- Email: [email protected]
Africa is desperate for praziquantel
Comment
the term “PrEP” defines oral delivery. These categories are outdated and inefficient. They spawn separate scientific meetings, publications, and discourse. Thus they limit a more integrated approach to combination prevention of HIV infection. Just as the VOICE trial is able to compare these two modes of delivery, similarly, the antiretrovirals for prevention field needs to consolidate its terminology. In 2008, we had suggested a new lexicon to categorise HIV-prevention interventions.6 As we have seen with CAPRISA 004, use of antiretrovirals to prevent HIV transmission has become a broad field of its own, encompassing many overlapping scientific issues.7 As with hormonal contraception as a method to prevent unintended pregnancy, future evaluations of antiretroviral prophylaxis will focus on methods of delivery (oral, topical [vaginal, rectal], injectable), regimens (daily, monthly, intermittent/exposure related, pre and post), single versus combination products, and what works in specific target populations (defined by risk, behaviour, and infection status). As a semantic starter, we might use the generic category “pre-exposure prophylaxis”, and break it down by the mode of delivery: oral, topical, injectable, etc. Future scientific meetings would address these topics jointly. Collaboration has been the hallmark of shared information across the microbicide and PrEP fields. It is time now to unify the terminology and share information even more broadly. CAPRISA 004 changes the model for HIV-prevention research. A WHO/UNAIDS meeting in South Africa in late August will examine the next steps for the many trials already underway, in addition to those on the drawing
board. A careful, coordinated, and cooperative approach among the four main HIV-prevention research funders— NIH, the US Agency for International Development, the Bill & Melinda Gates Foundation, and the UK Department for International Development—is crucial to assure the research portfolio for HIV prevention will advance in the most efficient way. Proposed next steps involve investigations at multiple levels: molecular, clinical, and population. A new era indeed. Willard Cates Jr FHI, Research Triangle Park, NC 27709, USA [email protected] I am an FHI member of the CAPRISA 004 Trial Oversight Committee. FHI is one of the five CAPRISA 004 partners who provided support to the trial. FHI helped with study design, protocol development, behavioural intervention assessment, statistical and safety oversight, and clinical monitoring. My participation on the CAPRISA 004 team was funded by USAID grant #GHO-A-00-09-00016-00. 1
2 3
4
5
6
7
Abdool Karim Q, Abdool Karim SS, Frolich JA, et al, on behalf of the CAPRISA 004 Trial Study Group. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 2010; published online July 19. DOI:10.1126/ science.1193748. Grant RM, Hamer D, Hope T, et al. Whither or wither microbicides? Science 2008; 321: 532–34. Anon. Safety and effectiveness of tenofovir 1% gel, tenofovir disproxil fumarate, and emtricitabine/tenofovir disoproxil fumarate tablets in preventing HIV in women (VOICE, MTN-003). June 22, 2010. http:// clinicaltrials.gov/ct2/show/NCT00705679 (accessed Aug 1, 2010). Anon. A pilot study of pre-exposure prophylaxis (PrEP) to evaluate safety, acceptability, and adherence in at-risk populations in Kenya, Africa (IAVI E001). Jan 11, 2010. http://clinicaltrials.gov/ct2/show/ NCT00971230 (accessed Aug 1, 2010). Anon. A pilot study of pre-exposure prophylaxis (PrEP) to evaluate safety, acceptability, and adherence in at-risk populations in Uganda, Africa (IAVI E002). April 19, 2010. http://clinicaltrials.gov/ct2/show/ NCT00931346 (accessed Aug 1, 2010). Padian NS, Buve A, Balkus J, Serwadda D, Cates W Jr. Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward. Lancet 2008; 372: 585–99. Cohen MS, Gay C, Kashuba ADM, Blower S, Paxton L. Narrative review: Antiretroviral therapy to prevent the sexual transmission of HIV-1. Ann Intern Med 2007; 146: 591–601.
Africa is desperate for praziquantel The health and economic effects of schistosomiasis in Africa are not well known, but new information reveals that the neglect of this parasitic infection despite its potential for control through mass treatment with praziquantel represents a monumental global public health disparity.1 Today, we are failing to provide praziquantel, costing just a few cents per tablet, and yet when given once yearly to children, this drug could avert a level of morbidity in Africa that exceeds that of malaria or other disease scourges.1,2 496
Praziquantel was developed in Germany during the 1970s as a joint project between Bayer AG, now Bayer Schering Pharma, and Merck Darmstadt, now Merck KGaA.3 Praziquantel is the only commercially available treatment for human schistosomiasis.4 The drug is highly suitable for use in annual or 2-yearly large-scale campaigns for drug delivery;4 when used as such, praziquantel reduces the prevalence and intensity of schistosomiasis, thereby greatly reducing morbidity.5,6 Schistosomiasis is recognised as one of the most devastating neglected www.thelancet.com Vol 376 August 14, 2010
tropical diseases (NTDs) in sub-Saharan Africa, affecting almost 200 million people (although even these numbers might be substantially higher), and producing a disease burden that could exceed that of malaria.2,7 Moreover, female genital schistosomiasis is a co-factor in the transmission of HIV.8 Successful control programmes in China, Egypt, and Uganda show that treating the total eligible population in areas that are highly endemic for schistosomiasis with praziquantel for a few years results in substantial reductions in the indices (eg, prevalence, parasite intensity, and anaemia) of disease and in the amount of maintenance drug required.9–11 Yet, almost a decade after a World Health Assembly’s resolution to provide complete drug coverage for schistosomiasis, less than 10% of school-aged children at risk receive praziquantel.1,4 This low coverage reflects the limited access to praziquantel because the US$0·08 cost per tablet is too expensive for many African health ministries. Whereas the private sector is donating unlimited quantities of other drugs for NTDs— such as ivermectin (Merck & Co) for onchocerciasis and albendazole (GlaxoSmithKline) for lymphatic filariasis4— for praziquantel, Merck KGaA’s contribution has been fixed at a maximum donation of 200 million tablets over 10 years, with an additional supply of up to 100 million tablets per year at production cost. However, an estimated 1 billion tablets are needed to treat 400 million people annually or every other year,1 and WHO determined that 2 billion tablets might be required over the next 5 years. Thus at least 10–20 times the praziquantel donated currently must be provided free to increase coverage in Africa at a level similar to that of other donated drugs. Wide-scale availability of praziquantel would have an immediate effect on reversing morbidity in schoolaged children and could prevent up to 70 million cases of haematuria, 8·5 million cases of splenomegaly, and 280 000 deaths annually.12 The international community must rise to the challenge of filling in the gap for purchasing the remaining amounts of praziquantel. Without further donations from Merck KGaA, $100 million is required annually to purchase the drug.1 During an informal consultation in January, 2010, WHO acknowledged that, in view of current funding pledges for NTDs, some of these resources could be used to provide sufficient quantities of praziquantel at no cost to endemic countries. This increased access to praziquantel would allow for rapid expansion of multidrug packages www.thelancet.com Vol 376 August 14, 2010
Albis Francesco Gabrielli
Comment
Figure: Haematuria in schistosomiasis Urine samples from school-aged children from Nérékoro in Ségou region of Mali. Three samples on right show visible haematuria, which indicates infection with S haematobium. Three samples on left are not haematuric at visual inspection but could still contain abnormal number of red blood cells. Urine cloudiness (third sample from left) is early sign of abnormality.
to communities affected by multiple NTDs. More recently, at a White House consultation on such diseases in May, the lack of praziquantel donations was identified as a major hurdle for disease-control efforts in Africa. We realise that praziquantel is not a panacea, and that this global action in itself will not result in elimination of schistosomiasis in sub-Saharan Africa. Accurate multiyear forecasts of amounts of drugs needed and better coordination to ensure good-quality supplies are vital. Concerns about possible drug resistance and posttreatment re-infection necessitate global investments in research and the development of new anti-schistosomal drugs and vaccines.1 However, praziquantel is urgently needed for sub-Saharan Africa now, and the current failure of the global community to provide access to this essential medicine is impeding sustainable development in Africa. The shortages of praziquantel should be treated as an African humanitarian crisis. *Peter J Hotez, Dirk Engels, Alan Fenwick, Lorenzo Savioli Department of Microbiology, Immunology, and Tropical Medicine, George Washington University and Sabin Vaccine Institute, Washington, DC 20037, USA (PJH); Department of Control of Neglected Tropical Diseases, WHO, Geneva, Switzerland (DE, LS); and Schistosomiasis Control Initiative, Imperial College London, London, UK (AF) [email protected]
497
Comment
We declare that we have no conflicts of interest. © World Health Organization, 2010. 1 2 3 4
5
6
Hotez PJ, Fenwick A. Schistosomiasis in Africa: an emerging tragedy in our new global health decade. PLoS Negl Trop Dis 2009; 3: 485. King CH, Dangerfield-Cha M. The unacknowledged impact of chronic schistosomiasis. Chronic Illn 2008; 4: 65–79. Anon. History of praziquantel. 2006. http://www.stanford.edu/group/ parasites/ParaSites2006/Praziquantel/history.html (accessed Feb 27, 2010). Hotez PJ. Mass drug administration and the integrated control of the world’s high prevalence neglected tropical diseases. Clin Pharmacol Ther 2009; 85: 659–64. Koukounari A, Gabrielli AF, Toure S, et al. Schistosoma haematobium infection and morbidity before and after large-scale administration of praziquantel in Burkina Faso. J Infect Dis 2007; 196: 659–69. Koukounari A, Fenwick A, Whawell S, et al. Morbidity indicators of Schistosoma mansoni: relationship between infection and anaemia in Ugandan schoolchildren before and after praziquantel and albendazole chemotherapy. Am J Trop Med Hyg 2006; 75: 278–86.
7
8
9
10
11
12
Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J. Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet Infect Dis 2006; 6: 411–25. Kjetland EF, Ndhlovu PD, Gomo E, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 2006; 20: 593–600. Chen MG. Use of praziquantel for clinical treatment and morbidity control of schistosomiasis japonica in China: a review of 30 years’ experience. Acta Trop 2005; 96: 168–76. Fenwick A, Rollinson D, Southgate V. Implementation of human schistosomiasis control: challenges and prospects. Adv Parasitol 2006; 61: 567–622. Zhang Y, Koukounari A, Kabatereine N, et al. Parasitological impact of 2-year preventive chemotherapy on schistosomiasis and soil-transmitted helminthiasis in Uganda. BMC Med 2007; 5: 27. Van der Werf MJ, de Vlas S, Brooker S, et al. Quantification of clinical morbidity associated with schistosome infection in sub-Saharan Africa. Acta Trop 2003; 86: 125–39.
Health workers lost to international bodies in poor countries Guidelines to help keep health workers in remote and rural areas, especially in poor countries, have just been issued by WHO.1 Other relevant issues relating to human resources in situations of poverty have been previously highlighted.2 Re-distribution of staff from the public (national) health service (NHS) to other countries, to the private sector (accessible by only a few patients), and away from remote or rural areas are additive and affect people who are the poorest the most.3 We draw attention to a further drain on the meagre numbers of doctors and nurses in most disadvantaged countries. Some international organisations, research institutions, and non-governmental organisations (NGOs) engaged in aiming to promote health and relieve suffering might, in one aspect of their approach, be having the opposite effect. We refer to their employment of locally trained health workers (often the most able) in countries where there is a shortage of NHS staff, the only source of health provision for poor people there. By offering better salaries and working conditions, such international organisations prevent government-trained doctors and nurses from contributing to their NHS. In an under-staffed NHS, this situation not only deprives patients but also demoralises the remaining staff as they carry an increased and often dangerous workload. We can illustrate this for The Gambia where, in partnership with the Ministry of Health, we have been trying to improve the emergency health-care system.4 The UK’s Medical Research Council (MRC) has been working in The Gambia for over 60 years, during which 498
time substantial numbers of Gambian-trained health workers have gone from the NHS to the MRC. In a letter on Dec 1, 2008, the MRC informed the Ministry of Health and Social Welfare (MC and OS) that 28 of the 96 nurses and midwives in the poorest Upper River Region (serving a population of over 250 000) and trained by the government were working for the MRC (Corrah T, Unit Director and Chairman, MRC [UK], Banjul, The Gambia; personal communication). He also informed us on Jan 25, 2010, that 27 of these 28 MRC nurses worked in government facilities alongside government staff providing health care to research and non-research patients alike. The Director of the Regional Health Team in the Upper River Region and the Officer in Charge of Basse Major Health Centre, the main hospital in that region, confirmed those numbers. Of the 28, three nurses are on the children’s ward helping with MRC study participants and offering about half the nursing care for NHS patients. Six nurses assist in paediatric and adult outpatients where they recruit patients for studies. There is a research nurse assisting in outpatients in minor health centres. Nine of these 28 nurses are qualified midwives but none support maternity services; they are all involved with patients under study (Sangria S, Badje B, Reproductive and Child Health Department, Basse, The Gambia; personal communication). The MRC also said they make every effort not to recruit nursing staff who are working in government facilities or have been so employed during the previous 6 months, pointing out that most of their recent recruits have come www.thelancet.com Vol 376 August 14, 2010
the term “PrEP” defines oral delivery. These categories are outdated and inefficient. They spawn separate scientific meetings, publications, and discourse. Thus they limit a more integrated approach to combination prevention of HIV infection. Just as the VOICE trial is able to compare these two modes of delivery, similarly, the antiretrovirals for prevention field needs to consolidate its terminology. In 2008, we had suggested a new lexicon to categorise HIV-prevention interventions.6 As we have seen with CAPRISA 004, use of antiretrovirals to prevent HIV transmission has become a broad field of its own, encompassing many overlapping scientific issues.7 As with hormonal contraception as a method to prevent unintended pregnancy, future evaluations of antiretroviral prophylaxis will focus on methods of delivery (oral, topical [vaginal, rectal], injectable), regimens (daily, monthly, intermittent/exposure related, pre and post), single versus combination products, and what works in specific target populations (defined by risk, behaviour, and infection status). As a semantic starter, we might use the generic category “pre-exposure prophylaxis”, and break it down by the mode of delivery: oral, topical, injectable, etc. Future scientific meetings would address these topics jointly. Collaboration has been the hallmark of shared information across the microbicide and PrEP fields. It is time now to unify the terminology and share information even more broadly. CAPRISA 004 changes the model for HIV-prevention research. A WHO/UNAIDS meeting in South Africa in late August will examine the next steps for the many trials already underway, in addition to those on the drawing
board. A careful, coordinated, and cooperative approach among the four main HIV-prevention research funders— NIH, the US Agency for International Development, the Bill & Melinda Gates Foundation, and the UK Department for International Development—is crucial to assure the research portfolio for HIV prevention will advance in the most efficient way. Proposed next steps involve investigations at multiple levels: molecular, clinical, and population. A new era indeed. Willard Cates Jr FHI, Research Triangle Park, NC 27709, USA [email protected] I am an FHI member of the CAPRISA 004 Trial Oversight Committee. FHI is one of the five CAPRISA 004 partners who provided support to the trial. FHI helped with study design, protocol development, behavioural intervention assessment, statistical and safety oversight, and clinical monitoring. My participation on the CAPRISA 004 team was funded by USAID grant #GHO-A-00-09-00016-00. 1
2 3
4
5
6
7
Abdool Karim Q, Abdool Karim SS, Frolich JA, et al, on behalf of the CAPRISA 004 Trial Study Group. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 2010; published online July 19. DOI:10.1126/ science.1193748. Grant RM, Hamer D, Hope T, et al. Whither or wither microbicides? Science 2008; 321: 532–34. Anon. Safety and effectiveness of tenofovir 1% gel, tenofovir disproxil fumarate, and emtricitabine/tenofovir disoproxil fumarate tablets in preventing HIV in women (VOICE, MTN-003). June 22, 2010. http:// clinicaltrials.gov/ct2/show/NCT00705679 (accessed Aug 1, 2010). Anon. A pilot study of pre-exposure prophylaxis (PrEP) to evaluate safety, acceptability, and adherence in at-risk populations in Kenya, Africa (IAVI E001). Jan 11, 2010. http://clinicaltrials.gov/ct2/show/ NCT00971230 (accessed Aug 1, 2010). Anon. A pilot study of pre-exposure prophylaxis (PrEP) to evaluate safety, acceptability, and adherence in at-risk populations in Uganda, Africa (IAVI E002). April 19, 2010. http://clinicaltrials.gov/ct2/show/ NCT00931346 (accessed Aug 1, 2010). Padian NS, Buve A, Balkus J, Serwadda D, Cates W Jr. Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward. Lancet 2008; 372: 585–99. Cohen MS, Gay C, Kashuba ADM, Blower S, Paxton L. Narrative review: Antiretroviral therapy to prevent the sexual transmission of HIV-1. Ann Intern Med 2007; 146: 591–601.
Africa is desperate for praziquantel The health and economic effects of schistosomiasis in Africa are not well known, but new information reveals that the neglect of this parasitic infection despite its potential for control through mass treatment with praziquantel represents a monumental global public health disparity.1 Today, we are failing to provide praziquantel, costing just a few cents per tablet, and yet when given once yearly to children, this drug could avert a level of morbidity in Africa that exceeds that of malaria or other disease scourges.1,2 496
Praziquantel was developed in Germany during the 1970s as a joint project between Bayer AG, now Bayer Schering Pharma, and Merck Darmstadt, now Merck KGaA.3 Praziquantel is the only commercially available treatment for human schistosomiasis.4 The drug is highly suitable for use in annual or 2-yearly large-scale campaigns for drug delivery;4 when used as such, praziquantel reduces the prevalence and intensity of schistosomiasis, thereby greatly reducing morbidity.5,6 Schistosomiasis is recognised as one of the most devastating neglected www.thelancet.com Vol 376 August 14, 2010
tropical diseases (NTDs) in sub-Saharan Africa, affecting almost 200 million people (although even these numbers might be substantially higher), and producing a disease burden that could exceed that of malaria.2,7 Moreover, female genital schistosomiasis is a co-factor in the transmission of HIV.8 Successful control programmes in China, Egypt, and Uganda show that treating the total eligible population in areas that are highly endemic for schistosomiasis with praziquantel for a few years results in substantial reductions in the indices (eg, prevalence, parasite intensity, and anaemia) of disease and in the amount of maintenance drug required.9–11 Yet, almost a decade after a World Health Assembly’s resolution to provide complete drug coverage for schistosomiasis, less than 10% of school-aged children at risk receive praziquantel.1,4 This low coverage reflects the limited access to praziquantel because the US$0·08 cost per tablet is too expensive for many African health ministries. Whereas the private sector is donating unlimited quantities of other drugs for NTDs— such as ivermectin (Merck & Co) for onchocerciasis and albendazole (GlaxoSmithKline) for lymphatic filariasis4— for praziquantel, Merck KGaA’s contribution has been fixed at a maximum donation of 200 million tablets over 10 years, with an additional supply of up to 100 million tablets per year at production cost. However, an estimated 1 billion tablets are needed to treat 400 million people annually or every other year,1 and WHO determined that 2 billion tablets might be required over the next 5 years. Thus at least 10–20 times the praziquantel donated currently must be provided free to increase coverage in Africa at a level similar to that of other donated drugs. Wide-scale availability of praziquantel would have an immediate effect on reversing morbidity in schoolaged children and could prevent up to 70 million cases of haematuria, 8·5 million cases of splenomegaly, and 280 000 deaths annually.12 The international community must rise to the challenge of filling in the gap for purchasing the remaining amounts of praziquantel. Without further donations from Merck KGaA, $100 million is required annually to purchase the drug.1 During an informal consultation in January, 2010, WHO acknowledged that, in view of current funding pledges for NTDs, some of these resources could be used to provide sufficient quantities of praziquantel at no cost to endemic countries. This increased access to praziquantel would allow for rapid expansion of multidrug packages www.thelancet.com Vol 376 August 14, 2010
Albis Francesco Gabrielli
Comment
Figure: Haematuria in schistosomiasis Urine samples from school-aged children from Nérékoro in Ségou region of Mali. Three samples on right show visible haematuria, which indicates infection with S haematobium. Three samples on left are not haematuric at visual inspection but could still contain abnormal number of red blood cells. Urine cloudiness (third sample from left) is early sign of abnormality.
to communities affected by multiple NTDs. More recently, at a White House consultation on such diseases in May, the lack of praziquantel donations was identified as a major hurdle for disease-control efforts in Africa. We realise that praziquantel is not a panacea, and that this global action in itself will not result in elimination of schistosomiasis in sub-Saharan Africa. Accurate multiyear forecasts of amounts of drugs needed and better coordination to ensure good-quality supplies are vital. Concerns about possible drug resistance and posttreatment re-infection necessitate global investments in research and the development of new anti-schistosomal drugs and vaccines.1 However, praziquantel is urgently needed for sub-Saharan Africa now, and the current failure of the global community to provide access to this essential medicine is impeding sustainable development in Africa. The shortages of praziquantel should be treated as an African humanitarian crisis. *Peter J Hotez, Dirk Engels, Alan Fenwick, Lorenzo Savioli Department of Microbiology, Immunology, and Tropical Medicine, George Washington University and Sabin Vaccine Institute, Washington, DC 20037, USA (PJH); Department of Control of Neglected Tropical Diseases, WHO, Geneva, Switzerland (DE, LS); and Schistosomiasis Control Initiative, Imperial College London, London, UK (AF) [email protected]
497
Comment
We declare that we have no conflicts of interest. © World Health Organization, 2010. 1 2 3 4
5
6
Hotez PJ, Fenwick A. Schistosomiasis in Africa: an emerging tragedy in our new global health decade. PLoS Negl Trop Dis 2009; 3: 485. King CH, Dangerfield-Cha M. The unacknowledged impact of chronic schistosomiasis. Chronic Illn 2008; 4: 65–79. Anon. History of praziquantel. 2006. http://www.stanford.edu/group/ parasites/ParaSites2006/Praziquantel/history.html (accessed Feb 27, 2010). Hotez PJ. Mass drug administration and the integrated control of the world’s high prevalence neglected tropical diseases. Clin Pharmacol Ther 2009; 85: 659–64. Koukounari A, Gabrielli AF, Toure S, et al. Schistosoma haematobium infection and morbidity before and after large-scale administration of praziquantel in Burkina Faso. J Infect Dis 2007; 196: 659–69. Koukounari A, Fenwick A, Whawell S, et al. Morbidity indicators of Schistosoma mansoni: relationship between infection and anaemia in Ugandan schoolchildren before and after praziquantel and albendazole chemotherapy. Am J Trop Med Hyg 2006; 75: 278–86.
7
8
9
10
11
12
Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J. Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet Infect Dis 2006; 6: 411–25. Kjetland EF, Ndhlovu PD, Gomo E, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 2006; 20: 593–600. Chen MG. Use of praziquantel for clinical treatment and morbidity control of schistosomiasis japonica in China: a review of 30 years’ experience. Acta Trop 2005; 96: 168–76. Fenwick A, Rollinson D, Southgate V. Implementation of human schistosomiasis control: challenges and prospects. Adv Parasitol 2006; 61: 567–622. Zhang Y, Koukounari A, Kabatereine N, et al. Parasitological impact of 2-year preventive chemotherapy on schistosomiasis and soil-transmitted helminthiasis in Uganda. BMC Med 2007; 5: 27. Van der Werf MJ, de Vlas S, Brooker S, et al. Quantification of clinical morbidity associated with schistosome infection in sub-Saharan Africa. Acta Trop 2003; 86: 125–39.
Health workers lost to international bodies in poor countries Guidelines to help keep health workers in remote and rural areas, especially in poor countries, have just been issued by WHO.1 Other relevant issues relating to human resources in situations of poverty have been previously highlighted.2 Re-distribution of staff from the public (national) health service (NHS) to other countries, to the private sector (accessible by only a few patients), and away from remote or rural areas are additive and affect people who are the poorest the most.3 We draw attention to a further drain on the meagre numbers of doctors and nurses in most disadvantaged countries. Some international organisations, research institutions, and non-governmental organisations (NGOs) engaged in aiming to promote health and relieve suffering might, in one aspect of their approach, be having the opposite effect. We refer to their employment of locally trained health workers (often the most able) in countries where there is a shortage of NHS staff, the only source of health provision for poor people there. By offering better salaries and working conditions, such international organisations prevent government-trained doctors and nurses from contributing to their NHS. In an under-staffed NHS, this situation not only deprives patients but also demoralises the remaining staff as they carry an increased and often dangerous workload. We can illustrate this for The Gambia where, in partnership with the Ministry of Health, we have been trying to improve the emergency health-care system.4 The UK’s Medical Research Council (MRC) has been working in The Gambia for over 60 years, during which 498
time substantial numbers of Gambian-trained health workers have gone from the NHS to the MRC. In a letter on Dec 1, 2008, the MRC informed the Ministry of Health and Social Welfare (MC and OS) that 28 of the 96 nurses and midwives in the poorest Upper River Region (serving a population of over 250 000) and trained by the government were working for the MRC (Corrah T, Unit Director and Chairman, MRC [UK], Banjul, The Gambia; personal communication). He also informed us on Jan 25, 2010, that 27 of these 28 MRC nurses worked in government facilities alongside government staff providing health care to research and non-research patients alike. The Director of the Regional Health Team in the Upper River Region and the Officer in Charge of Basse Major Health Centre, the main hospital in that region, confirmed those numbers. Of the 28, three nurses are on the children’s ward helping with MRC study participants and offering about half the nursing care for NHS patients. Six nurses assist in paediatric and adult outpatients where they recruit patients for studies. There is a research nurse assisting in outpatients in minor health centres. Nine of these 28 nurses are qualified midwives but none support maternity services; they are all involved with patients under study (Sangria S, Badje B, Reproductive and Child Health Department, Basse, The Gambia; personal communication). The MRC also said they make every effort not to recruit nursing staff who are working in government facilities or have been so employed during the previous 6 months, pointing out that most of their recent recruits have come www.thelancet.com Vol 376 August 14, 2010