Developments 45 by Brian Cumming

WHEN RATS RUN RIOT

LIFE CHANGE FOR VOLUNTEERS

REFUGEES REUNITED

CHIMAMANDA NGOZI ADICHIE SHORT STORY

ISSUE 45 2009 www.developments.org.uk

vital signs why boosting health is critical to global development

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contents SPECIAL FOCUS: GLOBAL HEALTH

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Global news

Why it’s critical that poor people get access to medicine.

Gaza’s children receive support. Official: travel does broaden the mind. Why ‘fast fashion’ must slow down. Hunger threatened by price and environment.

Health benefits

Billanthropy: good or bad?

Is the rise of private foundations like Bill and Melinda Gates’s good for development?

Falling short

Drug trade

The dearth of trained healthworkers in poor countries is at crisis point.

How China’s methadone replacement programme is reducing HIV infection.

The great stink

Head first

What smelly London 150 years ago teaches us about health.

Why we need to take mental health seriously in poor countries as well as rich ones.

Front cover: Feleke Shalachewu wants to be a doctor when he grows up. © Chris de Bode This page: Malaria ward in a hospital in the highlands of western Kenya. © Sven Torﬁnn/Panos

Developments magazine and website are produced by DFID to raise awareness of development issues. The views expressed do not necessarily reﬂect ofﬁcial policies.

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editors

Subscribe free to Developments at www.developments.org.uk

Martin Wroe Malcolm Doney

contributors Chimamanda Ngozi Adichie Tatum Anderson Steven Belmain Mathew Bishop Julie Ferry Michael Green

Louise Hill Rachel Jenkins Sarah Malian Paul Northup Beowulf Sheehan Louise Tickle Louisa Waugh

This magazine is printed on 90gsm Royal Web Silk, from 100% FSC (Forestry Stewardship Counci) certiﬁed pulp. It is manufactured in the UK and has a low carbon footprint on transport. Designed and printed by Engage Group www.engagegroup.co.uk

Leading the British Government’s ﬁght against world poverty.

www.dfid.gov.uk Public Enquiry Point: 0845 300 4100 (UK only) or +44 1355 84 3132 (from outside the UK) enquiry@dfid.gov.uk

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Global healthcheck

Willing volunteers

Volunteering offers disadvantaged young people the chance to see life in the developing world.

Reunited

A young Afghan refugee was the catalyst for an innovative social networking site reuniting lost families.

Rat race Research is helping farmers in Bangladesh win the fight against ‘rat floods’.

Chinasa

A short story with an educational twist by Orange Prize-winning author Chimamanda Ngozi Adichie.

ne minute you’re reading about pioneering medical technology behind a ‘bionic’ eye which might give the blind their sight again. The next you learn that a disease you’ve never heard of, bilharzias, infects 200 million people and leads to 200,000 deaths a year. Before you’ve taken in the fact that polio, which used to be a global killer, has almost been wiped out, you find a new killer stalking the global block – like SARS or Avian Flu. On the one hand we’re learning that, if we put in the resources and planning, we have the medical technology to eliminate many of history’s killer diseases. ‘Access to medicine’ is the global health mantra and, as Tatum Anderson reports in Health benefits (p13), where this is working in Africa, there’s been a phenomenal fall in deaths from malaria. But we’re also learning that in a highly mobile, cheek-by-jowl world, the poor health of someone in one country can affect (or infect) someone in another. Disease can leap the barriers of passport control. So, no sooner had SARS (sudden acute respiratory syndrome) hit the headlines than airports were full of masked passengers and this devastating illness had spread to 30 countries, infected 8,500 people and taken 900 lives. But perhaps the spread of information and technology will also be key in combating the globalisation of disease. Witness the success of DFID’s partnership in China (Drug trade p22) in both taking drug abusers off heroin and dramatically reducing the risk of HIV infection. Certainly investment is critical, which is why ‘philanthrocapitalism’ (p16) like that of the Bill & Melinda Gates Foundation may have a big role to play. But none of this will be effective unless ordinary people get the message that we are a global neighbourhood. That’s what the groundbreaking volunteering programme Platform2 is already doing (p27). Welder Shaun Welch, 22, from Birmingham, just back from working on a conservation project in north-east Ghana, couldn’t have put it better: “The people of Bledi Chebi showed me what the true essence of community is, and I think people could do with connecting to that – that sense of common unity.”

Martin Wroe and Malcolm Doney

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Does the scene seem a little implausible? Apparently affluent citizens of wealthy London taking their laundry down to the banks of the Thames. Squatting on the muddy shoreline to do their washing-up; taking a bath and relieving themselves; all in the same shared water source. It’s striking simply because it’s an everyday scene from cities all over the developing world starkly transposed onto a city where this kind of poverty was long ago made history. Only 150 years ago the scourge of untreated sewage made living in London a death trap. Clean water and sanitation are still critical for good health – as we report on page 25. Image © Squint/Opera

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Funny funds raise school smiles It was not funny money, but a lot of people were very funny for the money. And the cash ended up at around £60m in the UK’s bi-annual charitable fund-raiser Red Nose Day organised by Comic Relief in March. Celebrity climbers like Cheryl Cole, Chris Moyles, Denise Van Outen and Ronan Keating raised £3m by climbing Mount Kilimanjaro. Some of the world’s leading bands played on the return of Top of the Pops, while comedians and actors happily kept millions of UK TV viewers entertained and informed. And of the huge sums of money raised, a high proportion will go towards development work in the poorest countries, including £10m on a groundbreaking education initiative in partnership with DFID. As part of this year’s campaign, schools across the UK were asked to choose how the cash they raise gets spent to help overcome three of the major barriers that prevent kids across Africa from going to school. These obstacles are: that some children’s families are too poor to afford school; that other children can’t go because they have to help at home when someone in the family is sick; and that some are too busy fending for themselves away from home to get an education. DFID promised to add an additional £5m to the money raised by Comic Relief for education in Africa. DFID’s long-term education programmes have supported governments in countries such as Kenya, Malawi, Tanzania and Uganda to remove school fees – enabling more than four million children across Africa to enrol in primary school. However, many vulnerable children, particularly orphans, still face practical difficulties in getting to school – like finding money for uniforms and shoes. Grants of as little as £800 can enable local communities to identify the neediest children and help to support them, providing the essentials to get them into school. “It’s wonderful that, in more difficult times, people seem to understand that the need increases for people whose lives were impossibly tough in the first place,” explained co-founder and vice chairman of Comic Relief, Richard Curtis. Comic Relief Chief Executive, Kevin Cahill said: “We’re delighted that the Department for International Development have offered to add up to £5m to help get these children in Africa into school.” MORE INFORMATION www.rednoseday.com/schools www.dfid.gov.uk/discoveryzone

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Palestinian Fairtrade olive oil arrives Olive oil production plays an essential part in the economy of the West Bank. Now the first olive oil to carry the Fairtrade mark will provide vital income for Palestinian farmers struggling to make a living. Zaytoun extra virgin olive oil was launched at a Co-operative store in Archway, London – where Palestinian farmer Mahmoud Issa was joined by International Development Minister Mike Foster MP. “Trade is one of the most important ways in which a country can lift itself out of poverty,” said the minister, “and I hope that many more Palestinian products will appear on our shelves in the future. Shoppers will now be able to buy the product safe in the knowledge that their purchase will ensure that the producers are getting a fair price that helps them earn a living for them and their families.” Olive oil production provides many Palestinian farmers with as much as 50% of their annual income. Olive production also prevents the abandonment of the land and the spread of desertification. However, as a result of the conflict in the region, Palestinian farmers face severe barriers in carrying out their normal day-to-day agricultural activities, mainly through restrictions on movement, exacerbating levels of deprivation and marginalisation. Almost 75% of Palestinians live below the United Nations poverty line of $2 a day. “The olive means everything to us,” said olive farmer Mahmoud Issa. “My father and my grandfather farmed on this land, and now my children work alongside me harvesting. Our olive oil is of the highest quality because of the fertility of the land and we use traditional farming methods. Fairtrade will bring stability to our farmers with the Fairtrade premium allowing for investment.” Zaytoun olive oil is made by the Palestine Fair Trade Producers Company (PFTPC), which is made up of eight cooperatives, consisting of about 265 farmers, but the aim is to bring as many growers as possible into the scheme through the registered small farmers’ cooperatives, which include some 1,700 growers. MORE INFORMATION www.zaytoun.org

Olive farmer Mahmoud Issa with DFID minister Mike Foster.

Timber truck on the way to Moshi, Tanzania. © Heldur Netocny/Panos

New leaf for China-Africa timber trade East African countries like Tanzania and Mozambique export more than 50% of their timber to China, at a rate which is threatening the future of their forests. But a Worldwide Fund for Nature (WWF) project designed to develop a sustainable trade in forestry and timber between China and east Africa has received UK government backing. China has become a signiﬁcant investor and trade and aid partner for countries such as Tanzania, Mozambique, and Kenya in recent years as East Africa is so rich in natural resources. But timber is being harvested at such a rate that Mozambique’s resources could be exhausted within a decade. Collaboration between DFID and WWF will enable the environmental charity to improve the quality of aid, trade, and investment reaching East Africa, in order to safeguard the future of its natural resources and protect livelihoods. “China presents an enormous economic opportunity for East Africa, but the region is yet to fully reap the beneﬁts,” said David Nussbaum, Chief Executive of WWF UK. “WWF will help ensure east African countries can capitalise on this aid and investment to ensure the long-term sustainability of their resources and economies.” The EU is also playing a role in trade between China and Africa, since products made from Africa’s natural resources end up in European markets. Between 1997 and 2005, EU and US imports of Chinese forest products rose by between 700 and 900%. “We must hold China, Africa, the EU and other consumer countries accountable for improving the way our global market system functions and its impact on our planet,” said Dr Li Lin, Director of Conservation Strategies at WWF China. “There needs to be a shared responsibility between the resource provider, the producer, and the consumer.” WWF believes this new approach to China-Africa-EU trade can help build a global green economy. MORE INFORMATION www.wwf.org.uk/oneplanet

Slavery ‘not abolished’ Slavery is alive and well across the world according to reports by UN cultural organisation UNESCO and the United Nations Office on Drugs and Crime (UNODC). UNESCO’s paper Unfinished Business says human trafficking, sexual servitude and child labour have similar characteristics to historical slave systems. The UNODC report Global Report on Trafficking in Persons goes further. It notes 79% of trafficking is for sexual exploitation, mostly women and girls. The second most common form of human trafficking is forced labour (18%), although the agency fears it may be under-reported. Worldwide, almost 20% of all trafficking victims are children. However, in parts of Africa and the Mekong region, children make up the majority of victims (up to 100% in some west African countries). Contrary to conventional perceptions, in 30% of countries providing information on trafficker gender, women were found responsible for most of this crime.

Illegal ﬁshing left at sea Vessels involved in illegal, unreported and unregulated (IUU) fishing could be banned from ports worldwide, conserving fish stocks within developing country seas and oceans. The United Nations Food & Agriculture Organisation (FAO) has been hosting talks and negotiators are close to forging an international agreement. FAO reports that outline measures that would deny vessels engaged in illegal fishing access to fishing ports are “largely in place”. It says that port controls are considered the most efficient and cost-effective way of controlling illegal fishing. Out-at-sea policing is far more expensive and hard to control, especially for developing countries. FAO spokesman David Doulman said: “Strong oversight of fishing vessels at the ports where they land fish and refuel, take on supplies or make repairs will allow countries to cast a wider and more tightly woven anti-IUU net”.

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Travel does broaden the mind Travelling overseas while young can have a life-long impact on people from disadvantaged backgrounds. That’s the key finding from research by the Institute of Public Policy Research (IPPR) examining the long-term impact on former participants from disadvantaged and working-class backgrounds who had travelled abroad with the youth and education charity Raleigh International. Consulting more than 100 former Raleigh ‘venturers’ from disadvantaged backgrounds, who had been on expeditions between five and 20 years ago, the study included young people who had experienced a range of difficulties in their life such as unemployment, homelessness, drug and alcohol problems, mental illness and violence. Rallying Together: A case study of Raleigh’s work with disadvantaged young people found that mixing young people from different social backgrounds increased aspirations and interest in education and learning. The study also discovered that intensive experiences and breaks have the potential to widen young people’s horizons and networks and break away from destructive influences and patterns of behaviour. Participants described how the experience made them feel stronger, enabled them to take control and helped them cope subsequently with difficult periods in their life. The IPPR research commissioned by Raleigh is the first study of its kind to evaluate the long-term impact of overseas expeditions. “This research demonstrates that structured group activities play a powerful role in improving the emotional and social development of the UK’s young people,” said Lisa Harker, IPPR’s Co-Director. “It shows what an overwhelmingly positive experience expeditions like Raleigh, that test people and mix those from different social backgrounds, have proved in changing people’s lives.” MORE INFORMATION www.ippr.org www.raleighinternational.org

Broadening horizons

76%

said being with people from different social backgrounds to their own was an important part of the Raleigh experience.

81%

said the experience increased their friendships with people from different backgrounds.

94%

said their understanding of other people’s cultures and backgrounds had increased.

73%

reported increased participation in volunteering activities as a result of their involvement.

Mamouna Keita cotton farmer, Mali. © Simon Rawles

Campaign combats throwaway fashion More than 300 retailers, producers and designers have joined a sustainable clothing action plan launched by the UK government to tackle the environmental impact of the throwaway fashion culture, and improve the lot of developing world producers. The Sustainable Clothing Roadmap hopes to draw attention to the wasteful effect of ‘fast fashion’ where cheap high street clothes are worn just a few times and then discarded. About 1.5m tonnes of clothing end up in landﬁll every year. “This action plan represents a concerted effort from the fashion industry, including top names in the high street and manufacturers, to change the face of fashion,” said Minister for Sustainability Lord Philip Hunt. “Retailers have a big role to play in ensuring fashion is sustainable. We should all be able to walk into a shop and feel that the clothes we buy have been produced without damaging the environment or using poor labour practices, and that we will be able to reuse and recycle them when we no longer want them.” According to the Department for the Environment, Food and Rural Affairs (Defra), the clothing and textiles sector in the UK produces around 3.1m tonnes of carbon dioxide, 2m tonnes of waste and 70m tonnes of waste water a year. “(The Sustainable Clothing Roadmap) is going to be great for the fashion industry, great for the climate and for anyone who’s in the supply industry in developing countries to those working in retail,” said Lord Hunt. “We believe customers want sustainable clothing and we want to give them as much as possible.”

Fashion trends Marks & Spencer, Tesco and Sainsbury’s will increase their ranges of fair trade and organic clothing and support fabrics which can be recycled more easily. Tesco will ban cotton from countries known to use child labour. Nike will improve the sustainability performance and innovation of all their product ranges. Charity Shops, such as Oxfam and the Salvation Army will increase consumer awareness on the environmental benefits of clothing reuse, and open more ‘sustainable clothing’ boutiques of high quality second-hand clothing and new sustainably designed garments. The Fairtrade Foundation aim to increase the volume of Fairtrade cotton products to 10% of all cotton clothing in the UK by 2012.

MORE INFORMATION www.defra.gov.uk

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Hunger threat forecast Urgent action is needed to prevent hundreds of millions more people slipping into hunger as a result of volatile food prices and increasing energy and water scarcity, claims international agency Oxfam. Decades of underinvestment in agriculture coupled with the increasing threat of climate change mean that despite recent price falls, future food security is not guaranteed, and in fact the situation could get worse. The warning comes in two new reports, A Billion Hungry People and The Feeding of the Nine Billion, published by Oxfam and the UK think tank, Chatham House respectively Although global food prices have fallen in the last few months, they are not back to previous levels, and are likely to rise sharply again in the future. Furthermore, price volatility itself is a problem, and more needs to be done to address the underlying structural issues that cause the chronic hunger affecting one in six people in the world today, says Oxfam.

“This should be a wake-up call for all those who believe that the food crisis is over,” said Barbara Stocking, Oxfam Chief Executive. “World leaders have a window of opportunity to prevent a worse situation resulting from the triple crunch of the economic crisis, climate change, and energy and water scarcity. They must act urgently to turn their plans into coordinated action that addresses immediate needs and begins to implement long-term reforms. Failure to act will see millions more people falling into hunger.” Oxfam said current severe food shortages in Afghanistan, Ethiopia, Kenya, Mozambique and Zimbabwe are evidence that the global food crisis is far from over. Even before recent price rises, there were over 850 million people classiﬁed as undernourished. Now, there are nearly a billion, as a result of the price rises, alongside other factors such as political instability and conﬂict. The Feeding of the Nine Billion predicts demand for food will increase as the

world’s population grows by 2.5 billion to 9.2 billion by 2050. It also notes a UN forecast that climate change will increase the number of undernourished people worldwide by between 40 million and 170 million. The report includes recommendations for reform of the humanitarian aid system and makes a strident call to poor countries to do their bit by investing more in agriculture, targeting women and small-scale producers. Developing countries must increase social protection measures for vulnerable populations – including cash payments and employment creation schemes for those at risk of hunger. Rich countries must ensure long-term predictable funding to developing countries for investment in agriculture and climate change adaptation. MORE INFORMATION www.oxfam.org.uk

The food crisis in ﬁgures One in six of the world’s population is hungry, almost a billion people. Between 50% and 60% of all childhood deaths in the developing world are hunger related. The death risk is 2.5 times higher for children with only mild malnutrition than it is for children who are adequately nourished. The proportion of overseas development assistance spent on agriculture has fallen from almost 25% in 1980 to just 3% today. Poor people are particularly vulnerable to changes in food prices with many spending up to 80% of their income on food. North Eastern Province, Kenya. © Dieter Telemans/Panos

Figures from Oxfam

ISA to save children’s lives Investors in the UK are being offered the chance to save money and help save lives with a new Vaccine Investment ISA which aims to raise £50m to vaccinate children in the world’s poorest countries. Every £1,000 invested will immunise more than 130 children against five life-threatening diseases. As well as the Vaccine Investment ISA, there is a Vaccine Investment Plan for those who have used or are not entitled to an ISA allowance, for amounts up to £999,999. The funds raised by the International Finance Facility for Immunisation (IFFIm) will be used by the Global Alliance for Vaccines and Immunisation (GAVI Alliance) to support vaccination programmes in 70 developing countries. HSBC, in collaboration with IFFIm, the GAVI Alliance and the World Bank, designed the innovative schemes to provide a fixed return of 16.2%, together with the original capital repaid in full. This is not a donation, they emphasise, it’s an investment opportunity with an ethical bonus. “We are proud to be able to offer this innovative investment opportunity,” said Stephen Green, Group Chairman of HSBC, “while also supporting a most worthwhile humanitarian cause”.

MORE INFORMATION www. hsbc.co.uk/vaccine

Speak up Want to make your views known on how the UK government should fight global poverty? If you’re a UK citizen, now’s your chance. DFID will publish a new White Paper this summer Eliminating World Poverty: Assuring our Common Future. It will explore: • How we build a common future. • The kind of economic growth we need. • Tackling climate change. • Responding to fragile and conflict-affected countries. • Reforming international institutions. To get your voice heard, go to http://consultation.dfid.gov.uk and comment on the public consultation document.

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Gaza’s children given support Louisa Waugh reports on help for distressed children affected by the conﬂict as they try to put their lives back together again.

Palestinian families across the Gaza Strip are still reeling from the aftermath of the recent conflict, which killed over 1,400 Palestinians, including over 400 children. Israel says it launched the offensive in response to rockets being continually fired towards southern Israel from Palestinian militants inside the Gaza Strip. International and Palestinian human rights organisations report that the overwhelming majority of victims were civilians. Thousands of Gazan families are now facing poverty because their homes and places of work have been destroyed. Over 4,000 homes were completely destroyed and over 11,500 badly damaged during the conflict, especially in the border areas of northern Gaza. Many families are now staying with relatives, or living in tents erected by the United Nations Relief and Works Agency (UNRWA), the main UN agency working inside Gaza. UNRWA supplies humanitarian assistance to one million refugees across the Gaza Strip. But many adults and children also need ongoing psychological support in the aftermath of the conflict. The Gaza Community Mental Health Programme, which provides mental health services to adults and children across the Gaza Strip, estimates that up to half of children in Gaza, around 350,000, will suffer some form of post traumatic stress as a result of their experiences during the offensive. A number of local Palestinian NGOs are focusing their efforts on supporting children who have been distressed by their recent experiences. Sixteen-year-old Senah, from Jabalia refugee camp in the northern Gaza Strip, lost five members of her family,

Faten and her daughter Nagham. Nagham and the other children in her house still suffer nightmares from the bombardment. © Sarah Malian

A shelled building in Rafah – 15,500 homes in Gaza have been badly damaged or destroyed. © Sarah Malian

including her father, her elder sister and her two younger brothers, when her home was shelled by the Israeli military on 3 January, 2009. Senah witnessed the shelling, which completely destroyed her home, and was too frightened to leave her family and go back to school after the ceaseﬁre on 18 January. “Senah was scared she would lose the rest of her family while she was out at school”, says local community worker Ismail Dalmaily, who has supported Senah ever since the January ceaseﬁre. Ismail Dalmaily works with the Community Training Centre for Crisis Management (CTCCM), a Palestinian NGO that offers psycho-social

support to children across Gaza, and is now supporting hundreds of distressed children and their families, especially those who live in and around the border areas. CTCCM works in schools and local community centres. Its work is ﬁnancially supported by a British NGO, Medical Aid for Palestinians (MAP). “In Gaza, children are facing enormous psychological traumas as a direct result of the Israeli offensive”, says Andrea Becker, head of advocacy at MAP, which has been supporting health projects in the Gaza Strip for almost 20 years. “We are supporting local NGOs to support these children, as they attempt to rebuild their shattered lives.” Senah attends three CTCCM sessions a week, including personal support, group sessions and psycho-drama. She says the sessions “make a difference”, and is now back at school full time. In Khan Yunis, in the southern Gaza Strip, another local NGO has been supporting local children for almost two decades. The Culture and Free Thought Association (CFTA) was founded in 1991 by a group of local Palestinians, including Majeda al-Saqqa, who is a community worker at the association. “We do a whole range of activities with children, like expressive art, drama and sports” she says. “A lot of our work now is with children who live in the border areas of Gaza. Many of them are severely traumatized, and displaying symptoms of stress, depression and aggression – and also physical symptoms like headaches, stomachaches and nausea.” CFTA now supports around 500 Gazan children a day. The association also employs a team of outreach workers, but cannot now cope with the demand for its services, which surged immediately after the ceaseﬁre. “We work long term with the children” says Majeda. “We do follow-up with their families and schools - and we see the difference in their behaviours and feelings. Many of them

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Africa’s energy boosted

A boy participates in stress-release therapy at a CFTA ball pool. © Christian Aid/Sarah Malian

become less aggressive, more integrated into their families and schools, and their physical symptoms disappear.” During the conﬂict, schools across Gaza were closed, or converted into shelters for people who had nowhere else to go. Children were kept at home for their own safety, and Majeda says many children are now afraid to be alone. As well as supporting their psychological health, CFTA also encourages the children to have fun, taking them on trips to the coast, where they can run and play, and simply enjoy being children. Another local initiative, Give Gaza, dispatches teams of adults dressed as kangaroos to play with children and encourage them to laugh and relax.

Humanitarian assistance is now trickling into the Gaza Strip and there is a frail semblance of normality, as families attempt to rebuild their lives, and their homes, and move on from the events of the recent conﬂict. But thousands of families are coping with the violent deaths of people they loved. They are physically and mentally exhausted, and also nervous about what will happen next. As Israel and Hamas struggle to agree terms for a lasting ceaseﬁre, the borders remain effectively closed, and life inside Gaza continues to be fraught with uncertainty. These local psycho-social support projects offer a lifeline for thousands of Palestinian children who are continuing to live on the edge.

Meeting needs in Gaza “I have been horrified at the scale of human suffering that I have witnessed for myself… we must provide more than just basic humanitarian support if we are to help rebuild people’s lives.” Douglas Alexander, UK Secretary of State for International Development, visited Gaza in March and announced that £30m was being made available to help kick-start a recovery. This pledge brings the UK response to the recent conflict to nearly £47m. DFID has been supporting the Palestinian people for over 15 years. UK aid has been helping the Palestinians prepare for statehood and supporting the desperately needed peace process. See www.dﬁd.gov.uk for more details of DFID’s programme and updates on the response to the Gaza crisis.

Douglas Alexander meets people in Gaza.

A bounty of cheap carbon-free energy is lurking beneath many developing countries in the shape of geothermal power generation, and new technology will make it cheaper and easier to source than ever. The UN Environment Programme (UNEP), the Global Environment Facility (GEF) and Kenyan power company KenGen have carried out a demonstration project to make geothermal power plants cheaper to build. Working in Kenya’s geologically active Rift Valley, where high subterranean temperatures are close to the surface, the consortium uncovered wells of steam able to generate 4-5MW of electricity and one yielding 8MW. Executive director Achim Steiner said: “Geothermal is 100% indigenous, environmentallyfriendly and has been under-utilised for too long”. He claimed there was at least 4,000MW of geothermal sourced electricity available along the Rift Valley.

Potato prospects sliced Potatoes have become a lucrative cash crop for many developing countries, but this may grind to a halt because of the credit crunch and the global recession. A UN Food & Agriculture Organisation (FAO) report New light on a hidden treasure claims the potato has become the world’s number one non-cereal food crop, with global production reaching a record 325m tonnes in 2007 – more than half in developing countries. China is now the world’s biggest potato producer, with Bangladesh, India and Iran among the world’s leading potato consumers. However, this healthy south-to-south trade could falter under the recession, reducing investment in potato production, trade and farmers’ credit. “Dark clouds are gathering over prospects for the year ahead,” it warned. The FAO’s NeBambi Lutaladio wants to see action to stimulate production: “A vigorous new agenda for potato research and development… providing new market opportunities for potato producers”.

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health beneﬁts It’s not rocket science, it’s medical science: get medicines to people who are sick in the developing world and they will get better – and development will be accelerated. ‘Access to medicines’ is the mantra and the signs are encouraging, reports Tatum Anderson. toddler lies semi-conscious at the hospital in Kilifi, a small town on the Kenyan coast. Tiny, compared to the metal adult bed she lies on, she has a deadly form of malaria and has been comatose for days. Her mother holds a vigil at her bedside and members of staff say her chances are touch and go. But there’s something rather curious about the hospital ward where she lies. It’s half empty. Hospitals along this stretch of the Kenyan coast, have seen a massive drop in admissions for malaria. By March 2007 cases had declined by 63% in Kilifi alone. “This is the biggest killer of children on the coast,” says Dr Norbert Peshu, of Kenya Research Medical Institute, attached to the hospital in Kilifi. “The community in Kilifi district is very happy. They are seeing less of their children falling sick and dying of malaria.” It is a phenomenon being replayed all over Africa. Cases are down 60% in Rwanda and deaths halved in Zanzibar, says Christoph Benn, from the Global Fund for AIDS, TB and Malaria, the organisation formed to fund projects combating these diseases. “We see quite amazing results in some countries,” he says. “These are not small changes.” It’s not just malaria that’s receding. Tuberculosis has declined in Asia. Uganda has virtually eliminated Haemophilus influenzae type b (Hib),

a deadly disease that causes severe meningitis and pneumonia in very young children. And several countries are close to eliminating diseases that are virtually unheard of in the west but affect a billion of the poorest people on earth. While Lymphatic Filariasis (LF), which causes huge painful swellings in the limbs, remains a global challenge, real progress is being made and in some countries it is no longer a public health problem. And 14.5 million people have been cured of leprosy since 1985. The reasons for such improvements are simple – increased access to medicines, from malaria drugs to vaccinations. The numbers of people being treated are truly staggering – 62 million people across West Africa were treated for onchocerciasis, or riverblindness, in 2005 alone. As a result, a large number of deaths and severe disabilities have been averted. The GAVI Alliance, which works on expanding access to routine vaccinations, calculates that 3.4 million childrens’ lives have been saved. The effects of better health are obvious. But for the poorest people in the world, there are many more benefits. Ill-health and 3

In Rwanda malaria cases are down 60% and deaths have halved in Zanzibar.

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stories in development Kenya: a young boy gets a check-over prior to receiving a measles vaccination. © Dieter Telemans/ Panos

3 death can exacerbate poverty, because so few can benefit from safety nets taken for granted in the west – a free national health service, basic social services, sick pay and life insurance. Take an unvaccinated child, for instance. If they become sick, the family must pay for medicines themselves – a cost that can consume 80% of their income. They must pay for transport, hospitalisation and take time off work to provide long-term care too, especially if an illness results in lifelong disability, as Hib meningitis often does. These costs can bankrupt a household. “It can be a huge emotional and financial burden on the family,” says Lois PrivorDumm, Hib Initiative Communication Director based at Johns Hopkins Bloomberg School of Public Health. “Because the disease most often strikes poor families they are often forced to take loans to pay hospital bills, which can further spiral them into poverty.” But access to medicines does not only save lives, it can boost economies. That’s

because, by treating many neglected diseases, children become well enough to attend school and eventually become productive citizens, while adults can spend more time working. Economic rates of return of large-scale tropical disease treatments – such as Guinea worm – can be as much as 30%. When malaria was eradicated in Bangladesh, crop yields increased 15% because farmers could spend more time on cultivation. Vaccines are seen to be great investments too. Harvard researcher Dr David Bloom has predicted that rates of return on GAVI’s investments could be 18% by 2020. Newer pentavalent vaccines combine protection against five diseases in a single inoculation, and are likely to have even better rates of return. If a healthier and longer-lived population is better all round, why have the remarkable gains happened only recently? The reasons are legion – logistics problems, lack of knowledge

about good products and stigma can all affect access to medicines, according to two US researchers Michael R Reich and Laura J Frost. Often people live so remotely that healthcare is difficult. Dr Laurent Yameogo, who leads the African Programme for Onchocerciasis Control (APOC), says patients in Congo often walk 20km to the nearest clinic. But perhaps the most important factor has been the cost of medicines. Dr Zarir F Udwadia a consultant TB expert at Hinduja Hospital in Mumbai has seen this at first hand. “My patients bankrupt themselves trying to fund treatment,” he says. “The lack of funds forces these patients to quit treatment mid-stream.” The reality of the corporate world is that companies make medicines when the indications are that many patients can afford to pay for them. That way, the cost of developing the medicine can be recouped to ensure future research money for more new drugs. In the case of vaccines, manufacturers often wait until they have recouped their

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Paying the medicine bill The product development partnerships (PDPs) have inspired a host of innovative models to encourage manufacturers to create more drugs and vaccines. Today all sorts of models are being contemplated – from patent pools to prize funds. But one mechanism has already been used to finance vaccines by GAVI since 2006. The International Finance Facility for Immunisation (IFFIm) was developed in the UK with an aim to rapidly accelerate the amount of money available to buy vaccines. The idea is that if vaccine manufacturers know that there is money available to buy vaccines, they will invest in developing new products. IFFIm raises funds on the international bond markets. The so-called vaccine bonds are sold and backed by long-term, legallybinding grants from governments including the UK, to the tune of $5.3bn to IFFIm over 20 years. The bonds issued so far have attracted a diverse set of buyers from pension funds to insurance companies, and the money raised has been used to boost supplies of the pentavalent ‘five-in-one’ vaccine as well as for polio, yellow fever vaccine and maternal and neonatal tetanus. Speaking at a conference organised by Action for Global Health earlier this year, Dr Julian Lob-Levyt, chief executive officer of GAVI, said: “We have made a connection for the first time with the finance community.” costs in rich countries before offering them elsewhere. That can mean a timelag of 15 years. Sometimes drugs do exist, but they may be wholly inappropriate for poorer patients. For instance, they may require refrigeration, which is not ideal for patients living in rural villages without electricity. Ironically, some technologies that might make a drug more appropriate, are often more expensive because they are newer. There has been little incentive, also, to research new, better tools for diseases that disproportionately affect poor patients. For years patients with sleeping sickness have relied on an arsenic-based treatment unchanged since the 1940s and so toxic that it kills 5% of patients. There is no good test to diagnose leprosy, so sufferers can infect their own families before they begin showing symptoms. And while there are already many cheap medicines and vaccines it remains a huge challenge to get them to everyone who needs them and many gradually become useless as parasites evolve resistance to them. By the late 1990s chloroquine – Africa’s cheap malaria drug of choice for decades – was failing to help half of Tanzanian children with malaria.

In recent years, there has been a huge change as a new generation of players has transformed global health and unlocked unprecedented resources that were undreamt of 10 years ago. The emergence of organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, The President’s Emergency Plan for AIDS Relief (PEPFAR) and the Bill & Melinda Gates Foundation boosted funding for AIDS 30-fold to $10bn over a decade; the US has promised $39bn to HIV and AIDS over the next five years. At the same time AIDS drugs that had cost $15,000 per year in many low income countries plummeted to as low as $148 as Indian suppliers, such as Cipla, entered the market. The organisations work in two ways. Some pay for existing drugs, vaccines or insecticide-treated bednets so poor patients don’t have to – GAVI, for instance, subsidises the Hib vaccine, which costs $3.41 per dose. Others pay for research into new medicines for poorer patients. Indeed $2.5bn was spent on R&D on 30 diseases that affect poor countries by 134 funders in 43 countries in 2007. Research shows that three events sparked the change. One: the Bill & Melinda Gates Foundation with funds for health (see page 16). Two: campaigns promoting access to medicine by charities such as Médecins Sans Frontières (MSF) and Oxfam, which put pressure on pharmaceutical companies. Three: crucially, a new breed of nonprofit organisations, called product development partnerships (PDPs). PDPs have devised innovative ways to secure promising research from pharmaceutical companies, as well as paying development costs to produce badly-needed drugs, vaccines and diagnostic tools. Significantly PDP drugs are designed specifically for patients in poor countries. For instance, one PDP, Medicines for Malaria Venture (MMV), has just introduced a malaria medicine designed specifically for children. Affordable drugs are typically aimed at adults. George Jagoe, executive vice-president of global access at MMV says the organisation has assembled arguably the largest pipeline of malaria trial drugs ever, in order to ensure there are many more new drugs to come. “We have prepared the ground for an impact that will probably last for decades,” he says. And unexpectedly, PDPs have also ended up encouraging drug companies to put more money into research. Around half the pharmaceutical money circulating is there purely because of PDPs, says Dr Mary Moran, study leader at the George Institute. “There has been a real rejuvenation of the field,” she says. “Companies couldn’t

do it before because they’d have to say to shareholders, ‘I have to take $300m of your dividends to make products that make no money’.” This rejuvenation sparked by PDPs may just be the beginning. Momentum has led to lofty goals to eliminate malaria altogether and provide universal access to AIDS drugs. Recently GlaxoSmithKlein announced it would slash drug prices in developing countries and plough profits into health systems. Innovative finance mechanisms from airplane levies to bonds are being discussed worldwide. But there’s also a realisation that lots more must still be done to improve access to medicines. Money will be needed to fund large-scale clinical trials of PDP products in future years – only 28% of children have had the Hib vaccine and there is little or no research into tools for cholera and other big killers. Paul Sommerfeld of Action for Global Health, a group of 15 European health NGOs says: “We need more aid for health, and better spent.” But access to medicines won’t solve everything. More is required to prevent the spread of many diseases – thousands still contract HIV every day for instance. And increasing access to medicines will not solve the chronic shortage of healthcare workers and hospitals. That is where the focus, now, has turned.

DFID and health in Africa Increasing transparency and accountability in pharmaceutical systems on the price, quality, availability and promotion of medicines is the task of the Medicines Transparency Alliance (MeTA) which is being piloted with Ghana, Uganda and Zambia. Speeding up the introduction of new medicines and improving the regulation of drugs by harmonising the registration of pharmaceuticals in Africa countries. Working alongside the New Partnership for Africa’s Development, WHO, Bill & Melinda Gates Foundation and the Clinton Foundation. Strengthening drug procurement and supply systems through DFID’s new £148m PATHS2 Health Systems Strengthening programme in Nigeria. Improving access to essential medicines in Burundi – DFID is the lead donor working with the Burundi government. Increasing technical capacity on pharmaceutical policy in 14 African countries working together with WHO. Strengthening civil society to work with WHO and governments to increase access to medicines, active in Ghana, Kenya and Uganda. Improving the quality and reducing the price of selected malaria and HIV medicines by working with Indian manufacturers and with African partners to improve capacity to forecast the demand for these medicines. DFID is collaborating with the Clinton Foundation. Supporting drug and vaccine procurement in Africa through funding to the Global Fund to ﬁght AIDS Tuberculosis and Malaria, GFATM, UNITAID and the Global Alliance for Vaccines and Immunisation.

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billanthropy:

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“Gates releases more bugs into the world.” So quipped a wag among the world’s top techies earlier this year when retired software billionaire Bill Gates opened a jar full of mosquitos during a presentation at the annual TED (Technology Entertainment and Design) conference in California. Gates’s mosquito stunt was part of his campaign to rally support in the battle to end a million unnecessary deaths a year from malaria in the developing world. Having stepped down from Microsoft in the middle of 2008, Gates is now giving most of his time, as well as the $30bn or more that he has donated to the Bill & Melinda Gates Foundation, to doing good, with a particular focus on eradicating infectious diseases in the developing world. In doing so he has become the de facto leader of a remarkable new movement among rich business people who are dedicating their wealth and business skills to solving some of the world’s most intractable problems. We call this new movement “philanthrocapitalism”. Our interviews with many philanthrocapitalists have convinced us that, despite the current economic crisis, they mean business and are becoming a genuine force for good. For rich people to play such a prominent role in tackling society’s problems makes many people uncomfortable – Gates’s generosity has made him a controversial figure to some veterans in the fields of global health and development. Nevertheless, we believe that it is crucial that everyone from governments to non-governmental organisations to multinational businesses finds a way to partner effectively with them, so that philanthrocapitalism can achieve its

Bill Gates makes Ishaka Bashiru safe from polio at Bini Community Health post in Sokoto state, Nigeria. © Bill & Melinda Gates Foundation/ Prashant Panjiar

Gates now gives most of his time, as well as the 30bn he has donated, to the Foundation. full potential. Gates’s campaign against malaria shows why. The problem with malaria is clear, according to Gates. The vaccines and medicines to treat these ailments don’t exist simply because the people who suffer and die from them can’t afford to pay for them, and therefore no one invests in the research and development of these drugs. “How many people work on, say, brownie mix? How many people work on a soft drink?” he complains,

Is Bill Gates threatening to dominate global health the way Microsoft once monstered the computer industry? Matthew Bishop and Michael Green weigh up the pros and cons.

or bad?

to illustrate the point. “Go get 0.1% of the scientists working on erectile dysfunction to come and work on malaria and you will be making a huge contribution.” The Bill & Melinda Gates Foundation (Gates stresses that his wife is an equal partner) is already starting to turn around the battle against malaria. One thing he brings from his business success is a belief that ambitious goals can be set and achieved. Malaria, for instance, used to be classified as a ‘neglected disease’ because of the lack of money going into research to find a vaccine or a cure. But last September, Malaria No More – a coalition of governments, multilateral agencies, NGOs, celebrities and companies, catalysed by the Gates Foundation – pledged $3bn to reduce deaths from malaria to near zero by 2015, from over one million a year now. Malaria neglected no more. Gates’s interest in global health issues goes back to 1993 when he was shocked to discover that millions of people were suffering from diseases that the world had the technology to prevent or cure. He started giving his money away and lobbying others so that, before long, he says, “People would see me at cocktail parties and wonder ‘is he going to come up and talk to me about TB?’ I was the Tuberculosis Guy.” 3

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global health 3 Since then Gates’s portfolio of

Bill and Melinda Gates are equal partners in their foundation. © Bill & Melinda Gates Foundation

investments in fighting killer diseases has diversified. But, talking to Gates, it soon becomes clear that, for all his vast wealth, he knows that he cannot achieve his ambitious goals on his own. “We’re a tiny, tiny little organisation”, he told us. As a result, he has become increasingly keen on leveraging governments to do more to tackle killer diseases. In 2000 he launched the Global Alliance for Vaccines and Immunisation (GAVI), supported with $750m of his own money, to boost aid spending to prevent deaths from communicable diseases. By getting children in developing countries vaccinated, GAVI claims to have already saved more than three million lives. Yet Gates realised that by putting so much of his own money in up front he had let governments off the hook. So when he launched the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002, he made sure that his donation

Gates’s relationship with the UN, particularly the World Health Organisation, is controversial. was contingent on others chipping in too. Catalysing partnerships, with governments and also non-profits, businesses and other philanthropists, is now a core part of the Gates strategy, to ensure that his bucks generate a real bang. Billanthropy is not without its critics, however. Health professionals have repeatedly claimed that Gates’s interest in technological solutions focuses on particular diseases rather than building up the health systems of developing countries. You may get the drugs, they argue, but without the doctors and nurses to administer them they are

not going to do any good. Moreover, in running programmes to test and develop these drugs, donors such as the Gates Foundation are attracting skilled staff out of the already over-stretched health systems of poor countries, making matters even worse. Patti Stonesifer, a Microsoft veteran and chief executive of the foundation until last year, acknowledges that the criticism has some validity. “We expected to concentrate on developing drugs and so on,” she says. “We were a bunch of product developmentdevelopment people! We assumed that others would focus on getting the products out there.” That was then. Gates has learned quickly that leaving it to others while they focus on technology is not an option. “My favourite book is Disease Control Priorities in Developing Countries,” he explains in a way that sounds all too plausible “because it really goes through the system – what should be done at primary care and what should be done at secondary... The last thing you want to do is make a vaccine and not have the refrigerators.”

Gates is also adamant that he ‘gets’ the need for health systems. “Just pure sanitation is a huge thing,” he explains. “If you look at the dramatic improvement in infant mortality in the United States, it’s not when antibiotics come along; it’s when toilets and tennis shoes come along.” The Gates Foundation was also a signatory to the International Health Partnership, a 2007 UK initiative to get aid donors to commit to support rather than undermine the health systems of developing countries. Nor is it just health care systems he is getting; healthier people need work to do, and the Gates Foundation is now rapidly increasing its spending on promoting economic development, not least by promoting a green revolution in Africa. Gates’s relationship with the United Nations system, particularly the World Health Organisation (WHO), is also controversial. He doesn’t hide some of his frustrations with the UN system. “I don’t know every UN organisation yet,” he says, “though I think maybe in a few years I will.” A coalition of public health professionals used the 2008 report Global Health Watch 2 to criticise what they see as a tendency to bypass WHO, through mechanisms such as the Global Fund,

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and to reject the international consensus. Critics also worry about Gates’s legitimacy: when he is negotiating with governments, who chose him for this position of power? If he does the wrong thing, to whom is he accountable? Being free from the constraints of working according to the rules is, for some, one of the great strengths, not weaknesses, of the Gates approach. Peter Piot, the former head of the UN agency leading the fight against HIV and AIDS, is a fan of the way that philanthropists such as Gates are willing to fund risky ‘crazy ideas’ that governments would not touch. “You need a coalition, a brilliant coalition, that will use the best skills of business and non-governmental organisations and community groups, as well as governments.” Those words of praise for the role of philanthrocapitalists can also point to the most significant criticism of the Gates Foundation – that it has grown too big and too dominant in the global health sphere (much like Microsoft did in the personal computing business, mutter the critics). This was the line of attack taken by WHO’s then malaria czar, Arata Kochi, who argued that “a lot of money leads to monopoly, and discourages smaller rivals and intellectual competition”. According to Kochi and other critics, older foundations are being crowded out of the business because there’s no point in putting your money into a problem that is soon to be drowning in Gates’s dollars. No one can speak up against this new Gates ‘groupthink’, they say, because everyone has grown dependent on the his money. This charge is hard to prove or disprove. Gates insists that he would welcome more competition in taking on malaria and other infectious diseases. He also points out that there are huge global public health issues that he is leaving to others, such as tackling the millions of needless deaths each year from smoking-related diseases (a fight that is being led by New York mayor and billionaire philanthrocapitalist Michael Bloomberg). Even so, he admits that his influence on global health issues can “confuse” other participants in the field without his resources. “We need to be clear about what we want to take the lead on and where we are happy to be supportive.” He has given $105m to the University of Washington to provide independent analysis of all the work going on in global health, including that of his foundation. Gates has also committed to writing an annual letter to explain what he is up to, and how the work is progressing. The first letter appeared in January, and called on governments to honour their pledges of increased international aid

Foundation volunteer Charlene Hall helps deliver polio vaccine door to door. © Bill & Melinda Gates Foundation

that they made at the G8 in 2005. It also criticised the government of Italy for cutting its aid budget. Personally, Gates is leading by example: he is increasing the foundation’s giving in 2009 by over 10% to $3.8bn – the most that any foundation has ever given in one year. Gates is human – he, and his foundation staff, will make mistakes. We must hope that the University of Washington and others scrutinising his work will help him to pick up on these quickly and that he will admit where he has made errors. What he has achieved already is to inject not just new money, but new energy and ideas into the effort to prevent millions of unnecessary deaths. As even his critics from the Global Health Watch 2 freely acknowledge: “If ‘global health’ ten years ago was a moribund patient, the Gates

Foundation today could be described as a transfusion of fresh blood that has helped revive the patient”. Gates knows that he is taking on some huge challenges, compared to which his foundation is that “tiny, tiny little organisation”. But then again, there is an African proverb that “if you think you’re too small to make a difference, try sleeping in a room with a mosquito”. Perhaps that is the point he was making, to inspire some of the other Silicon Valley billionaires to make a contribution, when he released those mosquitoes in California in February. Matthew Bishop and Michael Green are the authors of Philanthrocapitalism: How the rich can save the world and why we should let them. They blog at www.philanthrocapitalism.net

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falling short The global shortage of trained health workers is at crisis level, argues Louise Hill. Just look at the Central African Republic. s Jonathan’s tiny, clothwrapped body is lowered into a hastily dug grave, the monsoon season starts in earnest. The soft hush of 50 or so villagers in unified mourning is drowned out as rain crashes through trees and drums on mud roofs. Five-year old Jonathan died 50km from here, a journey he and his mother had had to make to reach a qualified health worker. Their local clinic boasts a pharmacy stocked with medicine more than capable of curing the routine infections that claim so many children’s lives here. But drugs are not enough if there isn’t a health worker with the skills to diagnose and treat these illnesses in time. There are two health workers in Jonathan’s village. Neither is qualified. Welcome to life in the Central African Republic (CAR). Few people have heard of CAR yet a quarter of its population – one million people – have been affected by the constant insecurity that’s led to numerous coups in the last 10 years alone. This reign of conflict has all but destroyed the country’s health system. There are now just 43 midwives in CAR, a country the size of France – 40 of them based in the capital Bangui. More women die in childbirth here than virtually anywhere else on earth – in fact, maternal mortality has more than doubled since 1997. Of the approximately 2,900 health workers on the ground, no one really knows how many are actually qualified. Merlin, the international medical aid agency, has been working here since 2007. In one remote district where it supports 11 health facilities, nine are staffed by health workers with no formal qualifications. Some filled posts left vacant by health workers forced to flee the fighting, others have years of hands-on experience. The need now is to anchor any knowledge in much needed technical skills. So as well as renovating dilapidated clinics, ensuring drugs are available and educating villagers in basic hygiene and nutrition, the agency ensures health workers are regularly supervised and trained. Olga Yetikoua is one of five Merlin nurse supervisors working to improve standards and morale. She travels

Villagers observe a vigil to mourn the death of five-year-old Jonathan. © Frédéric Courbert

between three rural health clinics every week, training around 30 health workers as she goes. Having spent most of her life working in the capital, she was amazed to discover how little the health workers knew. A year on change is evident: “It’s staggering to see health workers who’ve been doing this for years – decades even – understanding for the first time how to heal people,” she explains. Africa, which shoulders over 90% of the global neglected disease burden, needs

at least one million more health workers to deliver essential care. But it’s fragile nations like CAR, sliding in and out of crises, where urgent attention and action is most needed. Liberia had approximately 200 doctors before civil war consumed the country for 14 years. Barely half remained when peace was declared in 2003. Five years on, a lack of health workers remains one of its major challenges, starkly

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midwives and doctors to come through the ranks. Health workers at their posts now must be trained, supported and motivated to give young children like Jonathan a chance of survival. “We have worked without equipment and support for such a long time,” explains Joel Ngamba, 28, a trainee health worker from CAR. “Now Merlin is training us, we’re more confident of being able to save people’s lives. And for the first time, we don’t feel so alone.”

demonstrated by the Minister of Health, Dr Gweningale, who sometimes spends his weekends working as a surgeon in the hospital where he trained. South Sudan, too, is mired in a health worker crisis, played out against 20 years of civil war. Here, there is only one doctor for every 100,000 people. Fragile nations like CAR, DRC, South Sudan and Ethiopia have some of the world’s worst health indicators but the research shows that more people die from disease post-conflict than are actually killed in the fighting. To be truly effective, any emergency response to a health crisis must take a long-term view. Strengthening a health system from the outset with the training, retention and recruitment of health workers must be made a priority by international donors. Long-term funding is also vital. Last November, 20 doctors qualified in Somalia, the first to graduate for 18 years. But the people of CAR cannot afford to wait for student nurses,

As part of the Hands Up for Health Workers campaign, calling attention to the shortage of four million doctors, nurses and midwives in the developing world, Merlin is hosting a series of photographic exhibitions featuring the work of Africa-based Panos photographer Frédéric Courbet. MORE INFORMATION www.handsupforhealthworkers.org www.merlin.org.uk

“I was really shocked when I first saw the standard of health workers here. Many of them didn’t even know the basics.” Olga Yetikoua (pictured above), Merlin nurse supervisor, Nana Gribizi district, the Central African Republic

There are 43 midwives in a country the size of France and 40 are in the capital.

Everyone likes Olga. It’s impossible not to. Her face is open, friendly and usually creased in a smile; an ideal mask for a driven, no-nonsense trained midwife. She’s a perfect candidate to help improve the standard of health workers in Merlinsupported clinics in the remote district of Nana Gribizi. But even she didn’t expect to be met with such a profound picture of neglect. “I’ve spent most of my professional life in the capital. Coming here, I realised for the ﬁrst time that my country doesn’t even have the minimum level of healthcare anymore. “When we arrived, the health posts had pretty much been abandoned by the health workers, the government, the community – everyone. I turned up at one health post and no one was there. Not even the head of the clinic. All the staff I spoke to were demotivated: they hadn’t been paid for months. The ones who’ve been trained – even a little – hadn’t put any of their knowledge into practice for years. How could they? They had no drugs, no equipment. So even basic things, they’d forgotten. We literally had to start from zero.” Olga’s job is to look after three of the 11 health facilities Merlin supports in Nana Gribizi. In total, she oversees the training of around 30 health workers. In six short months, the difference she’s helped bring about is enormous. “Our posts are seeing maybe 240-300 patients every month now. Before we’d be lucky to see 20. Every facility has drugs, which are free to patients. There are medical cards, equipment, newly built clinics – it’s unrecognisable. The difference in the health workers is inspiring. They understand what they’re doing so much better. It’s staggering to see health workers who’ve been doing this for years – decades even – understanding for the ﬁrst time how to heal people.” While progress is being made, there is still a tremendous amount to do in the Central African Republic. Training rural health workers is key. Developments 45

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drug trade China has embarked on a major methadone replacement programme which not only takes addicts off heroin, but dramatically reduces the risk of HIV infection. Report by Louise Tickle. 22 I Developments 45

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Heroin addicts shoot up in a back street of the border town of Ruili in China. © Nic Dunlop/Panos

hen you have, at a conservative count, 600,000 intravenous drug users spread across a country the size of China, the risks of an HIV and AIDS epidemic escalating fast are considerable. Facing up to the sheer scale of the problem however, is an important part of mitigating, if not solving, an impending health disaster. And China, says a significant body of experts, has been very good at taking the bad news on the chin and supporting international efforts to help it manage the progress of the disease. This management has taken the form of what is known as ‘harm reduction’ – which, translated, means needle exchanges and methadone replacement programmes. The reach of the initiative (part funded by DFID) has been remarkable, says John Leigh, DFID’s Millennium Development Goals team leader in China, particularly given the enormous scale of the country. “By 2007, 88,000 injecting drug users had been enrolled in the methadone programme, of whom 52,000 were still on treatment,” he says. “This service was being provided through 397 clinics in 22 provinces. This is impressive coverage, given that the programme was only approved for nationwide rollout in July 2006.” Methadone is taken orally, eliminating the need for a heroin user to inject. It also helps drug addicts to come off heroin

without the need to go cold turkey. However, despite the painstaking collection of data to provide a strong evidence base for the effectiveness of methadone replacement in fighting the spread of HIV and AIDS, it remains controversial for certain countries – the USA, Japan and Russia most prominent among them. On a wider international stage too, it turns out that the politics involved in getting agreement for an official rollout of a controlled drug such as methadone has been extremely contentious. Countries’ own police and border control authorities tend to warn of the dangers of governments importing drugs, and are thus at odds with their colleagues in healthcare agencies who urgently want to prevent blood-borne diseases, including HIV and AIDS, from running rampant through vulnerable sectors of the population. Sanctioning – and subsequently funding – state officials to hand out clean syringes and needles has also proved a hard nut to crack. It can be perceived as a government facilitating drug addiction. In the US, for example, this led to a long-term ban on federal funding for needle exchanges, though with the new administration, that position has just changed. Opposition to needle exchanges is a great pity, says Leigh, as getting an intravenous drug user – effectively a criminal – to knock

on the door of a government clinic and ask for methadone replacement treatment is rarely how contact is first made. A softlysoftly approach is the most effective way of persuading an addict to start to engage with healthcare workers. First, get them to inject more safely by providing clean needles and syringes, then require them to bring back their dirty equipment before handing out more. Gradually a relationship of trust is built up. After a while, a drug user might be ready to replace his or her heroin hit with methadone. Professor Scott Burris of Temple University in Philadelphia specialises in the relationship between law, health and vulnerable populations. He says that over the past decade, China has made great strides in coming to terms with the philosophical and logistical challenges involved in introducing methadone replacement for its large number of drug addicts. Officials have not accepted the need for needle exchanges with the same enthusiasm. Nevertheless, he observes that the national AIDS authority’s pragmatic approach to free methadone treatment suggests that those at the top have accepted the evidence that harm reduction measures are a cost-effective way of reducing the impact of HIV and AIDS. “This is due in no small measure to the advocacy and funding given by DFID and the Global Fund (to fight 3

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global health 3 AIDS, Tuberculosis and Malaria) in funding the original pilots in Yunan and Sichuan province, as well as further money and support from a range of other agencies,” Professor Burris says. “At the beginning, nobody had ever done this here, therefore those (officials) involved were taking a huge risk,” points out Qiao Jianrong, DFID’s health adviser in China. “The good thing is that given the very decentralised system here, you could get local people piloting ideas with grant support while the central authority kept one eye open and one eye closed.” Persuading officials to promote this kind of programme, she says, cannot be done initially by citing the human rights of intravenous drug users. “It is best done by making the public health argument, then eventually officials will change their attitudes and perceptions, and understand and respect their rights better. Looking back now, it is amazing how far China has travelled in harm reduction from the policy and regulation perspective. “Importantly, it also offers an example to the rest of world of how ideas (on harm reduction) can be transferred from one country to another at a relatively small cost. Here, those ideas are now being replicated by the government itself to achieve a nationwide methadone replacement programme led by the Chinese AIDS authority.” Worldwide, however, observes Professor Gerry Stimson, executive director of the International Harm Reduction Association, this approach is massively under-resourced. “These measures save lives and money, as the cost of an intervention is far less than the cost of treating an infection,” he says. “But it needs 20 to 30 times more money than is currently spent.” A political fight is being waged right now in Vienna around whether the term ‘harm reduction’ can be included in the UN declaration of intent, which is published every 10 years. Russia and Japan have explicitly opposed the phrase, and despite the new Obama regime, the US is also taking a hard line. These three nations have been backed by a number of others, but interestingly, countries don’t always practice what they preach. Indonesia, which has also opposed the use of the phrase, plays host to a large DFID-funded harm reduction programme. So does India, which has taken the same stance. Other

The methadone programme is now active in 397 clinics in 22 provinces. © Ping Gao\DFID

governments which internally fund harm reduction measures have stayed silent. All of which makes for a frustrating experience for those promoting adoption of harm reduction as an internationally endorsed principle – a principle, which, they say, has been proved in practice to save lives. DFID’s Minister for International Development Mike Foster recently paid a visit to one of China’s biggest methadone treatment centres in the sprawling city of Chengdu. Following conversations with drug users who had progressed so well on the methadone programme that they had been trained as drug educators themselves, the minister says he was impressed. Seeing the human face of the drug treatment programme may, it turns out, make an important difference to whether the UK funding continues after DFID’s bilateral healthcare money for China runs out in 2011. “My instinct is that we will have a change of policy (on funding for China) and that might include active projects like this,” says Mike Foster. Success in these programmes is not measured in terms of people coming off drugs altogether. Many will relapse and leave the programme, and those who continue are expected to carry on taking methadone indefinitely. But since the HIV transmission rate among needle-sharing drug users is extremely high, the more people who

If we can control the spread of HIV among drug users it’s unlikely to gain much further ground in China.

are prevented from sharing needles, the greater the number of HIV infections prevented. John Leigh cites a survey of methadone patients that shows those having injected within the last month had dropped from 76% to 11%. “Infection rates among injecting drug users have not sky-rocketed, which would be expected without any harm reduction programmes in place,” Leigh says. “In contrast, prevalence among men-who-have-sex-with-men is now increasing at an alarming rate, reflecting very low rates of condom use during anal sex. However, if we can successfully control the spread of HIV among drug users, it is extremely unlikely that HIV will gain much further ground in China. The patterns of sex work are not such as to be able to fuel an epidemic. The epidemic here is still predominantly driven by injecting drug use.” One beneficial spin-off of the methadone and needle exchange programmes, he points out, is that many drug users not currently enrolled in either of the official harm reduction programmes have been made aware of the risks and are taking steps on their own to avoid needle sharing. The human reality of this effort is that people who were once society’s pariahs are now able to hold down jobs, rejoin their families and end the criminal behaviour they once pursued to fund their addiction. Fewer babies will be born with HIV, and fewer children will lose their parents to infectious diseases. Those working in the sector believe these are good enough reasons to include a commitment to ‘harm reduction’ in the UN’s statement of intent, which will set the tone for how the ravages of HIV and AIDS are managed internationally over the coming decade.

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global health © Squint/Opera

the great

stink

150 years ago, the scourge of untreated sewage made living in London a risky business. Clean water and sanitation are critical for good health. eople in the developing world get sick far more than people in richer countries. And die far younger. But improving their health is not only about effective health systems delivering the right care and medicines at the right time. It’s also about preventing people getting sick. And that means

good sanitation and clean water. In London in 1858, the year of “the Great Stink”, the stench from untreated sewage in the Thames was so foul that windows in Parliament had to be sealed. Cholera outbreaks between 1848 and 1866 claimed the lives of 30,000 people. The medical orthodoxy at the time was

that cholera spread through the air. No one suspected the water until a local doctor, John Snow, isolated an outbreak in Broad Street, Soho, to one well. Snow removed the handle from the pump and saved many lives. His research with clergyman Henry Whitehead persuaded the authorities that cholera was spread in contaminated water, which eventually led to the creation of 1,240 miles of sewage tunnels. Cholera, in London, became a footnote in history. Today more than half the population of developing countries still lack basic sanitation. A billion people have no toilets, nearly as many have no clean water. The local river can be laundry, bathroom and toilet. As these images illustrate, this would be unthinkable in rich countries. At any given time, half the hospital beds in the poorest countries are taken up with patients with waterrelated diseases. Dirty water and poor sanitation kill 5,000 children every day. Women and girls pay a particularly heavy price – girls often don’t go to school because there are no toilets to use. Many avoid eating or drinking all day as they can only relieve themselves when it’s dark. Their health suffers. Esther Akales used to walk three kilometres every morning and carry 20 litres of water home in a jerrycan on her head. In her village in northern Kenya, diarrhoea and typhoid was common. Then the villagers helped lay a pipeline to bring clean water to their community – and things changed. “Our health is more vibrant now we use tap water,” she explains. “Since the water is nearer, we have more free time to weave baskets.” Failing to invest in clean water and sanitation undermines the fight against poverty – and keeps the world sick.

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global health

OPINION

head first Mental health doesn’t just affect people in rich countries, it’s a global issue and makes poverty worse. We need to make it a priority, argues Professor Rachel Jenkins. e all know that poor physical health is a barrier to the social and economic development of poor countries. This is why so much attention has been given to tackling infectious diseases – particularly malaria, HIV, cholera and infant diarrhoea. There is also concern about non-communicable (non-infectious) diseases such as heart disease, diabetes, stroke, and malignancy, but investment in these areas has, until recently, been relatively low in poorer countries. The argument is that these are largely found in rich populations. However, there is now a growing understanding of the importance of non-communicable diseases in poor countries and populations, so more attention is now being paid to them. But there is a glaring omission. Mental illness. This vital area of non-communicable disease is still almost completely neglected – left out of the dialogue between international donors and governments of low income countries. This is seriously bad news, because good mental health is essential if people are to participate effectively in society and the economy. Mental disorders are universal to all populations and countries. On average, common mental disorders (largely depression and anxiety) affect around 10% of people; psychosis affects 0.5-1%; dementia in people over 65 is around 5% – and there are increasing numbers of younger HIV related dementias; and alcohol abuse impacts 5% or more. Mental disorders are disabling. They can last a long time – especially if they are left untreated. And they influence the onset, progress and outcomes of both infectious diseases such as HIV and non-infectious conditions like diabetes – they influence the core priorities of maternal and child health. Mental disorders are not seen as major killers, but the fact is that they significantly increase the likelihood of premature death – not only from suicides and accidents – but also from infectious,

respiratory, cardiovascular disease and malignancy. The infant children of depressed mothers, too, are more likely to die from infectious diseases. Mental disorders play a significant role in perpetuating the cycle of poverty in a variety of ways. Production is lost through suicide and because people are simply unable to work. And family members cannot be fully productive either when they are caring for people with mental illness, and/or their dependents. Productivity is lost, too, when people can work, but because of their illness are unable to work very effectively.

Children with mental disorders often fail at school, which leads to unemployment and illness in adult life. Parents with mental illnesses have children whose emotional, intellectual and physical development is damaged. Mental disorders are made worse by conflict – pre-existing illnesses become more severe, and new disorders precipitated. Mental illness may even contribute to the eruption of conflict – where violence is fuelled by substance abuse or adolescent emotional and conduct disorders. Despite considerable efforts by WHO to raise the profile of mental health (for example the WHO 2001 Health Report), and, despite the known burden of disease and the links between mental and physical disorders, health sector reform strategies in low income countries rarely include integration of mental health concerns. Mental health cuts across a number of sectors, including, finance, industry and employment – as well as education, social welfare and criminal justice, but the health sector needs to make significant investment. At present there is far too little attention paid to mental health needs, and the health infrastructure needed to address those needs in low and middle income countries. On average there is only one psychiatrist for every million people in low income countries – in Malawi there is only one for over four million. And the situation is getting worse, because recruitment is not keeping pace with retirement, death and the brain drain. As a result, psychiatric services can only deal with a miniscule proportion of those in need. Most people with mental disorders need to be seen and treated in primary care, but the general primary care health infrastructure in developing countries is fragile. It has been weakened by HIV and AIDS, conflict, the lack of continuing professional development, lack of support and supervision from the district level, lack of transport and lack of access to medicines. Mental healthcare is not a luxury. Poor people deserve treatment for mental disorders as well as physical ones. But if they are to get access to decent mental health care, then we need to make strengthening of the primary care system a real priority, and to ensure that mental health is properly integrated into the primary care delivery system. Professor Rachel Jenkins is Director of the World Health Organisation Collaborating Centre at the Institute of Psychiatry, King’s College, London and Director of International Affairs for the Royal College of Psychiatrists.

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Platform2 is a global volunteering experience funded by DFID and run by Christian Aid, Islamic Relief and BUNAC (British Universities North American Club). It’s for 18-25 year-olds in the UK who wouldn’t otherwise be able to afford to volunteer. It aims to send 2,500 young people to work in a developing country between 2008 and 2010. Groups of 10-15 volunteers go away for about 10 weeks – this year to South Africa, Ghana, Peru, India and Nepal – to construct community buildings, care for and teach children, do ecological work and assist in HIV clinics. All volunteers are supported when they return home to reflect on their experiences and share them with others. Three volunteers spoke to Paul Northup.

willing volunteers MUNA SHEIKH, 22, a law student from east London, spent 10 weeks working in a community in Ventanilla, Peru. I’d always wanted this Volunteering overseas is something I’ve always wanted to do. You see so much going on in England and you can’t really do anything about it. You protest and you want things to change, but it’s not within your power to change anything. I also used to care for my bed-bound brother but I felt I couldn’t do anything for him. I wanted to get out of the country and do some good. So I grasped this opportunity with both hands.

My parents were worried I’ve got seven sisters and two brothers – all of them have stuck to the convention of getting married at 19 and so on. I’m the one to break the rules. They’ve never stopped me pursuing my dreams. But they were a bit hesitant and worried about what could happen when they weren’t there to protect me.

We all chipped in The school we were working at was for three to five-yearolds in Pachacutec, a village in a very dry, mountainous and poor area. The kids would take lots of days off school, or not eat when they were there, because they couldn’t afford their meals

even though they only cost £4 a year. We all put one week of our allowance aside and paid for a year’s meals for the four kids with the worst attendance.

The days were long From 8am until 1pm we worked on building the new toilet block. Then we’d come home and have activities – stilt-walking and guitar playing – from 3 to 6pm with another group of kids. Then we’d have dinner in our homes and then evening activities with the community – and Spanish lessons.

We want to go back

The people were so amazing – so warm, so welcoming. That’s why so many of us want to go back. I’ve been calling them every week. They talk so highly of all the things we’ve done for them. We think it was nothing, but they think it’s amazing that we took time out to do something for them.

at Nottingham University. I’ve always wanted to go into human rights and this experience has confirmed that. I’ve also caught the volunteering bug. Once you start you can’t stop. Because it really does open your eyes and it changes you as a person – you appreciate so much more. Were it not for Platform2, I wouldn’t have had the opportunity to go and see for myself.

You could see the potential I was shocked to find that young women who fell pregnant were not allowed to continue in education and over-16s had to pay. You could see the potential of these kids and yet because they had no means to carry on, they did nothing.

We changed the image

It opened my eyes

There weren’t enough tools for everyone to work on the toilets at the same time, so four of us started to work on the park in La Flores where we were living. There was a wall facing you as you entered the village with graffiti of a man with a bomb and one with a gun. It gave you an image of the community. A shame, because they were a lovely, warm community. It took a week to scrape off the paint! One of the volunteers was a graffiti artist and he made a lovely ‘La Flores’ sign. It gave a different feel to the area. And then we remade the park for the kids.

I’m studying for a law degree

I’m more independent If you’d asked me a year ago if I’d be living away from home now, I’d have said ‘no’. But when my parents saw me look after myself for 10 weeks away, things changed. I asked them if I could move away when I returned and they agreed! I think it’s made them trust and respect me a lot more.

Muna Sheikh – the experience changed her as a person.

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Platform2

SHAUN WELCH, 22, a welder and artist from Birmingham,

spent 10 weeks working in the Volta region of north-east of Ghana on a conservation and construction project. Right up my street

I was torn between my life as a welder and as a performer. I was looking for something to do and I’ve always wanted to travel the world. So when I saw the Platform2 ad I thought, “that’s right up my street.” I’d heard about this sort of thing, but never thought I’d have the chance to go. I felt I had to do it. Like it was a calling.

It was overwhelming I’d only been to Spain and France with school before. I was really excited, but wanted to go without any expectations. I’ve got a lot of streetwise friends and so I know that ‘the hustle’ is universal. But from the moment the airport taxi drivers flocked around us on arrival, it was overwhelming!

I’ve never seen rain like it We were based in a remote village called Bledi Chebi, an hour and half’s drive from the nearest town, and we worked in Bledi Begomme, a village about an hour’s walk away. We worked at the foot of the Afadjato mountain. We cleared forest, using the clearings for storage and the wood for building. We worked on the reserve, setting snares and traps, and monitoring the species and the health of the forest. We did a lot of physical labour: laying roads and paths, building sanitation blocks. What was challenging was the heat. It was so hot. And I’ve never seen rain like it!

You feel you’ve given them something Once you’ve built a path you can see that path being used and you feel like you’ve given something to the community because now people can walk safely from A to B. And I loved doing the small things, like communicating with the villagers themselves – especially the kids. We’d go into the schools and teach them – just basic maths, English, geography and history.

Shaun Welch discovered another reality.

It was mindblowing Our village was at the foot of a ridge, panning around – almost like you were inside the mouth of a volcano. From the top of the ridge you could see over the Volta region. On the slopes, it was like jungle, with waterfalls, leaves as big as my body and trees as tall as tower blocks. Dirt roads get destroyed in the rainy season. Cars were breaking down every day. Also, rain washed down the mountain, flooding the maize fields and eroding buildings at the foot.

It’s made me sharper I feel like it’s sharpened the tools I already had. I’ve always been focused on offering my services and doing what’s right. Now that I’m back I hope what I’ve been through can help people in street gangs I grew up with. A lot of my friends only live their lives like they do because they don’t know anything else. And I always say, “you can’t be somebody until you’ve experienced something”.

It changes you I think for someone who’s never had any experience like this, Platform2 will change who they are. This sort of thing would change them and their perception on life – it would open their eyes to the fact that our western way of life isn’t really reality. There’s another reality out there that people are living with all over the world.

We’re in this together Over there everybody was connected and out to help each other get by. They were all in the same boat. Here, everyone is trying to get into their own boat and sail their own course. Over there they know that if they don’t build a big boat together, they’re not going nowhere. The people of Bledi Chebi showed me what the true essence of community is and I think that people could do with connecting to that – that sense of common unity.

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CHARLOTTE SINGLETON, 20, a volunteer youthworker from Manchester, spent 10 weeks teaching in a school in Himachal Pradesh, northern India. I never thought I could I got expelled from school when I was 13 for basically being naughty and stuff. I never liked school and so I was causing trouble. I didn’t think that people like me could do something like this. I thought it was just for people who were rich. I started reading stuff. And, funnily enough, that Paul Merton in India series was on TV. So I watched that. I’d never been on an airplane before. The farthest I’d been was Wales.

I was shocked Everything was so different. There was nothing that was at all the same as here. What shocked me was the poverty. There were kids, naked on the streets and stuff. You wanted to help them. But you can’t help everybody. I found this really difficult at first.

I can’t do that! I was teaching kids English in a school. At first I was, like, “Teaching? How am I going to teach?” But the kids didn’t really know any English, so it was just the basic things. We started

Charlotte Singleton (left) on a life-changing journey.

with the alphabet and then the days of the week. Just before I left, they were starting to write sentences.

I loved them The school had 22 kids from five to 12 years old. I loved them and I miss them so much. And the kids loved me. Even the naughty ones. They used to shout, “Sharlie Gi, come and play.” (‘Gi’ means something like ‘nice person’.) And the wider community think it’s brilliant what Platform2 is doing, because school attendance has shot up.

It was so beautiful You’d look out of your window in the morning and, even if you were missing home, the scenery would put a big smile on your face.

You can see the difference I definitely felt like I was making a difference in the school, and even just playing with the kids outside. They were naughty because they had nothing to do. But if somebody puts the time and effort in you can see the change you’re making.

Now I’m another person It’s definitely made a difference. I’ve already applied for another VSO opportunity. I’m doing awareness-raising events with Platform2. And when I’m speaking to my friends I’m, like, “You don’t need that.” We spend our money on material things we don’t even need. Whereas in India they’ve got nothing and yet they’re so happy. It’s made me look at life in a different way. It’s definitely given me more confidence. I speak about things now. I never used to speak up about anything. It gives you something to be passionate about. It’s made me passionate about wanting better outcomes

for all young people, not just in India but in England as well. I didn’t like school, so I thought “these kids aren’t going to like school.” But it’s made me think: “What the hell were you doing?” Because these kids in India love to go to school. They walk, like, five miles up mountains just to get to school.

You can do it too I’d tell anyone to do it. I’d even help them fill the application form in! I’ve got eight more people to apply already. A year ago I’d never dreamed of anything like this. That’s why I’m saying to people: “If I can do it, you can do it as well”.

MORE INFORMATION www.myplatform2.com

Charlotte (back row far left) loved the children she worked with.

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The story of 12-year-old Mansour from Afghanistan, who found himself in Copenhagen, thousands of miles from his family, prompted two brothers to set up a social networking site with a difference. Julie Ferry reports.

reunited A

ccording to the UN Refugee Agency (UNHCR) over 37 million people were classed as refugees or internally displaced people in 2007. Aside from the challenges of day-to-day life they face, many also live apart from their family, not knowing whether their loved ones are alive or dead. Refugees like Mansour, who at the age of 12 fled Afghanistan and the Taliban with his family, only to find himself separated from them and alone in Copenhagen, Denmark, after an arduous six-week journey across Europe. It was Mansourâ&#x20AC;&#x2122;s story that inspired brothers Christopher and David Mikkelsen to set up Refugees United, an organisation that aims to help refugees reconnect with their loved ones. By harnessing the global reach of the internet, the newly-launched NGO has created a website, www.refunite.org which encourages refugees to upload an anonymous profile, describing details such as body markings, initials or nicknames that only family would recognise, enabling those searching for each other to make contact. Mansourâ&#x20AC;&#x2122;s story begins in Kabul in

Copenhagen

Moscow

Stavropol

Kabul Peshawar

2000 when he was poised to escape the Taliban and head to Peshawar, Pakistan, with his five siblings and parents. The family had paid a trafficker to assure their safe passage, but the day before the scheduled departure, they were told that there was only one vacant seat on the bus, which had to be taken by one

David and Christopher Mikkelsen, founders of Refugees United.

of the family. As the eldest, Mansour volunteered and agreed to meet them at a later stage. After a long journey across Europe, including spending two weeks hidden beneath floorboards with 10 other refugees somewhere in Russia, Mansour arrived in Copenhagen, alone and afraid. He was immediately picked up by the authorities and began the process of seeking asylum, all the time waiting for the imminent arrival of the rest of his family. They never came. Five years later, David Mikkelsen met Mansour through his role as a teacher at a school for young refugees. Mansour told him his story and of his hope that one day he would find his family. David immediately offered to help. Several monthsâ&#x20AC;&#x2122; research, with help from Christopher, ended up largely in dead-ends, so the brothers decided that Mansour should travel back to Peshawar to try and find some answers. Back in Peshawar, Mansour recognised the trafficker who had sent him to Denmark and confronted him. With the help of bribes, he managed to discover that his younger brother Ali had been sold into slavery in Stavropol, Russia,

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Mansour (right) and Ali, temporarily reunited.

not far from the Chechen border. He was given a phone number and, back in Denmark, the Mikkelsens and Mansour began calling the number. They soon discovered it was just a pay phone in the middle of a busy bazaar. However, after two weeks of calls, an elderly man answered the phone and recognised the description of Ali, and gave Mansour another number. A woman picked up, said that she knew Ali, promptly passed the phone to him and more than five years of silence was broken. Their joy was short-lived however, as Mansour discovered that Ali was living as a stateless person, working 16-hour days, unable to escape. Through another bribe Ali’s ‘owner’ arranged for the brothers to meet in Moscow. Finally, on 7 October 2005 they were reunited. “To try and describe the situation is nearly impossible,” says David, over three years later. “But there was palpable tension in the air, followed by relief and then ecstatic joy. The hairs on the back of our necks were standing up and tears flooded all of our eyes.” Mansour and Ali spent the next two days holed up in a hotel room catching up on the events of the past few years

until, on the third day, Ali had to return to Stavropol. “Mansour and Ali haven’t seen each other since Moscow but life has completely changed for both of them,” explains David. “Knowing there is family out there makes you feel better. Mansour called me the day after we returned and said that he had slept for eight hours in a row the night before – the first time he had done that for nine years.” The story could have ended there but the seeds for Refugees United had been planted. “We began discussing why no one had created a system, capable of transcending borders, barriers, conflicts and bureaucracy”, says Chris. “A personto-person network of hope, providing refugees and the NGOs assisting them with a multilingual, simple and streamlined family search engine, programmed to cater to the needs of people with low computer literacy but with a high degree of security and anonymity.” The Mikkelsens had long flirted with the idea of social entrepreneurship, so when the idea for the website came along

they say it was “too right” not to pursue it. They also knew that if they committed themselves they would have to see the project through. “You cannot do such a thing as Refugees United half-heartedly – that would be paying a huge disservice to the people we seek to aid.” They managed to secure funding for the fledgling organisation, which was found through the Bitten and Mads Clausen Foundation, The Way Forward and the Kirsten and Peter Bangs Foundation. They keep the organisation’s core costs to an absolute minimum and outsource most of their needs to high-profile partners like FedEx and others, who provide logistical, IT and communications support. “We don’t ask businesses for money, we ask them for what they do best. So, when we approached FedEx we asked them to help us send out material to all the refugee camps around the world, so they become part of the solution,” explains Chris. One of the keys to the website’s success is spreading the word: David and Chris have spent many months forging links with NGOs and refugee groups like the Congolese in Sao Paulo and the Burmese 3

Refugees United is a person-to-person network of hope.

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refugees 3 Diaspora in Thailand, trying to raise awareness. Maintaining anonymity is a major factor for most refugees, another conundrum to solve. “We advise everyone not to register with full details,” says David. “There is no need to provide information about your actual, physical whereabouts. There is no reason to give out a phone number. Except, of course, if you are like Mansour and have nothing to fear.” And what about those who do sign up

to refunite.org and ultimately receive bad news? “We worry about the plight of all refugees and have to take into consideration that some may encounter a harsh truth. So, the question remains, is it better to live in blind faith that somewhere your family is alive, without searching for them, or to begin the quest to be reconnected with missing loved ones and possibly discover a sad reality? This is not a question we can answer for

anyone,” says Chris. As for Mansour, David maintains that everyday he is getting closer to finding the rest of his family. “As soon as just one of his family members hears about refunite.org he will find them. Of course, there is the horrible possibility that they may be dead, but if Mansour and Ali are alive, why shouldn’t they be?” MORE INFORMATION www.refunite.org

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Rat ‘floods’ are a seasonal threat in rural Bangladesh. But a rodent research programme is starting to stop rats in their tracks. Steven Belmain reports. Bubonic plague – and 60 other diseases The most famous of all rat-borne diseases is bubonic plague – as in ‘the Black Death’ which swept through Europe in the 14th century. But plague is not consigned to history – it continues to be a problem today, where the disease persists in certain areas of North and South America, Africa and Asia, often within poor rural communities. Although the plague is readily treated with modern antibiotics, several hundred people continue to die from plague each year, particularly in Africa. Plague is not the only disease carried by rats – there are at least 60 more. Leptospirosis, lassa fever and typhus continue to devastate people’s lives, and often go undiagnosed and thus untreated in developing countries.

rat race T

he Chittagong Hill Tracts (CHT) in south eastern Bangladesh are among the most beautiful and untouched parts of the world. These foothills of the Himalayas stretch from Mizoram State in India, through the CHT and into Burma. The mountains here are covered in lush tropical jungle, and a large proportion of this forest is comprised of bamboo. Bamboo underpins the livelihoods of hill tribe communities – it is a major source of income through export to the rest of Bangladesh and beyond. Unlike the majority of plants, most types of bamboo do not flower every year. Some, remarkably, only flower every 50 years or so. The flowering cycle follows a predetermined ‘internal clock’ which means that, when the timer goes off, all the bamboo of that particular species starts to flower. As a result, every so often, entire forests of bamboo in the Bengal Bay Region (India, Bangladesh, Burma) begin to flower at the same time – an ‘event’ which can spread over two years or more. But this botanical curiosity has darker, consequences – the last major

flowering in 1958, for example, led to a large-scale food crisis and famine in Mizoram, India. This, in turn, inflamed underlying unrest and sparked a 20year civil war against central Indian authority which ultimately led to the creation of Mizoram State in 1987. Famine and bamboo flowering go together because the flowering sets off a chain reaction leading to ‘rat floods’. Once the process starts, rats living in the forest are suddenly provided with a lavish feast in the form of large and nutritious bamboo seeds. This huge increase in food supply causes a rat population explosion. But the supply of bamboo seeds eventually runs out, and the rats have to look elsewhere for food. So they leave the forests, eating everything else they can find, causing large-scale devastation to field crops planted by local villagers. This in turn leads to food shortages and regional famine. At the time of writing this is precisely what is happening in the Chittagong Hill Tracts. The bamboo has begun to flower, there has been a rat flood and local people are short of

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film festival

3 food. They have been provided with emergency aid, but this does not deal with the underlying problem. Rats. However, help is at hand in the form of a programme – part of DFID’s Research into Use (RIU) initiative – which aims to develop ecologically-based rodent management (EBRM) strategies. The aim is to produce a sustainable, costeffective means of dealing with rat floods which is easily implemented by farmers and communities. The Rat Management for Rural Communities project, started in 2008, builds on six years of research activity in Bangladesh. Since 2002, research on rodents – their biology, the damage they cause and prospective management – has been carried out with the help of rural communities in the Comilla region. They work in partnership with organizations which include AID-Comilla, the Bangladesh Rice Research Institute, the Bangladesh Agricultural Research Institute and the Natural Resources Institute of the University of Greenwich in the UK. This project is not only helping farmers in Bangladesh, it should have worldwide application. Rats are a global problem, affecting rich and poor alike. They eat our crops, contaminate stored food, damage our buildings and possessions, and spread dangerous diseases to people and livestock. And this is most acutely

experienced by those least able to manage it – the rural and urban poor. The reason we need a scientific, evidence-based programme for EBRM is because knowledge about the effect rats have on health and agriculture tends to be anecdotal. Unless we get an accurate understanding of the damage rats cause and how much this costs, it is difficult to convince people to invest in rodent control. Our monitoring activities in villages showed that rodent damage was common and considerable. Rice growers reported that rats ate up to 17% of the rice in the fields, and, after harvest, each farming household lost upwards of 200 kg of stored rice a year. There was also significant harm (10-50%) to other fruit and vegetable crops.

Beyond this, rats damaged house walls, personal possessions, roads and fields. And one in 20 households reported that, in any given month, members of their family had been bitten by rats in their sleep. “We didn’t realise how much the rats ate,” one villager said, “but now we do, since seeing the difference the community-based rat management programme can make.” But how to solve the rat infestation? Traditional methods of control, such as poisons, rarely work. They are often not used properly, and aren’t adapted to local conditions. At the same time, local awareness and knowledge of alternative means of rodent control is often low. The result is a kind of fatalism – people believe they will just have to put up with the problem.

Householders build bamboo fences around their fields, interspersed with traps – forming an effective rat barrier. © Steven Belmain

Putting research into practice The Research Into Use (RIU) programme aims to provide poor people, whose livelihood depends on natural resources, with access to knowledge and technology that will improve their lives. RIU is funded by DFID and takes previous and ongoing research and develops means by which its findings can be put into practice in the field. The EBRM programme in Bangladesh is a case in point. RIU works in four key regions of the world, identified because they have the most potential for large-scale improvements for poor communities. These are: Asia, east Africa, southern Africa and west Africa. MORE INFORMATION

www.researchintouse.com

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However, this mindset can be changed when people learn just how much rodent damage is costing them and their families, and when they are equipped with credible, effective tools and strategies for controlling rats. This we see happening in Comilla. Our experience points to three essential steps in developing an ecologicallybased rodent management strategy. The first is to find out what kinds of rats are involved and how they behave. Understanding the nature of the damage rats cause to different crops and human health is important for targeting control measures at the right time and place. Secondly, we need to understand the impact on those most affected by rats. Developing a locally acceptable strategy means taking into account people’s financial and time constraints, their knowledge levels and cultural attitudes. Would they, for instance, be willing to eat rats? Rats are considered a delicacy in some parts of the world, including some of the different cultures of the Chittagong Hill Tribes. Third, we need to evaluate the effectiveness of different rodent control measures in specific local circumstances, and select the most appropriate. We start by training 25-30 people from each village on basic rodent biology, common technology available to control rats and the principles of EBRM. These ‘trainees’ then spread the word, and we continue to work with them to demonstrate how EBRM works in practice where they live. For example, this involves showing villagers how traps should be placed and set for maximum efficiency, or helping people monitor changes in levels of rat damage. Within two to three months, households throughout the community can see for themselves that EBRM works better than the poisoning campaigns they previously employed. With first hand experience of the effectiveness of the approach, villagers are then ready to carry on with it by themselves. Our experience is that communitylevel intensive trapping should provide the backbone for any EBRM strategy in rural communities. Although trapping is relatively laborious, traps last a long time, and communities find traps easier and cheaper to use than poisons. Most will catch between 1,000 and 2,000 rats each and can last up to three years or more. Trapping as a communal activity spreads the cost and also means it operates on a scale big enough to minimise the migration of rats back to the treated area. Rural communities that have tried communal trapping have been very enthusiastic. For the first time in their lives they can see what it is like to live a life free of rats. “Since our village

started community-based rat trapping with the new traps, we have more food to eat,” said one villager. “Now that the rats are not eating our stored food, the rice in our food store lasts much longer and doesn’t go down so quickly.” This form of trapping is phenomenally successful – we have seen reductions in rat numbers and damage of more than 80%. It is environmentally sustainable – it does not use expensive, harmful chemicals. It is cheap – traps can be used again and again. It has proved a major time and money saver – there is less damage to repair. “Before we started the rat management programme, I would spend hours and hours repairing the walls of our house where the rats had made burrows,” said one participant. “Now that there are fewer rats around, there aren’t nearly so many holes in the walls, so I can spend the time doing other things.” And ultimately people are able to grow and store more food, either for their families or for sale.

One of the most rewarding results of this research programme is that once communities see exactly how effective communal trapping can be, they then purchase for themselves the rat traps they have seen in action and carry on their community-level trapping independently. Once these communities have bought-in to the programme, other communities can then be trained on EBRM in the same way. The Rat Management for Rural Communities project is now rolling out this ‘tried and tested’ strategy – spreading the word that rats can be controlled effectively and ecologically. Dr Steven Belmain is an ecologist and rodent expert based at the Natural Resources Institute, University of Greenwich, UK. MORE INFORMATION www.nri.org/bandicoot www.researchintouse.com

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Bradford Centre for International Development

Our Programmes MSc in Development and Project Planning MSc in Project Planning and Management MSc in Public Policy and Programme Management MA in International Development Management MSc in Macroeconomic Policy for Development MSc in International Economics PhD/MPhil Degree Each of the MSc or MA programmes can also be studied as a Postgraduate Certificate (60 credits) or Postgraduate Diploma (120 credits)

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Being a postgraduate student at the University of Bradford has been an unforgettable experience for me. The University of Bradford is the most multicultural place I have ever experienced. It is a microcosm of African, American, Asian, and European worlds. I have learnt a lot about the rich and diversified cultures of the citizens of the world.

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Mamadou Camara, MSc in Development and Project Planning

Special features of our courses High-quality teaching and learning Teaching informed by research and practice Flexible course structure Transferable skills and personal development Friendly and inclusive atmosphere The Bradford Centre for International Development (BCID) is one of the UK's leading university-based centres for development studies. The Centre has a particular reputation for excellence in professional development and training, having worked in a wide variety of countries across the world.

Contact Details BCID Postgraduate Office, Department of Development and Economic Studies, University of Bradford, Bradford, West Yorkshire, BD7 1DP, UK T: +44 (0)1274 233979 F: +44 (0)1274 235280 E: bcid-pgrad@bradford.ac.uk W: www.bradford.ac.uk/acad/bcid

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A short story written for the Global Education Campaign’s Big Read, by Orange prizewinning novelist Chimamanda Ngozi Adichie.

Chinasa I

think it happened in January. I think it was January because the soil was parched and the dry Harmattan winds had coated my skin and the house and the trees with yellow dust. But I’m not sure. I know it was in 1968 but it could have been December or February; I was never sure of dates during the war. I am sure, though, that it happened in the morning – the sun was still pleasant, the kind that they say forms vitamin D on the skin. When I heard the sounds – Boom! Boom! – I was sitting on the verandah of the house I shared with two families, re-reading my worn copy of Camara Laye’s The African Child. The owner of the house was a man who had known my father before the war and, when I arrived after my hometown fell, carrying my battered suitcase, and with nowhere else to go, he gave me a room for free because he said my father had been very good to him. The other women in the house gossiped about me, that I used to go to the room of the house owner at night, that it was the reason I did not pay rent. I was with one of those gossiping women outside that morning. She was sitting on the cracked stone steps, nursing her baby. I watched her for a while, her breast

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looked like a limp orange that had been sucked of all its juices and I wondered if the baby was getting anything at all. When we heard the booming, she immediately gathered her baby up and ran into the house to fetch her other children. Boom! It was like the rumblings of thunder, the kind that spread itself across the sky, the kind that heralded a thunderstorm. For a moment I stood there and imagined that it was really the thunder. I imagined that I was back in my father’s house before the war, in the yard, under the cashew tree, waiting for the rain. My father’s yard was full of fruit trees that I liked to climb even though my father teased me and said it was not proper for a young woman, that maybe some of the men who wanted to bring him wine would change their minds when they heard I behaved like a boy. But my father never made me stop. They say he spoiled me, that I was his favourite and even now some of our relatives say the reason I am still unmarried is because of my father. Anyway, on that Harmattan morning, the sound grew louder. The women were running out with their children. I wanted to run with them, but my legs

would not move. It was not the first time I had heard the sounds, of course, this was two years into the war and my parents had already died in a refugee camp in Uke and my aunt had died in Okija and my grandparents and cousins had died in Abagana when Nkwo market was bombed, a bombing that also blew off the roof of my father’s house and one that I barely survived. So, by that morning, that dusty Harmattan morning, I had heard the sounds before. Boom! I felt a slight quiver on the ground I was standing on. Still, I could not get myself to run. The sound was so loud it made my head throb and I felt as if somebody was blowing hot custard into my ears. Then I saw huge holes explode on the ground next to me. I saw smoke and flying bits of wood and glass and metal. I saw dust rise. I don’t remember much else. Something inside me was so tired that for a few minutes, I wished that the bombs had brought me rest. I don’t know the details of what I did – if I sat down, if I ducked into the farm, if I slumped to the ground. But when the bombing finally stopped, I walked down the street to the crowd gathered around the wounded, and found myself drawn to a body on the ground. A girl, perhaps 3

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short story 3 fifteen years old. Her arms were a mass of bloody flesh. It was the wrong time for humour but looking at her with mangled arms, she looked like a caterpillar. Why did I take that girl into my room? I don’t know. There had been many bombings before that – we were in Umuahia and we got the most bombing because we were the capital. And even though I helped to clean the wounded, I had never taken anyone into my room. But I took this girl into my room. Her name was Chinasa. I nursed Chinasa for weeks. The owner of the house made her crutches from old wood and even the gossiping women brought her small gifts of ukpaka or roast yam. She was thin, small for her age, as most children were during the war, but she had a way of looking at you straight in the eye, in a forthright but not impolite way, that made her seem much older than she was. She pretended she was not in pain when I cleaned her wounds with home made gin, but I saw the tears in her eyes and I, too, fought tears because this girl on the cusp of womanhood had, because of the war, grown up too quickly. She thanked me often, too often. She said she could not wait to be well enough to help me with the cooking and cleaning. In the evenings, after I had fed her some pap, I would sit next to her and read to her. Her arms were still and bandaged but she had the most expressive face and in the flickering naked light of the kerosene lamp, she would laugh, smile, sneer, as I read to her. I had lost many of my things, running from town to town, but I had always brought some of my books and reading those books to her brought me a new kind of joy because I saw them freshly, through Chinasa’s eyes. She began to ask questions, to challenge what some of the characters did in the stories. She asked questions about the war. She asked me questions about myself. I told her about my parents who had been determined that I would be educated, and who had sent me to a Teachers Training College. I told her how much I had enjoyed my job as a teacher in Enugu before the war started and how sad I was when our school was closed down to become a refugee camp. She looked at me with a great intensity as I spoke. Later, as she was teaching me how to play nchokolo one evening, asking me to move some stones between boxes drawn on the ground, she asked whether I might teach her how to read. I was startled. It did not occur to me that she could not read. Now that I think of it, I should not have been so presumptuous. Her personal story was familiar: her parents were farmers from Agulu who had scraped to send her two brothers to the mission school but kept her at home. Perhaps it was her brightness, her alertness, the great

intelligence about the way she watched everything, that had made me forget the reality of where she came from. We began lessons that night. She knew the alphabet because she had looked at some of her brother’s books, and I was not surprised by how quickly she learned, how hard she worked. By the time we heard, some months later, the rumour that our generals were about to surrender, Chinasa was reading to me from her favourite book, The African Child. On the day the war ended, Chinasa and I joined the gossipy women and other neighbours down the street. We cried and sang and laughed and danced. For those women crying, theirs were tears of exhaustion and uncertainty and relief. As were mine. But, also, I was crying because I wanted to take Chinasa back with me to my home, or whatever remained of my home in Enugu; I wanted her to become the daughter I would never have, to share my life now emptied of loved ones. But she hugged me and refused. She wanted to go and find which of her relatives had survived. I gave her my address in Enugu and the name of the school where I hoped to go back to my teaching. I gave her much of the little money I had. “I will come and see you soon,” she said. She was looking at me with tearful gratitude, and I held her close to me and felt a keen sense of future sadness. She would find her relatives and her life would intervene in this well-meant promise. I knew that she would not come back. It is now 2008 and yesterday morning, a morning not dissimilar to that one forty years ago, I opened the Guardian newspaper in the living room of my

house in Enugu. I had just returned from my morning walk – my friends say that my daily walk is the reason I do not look like a woman in her seventies – and was filled with the optimism that comes with the briskness, the raised heartbeat of walking. I had followed the recent national news about the government appointing new ministers, but only vaguely because after watching this country careen from one inept leadership to another, I no longer find much to be passionate about. I opened the paper to read that an education minister had been appointed, a woman, and she had just given her first interview. I was mildly pleased: we needed more women in government and Nigerians had seen how well the last female minister did in the ministry of finance. Then the face of the new minister, in a black and white photograph that took up half a page, struck me as familiar. I stared at it and before I read the name, I knew it was Chinasa. The cheeks had filled out, of course, and the face had lost the awkwardness of youth but little else had changed. I read the interview quickly, my hands a little shaky. She had been sent abroad shortly after the war, with one of the many international agencies that helped young people who had been affected by war. She had been awarded many scholarships. She was married with three children. She was a professor of literature. My hands began to shake furiously when I read about the beginning of her love for books: “I had a fairy godmother during the war,” was all that she said. I looked at her face for a long time, imagining the life she has had, playing with the idea of contacting her, realising that I had never before in my life felt quite so proud, before I closed the newspaper and put it away. © 2009 by Chimamanda Ngozi Adichie. Reproduced by permission. All rights reserved. Chimamanda Adichie’s story collection The Thing Around Your Neck will be published in April by Fourth Estate. The Big Read on April 22 is part of the Send My Friend to School campaign, which asks UK school pupils to join forces with young campaigners around the world to promote education for all. MORE INFORMATION www.campaignforeducation.org www.sendmyfriend.org

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Postgraduate Courses and Research in International Development The Institute for Development Policy and Management (IDPM) within the School of Environment and Development (SED) at the University of Manchester is one of the UK’s leading centres for training and research on international development issues. Our objective is to promote poverty-reducing social and economic development particularly within lowerincome countries, by enhancing the capabilities of individuals and organisations through education, training, research, consultancy and policy analysis. The results of the 2008 Research Assessment Exercise (RAE) show Development Studies (IDPM) ranked number one in this field based upon research power. IDPM research is assessed as ‘world-class’, and in significant areas is viewed as ‘world-leading’. This means that not only is IDPM contributing at a global level to debates about poverty and development, but in many areas is setting the pace. With the government having previously awarded its highest possible rating for the quality of IDPM’s postgraduate teaching, IDPM has now achieved national recognition as the UK’s leading centre for development research and teaching. IDPM provides: • A wide range of postgraduate degree programmes at Masters and Diploma level in development-related “ disciplines and specialisations, • Research of international excellence into major issues of development policy and practice, including two DFIDfunded Development Research centres, • An internationally renowned doctoral programme (PhD/MPhil) in development policy and management, • Consultancy, research and training work for international agencies, national governments and institutions, and the private sector, both in-country and in Manchester, • Distance learning study programmes.

www.sed.manchester.ac.uk/idpm

IDPM offers the following Postgraduate degree programmes:

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• MA/MSc (Research Training*) in International Development – with pathways in: - Development Management - Economics and Management of Rural Development - Environment and Development - Social Policy and Social Development - Urban Development - Poverty, Conflict and Reconstruction • MSc International Development: Public Policy and Management • MSc Human Resource Development: International Development • MSc Human Resource Management: International Development • MSc Human Resources for International Development: Human Resource Management and Development (Distance Learning)

• MA/MA (Research Training*) in Development Studies • MSc Poverty and Development • MSc Development Finance • MSc Globalisation and Development • MSc ICTs for Development • MSc Industry, Trade and Development • MSc Development Economics and Policy • MSc Management and Implementation of Development Projects • MSc Management and Information Systems: Change and Development • MSc Organisational Change and Development • PhD/MPhil

* ESRC 1+3 funding available for Research Training courses.

Since its foundation, the Institute has trained over 7000 individuals from 170 countries. For further information, and to order an application pack, please contact: Recruitment and Admissions Office School of Environment and Development Tel: +44(0)161 275 0969 The University of Manchester Fax: +44(0)161 275 0421 Oxford Road Email: sed.admissions@manchester.ac.uk Manchester, M13 9PL, UK Website: www.sed.manchester.ac.uk

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IMA International Training and Consultancy for Development

Upcoming Courses for Development Professionals Issues in International Development Brighton (UK),13-24 July 2009 Join us this July for our popular Issues course addressing the most important questions in the development world. Facilitated by world-class academics, leading development experts and trainers, the course is held at the Institute of Development Studies (IDS), Sussex University.

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Tailor-made Training Need to strengthen your skills, take your team to the next level or manage your projects better? A bespoke course will help your team achieve their goals, whatever their learning needs and objectives are. Choose the topics that will answer your exact needs, then let IMA do the hard work of designing, coordinating and running a course anywhere you choose. Rely on specially tailored materials, trainers with many years’ experience with development organisations around the world, and a support team ready to respond to all eventualities. We offer courses and programmes across the whole range of people and project management skills. More details at www.imainternational.com/tmt.php or e-mail helena@imainternational.com to request a no-obligation quote.

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