Tuesday, July 31, 2007

Sour Grapes

I heard an interesting story today from one of our CHAI Office Coordinators as we were driving from the Ministry of Health to the UNDP headquarters. It goes something like this:

A wolf is wandering the forest looking for dinner when he looks up and sees, as if from no where, a big bunch of grapes dangling from a branch. The grapes are green and plum, no doubt burst with sweetness. The wolf spends hours jumping to reach the grapes, but always in vain. The bunch hangs just out of reach. After hours on ends the wolf submits – exhausted and, without grapes, decides to look elsewhere for food. “The grapes,” he decided, “were probably sour anyway.”

The past two days, my first in Liberia, have been pretty discouraging with only moments of inspiration scattered throughout. My surroundings, more or less, are as I expected. Airport and border were elementary, and baggage claim was chaotic but functional. Ironic, that the only international flight which hasn’t lost my luggage was to Liberia – well done, Brussels Air. Because we arrived at night, I could see much during the 40 minute drive from the airport to the apartment in Sincor (a neighborhood in Monrovia). I went with the current Supply Chain Analyst for dinner where the menu was western/Lebanese (there’s a huge Lebanese influence in Monrovia) and we only lost power once. The apartment building is fortified by high walls, barbed wire, and guards; the tenants are mostly Clinton Foundation, Red Cross, and Canadian and Ukrainian helicopter pilots. I fell asleep quickly, after a brief conversation with the Country Director and a short moment of reflection on the porch looking out over the beach.

On Monday morning one of the drivers, drove us to the CHAI headquarters at the Ministry of Health (MoH) where I met the rest of the team and got a pretty preliminary overview of office. During the drive I got my first glances at Monrovia. The city is just as you would imagine a community reemerging from total disaster: the roads are pot hole covered, sewage and trash run through the streets, skeletal frames pose as buildings, street vendors push trinkets that are god-knows-how-old, and the streets are packed (recall the 85% unemployment figure). Any further description is really unnecessary – imagine the worst case scenario and you almost have a visual. From the Ministry we went to the National AIDS Control Program (NACP), where I met the Supply Chain Manager, before heading to UNDP.

The funding for HIV/AIDS test and treatment procurement comes from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Because UNDP is the primary recipient of this grant and NACP is the key implementation partner, I will spend the majority of my time working between UNDP and NACP (with occasional trips to field offices). On this Monday afternoon, I worked through a couple of the forecasting tools that will be essential to my job and continued doing back reading. My orientation was somewhat stunted by the fact that CHAI and UNDP had to attend to a stock out of one of the drugs - but I have no doubt that I'll orient myself quickly come September.

Tuesday morning was refreshing – as mornings tend to be. It was pouring. Apparently the rainy season lasts from May to early October. With a much clearer mission for today, we set out to meet James at NACP and look over a number of the Health Status Reports and Drug Requisitions from a number of the local facilities. I felt this level of involvement helped slightly to clarify my daily activities, but the afternoon session proved far more productive in this regard.

We split the afternoon between two activities: reviewing the Procurement and Supply Chain Management (PSCM) Standard Operating Procedure (SOP) Working Plan and reviewing the ARV Quantification Tool.

Friday, July 27, 2007

Limbo in Brussels... and thoughts on IP

The flight from DC arrived at Brussels International at 7:30 this morning - and as of 3:30 in the afternoon we were still waiting for our connection to Monrovia. The crowd has been building around the Brussels Air check-in stand as more and more people are beginning to suspect that we won't fly out today. Actually, the controversy is over whether the "replacement" jet will fly to Dhaka first, or Monrovia. At their most impassioned, the crowd had split and was chanting back and forth, in the airport, "Dha-ka," "Mon-ro-vi-a." Personally, I think I'd almost rather leave tomorrow morning at this point than arrive at 2 or 3 this morning.

On a positive note, I've had more than enough time to dig into the background reading I received from the CHAI team (and augmented with a couple books from the World Bank Library). Reading about the impact of intellectual property rights to HIV/AIDS treatment in development countries has been among the more interesting subjects of today. A significant part of crafting an efficient/effective supply chain for any medical treatment is selecting the proper product line. The controversy comes in determining how much flexibility [the host country] has in purchasing generic drugs. While big name manufacturers (such as GlaxoSmithKline, Merck & Co, Roche, and Bristol-Myers Squibb) have generated HIV/AIDS tests and treatments that are more specific (meaning they produce a fewer false positives) and sensitive (meaning they detect HIV before it has reproduced large quantity antibodies), these innovative drugs come at a price. A price that aflicted populations in developing nations (and developed nations at that rate!) cannot pay.

Subsequently, public policy has intervened. During 2001 negotiations in Doha, Quatar, the WTO wrote a clause into the Trade Related Agreemnet on Intellectual Property Rights (TRIPS) allowing developing nations to source generic forms of patented drugs. Generic competition has since been hugely successful in driving down the costs of ARVs (antiretrovirals) in many developing nations. In fact, the generic supply has reduced the costs globally from 10,000 USD/patient/year to 350 USD/patient/year. Brazil, for example, has used generic brands to dirve down the ARV costs by 82% in 5 years. Kind of sheds a dimming light on how over-priced drugs must be in developed nations like our own, eh?

Naturally, pharma-lobbiests argue that such concessions threaten the incentive they offer their research and development teams. I see little merit to this argument because the patent holders still increase their revenues through sales to developing nations. In most instances, either international organizations or the developing country governments offer an "honorarium," if you will, to the patent holders. In more recent years, country and county governments have engaged in parallel trading. Parallel trades occur when developing nations coordinate with developed nations to import generic drugs that are neither produced domestically nor available at a subsidized cost from the patent holders. The patent holder profits from these sales as well because the exporting producer of the generic drug already paid its royalties. All of which leads me to wonder in what form pharmaceuticals lobby the WHO (World Health Organization) and what happened in 2001 to generate more development-friendly trade agreements.

This was just one of a handful of new topics I'm exploring as I prep for this job. I'm continuously excited about how "scaleable" this experience will be. The stated objective is the improvement of the HIV/AIDS procurement and supply chain managment standard operation procedure (PSM SOP) ... but I feel like this experience will be relevent to more diverse work down the road.

On a (way) lighter note - I get to play in Brussels tomorrow! Our flight was rescheduled for Sunday a.m. (fingers crossed) which gives me more than 30 hours in Belgium's capital. I'm headed to the city center tomorrow with a few unbelievably interesting people - one Stanford professor of management, one UNMIL (UN Mission in Liberia) officer, a World Bank-er, and a carpenter from Oregan who's headed to Liberia to meet his newly adopted daughter. We'll hit a couple tourist sites, and keep waffles and beer top on the list... but maybe not together.

Tuesday, July 24, 2007

Malarone, Mefloquine and Malaria... O My!

I've never been a very big medicator; in fact, I'm of the opinion that most ailments can be cured with a lot of water, a lot of sleep, and maybe a jog if you feel the need to sweat something out. However, I'm willing to bet that Malaria is somewhat of a more formidable opponent that your average winter cold. At the suggestion of my friendly vaccinator (whom I got to know well as I sat for the first rounds of Yellow Fever, Hep A and Typhoid), I decided to use an antimalarial for this first week.

The options are not inviting.

Mefloquin is a lariam-based antimalarial that you take weekly starting 1-2 weeks before your trip - which is clearly not an option for me. Mefloquine is the most common, the strongest, and a comparatively cheaper antimalarial treatment. The potential side effects, however, are pretty off-putting. They include, in no particular order, nausea, dizziness, headache, weakness, insomnia, "strange dreams," nightmares, depression and anxiety. Mefloquin has also been suspected of causing long-term liver damage. Hmmmmm. As appealing as hallucinogenic dreams are, I decided to seek an alternative.

Doxycycline is a daily tablet which one must begin 1-2 days before a trip to a malaria prone region. The cheapest of the antimalarials, one must continue the medication for a month after returning and should refrain from taking a tablet with dairy products or before bed. Doxycycline's side effects include nausea, vomiting, diarrhea, dizziness, headache, photosensitivity (recall the title of the blog), vaginal infections, and intracranial hypertension. Once again, I passed.

Malarone is a daily tablet with "low incidence of side effects." Dosage begins 1-2 days beforehand - much better timing for me. The down side, in this case, is that Malarone is a whopping $6/tablet. Hardly sustainable for a year.

The ideal antimalarial (in my untrained opinion) is Chloroquin. A weekly tablet, the side effects are milder than those of doxycycline and mefloquin (though it may cause blurred vision), and one tablet costs the same as the daily malarone. The downside, for me, is that the strains of malaria found in West Africa are resistant to chloroquin. Bummer.

In the end, I opted to take malarone for this short term trip. I figure once I'm on the ground in Monrovia I'll see what everyone else is doing.

If anyone reading this has any suggestions (or better yet, experience with any of these drugs) then feel free to post them up!

Monday, July 23, 2007

A little backdrop...

Monrovia, Liberia lies 6 degrees north of the equator, making it officially the closest to the Southern Hemisphere I've been to date. I leave on Thursday for 9 days to observe the work I will be doing over the next year as the Supply Chain Analyst for the Clinton Foundation. I have no doubt that the expeirence will present challenges of an overwhelming variety. I'm hoping this blog is a fun way to share those moments and, perhaps, entice one or two of you to plan a trip to West Africa. But, before diving striaght into the details of life on the ground, I wanted to share just a few of the reasons that I'm thrilled about this opportunity.

Cum Grano Salis: All of the following is from an exterior perspective; I fully expect to eat more than a couple words throughout the next year.

I knew next to nothing about the country as of a month ago. My knowledge was limited, more or less, to the coverage of Charles Taylor's extradition to the Hague. However, over the past few weeks I've been absolutely captivated by stories of the progress being made and unique challenges facing the newly elected government.

Liberia's recent history is nothing short of heartbreaking (for more info, Wiki Liberia). In late 1989, the authoritarian Samuel Doe was ousted from the presidency and killed by followers of Yormie Johnson and members of the Gio tribe; from that point forward Liberia has been rought with civil strife. Warring factions competed over the capital until 1997 when Charles Taylor, backed by Libya's Muammar Qaddafi, was elected President. Civil war intensfied in '99 and lasted more than five years, during which time more than 200,000 people were killed and the country's infrastructure devastated. Monrovia fell in 2003, shortly before Charles Taylor was exiled to Nigeria. UNMIL (the UN Mission in Liberia) assumed a supervisory position over an interim government led by Gyude Bryant. Liberia's transitional government was enrolled in a unique anti-corruption campaign (GEMAP) and successfully held elections in 2005. Ellen Sirleaf Johnson was elected in November 2005. The first popularly elected female head of state in Africa, Johnson is a Harvard-trained economist and former Citibank and World Bank employee. This "Iron Lady" has established herself as a force for reform in West Africa; check this site for a preview of a documentary on Johnson out in October.

While Johnson's administration has led impressive reconciliation and reconstruction efforts, Liberia still has a great way to go before returning its infrastructure and public services to their pre-war, operational levels. In a few statistics: Liberia has the highest unemployment level in the world (85%), 75% of the population is without means for sanitation, 40% are without water, 230,000 children have been orphaned, half a million do not attend school, preventable diseases such as Malaria and Measles are the leading causes of death, and more than 6% of the population is known to be HIV positive( for more info, check the UNICEF country page). The good news is the current administration is committed to reforms and many of the international efforts have been well received. In speaking with friends at the Bank, USAID, and other international orgs. I gathered that Liberia's government is among the most progressive in the region. Furthermore, those working with the Clinton Foundation HIV/AIDS (CHAI) program in Monrovia report that, while there are daily challenges and setbacks, the Ministry of Health has made great progress over the past year in establishing a more accurate and efficient way to assess health needs and deliver treatments to facilities in the regions. The challenge they face is an increasing need for someone to focus exclusively on supply chain issues, freeing up others to concentrate on programmatic and clinical challenges. Given the chance to do so, I think this as a truly unique opportunity.

The Clinton Foundation

At present, the Clinton Foundation is hoping to bring a fresh, private sector approach to international development. More specifically, the Clinton Foundation is targeting young professionals with management consulting backgrounds and a passion for development to staff its various initiatives around the world. The idea is to employ talent on the ground for extended periods of time such that they can act as extensions of local partners - embedded in the challenges that local implementers manage and invested in the success of each project. This is in contrast to many development efforts wherein the turnover is high and the actors serve as "consultants." The concept is hardly novel - what is unique, however, is the resources Clinton can garner and the reception CHAI has experienced thus far. The primary initiatives of the Clinton Foundation include: the Global Initiative, the Climate Initiative, Healthier Generation, The Clinton Hunter Development Initiative, and the Economic Opportunity Initiative, and (where I'm headed on Thursday) the HIV/AIDS Initiative. I see myself happily engaged with each of these initiatives, currently employed with the final intitiave, and working towards involvement with GI, HG, or EOI in the long run.

The Clinton HIV and AIDS Initiative (CHAI) is focused specifically on availing lower cost HIV/AIDS treatments around the world and partnering with local government to establish large scale treatment and prevention plans. Liberia is one of nine partner countries in Africa, with a relatively new (2 years) and quickly developing program. Though I'm maintaining sobered expectations about what I will see on the ground, I also believe that the Clinton Foundation may just facilitate the kind of institutional reforms that have a sustainable effect in post conflict regions. Most of you reading this blog have heard me babble about my long-run interests in rule of law initiatives. My hope is that, in this job, I will not only observe key elements of institutional reform in post-conflict areas but also be a part of a uniquely effective team. And what role, exactly, I'm I playing in this team...

The Job

I've been offered a position as the Supply Chain Analyst. While I expect this role may evolve and develop as I go, my primary responsibility is to provide the Liberian Ministry of Health with "best practices in the procurement of products related to antiretroviral treatment (ARVs), including medicine and diagnostics, with the ultimate objective of ensuring the scale up and effective management of high quality ARV treatment for patients."

I can hear most of you right now: "Amanda, what are you doing. What in the world do you know about supply chains?" Well, luckily for me, in my past position I had access to a wealth of business resources and a number of quite random assignments. On more than one occasion I've wandered onto the Supply Chain Executive Board site to read the latest info and, nerdily enough, was pretty fascinated by what I found. One of my premier interests in the work at CEB was observing how companies were responding to the growing Corporate Social Responsibility (CSR) pressures. While the bulk of the CSR burden often falls to the Communications or Marketing C-Suite, there is also a growing trend to "green" or "lean" (both are positive steps) the supply chain to demonstrate more environmental, social, and fiscal responsibility. As such, I've been actively reading supply chain material.

In Liberia, however, the focus will hardly be on "environmentally friendly" procurement methods. As I understand it, the chief challenge is to create a tool that local facilities in Liberia can use to more accurately forecast the ARV tests and treatments they will need the following year. There are a number of contributing factors: communication barriers, transportation failures, and equipment mismanagement to name a few. I will work daily with four parties: Liberia's Supply Chain Manager, the National AIDS Control Program (NACP), the National Drug Service (NDS), and UNDP (the primary ARV recipient). As for the daily activity ... well... we'll just have to wait and see...