HCGHR Spring 2012 - Financing Global Health

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!"#$%&'(%)*+&#", Dear Readers, Since 2008, the global economic recession has profoundly impacted health priorities in both the developed and developing world. As funding for international aid continues to be cut in an age of austerity, the stark contrasts between the health and wealth of nations have become increasingly apparent. Much of the international community’s enthusiasm seen at the turn of the millennium has been tempered by hardship and a growing realization that existing global health financing mechanisms may not be sustainable. While the effect has been felt at the policy level, the repercussions have been more salient on the ground and in the lives of patients who depend on access to affordable health care. Stories of families, communities, and entire regions being deprived of essential care evoke a sense of the humanity attached to the economic crisis. However, this issue of the HCGHR takes inspiration not just from the challenges presented by the recession, but more importantly from the global health community’s innovative efforts to overcome them. Creative partnerships and a steadfast commitment to the human right of healthcare have spurred practitioners and communities to challenge the status quo. We hope that our readers will be likewise motivated to not only discuss and debate the analyses presented in the following pages, but ultimately to take action on these issues. The articles in our Features section investigate emerging health financing mechanisms that aim to sustain progress made in the past decades and provide support for future initiatives. In the rapidly expanding field of women’s health, the rise of non-profit and hybrid-model pharmaceuticals has reinvigorated efforts to provide reproductive healthcare to women across the globe. An experiment in Sugha Vazhvu, India, hopes to change the way that the country finances and delivers essential primary care to impoverished rural areas. New public private partnerships (PPPs) such as Uniting to Combat Neglected Tropical Diseases (UTCNTDs) can help galvanize international cooperation in addressing overlooked healthcare needs that are often the first to be dropped from tightened budgets. Existing financial structures such as the Global Fund to Fight AIDS, Tuberculosis and Malaria struggle amidst the ailing global economy to continue to provide critical resources. Our Panorama section presents an eclectic collection of stories often underrepresented in the mainstream media. From the impact of the Arab Spring on health system reform in the Middle East to the silent tragedy of stillbirths across the globe, our writers bring fresh perspectives to events both highly visible and largely invisible. In addition, we are excited to publish exclusive interviews with Howard G. Buffett, President of the Howard G. Buffett Foundation, and Anthony Lake, Executive Director of the United Nations Children Fund (UNICEF). Last but not least, we hope our readers take equal inspiration from a collection of student submissions that offer insights both from the classroom and from the field. As the global health community has had to reorient itself in a rapidly changing world, so too has the HCGHR refocused its priorities to maximize the publication’s impact. In an effort to reach a broader audience, the organization plans to greatly expand its online presence through a dynamic new website with diverse multimedia content. For the first time, we opened up staff writing positions to graduate students across Harvard’s professional schools, taking one step further towards our goal of becoming a truly University-wide publication. For more information on opportunities to get involved in our work, please visit our website at www.hcghronline.org. Warm regards, Justin Banerdt and Judy Park Editors-in-Chief

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Features

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Who Pays for Global Health? Global Health Financing Today and Tomorrow Jonathan Quick, MD, MPH and Angie Lee, MPH

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Public Private Partnerships: A Double-Edged Sword Adam Joseph

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Medicines360 and the Rise of Non-Profit Pharmaceuticals Audrey Zhang

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The Story of SughaVazhvu: How a few rural health centers in southern India might change its primary care Rajarshi Banerjee

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An Inverted Pyramid: Three-tier Public Financing for Health in Nigeria Yangfang Su

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Hope for Millions: Challenges ahead for The Global Fund to Fight AIDS, Tuberculosis and Malaria Shalini Pammal

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Interviews and Experts

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Interview with Anthony Lake, Executive Director of UNICEF Hannah Semigran

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Interview with Howard G. Buffett, President of the Howard G. Buffett Foundation Alison Kraemer

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Harvard’s “Aid for Health” Simulation in its Third Year Manpreet Singh, Peregrine Dalziel, Wei Aun Yap, Cecil Haverkamp

Panorama 23

Reconstructing Lives: A Broader Perspective on Global Health Alexander Ryu

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Social Movements and Health System Reform: The Impact of the Arab Spring in Reconceptualizing Health Delivery in the Middle East Sonya Soni, MPH

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Basic Science as a Global Health Tool: Lessons from an Innovative Harvard Life Sciences Course Alison Kraemer

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The Devastations of Stillbirth: Defining the Global Tragedy Rachel Sapire

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Evaluating Recent Developments in HIV Drugs and Vaccines Andrew Lea

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Smoking: The Oldest Dieting Trick on the Books, and the One That’s Sure to Kill Katherine Record, JD, MA, MPH

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Brain Drain: Challenges of Global Medical Education in an Unequal World Michelle Lee

Student Submissions 41

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An Incurable, Curable Disease: The Curious Case of Leprosy in Southeast Asia Matthew Condakes

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Management and Maternal Mortality in Kenya Hoffman Moka Lantum, MD, PhD

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Indecent Exposure: How Photographic Coverage of Post-Earthquake Haiti Darkened the Nation’s Future Monika Lutz

Harvard College Global Health Review Co-Editors-in-Chief Judy Park ’13 Justin Banerdt ’13 Managing Editors Danny Wilson ’14 Tarina Quraishi ’14 Section Editors Leeann Saw ’13 | Features Sarah McCuskee ’13 | Panorama Hannah Semigran ’14 | Experts and Interviews Vishal Arora ’14 | Online Content Megan Parsons ’15 | Online Content Charlotte Lee ’14 | Student Spotlight Staff Writers Shaira Bhanji ’14 Nora Eccles ’14 Frederic Hua ’14 Adam Joseph ’15 Camerone Johnstone ’13 Young Kwon ’15 Andrew Lea ’14 Michelle Lee ’15 Corinne Maguire ’15 Joy Ming ’15 Dylan Neel ’15 Alexandra Pace ’14 Samuel Parker ’14 Rachel Sapire ’15 Carlos Schmidt ’15 Audrey Zhang ’15 Fatima Mirza ’15 Kieley O’Connor-Chapman ’14 Jenny Shih ’15

Alison Kraemer ’12 Staff Interviewers Ava Carter ’13 Natasha Dalomba ’14 Sheila Ojeaburu ’15

Board of Expert and Faculty Advisers Prerna Banati, PhD, MPH Takemi Fellow, Department of Global Health and Population, Harvard School of Public Health

Design Herbert Castillo ‘14 (Chair)

David Bloom, PhD Clarence James Gamble Professor of Economics and Demography, Department of Global Health and Population, Harvard School of Public Health

Board of Graduate Advisers Riad Abdelkarim Adriana Benedict Aparna Chandrasekhar Vivek Datta Geethika Fernando Ana Luíza Gibertoni Cruz Alexander Hawkins Hoffman Moka Lantum Natalia Linos Mathieu Maheu-Giroux Melissa Neuman Tej Nuthulaganti Daniel Oh Sophia Qiu Minal Rahimtoola Katherine Record Danae Roumis Alex Ryu Jose Sarmiento Sonya Soni Amy VanderZanden Jennifer Ward

Allan Brandt, PhD Amalie Moses Kass Professor of the History of Medicine, Department of Global Health and Social Medicine, Harvard Medical School Arachu Castro, PhD, MPH Assistant Professor of Social Medicine, Department of Global Health and Social Medicine, Harvard Medical School Paul Farmer, MD, PhD Kolokotrones University Professor, Department of Global Health and Social Medicine, Harvard Medical School Jeremy Greene, MD, PhD Assistant Professor of the History of Science at Harvard University; Associate Physician at Brigham & Women’s Hospital Cecil Haverkamp Former Coordinator of Strategic Partnerships and Global Health Practice, Harvard School of Public Health

Joel Lamstein CEO, President, and Co-Founder of John Snow, Inc.; Co-Founder of Management Sciences for Health Ana Langer, MD Professor, and Coordinator of the Dean’s Special Initiative on Women and Health, Department of Global Health and Population; Former President and CEO of EngenderHealth Allison Linden, MD Paul Farmer Global Surgery Research Fellow, Children’s Hospital Boston Surgical Research Fellow, Harvard Humanitarian Initiative Michael Murphy Co-Founder and Executive Director of MASS Design Group Conrad Muzoora, MD, MMed Global Health Scholar, Harvard Global Health Institute; Lecturer, Mbarara University of Science and Technology, Uganda Jonathan Quick, MD, MPH CEO and President of Management Sciences for Health; Former Director of Essential Drugs and Medicines Policy at the World Health Organization

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Who Pays for Health? Global Health Financing Today and Tomorrow -#./&'/.%01+234%564%578%/.*%9.:+(%;((4%578%% 5/./:($(.&%<2+(.2(,%=#"%8(/>&' Baby Janelle, a two-year old living outside Kampala, Uganda, falls sick with cough, vomiting and fever. Her single mother, a day laborer in the stone quarries, is forced to choose between taking Janelle to the health center – for which she must pay herself – and paying school fees for her other two children. Jonathan is a two-year old with pneumonia living in Manila, Philippines. Because his family is among the poorest quintile, they are covered by Philippine National Health Insurance scheme. Without hesitation, Jonathan’s mother takes him to the nearest health center and receives treatment. Everyone deserves an opportunity for good health. Too often who receives needed care – and who lives or dies – depends greatly on who pays. Most high income countries spend at least $3000 per person per year on health. Over 80% of this is from taxes, national health insurance, employer-sponsored health plans, or other collective sources. In contrast, most developing countries spend less than $100 per person per year and in the worst cases, as little as $20 per person per year. In Africa and Asia out-of-pocket health spending accounts for 50-80% of total health expenditures. Like Janelle’s mother, families are often forced to choose between seeking care at an impoverishing cost, or letting a loved one fall into a downward spiral of illness and premature death. Against this global health financing landscape, the decade of the 2000s produced a dramatic and unprecedented outpouring of financial commitments from high income donor country governments and private sources such as The Bill and Melinda Gates Foundation. From 2002 to 2008, roughly $80 billion was committed – largely in support of AIDS, tuberculosis and malaria, and to a lesser extent for maternal and child health. For many donors the global recession that started in 2008 has markedly slowed this trend. The absolute value of total development spending on health continues to rise. But looming budget pressures in donor countries threaten future commitments. As the economies of traditional donor countries struggle and their development assistance funding wanes, many emerging economies in Africa, Asia and elsewhere are experiencing economic growth. With growth comes greater demand for health services and increased local spending for health. The challenge is to channel increased spending to achieve the greatest health impact. More than 20 developing countries, including India, Ghana, Mexico, Rwanda, Thailand and Vietnam, are responding by pursuing a vision of universal health coverage (UHC). Based on principles of equity and human rights, UHC shares the risk of ill health (“pooling”) so the healthy help pay for the sick, and the rich for the poor. The funding mix differs among countries, with varying combinations of general taxes, social health insurance social, community health insurance, and employer-based financing. Just as the global economic and health financing picture is changing, so too is the epidemiologic picture. The World Health Organization projects that between 2004 and 2030, chronic non-communicable disease (NCD) deaths in low income countries will double to 18 million per year. The need for prevention, care and treatment will escalate accordingly. In this context the dictum, “More money for health and more health for the money,” requires that we seek both innovative mechanisms for health financing and build strong health systems that achieve the greatest impact with available funds. New leaders in global health must expand the existing health financing mechanisms, while pursuing innovative health financing. Examples include developing the economic advocacy skills of national health leaders to garner adequate health funding from their national budget-keepers, performance-based financing to increase efficient use of funds, the UNITAID creation of Brazil and France that has generated over $1 billion for global health from airline ticket fees, use of crowd-funding to engage ordinary citizens in donating to a health equity fund that protects poor Pakistanis from catastrophic health spending, and licensed brand Product Red that rock-star activist Bono co-founded to help finance the Global Fund. A common feature of such innovations is that – in addition to medicine and other health professions – they draw on a variety of talents and disciplines, including economics, systems engineering, communications, and social media. For every Janelle and Jonathan in the world, the opportunity to pursue long life and good health should not be an accident of birth. It should a matter of realizing their human rights through adequate and equitable health financing.

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Public Private Partnerships: A Double-Edged Sword

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he varied financial models for funding global health have caused uncertainty regarding the ideal structure of global health organizations. With a number of interests at stake – including those of governments, profit-driven initiatives, and philanthropic organizations – there are often conflicts between groups whose goals do not align. Public-Private Partnerships (PPPs) is a term used to describe organizations that are governed and funded by both public and private sector groups. The World Health Organization (WHO) defines PPPs as a “wide variety of ventures involving a diversity of arrangements, varying with regard to participants, legal status, governance, management, policy-setting prerogatives.”1 One recently formed PPP, Uniting to Combat Neglected Tropical Diseases (UTCNTDs), combines the financing resources of the Bill & Melinda Gates Foundation, a number of pharmaceuti-

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UTCNTDs is a perfect example of the underlying power of PPPs. Thanks to the mammoth organizations that are

“It’s a misnomer that it’s a partnership – there is a senior partner – the donors from outside of the host countries. This is what drives it.” cal companies, and the governments of the United States, the United Kingdom, and the United Arab Emirates. By combining their resources, these influential entities are able to contribute a total of US$785 million through 2020 to research initiatives aimed at eliminating Neglected Tropical Disease (NTD).2

behind the initiative, raising nearly one billion dollars is an seemingly effortless task. However, criticisms of the PPP model can overshadow its financial power. Consider the donors that are contributing partners to UTCNTDs; they come from the pharmaceutical

industry, different world governments, and from non-profit organizations. These donors can have very different goals and priorities. These differences, even when related to the common goal of eliminating NTDs, can have a profound effect on the structure of the PPP. For instance, pharmaceutical companies need to earn a profit in order to cover research expenses from the creation of new drugs. Likewise, the Bill and Melinda Gates Foundation might prioritize technological solutions. In an interview with HCGHR, Harvard School of Public Health Professor Yuanli Liu stated that, “you have to realize that private sector concerns are legitimate. Making money isn’t just for rich investors – it assures that technological innovation continues.”3

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# However, the non-profit donors might have less interest in profits, instead placing emphasis on providing direct care and training to front-line staff. Though the various motives of donors are legitimate, it is important to note that differing goals can make the dynamics of the partnership less than ideal. This problem of internal dynamics mirrors the more severe issue of lack of cooperation between the PPP and the host nation. Although they offer huge sums of money that can make significant contributions, PPPs often do not harmonize structurally with their host countries. Harvard School of Public Health Professor William Hsiao stated in an interview with HCGHR that, “It’s a misnomer that it’s a partnership – there is a senior partner – the donors from outside of the host countries. This is what drives it.”4 The immediate

changes. These countries need money so the donors can help fulfill this very important role. But that money may not be used very effectively.” Thus, perhaps the very presence of PPPs distracts from the important issues in global health. Instead of promoting social change within countries and helping developing nations create their own productive healthcare infrastructure, PPPs attract attention to large sums of money that do not solve the underlying problems. For instance, UTCNTDs chooses to focus on NTDs. Although these diseases are a very severe problem, they are just some of the many health challenges facing developing nations. However, with a large amount of money flowing into fighting NTDs specifically, a number of countries may send their best staff to administer treatments provided by UTCNTDs. Professor Hsiao described the money as gravitational

“Although [PPPs] are able to provide large amounts of money, they do not allow for a holistic view of the healthcare concerns faced by a country.” goals of donors are often not amenable to the larger structural problems faced by each individual developing nation. Professor Hsiao stated that, “the immediate problem for low income countries is money. However, I would argue that donors should actually focus on the fundamental social change as well as health

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force, warning that “all of this attention would be drawn to NTDs. Maternal/ child health could be neglected. Primary care could be neglected.” PPPs can thus be characterized as a double–edged sword. Although they are able to provide large amounts of money, they do not allow for a holistic

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view of the healthcare concerns faced by a country. Professor Liu stressed that PPPs need to create innovative solutions to structural problems faced by developing nations rather than focusing exclusively on delivering healthcare services themselves. His own initiative, Rural Mobile Health Demonstration Project, provides mobile healthcare to marginalized villagers in various regions of China.3 It aligned its various partners with the Chinese government by approaching the government from the outset to gain its support. The Chinese government enthusiastically supported the project and actively facilitated its development. Liu explained that the Project “donated the vehicle [and] the technicians” while the Chinese government “allocated money to support the personnel of the mobile center.” The Rural Mobile Health Demonstration Project is clearly trying to address the problems of being out of phase with government priorities, but it remains to be seen if this will be an effect way to bridge the gap between funders and the needs of the target population. Regardless, initiatives that harness government support seem to be a step in the right direction. Perhaps this initiative offers a model that is more sustainable. PPPs, given their huge funds and research power, can investigate ways to establish infrastructure-oriented projects that can be sustained by the government. This would put the nation’s healthcare into the hands of the citizens, and would create less discord between different parties in the PPPs.

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Medicines360 and the Rise of Non-Profit Pharmaceuticals 91*"(M%\'/.:%

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eproductive health is becoming an increasingly important concern in developing countries, where it represents the confluence of three essential issues: women’s rights, health, and economics. Increasing the availability of contraceptives can address all three of these issues, yet pharmaceutical companies are often reluctant to pursue these projects because the available profit margin is small. A new, innovative cancer drug can be priced at thousands of dollars a dose, but a new hormonal contraceptive must be made much more affordable to be a viable business venture. But effective solutions to this and other global health problems need not be reliant on large pharmaceutical companies that garner billions of dollars of profit. New non-profit and hybridmodel pharmaceuticals, for instance, are now being formed to address specific niches that larger investor-based pharmaceuticals may neglect. The nonprofit OneWorld Health was founded in 2000 to address neglected infectious diseases in developing countries, such as leishmaniasis and helminthiasis, as well as cholera and malaria. This model allows non-profit pharmaceutical companies to collaborate with major pharmaceuticals that possess the scientific manpower to develop drugs that the for-profit industry ignores. For instance, today’s major pharmaceutical companies often invest in me-toos, slightly altered versions of existing drugs that have a guaranteed market. While these become highly profitable, they have marginal utility, because they reach an audience that

already has other options. In contrast, product development partnerships (PDPs) between non-profit and forprofit pharmaceutical companies focus on developing abandoned orphan drugs. These may have been deemed potentially

development of more needed drugs at limited cost to the for-profit pharmaceutical company and great benefit to the target populations.1 However, OneWorld Health founder Victoria Hale saw an oppor-

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efficacious by the major pharmaceutical company, but would serve only small or poor populations for which potential returns would not recoup investment costs. PDPs would thus allow the

tunity to build on a new model that would create even greater independence from for-profit pharmaceuticals, and went on to found the hybridmodel Medicines360, focusing on

“Because the profits generated by the for-profit arm in the United States will be used to fund the global health efforts of the non-profit arm, [the Medicines360] hybrid model should be self-sufficient.”

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% often-neglected women’s health. Unlike OneWorld Health, Medicines360 will run on a unique hybrid funding model. Hale explained in an interview with the HCGHR, “We will have a commercial sector price, which will move through the United States through the traditional marketing pathway‌ and we will provide the same product, sold at a significantly reduced price, to the public sector, to women who are uninsured, or to other programs.â€?2 Because the profits generated by the for-profit arm in the United States will be used to fund the global health efforts of the non-profit arm, this hybrid model should be selfsufficient, and will ideally divorce the company from the need to secure investor funding. Medicines360’s first project is an intra-uterine device (IUD) that is still undergoing clinical trials. Because they only need to be inserted once to provide years of benefit, IUDs have long been considered an inexpensive, reliable, long-term alternative to other forms of contraception such as condoms.3 According to Hale, IUDs thus have particular appeal to applications in global health, where such a device would place the reproductive choice in hands of women, who would then be “set for several years with this product.â€?4 Though IUDs are currently a popular form of contraception in Asia, they do present some disadvantages that companies like Medicines360 will have to overcome in order to make IUDs widely

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“[F]inding the ‘growing market,’ driving demand for that market, and innovating to meet the needs of that market, will be key to the success of Medicines360 and companies like it.� accepted in new markets, like Africa. For one, the complications resulting from a misplaced IUD are serious, and can lead to dangerous pelvic inflammatory disease5, as well as painful IUD withdrawal. There has also been some evidence that hormone-releasing IUDs are linked with a higher risk of HIV transmission, an issue particularly challenging in sub-Saharan Africa, where HIV is increasingly prevalent.6 In addition, the time and skill needed to provide a woman with an IUD is much greater than those needed to provide a man with a condom.7 Hale acknowledged that insertion would require a healthcare provider who was trained, but also noted that “[one would] just have to touch that infrastructure one time, and then you have

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five, seven, ten years of contraception.� One solution is to equip medical camps that travel to the women to offer contraception, much in the same way that camps currently travel to deliver vaccines and medicines for tropical diseases. “That infrastructure can reach parts of the world by coming to the world itself, instead of waiting for women to travel to cities,� Hale stated.8 Although non-profit and hybridmodel pharmaceuticals have been working to increase their independence from third parties, the reliance on existing infrastructure for distribution is one of several gaps in the model that is not fully resolved. Non-profits are still developing a long-term secure funding model, which the hybrid-model attempts to address, so that they can become less reliant on grants from global health initiatives such as the Gates Foundation. In addition, the sheer cost of drug development from clinical trials through distribution represents a high entry barrier to the market. Hale is hopeful, though, stating that she believes the hybrid-model for pharmaceuticals is a “great opportunity.� She highlighted that finding the “growing market,� driving demand for that market, and innovating to meet the needs of that market, will be key to the success of Medicines360 and companies like it.9 Only then can new funding methods hope to impact not only the biomedical market but also the social aspects of global health.

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The Story of SughaVazhvu: How a few rural health centers in southern India might change its primary care W/j/",'+%`/.("j((% 8/"D/"*%;/F%<2'##>%

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he Alakuddi Rural Micro Health Centre (RHMC) is a tidy little place, with peach-colored walls and a tin awning that shades waiting patients from the strong midday sun. Inside, the Centre has only two small rooms, and is staffed by just a nurse and a traditional medical practitioner. Other than its fresh coat of paint, there is little that makes the Centre stand out from the hundreds of other primary health centers dotting the southern Indian state of Tamil Nadu.1 Yet the privatelyrun Centre is home to an experiment that might help change the way primary health care is provided and financed in India. Can India provide all its citizens low-cost, good-quality primary healthcare? At present, you would be inclined to say no. There are about 700,000 physicians practicing in the country, and many of these physicians do not venture beyond urban India.2 Moreover, the Indian government spends a minuscule 0.9% of the country’s GDP--about $10 for every Indian--on public healthcare.3 Consequently, government-run clinics and hospitals in rural India tend to be ill-stocked and ill-staffed. The dismal state of public healthcare in India only serves to remind us of the importance of primary care. The country’s poor public health infrastructure discourages many Indians from seeking healthcare until a medical emergency demands it, and this in

turn allows easily treatable conditions to morph into life-threatening, and financially draining, events. In a country where over a third of the population lives on less than $1.25 a day,4 Indians shell out an average of $40 per person each year for healthcare.3 For $40 a year, can Indians get better healthcare than they currently receive? The IKP Trust, an Indian nonprofit, set out to answer this question in 2009

technology and strict protocols can replace much of what primary care doctors do. “Medicine is driven by rules,” says Dr. Zeena Johar, one of SughaVazhvu’s two directors.1 And SughaVazhvu follows rules for everything: from capturing medical information to performing basic tests to diagnosing ailments ranging from respiratory infections to diabetes. Johar stated last year that such protocols can deal with 80% of diseases.

“For $40 a year, can Indians get better healthcare than they currently receive?” when it launched SughaVazhvu, the rural healthcare project that operates the Alakuddi RHMC. SughaVazhvu (meaning ‘happy life’ in Tamil) is an experiment in managed care--with a few trained health practitioners, electronic medical records, and simple diagnostic devices, the project eventually aims to closely track and meet the healthcare needs of about 50,000 families.3

“Medicine is driven by rules” SughaVazhvu does not expect to lure urban doctors to sleepy villages such as Alakuddi. Instead, the project attempts to see if medical records,

To further drive home this assertion, SughaVazhvu has informed the Medical Council of India (which mandates that a doctor staff every health center) that a single doctor should be able to manage as many as 20 of their centers.

A $20-a-year managed care plan SughaVazhvu’s five RHMCs cost an average of $6,000 to construct and set up.3 Every five such Centres are expected to share a $10,000 diagnostics center.3 The Centres’ ‘physicians’--people with degrees in traditional medicine who are legally permitted to prescribe allopathic medicines--command an annual salary

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of $3,000.3 These doctors are supported by trained local health extension workers who receive about $600 a year for their services.3 Considering that each Centre sees 40 patients a day, and spends about $1 per patient and drugs and diagnostics, SughaVazhvu estimates that it can put together a comprehensive managed care plan (without any co-pays) at an annual cost of $20 per person.3 Since there are large parts of rural India where the cost of living is even lower than in rural Tamil Nadu, it might be possible to put together a national managed care plan at a cost lower than the $20 figure. With the Indian government spending about $10 per person each year on public health, as discussed above, it is possible that a national SughaVazhvu-style model could charge Indians less than $10 a year for comprehensive primary I%

care. Since dedicated primary care can stave off many medical emergencies, a SughaVazhvu-style model can put a huge dent in the $40 per person average that Indians currently pay for healthcare.

Too small a microcosm? For all these extrapolations, SughaVazhvu does not immediately intend to go national--for now, it is quite content using Alakuddi and its neighboring villages as a microcosm for India and its healthcare issues. This, however, calls into question whether SughaVazhvu’s successes, failures, and observations can be replicated on a national scale. SughaVazhvu currently serves only 200,000 people, a minuscule fraction of the Indian population. The project also operates in Tamil Nadu,

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which fares better than the national average on a number of health indicators and boasts a relatively well-run government health service. In a state with less healthy people and a less competent health service, a SughaVazhvu-style project may have to provide people with more treatment, but may also be able to take advantage of the economies of scale that come with a higher demand for the project’s services. Nachiket Mor, who co-directs SughaVazhvu with Dr. Johar, addressed these issues in a conversation with HCGHR on the sidelines of the recent India Conference at Harvard. Dr. Mor, who was until recently a prominent banker1, noted that the SughaVazhvu model, if it is to scale up, must adapt to whatever local environment it finds itself in. Certain aspects of the model that worked in Tamil Nadu, he reasoned, might not work, or might work better, in other states. Regardless, Dr. Mor is confident about SughaVazhvu’s ability to address some of the most fundamental issues that plague rural healthcare in India.

A clinic is a clinic The Alakuddi RHMC offers an exciting potential solution to some of India’s most pressing healthcare problems. To Alakuddi’s residents, however, it serves an even more important and immediate role: as a place where they can address their own most pressing healthcare needs.

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An Inverted Pyramid: Three-tier Public Financing for Health in Nigeria Z/.=/.:%<1 8/"D/"*%<2'##>%#=%71G>+2%8(/>&'

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igeria consists of 36 states and the Federal Capital Territory, as well as 774 local government areas (LGAs). Though healthcare delivery was decentralized to local governments in 1999, the main contributor of public financing for health continues to be the federal government, followed by state governments (see diagram below). In 2005, the federal government, state governments, and LGAs contributed 50%, 31%, and 19% of government expenditure on health, respectively.1 This inverted pyramid structure of public financing presents critical challenges to delivering primary healthcare, especially because it enables leakage and corruption.

How did the federal government become the main contributor of public financing for health in a decentralized system? In the 1970s, the state became the owner, producer, and marketer of oil. The oil sector now accounts for

/0#1%(2$3#1)#*+$4%+4)2$"()536+3#1+'"6)$)536+ 1%7%6"'8%#$+"9 +:)*%()3;2+)#7%($%1+'<(38)1+ RI KHDOWK ÀQDQFLQJ LV HVVHQWLDO WR JUDSSOLQJ ZLWK PRGHUQ GD\ LQHIÀFLHQFLHV LQ KHDOWKFDUH 1%6)7%(<=>+ 85% of the government budget revenue and this revenue is clustered at the federal level.2 The policy of distributing the Federal Account revenues to states and LGAs gives inadequate consideration to population needs. In the formula of resource allocation, only 30% of the Federal Account is distributed according to population base, and the least populous states often receive more revenues.3 At the state level, budget patterns have been systematically inequitable between the north and the south due to historical and political factors. Even though the Niger area was formally united in 1914, Nigeria remains divided into northern and southern parts, each distinct in their racial and ethnic makeup. Presidents Obasanjo (1999.5-2007.5), Yar’Adua (2007.52010.5), and Jonathan (2010.5-,

Incumbent) were from the south, the north, and the south, respectively, and resource allocation fluctuates significantly depending on the president’s regional background. Furthermore, studies show that the discrepancy in the distribution of resources against rural areas is largely influenced by existing political power, rather than by varying regional health needs.4 Current state budgets for health remain far from the target established by the Commission for Macroeconomics and Health and agreed upon in the Abuja Declaration of 2001. Understanding the historical and political development of Nigeria’s inverted pyramid of health financing is essential to grappling with modernday inefficiencies in healthcare delivery. Tracing health finances to the end-user, while difficult, can lead to high levels of efficiency in the health system. Even though the Auditor General of Local Governments presents both budget reports and expenditure reports to the state assemblies, the financial flow to

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') LGAs is not easily monitored.5 From a political economy perspective, financial flows finally trickle down to health facilities and front line workers. Thus, one of the best ways to estimate efficiency of financial resource allocation is by collecting feedback from front-line workers. In 2002, 30 LGAs were sampled and more than 700 health workers were surveyed about salary payment. Evidence of large-scale leakage of public resources away from original budget allocations was found in this public expenditure tracing survey.6 7 These inefficiencies and corruption in the health sector have not escaped the public eye. Overall, government expenditure on health (GEH) in Nigeria remains low and has not been boosted by the growth in total government expenditure (TGE).8 Even

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though Nigeria experienced economic growth with 2.5% annual growth rate from 2002 to 2006, the investment in health out of TGE remained around 5% to 7%. It is possible that the increase in public revenue was absorbed by other sectors, such as education, pension, and basic infrastructure, indicating that health investment was not prioritized in public financing. But a more plausible explanation is that public revenue leaked to the privileged elites due to corruption, which Nigerians experience in their daily lives and recognize in elite-sponsored programs. For instance, the program “Better Life for Rural Women” (BLRW), founded by first lady Maryam, was labeled “Better Life for Rich Women” by the Nigerian public.9 Ultimately, what steps can be taken

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to improve health financing and political accountability in Nigeria? Nigeria can come closer to achieving universal access to healthcare by establishing a permanent fund based on oil revenue to directly invest in health. Meanwhile, a matching mechanism between the threetiers of the government will make local governments accountable for efficient allocation of financial resources to purchase healthcare. Last but not the least, Nigeria must fix its fundamental political and economic hurdles from a systematic perspective.10 This includes mechanisms to empower political activists who will keep the federal government accountable for their resource allocation. Shaping financial flows in innovative ways is challenging but critical to the long-term health of the Nigerian population.

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global health review

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Hope for Millions:

Challenges ahead for The Global Fund to Fight AIDS, Tuberculosis and Malaria

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ncle, you are shivering and your skin seems to be hot, you must go quickly to a health clinic to get a malaria test.” This critical message travels radio waves across Papua New Guinea—a country with an extraordinarily high incidence of malaria. Financed by the Global Fund, “Lisa’s Story” is a radio soap opera that uses an accessible entertainment forum to communicate important health messages about malaria prevention and treatment centers to its listeners.1 This awareness program is one of many incountry initiatives supported by the Global Fund. Since its inception, the Global Fund to Fight AIDS, TB and Malaria has approved US $22.6 billion in funding for more than 1000 programs in 150 countries, investing money in lifesaving treatment, prevention and care efforts to fight three devastating diseases. The most recent statistics indicate that 3.3 million people are receiving antiretroviral treatment for HIV, 8.6 million new cases of tuberculosis have been detected and treated, and 230 million insecticidetreated nets have been distributed for malaria prevention.2 “The Global Fund has led the way as the first organization to be established on the principle of a performance-based funding model,” says Nicole Delaney, Fund Portfolio Manager at The Global Fund.3 In this approach, demonstrable results are rewarded with continued funding following an extensive grant proposal review. Furthermore, Delaney states that a hallmark of the Global Fund standard is its adherence to enabling sustainable programs in which “proposals are designed at the country level and the

Global Fund has no on-the-ground presence, offering complete country ownership.” Fund disbursements are conditional upon the ability of a country to successfully and autonomously implement its proposed program. An independent unit of the Global Fund known as the Office of the Inspector General monitors all activities and operations, including those carried out by recipient countries, to ensure accountability and the ultimate success of funded projects.4 While the Global Fund strives to provide all necessary resources for partner countries receiving funding, its success is largely reliant upon consistent transparency and mutual confidence in these new partnerships. The Global Fund aims to bring diverse voices and powers to the decision-making table, including The World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS), non-governmental organizations, private foundations, most notably the Bill and Melinda Gates Foundation, and health care deliverers, for a powerful assembly of individuals devoted to the same health issues. “For the first time ever in many countries, governments have had to work with NGOs, bi-laterals and other multi-laterals…communication channels are definitely improving,” says Delaney. However, the magnitude of the Global Fund grant portfolio over the past decade has led to a complex system requiring greater accountability and transparency from country coordinating mechanisms— public and private sector representatives that “develop and submit grant proposals to the Global Fund based on priority needs at the national

level.”5 According to Grant Management Solutions, a major technical support provider to the Global Fund grantees, “the transition to single-stream-of-funding grants… has contributed to a growing complexity in Global Fund grants… as have the global economic crisis and political events in some countries.”6 In addition to the growing complexity of its fund disbursement and governance, the Global Fund also faced challenges to its reputation in 2011 when its accountability and general operations were called into question.7 In the case of disappearing medicines in Africa, where one third of nearly $10 million worth of donated antimalarial drugs were stolen and sold for exorbitant prices instead of being distributed for free in Togolese government clinics, talk of insufficient accountability standards surfaced.8 Critics stated that local institutions and recipient governments were simply not equipped to responsibly manage the funds they received and that the Global Fund was not effectively addressing corruption. These reports led to reduced funding and hesitation from donor countries to continue their support. Though it is important that such issues are brought to light, it is also essential to realize that a major funding crisis now threatens the life-saving treatment programs and flourishing partnerships enabled by the Global Fund. Prominent leaders in the global health field have continued to voice their strong support for the Fund’s activities in light of this funding crisis. Dr. Paul Farmer, Kolokotrones University Professor at Harvard University and Co-Founder of Partners in Health, wrote in the New

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'! York Times that “it would be a great mistake to allow one of the world’s most effective global health institutions to fail… if we allow the fund to fail, many

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people will die.”9 Similarly, Bill Gates focused his 2011 Annual Bill & Melinda Gates Foundation Letter on the importance of country investment in tackling I

these devastating diseases: “It is in the rich world’s enlightened self-interest to continue investing in foreign aid. If societies can’t provide for people’s basic health, if they can’t feed and educate people, then their populations and problems will grow and the world will be a less stable place.”10 The Global Fund’s future impact is contingent upon the lasting support of donor nations to fuel essential treatment and prevention efforts for AIDS, TB and malaria across the world. “The Global Fund made financing global health the baseline and an expectation, which is a hugely important transformation,” says Alanna Shaikh, MPH, a 2011 senior TED fellow and international aid worker in Tajikistan. “In the end, there is too much need and not enough money. It is not realistic to expect the poorest countries to provide for diseases like MDR-TB [multidrug-resistant tuberculosis] and XDR-TB [extensive drug-resistant tuberculosis]... there is no earthly way they will ever have enough money to afford such costly treatments,” says Shaikh.11 The imperative to maintain efforts to combat specific diseases and thereby strengthen entire health systems is what may drive forth greater international

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appeal for sustained and possibly even increased funding. While the financial crisis has certainly cast a shadow on the future of the Global Fund, there have been great strides toward effectively addressing AIDS, TB and malaria in the most affected communities. “Accountability is an important part of the Global Fund model and the global community, new donors and countries need to step up and respond even in these trying times,” says Dr. Prerna Banati, former Senior Technical Specialist at the Global Fund.12 In the decade since its inception, the Global Fund has saved millions of lives and supported vital treatment programs in affected areas around the world. Though the Global Fund’s efforts are not without flaws, it has had tremendous impact in transforming disease treatment and disaster relief into a global responsibility rather than a local burden. In the coming years, the United States can be a world leader, as the largest single donor to the Global Fund, by pushing other countries to meet their commitments and ensuring that the Fund has the resources it needs to maintain and expand life-saving treatment programs.13 Sustained financial support from donor countries will be necessary to save millions more afflicted by AIDS/ HIV, TB and malaria.

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An Interview with Executive Director of UNICEF

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UNICEF was created with the purpose of “working with others to overcome the obstacles that poverty, violence, disease, and discrimination place in a child’s path.� How have your previous roles in national security and advising influenced and been beneficial to your leadership position at this organization? I think it was useful, certainly, in teaching me a lot about the world and

issues. Having positions like that is the greatest seminar you can imagine about American foreign policy and about international events. And it helps me wrestle with a dilemma at the heart of a lot of our work here. One of the reasons we are able to work in almost every country is that we are known for being non-political. So we need to be able to understand politics well enough to stay

out of politics. My previous life helped me see where the red lines are that we shouldn’t cross. Another dilemma that we have faced is that we have to be relentless in our advocacy for children’s rights— but diplomatic enough to avoid governments’ putting an end to our programs for children in those same countries. I suppose that previous training as a

'# diplomat helped me with addressing that part of the job. As a foreign policy adviser to President Obama during his 2008 presidential campaign, has your vision of U.S. involvement abroad come to fruition during Obama’s presidency? And, with the upcoming presidential elections, what humanitarian foreign policy do you think should be a priority for the next president of the United States? Yes, I was a principal foreign policy adviser—the other was Susan Rice—but as I said, in this job, I am determinately non-political. In connection with the discussion of equity and rights, I think one of the most important aspects of that is, while we need to be unrelenting in advocacy for the rights of children, at the same time we have to avoid the perils of orthodoxy because what we believe is less important than what we achieve. The point is to be persuasive and to concentrate on our programs to benefit children’s’ lives, and thus their rights, rather than to become seen as ideologues, which would interfere with our effectiveness. There is not and cannot be a clear distinction between humanitarian policies and development policies, and I would hope that, whatever the specific nature of those policies under the next president and the next Congress, they would of course take into account the needs of children because—I am trying to avoid a cliché here—what happens to children is going to shape what happens in the world in the next generation or two. More, these policies should increasingly focus, as UNICEF is, on issues of equity and reaching the poorest and most disadvantaged communities around the world. The reason I say this is not only out of principle but also because—and I want to emphasize this—it is practical and cost-effective. This is because where

the needs are greatest, you achieve the greatest results. For example, the same immunization program in an area with lots of disease is going to save more lives than the same program in an area of less disease. But, the conventional wisdom has always been that, while that may be true and while it would be “nice” to focus on those most endangered children, it’s too expensive and too difficult. So, we did a study—an exhaustive modeling exercise—that shows very clearly that the additional results in those areas are greater than the additional costs. Therefore, it is not only the right thing but also the cost effective thing to pursue a strategy of equity and, for example, to build health systems—not only from the center out, but to leap frog into reaching the poorest communities through village health workers and healthy community practices such as breast-feeding and hand washing. In UNICEF and the WHO’s recent report entitled “Progress on Drinking Water and Sanitation 2012,” it was announced that the UN Millennium Development Goal (MDG) of halving the proportion of people without access to clean water has been met, even before the 2015 deadline. What does this mean for UNICEF’s focus on water, sanitation, and hygiene, and what still must be accomplished? In your opinion, are the other MDGs in relation to child health experiencing a similar track to success? What it shows is that you can make progress. That should encourage us to persist rather than declare victory. The glass may now be half full of potable water, but too much of it is still empty. For example, almost 800 million of the world’s poorest women, men, and children still have little choice but to drink dirty water. Over one billion people around the world are still practicing open field defecation. We have made very little progress on the part of the Millennium Development Goal

that refers to sanitation, which in turns means that we haven’t made nearly enough progress on combating diarrhea that, together with pneumonia, is one of the two biggest killers of children in the world. So, we need to celebrate the progress that is being made but have to remember two things; one, that almost all of the MDGs are percentage goals, which is to say that we need to cut by two-thirds this or one-third that. This means that we always have farther to go. Secondly, we need to remember that all of the MDGs are based on national averaging, which often disguises the fact that within those nations, progress is generally more rapid among the better off than among the most disadvantaged. So, in many cases the gap between rich and poor in these various areas is widening, which is simply wrong. Statistical successes can be masking moral failures. Finally, with some of the MDGs, for example on sanitation or maternal health, we are lagging way behind where we ought to be. So let’s celebrate the relative successes as the progress they represent and the hope they represent for the future, but let’s also pay attention to all that needs to be done and work all the harder. UNICEF’s State of the World’s Children, 2012 emphasized the importance of protecting children in urban environments from the pitfalls associated with urbanization, including disparities in health, education, and opportunities. What are UNICEF’s priorities in focusing on children in urban environments, and what issues do you think will be the hardest to overcome? Well, the first priority is to encourage all of us to focus on the fact that rapid urbanization is inevitable and that inequities exist not only between rural and urban communities, but right there in the cities themselves—even if, too often, the disadvantaged are nearly

!"#$%&!$'( '$ invisible. Children in cities are very vulnerable to exploitation and disease For example, when families are living packed together in these squalid urban neighborhoods, diseases like TB can spread much more rapidly than they would in rural places. So, we are working hard to encourage governments and others to simply pay more attention to the plight of children in urban areas. The neglect of urban kids is reflected in the fact that one of our first challenges is simply to develop better and more disaggregated statistics as to where those needs are greatest within the cities, in order better to target interventions for education, sanitation, etc. Beginning with your official entrance of the post of Executive Director just two years ago, what has been your most memorable experience in this role? What do you view as your greatest accomplishment as Executive Director? Almost all my most memorable experiences came when I visited children in the most disadvantaged communities. These visits are very vivid, very memorable and—I mean this quite seriously— very inspiring. I say inspiring because the thing that always amazes me is how children living in extreme poverty, children who are malnourished, children who wish they could attend school and can’t - the children nonetheless find ways to laugh and to play—often with rags that they have tied together into a ball so that they can play soccer, what I find inspiring about that is their bravery. What I also find inspiring is the lengths to which their parents, especially their mothers, are going to try to get [their children] educated; or, as I saw in the drought stricken area of Kenya, and in the flooded areas of Pakistan, the lengths they will go to save their kids’ lives. What inspires me should also affect the attitude that we all have towards those children and toward those mothers. We see them far too often simply

as objects of charity or as patients to be saved when they come in to the clinics, when we should be looking on them not so much as victims but as people who are overcoming incredible challenges and odds that I’m not sure that I or my children or grandchildren would be able to overcome. So, we are not just offering them charity—we are offering them support. We need to see them for what they are, also, because after a lengthy period giving of charity, of pity, many people get fatigued. Support and admiration for their bravery may inspire us more to stay involved in the long run.

health and other issues. I was reminded at a recent event with Amartya Sen, when we participated in a debate as to the differences—and I don’t think there are any—between “equity” and “human rights”, of how much I enjoyed such discussions at Harvard.

As a graduate of Harvard College, how do you think your undergraduate career prepared you for a lifetime of involvement in public service? Is there anything in particular that you learned during your time at Harvard that has aided in your role as Executive Director?

I simply emphasize that, in the health field, we need to keep working on the development of new vaccines and innovation—the “supply side.” We also have to focus very strongly on delivery and reaching in to communities and, on the “demand side,” helping poor people access those supplies by reducing health fees and by giving them more access to health services through local community health workers. As to the next generation of young leaders in this field, they are well placed to build on the innovations that greatly extend our reach into the poorest communities is through advancements in information technologies. For example, we are using rapid SMS texting to help track nutrition patterns, track the movements of medical supplies and vaccines, greatly speed up getting the results of HIV testing to those who need them, remind people of appointments with clinics, etc. For the next generation of health leaders, bringing together those technologies with more traditional health practices is both a great challenge and a huge opportunity. I wouldn’t presume to suggest how to do that because your generation is so much better at it than I am. I will be excited to see this evolve in the future.

I think that what I learned most at Harvard that helped me throughout my career was not the study of issues that were directly relevant to my subsequent jobs, but the much broader education I got, which helped me develop my interests and which gave me more of a perspective on my work. I remember with particular pleasure and gratitude studying history and studying music and literature more than, without offense to the Government department, courses on government and economics. Those were things that I could learn in graduate school and in actual work. So, in short, I think there is no better preparation for any career than liberal arts. If you don’t have a broader sense of perspective about your career, I think you will be less successful in your career. Certainly, for my work here at UNICEF, courses in philosophy or courses that touched on human rights and issues of equity were very useful, as we discuss here at UNICEF thinking about the rights of children and debating what they mean when applied to

What issues do you believe have the greatest influence on the advancement of the global health field today, and what will the next generation of young leaders have to do differently in order to effectively resolve them?

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An Interview with Howard President of the Howard G. Buffett Foundation

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HCGHR: Much of your work has brought you to conflict areas in the world where most aid agencies would not consider going or are not able to go. What got you interested in these locations, and why did you choose to focus on agriculture? When we started the foundation, I thought that we should look at populations that are in the most difficult environments and that are the most disenfranchised. That automatically leads you to conflict and post-conflict areas. It leads you to refugees, IDPs (internally displaced persons), some of the immigration issues. So, for me,

it was just a personal decision that we should focus on those populations. In terms of agriculture, my dad always taught me to stay within what he calls your “circle of competence.” And my circle is really small! But one of the things I understand pretty well is agriculture. If you go around the world, the two most basic things that the poorest populations lack are often food – and many of those people are small farmers who don’t have the opportunity to reach the kind of levels of productivity they need to feed their families – and the other is water. We’ve done a lot of work on water, but that has been a big learning curve for me. On agriculture, I really felt like I understood the

basics and so it made sense for me to get involved in it.

HCGHR: Your Foundation is currently transitioning away from funding individual projects to focusing on more “transformative” ideas in development, as you put it. What is your vision for what a transformative project might be and what do you hope would be some of the pragmatic outcomes of this new approach? The reason we are changing our focus is we feel what we’ve done for the last ten years hasn’t worked as well as it should have. There are a couple

!"#$%&!$'( '& of things we’ve learned. One is, quite often, the people you bring in from the outside don’t understand the culture; they don’t really grasp all the issues that need to be addressed. And the other is that, at the end of the day, everybody goes home. How we’re trying to do it differently is, any project or activity that we fund, we really want to get three things out of it. First, we hope that we can come away with some really clear ideas about what will help us address policy issues so that when we can sit down with the Minister of Agriculture or the President of the country, we can say, “if you change these things, we believe they’ll have impact.” Second, on the agricultural side, you have to draw a line. There are going to be people above the line and people below the line and those below the line are the very poorest of the poor farmers – the subsistence farmers who are in very difficult areas to reach with very limited infrastructure. But you can take the farmers that are above that line and you can say your exit strategy is that they don’t need me anymore. We’ve really focused on projects in the last couple years where our efforts somehow connect those farmers who are just above the line to markets so that they don’t need our support anymore. Third, we think if we can show how those models work that we can advocate that those are the models that we need to bring to scale.

set certain goals to involve women. If it involves training extension agents or farmers in general, a certain amount of those need to be women. We’ve found it’s very hard to meet those objectives for different reasons. A lot of it is cultural because a lot of women don’t have the opportunity to have the same education. When you get into developing countries, you have an environment where sometimes women aren’t really even treated as human beings. They’re so often abused. They’re looked at as less important than sons within a family. My personal experience has been that oftentimes females will do a better job in many circumstances than many males do. So, I think globally we have a huge void in tapping into the most important skills and talents by denying females the same opportunities that males have. It doesn’t always work in everything we do, but where we can do it, where it’s appropriate, and where we can have some success, we absolutely try to look at this issue.

HCGHR: You mentioned in your recently published photo book entitled Fragile that gender inequality is one of the core issues that must be addressed in developing countries. Since gender inequality often has deep roots in certain societies, what approach has your Foundation taken to challenge norms and empower women across the world?

The first thing is I think that most Westerners don’t understand how to fund sustainable development for a continent like Africa. So, the starting point is we’ve got to get that right. And right now, I don’t think we’re getting it right. One of the big mistakes we make is we look at agriculture and think agriculture is agriculture. It’s not. Agriculture is about soil, it’s about microclimates, it’s about infrastructure, it’s about the impact of different inputs on different circumstances, it’s about training, it’s about education. So, it’s this big array

In most of the agriculture projects we’re involved with, we have actually

HCGHR: You are primarily interested in global food security, but you bring up in your book the challenging notion of a “conflict-resistant seed.” How do you balance the pressure to provide essential food aid with the need to address the roots of conflict that hinder more sustainable development?

of pieces that are all put together into a system to support the best way to farm based on local conditions. People in Western cultures need to understand that our way of doing things is not always the best way of doing it somewhere else. [Providing food aid and addressing the roots of conflicts] is a really difficult thing to balance out. The dynamics can change in an environment so quickly that you can be bringing food aid into an environment or situation where four months or three months earlier it was the right decision and by the time you get there things are different. So, the really key thing in food aid is to do your best job that you can at making sure the people who need it the most get it and that’s difficult. The flip side of it is also trying to make sure that you don’t deliver it and undermine local farmers and local markets. You can’t always predict the situation and the circumstances, so you don’t always know how that’s going to play out. That’s why it’s so challenging. Take an example from south Sudan during the war a few years ago. There was a village of several thousand people that were clearly starving, and some rebel group surrounded the village with land mines so no one would walk outside the village. They had this captive environment and if they did nothing, everybody would die and it’s a pretty painful, slow death. If they did do something, they also knew that those villagers would not get 100% of the food. So, it’s not always black and white in a situation like this; it can be pretty difficult. Do you let 2,000 people die because they are only going to get 70% of the food aid? It’s a really tough decision, and there isn’t necessarily a right or wrong decision either. I think when you talk about food aid, you get into a lot of situations where, number one, you’re working in horrendous conditions and, two, you don’t always know all the dynamics of how they’re going to play out. I think we have an obligation to help people in

)( the best way we can under the circumstances that exist. Circumstances are always far less than ideal and I think a lot of times people forget that.

HCGHR: Corruption is a major source of lost funds and lost trust in the developing world. What has been your personal approach to fostering principled leadership and partnerships that are committed to successfully combating hunger, poverty, and injustice? Once the corruption permeates a society, it is very difficult to get it out. I think for us to have any success longterm, you have to have good, clear land ownership. You have to have a system that protects land ownership so that you can transfer titled land and be sure that it’s respected. You have to be able to borrow against that land so that you can use it as an asset to build equity. You have to have rule of law. When you’re working in an environment and, in Africa’s case, in a continent where most of those things don’t exist, what happens is you constantly find ways to work around them. And that’s the huge mistake we’ve made for many years. We haven’t been willing to be politically incorrect and stand up and say things people don’t want to hear. I can tell you from personal experience, sometimes those things get misinterpreted and that’s very frustrating. If we aren’t willing to stand up and challenge the status quo and challenge it for the right reasons, then we will never be successful. We have to have the leadership to stand up and say things that aren’t popular, whether it’s in agricultural development or protection of our natural resources. We have to change the debate or it won’t get fixed.

HCGHR: Many current financing projects in global health and development are considered to be unstable or unsustainable. How do you think

funding strategies should change more people out of poverty at a rate that it needs to and sometimes not at all. If it broadly? I think people have to realize that if we just keep giving money the way we’ve done it, you’re going to get the same results. I think it was Einstein who said the definition of insanity is doing the same thing over and over and expecting a different result. That’s what we’ve been doing in development for 30 years. That’s what we’ve been doing in agricultural development in poor countries for 30 years. When we talk about what we do, what we spend our money on, we’re talking about trying to change lives. We’re talking about trying to help people feed themselves better for the long run. But you don’t hear people talking about exactly how they’re going to do it differently and what are they going to do differently. And part of that may be some really difficult decisions. Even though we want to help everybody we can help, is it the right long-term decision? It may always be the right shortterm decision. But if we haven’t figured it out by now, even particularly in this country, that short-term thinking doesn’t help create long-term solutions, we are blind. We have to do things differently. The problem in doing that is doing it in a way that you keep the dialogue open, because if you get too radical about it, people are going to close the door. They don’t want to talk to you. So, it’s a frustrating, difficult process. But I really don’t see how donors today can sit back and keep funding the things, the processes that have gotten us frankly not very far in terms of the goals that we set. We are not going to hit any of the Millennium Development Goals, not in the way or at the scale that they want to hit. We can pick individual countries and some of them will hit some of the goals. But, we set these goals and we keep doing things the same way. I’m saying that the status quo is not sufficient. The status quo is not pulling

takes upsetting a few Ministers or some other people to get things to change, then that’s what we have to do. I think human nature is to accept things that aren’t affecting your life, and to pretty much not want to rock the boat. And, my God, we better rock the boat because, if we don’t, we are not going to change the way the world looks.

HCGHR: Many students of our generation aim to be future global leaders involved in the areas of public health and development. Based on your experiences, what do you think these up-and-coming leaders can do to help achieve the goals of global justice and equality? Well, the first thing is they shouldn’t talk to me! I’m way too pessimistic about getting it changed. I think the thing that actually does give me hope is looking at some of the younger generation that I’ve met and visited with. They still have an incredible amount of hope. They are probably the single most inspiring thing that ever happens to me because I see that there’s a whole generation coming that will have better ideas, that will have different ideas. They won’t accept the status quo. In today’s world, they understand social media differently than I will ever understand it. They can use that as a tool to change things in a way that I would never know how to do. Actually, it’s the younger generation, it’s the students today at Harvard, it’s the students across this country that are determined to make something change that really give me the hope that maybe it can be done because, like I said, I’m pretty pessimistic about how things have been done. A generation of different thinking and a generation of different tools for their use – maybe that is what it takes to change things because we haven’t done it in my generation.

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Harvard’s “Aid for Healthâ€? Simulation in its Third Year 5/.?"((&%<+.:'4%7("(:"+.(%6/>L+(>4%J(+%91.%Z/?4%B(2+>%8/D("3/$? @'(%/1&'#",%/"(%&'(%2#E=#1.*(",%#=%9+*%!#"%8(/>&'4%&#:(&'("%F+&'%;1+L(%N1+$/"/(,%F'#%F"#&(%&'(%#"+:+./>%2/,(%$/&("+/>%/.*%2#E#":/.+L(*% –Š‡ ÍšÍ˜Í˜ÍĄ •‹Â?—Žƒ–‹‘Â? ’‹Ž‘–Ǥ Č? ĆĽÂŽÂ‹ÂƒÂ–Â‹Â‘Â?•ǣ ‡•– ‡”–• ”—•–ǥ Ǣ ƒ••ƒ…Š—•‡––• ‡Â?‡”ƒŽ Â‘Â•Â’Â‹Â–ÂƒÂŽÇĄ ‘•–‘Â?Ǣ Š‡ ‘”Ž† ƒÂ?Â?Ǣ Â?‹˜‡”•‹–› ‘ˆ `#&,F/./Q8/"D/"*%<2'##>%#=%71G>+2%8(/>&'Hs%%

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ast March, at Harvard’s Kennedy School, the Prime Minister of Malawi and his key ministers met representatives from the country’s main foreign donors for the negotiation of an aid package to help the country achieve internationally agreed targets for health development. In this situation, however, the Prime Minister of Malawi was Harvard professor Stephen Marks, playing the lead role in Aid for Health (A4H), a student-led simulation exercise meant to transform the way global health and development are taught across academic disciplines and schools. The idea for A4H emerged from discussions at the Harvard School of Public Health (HSPH), following a presentation on practices and politics of health aid during which presenters and students realized that existing coursework did not cover these issues. While Harvard certainly does a great job of teaching the core skills of public health, students were concerned that they were not sufficiently prepared to enter the professional world of global health with its crowded landscape of institutional agendas, mandates, politics, and programs. This gap between professional prospects and academic preparation is especially peculiar given the large number of Harvard alumni working for the WHO, CDC, USAID and other international organizations. Instead of developing a conventional academic course on these issues, the decision was made

to experiment with practice simulations, role-playing, and “dramatic immersion.� As every aid practitioner knows, technical knowledge is rarely sufficient to navigate interactions at country level. These tend to be highly political and socially complex, requiring skills that cannot easily be taught in a traditional classroom environment. At Harvard, A4H has been put into practice since 2009 by members of the Global Health Student Forum with staff and faculty support, with the objective to provide students with a unique interdisciplinary experience. From year to year, the simulation case scenario continues to evolve, but in its basics remains the same: The “Prime Minister� calls a meeting of all the major international donors and stakeholders in the Malawian health sector. His goal is to coax foreign donors into increasing their aid allocation for Malawi while preventing them from attaching too many conditionals. Issues such as Malawi’s acute shortage of health care workers and lagging progress on its MDG targets for health topped the agenda this year. The fourteen A4H participants this year came from Harvard, Boston University, MIT, Tufts, and Boston College. Each participant was assigned to a delegation and role to impersonate. Even before the actual negotiation, all participants underwent a special training session by MIT’s Lawrence Susskind, founder of the Consensus Building

Institute and one of the world’s most prominent experts on negotiations. Additionally, they were matched with aid practitioners and expert coaches for further preparation. At the beginning of the meeting, the “Prime Minister� welcomed all delegates and immediately issued the challenge: Malawi needs more aid to improve the health of its people. Though the international community had declared global goals for development, donors had not provided the money it would take for developing countries to actually achieve them. Moreover, the donor countries had signed declaration after declaration claiming that they would change their ways – most notably by increasing country ownership and working through existing systems. In the three hours that followed, the Ministers of Finance and Health tried to persuade bilateral donors, UN agencies, and development banks to commit more money and allow the country to decide where and how that money would be spent. Everyone strived to think beyond zero-sum-benefits for mutual gains. It was a much messier, challenging process than expected or reflected in textbooks. Many students looked stressed but also excited, and laughter filled the room when someone briefly slipped out of character. For many participants, this experience not only transformed their understanding of the issues but also affected their career planning. A4H might be a new and unique

)) experience at Harvard, but simulations and role-plays are already widely recognized as effective learning tools. They are frequently used in industries where it is desirable to program reflex responses in stressful situations (i.e. the airline industry, the military, or in critical care medicine) as well as in business and management. In the area of development and health, simulations have so far not been pursued. Simulations are particularly suited for learning intangible skills that are not easily taught through didactic methods. Critical thinking is difficult to learn in the absence of direct application and social interaction. Few would argue that “leadership skills” or “teamwork” are best taught by committing to memory a list of key features of great leaders or well functioning teams. In addition, in situations in which there are serious

consequences, they are skills that ideally should not be learned on the job. In group role-play simulations, participants benefit particularly from observing and interacting with their peers in a dynamic environment where they have ample opportunity to evaluate successful and unsuccessful strategies for dealing with novel problems. Importantly, they receive immediate feedback on the consequences of their positions in a forgiving, friendly atmosphere. As Nadler et al. (2004) found, negotiators who learn through peerobservation are considerably more successful at achieving negotiation goals in comparison to those who learn through didactic or analogical methods. Learning via simulation thus allows process rehearsal that is beneficial and informative, but also allows for critical experimentation. The opportunity

for reflection and structured debriefing while the experience and the immersion are still fresh is vital. Early in the process participants typically pursue “positional” tactics to persuade others. Later on, they begin to appreciate the value of reaching consensus and achieving “winwin” outcomes. Without the interactive emotional experience of the simulation, the value of these principles would be difficult to realize. Overall, apart from being an enjoyable way of learning about international affairs, the A4H simulation also reflects a broader move away from classroombased education towards a more fluid, learner-oriented, and experiential form of learning that may better equip students to become change agents and leaders.

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Reconstructing Lives:

A Broader Perspective on Global Health 9>(f/.*("%WM1 8/"D/"*%5(*+2/>%<2'##>

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round the world, not far removed from the broadlybased endeavors of public health experts and infectious disease specialists, plastic surgeons are operating to change lives in ways that statistics cannot fully capture. Unlike many parts of global health, the impact of plastic and reconstructive surgery on patients is characterized by profound depth, as opposed to breadth, which more easily lends itself to headlines. Specifically, although plastic surgical procedures often do not save lives, sixty-six percent of global disability-adjusted life years (DALYs) lost are attributable to conditions treated by plastic surgeons.1 Furthermore, the suffering these disabilities cause is often not effectively captured with DALY measures, the standard for most literature on global health morbidity. Yet, just beyond the reach of global public health initiatives, masses of patients suffer functional and developmental deformities in communities that are underequipped to perform the necessary reconstructive treatments. Plastic surgeons from the US and similarly developed nations frequently take time away from their domestic practices to travel and address these needs through practice and education; even though demand still eclipses supply, these individuals’ efforts are integral to global health. To understand the need for plastic surgical care in the larger global health arena, the lives of affected patients should be examined. Consider a oneyear-old boy with a cleft palate, born to a middle class family in Vientiane, Laos. His condition is not life threatening and

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thus is unlikely to receive care through any easily accessible sources. Yet, without surgical care in his near future, his speech will permanently suffer, drastically limiting his potential. With a skilled surgeon, this child’s life course could be dramatically altered in just two hours. A similarly high-impact case was successfully addressed by Dr. Stephen Sullivan, of the Alpert School of Medicine. As Sullivan told the HCGHR, a Haitian woman had been brutally burned on her face, neck and arms after igniting a kerosene lamp, which had accidentally been filled with gasoline. These burns had confined her to nearly two years of inpatient burn care, which had ultimately failed to heal her massive open wounds. It was not until she received skin grafts, performed by Sullivan on a volunteer trip, that she was able to return to her home and resume a normal life.2 Similar cases abound throughout less-developed countries. Given that the need for this care is tremendous, the

question then becomes: how can this be addressed effectively and sustainably? Plastic surgeons, like Drs. Samir Mardini of Mayo Clinic, Helena Taylor of Alpert School of Medicine and Dennis Orgilliv of Brigham and Women’s Hospital, are determined to spend time offering their skills abroad in order to serve pressing global needs, despite their hefty institutional case loads. They generally do so in the context of one- to two-week-long trips organized by their institutions or by charitable organizations. Along with Sullivan, these surgeons have treated hundreds of international patients–from earthquake victims in Haiti to previously-untreated middle-aged patients with facial deformities in India–but is this current model the most effective for serving the world’s plastic surgical burden? Like many other global health efforts, on the ground, the reality of this approach to care is simultaneously beautiful and tragic. Young surgeons often travel abroad

)! with the drive and enthusiasm to handle a continuous deluge of operations, and they are met by lines of patients, often hundreds long. From an idealistic approach, this isn’t initially a problem. As Mardini reflects, “the great thing about plastic surgery is the ability to treat ailments from head to toe.” 3 Despite the absence of much of the surgical technology available in the U.S., plastic surgeons are still uniquely able to perform many life-changing surgeries. Taylor echoes this sentiment: “[a plastic surgeon] can still do a lot with just the scalpel, pick-up and needle driver.” 4 However, hopes of addressing each patient’s concern collide with the reality of global health work all too soon. Even with extensive experience and the efficiency that comes with it, surgeons are unable to meet the massive need for their services in the relatively short time that these trips give them. They must resort to various methods of prioritizing patients: Mardini described to the HCGHR a numeric scale used by his teams to prioritize the potential developmental and functional restoration of his cases. Safety and a patient’s ability to maintain post-operative care are also considered, with some acknowledgement of aesthetic needs as well.3 The complexities of triaging, however, are a mere subset of the many considerations in orchestrating a successful service trip and, more importantly, in making a longitudinal impact. As all four surgeons told the HCGHR, political and cultural factors are strikingly relevant. Orgill receives many requests to meet from government officials and hospital administrators; he generally accepts, in order to better understand the local culture and to ensure that logistics flow smoothly. Although he is not I

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operating, he explains that this time is not wasted because collaboration with local surgeons and nurses is essential to providing a lasting impact. To that end, Orgill notes, “You simply can’t come in and say you’ll do it our way or the highway.” 5 Instead, teaching and learning flow reciprocally among all involved health professionals. Orgill has also participated in a mission to teach microsurgery to Vietnamese surgeons and, in the process, became aware of a painful reality: these surgeons stood only sustain their practices through cosmetic surgeries, as the government largely did not reimburse for reconstructions.5 Structural healthcare issues like these present a significant barrier to meeting global plastic surgery demand, which means that teaching local surgeons how to perform new procedures is only part of the solution. Taylor was forced to confront the structural barriers of disaster management when she found herself struggling to find an unoccupied operating room

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in post-earthquake Haiti, despite the constant influx of patients and doctors.4 Considering the experiences and contributions of plastic surgeons to global health, a formidable case can be made for their integral nature in the field, which is different, but no less important, than other medical specialties. The adaptability of their procedures to various contexts is notable and means plastic surgery has a high utility among many patient populations. However, there are presently multiple barriers which prevent the provision of care by local physicians, which is ultimately the most sustainable strategy for plastic surgical care. At this time, a combination of teaching and operating by foreign surgeons seems to be the best alternative. The next time “global health” enters a conversation, it is important to recognize the expansive scope of the field, which goes far beyond treatment of pandemic diseases to include profound impact on individuals’ lives and a diversity of involved medical professionals.

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Social Movements and Health System Reforms: The Impact of the Arab Spring in Reconceptualizing Health Delivery in the Middle East+ Sonya Soni, MPH Harvard School of Public Health

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n January 2011, the fast food chain Kentucky Fried Chicken was ironically transformed into Tahrir Square’s “KFC Clinic,” a makeshift healing center where Egyptian physicians and medical students volunteered their services to treat wounded protestors regardless of their socioeconomic status, religious identity, education level, or gender.1 The grassroots clinic served as a rebuke to the systemic injustices that burdened Egypt’s health care system long before the Arab Spring revolutions, which occurred in countries comprised of rapidly growing populations whose health crises are exacerbated by high unemployment rates, lack of food security, political corruption, and depleting

and mismanaged resources. Khairy Abdel Dayem, chairman of Egypt’s Medical Association, calls Egypt’s hospitals dysfunctional due to the absence of high-quality equipment, lack of trained health professions, and the mandate of patient user fees.2 With pervasive optimism for social change stemming from the Arab Spring in the midst of the Middle East’s deteriorating health systems, significant unanswered questions remain. Do broad social movements generate enough political will for non-democratic governments and social institutions to address health system reform? Is health system reform sufficient in these countries, or can the Arab Spring’s call for a political

revolution translate to a revolution of health system management and delivery of care? What new paradigms and lessons from social movements such as the Arab Spring inform how crumbling health systems should be restructured? Health systems undergo extreme stress when they attempt to provide public health services in a tumultuous political environment such as the Arab Spring. Conversely, political destabilization provides the opportunity for protestors, patients, global activists, and other stakeholders to fight for more just and effective public health systems. The redevelopment of health systems in post-conflict nations as a result of social movements has historically addressed acute and long-term population health needs, the state of health care infrastructure post-violence, and health work force strengthening.3 Furthermore, social movements are incited by both individual and societal suffering. This demands a wider lens that deconstructs categories normally construed as separate discourses in health system reform, such as the ‘medical’, the ‘legal,’ the ‘moral,’ the ‘religious,’ the ‘political,’ and the ‘economic.’ Since both social movements and inequitable health care systems arise from similar sources of structural violence, the Arab Spring has been central in redefining the health care system for both the people in power and the powerless. For the powerful, an early commitment to health system reform is one of the most effective tools new governments can use to prove their legitimacy

)# to their citizens and the global public.3 For the powerless, democratic transitions can create opportunities for social change coupled with community empowerment and hopes of redistributive justice. Social movements such as the Arab Spring provide a physical and conceptual space for the voicing of collective traumas, such as denial of access to basic primary care services. Within this space, Arab citizens have begun to reconceptualize their role and identity in society, as well as their relationship to their countries’ social public institu-

“Social movements such as the Arab Spring provide a physical and conceptual space for the voicing of collective traumas, such as denial of access to basic primary care services.” tions, including their health care system. Social movements alter the framework for addressing social inequalities from a technical development-based perspective to a human rights-based approach, which highlights structural issues, not simply technical inadequacies of the country’s health system.4 Hoda Rasha, director for Cairo’s American University Social Research Center, member of the World Health

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Organization’s Commission on the Social Determinants of Health, and Senate member of the Egyptian government, professes that the Arab Spring transformed Middle Eastern perceptions of social services such as health care from a welfare or charity-based approach to a rights-based model.4 As a result, she predicts that impoverished citizens will be awarded new sustainable opportunities in education, employment, and security, and eventually will be able to better recognize and demand their right to health services.4 Health professionals who participated in the Arab Spring uprisings argued that health systems are as central as their justice systems to the democratization process of their governments, and that rights-based reform can lead to effective, integrated, and accessible health systems in the Middle East.5 By redefining how health care should be structured, Egypt’s dedicated health professionals attempted to expand the visionary and administrative power of stakeholders beyond the State, such as patients and health professionals.5 Dr. Charles Clements, executive director of the Harvard John F. Kennedy School of Government’s Carr Center for Human Rights and former president of Physicians for Human Rights, echoed this sentiment in an interview with the HCGHR: “The framing of many social welfare issues into a rights-based framework allows the world to see the marginalized as protagonists rather than

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subjects of oppressive systems. That gives them agency to make social change, as opposed to when they are labeled as passive recipients of generosity bestowed on them.”6 Clements argues that social movements have historically contributed to drastic changes to public health.6 However, he hesitates to confirm whether social movements have brought drastic changes to the organization and management of health systems, cautioning that “it is still a little too early to tell if the Arab Spring will have a significant impact on the countries’ health care systems.”6 Rasha also believes that changes in Egypt’s health system are improbable until power rests in the hands of a new president, which may occur as late as 2013.4 She notes, “At present, in our efforts to improve people’s health and well-being, Egypt is very much healthsystems driven, rather than taking an approach that involves the whole of the government including the health system. [This] allows you to see the big picture, but not the inequities in different social groups or the structural determinants beyond the health system, such as unemployment, lack of education, and poverty.”4 If the spotlight shifts from health system inefficiencies to a demand for health equity, the Arab Spring’s call for freedom and democratization will likely transform into improved health outcomes for the marginalized in the Middle East.

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Basic Science as a Global Health Tool: Lessons from an Innovative Harvard Life Sciences Course

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hen Dr. Barry Bloom was first invited to a special meeting on leprosy by the World Health Organization (WHO) in India many years ago, he saw how his bench-science discovery of the first cytokines made from T cells might have a greater potential for applications outside the lab. The WHO believed these small cell-signaling protein molecules might hold the key to a cure for leprosy. Although this hope did not exactly manifest itself, following this initial immersion into the world of global health, Bloom reflects, “I never got over it.”1 Now serving as a professor at the Harvard School of Public Health and head of a tuberculosis laboratory, Bloom seeks to instill this love for the intersection of global health and basic science research in Harvard undergraduates. Along with Dr. Richard Losick, a Harvard professor of molecular and cellular biology, Bloom has organized a unique and transformative course in the Harvard life sciences curriculum entitled “Global Health Threats.” Responding to a growing need in global health, this course is intended to inspire student scientists and arm

them with the tools needed to solve the world’s most challenging global health problems as they pursue their scientific careers. Speaking to the decline of expertise in science, Bloom lamented that the WHO itself has suffered from a crowding of the field of global health and a decline in funding, causing it to abandon its mission for building a professional community of scientists. In fact, Bloom believes that a failure to

vaccine...is [one major] consequence.”1 As Dr. Ravi Raju, a teaching fellow for the course, views it, Bloom and Losick were inspired by the lack of basic scientists in the field who could be responding to the needs of the poor. “While direct care, advocacy, and policy work are all essential pillars of an effective attack on poverty and poor health abroad,” Raju noted, “there is a clear need for developing new technologies

“There is no single discipline that’s going to solve any major global health problem.” involve scientists in policy judgments at the WHO is what led partly to the devastation by cholera after the earthquake in Haiti.1 “Lots of people died because there was a bad scientific judgment,” Bloom told the HCGHR. “Not realizing what vaccines were available, what kind of cholera it was, and that it was going to kill as it is now 7,000 people, many of [whose deaths] could have been prevented by a vaccine, even if not a perfect

to improve our toolset at tackling the myriad of challenges.”2 Unlike many other thriving global health courses at Harvard, “Global Health Threats” is not a general education course. In fact, with its three science prerequisites, it was designed to be a rigorous course for students with a foundation in the sciences. The course is taught in modules, each of which covers a major disease of the developing world: pandemic influenza; diarrheal diseases;

)% tuberculosis; malaria; and the looming threat of metabolic diseases.3 Bloom and Losick drew from their respective science-informed public health and microbiology backgrounds to purposefully craft this course wherein each disease is explored through molecular biology mechanisms, epidemiology, and drug discovery as well as public policy and economics. “I think that is what’s exciting or, I hope, is somewhat novel in the presentations here,” Bloom told the HCGHR. “There is no single discipline that’s going to solve any major global health problem.” This is why the course was made into a scientific as well as multidisciplinary survey of major global health disease threats.1 The course’s cross-disciplinary nature especially manifests in its integration of instruction by guest speakers from across Harvard University and its affiliated teaching hospitals. The guest lecturers are often leading experts on the different diseases covered in the course, and they range from molecular biologists and clinicians to epidemiologists and vaccine developers.4 Speaking about the broader goal of enlisting guest speakers, Losick explained to the HCGHR, “I think it opens [students’] eyes to a wide range of individuals across the whole of the university that they can draw on for advice and interact with, as I think many of the students in the course are doing.”4 Dr. Walter Willett, a physician and I%

nutrition researcher who spoke about obesity and metabolic disease in one of the lectures, told the HCGHR about the importance in his work of bringing together science and skills from global health. Along with scientific data on genetics, he said, he needs data on social factors to really understand the impact of diet on disease risk: “to really understand why people get disease, you need to put all of those pieces together and that’s what we’re trying to do,” Willett explained.5 The culminating feature of the “Global Health Threats” course is a final paper in which students must write about a disease not covered in the course and imagine themselves to be the Minister of Health of an underdeveloped country where there is an outbreak. Applying the principles and concepts they learned in the course, students are to integrate their knowledge on that topic and come to a solution for the disease by way of both molecular mechanisms and public policy structures.1,4 Danai Chagwedera wrote her final paper on drug addiction and targeting the genetic and neurobiological determinants that make people prone to the disease. Chagwedera was born and raised in Zimbabwe and took the course as a senior concentrating in Human Developmental and Regenerative Biology because she has always been interested in global health.6 Chagwedera told the HCGHR in

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an interview that she has enjoyed the course because it has a strong global and public health component as well as a prominent molecular biology component. “Most classes would compromise one or the other,” Chagwedera suggested. “It’s rare to find a course that combines the two, and it’s a nice stepping stone for me because translational medicine will be my life.”6 Chagwedera will be pursing her MD/PhD at the University of California, San Francisco starting this fall. Given her interest in studying infectious disease while training to become a doctor, she is an ideal example of the type of student Bloom and Losick hoped would be drawn to the course. She acknowledged that many students at Harvard, like her, are very interested in both science and global health and would also benefit from the course.6 Course teaching fellow Jason Zhang argues that this course is important because it shows students that no matter their broader academic pursuits, there will be intersections between their field and global health in unforeseen but tremendous ways. In an interview, Zhang broadly urged students: “no matter what you are pursuing, dream about how your goals can be practically applied to affect people.”7 Losick agrees: “because our knowledge is still so incomplete, [global health] is a wonderful area for young people to go into and to bring to bear a wide variety of expertise.”4

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The Devastations of Stillbirth:

Defining the Global Tragedy W/2'(>%</?+"(

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espite wide-ranging improvements in obstetric care, the ability to give birth to a live baby has been largely absent from the maternal health agenda: stillbirth is a tragedy that afflicts mothers, after months of expectation and anticipation, with a sweeping and startling sadness. Plaguing both the developed and developing nations, stillbirth is a pervasive but surprisingly overlooked problem. Its causes vary between developing and developed nations, however, and so do the interventions it requires. The trouble in addressing stillbirth lies largely in its definition. Even within the United States, the classification of stillbirth varies in each state, making it extremely difficult to understand the scope of the problem. In an interview with the HCGHR, Catherine Spong, the author of “Stillbirth” and Branch Chief at the National Institute of Child Health & Human Development at NIH stated, “In some states the pregnancy has to last twenty weeks; in others, it has to be five hundred grams; other states it’s twenty-four weeks and even five months

in some, whatever that means.”1 This lack of standardization caused by the wide array of classification systems makes it extremely hard to locate the root causes of stillbirth. The global context magnifies these issues. In countries without readily available medical facilities, fetuses may not be delivered immediately after death, and maturation in the womb hinders the ability to discern their exact weight. Furthermore, without regular medical visits the mother may not know the exact stage of her pregnancy. The

Professor of the Practice of Public Health at the Harvard School of Public Health, remarked, “very often, the mother just stops feeling the fetus’s movement and then goes to a health clinic where they discover that is a stillbirth.”2 This is a distressing and disturbing experience for many women but basic research on prevention is obstructed by a lack of a common vocabulary. Langer noted, “this is an issue that could be potentially solved if people came together to agree on basic definitions, but that hasn’t happened yet in this field.”2

“The trouble in addressing stillbirth lies largely in its definition.” constructive classification systems for high-income countries, although not yet fully developed, rely on technology and a level of care that is unavailable in many places. In an interview with the HCGHR, Dr. Ana Langer, the leader of The Women and Health Initiative and

Building on the complexity of standardization, the circumstances of stillbirth are quite different between developed and developing countries. Data collected by the WHO suggest that the highest rates of stillbirth occur in South Asia and Sub-Saharan Africa.3

*( those countries the health systems are very weak, and therefore there aren’t enough trained providers, facilities, supplies, or all of the above. And at the same time women have poor access to whatever services do exist.�2 The disparity in stillbirth rates between developing and developed nations indicates a clear difference in the causes of these tragedies. Still, further research in obstetrics is needed: in the United States, a large portion of stillbirths occur as a result of unknown causes. Inequities in stillbirth rates do not just exist between developed and developing nations: they exist within the United States as well. The current stillbirth rate in the United States is approximately two to six per thousand deliveries at twenty 9%?"(:./.&%F#$/.%,+&,%#1&,+*(%&'(%*##"%#=%'("%'#$(% weeks’ gestation or greater.4 +.%[.*+/H%!"#$%&'()"*)+?()K-'%1.&D):<"%"'<-$&4 However, the stillbirth rate among black women in the United In developing countries, most stillbirth States is between one and eleven per cases are associated with obstetric com- thousand deliveries, revealing a huge plications, issues for which solutions racial disparity. Because of the comhave been found with the advance- plexity of classification that surrounds ment of care in developed countries. In the reporting of stillbirth, the causes addition to complications arising from of this difference are largely unknown. a lack of obstetric care, a large propor- However, Spong remarks, “If you look tion of stillbirths occurs during deliv- across preterm births, stillbirths, and ery, “a clear indication of a very poor infant mortality, there is a disparity quality of childbirth care or a lack of a across all three where there are higher skilled attendant,� according to Langer. rates among African American women “It’s a network of factors,� she says: “in than non-African American women.�1

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This imbalance affects all obstetrical conditions and many medical conditions as well. Stillbirth is an issue riddled with disparities and varied definitions, making it difficult for maternal health organizations and researchers to effect change.

“Further research in obstetrics is needed: in the United States, a large portion of stillbirths occur as a result of unknown causes.� However, much can and should be done to reduce stillbirth rates, taking into account the context in which they occur. Countries without a functional health care system require basic infrastructure development in order to establish a setting in which mothers can access treatment and evidence-based interventions.1 However, according to a series published by the Lancet highlighting the global rates and causes of stillbirth, the mission of stillbirth prevention alone cannot garner enough support to implement these critical programs, so the issue must be integrated with broader programs that attempt to reduce maternal, fetal, and neonatal mortality.5

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Evaluating Recent Developments in HIV Drugs and Vaccines 9.*"(F%;(/

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n 1984, just three years after the first case of AIDS was reported, US Secretary of Health and Human Services Margaret Heckler optimistically projected: “we hope to have a vaccine [against HIV/AIDS] ready for testing in approximately two years.”1 Twentyeight years and sixty million HIV infections later, it is clear just how inaccurate this initial prognosis was.2 The past year, however, has seen groundbreaking advancements in HIV/AIDS research, marked by promising developments both toward a preventative vaccine and in “treatment as prevention” with antiretroviral therapy. Although this recent progress is likely to make historic strides forward in treating and preventing HIV/AIDS, practical issues surrounding the real-world effectiveness of these advancements remain a key challenge in addressing the HIV epidemic. Hailed by Science as the “2011 Breakthrough of the Year,”3 the HIV Prevention Trials Network (HPTN) 052 study demonstrated that antiretroviral drugs (ARVs) could be used not only to treat HIV-infected people but also to reduce HIV transmission between serodiscordant (one infected and one uninfected) heterosexual couples by 96%.4 It was the degree of this reduced transmission that brought the study to international attention and made it a “gamechanger”5 in the treatment and prevention of HIV. As Dr. Myron Cohen, the team leader of the study, told the HCGHR, “had the result been only 20% then people would not call it a ‘gamechanger,’ but

the result was just so powerful.”5 Before the HPTN 052 study, `1**+.:%8[e%D+"1,(,%#.%/%>M$?'#2M&(H%A.>+3(%?"(D+#1,% the question of whether ARV ơ ǡ ͘​͙͘ drugs could reduce transmission +./2&+D/&+.:%&'(%(.&+"(%8[e%D+"1,H%!"#$%&'()"*)%<&)!&.L %&$')*"$)M1'&-'&)!".%$",)-.=):$&7&.%1".4 in addition to treating patients remained contentious, but such unambiguous results put much a vaccine, and there is no alternative.”5 of this debate to rest. Although the use Just months ago, Dr. Chil-Jong of ARVs to prevent mother-to-infant Kang, a professor at the University of transmission dates back almost 15 years, Western Ontario, announced that his Cohen’s study stands out as large-scale team passed a significant landmark in and convincing support for the preven- developing a vaccine.7 Their HIV pretative use of ARVs toward serodiscor- ventative vaccine (SAV001), after provdant couples. Dr. Max Essex, Chair of ing effective in animals, gained approval the Harvard School of Public Health from the FDA for testing in human cliniAIDS Initiative, explained in an inter- cal trails. “It does induce strong immune view with the HCGHR that “this study responses and no adverse effects [in aniextrapolated [the use of ARVs in preven- mals]” Kang told the HCGHR.8 With tion] in a very clear, controlled way… positive outcomes in animal trials, Kang and so I think it’s a very optimistic time and his team are hopeful that the vaccine for the use of these drugs and their use will be similarly effective in humans. in the future for the prevention of adult The SAV001 vaccine uses an inac6 infections on a community level.” tivated form of the entire AIDS virus Despite these promising results, and is designed exclusively for HIV subthere is a clear distinction between using type B, one of the genetic variants of ARVs to cut transmission and creating the virus. Even so, if the vaccine passes an actual HIV preventative vaccine. smoothly through human clinical trails Cohen reiterated the undiminished in the next five years, it can stand as a importance of as well as the difficulties model and be tailored for future vacin obtaining a vaccine: “the challenge cines for other subtypes. “I think we to making a vaccine that works—one can customize the vaccine for differthat is safe and effective and dura- ent regions of the world,” Kang said. ble—is very great, and that’s shown “If this [whole-killed virus] strategy now to have been going on for over 25 works, then we can prevent the infecyears.”5 But the most effective response tion of HIV, saving millions of lives.”8 to the HIV epidemic may be the joint Kang’s SAV001 vaccine, however, is use of ARVs and a vaccine. As Cohen not unique in reaching human clinical explained, “these things aren’t in con- trials: there have been a number of HIV flict; they are totally complementary.” vaccines that have worked in animals Nevertheless, “the Holy Grail is making but failed in humans.6 Only human

*) clinical trials can show with certainty the success of Kang’s vaccine. Citing this vaccine history, Essex qualified the current enthusiasm and noted that efficacy in animals “really is so far removed from tests in people that one can’t possibly extrapolate those result to people.”6 Although these two developments have so far operated effectively in controlled trials, their actual effectiveness in the real world—with various economic, health, and other barriers—remains an open question. “Absolutely we worry about these [real world variables],” Cohen explained, “and this relates to what we would call efficacy, which means that in a perfect world if we can get people to take their pills so that the HIV replication is suppressed, then this is going to work. But that’s very different from effectiveness; that is, the real world scenario. And this real world scenario has many barriers to achieving the maximal benefits of this therapy.”6 ARV therapy, for example, requires not only a regular supply of medication but also adherence to taking it and an understanding of how to do so properly. However, according to Essex, the challenges of medical supply and adherence to medical protocols are not

I

as great as one might imagine: “using drugs for therapy in Africa was much easier than anybody expected, not necessarily much less expensive…but it has been just as effective as in the best Boston hospitals because people are very conscientiously adherent.”6 Instead, ARVs can 9%,("#*+,2#"*/.&%2#1?>(%"(:+,&(",%=#"%&'(%87@C%RgU%,&1*M%/&%/% actually intensify other &"(/&$(.&%,+&(%+.%;+>#.:F(4%5/>/F+H%!"#$%&'()"*)N1'-)!<&.'7",=) -.=)!-1%,1.)O,&1F"&$4 health and economic pressures by increasing the risk for neurological disease, a single intervention. Essex recognized stroke, heart disease, and various can- the irony of the significant achievements cers, all chronic conditions that, Essex related to ARVs but the more modest claimed, “are more expensive to moni- advances in vaccine development: “as tor and therefore [more expensive] to someone involved in the early 1980s, I treat.”6 Already facing difficulties treat- thought that we would be much farther ing current rates of these chronic dis- ahead in the development of a vaccine eases, developing countries are not well and I didn’t think we would be as far equipped to handle further increases. ahead in drug development.”6 Despite Hidden problems like these help to their uneven progress and remaining explain why a vaccine is seen as irre- questions about real world effectiveplaceable. The real-world effectiveness of ness, the SAV001 vaccine and HTPN vaccines, though also limited by social, 052 study stand as developments that economic, and health barriers, is more have helped make the year 2011 a predictable as a vaccination requires only renaissance for HIV/AIDS research.

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Smoking: The Oldest Dieting Trick on the Books, and the One That’s Sure to Kill + ]/&'("+.(%;H%W(2#"*4%-64%594%578

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uccessful international health endeavors aimed at reducing the burden of disease are laudable, and all too rare. Yet when health benefits are disproportionately realized—or worse, the burden of disease is shifted from one group to another—close scrutiny is in order. Under the Framework Convention on Tobacco Control (FCTC),1 the only binding instrument signed under the auspices of the World Health Organization’s treaty making authority, the prevalence of smoking among men has peaked, while the number of female smokers continues to grow. The vast majority of smokers are still men: 47% of men versus 12% of women consume tobacco. Yet rates among the former are now stagnant, whereas women, particularly in low and middle-income countries, are beginning to smoke at growing rates. Indeed, women are now the most lucrative market for the tobacco industry, suggesting that national controls implemented in compliance with FCTC have neither slowed the industry’s ability to reach women with alluring advertisements nor succeeded in swaying women in light of the dangers of tobacco consumption. The FCTC requires that parties implement gender-specific control strategies,1 but little has been done to ensure that it protects women and men equally. This may seem like an urbane concern; an international instrument that slows the growth of tobacco consumption is a success by any measure. Yet the disparate impact of tobacco control measures violates the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW).2 In other words,

implementation of the FCTC (through health literacy, warning labels, smoking bans, and advertisement prohibitions) seem to reach men far more successfully than women, leaving the latter prone to the fatal harms associated with smoking. In an interview with the HCGHR, Allyn Taylor, Visiting Professor at Georgetown Law Center and University of California Hastings College of Law (and the first to conceive of the FCTC) described this as a problem of implementation: “All treaties are broadly drafted, and states have flexibility with regard to their implementation. Here, states need to focus on gender specific strategies to fully implement the FCTC.”3 Gender neutral implementation is difficult for many reasons; rarely do comprehensive public health strategies address only one root cause of illness. For example, the majority of illiterate persons in the world are women, making written health scares (warning labels, health literature, media campaigns) moot.4 Women are also more likely to work in tobacco fields than men, particularly in low-income countries. Exposure to toxins related to tobacco growth is detrimental to reproductive health,4 an example of the toll even non-smoking women and girls pay.4 Addressing these issues is critical yet complicated, and involves education campaigns, eliminating farm subsidies, and implementing crop substitution programs.5 Yet while empowering women—through education, better jobs, and improved welfare—is beneficial to many aspects of health, it further exacerbates the smoking dilemma: autonomous women not only gain control over their lifestyles but

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also have increased access to the discretionary goods that were once reserved for men, like tobacco. Industry also ironically capitalizes on female empowerment. For example, the company Phillip Morris ran a campaign slogan “find your voice,” suggesting to women that smoking would help them break free from their entrapments. Cutting across all these dynamics is the one of the primary reasons women choose to smoke. Many women are attracted to tobacco for a deep-rooted, even pathological, reason: the desire to be thin. Marketing cigarettes as accessories of the slender and beautiful has proven more powerful than even the “Joe Camel cool” that once tempted men. States must aggressively pursue

*! anti-tobacco measures that counteract this advertising strategy in order to reverse, or at least lessen, the shift of smoking and smoking related illnesses from men to women. Indeed, the tobacco industry has identified women as the ideal market as smoking among men begins to wane. Appealing to ideals of beauty, sexiness, thinness, or even emancipation, tobacco advertisements exploit women’s susceptibility to pressures that men do not face. In one analysis of tobacco consumption trends among women, 40 percent believed that smoking controlled body weight and 12 percent reported that weight loss or maintenance was the sole reason for the practice.6 The tobacco industry goes further than simply appealing to a desire for beauty: leaked industry documents reveal that tobacco targets young women with images provoking ideals of “camaraderie, self-confidence, freedom, and independence” whereas those targeting older women emphasized “needs for pleasure, relaxation, social acceptability, and escape from daily stresses.”7 Moreover, the industry appeals to women’s desire to maintain health, deceptively labeling cigarettes as “light” or “low tar.” These strategies are especially effective at targeting highincome women, who are most likely to prefer “feminine” cigarettes, and least

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susceptible to price increases imposed by taxes.8 This would suggest that effective anti-tobacco measures must similarly address health-related motives: women are more susceptible to depression and anxiety than men, and often lack access to mental healthcare, thus resorting to self-medication. Indeed, older women, who often smoke to suppress negative moods, have more difficulty quitting than their male counterparts.9 State implementation of tobacco control policies must include, at least in part, increased awareness of and access to mental health services. Yet existing gender-specific antitobacco measures most often focus not on the needs or desires of women, but rather on the health concerns of children, encouraging cessation for the sake of a fetus.10 These campaigns are effective at encouraging pregnant women to quit, but do not encourage abstinence from smoking after the birth of a child. They also have no relevance to women who are not pregnant, which includes most teenage girls, the demographic industry targets most aggressively. Moreover, measures that do address gender dynamics are often challenged under constitutional or international trade law. For example: plain packaging laws and bans on advertising preclude the tobacco industry from

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associating cigarettes with beauty or health. Yet these regulations are met with strong industry resistance11 and often fail under free speech grounds12,13 or trade agreements.14 The FCTC demands more. A gender sensitive tobacco control strategy must include, at the very least, comprehensive advertising and promotional bans (like those in India, Singapore, Thailand, Finland, France, and Norway),15 preventing industry from associating smoking with images, products, or events that attract women. Proactively de-linking smoking from weight also requires public health campaigns that project the very visible health impacts of smoking (such as trachea holes, premature aging, skin discoloration, facial tumors, burns, and chemotherapy related hair loss). As Professor Taylor summed it up: “the question is not whether the FCTC has failed women, but rather what are the relevant parties doing to make it relevant to women? What is the WHO and the Secretariat doing to ensure the Convention is a gender-neutral document?”3 In other words, the FCTC demands that beauty be divorced from tobacco. Preventing industry from linking the two is a basic tenet of a gender-neutral control strategy.

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5/&&'(F%B#.*/3(, how can they be overcome? From Biblical times, it has been common practice for society to turn afflicted individuals into outcasts, and in this process of stigmatization likely lies an explanation of leprosy’s persistence. Leprosy presents with skin lesions that lead to very visible outward deformities, instilling in others an aversion to the affected individuals. This aversion gives rise to stigmatization, with communities forcing lepers to live in isolation. Stigma presents significant barriers to treatment, as it is a strongly demoralizing force that can easily prevent affected individuals from obtaining the care they require. Therefore, although treatable, leprosy in Southeast Asia has failed to be eradicated because of conJ/".+.:%,+:.,%,12'%/,%&'+,%#.(%/&&($?&%&#%"/+,(%/F/"(.(,,%#=%>(?"#,M4%+&,%,M$?&#$,4% founding social stigma, suggesting /.*%&"(/&$(.&H)!"#$%&'()"*)-?-.=&$'".ID)U131?&=1-)!"??".'4) that any truly successful intervention must first unravel the complexities of y all rights, leprosy, an ancient almost 200,000 cases registered in the stigma before attempting to treat the disease dating back to pre-Bib- first quarter of 2011 and over 200,000 core biological illness. lical times, should have already new cases detected in 2010.2 In particuAs a term, stigma comes packed ceased being a concern. It is slow progressing, difficult to transmit, and bacterial, making it a prime target for antibiotics. In fact, effective and inexpensive antibiotics have been discovered that completely cure patients who adhere to the treatment regimen. In the developed world, leprosy has essentially been eliminated, with statistics on annual new cases lar, Southeast Asia contributes a dispro- with many layers of interpretations. One being either negligible or not reported.1 portionate 70% of leprosy cases to the interpretation of stigma can be thought However, leprosy is still prevalent in the total global burden.3 What, then, pres- of as “the psychological and interpermajority of the developing world, with ents such barriers to elimination? And sonal experiences of being discredited

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and discriminated against because of a particular condition.”4 Clearly, stigma is not a monolithic concept; rather, it is insidious and pervasive. Although it is a function of a particular condition, it does not affect only an individual’s psychology. It also involves the entire community and as a result has significant social and interpersonal components. Often, the most visible instances of stigma exist on the societal level, as it is easiest to determine general trends that speak to the marginalization of I

individuals with leprosy. To enumerate some noticeable societal effects of stigma, Omobolanle Kazeem and others write, “The far-reaching and unfavourable impact of leprosy stigma leads to avoidance of healthcare services, [and] deterioration of personal health and socio-economic status.”5 Societal stigmatization clearly works against leprosy elimination, as it deprives those suffering of opportunities to receive care. Prabhakara Rao and others conducted one productive study in India that analyzed the impact of social stigma on two groups – individuals with grade 1 (i.e., milder) disabilities (G1) and those with grade 2 (i.e., more severe) disabilities (G2). Unsurprisingly, G2 reported feeling significantly more discrimination, with a sobering 19% experiencing familial discrimination (compared to only 6% of G1).6 The study also showed that 44% of G2 experienced a drop in income due to leprosy.7 On a societal level, then, stigma serves to isolate affected individuals from important resources – both interpersonal and economic – making it challenging for them to obtain treatment for their condition. More difficult to isolate, however, is the effect of stigma on an individual; that is, the changes in how an individual views himself because of his disease. One of the more obvious effects of selfstigmatization, is a loss of self-esteem and self-confidence.8 A study by Carol

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Shieh and others of Taiwanese women with leprosy sought to unravel the extent of this drop in self-esteem. It found that the women took great care not to reveal their disease. They “avoided being seen” and would even try to pass their illness off as “arthritis or polio.”9 In fact, several took self-stigmatization to such a level that they “attempted or considered suicide.”10 Self-stigmatization, then, can also readily explain why elimination efforts fail. If individuals are too ashamed of their condition to even go out in public, it is doubtful that they would venture forth to a centralized health system to receive proper care. From a biological perspective, leprosy seems simple to eliminate: antibiotics are cheap and effective, and a cure is practically guaranteed. However, from a social perspective, almost everything works against leprosy elimination. Stigma is deep-seated and often keeps affected individuals from seeking out necessary care. Moving forward, we cannot underestimate the importance of both understanding and attempting to combat stigma. In Southeast Asia, then, leprosy elimination will be realized when interventions, grounded in a thorough knowledge of biology, start to truly focus on the patients themselves and in doing so tackle stigma and all the barriers it presents to disease elimination.

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F3#3*%8%#$+3#1+F3$%(#36+F"($36)$<+ )#+O%#<3 ‘ƥÂ?ƒÂ? ‘Â?ƒ ƒÂ?–—Â?ÇĄ ÇĄ Š 6+"(2&#"4%%URUR%5+2"#2>+.+2%[.+&+/&+D( The Rural Health Worker

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lice is a gregarious, witty 33-year-old female residing in Katito, rural Nyanza Province in Kenya. She is a nurse-midwife at the Kinasia Health Center seven kilometers away. Work mornings start with a 30–45 minute motorbike ride down the dusty road from Katito to Kinasia. On a good day she gets to work by 8:30 a.m., to be welcomed by a showering of greetings from patients sitting patiently on benches. She calls out to the cleaner, “Dina, why have you not cleaned the floor today?� Dina replies, “I am out of soap, miss.� Smiling, Alice retorts, “Soap? Every day? I just don’t have the cash. Do without soap.� Dina walks away sheepishly. A few steps down the hall, and Alice calls out again, “Mr. Hesbond is one of 10 community health workers (CHWs) on a per diem honorarium, who serve as sample transporters, outreach workers, and patient assistants, and none is to be found.� Alice is not surprised; it had been two weeks since they had been paid. Alice felt overwhelmed. She knew a tough day lay ahead and that any emergency would be extremely hard to manage. Her first eleven patients were five mothers with infants for Child Well Care visits, two elderly patients weakened by fevers and dehydration lay on a bench, a young male patient needed wound care for injuries sustained from a motorbike accident, and three very pregnant mothers came for antenatal care. Alice was acutely aware that the administrative challenges had done her

ĆĄÂ‡Â…Â–Â‹Â˜Â‡ Â?ƒÂ?ƒ‰‡Â?‡Â?– ‘ˆ ”—”ƒŽ Š‡ƒŽ–Š …Ž‹Â?‹…• •—…Š ĥ –Š‡ ‘Â?‡ ’‹…–—”‡† ƒ„‘˜‡ ‹• …”‹–‹…ƒŽ –‘ ”‡E *12+.:%$/&("./>%$#"&/>+&MH%!"#$%&'()"*)Q,1W-F&%<)5,-'&$):&=1-%$12)+8M>)/"#.=-%1".4

in. Without petty cash, Alice was unable to purchase gauze for the patient needing wound care. Without the CHWs, she would struggle to assist the malaria patients she had to observe throughout the day. Lacking lab supplies, she would be obliged to default on screening the pregnant mothers for anemia, and urine sugar and protein levels. The fate of these women was unknown: could they be anemic or at risk of eclampsia, or gestational diabetes? It was one of many frustrating days for Alice. She felt isolated and overburdened. Alice had never received practice management training, and the quality of care her clinic provided to her community and patients, especially the young pregnant mothers, was a source

of dissatisfaction. Management Challenges of the Rural Health Worker Alice is not alone. Her story is the narrative of the rural health nursemidwife. A focus group interview with 25 nurse-midwives in rural Nyanza Province in Kenya, in February 2012 found that the top five sources of nurse dissatisfaction were: 1. Lack of accommodations on site or close to the health center, hampering their accessibility after hours—especially critical for expectant mothers. 2. Lack of petty cash to pay support staff, notably CHWs and cleaners. 3. Lack of funds to cover discretionary expenses, including the ability

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to purchase consumables not supplied by the government. 4. Lack of continuing medical education for non-communicable diseases, notably, for gestational and obstetric emergencies. 5. Lack of appropriate training on practice management, including budgeting, resource planning and expense accounting. The nurses indicated that 50 percent of their daily chores are managerial in nature, as in managing support staff, compiling reports for the district health teams, paying utility bills, purchasing lab supplies, maintaining a drug formulary tailored to the local needs, and organizing transport for critical care patients, especially mothers in labor. The modern rural health workers must therefore be

Great Britain in 1890 and in the United States in 1935). It’s not that rural areas don’t have clinics, or nurse-practitioners, or many types of medicines. In Kenya, there are more than 4,077 health centers and 439 district hospitals that serve the rural population (Louma et al., 2010). During the February 2012 observational study we conducted in rural Nyanza Province, Kenya, the 10 health centers we evaluated had nurse-midwives and were overstocked with ergometrine, salbutamol, magnesium sulphate, and antibiotics, which are essential drugs to control post-partum hemorrhage, premature delivery, eclampsia and puerperal infections, respectively. Alice’s experiences suggest that training in midwifery and supplying facilities with essential drugs are insufficient to attend to the

“...training in midwifery and supplying facilities with essential drugs elevated maternal mortality ratesand also suggest that good practice management is of great moment.” prepared to deal with clinical as well as administrative emergencies. Management and Maternal Mortality In parts of rural Kenya, new mothers die at the rate of more than 500 per 100,000 live births, a rate that existed in

I

elevated maternal mortality rates and also suggest that good practice management is of great moment. Of great concern is the lack of accountability for the care that nurses and TBAs offer to rural mothers. Whether a mother has delivered her baby in a regional clinic or at home, the outcome too often remains unknown.

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Did the baby get sick during that first week after birth? Did the mother? Months later, who survived, who prospered? “There is no accountability in the system,” Alice says. Collecting information about the health care provided and the outcomes is vital. The lack of administrative mechanisms is at the root of Alice’s dissatisfaction as a rural worker. Previous studies have demonstrated the impact of managment training on health outcomes in Kenya.1 The 2020 MicroClinic Initiative is responding to this challenge by working with 25 rural nurses in Nyanza Province, Kenya, including Alice, to develop a rural health management information system to account for maternal services in their respective facilities.

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s the late afternoon sun gleamed over Haiti on January 12, 2010, a 7.0 magnitude earthquake wreaked havoc on the nation. The United States Agency for International Development (USAID) estimated a death toll of between 46,000 and 220,000 with over a million people left homeless.1 Additionally, the Haitian government reported that 52 percent of all buildings in Port-au-Prince and the surrounding regions –including vital infrastructure necessary to respond to the disaster – were either damaged or dilapidated.2 Instinctively, photojournalists flocked to the scene en masse. Due to the international language of imagery, photographers were able to articulately portray the presence of heart wrenching moments to audiences worldwide. But little did these photographers know the unintended consequences that would accompany their every exposure. While intended to communicate the shocking devastation of the nation

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individuals’ and societies’ perception of Haiti, and encouraged doctors to favor the visibly ill. Furthermore, it turned aid into a business, trauma into a cur-

/Y4"$"*(3'4<+$H(#%1+3)1+)#$"+3+EH2)#%22K+ $(3H83+)#$"+3+5H((%#5<K+3#1+2H99%()#*+)#$"+3+ 5"88"1)$<=> post-earthquake, photography unintentionally proved to be an effective vehicle in perpetuating social suffering. The medium reawakened social stigmas, facilitated a reconstruction of

rency, and suffering into a commodity while also providing a disincentive for government action. Through their depiction of suffering victims, photographs generated

international social consequences. The medium’s intrinsic ability to capture situations transformed Haitian’s local worlds and post-earthquake moments into exhibitions of analysis and proof of the poor’s vulnerability to disaster. According to trauma psychologist Vanessa Pupavac, this potentially results in dehumanization of subjects3 and, in turn, changes how foreigners treat Haitians. Further, each Haitian’s role and identity4 became a personification of suffering instead of an individual momentarily in need of assistance. Photographs delivered unintentional biological consequences as well. The images served as “before and after” proof for medical NGOs who used them to prove competency5 and hence

!) win donations. This created an incentive for NGOs to prioritize patients whose cases could be most easily documented by camera. Resultantly, attention and aid were disproportionately detracted from the “invisibly” ill, such as those who suffered from psychological trauma and mental illness, and onto the “physically” unwell. These actions neglected to reveal the less obvious social aspects of illness. The documentation of crisis also engendered important political ramifications for Haiti. Photography’s aesthetic tactics transformed a vast and distant

distributing healthcare after the news of dilapidated infrastructure spread. With so many active NGOs delivering aid, the Haitian government had a disincentive to maintain the responsibilities and burden of cost of providing adequate health services to its citizens. This potentially leads to a lower standard of living and vacuum of care once the NGOs leave. Furthermore, Haiti’s foreign aid relief fund will be diverted to (and crippled by) the operating medical NGOs as long as they remain. This is a prime explanation for why only three percent of the USD$1.8 billion of promised aid was

“A photograph is worth a thousand words, but in post-earthquake Haiti, each photograph was attempting to depict a million-word-worthy crisis.” horror into a sympathetic cause that translated sentiment into action.6 NGOs rushed to fill the administrative void in

I

received by the public sector.7 Some organizations are offering solutions to the quandaries that

Ǧ Ȁ Ǥ ȋ͚͙͘͘Ȍ Dz ƪ *(/&'%&#>>_4%-/?/.%@+$(,4%Y%-1.(H%7"+.&H U% !/"$("4%7/1>H%bURIIc%8/+&+%9=&("%&'(%)/"&'p1/3(H%C(F%Z#"3P%71G>+2% ơ Ǥ Y% 71?/D/24%e/.(,,/H%bURRVcH%7<ZB8K<KB[9;%[C@)We)C@[KC<%9C6% @8)%6)5KW9;[\9@[KC%K!%8A59C[@9W[9C[<5H%-#1"./>%#=%`+#,#E 2+/>%<2+(.2(4%YdP%VhIEgRVH V% 5/"2'4%-HNH%/.*%K>,#.4%-H7H%bIhahc%W(*+,2#D("+.:%[.,&+&1&+#.,P%@'(% K":/.+L/&+#./>%`/,+,%#=%7#>+&+2,H%!"((P%C(F%Z#"3H%?H%YH

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photography creates. For example, the nonprofit organization, International Justice Mission, has a child protection policy in which all minors must have their eyes blurred out in photographs to protect them from becoming reduced to mere personifications of suffering. However, proposing a limit on what can be photographed infringes upon the freedoms of the press in addition to directly contradicting the Code of Journalists and their mission to nonexclusively depict the “truth”. A photograph is worth a thousand words, but in post-earthquake Haiti, each photograph was attempting to depict a million-word-worthy crisis. To attain a deeper understanding of photography’s role in exacerbating suffering, one must understand how misery and inequality are interconnected in Haiti from social, political, and biological standpoints. We can then design interventions to avoid or minimize consequences. While it may be too late to undo what occurred in post-earthquake Haiti, we must learn from the mistakes so that they are not repeated in future crises.

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Photo by Matej Kastelic

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Global Health at Harvard !"#$%&'()&$"#)&*"$+',,-./*0$)*$1)23)24$/.+&-4#5$6)+-&*0$).4$5*-4#.*5$/.$7-(&/+$"#)&*"8$+&/./+)&$,#4/+/.#$ ĂŶĚ ĚĞŶƟƐƚƌLJ͕ ŝŶƚĞƌŶĂƟŽŶĂů ŚĞĂůƚŚ͕ ĂŶĚ ŐůŽďĂů ƉƵďůŝĐ ŚĞĂůƚŚ͕ ĂƐ ǁĞůů ĂƐ ŵĂŶLJ ŽƚŚĞƌƐ ŝŶ ƚŚĞ ŶŽŶͲŚĞĂůƚŚ ƐĞĐƚŽƌ͘ dŚĞ ĐŽŵŵƵŶŝƚLJ ŚĂƐ Ă ƐŚĂƌĞĚ ĐŽůůĞĐƟǀĞ ŐŽĂů͕ ͞ƚŽ ĞĚƵĐĂƚĞ Ă ĨƵƚƵƌĞ ŐĞŶĞƌĂƟŽŶ ŽĨ ŐůŽďĂů ŚĞĂůƚŚ ůĞĂĚĞƌƐ ĂŶĚ ƐĐŚŽůĂƌƐ͕ ƚŽ ƉƌŽĚƵĐĞ ŶĞǁ ŬŶŽǁůĞĚŐĞ͕ ĂŶĚ ƚŽ ĐĂƚĂůLJnjĞ ŝŶŶŽǀĂƟǀĞ ƐŽůƵƟŽŶƐ ƚŽ ŝŵƉƌŽǀĞ ǁŽƌůĚ ŚĞĂůƚŚ ĂŶĚ ƌĞĚƵĐĞ ŝŶĞƋƵŝƟĞƐ͘͟

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