Harvard College Global Health Review Fall 2009 Issue

harvard college

global health review Volume I, Number 1, Fall 2009

DELIVERY "Colonial Roots of Global Health"

The Cholera Epidemic in Zimbabwe

Paul Farmer et al.

Lavinia Mitroi

An Interview with Julio Frenk Dean of Harvard School of Public Health A publication of the Harvard College Global Health and AIDS Coalition

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global health review Volume I, Number 1, Fall 2009

FROM THE EDITOR

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Two Bills for Health Foundational approaches to global health

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R. Banarshi

DELIVERY BroadReach Health Care Where business and health care collide

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L. Mitroi

S. Littlehale

Operation ASHA Fighting tuberculosis in India

The Modern Plague The cholera epidemic in Zimbabwe

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Leprosy Now An ancient but still neglected disease

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K. Mengistu

B. Martinez

Community Health Workers The key to effective care in rural Rwanda

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A. Kraemer

Mobile Health Cell phones 4 p8tients n MDz

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A. Karlin

The PACT Project Health promotion from Haiti to Boston

INTERVIEWS Julio Frenk Dean of Harvard School of Public Health

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Greg Bisson Assistant Professor at University of Pennsylvania School of Medicine

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STUDENT SPOTLIGHT

L. Tsao

Physicians and the Pursuit of a Moral Life Morals and Medicine in Modern China

THE EXPERT PERSPECTIVE Colonial Roots of Global Health Lessons learned for modern humanitarian health

B. Verma

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P. Farmer and Others

PANORAMA Interventions 21 Targetting drug users in HIV prevention in China M. Tu

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Curing a Country China’s Challenges in Controlling Tuberculosis J. X. Chen

Read the HCGHR online: http://www.hcs.harvard.edu/globalhealthreview

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THE HARVARD COLLEGE GLOBAL HEALTH REVIEW

From the Editor

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Dear Reader, Editorial Board Editor-in-Chief Simin Gharib Lee Associate Editors Steven Barchick Henry Dawkins Dan Driscoll Michael Henderson

Staff Rajarshi Banerjee Kira Mengistu Alexis Karlin Lavinia Mitroi Alison Kraemer Angela Primbas Sarah Littlehale Susan Wang Carl Malm Lulu Tsao Rebecca Martinez Marianna Tu

Design Board Layout Editor Alan Chiu Cover Editor Ann Cheng

Board of Advisers Robin Herman JimYong Kim, MD, PhD Rebecca Weintraub, MD The Harvard College Global Health Review is a publication of the Harvard College Global Health and AIDS Coalition The Harvard name is a trademark of the President and Fellows of Harvard College. It is used with permission of Harvard University.

Opinions, views and statistics published in this journal are those presented by the contributors and not necessarily a reflection of the views of the editors. No part of this publication may be reproduced, sold or transmitted without written permission of the editor-inchief of HCGHR.

Global health is undergoing a drastic transformation. At the doorstep of a new decade in a new millennium, the world can recall a recent and fragmented past in which only the World Health Organization or individual governments were responsible for raising the health of developing nations. “Global health” quickly became a mere buzz phrase summoning images of disease eradication campaigns that splintered into country-specific efforts and – except for the case of small pox – subsequently failed.

But, at the turn of the century, a sudden confluence of funding from a critical mass of nongovernmental actors redirected the irrigation of global health.

Billions of dollars materialized from the deep pockets of new mega-foundations, nongovernmental organizations, philanthropists, and corporations. Governmental support for global health efforts appeared in the form of PEPFAR and the Global Fund to Fight HIV, TB, and Malaria.

For whatever reason, a new optimism and resolve to retackle the long list of the world’s health crises gripped both developed and developing nations. Two of the most important results have been the need for raised awareness about global health issues and the need for heightened scholarship among a generation of young individuals committed to fighting disease, poverty, and disenfranchisement around the world.

We formed the Harvard College Global Health Review (HCGHR) with the expressed goal of meeting these needs. We believe in the importance of wasting no time in educating ourselves and others. Without advanced degrees and the particular experiences that accompany such degrees, we turn to the one powerful tool that any student possesses: asking questions. Within the panoramic landscape of global health, we will ask ourselves, who is in need? Where are they? And who is helping them?

What strategies and technologies have successfully solved dark problems? When will the poor, the sick, and the suffering be relieved of hardship? How will the world help its own? We will ask these questions to ourselves. Then we will ask more questions to experts. And when we write the answers, we expect to help inspire and educate the current and future leaders in global health.

The inaugural issue of this magazine features the topic of global health delivery. The recent Health Affairs July/August 2009 issue also chose to scrutinize the science of untangling the knotty supply chains for health in low-resource environments. Together, several HCGHR staff writers have reported on individuals, organizations, and concepts that are creating innovative ways to harness available resources and generate high-value outcomes. The renowned Dr. Paul Farmer adds a historical perspective to the discussion with his contribution about global health in colonial times. Together, these pieces underscore the importance of delivering what we already have to the people who need it most in the most efficient way.

Finally, we would like to thank our supporters. Robin Herman, the recently departed Dr. Jim Kim, and Dr. Rebecca Weintraub gave HCGHR the sponsorship and guidance it needed to grow roots. Our gratitude extends to the Harvard College Global Health and AIDS Coalition (HCGHAC), the Harvard Institute of Global Health (HIGH), and the Harvard Undergraduate Council, who gave HCGHR the financial support it needed to fly. We are indebted to our writers, whose relentless work pulled this magazine up from our imaginations and into reality. And, of course, we deeply appreciate the time you, our reader, have taken to read our work. Enjoy!

Sincerely,

Simin Gharib Lee Editor In Chief

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BroadReach Healthcare Linking the World of Business and Health Care

Courtesy BroadReach Healthcare

“He who has health, has hope.

And he who has hope, has everything,” or so goes the Arab proverb.

Unfortunately, far too few people in this world have such hope. In the eyes of many, healthcare has become a luxury for the rich yet remains fragmented and uncoordinated in the world’s most impoverished regions. The founders of BroadReach Healthcare chose to imagine the world differently.

BroadReach is an international consulting firm based in Washington, D.C. and South Africa specializing in global healthcare management. They function with an “approach of bringing business efficiency and private sector discipline to address international health challenges and opportunities.”1 John Sargent and Ernest Darkoh

became close friends while attending Harvard Medical School. The two had similar backgrounds, Darkoh growing up in Eastern Africa and Sargent in Taiwan, both having personal experience with and a passion for global health. “We would stay up at night just talking about how we were going to save the world,” reminisced Sargent.2 Both saw that there were many issues inherent to the current global healthcare system. “You can be in a war zone,” Sargent remarked, “and you can find beer, cigarettes, anything like that, but often ... cannot find a single pill of aspirin.” How, they wondered, could companies like DHL and UPS manage to track and ship packages around the world, yet the healthcare industry could not manage to effectively

distribute something as essential as medicine to those who need it? These questions provided the seeds for BroadReach’s establishment.

In order to learn the ways of the private sector, both Darkoh and Sargent went to work in the field of management consulting after graduation from medical school.2 Darkoh worked more internationally with McKinsey & Co. while Sargent worked domestically at The Advisory Board Company. It was here that Sargent met the third founder of BroadReach, Jeff Butler.

In 2001, Darkoh was hired through McKinsey & Co. to work on the strategy for Africa’s first major antiretroviral drug rollout with the African Comprehensive HIV/AIDS Partnerships (a partnership between the Merck

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global health review and Gates Foundations and the Government of Botswana).3 Darkoh realized that to overcome a problem of such magnitude as the infection in Botswana, HIV care had to go beyond the typical Western medical methods of clinics and hospitals and incorporate many other sectors of the community.4 Darkoh and his team included everyone from local church groups and community members to tribal chiefs in working not only to raise awareness but to provide support for HIV/AIDS patients within the community.5 Of course, doctors and medical staff were still a necessity but by providing training HIV/AIDS training to community members would allow many more patients to be seen and diagnosed by taking the day-to-day maintenance out of the hands of the doctors.

This kind of inclusive and holistic approach aimed to get the treatments where they were needed, raise awareness and, perhaps most importantly, break the stigma of the disease. By including the community in the fight against the disease, infected patients would no longer have to weigh forgoing treatment or admitting being infected for fear of being shunned from society. Further, this approach would develop infrastructure by introducing job training and creating work. Darkoh recruited local leaders and community members, brought in outside distribution experts and fought for universal HIV testing, meaning that people visiting clinics would have to ask not to be tested rather than asking to be tested.6 Within three years, over a third of the nation’s HIV-positive people were receiving treatment.7 This work in Botswana helped propel the creation of BroadReach Healthcare. In 2003, Darkoh, Sargent, and Butler left their jobs8 to start the company that would specialize in “anti-retroviral treatment and

offering expertise in program design, implementation, monitoring, and evaluation to other countries around the world.”9 BroadReach considers its role that of a “systems architect,” organizing fragmented parts of the healthcare systems in impoverished and developing nations into a more integrated, communicative network in order to improve both the delivery and distribution of healthcare.10 The company offers strategic consulting, health systems strengthening, community mobilization and patient education, and program design & management to health-related organizations from multinational corporations to governments and NGOs. BroadReach has developed a model resembling that of a check-out line in order to tap excess capacity.11 There is an “express lane” consisting of trained medical workers and community volunteers for people in need of testing, medication, or treatment literacy and adherence support. There is also a “slow lane” of doctors, many of whom are private physicians willing to see public patients, for more advanced diagnoses, acute care, and for the gravely ill.

Further, “virtual preceptors,” physicians and HIV/AIDS experts, are available for remote clinical decision support.12 These elements create an efficient system capable of seeing and treating far more patients than would be possible in a solely hospital- or clinicbased system.

BroadReach is currently working in 15 countries with projects including HIV/AIDS support in South Africa, assisting China in drafting a treatment proposal for The Global Fund to Fight AIDS, Tuberculosis, and Malaria, and providing management training to local government health program managers in Ethiopia and Tanzania.13

John Sargent, the President of BroadReach, told the HCGHR that in the future the company envisions “having multiple companies under the umbrella of BroadReach all addressing developing world health care issues but in different ways.”

BroadReach was founded with “a vision of combining the best of the public sector with the best of the private sector.”14 In doing so, John Sargent, Ernest Darkoh, and Jeff Butler chose to imagine the world of healthcare “not only as it should be but as it could be.” Imagination is quickly becoming reality.

Sarah Littlehale, Staff Writer “BRHC Overview.” BroadReach Healthcare. Sep 2008.

Received from John Sargent. 10 Mar 2009.

2 Sargent, John. Personal Interview. 10 Mar 2009.

3 “Ernest Darkoh (00-01 NYO) Creates a New Health Care Model for Africa.” McKinsey News. 12 Jan 2006.

McKinsey&Company. 7 Mar 2009. <https://alumni.mckinsey. com/alumni/default/ public/content/jsp/alumni_news/20060112_ErnestDarkoh_ WhosNews.jsp>.

4 Kluger, Jeffrey. “Efficiency Expert: Ernest Darkoh.”

TIME Magazine. 31 Oct 2001. Accessed from: <http:// broadreachhealthcare.com/inTheNews.html>.

5 Ibid.

6 Ibid.

7 “Ernest Darkoh (00-01 NYO) Creates a New Health Care Model for Africa.” McKinsey News. 12 Jan 2006.

McKinsey&Company. 7 Mar 2009. <https://alumni.mckinsey. com/alumni/default/ public/content/jsp/alumni_news/20060112_ErnestDarkoh_ WhosNews.jsp>.

8 Sargent, John. Personal Interview. 10 Mar 2009.

9 “Ernest Darkoh.” Rx for Survival: Global Health Champions.

Mar 2006. Public Broadcasting Company. 8 Mar 2009. <http://www.pbs.org/wgbh/rxforsurvival/series/champions/ ernest_darkoh.html>.

10 “About BroadReach.” BroadReach Healthcare. 2008.

BroadReach Healthcare. 7 Mar 2009. < http://broadreachhealthcare.com/aboutBroadReach.html>.

11 Kluger, Jeffrey. “Efficiency Expert: Ernest Darkoh.”

TIME Magazine. 31 Oct 2001. Accessed from: <http:// broadreachhealthcare.com/inTheNews.html>.

12 “BroadReach World Bank Presentation.” 17 Jan 2005. The World Bank. 10 Mar 2009. <http://siteresources.worldbank. org/INTAFRREGTOPHIVAIDS/Resources/BroadReach_World_ Bank_Presentation_Jan_18.pdf>.

13 Kapp, Clare. “Ernest Darkoh: confronting the challenge of HIV/AIDS in Africa.” The Lancet. 5 Aug 2006. Accessed from: <http://broadreachhealthcare.com/inTheNews.html>.

14 Sargent, John. Personal Interview. 10 Mar 2009.

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Operation ASHA Fighting Tuberculosis in India

After day upon day of sifting through trash searching for small treasures that can be recycled for cash, 19-year-old Akhil begins having a simple cough. Soon this cough has spiraled out of control and is defined by the blood-tinged sputum. Akhil has tuberculosis. Soon he spreads the infection his four family members who all reside with him in a 64 square-foot hut.

Tuberculosis (TB) remains one of the most devastating diseases for humans, though more so in developing countries than in developed ones. In the United States, the prevalence of TB – 4.6 infected individuals per 100,000 citizens – is considered remarkably high, given the country’s economic prowess.1 However, these number pale in comparison to the TB rates in India, where 299 individuals are affected in a population sample of the same size.2

While Akhil is a fictional character, he represents one of the groups with the highest prevalence of TB in India. Known as the “ragpickers,” these individuals subsist by sifting through refuse to find recycled items to sell to large recycling companies.

Often in India, TB is found among those with the most limited resources and substandard living conditions.

Living in such poor economic conditions both facilitates transmission and compounds the difficulties of TB control.

Operation ASHA (asha is the Hindi word for “hope”), a nongovernmental organization based in Delhi, has provided a low-cost and efficient solution to TB-infected communities in India that have previously received little to no attention.

Operation ASHA’s unique approach of increasing availability of people who can administer directly

Courtesy Centers for Disease Control and Prevention

observed treatment short-course (DOTS) treatment seeks to fuse the ancient tradition of community care with the modern technology and health standards. Operation ASHA incorporates technological advances to treat the most economically marginalized citizens, moving healthcare to a patient-centered model in efforts to preempt the further spread of tuberculosis.

DOTS, as implemented by the World Health Organization (WHO), was recently adopted to achieve the following five outcomes: 1) Governmental support for universal treatment and preventative measures 2) Diagnosis using simple yet effective tests for individual treatment and global resistance monitoring 3) A standardized treatment regime to

ensure individual, and eventually, universal eradication 4) Readily accessible TB drugs 5) Accurate evaluations of the efficacy of the current anti-TB programs.

While these components have indeed succeeded in eradicating TB in certain communities, the biggest challenge to care still lies in its accessibility. Because DOTS requires that patients be monitored while consuming the drugs to ensure adherence to the treatment plans, often the logistical difficulties of arriving at an approved treatment site still remain too formidable. Public health experts worry that these DOTS programs miss the critical link to reach patients in greatest need of care.

Here, ASHA seeks to fill the gap between novel treatment approaches

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global health review and ancient societal customs. By relocating treatment facilities to local neighborhoods, ASHA aims to simplify and return care centers back to the community. This strategy has brought about several important changes to not only the medical care, but also social attention surrounding TB. Namely, this change increases access to care and augments community awareness to the dangers and treatments for TB, both of which contribute to lower levels of TB in the community.

Operation ASHA’s President, Dr. Shelly Batra told the HCGHR that this organization further succeeds in maintaining the privacy of patients by improving access to care to the degree that patients no longer need to ask their employer for permission to leave early to receive treatment for TB, “which often causes the patient to be fired.” This repercussion previously stemmed from social stigma surrounding TB infection. Batra cited 2007 government figures that estimate over 100,000 women and children

were thrown out of their homes because of the social stigma associated with TB, “which is probably only the tip of the iceberg.” By indirectly protecting job security and social standing for patients, Operation ASHA is able to boost adherence rates, which improves both individual health and minimizes the risk of multi-drug resistant TB.

Operation ASHA is not immune to criticism from outside sources that claim that, while the organization’s work is impressive, it received a disproportionate funding next to its counterparts. The average TB treatment costs $375 per patient in such settings as the ones in which Operation ASHA works, but Batra’s organization provides treatment at $15 per patient. In light of such figures, other non-governmental organizations think that Operation ASHA should not be considered in cost-analysis of TB treatment.

Despite this criticism, the number of patients ASHA claims to treat are impressive – with 34 centers,

over 3,000 patients receive treatment annually. However ASHA calculates that the benefits of their program extend far beyond these immediate individuals because while the treatment “raises the productivity and saves lives” it also “prevents 36,000 [future] infections,” based on the assumption that each person infects an average of 12 others.3

Ultimately, ASHA’s success lies in its ability to bring patient care to a level accessible by the population it serves. In adapting to the social structure of the environment as opposed to demanding unreasonable effort, ASHA brings together communities, raises awareness, and decreases the prevalence of one of the deadliest, but most treatable diseases.

ASHA gives the anonymous ragpickers like Akhil a chance.

Rebecca Martinez, Staff Writer Trends in Tuberculosis Incidence--United States, 2006. JAMA. 2007;297(16):1765-1767.

2 Global TB Database and Country Profiles, WHO 3 http://s01.opasha.org/index.php?option=com_conte nt&task=view&id=26&Itemid=47 1

Courtesy ASHA

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Community Health Workers The key to effective care in rural Rwanda

The primarily rural population of Rwanda faces seemingly overwhelming barriers to obtaining quality healthcare where there is only one doctor for every 20,000 people. The government of one of the world’s poorest nations has sought for over a decade to revitalize the shattered post-genocide health system. To strengthen public healthcare for the impoverished and underserved people of Rwanda, the non-governmental organization Partners In Health (PIH) partnered with the Clinton Foundation and the Rwandan Ministry of Health (MOH) in April 2005 to bring its model of comprehensive communitybased care, developed over several decades in rural Haiti, to Rwanda.1 In fact, PIH boldly instituted resources often overlooked in global health delivery – Community Health Workers, or CHWs. As members of their local villages, the CHWs are employed, trained, and compensated

by PIH and the Rwandan MOH to invest in personal home-based care.

“This program is giving value, recognition, and training to these community health workers,” says Melissa Gillooly, the Project Manager for PIH in Rwanda. “They are given the training needed to carry out these important jobs, allowing them to play an important role in the public health system as educators and providers and serving as a vital link to the health centers.”

When PIH arrived in 2005, community based-care providers already existed and comprised three types of health workers. The Animateurs de Santé (“Health Facilitators”) had been in place since 1995 and were involved in activities

such as vaccination, malnutrition, and growth monitoring programs as well as other preventative healthcare interventions for children and community sensitization activities.

The Home-Based Malaria (HBM) program started in 2005 and instituted community health workers who provided children under five with rapid access to malaria treatment at a cost of 100 Rwandan francs (approximately $0.20) per child. The third group, traditional birth attendants (TBAs), followed and monitored pregnant women. Most of these CHWs had no organized training and often worked without compensation.2

Thus, Inshuti Mu Buzima (“Partners In Health” in Kinyarwanda, the Rwandan national language) began to recruit a network of trained and paid CHWs to deliver high-quality primary care to two districts in southeastern Rwanda, which were without a doctor

Courtesy Partners in Health

or district hospital.3

For years, PIH has utilized accompagnateurs, CHWs that originated from PIH’s work in Haiti to provide locals with medical and socioeconomic aid. Following the positive results in the first two years of recruiting and training CHWs in Rwanda, in 2007 PIH began to work with the MOH on plans to harmonize the national community health worker system. Together, the Rwandan MOH and PIH have developed plans to expand a new, comprehensive system of CHWs that includes efforts to serve every umudugudu (village). This plan incorporates the successful approaches used in PIH’s work, which influenced the development of the Ten Principles of Rwanda Scale-Up and the Rwandan District Health System Strengthening Framework. This plan anticipates full scale up in five to seven years across

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global health review the country’s 27 districts with ten goals, including the delivery of highquality universal healthcare services, access to drugs and nutrition services, and socioeconomic aid to remove barriers to treatment.4 The success of the “Scale-Up” will rely upon the work of skilled and educated CHWs. As respected members of their local communities, CHWs are elected by community members and supported by local leaders. Most CHWs are unemployed or working as subsistence farmers before being elected to these positions. Yet, they are not without experience as a few are former Animateurs de Santé and some are even former patients with first-hand experience relating to HIV and/or TB.5

With the more comprehensive model that PIH began to carry out in 2008, “training [of CHWs] occurs in primary healthcare, including malnutrition, reproductive health, family planning, hygiene, and childhood illnesses,” says Jill Hackett, the Director of Training for PIH. “The content of training is decided and prioritized according to the Ministry of Health’s priorities.”

The new system ensures that each CHW visits 40-50 houses at least once a month.6 Due to the specialized training they receive in the treatment of HIV and TB and primary healthcare topics such as malaria, the CHWs administer medications to ensure that patients take the proper dose and avoid drugresistance. Additionally, CHWs provide psychosocial support by educating patients about strategies for following their often complex drug treatments.

They work to dispel stereotypes and misunderstandings about HIV, TB, or other diseases through education and the encouragement of preventative options.7

“Community involvement and the harmonized system of CHWs will ensure the delivery of effective Primary Health Care services by bringing health

services, social needs and institutional support closer to the community,” says Didi Bertrand Farmer, the PIH Director of Community Health Programs in Rwanda.

Despite recent worries that CHWs might not be compensated enough, Ishuti Mu Buzima can assure that it sets a high priority to compensating its CHWs fairly for their work. PIH believes that such compensation of these community members in settings of poverty and unemployment boosts local economies and stabilizes CHW commitment.8

Some may refute that, as members of the communities they serve, the CHWs may be tempted to reveal information about their patients to other locals and, thereby, exacerbate stigma concerns. However, CHWs are trained to respect the privacy and confidentiality of their patients. CHWs must also build the patient’s trust as they often grant sensitive emotional support and counseling.9

Indeed, CHWs are required to serve as the community’s link to the health facilities. The CHWs constantly feed back to their CHW leaders at the clinics who are responsible for supervising between 20 and 25 CHWs.10 If patients have non-medical problems – housing, nutritional, educational, or economic hardships – that could complicate care, the CHWs notify the clinical staff immediately to request aid.11

“Community health workers strengthen health systems overall,” says Hackett. “As the eyes and ears of the clinic, their role is very important in helping to strengthen the public health structure that they are referring to – not just in the community but in their ties to the clinic that is so vital, as well.”

Unlike health workers from certain non-governmental or aid organizations who set up shop temporarily in a rural village and leave after their work is ‘done,’ the Rwandan

CHWs are established members of their local communities and are there to stay. As such, Rwandan patients will not rely on foreign doctors and health workers for their well-being, but rather will be more self-sufficient and innovative in their health systems. The Community Health Worker model of the MOH-PIH partnership in Rwanda will continue to deliver these longterm, sustainable medical and social services to locals not only now but long into the future.

Based on the main principles of a sufficient number of CHWs per umudugudu, reception of standardized training, systematic supervision, fair compensation, and community involvement, the harmonized system of CHWs will ensure the delivery of effective Primary Health Care services by bringing health services as well as social needs and institutional support closer to the community.

These principals have integrated the CHWs into the formal health system and are securing the sustainability of the community health program in Rwanda. This approach will create enduring partnerships that will engage the community in their own development while improving equity of access to healthcare and helping the Rwandan MOH to meet the Millennium Development Goals.12 Alison Kraemer, Staff Writer Gillooly, Melissa. Partners In Health. E-mail to the author.

“Strengthening Health Systems with Community Health Workers; Rwanda’s Comprehensive Community Health Program.” Primary Reference: “The Rwandan District Health System Strengthening Framework, MOH July 2008.” 20 March 2009.

2 Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

3 Partners In Health. “Rwanda/Inshuti Mu Buzima.” Where We Work. 2006. <http://www.pih.org/where/Rwanda/Rwanda. html>.

4 Partners In Health. “Rwanda scales up PIH model as national rural health system.” PIH News. October 2007. < http://www. pih.org/inforesources/news/Rwanda_Scale-up.html>.

5 Partners In Health. “Community Health Workers.” Accessed Online on 27 February 2009. <http://model.pih.org/book/ export/html/4>.

6 Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

7 Partners In Health. <http://model.pih.org/book/export/ html/4>.

8 Gillooly, Melissa. Partners In Health. E-mail to the author. 20 March 2009.

9 Gillooly, Melissa. Partners In Health. E-mail to the author. 20 March 2009.

10 Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

11 Partners In Health. <http://model.pih.org/book/export/ html/4>.

12 Didi Bertrand Farmer. Partners In Health. E-mail to the author. 4 April 2009.

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Cell Phones 4 P8tients n MDz

Throughout the world, engineers and innovators have been asking themselves this question: what if cell phones played a key role in health care? What if all one needed to update and check one’s medical records and to communicate with one’s physician was a Blackberry, cellular phone, or Palm Pilot? From these questions grew the technological movement that is developing rapidly in the United States and elsewhere, promising great benefits for the health care system.

Experts say that this innovation, known as “Mobile Health,” could potentially save the American health system hundreds of thousands—if not millions—of dollars, if implemented within the coming years. Already utilized in Europe, Mobile Health has been steadily gaining momentum in the American system. Its imminent application into the medical world promises to bring financial benefits and improve the facility and efficiency of patientphysician relations. As the population

grows and ages, demand for doctors has increased sharply, but the time available to physicians to spend with patients is limited. Developers of Mobile Health technology hope that their products will remedy this issue.

Peter Waegemann of the Mobile Health Initiative in Boston, MA, told the HCGHR that the term “Mobile Health” refers to “all applications in health care where cell phones, PDAs, laptops, any kind of computer are being used.”1 Presently, Mobile Health Initiative and similar companies are working on ways for patients to check personal health records, make appointments, and communicate directly with their doctors through mobile technology.

The hope is that as communication between doctors and patients are condensed to SMS text and e-mail messaging, Mobile Health technology will save patients’ and doctors’ money and time, speeding up the follow-up process in particular.

Using this technology, patients will be able to receive instantaneous feedback

from their physicians when they have a complaint that needs immediate attention. Mobile Health technology will also improve patients’ adherence because their PDA devices will remind them to take their prescribed medication.

Mobile Health will enable doctors and patients to access medical records via cell phones or Blackberries—once these medical records are digitalized. The Obama administration is currently working with health experts to implement electronic health records, which it says will save millions of dollars in the future.2 Once this change takes effect, experts predict that mobile health technology will take off.

Waegemann predicts that by the end of 2009 and 2010, Mobile Health will be fully implemented in the U.S. health care system.

Mobile Health may reach even into the developing world, where medical health workers are striving to treat rare diseases in remote areas.

Currently, health workers often must

Courtesy Wikimedia Commons

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Courtesy Paranoid Images

travel long distances between rural villages and urban-area hospitals to test their samples. Armed with Mobile Health technology, they can drastically reduce time cost by simply sending a picture of the samples via PDAs to computers that can perform tests on the data. This could lead to significant improvements in health care of developing nations.

Despite the enthusiasm surrounding Mobile Health, some skeptics worry about privacy issues.

The companies developing the technology must ensure that patients’ privacy is not compromised through the digital exchange of medical records.

Those concerned about patient confidentiality call for the development of impenetrable firewalls to prevent the exploitation of patients’ medical histories, especially in today’s society, where identity theft is a common occurrence.

Hospitals also worry that

cell phones and PDAs will interfere with crucial medical machinery.

Many companies and hospitals are not forming what experts call the “right” kinds of policies to implement Mobile Health. Often, hospitals are so concerned with the drawbacks of Mobile Health that they are hesitant to try the new technology in their systems.

While this technology saves patients’ time and money, it also removes the personal contact between physician and patient. How can patients put their trust in a doctor with whom they hardly ever come into contact? How can a doctor fully diagnose patients’ complaints without hearing about and seeing the problem firsthand? Will Mobile Health enhance doctor-patient relations due to an increase in digital communications, or will it result in the deterioration of these relations? In today’s busy, technological world, Mobile Health has

a necessary function, but the personal relationship between doctor and patient will always be preferable to a faceless association, especially when the other aforementioned drawbacks are taken into account.

Mobile Health is still in its “embryonic stage,” and it is certain that engineers will at the least be able to solve the technological issues of the digital movement.3 Despite the drawbacks concerning patient-doctor relations, Mobile Health promises to be an important step forward in the American health care system, while other aspects of the technology suggest vast improvements in the health care of the developing world.

Alexis Karlin, Staff Writer Waegemann, Peter. Mobile Health Initiative. Interview 2009 Feb 23.

1

Lohr, Steve. How to Make Electronic Records a Reality. 2009 Feb 28. New York Times.

2

Waegemann, Peter. Mobile Health Initiative. Interview 2009 Feb 23.

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The PACT Project Health Promotion from Haiti to Boston

As she talks about the recovery of one of her clients, Magalie LamourMédé’s voice is filled with warmth and pride. When they first met, LamourMédé’s client was “literally at death’s door.” Struggling with HIV/AIDS, she weighed only 84 pounds and had difficulty adhering to her medications.

After joining the Prevention and Access to Care and Treatment project (PACT), the patient not only regained weight and suppressed her viral load, but also improved her relationship with her teenage daughter and overcame substance abuse.

As one of PACT’s community health promoters, Lamour-Médé serves some of the most marginalized AIDS patients in the Boston area. A joint project of the Brigham and Women’s Hospital and the nonprofit Partners in Health (PIH), PACT began in 1999 to assist patients who have poor access to and utilization of healthcare.

Its community-based model comes from PIH’s work in Haiti, where accompagnateurs provide directly observed therapy (DOT) and social support. Here in Boston, PACT’s major initiatives—harm reduction, health promotion, and DOT—seek to address AIDS from prevention to care.

At the simplest level, PACT’s work is about building relationships.

Because they share clients’ cultural and linguistic backgrounds, the staff feels they truly understand the social inequalities that interfere with adherence. Health promoter Jason Villarreal describes his day-to-day work as “walking with people.” He explains that such “walking” brings him to doctors’ offices, social services, and into patients’ homes. Here, he can “meet people where they’re at” by learning about the circumstances

Courtesy PACT Project

of their realities and then providing tailored assistance with their HIV treatment. In the case of one of his colleagues, “walking with people” can even mean sprinting through the hospital after a client is dropped off on the wrong side of the building.

PACT’s staff applies this “whatever it takes” approach to helping its patients not only with HIV treatment, but also with issues related to mental illness, unemployment, substance abuse, domestic violence, poverty, and homelessness.

A major goal of health promotion is to complement the medical system by building bridges between patients and their physicians.

Jessica Aguilera-Steinert, director of client services, describes health promoters as “hav[ing] a foot in both worlds—the medical world, with its education and language and

‘whiteness’—and the world of the patient.”

Specifically, health promoters understand and can translate both the language of the physician and the concerns of the client. While many physicians recognize that they themselves cannot conduct home visits, most do not actively seek out health promoters’ opinions. When physicians cannot identify reasons for non-adherence, health promoters help illuminate patients’ other sources of stress: threat of eviction, difficulty paying bills, or problems with family, to name a few. Villarreal has assisted in such a way, but notes that he was “stunned” at a recent case conference at Massachusetts General Hospital when the attending asked directly for his input.

According to PACT’s staff, the success of their program stems from

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Courtesy PACT Project

a holistic view of the nonadherent patient and the chance to truly connect with their clients. Providers have described feeling frustrated that, no matter how they try to encourage patients, many do not seem to care.

But, Lamour-Médé explains, “Often, people are screaming for help, screaming in the sense that ‘I’m not going to take these meds because I don’t mean much to society.’”

PACT not only addresses such health and emotional needs of patients, but also shapes its mission around empowerment. Aiming to encourage patients to advocate for themselves, PACT’s health promoters are trained to assist without creating excessive dependence in patients.

Villarreal explains, “I tell people, my goal is to work myself out of a job.”

If a patient is able to navigate an appointment independently, Villarreal is pleased with his work and optimistic that further adherence improvement will succeed.

Clinical data reflects these successes: on average, patients’ CD4

counts increase by over 100 in one year. Cost reductions also accompany these health improvements, with medical savings averaging $18,000 per year for an increase in CD4 count from less than 50 to over 200. The impact of PACT’s philosophy and delivery of care extends beyond these numbers, to increased healthcare utilization, mental health and substance abuse treatment, better relationships with families, and disclosure to partners.

While PACT’s model is grounded in the local, it is expanding geographically and clinically. Director Heidi Behforouz and AguileraSteinert have trained personnel at hospitals, universities, and healthcare organizations in Florida, New York, and Ohio. PACT’s Dorchester site receives many visitors, ranging from nurse practitioners from Michigan to Jamaica’s ministry of health. Within Massachusetts, a pilot project is funding health promotion services to address other chronic diseases like diabetes. While sustained funding remains a challenge, the widespread

recognition and interest in PACT’s work contributes to its energetic, hopeful atmosphere.

Another organization might be overwhelmed by the combined demands of direct service and technical assistance, but PACT’s entrepreneurial spirit enables it to do both. As Aguilera-Steinert states simply, “there’s no secret—it’s a good intervention with very, very caring people.” With a powerful and flexible communitybased model, their dedication is poised to reach patients across the rest of the country.

Lulu Tsao, Staff Writer Behforouz, Heidi and Aguilera-Steinert, Jessica.

“Health Disparities in Our Own Backyard.”

Replication training. St. Luke’s Roosevelt Hospital.

September 2008.

Aguilera-Steinert, Jessica. Personal interview. 12 March 2009.

Villarreal, Jason. Telephone interview. 19 March 2009.

Lamour-Médé, Magaile. Telephone interview. 19 March 2009.

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Colonial Roots of Global Health Lessons learned for modern humanitarian health

A piece in the Washington Post last September observed that “For a Global Generation, Public Health Is a Hot Field.”1 The generation in question was, of course, that of the primary readership of this journal. In the words of one American pollster, yours is the generation appositely termed the “First Global.” But even if this trend is new—and it seems to us that its scope is unprecedented—the collection of problems classed under the rubric of global health is not new, although there are many new twists (such as acquired resistance to antimicrobials, which could not have occurred prior to their invention and widespread use). The basic lineaments of the debates are not new, either, nor are efforts to affect the health of populations far from home. The issues facing those interested in global health are old ones; many of the institutions confronting these challenges are mature bureaucracies. Even the identification of ranking challenges— what historians of science have called “problem choice”—is constrained by social forces with roots in the 19th century and before.

Although we are not historians, we have been trained to recognize the importance of history in any serious exploration of contemporary health problems. To understand the trajectories of the intended and unintended consequences sparked by global health interventions, we have three goals in this essay: to trace, in however cursory a manner, the historical roots of global health; to reveal key continuities and also ruptures with the past; and to interrogate some of the work we do, by drawing on history and social theory to explore the limitations of humanitarian models of global health.

1. Vignettes from the Nineteenth Century

It’s hard to know when to start the clock ticking on modern public health, because every innovation— from quarantine to modern sewers to the stains that helped make modern microbiology possible—can be said to stem from previous ones. Instead, let us engage in a different and less obvious exercise: linking together an exploration of the roots of international health with one that looks at the way in which subjects (under others’ authority without autonomy), if they are lucky enough, become citizens (with rights and responsibilities to the state).

When Foucault writes of “biopower,”2 he illuminates our understanding of modern obsessions with the body as subject and citizen, showing us how knowledge-power (of medicine and of public health) transforms human life through mechanisms of control at the level of both the individual and population. Paul Rabinow’s term “biosociality”3 casts light on the links between biology and identity—for example, the redefinitions of self and social identity spurred by new genetic testing capabilities (hence his book French DNA4). Adriana Petryna uses the term “biocitizenship”5 to look at ways in which access to medical care and other limited social goods mediates the relationship of citizens to the state.6 It is this notion of biocitizenship that we wish to interrogate in the context of global health, colonial medicine, and history.

Whether we look in the past or the present, we’ll see continuities.

Thus is today’s “global health” the vigorous child of international health, which was itself begat by colonial enterprises large and small. Although historians of public health will reach back to maritime trade and efforts, usually fruitless, to contain plagues,7 colonial aspirations were often the crucible of transregional efforts to

Courtesy Partners in Health

improve health in order to reach other, usually extractive, goals. For some, the global era was unleashed not in the 20th century but rather at the close of the 15th: how else to understand efforts to protect property, including human property, in Europe’s first New World colonies?

Slaves, citizens, and notions of rights

We will speak of the French colony of Saint-Domingue, with which we have some familiarity and what would prove to be the most productive slave colony in the world. Haiti, as it’s now called, is a very important example of how subjects—not yet citizens— came to be regarded as investments.

That is the key to international health in this era: understanding that international and public health were being advanced through, and because of, commercial interests.

So let us return to Haiti, and to slaves. Haiti became the leading port of call for slavers in the 19th century, with up to 29,000 slaves brought in each year shortly before the French Revolution in 1789. And as we all know, slaves were considered even less than subjects: they were property, investments. By 1788, when

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global health review the burgeoning French Revolution led to the writing of France’s Declaration of the Rights of Man and the Citizen, the notion of rights was of widespread currency. But were these rights natural and universal? Or did they have to be conferred? The original Declaration, which underlined popular sovereignty as opposed to the divine right of kings, asserted that: “Men are born and remain free and equal in rights. Social distinctions may be founded only upon the general good.”8 This was of course a swipe at the special rights of the nobility and clergy, but no mention was made of women or of slaves, and it was of course slavery that interested the grand majority of the Haiti’s inhabitants.

The short version: when in the late 19th century the mulatto freedmen Jean-Baptiste Chavannes and Vincente Ogé traveled from Haiti to France to press for rights in Haiti, they went to press for the rights of mulattos to own slaves. Thus the distinction between human (or natural) rights—those rights inalienably endowed by being human (who is human?)—and citizens’ rights—those rights acquired through citizenship and sovereignty (who are citizens?)—took on a special meaning in Haiti and in the slave-owning swathes of the United States and parts of Latin America.9

Looking back, we could describe these hypocrisies—the French promoting human rights, but not so stridently that their own colonial subjects might be freed to enjoy such rights—as a tension between policy and practice. So it is with many policies, from slavery to Jim Crow to apartheid to Darfur: we tend to look back wondering, How could we have ever cautioned that?

We are not surprised, in retrospect, that the Haitians rejected Napoleon’s subsequent blandishments: it’s clear enough to us (given our access to available documents) that Napoleon planned to re-establish slavery in French holdings in the New World.10 And so a full decade of revolt and war led to the establishment, in November of 1803, of Latin America’s first

republic. But if slaves became citizens first in Haiti, and later in other settings, it did not mean that being nominally a citizen meant that one would enjoy the rights of the citizen as laid out in various declarations by that name.

Germs, poverty, and the birth of public health

But what of plague and other pandemics? Europe had been home not only to regular outbreaks of cholera, but also of smallpox and plague. In some ways, the latter half of the 19th century was the heyday of public health. Recall the example of John Snow and the Broad Street pump. [IMAGE – SNOW’S MAP Credit: The John Snow Archive and Research Companion.] By mid-century, there was still no agreement regarding discrepant claims of causality of epidemic disease.

Were these caused by miasmas, bad air, or by invisible microbes? In 1854, after investigating a London outbreak of cholera, Snow sought a meeting with the local health authority called, aptly enough, the Board of Governors and Directors of the Poor.

The Board’s records show that “Dr. John Snow has respectfully requested an interview with them. He was admitted and presented an account of his investigation so far. As a result the committee issued an order that the handle be removed from the Broad Street pump.”11 The pump handle was removed the next day, and the cholera epidemic subsided. [IMAGE – PUMP CARTOON. Credit: Drawing by George Pinwell, 1866. CDC Public Health Image Library (ID#:5292).]

There’s a lot more to this famous story. As a pioneering anesthesiologist and activist, John Snow fought suffering on several levels.

On March 5, 1855, for example, Snow walked to a poor neighborhood to administer chloroform so a young man with a “weak constitution” could have teeth extracted. Then on to the Mayfair district, where he chloroformed an old man having dead bone debrided from his leg (imagine having that done without any anesthesia, as had been standard practice). Then Snow crossed the River Thames to help remove a

kidney stone.12

That was just in the morning.

Later that day, Snow testified before the Houses of Parliament. The English were leaders in the process of gentrification and the city’s grandees were trying to get rid of what they called “the offensive trades.” They weren’t talking about the precursors of Lehman Brothers or AIG, but rather “trades that released foul-smelling, noxious fumes,”13 like bone boilers and tallow melters. In Snow’s biography, we read that the “sanitary reform movement was driven by the medical opinion that poisonous vapors, whether miasmas rising from marshes or from decomposing organic matter near human dwellings, were the main cause of disease, including epidemic cholera, which had killed tens of thousands of people in England since 1831.”14

Snow regarded the miasma theory as rubbish, and said as much to the select committee seeking to remove the offensive trades. In a famous book, he presented the two studies on cholera that would make him famous to future epidemiologists.

One traced the aforementioned link between a virulent Golden Square cholera outbreak and the contaminated water pump at Broad Street; the other analyzed differential mortality rates in London subdistricts against their water sources.15

The select committee was not very friendly to Dr. Snow. He noted, “I have paid a great deal of attention to epidemic diseases, more particularly to cholera, and in fact to the public health in general; and I have arrived at the conclusion with regard to what are called offensive trades, that many of them do not assist in the propagation of epidemic diseases, and that in fact they are not injurious to the public health.”16

Snow was then questioned by one Sir Benjamin Hall. “Are the Committee to understand,” Hall inquired incredulously, “taking the case of bone-boilers, that no matter how offensive to the sense of smell the effluvia that comes from the bone-

15 boiling establishments may be, yet you consider that it is not prejudicial in any way to the health of the inhabitants of the district?”

“That is my opinion,” Snow replied. The problem, he showed, lay elsewhere.17

Before the advent of germ theory, when epidemic disease began to be understood to be the result of microbes rather than of “miasmas” or the wrath of a divine being, the chief social responses to such epidemics often included accusations that one or another human group was responsible for propagating the affliction in question.18 Similarly inaccurate and ineffective beliefs abounded when the arrival of European colonists led to catastrophic outbreaks of communicable diseases among indigenous populations in the Americas, and these viewpoints continued to hold sway during subsequent pandemics of cholera.

But by the late 19th century, as public health historian Marcos Cueto observes, many influential public figures were convinced. He notes that, in 1903, “The Paris Conference brought together 21 countries, including the until-then reluctant Great Britain, which held that quarantines generally worked against trade…The Paris Sanitary Conference recommended implementation of John Snow’s discovery about cholera.”19

So how was this reflected in colonial medicine? By the time colonial medicine and public health became important forces in Latin America, Africa, and other locales, the notion of sanitation dominated. But claims of causality of disease in public health were also divided into broad categories of social causation and microbial causation at the start of the 20th century. The idea that social conditions (including fouled water) generated ill health versus the claims that organisms caused ill health became a central tension in public health during this time.

But it is impossible to move into the 20th century without mentioning the devastating impact of

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global health review the Columbian Exchange. To return to Haiti as an example, it is estimated that there were up to 8 million indigenous people living on the island of Hispaniola before the Spanish arrived in 1492. By the 17th century, not a single one had survived. They died from mistreatment at the hands of Europeans, but also in droves from measles, smallpox, and tuberculosis—a pattern that emerged all over the New World in the following centuries.

This widespread appearance of epidemic disease was the backdrop of 19th century endeavors, and fear of epidemic disease was inextricably tied to commerce (recall our earlier mention that the interests of trade and profit have long served to direct public health efforts). The notion of quarantine has its origins in the 18th century and earlier around shipping regulations and mitigating the spread of plagues; the United States’ acquisition of Cuba, Puerto Rico, Guam, and the Philippines through the Treaty of Paris at the end of the SpanishAmerican War of 1898 and subsequent terror of tropical disease for the troops permanently stationed in the Caribbean was another link between commercial interests and public health concerns.

2. The Panama Canal and the Roots of PAHO

Perhaps the best example of this symbiosis is that of the construction of the Panama Canal and the birth of the Pan American Health Organization (PAHO). Marcos Cueto writes that the “Organization’s creation was the product of the expansion of international commerce, medical advances, and a new political and diplomatic relationship among the countries of the Americas. From this confluence, a new concept of health, not just as an individual aspiration, but also as a right and a duty—a right of the people and a duty and responsibility of the State—was forged.”20

We will return, in closing, to the notion of health as “a right and a duty,” but here it is important to underline, as Cueto does, the role of

international commerce as midwife to what would prove the first real international health organization.

Linking the Atlantic and Pacific was a 16th century dream, one that was stalled until the completion of the Panama Railway in 1855. But a railroad was a modest endeavor compared to the one that would allow ships to cross the narrow isthmus separating the seas, as the Suez Canal did when completed in 1869.

But between 1881 and 1889, the period of active French construction of the Panama Canal, more than 21,000 employees died— many of them from yellow fever or malaria.21 The project floundered; epidemic disease had thus far defeated the dream.

One of the chief French players began pressing the United States government to bring the canal to life, hiring a well-known American lawyer, William Nelson Cromwell, as a lobbyist.

The United States was considering constructing a canal across Nicaragua, and Cromwell’s job was to convince members of Congress that Nicaragua would be a dangerous place to build such a canal. In one slick play, he had a stamp issued with an image of a longdormant volcano coming to life and later used it to mail letters to every member of the Senate.22 [IMAGE – STAMPS Credit: www.paperheritage. co.uk] In 1902, three days after senators received the stamps,23 the United States announced its plans to complete the canal in Panama.24 To be successful, and to complete the project designed to grease the wheels of international commerce, they would have to do what the French had been unable to: find a way to keep their workforce healthy.25

But epidemic disease is never eradicated by fiat. Something was killing thousands of laborers dispatched to build the canal, and many of their titular bosses, including engineers, were also dying. As noted, there were those who favored miasmas as explanation. But the notion of pathogen and vector was gaining ground. By the end of the 19th century,

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global health review as the canal lay stalled, there were advances in medical knowledge. Some, primary among them Dr. Carlos Finlay, began to argue that mosquitoes were the vector for two diseases: malaria and yellow fever.26 By 1898, Finlay’s colleague, Dr. Walter Reed, working in Cuba during the Spanish-American war, had come to agree. Both doctors, along with many others, turned their attentions to eradicating the mosquito vector and to making the construction area safe for workers.

Shortly after announcing the U.S. initiative to complete the Panama Canal (which they eventually did in 1914), President Theodore Roosevelt convened the First International Sanitary Convention of the American Republics in Washington D.C. in 1902.

Perhaps a signal of the rising currency of mosquito vector control, Dr. Finlay was one of four individuals appointed to the convention’s organizing committee. The First Convention focused on diseases’ impact on international trade generally, and discussed quarantine, prevention, and shipping regulations. 27 During the Second International Sanitary Convention in 1905, an American committee member, Dr. H.L.E. Johnson, explicitly acknowledged that U.S. strategic and commercial interests in the Panama Canal project were a driving force behind the new panAmerican effort:

I feel sure that as a few months or years pass by the diseases which have stood in the way of the completion of the Panama Canal, which we might term the ideal of the President of the United States to accomplish, will be removed and that the great good to this country which is expected in health, wealth, and prosperity will flow from it…28

President Roosevelt himself expressed “the greatest interest and confidence in the work of the sanitarians in the Isthmian Canal Zone.”29 The subsequent International Sanitary Bureau, led by U.S. Surgeon General Walter Wyman, spearheaded the eradication of yellow fever in Panama by 1905. The bureau was later

Courtesy Partners in Health

renamed the Pan American Health Organization (PAHO), now the world’s oldest international public health agency.

3. The Legacy of Colonialism

While roughly two-thirds of Latin America had achieved independence by 1900, there was only a single free state in Africa at the turn of the century. Thus the legacy of colonialism, particularly in regards to health and rights, lies especially heavy on that continent. Megan Vaughn’s Curing their Ills explores “colonial power and African illness” in certain parts of Africa, largely British colonies, between the 1890s and 1950 or so. She has “argued that the history of ‘bio-power’ in colonial Africa was rather different from that described by Foucault for Europe.

The fundamental difference was that Africans were always conceived of as members of a collectivity as colonial

people, and beyond that as members of collectivities in the forms of ‘tribes’ or cultural groups.”30

Rwanda offers a chilling example of the consequences of this overstate and largely externallyimposed social grouping. The history of the 1994 genocide in Rwanda will be contested terrain for generations, but some conclusions are inescapable: that European notions of race and ethnicity, including those inspired by colonialera eugenics, helped to harden the pre-colonial social categories of Hutu and Tutsi; that the biased bestowal of colonial-era privileges in a social field of scarcity laid the framework for intergroup violence that began in 1959, at the close of the colonial era; and that control over the state apparatus, and the economic and social privileges associated with proximity to political power, was the chief goal of the government leaders who were the

17 architects of the Rwandan genocide.31

Vaughn raises the “question of how far colonial power operated through the production of subjectivities at all, and how far it relied upon the kind of ‘repressive’ power which Foucault sees as characterizing premodern regimes.”32 In other words, Vaughn asks: how does power, and the lack thereof, get into the body and cause disease? In Rwanda, the internalization of disparity and inequity—Foucault’s “subjectivities”— was fostered by the objectification of ethnic division, initially through the faux science of eugenics and later for the political convenience (for the colonizers) of indirect rule by a privileged minority.

Lacking valuable natural resources or strategic position, there was little to extract from RwandaUrundi, as the colony was known. The colonial power, Belgium, therefore had no incentive to invest in public health or educational infrastructure.

As such, the “fruits” of development were enjoyed by a precious few in Rwanda, mostly belonging to that privileged minority. By independence in 1959, more than three decades after the introduction of ethnic identity cards, inequality among Rwandans was staggering. In the decades to follow, ethnic conflict proved a ready outlet for tensions over persistent social scarcity, such as land pressure, hunger, and poor health.

4. The Modern Era?

Even in the early heyday of vaccine development, no global institutions tackled the health problems of the world’s poor. Colonial powers did address (with varying degrees of effectiveness and sources of motivation) the ranking infectious killers in regions now known as the developing world, but universal standards or even aspirations for international public health and medicine were still far in the future.

Although the League of Nations concerned itself with health issues like malaria in the early 20th century, and although various organs of the nascent United Nations—including the United

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global health review Nations Development Program (UNDP) and the United Nations Children’s Fund (UNICEF)—also addressed health issues, the World Health Organization (WHO) was the first truly global health institution. Since its founding in 1948, the WHO has witnessed dramatic shifts in population health and in its own stature as the premier global health institution. In line with a long-standing focus on communicable diseases that readily cross administrative and political borders, leaders in global health, under the aegis of the WHO, initiated the effort that led to what some see as the greatest success in international health: the eradication of smallpox [IMAGE – WORLD HEALTH MAGAZINE COVER Credit: http://www. cdc.gov/Features/SmallpoxEradication].

Historians of the smallpox campaign note the preconditions that made eradication possible: international consensus regarding the potential for success, an effective vaccine, and the apparent lack of a nonhuman reservoir for the oftenlethal and highly infectious etiologic agent. The primary obstacle was the lack of effective delivery mechanisms for the vaccine in settings of poverty, where health personnel were scarce and health systems weak. Close collaborations across administrative and political borders were clearly necessary. Naysayers were surprised when the smallpox eradication campaign, which engaged public health officials throughout the world, proved successful at the height of the Cold War.33

The optimism born of the world’s first successful diseaseeradication campaign invigorated the international health community, if only briefly. Global consensus regarding the right to primary health care for all was reached at the International Conference on Primary Health Care in Alma-Ata (in what is now Kazakhstan) in 1978. However, the declaration of this collective vision was not followed by substantial funding, nor did the apparent consensus reflect universal commitment to the right to health care. Moreover, as is too often the

case, success paradoxically weakened commitment. Basic-science research that might lead to effective vaccines and therapies for tuberculosis and malaria faltered in the latter decades of the 20th century after these diseases were brought under control in the affluent countries where most such research is conducted. U.S. Surgeon General William H. Stewart supposedly declared in the late 1960s that it was time to “close the book on infectious diseases,”34 and attention was turned to the main health problems of countries that had already undergone an “epidemiological transition”35; that is, the focus shifted from premature deaths due to infectious diseases toward deaths from complications of chronic non-communicable diseases, including malignancies and complications of heart disease.

5. Citizen and Subject in Global Health

The rich and complex set of problems that all agree constitute today’s global health are linked to equally complex but more hidden concepts of power and control, and the question of who holds that power. How can any intervention, either simple or complex, be expanded—scaledup—outside of the public sector? How can any entity other than the state confer rights to citizens? The concepts with which we began this essay, social theory from Foucault and others, lead us to again consider who is a citizen and subject.

Returning to the example of Rwanda, the refugee crisis that developed in the wake of the 1994 genocide illustrates with terrible clarity the consequences of treating aid “recipients” as humanitarian subjects, rather than rights-bearing citizens. In July 1994 nearly two million mostly Hutu refugees, both innocent civilians and genocidaires, fled Rwanda into neighboring countries, predominantly what was then Zaire.

After reacting with quiet consternation but little action during the 100day massacre, the international community flooded the burgeoning Zairean camps. Struggling to maintain

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global health review order and contain outbreaks of epidemic disease, aid workers were largely oblivious when the former Rwandan (genocidaire) government reconstituted itself in the camps, which they used as civic and military bases of operation.36 Fiona Terry of Médecins Sans Frontières, which was working in the Goma camps, made no bones about it: the genocidaires, not the humanitarians, ran the camps. Aid organizations could not keep up with the need for sanitation facilities and subsequent epidemics of cholera and dysentery, which killed over 50,000 refugees in the month after their arrival.37 Continued militarization of the camps, under the watch of the humanitarian community, sparked a regional conflict that has since claimed approximately 3 million lives, the majority from starvation and disease.38

Moreover, the presence and actions of humanitarian groups presented their own complications.

By default, the intervention of these groups implies a perceived political or ethical failure of the host country, and is thus inevitably a politicized act.39 Extending this concept forward, Mahmood Mamdani, a government and anthropology professor at Columbia, makes a rather chilling argument that what he calls the “new humanitarian order” will ultimately undermine rights and sovereignty in Africa. Using the example of Darfur, Mamdani outlines the politicization of international aid and humanitarian efforts through the degradation of the concept of citizenship. He writes: That responsibility is said to belong to the ‘international community,’ to be exercised in practice by the UN, and in particular by the Security Council, whose permanent members are the great powers. This new order is sanctioned in a language that departs markedly from the older language of law and citizenship. It describes as ‘human’ the populations to be protected and as ‘humanitarian’ the crises these suffer from, the intervention that promises to rescue them and the agencies that seek to carry out intervention. Whereas the language of sovereignty is profoundly

political, that of humanitarian intervention is profoundly apolitical, and sometimes even antipolitical.

The international humanitarian order, in contrast, does not acknowledge citizenship. Instead, it turns citizens into wards. The language of humanitarian intervention has cut its ties with the language of citizen rights. To the extent the global humanitarian order claims to stand for these rights, these are residual rights of the human and not the full range of rights of the citizen. If the rights of the citizen are pointedly political, the rights of the human pertain to sheer survival; these are summed up in one word: protection.40

Rudolph Virchow, a contemporary of John Snow, once argued that “Medicine, as a social science, as the science of human beings, has the obligation to raise… problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”41 But this is never easy in the doing; the devil is often in the details, as anyone working to redress poverty and inequality will know. Just as daunting are the larger problems, which are almost philosophical in scope. For all of us who work in global health, it behooves us to think about these difficult questions of citizenship, power, and rights, and to remember the checkered history of this endeavor—from the eugenics that helped to spawn a genocide to the successful global cooperation that eliminated a deadly disease—as we develop the solutions for very practical problems.

Paul Farmer, Zoe Agoos, and Peter Drobac Brown, David. “For a Global Generation, Public Health is a Hot Field,” The Washington Post, September 19, 2008.

2 Foucault, Michel. The History of Sexuality: An Introduction.

London: Penguin, 1990.

3 Rabinow, Paul. “Artificiality and Enlightenment: From Sociobiology to Biosociality.” In The Science Studies Reader, ed.

M. Biagioli, 407- 416. New York and London: Routledge, 1999.

4 Rabinow, Paul. French DNA: Trouble in Purgatory. Chicago: University of Chicago Press, 2002.

5 Petryna, Adriana. Life Exposed: Biological Citizens after Chernobyl. Princeton: Princeton University Press, 2002.

6An illustration of this concept is the diagnosis of Posttraumatic Stress Disorder and its relation to entitlements. See: Young, Allan. The Harmony of Illusions: Inventing Posttraumatic Stress Disorder. Princeton: Princeton University Press, 1995.

7 Turshen, Meredith. The Politics of Public Health. New 1

Brunswick: Rutgers University Press, 1989.

8 Declaration of the Rights of Man and of the Citizen. Article 1. Approved by the National Assembly of France, August 26, 1789. Available at: http://www.hrcr.org/docs/frenchdec.html.

9 See: Farmer, Paul. The Uses of Haiti. Monroe, ME: Common Courage Press, 1994.

10 Auguste, C. and M. Auguste. L’Expedition Leclerc, 18011803. Port-au-Prince: Imprimerie Henri Deschamps, 1985.

11 Vinten-Johansen, Peter et. al., Cholera, Chloroform and the Science of Medicine: A Life of John Snow. Oxford: Oxford University Press, 2003, p. 294.

12 Vinten-Johansen, 2003, pp. 6-7.

13 Vinten-Johansen, 2003, p. 7.

14 Vinten-Johansen, 2003, p. 7.

15 Vinten-Johansen, 2003, p. 7.

16 Vinten-Johansen, 2003, p. 8.

17 Vinten-Johansen, 2003, p. 9.

18 McNeill, William H. Plagues and Peoples. New York: Bantam, Doubleday, Dell Group, 1976.

19 Cueto, Marcos. Missionaries of Science: the Rockefeller Foundation and Latin America. Bloomington, Indiana University Press, 1994, p. 12.

20 Cueto, 1994, p. 3.

21 Cueto, 1994.

22 Cueto, 1994.

23 Kinzer, Stephen. Overthrow: America’s Century of Regime Change from Hawaii to Iraq. New York: Henry Holt and Company, 2006, pp. 58–59.

24 Packard, Randall. The Making of a Tropical Disease: A Short History of Malaria. Baltimore: Johns Hopkins University Press, 2007.

25 Cueto, 1994, p. 20.

26 Packard, 2007.

27 Transactions of the First General International Sanitary Convention of the American Republics, Held in Washington, D.C., December 2, 3, and 4, 1902, Under the Auspices of the Governing Board of the International Union of the American Republics. Washington D.C.: Government Printing Office, 1903.

28 Transactions of the Second General International Sanitary Convention of the American Republics, Held in Washington, D.C., October 9, 10, 12, 13, and 14, 1905, Under the Auspices of the Governing Board of the International Union of the American Republics. Washington D.C.: Government Printing Office, 1906, p. 94.

29Transactions of the Second General International Sanitary Convention of the American Republics, p. 30.

30 Vaughn, Megan. Curing Their Ills: Colonial Power and African Illness. Stanford: Stanford University press, 1991. p. 202.

31 See: African Rights. Rwanda: Death, Despair and Defiance.

London: African Rights, 1995 (1994); Gourevitch, Philip. We Wish to Inform You that Tomorrow We Will Be Killed with Our Families. New York: Picador, 1999.

32 Vaughn, 1991, p. 203.

33 Koplow, David A. Smallpox: the Fight to Eradicate a Global Scourge. Berkeley: University of California Press, 2003.

34 Martin, Douglas. “William H. Stewart Is Dead at 86; Put First Warnings on Cigarette Packs [obituary].” The New York Times.

April 29, 2008.

35 Omran, A.R. “The Epidemiological Transition: A Theory of the Effects of Population Change.” Milbank Memorial Fund Quarterly, 1971. 49(4): 509-538.

36 Terry, Fiona. Condemned to Repeat? The Paradox of Humanitarian Action. Ithaca, NY: Cornell University Press, 2002.

37 Goma Epidemiological Group. “Public Health Impact of Rwandan Refugee Crisis: What Happened in Goma, Zaire, in July, 1994?” Lancet, 1995. 345(8946): 339-344, p. 342.

38 Prunier, Gérard. Africa’s World War: Congo, the Rwandan Genocide, and the Making of a Continental Catastrophe.

Oxford, UK: Oxford University Press, 2008.

39 Redfield, Peter. “Doctors, Borders, and Life in Crisis.” Cultural Anthropology 2005. 30(3): 328-361.

40 Mamdani, Mahmood. “The New Humanitarian Order.” The Nation, September 9, 2008, p.18.

41 Ackerknecht, Erwin. Rudolph Virchow: Doctor, Statesman, Anthropologist. Madison: the University of Wisconsin Press, 1953.

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Interventions

Targeting Drug Users in HIV Prevention in China

In 2007, 729 needle exchange programs were established in the People’s Republic of China as part of the effort to combat HIV/AIDS epidemic among intravenous (IV) drug users. These programs contribute to growing optimism surrounding government responses to HIV/AIDS, as demonstrated by UNAIDS public acknowledgment in July of 2007 of China’s Vice Minister of Health, Dr Wang Longde, and Qingdao University professor, Zhang Beichuan, for their

HIV/AIDS work (UNAIDS). Countrywide, HIV/AIDS interventions are being scaled up. The 729 needle exchange programs of 2007 represent over an 800% increase from 2004, when only 90 needle-exchange programs existed country-wide (harm reduction journal).

Today, although China’s AIDS epidemic has spread throughout the nation and touched all provinces, advocacy and intervention campaigns continue to heavily target a few subpopulations. These groups notably

include IV drug users, sex workers, men who have sex with men, and ethnic minorities. Experts worry that focused interventions, though innovative and localized, threaten to further harm already marginalized populations. In particular, as Chinese health workers, within and without the government, struggle to reach IV drug users in particular, legal and moral controversy abounds.

China’s stance on illegal drug is one of “zero tolerance.” In

Courtesy Romanian Ministry of Communications and Information Technology

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Courtesy Wikimedia Commons

2005 the government declared “the people’s war on drugs” and heroin (the most popular intravenous drug) trafficking in excess of 50 grams still warrants the death penalty.

Penalties for users include a system of voluntary detoxification, compulsory rehabilitation and reeducationthrough-labor (RTL) centers, depending on an individual’s criminal history.

Human Rights Watch has reported incidents of targeted drug-related arrests at the sites of prevention services. Human rights activists point to such reports as evidence that the government’s firm stance on drug use complicates HIV/AIDS prevention services.

Chinese citizens reflect the complexity of the matter, as they speak both in support of the police action and of HIV prevention programs. Commenting through email correspondence on arrests made at needle exchange programs, Beijing resident Gao Zishen writes “if the police arrest them based on their sin (something wrong them have done), that is justified. If they did not break

the rules, they should not be arrested.

So, I think we should show our respect to the law in China.” Zhang Xiaodong adds, “I can’t say if it’s justified for the drug users, but it’s useful. You know it’s totally illegal in China to sell drugs.”

However, Zhang and Gao both also speak in support of needle exchange programs. Zhang writes, “for IV drug users, I think the best way is to educate them. Not just tell them it’s harmful to use that, but also bring a new life to them… I think it’s useful to gather them together to give them medical treatment and prevent the spreading of diseases.”

Police presence outside prevention services seems to be only part of the controversy. Human Rights Watch also points out troubling practices within compulsory rehabilitation and RTL centers. Human Rights Watch claims residents at these centers are not provided with regular treatment, monitoring, or medical care.

Reports of unsafe sex between male guards and female inmates, as well as unsanitary drug use, raise concerns over transmission and sexual abuse.

In an environment of such high-risk sexual activity and drug use, HIV positive inmates taking antiretroviral (ARV) medicines are particularly endangered, experts worry.

Studies have found that recreational drugs can interfere with the effectiveness of ARV. The additional risk of drug resistance arises from irregular or interrupted ARV supplies due to systems of guard favoritism.

China is not the only country to receive criticism for its policies surrounding drugs use and HIV/AIDS. In fact, China has been favorably compared with Eastern Europe, where countries like Ukraine have documented accounts of arrests and beating by needle exchange programs.

The advocacy group AVERT suggests, “40% of countries have laws that interfere with their ability to reach injecting drug users.” And while China’s drug policies are indeed strict, the number of people arrested for drugs drug and the number sent to treatment centers combined still only match onefifth of US yearly drug arrests.

With around 44% of HIV prevalence in China attributed to IV drug use, effectively fighting this epidemic in the globe’s most populous nation requires reaching out to users.

As China embarks upon the new year of the ox, efforts against HIV/AIDS will continue to be at the forefront of national and international attention.

Marianna Tu, Staff Writer Alcorn, Keith. “Chinese HIV prevention with drug users undermined by police.” Aidsmap News. 11 December 2008. http://www.aidsmap.com/en/news/90DE9D1E-C677-4D2A92E4-65250632D62C.asp “China: UNAIDS awards leadership excellence.” UNAIDS. 17 July 2007 <http://www.unaids.org:80/en/KnowledgeCentre/ Resources/FeatureStories/archive/2007/20070717_China_ UNAIDS_awards_leadership_excellence.asp> ““China Says Drug War is Failing.” Stop the Drug War. 3 June 2005. <http://stopthedrugwar.org/chronicle/389/china. shtml> Injecting drugs,drug users, HIV & AIDS.”AVERT.13 March 2009 <http://www.avert.org/injecting.htm> Qian, Hanzhu, Joseph E Schumacher, Huey T Chen and YuHua Ruan. “Injection drug use and HIV/AIDS in China: Review of current situation, prevention and policy implications.”

Harm Reduction Journal 2006, 3:4 <http://www. harmreductionjournal.com/content/3/1/4>

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Two Bills for Health

global health review

Foundational Approaches to Global Health

Bill Gates made headlines earlier this year when he released a jar of mosquitoes onto an influential and unsuspecting audience during a talk on malaria at the Technology Entertainment Design (TED) Conference in Long Beach, California.

After a few moments of nervous laughter from around the auditorium, Gates had to assure everyone the insects were not infected, drawing his

loudest round of applause.1 Over the last couple of years his foundation, as well as The Clinton Foundation, has invested heavily in the fight against a disease that continues to affect millions annually. While both nongovernmental organizations (NGOs) claim they will achieve significant success against malaria by 2015, they have taken very different approaches to eradicating the disease.2, 3

Malaria is a leading cause of morbidity and mortality in many countries: there were over 247 million cases in 2006 alone,4 compared to 3.2 million cases of HIV/AIDS the previous year.5 The Gates Foundation carries out malaria control programs in several sub-Saharan countries, and Gates-funded initiatives have led to progress in malaria control in Zambia and Ethiopia.6 However, the foundation focuses much of its efforts on researching drugs, developing vaccines, and exploring new prevention strategies. This has occasionally led to controversy.

In a leaked internal memo in February 2008, Dr. Arata Kochi, the chief of malaria for the World Health Organization complained that the Gates Foundation’s tendency to spend heavily on a select few projects was stifling diversity in malaria research.7 This need not be a cause for alarm.

“Whether or not that’s a good thing depends on what you think of the Foundation’s research priorities,” says Dr. Jon Clardy of the Harvard Malaria Initiative. WHO scientists are also concerned about the NGO’s promotion of Intermittent Preventive Treatment for infants (IPTi) in Africa, which involves giving infants doses of anti-malaria drugs. Early studies have shown that this only offers short-term protection, and the adverse health effects of giving babies sulfa drugs could outweigh the benefits.8

Disputes aside, the Gates Foundation’s focus on research and new preventive strategies is noteworthy. The Foundation recognizes the need to delve into the underlying causes of malaria. Dr. Clardy told the HCGHR that although its 2015 deadline may divert funds away from “more basic research that could eventually

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global health review have an impact” the Gates Foundation remains “the only source for significant and sustained funding” for many scientists.

The Clinton Foundation has also set itself a deadline for 2015, but it focuses its relatively fewer antimalaria resources on shorter-term, more economical measures. Last year President Clinton noted, “Nearly every life lost to malaria could have been saved with access to effective [available] medicines.”9 His NGO had previously led efforts to increase access to affordable HIV medication, and applied the same strategies to malaria last year with great success.

Currently, the most effective anti-malaria drugs -- known as ACTs, for artemisinin-based combination therapies – cost as much as $10 per treatment in many African countries.

One of the reasons for this high price was that over the last few years the key ingredient, artemisinin, has fluctuated from between $150 and $1100 per kilogram.10

Last July, The Clinton Foundation unveiled a consortium of artemisinin suppliers and generic drug companies that would sell ACTs at a low price to developing countries.

Together with supply-side subsidies, the NGO claims this innovation could reduce the price of ACTs to as little as $0.50.11

Supply-side efforts alone cannot increase access to cheap drugs. In an interview with the HCGHR Inder Singh, who designed the price-stabilization plan for the Clinton Foundation, the NGO’s approach has been a “simultaneous engagement of both supply side and demand side issues”. Although Mr. Singh stresses that the Foundation is primarily focused on tangible onthe-ground measures like helping local governments implement malaria elimination plans, he admits that their high-impact economic achievements, especially in drug pricing, have made for better press.

Courtesy Wikimedia Commons

Despite their different focuses, the Clinton and Gates Foundation’s present efforts against malaria are complementary. Moreover, both foundations are heavily involved in simple, community-based prevention measures. Dr. Paul Campbell of the Harvard School of Public Health believes that “strategies to reduce the incidence and mortality from malaria need to include the reduction of standing water, the spraying of insecticide and the use of insecticidesoaked bed nets.” Neither the Clinton nor the Gates Foundation has lost sight of this.

As we head towards 2015, it is important to note the significant impact these foundations have already had: “Great progress has been made against malaria and should be celebrated even as advocates re-double

their efforts to eradicate the disease,” says an optimistic Dr. Campbell.

Rajarshi Banerjee, Staff Writer http://www.youtube.com/watch?v=ppDWD3VwxVg Accessed 3/3/09 2 Sarah Boseley “World leaders announce $3bn plan to end malaria deaths by 2015” The Guardian 25 Sep 2008 http://www.guardian.co.uk/society/2008/sep/25/ internationalaidanddevelopment.infectiousdiseases Accessed 3/3/09 3 Philip Rucker “World Leaders Embrace Goal of Ending Malaria Deaths by 2015” Washington Post 26 Sep 2008 http://www.washingtonpost.com/wp-dyn/content/ article/2008/09/25/AR2008092501815.html Accessed 3/3/09 4 WHO World Malaria Report 2008 http://www.who.int/ malaria/wmr2008/WMR08-news-summary.pdf. Accessed 3/3/09 5 BBC http://news.bbc.co.uk/2/hi/health/4456900.stm Accessed 3/10/09 6 Gates Foundation Press Release Sep. 25, 2008 http://www. gatesfoundation.org/press-releases/Pages/develop-nextgeneration-malaria-vaccine-080925.aspx Accessed 3/3/09 7 Donald G McNeil “Gates Foundation’s Influence Criticized” NYT Feb 16 2008 http://www.nytimes.com/2008/02/16/ science/16malaria.html Accessed 3/3/09 8 Ibid 9 Aziz Haniffa “Inder Singh heads Clinton Foundation’s malaria drug initiative” Rediff News Sep 04 2008 http://www.rediff. com/news/2008/sep/04malaria.htm Accessed 3/3/09 10 Mark Schoofs “Clinton Foundation Sets Up Malaria-Drug Price Plan” WSJ July 17 2008 http://online.wsj.com/article/ SB121626447476161201.html Accessed 3/3/09 11 Ibid 1

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The Modern Plague The Cholera Epidemic in Zimbabwe

Exceeding original worst-case scenario figures proposed by the World Health Organization (WHO), the ongoing cholera epidemic in Zimbabwe has infected over 93,000 individuals and taken the lives of over 4,000, according to a March 27 WHO update.

Since the outbreak began in August 2008, the Zimbabwean population’s needs have been difficult to meet with a heath care system that has been in decline since 2006, evidenced by the nation’s life expectancy at birth of 36 years, the lowest in the world.

Inadequate water treatment and sanitation systems have only provided an impetus for the spread of the infection, which has seen a cumulative death rate of over 5 percent, five times greater than the usual death rate from cholera, according to a report released in January by Physicians for Human Rights (PHR). The situation has only worsened with a spread of the epidemic to all ten of Zimbabwe’s provinces and exponential growth.

Cholera, an acute diarrheal infection caused by the bacterium Vibrio cholera, is contracted through the ingestion of contaminated food or water. Upon infection, even healthy adults can die in a matter of hours.

Dr. Howard Zucker, former Assistant Director-General of the WHO and current Harvard Institute of Politics Fellow, characterized some factors that lead to an outbreak: “Stagnant water will serve as a source for this widespread infection. Primarily it begins when sanitary conditions are so poor. That is why the need for public health measures is so critical.”

Experts in this field, however, argue that health measures capable of dealing with such a crisis were never something with which the Zimbabwean administration was equipped. One action taken was the Mugabe regime’s nationalization of water sanitation

Courtesy Julien Harneis

and trash collection systems. In their report, “Health in Ruins: A Man-Made Disaster in Zimbabwe,” PHR experts assert that this intervention effectively set the stage for the perfect storm of cholera infection.

With raw sewage flowing through the streets and clean water unavailable, the cholera infection established its foothold in Zimbabwe.

“I think the cholera epidemic is a terrible symptom of major underlying collapses of the social and economic infrastructure in Zimbabwe,” commented Dr. Jennifer Leaning, a PHR board member and reviewer of the report as well as Harvard School of Public Health professor.

Yet as the crisis has overtaken Zimbabwe and the ill look to hospitals for treatment, they find little comfort.

Sky-high inflation rates, surpassing 11 million percent in 2008, have immobilized the population and barred health professionals from collecting their salaries, gradually causing hospitals to close their doors. PHR reports that by December 2008 not

only was the patient-to-staff ratio too high, but there were no more critical care beds available for the public.

With Zimbabwe in a state of internal chaos, the global community has looked elsewhere for a solution.

“The success of this is really the collaboration between multiple organizations such as the WHO, UNICEF, the World Food Program, and NGO’s. They play a very significant role; often countries look to these organizations for assistance because they have dealt with situations of such nature before,” explains Dr. Zucker.

As for the United States’ role in this situation, Zucker told the HCGHR, “The U.S. effort to help is critical. It is important to separate our political views from our public health assistance. I would hope our country would do all that they can to assist the people of Zimbabwe. My experience is that the U.S. will rise to the challenge.”

However, with the transition of the U.S. presidency and a failing economy taking center stage, health professionals in Zimbabwe and across

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Donaghue, PHR CEO, commented, “It’s pretty surprising that the State Department can write thousands and thousands of words on Zimbabwe and fail to mention the right to health.

They have not acknowledged that Zimbabwe is currently experiencing one of the most egregious assaults on health in the world.”

As the crisis continues, the cumulative death rate has been slowly decreasing since early January, yet this in no way implies that the epidemic is over. Dr. Leaning describes that attention should instead be focused on maintaining and continuing this downward trend: “The most important intervention is to provide clean water for drinking and household use to the population in the regions affected by the epidemic… In the long run, this approach would mean rebuilding at least some of the key water systems in the country. For these measures to occur, the government of Zimbabwe must permit more international aid to reach the population in need.”

Lavinia Mitroi, Staff Writer

Courtesy Pierre Holtz

the world are concerned that the cholera crisis has been put on the backburner. “Part of the issue is that much of this crisis unfolded under the Bush administration, and now we have a new administration that has not yet fully articulated its Africa policy.

Under the Bush administration the U.S. position was to work with the national governments of Southern Africa to apply pressure on Zimbabwe, especially through urging the government of South Africa to exert more local and direct economic pressure on Zimbabwe,” describes Dr. Leaning.

U.S. humanitarian assistance

for the cholera crisis in Zimbabwe through the Agency for International Development (USAID) was reported as a little over $7 million for the 2009 fiscal year. These funds support water, hygiene, and sanitation programs, as well as the WHO’s Cholera Command and Control Centre in the capital city of Harare.

Some experts, nevertheless, assert that U.S. intervention has been insufficient. In reference to the annual human rights report card released by the Department of State, focusing 26,000 words on the Mugabe regime’s mismanagement of the nation, Frank

“Daily Cholera Update and Alerts.” World Health Organization. 27 March 2009. Office of the WHO Representative in Zimbabwe. 28 March 2009. <http://www. who.int/hac/crises/zmb/sitreps/ zimbabwe_cholera_update_27march2009.pdf>.

2 Sollom, Richard et. al. “Health in Ruins: A Man-Made Disaster in Zimbabwe.” Jan. 2009. 29 March 2009. <http://physiciansforhumanrights.org/library/documents/ reports/2009-health-in-ruins-zim-full.pdf>.

3 Ibid.

4 “Cholera in Zimbabwe- update 2.” World Health Organization. 20 Feb. 2009. The World Health Organization.

29 March 2009. < http://www.who.int/csr/don/2009_02_20/ en/index.html>.

5 “Cholera Fact Sheet.” World Health Organization. Nov. 2008. The World Health Organization. 29 March 2009. <http://www.who.int/mediacentre/factsheets/fs107/en/ index.html>.

6 Sollom, Richard et. al. “Health in Ruins: A Man-Made Disaster in Zimbabwe.” Jan. 2009. 29 March 2009. <http://physiciansforhumanrights.org/library/documents/ reports/2009-health-in-ruins-zim-full.pdf>.

7 Sollom, Richard et. al. “Health in Ruins: A Man-Made Disaster in Zimbabwe.” Jan. 2009. 29 March 2009. <http://physiciansforhumanrights.org/library/documents/ reports/2009-health-in-ruins-zim-full.pdf>.

“Zimbabwe inflation hits 11,200,000 percent.” CNN.com International. Aug. 19, 2008. CNN. 29 March 2009. <http:// edition.cnn.com/2008/BUSINESS/08/19/zimbabwe.inflation/ index.html>.

9 Sollom, Richard et. al. “Health in Ruins: A Man-Made Disaster in Zimbabwe.” Jan. 2009. 29 March 2009. <http://physiciansforhumanrights.org/library/documents/ reports/2009-health-in-ruins-zim-full.pdf>.

10 Sollom, Richard et. al. “Health in Ruins: A Man-Made Disaster in Zimbabwe.” Jan. 2009. 29 March 2009. <http://physiciansforhumanrights.org/library/documents/ reports/2009-health-in-ruins-zim-full.pdf>.

11 United States. USAID. Bureau for Democracy, Conflict, and Humanitarian Assistance and the Office of U.S. Foreign Disaster Assistance. Zimbabwe-Cholera Outbreak Fact Sheet #11, Fiscal Year (FY) 2009. Washington: March 6, 2009.

12 United States. USAID. Bureau for Democracy, Conflict, and Humanitarian Assistance and the Office of U.S. Foreign Disaster Assistance. Zimbabwe-Cholera Outbreak Fact Sheet #11, Fiscal Year (FY) 2009. Washington: March 6, 2009.

13 “Cholera in Zimbabwe- update 3.” World Health Organization. 23 March 2009. The World Health Organization. 29 March 2009. <http://www.who.int/csr/ don/2009_03_23/en/index.html>.

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Leprosy Now

An Ancient, But Still Neglected Disease

Since its first documentation, leprosy has been one of the most heavily chronicled diseases.

Unfortunately, some aspects of the disease and its treatment have remained obscure for thousands of years. It was not until the early years of modern medicine, in 1873, that Dr. Armauer Hansen of Norway made the astonishing discovery that leprosy was caused by a bacterium (Mycobacterium leprae) that this disease became known as a public health issue instead of a curse from God.

Over a hundred years later, technological advances have facilitated a greater understanding of the science behind the disease. Leprosy

is a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract and that it causes extensive damage to the skin, limbs, nerves and eyes. Fortunately, research has led to development of effective multidrug therapies (MDTs).

The MDT treatment course consists of 2 â&#x20AC;&#x201C; 3 powerful drugs that, taken together, can prevent transmission after the first dose and can cure patients within 6 â&#x20AC;&#x201C; 12 months.

However, what our technology has not afforded us is the insight into how we stomp this tragic disease out of existence. Since the introduction of MTDs in 1985, 14.5 million people have been cured of leprosy. Sadly, this

number is very low compared to what it could potentially be. But, the World Health Organization (WHO) still reports over 200,000 new cases of leprosy each year in addition to the tens of millions already infected. Most of these new cases occur in Sub-Saharan Africa, Brazil, India, and other countries in Southeast Asia.

In these developing areas of the world, combinations of social, economic, and political issues impede delivery to victims of leprosy of an already effective treatment. But millions more could be helped if the barriers to treatment delivery could be crossed.

One of the biggest barriers to treatment delivery is the stigma associated with being a leper. Although most of the developed world now recognizes that leprosy is caused by a pathogen, many in the developing world still fear the disease is a divine sign and shun or segregate lepers in leper colonies.

Fear of this segregation leads individuals with newly acquired infections to deny or hide their disease for as long

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as possible and avoid getting treatment in order to not reveal their status.

And yet, difficult as such cultural problems may be, economic obstacles to treatment delivery are even higher. Because leprosy, and other neglected tropical diseases, are often segregated to rural areas in the developing world, infrastructure development has often not reached the communities that are most hard hit. Roads to deliver the medicines

from WHO headquarters, hospitals to carry them, and doctors capable of prescribing the medicines and watching their progress are hard to come by in these impoverished situations.

Although the WHO provides MTDs free of charge in endemic countries, the lack of crucial infrastructure makes regular administration of MTDs – regardless of their availability – an ongoing challenge.

Leprosy is not alone in its frustrating barriers to eradication.

The thirteen other diseases, which 1/6 of the world’s population suffers from, are included in the category of neglected tropical diseases share the same problem.

Of the 14 disease listed as Neglected tropical diseases (NTD), most can be prevented or eliminated at a low cost. They do not transmit easily, but instead result from are instead the result of unsanitary living conditions, unsafe water, and insufficient access to medical care.

And though they cause much pain and social stigma to their victims, they do not receive much attention from the international health community. International public health bodies believe that, because these diseases are isolated in rural areas, carry such heavy stigmas, and – unlike SARS or AIDS – do not cause international outbreaks, they go relatively unnoticed.

Public health experts are trying to promote increased awareness around NTD. According to former U.S. Health and Human Services Secretary Tommy Thompson, controlling NTD is the key to not only reducing the amount of needless suffering in the developing world, but also to fostering positive relationships between developed and developing nations. Despite remaining infrastructural challenges for treatment implementation, many share Thompson’s passion and optimism as they look the future.

Kira Mengistu, Staff Writer

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Interview: Julio Frenk

A conversation with the new dean of the Harvard School of Public Health

Dr. Julio Frenk is an internationally renowned global health professional who has been one of the forerunners in calling for the establishment of an implementation science to better monitor and evaluate health programs.

As Mexico’s Health Minister from 2000 to 2006, he was responsible for the establishment of Seguro Popular, a comprehensive national health insurance program that has been credited with bringing access to tens of millions of previously uninsured Mexican citizens. He is currently a Senior Fellow at the Bill and Melinda Gates Foundation, lending his expertise to a variety of global problems. In July 2008, he was named the new Dean of Harvard School of Public Health, a position he currently fills.

HCGHR: Information dissemination is one of the most pressing problems in global health today. In your opinion, how can the field move forward in building sustainable and effective systems that share their methods, so that not everyone has to re-invent the wheel?

Dean Frenk: This is one of the positive sides of globalization, with all the

possibilities of engaging in a process of shared learning. If we don’t study it, if we don’t evaluate it, and then make the findings available, we’re condemning the rest of the world either to repeat past mistakes or not to learn from positive innovation.

This is one of the aspects where knowledge becomes a global public good. The way to achieve that is to make sure that every innovation is evaluated, and that’s the key to implementation science. I think this is one of the main areas where international collective action can work, where countries can agree that every new innovation in every country ought to be evaluated; I think there’s a role for universities to play, also for international organizations.

For example, if the World Bank funds a project or the Global Fund funds a project, there should always be, built in from the beginning, an element of assessing what the situation was before the innovation and then measuring what happened with that, and then making sure that that knowledge becomes an available public good by making it available in a way that’s accessible, and where one could then have a repository of best practice internationally. So, let’s say, a Minister of Health arrives in a country, a developing country, and he or she wants to introduce health insurance for the poor; then that Minister would know exactly where to go and would be able to get good indicators as to what worked and what didn’t work and in what conditions. But that needs to be orchestrated and be financed, and we have never had as many resources for global health as today. We need to make sure that in addition to bringing together the drugs and the vaccines, that we develop innovative systems of delivery and that we actually create a

science of implementation that deals with the scientific evaluation every step of the way, and make sure that that becomes available to everybody else by making knowledge truly a public good.

HCGHR: In the past, you’ve argued against what you believe to be a false dichotomy between horizontal approaches and vertical approaches in global health and in favor of a “diagonal” system. Could you explain this diagonal system and give an example?

Dean Frenk: There have been two traditions in public health. One is the vertical tradition, and it’s called this because it’s focused around a specific disease, and then you create a special system just to deal with that disease. The classical examples were the campaigns; they even used military terms like campaigns, the campaigns against malaria. So a country in the 1970s, when there was this push to try to eradicate malaria, they would create a separate organization, completely separate from the Ministry of Health, with its own logistics, its own health workers, its own vehicles, its own spraying units. It was vertical, one single disease with everything around it, from purchasing, logistics, the delivery of insecticides, to drugs to immunizations. Obviously, the health system deals with many more conditions and so people started advocating for a horizontal approach.

A horizontal approach means you deal with the general issues about how you organize health care, how you finance health care, and then you deal with whatever disease comes.

The horizontal approach aimed at strengthening and concentrating doctors’ training, nurses, but did not have a clear sense of priorities.

The shortcomings in the case of the

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global health review vertical approach is a fragmented system, very inefficient because you may have a workforce that’s only partially occupied with one disease, but they don’t know anything about anything else, plus people don’t interact with the health system like that, they don’t come in with diagnoses, they come with symptoms, with complaints, with problems. So you can’t have people pre-assigned to those disease categories, right? The horizontal approach, while being more comprehensive, had the problem that it didn’t have clear priorities, so in poor countries you would end up with health systems that cater to the needs of the better off. So you would have large hospitals in urban areas, but no primary care infrastructure in the rural areas. So to deal with the shortcomings and to try and bridge a divide between these two traditions which had been kind of in a very acrimonious debate for decades, several of us have been using the term of diagonal approach, which is just like in geometry, where a diagonal is what unites the vertical and horizontal.

This term was introduced by Dr. Jaime Sepulveda, who was a member of the Board of Overseers of Harvard University and a very distinguished public health professional who is currently at the Gates Foundation.

He coined this term diagonal to refer to an approach where you actually strengthen the health system but have a very clear sense of priorities among the most pressing problems of poor people and use those to drive general improvements in the health system so that then the health system can generally respond to other health problems. Good examples have been, good AIDS programs. You have a clear focus on AIDS, but then you use that. To give an example, in Mexico we’re trying to introduce insurance for poor people to deal with some very expensive diseases that were creating catastrophic expenditures. Because AIDS was such a difficult issue, we started the insurance program offering

coverage for the treatment of AIDS, very expensive. But that generated all of the advocacy to create a health insurance program that now covers everything else. By focusing initially on AIDS, we were able to secure the funding, get the logistical mechanisms, enrollment of people, etc…and now that insurance program covers a whole lot of things. That’s the essence of the diagonal approach.

HCGHR: Many people have criticized PEPFAR’s exclusive focus on one disease. Do you agree with such criticisms?

Dean Frenk: Well, I think that PEPFAR offers a great opportunity to implement the diagonal approach. It is focused on HIV/AIDS treatment; I think there’s been an effort to also expand it to prevention, but it offers the opportunity, if it’s done properly, of taking the fight against AIDS in Africa and using those resources, for example, to build laboratory capacity, so that you’re not just doing test for AIDS, but you actually now have labs that can test many things, training doctors and nurses that will be there for other things. So it is an example.

If it doesn’t take advantage, then yes, you could make that criticism. But I think it’s a great opportunity to adopt the diagonal approach.

HCGHR: As Dean of HSPH, what sort of initiatives do you hope to begin to lead the school in the direction of diagonal and holistic health system approaches that will be sustainable and effective in the future?

Dean Frenk: Well, I think the school has a great role to play and has been playing that role in three avenues.

First, being part of the research component and carrying out a lot of these evaluative researches. The School has already been very active there. I can tell you that in my own experience when I was minister of Health of Mexico, learning from the evaluation of Oportunidades, which

as I said was the product of a graduate of this school, we adopted the same strategy for the health insurance program for the poor called Seguro Popular. And the general evaluation was done here at HSPH, led by Chris Murray. So that’s a threshold for the school, and I think to continue to strengthen our capacity in the field of research is going to be one way of making that contribution, continuing to make that contribution. The second of course is in education. I would like, in addition to our degree programs, to get involved more in leadership development efforts. Again, already there’s a lot of activities in that field but I think certain forms of continuing executive education, which are more tailored to people who are already in the field and who can come for short periods of time. There’s a very successful program here called the clinical effectiveness program over the summers, and it’s meant to evaluate clinical interventions. So we’ve been talking about extending that to some of these large scale global health issues in a similar format. So in addition to continuing to train the future leaders through our degree programs, I think addition of executive and continuing education using the tools of telecommunications would be important. And then, third, I think this school has a role to play in translating knowledge into evidence so that it can be useful in policy making. Again, we have a long tradition in our department of Global Health and Population and our Health Systems Program that’s been doing a lot of this translation effort and building capacity. The team here was very much involved in the health reforming in the country of Columbia. So in research, especially rigorous evaluation, and education all through the degree programs and in new innovative mechanisms of executive and continuing education and in translation of research findings into evidence, I think this school can make a major contribution in improving global health.

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Interview: Gregory Bisson

UPenn’s rising star in infectious disease and epidemiology

Gregory Bisson is an Assistant Professor at the University of Pennsylvania in the Department of Medicine’s Infectious Disease Division and a Senior Scholar at the Center for Clinical Epidemiology and Biostatistics. His work focuses primarily on the study of HIV and its co-infections with an emphasis on its presence in Africa. Dr. Bisson aims to bridge the gap between epidemiological research and clinical medicine to improve healthcare for HIV patients in Africa.

HCGHR: Tell me a little bit about yourself and how you got to where you are now.

Bisson: I originally was a Japanese language and literature major in college and was interested in politics and working for the State Department.

I was initially not thinking about being a doctor and then I did a year abroad in an exchange program through the University of Madison Wisconsin with a University in Japan (Nanzan University in Nagoya). It was a transformational experience and I fell in love with Japan and became even more interested in international relations (vaguely defined).

Then when I traveled around South East Asia and I became very impressed with what I felt to be a challenging state of global public health. I had a glimpse of this through traveling in some parts of Asia. At that point I started to question what my mission in life would be about and

after seeing people that are suffering in developing countries and that are suffering from things that are often preventable and treatable really was something that motivated me to eventually go into medicine.

he is fundamentally a basic scientist as well as being the Chief of the Division.

One of the things that he was always interested in was getting a research aspect to Penn’s involvement in Botswana up and running.

When I came back from Japan I was a senior in college. Then I took a year off and applied to medical school and worked at the U.S. Senate and got a close up look at how certain aspects of healthcare legislation were being created. I got into medical school and went back to the state where I am from (University of Minnesota).

When I applied to the Internal Medicine Residency and Infectious Disease Fellowship all of my statements were ever about were doing global health and doing research. To me, the way I wanted to make a difference was by doing research and that differs I think than primarily being involved and implementing the work. I was a Fellow in Infectious Disease and at the time we were on a clinical rotation together and he said why don’t you think about going to Botswana and I was increasingly interested in focusing on HIV research at the time so it made sense.

Ever since my travel in South East Asia I was always looking at international health as being my career.

At the very beginning I wanted to get at the big picture as much as possible and I think I didn’t really know what epidemiology was at the time but I became increasingly interested in doing that for my career over time. At that point during medical school I realized what I wanted to do was something that would be most applicable to global health and that for me was Infectious Disease. So I decided to go into Internal Medicine and later specialized in Infectious Disease. I went to the University of Pennsylvania to do an Internal Medicine Residency and then continued there to do my Infectious Disease Fellowship.

HCGHR: You’ve done a lot of work in Botswana. What inspired you to go there in the first place and what was your first trip like?

Bisson: The Chief of the Infectious Disease Division at Penn was invited to be involved and have the Infectious Disease Dept. at Penn be involved in scaling the HIV therapy in Botswana by some of the stake holders that were concerting that massive treatment in Botswana. This is Dr. Harvey Friedman;

The first trip took place several years ago and I went knowing no one except some introductions that were made. I met a lot of people, sat down and tried to listen as much as I could and really had to ask myself what could I do to add value to this situation. The first trip was sort of daunting. You are meeting people trying to work together to address this massive epidemic but people do not necessarily know what you are about. The first trip was a lot of meeting people and trying to think and then explain how I could potentially try to do something worthwhile. It felt like I was not just going there on a mission to help, it was something I always wanted to do and so it was an opportunity of a lifetime for me.

HCGHR: There are a lot of Harvard students interested in the kind of research you do, based on your two major studies. Can you describe your research for those two projects –

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global health review specifically, some challenges you faced, how you got around them, and what your results revealed?

Bisson: The initial projects that I wanted to focus on, I was interested in the treatment of HIV. That was my primary interest and still is. I wanted to try and figure out what I could do to improve outcomes. One of the things I began to look at was how paying out of pocket for therapy medications influences outcomes on treatment.

It can be an inherently intense situation where you have a place where people have a certain income per year and drugs can take up a substantial amount of that income. I wanted to see if higher out of pocket costs are related to worse outcomes.

We went through clinic records trying to characterize patients with respect to their co-morbidities and demographic characteristics also how they did with respect with their antiretroviral treatments and in particular how much they paid for medications and then went forward on treatment.

One of the major challenges was trying to just logistically deal with the situation there in terms of getting valid information from the medical charts. But, my goal was initially to succeed at something that was relatively small. I looked at outcomes among individuals in one of the main public clinics and in a private clinic. What we found was that, of all the people that died in the first year of antiretroviral therapy studying withdrawal therapy, 90% had CD4 counts of <100 and 90% of the deaths occurred within the first 6 months. We called this phenomenon “early death.” Early death was highly concentrated among individuals with advanced HIV and it brought up the question of why do these patients – even despite accessing and initiating potent medications that we know treat HIV – still die?

The fundamental paradigm is if you take your medicines your viral load goes down and your immune

system recovers. That may be different in these people if they take their medicines and their viral loads don’t go down because their system cannot absorb the drugs because they are so sick, or their gastrointestinal system doesn’t work the way we think it does, or other reasons. That study led to our hypothesis and that there may be a U shaped relationship between immune recovery and antiretroviral therapy and survival in very late stage disease.

This made me think a lot about monitoring and trying to evaluate from a clinical care perspective and from a health perspective how patients are doing in this global antiretroviral therapy effort. In many of these places the first thing you need to do is get people on antiretroviral therapy and then you want to ensure good followup. In our first study, almost 60% of the patients were lost to follow-up after antiretroviral therapy initiation actually died. What we showed on the Plus One paper was that unless you count lost to follow-ups as deaths, you may very well overestimate your survival.

Later we did something larger looking at several countries from Southern Africa that were trying to scale up CD4 counts monitoring. CD4 count changes essentially relate to whether or not you are taking your HIV medications or whether your virus is suppressed. If you take your medication and your viral load goes down then your CD4 count goes up.

Many programs were trying to monitor CD4 counts among these patients.

We found a more direct measure of monitoring their virus that was not a laboratory test at all.

It was actually looking at how consistently and completely patients were taking their medications. We relied on the cards that the patients carry with information about when they get their drugs refilled to predict virologic failure. We compared adherence as measured by pharmacy refills by CD4 count monitoring and we found that adherence was a more

accurate predictor.

We said that you should think about taking away this monitoring test and just monitor adherence because that is the most essential. You want to keep patients on the same drug regimen that they started initially. That is the cheapest and the best regimen.

You want to detect lapses in adherence early as possible in order to prevent subsequent resistance. What you are doing with CD4 count monitoring is finding patients too late. When you are seeing their CD4 counts going down, their virus is already out of control.

What we suggested in the article is that monitoring adherence could identify virologic failure earlier than monitoring CD4 count. The big idea was maybe we should think about doing away with CD4 count monitoring for patients on antiretroviral therapy. Pharmacy refill adherence is something that can be automated by computerized approaches or it could be something very simple as in Botswana.

HCGHR: Finally, students interested in global health often encounter obstacles related to their qualifications when trying to pursue learning opportunities outside of the classroom. What kind of advice can you offer such students?

Bisson: Be persistent. In high school one of things my brothers and I did to make money over the summer was sell meat and seafood door to door.

The one thing it taught me was that every part of life is sales. You need to have good things that you are trying to accomplish but you really have to believe in your product and you also need to be persistent and go out there and really try to sell your idea. Many of the research projects that I have gotten involved in or even some of the biggest projects that I have done, people have initially said are not good ideas. Knowledge combined with persistence essentially can make many of the people interested in global health highly successful.

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Physicians in Pursuit of a Moral Life Morals and Medicine in Modern China

Socialist ideology is pervasive in Chinese life, and thus digs deep into the moral core of individuals within the society. Arthur Kleinman defines a moral life is as “one that embodies our own moral commitments” (Kleinman 2). He goes further to note that those “who seek to live a moral life may develop an awareness that their moral environment, in the first sense, is wrong” (Kleinman 3). While businessmen and politicians may already operate in accordance with socialist-capitalist ideals, and thus embody their “moral environment” in that they are profit-driven and competitively seek to achieve their own ends, physicians are posed with a dilemma. While we hold American physicians to an ethical code that stresses the greater good of humanity and puts the patient before self, the temptation for individualistic motivations are thrust upon physicians in reform era China. In Priscilla Song’s article, “Cutting Edge Tactics: Practicing Health Care with Chinese Characteristics,” the nation clearly does not provide adequate financial or institutional support to physicians (only stringent laws and censorship), making it very difficult for physicians to survive without incorporating more selfish actions. However, while these actions may appear to be profiteering and selfinterested, in reality, their moral frames have only modified to accommodate for the state’s external pressures, while still ideologically working for the greater good of the nation. In “The Honest Doctor” by Philip Pan, we find that even despite political secrecy and

immorality, the unique morality of the physician can indeed shine through.

Thus, we cannot necessarily proclaim that physician morality has degraded in reform era China, but rather altered under political and economic pressure.

The government’s attitude towards medicine in reform era China is best characterized by a quote in “The Honest Doctor” highlighting the government’s response to SARS: “When is the best time for the party to break bad news to the public?

Never” (Pan 203). On many levels of intervention, the socialist-capitalist government of China deceptively appears to act for the greater good but underlying these actions are greed and pride, especially with regards to public health. During the SARS epidemic and in the Chinese hospital setting (which we see in Song’s article), it is clear that socialist politics has exerted a kind of biopower which impacts the survival of the citizens within Chinese society. Biopower is defined as “an explosion of numerous and diverse techniques for achieving the subjugations of bodies and the control of populations” (Foucault 140), and functions as the Chinese government’s ability to control the life and death of their citizens by regulating the flow of health information to the public.

During SARS, they went so far as to issue a “feel-good statement about a mysterious disease they knew to be highly contagious and frequently lethal” (Pan 207). This statement is very clearly manipulated to present SARS as a simple problem that is under State control, in order to avoid careful

scrutiny by Chinese reporters and the world stage.

However, a number of physicians felt quite uneasy about the SARS cover-up, one of them being the surgeon Jiang Yanyong. While many physicians were “accepting bribes from patients or prescribing unnecessary drugs to boost profits” (Pan 208) and buying into the State’s ideology, Yanyong felt the immorality of covering up a dangerous public health crisis. He felt all physicians should share in the sense of outrage towards the Chinese government. A doctor, he thought, should know better” (Pan 212). To Yanyong, his moral obligation as a physician to provide for the greater good of his people trumped the fear he felt from repercussions by the State.

As we can see with Yanyong, physicians have to reaffirm and adjust their moral codes within this new system of biopower in which the citizens (including the physicians themselves) are told to keep silent and compliant. Yanyong’s contact with the external world, and insistence on taking note of the SARS outbreak, destabilized the government’s authority in the eyes of the press, the World Health Organization, and the people of Beijing (Pan 216). He forced the world to note the immoral (economic and political) motivations of the State, while acting morally on his own sense of what’s right for the greater good, risking his job and his life to live the “moral life” he imagined.

In Song’s article, we see a similar oppression on the medical field, in that the government has conflicting

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For example, there was a significant reduction in public funding of the urban medical sector while at the same time, enforcing below-cost charges on routine medical services (Song 3). The socialist-capitalist Chinese government was attempting to push a majority of medical service expenses onto private businesses and individuals, which elicited a strong reactionary response from both hospitals and physicians, forcing them to readjust their priorities in this adverse political and economic environment.

Hospitals, facing harsh regulations and government inquiry, began to act as real estate brokers for “medical entrepreneurs,” who are physicians that exploited this sudden opening of opportunities for economic success (Song 3). Hospitals were forced to think of profits and not necessarily services or quality provided, in order to maneuver the murky legal waters that made it very difficult to even remain open and operational. Even hospitals that went under because of illegal “unauthorized” departments were able to re-register with the state if they changed their name slightly, such as the Beijing City West Hill Hospital as though becoming a new reformed entity (Song 16). This reflects the definite moral corruption that categorizes the highly competitive, business-focused existence of hospitals in reform era China.

On the surface, even physicians could be viewed as having to manipulate the state political and legal systems in order to simply remain with a steady job. However, it can be argued that physicians have a different moral driver that dictates their actions than the profiteering focus of hospitals.

While physicians had to “deploy a myriad of creative tactics ranging from exploiting administrative loopholes to capitalizing on technological advances

in order to evade government scrutiny and attract new patients,” it is not explicit that they are seeking selfinterested, personal economic gain alone (Song 2). For example, Dr. Huang had to begin using the facilities at Wanjie Hospital in Qingdao as a satellite clinic, because it “enabled him to weather the sudden loss of operating privileges at West Hill” (Song 14). However, it is also important to understand the motivations of Dr. Huang in working hard to maintain his job. This will be further explored later.

Dr. Huang also began performing smaller surgeries that could be done without a fully equipped operating room, which were much more expensive and difficult to access.

For example, the procedure of treating ALS patients, while normally requiring larger procedures and producing more comprehensive results, was to now be treated with smaller procedures that could be done with local anesthesia and minor invasion. This way, Dr. Huang would still be able to treat these patients within the new facilities of Wanjie Hospital without having to work around the law. Although this option could be seen as a breach in the ethical obligations of a physician to provide the best possible care, Dr. Huang himself said his choice of treatment was “eminently a moral decision that prioritized patients’ well-being over petty bureaucratic wrangling” (Song 15). It is difficult to find argument with this explanation of Dr. Huang’s ethical decision, for it does, in its own way, conform to the new moral stance expected of physicians in China at this time – to do whatever they can in the position they are in, with what they have.

In some sense, the fact that physicians have had to struggle to assert their individual identity and moral values into an oppressive State only furthers their conviction in

their own beliefs. As Kleinman has said, “radical changes in politics and the economy refashion moral life” (Song 16). Physicians and hospitals both stretch and blur the boundaries between what is moral and immoral, ethical and unethical. However, while hospitals undeniably turn to businessminded ventures, in both action and motive, physicians maintain a sense of moral integrity, even while integrating a degree of politics and economics into their practices. In reform era China, one cannot fully live a moral life as a detached, freethinking individual, especially not as a physician with external medical ethics codes placed upon them. Both Yanyong and Huang display this effort to protect what is most important to them – their nation and their patients, even in a corrupting and politically charged environment – and thus indeed live the moral life Kleinman defines. Physicians in China must constantly negotiate the line between moral drivers of government or institutions and an individual’s own moral code. This complicates our understanding of the moral changes that physicians’ experience. We cannot simply categorize these changes as moral degradation, but rather reorient our definition of what is moral and ethical back to the individual in hard times.

Bianca Verma ‘09, Contributing Writer Foucault, Michel. The History of Sexuality Vol.1: The Will to Knowledge. London: Penguin, 1998.

Kleinman, Arthur. What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. New York: Oxford UP, 2006.

Pan, Philip P. 2008. Out of Mao’s Shadow: The Struggle for the Soul of a New China. New York: Simon and Schuster. “The Honest Doctor.” pp. 199234.

Song, Priscilla. “Cutting Edge Tactics: Practicing Health Care with Chinese Characteristics.” Yale University.

Dissertation excerpt.

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Curing a Country China’s Challenges in Controlling Tuberculosis

I was let out of school early because I had been coughing, with a low fever of a hundred degrees.

My mother said to sleep it off, that it would be okay. There was not much to do but grimace and wonder when the dizziness and breathlessness would end, when everything would around me would stop sounding so muffled, overshadowed by the loud, insolent thudding of an overworked heart.

There was not much I could do but try to sleep it off.

Sometime, later that night, my illness went away. And, in a way, so did his. But, while I woke to a school day and a crying mother, lost in a phone call to China, my cousin never woke. And his mother has never really stopped crying.

Separated by some 7000 miles, the United States and China differ in more than just geographical location.

Cultures change as we sidestep the time-zones, and the diseases of the world ebb and flow across the geographical and political borders. TB bacillus, a threat to life in China that is incomprehensible to most Americans, currently affects nearly one third of the human population of the world; 1 in 10 of those affected contract active TB. In China, TB is the number one cause of death due to infectious disease in adults.

My cousin was barely an adult, twenty-one with a persisting cough and a grimace. He told his mother he’d sleep it off for another week, that it would be okay, even when she suspected that it wouldn’t. But

she didn’t argue; hospital visits are expensive and maybe it was just a cold.

In the West, those interested in “Global Health” often see health as a statistic, and a universal concept. A small number recognize that this is simply not true. There are definitions of health that are founded not only on a given individual’s field of interest, but also on the culture of such a person’s society. In this particular scenario, I was sick in North America because other people - my mother, my classmates and teacher – recognized my flu symptoms.

My cousin in China, however, was not allowed the privilege of being sick; no one there would read it as such because to do so would translate directly into heavy medical costs that are seen as unjustifiable for someone so young. Interestingly enough,

Courtesy Negi Images

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global health review my family in China is by no means impoverished, living well above the poverty line; the costs of treatment, however, are often outside of what even the lower-middle class can afford.

So, if it all boiled down to money, then developed countries may be rightfully optimistic in their crusade for success in global health. In 1991, with financial backing, The World Bank, the Department for International Development of the United Kingdom, the government of Japan through the Japan International Cooperation Agency, the Damien Foundation Belgium, the Global Fund to Fight AIDS, TB, and Malaria, and other organizations in China implemented DOTS (Directly Observed Treatment, Short-course): a TB control strategy recommended by the World Health Organization that screened citizens for TB bacillus. Between 1991 and 2000, the program evaluated some 8 million people who exhibited the symptoms of tuberculosis, and the project was deemed highly successful; it cured 95% of new cases compared to the 52% success rate before the program had been implemented.

Moreover, the program was deemed one of the most cost effective global health interventions ever used, costing only $100 for every cured patient.

Approximately one life-year was saved for every $15-$20, with a rate of return of $60 for every dollar spent.

By 2005, DOTS had been implemented for over a decade, and the developed world had spent much of the latter half of it patting itself on the back for saving those 8 million people in the first ten years. While it was a substantial achievement, it is important to remember that over 1.4 million people in China still contract active TB every year. In 2005, my cousin became a statistic.

The obvious conclusion is that there is still more to be done. China

Courtesy Centers for Disease Control and Prevention’s Public Health Image Library

is treating an illness with borrowed money. As altruistic as that may be of the developed world, there is still the untouched subject of how money factors into this problem at, not a global health or even national health level, but at the personal level.

Being told at the age of 15 that my cousin, the one who had always been a more obedient and quieter child than I, had died because he had denied his illness was something I could not understand. Growing up in North America, I had no way of understanding, at the personal level, what it meant to be sick in a family that was just starting to find financial stability. Treating TB using programs like DOTS may be beneficial when inspecting the raw data, but in some ways, it treats only the symptoms of a much larger illness. There are fundamental differences between health care in the West, and that in other places around the world. And, although it may be simpler to provide

the financial backing to rescue a less fortunate country from one disease or another, it will not change the fact that the root of all the problems lies more often in their health care systems - institutions that cannot be revived through individual campaigns against specific diseases.

The heart of a country’s infrastructure can be found in its health care system as the overall health of a country depends on the health of its individual citizens. If the heart itself is failing, there is little long term wisdom in tending to the cough and other less menacing symptoms. If China’s health care system is insufficient to tend to the millions of people who don’t count themselves to be of the higher income class, treating the individual diseases plaguing the country may be only a temporary fix. Until this is recognized, we are only drowning out the beating of an overworked heart.

Jenny X. Chen ‘12, Contributing Writer