Harvard College Global Health Review Winter 2009 by Rajarshi Banerjee

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global health review Volume I, Number 2, Winter 2009

GLOBAL ACCESS Medication for Every Nation: Changing University Access Policies Jenny Chen

At a Crossroads in the Battle for AIDS Treatment Sophie Delaunay & Emi MacLean

An Interview with Jeffrey Sachs

A publication of the Harvard College Global Health and AIDS Coalition

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global health review Volume I, Number 2, Winter 2009

From the Editors

Global Access 4 6

Medication for Every Nation: Changing University Access Policies

Justin Banerdt

Hemali Thakkar

Jenny Chen

Inequality in a Global Pandemic Response Battle in India: Novartis, Gilead, and Generic Drug Production

10 Universal Access to Reproductive Health Care and Family Planning

Susan Wang

12 Community-Based Malaria Control in War-Torn Burma

Alison Kraemer

Panorama 24 The Malawi Nursing Crisis: No End in Sight?

Angela Primbas

26 The Fat of the Land: The WHO Joins the Fight Against Obesity

Neda Shahriari

28 A Story that Doesnâ&#x20AC;&#x2122;t Sell: Violence Against Women in Kenya

Taylor Poor

30 Under the Knife: Can America Learn from Japanâ&#x20AC;&#x2122;s Success In Cutting Healthcare Costs?

Yuying Luo

32 Stamping Out Polio: Vaccines and Postage Stamps in Pakistan

Jessica Villegas

34 Simply No Room: AIDS Outreach in Pakistan and Bangladesh

Meghan Houser

The Expert Perspective 14 At a Crossroads in the Battle for AIDS Treatment

Sophie Delaunay & Emi MacLean

18 Beyond Good Intentions

36 An Interview with Jeffrey Sachs 39 An Interview with Ed Hunter 41 An Interview with Frank Donaghue

Dr. Mathew Craven

21 Reflections on Reconstruction of the Afghan Health Care System

Interviews

Dr. Abdullah Sherzai

Student Spotlight 45 We Eradicated Smallpox, So Why Not Malaria?

Annemarie Ryu

47 Say Yes to Drugs: The Anatomy of a Campaign

Abby Schiff

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global health review

Like what you see? Then check out the Harvard College Global Health Review online at: http://www.hcghr.org/

• Browse current and past issues through our archive... • Get the Expert Perspective... • View our Student Spotlight... Features, Panorama, Interviews with Julio Frenk, Jeffrey Sachs, and more...

Check back soon for web-exclusive materials and added features!

The Harvard College Global Health Review, Winter 2009 Editorial Board Editors-in-Chief Simin Gharib Lee Michael Henderson Managing Editor Daniel Driscoll Assistant Managing Editor Alison Kraemer

Board of Advisers Business Manager Henry Dawkins Section Editors Sarah Littlehale (Features) Raj Banerjee (Panorama) Lavinia Mitroi (Experts and Interviews) Lulu Tsao (Student Spotlight)

Staff Jenny Chen Justin Banerdt Hyunje Grace Cho Meghan Houser Yuying Luo Farhan Murshed Taylor Poor

DESIGN Board Angela Primbas Neda Shahriari Alexa Stern Hemali Thakkar Jessica Villegas Susan Wang

The Harvard College Global Health Review is a publication of the Harvard College Global Health and AIDS Coalition.

Executive Design Editors Alan Chiu Erin McCormick Layout Editors Whitney Adair Lavinia Mitroi 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-

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 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 2, Winter 2009

From the Editors Dear Reader, In the great health care reform debate that has gripped the United States this year, many experts have said that policy can address two, but never all of the following: access, delivery, and cost. In our first issue, we addressed current issues facing global health leaders in delivery of care. Following that labor of love, however, we stepped back and realized that, as with domestic health care, a closely linked and equally problem-ridden face of global health is access to care. Increasing access in the global health arena has been significantly successful in isolated cases. One has only to look at antiretroviral (ARV) drug therapy for HIV/AIDS. Since 2001, the cost of first-line ARV combination therapy has fallen from $1000 to $87. Another great achievement around access is the dramatic reduction in second-line drug therapy for multidrug-resistant tuberculosis. In Mountains Beyond Mountains, Tracy Kidder dramatically narrates the campaign that our former advisor and newly inaugurated President of Dartmouth, Jim Kim, led to successfully force the price of MDR drug prices by 95%. These examples serve as sources of inspiration for the substantial work that remains to increase access everywhere. Global knowledge, technology, and funding have all multiplied, yet many essential medicines are still unambiguously unaffordable to patients in developing countries. In this second issue, staff writer Jenny Chen presents one “Medication for Every Nation,” an exploration of controversial university access policies that echoes the message of the “Say Yes to Drugs” campus-wide campaign led by our sponsoring organization, the Harvard College Global Health and AIDS Coalition (HCGHAC). Staff writer Justin Banerdt’s article on “Access to Flu Vaccines in a Pandemic” considers access problems in another context that hits home for many Harvard students. Our other content outside of the Features Section guarantees that our discussion and exploration is not too narrow in focus. Staff writer Neda Shahriari

presents a problem observed in an increasing number of countries in her article about obesity, “The Fat of the Land” in the Panorma Section. Contributing student writer Annemarie Ryu presses discussion on disease eradication with her piece “We Eradicated Smallpox, So Why Not Malaria?” in the Student Spotlight Section. And finally, we turn to contributions from experts like Sophie Delaunay, the Executive Director of Médecins Sans Frontières in the U.S., and economist Jeff Sachs for more experienced perspectives on a wide array of global health questions. This much-improved second issue would not be possible without the humbling flood of support we have received across Harvard. We must first welcome and thank our newest advisors, Professors David Bloom of the Harvard School of Public Health and Arachu Castro of Harvard Medical School. Although the departure of Jim Kim from Harvard leaves large shoes to fill both on our Board of Advisers and in the greater Harvard community, we are confident that these new additions along with our remaining sources of advising support, Robin Herman of HSPH and Dr. Rebecca Weintraub of HMS, will help this publication further its mission to educate and inspire the current and future generations of global health leaders. As always, we extend our deepest gratitude to our writers, whose relentless hard work continues to make publication of thoughtful content a reality. We are also indebted to HCGHAC for their continuing support, the Institute of Politics, the Weatherhead Center, and the Undergraduate Council, without whom we could not have produced this issue we present to you today. And finally, thank you, reader. Ultimately, we only write for you and simply hope that you enjoy it. Sincerely, Simin Gharib Lee and Michael Henderson Editors-In-Chief

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Medication for Every Nation: Changing University Access Policies Jenny Chen, Staff Writer

ince the advent of the internet, the open access model of publication distribution has emerged as a serious contender in the battle over how the next generation of scientists will share their findings. The definition of open access publishing that is most often used is known as the Bethesda Statement on Open Access Publishing. It states that authors and copyright holders will deposit their work into open online repositories and grant universal access rights to their work, as well as the right to copy, republish, redistribute, and create derivative works as long as the authorship is properly attributed.1 While the debate has raged on, proponents of the open access model have long called on universities to be the first to commit to the model. In response, on February 12, 2008, Harvard became the first university in the United States to mandate the open access policy in its Faculty of Arts and Sciences. Since then, the Harvard Law School, the Harvard Kennedy School of Government, and the Harvard Graduate School of Education have adopted similar policies. Leading the crusade for more accessible scientific dialogue is Dr. Stuart Shieber, a Harvard professor of computer science. “The goal here is twofold,” says Shieber. “First of all, to make sure that there is the broadest possible dissemination of the work of the faculty and research at Harvard, and secondly, to help scientists everywhere to research as broadly as possible.”

Critics of Harvard University’s open access policy cite that there is no true mandate on Harvard-affiliated authors. The university’s policy stipulates that faculty members and researches at Harvard must grant the rights to their publications to Harvard and deposit their papers into open depositories. However, authors may petition for the rights to a particularly paper by writing to the Dean.2 However, Professor Shieber points out that Harvard’s open access policy

“You just can’t do research if you can’t read the literature” is the first rights retention policy at a major academic institution in the United States that uses an “opt-out” system rather than an “opt-in” one, which has been shown in various decision-making studies to be far more effective at retaining participants.3 Proponents claim that the need for open access publications in universities stems from the soaring subscription costs that consume the dwindling budgets of even the largest academic libraries.4 In light of the recent recession, Harvard College Library has been selective on its subscription renewals, forced to cancel print subscriptions to a variety of publications.5 If these prices have become problematic for a university as well endowed as Harvard, it is not difficult to imagine that they could bar access to new literature for re-

searchers in universities of less affluent nations. “You just can’t do research if you can’t read the literature,” Professor Shieber laments. The history of open access can be traced by to early days of the internet and the emergence of the first preprint service online in 1991 called arXiv. Significant attention was not drawn to the issue until later in 1998 when the Scholarly Publishing and Academic Resources Coalition was founded – a group that advocates strongly for alternative communication strategies between academic researchers.5 Soon after, online efforts to generate open access communities resulted in the development of new open access projects. Dr. David Lipman, the director of the National Center for Biotechnology Information (NCBI) was there when the NCBI began experimenting with database integrations, which resulted in Pubmed – a citation and abstract archiving database. Soon after, Pubmed Central came about as a digital archive of abstracts and full-length papers available free on the internet – a precursor to the modern online open access journal. Dr. Lipman stresses, however, that “Pubmed Central is not open access. Readers often confuse open access with public access. Open access means content that can, except for commercial distribution, be used in any way.” In contrast, public access journals like Pubmed Central allow researchers to read the work while they cannot necessarily redistribute

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global health review it or reproduce it for other purposes.6 “However, what we have done is shown that this kind of [system] can be done cost effectively,” says Dr. Lipman. Forerunners like Pubmed Central “are part of the equation, but only a part. The other part is the scientists and the universities themselves,” he stresses. As a part of this initial push, Nobel Prize winner, former NIH director and current President of the Memorial Sloan-Kettering Cancer Center, Dr. Harold Varmus co-founded the Public Library of Science (PLoS) – the largest open access journal in the world. Dr. Varmus agrees with Dr. Lipman that there are many who criticize the financial viability of the open access business plan. “Many people say that the business model won’t work,” Dr. Varmus says. “PLoS and BioMedCentral [an open access publisher in the United Kingdom] have proved that it does work. PLoS is now breaking even.”7 In addition to criticisms regarding the financial sensibilities of the open access model, opponents have argued that the model will actually inhibit the dissemination of information, as it often requires authors to pay the publishing costs. While Professor Shieber of Harvard concedes that that “sometimes there’s a fee in an open access journal,” he also notes that, “in general there’s no fee to post to, for example, the arXiv. So there’s no impediment to making articles available.” What is more compelling is that open access publications charge a median publication fee of zero dollars, points out Professor Shieber: “More than half of the journals don’t charge author fees. Only about 25% charge author side fees. In contrast, more than half of closed journals charge author side fees. What the subscription journals say is that if you can’t afford

the fees, we will waive the fees. But so do the open access journals.” In fact, in Harvard’s implementation of the open access compact, the fund constructed to pay open access publishing fees only covers journals that waive this fee to those that cannot afford to pay, he says. There are various other problems that stand in the way of immediately implementing the open access model of publication. However, from Dr. Harold Varmus’ perspective, there looms a larger obstacle than these criticisms. “The biggest obstacle right now is an obstacle that faces any kind of new journal and that obstacle is deeply embedded at Harvard and every other institution. And that is that people in the sciences continually use a false metric in analyzing the success of a researcher and that false value is dependent on the success candidates have had in publishing in ‘high impact journals.’” That is inherently different from using questions like “what has this person done” or “how important is their impact on science,” Dr. Varmus emphasizes. In terms of the implications of open access publishing for global health issues, Professor Shieber recognizes that we do not even need to leave the first world country to understand that research is currently inaccessible to those unaffiliated with large, well-endowed academic institutions.

“Speaking even in the first world country, most of the people within the United States are not within the scope of a major research library,” Professor Shieber reminds us. “Patients who need to read studies about the effectiveness about certain medical treatments that they are considering cannot get the information they need unless they’re attached to an institution like Harvard.” In short, the open access publishing movement hopes to expand communication of scientific research to all those who need it, whether it be researchers at a neighboring East Coast institution, doctors in third world countries or patients on the West Coast. In this movement, “universities should have and can have a leading role,” says Dr. Lipman. With optimism, Professor Shieber responds that Harvard appears ready to play a leading role. “At Harvard, we want to broaden the open access policy to more faculties. We would like to make sure that certain types of student writings are available, especially dissertations and theses. We are active in helping other universities with thinking about open access and working towards their own solutions.” “There is no one thing that will solve the problem,” says Professor Shieber. “We have to be responsive to how things change over time.” And Harvard can help lead the way.

1 Suber, Peter. “Bethesda Statement on Open Access Publishing.” Earlham College Earlham College, 20 June 2003. Web. 1 Oct. 2009 <http://www.earlham.edu/~peters/ fos/bethesda.htm>. 2 “Harvard Open-Access Policies.” Harvard University Library Harvard University, 2008. Web. 1 Oct. 2009 <http://osc.hul. harvard.edu/OpenAccess/policytexts. php>. 3 Shieber, Stuart. Personal INTERVIEW. 7th October 2009. 4 Albert, Karen. “Open access: implications for scholarly publishing and medical libraries.” Journal of the Medical Library Association 94.3 (2006): 253-62. Web.

PubMed Central. 1 Oct. 2009 <http://www. pubmedcentral.nih.gov/articlerender. fcgi?artid=1525322#i1536-5050-094-030253-b1>. 5 “Changes in Programs and Services: Journal Subscriptions.” Harvard Faculty of Arts and Sciences: FAS Planning Open access: implications for scholarly publishing and medical libraries. Harvard University, 11 May 2009. Web. 1 Oct. 2009 <https://planning. fas.harvard.edu/c/index.html>. 6 Lipman, David. Personal INTERVIEW. 5th October 2009. 7 Varmus, Harold. Personal INTERVIEW. 6th October 2009.

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Inequality in a Global Pandemic Response Justin Banerdt, Staff Writer

s the flu season arrives in the northern hemisphere, governments are preparing for a resurgence of the H1N1 pandemic as they rush to produce vaccines. Questions remain though as to whether there will be enough vaccine stock, whether will it arrive in time, and if there is a shortage, who will have access. These questions are even more disconcerting for developing countries that likely will not have the resources to vaccinate the majority, and in some cases even minority, of their population. In what is a sobering take on history, the last time the United States government dealt with the H1N1 flu in 1976 resulted in an immunization campaign riddled with difficulties. The most fundamental of these was a striking disconnect in communication between the general populace and high-ranking health officials when a handful of vaccinated patients developed Guillain-Barré syndrome. This led to widespread panic about the safety of the vaccine. These incidences of Guillain-Barré syndrome would later prove to be unrelated to the vaccine.1 Recently several representatives from the Centers for Disease Control (CDC) have publicly affirmed the safety of the vaccine. Dr. Melinda Wharton MD, Acting Director for the National Center for Immunization and Respiratory Diseases, commented in an interview with the HCGHR that “the new H1N1 vaccine that is just now being distributed is being made exactly same way as the

seasonal influenza vaccine that we use more than a 100 million doses of each year and that vaccine has an excellent safety record.”14 This reassurance has not stopped several advocacy groups and concerned parents from continuing to raise questions.7 There still appears to be a notable divide in the public knowledge and opinion on the matter. By now, the southern hemisphere has already experienced its flu season, and our best way to understand the dynamics of such antiviral campaigns lies in the experiences of these countries such as Australia, Argentina, Chile, and New Zealand. Recent data shows that the viral strains and at risk populations were similar to that of the US. Dr. Stephanie Bailey MD, the Chief of Public Health Practice at the CDC, who has been involved in state and local preparedness to the pandemic, confirmed to the HCGHR that the CDC’s “vigilance takes into account the whole world.”13 It is now evident that their flu season was of comparable length to

previous seasons and that, although health care centers experienced additional stress, this was neither prolonged nor overwhelming. Additionally, the virus seems to have mutated little, bolstering hope that the current vaccine in development will be effective.4 Dr. Wharton predicts that “If the virus evolved I would expect that that evolved strain could be included in our seasonal vaccine for next year.”14 With new H1N1 cases spreading rapidly throughout the States5, some are beginning to raise concerns that the vaccine is yet to be available to the general public. The US has purchased 250 million doses of the vaccine, enough for most of the populace, but distribution is not set to begin until October8, already well into the flu season. Several other countries such as China, Australia, France, and Britain have been independently working on vaccines, with the world production capacity estimated at roughly 3 billion doses per year—less than half of the world’s total population

Photos courtesy of FLU.gov

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global health review and 1.9 billion less than previous estimates. A total of nine countries so far including the United States have pledged to share their vaccine stocks with developing countries that have little to no access.9 While White House spokesmen Reid Cherlin promised that there would be enough vaccine for every US citizen that wanted to be vaccinated, the reality is that in a global context there exists a significant disparity between those in developing nations that have access to vaccination and those in developed areas.10 According to a recently proposed United Nations plan, only 5-10% of the population in poor countries will be vaccinated in the coming season, with an additional $1.48 billion in aid for antiviral drugs such as Tamiflu that can slow the spread of the virus. Eighty-five of the 195 member states of the WHO have stated they have no vaccine supplies.11 Dr. Wharton points out, however, that “that the burdens associated with seasonal and pandemic influenza certainly need to be considered in the context of other health issues some of which in a global context may be a higher priority in other countries than this one is.”14 Director-general of the World

Health Organization Margaret Chan has raised concerns about the likelihood of regions with endemic disease being especially hard hit by the virus.11 While the virus is rarely fatal in healthy populations, immuno-compromised individuals could experience vastly higher mortality rates. This has already become apparent in countries such as Australia where the aboriginal community’s infection rates are higher than that of the general population.12 While the aboriginal population is small, other wealthy nations have significantly larger low-income and disadvantaged populations with unequal access to health care services. Dr. Bailey told the HCGHR that “the risk factors from chronic disease to STDs, to poverty, to environmental factors are all part of our surveillance so that when we give our vaccine information cautions and our protocol it takes that into mind.”13 The fact that agencies such as the CDC are directing attention to these risk groups creates hope that impoverished and diseased populations will gain better access to healthcare, especially during a pandemic. In developed countries, priority will be given to pregnant women,

health care workers, people under the age of 24, and to those who are older and have chronic health issues.8 This list does not, however, include several impoverished groups that should be deemed as risk groups based on experiences of nations in the southern hemisphere. Dr. Wharton informed us that the WHO “is working to ensure the donated vaccine are distributed where they are most needed.”14 The H1N1 virus is predicted to stay in a relatively mild form that will not significantly increase the mortality rates of this year’s flu season.3 Nevertheless, the WHO has classified this as a global pandemic, and the world’s response must be viewed in this context. With delayed production schedules and disparities in global access to the vaccine, the H1N1 virus provides governments with a valuable chance to reconsider and better control pandemic policy and health systems before another more deadly virus arises. As Dr. Bailey concluded, it is important to realize “what we can control and what we cannot control.”13

1 Neustadt, Richard and Fineberg, Harvey. The Swine Flu Affair: Decision-Making on a Slippery Disease. Department of Health, Education, and Welfare Report: 1976. <http://www.nap.edu/catalog.php?record_ id=12660> 2 Haskell, Meg. “Officials tout safety, efficacy of H1N1 vaccine.” Bangordailynews.com. 25th Sept. 2009. <http://www.bangordailynews.com/detail/122422.html> 3 “H1N1 virus not mutated, vaccine still works.” The Med Guru. 26th Sept. 2009. <http://www.themedguru.com/20090926/ news/h1n1-virus-not-mutated-vaccine-stillworks-86128351.html> 4 “Assessment of the 2009 Influenza A (H1N1) Outbreak on Selected Countries in the Southern Hemisphere.” Flu.gov. Aug. 2009. <http://www.flu.gov/professional/global/ southhemisphere.html> 5 Simmins, Charles. “Swine Flu Continues to Spread in United States.” Examiner.com.

26th Sept. 2009. <http://www.examiner. com/x-18444-Rochester-Infectious-DiseaseExaminer~y2009m9d26-Swine-Flu-continues-to-spread-in-United-States> Alan, Reed. “Vaccine concerns increase.” Willston Herald. 21st Sept. 2009. <http://www. willistonherald.com/articles/2009/09/21/ news/doc4ab7a9547a040396298984.txt> Boyd, Leah. “Vaccine Raises Safety Concerns.” Livingston Daily.com. 27th Sept. 2009. <http://www.livingstondaily.com/ article/20090927/NEWS01/909270323/-1/ NEWSFRONT2> Sweet, Lynn. “Free H1N1 Flu Vaccine for Everyone in the Country.” Politics Daily. 25th Sept. 2009. <http://www.politicsdaily. com/2009/09/25/free-h1n1-flu-vaccinesfor-everyone-in-the-country/> “H1N1 vaccine production far less than forecast: WHO.” Reuters. 18th Sept. 2009. <http://www.reuters.com/article/healthNews/idUSTRE58H1N120090918?pageNu

mber=2&virtualBrandChannel=11604> 10 “UPDATE 1-Rich countries to share some swine flu vaccine.” Reuters. 17th Sept. 2009. <http://www.reuters.com/article/ marketsNews/idUSN1756571620090917> 11 “A(H1N1) may have ‘damaging consequences’ for poor.” Business Mirror. 21st Sept. 2009. <http://businessmirror.com. ph/home/world/16301-ah1n1-may-havedamaging-consequences-for-poor.html> 12 “Aborigines at high H1N1 flu risk.” The Associated Press. 24th June 2009. <http:// www.news24.com/Content/World/News /1073/567ce519ea8e471dbd0616035cc9 cd47/24-06-2009-01-00/Aborigines_at_ high_H1N1_flu_risk> 13 Bailey, Stephanie B. Coursey. Telephone INTERVIEW. 29th Sept. 2009. 14 Wharton, Melinda. Telephone INTERVIEW. 6th Oct. 2009.

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Battle in India: Novartis, Gilead and Generic Drug Production Hemali Thakkar, Staff Writer

s the prices of drugs increase, it is becoming more difficult for those living in the developing world to access generic drugs. One third of the world’s population lacks access to essential medicines, which translates to nearly one half of the population in the poorest regions.1 In recent years, India has become one of the main sources of inexpensive drugs for those living in the world’s low-income regions. Currently, Indian pharmaceutical companies provide two of the world’s most inexpensive therapies for treating HIV/AIDS.1 Drugs manufactured in India cost as little as 1 – 2% of the price of those sold by large pharmaceutical companies, and a recent report on The World Medicines Situation illustrates that this is because “generic competition and differential

A man handles stock at an international drug mart (Wikimedia Commons).

Kesselheim, M.D., J.D. in the Division of Pharmacoepidemiology and Pharmacoeconomics from Brigham and Women’s Hospital.3 With the rapid escalation of the

“[T]hese multibillion-dollar drug companies argued in their 2006 statement to the NGO community that patents ‘save lives by stimulating research’ ” pricing can contribute substantially to the affordability of medicines in lowincome countries.”2 As a result, India’s cheap drug production makes drugs such as Tenofovir, an antiretroviral drug used to treat HIV, more accessible in resource poor settings. “There are many, many reasons why people are not getting access to essential medicines. [Generic drug production] is just one of the ways people are trying to rectify that imbalance,” says Dr.

middle class in India, pharmaceutical giants are ruthlessly trying to tap into this market by filing as many patents as possible on slightly modified forms of existing drugs.3 Section 3(d) of India’s Patents Act, enacted to safeguard public health, presents these companies with the biggest obstacle in their profit-seeking venture. In March 2005, India enacted Section 3(d) to curtail the ability of pharmaceutical giants from extending their patent rights on treat-

ments that “do not result in increased efficacy” beyond a 20-year period by simply making small adjustments to already-known medicines.4,5 Not surprisingly, Swiss and US pharmaceutical giants Novartis and Gilead both challenged India’s Patent Act, Section 3(d) after having their patent applications for their respective drugs rejected by India’s Patent Office.6 Novartis and Gilead’s patents for already existing forms of treatment have led to a massive upheaval of response in the international health community. Protesters harshly criticized Gliead’s patent for Tenofovir and Novartis’s patent for Gleevec, a drug used to treat chronic myeloid leukemia because both drugs consist of alreadyknown substances and are not patentable under Section 3(d). In response to such protests, these multibillion-dollar drug companies argued in their 2006 statement to the NGO community that patents “save lives by stimulating research.”7

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Photo courtesy of Wikimedia Commons

Nevertheless, according to the world’s leading independent medical aid organization, Médecins Sans Frontières, “granting the patent would set a dangerous precedent,” thereby further limiting access to drugs in resource poor areas.8 The knowledge-action gap, which refers to the gap between our knowledge of disease and the implementation of that knowledge for the design and production of health systems, is widening. “There are problems with even getting the cheapest generic drugs to people who need them,” asserts Dr. Kesselheim.3 As a result, the number of drugs capable of treating global illnesses is increasing while access to such drugs in these resource-poor settings remains extremely limited. Gilead slyly attempted to combat its patent challengers by providing voluntary licenses to these generic drug production companies in India. In return, these Indian companies were required to withdraw their patent opposition to Gilead and give the company exclusive rights to a drug that was not patentable under Indian law.5 Gilead’s voluntary licenses have limited the sale of the drug to only India, allowing Gilead to maintain its competitive edge in markets in other parts

of the world while preventing access to cheap versions of the same drug to those regions. The conflict between large pharmaceuticals and Indian drug companies has united health experts, activists, local Indian pharmaceutical

generic drugs. In August 2006, health activists celebrated the rejection of the Gilead patent challenge by the Madras High Court of India. According to Médecins Sans Frontières, granting the patent to Gilead would have prevented the cheap production of essential drugs until 2016, inhibited future generic drug production, and set a precedent for other pharmaceutical giants to follow suit. 8 With the battle against large pharmaceuticals still raging, India remains the leading generic drug manufacturer of the world, not yet infected by pharmaceutical giants. Nevertheless, the future is still unclear as pharmaceutical companies attempt to maneuver around India’s 2005 Patent legislation. As the WHO claims, “by 2015, over 10 million deaths per year could be avoided by scaling up certain health interventions, the majority of which

“With the rapid escalation of the middle class in India, pharmaceutical giants are ruthlessly trying to tap into this market” companies, and also those living with illnesses such as HIV/AIDS in preventing these pharmaceutical giants from restricting India from mass-producing

depend on essential medicines.”9 The question remains whether India will rise to meet these challenges in the coming years.

1 Ramesh, Randeep. “Drug firms seek to stop generic HIV treatment”. NATAP. October 1, 2009 <http://www.natap.org/2006/newsUpdates/051106_03.htm>. 2 World Health Organization, “The World Medicines Situation”. 2004: 1-145. 3 Kesselheim, Aaron. Telephone INTERVIEW. 24 October 2009. 4 Batty, David. “The battle for cheap Aids drugs”. The Guardian. September 27, 2009 <http:// www.guardian.co.uk/world/2007/may/09/ aids.comment>. 5 Park, Chen. “The Struggle for Affordable Medicnes”. Infochange. September 27, 2009 <http://infochangeindia. org/200703136078/Trade-Development/ Backgrounder/The-struggle-for-affordablemedicines.html>.

6 “The Novartis Case and Access to Affordable Drugs”. Care. September 27, 2009. <http://www.care.org/newsroom/articles/2007/06/20070613_novartis.asp>. 7 Novartis. “An open letter from Novartis regarding the Glivec legal challenge in India”. January 29, 2007. <http://www. maketradefair.com/assets/english/novartisopen-letter-organizations.pdf>. 8 Médecins Sans Frontiéres. “MSF Supports Opposition to Giliead’s Tenofovir Patent Application in India”. October 1, 2009. <http:// doctorswithoutborders.org/press/release. cfm?id=1793&cat=press-release>. 9 World Health Organization. “10 facts on essential medicines”. October 17, 2009. <http://www.who.int/features/factfiles/essential_medicines/en/>.

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Universal Access to Reproductive Health Care and Family Planning Susan Wang, Staff Writer

ccording to the United Nations, in 2008 nearly 536,000 women died worldwide from preventable and treatable child-bearing and pregnancy-related causes. Half of these women live in Africa. In the United States, 1 in 4800 dies from a prenatal or birthing complication. In Liberia, however, the rate of maternal death is 1 in 12. With such startling statistics, it becomes evident that action must be taken in order to increase access to reproductive health care. However, to increase access, both funding and social awareness of health-related issues are needed. Financial challenges are one of the most obvious problems with access and the problem that is on the forefront of every organization dedicated

to increase access. The GDP of all of Sub-Saharan Africa was $744 billion in 20081; for comparison, the state of Florida’s GDP was also $744 in 2008.2 Due to this economic disparity, Sub-Saharan Africa continues to possess wide gaps in accessibility to maternal health care. A quarter

family planning. Furthermore, SubSaharan Africa also suffers from a disproportionate amount of HIV/ AIDS: 22 million people there have HIV/AIDS, which accounts for 67% of those with HIV/AIDS worldwide.3 However, financial challenges are merely the tip of the ice-

Even in the United States, where the GDP is the highest in the world and people are among the richest, universal reproductive health care is not yet attainable of the women in Sub-Saharan Africa claim they prefer to stop having children or delay their next pregnancies but are unable to practice

Photo courtesy of UNFPA

berg. Even in the United States, where the GDP is the highest in the world and people are among the richest, universal reproductive health care is not yet attainable. In an interview with HCGHR, Lisa Maldonado, executive director of the Reproductive Health Access Project, an organization dedicated to training health care professionals about reproductive health care, claimed that part of the problem is that “clinicians are not trained sufficiently in the area of reproductive health. Less than five percent of medical schools are covering reproductive health problems so medical students must take it upon themselves to educate themselves in these issues.”4 Why do problems with providing reproductive health services persist globally? The reason is that besides poverty, other underlying problems are still impeding universal access to reproductive health care.

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global health review One such prominent obstruction is religious beliefs. Female circumcision is a common practice in many Islamic countries: in fact, 80% of girls in north and central Sudan are circumcised. However, the practice of female circumcision has been shown to lead to lifelong reproductive health problems including scar formation, cyst growth, pain during urination, and difficulties with childbirth. Indeed, this contributes significantly to the high maternal mortality rate in Sudan.5 Even in the United States, religious beliefs can hinder women’s access to reproductive health care. Eesha Pandit, Director of Advocacy at MergerWatch, an advocacy group for women’s health care services, commented to HCGHR that in New York, religious hospitals were acquiring secular ones and “in the process of merging, the secular hospitals are obliged by the Catholic directives for health care. Therefore, those hospitals will not be able to provide emergency contraceptives, abortions, information about HIV/AIDS and a whole host of other critically important services for women.”6 Religious obstacles aside, many cultural beliefs also pose problems in the delivery of reproductive health care. Newly-wed wives in India are under considerable pressure from parents and relatives to have children quickly because it is believed that fertility decreases with age.7 These women also receive false information from village doctors that causes them to

mistrust spacing methods such as the pill and Intrauterine Devices, which are contraceptives devices for women similar to condoms for

creative solutions tailored to each individual community or country. Eesha Pandit gives her account of how MergerWatch helped a merger

men.7 This reduces these women’s likelihood of using such methods to space their pregnancies and may contribute to more complications related to pregnancies and childbirths. Around the world, many stigmas persist in obstructing universal access to reproductive health care. Eesha Pandit noted that “abortion services are the only health care service that is both safe and legal in most developed countries that is singled out for exclusion under bills such as the Hyde amendment, which prohibits the use of federal funding for abortion care.”6 Globally, unsafe abortions kill approximately 70,000 women each year. Three million women who experience serious complications from unsafe procedures are left untreated.8 What does this mean for attempts to increase reproductive health care access? As Dr. Yves Bergevin commented to the HCGHR, “medical services must be offered in a way that is socially and culturally acceptable and welcomed in a community.”9 These obstacles may also require

of a secular and religious hospital in New York keep critical reproductive health services for women: “We discovered money available to alleviate the process of this merger and we brought the community together to protest about this issue. Therefore, the hospital ended up keeping the services in the Ambulatory Care building which was in a separate building, so the hospital could still comply with the directive and still keep the services.”6 Indeed, without these creative solutions, dedicated organizations, politicians, and individuals, and sufficient funding, situations such as the one described by Dr. Bergevin may become commonplace. “Women without proper access may seek illegal means of abortive care and die from these unsafe procedures. All of these nightmares that you see in the Bronx that you do not see in Canada will all be multiplied in developing countries, simply because the government does not have enough resolve to have universal access to reproductive health care.”9

1 “50 Factoids About Sub-Saharan Africa.” Africa Development Indicators, 2008. 15 Oct. 2009. Web. http://web.worldbank. org/WBSITE/EXTERNAL/COUNTRIES/ AFRICAEXT/EXTPUBREP/EXTSTATINAFR /0,,contentMDK:21106218~menuPK:8240 80~pagePK:64168445~piPK:64168309~th eSitePK:824043,00.html 2 Gross Domestic Product by State. Bureau of Economic Analysis, 2008. 15 Oct. 2009. Web. http://www.bea.gov/regional/gsp/

action.cfm 3 Gribble, James and Haffey, Joan. “Reproductive Health in Sub-Saharan Africa.” Population Reference Bureau, 2008. 4 Maldonado, Lisa. Personal Interview. 13 Oct. 2009. 5 Gruenbaum, Ellen. “Islam, Gender, and Reproductive Health.” Woodrow Wilson Center for International Scholars. 5 Nov. 2004. Address. 6 Pandit, Eesha. Personal Interview. 15 Oct.

2009. 7 Greydanus, Donald, Senanyake, Pramilla, and Gains, Michelé. “Reproductive Health: An International Perspective.” Indian J Pediatrics: 1999, 415-424. 8 “Abortion and Unintended Pregnancy Decline Worldwide as Contraceptive Use Increases.” Guttmacher Institute, 2006. 9 Bergevin, Yves. Personal Interview. 13 Oct. 2009.

Around the world, many stigmas persist in obstructing universal access to reproductive health care

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global health review

Community-Based Malaria Control in War-Torn Burma Alison Kraemer, Assistant Managing Editor

n the conflict region of Karen State in eastern Myanmar, or Burma, the ruling military junta impedes the provision of vital healthcare to thousands of villagers. Despite an unparalleled prevalence of malaria-related deaths, the Karen State is cut off from any major international malaria programs to aid the marginalized and conflict-worn population. Therefore, the Karen Department of Health and Welfare (KDHW), with assistance from the Global Health Access Program (GHAP), has implemented a Malaria Control Program with the mission of providing the people of conflictworn eastern Burma with access to quality malaria control strategies. This community-based program now provides over 40,000 people in 44 villages with malaria control services based on the World Health Organization’s (WHO) Roll Back Malaria Principles. KDHW was established in 1976 and manages 33 mobile clinics across eastern Burma with primary and emergency healthcare for internally displaced persons (IDPs). However, KDHW faces serious challenges in managing these clinics in the ‘black zones’ of eastern Burma. In these free-fire zones, the Burmese military carries out active conflict with armed opposition groups as well as human rights violations of civilians involving forced labor and forced relocation. Here, the Burmese military also targets clinics for providing health services to the ethnic villagers, regarding the clinic health workers (CHWs)

as accomplices and threats to the Burmese government.1 As a result, KDHW needed to find a new strategy for its Malaria Control Program, which it began in 2003 as a pilot program. The predominance of malaria in the region called for the expansion of skilled human resources with more health workers who could effectively and consistently deliver malaria control services to people in desperate need in the black zones. To fulfill this need, KDHW has employed, surprisingly, the IDPs themselves to be village health workers (VHWs) in their program. Since there are no doctors and few nurses in the conflict regions, KDHW decided to have the CHWs enlist villagers, such as school teachers and retired health workers, to assist with malaria program duties.2 Currently, recruiting and training for the Malaria Control Program

is a more formal process. The CHWs attend healthcare workshops on the Thailand-Burma border to enhance their strategies for diagnosing and treating malaria. They then return to their communities to train their fellow villagers, who have been identified by village leaders, to become VHWs.2 Essentially, due to this “trainingof-trainers” model, the Karen malaria program was able to rapidly expand its services so that, within a few months after its launch, it witnessed a remarkable drop in the percentage of people infected with malaria – from about ten percent to less than four percent.3 “Typically, malaria testing and treatment is carried out in a clinic setting,” GHAP told the HCGHR. “However, this program is designed to have more mobility and increase villagers’ access to services.” The Global Health Access Pro-

Photo courtesy of the Global Health Access Program

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global health review gram (GHAP) is a non-governmental health organization in the United States that gives assistance to its local partner organizations in various countries. In Burma, GHAP provides technical support to KDHW for building the capacity of its communitybased program. GHAP and KDHW encourage the capacity building of IDPs in conflict regions where there exists no option for outside international aid. As members of the communities they serve, the VHWs can make regular house visits to patients. A further benefit is that the health workers can stay with villagers and continue health services when the Burmese military targets civilians and forces them to relocate.4 The VHWs are integral for the incorporation of the WHO’s strategies of early diagnosis and treatment (EDT), vector control with mosquito nets, and education programs. They are primarily responsible for EDT; when patients present a fever, the VHWs test for plasmodium falciparum malaria using a Paracheck rapid diagnostic test that uses a small pinprick of blood.4 If the test is positive, the patient receives a three-day course of first-line treatment. Each screen costs only 62 cents, provides a result in minutes, and is 95 percent accurate. This EDT service demonstrates how new malaria screening technologies can bring strategies previously only available in a laboratory directly to IDPs in conflict areas.5 Furthermore, VHWs make regular house visits to monitor treatment adherence of infected patients. They are trained to recognize more severe patients in need of specialized care and to refer them to the CHWs at the KDHW clinics. VHWs also supervise the use of the long-lasting insecticide treated nets that KDHW makes available to the villagers. If neces-

sary, they distribute Ko-Tabs, which are small tablets of insecticide that, when dissolved in water, can treat or re-treat a simple net. These house

Still, “KDHW faces challenges not only in the field during times of service implementation, but also must overcome obstacles in manag-

Since there are no doctors and few nurses in the conflict regions, KDHW decided to have the CHWs enlist villagers, such as school teachers and retired health workers, to assist with malaria program duties visits further comprise malaria education and treatment data collection for KDHW’s bi-annual surveys. The VHWs receive a small monthly stipend in compensation for their work.6 The VHWs and the CHWs still face many challenges due to the active conflict. Sometimes the health workers have to suspend services if they find out the Burmese military is approaching. They will even hide their medical supplies in the jungle so they do not get confiscated. Despite the lack of cellular phones, internet, and electricity in the conflict zones, KDHW uses satellite phones and courier messaging systems for communication between the main clinics and the field sites. Solar panels and generators provide some power for microscopy and refrigeration of immunizations in the clinics.4

ing supply delivery to the clinics,” GHAP explained to HCGHR. “The terrain inside Karen state is treacherous and they carry all supplies on foot, often through areas known to have landmines.” Despite these barriers, the ability for KDHW to rapidly train IDPs to become VHWs and deploy them to places of intense conflict and, therefore, in danger of a malaria epidemic, has been vital for decreasing malaria’s prevalence in Karen State.7 KDHW has learned that communitylevel care is the only way to access vulnerable, displaced populations. Therefore, the home-based management of malaria is a model GHAP is working to expand to other areas with armed conflict and high rates of malaria.

1 Lee, Catherine, Senior Field Adviser. Smith, Linda, Program Director. Global Health Access Program. E-mail Interview. 16 October 2009. 2 Lee, Catherine. Smith, Linda. Et al. Internally displaced human resources for health: villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma. <http://www.ghap.org/ reports/pdfs/Final%20VHW%20Paper%20 MCP.pdf>. 3 Global Health Access Program. “Annual Report 2008.” <http://www.ghap.org/reports/pdfs/ anual_report2008.pdf>. 4 Lee, Catherine, Senior Field Adviser. Smith, Linda, Program Director. Global Health Access Program. E-mail Interview. 16 October 2009.

5 Global Health Access Program. “Annual Report 2008.” <http://www.ghap.org/reports/pdfs/ anual_report2008.pdf>. 6 Lee, Catherine. Smith, Linda. Et al. Internally displaced human resources for health: villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma. <http://www.ghap.org/ reports/pdfs/Final%20VHW%20Paper%20 MCP.pdf>. 7 Lee, Catherine. Smith, Linda. Et al. Internally displaced human resources for health: villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma. <http://www.ghap.org/ reports/pdfs/Final%20VHW%20Paper%20 MCP.pdf>.

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At a Crossroads in the Battle for AIDS Treatment Sophie Delaunay & Emi MacLean, Contributing Experts

he treatment of HIV/AIDS in developing countries is today at a crossroads. On the one hand, significant progress has been achieved since Médecins Sans Frontières (MSF)/Doctors Without Borders, in the face of considerable skepticism, began treating people in poor countries with antiretroviral therapy almost ten years ago. The international community has mobilized political zeal and financial resources to respond to the pandemic. The World Health Organization (WHO) reports that there are now four million people on AIDS treatment in developing countries.1 The price of medicines has, thanks to the effects of generic competition, plunged—from costs approaching $10,000 to $15,000 per year a decade ago to a year’s treatment now priced at $80.2 Three-inone fixed-dose combinations (FDCs) have greatly facilitated treatment, making it easier for patients and practitioners alike, and enabling scale-up of treatment programs.3 But today this progress is under threat. First, the majority of people in need of treatment still do not have access to it. Six million people are in immediate need, a testament to the persistent emergency.4 Next, there is a growing gap between the AIDS treatment available to people in developed countries where AIDS now largely resembles a chronic disease,5 much like heart disease or cancer - and to those in poor countries. In developing countries, even those fortunate enough

to be on treatment all too often do not have access to the first-line treatment currently recommended by WHO. The most commonly used treatment in the global South remains an older regimen – less expensive, perhaps, but crucially now mostly abandoned in the West because of associated side effects.6 Further, with growing numbers of patients in developing countries having been on treatment for five years or longer, new challenges are emerging to ensure their long-term survival. Over time, patients invariably develop resistance or intolerance to their first line of drugs and need to transition to second- or third-line treatment to survive.7 These newer drugs are significantly more expensive than the most common first-line treatment and thus often out of reach of poor populations and unavailable within public health systems. Moreover, there are drugs and drug combinations that either do not exist or are not formulated to respond to the needs of patients in developing countries. The clearest example of this is pediatric formulations – undeveloped or untested in part due to the limited market for pediatric AIDS drugs in rich countries, where the transmission from mother to child has been successfully contained. As a result, pediatric AIDS has now become almost exclusively a disease of the global South.8 As a final caveat, even the limited successes are in jeopardy as the global financial crisis has provided

cover for both donor countries in the North and deeply affected Southern countries to renege on crucial commitments for universal treatment access, and funding to support it.9 In short, developments over the last decade have demonstrated that it is both possible and necessary for the international community to respond to the devastating humanitarian catastrophe of AIDS. But we must act now: to address the dramatically inflating prices of newer drugs; to remove the barriers related to patents and incentives for drug development standing in the way of crucial innovations that respond to patients’ needs; and to put in place mechanisms that ensure treatment scale-up is made sustainable. The patent pool is one response to these many challenges. A patent pool is a collective management structure for intellectual property to allow for licensing on pre-defined terms. A patent pool for AIDS medicines would allow poorer populations access to currently high-priced, newer and better medicines for first-, second-, and third-line treatment. It would also encourage innovation into new drug combinations, formulations, and indeed new drugs where patent barriers have prevented or delayed such research and development. A patent pool is by no means the only solution: other mechanisms that boost innovation and overcome barriers to access must similarly be embraced. But without a patent pool for medicines, the promise of AIDS treatment for poor populations

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global health review will be extraordinarily limited. AIDS treatment in wealthy countries virtually guarantees a return to a normal life, with available lifetime treatment for a chronic disease.10 Yet without a system to allow affordable access to necessary newer drugs, of which the patent pool is part, people living with HIV/AIDS in developing countries will only have less effective first-line drugs and the promise of a few additional years of life. This discrepancy is both unacceptable and possible to overcome.

Why a Patent Pool Is Necessary For first-generation antiretroviral drugs – most commonly in use in developing countries – the absence of patents in countries with generic manufacturing capacity allowed for competition and resultant dramatic

with generic production capacity and an industry directed in part towards the needs of developing countries – India and Brazil most prominently – are now mandated to grant 20-year pharmaceutical patents. During the patent term, generic companies cannot produce the same medicines at competitive prices and the originator company can market the drug wherever it is patent-protected at inflated monopoly prices. The effect of the patent protection of newer drugs is markedly apparent. The WHO-recommended first-line, if purchased from the originator companies, costs almost 13 times more than the most commonly used first-line regimen.13 In some countries, a second-line regimen can cost 17 times more than the firstline regimen.14 A third-line regimen

entry into the marketplace of products that would rely on intellectual property held by different parties. Patent pools are, for example, widely used in technology fields dependent on uniform standards, such as radio and DVD technology.19 A patent pool was previously established by the U.S. government to ensure access to airplane technology when the patents exclusively held threatened to undermine access to this crucial technology in wartime.20 For an AIDS medicines patent pool to function, companies, researchers and universities would voluntarily license the patents on their inventions to the pool for use in developing countries. The pool would then act as a “one-stop shop” for multiple patents, from which any company or entity could obtain a

Developments over the last decade have demonstrated that it is both possible and necessary for the international community to respond to the devastating humanitarian catastrophe of AIDS price reductions. This provided the catalyst for scale-up of programs to reach many more in need. For instance, Indian generic pharmaceutical companies are estimated to provide 80 % of the first-line AIDS drugs in use by MSF in sub-Saharan Africa and nearly 60 % of all the drugs used in PEPFAR programs in 2007.11 The lowest price for the most commonly used FDC (stavudine, lamivudine, and nevirapine produced by an Indian generic pharmaceutical company) is $80 per patient per year.12 Yet today, we can’t expect generic competition to come to the rescue as it did ten years ago. The widespread implementation of the World Trade Organization TRIPS Agreement (Trade-Related Aspects of Intellectual Property Rights) presents barriers to generic competition. Countries

at the originator price costs 28 times more than the first-line regimen at generic price.15 The high prices of newer drugs, preventing access in poorer countries, can be overcome through various mechanisms, including the restriction of patentability criteria16; and the use of TRIPS flexibilities, including compulsory licenses.17 A voluntary patent pool, such as the one being developed by the international drug financing agency UNITAID, is another such way to increase access to necessary drugs in developing countries.18

How a Patent Pool for AIDS Medicines Would Operate Patent pools have been used in various industries to ensure that patent barriers do not prevent the

license under established and uniform licensing terms. This would include the payment of a royalty to the patent holder, ensuring originator companies still get rewarded for their innovations. It provides an alternative to complex negotiations and litigation over patent rights. Companies could produce generic versions of the patented drugs for export to countries covered by the license, and thus bring the price of medicines down. Populations in low and middle-income countries would have access to affordable drugs closer to the time of their invention and would not be required to wait 20 years for generic companies to produce affordable versions – a luxury that people living with HIV/AIDS do not have.

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global health review Companies and researchers would also be able to pursue follow-on innovation on existing drugs â&#x20AC;&#x201C; for instance, by combining different drugs owned by different patent owners into much needed new FDCs which are easier for patients to take, which can enhance adherence, improve health outcomes and reduce the risk of resistance; or by developing pediatric versions of drugs already developed for adults. Thus, a patent pool for AIDS medicines would enable necessary innovation responsive to the needs of developing countries as well as generic competition prior to the end of the patent term.

A Patent Pool, But Not at Any Cost

In order for a patent pool for AIDS medicines to be effective, cer-

tain conditions must be met. First, the right drugs must be included within the pool, including the newest and most effective drugs necessary as a first-, second-, or third-line response to HIV/AIDS. A pool with only outdated or insufficient drugs does not serve the intended purpose of the collective management structure and the needs of patients. Further, a pool must have both lowand middle-income countries within its geographic scope. This is essential as income disparities deprive poor people in middle-income countries of essential medicines unless generic competition forces further price reductions. It is also essential in order to ensure that there are sufficient economies of scale to make generic manufacturing attractive and effective. UNITAID has agreed in principle

to the establishment of a patent pool for AIDS drugs.21 Based on our work providing AIDS treatment to more than 140,000 patients in over 30 developing countries, MSF has identified 21 patent-protected drugs and combinations thereof that are necessary for the long-term survival of our patients: lopinavir, ritonavir, didanosine, atazanavir, tenofovir, embricitabine, GS-9350, elvitegravir, efavirenz, raltegravir, maraviroc, SPI-452, darunavir, etravirine, rilpivirine, nevirapine, tipranavir, lamivudine, abacavir, fosamprenavir, and S/GSK 1349572. These drugs are either newer first-, second- or thirdline drugs22, or promising drugs that are in the pipeline in clinical trials.23 These medicines are in use or expected to be in use in rich countries. They are necessary to save the lives of patients for whom existing treat-

Photo by Tibor KĂĄdek (Wikimedia Commons)

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global health review ment lines are no longer effective. Their availability in poor countries must not be denied because of inability to pay monopoly prices. On September 30, 2009, MSF launched an e-mail writing campaign calling on Abbott Laboratories, Boehringer Ingelheim, Bristol-Myers Squibb, Johnson & Johnson, Gilead Sciences, GlaxoSmithKline, Merck & Co, Pfizer, and Sequoia Pharmaceuticals to meet the promise afforded by this mechanism and put their identified drug patents in the UNITAID pool.24

tries. People living with HIV in poor countries must not be forced to wait on borrowed time they do not have for lifesaving drugs that are priced out of reach.

The introduction and scale-up

of antiretroviral treatment in developing countries made possible by international donors and national governments have allowed people to live longer and have a better quality of life.25 At this critical juncture, however, commitment to universal access must be maintained – and the tools and policies must be available to ensure that the promise of universal access is not undermined by monopoly prices of newer drugs. A patent pool for AIDS medicines is one such mechanism to ensure further innovation and sustainable access to newer medicines necessary for the long-term survival of HIVpositive people in developing coun-

1 WHO Progress Report. 2009. Towards universal access: scaling up priority HIV/ AIDS interventions in the health sector (September 30): 53, http://www.who.int/ hiv/pub/2009progressreport/en/index. html, http://www.who.int/hiv/pub/tuapr_2009_c4_en.pdf. 2 Ibid at 74-76. 3 FDCs combine multiple drugs into a single pill. 4 WHO HIV/AIDS data and statistics. 2008. Coverage and need for antiretroviral treatment (ART): Estimated number of people receiving ART, needing ART and percentage coverage in low- and middle-income countries according to region (December), http://www.who.int/hiv/data/coverage2008/en/index.html. 5 The Antiretroviral Therapy Cohort Collaboration. 2008. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet, 372, no. 9635 (July 26): 293-299, http:// www.thelancet.com/journals/lancet/article/ PIIS0140-6736(08)61113-7/fulltext. 6 WHO Recommendations for a Public Health Approach. 2006. Antiretroviral Therapy for HIV Infection in Adults and Adolescents in Resource Limited Settings: Towards Universal Access (August 7), http://www.who.int/ hiv/pub/guidelines/adult/en/index.html. 7 WHO Progress Report. 2009. Towards universal access: scaling up priority HIV/ AIDS interventions in the health sector (September 30): 68, http://www.who.int/ hiv/pub/2009progressreport/en/index. html, http://www.who.int/hiv/pub/tuapr_2009_c4_en.pdf. 8 WHO, Paediatric HIV data and statistics. Percentage of children receiving antiretroviral therapy in low- and middle-income coun-

tries, 2005-2008, http://www.who.int/hiv/ topics/paediatric/data/en/index.html. 9 The Global Fund to Fight AIDS, Tuberculosis and Malaria faces a shortfall of at least $ 3 billion in 2010. This severe funding shortfall places at great risk proposals to scale up treatment—with both the current round of proposals and future rounds in jeopardy. The U.S. government’s bilateral President’s Emergency Plan for AIDS Relief (PEPFAR) has reported stagnating funds for global AIDS, including for treatment. National governments have downsized ART coverage goals in Swaziland, South Africa, Botswana, and Tanzania. 10 The Antiretroviral Therapy Cohort Collaboration. 2008. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet, 372, no. 9635 (July 26): 293-299, http:// www.thelancet.com/journals/lancet/article/ PIIS0140-6736(08)61113-7/fulltext. 11 Lueck, Sarah. 2008. Generics Fuel AIDS Program. Wall Street Journal, 31 July, http://online.wsj.com/public/article/ SB121746894789699503.html 12 MSF Access to Essential Medicines Campaign. 2009. HIV/AIDS treatment in developing countries: The battle for long-term survival has just begun (July): 2-4, http:// doctorswithoutborders.org/publications/reports/2009/msf_hiv-aids-treatment_battlefor-long-term-survival.pdf. (13) Ibid. (14) Ibid at 4. (15) Ibid. 13 (16) TRIPS Art. 27. 14 (17) TRIPS Art. 31; Musungu, Sisule and Cecilia Oh. The use of flexibilities in TRIPS by developing countries: can they promote access to medicines? Commission on Intellectual Property Rights, Innovation and Health (CIPIH) Report Study 4C.

15 (18) All-Party Parliamentary Group (APPG) on AIDS. 2009. The Treatment Timebomb (July); Political activism needed for patent pools for HIV drugs. 2009. The Lancet. 2009. Editorial 374, no. 9686 (July 25): 266. 16 (19)See, e.g., KEI. 2007. Collective management of intellectual property – the use of patent pools to expand access to essential medical technologies (January 23). 17 (20) US Patent and Trademark Office. 2000. Patent Pools: A Solution to the Problem of Access in Biotechnology Patents? (December). 18 (21) UNITAID. The Medicines Patent Pool Initiative (factsheet), http://www.unitaid. eu/en/Patent-pool-resources.html. 19 (22) Newer drugs, such as raltegravir, etravirine and darunavir are part of treatment recommendations in developed countries. Patent barriers and high prices make them virtually unavailable for poor populations. 20 (23) New medicines, still in development, such as rilpivirine, have the potential to be co-formulated, low-dose and affordable and can be used either in treatment-experienced or naïve patients. Also, new booster medicines such as GS-9350 and SPI-452 are needed to avoid the current monopoly by one company on ritonavir. 21 (24) MSF Campaign for Access to Essential Medicines. Make It Happen Campaign, http://www.msfaccess.org/main/accesspatents/make-it-happen-campaign/. 22 (25) Van Cutsem G, et al. 2007. Clinical Outcomes and Emerging Challenges after 5 years of ART in Khayelitsha, South Africa. 14th Conference on Retroviruses and Opportunistic Infections [abstract 535]; Bendavid E. and J. Bhattacharya. 2009. The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes. Annals of Int Med 150, no. 10 (May 19): 689.

Conclusion

Sophie Delaunay, M.I.B., M.A. Executive Director of Médecins Sans Frontières (MSF) / Doctors without Borders USA, and Emi MacLean, US Director for the MSF Campaign for Access to Essential Medicines

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global health review

Beyond Good Intentions Dr. Mathew Craven, Contributing Expert

n unfinished mural covers part of the end wall of Silela Primary School in Tanzania’s Monduli District. The mural shows the beginnings of a public health message, depicting the left side of a woman teaching her children to wash their hands. The outline of the right was originally traced in charcoal and pencil, but it was never painted in, and successive wet seasons have washed it away. The half-mural was drawn by a group of American volunteers – high school students who arrived with much energy and left four days later when their schedule called them away, but before they finished painting. Vague promises were made about returning to finish another time, but the group has never been heard from again. Other volunteers have since come and gone, but the new groups had little interest in finishing someone else’s mural. The image has faded into the landscape of the village, a vague reminder of the difference between the promise and reality of development. A half-finished paint job may seem harmless, but volunteering is not always so benign. Pre-medical students sometimes choose clinical experiences in developing countries because they expect to be allowed greater autonomy than they would in hospitals back home. This expectation is often realized, and while it may lead to more freedom for students, the tradeoff is sometimes in lower quality care for patients. Delivering a baby unsupervised may sound exciting to a student, but not to a mother with a post-partum hemorrhage or perineal tear. More common than

volunteer work causing direct harm are projects that waste time or repeat prior mistakes. Many students find experiences that sound good on paper, but provide them with little meaningful work to do when they arrive in the field. Alternatively, volunteers might spend weeks or months working on a project that is doomed to fail by an obstacle that someone with more experience or knowledge of local culture would have foreseen. Half-finished projects and unfulfilled promises are not costless. Even aside from wasted resources, developing world communities understandably become wary of partnering with well-intentioned foreigners when previous projects have yielded little discernable benefit. Ivan Illich was an Austrian philosopher and vocal critic of the work of American volunteers in Latin America during the Vietnam Era. In 1968 he gave a speech titled, “To Hell With Good Intentions” excoriating the work of a group who were vol-

unteering in Mexico. More broadly, Dr. Illich campaigned to “obtain the voluntary withdrawal of all North American volunteer armies from Latin America - missionaries, Peace Corps members and groups like yours, a ‘division’ organized for the benevolent invasion of Mexico.” He argued that volunteers were “agents of American culture,” spreading ideas that were unwelcome and counterproductive, and doing so in a lazy and haphazard manner. Many of the arguments put forward in “To Hell With Good Intentions” can be dismissed as Vietnam era specific. Nevertheless, the speech is a worthwhile read for all prospective international volunteers. It serves as a reminder that regardless of our intentions, our work should be judged on the final outcomes for the communities we aim to assist. Without using Dr. Illich’s rhetoric, professionally staffed development organizations are often wary of volunteer groups because of their

Photo by Fanny Schertzer (Wikimedia Commons)

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global health review uncertain skills, perceived lack of follow through, and poor understanding of local communities. There is some hypocrisy in this view, since many of the expatriate professionals staffing those organizations got their start through a volunteer experience of some kind. Most would admit that they knew little about local culture when they started, and became better at their work over time through hands-on experience. Partners in Health was started when its founders saw the consequences of poverty and social injustice firsthand. While their academic training was important, they did not just hear about Haiti in a classroom or read about it in a book. Even amongst those working for improvements in global health through advocacy or basic science in their home countries, many acknowledge that their early field experiences were career shaping. It should be noted that this essay focuses on the work of people from rich countries who travel to the developing world to volunteer. Many successful health programs in Africa are run by local people, for local people, and many others view the eventual transfer of authority to the community as a goal of their work. Nevertheless, our current paradigm of global health funding and programming assumes that intervention from outsiders is often necessary to tackle difficult problems. As long as we continue with this interventionalist model, the skills of those who implement programs will be relevant. With this caveat, introductory field experiences are important in the development of leaders for global health and development. However, the examples above illustrate ways in which current models risk harm to individuals and communities in the developing world.

the impact that volunteers can have during a short experience, but the training provided is often cursory and such companies usually employ no field staff beyond those needed to manage volunteer logistics. Unsurprisingly, most participating students achieve negligible lasting impact (or

Whatever the long-term benefits, it is morally repugnant to subject the world’s most vulnerable people to the short-term risk of harm in order to provide someone with an educational experience the need to train the next generation of doctors, but society views it as unacceptable that medical students harm individual patients as they practice their skills. Our solution in medicine is an apprenticeship model, through which student doctors learn their craft under the close supervision of a formally structured team. After graduation, students become residents with more autonomy, but still act under the supervision of an attending physician. The attending is an experienced clinician who bears ultimate responsibility for patient outcomes, and has an explicit mandate to teach the more junior members of the team. Few experiences in global health work like this. Whereas the attitude in medicine is that students should be taught, supervised, and gradually encouraged to take on more responsibility, many global health programs require that students learn on the job with minimal training and little supervision. The most striking examples are often seen with international volunteering companies, many of which exist only to provide experiences for their customers. Their program marketing materials play up

worse, a negative impact) and learn less than they would through a wellmentored project. Plenty of exceptions to this paradigm exist, but there are far too many low quality international volunteer programs, and it is hard for students to distinguish the good from the bad. Few universities offer field experiences in developing countries, so students are forced to look beyond their campuses and find placements of variable quality, often with volunteering companies using the model described above. University funding mechanisms sometimes make student choices still harder by offering grants to those who independently create their own international experiences, but not covering participation in structured servicelearning programs. Factoring in travel, insurance, and living expenses, many summer volunteer experiences cost more than $5,000. In the world’s poorest countries this is more than enough to pay a local person’s salary for five years. Even ignoring the benefits for the local economy of creating jobs, there are few tasks undertaken by undergraduate volunteers during a

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global health review summer than cannot be done more effectively and efficiently by local people. Locals don’t face a language or cultural barrier and have much greater long-term investment in their communities. So even when they do good work, it is impossible to argue that international volunteers are a cost-effective solution to problems in the developing world. Given this, the best justification for international volunteering is as an explicit investment in the future. Field experiences must be structured so that target populations are protected from any negative impact, but we should recognize that the main beneficiaries, at least in the shortterm, are the students participating. It is both dangerous and self-defeating to pretend that student volunteers alone will have a significant impact on complex development problems. The danger arises from the possibility of harm to communities when students are inadequately trained and supported, and in such situations we lose an opportunity to better develop volunteers as future global health professionals. In my opinion, volunteer experiences should be explicitly focused on the development of those participating and well integrated with sustainable development programs. Those leading them must recognize their educational mandate as well as their responsibility to protect communities from harm. I believe the most effective way to operationalize this model of volunteering is through partnerships between academic institutions and non-governmental organizations (NGOs). Universities are best placed to provide the educational component of programs, through pre-travel preparation, sending faculty to the field and following-up after students return home. In this way they can integrate field experiences with broader pro-

grams of study. To complement this, reputable NGOs can offer meaningful field experiences whose content is part of an ongoing project. They are also able to provide students with exposure to their staff, who can mentor program participants. Partnerships of this kind would recognize that it is in the long-term interest of both universities and NGOs to invest in the training of the next generation of global health professionals. Despite the explosion of interest in global health among students during the past decade, most universities still view providing field experiences in developing countries to be too difficult or beyond their mandate. Many of the logistical challenges can be solved through partnerships with established NGOs, who are often experts in operations and supporting staff in the field. U.S. universities have long offered overseas experiences in the developed world as part of an integrated course of study. By doing the same for students interested in global health they can help to both improve quality through better training and equalize access to opportunities in the field. Fees and travel costs often put existing programs beyond the reach of lowerincome students. Institutionalizing global health training would make it easier for universities to offer financial aid, with the added benefit that careers in global health would become more open to all students, regardless of income. Partnerships of this kind have significant potential benefits for NGOs as well, and overcoming the practice within many organizations of shunning volunteers is a worthwhile investment in their own future. Improved knowledge transfer through structured field experiences and mentoring will help to reduce the repetition of mistakes common in global health programming.

Finding quality field staff is a perennial problem for many organizations, and those working with volunteers will be well placed to recruit the best to permanent positions in the future. Finally, facilitating volunteer programs and entering into partnerships with universities have the potential to open valuable new revenue streams for NGOs. Ivan Illich was partly right – good intentions alone are not enough and by themselves they don’t protect the world’s most vulnerable people from the risk of harm from volunteers. However, early field experiences were critical learning opportunities for many of today’s global health leaders and they remain just as important for future generations. The current paradigm of international volunteering includes too many programs that provide little training and create dangerously unrealistic expectations for what students can achieve. Those providing field experiences need to better train and support their volunteers and recognize the education of student participants as an explicit and central goal of their work. One way to operationalize this model of volunteering is through partnerships between universities and reputable NGOs with robust field operations. By dealing honestly with the value and limitations of volunteers we can move beyond good intentions to good outcomes and a better trained global health workforce.

Mathew Craven, M.D. Resident physician in Internal Medicine and Global Health Equity at Brigham and Women’s Hospital, Co-Founder and Chairman of Support for International Change (SIC), member of Partners in Health

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Reflections on Reconstruction of the Afghan Health Care System Dr. Abdullah Sherzai, Contributing Expert

arly in spring of 2002 I lived on a serine lakeshore home in Reston, Virginia. At the time I was employed as a Neuroscientist at the National Institutes of Health. Being of Afghan descent and a refugee of the 1978 Soviet invasion, I was always drawn to the desperate plight of refugees around the world. In the years leading to the turbulent period around 2002 I helped found two non-governmental organizations (NGOs) that focused on aide to Afghanistan, as well as spearheaded a modest effort for reform in the country. But in those halcyon years I could never have imagined abandoning my career and embarking on an adventure in Afghanistan. In the summer of that year I was approached by the World Bank Health Division to join them on a trip and help contribute to their efforts in Afghanistan. While there, unexpected circumstances led to a life altering decision to work within Mr. Karzaiâ&#x20AC;&#x2122;s government. Initially I was asked to be the Director of Policy and Planning and within a few months to serve as the Deputy Minister of Management. The quixotic decision to be part of the rebuilding efforts of this beleaguered nation turned out to be an enduring life lesson as well as an unconventional lesson in postconflict health care delivery. From the inception, it was apparent that Afghanistan and in particular its health care faced tremendous challenges. This was a country that had seen more than 20 years of war, and six failed governments which

culminated in the tyrannical Taliban regime. The health care system had degraded to standards rarely observed in recorded history. Resources as defined by human capacity, durable equipment, and pharmaceutical goods were nonexistent. The

monia, which took the lives of one in four children younger than five years of age. During the Taliban era, health care was no more than what was being done by a small contingency of WHO, UNICEF, NGOs - such as Swedish Committee- and a lone academic

The quixotic decision to be part of the rebuilding efforts of this beleaguered nation turned out to be an enduring life lesson as well as an unconventional lesson in postconflict health care delivery bulk of the mortality and morbidity was among women and children and tragically consisted of pregnancyrelated complications and simple infections such as diarrhea and pneu-

institution called Loma Linda University, which managed to maintain a presence in Afghanistan throughout the devastating civil war. Human capacity was nominal.

Photo by the United States Agency for International Development (USAID)

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global health review The brain-drain had been massive and involved all sectors. The few health care providers that demonstrated any knowledge of management had been trained by the NGOs, WHO, and UNICEF, and were recycled among the different organizations. Our international partners were also overwhelmed with the task at hand. We needed to prioritize health care delivery according to resources and yet, we could not fathom the nature and enormity of the task at hand. Our mission was further complicated by the disparate mandates of the partners and the ubiquitous presence of corrupt politicians within each ministry. The plethora of warlords and anyone with a scintilla of political influence all had their cronies installed at all levels of government. Within a few months, the numbers of Ministry of Health employees burgeoned to more than 25,000 men, women, and even children. Yet, there was no accounting of the finances and disbursements. The few hospitals that endured the ravages of war only served as transient residence and hospice. Within Kabul, 21 hospitals continued to function, but only by name. Only a handful of basic diagnostic equipment sporadically operated in the main cities. Essential medications were scarce and those rarely found at local pharmacies were of questionable quality. Although there was a serious effort to coordinate the delivery of health care with the Ministry in the lead, it was almost impossible to get beyond each of the bilateralsâ&#x20AC;&#x2122; immutable mandates. From the very beginning, the World Bank had decided that it would pursue a province-wide, contract-based approach whereby they would contract the delivery of health care for a given province to one or more NGOs. Yet, with a finite budget, they could only hope to deliver the basic package to

10 out of the 31 provinces. USAID also decided to pursue a contractual approach, but theirs was not an allencompassing vision and aimed at having a presence in as many provinces as possible, patchy though it may have been. USAID was also interested in building clinics throughout the country, which turned out to

for the next decade if not more, in establishing the semblance of an infrastructure, education, and provision of the bare necessities. Most of the rural population was illiterate, and by extension, lacked any knowledge of hygiene, preventive measures, immunization, and peri-natal care. The challenges were herculean, and

Although some great strides have since been taken in Afghanistan with the immunization campaigns, health care training, and basic infrastructure, there is much inefficiency and corruption at all levelsâ&#x20AC;&#x201D; both nationally and internationally be a misadventure in its own rights. All of the partners working with the Ministry focused on delivery of a basic health care package, centered on reduction of mortality and morbidity in women and children, though each partner differed in its vision of how to achieve the latter aim. The task of immunization, which was urgent and colossal, fell on the two tried and tested organizations which had long term experience in Afghanistan: WHO and UNICEF. The daunting and potentially prohibitive impasse facing the team was poverty of any infrastructure. More than 90 percent of mortality was secondary to easily preventable conditions that could be averted with simple measures such as basic hygiene, oral rehydration therapy, and first-line antibiotics. Yet, the majority of the population lived in distant inaccessible villages and hamlets. An average Afghan woman would travel on horseback over two days across the most treacherous landscape in order to reach the nearest clinic. It shortly became evident that the available resources were to be used,

we recognized the urgency of acting swiftly and comprehensively. Cognizant of the fact that this might be the only opportunity this poor nation might have to emerge from the primeval dust, we were resolved to convince the donors to invest in the future and concurrently set in place a framework for a long-term health care system. The most important component of this new system would have to be an investment in human capitalin particular women. Ironically, in a country like Afghanistan, where decades of calamitous war left behind an antediluvian social structure, women still served a centrally cohesive function. As men had gone to war, they had created a rudimentary community support system. They were the ones that continued to provide care for other women, children, and often, men. Our efforts consisted of delivering preventive measures, immunization, basic health care, and peri-natal support through local women trained to deliver these basic needs. These women were not college or high school graduates, but

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Photo by the United States Agency for International Development (USAID)

had minimal education sufficient to provide these elementary lifesaving necessities. Another benefit of this investment in human capital, in the form of nurses and midwives, was its political and social empowering consequences. Even in Taliban-infested regions of Afghanistan, with their draconian standards for woman, health care providers are deemed as community leaders. This unique status is not afforded to any other sector, including education. Although some great strides have since been taken in Afghanistan with the immunization campaigns, health care training, and basic infrastructure, there is much inefficiency and corruption at all levels-both nationally and internationally. Hospital construction should never have been the focus of an efficient plan. Millions of dollars were spent

on Kabul hospitals ineffectively, by partners who had no idea of implementing health care in a country like Afghanistan, simply for the sake of visibility. This was done through redundant and wasteful conferences and spending on tools of implementation that were simply not applicable in Afghanistan. Though there were a few who participated in international development for personal gain, most of the opportunity lost was simply due to lack of a coordinated, global, and phased approach at the country level. I came home with a sinking feel-

ing that many in the development world are resigned to the cynical belief that there is only so much they can do to change the underlying intransigent political landscape, and thus simply go through the motions. In a world where we, the developed nations, are being called upon with greater frequency to help rebuild countries, avert massive catastrophes, and establish cross-border and cross-continental programs, uncompromising mandates, myopic interests, and cynical perfunctory action can lead to opportunity lost and hopes extinguished.

Abdullah Sherzai, M.D. Former Deputy Minister of Health for the transitional Afghan government; Director of Research, Loma Linda University, Department of Neurology; Director of the Memory and Aging Center, Loma Linda University, Department of Neurology.

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The Malawi Nursing Crisis: No End in Sight? Angela Primbas, Staff Writer

ach year, the African country of Malawi trains and educates 60 nurses and midwives in an effort to rejuvenate the country’s ailing healthcare system. In the eyes of many public health experts, however, this effort has fallen short. While Malawi’s health officials may be optimizing available resources to provide what health training they can, around a hundred nurses leave Malawi in pursuit of better wages and a higher standard of living for every 60 that are trained.1 Malawi’s predicament is a trend that extends over many developing countries and has become known as “the brain drain.” Seasoned and educated professionals, particularly those with medical training, leave their native countries in search of greater professional opportunities in the developed world. Unlike in other African nations, however, health officials are concerned that the shortage of nurses in Malawi has reached critical levels. Patients in Malawi, if they can even afford transportation to one of a handful of hospitals, stand a slim chance of survival simply because there are not enough nurses and professional staff to tend to those in need. Critics outside of the crisis in Malawi ask how these nurses that leave can turn a blind eye and allow people to perish without attention. The simple answer is that life is difficult for a nurse in Malawi. Marguerite Thorpe, a Harvard

undergraduate who worked in Malawi last year, described these nurses’ reality to the HCGHR: “The nurses that do work here work fairly long hours and spend one week out of four or five on-call every night. Though the hospital at which I work is better-staffed than others (I believe this might in part be thanks to the US-based NGO paying nurses a

small bonus in addition to the public salary they receive), I have heard reports of how overworked nurses are at other public clinics. The result is that the most basic care (feeding, bathing, and monitoring the patient) is done by ‘guardians’ that accompany the patient to the hospital, usually family members.” If nurses continue to leave Ma-

A mother sits with her child in a village in Malawi (Wikimedia Commons).

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global health review ic or political security. Sub-Saharan Africa has one-fourth of the global disease burden and they have three percent of all the health workers.

workers in Kenya, Tanzania and Uganda. Because of this spike in volume of healthcare providers, there were large increases in successful

“Sub-Saharan Africa has one-fourth of the global disease burden and they have three percent of all the health workers”

Malawi (Wikimedia Commons)

lawi and the country’s inefficiencyridden healthcare system, experts worry that the situation for healthcare professionals who remain will include a much higher workload. Government officials, physicians, and patients alike are concerned that this change will leave nurses with insufficient time to effectively manage patient care. Malawi nurses simply cannot be everywhere at every moment, and as a result, the tasks and jobs that should be delegated to highly skilled staff will be allotted to unqualified employees. Dr. Howard Zucker, a Harvard Institute of Politics Fellow for the 2008-2009 school year and former Assistant Director-General of the World Health Organization, described the main problem to HCGHR: “If you don’t have doctors or nurses then you won’t have a healthy population, which means you can’t have health security and thus no econom-

What happens is that nurses are demoralized, and they recognize that the effort to try to maintain effective or basic healthcare is quickly diminished.” “The situation is a catch-22,” Zucker went on. “Malawi needs to improve healthcare conditions so nurses and doctors are more willing to stay, but you need these people there in order to make the conditions better.” There are ways, however, to alleviate the problem. For starters, costs need to be decreased. The presence of nurses in hospitals in Malawi is expensive, costing hospitals up to $10,000 per nursing student and $31,000 per degree-certified nurse. However, despite the apparent costliness of hiring, training and paying more nurses, it may end up saving the government’s money in addition to the lives of its citizens.2 Among more cost-effective and productive solutions currently under exploration, one approach is for the Malawi government to pursue the option of employing community healthcare workers to staff hospitals and provide aid. A project of this nature involved almost 1000 community health

treatment of patients and in overall satisfaction of healthcare professionals and patients. The use of community health workers has provided an excellent asset to the communities they worked within and more than likely would benefit the situation in Malawi.3 Both the government and health professionals in Malawi agree that there must be progressive planning and movement towards alleviating the nursing crisis in Malawi. There are very few nurses willing enough to accept minimal pay, excruciating hours and a one to eighty nurse to patient ratio. Although the situation seems dire and difficult, those more intimately involved in the solution process encourage the global health community to support their efforts with attention and care. Zucker adds perspective, “Imagine if you were sick and went to the emergency room and the staff there told you ‘I’m sorry, there are no doctors or nurses here to treat you.’ People would be appalled! The story would make the front page of every newspaper and be covered on every major television station.

1 Jane Elliot, “Reversing Malawi’s Nurse Brain Drain,” http://news.bbc.co.uk/2/hi/ health/4471739.stm 2 Adamson S Muula, Ben Panulo Jr, and Fresier C Maseko, “The Financial Losses From The Migration of Nurses from Malawi,” BioMed Central Nursing (Nov 2006).

Available at: http://www.biomedcentral. com/1472-6955/5/9 3 N Martin, C Karutu, A Ragi, “Educating and Training Community-Based Healthcare Workers—an Affective, Adaptable Model for Resource Poor Countries,” Int. Conf. AIDS, no. 13, (Jul 2000): 9-14.

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The Fat of the Land: The WHO Joins the Fight Against Obesity Neda Shahriari, Staff Writer

here is a bit of irony in thinking about obesity in developing countries: it was only recently that health advocates were raising awareness about malnutrition in middle-income to low-income nations. Unfortunately, rapid industrialization has created a burgeoning population afflicted with obesity in these countries, forcing their healthcare systems to deal with alarming increases in non-communicable diseases—from cardiovascular diseases to diabetes and cancer. Taking cognizance of this, the World Health Organization (WHO) has created an antiobesity strategy that is now starting to take effect. The correlation between obesity and morbidity is quite apparent in Egypt, a developing country where cardiovascular disease-related mor-

talities have increased from 5% of deaths to 39.1% in males and 2.9% of deaths to 27.2% in females between 1961 and 1985.1 In an effort to bring this emergent issue to light

Timothy Armstrong, of the WHO’s Department of Chronic Diseases and Health Promotion in Geneva, informed HCGHR that, “In the 2002 World Health Assembly the secre-

Egypt has observed a sudden shift in dietary lifestyles in the past 50 years the WHO developed the Global Strategy on Diet, Physical Activity, and Health (DPAS) in 2004. As its name suggests, DPAS seeks to address two risk factors—diet and physical activity—that play a hand in promulgating obesity.2 DPAS was designed upon the request of several developing countries in the WHO that were alarmed by their rising rates of obesity. Dr.

tariat was asked to develop DPAS, in order to reduce the risk factors that were contributing to the increase in cardiovascular diseases, diabetes, and cancers that were not just being observed in the developed world, but particularly in developing countries.” In Dr. Armstrong’s view, DPAS is to be utilized as a set of “health tools” that can assist member states in addressing the risk factors for non-communicable diseases in the context of their own country. Egypt has observed a sudden shift in dietary lifestyles in the past 50 years, brought on by rapid urbanization and industrialization. As more people abandoned agriculture to settle in the cities, Egypt lost its self-sufficiency in food production, resulting in an increase in food imports. This

Obesity lets women be seen as symbols of “beauty, fertility, and prosperity” Photos courtesy the World Health Organization (Pierre Virot)

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global health review led to the introduction of new foods that were not originally a component of the traditional cuisine.3 This dietary shift—compounded by the relative physical inactivity of a more urban lifestyle—has contributed to the county’s rise in obesity. Under the WHO’s guidance, Egypt has now made use of DPAS and implemented policies to tackle obesity. According to Dr. Armstrong, “The primary thing that Egypt has done most recently is look at the issue of marketing food to children. It has put in regulatory responses to ensure that ‘fast foods’ are being restricted in the way that they are being advertised to children.” The promotion of physical activity in Egypt is more challenging, as a result of the country’s fragile infrastructure and highly urbanized population. Nevertheless, Dr. Armstrong asserts that Egypt is moving in the right direction as “one of the leaders [in tackling obesity] in the Mediterranean region.” Despite the standardized nature of DPAS, any effort to tackle obesity must deal with conditions specific to particular countries. In Egypt, it has been found that women are more prominently affected by obesity. This has been attributed to their greater inactivity as a result of urbanization, greater illiteracy, and the fact that obesity lets women be seen as symbols of “beauty, fertility, and prosperity.”4 In an interview with HCGHR, Dr. Frank Hu, Professor of Nutrition and Epidemiology at the Harvard School of Public Health, pointed out that looking at such unique local factors helps bring context to the policies, initiatives, and programs that are implemented. Dr. Armstrong agrees: “When you get down to working with a particular country, it’s really taking some of the key messages in the Global Strategy document and

Photo by Marco Bellucci (Wikimedia Commons)

adapting those for the particular geopolitical, cultural country. When we turn our strategies into policies, we want the programs that come from those policies to be relevant to that particular population.” Egypt does not stand alone in its fight against obesity. Dr. Hu notes

similar to what we observe in Egypt. It will take several years before one observes a reversal in obesity and the rate of non-communicable diseases in developing countries, but to Dr. Armstrong, success at this point represents the growing number of countries that have joined

“When we turn our strategies into policies, we want the programs that come with those policies to be relevant to that particular population” that in Asia’s developing economies “increasing globalization and EastWest exchanges have been accompanied by increasing population movements, changes in food supply and dietary patterns, technology transfer, and cultural admixtures,” that have created obesity epidemics

Egypt in implementing DPAS and adopting policies to counter obesity: “It’s really through all of us taking appropriate action that we can reverse this trend.”

1 Galal, Osman. “The Nutrition Transition in Egypt: Obesity, Undernutrition and the Food Consumption Context,” Public Health Nutrition. 2002, pg. 145. 2 World Health Organization. “World Health Organization Process for a Global Strategy on Diet, Physical Activity and Health,” Publications of the WHO. February 2003, pg. 1.

3 Galal, Osman. “The Nutrition Transition in Egypt: Obesity, Undernutrition and the Food Consumption Context,” Public Health Nutrition. 2002, pg. 142-143. 4 Mokhtar, Najat et al. “Diet Culture and Obesity in Northern Africa.” JN: The Journal of Nutrition. 2001, pg. 888.

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A Story that Doesn’t Sell: Violence Against Women in Kenya Taylor Poor, Staff Writer

he night after Kenya’s hotly contested presidential elections of December 30, 2007, confirmed President Mwai Kibaki for his second term and threw the country into vicious ethnic turmoil, Sarah Maluu was raped by three security officers in full uniform.1 In the violent aftermath of the elections that lasted into the spring of 2008, Florence Mukambi lost her two children and part of her face to arson,2 Jacqueline Imakokha and her mother were gang raped by 20 rioters, and thousands of other Kenyan women suffered sadistic brutality at the hands of angry protesters.3 A report by the UN Population Fund (UNFPA), The UN Children’s Fund (UNICEF), and the Christian Children’s Fund (CCF) from February 2008 announced the continued use

of sexual and gender-based violence as a weapon of ethnic tension in the aftermath of Kenya’s December 2007 elections.4 This post-election devastation is perhaps the best thing that could have happened to the battered women of Nairobi—it carries stories of rape and gender-based violence to the rest of the world. The type of gender-based violence (or GBV) seen in post-election Nairobi is not a new problem for female Kenyans. It is a symptom of a much larger concern, to which nobody has been paying any attention. Susan Wabala, of Kenya’s Peace Pen Communications, recently presented a story about the sexual assault of a ten-year-old girl to her editors only to be told it was “one of those stories that don’t sell.”5 These

Criminalization of marital rape is shown on the map above (photo courtesy of UNICEF).

heartbreaking tales of pre-election violence abound: there is the story of the five-year-old girl left at home with her twin 14-year-old brothers, who dragged her outside to rape her repeatedly6; and Margaret, gang-raped by 10 men throughout the course of a single night and rudely treated by the doctor who examined her after her ordeal.7 “Kenya has an epidemic of gen-der-based violence,” wrote Makau Metua, Chair of the Kenya Human Rights Commission, in August 2009,8 rampant long before the 2007 elections brought it to international attention. If GBV is in fact a long-standing source of distress to Kenyan women, where in Kenyan society is the basis for this crisis, and why are the perpetrators escaping justice? Experts point out that age-old customs may translate in today’s society to the fact that women have few rights protecting them from violent acts. Ann Njogu, Executive Director of the Nairobi’s Center for Rights Education and Awareness (CREAW), links violence against Kenyan women to traditional customs that “contribute to the entrenchment of gender based violence.”9 She explains that in Kenya, women have almost no control over their sexuality, if any at all, while violence erupts from countless sources in everyday life: “intimate partner violence, sexual abuse, rape, widow inheritance, dowry related violence, and female genital mutilation.”10 50% of Kenyan women have undergone female genital mutilation; in some areas the figure is as high as 95%.11

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global health review Njogu cites ancient, ingrained practices such as the payment of bride price at marriages, wife inheritance by other members of the family after her husband has died, “cleansing” a widow through often-forced intercourse, and the traditional avoidance of sexuality in discussion in Kenyan society as customs that could be seen to help perpetuate the concept that women are property, rendering gender-based violence less reprehensible in the eyes of authorities. Further, Metua cites the “irrevocable consent [for sexual intercourse]… given by marriage,”12 explaining, men and boys “are socialized by patriarchy…to abuse women, and to treat them as chattel.”13 Njogu and Dr. Seggane Musisi, head of psychiatric consultation at Mulago Hospital, Uganda, both understand a fundamental lack of public awareness and political appreciation to be at the root of the pervasiveness of the current GBV crisis (which Musisi has connected to many countries in Africa that have experienced “lowintensity,” “chronic” warfare).14 Not only do governments internation-ally fail to comprehend the scope of the global causes and consequences of Africa’s “chronic war-fare,”15 but community professionals seem unwilling to contribute their authority toward solving violence problems. Due to public pressure to keep quiet, cases of abuse often go unreported. Njogu submits, “frequent mismanagement of court cases” and the humiliation of hospital procedures “penalize survivors.”16 The doctor treating Margaret after her rape, for example, exhibited such distaste toward examining her that she felt as though she were being violated yet again.17 Patricia Nyaundi, executive director of Kenya Federation of Women Lawyers, laments how the justice system reacts to women seeking retribution for abuse, with police of-

ficers asking women “why they were out that late.” “In courts, it’s the same story,” Nyaundi says.18 The flawed Kenyan justice system has also taken its toll on the post-election investigations ordered by Kenya’s brand-new first lady, Lucy Kibaki, in outrage at the post-election violence:

neighbour, shop keeper—you name it.”21 Surely a community-centered approach is necessary for long-term advances in Kenyan women’s rights. Njogu and others are taking steps against GBV at the community level by raising awareness and access to

50% of Kenyan women have undergone female genital mutilation; in some areas the figure is as high as 95% a year’s worth of thousands of rape investigations brought all of four cases to court.19 Nyaundi, who directed the investigations, told the HCGHR that “Police were not cooperative. They refused to share infor-mation… Eventually we felt that we were just [there] to rubberstamp the process and we therefore pulled out.”20 Teresa Omondi, of the Gender Violence Recovery Center at the Nairobi Women’s Hospital, blames women’s unwillingness to pursue justice in cases of abuse on the fact that “in most cases it’s father, uncle, cousin,

education. Njogu is currently working to spread CREAW’s “Rape Red Spot” campaign in Kenya, which identifies dangerous areas so that women like Margaret can avoid them in the future.22 Her organization enlists the cooperation of men and boys in the communities it has accessed. Perhaps once GBV-plagued societies start to think differently about a crisis they have taken for granted for so long, stories like Margaret’s will win their place in the international spotlight, and their heroines the relief they so desperately need.

1 Alsop, Zoe. “Kenya’s Rape Probe Falters After Lawyers Drop Out.” Women’s eNews 14 Dec. 2008. <http://www.pubmedcentral. nih.gov/articlerender.fcgi?artid=2141620>. (Accessed 8 Oct. 2009) 2 Kyalimpa, Joshua. “Kenya: Elusive Justice for Victims of Gender-Based Violence.” AllAfrica Global Media 14 Aug. 2009. <http:// allafrica.com/stories/200908140643.html>. (Accessed 8 Oct. 2009) 3 Alsop, 2008. 4 Some, Jane. “GBV in post-election Kenya.” IRIN News. <http://www.fmreview.org/FMRpdfs/ FMR30/56.pdf>. (Accessed 8 Oct. 2009) 5 Mwita, George. “AFRICA: Raising the Profile of Gender-Based Violence.” IPS 8 Aug. 2009. <http://ipsnews.net/news. asp?idnews=48010>. (Accessed 8 Oct. 2009) 6 Kyalimpa, 2009. 7 Thomas, Rachel. “Spotlight on Ann Njogu, CREAW: Taking a Stand Against GenderBased Violence in Kenya.” OSI 26 July, 2006. <http://www.soros.org/initiatives/ health/focus/sharp/articles_publications/ articles/njogu_2006072>. (Accessed 8 Oct. 2009) 8 Mutua, Makau. “Kenya: The Epidemic of Gen-

der0Based Violence.” AllAfrica Global Media 29 August 2009. <http://allafrica.com/ stories/200908310800.html>. (Ac-cessed 8 Oct. 2009) 9 Thomas, 2006. 10 Thomas, 2006. 11 Mbugua, Isabel. “Ending the Mutilation.” WomenAid International 1997. <http:// www.womenaid.org/press/info/fgm/fgmkenya.htm>. (Accessed 8 Oct. 2009) 12 Mutua, 2009. 13 Mutua, 2009. 14 Musisi, Seggane. “Mass trauma and mental health in Africa.” African Health Sci-ences August 2004. <http://www.pubmedcentral. nih.gov/articlerender.fcgi?artid=2141620>. (Accessed 8 Oct. 2009) 15 Musisi, 2004. 16 Thomas, 2006. 17 Thomas, 2006. 18 Kyalimpa, 2009. 19 Alsop, 2008. 20 Nyaundi, Patricia. Personal interview by email. 7 October 2009. 21 Kyalimpa, 2009. 22 Thomas, 2006.

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Under the Knife: Can America Learn from Japan’s Success in Cutting Healthcare Costs? Yuying Luo, Staff Writer

here is little debate that the United States health care system is broken: it is one of the most expensive and inefficient of its kind in the developed world. The National Health Expenditure Accounts estimates that health care spending in the US increased by an average of 7.7 percent per year between 1985 and 20061. In 2006, health care cost the United States some $2.1 trillion, or a staggering 16 percent of the gross domestic product1. This figure is more than six percentage points higher than the

average for other OECD (Organisation for Economic Cooperation and Development) countries including Japan, where health expenditures increased by a mere 0.1 percent in 20062. Experts estimate that a driving force behind the escalating health care costs is medical technology, which contributes between 38 percent to more than 65 percent to the rise in healthcare spending2. Dr. John C. Campbell, a Professor Emeritus at the University of Michigan and a visiting scholar at the Institute of Gerontology at Tokyo

Photo courtesy of Emily Hsu ‘10

University, is hesitant to back that statement wholly in an interview with HCGHR: “It’s not the technology that’s available that’s driving up the cost, but rather how we use it.” “If you think about it, technology is the same all over the world. When new technology is invented, it becomes available to everybody. The cost [of the technology] is more and less level in all the countries, yet some countries’ health care expenditures increase 6-10% year. So it’s an indirect cause.” Dr. Campbell, who has co-authored The Art of Balance in Health Policy: Maintaining Japan’s LowCost, Egalitarian System, is quick to pinpoint what he thinks is the cause. “It’s not that Americans use more health care than anybody else. It’s tempting to say that Americans go to the doctor for every little thing. But the fact is that Americans go to the doctors 4 times per year, compared to 13 times per year for Japanese. It’s just [that] we pay too high a price for it.” The Japanese, who are among of the healthiest in the world in terms of life expectancy and infant mortality, actually stay in the hospital much longer than Americans and even have nearly twice as many diagnostic scans per capita as Americans do3. Yet they pay less for MRIs than Americans do, despite the fact it is a service more in demand there

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than here. “It’s how the system is set up to use technology to make profit that’s the problem,” Dr. Campbell emphasizes. A McKinsey Global Institute (MGI) study in 2007 showed that the United States spends 54 percent more than OECD countries for the top-five inpatient medical devices such as stents and implants4. Dr. Andrea Louise Campbell, an Associate Professor of Political Science at MIT, informs HCGHR that new technology is not necessarily better either, “When we do comparative effective analyses, we often, although not always, find older and cheaper technology to be just as effective as new and more expensive treatment.” So is Japan’s low-cost health care system an anomaly? According to Dr. Campbell, the overwhelming answer is no: the cost of healthcare technology is regulated in all advanced nations—with the notable exception of the United States. Every two years, the Japanese government decides on a “global figure” of how much money is to be allocated to health care in the next two years. The individual components of the budget are not fixed to ensure flexibility in spending. “There is one big negotiation between the government, which is representing all health insurers, and providers—actually, mainly doctors rather than hospitals or pharmaceutical companies,” Dr. John Campbell describes. The negotiation produces a ‘fee schedule’ that establishes the price for each procedure, test, medication and device throughout Japan. It is meticulously detailed: there are two different price points for stitches—one for stitches larger

than ten inches, and one for stitches smaller than ten inches. Providers are legally bound to charge the amounts determined by the fee schedule—no more, no less. There is a clear logic to the Japanese government’s decisions, “The

test the stability of Japan’s health care system. And moreover, there are worries about Japan’s aging population inflating healthcare costs. However, as Dr. Campbell points out,“The growth of the elderly population in Japan is about to level off—

The cost of healthcare technology is regulated in all advanced nations—with the notable exception of the United States government keeps a close eye on trends in all medical treatments, particularly those which have increased a lot in the last two years or so,” Dr. Campbell explains. “If the reason for the growth is some technological change that had made a procedure more profitable (a famous example is multichannel blood testing machines), the fee is knocked down.’’ In 2002, the Japanese government decided that the price of MRIs had become exorbitant. So they slashed the cost by 35 percent. This had a cascading effect; as a result, the supply industry had to lower the price of MRI machines to help the health care industry meet the standards set by the government2. The current economic crisis will

it will only be about 1% a year from now until 2030”. Indeed, much of Japan’s success in controlling health expenditure was actually achieved when their aging population was growing rapidly, doubling from 1997 to 20065. The United States’ current situation is direr. Left unchecked, health care spending threatens to consume the majority of the GDP1. “In the US, the 65+ population will be rising 3% a year in the same period—one more reason for doing something to control health care spending,” Dr. Campbell says. “The key is to fix prices. It’s the only way we can get a handle on health care spending.”

1 Ginsburg, Paul. “High and Rising Health Care Costs Report.” Robert Wood Johnson Foundation. October 2008. <http://www.rwjf. org/pr/product.jsp?id=35368> (Accessed 16 Oct 2009) 2 Reid, T. R. “Interview with Naoki Ikegami.” Frontline: Sick Around the World. April 2008. <http://www.pbs.org/wgbh/pages/ frontline/sickaroundtheworld/interviews/ ikegami.html> (Accessed 16 Oct 2009) 3 Reid, T.R. “Japanese Pay Less for Health Care.” NPR. April 14, 2008. <http:// www.npr.org/templates/story/story. php?storyId=89626309> (Accessed 16 Oct

2009) 4 McKinsey & Company. “Accounting for the cost of health care in the United States.” Mckinsey Global Institute. October 2007. <http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp> (Accessed 16 Oct 2009) 5 Harden, Blaine. “Health-care in Japan.” The Washington Post. September 7, 2009. <http://www.washingtonpost.com/ wp-dyn/content/article/2009/09/06/ AR2009090601630.html> (Accessed 16 Oct 2009)

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Stamping Out Polio: Vaccines and Postage Stamps in Pakistan Jessica Villegas, Staff Writer

eceive a letter from Pakistan, and chances are your stamp will feature a touching picture of former Prime Minister Benazir Bhutto immunizing her youngest daughter, Aseefa Bhutto Zardari, with the oral polio vaccine. Pakistan’s President Asif Ali Zardari, Ms. Bhutto’s widower, has requested that this photograph of his late wife be issued as a postage stamp to raise awareness of Pakistan’s polio eradication efforts amidst an alarming resurgence of the crippling disease.1 Pakistan is one of four countries worldwide where polio is still endemic, the others being Afghanistan, Nigeria and India. In 2008, Pakistan reported 118 cases of polio, up from 32 in 2007.2,3 In the first nine months

of 2009, health officials reported 62 new cases of the disease.4 While there is no cure for polio, eradication efforts focus on the

conservative and unstable northwest parts of the country, where the Pakistani army is presently locked in battle with Taliban troops.

President Zardari’s urgent call for “no child missed” has been rendered silent widespread administration of polio vaccines. The Global Polio Eradication Initiative (GPEI) was launched in 1988, but it was not initiated in Pakistan until 1994, with the first two National Immunization Days (NIDs) held that same year.5 In 2001, a door-todoor strategy of administering vaccines was adopted in Pakistan, but its efficiency is now left vulnerable to security threats that arise in the

Pakistan, 2001: Polio vaccination in the village of Hinsho-Jo Whandhio, situated in Nagar Parkar Region, Mithi District, in the desert of Thar, frontier of Pakistan with Rajasthan State (India). © Sebastiao Salgado/Amazonas Images - Contact Press Images, courtesy of the artist.

In October 2009, polio vaccination efforts in Pakistan received a heavy blow. Four serious security incidents, including an attack on the United Nations World Food Programme offices in the capital Islamabad, left areas of northern Pakistan inaccessible to immunization officers. A polio team in the country’s volatile North West Frontier Province (NWFP) is presently trying to grasp the number of children under five who will be missed during the next round of NIDs due to the current military action against the Taliban.6 President Zardari’s urgent call for “no child missed” in the October NIDs has been rendered silent. Conservative areas like the NWFP witness campaigns that equate anti-polio efforts with federal and even American interference. Local clergymen oppose the idea of vaccination, calling it a conspiracy of the West against Muslims to make them sterile and curtail their population growth.Using mosque loudspeakers and illegal radio stations, these clerics denounce polio vaccination before a population vulnerable to a disabling disease that has already eradicated from most of the world.7 With fiery anti-vaccination

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global health review voices and literacy rates hovering below the national average of 48%, these areas pose a serious challenge to health workers.8 To highlight the virulence of this opposition, in 2007 health workers in Bannu, near North Waziristan (in the Federally-administered Tribal Area, or FATA, near NWFP) were sent a letter and a 500 Rupee note giving them two choices—to stop the polio immunization of local children or to buy their own coffins.9 Health workers in Pakistan retaliated against these anti-vaccination sentiments with a fatwa, a religious opinion concerning Islamic law, endorsing polio vaccination campaigns. Maulana Fazlur Rehman and Qazi Hussain Ahmed, the leaders of Pakistan’s largest religious parties, endorsed this fatwa. Health workers and volunteers now travel with these papers, hoping to dispel fears and myths about polio immunization campaigns.10 Intriguingly, Oliver Rosenbauer, a WHO spokesperson for the Global Polio Eradication Initiative, informs HCGHR that, “Refusals due to religious reasons are actually extremely low in Pakistan, well below 1%.” The support from religious leadership garnered by local health workers still does little to combat both the security risks and inaccessibility of Pakistani children, and political intimidation from conservative leaders. Of the 54 new cases of polio reported before October this year, 34 are in the NWFP and FATA.11 Rosenbauer notes that active surveillance of the poliovirus by WHO experts revealed reservoirs of the virus in these regions, making them priority areas for health workers. The government does not have much authority or control in most of these areas, and so NGOs need to negotiate with local leadership ahead of time to gain access to children.

A lack of government oversight can lead to more mundane problems. Responding to HCGHR’s queries, Aziz Menon, the National Chair of the Rotary International Polio Plus

official outreach, creative strategies for reaching families in regions like NWFP might be the best way to raise people’s awareness of the polio problem. There have been complaints

Health workers were sent a letter and a 500 Rupee note giving them two choices— to stop the polio immunization of local children or buy their own coffins Committee in Pakistan, lists managerial problems as an important reason for the rise in polio cases. The prevalence of “Population movements” between infected populations, unbeknownst to any authority, only complicates matters for health workers. This is where Bhutto’s stamp might help. Amidst a prolonged struggle between the government and powerful militants, and limited

that Bhutto’s image might fuel even further anger among conservative clerics due to the former Prime Minister’s anti-Taliban stance.12,13 Nevertheless, in the absence of a vaccine against opposition rooted in cultural, religious, or political contexts, a simple postage stamp is more likely to make it into the homes of Pakistan’s conflict-ridden, insecure areas before any health worker.

1 “No child should be missed: Zardari.” Global Polio Eradication Initiative News 13 Oct 2009. <http://www.polioeradication.org/ content/general/LatestNews200910. asp#03> (Accessed 16 Oct 2009) 2 “Monthly Situation Reports.” Global Polio Eradication Initiative. 7 Oct 2009. <http:// www.polioeradication.org/content/general/ current_monthly_sitrep.asp>. (Accessed 16 Oct 2009) 3 PAKISTAN: Record number of polio cases in 2008.” IRIN: A Project of the UN Office for the Coordination of Humanitarian Affairs. 13 Jan 2009. <http://www.irinnews.org/ Report.aspx?ReportId=82333>. (Accessed 16 Oct 2009) 4 “Global Case Count.” Global Polio Eradication Initiative < http://www.polioeradication.org/ casecount.asp> (Accessed 16 Oct 2009) 5 “The History.” Global Polio Eradication Initiative Background. 26 Sep 2009 <http:// www.polioeradication.org/history.asp> (Accessed 16 Oct 2009) 6 “Wild Poliovirus Weekly Update.” Global Polio Eradication Initiative. 14 Oct 2009. <http:// www.polioeradication.org/casecount.asp>. (Accessed 16 Oct 2009) 7 Nizza, Mike. “When Polio Reappears in Tribal Pakistan.” New York Times. 17 Jul 2008. <http://thelede.blogs.nytimes. com/2008/07/17/when-polio-reappears-in-

tribal-pakistan/>. (Accessed 16 Oct 2009) 8 “PAKISTAN: New tactics in anti-polio drive as more cases emerge.” IRIN: A Project of the UN Office for the Coordination of Humanitarian Affairs. 18 Aug 2008. <http://www.irinnews.org/Report.aspx?ReportId=79864>. (Accessed 16 Oct 2009) 9 “Jahalat: Polio Vaccination Campaign Facing Threats.” All Things Pakistan. 4 May 2007. <http://pakistaniat.com/2007/05/04/ jahalat-polio-vaccination-campaign-facingthreats/>. (Accessed 16 Oct 2009) 10 Walsh, Declan. “Polio cases jump in Pakistan as clerics declare vaccination an American plot.” The Guardian 15 Feb 2007. <http:// www.guardian.co.uk/world/2007/feb/15/ pakistan.topstories3> (Accessed 16 Oct 2009) 11 “Most polio victims belong to conflict zones” The Dawn 29 Sep 2009. <http://www.dawn. com/wps/wcm/connect/dawn-contentlibrary/dawn/news/pakistan/provinces/07most-polio-victims-belong-to-conflictzones-ha-07 > (Accessed 16 Oct 2009) 12 “Bhutto blames Taliban, al-Qaida for explosions”. MSNBC.com. 19 Oct 2007. <http:// www.msnbc.msn.com/id/21374344/. Retrieved 2008-09-13>. (Accessed 16 Oct 2009) 13 Afzal, Omer and Rai, Mohammad A., “Battling polio in Pakistan: Breaking new ground” Vaccine Sep 2009, Vol. 27 Issue 40, p. 5431

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Simply No Room: AIDS Outreach in Pakistan and Bangladesh Meghan Houser, Staff Writer

t an international forum this September, UNAIDS director Michel Sidibé spoke out against the criminalization of homosexuality for hindering global efforts against AIDS: “We have to remove these laws as they reflect deep-seated stigma and prejudice…Gay people are the ones who brought attention to HIV and AIDS but as we moved on to generalizing services for people with the virus, we forgot them.” 1 80 countries worldwide consider homosexuality illegal. There are movements across the globe to overcome these sanctions, often led as much by public health and AIDS relief groups as human rights advocates. These advocates have gained major recent victories, such as a decriminalization ruling in India in July, a decision Sidibé dubbed a huge victory because “removing laws that criminalize and discriminate herald

government denial and cultural phobia. Islam is the state religion of Bangladesh and Pakistan—two nations that share British India’s old penal system—and while these countries do not necessarily invoke Sha’aria (under which the penalty for sodomy is death), their cultural climate grievously complicates any effort to decriminalize homosexuality. Until the legal tide turns, how can HIV treatment for homosexuals be promoted in these countries? National approaches range from near total denial of the issue in Pakistan to promising cooperation with NGOs in Bangladesh. This has produced varying results in the treatment and containment of the epidemic. In Pakistan, where an official in the National AIDS program stated in 2005 that “our better social and Islamic values” keep AIDs prevalence

“99% of families in Pakistan can’t even begin to discuss the issue. Not won’t but can’t.” a new framework and new commitment and a new movement to universal access to health and human rights.”2 Some activists hoped that India’s “new commitment” to discrimination-free access to AIDS services would spread beyond its borders. But in some of these nations, antihomosexuality laws seem hopelessly entrenched through complexes of

lower in the country,3 the epidemic is undeniably growing: the first case was reported in 1987, which had grown to 1913 cases by 2002, and ballooned to 96,000 by 2007.4 In 2006, a full seven percent of HIV positive individuals in Pakistan were gay men, a figure most likely underestimated due to difficulties in data collection.5 The paradox of Pakistan’s han-

dling of the AIDS crisis is that at-risk groups such as homosexuals are the ones most often bereft of outreach, driven underground by Pakistan’s strict Islamic moral and behavioral codes. “If my family found out they would kill me, I mean really kill me,” says Shelley, 23, a sometime male sex worker from Rawalpindi. “There is simply no room for what we are in Islam, which is very difficult for me as a Muslim and a gay man to live with.”6 This taboo makes even finding volunteers for treatment difficult. Abid Atiq, program director of a sexual health NGO called Interact Pakistan, notes, ““We have to find them [homosexuals at risk] because they cannot find us…there’s a lot of distrust … They want to know who we are. Are we the police? Will we arrest them?”7 Pakistani officials also refuse, in large part, to endorse preventative sexual health education—a sentiment reflected in cultural perceptions as much as law. “When I go home at night I simply can’t talk about the work I do with my wife, my parents, my brothers or sisters,” says Atiq. “99% of families in Pakistan can’t even begin to discuss the issue. Not won’t but can’t.”8 While there have been advertisements to promote AIDS awareness since 1993, words such as “sex” and “condom” are often ommitted. Even possessing a condom is discouraged: A male sex worker interviewed in 2005 cited fear of law enforcement as his main reason to go without.9 Unsurprisingly, a UNAIDS sur-

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global health review vey in 2007 found that around 90% of male sex workers had unprotected anal sex on a regular basis. It has been estimated that only about 20% of sexually active gay men were being reached by any sort of AIDS prevention program.10 Though Bangladesh shares Pakistan’s religion and British India’s Penal Code, the outlook for HIV management among homosexuals seems brighter. The Bandhu Social Welfare Society, an NGO that has provided more than 76,000 gay men with sexual health education, is expanding with government support.11 Interestingly, Bangladesh often centers AIDS awareness drives around mosques. Since 1998, some 20,000 Bangladeshi imams have been coached to spread the word about high-risk practices and resources for treatment. ‘’They can easily overcome the social taboo against discussing HIV/AIDS,’’ says Syed Ashraf Ali, director general of the Islamic Foundation Bangladesh. ‘’An imam addresses a familiar cohort, one that he meets every week.’’12 These and other widespread, state-advocated AIDS initiatives have led to a more hopeful statistical picture for Bangladeshi homosexuals: a UNAIDS study in 2005 found that almost 80% of homosexual men were reached by prevention programs, and more than 45% of sexually active gay men reported using a condom at their last intercourse.13 Some admissions must be made in comparing these two profiles. Bangladesh still has a long way to go in addressing the AIDS epidemic among its homosexuals, and maintaining the illegality of same-sex relations can only hamper further efforts by keeping the homosexual community silent. It is equally true that Pakistan’s government is not wholly in denial about the need to address AIDS among homosexu-

Pakistani women protest in the city of Islamabad (Wikimedia Commons).

als: the government recently developed an “Enhanced HIV & AIDS Control Program” targeting high-risk groups.14 Whether one focuses on the clouds or their silver linings in Pakistan and Bangladesh, one can only

hope that Mr. Sidibé’s “new movement” towards universal human rights and healthcare is truly afoot, leaving prejudice by the wayside.

1 IGLHRC, “India: Government Defers Decision on 377 to Supreme Court,” International Gay and Lesbian Human Rights Commission, September 18, 2009, http://www. iglhrc.org/cgi-bin/iowa/article/takeaction/ resourcecenter/974.html# 2 Ibid. 3 Laura M. Kelley and Nicholas Eberstadt, “Behind the veil of a public health crisis: HIV / AIDS in the Muslim World,” National Bureau of Asian Research, June 2005 (NBR Special Report), 4. 4 2007 AIDS Epidemic Regional Update Summary: Asia. UNAIDS, 2007. <http://www. unaids.org/en/KnowledgeCentre/HIVData/ EpiUpdate/EpiUpdArchive/2007/default. asp> (Accessed 17 Oct 2009) 5 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007. <http://cfs.unaids.org/country_factsheet.aspx?ISO=PAK> (Accessed 17 Oct 2009) 6 Nicholas Harvey. “An Inconsistent Truth.” Fyne Times, 2008, 2-6, <http://www. nickandmaggie.com/article/An_Inconsistent_Truth,_Fyne_Times.pdf> (Accessed 17 Oct 2009)

7 Ibid. 3. 8 Ibid. 1. 9 Alefiyah Rajabali et al., “HIV and Homosexuality in Pakistan,” The Lancet Infectious Diseases (vol.8, issue 8), August 2008, 511 - 515. 10 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007. 11 2007 AIDS Epidemic Regional Update Summary: Asia. UNAIDS, 2007. 12 Qurratul Ain Tahmina, “Bangladesh: Anti AIDS /HIV Efforts Follow Men To the Mosques,” Inter Press Service, November 15, 2002. <http://ipsnews.net/interna. asp?idnews=13898> (Accessed 17 Oct 2009) 13 “Bangladesh: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007. <http://cfs.indicatorregistry.org/ country_factsheet.aspx?ISO=BAN> (Accessed 17 Oct 2009) 14 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007.

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An Interview with Jeffrey Sachs Angela Primbas, Interviewer

Photo courtesy of the Earth Institute

effrey Sachs is the Director of The Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University. He is also Special Advisor to United Nations Secretary-General Ban Ki-moon. From 2002 to 2006, he was Director of the UN Millennium Project and Special Advisor to United Nations Secretary-General Kofi Annan on the Millennium Development Goals, the internationally agreed goals to reduce extreme poverty, disease, and hunger by the year 2015. Sachs is also President and CoFounder of Millennium Promise Alliance, a nonprofit organization aimed at ending extreme global poverty. HCGHR: You are co-founder of Millennium Promise, an organization aimed at ending extreme poverty worldwide by 2025. Could you please describe the ways in which your organization seeks to do this, and how it differs from other global health and development organizations, such as the Gates or Clinton foundations?

Sachs: We aim to eliminate all extreme poverty by 2025. Millennium Promise Alliance is really an alliance. It’s an NGO that aims through partnerships to promote the achievement of the Millennium Development Goals and the flagship of the Millennium Promise is the Millennium Villages Project, which is a large-scale concept that operates throughout Africa and increasingly in other parts of the world. It’s a [tool] for achieving the millennium goals in impoverished areas through integrated investment strategy. In addition, Millennium Promise is active in policy discussions and debates and in public education and awareness around the Millennium Development Goals. We differ from the Gates Foundation by several billions of dollars. We’re not a foundationwe’re an NGO that is pursuing specific projects and public advocacy. Second, we believe that we’re the leading organization that is specifically devoted to the success of the Millennium Development Goals. Many organizations are supporting and promoting the Millennium Development Goals, thank goodness, but Millennium Promise was created specifically to champion those goals and to find ways to prevent things that are slowing the progress to the goals and, of course, towards raising funds and developing systems that have the capacity to actually achieve the goals in places like the Millennium Villages or like the millennium cities--which is the urban partner of the Millennium Villages Project.

In this sense, Millennium Promise is a wonderful opportunity to build strong and increasingly global relationships to successfully forward the Millennium Development Goals. HCGHR: The recent economic crisis’ impact is ongoing, and many organizations, both governmental and non-governmental, have cited the need to decrease global health expenditures. How do you see this affecting global health efforts, and what argument would you make against it? Sachs: I’ve been involved in several large scale efforts to bring primary healthcare to very poor regions and nations, first as chairman for the Commission of Economics and Health and then as director of the Millennium Project and as the leader of the Millennium Villages Project. And the point that I’ve emphasized in all of those capacities--through research that we’ve undertaken and the experience that we’ve shown--is that the cost of bringing a rigorous, lifesaving primary healthcare system to neglected and impoverished areas in the world is about 0.1 of 1 percent of the income of the rich world. So this is the starting point to understand that rich world combined income is somewhere between 35 and 30 trillion dollars a year. That means that 0.1 of 1 percent of the combined income of the rich world is somewhere between 35 and 40 billion dollars a year. And the point of all those efforts that I’ve mentioned earlier has been to show that, if we mobilized

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global health review that level of financing, what that would do would be to enable impoverished countries, say Tanzania or Uganda or Rwanda, to be able to ensure that there are physical facilities available, dispensary clinics, that there are community health workers on payroll; that there’s a supply of diagnostics and medicines and other needs; and that systems are put in place for safe child-birth or to control malaria or to fight AIDS, or other basic functional units of a primary health system. Your question is in relation to that baseline. What happened when I first chaired the Commission of Economics and Health, [was that] the actual amount of international funding available for these efforts was about three billion dollars a year, or 0.01 of 1 percent of the rich world’s income. Now there has been an increase to something like 12 billion dollars annual flow of development aid. It’s more or less quadrupled because of the efforts and advocacy and the demonstrative programs between 2000 and 2009. And a lot of progress has been made in fighting AIDS and fighting malaria and increased immunizations and so on. But we still need to increase what we’re doing roughly by a factor of 3, up to something on the order of 35-40 billion dollars a year.

The key point to recognize, though, while that seems like a lot (and that’s for 20-25 billion dollars a year), is that it’s not large relative to the size of our economies. Just watch the Wall Street bonuses. They’re again going to be something on the order of what’s needed for primary health in the world and those are just the bonuses on Wall Street for some thousands of people. So the point

Millennium Promise is a wonderful opportunity to build strong and increasingly global relationships I’ve been making for years is what needs to be done to save millions of lives is really a very, very modest effort from the rich world helping the poor countries. And financial crisis or not, this is not a big deal when it’s put in comparison with the millions of lives that would be saved.

lem solving agenda. We mean bringing science and technology to bare so that the poor can progressively close the gap with the rich, the rich can continue to improve their quality of life, and all of this can be done in an environmentally sustainable manner.

Of course, one direct way that I wouldn’t mind doing this is to put surtax on Wall Street right now rather than paying out these incredible bonuses which came, in any event, in part through the bailouts. I would rather have that money devoted to saving lives for the poorest people in the world. But that’s just one example of how this could be readily financed.

Now, that’s a tall order because the world is not on a sustainable trajectory right now, not even close. We have major crises of climate change, of fresh water, of loss of habitat and biodiversity, of pollution and so forth, and it’s getting worse not better. At the same time, many of these changes threaten the poorest of the poor. For instance, the climate change is leading to more unstable weather and more droughts in dry areas in the poor world, that when they face droughts they face death. We see this happening in many parts of Africa and I believe in central Asia as well. We’re seeing instability in places like Afghanistan and it’s not all politics--it’s also environment and climate.

HCGHR: As director of the Earth Institute, you have a big role in global sustainable development. What role does sustainable development have in poverty eradication and how is the Earth Institute involved in this endeavor?

Image courtesy of Millennium Promise

isn’t only, and I put “only” in quotations, changing the environment or fighting climate change. It is joined together with the fight against poverty. So we at the EI [Earth Institute] focus on sustainable development, and that is the main objective of the Earth Institute: to help create a new discipline of sustainable development, a new research agenda, a new education agenda and a new prob-

Sachs: I define sustainable development as combining environmental sustainability with economic development. That’s the challenge. So I say that sustainable development

So the Earth Institute is aiming to promote technological and scientific solutions that can address both the problems of development and sus-

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global health review tainability simultaneously. One of the ways we do that is to think about the working models for agriculture, pasturalism, disease control or new kinds of infrastructure. For instance, using solar power effectively is an off-grid technology in low income Africa and this is therefore so deeply meshed in the challenge of poverty reduction that it’s really a core part of the whole agenda and the whole process. HCGHR: As Chairman of the Commission on Macroeconomics and Health of the World Health Organization, what is the most memorable project on which you worked and can you please describe why? Sachs: The biggest breakthrough of that project was the conceptualization of the global fund to fight AIDS, tuberculosis, and malaria. When the project started, I knew that we would be asking for greater development assistance in the project and I hoped at least the commission would agree on that. I didn’t know the numbers. We had to study the problems in detail and it turns out that the commission as a whole, after reviewing the evidence over a couple of years, really stepped forward and made some very bold recommendations unanimously. One of them was that impoverished people in Africa and other regions should have access to antiretroviral medicines to keep them alive from AIDS and while that’s a commonplace idea right now, it was a breakthrough idea in 2000 and 2001. So, I recommended to UN SecretaryGeneral Kofi Annan and to the Director-General of WHO… that we start a global fund to fight AIDS and Kofi Annan very wisely thought that such a fund should also take on AIDS, TB, and malaria simultaneously. I helped

work on some core concepts of that fund and the Secretary-General launched the idea in April 2001 and by May 2001 it was becoming established. So this was an extremely gratifying part of that process. But I see the fruits of that mission continue in many parts of the world today. One of the members of that commission was the Prime Minister of India and the prime minister has championed the scale-up of primary health in rural India and it’s very exciting to see ideas that we’ve developed in the commission be put into practice on the scale of hundreds of millions of people in India right now. HCGHR: In your book, The End of Poverty, you say that extreme poverty can be eradicated in 20 years (beginning in 2005). What role should the average American (and college students in particular) have in this endeavor? Sachs: I think that today’s college students will be the leaders of this process. They’re already leading in college by taking on the challenge, studying it, learning about practical solutions, often forming organizations that take on various aspects of the problem. Students can contribute directly through their work. There are a number of student-led groups that are writing handbooks and guidelines for certain parts of the poverty eradication strategy. Students are volunteering, they’re interning in important projects, including the Millennium Villages Project. Students have set up NGOs, one of them being Unite for Sight which is an NGO that was created by a student at Yale to take on the challenge of preventable blindness in poor countries. There are definitely success stories. In addition, these goals stretch into 2025 and these will be the professional years of today’s stu-

dents, and I think students are going to bring unique skills. For example, all of the social networking skills are going to make it possible to reach hundreds of thousands of villages around the world in ways that were unimaginable even a few years ago. The connectivity of information, the online services can be used to create a highly connected world information network. It’s something that today’s students will know how to do a lot better than I and my colleagues’ generation. So I’m very excited by the fact that across America’s campuses I see tremendous amounts of creativity and dynamism around these issues. I think this is where the solutions are going to be found. HCGHR: Based on a career as an economist with a broad range of experience in the field of global health, what type of synergy do you see between the fields of economics and global public health? Sachs: First, these are two of my favorite areas of study and work, so I would recommend them highly to anyone interested in them. I’ve lived in both sides of this field now for more than 30 years and I find both fields incredibly exciting, connected, rich areas of work. Economics helps you to think through the mobilization of resources. Public health is a thoughtful and interesting discipline to understand how to improve health at a population scale as opposed to an individual patient scale. Since both professions work at the population scale, and since economics is so important in the determination of health outcomes and health is so important in the determination of economics, it’s a great partnership and a wonderful area for joint study, joint research and for joint advanced degrees.

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An Interview with Ed Hunter Justin Banerdt, Staff Writer

deal a lot with Congress and other federal agencies and our Washington partners have a big stake in the 2009 H1N1 as well…

Photo courtesy of CDC

d Hunter represents the Centers for Disease Control and Prevention in Washington before the United States Department of Health and Human Services, other Administration officials, and non-governmental entities. He also directs and oversees CDC’s legislative strategy. Since 2003, Mr. Hunter has been Deputy Director of CDC’s Washington Office. This office is the Washington, D.C. arm of the CDC Office of the Director, serving as a bridge between CDC and the Washington policy community. HCGHR: What is your agenda while at the CDC and what changes do you hope to bring to the organization? Hunter: The CDC is engaged very directly in a number of really high profile things right now. Obviously, getting the effective response to the H1N1 epidemic is key right now. That in many ways is dominating our leadership and much of our science base and certainly my office here in Washington. I am the head of the CDC Washington office where we

There’s a lot of federal engagement and also clearly congressional engagement in a response of this magnitude. So our office is very much engaged in that and that is sort of a dominant thing for the agency since this virus appeared in April and it will certainly continue through the fall and throughout the flu season… Another is health reform. [Health reform is] a Washington policy agenda and there is a lot at stake for prevention through health reform, not just in health insurance and financing and whether there’s a public option and a lot of the other more visible things that are covered very well in the press. But there’s a lot of concrete things about what we can do to advance health, what we can do to advance prevention through the health system in terms of benefits and coverage for preventive screening and interventions. Also, what we can do at the community level to promote and protect health, [such as] setting the policies and other things in place in communities that actually keep people from needing medical care down the road. So that’s something that we are actively engaged in. Those are the two biggest things that I devote a lot of attention to and that

the leadership of the CDC is very focused on right now. HCGHR: How will the hype around H1N1 be affecting the CDC’s other activities this year? Will resources be shifted to deal with this problem and do you foresee that other projects may suffer from this? Hunter: The CDC has a very well established preparedness and emergency response mechanism and we’re really using that mechanism to its fullest for this response… We have a whole network of staffing, roles, and capabilities that we’ve been sort of rehearsing and exercising over the past four or five years--not only for a pandemic but also for a response to naturally occurring disasters and other illnesses. A lot of this is built in anticipation of something like an anthrax attack that we suffered in 2001. So that mechanism and the roles and the exercises… are being brought into play… so we actually have a structure and a framework to use for this response. It obviously pulls in a tremendous amount of resources from across the agency. We have somewhere between 1,000 and 1,500 of our staff that’s actually actively engaged in the H1N1 response, from an epidemiology and investigation point of view, for vaccine distribution, vaccine safety monitoring--preparing those guidelines, the laboratory elements of this, and of course the communication and IT aspects of

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this are really normative. It is pulling from every part of the organization and obviously it is partly paid for by emergency supplemental funding from the Congress [and] partly paid for from resources the agency already had. So it certainly is extending us to the max for the capabilities that we have…. Many resources are from the state and local level and health departments that are already stressed from state budget cuts and just because of the economic situation. There have been some federal resources that have been brought to bare--to help them do vaccine planning and distribution [and] some of the other preparedness side. [However] that’s

in severity. But I think we have a long history of doing after-actions and corrective actions in every public health event that we are in. On this type of emergency response we do a systematic after-action; we’ve done some of these on an interim basis from the spring. We are better at communicating with our counterparts in state and local governments and around the world. I think we are learning a lot about how we communicate well with the public and with our partner organizations… Tracking I think is tremendously improved from where we might have been a year ago… We have tried very hard to rebuild some of the capacity at the state and local levels and to

starts to affect all of society as opposed to a more limited medical or public health world… I think we have learned a lot about what’s involved in trying to coordinate/motivate across all parts of the government and to talk to the public directly and healthcare systems… [In the end] we hope that every response we do gives us information to improve the next one. HCGHR: The topic of our upcoming publication is health, equity, and health access. How is CDC policy trying to currently address health inequity in developing countries and what are common obstacles in addressing this problem?

“One of the unique aspects of CDC is to help strengthen the health systems of countries around the world...” something where putting H1N1 on top of an already stressed state in local health department infrastructure is a real challenge. HCGHR: What lessons is the CDC taking away from the H1N1 pandemic in preparation for one that could potentially be far worse, such as avian influenza? Hunter: I think one thing is the premise of your question: that this one isn’t potentially bad is hopefully correct, but might be optimistic… We are not done with this one. Influenza is a very unpredictable virus, it’s very clever, it’s a worthy opponent to all the systems and technology that we have in place so one would like to think that this doesn’t change

understand what it takes to do things like that… I think we’ve learned a lot about all the different parts of the United States government that have something to contribute to making an effective guidance to the public or just, for example, to schools, where we are not the only experts on what happens… So working more closely with the Department of Education we know better how to communicate with schools about what they should do in a situation like this. We probably have been asked more questions, just by the nature of this as it unfolds and expands and consumes people’s attention. I think we’ve been coming to understand all the various dynamics of [how] something like this

Hunter: CDC has a big role in global health, partly through the president’s PEPFAR program… But one of the unique aspects of CDC is to help strengthen the health systems of countries around the world, particularly developing countries. That’s one of the really key things: to try and not just tackle one problem at a time but to build the infrastructure in countries for laboratory capacity, epidemiological capacity, and the overall health systems through the health ministry and others so that this can be sustainable and some health problems can be addressed in a real systemic level. I think that’s one of CDC’s major involvements on the global side.

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An Interview with Frank Donaghue Alexa Stern, Interviewer ties should be for human rights. So we really do work closely together.

Photo courtesy of PHR

rank Donaghue has served as Chief Executive Officer of Physicians for Human Rights since 2007. With more than three decades of experience in the nonprofit sector, Donaghue has a distinguished track record in humanitarian service, fundraising and management. Under Donaghue’s leadership, PHR has continued to increase its impact on issues of torture, asylum, conflict, global health, and forensics, and its student program continues to thrive. HCGHR: Over the past decades, numerous global health organizations have developed. What is your vision of the collaboration and cooperation between Physicians for Human Rights and these other organizations? Donaghue: First of all, I think there’s great collaboration. For example, we did a report on human torture with Human Rights Watch, and so we’re part of a broad group of human rights organizations that meet regularly. Whenever there’s a human rights issues we… talk about what position all of us would take in a kind of one voice way. For example, when Obama came into the administration, we sent together a document outlining basically what we think his priori-

Sometimes, however, organizations will take a position that another human rights organization doesn’t. We were the first organization to come out and call what is happening in Darfur “genocide,” and other organizations weren’t ready and still haven’t basically said that. So there’s times we agree, and times we disagree, but I think there’s a lot of collaboration. I meet with my colleagues at Amnesty [International], Human Rights First and Human Rights Watch (the mainstream human rights organizations) a lot. For example, in the campaign against torture, I think Human Rights Watch and Human Rights First each brought their own unique skills, particularly [for] the legal issues of torture. We brought the health issues to the table and together they’re the kinds of things that raise the bar and the visibility. So without the legal ramifications and the health documentation, you don’t move the bar as far as you can together. HCGHR: There has been a lot of talk about the “brain drain,” in which physicians and nurses from developing countries leave for jobs in more prosperous nations. This issue has come up in U.S. national news, as Congress considers a bill that would bring in more foreign health practitioners to augment the domestic healthcare workforce. What is your opinion on this legislation, and how do you think the problem of the “brain drain” can be solved? Donaghue: We’ve written a couple

of reports on brain drain, particularly in Africa, and we were particularly instrumental in the new PEPFAR reauthorization (the President’s AIDS funding) to get included in that reauthorization the money for 45,000 new health care workers in Africa. The brain drain issue is obviously complicated, but let me take it from the developing countries’ perspective, rather than the United States’ perspective. The vicious cycle that happens is: the United States sends money for PEPFAR to, let’s say, Uganda, and the money is going primarily to folks in the capital. And so, the doctors and nurses from the inner lands are coming into the capital to get much greater salaries than they were getting working out in a clinic. They come into the capital in Uganda, and then Americans and other Europeans come in and “poach” them from the capital because they are now the most skilled, have the most training and greatest ability. So it’s almost like this vicious circle: we fund them to help their people, we pull them into the city, then we steal them from them and do it again and again and again. So I think brain drain is a really complicated issue, both if you’re in Nebraska and if you’re also in Impala, and just taking doctors and nurses from developing countries to meet the growing need here is not helping the developing countries that we claim to be helping. I think we need to come up with some other solution. We’ve been working a lot with developing countries in how they build a workforce. We just published a document that is a sort of “how-to” for developing countries

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Brain drain is a really complicated issue…just taking doctors and nurses from developing countries to meet the growing need here is not helping the developing countries that we claim to be helping on how to build a health workforce system--how to retain health care workers. But I think it is wrong for the U.S. to fund getting doctors to move from the clinics to the capital and then stealing them for [ourselves]. We see that in Britain and we see that in the U.S. all the time. HCGHR: What do you believe to be one of PHR’s most successful campaigns/projects and why do you think that it has worked out so well? Donaghue: I’ve only been here for two years, so it’s hard for me to say. Obviously, being a co-receipient of the Nobel Peace Prize for our campaign to ban landmines is huge. There aren’t many organizations who have won a Nobel Peace Prize. I think it’s indicative of exactly what PHR does. We’re really good at creating a campaign, creating public pressure around an issue and mobilizing people to become activists. Since I’ve been here, certainly our Health Action AIDS program [has been successful], which is all about AIDS in Africa and getting PEPFAR reauthorized, getting language around health care workers, and the whole feminization of AIDS coming to light. During the Bush administration, PEPFAR was just dropping pills all over Africa, but you can’t stop AIDS that way. You can only stop AIDS when you take a more comprehensive approach. For example, teaching people about reproductive health, allowing women to say “no.” The

Bush administration said “reproductive health” was code for “abortion,” so you couldn’t get any money being used for reproductive health. Also [successful has been] lifting the travel ban on people who are HIVpositive. Those have been the big issues most recently. We did get the reproductive health in the reauthorization, we did get health care and health workforce in the reauthorization, and so I think those are all really positive accomplishments. Personally, I think Zimbabwe was amazing for us. I got a call in November from a medical student. I said, “How are you doing, Norman?” and he said, “I’m doing as well as everyone else.” I said, “No, how are you doing?” He said, “I’m just sitting here like everyone else waiting to die.” That was the day we decided to go, and we were on the ground in 30 days, and the report was released worldwide in another 30 days. I think it was a real indication that PHR and the way we operate is somewhat different. We can be much faster in the way we bring data to the field. For me, that personally has been the most rewarding. But I think everything we do, for example the work for the campaign against torture, is mind-boggling and astounding. We have a full-time person that just investigates… every single aspect of the administration (the previous administration) and what they did to perpetrate torture

on human beings. His work and the way we release it: we don’t always come out with what we know with the name PHR on it. We deal with a lot of media, reporters, providing them with information they can use to further our work because justice doesn’t need our name on it… HCGHR: In a Physicians for Human Rights article on health professionals’ involvement in monitoring and aiding torture, PHR calls for those who violated ethical standards to be held accountable through criminal prosecution. What about professionals who were truly just there to monitor the interrogations and did not contribute to the torture techniques? Donaghue: We believe that psychologists and physicians should not be present during any torture. That is a violation of the very core of why they’re healers. However, the psychologists that were involved primarily with the CIA developed a reverse interrogation technique... This was a training that we used to provide American soldiers when they were being tortured [on] how to avoid torture. That’s how it all started. It was invented by some psychologists in California, and they sold it (literally) for lots of money--how to teach that and how to break people. So we used it for our people on how to protect them, and we used it for our people on how to torture others. So a guy comes in to Guan-

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global health review tanamo, a psychologist meets with him, and determines that the issues that will really crack this guy are, say, sexual humiliation or isolation, because these are the things that they are psychologically most vulnerable to. Then they feed that information to the torturers so that the U.S. CIA can use those very specific techniques to break these people. It’s more than just being present. We wrote a report called “Broken Laws, Broken Lives,” which is our last report on torture. We sent doctors, psychologists to interview a dozen men who had been in Guantanamo Bay or Abu Ghraib. The stories in the books are so disgusting that the doctors that reviewed the document, our board of advisors, said it was almost something you couldn’t read-guys being face down in urine for weeks, soldiers sticking guns in them every day for weeks, untold sexual humiliation, isolation for months, never seeing another human being. There is one story where they would play [recordings of] screaming women in the next room and tell these guys it was their wife or their 12-year-old daughter that they were raping. Psychologists were present. You can’t tell me under any code of ethics that that is acceptable. It’s totally a lie that these psychologists were present to protect the victim of torture. They were there to empower the CIA on how to break these people more thoroughly. In the past six years, we’ve been really instrumental in getting the American Medical Association to adopt a policy that physicians could not be present during torture. It’s very clear that the American Psychological Association has, if you will, “gotten in bed with the Devil,” and they’ve made a lot of money on selling their “souls” to the CIA. We brought much of that to

light. It continues to come to light that the leadership of the American Psychological Association should be held accountable for the torture and destruction of the lives of thousands of people. HCGHR: Can you tell us more about a PHR project on which you are currently working? Donaghue: We have a couple of exciting projects. One is our continuing campaign against torture... It is being funded primarily by Atlantic philanthropies to continue to demand accountability and holding those who did this accountable and prosecuting them. We work full time on gathering evidence--everything from those doctors and psychologists engaged in it to others in the military and the government who knowingly committed these crimes at the high-

you don’t request asylum within 365 days, you are automatically refused it. Most people that come into this country to seek asylum don’t know that rule, first of all, and live in their own communities and they don’t get all their facts that they need. For a woman who was raped in her country, [who] is often afraid to tell her family what happened once she gets here, getting the opportunity and understanding the law in order to gain asylum is really difficult. Number two, border control people can meet an asylum seeker at the border in Mexico and decide that you’re lying and send you back. It’s totally up to the border control people, so there is no real filter to say if these people are telling the truth. It’s basically happening by some policeman at a border deciding if this woman is telling the truth

“We believe that psychologists and physicians should not be present during any torture. That is a violation of the very core of why they’re healers.” est level of the administration, including the [former] vice president. Asylum is another project we’re working on. Our custody work is around torture because it’s about being held in custody and also asylum seekers in this country. A woman who was genitally mutilated in her previous country, under the Bush administration, could be sent back to her country because she couldn’t be mutilated again… The arcane rules that are put in place for asylum seekers in this country are pretty outrageous. People are being put in mandatory detention and there is a crazy guideline that if

about her life being destroyed. Third, the health system in detention centers is deplorable. Often these people that come here to seek freedom from untold oppression and torture are treated very poorly. The government contracts with the same companies they contract to monitor “terrorists” and prisoners, so many detention seekers are treated like prisoners. They’re kept in detention centers just like prisoners; they’re treated like prisoners. The health care system is deplorable. So far this year, 60 people have died seeking asylum in this country for lack of medical care. These are peo-

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global health review ple that left their country where they were tortured or abused and come here for freedom and die in our care. That’s outrageous. So we’re working

vey women who had been raped in Darfur as a weapon of war. It’s about our third report on Darfur and our goal is to launch a major,

So far this year, 60 people have died seeking asylum in this country for lack of medical care on asylum. Basically, we’re pushing for removing mandatory detention, pushing for an improved health care system for asylum seekers… The other project is a study [we just released] called “Nowhere to Turn.” We sent doctors, women doctors, of course, into Chad to sur-

international project next year on how local NGOs can document rape and the impact of that in order to get the perpetrators. Right now, there’s obviously doctors doing this. I met a doctor from Congo, and I asked him what was the youngest and oldest female he had seen

who had been raped. The youngest was 5 and the oldest was 85! And they were repeatedly raped. Rape is an increasingly serious weapon of war. We know it is used in Uganda, Congo, and particularly throughout Southern Africa. So our project would be to work with local NGOs and teach them how to gather the forensic evidence and documentation to prosecute those who are guilty of rape. It really could be a significant change agent because the women and women doctors in these countries are just speaking to each other. They don’t have access, the Congolese people to the Ugandan people.

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We Eradicated Smallpox, So Why Not Malaria? Annemarie Ryu, Contributing Writer

wo infectious disease pandemics, two global eradication campaigns. The results? For one, complete eradication by 1970, within thirteen years of the campaign’s inauguration—there are no deaths today resulting from smallpox. And the other? The global malaria eradication campaign, begun in 1955, was abandoned in 1965, when goals shrank to “malaria control.”1 Today, malaria, though preventable and curable, causes between one and three million deaths per year and is among the top ten causes of death in developing countries.2 Why haven’t we eradicated malaria when we did eradicate smallpox? Comparing the two campaigns teaches us about past successes and failures and informs today’s eradication efforts. The drastic divergence in health outcomes is partly a result of differences in disease characteristics. One key difference between smallpox and malaria is that a smallpox survivor is immune to the disease for life while a malaria survivor may reacquire the infection. Whereas the smallpox vaccine could ensure lifelong protection from smallpox, malaria interventions and preventative measures required continuous management in all at-risk areas to actually eliminate malaria. Such management required restructuring fundamental health services, whereas smallpox programs could simply be administered temporarily by external groups.3

Another crucial distinction between smallpox and malaria is in ease of diagnosis and containment. Smallpox spreads through saliva droplets from coughing, sneezing, and speaking, as well as fluids contained in pustules of the infected individual. Fortunately, anyone with smallpox was easily recognizable due to smallpox’s main symptom: innumerable skin lesions. This easy recognition facilitated disease containment, as vaccinators and community members could readily identify individuals requiring treatment. In addition, vaccinators could administer preventative treatment to community members deemed at-risk due to contact with diseased individuals. The efficient containment and treatment of infected individuals was sufficient to control the spread of disease.3 Malaria, on the other hand, is far more difficult to recognize and contain because it is transmitted by mosquitoes carrying one of four types of malaria parasites. Thus, for malaria to be eradicated, not only did infected individuals need to be identified and treated, but infected mosquitoes also needed to be eliminated. Malaria-infected individuals were difficult to identify because common first symptoms of malaria include headache, chills, fever, and vomiting—symptoms similar to those of many other infections—and can appear seven days to several months after exposure, depending on the

incubation period of the parasite. Furthermore, due to the life cycle of malaria parasites, malaria-infected individuals often exhibit symptoms in cyclic patterns, with symptoms of different intensities appearing and disappearing.5 A major complication for malaria eradication was the need to prevent infected mosquitoes from transmitting the parasite to humans. The main strategy was mass spraying of the insecticide DDT inside homes. This strategy, coupled with administration of chloroquine, a drug that kills malarial parasites, led to significant decreases in mortality rates during the first decade of the eradication campaign. However, DDT and chloroquine as applied were insufficient to halt infection by mosquitoes, which flourished in the fields and swamps often located near villages. It became clear that difficult environmental reconstruction would be necessary to eradicate malaria.3 Support for the malaria eradication campaign waned for several reasons. First, increasing mosquito resistance to DDT and parasite resistance to chloroquine meant higher costs and slower progress. The initial popularity of the campaign was tied to the post-WWII faith of Americans in easy solutions provided by new science and technology. Western enthusiasm dwindled as DDT failed to efficiently solve the malaria problem.3 Second, economic consider-

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In this 1980 file photo, Directors of the Global Smallpox Eradication Program (left to right) Drs. J. Donald Millar, William H. Foege, and J. Michael Lane celebrate after learning that smallpox had been eradicated on a global scale (Photo courtesy of CDC).

ations played a significant role in the decline of the campaign. Initial support for the campaign was partly founded on the belief that the eradication of malaria would lead to great economic benefits for developing countries, where a significant expansion in the healthy labor force would heighten productivity, and developed countries, which could utilize the new foreign markets. In addition, campaign proponents promoted malaria eradication as a way to increase agricultural production and address the world food shortage. However, the increasing costs associated with the campaign, as well as the poor agricultural conditions induced by extensive application of insecticides, diminished hopes for economic gains. Other economic problems included pressure from pharmaceutical firms and chemical companies for continued use of DDT and drugs that were losing effectiveness. The practice of pesticide-intensive cash cropping in developing countries also encouraged mosquito growth and conflicted with much needed

environmental transformation.1 Third, the political atmosphere ceased to favor the campaign. The United States had strongly supported the campaign at its inception as a straightforward way to win over nonaligned developing countries during the Cold War.3 However, when over a decade of exhaustive campaign efforts met with decreasing rates of improvement rather than complete success, the campaign faced international criticism. Changes in foreign relations and public health caused WHO to broaden its focus to development of primary health services rather than simply malaria eradication, and this change led to a weakening in traditional malaria control

1 Turshen, Meredith. The Politics of Public Health. New Brunswick: Rutgers University Press, 1989. 2 Millennium Project. “Global Burden of Malaria.” 2006. 28 Sept. 2009 <http:// www.unmillenniumproject.org/documents/ GlobalBurdenofMalaria.pdf>. 3 Farmer, Paul. “A Social Analysis of Past Global Medicine.” Northwest Biolabs B103, Cambridge. 17 Sept. 2009. Lecture.

programs.4 With such decreases in global support of malaria eradication, malaria prevalence began to climb again by the 1970s.3 Today, malaria has nonetheless has been eradicated from many regions of the world. In developed countries, fundamental changes in living conditions and agricultural practices have led to environmental transformation. Socialist countries, such as Romania and Poland, eradicated malaria by means of strong health delivery systems that upheld intervention programs. Islands such as Jamaica and Taiwan have benefited from geographical barriers hindering re-introduction of the disease.1 Still, malaria continues to thrive in developing countries. Fortunately, there is much hope for its future eradication. The latter decades of the twentieth century contributed new developments and advances in disease vector control, vaccines and drugs, and insecticide-treated mosquito nets. In addition, today we have a much better understanding of the cultural, economic, and social dimensions of malaria, as well as renewed financial support and enthusiasm for malaria eradication.6 With the Roll Back Malaria campaign targeting 50% decreases in malaria mortality by 2010 and 2015, and the Millennium Development Goal of zero malaria incidence by 2015, the goal of global malaria eradication has returned to our vision for the future.

4 Cueto, Marcos. The origins of primary health care and selective primary health care. American Journal of Public Health. 2004;94(11) 5 “Malaria.” Drugs.com. 2009. 28 Sept. 2009 <http://www.drugs.com/cg/malaria.html>. 6 World Health Organization. “Malaria Eradication Back on the Table.” Bulletin of the World Health Organization. 2008;86(2)

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Say Yes to Drugs: The Anatomy of a Campaign Abby Schiff, Contributing Writer

lobal health work occurs on many scales, from policy rooms to rural health clinics, from research laboratories to pharmacies in far-flung parts of the world, and each setting has its own language and challenges. As students, we are most comfortable in the world of the university. We can use our position to change the way Harvard licenses drugs developed here to increase access in developing countries. This fall, the Harvard College Global Health and AIDS Coalition (HCGHAC) teamed up with four other on-campus organizations (the Harvard South Asian Men’s Collective, the Association of Black Harvard Women, the Harvard South Asian Women’s Collective, and the Harvard Black Men’s Forum) for the “Say Yes to Drugs” campaign, which focused on putting pressure on Harvard to change its licensing policies. The campaign quickly gained visibility on campus, got 943 signatures on a petition that will be delivered to administrators, and raised about $5000 for global health non-profits Asha and Partners in Health. This campaign can serve as a model for raising global health awareness, working with many different sectors of the university, and taking action on what can be a complicated technical issue. The cause is pressing. 10 million people die every year from treatable diseases. These are deaths that could be prevented if there were greater access to existing medicines, many of which are developed at

universities. In fact, every vaccine in the last 25 years and 35% of all HIV drugs were developed at universities. Harvard made $24 million in 2004 from the sale of medical technologies, and continues to be a leader in research. When a potential therapy is developed by Harvard researchers, the Office of Technology Development helps the research team sign a license with pharmaceutical companies, who then price the product according to a profit-maximizing strategy. Universities Allied for Essential Medicines (UAEM), a national student group, is working to change this situation by pushing for universities to write licenses that allow for generic competition in developing countries. Because drug sales in developing countries only make up a small percentage of pharmaceutical companies’ profits (Africa is 1.3% of the pharmaceutical market), licensing for essential medicines is an innovation that would increase access to medicines without significantly harming pharmaceutical companies’ or universities’ incentive to innovate. HCGHAC, which is the undergraduate chapter of UAEM, worked on licensing during the 2008-2009 school year, but decided to intensify its efforts and focus on the issue for the fall of 2009. In addition to continuing to hold conversations with faculty and administration, we decided to launch a high-profile student campaign to get the administration’s attention and show the importance of this issue to the stu-

dent body. We also sought to build off the groundbreaking work on this issue initiated by Yale’s UAEM chapter in 2001. Their student campaign, which included mobilizing student support and working directly with the inventor of the HIV drug D4T, led to the drug becoming available as a generic antiretroviral in developing countries. 800,000 people since then have been placed on treatment with the medicine. After settling on a catchy name—Say Yes to Drugs— we got to work, with emails flying back and forth over the summer. In order to target the three constituencies, we decided to meet with the Office of Technology Transfer and other administration figures; meet with professors and researchers; and plan a campaign with a dance launch to gain student support. We also held a speaker event in order to raise more informed awareness about the issue. Recognizing the fact that licensing can be opaque, we talked about how to best present it to other students, administrators, and professors. We held teach-ins with the Harvard Law School chapter of UAEM, learned about legal details of licensing, and practiced giving mock presentations to student groups before dispersing to spread the message. Developing this part of the campaign was difficult. As Krishna Prabhu ’11 said, “It’s a different thing having to make an argument on a test and having to convince your peers about the urgency, importance, and gravity of an issue like access to medicines. It’s

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global health review required me to think critically about how to deliver a complex message.” Teams of HCGHAC and other group members split off into groups of two to present to student organizations and gain broader support. At times, the groups were asked challenging questions. Alyssa Yamamoto ’12 reflected that “receiving critical responses to my presentations of the campaign has been especially worthwhile—forcing me to comprehend common critiques of our cause and still defend the campaign.” At the same time, we started meeting with co-organizers SAMC, SAWC, BMF and ABHW to plan the dance, the petition, the speaker event, and the surrounding campaign. Prabhu explained that “probably one of the best things that is materializing from this campaign is the alliances we’re making with other student groups… to not only inform students about the issues, but create a support base for future actions.” The five groups designed and ordered shirts, and everyone took shifts to poster, build two giant pill bottles representing the amount of generic or brand-name pills available for the same cost, sell tickets, and staff our booth outside of the Science Center for a week to solicit petition signatures. Crowds of people wearing trademark bold black tshirts could be seen dancing to music in the middle of the Science Center courtyard, handing out flyers and shouting “Say Yes to Drugs!” While the work was completely elective, some students threw themselves completely into the campaign—Yamamoto said “there certainly came to be a point at which I put more effort into SYTD than my own academic work or social life.” The hours spent together caused the group to become closer while working for a cause. Student response to the cam-

paign was mostly positive. By the end of the week, the campus was covered in “Say Yes to Drugs” posters, and most large classes were peppered with students wearing the t-shirts. Margie Thorp ’11 adds, “It’s very tough to disagree with the things for which SYTD is asking, so we have been able to get a high degree of approval from students across campus.” People came up to campaign members in dining halls and sparked conversations about Harvard’s pharmaceutical licensing policy. Jason Shah ’10 said, “From blog posts at each end of Harvard’s political spectrum, to confused stares outside of the public display, I have seen an overwhelming amount of interest sparked from this campaign. While the messaging initially is just catchy, the student population has come to see the true substance behind the campaign and has latched onto it.” We received positive reviews from both the campus Democrats and Republicans. A speaker event with Dr. Matt Craven of Support for International Change and Partners in Health attracted interested students. It’s debatable whether all of the 600 students who attended the benefit dance can hold their own about licensing policy, but we were able to raise money and awareness and col-

lect signatures for the student petition. The dance created publicity in a way that postering and speaker events could not, because it reached out to a larger segment of the Harvard population. The whole process involved a fair amount of delegating, and we were only able to get much of the work done thanks to the organizing power of a few individuals, especially Jason Shah. Having so many people involved in the process meant that it was easy to get large numbers of volunteers, but that it was a more difficult to administratively oversee progress. However, we benefited from having a wide distribution of talents and from having cooperation between groups. On a campus such as Harvard’s, where most people are busy and breaking through to the average student’s consciousness is particularly difficult, it was a huge help to have student cooperation. As the campaign progresses, the momentum from the kick-off and the partnerships that we have built will serve us well in convincing the administration to change its policy. We hope to build on the groundwork of this student movement in order to make essential medicines available to people who need them in the developing world.

Photo courtesy of HCGHAC

“The highest attainable standard of health is one of the fundamental rights of every human being.” Preamble to the Constitution of the World Health Organization

The Harvard School of Public Health’s (HSPH) overarching mission is to advance the public’s health through learning, discovery, and communication. Degree programs are offered at the master’s and doctoral levels in the areas of policy, management and research. We also offer a joint MD/MPH program with any medical school. Please visit www.hsph.harvard.edu for more information. If you are interested in HSPH, please contact the Admissions Office at 617-432-1031 or at admisofc@hsph.harvard.edu.

Harvard College Students in Chile, Summer 2010 (Monday June 14 – Friday August 6) Santiago, Chile

Health and Spanish Immersion (HIS) Program with credit for students interested in medicine and global health. • Spanish classes for credit focused on medicine, health and sciences • Shadow a doctor in a public hospital managed by Universidad de Chile • Work as a volunteer in a community health setting • Stay with a local family • Receive credit towards your Harvard degree • Total immersion in the local culture and language For more information contact: Pilo Mella at mella@fas.harvard.edu http://www.drclas.harvard.edu/regional_office/students/summer_course/hsi