Harvard College Global Health Review--Winter 2010

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From the Editors

The Geopolitics of health

content

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Building Better Global Health BRICS: Emerging Countries and Global Health

Shalini Pammal

Ryan Lee

Toward the Eradication of Polio: Negotiations in the Last Endemic Regions Leeann Saw

Answering a Global Appeal for Support: Triumphs and Limitations of International Humanitarian Response

10 The Challenges to Global Recognition of Cancer Burden in Developing Nations

Mark Ragheb

TABLE OF CONTENTS

Volume II, Number 1, Winter 2010

24 Deconstructing Barriers: Ending Discrimination Against the Disabled with Community-based Rehabilitation

Sarah McCuskee

26 HIV and Syphilis in Latin America:

Improving Maternal Health Systems

Melissa Barber

28 Project Health:

Advocates for Healthcare Beyond the Clinic

Alyssa Botelho

30 Deadly Mix: Injected Drug Use, HIV, and Street Children in Russia

Daniel Wilson

12 The Millenium Development Goals:

Now or Never

32 The Perfect Storm: Rising Health Concerns Due to Climate Change Alert the Pacific Islands

14 Human Trafficking: A Global Health Problem that Demands Local Attention

Interviews

Yuying Luo

Annemarie Ryu

16 Diplomacy, Ethics, and Global Health:

The Impact of U.S. Sanctions on Cuba and North Korea

Eesha Dave

Interviews 18 An Interview with Tachi Yamada Panorama

Hannah Semigran

34 An Interview with Elly T. Katabira The Expert Perspective 36 Saving Lives through Country Ownership: Three Steps for President Obama’s Global Health Initiative to Succeed

Raymond C. Offenheiser | President, Oxfam America 40 mHealth Basics and Human Scalability

Isaac Holeman & Josh Nesbit | Frontline SMS:Medic Cofounders

22 The Next Revolution: Making High-tech Diagnostics Accesible and Affordable

Judy Park

44 Community Participation: Who Participates, Who Decides?

Daniel Palazuelos | MD, MPH Interviews 49 An Interview with Daniel L. Shapiro Student Spotlight 55 Working in Tanzania

Debanjan Pain

57 A Summer in Costa Rica

Photo courtesy of Judy Park

Emelyn Rude

59 Quality-Improvement in Tanzanian Health Facilities

Anita Joseph

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The Harvard College Global Health Review, Winter 2010 EDITORIAL BOARD

BOARD OF ADVISERS

Editors-in-Chief Section Editors Rajarshi Banerjee Justin Banerdt (Features) Michael Henderson Alison Kraemer (Panorama) Lavinia Mitroi (Experts and Interviews) Managing Editors Angela Primbas (Student Spotlight) Daniel Driscoll Sarah Littlehale

David Bloom, Ph.D.

STAFF

Melissa Barber Alyssa Botelho Ava Carter Eesha Dave Ryan Lee Yuying Luo Sarah McCuskee Farhan Murshed

DESIGN BOARD

Shalini Pammal Judy Park Mark Ragheb Annemarie Ryu Leeann Saw Hannah Semigran Daniel Wilson Pratyusha Yalamanchi

Lavinia Mitroi (Chair) Whitney Adair Shilpa Ahuja Yingna Liu Samuel Mendez Florence On

Chair, Department of Global Health and Population, Harvard School of Public Health

Allan M. Brandt, Ph.D.

Dean, Graduate School of Arts and Sciences; Professor of the History of Science; Amalie Moses Kass Professor of the History of Medicine, Harvard Medical School

Arachu Castro, Ph.D., MPH

Assistant Professor of Social Medicine, Department of Global Health and Social Medicine, Harvard Medical School

Cecil Haverkamp

Project Manager, Harvard University Program on Humanitarian Policy and Conflict Research; Coordinator, Harvard School of Public Health Office for Educational Programs

Robin Herman

Associate Vice Dean for Communications, Harvard School of Public Health

GRADUATE STUDENT BOARD OF ADVISERS Eitan Bernstein Laura Khan Yvette Efevbera Sophie Miller Mike Frick Sophia Qiu Subhada Hooli Danae Roumis

Andrew Thorne-Lyman

The Harvard name is a trademark of the President and Fellows of Harvard College. It is used with the permission of Harvard University. Opinions, views, and statistics printed in this journal are those presented by the contributors and not necessarily a reflection of the views of the editors. No part of this publication may be reproduced, sold, or transmitted without written permission of the editor-in-chief of the HCGHR.

Like what you see? Check out the HCGHR’s new website at: http://hcghreview.org/hcghr/ Archives, web exclusives, events, and more...

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global health review From the Editors

Volume II, Number 1, Winter 2010

Dear Reader,

The world of global health is one of scant resources and competing interests. Just as delivery and access cannot be taken to operate in a vacuum, neither can the allocation of these valuable, and recently diminishing, resources. This issue of the Harvard College Global Health Review looks at the myriad reasons behind resource allocation within foreign policy frameworks meant to support larger political strategies in a seemingly altruistic field.

Countries, multinational agencies and large nonprofits are setting today’s global health agenda, and these actors’ motives, priorities and goals rarely align.

Consider the beleaguered nation of Pakistan, where many more people have been affected by the recent Indus river floods than were in the Haiti earthquake in January—the international community has pledged only $91 million in aid to the country, a mere one-tenth of the amount pledged to Haiti. Such an aid mismatch is rooted in something we call the geopolitics of global health.

In this issue, Shalini Pammal finds that Pakistan lost out in a lot of aid due to a lack of public donor support in Western countries; this lack of support can be attributed to Americans’ simplistic perception of Pakistan as a country that harbors al-Qaeda terrorists.

Ironically, in the absence of enough Western or governmental support, Pakistan’s militant Islamic groups have played a hugely important role in administering aid to the country’s flood victims, largely legitimizing themselves and gaining more influence than they have had in years.

While Pakistan’s case is one of negative unintended consequences, geopolitics can also have a positive effect on global health. Ryan Lee notes that today’s rising powers—Brazil, Russia, India and China, or the BRIC nations—are using their own experiences to help other developing countries fight their biggest health problems, all as a means of exercising their own soft power.

In an article on the United Nations’ Millennium Development Goals, Yuying Luo discovers that much progress towards achieving these very goals has been

hindered because different governments often have different, competing priorities, even when they all agree to the same multinational framework. The United States certainly has its own priorities, as explored by Eesha Dave in her article focusing on the impact of American sanctions on health care in Cuba and North Korea.

Our Features section devotes further attention to intriguing articles on humanitarian issues that warrant far greater attention than they currently receive: Annemarie Ryu exposes the grim truth around human trafficking, Mark Ragheb rightly points out that cancer is not only a rich nations’ disease, and Leeann Saw finds that anti-vaccine movements in Nigeria and Pakistan may prevent polio from being eradicated in those countries anytime soon.

Aside from looking at the geopolitics of global health, this issue explores a wide swath of topics in our most diverse Panorama section to date, and offers the expert perspectives, high-profile interviews and engaging student submissions for which HCGHR has become well-known.

Finally, we are proud to announce that HCGHR does not just limit itself to a once-a-semester publication. This Fall we helped begin GH|X, a new inter-disciplinary bi-weekly global health forum where anybody interested in global health can participate by discussing their and others’ work in a friendly and informal environment. We hope to further engage in similar initiatives in the future, especially as we now benefit from the tremendous support of the Harvard Institute for Global Health, to whom we owe enormous gratitude.

We also hope that you will visit our new and improved website at http://hcghreview.org/hcghr/ for online versions of the HCGHR, updates on global healthrelated events at Harvard, and supplementary articles by our staff.

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

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Building Better Global Health BRICs: Emerging Countries and Global Health

Ryan Lee, Staff Writer

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razil. Russia. India. China.

Together, these four countries lay claim to 42 percent of the world’s population and almost a quarter of global gross domestic product.1 They are the only developing economies whose annual GDPs clock in at over $1 trillion.2 This economic power translates into formidable political influence that only promises to grow apace with the four nations’ populations and economies in the coming decades.

How do the BRIC countries impact global health? The question is both vitally important and strikingly under-addressed.3 The effects of the BRIC countries on global health are as varied and complex as they are farreaching.

Since 2006, the foreign ministers of the four nations have convened annually. Last year marked the inaugural summit of the BRIC country leaders in Yekaterinburg, Russia. The four nations declared common stances on issues such as global food security, liquidity assistance to poorer countries, sustainable development, and energy security.4 Overarching was their commitment to sustainable health and security in a multipolar world. Their second summit this April further reflected this goal: the communiqué states “…the world is undergoing major and swift changes that highlight the need for corresponding transformations in global governance in all relevant areas. We underline our sup-

port for a multipolar, equitable and democratic world order…[with] collective decision-making of all States.”5 The economic and political roles of the BRIC nations have been highlighted by the global financial crisis.

While Western foreign direct investment (FDI) to poorer economies is on the decline, investment by BRIC countries is stepping in to fill that role.

Brazil states that it has invested $10 billion in Africa since 2003, and China last year pledged the same amount.6 As Jennifer Ruger of the Center for Interdisciplinary Research on AIDS at Yale School of Public Health commented to the HCGHR, “many of the emerging countries [are] working together as a bloc, working together through coalitions, and building their own networks.”7 These “south-south” currents of aid and trade reduce reliance on traditional “north-south” flows and bolster the multipolar worldview of the BRICs. Ruger also noted “the way [developing countries] are using their political influence as a group or bloc vis-à-vis the global health system.”7 In November 2009, Chinese premier Wen Jiabo pledged $73.2 million of medical equipment and anti-malarial drugs to Chinese-built hospitals and malaria prevention and treatment demonstration centers in Africa as well as training for 3,000 doctors and nurses.8 Brazil spends $120 million annually on programs such as foreign HIV/AIDS relief programs. Russia

provides medical staffing and material aid to both Africa and disaster areas such as Haiti and Chile. The BRICs also engage in health-related trade with each other: they are all involved in generic drug production, but China and India are also major producers of raw ingredients for drug manufacture.

Brazil purchases these components for its own national antiretroviral (ARV) program.3 Medical assistance is not the primary focus of the BRIC countries’ foreign policies. Joshua Michaud, Senior Research Associate with the Global Health and Foreign Policy Initiative at the Johns Hopkins University Paul H. Nitze School of Advanced International Studies, is quick to point out where global health issues fall in policy makers’ priorities: “Global health is one of them, but it’s not the pre-eminent one. When global health dovetails with foreign policy objectives… the issue gets traction.”9 Medical aid advances BRICs’ agenda of forming a network of developing countries as a counterbalance to Western aid. This assistance is a form of “soft power,” which revolves around indirect gains in influence from technology, education, and economics rather than military prowess.10 Taking soft power in a different sense, the BRICs are leading the way in improving access to medicine and intellectual property. Brazil in particular has played a pivotal role in providing access to ARVs, successfully negotiat-

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global health review ing a resolution with the World Trade Organization to meet its constitutional guarantee of antiretroviral therapy (ART) to its citizens, using a diplomatic and public relations campaign based on a “fight for life.” In addition, Brazilian leaders have been appointed to the WHO’s Tobacco Free Initiative (TFI) and the Intergovernmental Negotiating Body of the Framework Convention on Tobacco Control (FCTC), thus proving that emerging countries can engage fully in what had been considered by the industry a “first world issue.”10 Through these successful policy moves, Brazil has earned the respect of the global community as a leader in global health.

India, with a favorable population age ratio and a thriving capitalistic democracy, has become a hotbed for innovation.11 One such innovation is the Aravind Eye Care System, combining standardization, continuous improvement, specialized training, and low-cost technology to bring about a revolution in eye care.3 The model has impacted eye care in countries such as Bangladesh, Tanzania, and China, and is, according to Ruger, “frankly even a model for developed countries…they’re able to deliver extremely high quality care on as little resources as possible.”7 This highlights a new form of exchange where developing countries on the frontier of cost-

effectiveness can develop techniques that can be shared among more developed nations with entrenched and potentially less efficient forms of care.

While the BRICs stand to make more significant contributions to global health, they also face their own domestic public health challenges.

Brazil’s HIV/AIDS campaign has had significant success, but its tuberculosis treatment lags far behind.3 China has a HIV/AIDS population numbering in the hundreds of thousands and faces a growing population of tobacco-users.12 Of the BRICs, Russia in particular faces an unpalatable mix of public health problems. Coupled with the post-Soviet decentralization of the public health system, rapid, substantial increases in alcohol and substance abuse have compounded issues such as an HIV epidemic that ranks as one of the world’s fastest-growing.3 Clearly, the BRIC countries will require the continuing assistance of the international community.

However, the BRIC countries can act as platforms for addressing public and global health. China’s slow response to the SARS outbreak in 2003 garnered public criticism from the WHO. After this wake-up call, the Chinese government spending on public health increased nearly 100 percent between 2002 and 2006. China

nominated its first candidate, Margaret Chan, for the post of WHO Director-General in 2006. The response to the H1N1 outbreak was much swifter than that of SARS.13 Unfortunately, the reverse situation also exists: there are some global health issues which simply do not register as foreign policy concerns. Michaud warns, “in order to achieve the global health goals that many practitioners want to see achieved, it’s not just a matter of epidemiology and not even necessarily a matter of getting the money; it’s also a matter of getting the political will and priority.”9 This problem often leaves pressing global health concerns like the burden of chronic diseases and mental health out of the policy focus.

As for the BRIC countries and their increasing involvement in the governance of global health, Ruger is unequivocal about the coming changes: “We’re not really at the beginning any more, because there’s an established structure.”7 Whether the developed nations have recognized it or not, the BRICs and the other developing countries have been building their own network of global health interactions that may provide new innovations for all and may even come to change the way global health is governed. Ruger declares, “This is a turning point.”7 It certainly is. 

The BRIC leaders at the 2010 BRIC summit in Brasilia. Photo Courtesy of Agencia Brasil.

1. Budrys, Aleksandras. “BRIC farm ministers pledge to tackle world hunger.” Reuters. 26 Mar 21010. <http://in.reuters.com/article/ idINIndia-47249420100326?sp=true> 16 Oct 2010.

2. “The BRICs: The trillion-dollar club.” The Economist. 15 Apr 2010. <http://www. economist.com/node/15912964> 16 Oct. 2010 3. Ruger, Jennifer Prah and Nora Y. Ng. “Emerging and Transitioning Countries’ Role in Global Health.” Forthcoming in Saint Louis University Journal of Health Law & Policy (2010).

4. Chand, Manish. “BRIC nations seek bigger voice in world affairs.” World Latest News. <http://www.worldlatestnews.com/nationindia/politics/bric-nations-seek-bigger-

voice-in-world-affairs-34865> 16 Oct 2010.

5. “TEXT – Communique from BRIC summit in Brazil.” Reuters. 15 Apr 2010. <http://www.reuters.com/article/ idUSN1513243520100416> 16 Oct 2010.

6. “Middle-income and developing countries: Crumbs from the BRICs-man’s table.” The Economist. 18 Mar 2010. <http://www. economist.com/node/15731508> 16 Oct 2010.

7. Ruger, Jennifer Prah. Phone Interview. 8 Oct 2010.

8. “Chinese premier announces eight new measures to enhance cooperation with Africa.” People’s Daily Online. 9 Nov 2009. <http://english.peopledaily.com. cn/90001/90776/90883/6807055.html> 16 Oct 2010.

9. Michaud, Joshua. Phone Interview. 8 Oct 2010.

10. Lee, Kelley and Luiz Carlos Chagas et al.

“Brazil and the Framework Convention on Tobacco Control: Global Health Diplomacy as Soft Power.” PLoS Medicine 7 (2010): e1000232.

11. “India’s economy: India’s surprising economic miracle.” The Economist. 30 Sep 2010. <http://www.economist.com/ node/17147648> 16 Oct 2010.

12. “China: HIV/AIDS” UNICEF. 2004. <http:// www.unicef.org/china/hiv_aids.html> 16 Oct 2010.

13. Chan, Lai-Ha and Lucy Chen et al. “China’s Engagement with Global Health Diplomacy: Was SARS a Watershed?” PLoS Medicine 7 (2010): e1000266.

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Toward the Eradication of Polio: Negotiations in the Last Endemic Regions

Leeann Saw, Staff Writer

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he World Health Organization (WHO) adopted its official resolution to eradicate polio in 1988 during a time of great hope and expectation. The formation of the Global Polio Eradication Initiative (GPEI) was given inspiration by the global eradication of smallpox in 1980; at the time, the WHO’s goal of eliminating polio by the year 2000 did not seem unrealistic.1 Yet ten years after this deadline, four nations – Afghanistan, Pakistan, India, and Nigeria – continue to struggle to contain this crippling disease. Setbacks faced by the GPEI in these nations, particularly a Nigerian vaccine boycott in 2003, highlight the way in which global health initiatives have become fundamentally linked with political diplomacy. This link is especially relevant for the GPEI today as political diplomacy becomes increasingly essential to eradicating polio in Afghanistan and Pakistan.

The 2003 vaccination boycott in northern Nigeria brought needed attention to the diplomatic responses necessary to overcome the challenges that the GPEI is facing and will continue to face in years to come. In October of 2003, the Eradication Initiative commenced what it hoped would be its final assault on polio in Africa, placing special emphasis on executing successful vaccination campaigns in Nigeria, which at that time was responsible for 80 percent of the cases on the entire African continent.4 However, this approach would prove unsuccessful. Three of the predomi-

nantly Muslim states of northern Nigeria – Kano, Zamfara, and Kadunaan – shut down their vaccination programs at the urging of their state religious leaders, advising parents not to allow their children to be vaccinated.4 Sale Ya’u Sule, a spokesperson for the governor of Kano, stated that “Since September 11, the Muslim world is beginning to be suspicious of any move from the Western world…

Our people have become really concerned about polio vaccine.”4 These suspicions led the religious leaders to believe that the polio vaccine was contaminated with anti-fertility drugs, HIV, or cancerous agents aimed at harming the Muslim children of

The northern Nigerian boycott was eventually brought to a close in July 2004 by the diplomatic efforts of Nigeria’s federal government and the GPEI. The WHO organized meetings with religious leaders in which concerns were expressed about the possible spread of polio out of northern Nigeria during the impending Hajj, the annual Muslim pilgrimage to Mecca in Saudi Arabia. Additionally, the federal government agreed to have the vaccine tested for contamination in Muslim countries.4 First and foremost, the underlying causes of the boycott needed to be identified. Dr. David Heymann, who served as the Representative of

Photo PhotoCredit: Credit:WHO/Rod WHO/RodCurtis Curtis The Emir of Kano immunizes his grandson.

northern Nigeria.4 A Kano physician articulated this belief, stating that the vaccine had been “corrupted and tainted by evildoers from America and their Western allies.”4

the Director-General for Polio Eradication during the boycott and was active in the diplomatic negotiations, emphasized the importance of understanding that it was not the Islamic re-

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global health review ligion itself that objected to the polio vaccines. Instead, he states in an interview with the HCGHR, religion, “was used as a means of politically making a statement.”8 Dr. Jason Weisfeld, an instructor at the Harvard School of Public Health, agrees: “It was very political from the beginning; I think the religious aspects were probably secondary…they were convenient.”7 This politicization of global health has particular resonance today as the Taliban, an Islamic political group, continues to kill and threaten international aid workers in Afghanistan and Pakistan.10, 11 In October of 2009, a top Taliban commander informed CNN that under the group’s new constitution, foreign aid workers will be executed as spies or held in exchange for Taliban prisoners. He added that the group was “actively gathering information on foreign aid workers.”11 In August, the United Nations (UN) reported that there were seven killings of UN staff members and aid workers in Afghanistan during the first six months of this year.12 The actions of the Taliban have made it difficult for the GPEI to reach all children in these countries for immunization, and security remains one of the major barriers to eradication.8 Though the security situation in Afghanistan and Pakistan is grim, there remains the possibility that the GPEI will be able to institute diplomatic policies it developed in 2003 to address these challenges. In an article outlining the causes and effects of the Nigerian boycott, Ayodele Samuel

Jegede, a Senior Lecturer at the Uni- pect of things.”6 versity of Ibadan in Nigeria, urged The parallels between northern future global health groups to be sen- Nigeria in 2003 and Afghanistan and sitive to local politics by involving Pakistan today make it clear that this members of all government levels in new awareness will be essential as pothe delivery process.4 lio eradication progresses. Like NigeDr. Heymann highlighted the ria in 2003, Afghanistan and Pakistan importance of utilizing all available have strong federal government supsources of support to bring about ini- port for their polio eradication camtiative goals. In the case of the north- paigns but face challenges from other ern Nigerian boycott, the scientific political groups.9 As it learned in Nisupport was available, but “science geria, the GPEI will need to rely on could not overcome that political issue all available scientific, political, and alone. Public health requires many religious resources and involve all poskills in diplomacy and other issues; litical parties – including government, it’s not just enough to have a good anti-government, military, and local technology and a good strategy to get groups – in the elimination of polio. it to the people; you must also depend The lessons learned in 2003 in Nigeon political forces and religious forces ria will need to be adapted and apin some instances.”8 As Sona Bari, plied to overcome the obstacles posed a media representative of the WHO on polio, told the HCGHR, “I would say in the last decade, we’ve made huge strides in understanding the central role PhotoCredit: Credit:Steve SteveBrown/Rotary Brown - Rotary Photo of diplomacy and advocacy in Fary Moini administering the oral vaccine. public health.

We used to be very much driven by by the extremist opposition forces in doctors and the nature of the organi- Afghanistan and Pakistan. If the Pozation has changed very much since lio Eradication Initiative is to achieve then. The community perspective and total success, diplomacy will be necesthe country perspective are always tak- sary to establish the political neutrality en into account. The best run global of the GPEI and other global health health initiatives all have a branch or initiatives. sector that’s looking at the political as-

1. Heymann, David, et. al. “Polio eradication: interrupting transmission, toward a poliofree world.” Future Virology 1(2) (2006): 181-188.

2. Global Polio Eradication Initiative. “The History.” <http://www.polioeradication.org/ history.asp> 25 Sep 2010.

3. World Health Organization. “Media Page for Poliomyelitis.”<http://www.who.int/mediacentre/factsheets/fs114/en> 25 Sep 2010.

4. Jegede, Ayodele Samuel. “What Led to the Nigerian Boycott of the Polio Vaccination Campaign?” PloS Medicine 4(3) (Mar 2007): 417-422.

5. Kaufmann, Judith R. and Feldbaum, Harley.

“Diplomacy and the Polio Immunization Boycott in Northern Nigeria.” Health Affairs 28(4) (2009): 1091-1101.

6. Bari, Sona. Telephone INTERVIEW. 30 Sep 2010.

7. Weisfeld, Jason. Telephone INTERVIEW. 1 Oct 2010.

8. Heymann, David. Telephone INTERVIEW. 4 Oct 2010.

9. Global Polio Eradication Initiative. “Fact Sheets.”<http://www.polioeradication.org/ factsheets.asp> 11 Oct 2010.

10. Dawar, Rasool. “Pakistani Taliban hint at attacks on aid workers.” Associated Press. 26 Aug 2010. <http://dailycaller. com/2010/08/26/pakistan-floods-threaten3-towns-as-levee-fails/> 15 Oct 2010.

11. Newton, Paula. “Taliban threaten to kill aid workers as spies.” CNN. 15 Mar 2009. <http://edition.cnn.com/2009/WORLD/ asiapcf/03/15/afghan.taliban.threat/index. html> 15 Oct 2010.

12. Dougherty, Jill. “UN sees increase in humanitarian workers targeted.” CNN. 18 Aug 2010. < http://afghanistan.blogs.cnn. com/2010/08/18> 15 Oct 2010.

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Answering a Global Appeal for Support: Triumphs & Limitations of International Humanitarian Response

Shalini Pammal, Staff Writer

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n January 12, 2010, a 7.0 magnitude earthquake struck the fragile state of Haiti inciting a state of emergency in the global community to deliver aid to the devastated country. Approximately 220,000 people died, over 180,000 homes were destroyed and 1.5 million people were left homeless.1 Not only did international governments pledge substantial funding for Haiti, but a widespread compassion swept over the United States as individuals came forth with extraordinary monetary aid and solidarity for the Haitian people.

Six months later, heavy monsoon rains led to disastrous flooding in many regions of Pakistan. Millions were afflicted by the devastation, exceeding the number of victims from the 2004 Indian Ocean tsunami, the 2005 Kashmir earthquake, and the 2010 Haiti earthquake combined, according to the United Nations.2 While the earthquake in Haiti led to an unprecedented aid response, an arguably even larger disaster in Pakistan has received a relatively silent response from the world.

As of March 2010, Reliefweb, an online information portal on humanitarian emergencies and disasters, reported a total relief funding of $2.5 billion given and a further $1.3 billion pledged for relief efforts in Haiti.3 According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), the latest Haiti Flash Appeal for $1.4 billion, the largest ever humanitarian appeal following

a natural disaster, is now almost 48% funded.4 The Pakistan Initial Floods Emergency Response Plan has estimated a necessary $1.6 billion to enable international partners to support the Government of Pakistan in addressing residual relief and early recovery needs of those afflicted. The international response to Pakistan’s flood emergency has been “sluggish and ungenerous” in comparison to relief efforts following previous disasters of a similar scale.5 Oxfam estimated that as of August 9, 2010, governments had committed less than $45m and had pledged $91m—considerably smaller totals than collected for previous disasters over a similar period. According to Oxfam, $742m was committed to Haiti post-earthquake and $920m pledged.5 In spite of this unmistakable need, it appears that the world has seemed to generally fall silent to the pleas of the displaced, injured and vulnerable people of Pakistan in comparison to the widespread mobility of the international community in relief response to Haiti.

Dr. Michael J. VanRooyen, Director-in-Chief for the Division of International Health and Humanitarian Programs (DIHHP) and Co-Director of the Harvard Humanitarian Initiative stated in an interview with the HCGHR, “I think there are many drivers of humanitarian funding and assistance many of which stimulate governments to participate which are more needs driven based on size, scope,

intensity and after-effects of disaster.”

In the instances of Pakistan and Haiti, Consolidated Appeals Process, the United Nations, nongovernmental organizations and other institutions requested hundreds of billions of dollars to aid these devastated countries.

“The real difference is not in governments’ giving money or the UN identifying needs—it lies in public donor support,” said VanRooyen. Imbalance in donor aid is often driven by an unpredictable response from the donor community which funds humanitarian organizations.

Former Prime Minister of Haiti Michéle Pierre-Louis attributed the impassioned humanitarian response following the Haiti earthquake to vocal individuals who advocated for Haiti including Wyclef Jean, hugely televised marathons, celebrity contributions and the publicized work of former President Bill Clinton in his role as the United Nations Special Envoy to Haiti. Additionally, PierreLouis cited the large Haitian presence in the United States as having a hand in generating widespread response, commenting in an interview, “Haitians here have radio programs, TV programs, and people participating in local governments. Though Haitians have lost a lot—houses and jobs— they maintain the same level of large contribution.” Similarly Pierre-Louis said, “We should not underestimate the weight of the diaspora here and the fact that they [Haitians] all have families in Haiti. The proximity of

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global health review Haiti is also strategically important for geo-strategies of United States foreign policy in the region and should not be underestimated in terms of response.”

Along with donor reaction to disaster, governments and humanitarian organizations respond to situations considering a host of varied factors including safety of volunteers abroad, the stability of government, and existing relationships with a country. Dr. Shubhada Hooli, a pediatrician and graduate student at Harvard School of Public Health, notes “[There is] a lot of unrest in Haiti, but they don’t have a lot of gun violence. It is a sad and unfortunate situation but the threat isn’t there. If talking about the situa-

vard Law School and Harvard School of Public Health ’12, agrees, “I think that a big part of response has to do with stability and the broader political climate. It is really hard to judge public perception as well which in turn is influenced by the media.”

“The combination of it [the Haiti earthquake] being very impressive, very acute and a massive onset in a place we can identify with to some degree compared to a place that is so far away makes a huge difference,” said VanRooyen. “Pakistan floods happened afterward. Donor fatigue is such that people have already seen a huge emergency and the issue of massive displacement and statistics are something people can’t even wrap their heads around.”

The issues that thus stir donor responsiveness have to do with “proximity, participation, PhotoCourtesy CourtesyofofWikimedia WikimediaCommons Commons the epic and Photo impressive A United States Army sergeant provides water for a young Pakistani girl afflicted by nature [of disaster. disaster], and tion in Pakistan, one thinks about al- the deep, ongoing and emergent needs Qadea, the insurgency—it is a difficult which lead to an ongoing amount of place to be from a safety perspective support,” according to VanRooyen. and an even more stressful situation There are structures in place which with heightened security issues.” Eitan can be further supported and promotBernstein, a graduate student at Har- ed in order to enhance equitable dis-

tribution of aid to disaster-stricken nations. While differences naturally exist it is important to recognize the need to bolster mechanisms which provide real funding rather than rely on the fallibility of donor contributions in the wake of disaster. Existing systems like the Office for Coordination of Humanitarian Aid, United Nations Flash Appeals, and international funders, among other structures, can operate effectively and provide necessary support for disasters of such a catastrophic nature. The Humanitarian Response Review6 commissioned by the United Nations Emergency Relief Coordinator and the Under-Secretary-General for Humanitarian Affairs at OCHA further strives to ensure faster and more effective responses to disaster with recommendations for improved functionality of nongovernmental organizations and governments alike.

The question of how equitably humanitarian disasters receive aid, and specifically why Haiti garnered such passionate response while the cries of those afflicted in Pakistan have fallen on deaf ears, is attributed in part to the mobility of the donor population in feeling emotionally connected to the plight of a people following disaster.

The complexity associated with humanitarian aid response is entangled in donor interests and geographical and emotional accessibility that invites participation in the relief and recovery of disaster-stricken nations among a host of other intricate factors. 

1.”Haiti Earthquake- Facts And Figures.” Disasters Emergency Committee, 2008. Web. Oct. 2010. <http://www.dec.org.uk/item/425> 2. ”Floods in Pakistan worse than tsunami, Haiti.” Gulfnews.com. Al Nisr Publishing LLC, 10 Aug. 2010. Web. 6 Oct. 2010.

3. ”Humanitarian response to the 2010 Haiti earthquake.” Wikipedia:The Free Encyclopedia. MediaWiki, n.d. Web. 11 Oct. 2010. <http://en.wikipedia.org/wiki/Humanitarian_response_to_the_2010_Haiti_earthquake>.

4. ”OCHA’s Response Fact Sheet.” HaitiOCHA’s Response. United Nations OCHA, 24

ments/2005/ocha-gen-02sep.pdf>.

7. ”Pakistan Floods Emergency Response Plan, Revision, September 2010.” ReliefWeb. N.p., 17 Sept. 2010. Web. 27 Sept. 2010. <http:// www.reliefweb.int/rw/rwb.nsf/db900SID/ VDUX-89DTJ3?OpenDocument>.

8. VanRooyen, Michael J. Personal interview. 8 Oct. 2010.

9. Pierre-Louis, Michèle. Personal interview. 5 Oct. 2010.

10. Hooli, Shubhada. Phone interview. 4 Oct. 2010 11. Bernstein, Eitan. Personal interview. 1 Oct. 2010

Feb. 2010. Web. 4 Oct. 2010. <http://ochaonline.un.org/OCHAHome/WhereWeWork/ Haiti/HaitiOCHAsResponse/tabid/6422/ language/en-US/Default.aspx>.

5. Tisdall, Simon, and Maseeh Rahman.

“Pakistan flood toll rises but international aid fails to flow.” Guardian.co.uk. Guardian News & Media Limited, 10 Aug. 2010. Web. 9 Oct. 2010. < http://www.guardian.co.uk/ world/2010/aug/10/pakistan-flood-international-aid>.

6. ”Humanitarian Response Review.” United Nations, Aug. 2005. Web. 25 Sept. 2010. <http://www.reliefweb.int/library/docu-

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The Challenges to Global Recognition of Cancer Burden in Developing Nations Mark Ragheb, Staff Writer

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common perception exists that diseases are regionally divided, with infectious disease plaguing poor regions and chronic disease afflicting rich regions. While differences exist in the distribution of diseases between developing and developed nations, statistics show that this dichotomy is greatly exaggerated, and that non-communicable diseases are rising as a health concern in many developing countries. One of these non-communicable diseases, cancer, is the second largest killer in the world, claiming nearly eight million lives in 2005.1 From a global perspective, the burden of cancer is momentous: it kills more people than HIV/AIDS, malaria, and tuberculosis combined.2 Cancer is not only a disease of the rich; of those eight million deaths, roughly three-fourths are in low and middle-income countries.2 Moreover, the global resources allotted to cancer in these nations are dismal relative to the burden they face, with cumulative funding coming to a mere 5 percent of global cancer funding.3 The extreme burden of cancer faced by developing nations is driven by vast inequalities in region-specific research and epidemiological data; the human papillomavirus (HPV) vaccine exemplifies this trend. HPV causes 99% of cervical cancer, the most prevalent cancer in many nations in subSaharan Africa.4,5 The two most widely distributed HPV vaccines, Cervarix and Gardasil, provide protective immunity for specific HPV subtypes, all

of which are known to be the predominant subtypes in the west.6 Research, however, shows that the subtypes prevalent in Africa, Latin America, and Asia may vary from those that are targeted by Cervarix and Gardasil, thus raising questions about their efficacy in developing countries.7 This misappropriation of vaccines is representative of the underlying issue of unequal distribution of cancer research, with efforts focusing on treatments in regions of the world in which a profitable consumer market is available.

Not only does a lack of research exist for cancers in low-income regions, but country-specific data regarding the distribution and prevalence of cancers remains highly inadequate. Dr. Andrew Logan, a cancer researcher and Botswana native, told the HCGHR, “while Botswana is one of the few African nations with a cancer registry, some of the data is inadequate and while we know some information about cancer distribution, we know little about cancer incidence and mortality rates.”8 However, it is evident that the cancer burden in a nation like Botswana varies widely from the burden faced in Western nations. Dr. Logan notes, “of the ten most prevalent cancers in Botswana, five are virally related, while only two of the ten globally related cancers are virally related.”8 Botswana provides a unique example of the challenges faced by developing nations in providing adequate cancer services. “Botswana currently has the oldest living population on

antiretroviral therapy, and as people live longer on HIV therapy, it poses the unique challenge of monitoring the effects of chronically living on these drugs”, says Dr. Logan.8 And in fact, it has been shown that HIV increases susceptibility to not only AIDS-classifying cancers such as Kaposi’s sarcoma and cervical cancer, but also to many non-AIDS-classifying cancers such as liver and lung cancer.9 Dr. Logan concludes that having “functioning cancer registries which can report incidence and measure progress of the population is critical to understanding what interventions need to be established.”8 Unfortunately, the reality remains that many nations have little to no data on the cancer burden they face; of fifty six African nations, only eight have data on the incidence of different cancers and only one has data of mortality rates from cancer.10 In Asia, thirteen of forty-four nations had data on cancer incidence and seven have data on mortality.11 As described by Dr. Logan, “a well functioning national cancer registry is the beginning point from which you can generate hypothesis and conduct experiments which will provide answers about the steps to take in improving cancer care.”8 Why is there so little knowledge about cancer burden in these low and middle-income nations? According to Dr. Eric Ding, a Nutritionist and Epidemiologist at Harvard Medical School, the fundamental issue with regards to cancer and other non-communicable diseases is a misalignment

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global health review between international funding priorities and the most significant burdens of disease. As Dr. Ding describes, “many of the major donors, including the Gates Foundation, Clinton Foundation, and WHO, like to invest in projects which require less long term investment and have the potential to be more cost-effective.”12 Because of this, “we know for many developing nations, in great detail, the details of HIV prevalence, yet we know next to nothing about the prevalence of chronic disease risk factors such as smoking, cholesterol intake, etc.”12 The inequitable experience of cancer morbidity in developing nations has various causative mechanisms stemming from constraints in the health care system, which are overburdened by issues such as the AIDS epidemic and economic and political challenges.13 As a result, cancer has moved into the periphery, with many regarding the issue as too costly or challenging in aforementioned conditions, resulting in an excess of preventable deaths.2 Dr. Ding notes that the challenge in treating many of these cancers is rooted in the expense and the necessary infrastructure, and that funding sources often stray away from such challenges. As Dr. Ding explains, “providing mammograms for breast cancer diagnosis is useless without providing necessary chemotherapy drugs and surgical equipment.”12 Such extensive donor commitment is difficult again due to cost-effective issues.

Because many cancers affect older individuals relative to many of the com-

mon infectious diseases, “donors will be more apt to fund causes which are likely to save younger lives in order to maximize their resources.”12 While reduction of cancer mortality in developing nations is a complex task, with mobilization some progress can be made efficiently and quickly.

The recently established Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) has asserted that treatment strategies can be quickly established through the systemic delivery of low-cost generic drugs, and that cancers which are amenable through prevention, such as lung cancer through anti-smoking campaigns and cervical cancer through HPV immunization, can be reduced without the need for complex infrastructure.3 Dr. Logan stresses two areas that must be addressed in order to make progress in cancer treatment in Botswana: “a political will to increase

1. World Health Organization. “Fight Against Cancer: Strategies That Prevent, Cure, and Care.” Switzerland: WHO, 2007.

2. Ibid, 2007.

3. Farmer, Paul, et al. “Expansion of cancer care and control in countries of low and middle income: a call to action.” The Lancet. 2 Oct 2010.

4. Walboomers, et al. “Human papillomavirus is a necessary cause of invasive cervical cancer worldwide.” Pathology. 6 Dec 1999.

5. Parkin, Max, et al. “Global Cancer Statistics.”

Can J Clin. 2005 6. Dawar, Meenakshi, et al. “Human papillomavirus vaccines launch a new era in cervical care prevention.” CMAJ. 28 Aug 2007.

7. Clifford, GM, et al. “Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis.” The Lancet.

17 Sept 2005.

8. Logan, Andrew. Phone INTERVIEW. 17 Oct 2010

awareness and education about the rising prevalence of cancer” and “an increase in training of non-specialized staff to administer chemotherapy to cancer patients in order to decentralize the specificity of cancer treatment.”8 Members of Partners of Health (PIH) have shown that even in regions of extreme resource limitation, such as Malawi and Haiti, chemotherapy can be administered even in the absence of oncologists, through the training of local physicians.3 Such anecdotes show the promise in establishing simple, short-term strategies that can save lives by providing fundamental treatment and prevention of cancer.

These strategies must be emphasized in order to begin reducing the number of preventable deaths due to cancerhowever, the challenge of establishing sufficient infrastructure for long term and complex cancer care is one which will require a long term commitment from the global health community. 

Photo Courtesy of the National Cancer Institute

A cancer patient receives treatment from a physician.

9. Sasco, AJ, et al. “The Challenge of AIDSRelated Malignancies in Sub-Saharan Africa.”

PLoS ONE. 11 Jan 2010.

10. Kavanos, P. “The Rising Burden of Cancer in the Developing World.” Annals of Oncology.

June 2006.

11. Ibid, 2006.

12. Ding, Eric. Personal INTERVIEW. 09 Oct 2010.

13. World Health Organization, 2007.

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The Millennium Development Goals: Now or Never

Yuying Luo, Staff Writer

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n his Op-Ed in the New York Times, U2 front man Bono called the Millennium Development Goals, “possibly the most visionary deal that most people have never heard of.”1 Indeed, the MDGs maintain a low public profile, but they have catalyzed unparalleled global action in the past decade. The MDGs were adopted by all United Nations member states in the year 2000. At that time, all countries pledged to have met these goals by 2015.2 But now that we are only five years from the 2015 deadline, it is increasingly evident that despite unprecedented levels of global action, we are off-track in meeting several of the original eight goals.

“The MDGs allow for very focused targets around universally agreed objectives. They are a great mechanism for accountability because every country needs to report on the progress being made. The stipulation of goals and targets signifies a very important step forward in international development,” commented Dr. Julio Frenk, Dean of the Harvard School of Public Health, in an interview with the HCGHR.3 And undoubtedly, progress has been made. According to a recent UN report, the percentage of the world’s desperately poor are likely to shrink to 15 percent of the population by 2015, less than half of the original 42 percent.4 While estimates of progress vary because of different statistical assumptions and modeling approaches, it

is indisputable that maternal health remains the area where progress has been most disappointing. A recent systematic analysis of progress reports an annual global average rate of decline in maternal mortality of 1.3 percent over the period 1990-2008. This is well below the 5.5 percent reduction needed to achieve the MDG targets.5 “Maternal is the most inequitably distributed health indicator in the world,” says Dr. Frenk. “There are still some 380,000 maternal deaths each year, and 99 percent of those happen in developing countries.”

“The area of maternal and child health has seen a lot of increased political action, but that has not translated to focused and meaningful action,” says Todd Summer, the Global Health Policy Director for ONE, an advocacy organization co-founded by Bono committed to the fight against extreme poverty and preventable disease.6 The promotion of maternal and child health to meet MDG targets was central to the Muskoka Initiative adopted by G8 Nations at the G8 Summit in June.7 It was again a central focus at the MDG Summit in September, where UN Secretary-General Ban Ki-moon announced a landmark pledge of $40 billion from governments, private companies, and nonprofit organizations to improve child and maternity health across the globe.8 But it remains unclear where and how the money will be distributed.

Despite the increase in funding for maternal and child health, chal-

lenges still remain in translating these increases into positive results. “One of the critical challenges for us is to understand and respond to the interconnections between the different health and development issues,” identified Mr. Summer. “If you look at progress for HIV/AIDS, the past five years have been phenomenal in terms of getting more people access to treatment. But a lot of countries ignore the more politically challenging area of prevention and as a result, infection rates are rising faster than we can get people on treatment.”

“There is also good argument that we are not doing a good job of interconnecting the HIV system with maternal and child health. We need to put the two systems together to work for the women,” says Mr. Summer.

Dr. Frenk agrees, “The MDGs are highly interdependent and we need to take them as a whole set. We cannot talk about maternal mortality without dealing with gender inequality. We cannot talk about child health without dealing with reducing poverty. We cannot talk about education without dealing with child mortality.” Clearly, integration is high on the priority list for policymakers, but problems such as poor infrastructure, a substandard health system, and lack of crosstalk between different frontline MDG projects make it difficult for integration to be implemented.”

“A broader challenge for the health-related MDGs is also to strengthen health systems to effect

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global health review interventions. The challenge is not the fact that we do not have the scientific solutions to certain problems.

We have them and they are effective, but there is a huge gap between what is possible and what is delivered. There needs to be a policy in every country to address them as integrated set, and not as discrete entities.” Ultimately, there is only one health system to deal with every health issue, so strengthening and equipping health systems to be able to address a spectrum of health-related needs is paramount.

Another theme that emerged from the MDG summit was the issue of transparency and accountability.

“A big factor affecting development assistance is good governance. It is very difficult to achieve any development goals if there are no mechanisms against corruption and for accountability. However, developmental assistance themselves can trigger changes themselves, and many countries provide assistance to countries who demonstrate good governance,” says Dr. Frenk. In that sense, developmental assistance can both be the catalyst for political change and the leverage for continued governmental accountability.

Cooperation is also important, emphasized Mr. Summer, but often overshadowed when donors choose to operate independently of partnerships with the organizations in the recipient countries. “Where we have seen good progress are cases when donors work very closely with the recipient country. Working together with countries to develop robust strategies and to actually implement them helps foster an element of shared responsibility.”

Engaging broader public support and generating awareness about these issues is certainly something that is also important to ensuring accountability. Dr. Frenk is part of the MDG Advocacy Group established by UN Secretary-General Ban Ki-moon

The MDGs

are composed of eight international development goals that operate on a global and local scale.

They aim to: • Eradicate extreme poverty and hunger • Achieve universal primary education • Promote gender equality and empower women • Reduce childhood mortality • Improve maternal health • Combat HIV/AIDS, malaria and other diseases • Ensure environmental sustainability • Develop a global partnership for developmentent

Photo Courtesy of WAHA-international.org

whose goal is to “galvanize support and mobilize action for the Millennium Development Goals.” The committee is composed of key stakeholders in a wide array of arenas from singer-songwriter Bob Geldof to philanthropist Bill Gates.9 Dr. Frenk is hopeful that a group of people will be the catalyst needed as we head towards the 2015 deadline, “We need to engage more leadership in the different spheres [e.g. entertainment, politics and academia] and ultimately, engage the public at large.”

“There is still a lot of work to do,” commented Mr. Summer. “There is

danger that we may lose momentum after 2015, but it is important to realize that a lot of work still needs to be done after 2015.”

But he is hopeful about the power of grassroots advocacy. “It is amazing how little people can understand how much their voices count. A phone call, a signature on a petition, an email—it can make a difference. It sounds simplistic, but it really is all too rare. The system is geared to keep in the dark about how important their voice is, but there is truly a case that there is power in numbers. We have the resources to save lives.” 

1. The New York Times. “M.D.G.’s for Beginners…and Finishers.” 18 September 2010. <http://www.nytimes.com/2010/09/19/ opinion/19bono.html?_r=1&ref=bono> 2. UNDP. “United Nations Millennium Development Goals.” 27 September 2010. <http://www.un.org/millenniumgoals/bkgd. shtml> 3. Frenk, Julio. Phone Interview. 28 September 2010.

4. The Washington Post. “UN Sees Dramatic Reduction in Poverty.” 21 September 2010. <http://www.washingtonpost. com/wpdyn/content/article/2010/09/20/ AR2010092006231.html> 5. WHO. “Millennium Development Goals: progress towards health-related MDGs.” May 2010. <http://www.who.int/mediacentre/

factsheets/fs290/en/index.html> 6. Summer, Todd. Phone Interview. 30 September 2010.

7. The National Post. “G8 Communique.” 26 June 2010. <http://news.nationalpost. com/2010/06/26/full-text-g8-communique/> 8. AFP. “UN summit ends with pledges and lingering pessimism.” 22 September 2010. < http://www.google.com/hostednews/afp/ article/ALeqM5gOwm3l1tKEF1bUYUORixIdnn4Uxg> 9. UN Non-governmental Liaison Services. “UN Secretary-General Establishes MDG Advocacy Group.” 24 June 2010. <http://www. un-ngls.org/spip.php?article2686?>

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Human Trafficking: A Global Health Problem that Demands Local Attention

Annemarie Ryu, Staff Writer

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ver 12 million children and adults are engaged in forced labor and prostitution around the world today1. These forms of modern slavery are better known as human trafficking: the recruiting, harboring, transporting, or receiving of a person through coercion or force for the purpose of exploitation—now the fastest growing criminal industry in the world2. Among the primary reasons for the rise in human trafficking are the increasing demand for exploitable, cheap laborers and sex workers, the lack of effective anti-trafficking legislation, the lack of public awareness of trafficking and its dangers, and the escalation of the root causes of human trafficking—poverty, gender discrimination, and youth unemployment—due to the global economic crisis3. A view of human trafficking and efforts to combat it show that reducing and, eventually, eliminating human trafficking will require each nation’s dedication to prosecuting traffickers and protecting victims and persons vulnerable to trafficking.

Focused efforts to combat human trafficking are only recent. The first major legislation against trafficking in the United States was the Trafficking Victims Protection Act, enacted in 2000. In the same year, the United Nations adopted the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, the Palermo Protocol. This Protocol announced a global consen-

sus that human trafficking of all kinds was criminal and should be addressed by prevention, criminal prosecution, and victim protection4. The U.S. State Department reports, however, that “no country has yet attained a truly comprehensive response to this massive, ever increasing, ever changing crime,”4 and 62 of the countries that signed onto the Palermo Protocol have yet to convict a single trafficker1.

Striking failures to prosecute traffickers worldwide reflect the need to strengthen criminal justice systems.

There must be laws that mark human trafficking as a criminal offense and police who will enforce the laws without endangering the victims. In many countries, human trafficking laws are limited in application to the sexual exploitation of women and girls, thus leaving persons trafficked for work in sweatshops and domestic servitude without assistance. Meanwhile, victims may be unwilling to testify to the criminal behavior of their traffickers for fear of being convicted themselves. In order to prosecute human traffickers and remove them from the trade, governments must instate strict but specific legislation and train police, prosecutors, and judges in how to effectively handle cases5.

There is both domestic trafficking within and transnational trafficking into the U.S.2 Sally Engle Merry, a Professor of Anthropology at New York University and author of three recent books addressing international law,

human rights, and gender violence, notes that prosecutions for trafficking in the U.S. remain weak. She believes that the “Trafficking in Persons Report” reflects the U.S.’s greatest effort to end transnational trafficking into the U.S.6 This report, published annually since 2000, systematically ranks countries on one of three tiers based on the government’s action to combat trafficking and highlights the responsibility of other nations to police human trafficking within their borders1.

Nicholas Kristof, an Op-Ed Columnist for the New York Times who has investigated human trafficking, believes that this report has had a strong positive effect, as nations that have received poor rankings have begun investigating the problem within their borders. Sharing an anecdote from his experiences in Cambodia, he recalled that, once Cambodia began to worry about its ranking, police began looking for traffickers. Police made arrests of some of the less popular brothel owners, at least just to say they were doing something. Once police began to make arrests, traffickers began to be concerned about imprisonment, and some sought other work7.

While Kristof’s statements shine a positive light on the U.S.’s Trafficking in Persons Report, they also highlight the economic aspects of human trafficking: trafficking is propelled by the victims’ poverty and insecurity and, moreover, by the tremendous profits possible for traffickers. In the U.S.,

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global health review human trafficking is tied with arms dealing as the second-largest criminal industry in the world, just after drug dealing, according to the U.S. Department of Health and Human Services. In fact, a federal crackdown on drug dealers has pushed some drug dealers and gang leaders to pursue sex trafficking8. Human trafficking is growing, with various reports and studies suggesting that between 100,000 and 600,000 children may be involved in prostitution in the U.S.9.

While bringing an end to the problem of human trafficking globally is an imperative goal, we should also focus on greatly reducing human trafficking within U.S. borders, especially because, as U.S. citizens, our actions and our advocacy can have the greatest impact on our policymakers. Kristof writes that “Human trafficking tends to get ignored because it is an indelicate, sordid topic, with troubled victims,” and, “Because trafficking gets ignored, it rarely is a top priority for law enforcement officials.”9 We can change that.

Victims of trafficking need protection and support, and they must know that they will be safe from harm if they report their traffickers. Support for victims of trafficking in the U.S. must be increased: for the estimated 100,000 American children trafficked into the commercial sex industry each year, there are only 80 shelter beds in the entire country. Citizens of the United States can help end sex trafficking by asking their representatives to support the Trafficking Deterrence and Victims Support Act of 2010, which would provide block grants to “state or local government entities who have designed a holistic approach to investigating, prosecuting and deterring sex trafficking, and providing special services and shelter to the victims.”10 Furthermore, there are six states that have failed to enact a comprehensive bill to combat human traf-

Takenby byKay KayChernush Chernushfor forthe theU.S. U.S.State StateDepartmen Departmentt Photo taken Like marginalized immigrants everywhere, these Burmese laborers are at risk of being trafficked to exploiters.

ficking—Hawaii, Ohio, South Dakota, West Virginia, Wyoming, and Massachusetts11. A proposed antitrafficking law chiefly sponsored by Massaschusetts state Senator Mark Montigny has yet to pass through the Massachusetts House, although it was first introduced in 200712. Writing to policymakers about the importance of fighting human trafficking with firm laws, law enforcement, and protection and prevention services for victims and vulnerable persons will be key to

ending U.S. trafficking.

Human trafficking is an issue of health that transcends national boundaries and requires international cooperation to be resolved. As with all problems in global health, each country can alleviate the problem by comprehensively and diligently working to resolve it within national borders.

By working to end human trafficking, each citizen can simultaneously help solve a local and global problem. 

1. United States. State Dept. Trafficking in Persons Report 2010. State Dept., Jun. 2010.

Web. 1 Oct. 2010 <http://www.state.gov/g/ tip/rls/tiprpt/2010/>.

2. Polaris Project. Polaris Project: For a World Without Slavery. Web. 26 Sept. 2010 <http://www.polarisproject.org/content/ view/26/47/>.

3. United Nations. “U.N. Report: Human Trafficking Likely to Rise Due to Economic Decline.” 10 Sept. 2009. FoxNews.com.

9 Oct. 2010 <http://www.foxnews.com/ world/2009/09/10/report-human-trafficking-likely-rise-economic-decline/>.

4. Bureau of Public Affairs. “Trafficking in Persons: Ten Years of Partnering to Combat Modern Slavery.” U.S. Department of State.

U.S. Dept. of State, 14 Jun. 2010. Web. 10 Oct. 2010 <http://www.state.gov/r/pa/scp/ fs/2010/143115.htm>.

5. United Nations Office on Drugs and Crime.

“Prosecuting Human Traffickers.” UNODC. 2010. Web. 29 Sept. 2010 <http://www. unodc.org/unodc/en/human-trafficking/ prosecution.html?ref=menuside>.

6. Merry, Sally Engle. Perosnal interview. 20 Sept. 2010.

7. Kristof, Nicholas. “Half the Sky: Nicholas Kristof Talks About Women as a Solution to Global Problems.” Taubman Building, Harvard Kennedy School. 27 Sept. 2010.

Lecture.

8. Cramer, Maria. “Targeted, Some Drug Dealers Switch to Prostitution: Authorities Fear Surge in Human Trafficking.” Boston.com.

26 Oct. 2008. Web. 29 Sept. 2010 <http:// www.boston.com/news/local/massachusetts/articles/2008/10/26/targeted_some_ drug_dealers_switch_to_prostitution/>.

9. Kristof, Nicholas D. “Seduction, Slavery and Sex.” The New York Times. 14 Jul. 2010.

Web. 26 Sept. 2010 <http://www.nytimes. com/2010/07/15/opinion/15kristof. html?_r=1&scp=2&sq=kristof%20sex%20 trafficking&st=cse>.

10. Polaris Project. “Federal Legislation to Help End Sex Trafficking.” Polaris Project Action Center. 6 Aug. 2010. Web. 27 Sept. 2010 <http://actioncenter.polarisproject.org/ component/content/article/35-action/827wyden-bill>.

11. “A Strike Against Sex Trafficking.” Los Angeles Times. 21 Jun. 2010. Web. 28 Sept. 2010 <http://articles.latimes.com/2010/jun/21/ opinion/la-ed-trafficking-20100621>.

12. Martin, Phillip. “Child Sex Trafficking and The Politics of Pimping.” The Huffington Post. 7 Aug. 2010. Web. 28 Sept. 2010 <http://www.huffingtonpost.com/phillipmartin/child-sex-trafficking-and_b_674202. html>.

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Diplomacy, Ethics, and Global Health: The Impact of U.S. Sanctions on Cuba and North Korea

Eesha Dave, Staff Writer

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magine a hospital where even basic treatment is impossible, supplies are limited, and bed linens are a luxury. Such places could scarcely be called hospitals in the United States. However, in some parts of the world, like Cuba and the Democratic People’s Republic of Korea (DPRK), the seemingly small things the U.S. takes for granted have become medical luxuries.

While the Cuban and North Korean nationalized health care systems have their problems, the United States’ sanctions on these countries have undoubtedly had an impact. There have been claims that the U.S. has used soft power tactics to exert political and economic power- that to further its own interests, the U.S. has limited these nations’ access to food, medicine and technology. While the Cuban embargo and North Korea sanctions can be viewed as political strategies, these diplomatic maneuvers raise questions of an ethical nature particularly around health care. Both nations have been isolated, which has weakened their health care systems and exacerbated a lack of medical staff and supplies. This raises the question—should health care be a political pawn?

In general, Cuba’s health care system has flourished despite restrictions. According to the Pan-American Health Organization, it is the best in Latin America.1 The nation has focused on prevention and health promotion due to its limited resources and has made great strides because of this

preventative focus.3 It has the highest physician to population ratio of any country in the world2 (double the ratio of the United States) and has substantially reduced its infant and maternal mortality rates since 1959. According to Amnesty International (AI), however, the U.S. embargo on Cuba has exacerbated malnutrition, poor water quality, and a lack of medical supplies and technology.4 While humanitarian aid was once exempt from the embargo, these sanctions have been tightened over the past half-century5 when they are most needed.

Amnesty International published a report in 2009 titled “The US Embargo Against Cuba”, which states that the U.S. prevents all technologies, services and products that have been produced by the U.S. or are under a U.S. patent from entering Cuba. This bars many medical supplies and other elements of humanitarian assistance.

It also restricts U.S. companies from marketing or providing aid to Cubans.6 While the embargo allows the U.S. to take a hard-line stance consistent with its foreign policy towards Cuba, the ethical implications of denying people life-saving care transcends foreign policy. According to Steven G. Ullmann, Professor and Director, Programs in Health Sector Management and Policy, at the University of Miami School of Business, “politics and ethics sometimes are difficult… evolution is starting to occur in terms of what we’re starting to see in Cuba

and in U.S.-Cuba relations and ultimately there will be some significant adjustments in terms of what is going on there.”7 However, the U.S. is not the only nation arguably employing soft power tactics. Cuba has an agreement with Venezuela that exchanges Cuban doctors and health care workers for oil.

This program involves over 30,000 Cuban doctors and dentists. Despite economic benefits, some Cuban doctors have claimed that this exchange constitutes “modern slavery” and have sued the Venezuelan and Cuban governments.8 This loss of medical staff in Cuba is significant. Currently, about fifty percent of the Cuban-licensed physicians are practicing medicine abroad both through Cuba’s government and special contracts with foreign nations.

The Cuban Ministry of Public Health reports that over 120,000 medical workers have been sent overseas by the government since 1969.

How has this loss impacted Cubans? In an interview, Dr. Aliuska Hernandez, 38, who moved to New York from Cuba eight years ago, said, “They’re sending doctors outside, so you have less doctors in Cuba…they send a few to Africa, South America… right now they have too many outside the country and not enough doctors to take care of the population”.10 This loss of medical staff is also due to little freedom in the profession.

Physicians receive the equivalent of $25 monthly for their work. Although

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global health review they may elect to go abroad, doctors must return after a few years due to contract agreements or to prevent their families from suffering consequences at the hands of the government. Upon returning, these doctors have little freedom and the state assigns them positions in rural areas or slums.11 More so than Cuba, the DPRK’s universal health care system has suffered greatly from limited supplies and is extremely weak today. U.S. sanctions have hurt the nation. According to the 2003 Report for Congress, the U.S. restricts most trade, foreign aid and arm sales to North Korea under the Export Administration Act of 1979 on the grounds that it supports international terrorism. The country has been on this sanction list since 1988. This also impacts trade of medicine and food into the country.12 Amnesty International reports that hospitals in North Korea lack proper sanitation and sterilization materials and procedures. The government is unable to cover all of the health expenses, unlike the Cuban government, which devotes a large portion of its budget to health care. As a result, patients pay doctors in cigarettes and alcohol for simple consulta1. Frank, Marc. “Cuba Reorganizes Family Doctor Program”. Reuters. 8 Apr 2008. http://www.reuters.com/article/ idUSN0835601820080408 23 Sep 2010.

2. Dresang, Lee T. and Laurie Brebrick et al.

“Family Medicine in Cuba: Community-Oriented Primary Care and Complementary and Alternative Medicine”. Journal of the American Board of Family Practice. 2005. http:// www.jabfm.org/cgi/content/full/18/4/297 22 Sep 2010.

3. Garrett, Laurie. “Castrocare in Crisis”. Foreign Affairs. July/August 2010.

4. “The U.S. Embargo Against Cuba”. Amnesty International. 2009. http:// www.amnestyusa.org/document. php?id=ENGUSA20091207001&lang=e 24 Sep 2010.

5. “Case Studies in Sanctions and Terrorism”.

Peterson Institute for International Economics. http://www.petersoninstitute.org/ research/topics/sanctions/cuba.cfm 29 Sep 2010.

6. “The U.S. Embargo Against Cuba”. Amnesty International. 2009. http://

Photo Courtesy of HavanaTimes.org

Havana’s Calixto Garcia Hospital

tions, and doctors perform under the table procedures for cash.13 The food shortage in the DPRK is also responsible for widespread malnutrition and susceptibility to diseases like tuberculosis.14 According to Marcus Noland, Deputy Director and Senior Fellow, Peterson Institute for International Economics, food shortages are a large issue in North Korea. While aid is being sent, economic changes like currency reform have exacerbated www.amnestyusa.org/document. php?id=ENGUSA20091207001&lang=e 24 Sep 2010.

7. Ullmann, Steven G. Personal Interview. 11 Oct 2010.

8. Garrett, Laurie. “Castrocare in Crisis”. Foreign Affairs. July/August 2010.

9. Garrett, Laurie. “Castrocare in Crisis”. Foreign Affairs. July/August 2010.

10. Hernandez, Aliuska. Peronal Interview. 5 Oct 2010.

11. Garrett, Laurie. “Castrocare in Crisis”. Foreign Affairs. July/August 2010.

12. Rennack, Dianne E. Congressional Research Service. Foreign Affairs, Defense and Trade Division. “North Korea: Economic Sanctions”. CRS, 24 Jan 2003. www.au.af.mil/au/ awc/awcgate/crs/rl31696.pdf 23 Sep 2010.

13. “North Korea’s crumbling health system in dire need of aid”. Amnesty International.

15 July 2010. http://www.amnesty.org/ en/news-and-updates/report/northkoreas-crumbling-health-system-dire-needaid-2010-07-14 1 Oct 2010.

the situation15—doubling the price of staples like rice.16 Also, while international aid groups send food to North Korea for refugees, not all of it reaches this deprived population and is distributed for free. The elite and military classes divert the food away from pregnant women, orphans and hospital patients.17 It is understandable that North Korea blames the U.S. for its deteriorating health care system and limited food supply, and that DPRK and Cuba would benefit from eased sanctions. However, is it possible to exclude health care from diplomacy?

When sanctions are placed, they have political and economic impacts that have unavoidable ramifications for healthcare. It has become apparent that more so than the government, the citizens themselves would benefit from increased access to technologies and supplies. Political maneuvering often affects those at the margins of society with the least control over the political decisions being made, and yet world leaders show little impetus to invoke change on the stage of international relations, where ethics and human rights are often forgotten.  14. “North Korea’s crumbling health system in dire need of aid”. Amnesty International.

15 July 2010. http://www.amnesty.org/ en/news-and-updates/report/northkoreas-crumbling-health-system-dire-needaid-2010-07-14 1 Oct 2010.

15. Bajoria, Jayshree. “Interview: Why Sanctions Can Hurt North Korea”. Council on Foreign Relations. 14 Oct 2010. http://www.cfr.org/ publication/22762/why_sanctions_can_ hurt_north_korea.html 16. “North Korea’s crumbling health system in dire need of aid”. Amnesty International.

15 July 2010. http://www.amnesty.org/ en/news-and-updates/report/northkoreas-crumbling-health-system-dire-needaid-2010-07-14 1 Oct 2010.

17. Bajoria, Jayshree. “Interview: Why Sanctions Can Hurt North Korea”. Council on Foreign Relations. 14 Oct 2010. http://www.cfr.org/ publication/22762/why_sanctions_can_ hurt_north_korea.html

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An Interview with Tachi Yamada, M.D. Ava Carter, Staff Interviewer

© Bill & Melinda Gates Foundation, all rights reserved

HCGHR: With the recent U.N. Summit centered around the Millenium Development Goals (MDGs), there was an enormous focus on maternal and child health.

The slow progress in reducing infant and maternal mortality was highlighted and Secretary General Ban Ki Moon stated that. “…the 21st century must and will be different for every woman and every child.” How has the Gates Foundation learned from the worldwide failures of the

last decade in this field and how will you help to achieve MDGs 4, 5, and 6?

Yamada: First of all, we should actually reflect on the successes. It is very important to note that child mortality is dropping very quickly. The latest assessment done by the Institute for Health Metrics and Evaluation indicated that [there were] about 7.7 million child deaths in the world, [for children] under 5. This is way down

Dr. Tachi Yamada, president of the Bill & Melinda Gates Foundation’s Global Health Program, leads the foundation’s efforts to help develop and deliver lowcost, life-saving health tools for the developing world. He oversees Global Health’s grantmaking, which focuses on four major activities: discovery, development, delivery, and advocacy.

Before joining the foundation, Yamada served as chairman of research and development and was a member of the board of directors at GlaxoSmithKline.

Prior to that, he was chairman of the Department of Internal Medicine at the University of Michigan Medical School and physician-in-chief at the University of Michigan Medical Center. Yamada is a past president of the American Gastroenterological Association and the Association of American Physicians, a master of the American College of Physicians, and a member of the Institute of Medicine of the National Academy of Science in the United States and the Academy of Medical Sciences in the United Kingdom. (Courtesy of the Bill & Melinda Gates Foundation) from the number I remember reporting when I first came to the foundation in 2006, which was something on the order of 10.5 million. So this number is dropping very quickly and I think that is something important to note.

On the maternal side there is a fair amount of angst that we aren’t making progress but the latest figures again from the Institute for Health Metrics and Evaluation indicate that only about 350,000 women are dying in childbirth while the number in 1980 was about

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global health review 520,000 or 530,000. It seems to be holding steady at that number but we are making progress on those fronts.

[So] I think we should start with a recognition that some progress has been made.

Having said that, there are two elements to tackle… One is neonatal mortality and the other is child mortality. The child mortality data can be greatly improved by being successful with our vaccination programs. If we can get the right vaccines into the right hands there is a great opportunity to have a significant impact on that front.

It is a little bit different on the neonatal mortality front. [Neonatal mortality] is becoming an increasingly larger proportion of child deaths because it has not been decreasing as quickly as the number for the toddlers. And there are a number of different challenges beginning with making sure that the pregnancy is a wanted pregnancy…

Family planning is a critical element.

There is a period during gestation, the minus nine months until birth, where lifetimes of care applied in the prenatal setting will have a big impact on neonatal survival. Then once the child is born, there are some very critical things that can be done. A lot of simple things like warming the child, breastfeeding, [and] cleaning the cord…can have a big impact on neonatal mortality. So those are areas that we will be focusing a lot of attention on family planning, the right kind of antenatal care, and neonatal initiatives that can be applied to the newborn.

On the maternal side there are some very big issues that we are looking at carefully. To begin with, we start by making sure the pregnancy is a wanted pregnancy. The data on maternal mortality goes down as the age of first pregnancy is delayed and as the interval between pregnancies is lengthened.

That requires very careful family planning and we’ve invested in that.

If you look at the causes of maternal

death I think three elements are very important.

There’s post-partum hemorrhage, pre-eclampsia, and obstructed labor. Obstructed labor is a very complicated issue in infrastructure, and the appropriately trained birth attendants and obstetricians are critical for that. [It] might take a while before that problem can be tackled in a very extensive way. But the other two problems are problems that can be addressed.

[For] post-partum hemorrhage there are tools. There is of course Oxytocin, which is available. Even easier to use in oral form is Misoprostol, which is a product that has a significant impact on post-partum hemorrhage.

[For] pre-eclampsia the availability of magnesium sulfate can more broadly have an impact…but there I do think that more scientific discovery is necessary to understand the biological basis of pre-eclampsia and [to] identify potential pharmaceutical targets for the condition. So all in all I would

foundation collaborate with other members of the Alliance, and how do you feel you have impacted the number of children being vaccinated through this partnership?

say that [on] MDG 4 we are making big progress, and [on] MDG 5 we are making some progress but we have a ways to go. There are important and simple tools that can be applied that impact both. As far as MDG 6, the world has put a lot of money into HIV, TB, malaria, and other neglected tropical diseases and I think we are making significant headway on those fronts for the time being.

was announced by Bill Gates in Davos, [Switzerland] last year and he committed from the foundation $10 billion over the next ten years. We feel this is a very important initiative and one that can have a big impact on people all over. The key drivers of this initiative have been ourselves working with the WHO and UNICEF- the key partners on the GAVI alliance.

And this Decade of Vaccines Initiative is taking on several “work scenes” there, where we will develop strategic plans. One of course is on research and development... A second is on policy, a third is on financing and a fourth is on access issues. We feel this is an important initiative. We are working

Yamada: The GAVI Alliance relationship is one of the most important relationships that we have…

We believe that technology-based health solutions can deliver the highest impact for the lowest cost to the people we serve. That seems the top return on an investment, if you will. We’ve made GAVI our largest grantee and we’ve committed $1.5 billion to that over the last ten years. We are very happy that GAVI has been hugely successful vaccinating so many children and saving an estimated 5 million children from dying. We work very closely with the WHO and UNICEF and other donor partners like the U.S. government and Norway and other major donors.

Recently, we’ve embarked on a program called the Decade of Vaccines. This

about 350,000 women are dying in “...Only childbirth while the number in 1980 was about 520,000 or 530,000. ”

HCGHR: The Gates Foundation has a strong relationship with the GAVI Alliance which, since its inception in 2000, has served as a partnership to reduce child mortality by increasing access to vaccinations. How does the

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global health review closely with most of the members of the GAVI Alliance and we think overall this is one of the most important initiatives in the world to reduce child mortality.

HCGHR: GAVI has also worked extensively on the Advanced Market Commitment (AMC), a partnership with drug companies to assure new vaccinations to the poorest countries at affordable prices. Do you see this as an attainable goal despite the historic issues of access and affordability in the pharmaceutical industry?

Yamada: There are many different things that we are undertaking to try to increase access and affordability. The AMC is meant to be a subsidy of sorts so that the pharmaceutical companies can get a return on their investment in manufacturing or research and development and still have the vaccine provided to poor people at an affordable price.

But that’s just one of the mechanisms and there are some direct discussions that we also have with pharmaceutical companies to convince them to lower their prices. We also invest in competitive manufacturing from developing countries that have a lower cost base to their production of vaccines.

So it’s a combination of creating competitive low price vaccines and negotiating directly with pharmaceutical companies to provide low prices for the poorest people in the world, creating incentives for them to make investments on the research and development end, and manufacturing vaccines for the underserved populations.

Dr. Tachi Yamada (President, Global Health Program, BMGF) reviews the XCRay film of TB patient Li Yuangui while visiting his home in Xiaoyang Village, China. April 3, 2009. Photo courtesy of the Bill & Melinda Gates Foundation/ Lou Linwei.

HCGHR: Measuring success is a key element in implementing and improving global health interventions. How do you measure the success of an intervention like a new drug or vaccine in the field?

What are some challenges that you are faced with in this setting that you do not encounter in a lab or clinical trial?

Yamada: In a clinical trial you have data collection that’s routine and very systematized. In the field, [however] after an agent is available, it is very hard to measure the impact because there is very poor monitoring of clinical information, surveillance of incidence of disease, and impact of various interventions. I don’t think that there’s sufficient infrastructure and that is something that we’re looking into very carefully. There are different networks that have been formed over time [namely] the Department of Defense in the United States and the CDC. We’ve developed epidemiological surveillance programs for pneumonia and diarrhea.

Right now we’re trying to get our hands around how to get the info in a timely fashion [in order] to understand the impact of our interventions. I think that in addition to having the data it is also important to have very high

quality analysis of the data… Very early in my tenure here at the foundation I felt it was good to have an independent organization analyzing intervention data. That led to a grant that we gave to the Institute for Health Metrics and Evaluation that is set up here at the University of Washington under the leadership of Chris Murray.

HCGHR: The Gates Foundation puts an emphasis on neglected infectious diseases. What qualifies a disease as “neglected” and why do you think that these diseases should be important to the rest of the world?

What social, medical, and political factors have contributed to their being “neglected”?

Yamada: Well, I’m not sure how to define neglected diseases. You could argue that malaria is a neglected disease or that tuberculosis is a neglected disease. In fact, we do invest in research in diseases that don’t receive the kind of attention that other diseases do, either by major government funding agencies such as the NIH or by the pharmaceutical industry. We recognize that chronic diseases such as diabetes or heart disease or even psychiatric illnesses can present a very huge burden of illness on countries in the developing world, but we don’t invest in them because we feel that they do get a lot of attention from the NIH and the pharmaceutical industry. We focus our attention on areas where there isn’t as much innovation. Those include HIV- in certain kinds of prevention not treatmentmalaria, tuberculosis, and infectious diarrhea and infectious pneumonia.

There’s another whole category which some people called neglected tropical diseases. Sometimes it includes malaria and sometimes it doesn’t, but it represents primarily parasitic illnesses such as schistosomiasis, hookworm, guinea worm, and African sleeping sickness.

These are conditions which may not by

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global health review themselves kill as many people…but create a huge burden of illness on certain populations, sapping the population of energy, lowering the blood counts, creating iron deficiency and creating generalized malaise. And we have cures for many of these illnesses, but it is really about how to get those cures out there, how to pay for them, and how to have an impact [that is important].

There have been some very important initiatives that have worked. The guinea worm eradication program undertaken by the Carter Foundation was something that we supported. All that requires is a filter and it has been very successful. And I think that there is a motivation to end this problem in the next couple of years. An effort…for onchocerciasis has been undertaken by two pharmaceutical companies, Merck and Glaxo Smith Kline. Merck [has used] Ivermectin and Glaxo Smith Kline [has used] Bendazole. They’re providing millions upon millions of doses of these drugs to eliminate this disease. Merck of course pioneered this area with Ivermectin for treatment of river blindness. We’re really looking at these issues right now to see what new products are necessary, if any.

With the existing products we’re looking at how to get them out there to the people in an efficacious way and in a sustainable way, and I think we can make progress on this front.

There’s a lot of interest in this. I think the U.S. government is particularly motivated to do something about it and I think the WHO has always been a strong proponent of addressing these neglected diseases in a meaningful way.

HCGHR: The Features section of our publication this month focuses on “The Geopolitics of Health.”

Often, despite a treatment or vaccine being effective, it does not reach the people who are most in need of it. What kinds of geographical and political barriers have you

encountered in implementing new interventions? What difficulties have you encountered due to political instability, war, or religious and cultural differences?

Yamada: That’s a huge question. In terms of obstacles, we’ve encountered just about every kind. But having said that, there has also been tremendous success. Let me just refer to the polio eradication program. You may know that polio is persistently and endemically transmitted in poor countries [including] Nigeria, India, Afghanistan and Pakistan. In Nigeria, one of the big issues that we had was that there was some resistance to vaccination in the northern part of the country… At that time it was thought that there was little political backing for polio eradication and some resistance from religious leaders in the north to vaccinations in general. Through very big advocacy efforts and through direct interventions and appeals by our people, including Bill Gates himself, that situation has been turned around very significantly. In fact, now in northern Nigeria, the religious leaders are the drivers of the polio eradication campaign. And it looks like that’s been hugely successful. Last year there were over 300 cases in Nigeria, this year there are under 10. So it looks like those kinds of obstacles can be overcome.

Let’s take another circumstance. In India there is huge political commitment to eradication. They’ve done hugely successful vaccination campaigns, but we’ve been observing that somehow the vaccine is failing in certain parts of India, namely Bihar and Uttar Pradesh. [We] don’t know quite why and we’re doing some research to try to understand this… We realized that the trivalent vaccine had some problems because of interference between the different viruses, so we invested in a monovalent type I oral polio vaccine.

That was very successful but then it

Below: Dr. Tachi Yamada (President, Global Health Program, BMGF) holds a boy who had just been vaccinated against polio in the Nizamuddin railway station. Yamada was there to understand the importance of transit and migratory populations in contributing to polio transmission. New Delhi, India. April 5, 2009. Photo courtesy of the Bill & Melinda Gates Foundation/ Prashant Panjiar.

led to an increase of type III polio, so we invested in research and invented a bivalent vaccine for type I and type III, and that seems to have worked. Here the problem was a biological one and by investing in research we think we’ve actually made some progress.

Now the third area, Pakistan, is one that is more complicated. A combination of insufficient political commitment and armed conflict have created problems in vaccination. Even when the campaigns are done it doesn’t look like they are getting all of the kids when they go through an area. This is in contrast to India where, when we go through an area, every single child gets vaccinated.

More recently there has been heavy flooding occurring right at the heart of where polio is causing a problem. So we are encountering political issues, we are encountering issues of armed conflict, and we are encountering acts of god that have gotten in the way. Over time we hope to overcome them. 

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THE NEXT REVOLUTION: Making High-tech Diagnostics Accessible and Affordable Judy Park, Staff Writer Photo courtesy of Judy Park The Liver Function Test (LFT), DFA’s first project, is currently in clinical trials and is due to be released next year at certain locations. This test monitors the effect of hepatitis and HIV drug regimens on the patient’s liver. (From left to right: original test, positive result, negative result).

I

n a world where the gap between the supply and demand for healthcare is growing, the cost-effectiveness and sustainability of health interventions have become a major concern in global health decision-making. George M. Whitesides, renowned chemist and Harvard professor, aptly framed the issue at a 2009 Boston TED Talk with the question, “How does one supply healthcare in a world in which cost is everything?”1 Whitesides believes the first step to solving the problem is to improve diagnostics. “In order to treat disease, you first have to know what you’re treating,” he pointed out to the audience in Boston.1 Whitesides’ aim is to create “zerocost diagnostics,” or devices that provide accurate, user-friendly, and rapid diagnostic information, all manufactured at little to no cost. Instead of simply re-

ducing the cost of existing technologies, however, he opts to redefine the entire process and uses paper as the substrate for his devices, due to its low cost and abundance.1 While paper-based diagnostics are not a completely novel concept, Whitesides takes the idea a step further. His paper diagnostic “chips” are compact, user-friendly, easily disposable, and can be manufactured at the astounding cost of one cent per test. Rather than generating a simple positive or negative result, the devices can produce more functional values. These paper chips are treated with assays that change color in the presence of disease markers in a drop of blood or urine. Specific regions of the paper are coated with wax, whose hydrophobic polymers guide fluids to assay zones.

One wax printer, which costs around

800 dollars, can manufacture around ten million tests a year.1 Undoubtedly, these chips were designed with the developing world in mind. In countries that lack infrastructure and trained health workers, this kind of low-cost, accessible device can garner an enormous impact. Diagnostics-For-All (DFA), a small Cambridge-based company that Whitesides co-founded in 2007, is currently developing the technology specifically for this purpose. With the help of a ten million dollar grant from the Bill and Melinda Gates Foundation and exclusive licensing rights to Dr. Whitesides’ patents, DFA has been making immense strides towards bringing these technologies to the market.2 Una Ryan, who joined DFA as its CEO in 2009, is a seasoned veteran of

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global health review

AT A GLANCE Imagine a technology that costs less than a dollar and that could replace all of the sophisticated and expensive equipment usually used to perform basic medical tests. Dr. George M. Whitesides’ diagnostic chip technology is just that kind of innovation. His paper-based diagnostic devices are novel in their simple design, low cost, user-friendliness, and easy disposal. Most significantly, they are specically designed for use in the developing world, where lack of trained health workers, adequate infrastructure, and necessary equipment makes effective diagnosis complicated or inaccessible.

the biotechnology industry. In an interview with HCGHR, she remarked on the uniqueness of DFA’s approach. “We have taken a very novel technology and created a very novel, kind-of-backwards business plan,” she explained. “Most companies get profitable first and then they start their non-profit business. We made sure that our mission to deliver products to the developing world was the first priority of DFA.”3 DFA operates as a non-profit enterprise, in which the non-profit wholly owns a for-profit subsidiary.3 DFA’s first project, a liver function test designed to monitor the effects of hepatitis and HIV drug regimens, is currently in clinical trials and will be released next year at certain locations.

This test is especially crucial in the developing world, where 25 percent of HIV/AIDS patients develop liver complications during treatment.3 A more functional version of Whitesides’ initial prototype, the test itself is a laminated square no larger than a quarter.

Aside from the liver function test, DFA is working on tests for HIV, cholesterol, glucose, and kidney function, among many others.3 These tests can be performed simultaneously on the same

chip, even if testing mechanisms differ, through a process of layering.1 As a result, DFA is able to construct “fever panels” in which diseases with similar symptoms but separate treatments can be detected with one device. As Ryan noted, “It is not helpful to a mother who’s walked four days from the bush to come to a clinic with a sick child if she is, with exquisite accuracy, told [by] an American test, ‘Not malaria.’ You need to know how to treat the child.”3 Justin Koh, a junior at Harvard College who joined DFA as an intern scientist this past summer, is working to expand the range of what can be done with paper. His latest research, which he discussed in an interview with HCGHR, involves using paper and flexible electronics to perform transmittance detection. “One of our first application projects is a device to run a p24 assay, which is a very common HIV diagnostic,” he explained. “Imagine, for example, a credit card sized device… this thing can be solar powered, it can have all your systems on board, and even have a digital display readout, and it would all cost less than one dollar to create.”4 The plan is to couple diagnostics with the power of modern communications technology to increase healthcare access in remote areas.1 Using a regular camera phone, field workers can snap a picture of a chip’s results and send it to a lab. Moreover, if smart phone technology is employed, the phone itself can interpret the results by comparing against a database of color standards. DFA is partnering with telecommunications companies to make this possible.3 Ryan believes that “telemedicine” is radically changing the nature of healthcare. “You can get the same care in Bangladesh that you get in Boston, because it doesn’t take any time,” she said. She added how telemedicine can greatly advance the global tracking of pandemics and other diseases. “It is transforming medicine worldwide already,” she af-

firmed.3 Although DFA’s efforts are centered on developing nations, the implications are universal. “The reason why this technology works so well in the third world is because it develops quickly, and the doctor can perform everything on the spot,” stated Koh, “but there’s no reason why those benefits are limited to the third world.”4 Paper diagnostics can cut costs for hospitals by reducing turnaround time and the need for expensive equipment.

“It is a game-changer for the industry of diagnostics as we know it,” Koh asserted.4 These diagnostics can be especially useful in pediatric clinics, ambulances, emergency rooms, and military zones.2 They can have useful applications in industries outside of medicine, such as agriculture and food/water safety. “Your mind can go wild when you think of all the things you can do with it,” declared Ryan.3 The work of Whitesides and DFA signals the beginning of a powerful paradigm shift in how we approach healthcare. Healthcare does not need to be complicated or expensive; it can be cheap, portable, and accessible.

Cell phones will revolutionize the current system of care and transform the traditional doctor-patient interaction.

If a phone is able to diagnose disease, then it is not far-fetched to imagine it making treatment recommendations or even perhaps delivering treatment itself. With these innovations and many others, we will hopefully grow closer to achieving the goal of supplying quality healthcare to all.  1. Whitesides, George. “George Whitesides: A lab the size of a postage stamp.” TEDxBoston 2009. Jul 2009. <http://www.ted.com/ talks/george_whitesides_a_lab_the_size_ of_a_postage_stamp.html> 24 Sept 2010.

2. Diagnostics for All. “DFA Overview.” Diagnostics for All. 2009. <http://www.dfa. org/about/approach.html> 26 Sept 2010.

3. Ryan, Una. Personal INTERVIEW. 30 Sept 2010.

4. Koh, Justin. Personal INTERVIEW. 5 Oct 2010.

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DECONSTRUCTING BARRIERS:

Ending Discrimination Against the Disabled with Community-based Rehabilitation Sarah McCuskee, Staff Writer

O

n January 12, 2010, walls tumbled down in Haiti.

Sixteen-year-old Carmene Guerrier’s legs were crushed, and later amputated. Without prostheses for weeks, she struggled with depression and the added burden of disability amidst disaster. Eventually, Carmene received prostheses through the Partners in Health (PIH)/Zanmi Lasante (ZL) Rehabilitation Initiative. She is now part of their “mobile clinic,” working with physiotherapists, doctors, and psychologists to fit wheelchairs and provide rehabilitation and leadership training to physically disabled people.

Over the next 3-5 years, she will help take responsibility for rehabilitation in Haiti as leadership is transferred to Haitians, including, in particular, those with disabilities.

The PIH model seen in Haiti is revolutionary in several respects. First, it is community-based; Dr. Koji Nakashima, a physician in the PIH/ZL mobile clinic, told the HCGHR that “90 percent of the work happens in the community”1 rather than in hospitals.

Second, 50 percent of PIH/ZL’s em-

ployees are disabled and only a handful of PIH’s 3000 employees are expatriates.2 And third, PIH/ZL emphasizes listening to disabled people; Carmen Romero, rehabilitation coordinator and project manager for the PIH/ZL Rehabilitation Initiative, explained to the HCGHR that PIH “listens to [disabled people], values them and respects them, and that’s something that does not happen in Haiti.”2 The project is a stellar example of communitybased rehabilitation (CBR).

Some experts, however, criticize CBR because of a “dearth of robust research procedures and [a] paucity of systematic outcomes.”3 Yet Nakashima points out that “the experts on disability are those who are disabled.”1 Indeed, the 650 million disabled people worldwide make it impossible to cite a lack of expert opinion. The problem, then, is less lack of information than refusal to recognize those who have it. Dr. Paul Farmer, founder of PIH, told the HCGHR that the global community “ha[s]n’t done a good job in Haiti on disability rights. [It] hasn’t done a good job on rehabilitation.”4 As the editors

of The Lancet argued on 28 November 2009, “the medical profession has little to be proud about regarding its treatment of individuals with disabilities.”5 Twin problems stem from this attitude: lower standards for treatment of disability and a deep divide between rhetoric and policy implementation.

The Millennium Development Goals make no reference to disability, though 20 percent of people in developing nations are disabled. Injury accounts for ten percent of the world’s deaths, which is 32 percent more than malaria, tuberculosis, and HIV/AIDS combined.6 Farmer explained to the HCGHR that standard-setting organizations “realize [disability is] a big problem and that leads them to drop their standards,” but he disagrees with this approach. It is “better to set the goal high and then make a strategy for implementation,”4 he said. Policymakers have little more to be proud of than do medical professionals.

Perhaps even more harmful than low standards, however, is a loss of human rights in the transfer from rhetoric to policy. Alana Officer, Coordinator

Carmene Guerrier before receiving prothesis. Photo courtesy of Koji Nakashima.

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global health review for the WHO’s Disability and Rehabilitation Team, wrote in The Lancet on 29 November 2009 that an “overly medicalized view fails to address the social factors, discrimination, prejudice, and inaccessibility, that prevent full participation and contribute to the overall disability experience.”7 Yet the WHO’s 131-page policy document, “Guidelines on the provision of manual wheelchairs in less resourced settings,” includes less than a page on social integration. Their belief that “with a wheelchair and a barrier-free environment, a person with disability can easily participate with dignity in social and community life”8 is optimistic at best. As Romero pointed out, “If we just hand out wheelchairs… we’re missing the big picture that there’s the social stigma, there’s food security, there’s job creation.”2 Likewise, Farmer told the HCGHR that “without jobs… empowerment doesn’t mean anything.”4 Recognition of the social aspects of disability guides community-based approaches such as the one PIH has adopted. In contrast to this union of knowledge, ideology, and implementation, international policy has given only lip service to the social empowerment of disabled people.

The challenges of resource allocation mean that policymakers use generalized measures of disability to inform policies. Disability-adjusted life years (DALYs) are a popular measure of the burden of disability. However, since DALYs are a quantity which policymakers want to minimize, people with a disability—related or not to the medical intervention they require—are often disadvantaged because they may not return 1. Nakashima, Koji. Personal INTERVIEW. 27 Sept 2010.

2. Romero, Carmen. Personal INTERVIEW. 27 Sept 2010.

3. Hartley, Sally, et al. “Community-based rehabilitation: opportunity and challenge.”

The Lancet 374 (28 Nov 2009): 1803-1804.

4. Farmer, Paul. Personal INTERVIEW. 5 Oct 2010.

5. The Lancet. “Disability: beyond the medical

to full health even if the intervention is successful. Dr. Frances Kamm, Professor of Philosophy and Public Policy at the Kennedy School of Government, Harvard University, disagrees with this approach. She told the HCGHR that “relative to what they [individuals with disabilities] stand to gain, the difference [made by a prior disability] is irrelevant.”9 She argues that “you’ve got to look at what you do for each individual as an individual and what difference you make in their life.”9 This is a “philosopher’s solution,” Dr. Greg Bognar, Faculty Fellow of Bioethics at New York University, told the

found that CBR is cost-effective.3 This makes sense: CBR creates self-reliance, as Romero explained to the HCGHR, and this allows for leadership by locals with disabilities and, ultimately, no burden on expatriates. Farmer told the HCGHR that he is “pro-communitybased-endeavors for reasons that are really quite non-ideological—it’s just effectiveness.” He emphasized that treatment of chronic problems is “best done close to where people live.”4 To treat disability as an isolated problem which can be easily resolved through CBR would be to miss one of the largest lessons of the earthquake

HCGHR. “But it goes with people’s intuitions,” he added.10 On a case-by-case basis, Bognar argues, it is easier to take in enough information to intuitively make ethical choices about treatment, whereas large-scale measures are too general for this purpose.

Human-rights-based approaches, notably CBR after the PIH model, stress the ability of those familiar with the local situation, especially the disabled themselves, to make informed choices about treatment on a case-bycase basis. This, coupled with CBR’s link to social progress and inclusion for people with disabilities, makes it the preferable strategy both medically and socially. Although it is more difficult to quantify social benefits, reviews have

in Haiti. Seven percent of the Haitian population was disabled before the earthquake, and “would have likely remained marginalized”1 had disaster not drawn attention and funding to disability. While the walls which fell in Haiti may have drawn needed attention to people with disabilities—albeit at unjustifiable humanitarian cost—the walls which most need to crumble still stand. These are walls which exclude disabled people from social leadership and medical care. These are walls which will remain standing until international policymakers adopt a truly humanrights-based approach. These are walls which cause voluntary deafness to the voices of Guerrier and her peers. They must come down. 

model.” The Lancet 374 (28 Nov 2009): 1793.

6. World Health Organization. Department of Violence and Injury Prevention and Disability. Injuries and violence: the facts. Geneva: WHO, 2010. http://whqlibdoc.who.int/ publications/2010/9789241599375_eng. pdf.

7. Officer, Alana and Nora Ellen Groce. “Key concepts in disability.” The Lancet 374 (29 Nov 2009): 1795-1796.

8. World Health Organization. Guidelines on the provision of wheelchairs in less resourced settings. Geneva: WHO, 2008. http://www.who.int/disabilities/publications/technology/English%20Wheelchair%20Guidelines%20%28EN%20for%20 the%20web%29.pdf.

9. Kamm, Frances. Personal INTERVIEW. 29 Sept 2010.

10. Bognar, Greg. Personal INTERVIEW. 27 Sept 2010.

“Without jobs, empowerment doesn’t mean anything.­ ” —Paul Farmer

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HIV AND SYPHILIS IN LATIN AMERICA: Improving Maternal Health Systems Melissa Barber, Staff Writer Photo courtesy of Arachu Castro

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new initiative in Latin America seeks to halt maternal transmission of AIDS and syphilis and strengthen health systems. The Latin American and Caribbean Initiative for the Integration of Prenatal Care with the Testing and Treatment of HIV and Syphilis (ILAP) is a multinational research program looking to develop a methodology for reducing maternal mortality, strengthening health systems, and promoting Pan-American health and research dialogue. The program was launched in November 2007 in Panama City.

Mother-to-child transmission of

death or spontaneous abortion because of maternal syphilis. The prevalence of maternal syphilis in Latin America and the Caribbean is 39 per thousand births, which is more than twice the global average of 17.6.1 ILAP’ s goal is to reduce the transmission of congenital syphilis to less than 0.5 cases per 1,000 live births.2 ILAP is a methodological innovation in that it connects countries to each other and to research. The program is comprised of the National AIDS Programs from Brazil, Colombia, Cuba, Dominican Republic, Nicaragua, Paraguay, Peru, and Uruguay. Other

32 percent of infants exposed to HIV “ Only received antiretroviral prophylaxis (ARP) treatment in 2008.

HIV and syphilis is a significant problem in Latin America and the Caribbean. An estimated 4,200 to 8,300 children become infected with HIV each year.1 Furthermore, 250,000 children are born with congenital syphilis, which later in life may lead to mental retardation, deafness, and blindness.1 This tragic number does not include the 100,000 pregnancies that result in fetal

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members include the Regional Office of UNICEF for Latin America and the Caribbean, the Regional Support Team of UNAIDS for Latin America, and Harvard Medical School (HMS).2 While the number of infants born with HIV and syphilis is of enormous concern, ILAP is innovative in seeing maternal care as a uniquely powerful entry point for testing and treating

HIV/AIDS and syphilis in women. According to Project Director Dr. Arachu Castro of the Harvard Medical School, an intervention targeted around childbirth is uniquely effective because it breaks the generational transmission.

In an interview with the HCGHR, Castro stated that, historically, “ many PMTCT (preventing mother-to-child transmission) programs focus on preventing the transmission of HIV to the child without giving due attention to the follow-up of the pregnant or puerperal woman.”3 However, “universalized testing and treatment of AIDS and syphilis during pregnancy must not be seen as an HIV/AIDS or syphilis intervention,” she remarked, “ but rather [it must be seen as] a concerted effort to strengthen the health care system as a whole and incorporate women who may not have otherwise sought professional care.”3 A fragmented health system is one of the most significant barriers to testing. Laboratory-hospital communication is often poor, and women are sometimes expected to pick up the results themselves. Facilities that lack rapid tests may ask women to come back several days later. This provides a significant barrier to poor women who may not be able to afford to take off work or arrange for childcare. Furthermore, many clinics, especially in poor

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AT A GLANCE Dr. Arachu Castro works as a medical anthropologist on infectious disease and maternal health and is one of the collaborating directors of ILAP. Her main research interests concern how social inequalities contribute to disease risks among the poor and how public health policies can remove these inequalities.

Her expertise in the integration of prenatal care with the management of HIV and syphilis is helping to significantly improve health systems across Latin America and the Caribbean.

or rural settings, lack enough HIV and syphilis tests, reagents, antiretrovirals, and penicillin.

These and other barriers result in only 46 percent of pregnant women being tested for HIV in Latin America and the Caribbean. This is a dramatic improvement from 19 percent in 2004, but still intolerably low.2 Even women within the healthcare system who are known to be HIV positive may still not receive the necessary antiretroviral medicine during delivery because medical records are often disorganized.

Some women who receive antiretrovirals during pregnancy are lost within the system after childbirth. Furthermore, only 32 percent of infants exposed to HIV received antiretroviral prophylaxis (ARP) in 2008.2 High rates of maternal mortality despite encouraging economic growth highlight the role of gender as a factor in health outcomes. According to the study Preventable Maternal Mortality and Morbidity and Human Rights, “the scale of maternal mortality and morbidity across the world reflects a situation of inequality and discrimination suffered by women throughout

their lifetimes, perpetuated by formal laws, policies and harmful social norms and practices.”4 The ILAP program supports ongoing efforts related to Millennium Development Goal 5, which seeks to reduce the maternal mortality ratio by three quarters. Today, Goal 5 remains the most elusive of the MDGs because of the comprehensive health system it demands. Yet, this reliance on a variety of social programs and a robust, organized health system makes it a particularly important goal for the international community to focus on because it strengthens many sectors.

The extent of the problem is not fully known: ILAP seeks to not only reduce and identify barriers, but also to improve data collection to better inform future research.

Key to the program’s success is its emphasis on research being conducted by participating countries. The program seeks to create a forum for the exchange of research and information while also giving countries access to the public health research resources of the World Health Organization, the Pan-American Health Organization,

UNICEF, and HMS. However, each country funds its own programs and sets unique research goals and implementation agendas. By identifying barriers to care, ILAP will reduce maternal mortality. Importantly, this process will strengthen other health interventions by increasing research capacity and improving communication among both domestic agencies and between countries. The “unacceptably high global rate” of maternal mortality is a public health and human rights issue that crosses national borders;4 thus, ILAP’s solution transcends borders and provides the research and methodological innovation needed to combat maternal HIV and syphilis transmission.  1. Fescina R. “Atención de la Salud Materna.

Integración de programas.” Iniciativa para la Eliminación de la Sífilis Congénita y Reducción de la Transmisión Vertical del VIH en las Américas (2009).

2. Castro, Arachu. “Prevention of Mother-toChild Transmission of HIV and Syphilis in Latin America and the Caribbean.” Challenges Posed by the HIV Epidemic in Latin American and the Caribbean (2009): 55-73.

3. Castro, Arachu. Personal INTERVIEW. 29 September 2010.

4. Human Rights Council. “Preventable Maternal Mortality and Morbidity and Human Rights.” 2010.

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PROJECT HEALTH: Advocates for Healthcare Beyond the Clinic Alyssa Botelho, Staff Writer

Photo courtesy of Bette Walker College volunteers in Boston on shift at the Project HEALTH Family Help Desk.

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arah Littlehale ’11 remembers well her first Project HEALTH shift as a Harvard College sophomore.

Her client sat before her at the Family Help Desk on the quiet fifth-floor pediatric clinic of the Boston Medical Center (BMC) and described a story that extended far beyond his child’s new prescription. In less than two weeks, his wife had given birth to a new baby— and the family’s apartment had burned down. Instead of celebrating the new addition to their family, the client and his wife were scrambling to find shelter and replace the family immigration papers that had been lost in the flames. “I was simply overwhelmed by the sheer scope of this family’s hardships,” Littlehale said, “I hardly knew where to begin.”1 But somehow, no matter how high the client’s barriers, Project HEALTH begins. “We broke the enormous difficulties into manageable chunks and honed in on the most immediate, fixable solutions,” Littlehale continued.1 Soon, the family had been placed on

food stamps, found emergency family housing, and replaced their immigration documents.

Littlehale’s first client is not an uncommon one. Rebecca Onie, founder of Project HEALTH, heard the same stories at the BMC when she herself was a Harvard College sophomore 16 years ago. Noticing something that would be easy for preoccupied pediatricians to overlook, she wondered how effective a child’s antibiotic would be if the family were sleeping in a car, or had little food to eat. The link between poor health and poverty was glaringly obvious, and yet, nothing was being done. Onie brought her concerns to Dr. Barry Zuckerman, Chair of Pediatrics at the BMC—and in 1996, Project HEALTH was born.1 At the core of Project HEALTH’s philosophy is the Family Help Desk program model—a unique intermediary that brings together the care of the social worker and the physician for the patients at the hospital clinic. Danae Roumis, a former Project HEALTH volunteer at

the University of Chicago Medical Center, describes Project HEALTH as an “invaluable middle-man in the American healthcare system.”2 Each patient at these clinics receives two prescriptions from their physician—one prescription is for medicine, and the other prescription is for the resources needed to ensure that the drug is fully effective.2 The college volunteers at the Family Help Desk welcome these latter “prescriptions,” and work to access as many of the requested resources as possible—be it housing and utilities, food stamps, employment advice, healthcare, or childcare.

However, the care does not end on site. Project HEALTH volunteers continue to follow up on their clients by phone in the next months until every need is met. “In this way, the care becomes longitudinal,” Littlehale describes, “and we can develop a nuanced, more holistic understanding of the family’s difficulties and progress until the case is closed.”1 The success of the Family Help

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global health review Desk arises from the strength of Project HEALTH’s infrastructure and unwavering focus on the details. Precisely because the Family Help Desk is a model that is receptive to adaption and improvement, Project HEALTH developed a concept that is keenly attuned to the quality of health at the poverty line.

Sutton Kiplinger, Executive Director of Project HEALTH Boston, recalls the program’s humble “lemonade stand” beginnings.3 What began as a folding table in the corner of the BMC fifth-floor pediatric clinic is now a nation-wide organization that spans six cities around the nation. “Even though I’ve been here for seven years, I feel like I’ve been working for a different organization every six months,” she told the HCGHR. “That’s how quickly Project HEALTH is evolving.”3 Though the Family Help Desk’s evolution has been continuous over the past 16 years, today Project HEALTH has arrived at a particularly exciting moment of transition. “We are at an inflection point as an organization,” Kiplinger noted, “and are receiving requests from all over the nation for new sites.”3 In response, Project HEALTH has designed a strategic planning process at the highest national level called a “proof-plan.”3

AT A GLANCE From its humble beginnings in 1996, Boston-based Project HEALTH is in a remarkable period of growth as it tries to prove that its practice as the middle man between medicine and social programs has been widely effective. Boston’s enormous wealth of social work organizations has given Project HEALTH a golden opportunity to bring every low income family their own central case worker to care for non-medical needs as soon as they reach the hospital.

The organization aims to spend the next four years perfecting the program model in order to interface with clinics nation-wide and achieve systemic change through universal screening. The goal of this effort is to prove to hospitals, social workers, and medical insurers that Project HEALTH should indeed be integrated into standard patient care.

Project HEALTH’s “proof-plan” has three core aims. The first goal is

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communication with physicians. Rupak Bhuyan ’13, a Harvard student and maternity ward volunteer who brings Project HEALTH’s services to new mothers at the BMC, stresses the importance of Project HEALTH’s new database.

“Data collection is key to achieving universal screening and closing the loop of communication with the physician and client,” he noted to the HCGHR.5 “Because I focus on bringing Project

We are at an inflection point as an organization.

—Sutton Kiplinger

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to enhance the program model to significantly increase the client volume in current clinics and further increase the efficiency and efficacy of services for clients. Additionally, Project HEALTH is preparing its organizational model for expansion: broad growth geographically and deep involvement at current clinics.

Finally, Project HEALTH is focused on proving the return of investment on the program model in the hopes that the model can one day enter the revenue streams of Medicaid and national health insurers.3 Progress is already being made at the Boston site through what Kiplinger describes as “controlled growth for learning and improvement.”3 Project HEALTH has expanded its work to a new kind of clinic: the Codman Square Health Center and the Dimock Center in Roxbury, Mass. Monica Sawhney, Operations Coordinator of the Boston site, explains, “Community health centers are unique in that they offer many of their services on site, catered especially to a neighborhood’s needs.”4 By consolidating the center’s resources for each client, the new Family Help Desk can ensure that even the little details are not forgotten.

The BMC site has also integrated a new streamlined database, consolidating client resources and facilitating

HEALTH’s resources to as many new mothers as possible, this transition is especially exciting in the hopes for achieving universal screening.”5 As if these goals were not ambitious enough, Kiplinger hopes that in the future clinics will be able to bring every low income family their own central case worker to care for non-medical needs as soon as their child is screened at the hospital.3 Project HEALTH’s mission may be no better defined than by the charge given to its volunteers. “You are a volunteer, but you are also an advocate for someone,” Littlehale says.1 “You are a line of communication, you speak on the behalf of those who can’t, and you jump through the hoops that a family can’t jump alone.”1 Project HEALTH brings unimagined possibilities for both sides of the Family Help Desk. It is as empowering for the advocate as it is for the client.  1. Littlehale, Sarah. Personal INTERVIEW. 4 Oct 2010.

2. Kiplinger, Sutton. Personal INTERVIEW. 5 Oct 2010.

3. Roumis, Danae. Phone INTERVIEW. 27 Sept 2010.

4. Sawhney, Monica. Phone INTERVIEW. 6 Oct 2010.

5. Bhuyan, Rupak. Personal INTERVIEW. 10 Oct 2010.

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DEADLY MIX: Injected Drug Use,

HIV, and Street Children in Russia Daniel Wilson, Staff Writer

Photo courtesy of UNICEF A 17-year-old boy clasps his hands, revealing track marks from injecting drugs. He sleeps in a burnt-out abandoned house with other drug users in the port city of Odessa, capital of the southern Odessa region in Ukraine.

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ince the fall of the Soviet Union in 1991, the abuse of injected drugs has risen markedly in Russia.1 Despite the fact that this crisis disproportionately affects adolescents who are overwhelmingly poor, the stigma that envelopes the issue has led to general neglect by most governments in the region, with little infrastructure to prevent and combat the problem.2 Most significantly, there is a strong correlation between injected drug use and the HIV/AIDS epidem-

situation is not static throughout the region. Jon Cohen, a correspondent for Science magazine who has reported extensively on HIV/AIDS in Eastern Europe, told the HCGHR, “It is important to speak country-by-country.

There is a lot of similarity, but Russia and Ukraine have the vast majority of [HIV/AIDS] infections.”5 After the collapse of the Soviet Union, the shipment of drugs across recently formed borders was easy, with little risk of seizure.1 This ease of

ic.3 Very few adolescent drug users in Russia have access to sterile syringes, and as many as 80 percent of HIV patients in Russia are injecting drug users (IDUs).4 In effect, the prevalence of injected drugs has had a widespread impact on a single generation, triggering social and economic implications for societies still trying to rebuild in the aftermath of the Cold War. Although the problem is grave in most Eastern European countries, the

transport was coupled with the reestablishment of ties to Central Asia and Afghanistan that enabled new drug commerce. “Military ties from Soviet actions in Afghanistan were reestablished in the drug trade after the fall of the Soviet Union,” Cohen said. The United Nations Office on Drugs and Crime has identified two trade routes that leave Eastern Europe particularly susceptible: the Northern route, which travels through Central Asia and into

as 80 percent of HIV patients in “ As many Russia are injecting drug users. ”

Russia, and the Balkan route, which runs through Iran and Turkey to countries in south-eastern Europe.1 The most common drugs in Russia are taken via needle.2 The use of needles is more frequent in the region than it is in the West, and almost onequarter of the world’s injecting drug users live in Eastern Europe.2 Moreover, the tendency to share syringes increases as the age of the drug user decreases.6 The problem is exacerbated by the lack of prevention and rehabilitation programs in most Eastern European countries, Russia in particular.

Harm reduction, an approach successfully used to ameliorate some of the effects of drug-use, has not been adopted in Russia.7 In particular, harm reduction uses a tri-pronged method, mixing clean needle exchange, substitution treatment, and counseling to aid drug users.5 Russia has refused to provide access to clean syringes and has banned the prescription of methadone, a drug used to prevent the withdrawal symptoms that result from the use of illicit drugs. Some Russian scientists have justified their rejection based on the “Western” nature of the techniques, suggesting that methadone treatment is “a foreign trick.”8

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global health review The Eurasian Harm Reduction Network attributes the initial rise in drug use amongst adolescents to certain economic factors like unemployment and poverty.6 The increased prevalence of drug use continues to proliferate in communities of street children. Street children are injecting drugs as early as age 12 in certain countries. These children live without families or a social safety net, making the burgeoning drug use and HIV problem difficult to track and control.

Dr. Nina Ferencic, a regional advisor for HIV/AIDS in Eastern Europe for UNICEF, told the HCGHR that street children “use drugs to make them high and escape harsh realities.”9 Their realities are becoming increasingly harsh as the HIV/AIDS epidemic continues to spread. The rate of HIV infection is rising faster in Europe than in any other part of the world, and the epidemic is most acute in the poorest segments of the Russian population.

Despite the inability, or the lack of will, of the Russian government to stop the drug trade, punishment of adolescent drug users is harsh. Russia claims to have reformed its juvenile justice systems, but in practice, juvenile offenders are often imprisoned without access to rehabilitation programs.2 Ferencic noted, “Children who use drugs, including injecting drug users, often do not have sufficient access to any services. Often street children are pursued by law enforcement to bring them into state shelters. If they use drugs, they have even more reasons to hide and run away.”

1. United Nations. Office on Drugs and Crime. “World Drug Report 2010.” United Nations: New York. 2010.

2. United Nations. UNICEF. “Blame and Banishment.” New York: UN, 2010.

3. Acejas, Carmen and Gerry Stimson, et. al.

“Global Overview of Injecting Drug Use and HIV Infection Among Injecting Drug Users.” AIDS 18 (2004): 2295-2303.

4. United Nations. UNAIDS. “Country Progress Report of the Russian Federation.”

There are few bright spots, as nongovernmental organizations (NGOs) struggle to operate within the Russian infrastructure. Successful NGOs often require international funding and the ability to operate in the face of substantial social stigma. Organizations such as HealthRight International work to identify and counsel users on the streets, while UNICEF has started to promote peer-advising networks, where sufferers and recovering sufferers openly discuss their addiction.2, 11 The collapse of the Soviet Union had a vast impact on the stability of Central and Eastern Europe. Many large opiate producers were either Soviet territories or under Soviet influence, and the collapse of centralized Soviet power led to an increase in both opiate production and drug use. This drug use, however, has evolved into a massive crisis amongst Russia’s largest generational group, and lack of state intervention will only exacerbate the dire problems of drug use and the

AT A GLANCE The rise of injected drug use in Russia has been accompanied by a marked increase in the number of adolescent drug users but a standstill in the Russian government’s response to the issue. Despite the devastating correlation of injected drug use to HIV/AIDS, Russia fails to provide effective prevention and rehabilitation programs to its people. As a result, if more is not done, the young people in Russia today will be most severely affected in their lifetime by the HIV/AIDS epidemic and the perpetual economic instability that accompany the drug abuse problem.

education and social outreach to children living on the streets, Russia can make serious progress in stemming the advance of the HIV/AIDS epidemic.

Employing proven methods like harm reduction would alter the landscape of

Lack of state intervention will only exacer“bate the dire problems of drug use and the HIV/AIDS epidemic.

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HIV/AIDS epidemic. “Russian political officials make it clear they see drug users as criminals and don’t care about them,” Cohen said, “So the problem won’t be seriously curtailed until it is addressed in a responsible way.”

With the right combination of

the epidemic. In order to permanently change the devastating cycle of life on the street, however, it is imperative that action be taken on a national level to break down the structural barriers of poverty and lack of support that street children face. 

New York: UN, 2007.

5. Cohen, Jon. Telephone INTERVIEW. 3 Oct 2010.

6. Eurasian Harm Reduction Network.

“Young People and Injecting Drug Use.” Vilnius: EHRN, 2009.

7. Ritter, Alison and Jacqui Cameron. “A Review of the Efficacy and Effectiveness of Harm Reduction Strategies for Alcohol, Tobacco, and Illicit Drugs.” Drug and Alcohol Review 25 (2006): 611-624

8. Elovich, Richard and Ernest Drucker.

“On Drug Treatment and Social Control.”

Harm Reduction Journal 9. Ferencic, Nina. E-mail INTERVIEW. 5 Oct 2010.

10. United Nations. UNICEF. “Blame and Banishment.”

11. Cohen, Jon. “HIV Moves on in Homeless Youth.” Science 329 (2010): 170-171.

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THE PERFECT STORM:

Rising Health Concerns Due to Climate Change Alert the Pacific Islands Hannah Semigran, Staff Writer Photo courtesy of the Center for Disease Control

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iribati is a string of islands located in the central Pacific Ocean that is one of the first nations expected to disappear under the waves of climate change as early as 2050.

Due to rising sea levels and threatening weather patterns, President Anote Tong of Kiribati has already initiated a contingency plan to spread the inhabitants of Kiribati amongst other nations when parts of the islands become unlivable.1 In an interview with The Nation weekly magazine, published on 1 October 2010, President Tong stated, “We keep asking the international community to act…but now we have to prepare the public. Not to be refugees – because that’ s a world we don’ t like – but for relocation with dignity.”2 Nowhere are people more vulnerable to the effects of climate change than in the 20,000 to 30,000 islands that dot the Pacific. As the President of Kiribati so aptly stresses, a greater international effort is needed to reduce global greenhouse gas emissions, prepare the citizens for the risks of unpredictable weather patterns, and, more specifically, support local health systems in the Pacific islands to deal with the impending upheavals.

While small island nations account for less than one percent of all global greenhouse gas emissions,3 they will be the first places to experience problems due to climate change. For

instance, Kiribati emits one of the lowest amounts of greenhouse gases of all countries in the world at just 22 megatons of carbon dioxide per year.4 Yet, citizens of Kiribati and other Pacific islands are significantly at risk of experiencing health problems associated with increasingly violent weather patterns and rising sea levels. These health risks

ber of weather-related natural disasters has tripled.3 With increased warming, more water vapor is held in the atmosphere, resulting in both higher levels of humidity and more intense downpours.4 As a result, a greater number of tropical cyclones, storm surges, flooding, and drought are expected that can directly lead to injury and death.1

the world since the 1960s, the “Throughout number of weather-related natural disasters has tripled.

include injuries and loss of livelihood from severe storms, respiratory disease, vector-borne disease, and reduced access to clean drinking water, among others.

Dr. Paul Epstein, Associate Director of the Center for Health and the Global Environment at Harvard Medical School, commented in an interview with the HCGHR on one of the reasons for the environmental warming trend: “Black carbon, soot, and added greenhouse gases, particularly in Asia, are changing the local and global climate.” Epstein noted how “skeptics [of the connection between health and climate change] have really converted their views because of new data.”5 Throughout the world since the 1960s, the num-

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Many components of the health infrastructure in the Pacific islands, such as hospitals and clinics, are often located on the coast and are threatened by such extreme weather patterns. Destruction of coral reefs due to acidification of ocean water is decreasing the barriers around many Pacific islands, increasing storm surges, flooding, and the fetch of storms inland, and, thus, creating increased dangers for island residents.4 Furthermore, Epstein emphasized that “there are several things related to climate change that are conspiring against respiratory disease.”5 Increases in pollen levels in recent years correlate with extreme heat,1 and particles from burning fossil fuels are able to attach to

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global health review pollen and find their way into respiratory systems.5 Climate change has also greatly affected the prevalence of vector-borne diseases transmitted through mosquitoes, such as dengue fever, in the Pacific islands. The islands have often experienced the “El Niño Phenomenon,”7 during which outbreaks of vector-borne diseases have been particularly high.

When irregular weather patterns related to El Niño occurred in 1997, an outbreak of dengue fever in Fiji coincided with the increased temperatures, which had facilitated the growth of the mosquito population. As a result, dengue fever affected nearly three percent of Fiji’s population.4 Climate change promises to exacerbate these outbreaks.

Access to safe drinking water sources in the Pacific islands is also currently threatened by climate change. In the Pacific islands, around 2,800 deaths per year are associated with diarrheal illnesses, mostly in children under the age of five, caused by unsafe drinking water.8 Contamination of water sources following flooding is an area of great concern, as cholera is often linked to compromised waste management systems.9 It is estimated that due to waterborne disease, almost 52 percent of the population of the Pacific islands is at risk of consuming contaminated drinking water.10 Considering all of these risks to the residents of the Pacific islands, it is understandable that President Tong of Kiribati is worried. He notices how the international community fails to recognize the urgency of creating a plan for the relocation of Pacific island citizens.

At the 2009 global climate change negotiations in Copenhagen, President Tong was “extremely disappointed [because] no one has come forward with an offer [for relocating Kiribati’ s population].”1 Recent efforts to control the effects of climate change have been largely policy-based and ineffective.

For example, vertical programs led by the World Health Organization in Vanuatu to combat Dengue Fever have been unsuccessful in working with the Public Health Department to achieve a constructive result.6 In order to be effective, more international cooperation and a local grassroots approach is needed.

To highlight recent examples of grassroots-level progress, the Manples Community project is a local initiative to educate communities in Vanuatu about Dengue prevention and control.

Its work resulted in a reduced Dengue Fever outbreak in 1998 that had no mortalities and acted as a model for an approach to Dengue Fever.6 In addition, the Pacific Islands Applied Geoscience Commission (SOPAC) researches the ocean and islands and manages programs to encourage clean water usage and sanitation as well as prevent disasters. Leading a pilot program in Tonga, Vanuatu, Cook Islands, and Palau, SOPAC is training local facilitators to determine if their community’ s water is safe to drink, how to sterilize it, and how to protect the water source.10 Such programs will be highly valuable for serving the public as they face greater threats of vector-borne disease and contaminated water sources due to climate change.

As a result, enhanced international involvement is required to bring a grassroots-level solution to a mounting public health disaster. Since the Pacific islands have demonstrated success in their local programs that involve “horizontal partnerships,” encouraging community participation in the health care sector when the public faces environmental pressures could make a significant impact. In combination with global cooperation to reduce greenhouse gas emissions, local organizations deserve greater support from the international community in their fight against health problems associated with climate change. 

AT A GLANCE The connections between human health and climate change have recently emerged into a rapidly developing field. The Pacific Islands are arguably the most vulnerable nations to the effects of climate change on the health of their peoples. Still, international efforts to address the implications of rising global temperatures and resultant extreme weather patterns for susceptible populations have proven to be largely minimal.

1. Powell, Alvin. “Island nation president plans for extinction.” The Harvard Gazette. 25 Sep 2008. <http://news.harvard.edu/gazette/ story/2008/09/island-nation-presidentplans-for-extinction/>. 26 Sep 2010.

2. Helvard, David. “Interview with a Drowning President, Kiribati’s Anote Tong.” The Nation Online. 1 Oct 2010. <http://www. thenation.com/article/155134/interviewdrowning-president-kiribatis-anote-tong>.

18 Oct 2010.

3. World Health Organization. Fact Sheet No. 266. “Climate Change and Health.” Switzerland: WHO, 2010.

4. Ebi, Kristie et al. “Climate Variability and Change and Their Potential Health Effects in Small Island Nations: Information for Adaptation Planning in the Health Sector.”

Environmental Health Perspectives 114 (2006): 1957-1963.

5. Epstein, Paul. Personal INTERVIEW. 24 Sep. 2010.

6. Toaliu, Hilson and George Taleo. “Formation of Community Committees to Develop and Implement Dengue Fever Prevention and Control Activities in Vanuatu.” Dengue Bulletin 28 (2004): 53-56.

7. Woodward, Alistair et al. “Climate change and human health in the Asia Pacific region: who will be most vulnerable?” Climate Research 11 (1998): 31-38.

8. World Health Organization. Regional Office for the Western Pacific. “Eighth Meeting of Ministers of Health for the Pacific Island Countries.” Philippines: WHO, 2010.

9. World Health Organization. Fact Sheet No. 107. “Cholera.” Switzerland: WHO, 2010.

10. Pacific Islands Applied Geoscience Commission. News and Media Releases. SOPAC Addresses Unsafe Drinking Water in the Pacific Islands. Online: SOPAC, 2010.

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An Interview with Elly T. Katabira, M.D. Pratyusha Yalamanchi, Staff Interviewer Dr. Elly T. Katabira, MBChB, FRCP Edin., is currently president of the International AIDS Society (IAS). Previously, he served as a member of the IAS Governing Council for ten years, participating as co-chair of the IAS-Industrial Liaison Forum and the co-editor of eJAIS, the electronic journal of IAS. Katabira is a Professor of Medicine and former Deputy Dean for Research at the Faculty of Medicine, Makerere University.

He was trained as a medical doctor in Makerere University, Kampala, Uganda and later trained as a Photo courtesy of Dr. Katabira physician, specializing in Neurology HCGHR: What do you think are the key factors that will influence the way HIV/AIDS might unfold over the next 20 years?

Katabira: Well, I think one factor is the availability of treatment and access to treatment, particularly in countries where they have an actual demand, such as in sub-Saharan Africa. Then of course new effective, preventive measures through biomedical researchâ&#x20AC;Ś and the impact [of these measures] on health systems, because at the moment the drawback to better access to care and even prevention is the inadequacies of health systems and if these donâ&#x20AC;&#x2122;t improve, then we may have a worse scenario than what we have at the moment. But if they do, then I am more than optimistic that better care for HIV/AIDS will become available in the next 20 years.

HCGHR: How has societal stigma affected your advocacy efforts through

the International AIDS society as well as your own organization, The AIDS Support Organization (TASO)?

Katabira: First, let me start with TASO, my organization with which I was involved in the formation in 1987. One of the major campaigns at the time, and which still continues to be [important], is to involve as many people in the response and mitigation of HIV. The more we involve other people in caring and providing service and understanding the issues of AIDS, the less stigma and discrimination there is. This, of course, varies country to country, but that has been our major drive: to involve as many people [as possible] in the community and society to participate in HIV/AIDSrelated activities.As for the International AIDS Society, of course, one of our major strengths is advocacy, to involve as many stakeholders as possible in HIV activities. One of the major avenues we have is our international conferences.

(Manchester UK; 1984). Since his return to Uganda in 1985 he has worked extensively in the field of care and support for HIV infected people.

He is the Clinical Advisor at the AIDS Clinic in Mulago Hospital and at the Infectious Diseases Institute of Makerere University Medical School in Uganda.

Katabira is co-founder of The AIDS Support Organization (TASO) and has been their medical advisor since 1987. He is also a founding member of the Academic Alliance of AIDS Care and Prevention in Africa.

We hold two international conferences.

A big one which occurs every other year and then a smaller one, which is more scientific and involves people focused on HIV treatment and prevention. The big one involves other stakeholders such as particular leaders, youth, and everyone discussing how to involve all people in the HIV fight and [how to] minimize stigma and discrimination.

HCGHR: You mentioned in a UNAIDS interview that young people are needed for innovation and change in the fight against HIV/ AIDS. Can you please describe which aspect of the fight would benefit most from youth involvement and how young people can become engaged with this issue?

Katabira: The young people are, to me, by far the most vulnerable people as far as the epidemic is concerned because they are beginning [to explore] their

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global health review sexuality and therefore, some of them know very little about the risks of HIV transmission. It’s important that they know about the epidemic and how they can prevent themselves from becoming victims.

In addition to that, we are looking to identify ways in which they can participate constructively in the fight against HIV/AIDS… For instance, in parts of sub-Saharan Africa, youth are involved in supporting those already affected by HIV through emotional support systems. We are hoping to ensure that they participate in the various preventative activities like education through entertainment –as drama groups in some countries – or the establishment of clinics where they educate each other. It’s important to have them on our side of the fight. So that’s how the youth can be involved.

HCGHR: You have been involved in the fight against HIV/AIDS for a significant amount of time. How have efforts at advocacy, prevention, and care improved over the last few decades?

Katabira: Well, one way is that there are now many well-recognized advocacy and awareness groups, even in those

decades, there has been a change of hearts from indifference to understanding amongst wealthier nations that while they may have a lower incidence of HIV/AIDS, they have a responsibility to support the not so well off countries to fight against the epidemic. It is this recognized goal that has improved access to prevention and treatment efforts worldwide. For example, we see this in the creation and implementation of programs such as the United Nations’ Global Fund to fight HIV and malaria and the U.S. establishment of USAID. HCGHR: How does the International AIDS Society (IAS) plan on sustaining the fight against AIDS during this difficult period of economic uncertainty?

Katabira: One way of course, [though] we appreciate the financial constraints, is by advocating right now that…countries that are more affected, though perhaps not as well off, invest more in AIDS and device methods to ensure that services, which have been initiated by the Global Fund, can be sustained. That is one of our biggest drives. At the same time, in spite of the financial constraints, we also urge G8 and G20 countries to not abandon the support they have promised for these

HCGHR: Our Features topic for this next issue is “The Geopolitics of Health.” From your experience as President of the IAS, how do political and geographical boundaries come into play when attempting to foster collaboration among different nations in the fight against AIDS? Katabira: I think that it is important to note that despite the geographic boundaries, we still share a lot of things in common. With the advent of international travel, you cannot close borders from the entry of AIDS. As a result of that, we must work together, both those who can afford and those who cannot, to ensure that we fight this epidemic together without considering things like color, education, and so on.

HCGHR: Have you found any political or geographic obstacles in your line of work?

Katabira: Yes, for example, we know that, because of various [acts of ] legislation and laws within countries, some proven interventions may not be accessible to one part of the country. For instance, [take] opium substance interventions, where people on drugs can be given a substitute to help fight the habit and, as

parts of sub-Saharan Africa, youth are involved in supporting “...Inthose already affected by HIV through emotional support systems.

countries where the transmission or prevalence is very low. Nations have realized that it is in the interest of their people to improve access to HIV/AIDS awareness, testing, and treatment. This path or drive by more developed nations has helped many other countries to get involved. Sadly, there are big differences between wealthy and poor countries in terms of HIV/AIDS transmission rates and percent affected. Over the last few

countries that desperately need it. If this support continues, even if it is lower, and if the beneficiary countries put in more [capital] than they are now, it is very possible that gains may be sustained. The necessity of this pathway is evident; the gains made in recent history won’t be able to be sustained without continued prevention, advocacy, and treatment efforts.

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a result, reduce [their] vulnerability to HIV transmission. In some countries, particularly in Eastern Europe, these interventions are not available or are outlawed… It is our [responsibility] to work with various concerned societies to ensure that these obstacles are removed to ensure that people have equal rights and opportunities to fight and prevent HIV transmission. 

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global health review

Saving lives through country ownership: Three steps for President Obama’s Global Health Initiative to succeed

Raymond C. Offenheiser | President, Oxfam America

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t the International AIDS Conference last summer, a promising new microbicide debuted that reduced the risk of HIV transmission by 39 percent in clinical trials.1 The need for prevention has never been greater: for every two people put on antiretroviral treatment, another five are infected. But game-changing innovations like the new microbicide will need support from a functioning, sustainable health system to manage its adoption. Unfortunately, the current U.S. global health financing mechanisms have not always had the best track record at strengthening local systems.2 In recognition of this reality, President Obama announced the creation of the U.S. Global Health Initiative (GHI) in May 2009. It was a landmark announcement for global Author Bio Raymond C. Offenheiser has been President of Oxfam America for 13 years. During his tenure, he has overseen the growth of Oxfam America from a small non-profit agency into a recognized world leader in the global social justice movement.

Under his direction, Oxfam America has increased its annual budget fivefold to $75 million. With over 30 years of work in the field of international agricultural development, Offenheiser is active as member and advisor to numerous organizations on issues of food security, climate change, trade reform and sustainable development.

Offenheiser is currently active promoting foreign aid modernization in the U.S.

health, because it commits the U.S. government to country ownership.

Put simply, country ownership is the idea that we don’t “do” development; people develop themselves. This means helping countries strengthen their health systems so that patients can get the care they need, today and in the future. Now that GHI is in the implementation phase, the U.S. administration must deliver on its promises and fundamentally change the way the United States supports global health interventions.

programs have come to a close.4 This is because those countries lacked the infrastructure to vaccinate and treat diseases on a permanent basis. Often, these “big push” programs have not sufficiently supported the emergence of functioning, self-sustaining health systems.5 Improved maternal and child health, a litmus test of poor peoples’ access to healthcare, requires a functioning health system that is national in scope.6 The alternative to country ownership is setting targets in Washington, but over the years, pro-

If GHI is to have a lasting impact, it needs to “support active citizens and effective states in their own health and development.

Translating the commitment to country ownership from paper into practice will take three big “rethinks” for the Obama administration:

1. Actions speak louder than words: GHI needs to truly transfer ownership, not just talk about it Over the years, global health experts have learned that strengthening a country-led platform may be the only proven way to achieve long-term results from our global health dollars.

Achieving sustainable health results nearly always depends upon a country having a functioning healthcare system.3 Too often, diseases like polio that were nearly eradicated have reappeared, when global “big push”

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viders have learned that these targets are cumbersome to implement in the field, and tend to privilege short-term and easier to count outputs (i.e. bed nets, numbers of people on ARVs) over harder to count but longer-term outcomes, like more effective prevention and changing attitudes toward health service utilization.

Recently, the murmur about ownership’s centrality to effective, selfsustaining health programs has grown into a roar. The chorus has been led in particular by health experts in developing countries. According to Dr. Freddie Ssengooba, a health researcher at Makerere University in Uganda, “Citizens need to be able to hold their governments accountable, and when donors bypass ministries of health

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global health review and set up parallel HIV and AIDS programs, citizens give the credit or blame to donors, not their own government.”7 Mozambican Minister of Health Paulo Garrido has said, “I don’t want to be a minister of health projects, I want to be a minister of health.”8 The importance of country ownership was also echoed recently by Global Fund Chair and Minister of Health of Ethiopia Dr. Tedros Adhanom Ghebreyesus in an October Lancet piece.9 There is much that the GHI can do to help countries strengthen their own health systems and save more lives. GHI can reinforce recipient countries’ ownership of health investments by:

•• Giving citizens and governments full information about what, when, and where US health dollars are going in their country; •• Helping citizens and governments build their own capacity by using country systems rather than working around them and by supporting local NGOs directly; and •• Letting citizens and governments control how they direct GHI resources as part of a broader development agenda, through basket funding toward national health plans where appropriate.

National health plans, where they are consultative, must be the primary guide for U.S. health activities in a country. But what does this mean for

U.S. staff at the country level making decisions about the GHI right now?

Take the example of Malawi, which was named one of the GHI Plus countries in June. The health “sector wide approach” (SWAp) convenes all the major donors in Malawi, including the United States, in an effort to coordinate priorities for health investments.

The U.S. aligns its efforts broadly with the priorities in the national health plan, but it does not pool its funds with the UK, World Bank, and Norway/SIDA in the SWAp. Those donors who provide budget support in Malawi have agreed to a common set of benchmarks for performance fighting corruption, enforcing rule of law, and meeting the Millennium Devel-

Raquel Gomes/Oxfam America A poor US management structure filters down to the patient level and can affect the quality of care: Next door to the government clinic in Maganja da Costa district, Mozambique (pictured), there used to be a separate U.S.-funded clinic for HIV voluntary counseling and testing. Its lap equipment was not accessible to government clinic staff, which had no means to test blood without transporting it miles to the provincial capital. That changed when Minister of Health Paulo Garrido insisted in 2008 that separate HIV clinics across Mozambique be mainstreamed to prevent stigma. Fortunately, the U.S. was beginning to use PEPFAR II funding to strengthen systems, so the U.S. clinic was able to convert to a general counseling and testing center. The center now screens for diabetes and other diseases for patients referred by the main clinic. The GHI must take the next step in this transformation, directing U.S. funds toward supporting the main clinic (and others like it) directly to meet national goals on maternal and child health and health worker retention.

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Eva-Lotta Johnson/Oxfam America Nurse Khetase Kapira looks up from her work in the children’s ward at the Kamuzu Central Hospital in Lilongwe. GHI should be supporting agents of change like Khetase directly through public clinics run by the Ministry of Health, rather than setting up parallel health care systems.

opment Goals (MDGs), which hold the Malawian government accountable to concrete progress in exchange for direct support.10 However, when Malawian civil society has pressed the United States to participate fully in the SWAp to demonstrate its commitment to country ownership, U.S. officials have demurred. In a country like Malawi with a committed Ministry of Health and strong donor oversight and benchmarks, direct support must be a tool in the GHI toolbox.

GHI should use donor oversight mechanisms, but, ultimately, it is oversight from citizens that will keep governments on track to meet their health commitments. The following example helps illustrate the power of active citizens. In Malawi, civil society groups began monitoring the locations of stockouts of essential medicines at clinics, due to mismanagement or theft. By recruiting citizens to report stockouts where they occurred, they were able to reduce the stockout rate from 70 percent to 25 percent between 2008 and 2009.11 Because Malawians have the strongest interest in mak-

ing sure these stockouts continue to decline, they are one of the most effective hedges against corruption.

There have been promising signs from the Obama administration about the importance of supporting active citizens to hold their governments accountable. During Congressional testimony in September, U.S. Global AIDS Coordinator Eric Goosby announced: “We will increasingly emphasize a third dimension of activity: community empowerment… local community and civil society organizations can play the critical role of ensuring accountability for country structures in a way that outsiders never can.”12 If the United States can provide health assistance directly to active citizens and effective states as part of the GHI, it will go a long way to deliver both country ownership and development impact.

2. Model it: Streamline operations on the U.S. end The best way to encourage effective public management from developing country governments is

to model it ourselves. Unfortunately, the GHI is not there yet. The Initiative’s proposed management structure is byzantine: it is led by the GHI Operations Committee, which is composed of USAID Administrator Dr. Rajiv Shah, U.S. Global AIDS Coordinator Eric Goosby, and CDC Director Dr. Thomas Frieden. The Operations Committee, as announced, will “work in close coordination with” Jacob J. Lew, the State Department’s erstwhile Deputy Secretary of State for Management and Resources.

Below the Operations Committee in the pecking order is a “Strategic Council,” which includes anywhere from 7-12 U.S. agencies working on global health overseas, among them the Treasury Department, the Peace Corps, and the Department of Defense.

Now, imagine for a moment that there was one person in charge of GHI, who could be accountable for reconciling the competing perspectives and goals of different elements of the initiative. Imagine further if that person were the same person overseeing all U.S. efforts to implement the President’s Global Development Policy, a development professional with a background in the field — say, the administrator of the U.S. Agency for International Development? And imagine if this was also the case at the country level: one single development representative from the United States whose job it was to liaise with civil society and the Ministry of Health and coordinate all U.S. development efforts for maximum impact. That official would oversee all the parallel reporting processes, and hence would have a motive for reducing them so that partners and host governments could focus on saving lives. The United States could become a model for effective public management, both to other donors and to host governments themselves.

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global health review

3. Row in the same direction: GHI and the President’s new Global Development Policy Health and development are about more than just aid, but not all U.S. government agencies whose policies affect the health and development of the poor are on the same page. At the MDGs Summit in September, President Obama announced a new Global Development Policy that commits the United States to “establish mechanisms for ensuring coherence in U.S. development policy across the United States government.”13 Trade policy has long been a discordant note for U.S. global health assistance. For the GHI to have maximum impact for every dollar invested there must be policy coherence between U.S. global health policy and trade policy.

Currently, the U.S. Trade Representative’s office (USTR) and the GHI are initiating separate policies for poor countries. USTR has persistently sought, through trade agreements and unilateral pressure, to impose stricter levels of intellectual property (IP) protection that exceeds minimum obligations under global trade rules. These IP rules restrict or delay generic competition, a proven method to sustainably reduce medicine prices.14 This results in higher prices for medicines.

Because the cost of medicine represents the greatest share of healthcare expenditures for people in poor countries, these measures adversely affect the ability of developing countries and donors like the United States to maximize aid dollars to meet treatment needs.15 GHI and USTR need to arrive at a common understanding on medicine policies that affect the health of millions. Recently, the U.S. government took a first step in the right direction.

The National Institutes of Health, one of the world’s largest funders of medical research and development, agreed to provide a license for patents it owns

on the anti-retroviral medicine Darunavir to the Medicines Patent Pool.

This patent pool, originally hosted by UNITAID, was launched last year to sustainably reduce the cost of new anti-retroviral medicines and to keep people with HIV and AIDS alive.

From rhetoric to reality: Implementing the shift to country ownership The United States doesn’t “do” development; people and countries develop themselves. If GHI is to have a lasting impact, it needs to support active citizens and effective states in their own health and development. This means helping countries to strengthen their health systems so that patients can re-

ceive the care they need, both today and in the future. As Ethiopian Minister of Health and Global Fund Chair Dr. Tedros Adhanom Ghebreyesus remarked at an event earlier this summer, “People say country ownership is confusing. It’s not confusing, it’s actually really clear. What’s missing is the commitment to implement it.”16 To deliver on the GHI, the United States needs to fully transfer ownership to responsible ministries of health, not just flirt with it; streamline the U.S. management structure under development leadership; and ensure coherence among U.S. government agencies so as not to undo with its trade policies what it has worked so hard to achieve through its aid and development policies. 

Footnotes & References 1. USAID Press Release, “Statement from USAID Administrator Rajiv Shah in response to today’s historic progress in preventing HIV infection in women,” July 19, 2010, available at: http://www.usaid.gov/press/ releases/2010/pr100719.html 2. United States Government Accountability Office, “A More Country-Based Approach Could Improve Allocation of PEPFAR Funding (GAO-08-480),” April 2008, available at http://www.gao.gov/new.items/ d08480.pdf. In 2010, the GAO published a follow-up study that commends PEPFAR II for aligning better with country priorities. Available at: http://www.gao.gov/new.items/d10836.pdf 3. Laurie Garrett, “The Challenge of Global Health”, Foreign Affairs Magazine, January/February 2007.

4. Donald G. McNeil, “Polio spreads to new countries and increases where it’s endemic,” New York Times, October 27, 2008.

5. Robert Fryatt MD, Prof Anne Mills PhD, and Anders Nordstrom MD, “Financing of health systems to achieve the health Millennium Development Goals in low-income countries,”, The Lancet, Volume 375, Issue 9712, Pages 419 - 426, January 30, 2010.

6. WHO Partnership for Maternal, Newborn, and Child Health, “Every woman, every child: account for results and progress in maternal, newborn, and child health,” August 27, 2010, available: http://www.who. int/pmnch/activities/jointactionplan/100922_5_accounting.pdf 7. Dr. Ssengooba quoted in “Oxfam supports US Global Health Initiative emphasis on comprehensive health care,” July 18, 2010, available at: http://www.oxfamamerica.org/press/pressreleases/oxfam-supports-us-globalhealth-initiative-emphasis-on-comprehensive-health-care 8. The Supply Chain Management Systems (SCMS) (PEPFAR implementing partner), “Donor Coordination in Mozambique: the key to expanding a successful program,” SCMS in Brief. June 2007, pg. 2.

9. “Achieving the health MDGs: Country ownership in four steps,” Dr. Tedros Adhanom Ghebreyesus, The Lancet, Volume 376, Issue 9747, Pages 1127 - 1128, October 2, 2010, published online: September 22, 2010.

10. “Common Approach to Budget Support (CABS) in Malawi,” NORAD, July 2007, available at http://www. norad.no/en/Tools+and+publications/Publications/Publication+Page?key=109628 11. Oxfam Joint Program Malawi staff, “Aide Memoire May 2010: Review of Common Approach to Budget Support,” available: http://www.norad.no/en/Thematic+areas/Macroeconomics+and+public+administration/ Budget+support/Budget+Support+to+Malawi.124432.cms 12. Statement of Ambassador Eric Goosby MD, US Global AIDS Coordinator, US Department of State before the US House of Representatives Committee on Foreign Affairs, Washington, DC, September 29, 2010, available at: http://hirc.house.gov/111/goo092910.pdf 13. The White House: US Global Development Policy factsheet, available at: http://www.whitehouse.gov/thepress-office/2010/09/22/fact-sheet-us-global-development-policy 14. World Health Organization, “Report of the Commission on Intellectual Property Rights, Innovation, and Public Health,” April 2006, available at http://www.who.int/intellectualproperty/documents/thereport/ CIPIH23032006.pdf 15. For example, the United States has repeatedly pressured India to introduce stricter IP rules for medicines. Yet India’s generic companies currently produce over two-thirds of all generic medicines used in poor countries, and PEPFAR purchases over 80 percent of all anti-retroviral medicines it uses from India. If USTR efforts to increase IP protection in India were to succeed as they have in a number of other developing countries, this would dramatically undermine PEPFAR and its ability to control treatment costs.

16. Center for Global Development, “What is Country Ownership Anyway? Rethinking Global Health Partnerships,” June 21, 2010, video available at http://www.cgdev.org/content/calendar/detail/1424200

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mHealth Basics and Human Scalability Isaac Holeman & Josh Nesbit | FrontlineSMS:Medic Cofounders Introduction

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unteers; they are subsistence farmers, retired schoolteachers, and former and current patients — laypeople who have chosen to serve their communities.

Although they can improve overall patient-clinician accessibility, they are often as disconnected from health facilities as the communities they serve.

Great distances and a general lack of transportation limit CHW’s ability to obtain health care advice, distribute medical supplies, or access timely emergency services.

he World Health Organization estimates that 57 countries in the developing world face a collective shortfall of 4.3 million health care workers. Thirty-six of these countries are in sub- Saharan Africa1 and Malawi, a land-locked nation in southeastern Africa, exemplifies this shortage. Malawi has a population of approximately 14 million, and has only 1.1 doctors and 56.4 nurses per 100,000 people.2 Within Malawi, statistics concerning geographic disparities in access to health services paint an even bleaker picture. In 2007, 50 percent of physicians and 25 percent of nurses in Malawi were located in the four central hospitals, even though 87 percent of the population was living in rural areas.3 Infrastructural shortcomings that characterize developing economies are Mobile telecommunications most severe in rural areas; thus, most infrastructure Malawian hospitals serve populations Although penetration of information that are distributed across large catch- communication technologies in Africa ment areas with patients who travel generally lags far behind the rest of the primarily by foot or bicycle. world, the continent has the highest In response to these infrastruc- rate of growth in mobile phone penture and geographic circumstances, etration, increasing from 5 percent many organizations supplement​in 2003 to well over 30 percent penfacility-based health services with etration in 2009.5 The International community-based services. A sub- Telecommunications Union recently stantial body of literature has dem- estimated that 93 percent of the popuonstrated the utility of community lation of Malawi has access to mobile health workers (CHWs), locals re- network, and 12.5 out of every 100 Macruited from surrounding villages and lawians owns a phone.5 trained to provide basic services and This explosive growth in mobile act as intermediaries between health telephony is undergirded by several care facilities and the community.4 kinds of physical and human infraSome are employed but many are vol- structure. Access to electricity is an of-

ten overlooked barrier to using mobile phones in Africa. Few Malawians have access to grid electricity in their homes and yet a majority of the population uses mobile phones at least occasionally. The gap is explained by grass roots entrepreneurs that bring off-grid electricity to remote communities all over Malawi and the region, often by charging car batteries in cities, carrying them to villages, and connecting them to surge protectors which can charge many phones. Effectively distributing pre-paid airtime has also played a

In the case study... a rural Malawian “hospital saved an estimated total of 2,048 worker hours and about $3,000 in motorcycle fuel over a four-month period.

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critical role in enabling mobile telephony to spread. In Malawi over 99 percent of mobile phone subscriptions are pre-paid5 and purchased from airtime vendors that can be found in shops, sitting at plastic tables on street corners, or walking through streets, markets, and bus stops waiving packs of airtime vouchers.

Case Study, mHealth in Malawi St. Gabriel’s is a rural hospital that provides care to over 250,000 Malawians, the majority of whom are subsistence farmers living on less than one dollar per day, spread throughout a catchment area over 100 miles in diameter. To provide services in the dif-

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global health review ficult circumstances seen throughout Malawi and the region, St. Gabriel’s enlists several hundred CHWs to support antiretroviral treatment (ART), home-based care (HBC), and tuberculosis treatment (TB). These CHWs are coordinated by an HBC nurse and a TB coordinator who use a motorbike to make regular trips from the hospital to villages. To improve communication between CHWs and hospital staff, the nonprofit organization FrontlineSMS:Medic6 helped St. Gabriel’s set up a text message-based communication network utilizing the FrontlineSMS platform.

FrontlineSMS is a free, opensource software platform that enables large-scale, short message service (SMS) communication. A computer running FrontlineSMS becomes a two-way text-messaging hub when it connects to the mobile phone network via a modem or a cell phone. To initiate the program, a group of 75 CHWs at St. Gabriel’s Hospital were given Motorola Pebl cell phones. The HBC nurse led training sessions in Chichewa where groups of 10-15 CHWs were taught to use their phones and understand how the FrontlineSMS network would operate. The hospital was equipped with a mobile-network connected laptop running the FrontlineSMS software and hospital staff were trained to manage all communications within about two weeks. During the first four months of the pilot a total of 1,330 SMS messages were received at the central hub, spread across a number of use cases.7 Treatment adherence reports for TB and ART comprised 31.83 percent of all messages sent by CHWs. Whenever a patient missed their appointment at the clinic, health staff sent a tracking request by SMS to a CHW responsible for the patient. The CHW would visit the patient at their home and report the patient’s status via SMS. Usually this return report included an expected return date, or a note ex-

plaining why the patient was unable to travel to the clinic (e.g. illness, death, or moved). This system increased the average number of monthly adherence reports from 25 to 67. Since the reports were no longer delivered by hand, the ART monitors saved approximately 900 hours of transportation time.

Before the pilot, the TB coordinator reported that he was visiting seventeen patients per week for adherence monitoring, requiring three trips approximately nine hours each. The SMS system enabled the TB coordinator to outsource these monitoring tasks to local CHWs, saving the TB coordinator a total of 648 hours of transportation time.

Immediately after receiving phones, volunteers announced their ability to communicate with the hospital to their respective village councils, and the village councils would in turn refer community members to the volunteers whenever need arose. Frequently this involved reporting emergencies to the hospital to coordinate transportation.

The HBC nurse used symptom reports to triage and coordinate his home visits. This not only eliminated unnecessary check-in visits, but it also ensured that upon arrival the CHW

AT A GLANCE* mHealth & FrontlineSMS:Medic • mHealth: mobile-health • FrontlineSMS: Free short message service (SMS) platform used to expedite communication between hospitals and community health workers.

• Required devices: mobilenetwork equipped laptop running FrontlineSMS and text-enabled cell phones • Case study: During fourmonth trial in rural Malawi, saved 2,048 worker hours and $3,000 in fuel costs

would be available to direct him to the patient’s home (in a region where most homes lack formal addresses, the HBC nurse relied on CHWs to locate patients homes, and prior to SMS notification the HBC nurse’s visits were often fruitless because the CHW was in another village and unable to guide him). The HBC nurse estimated a time savings of 500 hours as a result of this triage system.

Finally, the TB coordinator was providing care to 100 patients before the pilot, seeing seventeen per week as

Community health workers at St. Gabriel’s Hospital in Malawi use mobile phones as part of FrontlineSMS:Medic’s mHealth program.

Photo courtesy of Frontline:SMS

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global health review noted above. With the free time that he gained during the pilot, he was able manage care for more patients as well as work with CHWs to report TB associated symptoms via SMS. This SMS referral system enabled the program to enroll an additional 100 patients, effectively doubling the size of the hospital’s TB treatment program.

St. Gabriel’s provides basic medicine kits for their CHWs to keep and use in the villages. Previously the kits were restocked quarterly and stock outs were common because the hospital lacked information about which supplies needed to be replenished and where. When CHWs began using SMS to notify the hospital of stock outs, staff were able to deliver supplies during regular field visits. We did not measure a baseline of stock outs prior to the SMS program, but CHWs and the HBC nurse reported a qualitative reduction in stock outs and the amount of time spent walking to the hospital to request necessary supplies.

Human scalability In the case study above, a rural Malawian hospital saved an estimated total of 2,048 worker hours and about $3,000 in motorcycle fuel over a four-month period. This trend is apparent in most of FrontlineSMS:Medic’s projects: saving time is perhaps the most valued consequence of communication technologies for overburdened health workers. Time efficiency aligns the agendas of frontline health workers and health system administrators, a chimeric and overlooked necessity in global health IT.8 Unfortunately, most discussions of scalability in the global health IT community still revolve around theoretical load bearing capacity (e.g. how many milliseconds slower would the page refresh be if the system contained one million patient records and needed to send ten thousand messages per day?). In contrast, we find that the proliferation and impact of health IT programs are

Photo courtesy of Frontline:SMS Community health workers learn to utilize mobile phone technology as part of a FrontlineSMS:Medic project in Malawi.

more frequently limited by the speed and ease with which ordinary health workers can appropriate a new technology and make it useful in their local context.

Ordinary CHWs usually prefer learning from their peers, rather than asking questions of the medical hierarchy. These peers include other minimally trained health workers, family and friends, and vendors of electricity and airtime. Only about one in five of the St. Gabriel’s CHWs had used a mobile phone extensively prior to this program, yet they were well aware of low-cost mobile phones and SMS being used in their communities. For tasks that were already common in the community, such as basic phone use, charging phones, using airtime, and sending SMS, we found that CHWs preferred to learn from their peers rather than the hospital. This may be due to the difficulty of traveling to the hospital and/or due to a culture that de-emphasizes self-advocacy directed at people of a higher social position (i.e. hospital staff). Our experience with smart phones, Internet over the mobile phone network etc., is that CHWs have fewer opportunities to continue learning in their communities, so they often require more time and follow-up training from hospital staff. This extra training can offset the time savings described above. Potential initiators

of mHealth programs should consider which specific technologies are prevalent in the communities where they work, who currently employs those technologies, and whether CHWs are likely to access free assistance.

Health facilities throughout Africa are understaffed; staff receive small salaries relative to the extended family they often support, and even those with impeccable work ethic find it difficult to manage the expected case load. In this context, extensive training, which does not pay, is seen as an unwise use of time. In contrast, health workers seek financially compensated trainings to supplement their salaries, and too often succumb to the financial incentive to not retain training material, and therefore require additional trainings (with additional money stipends for each training). Whether compensated or not, trainings become more efficient and less onerous when they focus on technologies and practices which comprise the everyday lives of ordinary health workers. Throughout Malawi and much of Africa, the vast majority of salaried health workers own a phone and can teach others the basics of phone maintenance, SMS and voice communication. Most district level and many smaller facilities have at least one employee who is familiar with computer use, but familiarity with Internet applications​ varies widely and is much less com-

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global health review mon in Malawi. A simple mHealth system can enable health workers to institutionalize skills with which they are already familiar. Trainings which redirect or sequentially build on existing skills tend to be shorter, and are more likely to ignite creative participation and ownership than training material which is so foreign that it must be learned by rote rather than being appropriated and adapted to pre-existing technological customs.

These considerations apply mainly to programs that revolve around ordinary health workers and are willing to accommodate human and programmatic imperfections in order to harvest low-hanging fruit. This approach is optional for many research projects and smaller health programs which receive a higher-than-ordinary level of funding and expertise per patient served, but it is necessary for regional or national programs which, due to their scale, must rely on ordinary human and financial resources. The inefficiency and poor coordination, which are ubiquitous across the African continent, are matters of communication as much as data acquisition, and they will be addressed largely by Africans employing technologies with which they are proficient. Wherever we experts wish for our solidarity to help ordinary Africans solve their own problems, an awareness of everyday technologies and their many uses should be the primary factor which helps us understand when and how to keep mHealth simple.  Author Bios Josh Nesbit and Isaac Holeman are cofounders of FrontlineSMS:Medic, a nonprofit organization using low-cost, mobile technology to create connected, coordinated health systems that save more lives. Since founding Medic during the fourth year of their bachelors programs, Isaac and Josh have led the organization to produce three software projects and leverage existing open source software with 18 organizations in 10 countries. Collectively these projects involve over 1,500 health workers who serve approximately 3.5 million patients. FrontlineSMS:Medic’s work has been covered by a variety of news outlets including The Economist, CNN, The Discovery Channel, Reuters, and The Guardian.

Footnotes & References 1. Smith MK and Henderson-Andrade N. Facing the health worker crisis in developing countries: a call for global solidarity. World Health Organization 2006.

2. Malawi: Country Cooperation Strategy. World Health Organization 2008.

3. “Bill Number S.805 for the 110th Congress,” Retrieved 20 August, 2010 http://thomas.loc.gov/ cgi-bin/query/z?c110:S.805: 4. Sundararaman T. Community health-workers: scaling up programmes. Lancet 2007; 369(9579): 2058-2059.

5. Information Society Statistical Profiles 2009- Africa. International Telecommunication Union.

Retrieved 27 January, 2010. http://www.itu.int/ publ/D-IND-RPM.AF-2009/en 6. More information about FrontlineSMS:Medic can be found at http://medic.frontlinesms.com.

7. Mahmud N, Rodriguez J, and Nesbit J. A text message-based intervention to bridge the healthcare communication gap in the rural developing world. Technol Health Care. 2010 Jan; 18(2): 137-44.

8. Ball MJ, Silva JS, Bierstock S, Douglas JV, Norcio AF, et al. (2008) Failure to provide clinicians useful IT systems: opportunities to leapfrog current technologies. Methods Inf Med 47: 4–7. *AT A GLANCE: mHealth & FrontlineSMS:Medic content compiled by Florence On

Patient Tracking is just one of the many tasks performed by community health workers that can be more efficient with FrontlineSMS:Medic

Community health workers learn to utilize mobile phone technology as part of a FrontlineSMS:Medic project in Malawi.

Photo courtesy of Frontline:SMS Josh Nesbit is FrontlineSMS:Medic’s Executive Director, based in Washington DC. As an international health and bioethics student at Stanford, his qualitative research focused on access to pediatric HIV/AIDS treatment. Josh has implemented text message networks in Malawi, Uganda, and Cameroon, advising ICT development projects in more than 15 countries. After the 2010 earthquake in Haiti, he helped coordinate the 4636 project, an SMS-based emergency response system.

He is a PopTech Social Innovation Fellow, Echoing Green Fellow, Rainer Arnhold Fellow, Strauss Scholar, and Haas Public Service Fellow. Josh also received the Truman Award for Innovation from the Society for International Development and was recently named in the Devex inaugural list of ‘top 40 international development leaders under 40 years of age.’

Isaac Holeman is FrontlineSMS:Medic’s Director of Strategy. While studying biochemistry and molecular biology at Lewis & Clark, Isaac conducted honors thesis research in ribosome biogenesis and was named a Pamplin Fellow, the highest honor Lewis & Clark awards its students. With a suitcase as head quarters, Isaac travels throughout East Africa to oversee the organization’s key program areas of research, product development, and implementation, ensuring that each area is in tune with the bigger picture for health systems strengthening as well as the local contexts of the places Medic works. Isaac is an Echoing Green and a 2009 Compton Mentor fellow. His research interests revolve around the social circumstances and technology that influence changing means of subsistence in low-income communities.

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Community Participation: Who participates, who decides?

Daniel Palazuelos | MD, MPH

Photo courtesy of Dr. Palazuelos A community pulling a bulldozer from the side of a cliff i.

The power to move mountains?

T

he commotion pealed like thunder in the distance. It was unmistakable. We turned the corner of the mountain dirt road and came upon over 40 farmers heaving in unison on four ropes that dropped off the side of the cliff’s edge. The roads in this part of the Sierra Madre Mountains in southern Mexico are nothing more than an acute angle shaved into the crumbling earth. They hold up well in the dry season, allowing the farmers access to the local city where they can sell their coffee harvest; but now it was the rainy season, and some unfortunate driver had come too close to the edge and slipped off the overhang. Mud does not support sloppy driving.

We waited patiently, marveling at how each coordinated heave revealed that much more rope. Suddenly, a mangled mess of twisted metal and

broken glass emerged from the mist.

A few more tugs of the rope, and the truck now faced us head on, one headlight bent down as if shamed, the other bright and boasting. Everyone who had come out to watch or help, from the women and men to the chamacos and viejitos, erupted into spontaneous applause, hoots, and hugs. Even the driver, who miraculously was unharmed from tumbling halfway down the mountain, smiled a satisfied smile.

A group of women had prepared pozol (a sweet crushed corn drink) to celebrate the success, and once everyone had a glass, we lingered for hours, chatting, retelling the story, joking about who was pulling the hardest and who was just faking it. The car would be repaired, but something bigger had been fixed. I marveled at how powerful a community of concerned individuals could become if given a

common purpose and the belief that with tools and effort, anything was possible.

Even though we are from very different worlds, I felt viscerally at that moment that these are my people.

They are mountain coffee farmers whose grandparents escaped from the brutal life on the coffee fincas to form collective farming communities (called “ejidos”) once the Mexican revolution made it legal for those who work the land to also own it. I’m a MexicanAmerican, born to a Mexican father and a New Yorker mother. Raised in New York, educated at Brown and now faculty at Harvard Medical School, I work with the Boston-based NGO Partners In Health in their supported projects in Mexico and Guatemala. As a physician, I began to volunteer with this work after Hurricane Stan devastated much of the state of Chiapas in 2005. Once the disaster response was over, the medical brigades completed, and the acutely ill patched up, our Mexican colleagues and the affected communities made it clear to me that they didn’t want me to be their doctor anymore; instead, they wanted me to accompany them in the creation of a local community-based system of Community Health Workers. This was my first important lesson: in Chiapas, autonomy is everything.

This made sense to me. The idea of communities taking control of their health care and public health was not a new one. In 1978, in fact, the world recognized this possibility in one of the most influential global meetings of its kind, Alma Ata. Called this for the city in which it was hosted, the WHO

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global health review held a conference in which all attending countries unanimously voted to ratify a declaration vowing to achieve “health for all by the year 2000.” This was to be done through the provision of Primary Health Care, but with a twist: article 4 of the Alma Ata declaration asserts, “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” This entails “full participation” in a “spirit of self-reliance and self-determination.”

Hopes were high back then: it was the 70’s, China’s Barefoot doctors were seen as a huge success and Where There is No Doctor was quickly becoming a house-hold classic. Even Ted Kennedy made a surprise visit to Alma Ata, and he had a great pair of side-burns!

The bar was set high. What wasn’t set, however, was how these goals were to be accomplished specifically. The Cold War shaped all international engagement, and even though representatives from all over the world could meet in Alma Ata, Kazakhstan, in the middle of the communist bloc, and sign an agreement declaring health a human right, they didn’t dare try to agree on how their goals would take form socially, economically and politically. Perhaps this is part of the reason why, now more than 30 years after Alma Ata, Community Participation in Health remains a “perpetual allure, persistent challenge.”1 Now a decade after the year 2000, when it is clear that we are ever further from health for all, some have quipped that perhaps the declaration had a typo and should have read “health for all by the year 3000.”2 A lot can be said about what else happened to Comprehensive Primary Health Care since Alma Ata, how it was sapped of its energy by the creation of a Selective Primary Health Care, and about how Neoliberal economic reforms undermined the Public Sector. I refer the reader to one

particularly good review.3 Yet, on the ground at our project site in the Sierra Madre Mountains, the promise of this one element of Primary Health Care, of working with the power of the community, has been the backbone of our work. We’re exploring a number of questions: can assisting organized communities improve government health services? How about improve infant mortality, eliminate maternal mortality, lower domestic violence, increase food security, provide first line care to the destitute sick who have never received care before? And above all else, if these improvements come from within the community, can the initiatives be more sustainable, free from the whims of international forces because they are bolstered by the homegrown participation of end-users? ii.

Grassroots fertilizer

Community Participation has had many forms. One of the easiest to recognize is how communities have been involved in the provision of health care. Examples run the spectrum from representation on hospital advisory boards to community activity at all levels, including the direct provision of care.4 Our work in Mesoamerica, therefore, has many other historical efforts from which we can learn. One effort in particular illustrates important les-

sons: the Community Health Center (CHC) model of care that first took root in Boston at the Columbia Point public housing projects. Designed by two physicians, Dr. H. Jack Geiger and Dr. Count Gibson, the health center began as an experiment in a different model of care; “the hospital as we know it is an obsolete and ineffective institution for ambulatory care…” said Dr. Geiger in 1968.5 They were bold indeed, but at the time so was the government- when they asked for a $25,000 grant from President Johnson, they instead received a million dollar grant from the Office of Economic Opportunity as part of the War of Poverty. Years later it’s clear that the investment paid off, as countless studies have demonstrated CHCs’ significant contributions to the health of marginalized populations traditionally disenfranchised from the modern medical system. But beyond merely moving the provision of care to a more accessible location, the CHC hoped to engage the communities in ways that got to the root of what it means to be a community. The grant application in 1965 read: “The need is not for the distribution of services to passive recipients, but for the active involvement of local populations in ways which will change their knowledge, attitudes and motivation...” Reading this now, over 40 years after it was written, this may

Source: Lecture by David Warner, http://www.healthwrights.org/dwpapers.htm

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global health review seem benign, even a platitude. We should not, however, underestimate just how revolutionary this idea was.

In short, the doctors charged that a power shift needed to occur – a swing from the notion of doctor as all-powerful, to that of doctor as only one of many participants. If social determinants such as poverty and marginalization were making people sick, then their health would need to come from a process of overall change, not just the application of an esoteric art by a great individual. Dr. Geiger continues: “they will emphasize the formation of community health associations and the training of local residents as community health assistants to stimulate change... Health associations [should be] capable of studying the community’s problems and negotiating with

This reminds me of the wry saying Cubans have about government mandated community participation: “yes, we participate…. but they decide.”

Perhaps the attendees at Alma Ata kept the issue of community participation vague because they recognized that there were many different ways to implement it; keeping it imprecise would keep the door open for interpretation and, hopefully, innovation.

David Werner, author of one of the most influential books ever written in Global Health, Where There Is No Doctor (aka. Donde No Hay Doctor), summed up two possibilities well.

In his lecture entitled “The Village Health Worker – Lackey or Liberator,” delivered in Tokyo, Japan just months before Alma Ata, he explained two different models of how communities

over-used, often being the must-have word in any Global Health application hoping to secure a grant, it goes without saying that this concept has been hard to incorporate in its purest form. By definition, one cannot “empower” someone else – empowerment, instead, is a dynamic process by which a person or group themselves gain increased ability to control the factors influencing their health. But what if this process threatens the status quo?

It is always easier for those who currently benefit from business-as-usual to say that one should strive for equity and empowerment than to actually give up control of how resources might be used.

The question remains: if participation is about transferring power, how much is enough? And if the power-

The need is not for the distribution of services to passive recipi“ents, but for the active involvement of local populations in ways which will change their knowledge, attitude and motivation. ” Dr H. Jack Geiger and Dr. Count Gibson,

1965 grant request for a community health center

the administration of the health center in a meaningful way.” Ultimately, this value would become institutionalized when CHCs were mandated to have 51 percent of their board be comprised of patients from the same health center in order to receive federal funding; you can be sure that made more than a few project leaders take notice.

But what does it mean to negotiate in a “meaningful way” with the administration? Who would decide what was meaningful? As one might expect, doctors and administrators did not always ride these shifting tides easily. In many projects, the associations quickly recognized that their participation was often only advisory, and when the decision to take advice or ignore it lay with another group outside of their community, community participation quickly ran the risk of being diluted at best, or empty at worst.

can participate in health, as evident by how one interacts with another manifestation of community participation, the Village Health Worker. On one hand were the top-down approaches, where professionals and experts determine what poor communities need and then find ways to let community members contribute to these objectives as, in his words, “lackeys” for someone else’s goals.

On the other hand were the bottom-up approaches, where through the process of a participatory, Freirean approach to education, community members are taught to analyze their situation, consider possible solutions, and then lead initiatives that will “liberate” them from the clutches of disease and poverty.6 This latter approach has often been termed the “empowerment” model.7 While the term “empowerment” has of late become

ful don’t give up power easily, which is short hand for resources and the ability to decide how to use them, what is the true golden path to helping communities empower themselves? iii. Whose

anyway?

community is it

There is no magic formula for how to work with communities in a way that perfectly balances power sharing with meaningful change.8 Many of the experiences that I have had in the Partners In Health supported projects in Mesoamerica have been incredible reminders of just how complicated this work can be. Nevertheless, like the practice of medicine, there is both a science and art to the vocation. Inspired by my readings and experiences, I offer a few key considerations, certainly not exhaustive, for those who may find themselves in the tumult of

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global health review

Author Bio Daniel Palazuelos, M.D., M.P.H., is an Associate Physician at the Brigham and Women’s Hospital and an Instructor of Medicine at Harvard Medical School. He graduated from Brown Medical School and completed a residency in Internal Medicine and Global Health Equity at BWH. In his role as the Clinical Director of the Partners In Health-supported projects in Chiapas, Mexico and Guatemala, he lives for half of the year in isolated and impoverished rural communities, training local Community Health Promoters, providing medical care, conducting research, hosting medical student projects, and creating original curricula. For the other half of the year, he lives in Boston and practices inpatient medicine with the Hospitalist Group at BWH. Recently, his work in Mexico/Guatemala has included the development of original Decision Support Software to be used on mobile electronic devices by Community Health Workers. community participation:9 1. Communities are people, so don’t forget you are too: If you want to work with communities, you have to work in communities. This means being present, eating what they eat, sleeping where they sleep, sharing with the community members both the joys and difficulties of everyday life.

White 4x4 trucks that allow for easy access and egress can be destructive if they are used as a means of separating ourselves from the challenges that our local partners live every day. Personal safety is certainly paramount, but we should be careful to not fool ourselves about what is safe and what is merely comfortable privilege.

2. People often prefer accompaniment to overt leadership: Your partners on-site have thought and acted before you ever came, and will continue to think and act long after you’ve left. Each one has a personal

understanding of their own world, and of the logic that connects them to it. If we are outsiders bringing in new elements, albeit positive elements, the onus is on us to understand how this element fits within established paradigms. By hoping to accompany local processes as a humble partner, we can hopefully meet the inevitable challenges with a spirit of compassion, ingenuity and equal collaboration.

3. Communities are actually made up of many communities: When many people think of the good community, they often envision a collection of quaint houses along a mountain’s edge where everyone comes together on Sundays to democratically arbitrate disputes and then celebrate life. If this evokes in you a warm and fuzzy feeling, then you simply don’t know communities.

They aren’t perfect, and they certainly aren’t singular entities that share one mind and speak with one voice. This is most true in modern communities, such as in urbanized areas and slums, where people are forced to live next to each other as economic refugees. We need to accept that community work may mean long conversations with different factions, trying to sort out who is working well together and who is gearing up for battle. All community participatory work runs the risk of what has been called “elite capture” – a process by which the locals that are relatively more well off, usually men and majority groups, influence resources and projects such that they make out with more of the benefits.10 Knowing this ahead of time, you can work towards creating systems that minimize this corrosive process.

4. Participation needs investments: Community participation is sometimes seen as a “cost-effective” panacea: a yellow brick road to empowerment and sustainability that presents little need for increased material resources.

Photo courtesy of PAHO

Ted Kennedy at Alma- Ata.

This is wrong, because even the most organized and active communities can always do more with new tools and new initiatives. Without tools, the glass ceiling of achievement will be low; but once the tools are available, an engaged and involved community has the possibility of adapting them to local needs. Equity in action is the sharing and redistribution of resources, good resources. One can see this taking shape in initiatives such as improved housing, quality HIV care, electronic medical records, etc. In our work, as one of many examples, we are piloting the use of original computer applications, programmed on cell phones, as decision support tools for Village Health Workers.

5. Hierarchies only crush those at the bottom: Whether they are liberators or lackeys, if Village Health Workers are only the last rung on a steep ladder of participation, they will be crushed by the weight of those above them. It sends the wrong message. Initiatives are better managed horizontally, and incentives have to be distributed transparently and equitably.

6. Communities exist in a context: Even the most isolated and marginalized communities exist within countries, and countries almost always have governments. Even if communities decide not to work directly with government services because of past abuses, efforts should still be made to encourage communities to envision

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global health review how local efforts will exist within the larger context of government programs.

This is not only to prevent parallel services that waste resources through duplicate efforts, but also to potentially strengthen the rights afforded to them that only governments can supply. There are many different mechanisms by which this can occur, and a number of studies have looked at which are more effective then others11, but the first step is to recognize that while completely rejecting government services may be appealing to some in the short run, this strategy threatens to undermine the very foundation of peoples’ rights in the long term. iv.

They decide, and we participate: Community participation is actually not only about communities; it is also about us, the privileged who hope to help them. It is: a constant reassessment of what drives our motivations, and how we are interacting with our

on-site colleagues; a daily practice of active patience and cultivated humility; a gentle reminder that while we bring new tools and materials, we will always have yet more to learn about how to use them best on-site.12 As a personal barometer, I regularly ask myself: who’s deciding and who’s par-

ticipating? I know I’m getting close to being right when I find myself participating in and accompanying initiatives that our colleagues have decided upon themselves, hopefully, as a community. While the weight of the world’s problems far exceeds the mass of a car, we all have our part to pull. 

Footnotes & References 1. Morgan, LM. Community Participation in Health: perpetual allure, persistent challenge. Health Policy and Planning. 2001 Oct 11;16(3):221-230.

2. Walton DA, Farmer PE, Lambert W, Léandre F, Koenig SP, Mukherjee JS. Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti. Journal of Public Health Policy. 2004 Nov 2(25):37-158.

3. Bryant JH, Richmond JB. Alma-Ata and Primary Health Care: An Evolving Story. Health Systems Policy Finance and Organization. Carrin G, Buse K, Heggenhougen KH, Quah SR, editors. USA: Elsevier; 2009.

4. Maher D, Floyd K, Jaramillo E, Nkhoma W, Nyarko E, Wilkinson D, Raviglione M. Community Contribution to TB Care: Practice and Policy. Geneva: WHO; 2003.

5. Geiger HJ. The First Community Health Centers: A Model of Enduring Value. J Ambulatory Care Management. 2005; 28(4):313-320.

6. The Freirean approach to education comes from Paolo Freire, perhaps one of the most influential philosophers about education in the 20th century. His most famous book, Pedagogy of the Oppressed, explains the ways in which education can be used as either a tool of oppression or a tool for liberation. Without these ideas, Donde No Hay Doctor would probably have never been written.

7. Laverack G. Improving Health Outcomes through Community Empowerment: A Review of the Literature.

J Health Popul Nutr. Mar 2006; 24(1):113-120.

8. Rifkin, SB. Paradigms Lost: Toward a new understanding of community participation in health programmes. Acta Tropica. 1996: 61;79-92.

9. Kahssay HM, Oakley P. Community Involvement in Health Development: a review of concept and practice. Geneva: WHO; 1999.

10. Platteau JP. Monitoring Elite Capture in Community-Driven Development. Development and Change.

2004 April; 35(2): 223–246.

11. The Poverty Action Lab at MIT has done a particularly nice job in this: http://www.povertyactionlab.org/

A community pulls a tractor from the side of a cliff.

Photo courtesy of Dr. Palazuelos

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global health review

Farhan Murshed, Staff Interviewer

Photo courtesy of Dr. Katabira

Photo by Tom Fitzsimmons

Daniel L. Shapiro, Ph.D., is founder and director of the Harvard International Negotiation Program. He is on the faculty of the Program on Negotiation at Harvard Law School and in the psychology department at Harvard Medical School/ McLean Hospital.

He has contributed to a wide array of scholarly journals and practical books, including the bestselling Beyond Reason:

Using Emotions as You Negotiate (with Roger Fisher).

Dr. Shapiro chairs the World Economic Forumâ&#x20AC;&#x2122;s Global Agenda Council on Conflict Prevention, a high-level group of security experts, leading academics, and former heads of state who establish global priorities around conflict resolution. He has trained Chinese officials, Serbian Members of Parliament, Middle East

negotiators, Macedonian politicians, and senior U.S. officials.

He has co-facilitated workshops with international leaders including Her Majesty Queen Rania of Jordan and Tony Blair, former Prime Minister of the United Kingdom. Through non-profit funding, he developed a conflict management program that now reaches one million youth across more than 30 countries.

INTERVIEWS

An Interview with Daniel L. Shapiro, Ph.D.

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global health review HCGHR: How can the tools of negotiation be applied to the field of global health, where only a small fraction of resources are committed to the large majority of the world’s population? For example, how does one negotiate intellectual property when trying to provide affordable medicine for the third world?

Shapiro: There are a few ways to go. One way would be trying to influence norms in a positive way, as we’re seeing with social philanthropy in the United States and many parts of the world. A lot of companies are doing social philanthropy because it’s the norm- you are supposed to be doing this. You know that the people using your service or product are going to come back to you and say, “Hey what are you doing to help our society?”

There’s a norm out there. It’s not a legal matter per se... But it certainly is a norm to have; it’s common practice now in many organizations to have some wing for social philanthropy.

Along those lines, I can imagine a concerted effort to change norms so that pharmaceuticals and other companies feel more of a social responsibility rather than an obligation to commit more resources to areas that are less developed and desperately in need. What can be done to influence social pressure -- and peer pressure among the top leadership of these companies?

Second: law. Can there be laws -domestic laws, perhaps international laws-- that require a greater level of responsibility and resource commitment to less developed countries?

A third form of influence is through explicit negotiation. This isn’t through brute force. This isn’t through social change broadly.

This is through individuals in the global health realm perhaps those of influence, supported by others – who talk to the pharmaceutical leaders and negotiate. This involves mutual understanding with the goal of arriving at agreement that satisfies

everyone’s interests.

HCGHR: Could you explain in more detail how the process of negotiation can be used to encourage pharmaceutical companies to expand their medical support to developing countries?

Global health “workers are working in tremendously complicated institutions… and contexts, such as a war zone or a postconflict war zone.

”

Shapiro: Negotiation requires trying to understand what the pharmaceutical company cares about. Are there creative ways to get that pharmaceutical company to, in fact, enhance their bottom line while still helping the less developed areas, while still donating significant resources and medicines to these areas, while still building infrastructure in these other areas that desperately need it? What’s in it for the company?

The company will undoubtedly resist change, especially if change means that it will lose – lose more money, lose more power, lose more star employees.

So what’s the best proposition for the company? Creativity is key.

Negotiation can work, but it entails skilled negotiators, or at least bringing in a talented mediator to help the parties understand one another. I think that’s possible.

People often wrongly view negotiation as a zero-sum situation: more for one side means less for the

other. This may be true in the world of pharmaceuticals and global aid. If if I donate more money, that means my company’s losing. And the other side, if you don’t donate more resources, we’re stuck. And it’s too simple that way.

The reality is much more complicated.

There are multiple different interests that the global health company has.

There are multiple interests that the big corporation has. If you get these two sides together, sit them down, have them really listen to one another, understand what each side’s full interests are, they may discover an interest in money, reputation, marketing, helping people, designing new infrastructure, designing good studies, … it’s ensuring health care for all, and it’s 100 different interests when you break open the issue.

If you can get some people sitting down to really understand each side’s interest and to brainstorm options that can meet each sides’ interests – you’re going to find some idea that’s better, I’d imagine, than going to court and trying to battle it out.

At the end of the day you want the parties to work side-by-side enthusiastically rather than spending many millions of dollars in court duking this out or in the public realm putting each other down. I think negotiation has a lot of value when trying to gain more support for those who really need it.

HCGHR: It sounds like negotiation is a critical skill for the global health worker.

Shapiro: Exactly. Anytime you are interacting with someone else for some purpose, you are negotiating. So the global health worker is negotiating all the time. And the ability to negotiate effectively ultimately boils down to life or death for many people. If you, the global health worker, cannot effectively negotiate to get that medicine into Haiti this morning, guess how many people just died? It’s not the fact that the good

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global health review technical solution or the medicine isn’t there – the problem is a people problem.

And I think so much of global health involves people problems.

People problems entail people answers. Negotiation offers a whole field of ideas to help global health workers deal more effectively with one another, to build relationships and to get a better substantive outcome at the same time.

The global health worker who is completely naive to negotiation is a much less effective global health worker... I think that’s critical for the global health community to recognize.

It’s really complex. So healthcare workers and global health workers are working in a very complex environment and negotiation becomes a - if not the - key skill to function effectively in that complex environment.

Negotiation isn’t just about business people formally negotiating an agreement to a business contract. It is about all of us, in our daily work, talking back and forth and coming to some agreement about some issue.

You talk about health care delivery: what’s the essential element of health care delivery? It’s people working with people. And those people can work effectively with one another or they can be working miserably with one another.

Effective work entails negotiation.

And we’ve put together a whole body of ideas that can help negotiators negotiate more effectively, in a sense helping global health workers negotiate more effectively internal to the organization, externally as well.

Global health workers are working in tremendously complicated institutions and contexts, such as a war zone or a postconflict war zone. You’re dealing with a complex set of actors: internally within a medical institution you’re dealing with a hierarchy of a hospital system, so you’re dealing with your colleagues, with those above you, with those beneath you, and then you’re expected also to be interacting with those outside of that particular system- those asking or needing particular health care.

You’re often dealing with governmental systems and educational systems, where healthcare is probably provided or authorized for provisions.

delivery when powerful forces work against immediate health interests?

HCGHR: How should the global health worker negotiate health care

level of interests, you start to unravel the complexity of the situation – what people’s needs, concerns, and interests are.

Once you understand that the political figure’s interests in not allowing the medicine in right now, you can start to come up with creative options to meet each side’s interests at the same time.

So if it’s a security issue and this political leader is afraid that there’s going to be some sort of major run for the medicine because so many people need it, that’s good to know. Maybe the committee that’s meeting on security

“The global health worker who is completely naive to negotiation is a much less effective global health worker... ” Shapiro: So let’s say you are a global health worker trying to get medicines into Haiti, and you’re trying to negotiate with a political leader and the political leader says, “No, not right now. You can’t yet.” Maybe it’s for security reasons or something else, you don’t know, but you do know people are suffering, people are about to die, and someone is saying no.

What do you do? What’s your strategy?

I think most people who don’t have negotiation training don’t have a clear strategy in mind. And in a sense we’ve built two different approaches– one is around building the best substantive outcome you can and the other is about building the best relationship you can as you’re dealing with differences.

On the substantive side, the key insight is to focus not on positions, but on the underlying interest. A position is what someone says they want: “I want the medicine.” “Well we don’t want you to bring the medicine in.” An interest is the underlying motivation. Why do you want the medicine in? Why do they not want the medicine in? Focusing at the

issues is meeting next week.

So once I understand that, it can now help me to develop some sort of option that can meet this political figure’s interests in maintaining office and security -- and not causing mass chaos. And a good creative option would [also] meet my interests in getting this medicine to the population that needs it now.

HCGHR: You’ve developed a framework to help people deal with heated emotions. How does this work for the global health worker?

Shapiro: Certainly in issues of global health concern, where life and limb are on the line, emotions are incredibly complicated. Hundreds of emotions bouncing around: anger, fear, frustration, annoyance, humiliation, and so on. So how do you deal with all of that?

If you are a young global health worker helping out in the tragic reality of the floods in Pakistan, or the aftermath of the earthquake in Haiti, how are you going to deal with all these different emotions to get your job done? Most people tend to throw up their hands and

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global health review try to ignore the emotions. They can be too much to bear. But the reality is that we cannot avoid emotions. We are emotional human beings.

An alternative approach is to turn your attention away from all of those emotions and toward five core concerns that stimulate them. My colleague, Roger Fisher, and I wrote a book called, Beyond Reason: Using Emotions as You Negotiate. In it we articulate five core concerns – matters that are important to all of us.

Whether we are in Pakistan, Haiti, or Cambridge or elsewhere, if you deal with these core concerns well, you can stimulate positive emotions and cooperative behavior. [But if ] you deal with these things poorly, watch out.

Let me share the five core concerns with you briefly: Appreciation. Do the people with whom the global health worker is interacting feel appreciated and valued?

This is essential for cooperative relations.

And at the same time, does the global health worker feel appreciated? Does the doctor in Uganda think, “Boy I’m working all day but no one thanks me for all the work I’m doing…”

Core concern number two is autonomy. It’s the freedom to make decisions without someone imposing their decision on you. As the global health worker comes into the community, does the local community start feeling like that global health facility is treading upon their autonomy, telling them what to do, rather than consulting them? I think this is a huge issue when outsiders intervene in another situation.

“Who are you to tell me what to do in this situation? This is my country.

This is my community. You think you can tell me where to put my belongings, how to do what my people have done for centuries here? Don’t tell me what to do.” The problem isn’t essentially about substantive issues, but about the way decisions are made. If I feel like

Beyond Reason: Using Emotions As You Negotiate Roger Fisher, LLM. and Daniel L. Shapiro, Ph.D. Emotions matter:

Emotions can be used to turn a disagreement- big or small, professional or personal- into an opportunity for mutual gain.

Five keys to unlock the power of emotions...

The five core concerns that lie at the heart of most emotional challenges are: One - Appreciation Two - Autonomy Three - Affiliation Four - Status Five - Role *All information courtesy of Dr. Shapiro and the Beyond Reason webpage: http://www.beyond-reason.net/

you’re impinging upon my autonomy, I’m much less likely to work with you effectively, even if I feel that you have good ideas that can help me.

Core concern number three is affiliation. So the idea here is: What can the global health worker do to try to build a sense of emotional connection with the populace with whom they’re working? How can they work most effectively together?

Core concern number four is status: who’s up, who’s down. I think it’s common for international people to come into a crisis situation assuming they have superior knowledge, superior ways of being, superior ways of treatment.

Yes, their treatment approach may be effective, but the moment the other side feels their status is being belittled, the other’s emotions will get rocked and you’ll have less cooperation between the sides.

The fifth core concern that we’ve noted is role. Do you have a fulfilling role in your negotiations and more broadly in the community? Is it just that I, a physician, come in and operate on you as though you are an object, or are we working together, each inviting the other into fulfilling roles as we work to help this community that desperately needs the help?

So these five core concerns ultimately can become a prescriptive guide for the global health worker because they offer a very practical way of dealing with the very complex realm of human interactions.

First, appreciate the other as you go into that situation in Pakistan or Haiti or wherever. Appreciate their feelings, their perspective, their experience – and that means listening, asking good, openended questions, and showing you’re curious.

Second, build affiliation. How are you going to build affiliation with the other side? “You have kids? I have kids.

What advice do you have for me for raising my kids?” Build a connection

harvard college

global health review through personal revelations. Take some risks and open up a bit.

Third, respect autonomy. The global health worker does not want to tell the population what to do, but rather to offer ideas, recognizing that the population has full autonomy to take or leave any ideas as they like.

Fourth, acknowledge status. Yes, I as the global health worker may have the benefit of having studied medicine of a particular kind that your community needs. But at the same time, you -- the patient who I’m working with– have much more knowledge about what your community needs are, and how we can deliver this medication in the most efficient way possible. You have important insights, and I want to acknowledge that.

Fifth, let’s figure out how we can effectively work together: What roles can I play that are helpful for you? What constructive roles might I invite you to play?

So those five core concerns help structure positive relations for the global health worker going in to help in a “foreign land.”

HCGHR: Conflict can jeopardize indigenous and global health initiatives, as evidenced by the challenges of the polio eradication campaign in Afghanistan and Pakistan. What framework, if any, can be used to negotiate necessary health care for all parties in such a conflict?

Shapiro: I think the first step is to realize that there’s no longer a distinct line between medicine, government, health care, security- all of these different issues.

The boundaries between these different disciplines made more sense 50 years ago than they do now. Now the moment we even start thinking about the concept of global health, it means we must have multiple disciplines working together side by side to deal with these differences.

INTERVIEWS I don’t think that the medical doctor trying to effect positive change in the aftermath of floods in Pakistan is going to be near as effective if he or she goes as an individual rather than as an organization aligned with government and non-government support groups d o m e s t i c a l l y, regionally, and globally.

So I think the first step is to recognize it’s a different world.

Treat it as such: Photo courtesy of the U.S. Army build strategic Flood waters wash away ground in the northern areas of the alliances and Swat valley in Pakistan. cooperative – but to be working preventively. relationships The problems of prevention are with other individuals and institutions numerous. Without crisis, it’s a lot with that purpose in mind.

Second, I think we’re good at harder to get funding. Without crisis, reacting after the fact. Disaster happens it’s a lot harder to get the rock stars and the world comes in to fix it – and philanthropists of the world to Haiti is a perfect example. The terrible contribute donations. Will major and philanthropic earthquakes happened and you have this corporations international outpouring of assistance – organizations donate without a tangible I’m sure it’s declined significantly since crisis at hand? Good luck trying to raise the time the earthquake’s happened. At the funds. It’s not easy.

Our world is much more inclined to the same time, why did this catastrophe happen in the first place? You have respond after the fact, after the violence earthquakes in a number of places in the has occurred, after the horrible global world, and you have a wholly different health situation has emerged, than beforehand. infrastructure.

At the same time, I think we need In some other locations, there’s an our prevention heroes. We don’t have equally severe earthquake but almost not even a blip on the radar screen in prevention heroes right now – we terms of the amount of casualties and need them. People working behind injuries. This points to the need for the the scenes, people who are working to field of global health to think not just build the structures, the infrastructures, reactively – about how to deal with the the cooperative networks, so that when humanitarian aftermath of these disasters an earthquake does happen, there are

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global health review already people on the ground and it doesn’t have the human costs and economic costs it otherwise does.

HCGHR: Natural disasters often have severe health consequences, but the ensuing international humanitarian response can vary significantly. For example, one calculation estimates that Haiti received 60 times more funding per affected person than Pakistan. What insight would you offer to humanitarian health disaster organizers to overcome this type of disparity?

Shapiro: First, to the difference of funding, people are people. Suffering people are suffering people. Whether the suffering is in Pakistan or Haiti or Boston, Massachusetts. It doesn’t make a difference. It just doesn’t make a difference: suffering is suffering. Global health is global health.

Second, if a group wants and needs funding, how should they negotiate effectively? People have selfinterests, and if I were advising a health organization, the most important piece of advice would be to think through: What are the interests of the funding group? What do they care about? Who are the decision makers? Who are the specific decision makers that will be judging your proposal? What makes your proposal not only unique but something that fulfills the interests of that organization or that single person reading it and trying to make a decision?

So it’s really looking at the other person’s perspective, looking at the decision from the other person’s perspective: How can I make the most persuasive arguments and narratives -- not from my eyes, not from my perspective, not even from the perspective of the people I’m trying to help -- but from the perspective of the decision maker I’m trying to influence?

That’s the biggest piece of very general advice that I’d offer. Figure out as much

as you can about the decision maker and align with their interests in a way that doesn’t demean your interests, that still recognizes everything you’re trying to do.

If I’m trying to persuade someone, I need to know where their mind is at right now.

It can be helpful to build personal ties with potential funders. If I’m working to help the people in Pakistan and the potential funding organization is in New York City - and I’ve never gone to get funding from this group before – I’d guess that I’d be less likely to get that funding.

Conversely, I’d have a better shot at the funds if I knew the specific decision maker, or if I knew someone who knew that person, knew their interests, knew what they cared about, and knew how

people over here are really important but you’re funding those people over there…so please fund our people because it’s what we’re working [on].” Not very persuasive. I think a better way would be trying to align with the decision maker.

A very powerful way to do that is to ask advice.

“We are here in Pakistan. There’s devastation here in Pakistan. You’ve seen it in the news, we’re seeing it live in person and the people here desperately need additional support. Here are the constraints we’re under. What’s your advice on how we might best tailor some sort of proposal that can get the most attention and interests within your organization?” By asking that question, it completely changes the dynamic from two separate individuals representing two separate entities to the dynamic of

no longer “...there’s a distinct line

the two of us, sitting side-by side, thinking through the same shared problem of alleviating some of the suffering on this earth. In short, ask for advice. 

between medicine, government, healthcare, security- all of these different issues. The boundaries between these different disciplines made more sense 50 years ago than they do now.

Flood waters in the Swat valley of Pakistan.

”

to frame a proposal in a way that would appeal to the funding organization.

But what should you do if you don’t have links to the specific funder? It’s hard to just get on the phone and say, “These

Photo courtesy of the U.S. Army

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Harvard College 2013

I found out about volunteering with Support for International Change (SIC) from two past volunteers, and after hearing about their amazing experiences, I was motivated to learn more about the organization and the summer awareness campaign. From the beginning of my freshman year, I knew that I wanted to go abroad for the summer and work in a developing country. From the info-sessions, it became clear to me that SIC put a lot of thought into integrating the volunteers into the community and creating a sustainable framework for HIV education and prevention. From the pre-field training in the months before the summer to the intense ten-day volunteer orientation in Tanzania, I felt confident that I would be prepared to teach in the villages. I was also attracted to SIC because it would provide me the unique opportunity to live with a homestay family and experience a different culture and way of life. Ultimately, the experience instilled within me a passion for HIV/AIDSrelated work and activism.

Debanjan Pain

I

see my Bibi sitting on a small wooden chair and cooking over the fire with her bare hands, smiling enthusiastically. She leans over to tickle the youngest boy of our family, who then chuckles and shrugs his shoulders. He curls up in her lap, and she begins to stroke his hair while continuing to cook Chapatti, a traditional Tanzanian dish. This scene is a memory from my work as a volunteer with an NGO called Support for International Change. I had the opportunity to live with and integrate into a family in rural Tanzania this past summer. During my stay, I

taught about HIV prevention and behavior change, visited the HIV positive members of our village, and worked on sustainable projects for the community. Over the two-month period, I grew close to my new Mama (mother), Baba (father), and Bibi (grandmother). The nights of card playing and singing with younger brothers and sisters were as impressionable for me as my experiences teaching during the day. My family not only welcomed me with open arms, but also exposed me to all aspects of their livesâ&#x20AC;&#x201D;from Tanzanian culture to their recent struggles and subsequent

Teaching the ABCâ&#x20AC;&#x2122;s (Abstinence, Be Faithful, Condoms) to Standard VII (aged 14-15) with the other Gijedabung volunteers and teaching partners.

Photo courtesy of Debanjan Pain

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Debanjan Pain

HIV/AIDS Education in Tanzania

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global health review

Photo courtesy of Debanjan Pain My homestay family and me outside our home in the village of Gijedabung.

strength and willpower. While I went to to lead a support group for HIV posi- I worked alongside her, I couldn’t help Tanzania as an educator, during the ex- tive members of the community, where but be influenced and inspired. My perience, I became a student. she advised younger women on how to Bibi taught me to never abandon my During my time with my family, I live healthy lifestyles. She chose to cre- passion because of adversity and to stay discovered that my Bibi was HIV posi- ate an open and safe space for discussion true to my values and ideals in all my futive. As a paragon of the selfless care- within the community. In many ways, I ture endeavors. giver, she taught me what it meant to be was trying to help with and continue From all that I learned, I hope to be a bold leader and respected community the movement of education and open a stronger teacher and leader who truly member. In 2006, doctors informed communication that she had already cares about the community around me. her that she most likely contracted the begun in the village.

Following in my Bibi’s footsteps, I hope virus through blood-to-blood transmisto provide care sion. For years, she had taken to those in need, care of a young woman with “...she taught me what it meant to be a bold educate and emAIDS, and it was likely that leader and respected community member.” power youth, she became infected while and combat inproviding care. What I found justices, no matmore shocking, however, was that she In these endeavors, my Bibi was ter their form. My experience taught still continued to perform her daily ac- determined to share her experience, in me that global health work is not only tivities despite her age and affliction. the face of whatever shame or discrimi- a chance to make an impact, though My Bibi embodies the kind of care- nation would come her way. From my small, but it is also an opportunity to giver and citizen that I strive to be in the Bibi, I learned that education has the learn from those who make big impacts future. While my Bibi could not change power to clear up misconceptions and where they live, everyday. With my the fact that she contracted HIV, she decrease stigma. Through her efforts Bibi’s unwavering determination and could choose how she would lead the to encourage villagers to get tested, positive attitude in mind, I strive to be rest of her life. My Bibi chose to reveal I witnessed a single individual’s abil- a compassionate caregiver and provide her status to the community. She chose ity to motivate and inspire others. As assistance to those who need it most. n

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I

n my mind, Costa Rica was paradise on earth. My first visit was in middle school, spending a week traveling to hot springs and beautiful beaches, zip lining through the rainforest, and eating all the fresh fruit I could. While the country was just as beautiful when I returned as an adult, I gained a whole new perspective of the place and of the people. Ideologically speaking, I have always been uncertain of where I stand as a westerner volunteering in a developing nation to ‘save the children’ or ‘enact my vision of social change’. Despite these reservations, I decided to try volunteering in this capacity and decipher what my role actually is in this setting.

My task for that summer was to

Emelyn Rude lead a small day camp for the elementary school children of the small town of Berlin during their winter break. This program, which I designed with my fellow volunteer Shyla, was focused purely on health. I was told that, aside from the volunteers from the year before, these children had never had any formal activities outside of their schooling.

I remained as a volunteer after classes resumed, only to realize how little organized activities these children had at all times. For the class I worked with, the teacher was obviously disinterested, choosing to spend more time with his girlfriend while the kids watched a bootleg copy of Shrek Tercero. While my peers and I could never take the official role of

Camp in the centro making collages about ‘Myself.’

Photo courtesy of Emelyn Rude

Fabian during a hike up the mountain.

Photo courtesy of Emelyn Rude

the children’s teacher, we tried to do our best to teach our children within our capacity. Our health curriculum expanded to incorporate a little math, a little English, and a little on the environment, but still held a steady basis in the importance of personal care. Teaching is truly surprising, because you can never anticipate how much a little attention and care can encourage a child to learn. I had never seen children take so quickly and so excitedly to an activity, “the hand-washing game,” which was a relay to see which team could wash their hands properly and thoroughly (for at least 30 seconds).

Similarly, I never imagined that the small gift of toothbrushes could make such large beautiful, smiles.

From this experience, I realize that knowledge is power and knowledge of one’s health is even more so.

These kids may only remember me as that “gringa” from that one summer, but they probably still brush their teeth properly, they are probably still washing their hands, and their lives are probably

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A Summer in Costa Rica

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Emelyn Rude Harvard College 2013

This project was done as part of the volunteer program, Amigos de las Americas, a NGO based in the United States that sends high school and college aged students to countries throughout Latin America just a little improved because of these small things they had learned that later become routine behaviors. I didnâ&#x20AC;&#x2122;t intend to become a teacher and an advocate for public health, but that summer made me realize that such advocacy

in order to develop meaningful and sustainable cross-cultural relationships. I got involved after hearing from a friend who had worked with this program in Panama previously and recommended it. I had been and such awareness is important for all people, whether they are Costa Rican or from the United States. I realize now that sharing what I know about taking care of my body, something I have long taken for granted, is something these

looking for a meaningful way to work in global health to the best of my ability, and teaching in Costa Rica was a great fit.

children would never have learned from spending their day looking at Shrek or Donkey. Getting involved in teaching health is not an individual thing; itâ&#x20AC;&#x2122;s an act and an event that shapes everybody involved, one smiling tooth at a time. n

Berlin, Costa Rica.

Photo courtesy of Emelyn Rude

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Harvard College 2012

I became interested in global health after living on the East Coast of Zanzibar for four months during my gap year. I was teaching at the Jambiani Tourism Training Institute and the local secondary school, and the Institute adjoined the only alternative-medicine clinic in East Africa. It may seem small, but getting their back problems worked out or getting a physical check-up seemed to bring a lot of relief to Jambiani residents. On Zanzibar everyone knows of the kindness of the owners of the clinic and school, Alistair Pirie and Patricia Elias, and they are called “Ali Baba and Mama Pat.” I saw, then, that health is not a niche issue; it affects everyone, and involves many parts of society. The provision of health reflects and can affect how the rest of a community works, and should be the locus of development work.

C

Anita Joseph

an you explain to me how you throw away your needles?” Rachel questioned the lab technician, her pen hovering over her notebook expectantly. I translated, “unaweza kunieleza njia ya kutupa masindano?” The lab technician, who tolerated this interruption in her day’s schedule with grace, pointed to a cardboard box with a “hazard” sign on it. “Nzuri” I said, ‘good,’ while Rachel flipped open the normal trash and scanned the counters to check to see if any needles had found there way into there. We were at Mji Mwema Dispensary twenty minutes outside of Arusha, the second-largest cityin Tanzania, and we were halfway through our inspection.

Right: Children from a clinic in Dar es Salaam wait to be treated.

Photo courtesy of Anita Joseph

This past summer, Rachel Bervell ’13, Peggy Su ’13, Byran Dai ’11, and I worked with 21 health facilities in Tanzania on how to improve their quality. While interning with the Association of Private Health Facilities in Tanzania, we had the opportunity to visit their member health institutions. We developed an inspection process for them by creating a checklist of “best practices,” with nine categories ranging from “leadership” to “infection control” to “environment of care.” We were influenced by observation of Dar es Salaam clinics, the Zambian Hospital Accreditation Council checklist, UNICEF’s Baby-Friendly Hospital program, and the World Health Organization’s “Surgical Safety Checklist.”

We used the checklist in three cities: Tanga, Moshi, and Arusha. Upon arrival in each city, we visited APHFTA facilities by public transportation or bargained-for private taxi, inspected them, and returned with a Quality-Improvement Report. The report included their checklist, their “strengths,” their “areas of improvement,” and “recommendations.” While the reactions were overwhelmingly positive, there were notable exceptions. “Fix the cracks in my walls?”

Dr. Abbas asked us incredulously, “my patients are coming to see me, not my walls!” A common objection to suggestions was “it costs too much,” so we tried to develop low-cost solutions. Three Arusha facilities served significant Maasai populations, and many of the Maasai women spoke only Maa and no Swahili.

Since doctors couldn’t communicate

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Quality-Improvement in Tanzanian Health Facilities

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Photo courtesy of Anita Joseph The group at the Besha Health Centre after giving a quality improvement report to the chief clinical officer and hospital administrator. Pictured (left to right): Byran Dai (‘11), the hospital administrator, Anita Joseph (‘12), Peggy Su (‘13), Rachel Bervell (‘13), and the chief clinical officer of the health center.

fully with them, they didn’t fully understand why they were sick. Instead of recommending the clinic hire an interpreter or train their staff in Maa—a natural responses in the U.S.—we recommended that the doctors use visuals to explain the basics of common issues like malaria, pregnancy problems, and skin infections.

As we moved from city to city, we adapted our project as we learned. For example, as we started noticing that health facilities often had damaged ceiling tiles; we added a lack of this to our checklist.

Our inspection methodology changed; in our first two cities we interviewed only hospital administrators for our checklist, in our second two we interviewed administrators, the nurse matron, the lab technician, and receptionist, to confirm answers. I speak Swahili, and randomly questioned patients and nurses.

Each of us took a fourth of the template to specialize in as our own, and wrote the portion of the final report that

dealt with that fourth, to allow for better facility-to-facility comparison.

Our work, similar to much of the work done in global health, had many strengths and many areas that need improvement. Our project worked because it was simple —we left behind a copy of our template with each facility so they could survey themselves if they wanted, including the low cost of the recommendations, and the systemization of our methodology.

While the project had strengths, it also had weaknesses in many areas, only some of which can be outlined here.

Having to visit as many facilities as we did in a short time span, we weren’t able to work with clinics in depth to better develop strategies for improvement. We also developed our template from observation in four metropolitan areas, and more than 80 percent of Tanzania lives in rural areas. Furthermore, it’s especially difficult to work in health in other coun-

tries without being influenced by a Western conception of what health facilities should look like. With more experience with small health clinics in other countries, we would not have seen the Tanzania and American clinics as such a binary.

While global health work is imperfect and projects are constantly adapting and changing, my peers and I learned that basic quality-improvement consulting is a low-cost and efficient way for outside observers to help Tanzanians build healthcare infrastructure on our own. It’s important to take on global health projects where you can be most effective in your time and familiarity with the area.

Additionally, your involvement doesn’t have to end after one summer, or one internship. We hope to return to Tanzania in the future and help other students continue our work next summer to further explore our project methodology may be improved and expanded. n

GH|X is a new social discussion and networking format for, by, and of students across Harvard who are interested in global health and issues related to international development.

GH|X provides students with an informal and fun opportunity to exchange, explore, and experience global health together, and to learn with and from each other.

GH|X is more multimedia â&#x20AC;&#x153;show and tellâ&#x20AC;? than conventional academic presentation- an informal sharing of hands-on experiences gained from summer internships, volunteer jobs, and other occasions.

GH|X presentations focus on the comprehensive impressions gained from the experience, not the mere presentation of knowledge. They are also meant to include the many questions and dilemmas which arise during such experiences, in order to facilitate the exchange of tips and ideas among like-minded students and perhaps the planning of joint initiatives.

GH|X is not a university lecture! It more closely resembles a personal media show and reflection, as you would hope to experience with close friends, roommates and relatives after they return from really interesting jobs or journeys!