"Bear in mind that the wonderful things you learn in your schools are the work of many generations, produced by enthusiastic effort and infinite labor in every country of the world. All this is put into your hands as your inheritance in order that you may receive it, honor it, add to it, and one day faithfully hand it to your children. Thus do we mortals achieve immortality in the permanent things which we create in common." - Albert Einstein

Saturday, December 16, 2017

A Photoshoot Does Not Cost Three Billion

What should we think when we see a head of a household purchase a smartphone on a loan instead of buying food for his or her family who are barely eating one meal a day? With a smartphone, of course, one can keep in touch with friends and family. One can even browse through Facebook. Perhaps, this is a good intention. However, a good intention is not enough to justify such waste especially when we are not meeting so many other much more basic needs. We indeed expect so much more from a parent. Yet, we do not seem to expect the same from a national leader. More than three billion were spent on a vaccine that was still unproven. In fact, it is now known to be likely harmful to some. Billions and billions were likewise spent on a basic education program that was not of utmost importance. Similar to the dengvaxia vaccine, the supporting evidence was also weak and more importantly, the potential for harm was there, 

Above copied from BusinessWorld

On the dengue vaccine, the former president of the Philippines Aquino made so many claims that actually illustrate how much lacking the Philippines Senate is in intellect. When Aquino falsely stated that the vaccine was approved by the United States Food and Drug Administration, there was no debunking. And when Aquino told that millions of dengue cases were already in the horizon for the Philippines, no one in the Senate tried to quash this grossly unfounded assertion. Ironically, the former president also mentioned in the same statement the importance of not sowing fear in the public.

Above copied from the World Health Organization

Epidemiology is a serious discipline and Aquino is definitely not qualified to project the extent of an outbreak. For the first three months of this year, the number of reported dengue cases for the entire world is about 50,000.

What is lacking in the Senate, fortunately, is present in some citizens of the Philippines. Here is one, a former health official, Dr. Susan Mercado:

I find it very disturbing that President Aquino opened his statement yesterday with data that borders on the absurd.
He said that there was an increase in dengue cases by 100% in Region 3 and 5 and 1,409.5% in Region 8. "What is frightening here is, if there are an estimated 200,000 cases of dengue each year, and it is possible for them to increase 14 times like what happened in Region 8, the number of those who may potentially be infected is 2.8 million".
A quick search will show that the entire Western Pacific Region (including China, Fiji, Viet Nam and other countries with dengue problems) with a total population of 1.9 billion people only reported 500,000 cases in 2016. (WHO Western Pacific Region Dengue Fact Sheet)
Students of public health will quickly point out that you cannot take an increased incidence rate of dengue in a LOCALITY and multiply it by the NATIONAL number of cases.
There may have been a number of reasons for hyperactivity of the mosquitoes in Region 8, but mosquitoes can only live for 2-3 days, and they can only fly for 400 meters. So an outbreak is usually localized.
It is inconsistent for President Aquino to say that governments role is "to calm people down" while he did just the opposite. Using a speculative mathematical twist he has scared the public into thinking that we could have as many as 2.8 million cases of dengue.
Is this faulty statistic the justification for buying 3.0 billion worth of vaccines that had never been tested in a population - at phenomenal speed?
No, we cannot possibly be in any imaginable situation where we would have 2.8 million cases of dengue. No country in this region has ever had numbers close to this. Viet Nam, has always had the largest number of cases, and at its peak it was close to a million cases.
With due respect, that opening statement was alarmist, cannot be backed up by epidemiological modeling and is yet another insult to the intelligence of the public health community in this country.

And 
Rebecca T. AƱonuevo did not fail to see the striking similarity between Dengvaxia and K to 12.

The calm demeanor of ex-President Aquino is cold remorselessness in my view. So typical of people in positions of power. That’s how the teachers of an expensive college in QC got kicked out, in spite of their tenure. We were after the best interest of teachers and the school, they said. That’s how K12 was implemented: We look after the best interest of the nation, Aquino and Armin said. In spite of the massive displacement of teachers (may namatay ba sa gutom sa atin?), and the impending ignorance of a generation ill prepared but forced to swallow the bitter pill of a neo-colonial education that becomes more and more inaccessible to ordinary Filipinos. Mahinay magsalita pero nginungudngod ang taumbayan. Hindi ko namimiss ang dating Pangulo. At hindi siya maisasalba ng bad science. Kung puwedeng pumugot ng ulo si Solomon, harinawa, dahil ang namumuno ay nagpatunay ng katangahan o katamaran sa pagpapasiya sa buhay at kinabukasan ng daan-libong bata ng ating bansa.

But the above people are not in the Senate. The above people are only heard on social media where supporters of the previous administration are also present. These supporters cannot be bothered with Dengvaxia and K to 12. They would rather spend time criticizing a photoshoot that recently happened in the presidential palace. A photoshoot does not cost three billion and will not possibly harm thousands of children. And by the way, a photoshoot likewise does not cost 150 billion.


Blogger Tricks

Friday, December 15, 2017

What Is "Bad Science?

With regard to the dengue vaccine fiasco, Antonio Dans, a scientist at the National Academy of Science and Technology in the Philippines, places the blame on "bad science". The phrase "bad science" actually appears on a book by Ben Goldacre. The complete title is "Bad Science: Quacks, Hacks, and Big Pharma Flacks". Unfortunately, with a small twist, the phrase can be easily misunderstood as "Science is bad". What Goldacre's "bad science" really refers to is neither insufficient information nor honest errors, but misconduct.

Above copied from ABS-CBN
A study published in the Proceeedings of the National Academy of Sciences of the United States of America  finds that majority of retractions in peer-reviewed literature can be attributed to misconduct.

Above copied from
Ferric C. Fang, R. Grant Steen, and Arturo Casadevall. Misconduct accounts for the majority of retracted scientific publications. PNAS 2012 109 (42) 17028-17033; published ahead of print October 1, 2012, doi:10.1073/pnas.1212247109

Blaming "bad science" therefore may not be correctly informing the public especially when "bad science" is really a misconduct. 

The former president of the Philippines, Aquino, testified recently in front of the Senate regarding the dengvaxia problem. In his testimony, Aquino makes the claim that the vaccine passed through the United States Food and Drug Administration.

Above copied from ANC
There were no clinical trials in the United States for the obvious reason that there had not been enough dengue cases in that country. The US National Library of Medicine did list the Dengvaxia's trials on its site, but this listing was in no way providing an imprimatur to the clinical trial.

Above copied from
ClinicalTrials.gov

The disclaimer is clearly visible. It states, "The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government."

Misinformation is misconduct. And we should not use "bad science" as a euphemism or excuse. 

Aquino also claims that there is no information that will cast doubts on the vaccine when he made the decision in December 2015. I guess Aquino does not really read papers from Harvard:

Above copied from Harvard Business School

When a bad decision is made, we must call it a bad decision. We should not call it "bad science". A misconduct is a misconduct.


Wednesday, December 13, 2017

When Scholarships Become Oppressive

There is a reason why scholarships often come with a stipend. A government scholarship after all is an investment made by the public on a promising student. These awards are meant to support the student in every possible way. Without a stipend, a student may not be able to concentrate on his or her studies if such student is still forced to earn a living. Therefore, it goes without saying that the recipients will rely on this stipend to meet their basic needs. After all, it is not a "luxury allowance" but a "living allowance". When I started college, I was rudely awakened to bureaucratic incompetence. As a scholar, I was counting on the monthly allowance for my daily expenses. But months after the first day of school, there was no sign of such an allowance. It was delayed. Without a living wage and a stipend, it is no wonder that some bright people still find themselves buried in debt. 

With the transition to the new K+12 curriculum in the Philippines, teachers in colleges have found their jobs in peril because of the low enrollment. High school students are now spending two more years before entering college. To help these teachers during the transition, the country's Commission on Higher Education (CHED) now provides scholarships so that college teachers can begin working on their graduate degrees at this idle time. These scholarships will likewise address the lack of graduate degrees among instructors in higher education. These teachers obviously are a bit different from my situation when I was a college student. These teachers are very much likely breadwinners.  Sadly, things have not changed. Similar to my time, their allowances are also delayed. 

Above copied from Mahds Guinto

Acknowledging that these delays can cause inconvenience highlights a gross lack of awareness of how important these allowances are and how urgent it is to release these funds on time. This allowance is a lifeline.

CHED shares information on these programs through a blog on WordPress. From that blog, it can be seen that for most of the 4000 recipients, allowances as far back as March of this year have not been released.

Above copied from CHED

I am sharing here a couple of posts on Facebook from scholars that are suffering from this gross negligence and incompetence. Not having a living allowance for the past seven months (more than half a year) is truly oppressive.


Mahds Guinto
6 hrs
Nag-December na lang, Wala gihapon. So I’m posting this again.
Dear Commission on Higher Education,
While this advisory informs us, your scholars, of the further delay in the disbursement of our living allowance, this does not cancel your gross incompetence as an agency. You said you apologize for this unforeseen development, but that does not reduce our anxiety as we try to survive our everyday lives as graduate students away from our families and loved ones. You said you are trying your best, but you can't even provide us exact dates when you would finally solve all of these inconsistencies.
I refuse to believe that CHED is an inefficient agency, nor do I think it is corrupt. However, with the way things are going for us scholars, we cannot help but question this very Institution whose mandate is to uphold reforms in higher education. With the delays of delivering our allowances, we cannot help but doubt if the K to 12 Transition Program is indeed the right program which promised to help displaced teachers get the degrees required so that they could effectively teach again and teach more in their respective institutions with no fear of demotion or removal from their teaching posts.
We are doing our part as scholars by doing well in our studies. We always submit our documents on time. We made sure to give the necessary requirements to you even before we started schooling. The double bind with our contract as scholars is that we will be compelled to pay back the allowances we received should we fail in our courses. But how are we supposed to focus on our studies when we are hungry and/or are about to be kicked out from our boarding houses and dormitories because we couldn't pay our dues on time? How are we supposed to give our best when we are demoralized, and our dignity broken?
The delay is unbearable as it is oppressive. We are scholars, yet we feel like beggars.
Please release the delayed allowances now. It has been SEVEN months already.

Fatimah Joy
Dear CHED,
We are teachers. But more than that, we are wives, husbands, fathers, mothers, daughters, sons, friends, sisters, brothers, human beings. You have tried to reduce us into insignificance for the last time.
This is a warning. Make no mistake. You will pay for your gross negligence of duty, and inhumanity. So much talk about human rights violations in this country. CHED scholars have been kicked out of boarding houses, have been getting stressed out of their wits' ends... and could you imagine the talks in families where for 8 months, the financial strain has mounted, and without hope of resolution? What kind of monsters are you?
You looked my boss, straight in the eye and told him we will get our LIVING allowances before this year closes. We have not received a cent since we started studying here, and we are now about to go home for term end. So imagine our shock earlier when DBP informed me and my friend you have not endorsed our names yet, and we don't even have bank accounts. We have submitted all our requirements for the SECOND time last October.
Sloths!
And we did not ASK to study here. You deceived our Institutions into sending us HERE in Manila where a kilo of my favorite orange camote is 174 pesos! I had to defer because it was a struggle for me to leave my home, my family, debate, teaching, my boyfriend, my friends... Everything I've known and loved.
Yep. I am FURIOUS. And trust me, you WILL NOT get away with this. If I weren't a teacher from one of the best universities in this country, I'd say F U.
You have made your last excuse.


How inefficient the administration is in releasing these allowances is truly in stark contrast on how quickly the past administration of Aquino managed to release funds for the highly questionable dengue vaccine.

Above copied from News5

The past Aquino administration could indeed execute. The makeup of the Commission on Higher Education is still largely from this past administration, yet this commission seems to be an exception when it comes to timely action. Perhaps, what makes this an exception is the fact that scholarships are really meant to help people while the vaccine maybe important for a more urgent reason for Aquino other than the well-being of the Filipino people.


Monday, December 11, 2017

What It Takes to Help Poor Children Learn in Schools

The statistics are widely known, a child growing up in a poor family has heard tens of million words less than a privileged child. This advantage translates to a poor child working his brain a lot harder just to keep up with his or her more fortunate classmates. The inequity sadly does not cease at the beginning of formal schooling. Children from poor families tend to enroll in the same school with income segregation of neighborhoods. Lacking resources and facing mounting challenges, schools that serve low income families are often unable to provide what these children desperately need to thrive in their classrooms. In addition, due to mounting pressure to perform well in standardized tests in reading and math, equally important subjects such as music, arts and physical education are often sacrificed. Such policy actually goes against what we now know from research in neuroscience. For example, "Music lessons may boost poor kids' brainpower, study suggests" by Linda Carroll on Today talks about research done at Northwestern University which now shows how the "sound of music is truly an invisible but powerful force that is central to everyday life".

I recently volunteered in my son's school, Poe Middle School, to help check attendance, check instruments and costumes an hour before their strings concert this winter. I was in one classroom and was expecting about four scores of children showing up to perform. And close to a hundred percent did. The number of instruments in that room was staggering especially if one considered that a used violin would cost anywhere between $1500 to $3000. The boys and girls also looked proud with their costumes. There was definitely a lot of noise in the air but one could not miss an aura of excitement and joy. It was simply amazing to see how these children were given the opportunity to learn and play a musical instrument.

Katherine Augustine teaches Orchestra at Poe Middle School
Watching the kids rehearse before the concert was already an eye-opener, but listening to these middle schoolers was certainly witnessing a miracle. This is why.

Two out of three children attending Poe Middle School come from low-income families. That is a huge percentage especially if one compares this against another middle school in the county, Cooper Middle School. Cooper Middle School is rated 10 while Poe Middle School is rated in 3 in GreatSchools. 



Of course, the above is really a comparison between apples and oranges. Only 2 percent of Cooper students come from poor families:




Poe Middle School, as mentioned previously, is 67% low-income.



Students that do not come from low-income families at Poe are doing just fine. The average for all students is obviously going to be lower at Poe simply because of the much larger number of disadvantaged students enrolled in the school.

It is only within this context that one can fully appreciate what the musical director at Poe, Katherine Augustine, is doing for her students. With that one hour I spent with a fraction of her students, I could only imagine the patience, hardwork and commitment she provides. And that night is indeed memorable.

Research is clear on this subject. "In addition to enhancing cognitive skills, music training can lead to stronger reading, language, and academic skills in children (Schellenberg, 2004, 2006; Hetland and Winner, 2010; Corrigall and Trainor, 2011; Dege and Schwarzer, 2012; Francois et al., 2013; Seither-Preisler et al., 2014; Slater et al., 2014a; see Tierney and Kraus, 2013 for a review), including those with reading impairments (Overy, 2003; Bhide et al., 2013)."

And on that night, the students did shine. I know my son did.


Sunday, December 10, 2017

Not Knowing What It Means to Be Poor and Incompetence Spells Disaster

Poverty creeps into every challenge a society faces. Poverty has a strong and crippling grip on both health and education. Tackling problems in these areas requires an awareness of what a general lack of resources and privilege really entails. It is helpful to walk with the poor yet even immersions do not necessarily capture everything about being poor. The poor faces an enormous fraction of society's major problems in education, health and crimes. Unfortunately, the poor is also the least equipped to handle these challenges. Power, resources, and eventually, policy making all belong to the privileged. And in public school education, those who decide what happens in these schools often send their children to other schools. The people who decide are not real stakeholders. Of course, the privileged is supposed to be more enlightened and educated, and therefore, more equipped to examine problems, suggest solutions, and decide what action needs to be taken. Sadly, nowadays, not only do these people not know what poverty really entails, they are also often incompetent.

The dengvaxia fiasco in the Philippines demonstrates a general lack of competence among government officials but it also illustrates how much out of touch people in power are with poverty. The health secretary who worked with the Aquino administration on this vaccination recently remarked that she was likewise a parent, she had herself vaccinated and so were her children. Such statement is callous and ignorant. The former secretary is a physician and yet, she fails to recognize what a severe dengue infection really means to the poor. Dengue can easily mean death to a a poor child. Growing up poor, I know that I never had annual visits to a pediatrician. In fact, I can get high fever and I still will not be able to visit a doctor. I am confident that most of the poor children in the Philippines are still living this way. Getting a check-up is a luxury that the poor can not really afford. Dengvaxia makes children more vulnerable to a severe dengue infection and without access to health services, these children are more likely to die. Privileged people decide on what happens to the underprivileged. It would really be nice if at least they were competent.

Former Health Secretary Garin
Above copied from ABS-CBN

Dengvaxia, however, is only one small example. There is truly a huge disconnect between the elite and the poor. The poor in the Philippines have to deal not only with low quality basic education and lack of access to good healthcare, but also with crime and violence due to drug abuse. It is no wonder that the majority are supporting the current administration in its drug war inspite of the elite criticizing and moaning about human rights and extrajudicial killings. The elites of the previous administration drew policies and programs that do not really help the poor. In education, this is so evident. Launching K to 12 without resources is really a prescription for disaster that obviously affects negatively poor children much more than their own children. K to 12 and Dengvaxia are really the same prescriptions from out of touch and incompetent people.


Saturday, December 9, 2017

Education and Breaking Out of Poverty

It has been four years since Nelson Mandela left us, but his words on education and poverty remain as true challenges to mankind: "There are two ways to break out of poverty. The first is by formal education, and the second is by the worker acquiring a greater skill at his work and thus higher wages." The challenge remains essentially because the barriers through these avenues are not easily dismantled. One obvious reason is not fully understanding how poverty and poor learning outcomes are really coupled.

Nelson Rolihlahla Mandela
1918-2013

Recognizing that poverty makes education more challenging is the first step. Realizing what privilege entails and how it influences future achievement and performance is the next step. And one must fully grasp the gravity of these facts in order to appreciate what steps are then necessary to address the challenge.

Yes, everyone has an opinion. And anecdotally, we can always point out so many examples to illustrate that it is possible for a child to be born in poverty and yet still succeed in school. I do not have to look too far. In fact, I am one of those instances. Doing this, however, is actually denying the facts I have just mentioned above. My experience alone cannot erase the truth that learning outcomes are inversely proportional to family income. And having more examples cannot dispute this established trend. Going along this line of thought is perhaps one of the reasons why decoupling poverty from education has appeared to be insurmountable over the past decades. Walt Gardner's opinion, recently posted in the Education Week blog, illustrates this misdirection:


Success Academy does have a large fraction of its students coming from lower income families (about 60%), but it pays its teachers on average about $100,000 per year, about 50% higher than most public school teachers. There is no doubt that schools that attend to a larger fraction of low income households face greater challenges. That is why they need a lot of support. And it is not linear. One can see this in the PIRLS reading scores (discussed in a previous post on this blog). Here it is again drawn with lines:


From the above, one can clearly see that if I try to describe quantitatively the relationship between reduced/free lunch eligibility and scores on the reading test, I will get a steeper line as I choose higher percentages of free lunch eligibility. This shows clearly that the challenge does not scale linearly with the percentage of low income children enrolled in a school. As mentioned in the previous post, compared to the top performing education systems, even schools with as much as half of their students qualifying for free luch are performing as well, if not better. Schools only begin to perform signficantly poorly compared to top countries when the percentage of poor children enrolled in a school passes 75%.

Schools serving poor neighborhoods evidently need more resources. These students need more guidance and support from their teachers. With Success Academy paying its teachers significantly more, perhaps, this charter school does realize what it takes to address poverty and education.


Thursday, December 7, 2017

Another Round of International Reading Scores

In 2013, the Department of Health in the Philippines shared data that showed diseases of the heart as the top cause of deaths in the country. Infant mortality is significant but the main causes are pneumonia, bacterial infection, and other respiratory diseases. Acute respiratory infection is the most common disease in 2014 in the Philippines. Yet, the Aquino administration worked with haste even without a congressional budget appropriation to launch a massive dengue vaccination with still ongoing clinical trials. The question of lack of prioritization is undeniable. But enough about Dengvaxia, such neglect is evident is so many government policies including especially those that pertain to public education. And the reason is simple. People are either not seeing what the real problems are or they merely have an agenda that is different from actually solving the problem.

Above copied from the Philippines' Department of Health
Above copied from the Philippines' Department of Health

In Philippine basic education, one of the biggest challenges is that fourth grade students are unable to demonstrate proficiency in what they should have learned in classrooms. International tests point out major shortcomings in primary education. Yet, instead of addressing problems in the early years of basic education, the Aquino administration launches a very expensive program that adds two years to the end of high school. The similarity between Dengvaxia and Deped's K to 12 is truly undeniable.

Part of the reason why national policies seem totally distracted from the real issues is mass media. The public's understanding of the problem is often shaped by how the information is presented. What is given in bold and large font size often hides the much more important details. This problem, of course, is not exclusive to the Philippines.

One specific instance, and this is very recent, is the release of International Reading Test Results in the United States. US News comes with the following headline:

Above copied from US News

Students did score a lower average than the three top scorers: Russia (581), Singapore (576) and HongKong (569). The US scored only 549 - Still, this score is still on a relatively high end compared to the fixed scale centerpoint of 500. And when the scores are examined in greater detail, one can see that the average does not really tell the complete story.

Here are the average scores for year 2011 and 2016 based on race. Every race is above the centerpoint although both Blacks and Hispanics are not performing as well as Whites and Asians.

Above drawn from data obtained from PIRLS 2011 and PIRLS 2016

Looking at race, however, likewise does not provide a complete picture since there is another factor that also separates high-performers from low-performers. That factor is poverty. Using data regarding how many of the students in a particular school qualify for reduced/free lunch, one finds the following distribution.

Above drawn from data obtained from PIRLS 2011 and PIRLS 2016

Schools that are attended more by poor children score lower in this reading exam. Seeing the above results, a more appropriate and informative title should be:

Reading Scores Show US Schools Still Failing to Provide Equity in Education.

Fourth graders in the US are definitely not lagging behind other countries. Students in schools where the reduced/free lunch eligibility is less than 50% are performing as well as the students in the top countries. Only by seeing what the data really tell us can we decide on what is appropriate to do. It is clear that the problem lies in the challenges faced by schools that mainly serve children from poor families. The more proper solution then is to put more resources to these schools and communities to help teachers address the greater needs in these impoverished neighborhoods. Solutions other than this is really no different from spending billions of cash to purchase a vaccine that does not really address the major disease a country is facing.







Wednesday, December 6, 2017

"It's Happened. We Have a Vaccine that Enhances Dengue" - We Should Listen to Experts

“It's clear as the nose on my face: Vaccine recipients less than 5 years old had five to seven times more rates of hospitalizations for severe dengue virus than placebo controls."

These were the words of the one of the world's leading experts on dengue and vaccines, Dr. Scott Halstead. He even added the following remarks after raising serious concerns regarding the mass dengue vaccination program launched in the Philippines:

"Seronegatives are going to be sensitized to dengue virus for the rest of their lives, and it's not going to stop at hospitalizations. Someone is going to die. Once that happens there's enough lawyers that are going to do something about it."
As noted in two previous posts on this blog, the warning signs were already there during the summer of 2015, long before the Philippines president met with executives at Sanofi (the maker of Dengvaxia) on December 2015. The fear has always been there and results laid out that summer in fact proved to Halstead that his hypothesis was correct. The hypothesis is that vaccines can raise a body's sensitivity to a disease.  This is called antibody-dependent enhancement or ADE. Dengue is particularly a good candidate for this hypothesis because of its widely known more severe second infection. The dengue epidemics in Cuba served as a good real life lesson on this disease, which also indicated that "the longer interval [between infection with different dengue strains], the more severe the disease", according to Halstead. Thus, the full ramification of the ill-advised mass vaccinations of children in the Philippines may not be realized until a few years. And with a report today from the Philippine Star, initial results already do not look good.

Above copied from the Philippine Star

Facing a crisis, it is clear that a suitable response is required. Of course, it goes without saying that the government must monitor the health of the children that were vaccinated. Dengue, like any disease, requires care. Death often happens when complications arise like hemorrhage and high fever. Dengue is transmitted through mosquitoes so in places where mass vaccinations happened, measures should be taken to reduce the mosquito population and people should take extra steps to prevent mosquito bites. Aedes aegypti, the mosquito that carries dengue, bites during the day (hours after sunrise and hours before sunset).

With regard to national leaders and policy makers, there are very important lessons to be learned. "Do no harm" is never a rule one can ignore. One cannot use the excuse of desperate circumstances. After all, things can always get worse. Simply because there seems to be an increase in hospitalization due to dengue, one is still and should never be justified to take unproven measures.

The Aquino administration bears full responsibility for the Dengvaxia fiasco. There is indeed plenty of opportunity to learn more about this unproven vaccine yet the Aquino administration even with huge financial challenges has managed to embark on a mass vaccination program in a short period of time. It is reckless and the funding itself seems unconstitutional.

This blog has followed how the Aquino administration instituted reforms in basic education and one can not fail to see a striking similarity. The haste, the recklessness, and the complete disregard of evidence-based research are all present. Not blaming how these leaders arrive irresponsibly at policies is really tantamount to not learning important lessons from these huge disasters that are of our own making. In these cases, placing blame is important. Otherwise, we will not change and will keep making the same mistakes over and over again.



Monday, December 4, 2017

Lessons from Dengue: Due Diligence and Expertise Are Necessary for National Programs

When confronting an issue that involves the lives of millions of children as well as billions of cash, we expect leaders to exercise due diligence. It is assumed that our leaders will at least do their homework. The Dengue vaccine fiasco in the Philippines illustrates what is terribly wrong with its leadership. The Philippines has embarked on gigantic national programs on education, and this time, on health, without due diligence. The preliminary data on the efficacy of Dengvaxia have been available even before Aquino met with Sanofi on December 2015 in Paris, France. The data published in the New England Journal of Medicine on September 2015 certainly do not support a large scale vaccination without further studies.

One troubling aspect of the results involves the difference between individuals who have had been infected with Dengue and those who have not been. These are shown in the following tables:

Younger than 9 years

Older than 9 years

CYD14 and CYD15 are the current trials in Asia and Latin America, respectively. The Asia study is smaller but more troublesome is the small number of participants who have not been infected with Dengue (Seronegative). However, even with this sample, the lower and sometimes negative efficacy of the vaccine is an obvious warning sign. From these numbers, serious concerns regarding vaccinating seronegative individuals are already justified.

Scott Halstead of the Uniformed Services in the United States has long been critical of Dengvaxia. He noted earlier that the age profile of the trials looks similar to what has happened in Cuba decades ago, and suspected that the vaccine was sensitizing individuals who have not contracted dengue. In December 2016, Halstead and coworkers wrote, "We believe that the allocation of financial resources implementing the screening, in order to use this “imperfect” vaccine most efficiently and to optimize a beneficial outcome, is justified to avoid an eventual burden of vaccine enhanced disease in vaccinated seronegative individuals." Fast forward, in a paper recently published in Vaccine, Halstead vividly shows what he has been trying to say all this time.

Cuba had a dengue outbreak in 1977. Four years later, another outbreak occurred. Below is the age profile of severe dengue cases in 1981:

Above copied from
Vaccine. 2017 Nov 7;35(47):6355-6358. doi: 10.1016/j.vaccine.2017.09.089. Epub 2017 Oct 10.

The bar chart shown above shows hospitalizations are highest at the youngest age and decreases with age. Focusing on the age 3-14 years, and comparing the cases in these age groups to those of the clinical studies - one sees a very strong resemblance of the Havana data to the results of the Dengvaxia trials:

Top: Havana, 1981, 
Middle: Trial results (Vaccinated), 
Bottom: Trial Results (Placebo, no vaccination)
Above copied from
Vaccine. 2017 Nov 7;35(47):6355-6358. doi: 10.1016/j.vaccine.2017.09.089. Epub 2017 Oct 10.

The age profile for those who have been vaccinated is similar to that of Havana in 1981. In other words, introducing the vaccine has similar effects as the first epidemic. A second infection of dengue is often worse than the first one. The vaccine seems to serve as an initial infection to seronegative individuals such that if these individuals do get infected in the future, it will be more severe. On the other hand, the data on placebo children paint a clearly different age profile.

Thus, it is important that candidates for Dengvaxia are screened. What happened in the Philippines during the Aquino administration clearly did not consider these early warnings. The current administration of Duterte is basically crossing their fingers that the infection rate is about 90% before the vaccine was introduced limiting the number of seronegative 9-year olds to one in ten. Perhaps, this is true for some locations like Cebu where there is indeed a high incidence of dengue. But even in this setting, 15% -40% among 8-10 year olds still appear to be seronegative:

Above copied from
Incidence of Dengue Virus Infection in Adults and Children in a Prospective Longitudinal Cohort in the Philippines
Alera M.T., Srikiatkhachorn A., Velasco J.M., Tac-An I.A., Lago C.B., Clapham H.E., Fernandez S., (...), Yoon I.-K.
(2016) PLoS Neglected Tropical Diseases, 10 (2) , art. no. e0004337

It is true that mistakes happen and in matters of urgency, the potential of making the wrong decision even becomes higher. Sanofi and the previous administration are not necesarily criminally liable for these mistakes unless there are anomalies that occurred during deliberation and procurement of funds. However, there are important lessons to be learned. For programs that are so wide in scope and highly consequential, there is no substitute for due diligence and expertise. Leaders need to be fully informed and it is their responsibility to consult evidence-based research especially on matters that involve health and education. Unfortunately, leaders often go with fads without consulting what is already known. Without learning this important lesson, it is only a matter of time that similar errors are going to happen again and again.


Saturday, December 2, 2017

It Is Our Responsibility

Facing a worrisome dengue epidemic, the Aquino administration approved the use of the Dengvaxia vaccine in December, 2015. Its Department of Health, a few weeks later, launched a massive vaccination program of more than 1 million children, costing 3.5 billion pesos. The Health Secretary, Janette Garin, was touting that the vaccine earned approval from the World Health Organization. With a change in administration, the new Health secretary, Paulyn Ubial, suspended the vaccination program in July 2016, citing that the vaccine has not been proven safe. However, on September 2016, Ubial issued a certificate of exemption for Dengvaxia amidst continuing issues. This timeline was provided by Rappler.

Above copied from Rappler

It was nice for Rappler to provide a timeline. However, as usual, Rappler fails to provide important information for an issue that is of utmost significance. First, the World Health Organization does not have the authority to approve vaccines. That authority falls solely on the shoulder of each country's drug regulatory body. This is a misconception that is sometimes present in scientific journals but has been corrected:

"In his article in The Journal of Infectious Diseases, Halstead stated in the title that “WHO approves the CYD-TDV dengue vaccine”. This statement is misleading, and it is hence important to elaborate on the role of the World Health Organization (WHO). It does not fall under the purview of the WHO to approve vaccines; the power to license vaccines belongs to national regulatory authorities who follow their own rigorous evaluations and approval processes on the basis of the quality, safety, and efficacy of the product." (Journal of Infectious Diseases, December, 2016)

One must note, however, that the actual title of Halstead article is "Critique of World Health Organization Recommendation of a Dengue Vaccine" and not "WHO approves the CYD-TDV dengue vaccine”. A recommendation is different from an approval. Halstead, is in fact, very wary of WHO's recommendation. In a letter published in the same issue of the journal, Halstead adds:

"For dengue virus (DENV) infections, almost all hospitalizations in the placebo group are expected to result from secondary infections. But what about the 295 vaccinated children who were hospitalized for dengue after the onset of clinical trials [2]? Given that children aged 2–5 years had vaccine-enhanced disease..."

Although Halstead's article was only published in August, 2016, issues regarding Dengvaxia have been known before the Aquino administration in the Philippines approved the vaccine in December 2015:

"... there were more hospitalizations and cases of severe dengue reported among participants under the age of 9 years than among those older than 9 years of age in the vaccine group... ...Available clinical data are insufficient for drawing definitive conclusions about the observed imbalance in younger children...." (New England Journal of Medicine, July, 2015)

There are obvious reasons for concern. And the Aquino administration bears the responsibility of performing due diligence. Fast forward to Novermber 2017, the maker of the Dengvaxia vaccine finally issues a press release:

"For those not previously infected by dengue virus, however, the analysis found that in the longer term, more cases of severe disease could occur following vaccination upon a subsequent dengue infection." (Sanofi Pasteur, Press Release, November, 2017)

The Dengvaxia vaccine is a simple illustration of how the Aquino administration handled a problem without doing its homework. This example is no different from how it handled the challenges faced by its basic education system. The Aquino administration is known for jumping into consequential decisions without looking closely at evidenced based research. Such irresponsibility not only costs billions of pesos but also harms Filipino children.