Harvard College Global Health Review Spring 2010 Issue

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From the Editors

CHRONIC DISEASE 4

Alcoholism in Russia: Curbing Dependency at the Community Level

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Judy Park

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Susan Wang

Yuying Luo

Changing Economy, Changing Waist Sizes Butting Out: China’s Anti-Smoking Efforts

10 Developing Countries Feel the Pulse: Cardiovascular Disease Emerges in Latin America

Shalini Pammal

12 Moving Forward in an Era of Reconciliation: Mental Health in Rwanda

Maryell Hernandez

THE EXPERT PERSPECTIVE 14 Global Mental Health, Post-War Liberia, and the Urgent Need for Better Primary Care Systems

Drs. Pat Lee & Raj Panjabi

18 A Duality in Health Care Delivery: Between Boston and Rural Rajasthan

Dr. Sachin H. Jain

PANORAMA 22 Dangerous Driving in Brazil: The Overlooked Epidemic of Traffic-Related Deaths

Mark Ragheb

24 Ensuring a Brighter Future for Haiti: A Critical Assessment of Present and Future Needs

Annemarie Ryu

26 Kicking HIV to the Curb: Grassroot Soccer Scores New Goals for HIV Prevention

Hemali Thakkar

28 Taking Tips from Iranian Primary Health Care: ‘Health Houses’ Serve as Model for Mississippi Health Advocate

Neda Shahriari

30 A Race Against Time: Global Efforts to Address the Urgent Needs of the Elderly

Pratyusha Yalamanchi

INTERVIEWS 32 An Interview with Dr. Mirta Roses Periago 36 An Interview with Dr. Jennifer Leaning 40 An Interview with Jacqueline Novogratz STUDENT SPOTLIGHT 43 The Complexity of Urban Public Health: Mumbai, India

Laura Nolan Khan

45 Deconstructing the Masculine Gender Identity and its Influence on HIV/AIDS Prevention Policy in Peru

Anisha Kumar

47 Problems with the BRAC Bond:

Neglecting Tuberculosis Patients

Lauren Onofrey

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The Harvard College Global Health Review, Spring 2010 EDITORIAL BOARD Editors-in-Chief Michael Henderson Rajarshi Banerjee

BOARD OF ADVISERS Section Editors Justin Banerdt (Features) Alison Kraemer (Panorama) Lavinia Mitroi (Experts and Interviews) Angela Primbas (Student Spotlight)

Managing Editors Sarah Littlehale Daniel Driscoll STAFF Maryell Hernandez Yuying Luo Farhan Murshed Shalini Pammal Judy Park Mark Ragheb

DESIGN BOARD Annemarie Ryu Neda Shahriari Hemali Thakkar Susan Wang Pratyusha Yalamanchi

Whitney Adair Meghan Houser Erin McCormick Lavinia Mitroi

GRADUATE STUDENT ADVISERS Yvette Efevbera Michael Frick Jenna Golan Esther Hsu Laura Khan

David Bloom, PhD Chair, Department of Global Health and Population, Harvard School of Public Health Arachu Castro, PhD, MPH Assistant Professor of Social Medicine, Department of Global Health and Social Medicine, Harvard Medical School Robin Herman Associate Vice Dean for Communications, Harvard School of Public Health Rebecca Weintraub, MD Associate Physician, Division of Global Health Equity, Harvard Medical School Instructor in Medicine, Harvard Medical School

Sophie Miller Jessica Perkins Caitlin Powers Sophia Qiu Sarah Sorscher

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 con-

tributors 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 editorin-chief of HCGHR.

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global health review Volume I, Number 3, Spring 2010

From the Editors Dear Reader, This past year has seen the world’s wealthiest nation come to terms with the looming threat of chronic disease.

Chronic conditions like stroke, diabetes and cancer account for 7 out of every 10 deaths in the United States.

Without early detection and proper management, they can also be a massive drain on the economy. By signing the Patient Protection and Affordable Care Act this March, President Obama has extended health insurance coverage to the millions of Americans most at risk of suffering from chronic conditions.

Unfortunately, the same diseases that threaten Americans are all too real in developing countries as well.

Non-communicable chronic diseases are responsible for a staggering 35 million deaths every year, and are far more prevalent in resource-poor settings than traditionally feared infectious diseases such as HIV and Malaria. The burden of these chronic diseases--in addition to infectious diseases--overwhelms healthcare systems in many developing countries.

Around the world, experts and policymakers are becoming increasingly aware of the menace of certain chronic conditions. Last year, Russian President President Dmitri Medvedev declared his country’s rampant alcoholism a “national calamity”--his country’s lawmakers are trying to tackle the condition that has reduced male life expectancy to less than 59 years. Meanwhile in China, home to a third of the world’s smokers, health officials are calling for more stringent anti-tobacco legislation in an effort to reduce the country’s high incidence of chronic respiratory illnesses.

Still, there remains an immense disparity in awareness and funding for other chronic illnesses, particularly mental health. Most developing countries focus less than 1% of their health expenditure on treating mental illnesses. In countries like Rwanda, where hundreds of thousands of adolescents remember the 1994 genocide, that 1% figure is of little help. Projects dealing with men-

tal illnesses remain heavily stigmatized and underfunded, despite analyses having shown them to be very cost-effective.

With this issue of the Harvard College Global Health Review we hope to initiate a dialogue on issues related to chronic disease among the global health community at Harvard, primarily because these diseases often remain out of sight. In Haiti, for example, the devastating earthquake in January has led to an outpouring of support worldwide, with thousands of initiatives like “Harvard for Haiti” (co-sponsored by the Review) helping to fund emergency medical care for the many thousand survivors in need of treatment. However, as the beleaguered nation begins to slip off the global radar once again, there is a fear that its population will be left to deal with its own mental scars as a distracted world focuses on the next emergency. The WHO has issued a guidance report for providing psychological care in Haiti over the coming months; the extent to which organizations will follow this report remains to be seen.

Despite the grim picture we paint, the past few decades have witnessed major strides towards the development of robust systems of care for many chronic conditions, in countries around the world. This issue of the Review highlights the success stories as much as it investigates the shortcomings, offering a glimpse into the global health community’s continued search for effective and sustainable ways to manage this chronic problem.

Sincerely, Michael Henderson and Rajarshi Banerjee Editors-In-Chief

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Alcoholism in Russia: Curbing Dependency at the Community Level Judy Park, Staff Writer

F

rom the fall of the Romanov dynasty to the dissolution of the Soviet Union and the advent of capitalism, Russia has had a turbulent and dynamic history. However, one aspect of Russia has always remained constant: its love for alcohol.

After centuries of failed attempts to keep it at bay, alcohol consumption has severely damaged the health, life expectancy, growth, and productivity of the Russian population over the past decade. The situation has escalated to a point where President Dimitry Medvedev, in a meeting with senior Russian officials at the Black Sea resort of Sochi, has called it a “national disaster.”1,13 The alarming tone of his statement is warranted. Russians drink approximately 18 liters of pure alcohol a year, equal to over 50 bottles of vodka per citizen. This is nearly double the amount that the World Health Organization prescribes as a safe level of alcohol consumption.2 Among men, life ex-

pectancy has decreased to 59 years, the lowest in the WHO European region.

There are an estimated 2.3 million alcoholics in Russia, with children drinking and becoming addicted as early as age 13. The population is shrinking by 700,000 annually.3 A study published in the Lancet last year found that since the Soviet collapse, half of all deaths among Russians aged 15 – 54 have been caused by alcohol consumption.1 The goal of curbing the nation’s tremendous level of consumption has been commonly sought by several administrations. Former Soviet president Mikhail Gorbachev, nicknamed the “Mineral-Water Secretary,” launched one of the most notable anti-alcohol campaigns in 1985. His crusade for nationwide sobriety included implementing restrictions on the sale and consumption of alcohol to certain locations and times and drastically reducing production rates. Forceful methods, such as the destruction of vineyards,

Left: Photo courtesy of Kenny13 (Flickr); Right: Photo courtesy of Normxn (Flickr)

were employed.4 Although the campaign temporarily succeeded in reducing rates of consumption and alcohol-related mortality, the effects were fleeting. Illicit alcohol production increased significantly during this period, and desperate citizens turned to home-brewed liquors and industrial alcohols like cleaning fluids to satisfy their thirst. As the government relied heavily on alcohol sales to generate revenue for the state, the negative effect on the economy and public backlash eventually led to the termination of the campaign in 1988.5 Medvedev intends to succeed where his predecessors have failed.

While praising the Gorbachev campaign for its success in spurring demographic growth, he alternately criticized it for its “idiotic bans and mistakes,” and called for a more comprehensive, moderate approach.6 “On the one hand, we need to introduce restrictive measures, and on the other hand, we need to carry out educational work, promote a normal, healthy lifestyle,” he stated during a meeting in August discussing the new measures.7 The new campaign aims to bring down the liters of alcohol consumed annually per person from 18 liters to 8 by 2020.8 Some proposed measures include stricter penalties for selling alcohol to minors, bans on liquor advertising, restricting the sale of alcohol to certain locations, tripling the tax on beer, and perhaps most controversially, fixing the price of vodka at 89 roubles

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global health review (roughly $3 US), more than double the current retail price.8 Without a minimum price standard, vodka is often cheaper to obtain than water.9 William Pridemore, a former research fellow at the Harvard’s Davis Center for Russian and Eurasian Studies, believes the success of the campaign will depend on if these rules are actually enforced. Pridemore, who studied the effect of alcohol consumption on homicide and suicide rates in Russia, says Russia’s drinking problem is unique not only because of the total amount of alcohol consumed, but also the type and pattern of consumption. Vodka is the drink of choice. Pridemore likens Russians to college undergraduates in that the average pattern of consumption for both groups is binge drinking.10 James*, who currently leads an English-speaking Alcoholics Anonymous group in Moscow, states that there is a limit to how effective restrictive measures can be. “If people want to drink, they will,” he said frankly. When asked if he noticed any changes in the public consumption of alcohol, he answered, “No, not really. There’s more coverage of the issue in the press, and from time to time you get waves of coverage in the press, which comes and goes. But as a general rule, if there’s this kind of

publicity around alcohol and drinking, then we do tend to get more people at the [AA meetings].” He also cites the need to tackle the stigma surrounding alcoholism and recognize that alcoholism is a disease;“Education is really the focus,” he says, to combat the stigma.

Alcoholics Anonymous, which was first established in Russia in 1989, now has nearly 300 groups meeting in 100 towns.11 Medvedev’s reforms have yet to be fully adopted, and their intended impact has fallen short of initial goals.8 The campaign has chronically failed to address the needs of existing alcoholics, and health care for alcoholism remains chronically under-resourced. Public health infrastructure, including rehabilitation centers, is unable to provide the treatment that alcoholics across Russia, especially those who are poor, need.11 In what has become a mostly topdown campaign, local temperance societies or groups like Alcoholics Anonymous are not directly involved with the government’s activities. Gathmann notes that these groups “don’t seem to be very powerful or engaged in a nationwide network.”12 Gorbachev’s campaign was actually more successful in this effort: the All-Union Voluntary Society for the Struggle for Sobriety, an

organization consisting of 12 million members, was formed in 1985 to mobilize citizens and raise awareness.5 Furthermore, whether Medvedev’s campaign will follow through in policy for emphasis on educational measures remains to be seen. As Christina Gathmann, a professor at the University of Mannheim who researched the effects of the Gorbachev campaign on the Russian mortality crisis, remarks, “Educating people about the dangers [of alcohol] and also giving them better prospects is very important. Changing the norms of the culture in the long run is a big issue, and in Russia it seems if all the campaigns have failed at doing that.”12 Some believe that alcohol is irremovably entrenched in Russian culture.

As Pridemore points out, however, the drinking culture already shows signs of shifting: beverage preference among young people has moved from vodka towards a less potent cousin, beer, and 12 step programs (like AA) have been on the rise. He remains optimistic, reminding us “Over the short term, you’re not going to see tremendous amount of change. But that doesn’t mean that step by step, over time, that you’re not going to get change – I think that you can.”10 *Name has been changed.

1. “Russia to Enact New Curbs on Alcohol.”

Newsgroup. CBC News. Canadian Broadcasting Centre, 11 Sept. 2009. Web. <http:// www.cbc.ca/health/story/2009/09/11/ russia-alcohol011.html?ref=rss>. 20 Feb 2010.

2. “Russia’s Alcohol Consumption More than 100% above Critical Level.” Ria Novosti.

Russian News and Information Agency, 24 Sept. 2009. Web. <http://en.rian.ru/russia/20090924/156238102.html>. 20 Feb 2010.

3. Halpin, Tony. “Health Alert as Russia’s Alcohol Consumption Triples.” The Times Online. News International Group, 13 Apr. 2007. Web. <http://www.timesonline.co.uk/ tol/news/uk/health/article1647475.ece>.

20 Feb 2010.

4. Von Geldern, James. “Gorbachev’s Anti Alcohol Campaign.” Seventeen Moments in Soviet History. National Endowment for the Humanities, 2007. Web. <http://soviethistory.org/index.php?page=subject&SubjectI D=1985drylaw&Year=1985%2520news/uk/

health/article1647475.ece>. 20 Feb 2010.

5. McKee, Martin. “Alcohol in Russia.” Alcohol and Alcoholism 34.6 (1999): 824-29. Oxford Journals. Oxford University Press. Web. <http://alcalc.oxfordjournals.org/cgi/content/full/34/6/824>. 20 Feb 2010.

6. Shchedrov, Oleg. “Russia’s Medvedev Praises Gorbachev’s Anti-alcohol Campaign.” Newsgroup. Reuters Online. Thomas Reuters, 17 July 2009. Web. <http://www. reuters.com/article/idUSLH51350>. 24 Feb 2010.

7. Medvedev, Dimitry. “Meeting on Measures to Reduce Alcohol Consumption in Russia.” Speech. Meeting on Measures to Reduce Alcohol Consumption in Russia. Moscow. 12 Aug. 2009.

President of Russia. Web. <http://eng. kremlin.ru/speeches/2009/08/12/1845_type82912type82913_220798.shtml>. 24 Feb 2010.

8. “Russia’s Anti-Alcohol Campaign SlowGoing.” The School of Russian and Asian Studies News. The School of Russian and

Asian Studies, 2 Feb. 2010. Web. <http:// www.sras.org/russias_anti_alcohol_campaign_proves_slow_going?print=1>.25 Feb 2010.

9. Belluz, Julia. “Supermarkets Selling Alcohol Cheaper than Water.” The Times Online.

News International Group, 1 Dec. 2008.

Web. <http://www.timesonline.co.uk/tol/ news/uk/health/article5264677.ece>. 2 Mar 2010.

10. Pridemore, William. Phone Interview. 25 Feb 2010.

11. Anonymous Moscow AA Member. Phone Interview. 2 Mar 2010.

12. Gathmann, Christina. Phone Interview. 19 Feb 2010.

13. Faulconbridge, Guy. “Russia’s President Calls Widespread Alcohol Abuse a ‘national Disaster’” National Post. Canada.com Network, 13 Aug. 2009. Web. 20 Feb. 2010. <http://www.nationalpost.com/life/health/ story.html?id=1889035>.

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Changing Economy, Changing Waist Sizes Susan Wang, Staff Writer

Q

ian Zhang is an average Chinese boy living in Shanghai – average in every way except for his weight. “I know he is fat and he also knows he needs to lose weight,” says Qian’s grandmother, “But whenever he starts eating, he forgets about losing weight and I cannot stay tough and take the food away.” 1 At the age of 11 and standing 4’ 8”, he already weighs 106 pounds and is considered overweight

by Chinese standards. 1 “China was once considered to have one of the leanest populations, but it is fast catching up with the West,” writes Wu Yangfeng, professor of the Cardiovascular Institute and Fuwai Hospital in Beijing. “Disturbingly, this has occurred in a remarkably short time.” 2 In fact, according to a 2006 study, about one fifth of the one billion overweight or obese people in the world are Chinese. 2 Children have been hardest hit by this burgeoning crisis.

One of the underlying causes has proven to be the growth of fast food restaurants in the local cities, especially McDonald’s.3 In fact, McDonald’s has become so popular among children that parents take their children to eat there as a reward for good behavior, or as a way to threaten them into performing well. 3 One parent has claimed that “It is my nuclear deterrent.” 3 The real problem does not only lie in fast food. As Dr. James L. Watson, Fairbank Professor of Chinese Society and Professor of Anthropology at Harvard College, pointed out, “More and more energy, time, and money began to be invested in children and one of the

consequences of that is that parents began to literally overfeed their kids.” 4 What is the reason for this obsession with overfeeding children? Dr. Watson responded that “In the past, thin children were considered ill. If you look at the iconography of Chinese temples, especially for fertility deities, you’ll find representations of children, almost all of whom are male and all of whom are fat with big chubby cheeks.

This earlier peasant culture represented healthy children as fat because thin children had less of a chance to live. So you find older people in China, grandparents and some parents, that still have this idea that a healthy child is an overfed child is a chubby child.” 4 Even old proverbs such as “Hu tou,

hu nao,” (directly translated as “tiger head, tiger brain”) prevent parents from taking obesity seriously. 1 This proverb asserts that a person with a round, chubby head will be intelligent, and many traditional Chinese families still believe in its wisdom. 1 It is perhaps this reason that the rapid economic growth of China is leading to the growth of its children’s waistlines; in fact, the number of overweight children ages 7 – 18 increased 28 fold between 1985 and 2000.5 Therefore, it comes at no surprise that China is launching health campaigns to reduce food intake and to increase physical activities among children, especially in the major cities. 6 According to the China Daily

Photo courtesy of Susan Wang

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global health review newspaper, “Over the next three years, the anti-diabetes campaign, which will include the training of doctors in the 31 cities, will be conducted by experts from the Chinese Medical Doctor Association (CMDA) and Bayer Healthcare China. Yang Jing of the CMDA said the anti-diabetes campaign is in line with the goals of the country’s three-year, 850 billion yuan medical

correct this problem. For girls, though, it is not a problem of overweight but underweight.” 4 As Dr. Watson emphasizes, “Obesity is directly related to the obsession with thin body image. The two go hand in hand and they both reflect China’s entry into the world.” 4 Weight dissatisfaction is now becoming more and more of a problem

“…in China it’s not the kids, it’s the parents and grandparents that don’t listen.”

—Dr. James L. Watson system reform package.” 6 However, this will not solve the problem according to Dr. Watson. He comments, “The government has been promoting anti-obesity campaigns but it’s like shouting in the wind. When you tell kids [in the United States], don’t drink Coca-Cola, don’t eat Big Macs, kids are not going to listen to you; in China it’s not the kids, it’s the parents and grandparents that don’t listen.” 4 “One always has to be careful about focusing on one issue, thinking that one issue can be controlled with a little bit of social engineering. Like if somehow if we can just worry about the kid’s diet, if we can encourage them to drink juice as opposed to coco-cola that we can

among youth, especially for girls.7 In a study conducted by University of Southern California Professor Bin Xie, girls who have been exposed to media from Japan, Korea, Hong Kong, and Taiwan place great importance on their physical appearance, and are very likely to describe themselves as overweight despite maintaining a normal or even lower than average weight.7 This can lead to many eating disorder such as anorexia nervosa or bulimia. 7 Dr. Watson comments that “I’ve taught in Hong Kong and China several times and each time I go, young women are thinner and thinner to the point now when it’s almost clinically distressing. Body images among wom-

Photo courtesy of Ernop (Flickr)

en are a consequence of elite aspirations and class definition. In this country, body image reflects power, money and status. Similar things are happening in China because China is modernizing and there’s more money and people are conscious of these things.” 4 What can be done about these problems concerning weight? Dr. Watson concludes, “It’s always distressing to me that journalists and politicians and others think that you can deal with something like obesity just by passing a law prohibiting Coco-cola machines in school or something like that. It’s as complicated as the health care debate in our society now and China has yet to face these questions.” 4 1.

2.

3.

4.

5.

6.

7.

“Fat City, Fat Kids.” Shanghai Daily. 26 Jan, 2010: Print.

Wu, Yangfeng. “Overweight and obesity in China.” BMJ 19. Aug, 2006: 333.

Watson, James L. Golden arches east: McDonald’s in East Asia. Stanford: Stanford University Press, 1997.

Watson, James L. Personal Interview. 1 Mar 2010.

Z Yu, J Q Sun, J D Haas, Y Gu, Z Li and X Lin. “Macrosomia is associated with high weight-for-height in children aged 1–3 years in Shanghai, ChinaMacrosomia and high weight-for-height.” International Journal of Obesity 32, Jan 2008: 55-60.

“Anti-diabetes campaign under way.” China Daily. 27 Jul, 2009: Print.

Xie B, Chou C, Spruijt-Metz D, Reynolds K, Palmer PH, Gallaher P, Sun P, Qian G, Johnson CA. Weight Perceptions and Weight-related Socio-cultural and Behavioral Factors in Chinese Adolescents.

Preventive Medicine 42. 2006: 229-34.

Photo courtesy of Flickr Commons

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Butting Out: China’s Anti-Smoking Efforts Yuying Luo, Staff Writer

T

he global smoking epidemic is an emerging health crisis that often flies under the radar of public health. China, in particular, has been struggling to contain its burgeoning smoking population for the past few decades: it has more smokers than any other country in the world. Its 350 million smokers consume 37 percent of the world’s cigarettes1, and more than 1 million people2 are expected to die of tobacco-related diseases every year in China.

“Today, in most contexts across China, there is a positive moral force attached to the act of offering a cigarette to someone, at least among men. Cigarette exchange is saturated with positive ethics and meanings. Social practices have developed over time, cultivated by social, political, and economic interests that make it very difficult for many men to avoid cigarettes,” explained Dr. Matthew Kohrman5, an anthropology professor at Stanford University who has

Societal pressures to smoke are prominent: there is an unspoken rule that to be a real man in China, one has to smoke.

“The smoking epidemic in China is potentially gigantic because the country is so heavily populated. There is a set of epidemiological data from Richard Peto, the great UK epidemiologist, which shows that in 1996, there were 500,000 tobacco-related deaths in China. He predicted that by 2025, there would be 2 million annual deaths related to tobacco, accounting for one third of all deaths for people between thirty-five and sixty-nine,” commented Dr. Allan Brandt3, Dean of Harvard’s Graduate School of Arts and Sciences, and public health expert.

What is striking about China’s smoking epidemic is that it is mostly a male phenomenon, with a staggering 60 percent of Chinese men choosing to smoke4. Societal pressures to smoke are prominent: there is an unspoken rule that to be a real man in China, one has to smoke.

conducted extensive research on the issue of cigarette smoking among Chinese citizens.

The vast price range for Chinese cigarettes has also helped create certain socioeconomic stratifications.

“There is a 100-fold variation between the cheapest and most expensive cigarettes. Price variation allows cigarettes to take on all sorts of important meanings they don’t have in other countries. What cigarette you smoke has come to serve as a significant index of social status, politico-economic standing, and even of career development,” said Dr. Kohrman.

And most of these cigarettes are produced locally and specifically marketed to the Chinese population. Chinese tobacco companies are responsible for more than 95 percent of cigarettes smoked in the country today6, and the China National Tobacco Corporation

monopolizes the market in a way that Western tobacco companies cannot: sponsoring rural schools and holding promotional events in shopping malls to entice crowds, especially youth.

“One of the big problems for China is the fact that the Chinese government derives very significant revenues from the state-owned tobacco monopoly.

The Chinese government needs to find a strategy to reduce immediate revenues in favor of long term health goals,” said Dr. Brandt.

Tobacco taxation is lower in China compared to international standards.

The international norm for tobacco tax is 65 percent of the retail price, but that number hovers around 40 percent in China. Nevertheless, tobacco taxes generated $61 billion in revenue in 2009, a 26.2 percent increase from 20087.

“Tobacco control experts working on China like to focus their energies on reducing the consumption of cigarettes

Photo courtesy of Proggie (Flickr)

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global health review particularly by making [cigarette] taxes higher. But so far, the Chinese government has been unwilling to budge on raising taxes cigarette smokers must pay. And given that tobacco companies flood China with 2 and 3 trillion cigarettes every year, does it make sense to focus so much on the demand side of things?” said Dr. Kohrman.

Undoubtedly, raising taxes can help reduce tobacco-related illnesses, but the epidemic has proved more complex than just an issue of economics.

“There is a general lack of knowledge and awareness about tobacco harm. Many smokers think smoking can help to calm emotion and build relationship, and when they want to quit, they are hard to find professional support,” said Li Xiao Liang8, director of Pioneers for Health, an NGO based in Yunnan, China dedicated to fighting the epidemic.

In the last two years, PFH has initiated a campaign against tobacco advertisements among young students and conducted several small scale surveys that have provided local evidence for public policy reform, such as public opinion towards tobacco warning labels.

PFH’s might prove the tipping point of similar grassroots interventions across the nation pushing China to act on past promises. The Framework Convention on Tobacco Control (FCTC), ratified by China in 20059, recommends a network of approaches including strong public education campaigns, and a variety of measures ranging from bans on smoking in public places, workplaces and public transportation to bans on tobacco advertising, promotion and sponsorship to combat this epidemic. China plans to fully implement these standards by January 2011.

Dr. Kohrman believes it is time for China to begin aggressive awareness campaigns against smoking. “People need to be become increasingly dis-

turbed by cigarettes and second-hand smoke, to feel it is impolite to offer someone a cigarette.”

“China’s domestic tobacco compa-

constricting free tobacco sales. At the same time, the tobacco companies will not be going away, so any intervention will require aggressive public health—

Chinese tobacco companies are responsible for more than 95% of cigarettes smoked in the country today. nies need to be vilified. There is room for that, despite what some may think, because tobacco companies are highly localized. Even though the tobacco industry is state run, there is structural daylight for public health advocates to criticize the individual companies manufacturing cigarettes and the marketers hired by those companies.” Dr. Kohrman points to the Chinese health NGO Think Tank as an example of an organization that has publicly criticized local companies. They have done so unscathed because their criticisms are targeted at local companies, and not the central government.

“If we include cigarettes as part of the expansion of trade, the epidemic will worsen significantly in a place like China,” said Dr. Brandt.

“But I am very hopeful about the influence of The Framework Convention on Tobacco Control, especially in

similar to the ones we’ve seen in US, but even beyond.”

There are encouraging signs that the Chinese government is taking action. A campaign was launched in January 2010 by the China’s Center for Disease Control and Prevention agency (CCDC) to enforce smoking bans in seven major cities10.

Co-sponsored by the International Union Against Tuberculosis and Lung Disease, the campaign seeks to enforce an existing ban on indoor smoking in public places while closing existing loopholes.

But that must prove only the beginning if change is to occur. “It is key for the Chinese government to seriously develop a variety of preventive and control programs to combat this epidemic,” said Dr. Brandt.

1 Mackay, Judy. “China’s Smoking Epidemic”.

February 5, 2010. <http://china.usc. edu/%28X%281%29A%28rHAyAC_ dygEkAAAANWY1MDg2NTUtOThjMC00YjBiLWI2MzEtODg1NWQ3YzYyNGRlQId3y2ZIFYippDA5N0gQuefMdg1%29S%28jo0ndcy3c3ppir45dwg441nv%29%29/ShowArticle. aspx?articleID=1991> 2 ABC Radio Australia. “Tobacco Firms Target China.” April 22, 2009. <http://www. radioaustralia.net.au/connectasia/stories/200904/s2549482.htm> 3 Brandt, Allan. Phone Interview. 19 Feb. 2010.

4 R. Peto, Z.M. Chen and J. Boreham, Tabacco: The growing epidemic in China, CVD Prevention and Control (2009) 5 Kohrman, Matthew. Phone Interview. 16 February 2010.

6 ABC Radio Australia. “Tobacco Firms Target China.” April 22, 2009. <http://www. radioaustralia.net.au/connectasia/stories/200904/s2549482.htm> 7 People’s Daily Online. “Tax Hike Has Little Effect on Tobacco Use.” January 18, 2010. <http://english.people.com. cn/90001/90782/6871640.html> 8 Li, Xiao Liang. Email Interview. 23 Feb. 2010.

9 Framework Convention on Tobacco Control.

“Parties to the WHO Framework Convention on Tobacco Control”. World Health Organization. <http://www.who.int/fctc/ signatories_parties/en/index.html> January 27, 2010.

10 China Daily. “Cities Set to Order Ban on Smoking.” January 18, 2010. <http:// www.china.org.cn/china/2010-01/18/content_19256993.htm>

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Developing Countries Feel the Pulse: Cardiovascular Disease Emerges in Latin America

Shalini Pammal, Staff Writer

M

illions are confronted by emerging diseases and health crises ranging from recent natural disasters and rapidly mutating viruses to widespread flu pandemics; however, the equally important issue of chronic disease affliction often goes unnoticed.

According to the World Health Organization (WHO), cardiovascular disease (CVD) is the number one cause of death globally and leads to more deaths annually than any other single cause.

An estimated 17.1 million people died from cardiovascular diseases in 2004, representing 29 percent of all global deaths. Particularly interesting to note is the disproportionally affected low- and middle-income countries, where 82 percent of CVD deaths have been reported according to the latest WHO statistics.1 Due to the dearth of information available regarding hypertension and CVD in Latin America, the Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study was conducted by research collaborators from the InterAmerican Heart Foundation based in Argentina, and has

been published in The Journal of Hypertension. According to this research, “cardiovascular diseases are already the leading cause of death and disability.”2 They go on to predict that “the next two decades include a near tripling of ischemic heart disease and stroke mortality in Latin American countries.”

Results of the CARMELA stud-

vices which respond to their needs (including early detection services).

Public health programs need to target prevention, detection, treatment, and control of total CVD risk in Latin America3; the difficulty in implementing these programs lies in rural disparities with urbanized methodologies.

Literature affirms that “several car-

Reversing current trends would require a wide range of strategies in this region, and some of this effort is beyond the traditional realm of public health.

ies indicate that 13.4 to 44.2 percent of populations in seven major Latin American cities were hypertensive or had high normal BP values. Moreover, recent declines in CVD seen in the developed world are absent in developing Latin American countries.2 People in low- and middle-income nations are more exposed to risk factors leading to CVDs and are less exposed to prevention efforts than people in high-income regions.1 Likewise, lowincome populations in these areas who suffer from CVDs have less access to effective and equitable Photo courtesy of www.defense.gov health care ser-

diovascular risk factors have a great health impact in the Latin America region,” including tobacco, hypertension, diabetes, obesity and physical inactivity among the five most important causes of ill health and premature death in the Americas.5 Ms. Jia Shen, MD/MPH Candidate at the Harvard School of Public Health who has experience working with CVD in China, referred to this wide gap in mortality rates between developed and developing countries as a result of lagging education campaigns in developing regions compared to developed nations where such CVD risk factor awareness and education has already taken effect. “We [America] were the highest population that smoked cigarettes (tobacco is a major contributor to CVD) and now we are on the decline,” said Shen. “We’ve already hit the peak because we educated many people… that hasn’t happened [in developing countries] yet. There is a high incidence of tobacco use and smoking without regu-

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global health review lation. Developing countries are years or decades behind the education push.”4 As CVDs in developing regions are on the rise, their future burden on fragile, poorly developed health care systems is enormous. Shen commented on the need for strengthening health systems in developing nations, saying that, “developing countries are adopting a chronic disease profile but their health care systems [haven’t] adapted accordingly.”4 Furthermore in terms of addressing the problem, Shen said that “education affects management of disease and in developing countries where people are not literate, complex diseases like hypertension are difficult to explain... health care systems and education about risk factors in developing countries are decades behind developed nations.”

Additionally, Latin American populations, among other developing countries, are becoming more sedentary, engaging in jobs that require less manual activity. Dr. Melissa Burroughs Peña, an internal medicine resident physician at the University of California, San Francisco, who has also worked in the Caribbean and more recently in Cuba, discussed this shift in developing regions in a conversation with the Harvard College Global Health Review.

“In the developing world in Latin America, people who were once living a very agricultural lifestyle are moving to cities and living a totally different lifestyle with more processed foods, high fat, high salt, and high sugar diets, so this is helping a rising epidemic which people project will allow coronary artery disease to continue [in these regions].”6 In developing nations, fewer people are diagnosed and when diagnosed, diseases are poorly managed.4 InterAmerican Heart Foundation researchers in Argentina conclude that the resources available to implement prevention and control programs for CVD are still very limited. Reversing current trends would require a wide range of strategies in this region, and

some of this effort is beyond the traditional realm of public health.

Sustainable programs are needed in combination with effective policies to support the adoption of healthy Photo courtesy of U.S. Navy (Wikimedia Commons) lifestyles.5 Accordtive measures is important, especially ing to studies published by the Journal considering the nature of chronic disof Cardiovascular Nursing, there is a eases like CVD, where an immediate high prevalence of risk factors in Latin benefit is not seen. “Use local cultures America that significantly expands and things that people understand… the incidence of cardiovascular dis- we’ve all gone through this epideease. This mandates the development miological transition, but we’re dealand implementation of preventive and ing with it differently…we need to see promotional healthcare strategies.7 what worked in some places that can “Interventions where people are be applied to other places,” said Shen. creative are bound to be more effective.

“The cost of check-ups, immuniYou have to meet people where they are zations and care for chronic disease at and make it [interventions] part of is a lot for people who have barely the culture or whatever environment or nothing… we need to devise methinstitution they are in,” said Burroughs- ods for people to see the benefits of Peña. While the WHO has put forth care and preventative measures in orguidelines and protocols to educate min- der to begin addressing this issue.” imally-trained health workers, this only addresses one component of the issue.4 Shen also agrees that an active approach to enforcing sound correc1. “Cardiovascular diseases (CVDs)” World Health Organization. 16 Feb 2010. <http://www. who.int/mediacentre/factsheets/fs317/en/ index.html>.

2. Hernández-Hernández, Rafael, Honorio Silva, Manuel Velasco, Fabio Pellegrini, Alejandro Macchia, Jorge Escobedo, Raul Vinueza, Herman Schargrodsky, Beatriz Champagne, Palmira Pramaro and Elinor Wilson. “Hypertension in seven Latin American cities: the Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study.”

Journal of Hypertension (2010), 28: 24-34.

3. Schargrodsky, Maria C. Escobar and Edgardo Escobar. “Cardiovascular Disease Prevention: A Challenge for Latin America.” Circulation: Journal of the American Heart Association (1998): 2103-2104.

4. Shen, Jia. Phone INTERVIEW. 26 Feb 2010.

5. Pramparo, Palmira, Carlose Mendoza Montano, Alberto Barceló, Alvaro Avezum and Rainford Wilks. “Cardiovascular diseases in Latin America and the Caribbean: The present situation.” InterAmerican Heart Foundation, Epidemiology and Prevention, Pena 3070 5B, Buenos Aires, 1425 Ciudad Autonoma de Buenos Aires, Argentina.

6. Burroughs-Peña, Melissa. Phone INTERVIEW. 28 Feb 2010.

7. Andrews, Jeannette, Judy Graham-Garcia, and Terri L. Raines. “Heart Disease Mortality in Women: Racial, Ethnic, and Geographic Disparities.” The Journal of Cardiovascular Nursing Volume 15 Issue 3 (2001): 83-87.

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global health review

Moving Forward in an Era of Reconciliation: Mental Health in Rwanda Maryell Hernandez, Staff Writer

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n an era of racial reconciliation and renewed national hope, the divisions created in Rwandan society by the genocide are slowly healing. Rwanda has become a model in development for countries afflicted with full-scale conflict and the emergence of educational opportunities, attention to human rights, and the forging of a united Rwandan identity has improved conditions profoundly in the country.1 However, complex issues lie beneath the surface of Rwanda’s progress, particularly in the realm of mental health.

To ease tensions, ethnic markers and significant racial distinctions among citizens have become punishable by law; additionally, the government has promoted initiatives and activities to encourage racial healing among the population.2 Although there has been community involvement and participation throughout the country encouraging these actions, a study conducted eight years after the genocide revealed that 94.1 percent of people in Rwanda had experienced at least one traumatic event during the conflict and massacre.3 Furthermore, 24.8 percent

of over 2,000 people interviewed in a diverse range of communes throughout the country met the criteria for post-traumatic stress disorder.4 In a recent study published in the International Journal of Epidemiology in 2009, the authors investigate the findings of a 1995 psychiatric community-based epidemiological survey of young survivors of the genocide. These findings demonstrate the incredible effect of the conflict on children and adolescents. In the various populations surveyed, over 90 percent witnessed killings and had their lives threatened, 35 percent witnessed rape or sexual mutilation, and 15 percent hid under corpses.5 The individuals who were children and adolescents during the era of the genocide are now young adults growing up in a society that promotes confusing messages of racial reconciliation that contrast with emotions of loss and fear.

In understanding the complexity of mental health in Rwanda, the link to HIV and AIDS in the population becomes clear. As Dr. Patrick Lee, Partners in Health Clinical Mentor and Harvard Medical School Clinical Instructor suggests, there is a type of “synergy” in the study between mental health and HIV where the effects of the two go hand in hand.6 “Mental health certainly affects the outcomes that HIV patients are able to achieve; whether they adhere to their medication or if they miss a few doses Photo courtesy of Flickr Commons and become resistant and

then get infections…mental health affects the immune system and the overall functioning of the body and homeostasis,” he explains.7 Additionally, Dr. Lee describes the ways in which HIV fosters stigma, social exclusion, unemployment, and even poverty, all factors that have a great effect on mental health.8 These effects, localized in a country where it becomes almost impossible to find a person spared by the tragedy and responsibility of genocide, sets a stage where mental health is “part of the national conscience and is rapidly endemic in the country [and] as a result manifests itself in different ways.”9 Social stigma and culturally coded displays of mental health play a role in understanding the indicators of mental health in this particular region.

Research by Paul Bolton in “Local Perceptions of the Mental Health Effects of the Rwandan Genocide” concluded that symptoms of depression and posttraumatic stress disorder “support the local content validity of depression assessment instruments” and verify the presence of these two diseases in the national conscience.10 Even more profound, among the diagnostic systems presented, interviewees described, “associated ‘local’ symptoms not included in the established diagnostic criteria” revealing the specificity of mental health problems in the region.11 Bolton’s research brings needed attention to mental health problems that manifest in forms less recognizable by Western audiences.

Remembering his direct contact with patients in Rwanda, Dr. Lee elucidates that in countries such as this, people may not necessarily cry or display typical forms

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global health review of depression or sadness to which Western societies may be accustomed. Instead, they may “present many more somatic complaints like unexplainable abdominal pain, headaches, nausea, cramping; similarly dysfunctional and debilitating their ability to carry on with the important things in their lives, but with a different, general phenotype.”12 The effects of these culturally coded forms of mental problems can prove incredibly detrimental to the productivity and quality of these individuals’ lives.

As the World Health Organization explains, “recognition of the mental health needs of refugees is emerging but remains poorly addressed as allocation of resources does not follow. Despite scientific evidence in support of the fact that conflict has a devastating impact on health and on mental health, the latter is not seen as priority by many decision-makers.”13 Programs like Partners in Health, with an eye towards cultural understanding, as well as the multitude of programs instituted to aid mental health and HIV awareness, are creating a positive change in countries like Rwanda. However, in terms of recognition, efforts to validate the importance and powerful effects of mental health problems in the daily lives of people emerging from conflict remain scattered at best.

The Rwandan narrative is complex and continues to unfold. On the one hand, the government has strongly advocated for a united Rwandan identity imbued with the desire to move away from memories of genocide and conflict. The revised Rwandan Nationality Code published in 2004 reflects the incorporation of different ethnic groups and identities into a sole Rwandan nationality.14 These efforts to move forward from the past, however, often neglect the impact of the genocide and the psychologi-

cal disorders that follow.

In a nation that yearns to move on, it would be a daunting step to tackle the suffering of the genocide head-on. Ethnic

approached, and although a number of Non-Governmental Organizations like Partners in Health are addressing mental and psychological treatments, an organized government response has yet to materialize.

On the tenth anniversary of the Rwandan genocide, President Kagame stated, “We cannot turn the clock back nor can we undo the harm caused, but we have the power to determine the future and to ensure that what happened never happens again.”15 With this power, Rwanda has emerged, by many accounts, as a “success story” in Africa and continues on an Photo courtesy of TKnoxB (Flickr) apparent path toward development.16 conflicts could arise from differing tenNevertheless, the phantoms of this sions and there is a possibility that the nation’s past will remain until the governcalm of previous years may be disrupted ment fully addresses the mental health through an examination of Rwanda’s needs of its younger generation. difficult past. However, an entire generation from the massacre needs to be 1. United States Institute of Peace. Center for Post-Conflict Peace and Stability Operations. “Post-Genocidal Reconstruction: Building Peace in Rwanda and Burundi.”

United States: United States Institute of Peace, 1999. http://www.usip.org/resources/post-genocidal-reconstruction-buildingpeace-rwanda-and-burundi 24 Feb 2010.

2. Rwandan Embassy to Japan. H.E. Dr. Emile Rwamasirabo. “The Management of Post Genocide Challenges.” Hiroshima: Rwandan Embassy, 2006. http://www2.unitar. org/hiroshima/roundtables/materials/ RT_H.E.Rwamasirabo.pdf 24 Feb 2010.

3. Pham, Phuong; Weinstein, Harvey, Longman, Timothy. “Trauma and PTSD Symptoms in Rwanda: Implications for Attitudes Toward Justice and Reconciliation” The Journal of the American Medical Association 292 (2004): 602-612 4. Ibid.

5. Fisher PW and R Neugebauer et. al. “Posttraumatic stress reactions among Rwandan children and adolescent in the early aftermath of genocide.” International Journal of Epidemiology 38 (2009) 1033-45. http:// www.ncbi.nlm.nih.gov/pubmed/19204009 24 Feb 2010.

6. Lee, Patrick. Personal INTERVIEW. 1 March 2010.

7. Ibid.

8. Ibid.

9. Ibid.

10. Bolton, Paul. “Local Perceptions of the Mental Health Effects of the Rwandan Genocide” The Journal of Nervous and Mental Disease 189 (2001): 243-248. http://journals.lww. com/jonmd/Abstract/2001/04000/Local_Perceptions_of_the_Mental_Health_Effects_of.6.aspx 24 Feb 2010.

11. Ibid.

12. Lee, Patrick. Personal INTERVIEW. 13. World Health Organization. Health Action in Crises. “Mental health of refugees, internally displaced persons and other populations affected by conflict.” WHO, 2010.

14. Rwandan Directorate General of Immigration and Emigration. “Organic Law on Rwandan Nationality Code.” Rwanda: Rwandan Directorate General of Immigration and Emigration, 2004. http://www.migration. gov.rw/Laws_Acts/Nationality%20Law%20 -%20English%20version.pdf 24 Feb 2010.

15. “Excerpts: Kagame marks genocide.” BBC News. April 7 April 2004. http://news.bbc. co.uk/2/hi/africa/3609001.stm 7 March 2010.

16. “Zakaria: Africa’s Biggest Success Story.”

Cable News Network. 17 July 2009. <http://edition.cnn.com/2009/WORLD/ africa/07/17/zakaria.rwanda/> 7 March 2010.

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global health review

Global Mental Health, Post-War Liberia, and the Urgent Need for Better Primary Care Systems Drs. Patrick T. Lee and Raj Panjabi, Contributing Experts

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ary was thirty-six, but looked much older. Burn scars disfigured half of her face and most of the right side of her body. We asked her, “What is it like when you seize?”

“I can fall down…” she started to say, then her head thumped the desk and she began to foam from the mouth.

My colleague and I lowered her to the floor as she continued to seize, her body alternately stiffening and convulsing for two long minutes.

This is Zwedru, in rural southeastern Liberia, where people with epilepsy have never received proper medical treatment, where the condition is viewed as a curse, as contagion, where victims may seize into fires and be left to burn while others look on – certain that if they touch or come too close, they will be cursed and share the same horrible fate.

Two decades of brutal conflict have rendered Liberia one of the world’s five poorest countries. Per capita GDP has fallen 90 percent, unemployment hovers near 85 percent, and over 80 percent of Liberians survive on less than $1USD per day. Life expectancy at birth is 42 years, with nearly a quarter of children under-five and one in every 20 mothers suffering preventable deaths. Worse still, Liberia has one of the most severe health workforce crises in the world, with only 51 public sector physicians to serve a population of 3.5 million.1 Yet in recent years, Liberia has emerged as a beacon of hope. Under the leadership of President Ellen Johnson Sirleaf, MPA ‘91, Liberia has set itself the goal of becoming “an international

model for post-conflict recovery.” In 2008, the Liberian Ministry of Health and Social Welfare put forward the Basic Package of Health Services – a pragmatic and forward-looking national health policy identifying a concise set of objectives to “[improve] the Liberian people’s health and well-being by creating equitable access to quality health care, [serving] not only humanitarian, but also political and economic purposes.”2 This remarkable document limited itself to six areas of focus. Mental health made the short list (along with maternal and newborn health, child health, reproductive and adolescent health, communicable disease control, and emergency care); notably, other chronic diseases did not.

Why focus on mental health?

First, it should be noted that mental health in this context encompasses a broad range of conditions, including the more traditional psychiatric disorders (e.g., depression, mania, psychosis, post-traumatic stress disorder), but also substance abuse (a form of self-medication), epilepsy (which presents as a mental disorder in this setting and is much more common here than in richer countries), and sexual violence (in some parts of the country, an estimated 90 percent of females over age three have been raped).

From a global vantage point, most deaths result from chronic diseases – primarily cardiovascular causes (including stroke), certain cancers, and chronic respira-

tory conditions.3 A great deal of global mortality and disease burden, along with billions of dollars of lost worker productivity, could be prevented with cost-effective strategies to modify three powerful risk factors – unhealthy diet, physical inactivity, and smoking.4,5,6 International resources and focus have appropriately been brought to bear on generating research, policy, and momentum to tackle these upstream targets.7,8 But if we broaden our focus from mortality to global burden of disease (factoring in years lost to premature death and years lived with chronic disability), a different picture emerges. In these terms, depression is the most important chronic disease today and, according to current projections, rises to

Photo courtesy of Tiyatien Health

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global health review become the number one cause of overall disease burden in 2030.3 This is in itself a gross underestimate. We know that mental disorders increase the morbidity and mortality of a broad range of conditions ranging from cardiovascular disease, to HIV, to road traffic accidents.9 As with smoking and malnutrition – two of the most important “hidden” behemoths in the global burden of disease estimates – a substantial proportion of deaths attributed to other causes are in fact driven by disorders of mental health.

We also know that the poorer the setting, the worse the data, resulting in broad swaths of invisible disease. In areas of grinding poverty, and especially those that have also been ravaged by recent conflict, we are seeing the “ears of the hippopotamus” only. This is, of course, precisely where mental disorders flourish.

There is a social gradient of chronic diseases across the wealth of nations.

Where populations are aging, urbanizing, and have sufficient disposable income to choose unhealthy lifestyles, cardiovascular diseases either dominate (as in rich countries such as the U.S. or Norway), or are rapidly accelerating (as in developing countries such as China or Nigeria). But in the bottom billion countries – especially among rural populations where hard physical labor, low-cholesterol diets, and few luxuries (including cigarettes) are the rule – atherosclerotic disease is almost unknown.10 Importantly, though cardiovascular disease tapers off in poor, rural settings, disorders of mental health do not.

Zeroing in on Liberia, the Global Burden of Disease Report estimates de-

pression prevalence in Liberia at less than one percent.3 In striking contrast, a recent nationwide survey found depression in 40 percent of Liberian adults, with 44 percent suffering from post-traumatic stress disorder and an astounding six percent of all adults reporting a previous suicide attempt.11 No wonder the national health policy emphasizes mental health! Taking

society, and the economy are only realized in the medium- to long-term.

Additionally, mental health keeps particularly close company with social determinants such as poverty and stigma, accentuating the need for an integrated approach to treating disease as well as the conditions that underlie and exacerbate the patient’s illness.12 In fact, nothing short of a comprehensive overhaul of primary care systems will do. This is, of course, an inversion of the usual argument that mental health should be integrated within primary health care.13,14 In post-war Liberia where shattered health services are only beginning to be rebuilt, it is the enormous burden of mental health disorders that underlines and argues most strongly for sustained investment in primary care systems. This is probably Photo courtesy of Tiyatien Health equally true for other coninto account direct health care costs, lost flict-affected countries, such as Rwanworker productivity, and the less easily da, Sudan, or the Democratic Republic measured contributions to the risk of re- of Congo. newed violence and the morbidity/morThis argument – that mental health tality of other priority diseases, mental disorders in post-conflict countries are a health ranks as one of Liberia’s most im- major threat to security and economic portant overall development priorities. development, and therefore the difficult What about effective solutions? work of building primary care systems Delivery of chronic disease care is should be prioritized in these settings more complex than episodic interven- – is a minority viewpoint. But it is, we tions such as vaccinations, antibiotics believe, an evidence-based perspective for acute infections, or even intensive that warrants greater international atbut time-limited packages of prenatal tention than it currently receives. For if and neonatal care. Challenges include it is true that strengthening primary care supply-side activities such as training systems in post-conflict settings is a costand retaining qualified health workers, effective hedge against renewed violence strengthening infrastructure and the and stagnant economic growth, then we supply chain for drugs and diagnos- need new, effective delivery solutions for tics, and reforming policies to improve these extraordinarily challenging enviequitable access and broad coverage in ronments. And we need them now. remote areas. But demand-side initiaLiberia recognizes this urgency tives are equally vital, as chronic care and appears up to the challenge. Less requires full participation by patients than a year after completing its national and communities, and gains to health, health policy identifying mental health

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THE EXPERT PERSPECTIVE as one of six priority areas, the Liberian Ministry of Health and Social Welfare published the National Mental Health Policy (NMHP),15 a notable achievement for a country so recently emerged from conflict [the NMHP “represents Liberia’s first major attempt to address the diverse range of mental health problems in the country in a comprehensive and integrative way.”] The policy “reflects the commitment of the Government of Liberia to address all areas of health care and delivery…[and] fully recognizes that mental health is the foundation for well-being and effective functioning for an individual and for a community.”

To her immense credit, President Sirleaf asserts that “for capacity building in any area of our country’s recovery to be truly sustainable, it must be indigenous…it must flow from the people themselves.”2 It is in this spirit of sustainable, grassroots partnership that our organization, Tiyatien Health (TH), aims to develop effective delivery solutions for Liberia’s rural populations.

Tiyatien Health (“Justice in Health” in the local Kwa dialect) is a community-based social justice organization founded by local war survivors and HIV-positive women. Based in rural Zwedru, TH works in partnership with local communities and the Liberian Government to promote health care equity and the fundamental rights of the poor. A sister project of Partners In Health, TH employs a similar STAR approach of services, training, advocacy, and research to improve access to HIV care and treatment, deliver primary health care fairly and for all, and bolster social justice in rural Liberia.

Since 2006, TH has worked with the Liberian Ministry of Health and Social Welfare to achieve its vision to become a model for post-conflict re-

global health review separating people from facility-based services. Community health workers in this model, for example, triage and diagnose depression using the same nine-question instrument employed in the earlier nationwide mental health survey.11 They facilitate support groups for patients with moderate and severe depression and provide adherence support and education in the community.

This aggressive task-shifting strategy opens up the usual chokepoint at the prescriber level, enabling TH’s physician assistant to focus on titration of antidepressant and antiepileptic medicines for a larger number of patients.

TH’s mental health program is informed by careful review of the available literature and consultation with a range of international experts, including notable thought leaders such as Dr. Photo courtesy of Tiyatien Health Vikram Patel, Professor of International Mental Health example, our community health work- at the London School of Hygiene and ers accompany HIV patients in their Tropical Medicine and an editor of the illness and recovery – providing daily influential 2007 Lancet series on Globadherence support, dispelling stigma al Mental Health.

But thoughtful design does not and misinformation in the community, guarantee results. We recognize the critiand empowering patients economically cal importance of rigorous assessment and politically through a range of liveliand place the highest priority on timely hood services.

In September 2009, TH imple- and effective monitoring and evaluamented a community-based model of tion. In addition to clinical outcomes mental health and epilepsy care – the and operational parameters, we will adfirst program of its kind in rural Libe- dress solutions for patients who fall out ria.18,19 Building on the years of expe- of care (the so-called “lost-to-follow-up” rience delivering HIV care to the rural population), attempt to tease apart the communities around Zwedru, we de- co-mingled presentation of poverty and signed a system to simplify and delegate depression, and implement continuous tasks usually reserved for psychiatrists quality improvement initiatives to supand social workers in high-income port and strengthen the broad range of care delivered by our community health countries.

This task-shifted, decentralized workers.

In the context of Liberia’s ambimental health program responds ditious aim to become an international rectly to three intersecting challenges model for post-conflict recovery, TH – grinding poverty, far too few trained plays a dual role as local partner and health workers, and long distances covery. The partnership is centered on strengthening rural delivery of the Basic Package of Health Services at a district hospital in Zwedru. In March 2007, with support from the Global Fund for AIDS, Tuberculosis, and Malaria, TH pioneered a model of community-based antiretroviral therapy as the sole provider of HIV care in southeastern Liberia.16,17 Following Partners In Health’s

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global health review change agent. The work is timely. If successful, these community-driven delivery solutions could provide a scalable blueprint for decentralized mental health care in Liberia and other postconflict countries in Africa. We intend, through sustained advocacy and research, to stimulate international interest in the neglected epidemic of global mental health and argue for greater investment in primary care systems to address the particularly heavy burden of mental disorders in poor, post-conflict settings.

Though early and still unproven, our work is already changing a small part of history. There has never been organized treatment for epilepsy or depression in rural Liberia. Now over 100 patients – soon to be 1000 – are being treated in Zwedru. The word is out, and people are flocking to the clinic. A community health worker reported that now, instead of shunning their friends and relatives when they seize, people are taking them straight to the hospital for treatment. In this one small corner of the world, our work is spreading hope and bringing justice in health to the community.

When she finished seizing, my colleague and I placed Mary on the exam table and watched over her as she roused. Toward the end of her intake visit, we asked Mary, as we do of all patients, “Would you be willing to take these medicines and return to clinic for regular follow-up?”

Mary straightened in her chair and held our gaze fiercely. “I want to be free,” she said. “Yes, I will come.”

1. Government of Liberia. Poverty Reduction Strategy. Republic of Liberia: 2007.

2. Liberia Ministry of Health and Social Welfare.

Basic package of health and social welfare services for Liberia. Republic of Liberia: 2008.

3. World Health Organization. The global burden of disease: 2004 update. World Health Organization, Geneva, Switzerland: 2008.

4. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middleincome countries. Lancet 2007; 370: 192938.

5. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? Lancet 2007; 366: 157882.

6. Beaglehole R, Ebrahim S, Reddy S, Voute J, Leeder S. Prevention of chronic diseases: a call to action. Lancet 2007; 370: 2152-57.

7. World Health Organization. 2008-2013 Action plan for the global strategy for the prevention and control of non-communicable diseases. World Health Organization, Geneva, Switzerland: 2008.

8. Nabel EG, Stevens S, Smith R. Combating chronic disease in developing countries.

Lancet Epub 2009: DOI:10.1016/S01406736(09)61074-6.

9. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet 2007; 370: 859-77.

10. Soliman EZ, Juma H. Cardiac disease patterns in northern Malawi: epidemiologic transition perspective. J Epidemiol 2008; 18(5): 204-208.

11. Johnson K, Asher J, Rosborough S, Raja A, Panjabi R, Beadling C, Lawry L. Association of combatant status and sexual violence with health and mental health outcomes in postconflict Liberia. JAMA 2008; 300(6): 676-690.

12. World Health Organization. Commission on social determinants of health: closing the gap in a generation. World Health Organization, Geneva, Switzerland: 2008.

13. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, Hosman C, McGuire H, Rojas G, van Ommeren M. Treatment and prevention of mental disorders in low-income and middle-income countries.

Lancet 2007; 370: 991-1005.

14. Patel V et al. [Lancet Global Mental Health Group]. Scale up services for mental disorders: a call to action. Lancet 2007; 370: 1241-52.

15. Liberia Ministry of Health and Social Welfare. National mental health policy.

Republic of Liberia: 2009.

16. Panjabi R., Aderibigbe O., & Quitoe W. Towards universal outcomes: a community-based approach to improve HIV care in post-conflict Liberia. XVII International AIDS Conference, Mexico City, Mexico;

Aug 3–8, 2008: CDB030 (abstr).

17. Panjabi R, Aderibigbe O, Quitoe W, et al. A community-based approach to HIV care in rural Liberia: Liberia’s HIV equity initiative. National AIDS & STI Control Program, Liberia Ministry of Health & Social Welfare: 2007.

18. Raja A, Chang B, Schaaf M, Stone G, Levey E, Weil A, Quitoe W, Sawyer D, Tenty G, Solo J, Lee PT. Strengthening health systems through equitable rollout of mental health and epilepsy services in rural Liberia. World Psychiatry Association Regional Meeting, Abuja, Nigeria; Oct 22-24, 2009 (abstr).

19. Lee PT. Partnering for primary care in rural Africa. Health Affairs 2010; 29(1): 222.

About the Authors Dr. Patrick T. Lee

is an Assistant Physician at the Massachusetts General Hospital and an Instructor in Medicine at Harvard Medical School. He serves as the Director of Chronic Diseases and a member of the Executive Committee for Tiyatien Health.

Dr. Raj Panjabi is a Clinical Fellow in Medicine at Harvard Medical School and a Resident Physician at Massachusetts General Hospital, as well as a founding director of Tiyatien Health.

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global health review

A Duality in Healthcare Delivery: Between Boston and Rural Rajasthan Sachin H. Jain (MD, MBA), Contributing Expert

B

apu ji chose to send my father and his siblings to schools primarily reserved for harijans or untouchables. In India’s Jain community, harijans worked primarily as domestic servants. My grandfather wanted to make clear to his children his belief in Gandhian social equality and serve as an example to others in the community.

Perhaps even more strikingly, he encouraged his three daughters to vigorously pursue education. In an era when women were educated solely for the purpose of occupying them until marriage, my three aunts became a doctor, research

scientist, and attorney, respectively.

Bapu ji’s enduring mark on our family was a deep-seated commitment to service to others.

At age 12, he migrated from Phalodi, a forgotten farming village deep in Rajasthan’s deserts to Jodhpur, a relative metropolis. The striking contrasts between the two seeded in him outrage at the social, political, economic, and geographic inequality that marked colonial India. This outrage, I am told frequently permeated dinner table conversation and manifested most strongly in a feeling of indebtedness to Phalodi—a debt

at a glance...

HUMAN BENEFIT SERVICES

BOX 1

• Founded in 1978 by Dr. Shanti Jain • Operates with a dual mission of providing health care and education to residents of rural Rajasthan, India • Hospital and mobile medical clinic model provides medical care to a region with population 300,000; special focus on infant and maternal health • Hospital furnished with US medical supplies and equipment after US-based volunteers raised funds to purchase and ship equipment from a bankrupt Kansas hospital • Partnerships with international organizations allow HBS to provide specialty services including cataract surgery, cleft lip and palate surgery, and kidney dialysis • School provides English-medium education to children in grades K-12 • Women’s empowerment program teaches women basic job skills to allow them to become economically self-sufficient

that he hoped his children might recognize and repay. Though our family had been barely middle class, he marked it with the burden of privilege.

In the summer following my first year of medical school, I spent my days eating and sleeping in Bapu ji’s legacy: a 100 bed hospital admidst the Khichaan district of Phalodi (see Figure 1). For the past three decades, it has been a family preoccupation of sorts, involving every member of my nuclear and extended family in some way.

My two aunts, Shanti Auntie, before she succumbed to ovarian cancer, and Kanti Auntie both committed the bulk of their professional lives to planning, building, and, now operating a hospital in our ancestral village. The name they chose for their efforts— ”Human Benefit Services” or HBS— reflects the simple aim of their work.

HBS was founded in 1978 (see box 1) and today collectively includes the hospital whose construction took 10 years to complete; a school for children in Grades K-12; and a women’s empowerment program to provide vocational skills to local women (see figure 2). Unmarried and wholly devoted to an expansive notion of social service, Shanti Auntie and Kanti Auntie wanted to be where their efforts were most needed and led others by demonstrating courage and persistence in the face of obstacles. Their embodiment of Bapu ji’s teaching has since translated into meaningful action.

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global health review Arriving in Phalodi in 2003 seemed to me like the fulfillment of a lifetime dream, a phase of transition of a family commitment from generation to the next. Until that summer, my contributions to HBS had been primarily around writing brochures and raising funds. Still, I had always felt that I would assume greater responsibility at a time when I had more to offer.

By that summer, I felt that I was no longer a child precociously soliciting family friends and acquaintances with my pitch to “support the care of only one patient,” but was a medical student on the threshold of being able to offer meaningful service in a hospital with a short, but proud history.

To the surprise of my extended family, I immersed myself within life in Phalodi and elected to spend weeks sleeping in a hospital bed there in order to fully absorb the vibe of the workers, doctors, and patients who kept it running 24 hours a day. Starting at 7:30 AM each morning, I rounded with physicians and closely

observed the care of patients. They came in droves with illnesses as severe and different as tuberculosis and clinical depression. I was always struck by the vivid image of the villagers—some

of whom had traveled over 40 miles for care—collected anxiously in the waiting area in traditional Rajasthani garb.

It occurred to me that only a few critical decisions—first by my grandfather and,

Figure 2- Photo courtesy of Human Benefit Services

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Figure 3 (below): A patient receiving dialysis services at one of two HBSDaVita Bridge of Life Dialysis Centers for patients with kidney failure.

Photo courtesy of Human Benefit Services

Photo courtesy of Human Benefit Services Figure 1 (above): The face of the Kalapurnam General Hospital, the 100 bed hospital of the Human Benefit Services.

then, by my father, separated me from them.

With a background of research and coursework in health care delivery, I saw myself as a troubleshooter. My aunt

of any kind, but it was apparent that a few simple interventions might help.

In a short time, I observed that our patients—most of whom were illiterate—usually left highly confused about

labeling that would help patients know when and how to take their prescriptions.

Interacting with patients, hospital workers, physician staff, and Kanti

While I quickly grew comfortable and felt useful in Phalodi, something entirely unexpected happened. I started to think about my life in the U.S. - and just knew that my true place was there. was already using such innovations as community health workers—but I was trying to understand ways in which we might better serve our patients. Local residents were thrilled to have care

their medication instructions. Working with Kanti Auntie and the hospital’s pharmacy technicians, I implemented a simple system of dispensing medication based on color coding and numerical

Auntie, I felt satisfaction that I was finding my place in our family’s undertaking. There was a simplicity to the life and the work. I felt part of a rich tradition. At the same time, I somehow

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global health review felt that I did not fit in. While I quickly grew comfortable and felt useful in Phalodi, something entirely unexpected happened. I started to think about my life in the US—and just knew that my

India.

Returning to Boston that fall, I endeavored to find programs and institutions in the US through which we might be able to deliver better services

I never met him, my father tells me that he emphasized simple things: personal responsibility, hard work, and a commitment to do right. I hope that I do right by his ideal.

My first impulse was to reject the part of me that felt separate from the village and the institution. After all, weren’t all patients the same in the eyes of a physician? Couldn’t I eventually feel comfortable with the people of Phalodi? Wouldn’t my training be relatively more useful in Phalodi than in Boston? true place was there.

As much as the patients in Phalodi represented my ancestral heritage, and the hospital, my family’s deep commitment to the region, I felt more detached than I was comfortable with. While I cared about the patients in Phalodi, I didn’t really understand their lives or the colloquial marwari they were speaking. I started to feel that my real ties lay elsewhere.

My first impulse was to reject the part of me that felt separate from the village and the institution. After all, weren’t all patients the same in the eyes of a physician? Couldn’t I eventually feel comfortable with the people of Phalodi? Wouldn’t my training be relatively more useful to patients in Phalodi than in Boston?

I began to feel that I was somehow letting others down—the patients of Phalodi, my family, and myself. I struggled with the question of what it means to contribute—and how I might fulfill the expectations I had set for myself, while respecting my need for belonging.

As difficult as it was to arrive at, I reconciled that my more fundamental attachment to my life in the US wasn’t something to be ashamed of, but to channel as fuel for my work. It simply meant that my contributions to our work in India would be different— grounded in a life based in the US, not

to patients in Rajasthan.

Over the next several years, I would use my network of relationships to form partnerships with various organizations: with DaVita Bridge of Life to create two dialysis centers in rural Rajasthan (see figure 3); with Boston-based Medical Missions for Children to annually bring cleft lip and palate surgery to the region; and with the University of Miami’s Global Health Residency program to shepherd rotating residents from Miami to Phalodi.

I also successfully rallied my classmates at Harvard Business School to fundraise for our work, with Human Benefit Services as one of the recipients of our annual charity auction.

In building these relationships and raising these funds, I resolved a tension that many of us who wish to contribute to global health face. My desire for a career and life based in the US would not be incompatible with contributions to health care in India—but instead be complementary to it.

Indeed, my work building bridges to the US created new platforms for caring for others that had not previously existed. ....

My Bapu ji led his life as a catalyst for others to recognize problems in the world around him—and to work unrelentingly to address them. Though

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About the Author Sachin H. Jain is

a graduate of Harvard College (2002); Harvard Business School (2007); and Harvard Medical School (2008). He is presently special assistant to the National Coordinator for Health Care Information Technology in the Obama Administration. Previously, he was associate director of Harvard’s Global Health Delivery Project, research fellow at Harvard Business School, and resident physician in the Department of Medicine at the Brigham and Women’s Hospital.

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Dangerous Driving in Brazil: The Overlooked Epidemic of Traffic-Related Deaths Mark Ragheb, Staff Writer

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ew would consider road traffic injuries to be a significant global health concern. Injuries and deaths caused by transportation issues are merely viewed as “accidents,” with little thought put into the associations between infrastructure and health care development and mortality rates from traffic accidents.

However, the statistics and current trends do not lie. According to the World Health Organization, there may be up to 1.1 million lives lost in traffic accidents throughout the world.1 This implies 3,000 traffic mortalities occur daily, with a notable proportion of these in low and middle income nations.

This burden on low and middle income nations is expected to increase; as industrialization and urbanization expands throughout the globe, it is unlikely that current infrastructure will be adequate enough to even sustain the already disturbing rates of traffic related accidents in many of these developing nations. In fact, it is predicted that by 2020, traffic related accidents will be the third leading cause of disability-adjusted life years lost, a measure of overall disease burden.2 The need to act on and recognize these projections is now. In an interview with the HCGHR, Dr. Kavi Bhalla, who is a researcher studying the global burden of road injuries at the Harvard Initiative for Global Health, cautioned that “if we sit back and do nothing, it’s guaranteed the situation

will worsen.”3 In a nation like Brazil, with large urban cities such as Sao Paulo and Rio de Janeiro, this could become a growing public health concern. The current mortality rate due to traffic accidents in Brazil is approximately 24 deaths per 100,000 persons.4 This value is significantly higher than mortality rates for developed nations such as the United States, where there are as few as nine deaths per 100,000 persons.4 Even more striking is the relative rise in Brazil of traffic related deaths over the last few decades. In 1961, the fatality rate per 100,000 persons was 4.1. By 1991, this number had jumped to 15.1, and it has continued to increase.4 Undoubtedly, this increased

rate is correlated with increased urbanization. From 1950 to 1995, the urban population increased from 36 percent to 79 percent and the number of vehicles increased from 426,000 to over 25 million.4 The reasons behind the abnormal rates of death in a middle-income nation such as Brazil are varied and complex. The lack of infrastructural safety present in Brazilian urban areas is a foremost concern. Because of the benefits of mobility in high traffic areas, it has become a common occurrence for local governments to put forth efforts towards reaching optimal traffic fluidity, many times leaving safety in the background.4 For example, many streets have been built with a focus on

Photo courtesy of Wikimedia Commons

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street widening as a means of increasing transportation fluidity. This road expansion has come with the expense of decreasing pedestrian sidewalks, prioritizing speed while diminishing the overall safety of the transportation system.

Lack of law enforcement has also had a significant effect on the impact of traffic accidents on population health.

For example, from 1970 to 1990, Sao Paulo experienced an increase from 640,000 to 3 million cars on its roads with no increase in the number of traffic enforcement officials.4 Looking in depth at the context of some of the accidents in Brazil is also quite telling as to the lack of enforcement. In a 1997 study conducted in large hospitals of four major Brazilian cities, it was discovered that of the patient’s seen for traffic related injuries, 22 percent of drivers had no driver’s license, 27 percent were over the legal blood alcohol concentration limit, 33 percent were not wearing safety belts, and 48 percent of the motorcyclists were not wearing helmets.4 Lack of law enforcement and underdeveloped infrastructure are only two of a plethora of reasons behind traffic related mortalities in Brazil. Possible contributions to these accidents may also include a lack of automobile oriented education and deficiencies in ambulance and emergency care.4 Reversing the increasing trend of road traffic deaths as countries continue to develop will be a significant global health challenge. However, we can learn useful lessons from the United States and Western Europe. As Dr. Bhalla noted, “in the 1970’s, there was a major transition in the U.S. and other Western nations when they noticed the trend of rising vehicle accidents. All of these counties began establishing road traffic agencies, which were given funding and legislative power”.3 This, in turn, led to the “establishment of speed

Photo courtesy of Wikimedia Commons

limits, seat belts, and air bags. While traffic accidents are still a major problem, western nations have been seeing decreasing trends in traffic accidents since the 1970’s,”3 Dr. Bhalla recognized.

The key for nations in mobilizing change is recognition of the problem and a will to make changes. As Dr. Bhalla sees it, previous successes in decreasing traffic accidents in the West “are proof that if a government decides they want to tackle the problem of traffic accidents, and they set up structures to do so, then the problem can be controlled.”3 Along with a broad awareness, Dr. Bhalla believes it is also imperative to have “statistics on who’s dying on the road and from what causes, and then once you have a sense of this you need to have targeted interventions”3 For example, in Brazil, data indicates that the rate of motorcycle related accidents is rapidly growing. In the last decade, motorcycles have increased fourfold.5 Motorcycle deaths have followed suit, with 23 percent of these accounting for all road deaths in Brazil in 2005, up from only 4.5 percent in 1996.5 This type of data is critical for developing countryspecific policies and structures with the

intent of addressing the root causes.

While many issues still exist which result in abnormally high traffic accident rates in Brazil, the government has made efforts to increase transportation safety in the country. In light of the growing awareness of traffic safety, Brazil has made attempts to increase road security and educational campaigns related to traffic safety.1 As economic and infrastructural development continues to thrive and expand throughout the country, however, it is crucial that the Brazilian government takes more significant steps to improve traffic safety before it becomes a greater public health issue.

1.

2.

3.

4.

5.

Peden, Marge, et al. “World Report on Road Traffic Injury Prevention.” World Health Organization. 2004. <http://books. google.com/books?id=iY5RrUKTkeQC &printsec=frontcover&cd=1&source=g bs_ViewAPI#v=onepage&q=&f=false>. 18 February 2010 Nantulya, Vinand and Michael Reich. “The Neglected Epidemic: Road Traffic injuries In Developing Countries.” BJM. 11 May 2002.

Bhalla, Kavi. Personal INTERVIEW. 26 February 2010.

Vasconcellos, Eduardo Alcantara. “Urban Development and Traffic Accidents in Brazil.” Accident Analysis and Prevention.

July 1999.

Bhalla, Kavi. “Global Burden of Road Injuries.” 27 Sept 2009. <http:// roadinjuries.globalburdenofinjuries.org/

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Ensuring a Brighter Future for Haiti: A Critical Assessment of Present and Future Needs Annemarie Ryu, Staff Writer

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ecently struck by its most destructive earthquake in 200 years, Haiti is now beginning a rebuilding process of colossal scale. Given that the country’s population had the worst health indices in the Western hemisphere even before the quake,1 ensuring that reasonable living conditions arise from the present devastation is a challenge that is overwhelming the international community’s response capacity.

The crisis in Haiti promises to redefine the perception of “crisis” as a short-term phenomenon – critical needs there will extend far into the future.

Initial progress in Haiti reveals both the strength of the international relief efforts thus far and the tremendous difficulty of addressing even the most immediate needs in Haiti. In an interview with the HCGHR, Peter Bell, a senior research fellow at the Hauser Center for Nonprofit Organizations at Harvard and the former president of CARE, recognized “the challenge is that everything is needed and everything is needed at once.”2 The earliest priorities in the wake of the earthquake have included rescuing people buried under rubble, providing medical care for the critically wounded, and offering food, water, and shelter to the Haitian people. As of February 18, just over a month after the quake, the World Food Programme and its partners had reached over 3.7 million persons with food assistance.

The United Nations’ Water, Sanitation, and Health (WASH) project also

was providing an average of 850,000 people with five liters of safe drinking water per day in over 300 sites across the most devastated areas.

Despite these efforts, a month after the quake, hygiene kits had reached only 40 percent of the target population and latrines had been provided for just 12 percent of those in greatest need.3 Moreover, severe damage to critical national infrastructure, including transportation, communication, health, and basic utilities, and the significant loss of the workforce have greatly weakened Haiti’s capacity to respond to the crisis.4

eases spread through respiratory droplets, such as measles, diphtheria, and tuberculosis.

Ensuring continuous provision of safe drinking water, providing shelter for the displaced and homeless, and providing early treatment of affected individuals will be key to reducing the impact of communicable diseases.4 These needs are made even more pressing by spring rains and the approach of the hurricane season.

At the same time, protection of vulnerable populations continues to be a critical concern, especially as thousands of children remain separated from their families and are at risk of falling prey

The foundation of these reconstruction efforts must be the empowerment of the Haitian people, as they will define the “new” Haiti.

As governments, organizations, and individual citizens continue to address these most basic needs, the aid response must further stabilize the situation by working to prevent epidemics and provide security, education, and employment. The WHO warns that with reduced access to sanitation systems and safe water, the large displaced population in Haiti is at risk of contracting Hepatitis A, Hepatitis E and typhoid. In addition, overcrowding in resettlement areas heightens risk of disease transmission, especially for dis-

to the human trafficking trade. Jennifer Leaning, the new director of the Francois-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, told the HCGHR that hundreds of orphanages prior to the quake housed many children not actually orphaned, but rather temporarily surrendered by desperate parents. These orphanages gave many children to the international adoption trade or to traffickers.

Leaning emphasizes the importance of identifying and reunifying

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global health review children with their families and improving settings for child care in the upcoming months.5 Ensuring security for displaced children will be crucial to the sustainable development of a stable society.

Securing the basic standards for health and security will help enable the reconstruction of Haiti’s education system and economy.

Yet, most importantly, the foundation of these reconstruction efforts must be the empowerment of the Haitian people, as the Haitian people will define the “new” Haiti.

Haiti’s education system must be rebuilt so that the next generation of Haitians can be prepared to lead their country. Leaning says that returning students to schools as soon as possible will additionally help to restore a sense of normality and will enable more parents to join the decimated and much needed workforce.5 The underlying necessity for the revitalization of Haiti’s economy will be job creation. In a testimony on January 27, 2010 to the U.S. Senate Committee on Foreign Relations, Dr. Paul Farmer, co-founder of Partners in Health (PIH) and United Nations (UN) Deputy Special Envoy to Haiti, emphasized the need for foreign assistance to focus on local job creation and the rebuilding of infrastructure.

This action will ensure sustainable growth that will ultimately reduce Haiti’s dependence on foreign aid. Farmer called for a way of rebuilding Haiti that “strengthens the Haitian economy to provide for the needs of its people, especially the vast majority of Haitians

who are desperately poor.” Also crucial to rebuilding of the economy will be private investment in Haitian businesses, improvement of agricultural yield, the core of Haiti’s economy, and

months, one year, and ten years from now, the international community is upholding its promises made in the immediate aftermath of the earthquake.

Additionally, we can continue to contribute funds to aid efforts, both through Haitian homegrown organizations as well as foreign ones. Also, in the upcoming months, prepared volunteers will be able to serve as English teachers and to assist organizations in Haiti with reconstruction efforts.5 Rebuilding Haiti will likely be a decadeslong process, but we should remember that this is in part because the Haiti before the quake was far from the Haiti we Photo courtesy of Wikimedia Commons now envision.

The Haitian people the forgiving of Haiti’s crippling debts.6 have proven remarkably hardworking As recovery continues, all plans and resilient. Enduring and unwavermust be made in collaboration with ing global solidarity will ensure that Haiti’s government and people. The the future of Haiti is bright. key to any significant recovery will be the international understanding that Haiti’s needs extend far beyond the relief of an acute crisis, that strong sup1. Central Intelligence Agency. “Haiti.” The World port for Haiti must be sustained.

Factbook. 4 February 2010. <https://www.cia. gov/library/publications/the-world-factbook/ Statements of support must be geos/ha.html>. 18 February 2010. fully followed with resolute action for 2. Bell, Peter. Personal INTERVIEW. 18 February 2010. years to come. When Haiti was strug3. United Nations Office for the Coordination of Humanitarian Affairs. “Haiti Earthquake: Situation gling to recover from a series of natuReport #22.” New York: OCHA, 2010. ral disasters in 2008 and 2009 that re4. World Health Organization. Communicable Disease Working Group on Emergencies. sulted in a 15 percent reduction of “Public health risk assessment and the country’s GDP, the international interventions: Earthquake: Haiti.” Geneva: community pledged $402 million to WHO, 2010.

5. Leaning, Jennifer. Telephone INTERVIEW. 19 support the Haitian government’s EcoFebruary 2010. nomic Recovery Program. As of mid6. U.S. Senate Committee on Foreign Relations.

January 2010, it was estimated that 85 “Haiti: From Rescue to Reconstruction” Hearing. Testimony of Dr. Paul Farmer. percent of these pledges remained un27 January 2010. <http://standwithhaiti.

6 disbursed. org/haiti/news-entry/pih-co-founder-paulfarmer-testifies-at-senate-foreign-relationsNow, international donors have committee/>. 19 February 2010. agreed to a 10-year rebuilding effort for 7. Lacey, Marc, and Ginger Thompson.

Haiti estimated at $3 billion.7 We can “Agreement on Effort to Help Haiti Rebuild.”

The New York Times. 25 January 2010. support Haiti by making sure that six

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Kicking HIV to the Curb: Grassroot Soccer Scores New Goals for HIV Prevention Hemali Thakkar, Staff Writer

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even years ago, young Tshepo joined Zimbabwe’s Grassroot Soccer program, compelled by HIV’s destabilizing force to learn more about the epidemic that has been shattering his country for decades. He was one of hundreds of students actively engaged in the Grassroot Soccer (GRS) program, instigated to confront one of the world’s most pressing problems with an innovative solution - soccer.

Capitalizing on the popularity of soccer, GRS was created in 2002 by a group of friends, all former professional soccer players, with the aim to improve awareness and prevention strategies regarding the growing HIV/AIDS epidemic. It leverages the youth’s love of soccer to make a difference through education and life skills. “You can pretty much walk to any street corner in the world, put down a soccer ball, and you would suddenly have 25 friends. This is a game that breaks down barriers and opens up the community,” said Grassroot Soccer Co-Founder Ethan Zhon in an interview with the HCGHR.1 Grassroot Soccer operates mainly in South Africa, Zambia, and Zimbabwe, but it also has technical assistance partnerships with ten other African countries and outreach projects that deliver the GRS model internationally.

With the support of local organizations, Grassroot Soccer provides the youth of Africa with “the knowledge, life-skills, and support to live HIV free.”2 The key to its success is working within existing infrastructure rather

than creating brand new infrastructure that may be opposed by the community. “We feel we’re best utilized when another organization might have a good sports development program and they’ll have us come in and act as

lives of millions of youth all around the world. While most of GRS’s projects are based in Africa, they have begun to expand and launch sustainable projects in the Dominican Republic and Guatemala with the assistance of partner

Children and young adults…have such a strong commitment to this extra-curricular activity mostly because all around them are people whose lives have been utterly destroyed by the epidemic. consultants or technicians and we teach them how to use our curriculum so that they can go out and run our program on their own,” said Zhon.2 Furthermore, soccer brings together youth by generating instant friendships, initiating teamwork, and involving the entire community. Children and young adults like Tshepo, who participate in Grassroot Soccer’s intense ten-week curriculum, have such a strong commitment to this extra-curricular activity mostly because all around them are people whose lives have been utterly destroyed by the epidemic. The World Health Organization (WHO) estimates that the number of adults and children living with HIV in the country of South Africa alone could be as high as 6.6 million.3 Grassroot Soccer is surely on its way to making a huge difference in the

organizations. The impact it is making is astounding. A recent evaluation conducted in 2008 found that after participating in the Skillz Curriculum, the percentage of students who believed in the effectiveness of condoms increased from 49 percent to 71 percent.4 One of the greatest challenges to treating HIV/AIDS in Africa is the extreme stigmatization of the disease in these regions. Thus, the creation of an environment where HIV/AIDS is openly discussed helps to decrease stigma and promotes trust among the youth so that if they are in trouble, they feel comfortable asking for support from their peers. “They don’t have a safe space to talk about issues such as multiple partners,” says Jeff Decelles, the Global Research and Development Manager for GRS.5 Yet, as the evaluation also revealed, the percentage of

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Permission to use photo granted by Alice Keeney Photography

students who could list three people they felt comfortable talking with about HIV increased from a mere 33 percent to 72 percent after participation in the curriculum.4 From its inception, GRS has won the support of many prominent organizations involved in health interventions around the world. These include the Bill & Melinda Gates foundation, USAID, NIKE Gamechangers, FIFA, and more.

It has collaborated with over 30 NGOs to launch projects all over Africa and Latin America, building peak capacity to adapt, deliver, and evaluate the GRS model in existing programs.

GRS hopes to install projects that are sustainable and expand wherever possible. Zhon explained to the HCGHR that GRS will go “anywhere that’s got HIV and soccer, which is pretty much all of Africa as we know.”

He said, “We don’t want to go in there

for a week or two weeks, drop off a couple of soccer balls, run a few programs, and leave. We want them to be able to continue after we’re gone.”

Given that GRS is still a relatively new organization, they hope to keep their focus on preventing HIV/AIDS, but they may take on other infectious diseases in the future. However, as Zhon clearly described, “As of right now, we’re pretty focused on HIV prevention. That’s where all our research has gone; that’s where all our monitoring has gone.” Regardless, GRS has plans to expand all around the world,

increase its number of partnerships, and improve its curriculum.

GRS provides a workable model that successfully addresses many of the problems faced by similar HIV awareness organizations. It allows the community members to become actively involved and eventually take charge of the project on the ground. Such sustainable progress can be seen in the example of Tshepo, who seven years later, is a fullfledged coach, teaching kids about ways to avoid HIV through GRS. Grassroot Soccer is surely scoring big against HIV.

1. Grassroot Soccer. “What We Do.” <http:// www.grassrootsoccer.org/what-we-do/>. 6 February 2010.

2. World Health Organization. Epidemiological Fact Sheet on HIV and AIDS. <http:// apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_ZA.pdf>. 7 February 2010.

3. Zhon, Ethan. Telephone INTERVIEW. 19 February 2010.

4. Grassroot Soccer, “Proven Results.” <http:// www.grassrootsoccer.org/proven-results/>.

6 February 2010.

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Taking Tips from Iran: ‘Health Houses’ Serve as Model for Mississippi Health Advocate Neda Shahriari, Staff Writer

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ith the many issues facing health care access on the global scale, the search for an exemplary model that can serve as a template of success has been discovered in the most unlikely place: Iran, a developing country. Although it is the expected norm to look to Western nations for advice on health care, the Iranian primary health care system contains innovative ideas that have drawn attention from within the United States.

With 64 million individuals comprising the Iranian population, approximately more than half of these individuals are dispersed amongst 70,000

villages across the country.1 In order to cater to the needs of such scattered clusters of individuals, the concept of “health houses” has been the source of an effective health care model in Iran.

Mohsen Naghavi, Associate Professor of Global Health at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, wrote in December 2008 in the Asia-Pacific Population Journal that “the lowest and most essential parts of the district health network are the rural health houses and urban health posts, both of which are designed to deliver the variety of services envisaged by the PHC [Primary Health

Photo courtesy of Neda Shahriari

Care] concept at the grass-roots rural and urban levels, respectively.”2 He explained that “the chief responsibilities of a rural health centre are to support and supervise rural health house activities, accept referred cases and maintain proper contact with higher levels of the health system, particularly the district general hospital.”2 The Iranian government developed these “health houses” during a period of dire need for access to health care: the Iran-Iraq war from 1980 to 1988. The effectiveness of these health houses arises from the fact that over 90 percent of rural Iranians benefit from the free health care provided from these houses. Each small village has a central health house that provides service to approximately 1500 individuals and enables easy, proximate access.

Most importantly, the health houses in each region operate via the work of trained community health workers known as “behvarzan” (plural). The success of these health houses is rooted in their constant emphasis on preventative care—the female “behvarz” maintains child and maternal health while the male “behvarz” monitors sanitation and environmental factors.3,4 The “community participation and intersectoral participation” that is inherent within these health houses, due to the trust embedded within the “behvarzan” as a result of their communal ties, fosters a sound system for delivery of health care.4 More explicitly, since the “behvarz” is from the village he/she serves, reciprocity and mutual trust defines the relationship between the people and the

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Photo courtesy of Neda Shahriari

health houses.

As Mohammad Esmael Motlaq, the director of the Centre for Healthcare Promotion affiliated with the Ministry of Health, expressed to Mojgan Tavassoli in a report that appeared in the World Health Organization Bulletin, “the health workers are well familiar with the culture and traditions and that is a big advantage.”4 Furthermore, the “behvarzan” are crucial components of the health information recording system, specifically through what is known as the “vital horoscope.” As Naghavi described, “the vital horoscope, which is printed on a 50 x 70 cm sheet of paper, is designed to display an up-to-the-hour account of the vital events recorded by the ‘behvarz’ and the services provided by the health house during the year.”4 Through this effective means of keeping record, the PHC Network is able to evaluate the efficacy of its interventions and seek out improvements if necessary. Statistics obtained from various “vital horoscopes”, thus, have suggested noticeable improvements with respect to infant and childcare.2 Dr. Aaron Shirley, a healthcare ad-

vocate from Mississippi, viewed the successful outcomes through Iran’s method of health care delivery, particularly in reducing infant mortality rates. He visited Iran to understand their methods and potentially adopt it in the urban and underserved Mississippi Delta region.5 According to statistics offered by the United Health Foundation, the urban Mississippi regions are plagued with infant deaths rates as high as Libya and Thailand, and 20 percent of the population is without health insur1.

2.

3.

4.

Ayatollahi SM. “Growth Monitoring in Iran’s Primary Health Care Network: a Practical Approach for a Successful Outcome,” International Society of Technology Assessment in Health Care. Department of Biostatistics, Shiraz University of Medical Sciences, Iran. <http://gateway.nlm.nih.gov/ MeetingAbstracts/ma?f=102215778.html>.

15 February 2010.

Naghavi, et al. “Vital Horoscope: Longitudinal Data Collection in the Iranian Primary Health Care System.”

Asia-Pacific Population Journal, December 2008.

“Present and Future of Primary Health Care in Iran,” Compilation: Global PHM Secretariat, Bangalore, India. Online Google pdf file. 5 March 2010.

Tavassoli, Mojgan. “Iranian Health Houses

ance. Moreover, obesity, hypertension, and teen pregnancy are at a record high compared to the rest of the United States.5 Observing Iran as a nation plagued with similar problems—scarce funding and limited trained personnel—Shirley sought out the methods Iran was utilizing to achieve success in reducing child mortality rates by approximately 70 percent and increasing contraception use to 90 percent, despite the limitations.5 Visiting Shiraz, Iran in the May of 2009, Shirley understood the concept of health houses and the emphasis on preventative care, particularly for at-risk groups like mothers and children. Upon their return, Shirley and his team developed a health house plan for Mississippi, and the project sites are under current research.

As Naghavi stated, “government investment in a low-cost, culturally acceptable and locally supported primary health care system can effectively change the health status of rural population and thus contribute to rural poverty alleviation programs.”6 This model can serve as a template for other health care systems globally. As in the case of Dr. Shirley’s adoption of the model in Mississippi, there is great potential for health care improvement in other regions if the intricacies of the Iranian Primary Health Care system are effectively understood and implemented.

5.

6.

Open the Door to Primary Care,” Bulletin of the World Health Organization, August 2008. <http://www.who.int/bulletin/ volumes/86/8/08-030808/en/>. 22 February 2010.

Puderbaugh, Ann. “Iran’s Health Houses Provide Model for Mississippi Delta,” U.S. National Institutes of Health, John E. Fogarty International Center for Advanced Study in the Health Sciences, December 2009. <http://www.fic.nih. gov/news/publications/global_health_ matters/2009/1209_health-house.htm>. 15 February 2010.

Naghavi, Mohsen et al. “Primary Health Care System, Narrowing of Rural-Urban Gap in Health Indicators, and Rural Poverty Reduction: The Experience of Iran.”

Population Studies and Research Center: Tehran, Iran. July 2005.

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A Race Against Time: Global Efforts to Address the Urgent Needs of the Elderly Pratyusha Yalamanchi, Staff Writer

I

t’s not easy to downsize. With age, that reality becomes more and more familiar as one’s income decreases, personal health deteriorates, and living conditions are forced to change. Ildiko Szabo, Director of Community Life at Youville House, a Cambridge Assisted Living Residence, explained in an interview with HCGHR, “Most residents in our community face tremendous challenges when it comes to downsizing.

Downsizing to a smaller home forces people to [deal with] the psychological ramifications of what it means to be in assisted living, the reality of loved ones becoming ill and dying, and possible feelings of isolation.”1 Scaling back is no easy task in the Land of the Plenty.

Yet, this difficulty is only one of the numerous issues facing the elderly in domestic and international settings, of which health care and human rights are perhaps the most pressing.

Health care and human rights for the elderly have clearly been issues of concern for generations so why all the recent attention? As the Former Subcommission on the Promotion and

Protection of Human Rights established, the world is aging: elderly are the fastest growing population and by 2050, people aged 65 or older will outnumber children aged 0 to 14. Many nations, particularly China, will be transitioning to what are known as “age-old societies”, where at least 11 of population is of 65+ years.2 Though aging is the outcome of improved public health and living conditions, growing older clearly has its problems: over 184 million older people live in poverty worldwide.3 Bridget Sleap, Rights Policy Advisor for HelpAge International (HAI), a network of organizations for the rights of the elderly, told the HCGHR that the greatest issue fac-

ing the elderly is “age discrimination and ageism because it is a form of discrimination that has not been adequately addressed and continues to be tolerated.”4 There are several major universal issues from social welfare to the right to work that need to be addressed, but perhaps the most pressing matter for the elderly is a guarantee towards the right to health. Age discrimination often gets played out in the health sector. As Sleap points out, “most older men and women told us they are discriminated against when trying to get health services.”4 While generalizations cannot be made from nation to nation, it is fair to say that health services are often unavailable or unaffordable for older people. In the limited number of nations where legislation is in place to guarantee health care for the elderly, older people are often refused on account of their age.

For instance, HAI showed through 2008 research in Mozambique that despite the fact that older people are exempt from paying for medication at health centers, 86% of the elderly in 15 surveyed commuPhoto courtesy of Flickr Commons nities in the Gaza

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Photo courtesy of Flickr Commons

province had to pay for their medication on a health visit.5 In times of strife, elderly are often the first to be compromised when it comes to allocation of health resources.

In Buhimba, a camp for displaced people in the Democratic Republic of the Congo in central Africa, the elderly are deemed unproductive and no longer of a significant contribution to society.

They are typically not treated for their age-related illnesses and are often given the wrong drugs for their conditions.5 As for how to tackle these issues, Sleap offers some advice. First and foremost, we must “build recognition of what age discrimination is and have it taken seriously so that governments may recognize that ageing is an issue that needs to be addressed across many different sectors.”4 The Madrid International Plan of Action on Ageing, adopted in 2002 by the Second World Assembly on Ageing, aims to improve attitudes and policies concerning the

elderly to address ageing in the 21st century.6 As for Sleap’s thoughts on the

resources must be allocated towards the UN Trust Fund for Ageing and poverty eradication programs for the elderly.

The review noted that an overall stronger UN system must be in place.6 Yet, as the Madrid Plan is not legally binding, governments in developing nations do not see ageing as a priority. As Sleap suggests, “there is an attitude that families will provide for the elderly and that it is not a state obligation.”

The solution Sleap offers has two parts: increasing awareness of ageism to develop non-discriminatory legislation and making older men and women aware of their rights. In order to make a case for the rights of the elderly, however, the lack of data must first be addressed.

Sleap recognizes, “You don’t have the evidence needed to advocate for change. HIV prevalence data is only collected for men and women between the ages of 15 and 49. Statistics related to violence against women above age 49 is extremely limited.”4 It is essential that the UN and the global community collect and dis-

[B]y 2050, people aged 65 or older will outnumber children aged 0 to 14. plan, she says, “As a document, it is very comprehensive with hundreds of recommendations. As for implementation, there is a problem in terms of government commitment.”4 In a February 2008 review of the process, it was determined that more

seminate data associated with elderly living conditions and advocate for an end to ageism. Ageing is a triumph of 20th century advances, but the health care and human rights issues that come with age must be addressed now in the 21st century.

1. Szabo, Ildiko. Telephone INTERVIEW. 22 February 2010.

2. Office of the High Commissioner for Human Rights. “Advisory Committee discusses working paper on Human Rights of Elderly.” <http://www.ohchr. org/en/NewsEvents/Pages/DisplayNews. aspx?NewsID=9779&LangID=E>. 15 February 2010.

3. HelpAge International. “An ageing world.” <http://www.helpage.org/Aboutus/ Anageingworld>. 15 February 2010.

4. Sleap, Bridget. Telephone INTERVIEW. 2 March 2010.

5. Sleap, Bridget. HelpAge International 2009 Position Paper. “Why it’s time for a convention on the rights of older people.”

15 Feb 2010.

6. United Nations Programme on Ageing.

“Report of the Second World Assembly on Ageing – Madrid International Plan of Action on Ageing, 2002.” <http:// www.un.org/esa/socdev/ageing/madrid_ intlplanaction.html>. 15 February 2010.

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An Interview with Dr. Mirta Roses Periago Farhan Murshed, Staff Interviewer example of a Primary Health Care system in the Americas?

Dr. Roses: There are several successful experiences of implementing PHCbased health systems in the Americas.

Some of the most consolidated experiences can be found in countries such as Canada, Costa Rica, Cuba and Chile.

They all have universal coverage and access to health care, and the ability to pay for services is not a barrier to accessing care.

Photo courtesy of PAHO

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r. Mirta Roses Periago is the Director of the Pan American Health Organization (PAHO)the World Health Organization’s regional office for the Americas. Previously, she served as the Director of the Pan American Sanitary Bureau, becoming the first Argentine and the first woman to hold that position in the history of the world’s oldest public health agency. Dr. Roses has worked with PAHO/WHO since 1984, previously serving as coordinator of the Epidemiology Unit at the Caribbean Epidemiology Center in Trinidad and Tobago, PAHO/WHO Representative to the Dominican Republic and Bolivia, and Assistant Director of PAHO. HCGHR: In your annual report as Director of PAHO, you strongly advocate for Primary Health Care systemscan you describe the most successful

Their health systems are based on the health needs of individuals, families and communities. They are all built on strong first levels of care, providing comprehensive care which is well integrated with the specialized levels of care. They emphasize promotion and prevention and encourage inter-sectoral actions, including the private sector, to address the most distal determinants of health.

They stimulate social participation and accountability for results.

They have strong information systems to inform decision-making and the evaluation of services, and strong government involvement in both the financing and the steering of the health system. They have sound policies for guaranteeing quality of care and availability of well trained health care workers across the system.

Several other countries of the Americas are moving towards implementing Primary Health Care-based systems including countries such as Brazil, Uruguay, Venezuela, Nicaragua, El Salvador,

Paraguay and Ecuador, among others.

HCGHR: You are leading the fight against health care inequity; in your opinion what are some of the most daunting challenges in this fight and what have been some of the most innovative solutions to date?

Dr. Roses: Large inequity in income and high poverty levels are chronic problems in Latin American and the Caribbean. Lack of access to basic health services affects 125 million people, approximately 230 million people are not covered by health insurance, and 17 percent of births are not attended by qualified health personnel.

Thus, the Organization’s strategic vision for 2008-2012 identifies equity in access to timely and quality health goods and services as a necessary feature of health systems, in order to reduce the unacceptable gaps that hinder sustainable growth and development in this Region.

It is critical that inequities are visible if we want them to be corrected. Lack of data and data quality to produce necessary evidence at local levels regarding financial and geographic barriers to access for disadvantaged groups, intercultural competencies of health workers and institutional practices, health needs of the population, disparities in public health care spending among the rich and the poor, among others, continue to be a problem for many countries, usually the poorest ones.

While national health indicators such

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global health review as maternal and infant mortality can give us some idea, disaggregated data that can discriminate the real situation within the country and lead to actionable information, are still lacking.

There are innovative solutions to target healthcare inequity from countries like Brazil and Chile. In 1996 Brazil implemented the Family Health Program to provide community-based primary health care services in an effort to improve access to the poorest population in the country. Services are delivered by a primary health care team, targeting the poorest areas first and prioritizing those who have never received health services.

The social protection program â&#x20AC;&#x153;Chile Solidario,â&#x20AC;? implemented since 2002, is a good example of a strategy addressing the social determinants of health.

Preferential access is provided to programs in health, education, and justice to the poorest households in the country to improve their living conditions, promote social inclusion, and eliminate indigence. Colombia, Mexico, Bolivia, Argentina are also among countries that have created innovative social and

nually held, it advocates for equity and access to vaccination and promotes PanAmericanism. Its overarching objective is to strengthen the Expanded Programs on Immunization in the Region by vaccinating populations with otherwise limited access to regular health services and at heightened risk of contracting vaccine-preventable diseases, like those living in border and rural areas, urban margins, indigenous communities, and in municipalities with low vaccination coverage.

Since 2003, VWA has grown to be the largest multi-country health effort, with the participation of all countries and territories in the Region. Country participation in VWA is flexible and goals and activities are specific to national health objectives, from large scale vaccination campaigns during VWA to communication initiatives and health promotion campaigns. The widespread media coverage of the initiative has been essential to highlight the importance of immunization to the general public.

Some outreach opportunities generated

by VWA immunization campaigns inte-

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Organization (WHO). Beginning in 2005, the European Region launched its own Immunization Week, and in 2010, the Eastern Mediterranean Region of WHO will join the effort with its first Vaccination Week.

Significant challenges include continuing to maintain the VWA on the political agendas of leaders in the Americas, as well as expanding the initiative to other WHO Regions, with the ultimate goal of achieving a Global Vaccination Week in the near future.

HCGHR: You were trained as an epidemiologist - how has your educational background informed and influenced your career as a director of a public health organization?

Dr. Roses: In elementary school I was a Red Cross volunteer, in high school I pursued studies as a teacher, and then in medical school I volunteered as a houseto-house vaccinator and I had an excellent training in clinical medicine.

All these experiences and skills were reinforced with public health and epide-

...the Organizationâ&#x20AC;&#x2122;s strategic vision for 2008-2012 identifies equity in access to timely and quality health goods and services as a necessary feature of health systems... health programs to expand coverage to the poor and protect them from the economic crisis.

HCGHR: One of the initiatives your organization has taken was Vaccination Week of the Americas. Can you describe the impact of that initiative and its successes and challenges?

Dr. Roses: More than 288 million individuals have been vaccinated as a result of the Vaccination Week in the Americas (VWA) initiative, as of 2009. An-

grate other preventative and educational interventions (i.e. administration of vitamin A, anti-parasite medication, eye examinations, dental checks, and various screenings). Over its tenure, the Vaccination Week of the Americas initiative has garnered increasing political visibility; presidents, ministers of health, celebrities and leaders of international agencies have attended VWA launching events.

VWA has also served as a model for other Regions of the World Health

miology training. The analytical methods, the value of sound information for decision making, the awareness about the interaction of host/agent/environment and the multi-causality of diseases, the need to be a good listener and observer before jumping to conclusions, and the patience to define a good strategy to address problems based on trends and to keep always open to innovation.

These are just a few of the competencies that help me in managing PAHO. But most importantly, the sound ethics and

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moral principles learned from teachers and elders.

global health review

HCGHR: What advice do you have for college undergraduates who desire “Health for All”?

sume its leadership and overall coordination responsibility, since the massive damage of most governmental buildings, including the collapse of the ministry of health main building, reduced Haiti’s administrative institutional capacity.

Dr. Roses: “Health for All” is a call for equity, inclusiveness and solidarity, all

PAHO is serving as the leader of the Health Cluster activities in Haiti and

PAHO is supporting an outbreak early warning system, key program activities related to health services, mother and child care, outbreak alert, disease surveillance, mental health, water supply, immunizations, HIV/AIDS, and tuberculosis, among others. [PAHO is also supporting the implementation of a] Post Disaster Needs Assessment in the

Health is a powerful tool to make a safer and durable world for all.

Peoples’ well-being and public health must be our foremost consideration. values that rank high among the youth.

The increasing awareness of an interconnected and interdependent world makes this call even more compelling.

Health is a powerful tool to make a safer and durable world for all. Peoples’ wellbeing and public health must be our foremost consideration. How could we ignore and condone exclusions that deprive people from reaching the highest attainable level of health?

For those that really want to talk the talk and walk the walk it is, therefore, a moral imperative to contribute to making visible the inequities in access to healthcare, developing evidence-based solutions addressing them, and advocating for the adoption of public policies implementing those solutions.

To achieve health for all we must include health in all policies. Any professional battleground is good to fight for health for all if we truly care for people.

HCGHR: Which aspects of relief work in Haiti is PAHO overseeing and what challenges has your organization faced with this work?

Dr. Roses: Our first task is to support the Ministry of Health (MoH) to re-

the Dominican Republic, which encompasses coordinating with more than 390 international agencies, institutions and teams working in health related activities to ensure a better response from the sector as a whole, which includes: •Initial assessment, monitoring and information management •Outbreak control, disease surveillance •Water supply and environmental health •Reactivation of the basic health services •Ensuring treatment and rehabilitation of injured people •Ensuring the availability of essential drugs and medical supplies PAHO is mobilizing multidisciplinary expertise, purchasing medicines, medical supplies and equipment, implementing a supply management system at entry and distribution points, and supporting the Program on Essential Medicines and Supplies (PROMESS) for the distribution of vaccines and medicines and supplies to more than 80 health institutions.

PROMESS is pivotal to making sure that the people most in need will receive the necessary medicines, and following the quake, it was virtually the only source of drugs and medical supplies in the country.

health sector as an important step towards early recovery and reconstruction.

Challenges are huge, of course, given the scope of the catastrophe faced by Haiti, including the proximity of the presidential and parliamentary elections and the limitations in logistics, telecommunications, security, and language.

But I think we should focus in on the two most significant ones: to make sure that we help Haiti to have a functional, strengthened and more equitable health system and to do our utmost effort to remind the international community that Haiti is going to need a long-sustained and ambitious support program in order to fulfill the most basic needs of the population.

HCGHR: The current issue of HCGHR focuses on chronic diseases, such as mental illnesses. Haiti, after experiencing such mass devastation, will undoubtedly experience a wave of mental illness that could cripple their development for generations to come if proper action is not taken during their recovery. What sorts of initiatives is PAHO undertaking to ensure Haiti can properly treat mental illness in sustainable and cost-effective ways?

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Challenges are huge, of course, given the scope of the catastrophe faced by Haiti, including the proximity of the presidential and parliamentary elections and the limitations in logistics, telecommunications, security and language.

Dr. Roses: Emergencies create a wide range of psychosocial problems experienced at the individual, family, and community level. Disaster situations damage social support, increase the risk of mental disorders and amplify pre-existing conditions.

Social support is essential to protect mental health in disaster situations.

Support should be organized through multiple sectors, for instance: health, education, food security and nutrition, social protection, shelter, and sanitation. Affected groups have assets that support psychosocial well-being; a common error is to ignore these resources and protective factors and focus solely on deficits (weaknesses, suffering and pathology).

Since the early stages of the emergency, PAHO is helping to build local capacities, support self-help, and strengthen resources already present, promoting the participation of the local populations in the response.

Activities and programs are being inte-

dealing only with violence survivors or those people with a specific diagnosis, can create a highly fragmented support and care system.

Activities integrated into wider systems (e.g. existing community support mechanisms, school systems, general health services, mental health services, social services, etc.) tend to reach more people, are often more sustainable, and tend to carry less stigma. Relief and health workers are being included to protect them and help them deal with traumatic and exhausting experiences while providing care services.

PAHO has been working with other agencies of the United Nations system and with NGOs to coordinate actions in the field of psychosocial and mental health care, as well as providing technical cooperation to the plan being developed by Haitiâ&#x20AC;&#x2122;s MoH to strengthen its response capacity in mental health.

The main objective is to ensure that Haitiâ&#x20AC;&#x2122;s health sector can treat people with mental disorders in sustainable and cost-

...public health is in essence a social network that puts together the isolated actions of millions of individuals to create a common good, a protective net that covers each and everyone... grated as much as possible. Proliferation of stand-alone services, such as those

effective ways. Thus, the strengthening and decentralization of mental health

services are a priority of the plan.

The purpose is to develop an ambulatory and community model that is able to provide access to care for people with mental disorders. By inserting the mental health component into Primary Health Care, psychological and social considerations are included when providing general health care.

HCGHR: You recently opened a Twitter account- can you please explain your motivations for doing so and how you hope to use it?

Dr. Roses: Our era is characterized by an ever-deepening social networking. That is very fitting for public health practitioners since public health is in essence a social network that puts together the isolated actions of millions of individuals to create a common good, a protective net that covers each and everyone â&#x20AC;&#x201C;think about the protection you create not only for yourself but also for others by the mere act of getting a vaccine.

We are in Twitter precisely because for public health it is a must to keep pace with all of the developments related to the massive exchange of information and knowledge. There is a need for maximizing as much as possible all available technological tools to keep in contact with our audiences.

We are living in a world where users will interact with, and also add value to, public health contents, and for that reason we try to use Twitter and other social networking possibilities.

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An Interview with Dr. Jennifer Leaning Lavinia Mitroi & Michael Henderson, Experts and Interviews Section Editor and Editor in Chief Congratulations! Are there any new initiatives that you are particularly interested in implementing? Or, are there any existing projects which you are especially dedicated to continuing?

Dr. Leaning: The focus of the FXB Center is going to be a redoubled and intense one on the problems facing children and adolescents in very dire circumstances: extreme poverty, postconflict settings, high levels of disease, endemic disease, disease outbreaks, [as well as] children and adolescents caught in oppressive state regimes or part of stigmatized minorities. That will be our scan across the world.

Photo courtesy of the FXB Center

D

r. Jennifer Leaning is the Director of the Francois-Xavier Bagnoud Center for Health and Human Rights and the Francois-Xavier Bagnoud Professor of the Practice of Health and Human Rights in the Department of Global Health and Population at the Harvard School of Public Health. She is also the Co-Director of the Harvard Humanitarian Initiative and an Associate Professor of Medicine at Harvard Medical School. Her field experience concerning issues of public health assessment and human rights includes Afghanistan, Angola, Kosovo, the Chad-Darfur border, and the African Great Lakes region.

HCGHR: You were recently selected to replace Dr. Jim Kim as the new Director of the Francois-Xavier Bagnoud Center for Health and Human Rights.

There are [also] a couple of ongoing programs that we certainly are going to be maintaining and strengthening.

One will be a program that Theresa Betancourt is running, which [involves] dislocated child soldiers and models of human security in various crisis settings.

The Health and Human Rights Journal, which has been around for a long time, since the inception of the FXB Center, is going to continue. We are delighted that it is now online, which was something that occurred under the time that Jim Kim was here. [Also] Paul Farmer… is going to continue to be editor, which is excellent. That is going to move ahead, and our role there is to make sure that we have the best spin on this journal so that we really accelerate readership.

Now that it’s online, the task is to get it read by everyone on Earth.

There’s an ongoing initiative which is technically complex that is a combination of economics and health assessment [looking at] particular populations of HIV/AIDS affected children [and] the measures that would have had a major impact [on these populations] had they been delivered. [We will also be asking] what are the social costs both to the individual [and] the larger family and community of [these measures] not having been implemented? That’s called the cost of inaction and that’s a program that was started a year to a year and a half ago and we are going to be continuing that.

The new programs are going to be looking at a number of thematic issues relating to criminal trade in children and adolescents- that is trafficking for the sex trade or for the wide span of labor markets. We are going to be looking at ways in which we can, on a positive level, raise the self-esteem and sense of agency among adolescent girls- which we think is going to be very protective and also lead to a real flourishing of their capacities if we catch girls early enough, before they’re crushed in certain types of patriarchal systems. And we will be looking at country areas where that assessment will take place and there will be some progress involved in that.

We are planning to work more closely with the virtual villages that are established by FXB International, which is the other major program set up by the founder of the FXB Center, the Countess Albina du Boisrouvray. She and her

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global health review associates have a number of villages and financial and cooperative engagements where we may put some of our effortsanalytically or perhaps [to] graft a new program of interactions. So there are a number of things that we are considering [as we move forward at the FXB Center].

HCGHR: In response to the tragedy in Haiti, the FXB Center sent a Child Protection Assessment Team immediately following the earthquake. Can you please describe the actions undertaken by the team, and how the center will continue their work in the future to rebuild Haiti?

Dr. Leaning: We were immediately caught up in the disaster in Haiti, where within the first several days of the massive earthquake it became apparent to me that the problems of child tracing and family reunification were going to be huge. We sent down a nine day, threeperson team (a fourth person joined later) to assess the protection mechanisms and the gaps that were at least understandable at that phase of disaster. And the team came back; we have a report of the findings in the New England Journal of Medicine- a Perspectives article from last week and we have a very full report that is about to go up on the website.

The bottom line is that there were approximately 350,000 orphans- and that should be put in quotes- prior to the earthquake and there are [now] tens of thousands of children, it not clear what the number is, who have been separated and have lost parents, who are in situations of unclear family status. And so the problem of identifying and reuniting them and keeping them from harm- that is unscrupulous traffickers or precipitous transnational adoption- are quite significant.

We are engaged with UNICEF on a number of projects that will help miti-

gate this problem and we are hoping to have an ongoing engagement in Haiti for the next six months to a year. We are now looking at a very interesting way of building electronic face recognition into smart-phones so that we can augment what is essentially a paper-based record, that has several manual transfers of information, into [a record] that is much more seamlessly transferred into a large database but even at the sight of entry is going to be very precise. This links to my engagement with the crisis mapping community, which is getting to be more robust and galvanized during the response to the Haiti earthquake.

Some of our people in the FXB Center are now working with a number of people in UNICEF and elsewhere and it is now a wide community that is intrigued by this idea. We are definitely not taking the lead but we are participating in that discussion which I think is going to leapfrog the whole family tracing and reunification crisis that is always an essential element of response in war and disaster- leapfrog that process into something that will be much more comprehensive, coherent, and accurate, right from the start.

HCGHR: Mental illnesses are arguably the most stigmatized and undertreated diseases, representing an ‘invisible epidemic’ that receives too little attention in global health advocacy and funding. Diseases such as schizophrenia and PTSD result in stigmatization and the stripping of a patient’s rights.

How will the FXB Center continue to maintain a presence in Haiti and work with children to address this cascade of mental illness that will undoubtedly occur after the disaster?

Dr. Leaning: I think we first have to access what the situation is, so that’s the first effort that is now underway. We are developing a tool that will serve as a population-based rapid assessment tool

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to assess the situation and circumstances of children all across the country. It’s not now just a question of looking at the geographic area where the earthquake was most intense, despite the fact that that is where most of the affected population is.

People have moved and are fleeing and are trying to find sights of refuge and welcoming families all across the country. So even in areas that are quite remote from the actual epicenter of the earthquake, that have not sustained physical damage, the families are now dealing with many people coming from Port au Prince and affected areas who are trying to find economic life and shelter and staying with extended family or just generous community people who will take them in. That’s putting great pressure on these more distant communities and families because no one has much money out in the rural areas of Haiti.

The assessment we are trying to do is going to be looking at the entire span of Haitian conditions and where children now are [located] and in what kinds of family or custodial settings. Also, what are the welfare and rights parameters that are being met for the children in these settings? It is from that point, that we will then begin to develop a sense of the risk profile for kids who are going to be in pretty serious circumstances, whether it is physical health or overall mental health and social well-being. So we are first going to start in assessment mode.

The point about FXB is that we are a research center, we have a really strong policy interest so that the research will be oriented towards policy development and affecting policy at state and national and international levels. [Later] we will be doing some sophisticated advocacy, again usually at the governmental level, although it may be at the major NGO level, depending on the policy and the

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findings. So we are not going to be operational in the actual countryside in terms of running programs.

We will have, in any particular setting where we concentrate, a responsibility with whoever our partnering groups are, to analyze and evaluate proposed interventions and suggest new changes. We are going to have an accompaniment relationship with what we call operational agencies; that will be the way that it will work in Haiti. There are a large number of NGO’s, many major governments, and the U.N. are involved. [Also] the Haitian government is to going to get back on its feet, so the operational landscape is actually going to be quite complicated.

We see our role as being analytic with a particularly strong understanding of the practical implications of a human rights lens. [We ask:] what happens when a child is torn away from his parents or from the family that wants him?

What is the violation and law? What policy regulations are being broken, at the Haiti level and internationally? And then what do we know from the research [concerning] the psycho-social and economic consequences for that child and for the family that has lost him or her?

So we are a university-based center and that’s the role we think we should be playing.

HCGHR: Your previous work at the Chad-Sudan border has been instrumental in identifying the genocide in Darfur. Can you please describe what difficulties were faced in utilizing the term genocide to describe the situation there?

Dr. Leaning: Now we are seven years after the start of that war, which began in February of 2003. The international community did not begin to pay robust attention to this conflict for about a year and so a number of people had

global health review been killed and forced to flee either internally in Darfur or had begun to cross the border into Chad. The Harvard Humanitarian Initiative and Physicians for Human Rights decided to form a cooperative effort to go to the refugee camps in Chad in the spring of 2004 and interview the surviving people there to find out what had happened to them when they were being attacked and what had prompted them to flee their homes and villages and farms...

And the stories were all the same-essentially destruction of villages, raping and killing of women and small children, a real focus on killing of men, and then hot pursuit of women and children and female survivors who are fleeing the villages. Consequently, only the villages that were relatively close to the Chad border had people who had survived to come to them- within maybe 50 miles.

The desert and heat and lack of water meant any longer terrain travel was going to be [lethal] for the people who had been forced to flee. The other people who were too inland, inside Darfur, had to flee elsewhere in Darfur to avoid these killings. And hence you have the IDP (internally displaced peoples) camps that are now quite huge within Darfur.

But the stories were very consistent with certain parameters of the genocide convention in terms of organized, structured, routine, systematic, and highly consistent testimony of what had happened to people, across a very long and big area of Darfur… So we came back and wrote a report that said it looked to us as if the killings and the attacks and the conflict itself in Darfur were based on a direct attack on civilians, not the rebel groups that had prompted this overwhelming response from the government of Sudan and the Janjaweed.

[We wrote] that the government of Sudan and their Janjaweed proxies were going after civilians. They were killing them in large numbers- rape is an inde-

pendent atrocity- and then they were destroying all their capacity to make a living and survive in Darfur. That is, disrupting irrigation, cutting down the trees, burning the villages, trashing every small piece of pottery and pots that they had and in some ways, most significantly, taking all the livestock, which are major sources of wealth and food…

So we identified this as a possible genocidal campaign. We didn’t say it was genocide, but we said it looked as if it might be genocide. And our report came out in summer of 2004, and it blended with a few reports that started to come out in the fall of 2004. Actually, in August of 2004, the U.S. government- Colin Powell, then Secretary of State- called what was going on in Darfur a genocide. Our report I think had some influence. It was not a report that had enormous numbers of independent statistical units in it. In other words, it took a long time to get to these refugee camps, a long time to get access, so the numbers on which our findings were dependent were relatively small. That was another reason why we said this is our sense of what is going on and we were basically calling for a much more robust exploration. But we were very early in calling this genocide.

Now the problem is that to establish the charge of genocide, one has to have pretty clear indication that there is an intent at a high level of government or military to carry out these attacks, as well as what the nature of the attacks are, and this is not to prove genocide but this is just to go far enough to say, ‘We are going to charge the government of Sudan with genocide.’ We have to have a pretty good sense that there is intent there. And we thought that [there was intent] as the story unfolded after our assessment and subsequent assessments…

Our assessment [demonstrated] indeed, given consistency and wide geographic area of these consistent stories, that it

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global health review had to be directed by some senior officials back in Khartoum, that this is not any kind of attack that would occur spontaneously. It was too robust, too heavily militarized, too systematic, too filled with command and responsibility at various levels.

Over the years since, the difficulty of getting substantial numbers [has been an issue], because the Sudanese government stopped anybody from trying to collect population-based data in Darfur… We have estimates. [Another issue has been] the difficulty of finding senior layers of command within the government of Sudan, the GOS formal military, or the Janjaweed, to come forward and say, ‘Yes indeed we were ordered to do this.’

The charge of genocide has been legally somewhat difficult to structure, and you can see that in the fascinating way in which the International Criminal Court (ICC) has dealt with it. They had the courage to gather as much data as they could; they were relentless in talking to everybody and sometimes getting their own data. They placed a charge against [Sudanese president Omar] al-Bashir for crimes against humanity, which is an extraordinarily important crime in its own right, but does not have legally imbedded in it the fact that you have to prove intent. It can just mean that the government did these things and the consequences of these things wound up being massive war crimes, massive atrocities, massive death. You have a government criminally responsible for mass killings and mass atrocities, but you do not have to specifically say, ‘This government set out in its course of action to do that.’

So the ICC decided that it was going to be somewhat easier to prove and convict on the charge of crimes against humanity then genocide. And that was accepted by the Security Council, they referred the case to the ICC. But just in the last year, the last few

months, the ICC has added to its charges against al-Bashir the charge of genocide, because the appeals judge looking at the initial charge has said that there is evidence. [He said] you don’t have to prove intent in order to charge genocide; you just have to have good enough data and evidence to suggest that it might be there to advance the charge of genocide. Because if you had to prove genocide, before you charged somebody, what’s the point of having a court case, right? So it’s a legal nicety but it is an important one to understand and it is very, very powerful now that you have the ICC going after al-Bashir, not only for crimes against humanity, but also for the crime of genocide.

Those of us who have been saying that this has been going on in Darfur are very pleased, but it’s just the first phase in what’s going to be a long battle and a long problem of documentation and argument…

HCGHR: If you could go back to Darfur, what would you do differently perhaps, or do you think that there was nothing you could have changed?

Dr. Leaning: That’s a great question.

What we, that is Harvard Humanitarian Initiative or me, with my colleagues or Physicians for Human Rights, what we should have done in hindsight, is galvanized much larger investigative enterprise: many more teams on the ground, there for a much longer time, developing a water-tight sampling frame, water-tight investigative instrument, and coming back with much more population-based data. And in that period, ’04-’05, if we had been able to raise the money to do that, we would have collected information that has since gotten muddy with new war experience, new arrivals...

And it wasn’t that we didn’t try, but it was really hard to raise the money for it, and to do this type of population

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sampling in the circumstances of Chad wound up being very, very expensive.

This is what the international humanitarian community found when it began to pour resources into supporting the several hundred thousand refugees who wound up being there...

We missed that opportunity. It wasn’t for lack of trying, but we missed it, and when I say we, I don’t mean my colleagues at Harvard and at PHR; I mean the international war epidemiology community and human rights community... So the arguments now pivot on small amounts of data that can be criticized for methodological reasons.

That difficulty, of getting there on the ground in robust numbers to do good sampling... is what really galvanized the international human rights and technology and humanitarian communities to come together around the indirect ways of ascertaining what’s going on in a war or crisis. [We asked], ‘How can we sort of virtually leap high up in the air and look over the geo-political boundaries in between Chad and Darfur and see what is going on?’ Had you had aerial surveillance at 300 feet, 2000 feet, or 30,000 feet- given the technologies- you could have tracked what was going on in a really robust and fascinating way.

There was the start of that, in the sense that the U.S. Holocaust Museum had its Darfur project, where they worked with Google to have the map of Darfur that showed all the burnt villages, and they kept that updated. That was basically with Google Earth and satellite imagery and their ground imagery.

So you can begin to see the potential of this evolving. The crisis-mappers that are essentially linked to cell phones, crowd-sourcing, SMS texting, all forms of satellite imagery, have become a very, very fascinating and highly informed community that I think are going to be deployable in these human rights crises [in the future]…

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global health review

An Interview with Jacqueline Novogratz Daniel Driscoll, Managing Editor describe how it fits into the Acumen Fund agenda?

Novogratz: It is the crux of the Acumen Fund agenda. The idea is that, on the one hand, the market alone has not solved the problems of poverty. We have seen an increase in the gap between rich and poor. On the other hand, traditional… top-down aid and charity will not alone solve the problems of poverty and too often creates dependence, not dignity….

If I’ve learned anything it is that dignity is more important than wealth.

Photo courtesy of Acumen Fund

J

acqueline Novogratz is the Founder and CEO of the Acumen Fund, a non-profit global venture fund that uses entrepreneurial approaches to solve the problems of global poverty. Under her leadership, Acumen Fund has invested $40 million in over 35 companies serving 25 million low-income customers in the developing world. Prior to Acumen Fund, Novogratz founded and directed The Philanthropy Workshop and The Next Generation Leadership program at the Rockefeller Foundation. She is the author of the best-selling memoir, The Blue Sweater: Bridging the Gap Between Rich and Poor in an Interconnected World.

HCGHR: One of the doctrines that you stress is the idea of “patient capital.” Could you please offer an explanation of the concept for our readers and

The idea of patient capital is that in this interconnected world, if we thought of ourselves as one tribe, there is actually excess capital, excess money, at the upper end of the natural spectrum…. That money can be used not for handouts… but for investing… in a way that we used to do in difficult times in tribal towns where capital has been used to keep us close together. For example, we’ll invest in a neighbor to send our child to school…. We pay not for profit but so that we can invest in others again. The tribe stays close.

Outside the tribe you can use moneylenders and pay them back for [their] profit. But, that is a distant thing. Patient capital goes back, if you will, to what we did when we were in smaller communities…. [The point] is [to] have some capital that is set aside to invest in enterprises [and] innovations that serve low-income people, allows for experimentation, can wait a long time, expects at or below market rate return, combines with a lot of management

assistance, and at the end of the day expects repayment. But that repayment is not repaid for profit. The repayment is paid so that Acumen Fund can reinvest.

That’s really the heart and soul of what “patient capital” means.

HCGHR: You recently published a memoir, The Blue Sweater. Many times, books written about the developing world inspire their readers to donate either time or money towards the cause. How would you like your readers to respond to the message of The Blue Sweater?

Novogratz: [I would like readers to respond] in a number of ways. The most important [idea] is that The Blue Sweater is my own journey and I hope that people go on it with me and then take the idea…that every human being has unlimited potential. If we could start from that place as we devised programs and policies that ultimately were impacting the poor, I think we could do a lot better than we have been doing.

Second, [readers should know] that patient capital has a real place in society as a new asset class.

Third, …we need everybody to get involved….There are ways for everyone to get involved, not necessarily only by giving money towards a foundation like Acumen Fund, [but by] getting more involved at the local areas level as well as the global level…. We would love to see people forming book clubs to move the ideas out [and] writing reviews for Amazon and other [websites]….We

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would love to see them starting Acumen Fund community chapters so that they can get others more aware of the issues and more involved. Quite frankly, [we would like] for them to make changes in their own lives—whatever their passion

We have other companies that make a decision where it would close down plants that are not working at local village areas and then we come in and say, ‘Is this not working because the volume of people in this village is too small to

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ter rather than build houses that they can buy, in the short term it is going to be cheaper usually to just pay for someone’s rent or give them a home. But, [in the] long term, if you can create a system in which people actually repay you, [this

There are ways for everyone to get involved, not necessarily only by giving money towards a foundation like Acumen Fund, [but by] getting more involved at the local areas level as well as the global level. is. [That is] ultimately what it is really about…. We want people to spread the ideas.

HCGHR: One issue concerning micro-finance is the question of profitable return and the possible burden imposed on those benefiting from the investment in developing nations who may be pressured for results. How does the Acumen Fund deal with an investment that may not appear to be profitable? What type of moral or ethical dilemmas are involved in making decisions concerning which projects are continued and which are not?

Novogratz: Every day is a moral and ethical dilemma for Acumen Fund. I think that it is inherent in the work that we do. [There] is a dynamic tension of values…. The most important thing for people who get connected to and are part of Acumen Fund, stakeholders of Acumen Fund if you will, is a comfort that we are on a journey….

We have some investees that would not close down a clinic, for instance, in a low-income area if it were not profitable because they feel, ‘What will people do otherwise?’ From Acumen’s perspective we say, ‘Well, that’s fine but then somewhere within the overall entity—that can include government subsidy or other kinds of subsidy—the overall entity needs to make itself whole or over time it will collapse.’

support the work? Is it not working because people are too poor? Is it not working because of poor management?

Is it not working because of something else?’

is] not only… sustainable but over time you see that it typically costs the philanthropic giver less. That is really what we measure. Is it cheaper? Is it more effective….

For us, it is…an ethical discussion. Although [on] some level…we are betting on the entrepreneurs, so we have to take their lead until we decide we fundamentally disagree with their lead. We have done that before in which case we exit the investment. We are always asking the hard questions: ‘What are the right models that will reach the most people in the most efficient way?’ and ‘To those people who cannot be reached through the market, what is the level that we are talking about and are there different approaches that help extend that market to reach everyone ultimately?’

In terms of water delivery, you can keep giving people water every single day and you know how much that costs or you can create a system whereby people buy their water. It costs, in the case of Water Health International, $600,000. But, we got…[the money] back. It probably cost us another $250,000 over the last 6 years to provide management assistance ….If you get the $600,000 back, which we ultimately will, then that $250,000 has translated into 400,000 customers that are getting access to safe, affordable water on a daily basis. It has brought in $40 million of additional capital to a market that had never existed.

HCGHR: One of the metrics used by the Acumen Fund to evaluate the efficacy of the Fund’s investments is the “best available charitable option” ratio (or BACO). This measure aims to “quantify an investment’s social impact and compare it to the universe of existing charitable options for that explicit social issue.” Can you explain how this evaluation method works? How are future benchmarks for improvement created if comparing to existing standards?

Novogratz: If we look at what it would cost, for instance, to give somebody shel-

We look at that as a pretty amazing return on the charitable dollar and we compare it to what otherwise you would have to spend to get those people, every single day, clean water.

HCGHR: How do you think that your background in international banking, working for Chase Manhattan Bank, for example, has influenced your philanthropic work?

Novogratz: Chase taught me the power of financial systems. Chase taught me the power of investing money in compa-

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The people who support Acumen financially are really invested in so many ways in Acumen Fund as an organization and as a...philosophy of how to make change... nies…. [I watched] those companies use capital to grow, to create jobs, [and] to bring services in a very systematic way that is very much part of the Acumen Fund. We have the discipline of a bank or an investment firm as part of our culture. I wouldn’t have traded that experience for the world.

what we were saying at the very beginning that Acumen Fund has a stakeholder model. The people who support Acumen financially are really invested in so many ways in Acumen Fund as an organization and as a …philosophy of how to make change…. They want to be part of helping us grow that change.

HCGHR: One of your many accomplishments thus far has been the founding of Duterimbere, a micro-finance institution in Rwanda. Can you please describe what type of work this organization does?

In the United States, there are individuals like Seth Godin who gives enormously of his time as well as financial resources even in so far as hosting seminars and selling books and using all of the proceeds to give directly to Acumen Fund. He works closely with the organization on messaging and communications in ways that leave us changed as an organization.

Novogratz: It is a microfinance organization that started way back in 1986…. It lends to low-income women very small amounts of money so that they can start their own businesses. It has also created… a for-profit credit union for farmers as well as for businesspeople that it is associated with. It has grown up over the last 25 years and that makes me very proud.

HCGHR: One of the Acumen Fund’s stated goals is the building of a global community of professionals, donors, and institutional partners to work towards the goal of solving some of the

The company IDEO in California which has such a unique and wonderful approach to building solutions from the perspective of the users, of customers, and seeing the world through a designed lens…has significantly impacted the culture and the approaches that the Acumen Fund takes.

The Gates Foundation has been a wonderful partner of ours both providing financing as well as intellectual col-

feller Foundation worked hand-in-hand with us in developing “Pulse,” the metrics platform that … enables Acumen Fund to measure and monitor the work that we’re doing. But also now with over 50 users it (“Pulse”) is creating more of an ecosystem where ultimately we hope to see real benchmarks…. [The creation of “Pulse”] would not have been possible without the funding and also the intellectual collaboration of those two organizations.

If you go into Pakistan or India or Kenya, you will see other kinds of collaborations, both with business individuals who serve on our advisories, our ethnic committees, [and] work with our young teams… and with companies like Citibank in Pakistan that have helped us with research on our housing, provided mentorship …[and have] been a real partner to us.

The list is so long—our offices are provided free by Google—and I think what it attests to is how people like to bring their whole selves to the work of building a world where everyone has access to services [and] where we can really have dignity rather than dependence. For me, the community, which is increas-

...people like to bring their whole selves to the work of building a world where everyone has access to services [and] where we can really have dignity rather than dependence. world’s most distressing poverty problems. Who are some of the Acumen Fund’s closest collaborators and how do you work together?

laboration trying to understand what it takes to deliver clean water, sanitation [and] agricultural inputs to low-income people.

Novogratz: It goes back a little bit to

The Skoll Foundation and the Rocke-

ingly global with people who give to us…from 16 countries- both individuals and corporations- is as important as anything we do.

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The Complexity of Urban Public Health: Mumbai, India Laura Nolan Khan, Contributing Writer

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treets are choked with children playing in the dirt as auto -rickshaws rattle past within inches of their outstretched arms.

Whole families fly by packed on one weaving motorcycle. Seas of pedestrians make their way through the traffic selling, crossing and expertly dodging the beeping buses and taxis. The street is full to bursting, as are the slums that house 55 percent of Mumbai’s population in just 6 percent of the city’s land area.

Slums have increasingly been featured dramatically in the media and have given the more privileged corners of the world a glimpse of urban hardship and the deprivation in which millions of people live. But slums and the people who occupy them are hardly homogeneous the world over, let alone in a single country or even a single city. For example, slum dwellers in Mumbai suffer from a plethora of infectious diseases (malaria, typhoid, HIV/ AIDS, hepatitis, tuberculosis, RTIs) and increasingly from non-communicable diseases such as cancer, mental health problems, high blood pressure, accidents and respiratory conditions. Dr. C.A.K. Yesudian, Dean of the School of Health Sys-

I interviewed a mere 31 women (who represented only those voluntarily visiting the clinic), we documented monthly family earnings ranging from 800 rupees (approximately $20 US) to 10,000 rupees (approximately $230 US), ages of marriage ranging from 12 to 24 and levels of education from none to Bachelor of Arts.

Women came in dirty, clean, with and without their Photo courtesy of Laura Khan husbands and most often with tem Studies at the Tata Institute of Social their children. We Sciences (TISS) has written extensively asked them about their utilization and on the heterogeneity of Mumbai’s urban knowledge of family planning methods. poor and the impact such diversity has on We met a woman who had come to the health status and health-seeking behavior. clinic exclusively to receive oral contraIn the throes of its epidemiological transi- ceptives. However, we met more who tion, underweight and anemia manifest had never heard of any method of conalongside lifestyle-related conditions such traception ever. as cardiovascular disease and diabetes, Such economic and social diversity most notably in urban areas. in the slum population of Mumbai in adMy experience doing field work at a dition to the enormous divide between primary health clinic in the Shivaji Nagar rich and poor in the city as a whole has slum confirmed, albeit anecdotally, the di- given rise to a peculiar and vastly comversity of one slum population. Located in plex health system. BMC estimates they the northeast corner of the city, the Shivaji service approximately 20 percent of the Nagar Urban Health Center (SNUHC) population at their teaching hospitals serves people who need access to free ba- and other facilities. The state provides sic health care, most of whom arrive on care as well, but the largest proportion is foot to receive it. Though my team and covered by the notoriously unregulated

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STUDENT SPOTLIGHT private sector – accounting for approximately 80 percent of health service delivery in the city. “The field is open, you can go wherever you want to” says Dr. Anita Shenoy of SNUHC. Her patients, even the poorest, split their utilization between free facilities and private practitioners depending on time, available services, location, family contacts and perceptions of quality.

Historically, the Indian government has maintained a focus on national programs, such as the National Rural Health Mission, to combat communicable diseases and generally serve the three-quarters of India’s population still living in rural areas.

As the health status of India’s urban poor declines compared to the rural population, there is an increasing concern about the burden of disease and the quality of health service in urban areas.

“In big cities it is really chaotic because the options are so many” says Dr. Yesudian. With three excellent but overcrowded teaching hospitals, 23 secondary hospitals and hundreds of ill-equipped dispensaries, Mumbai’s public health facilities, according to Yesudian, “are run just like any government department”. Interestingly, the private sector is just the opposite. A new clinic only needs registration by the Shop and Establishment Act to begin doing business. The Center for Enquiry into Health and Allied Themes (CEHAT) estimates there to be over one thousand private hospitals and nursing homes in Mumbai run by individuals, NGOs, religious bodies and companies, apart from the plethora of private practitioners, polyclinics and dispensaries.

The health challenges of India’s urban poor are complex and multifaceted, yet according to Yesudian, not insurmountable. Through innovation, creativity and perseverance, health indicators have been gradually improving throughout the country and in some states, like Kerala, quite significantly.

Yesudian believes urban health can also progress if the right attention is given to the complex health system. He insists

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Photo courtesy of Laura Khan

that Mumbai “has a very strong [public] health service” and that it “just needs to be restructured”. He proposes revamping management to increase efficiency, strengthening lower level dispensaries to decrease load on teaching hospitals and setting up a functional referral system to organize a continuum of care.

Additionally, one of the best ways to improve the health of the urban poor in India, would be to regulate the private sector to ensure basic standards are met such as mandatory hygienic conditions and instruments “so that private services are of some quality”.

Such a systems-wide approach is warranted as patterns of service utilization are so varying and unpredictable.

A public health systems interven-

tion alone, however, will not sufficiently improve the health status of the urban poor. Basic knowledge of services available is as essential as the services themselves. This kind of empowerment and knowledge transfer, in combination with broad systems reform, is essential to improve the health and well-being of India’s urban poor. There’s a long road ahead but acknowledgement of the particular challenges and complexities of urban health and healthcare is a first step in the right direction.

Agarwal, Siddarth, Satyavada, Aravinda, Kaushik, S. and Kumar, Rajeev. “Urbanization, Urban Poverty and Health of the Urban Poor: Status, Challenges and the Way Forward.”

Demography India. 2007; 36(1) pp. 121134 Agarwal, Siddarth and Sangar, K. “Need for Dedicated Focus on Urban Health within National Health Mission.” Indian Journal of Public Health. 2005;XXXXIX(3) pp. 141-151 De, Jayashree. “Development, Environment and Urban Health in India.” Geography.

FindArticles.com 31 December 2009.

http://finarticles.com/p/articles/mi_7545/ is-200707/ai_n32257058 More, Neena Shah, Bapat, Ujwala, Das, Sushmita, Barnett, Sarah, Costello, Anthony, Fernandez, Armida, Osrin,

David. “Inequalities in Maternal Care and Newborn outcomes: one-year surveillance of births in vulnerable slum communities in Mumbai.” International Journal for Equity in Health. 2009; 8(21) Vasi, Ashifa Sarkar. Society for Nutrition, Education and Health Action. Presentation.

2010 Jan 13.

Shenoy, Anita. Shivaji Nagar Urban Health Center. Personal Interview 2010 Jan 18.

Thakur, Harshad. Tata Institute of Social Sciences. Personal Interview 2010 Jan 20.

Yesudian, C.A.K. “Pattern of Utilization of Health Services: Policy Implications.” Economic and Political Weekly January 30, 1999 Yesudian, C.A.K. Tata Institute of Social Sciences. Personal Interview 2010 Jan 20.

Laura Khan is a first year Masters student in the Global Health and Population Department of the Harvard School of Public Health.

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Deconstructing the Masculine Gender Identity and its Influence on HIV/AIDS Prevention Policy in Peru Anisha Kumar, Contributing Writer

S

ince its first recorded case of HIV/ AIDS in 1983, Peru has developed a nationally coordinated approach to address its HIV/AIDS epidemic. However, despite the integration of biomedical and social prevention methods in the Peruvian government’s response to this health crisis, certain marginalized groups in Peru lack prevention and care programs. These programs may decrease the prevalence rate of the disease if they are designed to specifically target these groups. The HIV/AIDS prevalence rate in Peru is 0.5 percent while the prevalence among men who sleep with men (MSM) is estimated as eleven percent based on limited data on MSM.1 The relation between MSM and HIV/ AIDS treatment in Peru can be improved through public policy changes based on cultural values. Ethnographic research shows that the circumstances affecting the high prevalence of HIV among MSM is rooted in the culturally constructed masculine gender identity. The masculine gender identity that has been constructed in today’s global society has three components: ability to father children, attractiveness derived from a large number of sexual conquests, and economic capability. 2 This masculine gender identity influences why the health sector may not implement interventions such as awareness campaigns that specifically address MSM with HIV/ AIDS. Homosexual men who are open about their sexual practices may not fulfill the component of exert paternity, so MSM do not fit the culturally constructed and acceptable terms of their gender identity. Stigma against MSM is prevalent and Peruvian government programs and

NGOs do not directly target MSM for HIV/AIDS prevention and treatment.

Furthermore, ethnographic research in a cross-cultural study indicates that many people believe that homosexuality is a temporary phase rather than a life-long sexual preference.3 If people believe that MSM will change their practices and move out of their “phase” of homosexuality, there is less incentive to utilize funds and effort to create health care and education programs to exclusively target MSM. In addition to the three general components of masculine gender identity, the concept of “machismo” is another possible reason why MSM are not directly targeted for HIV/AIDS care. In Latino culture, “machismo” describes how men should exercise authority over women.4 The machismo is evident through ethnographic accounts of Latinos in America; though machismo in American Latinos may be accentuated differently because of U.S. cultural influence, such a concept may have originated from the native cultures of American Latinos, like Peruvian culture. Using the culturally constructed machismo concept as a framework, one can speculate that the idea of targeting MSM as a group for HIV treatment may imply exerting authority over this group of men; exerting authority over men veers from the machismo concept and the culturally constructed gender hierarchy.

While masculine gender identity influences why the health sector may not implement interventions for MSM with HIV/AIDS, it also affects how the health sector should design and imple-

ment these interventions. Gender and sexual identity affect the behaviors of MSM and their approach to HIV/AIDS treatment, and specific policy should be designed based on their behaviors and mentality. Several ethnographic studies have found that MSM self-identify with different subgroups. In Bangladesh, MSM do not identify themselves as a single group of people with common social factors. The Western-constructed category “MSM” is subdivided into kothi—“feminized” men who do not enjoy heterosexual intercourse, panthis— men who sleep with men until marriage, and giriyas—men who sleep with men for money but not for pleasure.5 Since these MSM believe that their motivations to participate in homosexual activities are different, perhaps public health measures should utilize these anthropological findings to specifically target the subgroups among MSM. Many MSM have certain sexual practices for economic reasons, and their high-risk behaviors can be reduced with carefully designed economic and education interventions by the government or NGOs. Therefore, a more effective way to decrease the HIV prevalence among MSM may be to evaluate each subgroup separately and to understand their structural barriers to prevention and treatment.6 Additionally, an ethnographic study of urban, low-income African American men in Baltimore had similar findings about the subcategories with the MSM category. The men in this study identified themselves as completely homosexual, mostly homosexual, mostly heterosexual,

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Photo by Daniel Bacchuber (Flickr Commons)

or bisexual.7 This subdivision within the MSM category is rarely considered when designing public interventions for HIV/ AIDS, yet these nuances affect how men identify themselves. One’s gender and sexual identity affects the approach to preventative health care, and MSM who do not self-identify as “homosexual” may not participate in interventions or measure specifically designed for people with certain high-risk sexual behaviors.

Since the constructed masculine identity affects whether specific public prevention measures of HIV/AIDS are implemented and who these interventions target, constructed gender identity dictates sexual behavior with partners of either gender. Though there is little medical anthropological research on the role of gender constructs in HIV/AIDS transmission and prevention specifically in Peru, cross-cultural ethnographic studies can be applicable to Peru.8 Cross-cultural ethnographic

research indicates that the culturally constructed masculine gender identity plays a significant role in determining the relationship between MSM, specific HIV/AIDS prevention methods, and high-risk sexual behaviors. Acknowledging and understanding such a gender identity construct can help to fuel 1.

2.

3.

4.

5.

AVERT. (2009, Dec. 04). Latin America Statistics Summary. Retrived from http:// www.avert.org/southamerica.htm.

Whitehead, T. L. (1997). Urban LowIncome African American Men, HIV/AIDS, and Gender Identity. Medical Anthropology Quarterly, 417. Retrieved from http://www. jstor.org/stable/649531 Davis, D. L., & Whitten, R. G. (1987). The Cross-Cultural Study of Human Sexuality.

Annual Review of Anthropology, 16, 80.

Retrieved from http://www.jstor.org/ stable/2155864 Singer, M., et al. (1990). SIDA: The Economic, Social, and Cultural Context of AIDS among Latinos. Medical Anthropology Quarterly, 4(1), 72-114. Retrieved from http://www.jstor.org/stable/648524 Khan, S. I., et al. (2005). Men Who Have Sex with Men’s Sexual Relations with

more specific, effective interventions for prevention of HIV transmission in countries like Peru.

Anisha Kumar is a sophomore from Pforzheimer House studying Anthropology.

6.

7.

8.

Women in Bangladesh. Culture, Health, & Sexuality, 7(2), 159-169. Retrieved from http://www.jstor.org/stable/4005447 Farmer, P., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural Violence and Clinical medicine. PLoSMedicine, 3(10): e449. doi:10.1371/journal. pmed.0030449 Whitehead, T. L. (1997). Urban LowIncome African American Men, HIV/AIDS, and Gender Identity. Medical Anthropology Quarterly, 417. Retrieved from http://www.jstor.org/stable/649531 Davis, D. L., & Whitten, R. G. (1987). The Cross-Cultural Study of Human Sexuality.

Annual Review of Anthropology, 16, 6998. Retrieved from http://www.jstor.org/ stable/2155864

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Problems with the BRAC Bond: Neglecting Tuberculosis Patients Lauren Onofrey, Contributing Writer

T

Photo courtesy of U.S Department of Defense Public Domain

he largest NGO in the developing world, BRAC has reached an estimated 110 million individuals with its initiatives in microfinance, health, education, social development, human rights, and legal services.1 BRAC emphasizes empowerment and sustainability in all its endeavors and has accordingly developed an innovative approach to health services for tuberculosis patients in resource-poor settings.

BRAC’s community-based model utilizes directly observed therapy, short course (DOTS), in which a female community health worker is responsible for 300 households2 and visits patients to observe their adherence to their medications.3 Despite the substantial number of patients assigned to each health worker, BRAC rivals many expensive programs with its remarkably high rates of adherence for patients who agree to enter therapy. 4

The secret to BRAC’s success is its bond system. According to an adulatory analysis, “The bond acts as an incentive to both the patient and their community for the regular intake of drugs.”5 Without bonds, a program would require 96 US dollars (USD) per patient, while with bonds, BRAC is able to use 64 USD and achieve similar outcomes.6 Patients who cannot afford the bond must involve their communities in raising the funds for their treatment7 or, in rare cases, might qualify for a fee waiver.8 However, BRAC failed to consider fully the difference between healthcare and microfinance when it expanded its services to include healthcare and implemented the bond system. In the context of tuberculosis treatment, BRAC “clients” are constrained in agency not only by poverty, structural violence, and unfavorable circumstance, but also by ill health. They cannot attain the self-

reliance that BRAC claims is the “only abiding answer” for the poor.9 Due to this fundamental difference, the use of bonds to promote patient adherence has measurable undesired consequences of failure to cover the ultra-poor, promotion of gender inequality, and social harm committed against patients. Traditional metrics of cost-per-patient, treatment adherence, and clinical outcomes fail to consider these effects.

Like user fees for healthcare,10 BRAC’s bonds exclude from treatment those who cannot afford the amount, which is equivalent to a few days’ wages in the rural areas of BRAC programs.11 The organization attempted to reach these individuals with bond waivers,12 but Christopher Colclough’s research at the Institute of Development Studies suggests that exemptions are ineffective at improving the equity of service provision because “implementation often varies from policy intent”13 and the administrative difficulty of discerning the poor from the ultra-poor is insurmountable.14 Furthermore, patients immediately above the threshold for free care would continue to have difficulty paying the bond.

These assertions correlate with data from BRAC programs, which indicate an unexpected 10% refusal rate for services,15 as well as with analyses for BRAC criteria for exemptions, which have been described as “ad hoc” by research published in Health Financing Reforms.16 These deterrents from care for the ultra-poor also reinforce gender inequality. A study published in Health Policy and Planning concluded that women experienced longer delays in the health system when a bond was required due to their “inaccessibility to financial

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STUDENT SPOTLIGHT

resources”17despite equal likelihood of seeking care.18 This disparity arises because BRAC’s fixed bond is effectively higher for women due to gendered differences in domestic responsibility, activity in the formal economic market, and rates of compensation.19 A woman’s financial resources cannot be considered with her household because men in resource-poor settings can be reticent to spend on their wives’ healthcare.20 Much more difficult to measure, the public health effect of these gender inequalities can hurt the population as a whole, because women more often engage in care-giving for dependents and immune-compromised individuals.21 Even for patients who receive care, community involvement through the bond system inflicts severe social harm.

BRAC champions community involvement as a strength of the program, but the stigmatization of tuberculosis patients challenges this analysis.22 BRAC is familiar with the perception of tuberculosis: its application to the Global Fund explicitly notes “TB related stigma particularly amongst females.”23 Despite this knowledge, the bond system publicizes poor patients’ tuberculosis status to their communities. Recent research published in the International Journal of Tuberculosis and Lung Disease has confirmed this reality even in the context of effective treatment, citing a cultural association between tuberculosis and socially unacceptable lifestyles and behavior such as dirtiness, alcohol, smoking, and promiscuity; and the study also concluded that these associations are particularly strong for women in Bangladesh,24 where BRAC pioneered its tuberculosis program and continues to care for patients.

Furthermore, BRAC’s own data has revealed similar trends: one of its surveys found that 25 percent of BRAC tuberculosis patients reported isolation from family members and that an additional 25 percent said that villagers “both hated and were scared of them.”25 By traditional metrics, the treatment of such patients through community involvement is of-

global health review

ten successful in that the patient is cured, but the bond system renders immeasurable, enduring harm in the process and ultimately affects future opportunities and social interactions.

The efficacy and the unintended consequences of the bond system thus create a difficult tension: how can BRAC both maintain low-cost adherence and eliminate the problems of inaccessibility for the ultra-poor, inequality for women, and social harm for patients? The use of bonds seems indispensible for BRAC’s program for philosophical and pragmatic reasons, but this analysis suggests that BRAC must revise the current system.

1.

BRAC. Overview. (2010). <http://www. brac.net/index.php?nid=69>.

2. Faruque, A., M.A. Islam, M.K. Barua, M.A. Alam Community-Based Tuberculosis Care in Achieving High Case Detection and Cure Rates in Bangladesh. (2003). [PowerPoint slides].

3,4,5. Chowdhury, A.M.R., J.P. Vaughan, S. Chowdhury, F.H. Abed, “Demystifying the Control of Tuberculosis in Rural Bandgladesh.” In Porter, J.D.H., and Grange, J.M., Tuberculosis: an interdisciplinary perspective (379-396). Imperial College Press: London, (1999).

6. Islam, M.A., S. Wakai, N. Ishikawa, A.M.R. Chowdury, J.P. Vaughan, “Costeffectiveness of community health workers in tuberculosis control in Bangladesh.” Bulletin of the World Health Organization, (2002), 80: 6.

7. BRAC. “Institution Implementing Scheme: Bangladesh. BRAC’s response to a survey sent out by RPM Plus, Stop TB, WHO, and the World Bank.” (2001). (http://www.msh. org/projects/rpmplus/documents/upload/ Bangladesh_Summary_Experience_IE.pdf) 8. Faruque, A., M.A. Islam, M.K. Barua, M.A. Alam Community-Based Tuberculosis Care in Achieving High Case Detection and Cure Rates in Bangladesh. (2003). [PowerPoint slides].

9. Uphoff, N., M.J. Esman, A. Krishna Reasons for Success: Learning from Instructive Experiences in Rural Development. (Kumarian Press: West Hartford, CT, 1998).

10. Gao, J., S. Tang, R. Tolhurst et. al “Changing access to health services in urban China: implications for equity.” Health Policy and Planning, (1998) 16, 3: 302-12.

11,12.Faruque, 2003. [PowerPoint slides].

13,14.Colclough, C. Marketizing education and health in developing countries: miracle or mirage? Oxford: Oxford University Press (1997), 53.

15. Chowdury, 1999.

16. Ravindran, T.K.S., D. Maceira, with

One option is the implementation of a sliding scale: the lowest end of the scale could be a written contract; BRAC could evaluate a woman’s assets separately from her household to calculate the reduced amount of her bond; and patients could avoid public disclosure of their tuberculosis status. By applying a sliding scale to its existing bond system, BRAC could retain the innovations of its model while reducing its harm. ­­­Lauren Onofrey is a sophomore from Cabot House studying Molecular and Cellular Biology. contributions from D. Kikomba. “The Right Reforms? Health Sector Reforms and Sexual Reproductive Health.” Health Financing Reforms. (2004), 43.

17. Karim, F.; M.A. Islam, A.M.R. Chowdhury, E. Johansson, V.K. Diwan. “Gender differences in delays in diagnosis and treatment of tuberculosis.” Health Policy and Planning, (2007) 22: 329-334.

18. Ahmed, S.M., G. Tomson, M. Petzold, Z.N. Kabir, “Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh.” Bulletin of the World Health Organization,(Feb 2005) 83, 2: 109-115.

19. United Nations Research Institute for Social Development (UNRISD). “Who Pays?

Financing Social Development.” Visible Hands -Taking Responsibility for Social Development. Geneva: UNRISD, ( 2000), 39.

20. Schuler, S.R., L.M. Bates, M.D.K. Islam, “Paying for reproductive health services in Bangladesh: intersections between cost, quality and culture.” Health Policy and Planning, ( 2000) 17, 3, 273-280.

21. Schiller, N. G, “The invisible women: Caregiving and the construction of AIDS health services,” Culture, Medicine, and Psychiatry, (1993), 17, 487–512.

22. Chowdhury, 1999.

23. The Global Fund. (2008 July 1). Proposal Form – Round 8 (Tuberculosis). Applicant: Afghanistan Country Coordination Mechanism (BRAC was the Principle Recipient). <http://www.theglobalfund.org/ grantdocuments/8AFGT_1613_0_full.pdf>.

(Accessed 11 December 2009), 49.

24. Somma, D., B.E. Thomas, F. Karim, J. Kemp, N. Arias, C. Auer, G.D. Gosoniu, A. Abouihia, M.G. Weiss. “Gender and socio-cultural determinants of TB-related stigma in Bangladesh, India, Malawi and Columbia.” Int J Tuberc Lung Dis, (2008), 12, 7: 856-866.

25. Chowdhury, 1999.

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