Juxtaposition 7.1 by Juxtaposition Global Health Magazine

GLOBAL HEALTH MAGAZINE

JUXTAPOSITION UNIVERSITY OF TORONTO

12 GLOBAL HEALTH DIPLOMACY: THE INEXTRICABLE LINKS BETWEEN HEALTH AND FOREIGN POLICY

22 TORONTO THINKS: A LOOK BACK AT CANADA’S FIRST UNDERGRADUATE GLOBAL HEALTH CASE-COMPETITION

Malaria poems Volume 7 issue 1

ISSN 1918-7653

Table of contents

index HEALTH AND INNOVATION

Golden Rice: a Promising Solution to Vitamin A Deficiency and Child Mortality?

07 Malaria Poems The Burden of Hib Disease in Indonesia and Actions 11 HIB: Taken to Mitigate its Effects POLICY AND PRACTICE the Wake of Typhoon Haiyan: Examining the 13 InDecentralization of Health Care Within the Philippines Health Diplomacy: The Inextricable Links 15 Global between Health and Foreign Policy & Neo-Colonialism: Pharmaceutical 17 Antiretrovirals Companies And The HIV/AIDS Epidemic = death: Uganda’s Anti-Homosexuality Bill and 21 Gay what it means for HIV

EDUCATION AND DEVELOPMENT

25 Wha66: THROUGH THE EYES OF A GLOBAL HEALTH STUDENT Global Health and Medicine: A Closer Look at PGME’s 29 Global Health Education Initiative Thinks: a look back at Canada’s first 32 Toronto Undergraduate global health Case-competition

Cover Photo: ©James Gathany/CDC

Executive Team Executive Editor-in-Chief: Abtin Parnia Editorial Editor-in-Chief: Kaleem Hawa Administrative Director: Molly McGillis Event Planning Co-Director: Ruhi Kiflen Buddhi Hatharaliyadda Managing Editor: Jacqueline Parrish Vipal Jain Production Editor: Leigh Cavanaugh Michelle Volpe Publicity Co-director: Elisabeth Foerster Jasleen Arneja Section Editor: Antu Hossain Gail Robson Jelena Savic Jerico Espinas Marisa Leon Carlyle Melissa Patania Sabrina Jassemi Seung Gwan Ryoo Sophia Lu Tahsin Khan Social Networker: Anjum Sultana Sponsorship Co-Director: Erfan Farno Salem Raman

UTSC Executives List UTSC co-director: Aidan McNeil Rashi Gupta Editor: Talha Sadiq Yoser Alarashi Gabriela Osorio Printed with:

Content © 2014 by Juxtaposition Global Health Magazine. All rights reserved. Neither this publication nor any part of it may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Juxtaposition Global Health Magazine. Juxtaposition Global Health Magazine reserves the right to edit all submissions.

editor’s note

Dear Juxta Readers,

s we passed the milestone of a decade of publishing, we began creating new initiatives to revolutionize global health education. Juxtaposition has a vast community of enthusiastic and committed individuals. During the last year we have attempted to create a global health laboratory for University of Toronto students. A space for students to learn and practice skills required for a global health career. Juxtaposinovations and Solutions. By using the principles of problem-based learning, Toronto Thinks brought together multidisciplinary teams to compete and to learn how to create solutions for complex global health challenges. JuxtaTalks this year involved a collaboration with Dignitas Youth and focused on illustrating the complexity of the diseases of poverty. This year also brought the establishment of Juxtaposition at UTSC. Under the leadership of Rashi Gupta and Aidan McNeill, we reached out to the UTSC community. We hope to engage UTSC students in an interdisciplinary discussion on important global health issues. , Policy & Practice, and Education & Development. Each section brings together articles that explore the complexity of human health and the systems with which it interacts. We start this issue with “Golden Rice,” an intriguing piece that explores section with an innovative piece by Cameron Conaway. He utilizes the power of poetry to discuss malaria, one of the most notorious infections of the developing world. Next, in the Policy & Practice section we visit Phillipines and the response to the Typhoon Haiyan. Writers in this section introduce us to the complexities of global health diplomacy, the role of pharmaceuticals in the law.

Education & Development our writers provide a student prespective on global health. We will take a look at 66th World Health Assembly and an interview with a student in Post-Graduate Medical winning team of Toronto Thinks inaugural case-competition. We sincerely hope that this issue presents you with an enlightening yet complex narrative about global health.

Best Regards,

Abtin Parnia

Kaleem Hawa

Editor-In-Chief, 2013-2014 Executive Division

Editor-In-Chief, 2013-2014 Editorial Division

For this issue’s web content, please visit: www.Juxtamagazine.org

sponsors

Post-Graduate Medical Education University of Toronto International Health Program Trinity College Human Biology Program University of Toronto Students’ Union

GENERAL

foreword

rom the dawn of multicellular life, complex organisms have had to protect themselves against pathogenic -

infectious diseases cause about one third of annual global mortality imposing an enormous burden on national and international health care systems. From Edward Jenner’s initial demonstration of acquired immunity to smallpox following vaccination over This means that while vaccination against smallpox confers immunity to smallpox it does not confer immunithe complex interactions of lymphocytic receptors that represent the adaptive immune system. Scientists and public health professionals are better able to understand disease and vaccination through the lens of genetic recombination events that produce these receptors – the only known situation in which the genetic composition of cells in an individual is programmed to undergo change. Vaccination has been one of the most important advances in global health over the last century and has been

for policymakers across the world who are tackling a variety challenges associated with the generation of new formulation required to induce the right type of immune response, from the costs of vaccine storage and delivery to the political and logistic barriers that make vaccinating rural populations in developing parts of the world vaccination. Understanding the immune system and its how its response to pathogens can be regulated is an essential part of process of controlling and eliminating infectious disease. This is why it is so exciting to see student involvement in researching and publishing about international editors – as well as for Toronto’s global health community.

MICHAEL RATCLIFFE. PhD Interim Provost and Dean of Arts at Trinity College Professor, Department of Immunology, University of Toronto, Trinity College, 6 Hoskin Avenue, Toronto, Ontario, Canada M5S 1H8

Health and innovation

Golden Rice A Promising Solution to Vitamin A Deficiency and Child Mortality? Lena Elisabeth Faust

Abstract Vitamin A deficiency is a condition primarily affecting young children and pregnant or breastfeeding mothers in South Asia and Sub-Saharan Africa, who do not have regular access to Vitamin A-rich foods. Vitamin A deficiency is the cause of over 5.2 million cases of blindness in children around the world. Furthermore, this deficiency has even more severe immunological effects, which can lead to increased mortality rates among affected individuals. It is estimated that Vitamin A deficiency causes up to 2.5 million deaths per year. A promising development in the field of genetic engineering hopes to provide a sustainable solution to the problem in the form of biosynthetic, Vitamin A-rich rice, but its commercial implementation remains a challenge.

We have all heard that carrots are “good for our eyes”…but is that all there is to it?

e have all heard that carrots are “good for our eyes”…but is that all there is to it? With easy access to nutrient-rich foods, this phrase may seem like a trivial statement to those of us living in developed countries and high-income households. certain fruits, milk, eggs, and liver are all rich in Vitamin A, but these nutritious foods are ple, particularly in low-income countries.1 According to the World Health Organihealth concern in 49 countries and a severe 2

Vitamin A has several important roles in the human body, one of which is the maintenance of constituents of the human eye such as the cornea and the protein rhodopsin. Since rhodopsin enables the absorption (VAD) can impair vision and prevent the

eyes from adapting to darkness. This condition, known as night blindness, can eventually progress to complete blindness.4 As the largest contributor to preventable child blindness in the world, VAD remains a persistent global health issue.5 Due to a lack of regular access to Vitamin A-rich foods, 5.2 night blindness,2 with 250,000 to 500,000 new cases occurring among children each year.5 Apart from leading to impaired vimune system. By increasing the severity of diarrheal diseases and the likelihood of contracting other diseases such as measles and malaria, VAD contributes to increase child mortality.4,6 tioned new cases of night blindness among children, the child will die less than a year after becoming blind5. Globally, VAD is estimated to be responsible for approximately 7

An Important Discovery: the Immunological Effects

of VAD

n the early 1980s, ophthalmologist Dr.

of Vitamin A supplementation (VAS) on alleviating vision loss in children when he child mortality. Despite evidence for this theory, it was not immediately accepted ther data was collected. To this end, Dr. some of whom received VAS whilst others did not. The results were incredibly surprising – the children who did not receive

who did.4 To explain these deaths, studies conductlogical role of Vitamin A. Firstly, Vitamin A supports the function of macrophages, which are cells that destroy pathogens and activate further immune responses. Secondly, Vitamin A contributes to the production of T helper cells, which are white blood cells that take part in the adaptive

Health and innovation

Golden Rice continued cy of processes such as the elimination of bacteria from the body. The obstruction of these processes therefore leads to increased children.6 Thirdly, when mucosal barriers are damaged due to an infection, Vitamin A would normally support the innate immune system in the regeneration of child, the innate immune response is suppressed, and therefore mucosal barrier regeneration is hindered. This increases the severity of other infectious diseases and the likelihood of these diseases resulting in death.8 For example, studies in Papua New Guinea and Burkina Faso have shown that VAD increases the incidence 6 .

What is Being Done?

s a result of this discovery, VAS programs were scaled up in various mentation programs usually involve the provision of Vitamin A capsules on a bianwho are at the highest risk of developing ing governmental programs, such as the National Nutrient Program in Cambodia, and international non-governmental 9

VAS programs, the Homestead Food that enables families to grow produce in cal ponds as sources of Vitamin A.9

The Challenge of Complete VAS Coverage

lthough the World Bank has identitive global health solutions in terms of its potential to improve a vast number of lives at a relatively low cost,10 barriers to eliminating the problem remain. reaches as many children as possible. This national organisations are operating in various provinces across the country, leading to a lack of coordination between them. Also, the distribution of international aid in the country is unequal, and some provinces have multiple international organisations working in them whilst others remain completely without foreign aid. As the training of health workers to administer VAS is still reliant on external funding, provinces in which international organisations are not yet working often lack trained VAS personnel and consequently have lower coverage rates.10 Therefore, although the national average coverage rates for VAS have been as remote provinces have coverage rates that fall far below this average.10

A Golden Alternative

ather than international organisations looking for ways to expand their pro-

in remote locations underlines the need to establish a more sustainable way of addressing VAD by increasing Vitamin A intake in children’s regular diets. Genetic engineering may provide a fascinating solution. “golden rice”, a genetically engineered form of contain the Vitamin A precursor beta-carootene than the original,11 therefore being an excellent source of Vitamin A and a promising solution to VAD.

Who’s Going Against the Grain?

espite its potential to ameliorate VAD, golden rice has faced criticism from organisations such as Greenpeace and

Greenpeace primarily raises the long-standing controversies associated with geneticalhorizontal gene transfer and the claim that to human health.12 hand, is concerned that the patent laws associated with the commercialisation of golden rice would lead to the limitation of farmer’s rights regarding the distribution, re-selling, and re-planting of seeds due to the modiproperty of the manufacturing biotechnology company.11 Consequently, farmers would have less of a say as to what crops to plant, and would no longer be able to trade seeds with other farmers or store seeds for use in future seasons due to stricter regulation. Farmers therefore risk accumulating an excess of thus fears that the commercialisation of the genetically engineered crop would cause a concentration of economic and legal authority among its manufacturers and threaten the livelihoods of subsistence farmers.11 Greenpeace has suggested that a sustainable and accessible source of Vitamin A could also be established through the expansion of pre-existing home gardening programs rather than turning to golden rice12. However, factors such as space, agricultural conditions, lack of knowledge of agricultural practices pertaining to fruits and vegetables that were not previously grown, and the availability of farming tools all make such programs unrealistic on a large scale. The advantage of golden rice in this aspect is that it can draw on an agricultural system that is already in place all over South Asia and many parts of

Health and innovation Africa. Rice farmers in these regions already possess the skills and tools to grow rice, and than thousands of families each attempting to keep their own small gardens.

Working With What We Have

ice is the staple food and the predominant crop grown in many parts of South Asia, making golden rice a suitable option to target VAD in this region, which has one of the highest VAD prevalence rates worldwide1. For example, in Nepal, golden rice may be a viable alternative to conventional VAS programs such as homestead food production, due to the countryâ&#x20AC;&#x2122;s topography being ill-suited to growing Vitamin A rich fruits and vegetables. Consequently, these foods remain largely inaccessible to low-income families, and establishing a sustainable source of Vitamin 4 . Rice on the other hand can be grown not only in the subtropical Terai region of Nepal, but also in the Hilly Regions , which are home to a greater percentage of low-income families than the Terai region14 of the total land area15. The implementation of golden rice agriculture would therefore terms of reaching those who need it.

References

Along with South Asia, children in Sub-SaVAD.1 Rice agriculture has been a concern in Africa in recent years, as the continent consumes.10 Six million tonnes of rice annually,

of their rice in order to meet their needs.16 This means that demand far outweighs supply, leading to reliance on imports and large price increases.16 suitable for farming, many African regions possess the resources to increase their local rice output. 16 Unfortunately, rice produces lower crop yields than other crops, such as maize, and thus an increasing amount of land is allocated to the farming of these high-yielding crops. Fortunately however, Sub-Saharan Africa consists of 24 million hectares of wetlands, which have been idenother crop types.16 Cultivating golden rice in these regions would not only alleviate the burden of disease caused by VAD in Africa, uting to the expansion of Africaâ&#x20AC;&#x2122;s rice agriculture, which has gained importance in light of its growing demand. rice may therefore serve as a viable and sustainable long-term solution to VAD by minimizing the amount of external intervention whilst establishing an accessible source of Vi-

also eliminate the need for training healthcare workers and the need to continuously monitor biannual VAS campaigns.

Prospects for Progress

he cynicism that slowed the acceptance of Dr. Sommerâ&#x20AC;&#x2122;s theory linking VAD to child mortality is now also an obstacle to the commercialization of golden rice, which was scheduled to begin this year11. While the rights of farmers should not be disregarded, neither should the fact that many of the poorest families living in not receiving any form of VAS. We must therefore reach an acceptable compromise. For example, with the implementation of ed to VAS programs could instead be used to subsidize the increased cost of genetically engineered rice to farmers, which in the conducive to eliminating VAD than con-

tributors to the global burden of disease.10 Therefore, coming to an agreement is imperative for progress, and addressing VAD remains a pertinent example of how discoveries in immunology and biotechnology must be combined with an understanding of the political, social, and economic barriers to implementing solutions to current ly address them.

health and innovation

malaria poems

Cameron Conaway

Still Born As the shadow attaches to her toes so the mother slings the still born over her shoulder until night when her birthed treasure is buried with the others under the blankets. At cock’s crow she presses the pink of his unformed lips to her breast. Soon the dead will have another birthday and she will tell him stories. Though skin worked as silk turns rough as road she will caress river rock moss with her bare feet there of his black downy hair. around her like fog it will be him and she will match her breath to his. Unlike most in these hills she knows miracles aren’t and will can’t but she is dreaming deeply and nothing beats back cold like real or imagined smiles.

“Grip, Coughs, Colds, Bronchitis, Asthma, Consumption, Catarrh, Malaria, Fevers, Chills and Dyspepsia, of whatever form, quickly cured by taking Duffy’s Pure Malt Whiskey.”1 - 1902

health and innovation

Counterfeit

Wrapped Up, In

Third of malaria drugs ‘are fake’ 2

What’s worse? Fire brighter. Cold wins. She drummed words out between beating teeth. Body of bone bundled in the ashes of her skin then sealed in the dazzling beads of needing and sweat. Her eyes are swathed in jaundice yellow but reach like ears far beyond the bush to the crushing hum of the waterfall mask. A blanket of sound that hides the way freezing now has her heels denting dirt. Please try to hold still, the doctor whispers. Warm rag on forehead like a kiss too brief and barely too long. she says as . Birdsong along the river. A drum signals dinner. The waterfall explodes. Chickens cock-a-doodle. Children laugh loudly. Please stay still. She is still. Children laugh louder.

in turns inside the shadow trail cast by the steady sway of the single yellow bulb in the cobwebbed basement. Two cut the powder and two clean tubes and one with gun is as natural as moon song. Borrow bright, borrow blues.

making a living by taking the living left in the dying and knowing it or knowing not. There the whirling fan blades measure the bulb’s pulse, count silhouettes not seconds, swing night like clock tongue on artemisinin white sand beaches. There the young men, boys really, hired for their inability to break or take or seize Blinking days split like grieving. Boys, stencil-stashed kids really, who know not their father or Artemis’s and hourglass of arrow’s entry wound. Not yet how time tweaks string. There the kids, slaves really, who know not the story beneath in Chinese means fate? Take them to make them.

of then and then getting caught, lost in the dust of the cobwebs.

“The war against infectious disease has been won.”3 - 1969

I Want To Go before going in. The concrete wall seems grayed with knowing. Ear pressed against the grain hears the cold simmer of silence

in to see brown babies breaking in their voices. Where walls meet a young boy plays with shadows and over and over kisses the static outline of his mother’s pregnant belly. Her temples show no trace of voice and somehow come to on all fours. a river, now dried to open scabs, taste the wink of wounds under scars. Maybe my eyes are closed. Life still

Author bio Cameron Conaway is the Social Justice Editor at The Good Men Project. He was the 2011-2012 Poet-in-Residence at the Mahidol Oxford Tropical Medicine Research Unit in Thailand and the 2007-2009 Poet-in-Residence at the University of Arizona’s MFA Creative Writing Program. His work has appeared or been reviewed in ESPN, The Huffington Post, Rattle, Teach Magazine, Möbius The Australian, Cosmopolitan and the Ottawa Arts Review, among others. His first book of poems, “Until You Make the Shore,” was released Winter 2013 from Salmon Poetry. For more information visit CameronConaway.com.

health and innovation

Okapi

That’s cerebral the doctor said

is green but my eyes To them green burns black and white sun splinters blades like bad memory or the legs of the okapi the students work to draw from inside their hut. The teacher carries on

to draw the great animal. Feel its shapes in your hands.

and it dispersed

slick through thick air quiet barracuda shuttling sound

away

from mouth

mutating it to mean.

A compliment

in another place

here sticks here clots here a death sentence this time

her head a basket of stones and gives each student one.

Your own stone, she says, has all you’ll ever need

“Roughly one in ten children will suffer from neurological impairment after cerebral malaria, be it epilepsy, learning disability, changes in behaviour, loss of coordination or impairments to speech. As well as being discomforting physically, these problems can also lead to stigmatisation in the community and can reduce individuals’ capacity for work, imposing an additional economic burden.”4

to a tribe full of other times. There

a strong man

whose great ideas cannot be said a lone umbrella acacia alone.

Here

See its shadows on the paper. Trace its ridges as a compass.

a girl of ten confused why her arms won’t raise

Press it hard and it will give itself until it is no longer.

when she’s asked to raise them and her baby brothers.

Hear them groan at the task.

with dwindling

But cast in the air’s canvas is the gang-raped teacher

where cured malaria leaves trails like listening.

A tribe muscled

who tells me only that it was “by more than ten” last week. home and starve or leave Something about the silence of a place where wails were. Something about how violence seals itself silently within us and we sometimes carry on.

References

Pregnant women are “four times more likely to contract and twice as likely to die from malaria than other adults.”5 “Malaria in pregnancy causes 200,000 still births in Africa.”6

Health and innovation

Hib Disease The Burden of Hib Disease in Indonesia and Actions Taken to Mitigate its Effects Faraz Honarvar

Abstract Haemophilus influenzae type b (Hib) disease is a dangerous communicable disease that has the potential to propagate many life-threatening illnesses such as meningitis and pneumonia, mainly amongst children 3 months to 3 years of age. The disease has been a significant threat to infants in Indonesia for many years, but with new vaccination programs being implemented and significant collaboration between organizations such as the Indonesian government, UNICEF, The GAVI and the WHO, promising results have been achieved. This paper focuses on challenges Indonesia â&#x20AC;&#x201C; as the fourth largest populated country in the world â&#x20AC;&#x201C; has had in attempting to mitigate the effects of Hib and also provides an in depth explanation of the newly implemented plans to provide vaccines for all infants in the country.

es pneumonia, symptoms include rapid breathing and mucus-containing coughs.

The disease causes, transmission, and symptoms

sore throats and noisy breathing.1

(Hib) disease is one of the main causes of meningitis, pneumonia, epiglottitis, arthritis, and blood stream infections and most often targets chil1 Hib is considered a communicable disease and is usually transmitted through the mucus of an infected personâ&#x20AC;&#x2122;s mouth or nose. There is a possibility for an individual to be a carrier and a threat to surrounding individuals without manifesting any signs of the disease.1 The main symptom of the Hib disease is fever.1 -

(DALYs). This clearly highlights the severe consequences of Hib disease in

Burden of disease

study estimated that more than 84,100 infants develop Hib infection and 7,846 die each year. The burden of disease was also suggested to be approximate-

n a study conducted in 1998 in Lom-

document the burden of Hib disease 2

Before this study, there was no data suggesting the burden of Hib disease in the fourth most populated country in the world. Scientists discovered that more natal deaths, occurring at a prevalence of 90 in 100,000 infants, were associated with pneumonia caused by Hib disease.2 Less than a decade later, another

Early efforts

been performing Hib vaccination in Lombok since 2000.4 The government implemented the vaccination program against Hib disease and analyzed pneumonia and pneumonia with radio-

Health and innovation

HIB continued graphic consolidation. The results indimonia due to Hib disease; however there was no sign of prevention of pneumonia with radiographic consolidation. The compared to that of other countries such as the Gambia, Bangladesh, or Chile, venting pneumonia with radiographic consolidation. 4 Taking those results into od needed to be implemented.

New program

collaboration with The Global Al-

Health Organization (WHO) to mitigate started in 2012 when pentavalent vaccinations protecting against diphtheria-tetanus-pertussis (DTP), hepatitis B and Hib were licensed and bought from the 5 As considered an attractive investment for the government due to the money spent strengthening the countryâ&#x20AC;&#x2122;s economy instead of leaving the country. By the end

References

lion instead of tripling the costs. The located in the West Java, Bali, West Nusa

the practicality of implementing the

end of 2014, it is predicted that more than half the infant population in Java, South Sulawesi, Bangka, Belitung, North and South Sumatera, Jumbi and Lampung will be vaccinated. Finally, if everything is conducted as planned, by the end of 2015 the government hopes to have vaccinated 6 The vaccination program is gradually covering

This plan is predicted to avert approximately 76,700 cases of infection, 7,150

spread across the countryâ&#x20AC;&#x2122;s many islands.6

Impact

ithout vaccination, every year more than US $9.06 million is spent treating Hib disease worldwide. On the other hand, the menting the Hib vaccination program alongside the existing DTP-Hep B vaccination and Hib disease treatment is around US $28.5 million. This costs more than three times the cost associated with treating Hib disease without pricing for the cost of Hib vaccination program and Hib disease treatment is -

numbers were calculated by subtracting the predicted cases of infection (7460) and DALYs (26600) after the national herd immunity taken into account) from the total infants expected to have Hib infection in one year without vaccination (84100 cases of infection with a burden of

Conclusion

he prevention of Hib disease in

due to the high population, sets yet another example for developing countries that through global cooperation great results can be achieved and many lives can be saved. Patience and careful planning also play major roles in achieving in-one vaccination has been shown to be and with this model can now be implemented in other developing countries facing the same problem.

Policy and Practice

In the Wake of Typhoon Haiyan

Examining the Decentralization of Health Care Within the Philippines Marcus Tutert

Abstract On November 22nd 2013, the fourth strongest typhoon ever recorded struck the Philippines, leaving devastation in its wake. Over a million residents have been left homeless while the death toll has climbed to over 5,000. In addition to this, a lack of effective healthcare provision from the Philippine government has left the region exceedingly vulnerable in the aftermath. Over the past couple of years, the Philippine policy of decentralization has left the countryâ&#x20AC;&#x2122;s healthcare provision under the jurisdiction of smaller organizations. This policy was initiated because larger central bodies have historically lacked accountability and responsiveness. This article will explore this decentralization of healthcare within the Philippines, examine its potential strengths and address its most significant failings and how they contributed to the ineffective national typhoon response. Following that, the article will comment on the challenges involved with improving systems of care within developing nations as a whole, while assessing possible alternatives proposed by the global health community.

Pre-Existing Vulnerabilities

he pre-existing vulnerabilities in the system are an assortment of both geographic conditions and inadequate governmental oversight. The former is an immutable reality that creates dangerous conditions for the inhabitants of the Philippines. As an archipelago located in the Southeast region of Asia, the Philippines are composed of coastal lowlands, which are susceptible to harsh 1

the population, resulting in adverse health

ination, increased spread of infectious diseases, and malnutrition.2 The pre-existing vulnerabilities in the system are an assortment of both geographic conditions and inadequate governmental oversight. A recent â&#x20AC;&#x153;Health Systems Reviewâ&#x20AC;? done by the World Health Organization (WHO) in 2011 cited several critical issues related with the breadth of healthcare provided by the government to various sectors of the population. Large income inequalities have an impact on the geographic layout of urban housing. This layout forces those with low incomes to not only live in less developed housing, but also to reside in far more vulnerable regions.4 This is a substantial

contributing factor to the high health inequity between income levels in the nation.5 Furthermore, populations living in vulnerable regions often require the most substantive health treatments, creating a large strain on the health care system. This arrangement leads to the adoption and development of new health practices that are limited to populations living in more developed regions.

Undergoing Decentralization

o remedy the vulnerabilities that exist within the healthcare system, the Philippine government has

Policy and Practice

shifted to a far more decentralized form of health care. As a result, the formerly centralized operating branch known as the Department of Health (DOH) has begun to shift focus away from its formerly overarching public health man-

regions.6 the DOH now form a hierarchy of sevwith the private sector to produce further specialized and independent units. Some examples include Health Regulation Units and Rural Health Units.5 health systems, LGUs are responsible for enforcing and creating new policies 7 pects of the overall health care system. country such as the Philippines creates tions are better able to respond to local needs and are able to craft more specifsystem of decentralization was created to foster increasing amounts of autonomy for each LGU. This system allows each unit to retain an increased surplus of revenue that they can then put towards various health mandates10. For example, they allowed the local government expenditures to increase decentralization), as documented by a recent study.5 icant problems stemmed from the decentralization of the nation’s health-

References

care systems. When such a high degree of autonomy is present in each of to observe national policy. The LGUs began to make decisions based on what they felt was best for their own units rather than what is best for the country as a whole. For instance, in a study done by “Health Policy Planning,” it was demonstrated that each LGU possessed unique target goals that often remained mutually exclusive to the needs of the country itself.8 Furthermore, these goals are often tied to ample of this arose when an LGU targeted the agricultural sector and other commercial marketing avenues to against the overarching mandates that food security for related LGU’s are of the utmost importance.5

Proposed Solutions

any solutions have been proposed

the Philippines but also to apply this concept of decentralization in a better form to other developing countries in similar circumstances. The primary concern overall is the degree of autonomy within the decentralized system. To remedy this issue, a more central organization body can be used to keep the agents more accountable for their actions and to establish broader operating mandates.7 This Philippine method of decentralizing the healthcare system can also be analyzed and evaluated as a possible

model for other developing countries. However, a host of other potential problems may arise in its application. transference of power from a DOH to ing to delay in governmental action. For example, a study done in Ghana and Uganda found that the logistical issues and transference of power in these two new system.5 A report by the European Observatory--a world-wide organization that examines health policy’s and mandates--sugof decentralization.7 With regards to the purview of smaller organizations, one accessible solution is to ensure that they maintain a strong relation with the central authorities. An alternative solution is a far more reduced form of recentralization. Systems should continue with a larger central body while limiting both the amount of LGU groups present along with the power they contain. This alternative strategy suggests that a complete decentralization of the system may not be ideal in the long term, and that the discretion of these smaller organizations must be reviewed and often times limited. The process of decentralization is a long-term movement that fosters better individual health while allowing for a there are issues with decentralization, the Philippine system is making steady strides towards an improved health care system, ensuring the safety and health of its citizens into the future.

Policy and Practice

Global Health Diplomacy The Inextricable Links between Health and Foreign Policy Kaleem Hawa

INTRO In the past decade, health issues have become more prominent in the foreign policies of the worldâ&#x20AC;&#x2122;s nations. Broad strategies have been formulated to address health challenges and global health has begun to enjoy greater acknowledgment in the interplay of global political relationships.1 Normally, when foreign policy-makers have focused on public health, it has been in times of major crisis, as was the case with SARS and avian flu; in the absence of such crises, health has often fared poorly when weighed against more pressing and politically-driven priorities such as international trade or security. No doubt, the onset of greater interdependence brought on by globalization has resulted in a collective vulnerability that requires nations to care more strongly about the systems of health in the developing world and thus, to tailor their foreign policies to better advocate on behalf of proven health systems.2 This research article will uncouple the roots of the global health-foreign policy framework, explore examples of how global health has become a tool of national foreign policies, and summarize World Health Organization (WHO) developments in merging the two areas on the global stage.

The Link Between Health and Foreign Policy

wo major global agendas have become inextricably linked to global health issues. As a result, foreign policy has needed to adapt to better accommodate health in its prioritization of global socio-economic policy. major area is security. Fear of global pandemics enhanced by humanitarian conness has made the concept of biosecurity a very prominent one. Biosecurity originally found its roots in the exploration of preventative measures to combat the

growing use of biological weaponry in modern warfare. Recently though, pandemics originating in nations with poor danger to the rest of the world and thus have become a prominent feature in foreign policy decision calculus.4 This is a new threat to security - one that requires neither malicious intent nor technologimerely by the natural agents of modernism around the globe. The immateriality of global health security threats does not mean, however, that it exists outside the corrective realm of diplomatic policy; in fact, nations are increasingly seeing the need to strongly integrate health consid-

erations into national foreign policy. The second global agenda that has had to come to grips with global health challenges is the global economy. A report by Thomas N. Chirikos in the Review of Economics and Statistics found that poor health history is one of the single largest determinants of annual hours of work for employed individuals.5 Thus, it is clear that poor systems of health in the nations will produce ancillary harms in the realm of economic advancement and opportunity. Given how reliant the world has become on globalized forces of labour, adopting health as part of foreign policy goals could be a powerful way to improve trade relationships and productivity for

Policy and Practice

both the developed and developing world.

Global Health as a Tool of Foreign Policy

rom our understanding of the bene-

health and foreign policy comes an exploration of how those links have been adopted by the nations of the world. Most of the health and foreign policy linkages come from the lens of relationship building. Brazil is perhaps the best example of a nation that has successfully integrated global health activities into its economic and political agenda. After publicly declaring global health and the combat of in 2009, Brazil established stronger pro-

countries such as South Africa. so, Brazil strengthened its economic trade relationships with African countries and built alliances of trust that helped it gain support for its political agendas within the United Nations. This meant that Brazil could now count on the support of many African nations as it pursued Security Council reform, among other initiatives. role in the advancement of both Brazil’s economic and political goals. The other side of relationship building a larger nuance within the global health as a primary antagonist when trying to promote global health goals.6 Excluding

REFERENCES

are often indirect deaths stemming from war-induced violence, injury, disease, and malnutrition. Thus, it becomes especially important to transform the foreign policy trust-builder. Health can serve as a good entry point by which to initiate dialogue across borders and thus contribute to building trust between parties; despite animosities between nations, establishment of temporary medical clinics and transfer of medical aid can be powerful tools in the mitigation of civilian casualties because they are unlikely to be opposed by the recipient party.6

WHO Developments

ne of the most powerful vindications of global health as part of the foreign policy framework was the Foreign Policy and Global Health by the WHO and the foreign ministers Senegal, South Africa, and Thailand, it sought to promote the use of a health lens in formulating foreign policy. A joint statement released by the Minisin 2007 is particularly indicative of the “In today’s era of globalization and interdependence there is an urgent need to broaden the scope of foreign policy. We believe that health is one of the most important, yet still broadly neglected, long-term foreign policy issues of our time. There is a growing awareness that

investment in health is fundamental to economic growth and development. It is generally acknowledged that threats to health may compromise a country’s stability and security. We believe that health as a foreign policy issue needs a stronger strategic focus in the international agenda” - Oslo Ministerial Declaration6 Another global policy network produced from the interaction of the global health and foreign policy issue areas is “international partnership to strengthen health preparedness and global response to biological, chemical, radio-nuclear launched in November 2001 by Canada, the European Commission, France, ed Kingdom, and the United States of America.7 Again, this initiative indicated that the WHO has been attempting to bridge the divide between the two issue areas through an active policy of global health diplomacy. have adopted global health in their foreign policy agendas coupled with an increased focus on the topics within the realm of NGOs and policy institutions like the WHO symbolizes the growth this new policy area has enjoyed. More focus will be needed to adequately face the challenges on the horizon but it is now clear that a unique set of foreign policy tools – once thought to be solely within the domain of state-centric military and economic negotiations – can become even better utilized within the context of international health.

Policy and Practice

Antiretrovirals & Neo-Colonialism: Pharmaceutical Companies And The HIV/ AIDS Epidemic Matt Douglas-Vail

ABSTRACT For people living with HIV in sub-Saharan Africa, living or dying depends on access to antiretrovirals (ARVs), which is determined largely by pharmaceutical companies. In order to understand the epidemic, it is important to examine how the pharmaceutical companiesâ&#x20AC;&#x2122; distribution of ARVs has contributed to and exacerbated the climate of HIV/AIDS in sub-Saharan Africa. This paper aims to examine the ways in which pharmaceutical companies, through the unequal distribution of ARVs, have participated in the implementation of contemporary neo-colonialism and thereby worsened the HIV epidemic in sub-Saharan Africa. Briefly, neo-colonialism is the practice of using multi-national corporations to ensure vulnerability, dependency and maintain control over nations. The importance of ARVs will be examined in conjunction with the official policies on access to medications and the role of structural adjustment programs in exacerbating the epidemic.

n order to understand the harm pharmaceutical companies have done to sub-Saharan Africa, the current climate of the epidemic must be examined. The Joint United Na-

million people worldwide were living

tions however, occur in sub-Saharan 1

haran Africa. Among the 1.6 million lion occurred in sub-Saharan Africa.1 arose globally, 1.6 million occurred in

this same region.

he importance of ARVs in epidemic cannot be under-

drugs directly corresponds to pecially in sub-Saharan Africa.2

Policy and Practice

Extensive evidence demonstrates that combined ARVs can substantially extend the life of people livin risk factors for transmission of

to this disparity. While the WHO 7 haran African and the Caribbean. This program aimed to purchase and distribute ARVs in a safe, eq-

treatment in low and middle-income are currently receiving ARVs.5 -

of ARVs can also delay the onset 4

RV treatment is also capable of preventing transmission

Organization notes that early ini-

transmission between couples with 5 As well, ARVs decreased mother-to-child prenatal 6

that pharmaceutical companies have on restricting access to medication and thereby exacer-

policies outlined by governing bodies like the United Nation and World Health Organization (WHO). These policies represent global expectations 2001, the UN Commission of Human Rights declared that access to medications is a fundamental process in the goal of achieving the highest attainable standards of health.7 Therefore, in 2002, 12 ARVs were added to the WHO Model List of Essential Medicines.7 Essential Medicines are as absolutely necessary for a “basic health care system.”7 These drugs are intended to be consistently “available in adequate amounts at prices the individual and the community 8

Bank founded the Multi-Country

ARVs for 15 million people by 2015 and eventually universal coverage.1 Unfortunately, 15 million people nition of universal coverage itself is of universal coverage only means 1 ment receive ARVs. This means

African received ARVs to prevent mother-to-child transmission. This trend of disparaging coverage is not

zidovudine or AZT was released in the United States in 1987.9 By 2002, 800,000 people worldwide were on ARVs. Unfortunately, less than developing countries even though

have achieved their goal, 1 in 5 people will still be without treatment.

doubt to the public that access to medication is vital to mitigating and reducing the burden of the epidemic in sub-Saharan Africa, which puts enormous power in the hands of the pharmaceutical companies. The legitimization of these prodallow pharmaceutical companies the ability to argue they are providing an invaluable service. That claim however, must be examined more closely. This legitimization gives control to the pharmaceutical companies and by HV are dependent. This dependence embodies the contemporary neo-colonialism.

here is unfortunately a great

policies on access to medications and the number of people who are actually receiving ARVs. The neo-colonial agenda of pharmaceutical companies has contributed

parison, ARVs are widely available in the developed world and almost universally available in Canada.10 7

he United Nations recently reported that a “tipping point” had been reached where the number of people receiving ARVs outpaced the number of new infections.1 This is dangerously misleading. The veritable “tipping point” should actually be -

breadth of statistics available seem impressive, closer examination shows that access to treatment is oftentimes limited and inadequate. Pharmaceutical companies, although responsible for developing these invaluable products, are also responsible for controlling access to treatment. Pharmaceutical companies embodying neo-colonialism by attempting to exploit and assimilate sub-Saharan countries

Policy and Practice

Antiretrovirals continued into the capitalist market have severely restricted access to treatment. This limited access and neo-colonial ethic has exacerbated the epidemic by denying treatment to those clearly in need of ARVs.

harmaceutical companies in conjunction with international intellectual property laws have ensured that developing countries remain dependent on the production of ARVs. This depen-

Organization (WTO) passed the Agreement on Trade-Related 11

All countries

sub-Saharan countries, are bound 12 Each country is now required to grant patents for inventions “in all fields of technology” including pharmaceuticals, for 20 years without discrimination to availability. This allows companies holding drug patents to charge artificially high prices for the drug and ensure monopolies over their production.

eneric drugs provided a possible alternative to brand name pharmaceuticals.

patents on pharmaceuticals and permitted reverse-engineering of generic drugs. Becoming known as the “pharmacy of the develop-

ment.14 Drugs patented between 1995 and 2005 can be reverse-engineered in generic form as long

“GENERIC DRUGS PROVIDED A POSSIBLE ALTERNATIVE TO BRAND NAME PHARMACEUTICALS. UNTIL 1995, INDIA DID NOT GRAND PATENTS ON PHARMACEUTICALS AND PERMITTED REVERSEENGINEERING OF GENERIC DRUGS.” as royalties are paid to the patent holders and drugs patented after 2005 cannot be made in generic form. Through these regulations, courages the production of genersigned the Doha Declaration to allow members to grant domestic compulsory licenses to protect the public health of their citizens.14 Unfortunately, countries attempting to procure these licenses faced enormous pressure from foreign governments and pharmaceutical companies. To illustrate, Thailand

issued two compulsory licenses and in response, Abbott stopped launching drugs in Thailand and the US government downgraded Thailand’s trade status to poor in-

of compulsory licenses to allow for the export of generic medicines to countries in crisis.14 Pressure from pharmaceutical companies backed by the US, ensured narrow interpretations of these new regulations to deter countries from applying to import generic drugs. The United States Trade Representative listed South Africa as a priority perpetrator after attempting to import generic drugs.14

andating the issuing of product patents has prioritized market dominance over public health and access to medications. The pharmaceutical companies strike again in neo-colonial fashion. These companies advocate for and employ international trade agreements to develop and sustain a global monopoly of ARVs. This allows these companies to limit the access of these essential medicines to the few who can afford them in an attempt to assimilate sub-Saharan countries into global markets. By producing and subsequently limiting access to essential medicines, pharmaceutical companies ensure the vulnerability and dependence of sub-Saharan countries.

Policy and Practice

lthough pharmaceutical companies are not directly responsible for the implementation of structural adjustment programs (SAPs), they have vested interests in reaping the rewards. As the majority of people in the developing world receive medications through government-sponsored programs, the stateâ&#x20AC;&#x2122;s capacity to provide ARVs is crucial. SAPs have significantly impacted this capacity and pharmaceutical companies have profited. A global oping countries in debt.15 Continual economic decline meant that developing nations had to turn to

Bank to cover foreign debts. To receive this coverage, countries had to agree to the precondition of â&#x20AC;&#x153;stabilizing programsâ&#x20AC;? and un-

References

dergo drastic economic restructuring.15 These SAPs are violent to developing countries and have only contributed to debt. This has severe downstream effects including worsening poverty.

APs have left countries unable to

tion program would cost $2.6 billion, saving $90 billion by 2020.15 The economic constraints of SAPs left countries unable to fund prevention programs and much of the direct cost of tions and consequently pharmaceutical companies. SAPs have mandates, which require countries to curb health services.15 This has forced developing countries to charge for previously free services, including accessing essential medicines. The pharmaceutical companies again, reap the rewards. This

treatment receive it.

he preoccupation with internasire to achieve economic balance has jeopardized the right to health of many in sub-Saharan Africa. SAPs and the compliance of pharmaceutical companies with these programs maintain the exploitation of the global South by the North. By utilizing the social and economic conditions created by SAPS, the pharmaceutical companies have limited access and ensured uneven distribution of ARVs. Sub-Saharan countries are left vulnerable and dependent. This exploitation and the attempted assimilation of sub-Saharan countries into western lifestyles of consumption again expose the neo-colonial project by pharmaceutical companies that has exacer-

Policy and Practice

GAY = DEATH Uganda’s Anti-Homosexuality Bill and what it means for HIV Amy C. Willis

ABSTRACT With the introduction of the Anti-Homosexuality Bill (AHB) in Uganda in 2009, an environment of fear, stigma and shame now envelopes the country’s lesbian, gay, bisexual and trans (LGBT) community. Uganda’s LGBT population is under constant fear of social and legal punishment, with threats of persecution, public outings, and violence constantly bubbling under the surface. To make matters worse, the AHB includes a clause specific to HIV-positive LGBT-identified people under its aggravated homosexuality charge, with the death penalty as the punishment that accompanies a conviction of aggravated homosexuali-ty. The impact of this proposed legislation on the LGBT community and HIV education and prevention is vast and can have a potentially negative impact on the LGBT and men who have sex with men (MSM) communities and beyond.

Policy and Practice

editor’s note Under the recommendation of a Special Advisory Committee appointed by the government, the final version of the Ugandan Bill did not include a death penalty clause. The bill was signed into law on Feb 24, 2014 with further revisions.10

n 2009, Ugandan parliamentarian David Bahati introduced the Anti-Homosexuality Bill (AHB), new legislation that aimed to further criminalize the LGBT population and their “homo-sexual” behaviours. The purpose of the bill was to uphold, preserve and maintain the traditional, socio-cultural construct of marriage between a man and a woman while simultaneously protect-ing children – the future of Uganda – from the clutches of the homosexual lifestyle and, most im-portantly, prohibiting the acknowledgement and promotion of anything other than heternorma-tivity. Though the Bill was initially proposed in 2009, it lay mostly dormant until the Ugandan government aggressively resurrected the legislation in November 2012, in That being said, the government has received a considerable amount of negative attention from other governments and activists globally around this proposed legislation, which has been tabled month after month and is currently sitting in a state of limbo.

ganda is a heavily religious

of its citizens identifying as Christian.1 Many believe that the introduction of the Bill was fuelled by evangelical beliefs and that Ugandan religious leaders and politicians receive considerable support from their American Evangelist counterparts.2

in-tentional touching, penetrating, or stimulation of sexual organs between two people of the same sex; if found be imprisoned for life. “Aggravated

“MANY BELIEVE THAT THE INTRODUCTION OF THE BILL WAS FUELLED BY EVANGELICAL BELIEFS AND THAT UGANDAN RELIGIOUS LEADERS AND POLITICIANS RECEIVE CONSIDERABLE SUPPORT FROM THEIR AMERICAN EVANGELIST COUNTERPARTS.” severe charge, is used as an umbrella term under which numer-ous activiminor (a person below the age of 18), sexual abuse of a person with a disabilothers. Upon conviction, those who commit “aggravated homosexuality” to the LGBT population, LGBT empathizers and supporters also face

legal threats for failing to report people known or suspected to identify as LGBT; the Ugandan government tioned witch hunt, whereby all citizens are expected to report suspected or known LGBT persons to the authorities within a 24-hour period or face There problematic aspects of Uganda’s proposed anti-legislation, including but not limited to the considerable human rights violations it poses. This paper will focus primarily on the potential havoc this proposed legislation may

clause in the AHB serves to reinforce the historical, troublesome and erroneous relationship that exists

disease” even though in many Af-rican countries, Uganda included, the epidemic is more generalized and thus, is also prevalent in heterosexual populations. This unfounded association may therefore inadvertently give the het-erosexual population permission to tion, awareness and pre-vention and to disassociate from better sexual health is as relevant to them. Further, with the increased state-sanctioned discrimination against the LGBT population

Policy and Practice

education targeting this demographic would likely be scaled down if it has AHB has the potential to nega-tively for both the LGBT and heterosexual populations alike.

particularly in relation to testing, is also under immediate threat for the LGBT community should the proposed legislation pass. According to a report pro-duced by UNGASS en and men between 25 and 49 years

ness, education and prevention has been widely documented.5,6,7,8 When coupled with state-sanctioned homophobia, an environment of fear, shame, and hostility is created. This is evi-denced in the Crane Survey,8 one of the only studies to date which who have sex with men (MSM) in Uganda. Not surprisingly, after the introduction of the AHB in 2009 and groups, Uganda’s Ministry of Health (MoH) stopped collecting data on

currently living with a female partner.8 What this potentially indicates is an environment of embedded stigma where MSM do not feel they can openly identify as gay or bisexual and subsequently live their lives in heterosexual relationships in public while engaging in underground or secretive sexual transactions with other men. Because the sexual relations between men are hidden and taboo, there likely is not much opportunity to discuss safer sexual practices and sexually transmitted infections associated with these sexual encoun-

the only data that has become availprevious 12 months and knew the result of that test.4 What complicates this issue even further is that should ships previ-ously shared between healthcare providers and patients would no longer exist, as doctors report any patients whom they suspect ing legislation and its call for the death penalty for those who are both LGBT

Crane Survey. Based on the 2009 population,9 though it is safe to assume that this number has increased, particularly in light of the AHB and the stigmatizing environment created by this legislation. The Crane Survey, (conducted in col-laboration among the United States’ and Uganda’s Centers for Disease Control and Prevention’s (CDC) Division

also currently in a sexual relationship with a female partner, unless safer sex is practiced consistently, the female partner is also at risk of contracting self-reports regarding condom use by of the sample reported condom use of the sample said they used condoms condoms were used with casual male with steady male partners.8

many Ugandans in the LGBT comprevent themselves from becoming susceptible to the government’s draconian laws. While not knowing their status may protect them from a death sentence at the hands of the Ugandan government, the LGBT population access life-saving antiretroviral drugs (ARVs), inadvertently transmit the virus to others and subsequently die due the LGBT population in Uganda, the proposed AHB is a deadly catch-22.

he negative and insidious impact that stigma and discrim-

for Global Health at the University of Amster-dam, Uganda’s MoH, and the School of Public Health at Makerere University in Uganda), involved respondent-driven sampling 18 years old, being a resident of Kampala and having had anal sex with a man in the last three months.8 Many

of the Crane Survey included that the MSM within the study sample were found to have relatively in relation to anal sex. For example, when asked, “What kind of anal sex do you think is more dangerous to both insertive and receptive sex had

LGBT-related stigma, pointing toward dangerous outcomes regarding community and the sex-ual networks to which MSM are connected. For

receptive anal sex was riskier. This is especially concerning given that the for the receptive partner in both anal

Policy and Practice

and vaginal sex.8 When asked, “Compared to vaginal sex how important is

health, safer sex practices and risk-reduction strategies, thereby resulting in

reported that it is less important to use condoms for anal sex compared to vaginal sex, which is a troubling percentage given that in terms of the sexual health of MSM, condom-less anal sex is generally riskier than con-

– not only within the MSM population but also for their female partners and any other subse-quent partners in their sexual networks. Second, many tus yet are still engaging in sex without condoms, which may potentially heighten the level of risk for everyone involved. With the proposed legisla-

transmission.8 indicate is that there is a considerable gap in terms of the sexual health and safer sex education that is being provided and that MSM in particular are not receiving the sexual health education that is targeted at them. When asked about their last MSM sex act, -

under the aggravated homosexuality charge, many MSM may actively avoid getting tested, since not knowing their status decreases their risk of legal consequence and possibly the MSM who have had unpleasant expe-

perceived their partner’s serostatus to

stigmatization presents further barriers to access testing and treatment for those who are positive. As of 2010, were receiving ARVs;9 for any LGBT

hese data point to many troubling themes within the MSM community in Kampala. First, it is evident that there is a considerable lack of knowledge around sexual

References

concerns about possible barriers to accessing treatment, the poten-tial impact of future treatment should they develop any drug resistance, and how discontinuation of ARVs might also impact rates of transmission.

t the time of writing this article, the AHB has not been passed within Uganda’s parlia-ment. Numerous newspaper articles have suggested that the Ugandan government has made some amendments to the bill, including the removal of the death penalty under the aggravated homosexuality charge. However, the amended draft of the legislation has not yet been made available to the public and, therefore, it is not claims. None-theless, in many ways, the damage has already been done. The Ugandan government has set the stage for gross human rights violations against its LGBT population and, in doing so, has poten-tially encouraged considerable spread of and beyond. To argue that there is a lot at stake should the proposed Anti-Homosexuality Bill pass is a vast under-statement. The situation is dire and what is at risk is not only the lives, human rights and dignity dans, but also the potentially disasprevention, transmission, and treatment.

education and development Photo Courtesy: Trisa Taro

WHA66

THROUGH THE EYES OF A GLOBAL HEALTH STUDENT Delegates listening to a lecture at a WHA66 side event

s the 68th United Nations General Assembly came to a close last summer, it was the perfect

of global health policy last year. From debates on disabilities in the post-2015 agenda to rising concerns over the Middle East respiratory syndrome coronavirus (MERS-CoV), it has been a year of unprecedented transformations in public health and marked an exciting era to be an aspiring young

tending the 66th World Health Assembly (WHA) in Geneva, Swit-

zerland, as a student member of the coalition of NGOs working to promote the Global Non-Communicable Disease (NCD) Framework Campaign and the adoption of the Omnibus Resolution on NCDs. The resolution, which was recommendations on tackling non-communicable diseases around the world and includes an action plan, monitoring framework, and a global coordinating set nine comprehensive global voluntary targets, including the â&#x20AC;&#x153;25 by 25â&#x20AC;? mortality reduction target. These targets, which focus on both prevention and treatment, outlined in the global action plan. To

ensure that these goals are met in an efdinating mechanism will be set in place to unite all critical stakeholders working to deliver the action plan.

t was an unprecedented personal ex-

largest conference room at the World Health Organization (WHO) headquarters, surrounded by some of the brought together by a collective commitment to a burgeoning global health movement.

alking into the building on the The fact of the matter was that

education and development

WHA66 continued was entering into the very building where world leaders had come together in years past and made history. This was the same place where Professor Viktor Zhdanov proposed the worldwide eradication of smallpox, where the Framework Convention on Tobacco Control was adopted and where the worldwide eradication of po-

he extraordinary appeared to become the mundane in the high-powered world of the WHA.

to the Minister of Health from Sweden, share appetizers with The Lancet’s Editor-in-Chief Richard Norton at an evening side event, and ride the escalator with WHO Director-General Margaret Chan. Despite having grown up “star-struck” in my life.

The daily WHA Agenda Journal

eedless to say, it’s the one time of year that all the biggest names in global health come together. While only delegates of WHO Member States were allowed to vote on resolutions, armies of representatives from NGOs, the private sector, and other health organizations were present and ness of the WHA occurs in committee meetings, it’s clear that everything that is said in these meetings is planned and premeditated. The statements and debates that take place (or occur) are simply a formality. Therefore, one is unlikely to ever see the metaphorical claws come out in this arena. The real action takes place well in advance behind closed doors. As a student, this was an ideal opportunity to observe and learn, how delegates interacted with

education and development

Inside the Serpentine Lounge (the local coffee shop) one another and their strategies for advocating health needs of their country.

from Johnson&Johnson about the rea-

scholastic enrichment for one day, there was an endless agenda of meetings, lec-

my mornings in a committee meeting listening to delegates debate over the Omnibus Resolution for NCDs, ate my lunch while listening to a lecture on MDGs in the post-2015 development agenda, and spent my evenings rubbing elbows with delegates from around the world at cocktail hours discussing the use mHealth in developing nations.

connect Trisa received her Master of Public Health in Global Health Leadership at the University of Southern California in Los Angeles. Comments or questions can be directed to: taro@usc.edu. Twitter: @trisataro

get involved When people ask me to describe my time at WHA, my words fail to describe how inspiring the experience was – both on a professional and personal level. I would recommend to anyone interested in global health to go if you have the chance! As of now, the WHO does not have an official program for students specifically interested in attending the WHA, but there are still a few ways to get involved: Through a student-led delegation, such as the International Federation on Medical Students’ Associations (www.ifmsa.org) or Universities Allied for Essential Medicines (www.uaem. org) Through the WHO Internship Program – Interns during the spring are likely to participate in WHA activities as part of their internship. (http://www.who.int/employment/internship/en/) Through internships with NGOs participating in WHA. For a complete list of NGOs in official relationship with WHO, click here http://www.who.int/civilsociety/relations/NGOs-in-OfficialRelations-with-WHO.pdf Contact your local Ministry of Health for potential opportunities through their offices.

#HHR2014 From Twitter’s Perspective: On March 22nd and 23rd University of Toronto International Health Program held the 16th annual Health and Human Rights Conference. #HHR2014 focused on Global Health And Human Rights From a Child’s Perspective.

@HHRights

@OliverParnia

“Your job as the ‘young people’ is to catalyze innovation” #HHR2014

Global Health cannot be understood without looking at the history of the HIV epidemic #HHR2014

@NaheedD

@Juxtamagazine

34 countries worldwide account for 90% of global burden and malnutrition (Lancet, 2013) - Daniel Sellen #HHR2014 @HHRights #globalhealth

@anjumsultana “Public education campaigns are a tool to combat things such as child marriage.” - Angelique Jenney. #HHRights2014 @HHRights #HHR2014

Health disparity exists everywhere. [You need to take] the human rights approach to where you live #HHR2014

education and development

Global Health & Medicine A Closer Look at PGMEâ&#x20AC;&#x2122;s Global Health Education Initiative Raissa Chua

rapidly evolving, more students and professionals are looking for ways to incorporate global health into their respective disciplines. The Global Health Division at the Dala Lana School of Public Health and provides health professionals with rele-vant skills they can utilize within the global health realm.

ical residents can enrol in during training, and is taught by leading UofT global health faculty and practitioners. The program is delivered in a series of a choice of various elective modules nology in Global Health, Global Mental Health, Women and Child Health, ing countries. Each module is 2-4 ses-

Natalie Chan, a 2nd year paediatrics resident who is also currently a stu-

What is your background? What first sparked your interest in global health? Tell us more about your involvement.

education and development

Global health and medicine continued

completed my medical studies at Mc-

At the time there were limited choices in the global health courses available, but disciplines including sociology. One of the courses that greatly inspired me to further explore global and Human Rights, taught by Professor Paul Hamel. After taking this ate about many global health issues, which eventually led me to undertake further studies and involvement volved with the Canadian Federation of Medical Students (CFMS) as a ipated as a global health advocate on to get in-volved in national-level work concerning aboriginal health.

of the course had us submit things we had done in the past, where these experts would help us further develop it. is not to build expert knowledge, but to expose us to dif-ferent ideas in global health and make connections. We often have people come in to speak with us about how they built their cabecause it pro-vides us with many different options on how to integrate our medical expertise into several disci-

How are your colleagues? Were most from the same background as you?

How has your experience been so far in the GHEI curriculum and what do you think sets it apart from other programs?

cal Skills and Anes-thesia for Global Health, where orthopaedic surgeons and anesthesiologists came and pro-vided us with hands-on tutorials about working in a resource-limited pacity building and program planning during my second year. Many of our rience and worked with organizations

have had an overall good experience

involved in global health dialogue after medical school. -

met a range of people in the program â&#x20AC;&#x201C; almost all have a level of curiosity

to cater to all the levels and expertise and interest but it is also a great way to continues to address this challenge â&#x20AC;&#x201C; rial while keeping everyone interested.

What do you think is the greatest challenge in the field of global health, particularly regard-ing working abroad? What do you think about the ethical implications of doing service abroad?

uring my first year of medical school, McMaster had a training program that was part of our clinical electives which allowed me to travel to Uganda twice - once for two months af-ter my first year of medical school and again for five weeks as a third year student. During my secequip-ment donation program. Medical tourism has become a popular choice for many young adults, and it was initially a tough decision for of myself as a low-level junior trainee and often wondered about the ethical implications of whether or not it was bad idea to go, but that we should put more thought into which organizations we choose to vol-unteer with, outweigh the pros and cons, and ensure sustainable projects are being carried out within these communities. We often forget the resilience and capability these commu-nities abroad have to help themselves. They

education and development often just need funding or specialized skills which many volunteers lack. What many students don’t realize is that it is possible to make a larger impact for global health in our home countries than going abroad. Because this was a university level that it was a struc-tured program.

ers are undergraduates. Do you have any advice for students thinking about including global health in their future career plans?

opportunities around campus,

this experience as an opportunity to make a difference. During my time

putting the experience down on your

little money who could not afford

for a week to work at a foreign medical clinic is the best you can do for

helped to establish an organization to aid in the provision of medical equipment to these rural areas with an emphasis on communication with local physicians; it was an attempt to make the most of my experience abroad and to hopefully leave a lasting impact. and continuing my work in Uganda plan to go back or leave some sort of munity. Many people return to their home country and never visit again. sider ethical implications of doing service abroad and if people choose not to go back, we should strive to leave as few “bad footprints” as possible.

The majority of our read-

think-ing deeply enough and are being slightly naive. You must constantly consider longitudinal sustainability.

microeconomics initiatives in developing countries. Expertise from a variety of global health.

If you were uninhibited by rules or finances, what is the dream global health project that you would set up?

My background before medicine was to bring about positivity and good health.

Global health is more than short-term interventions – it is a partnership between groups of people from the north can help increase background knowledge and critical thinking about global some background information about the research, and local involvement before considering a trip abroad. Lastly, global health has so many key players, not just the doctors. We often logistics, engineering, etc. Everyone has a role to play in global health – for example, businessmen can become involved in

that they have huge potential to do good for all peoples. There is also evidence that there is a connection between neural de-velopment and health outcomes when exposed to music and arts. My second idea involves early development and the ability to bring about simple resuscita-tion techniques. This is somewhat similar to the Saving Lives at Birth initiative. With ad-vancement in technology and communication tools opportunity to better in an area which we are still very much behind on.

To learn more about the GHEI program, you can visit www.pgme.utoronto.ca

education and development

Toronto Thinks Danielle Smalling

INTRO In November 2013, undergraduate students gathered to compete in Toronto Thinks: Global Health Innovations and Solutions, Canada’s first undergraduate global health case competition. Hosted by Juxtaposition Global Health Magazine, Toronto Thinks is a global health laboratory that aims to stimulate learning and intellectual discussions on real-life global health challenges. This past year the inaugural competition highlighted the issues of motor vehicle accidents in Ghana. Eight teams participated in the competition to present innovative, realistic, and evidence-based solutions to a panel of experts in Global Health. The following article is the solution presented by the winning team of Toronto Thinks 2013.

tion published the following staggering statistics relating to road traf-

reported deaths occurred worldwide on highways, motorways, major roads, and minor roads. Cyclists and pedestriWith Africa’s growing population and steady urbanization, the rate at rising. Presented with the challenge to create a program to better understand and mitigate this problem, we focused region in Africa. Thus, our program had to minimize the occurrence and (MVAs) in Ghana.

The Mu Yensa Project

Hands”) is a proposed plan to tackle the MVA issue beginning in Ghana. The project is fashioned on three pillars Data Collection and Awareness. With a vision of using community engagement to shape the project’s foundation, we hope that local businesses, organizations and institutions can come together to ensure self-sustainability.

Madina Pilot Location

adina is a township of the Greater Accra region just outside Ghana’s capital city. As a microcosm of

Ghana, it reveals her rural, industrial and urban features creating an ideal environment for the Mu Yensa Project Pilot Prostakeholders, major and minor roads, the capital city and the George Walker Bush Motorway, which is referred to in colloquial terms as Accra’s “Death Trap Highway”. Today, more than half of all road accidents occurring in Ghana take place on the George Walker Bush Motorway.

The Initiative

u Yensa will follow a 4-phase cyclical approach – Red, yellow, green and black. These colours

the blood of those who die annually due

education and development

of the Mu Yensa initiative, as well as a

to preventable MVAs; Yellow represents the hope of the country; Green symbolizes the capacity for growth and Lastly,

free of charge and motorists who have their vehicle serviced regularly by certi-

Ghanaian people.

points through their existing driver’s licensing system.

RED PHASE: Stakeholder engageprimarily on networking with stakeholders and collecting and processing data.

YELLOW PHASE implementation. A 6-month action phase where we will distribute highly specialized kits to develop awareness for the initiative.

GREEN PHASE: Go. An 11-Month Action Plan in which full implementation of strategies occurs. Nearing the end of this phase, we begin to withdraw our resources and limit our presence to allow full community engagement. BLACK PHASE: Monitoring and Evaluation. We will complete each cycle with a 4-Month period of review where new data is collected, analyzed and used to update existing practices.

Major Strategies: MECHANIC CERTIFICATION PROGRAM: Poor vehicle condition is a leading cause of accidents in Ghana. The vast majority of cars are constructed using workable parts from old and damaged vehicles. Additionally, refurbished cars are assembled by untrained mechanics, further diminishing the vehicles’ safety. We plan on working in collaboration with the department of Mechanical Engineering at the University of Ghana to implement a training program. Through this, local mechanics will be taught highly specialized skills, and will gineering students running the course will ideally receive academic credit for

RECYCLED REFUSE ROAD DIVIDERS: Head on collisions are of critical concern. These kinds of accidents are most common on roads with caused by unlawful overtaking. We have designed this operation to not Located in Accra, the Oblogo landGhana. Adjacent to the Densu River, water, it collects 1200 tonnes of waste ists between the dumping site and the residential areas just 4km away from Oblogo. Modeled from compressed refuse cubes designed by Nargis Latif of Pakistan, we will collect, dry and compress waste material into slender barriers that will be strategically placed along roads and motorways to streampedestrians, cyclists and motorists and prevent drivers from overtaking on crowded streets. This initiative will be in collaboration with local company Equipment Depot Ghana Ltd. The proposed barrier is resistant to rainfall and wind, malleable and most impor-

Minor Strategies: The Mu Yensa project also involves several secondary strategies to build awareness and unity within the community. Firstly, a memorial statue will be constructed using the metal of vehicles destroyed in road accidents. This memorial will serve as a constant reminder

deceased loved ones. Secondly, a reallocation of resources within law enforcement will allow

Finally, modeled from successful efforts in Rwanda, soap operas, specifically radio soap operas will be used to create a discussion of the issues Urunana – a Rwandan Radio Soapreached an estimated 10 million people each week, spreading awareness of Health Poverty. project in the city, educational workshops will be held in the popular marketplaces and schools, along with accessories, which also function to increase pedestrian visibility. Reducing the number of deaths by and general citizens alike. Though our tip of iceberg, it is our hope that Mu Yensa will become a grassroots movement, sweeping the globe to create safer roads for all.

thank you Nour Bakhash, Betel Yibrehu, and I, would like to thank Toronto Thinks and Juxtaposition Global Health Magazine for this challenge. It has been a phenomenal opportunity for intellectual growth and it is our hope that you are able to provide this experience to many in the years to come.

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