global health. KFF is also studying global health journalism in a project led by former Boston Globe global health writer and Pulitzer Prize winner John Donnelly. Donnelly left the Globe in 2008 to join Burness Communications, a media consultancy, where he is vice president and senior editor. At the same time, Donnelly became a media fellow at Kaiser Family Foundation. (I was interviewed in June by a member of Donnelly’s project.)

“Newspapers,” Donnelly said in a telephone interview, “have very strict ethical standards that assure you’re unbiased.” He characterized his past work for the Globe as “independent,” his stories involving consultation only with editors. As budget cuts swept the newspaper industry, the Globe closed its foreign bureaus, about a year before Donnelly departed. “In global health,” said Donnelly, “there are really very few of those jobs left.”

Asked about the possible influence of Gates Foundation funding on journalism, Donnelly explained in email:

I'm rarely doing much pure journalism now, so I don't know if I can answer the question of whether Gates' underwriting of journalism creates a conflict for journalists. I would think that journalists working on global health issues at NewsHour and NPR would be in the best position.

Donnelly seemed to defend non-disclosure of Gates Foundation funding to certain media organizations. “Indirect funding is not really seen as independent journalism,” he said by phone. “It’s seen as advocacy-based journalism.”

Donnelly currently writes for Global Health, a magazine published by the Global Health Council. The council has a three-year, $10 million grant from the Gates Foundation to “to foster policies that accelerate scale-up of cost-effective, proven health approaches and diffusion of best practices and innovation that have policy significance.” The grant was awarded in October 2008, like those won by the NewsHour and KFF. Global Health, which began publication in the winter of 2009, does not disclose Gates funding, as of this writing.

Donnelly said he didn’t know if Gates funding supported Global Health. He recently blogged the Pacific Health Summit for that publication. The invitation-only summit paid most of his airfare with the balance coming from another non-profit receiving Gates Foundation support.  “I don’t know who funds the summit,” said Donnelly, other than numerous different organizations. On the summit website, the National Bureau of Asian Research (NBAR) sits atop the marquis of the four organizations behind the event, including the Gates Foundation. However, the Gates Foundation paid part or all of NBAR’s share of the Summit, $700,000. Again, the event and its coverage originate from the foundation whose role is larger than it appears.

Is this ubiquity simply a property of global health, a consequence of a generosity both welcome and immense? Should air have to disclose that it is 21% oxygen?

I used to write about the Gates Foundation for the Seattle-based Crosscut. I stopped in November of 2009 after Crosscut, following financial struggles and a switch to non-profit status, announced it had received a $100,000 grant from the Gates Foundation. Some weeks after learning about the Gates grant in Crosscut, I inquired of the editor, David Brewster: “Any thoughts about editorial policy with respect to coverage of the Gates Foundation under Crosscut's new funding paradigm?” Brewster responded:

No change at all. You should get it out of your head that Gates is funding us, and they insist they would be embarrassed if their funding in any way altered our independent reporting on them.

The episode is suggestive of the ubiquity of Gates funding in the media, from unknown Crosscut to the PBS NewsHour. The subject of Gates funding is uniformly uncomfortable to those receiving it—which should perhaps suggest that something is wrong. Finally, the effects of foundation funding are quite universal:  journalists who need the money seem to believe they can remain objective about their coverage.

John Donnelly says his study of global health journalism examines “what’s going on, how things have changed,” and what the future might look like. Perhaps it will conclude that the objectives of global health might not be harmed by increased transparency of funding sources. Journalism and the processes of an open society, quite obviously, are harmed when money influences coverage invisibly.

Certainly, Ray Suarez should be asking questions of the Gates Foundation, not the other way around.