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Partnership And Progress On The Path To Achieving Millennium Development Goal 6


August 25th, 2014

Editor’s note: For more on global health, stay tuned for the upcoming September issue of Health Affairs.

In 2000, nearly 200 world leaders came together and agreed on a set of objectives intended to tackle some of the most pressing development challenges of our time, such as poverty, AIDS, and child mortality. With a target date of December 31, 2015, the Millennium Development Goals (MDGs) provided a clear path for progress and a platform for immediate action. Last week, on August 18, we reached a milestone on that path –- as of that date, 500 days remained to achieve these eight goals. So where do we stand, and what more must be done?

Combatting HIV/AIDS, Malaria, and Other Diseases

For those of us focused acutely on MDG number 6—combatting HIV/AIDS, malaria, and other diseases—the recent Millennium Development Goals Report had encouraging news. An estimated 3.3 million deaths from malaria were averted between 2000 and 2012 due to the expansion of malaria interventions, and efforts to fight tuberculosis have saved an estimated 22 million lives since 1995.

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Health Affairs Briefing: Advancing Global Health Policy


August 22nd, 2014

Please join us on Monday, September 8, when Health Affairs Editor-in-Chief Alan Weil will host a briefing to discuss our September 2014 thematic issue, “Advancing Global Health Policy.”  In an expansion of last year’s theme, “The ‘Triple Aim’ Goes Global,” we explore how developing and industrialized countries around the world are confronting challenges and learning from each other on three aims: cost, quality, and population health.

A highlight of the event will be a discussion of international health policy—led by Weil—featuring former CMS and FDA administrator and current Brookings Institution Senior Fellow Mark McClellan and Lord Ara Darzi, surgeon, scholar, and former UK Health Minister. Additional panels will look at how countries are transforming chronic care, lowering costs, and redesigning delivery systems.

WHEN: 
Monday, September 8, 2014
9:00 a.m. – 12:30 p.m.

WHERE: 
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW!

Follow Live Tweets from the briefing @HA_Events, and join in the conversation with #HA_GlobalHealth.

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Roll-Out Of New TB Drug Must Be Handled With Care


June 13th, 2014

Janssen Pharmaceuticals, a subsidiary of Johnson and Johnson, has announced that it will make its breakthrough new tuberculosis (TB) drug, Sirturo, available at a discount in 130 developing countries. As the first new antibiotic to be approved to treat TB in over 40 years, Sirturo will be an important new weapon in the aging arsenal of medicines used to treat this deadly disease.

Sirturo’s approval was a breakthrough for global health and TB treatment. In 2012, the airborne disease killed about 1.3 million people, making it second only to HIV/AIDS in the ranks of infectious killers. While the number of people dying from TB each year is slowly falling, drug-resistant strains are proliferating. According to the World Health Organization, ninety two countries have reported cases of extensively drug resistant TB since it was first reported in 2006.

Tuberculosis Treatment Programs

Now that Sirturo is ready for prime time – and poised for international distribution – it’s critical that the roll-out is meticulously managed by health care systems in each and every country that plans to administer it. TB drug resistance usually arises from poorly managed tuberculosis treatment programs. Treatment is long – about six months for basic treatment, and up to two years for drug-resistant strains – and only adds to the challenge of successful treatment completion. With improper or inadequate treatment, virulent new forms can evolve.

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Chinese Doctors In Crisis: Discontented And In Danger


May 27th, 2014

Chinese doctors are unhappy about their pay and work conditions.  Moreover, they are in danger of physical attack by angry patients and families.  The Ministry of Health estimated that in 2010, 17,243 attack and agitation incidents occurred in Chinese hospitals, an increase of almost 7,000 over five years. Patients, bereaved families of patients who have died in hospitals, and sometimes paid protestors called yinao or “medical troublemakers,” invade hospitals, berate or attack staff, create loud disruptions, and stage mock funerals.

About 30 percent of the attacks were carried out by patients, 60 percent by family members, and the remainder by others, including yinao. About 75 percent of attacks were aimed at doctors.  According to a 2012 survey of nearly 6,000 Chinese physicians in 3,300 hospitals, 59 percent of doctors had been verbally assaulted and 6 percent had been physically assaulted. News accounts for 2002-2011 yielded 124 incidents of “serious violence” against hospitals, including 29 murders and 52 serious injuries. Often violence accompanies demands for cash compensation for harm to patients, including patient deaths in hospitals.

In response, the Chinese Ministry of Public Security has recently announced a new set of security measures for hospitals. Approximately one thousand top-tier hospitals will now have a police presence in addition to their own security guards; alarm systems linked with local law enforcement; enhanced audio-visual surveillance systems; and security posts at entrances similar to those at airports.

The wave of violent attacks on doctors and other medical workers constitutes a significant problem in its own right.  But it is also a reflection of a broader set of problems faced by today’s generation of Chinese doctors.  They are badly paid, both in relation to doctors in other countries, and in relation to other Chinese professionals. As a result, doctors often supplement their low salaries in ways that strengthen the popular impression that they are corrupt, fostering still greater distrust and anger among their patients and patients’ families. A recent survey showed that 67 percent of the Chinese public does not trust doctors’ professional diagnoses and treatment.

The doctors themselves are also dissatisfied with the current state of affairs. A 2011 Chinese Medical Association survey of its members showed fewer than 20 percent of responding doctors to be satisfied with their medical practice environments, while 48 percent rated them “poor” or “very poor”. Doctors were particularly dissatisfied with their pay. They were also concerned about their work conditions.

When respondents were asked to identify sources of work pressure, the most frequent response, at 77 percent, was “high patient expectations.”  Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.

In this post, we review that system and highlight sources of doctors’ discontent and the distrust between doctors and patients.

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Development Assistance For Global Health: Is The Funding Revolution Over?


April 17th, 2014

In many ways, the last twenty years have been somewhat of a “revolution” in global health, as marked by rising attention, growing funding, and the creation of new, large scale initiatives to address global health challenges in low and middle income countries.  Indeed, the 1990s brought a steady increase in global concern about health, largely centered on the HIV epidemic and due to civil society organizing to draw attention to the growing crisis, leading to the creation of the Millennium Development Goals, and soon thereafter, the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the U.S. President’s Emergency Plan for AIDS Relief, and other efforts.

A key driver of increased funding has been donors – governments and multilateral agencies, non-governmental organizations (NGOs), and foundations.  And tracking their funding has become one of the critical measures of the global health response.

A new analysis from Dieleman et al., published as a Health Affairs Web First on April 8, provides a needed contribution to the literature on donor funding for health, including an understanding not just of where donor funding is going but of the relationship between aid, burden, and income.

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The Case For Global Health Diplomacy


April 14th, 2014

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies.

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Health Affairs Web First: Global Health Funding In 2013 Five Times Greater Than 1990


April 8th, 2014

Development assistance for health (DAH) to low- and middle-income countries provided by donors and international agencies are given in the form of grants, low-cost loans, and goods and services. Without this assistance, some of the poorest countries would be less able to supply basic health care.

A new study, being released today as a Web First by Health Affairs, tracked the flow of development assistance for health and estimated that in 2013 it reached $31.3 billion.

Looking at past growth patterns of these international transfers of funds for health, authors Joseph Dieleman, Casey Graves, Tara Templin, Elizabeth Johnson, Ranju Baral, Katherine Leach-Kemon, Anne Haakenstad, and Christopher Murray identified a steady 6.5 percent annualized growth rate between 1990 and 2000, which nearly doubled to 11.3 percent between 2001 and 2010 with the burgeoning of many public-private partnerships. Since 2011, however, annualized growth has dramatically dropped, to 1.1 percent, due, in part, to the effect of the global economic crisis.

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Embarking On A New Journey With Health Affairs


March 31st, 2014

I am delighted to be taking on the role of editor-in-chief of Health Affairs. This is a dynamic time in all aspects of health and health care: insurance coverage expansions, delivery system changes, and growing attention to population health.  Building upon thirty-three years of peer-reviewed scholarship, Health Affairs will continue to serve as the nation’s primary resource for the health policy community.

My goals for Health Affairs coalesce around a single theme: broadening the reach of the journal.

Health Affairs is strong in the core health policy community, but our scholarship is relevant to myriad actors in the one-sixth of the United States economy represented by health care.  My goal is to broaden our engagement with the worlds of law, finance, design, and many others.

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The Health Workforce: A Critical Component Of The Health Care Infrastructure


March 24th, 2014

Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University where they are establishing a new Center for Health Workforce Research and Policy.

In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.

It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.

For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.

What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.

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Countering Cancer: The New Foreign Policy Issue


March 21st, 2014

For years internationalists have being trying to make the argument to ordinary Americans that foreign policy matters — that we must contend with complex issues overseas like countering terrorism while also focusing resources and energies on economic issues at home. We have posed it as a trade-off.

We are making the foreign affairs case the wrong way. Rather than argue the positive merits of trade or the negative repercussions of unchecked global terrorism, we (all of us in the international arena) should be talking more about cancer — something every citizen understands. Countering cancer is akin to countering terrorism and, like most global issues, demands international cooperation.

Cancer is a war and peace issue. The enemy– a foreign mutated cell– spreads destruction with no regard to human life. Cancer does not discriminate against religions or ideology. It invades lungs, livers, breasts, colons, bowels and every conceivable organ. The warriors are good cells and good doctors, reliant on the best research and medicine available—wherever in the world we can find it.

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HA Web First: Improved Prescribing And Reimbursement Practices In China


February 26th, 2014

Pay-for-performance—reimbursing health care providers based on the results they achieved with their patients as a way to improve quality and efficiency—has become a major component of health reforms in the United States, the United Kingdom, and other affluent countries. Although the approach has also become popular in the developing world, there has been little evaluation of its impact. A new study, released today as a Web First by Health Affairs, examines the effects of pay-for-performance, combined with capitation, in China’s largely rural Ningxia Province.

Between 2009 and 2012, authors Winnie Yip, Timothy Powell-Jackson, Wen Chen, Min Hu, Eduardo Fe, Mu Hu, Weiyan Jian, Ming Lu, Wei Han, and William C. Hsiao, in collaboration with the provincial government, conducted a matched-pair, cluster-randomized experiment to review that province’s primary care providers’ antibiotic prescribing practices, health spending, and several other factors. They found a near-15 percent reduction in antibiotic prescriptions and a small decline in total spending per visit to community clinics.

The authors note that the success of this experiment has motivated the government of Ningxia Province to expand this intervention to the entire province. “From a policy perspective, our study offers several additional valuable lessons,” they conclude. “Provider patterns of overprescribing and inappropriate prescribing cannot be changed overnight; nor can patient demand, for which antibiotics are synonymous with quality care. Provider payment reform probably needs to be accompanied by training for providers and health education for patients.”

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Cesarean Rates: A Global Perspective


February 24th, 2014

As noted in a previous Health Affairs Blog post by Katy Kozhimannil and Ezra Golberstein, there is significant variability in cesarean delivery rates across the United States, but this is also true worldwide. Worldwide cesarean delivery rates have come under scrutiny and criticism since the World Health Organization (WHO) suggested in 1985 that the optimal rate should not exceed 10 to 15 percent.

Although currently there is no expert agreement on a single optimal level, a general consensus has emerged that extremely low rates (less than 5 percent) suggest underuse and higher rates (greater than 10-15 percent) suggest overuse. Globally, the average rate sits slightly above that recommended level at 16 percent. However, the mean value masks the underlying variability that exists across countries and the different issues inherent in the variation. Of countries which report at least some cesarean deliveries, the range of use runs from 1 percent (Niger) to 52 percent (Brazil) of live child births.

Middle and High-Income Countries

Cesarean rates in middle and high-income countries have continued to increase over the last decade (most are significantly over 15 percent). The average rate among the Organisation for Economic Co-operation and Development (OECD)-member countries is 26.9 per 100 live births (range: 14.7 to 49.0). Comparatively, the United States has a very high rate of cesarean delivery (31.4 per 100 live births). In Switzerland, for example, cesarean section rates varied in 2010 from less than 20 percent to over 40 percent in a region. Within a region, the rates also varied by hospital. A study in France found more cesarean sections were performed in for-profit hospitals than in public hospitals, which treat more complicated pregnancies, suggesting that financial incentives may also play a role in explaining excess cesarean deliveries.

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A Cure For Physician Shortage: Lessons From Indonesia


February 2nd, 2014

Recent literature has shown the growing mismatch between health care demand and supply. Insurance expansion under ACA, demographic changes, and population growth will require 30,000 more primary care physicians (PCPs) in 2025. Despite the growing need for PCPs, only less than 25 percent of newly qualified doctors go into primary care, and just 4.8 percent move into rural areas. This worsening shortage is expected to extend PCP wait time and increase the number of preventable ER admission and hospitalization.

An efficient solution to overcome this problem is by improving care capacity using an integrated care model, sharing the care between physicians and non-physician clinicians (NPCs) including nurses, physician assistants, and certified nurse-midwives. Although a partial implementation of this model has improved efficiency and quality of Kaiser Permanente, Clinica Family Health Services, and Group Health Olympia, these institutions have yet to fully shift the point of care to non-physicians, which is important in improving primary care capacity. This article will elaborate how Indonesia’s Jampersal program shifts maternal services point of care to non-physicians and improves maternal primary care capacity.

Indonesia is a developing country with scarce physician resources, 0.2 physicians per one person (as opposed to 2.4 per one person in the US). Despite having the lowest physician ratio in ASEAN countries, the Indonesian government tries to improve the number of attended deliveries by providing universal and free maternity care benefit (Jampersal) in 2011. Practicing as a physician in Indonesia, I expected a significantly higher number of maternity care patients following the implementation of this program, but that was not the case.

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Can Online Learning Solve The Global Health Care Capacity Crisis?


January 31st, 2014

Health care systems cannot be supported by the efforts of a few. But in many low- and middle-income countries worldwide, one medical specialist may be responsible for the health of millions. In Vietnam, where I work, there is one psychiatrist for 300,000 people. For many people in need, health care is simply unavailable. The inability to provide care, particularly in rural areas, results in increased morbidity and mortality. More community health workers (CHWs) are necessary to provide care where treatment is unavailable.

CHWs are lay people or non-professional health personnel who provide focused health care in local communities. CHWs work with health ministries, non-governmental organizations (NGOs), international organizations, and many other groups. From malaria to mental health, studies find that CHW interventions improve health and are cost-effective.

Despite their merits, many CHWs are employed as temporary workers. After projects end or funding runs out, many CHWs no longer work in a health care capacity. Whether CHWs retain the skills (e.g., data collection) and knowledge (nutrition counseling) they have gained is unknown. Even with long-term projects, education and career advancement may be unavailable, which are important reasons for attrition among CHWs. Poor retention leads to poorer health outcomes for populations served, higher program costs, and threatens program sustainability.

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Don’t Put The Brakes On Ending AIDS


January 27th, 2014

One year ago in his State of the Union Address, President Obama reaffirmed the United States’ goal of achieving an AIDS-Free Generation.  The year that followed brought fresh evidence that this goal is within reach: new HIV infection rates are beginning to fall in countries where people have access to HIV programs.

A major part of this success is the result of expanded access to HIV treatment, which has been shown to both save millions of lives and prevent HIV transmission.  Moreover, an analysis by UNAIDS found that the faster countries scaled up access to HIV treatment, the faster their rate of new HIV cases fell.  A study in KwaZulu-Natal, South Africa, determined that the risk of HIV infection was 38 percent lower in communities where HIV treatment had been scaled up.

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), regarded as one of the most successful global health programs in history, is currently helping provide lifesaving HIV treatment to 6.7 million people.  The program has the potential to make major additional contributions in this area—and indeed 40 members of Congress recently asked that the program be expanded to reach 12 million people by 2016.

But it is deeply concerning that instead of reaching this bold goal, the pace of HIV treatment scale-up could slow considerably in the coming years because of budget cuts to U.S. global AIDS programs.  Without new resources for PEPFAR, as well as additional program efficiencies, the number of new people put on HIV treatment with U.S. support will plummet. The graph below shows our analysis of the pace of scale-up under PEPFAR, based on publicly available data and consultation with experts in the field.

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Health Affairs Interview: Shanghai’s Health Care Reforms Explained


November 6th, 2013

“I think health reform is not like what some say—a matter of two, three, or four years of efforts, and you get a brand-new health system. So I do not look for one-shot earthshaking effects. Instead, I focus on whether the policies we put in place will be sustainable,” says former Shanghai Vice Mayor Shen Xiaoming in an interview released today as a Web First by Health Affairs. Shanghai, China’s largest city, offers its residents the country’s most advanced health care system. Through a powerful health information technology system, there have been great strides, though challenges remain.

Shen, who served as vice mayor from January 2008 through July 2013, spoke to Tung-Mei Cheng, Policy Research Analyst at the Woodrow Wilson School of Public and International Affairs at Princeton University, in Shanghai on June 18, 2013. In addition to reading the interview, you can listen to Cheng discuss her conversation with Vice Mayor Shen and the lessons of the Shanghai experience.

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Request For Abstracts: Health Affairs Alzheimer’s Disease Theme Issue


June 13th, 2013

Health Affairs plans a thematic issue on Alzheimer’s disease in April 2014. We plan to cover a range of topics with the aim of providing “one stop shopping” for our policy-oriented audience. Topics include overview papers on the state of the science of causes and treatment, costs, screening and diagnosis, drug development, medical and non-medical management, caregiver populations, federal and state roles, and more.

Request for abstracts

In addition to the papers we have already invited, we are seeking papers on several additional topics and therefore welcome proposals for papers, analyses, and commentaries on the following topics:
.

  • Exemplary models from around the globe (either individual countries or comparative pieces with lessons for other countries)
  • Exemplary state or local approaches to care and treatment
  • Opportunities for primary prevention

In order to be considered, abstracts must be submitted by August 1, 2013. We regret that we will not be able to consider any abstracts submitted after that date.

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A Life-Course Approach to Vaccination Can Drive Healthy Aging


May 22nd, 2013

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits.

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Narrative Matters: Wrestling With Obesity, Individually And Globally


April 22nd, 2013

In the Narrative Matters essay in the April Health Affairs issue, Laura Blinkhorn and Mascha Davis write about how working with an obese woman in a Gabon hospital led them to seek solutions to obesity and its related health problems in the developing world. “Public health campaigns, government regulation, and improved education are necessary to bring about real change,” write Blinkhorn, a fourth-year medical student at the Pritzker School of Medicine, University of Chicago, and Davis, a registered dietician and public health professional who lives in Addis Ababa, Ethiopia, and works for Catholic Relief Services.

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Substandard Drugs And The Fight Against TB: The Challenge And The Opportunity


April 15th, 2013

Poorly manufactured and fraudulent medicines kill thousands of people around the world each year. For infectious diseases like malaria and HIV, shoddy medicines also accelerate drug resistance and dramatically alter the course of epidemics. With few new drugs under development, recent progress against these major killers in the poorest countries is precarious.

Bad drugs have become a big problem for one major infectious disease in particular: tuberculosis. If we don’t solve this issue, we may see the gains we’ve made against TB slip away.

According to the World Health Organization, global TB cases continued on a slow downward trend in 2011. While this is good news, the disease still claimed 1.4 million lives that year—more than any other infectious disease except HIV/AIDS. Meanwhile, multidrug-resistant TB cases rose to 630,000 worldwide. Resistant TB is deadly and costs significantly more to treat. For example, curing a single case of it in the United States can cost more than $200,000. Treatment takes two years, and the side effects can be severe, including nausea, vomiting, joint pain, and even hearing loss.

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