Juxtaposition Magazine issue 7

GLOBAL HEALTH MAGAZINE

JUXTAPOSITION UNIVERSITY OF TORONTO

13 GLOBAL HEALTH DIPLIMACY: THE INEXTRICABLE LINKS BETWEEN HEALTH AND FOREIGN POLICY

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

7 Malaria poems

Volume 7 issue 1

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Table of contents

index THE VECTOR AND THE HOST Rice: a Promising Solution to Vitamin A 05 Golden Deficiency and Child Mortality?

Executives List Administrative Director: Molly McGillis Editorial Editor-in-Chief: Kaleem Hawa Executive Editor-in-Chief: Abtin Parnia

FEATURE

07 malaria POems POLICY AND PRACTICES the Wake of Typhoon Haiyan: Examining the 10 InDecentralization of Health Care Within the Philippines health diplomacy: The Inextricable Links 13 global between Health and Foreign Policy & Neo-Colonialism: Pharmaceutical 15 Antiretrovirals Companies And The HIV/AIDS Epidemic

EDUCATION AND DEVELOPMENT Health and Medicine: A Closer Look at PGME’s 19 Global Global Health Education Initiative thinks: a look back at Canada’s first22 toronto ever global health competition

sponsors

Cover Photo Courtesy: James Gathany

l l l l l

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

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

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

editor’s note

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Dear Juxta Readers,

A

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 to global health. During the last year we have attempted to provide a global health laboratory for University of Toronto Students. Juxtaposition hosted Canada’s first undergraduate global health case competition, Toronto Thinks: Global Health Innovations and Solutions. By using the principles of problem-based learning, Toronto Thinks brought together multidisciplinary teams to compete, and learn how to create solutions for complex global health challenges.

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 in an interdisciplinary discussion on important global health issues.

In this issue we will explore global health in 3 different areas: “The Vector & The Host,” “Policy & Practices,” 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 by Lena Elisabeth Faust that explores Vitamin A deficiency. This is followed by a discussion on the burden of Hib disease in Indonesia by Faraz Honarvar. We end the section with an innovative piece by Cameron Conaway that utilizes the power of poetry to discuss one of the most notorious infections of the developing world: Malaria. Next, Marcus Tutert will explore “Policy & Practices” in response to the Typhoon Haiyan and its devastating impact on Indonesia. Kaleem Hawa presents a persuasive piece on the relationship between foreign policy and health. “Policies and Practices” also includes the actions of the private sector in relation to governments.

In a fascinating analysis, Matt Douglas-Vail explores the role of pharmaceuticals in the HIV epidemic and its connection to neocolonialism. We wrap up “Policies & Practices” with an article by Amy C. Willis on the infamous Ugandan Anti-homosexuality law. In our last section on “Education & Development” we will take a look at 66th World Health Assembly from the perspective of a global health student with Trisa Taro. As a tribute to the Post-Graduate Medical Education (PGME) programs, Raissa Chua interviews a medial residence about her experience with PGME’s Global Health Education Initiative. We finish this issue by featuring the solution presented by the winning team of Toronto Thinks inaugural case competition, on preventing motor vehicle accidents in Ghana, written by Danielle Smalling.

We sincerely hope that this issue presents you with an enlightening yet complex narrative about global health.

It is through understanding complexity of a challenge that comprehensive solutions are made.

Best Regards,

Abtin Parnia Kaleem Hawa

Editor-In-Chief, 2013-2014 Editor-In-Chief, 2013-2014 Executive Division Editorial Division

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GENERAL

foreword

F

rom the dawn of multicellular life, complex organisms have had to protect themselves against pathogenic microorganisms in their environment. The protection of the individual against such pathogens is significantly compromised in patients suffering from immune deficiencies, either inherited or acquired, as in the case of AIDS following HIV infection. Even among individuals with a fully functional immune system, 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 200 years ago, it has become clear that the immune system is adaptive and can exhibit remarkable specificity.

This means that while vaccination against smallpox confers immunity to smallpox it does not confer immunity to other diseases. As medicine and scientific research progressed, greater knowledge was amassed about the 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 a personal focus of mine in my capacity as Chair of the University of Toronto’s Immunology Program and as Interim Provost of Trinity College.

The development of effective new vaccines against existing and newly emerging diseases is a high priority for policymakers across the world who are tackling a variety challenges associated with the generation of new effective vaccines and their delivery. From the identification of vaccine targets to developing the appropriate 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 difficult, there are many stages between the characterization of an infectious disease and its control through 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 health; this undergraduate magazine represents a significant achievement for all involved - the authors and the editors – as well as for Toronto’s global health community.

MICHAEL RATCLIFFE. PhD

Vice-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 Tel (Trinity): (416) 978 2129 Email: michael.ratcliffe@utoronto.ca

The vector and the host

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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 – as the fourth largest populated country in the world – 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.

The disease causes, transmission, and symptoms Haemophilus influenzae type b (Hib) disease is one of the main causes of meningitis, pneumonia, epiglottitis, arthritis, and blood stream infections and most often targets children 3 months to 3 years of age.1 Hib is considered a communicable disease and is usually transmitted through the mucus of an infected person’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 If the disease develops into meningitis, symptoms include stiff neck, vomiting, and headache. If it causes pneumonia, symptoms include rapid breathing and mucus-containing coughs. If it causes epiglottitis, the symptoms are sore throats and noisy breathing.1

Burden of disease

I

n a study conducted in 1998 in Lombok, Indonesia, scientists were able to document the burden of Hib disease for the first time in Indonesian history.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 than 4.6% of the population carried the disease and one-third to one-fifth of the 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 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 approximately 300,000 disability-adjusted life years (DALYs).3

This clearly highlights the severe consequences of Hib disease in Indonesia and the urgent need for an effective vaccination to mitigate the disease’s pernicious effects.

Early efforts

T

he Indonesian government has been performing Hib vaccination in Lombok since 2000.4 The government implemented the vaccination program against Hib disease and analyzed the efficacy of this vaccination on two different types of pneumonia: the clinical pneumonia and pneumonia with radiographic consolidation. The results indicated a 3.8% prevention of clinical pneumonia due to Hib disease; however there was no sign of prevention of pneumonia with radiographic consolidation.4 Refer

to figure 1 for a comparison between the results of the same vaccination methods in the Gambia and Lombok, Indonesia.

Taking those results into account, the Indonesian government realized a more effective vaccination method needed to be implemented.

New program

T

he Indonesian government’s plan in collaboration with The Global Alliance for Vaccines and Immunizations (GAVI), The United Nations Children’s Fund (UNICEF), and the World Health Organization (WHO) to mitigate the effects of Hib disease on the country started in 2012 when pentavalent vaccinations protecting against diphtheria-tetanus-pertussis (DTP), hepatitis B and Hib were licensed and bought

6

The vector and the host

HIB

continued from the Indonesian manufacturer Bio Farma.5 As an Indonesian company, Bio Farma was considered an attractive investment for the government due to the money spent strengthening the country’s economy instead of leaving the country.

By the end of 2013 the government hoped to have vaccinated 20% of the infant population located in the West Java, Bali, West Nusa Tenggara and DIY provinces. By 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 100% of the infant population.6 The vaccination program is gradually covering the large Indonesian infant population spread across the country’s many islands.6

Impact

W

ithout vaccination, every year more than US $9.06 million is spent treating Hib disease worldwide.3 The cost of implementing the Hib vaccination program alongside the existing DTP-Hep B vaccination on the other hand is around US $27.7 million. The Incremental Cost-Effectiveness Ratio (ICER) based on UNICEF pricing predicts a US $67 per DALY aversion. However, when The GAVI’s pricing gets implemented, more than US $3.7 million will be saved.3 These results significantly strengthen the practicality of implementing the five-in-one vaccination plan. Refer to figure 2 for more detailed information on the comparison between the effects of no vaccination and vaccination on the burden of Hib disease and associated costs.

This plan is predicted to avert approximately 76,700 cases of infection, 7,150 deaths and 273,000 DALYs. These numbers were calculated by subtracting the predicted cases of infection (7460)

and DALYs (26600) after the national availability of five-in-one vaccine (with 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 300000 DALYs).3

Conclusion

T

he prevention of Hib disease in Indonesia, despite proving to be a very difficult and laborious task 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 this goal. If performed properly, the five-in-one vaccination has been shown to be an incredibly effective method for reducing DALYs and mortality in Indonesia and with this model can now be implemented in other developing countries facing the same problem.

Author bio University of Toronto Undergraduate Student I am a second-year undergraduate life sciences student at University of Toronto St. George campus and I am pursuing a double major in Global Health and Bioethics. As a first-world country citizen, my main goal in life is to make a positive impact on the lives of the ones who are not fortunate enough to have what I have and that is what gives my life a meaning.

References 1. Haemophilus Influenzae Type B (Hib) Disease. http://healthvermont.gov/prevent/hib_disease/hibdisease.aspx (2013).

2. Gessner, B. et al. A population-based survey of Haemophilus influenzae type b nasopharyngeal carriage prevalence in Lombok Island, Indonesia. Pediatric Infectious Disease Journal 17, S179-S182 (1998).

3. Broughton, E.I. Economic evaluation of Haemophilus influenzae type B vaccination in Indonesia: a cost-effectiveness analysis. J Public Health 29, 441-448 (2007).

4. Watt, J.P. et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. The Lancet 374, 903-911 (2009).

5. Indonesia introduces five-in-one vaccine for children. http://www.who.int/immunization/newsroom/indonesia_five_in_one_20130822/en/index.html (2013).

6. Comprehensive multi year plan national immunization program Indonesia 2010-2014. http://www.gavialliance.org/country/indonesia/documents/cmyps/comprehensive-multi-year-plan-for--2010-2014/ (2010).

feature

malaria poems 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 as she traps fish and recall the never there of his black downy hair.

In bed when the cold cat curls 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.”7 - 1902

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8

feature

Counterfeit

Wrapped Up, In

Third of malaria drugs ‘are fake’12 Their five faces fade black in turns inside the shadow trail cast by the steady sway of the single yellow bulb in the cobwebbed basement.

What’s worse? I asked.

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.

I am she says as I will.

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.

Two cut the powder and two clean tubes and one with gun to profit with pills on people is as natural as moon song.

Borrow bright, borrow blues.

My eye fills the floorboard hole and I look down on them 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 rights or all over the floors.

Blinking days split like grieving.

Boys, stencil-stashed kids really, who know not their father or Artemis’s or bow’s curve, but the butterfly and hourglass of arrow’s entry wound.

Not yet how time tweaks string.

There the kids, slaves really, who know not the story beneath their fingernails or the speed in their bloodstream: Amphetamine in Chinese means Isn’t this his fate? Take them to make them.

There the hate I held as hair bled through the floorboard hole, to and fro like a floating feather of then and then getting caught, lost in the dust of the cobwebs.

“The war against infectious disease has been won.”14 - 1969

I Want To Go I want to go in the moment before going in. The concrete wall seems grayed with knowing.

Ear pressed against the grain hears the cold simmer of silence then the boom and echo of flood in throat. Sound chokes me. I go 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 in veins and in that moment I go and somehow come to on all fours.

I reach, dip my hands in what was a river, now dried to open scabs, taste the wink of wounds under scars.

Maybe my eyes are closed. Life still needles through the water and I run cupfuls of absence through my fingers.

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,” will be released Winter 2013 from Salmon Poetry. For more information visit CameronConaway.com.

feature

Okapi

That’s cerebral

I know the field of grass is green but my eyes

the doctor said

know different knowings.

To them green burns black and white sun splinters blades like bad memory or the legs of the okapi the students work to draw

Your own stone, she says, has all you’ll ever need to draw the great animal.

Feel its shapes in your hands.

and it dispersed

shuttling sound

from mouth

away

mutating it to mean.

A compliment in another place here sticks here clots here a death sentence this time

from inside their hut.

The teacher carries on her head a basket of stones and gives each student one.

“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.”2

slick through thick air quiet barracuda

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.

I see students tap pencils.

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.

who tells me only that it was “by more than ten” last week.

Who tells me the choice: stay home and starve or leave to fields for food and be raped.

Something about the silence of a place where wails were.

Something about how violence seals itself silently within us and we sometimes carry on.

9

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

A tribe muscled

References 2. Neurological damage from malaria. Ian Jones. 06/12/2002. http://malaria.wellcome.ac.uk/doc_WTD023883. html 5. Malaria Consortium. The Challenges. Pregnant Women. http://www.malariaconsortium.org/pages/malaria_challenges.htm#Pregnant_Women 6. Ghana Web. Title. 06/12/2009. http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel. php?ID=163616 7. The Deseret News. Ad. 01/21/1902. http://news.google.com/newspapers?id=AQMvAAAAIBAJ&sjid=s9wFAAAAIBAJ&pg=2865,4076960&dq=duffy%27s+malt+whiskey+malaria&hl=en 12. BBC. Title. Michelle Roberts. 05/22/2012. http://www.bbc.co.uk/news/health-18147085 14. U.S. Surgeon General William H. Stewart, 1969. Quoted: Peoria Magazines, The Crisis of Antibiotic Resistance. Jonathan Wright. 05/2012. http://www.peoriamagazines.com/ibi/2012/may/crisis-antibiotic-resistance

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Policy and Practices

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 country’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.

Policy and Practices

11

Author bio Marcus Tutert is currently a first year student at the University of Toronto, Trinity College. He is pursuing a Bachelors of Science through a dual major in Global Health and Biochemistry. During his free time, Marcus enjoys debating, creative writing, and playing basketball. His global health pursuits revolve around developing a method to combine the theoretical research on new drugs with providing these drugs to vulnerable regions worldwide.

Pre-Existing Vulnerabilities

T

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 floods, torrential storms and typhoons1. These natural phenomena strongly affect the population, resulting in adverse health effects such as illness from water contamination, 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 “Health Systems Review” 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.3 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 regions4. This is a substantial contributing factor to the high health inequity between income levels in the nation5.

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.6

Undergoing Decentralization

T

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

“The primary concern overall is the degree of autonomy within the decentralized system.” date. Instead, the mandates are being assigned to specific Local Government Units (LGU) throughout the affected regions.7 In addition, the LGUs and the DOH now form a hierarchy of several specific task chains that collaborate with the private sector to produce further specialized and independent units.

Some examples include Health Regulation Units and Rural Health Units.8 In addition to being in charge of local

health systems, LGUs are responsible for enforcing and creating new policies and mandates that improve specific aspects of the overall health care system.9 In theory, the decentralization of a country such as the Philippines creates a far more fluid system. These organizations are better able to respond to local needs and are able to craft more specific policies. In particular, the Philippine system 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.

These financial surpluses are critical.

For example, they allowed the local government expenditures to increase by 10.7% in 1993 (during the process of decentralization), as documented by a recent study.11 It is also critical to note that significant problems stemmed from the decentralization of the nation’s healthcare systems. When such a high degree of autonomy is present in each of the newly formed groups, it is difficult 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.12 Furthermore, these goals are often tied to commercial profit. An important example of this arose when an LGU targeted the

12

Policy and Practices

In the Wake of Typhoon Haiyan continued

agricultural sector and other commercial marketing avenues to maximize profits. The decision went against the overarching mandates that food security for related LGU’s are of the utmost importance.13

Proposed Solutions

M

any solutions have been proposed not only to fix these problems in 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.14

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.

In countries outside the Philippines, the transference of power from a DOH to the LGUs may not be as effective, leading 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 states was difficult to overcome in the new system.15 A report by the European Observatory--a world-wide organization that examines health policy’s and mandates--suggests specific solutions to the problems of decentralization.16 With regards to the purview of smaller organizations, one accessible solution is to ensure that they maintain a strong rela-

tion 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 more fluid and dynamic response system when done effectively. Although 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.

References 1 Perez R, Amadore L, Feir R. 1999. Climate Change Impacts and Responses in the Philippines Coastal Sector. Climate Research. 12: 97-107.

2 Ahern M, Kovats, R, Wilkinson P, Few R, Matthies F. 2005. Global Health Impacts of Floods: Epidemiological Evidence. Epidemiologic Reviews. 27: 36-46.

3 Romauldez A, Frances J, Flavier J, Quimbo S, Hartigan-Go K, Lagrada L, David L. 2011. Phillipines Health System Review. Health Systems in Transition. 1(2).

4Tran T, Tran P, Tuan T. 2012. Review of Housing Vulnerability: Implications for Climate Resilient Houses. Discussion Paper Series.

5 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space. Health Policy Planning. 17(1): 14-31 6 Romauldez A, Frances J, Flavier J, Quimbo S, Hartigan-Go K, Lagrada L, David L. 2011. Phillipines Health System Review. Health Systems in Transition. 1(2).

7Healy V., Gorgolon L, Sandig E. 2003. Overview of Devolution of Health Services in Philippines. Rural and Remote Health. 3(2): 220.

8 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space. Health Policy Planning. 17(1): 14-31.

9 Bankauskaite V, Vrangbaek K, Saltman I Decentralization in Health Care: Strategies and Outcomes. Maidenhead: Open University Press, 2007.

10 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space.

Health Policy Planning. 17(1): 14-31.

11 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space.

Health Policy Planning. 17(1): 14-31.

12 Legaspi P. 2010. The Changing Role of Local Government Under a Decentralized State: The Case of the Philippines. Public Management Review. 3(1): 131-139.

13 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space.

Health Policy Planning. 17(1): 14-31.

14 Bankauskaite V, Vrangbaek K, Saltman I Decentralization in Health Care: Strategies and Outcomes. Maidenhead: Open University Press, 2007.

15 Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space.

Health Policy Planning. 17(1): 14-31.

16 Bankauskaite V, Vrangbaek K, Saltman I, Decentralization in Health Care.2007.Mcgraw Hill

Policy and Practices

13

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 world’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

T

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.3 The first major area is security. Fear of global pandemics enhanced by humanitarian con-

flict and transportation interconnectedness 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 healthcare systems present a significant 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 does not require malicious intent nor technological capacity – whose proliferation is catalyzed merely 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 considerations into national foreign policy.

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Policy and Practices

Global Health Diplomacy continued

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 of the world 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 both the developed and developing world.

Global Health as a Tool of Foreign Policy

F

rom our understanding of the benefitis associated with coupling global 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 HIV/AIDS as a tenet of its foreign policy in 2009, Brazil established stronger programmes of AIDS funding to developing countries such as South Africa.6 In doing so, Brazil strengthened its economic trade relationships with Africa and built alliances of trust that helped it gain support for political agendas it pursued within the United Nations7; this meant that Brazil could now count on the support of African nations as it pursued Security Council reform among other initiatives.

In this way, global health played a clear role in the advancement of both Brazil’s economic and political goals.

The other side of relationship building centres around military conflict and reflects a larger nuance within the global health and foreign policy framework.

In a military conflict, foreign policy can be seen as a primary antagonist when trying to promote global health goals.8 Excluding combat deaths in an armed conflict, there are often indirect deaths

stemming from war-induced violence, injury, disease, and malnutrition. Thus, it becomes especially important to transform the foreign policy goal of conflict into a harms mitigator and 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.9

WHO Developments

O

ne of the most powerful vindications of global health as part of the foreign policy framework was the Foreign Policy and Global Health Initiative (FPGHI). Launched jointly by the WHO and the foreign ministers of Brazil, France, Indonesia, Norway, 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 Ministers of Foreign Affairs

REFERENCES David P. Fidler, “Health as foreign policy: between principle and power,” Whitehead Journal of Diplomacy and International Relations, 6 (2005): 179-194.

2 Margaret Chan, and Kouchner Bernard, “Foreign policy and global public health: working together towards common goals,” Bulletin of the World Health Organization, 86, no. 7 (2008): 498.

3 Ilona Kickbusch, “Global health diplomacy: how foreign policy can influence health,” British Medical Journal, 342 (2011): 3154-3158.

4 Vincanne Adams, Thomas E. Novotny, and Hannah Leslie, “Global Health Diplomacy,” Medical Anthropology, 27, no. 4 (2008): 315-323.

5 Thomas Chirikos, and Gilbert Nestel, “Further Evidence on the Economic Effects of Poor Health,” The Review of Economics and Statistics, 67, no. 1 (1985): 61-69.

6 Kickbusch, 2011.

7 Ibid.

8 Minister of Foreign Affairs Brazil, Minister of Foreign Affairs France, Minister of Foreign Affairs Indonesia, Minister of Foreign Affairs Norway, Minister of Foreign Affairs Senegal, and Minister of Foreign Affairs South Africa, “Oslo Ministerial Declaration—global health: a pressing foreign policy issue of our time,” Lancet (2007): 1-6.

9 Ibid.

10 Ibid.

11 Global Health Security Initiative, Ottawa plan for improving health security. (Ottawa: November 7, 2001).

Policy and Practices of those nations in 2007 is particularly indicative of the dogmatic change: “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, longterm 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.” 10

Another global policy network produced from the interaction of the global health and foreign policy issue areas is the Global Health Security Initiative (GHSI). The GHSI was designed as an “international partnership to strengthen health preparedness and global response to biological, chemical, radio-nuclear and pandemic influenza threats” and was launched in November 2001 by Canada, the European Commission, France, Germany, Italy, Japan, Mexico, the United Kingdom, and the United States of America.11 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.

In the end, the number of nations that 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.

GAY = DEATH Uganda’s Anti-Homosexuality Bill and what it means for HIV Kaleem Hawa

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 homosexuality. 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.

I

n 2009, Ugandan parliamentarian David Bahati introduced the Anti-Homosexuality Bill (AHB), new legislation that aimed to further

criminalize the LGBT population and their “homosexual” behaviours.

The purpose of the bill was to uphold, preserve and maintain the tra-

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ditional, socio-cultural construct of marriage between a man and a woman while simultaneously protecting children – the future of Uganda –

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Policy and Practices

Gay = death continued

from the clutches of the homosexual lifestyle and, most importantly, prohibiting the acknowledgement and promotion of anything other than heternormativity. Though the Bill was initially proposed in 2009, it lay mostly dormant until the Ugandan government aggressively resurrected the legislation in November 2012, in a concerted effort to pass it swiftly.

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.

U

ganda is a heavily religious nation with more than 80% 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]. The AHB roughly defines “the offence of homosexuality” as any intentional touching, penetrating, or stimulation of sexual organs between two people of the same sex; if found guilty of this “offence”, a person can be imprisoned for life. “Aggravated homosexuality”, a significantly more severe charge, is used as an umbrella term under which numerous activities/offences fall, including sex with a minor (a person below the age of 18), sexual abuse of a person with a disability, and being HIV-positive, among others. Upon conviction, those who commit “aggravated homosexuality” can be sentenced to death.

In addition 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 has effectively created a state-sanctioned witch hunt, whereby all citizens are expected to report suspected or known LGBT persons to the authorities within a 24-hour period or face jail time and monetary fines [3]. There are many significant and extremely 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

“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.” on the potential havoc this proposed legislation may wreak on the country’s HIV epidemic.

T

he inclusion of the HIV-positive clause in the AHB serves to reinforce the historical, troublesome and erroneous relationship that exists between gay men and

HIV/AIDS. Highlighting HIV within this bill serves to suggest that HIV is “the gay disease” even though in many African countries, Uganda included, the epidemic is more generalized and thus, is also prevalent in heterosexual populations. This unfounded association may therefore inadvertently give the heterosexual population permission to distance themselves from HIV education, awareness and prevention and to disassociate from better sexual health practices because they do not feel HIV is as relevant to them. Further, with the increased state-sanctioned discrimination against the LGBT population in Uganda, HIV and sexual health education targeting this demographic would likely be scaled down if it has not already happened. Effectively, the AHB has the potential to negatively impact HIV education and prevention for both the LGBT and heterosexual populations alike.

H

IV awareness and prevention, particularly in relation to testing, is also under immediate threat for the LGBT community should the proposed legislation pass. According to a report produced by UNGASS in 2010, only 20% of Ugandan women and men between 25 and 49 years of age had been tested for HIV in the previous 12 months and knew the result of that test [4]. What complicates this issue even further is that should the AHB pass, confidential relationships previously shared between healthcare providers and patients would no longer exist, as doctors would effectively be required by law to report any patients whom they suspect

Policy and Practices

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.

(or know) to identify as LGBT and/ or are HIV-positive. Given the pending legislation and its call for the death penalty for those who are both LGBT and HIV-positive, it is easy to see why many Ugandans in the LGBT community may forego an HIV test to prevent 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 may suffer in silence by their inability to access life-saving antiretroviral drugs (ARVs), inadvertently transmit the virus to others and subsequently die due to AIDS-related complications. For the LGBT population in Uganda, the proposed AHB is a deadly catch-22.

T

he negative and insidious impact that stigma and discrimination have on HIV awareness, 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 evidenced in the Crane Survey [8], one of the only studies to date which examines HIV in relation to men who have sex with men (MSM) in Uganda. Not surprisingly, after the introduction of the AHB in 2009 and despite UNAIDS identifying MSM as one of the highest HIV at-risk groups, Uganda’s Ministry of Health (MoH) stopped collecting data on MSM in relation to HIV. Since then,

the only data that has become available is what is offered through the Crane Survey. Based on the 2009 UNAIDS report, MSM accounted for 13.7% of Uganda’s HIV-positive 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 collaboration among the United States’ and Uganda’s Centers for Disease Control and Prevention’s (CDC) Division of Global HIV/AIDS, the Center for Global Health at the University of Amsterdam, Uganda’s MoH, and the School of Public Health at Makerere University in Uganda), involved respondent-driven sampling to recruit 300 MSM in Kampala; eligibility criteria included being ≥ 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 findings indicated high levels of LGBT-related stigma, pointing toward dangerous outcomes regarding HIV transmission within the MSM community and the sexual networks to which MSM are connected. For example, of the 300 participants, 31% had been married, 44% had lived with a female partner, and 16% were 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 hetero-

sexual 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 (STIs), thereby increasing the risks associated with these sexual encounters. In addition, for MSM who are 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 STIs. This risk is reflected in MSM’s self-reports regarding condom use by partner type: in the last 3 months, 40% of the sample reported condom use with their casual female partners, 39% of the sample said they used condoms with steady female partners, 43% said condoms were used with casual male partners and 50% stated condom use with steady male partners [8].

O

ther key findings that came out of the Crane Survey included that the MSM within the study sample were found to have relatively low levels of knowledge on HIV risk in relation to anal sex. For example, when asked, “What kind of anal sex do you think is more dangerous to get HIV?”, 11% of the sample said that both insertive and receptive sex had no risk, 65% responded that the risk was equal, 13% thought that insertive sex was riskier and 11% reported that receptive anal sex was riskier. This is especially con-

17

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Policy and Practices

cerning given that the risk of contracting many STIs, including HIV, is considerably heightened for the receptive partner in both anal and vaginal sex [8].

When asked, “Compared to vaginal sex how important is it to use condoms for anal sex?”, 10% 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, condomless anal sex is generally riskier than condomless vaginal sex in terms of STI transmission [8]. What these findings 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, only 49% of respondents reported using condoms, only 53% had engaged in sex with a steady partner, and only 4% perceived their partner’s serostatus to be positive. In relation to knowledge of one’s own status, 45% of the sample did not know their own HIV status, 44% stated they were negative and 12% stated they were positive [8].

T

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 health, safer sex practices and risk-reduction strategies, thereby resulting in an increased risk of STI transmission – not only within the MSM population but also for their female partners and any other subsequent partners in their sexual networks.

Second, many MSM are unaware of their HIV status yet are still engaging in sex without condoms, which may potentially heighten the level of risk for everyone involved. With the proposed legislation including the HIV-positive clause 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 death penalty. In addition, for any MSM who have had unpleasant experiences within STI clinic settings, this stigmatization presents further barriers to access testing and treatment for those who are positive. As of 2010, only 54% of HIV-positive Ugandans were receiving ARVs [9]; for any LGBT HIV-positive Ugandans, there are concerns about possible barriers to accessing treatment, the potential impact of future treatment should they develop any drug resistance, and how

discontinuation of ARVs might also impact rates of transmission.

A

t the time of writing this article, the AHB has not been passed within Uganda’s parliament.

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 possible to confirm the truth of these claims.

Nonetheless, 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 potentially encouraged considerable spread of HIV among the MSM community and beyond. To argue that there is a lot at stake should the proposed Anti-Homosexuality Bill pass is a vast understatement. The situation is dire and what is at risk is not only the lives, human rights and dignity of many LGBT-identified Ugandans, but also the potentially disastrous cascade effect that this legislation could have on HIV awareness, prevention, transmission, and treatment.

References 1. Central Intelligence Agency. “CIA World Factbook.” Last modified February 5, 2013. https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html.

2. Jeffrey Gettleman, “Americans’ Role Seen in Uganda Anti-Gay Push,” New York Times, January 3, 2010, http://www.nytimes.com/2010/01/04/world/africa/04uganda.html?_r=2&.

3. The Government of Uganda’s Anti-Homosexuality Bill. Accessed January 29, 2013 http://wthrockmorton.com/wp-content/uploads/2009/10/anti-homosexuality-bill-2009.pdf 4. Uganda Country Report. UNGASS. Accessed February 9, 2013. http://www.unaids.org/en/regionscountries/countries/uganda/ 5. Epstein, Helen. The Invisible Cure: Why we are losing the fight against AIDS in Africa. New York: Picador, 2007.

6. Lane, Tim. “From Social Silence to Social Science: HIV research among township Men who have Sex with Men in South Africa,” In From Social Silence to Social Science: Same-sex sexuality, HIV & AIDS and Gender in South Africa, edited by Vasu Reddy, Theo Sandfort and Laetitia Rispel, 66-77. Cape Town: HSRC Press, 2009.

7. Steinberg, Jonny. Three-letter plague: A Young Man’s Journey through a Great Epidemic. Johannesburg: Jonathan Ball Publishers, 2008.

8. Hladik, Wolfgang., Joseph Barker, John M Ssenkusu, Alex Opio, Jordan W. Tappero, Avi Hakim, and David Serwass. “HIV Infection among Men who have Sex with Men in Kampala, Uganda – A respondent driven sampling survey.” PLoS ONE 7(2012): 1:9. Accessed February 9 10, 2013 http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0038143 9. Uganda Country Report. UNAIDS. Accessed February 9, 2013. http://www.unaids.org/en/regionscountries/countries/uganda/

education and development Photo Courtesy: Trisa Taro

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WHA66

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

A

s the 68th United Nations General Assembly came to a close last summer, it was the perfect time for me to reflect on the amazing things that had happened in the field 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 professional in this field.

L

ast year, I had the privilege of attending 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 officially adopted by Member States on May 27, 2013, encompasses major recommendations on tackling non-communicable diseases around the world and includes an action plan, monitoring framework, and a global coordinating mechanism. Specifically, the resolution set nine comprehensive global voluntary targets, including the “25 by 25� mortality reduction target. These targets, which focus on both prevention and treatment, are the final destination on the roadmap outlined in the global action plan. To

ensure that these goals are met in an efficient and timely manner, a global coordinating mechanism will be set in place to unite all critical stakeholders working to deliver the action plan.

I

t was an unprecedented personal experience to find myself sitting in the largest conference room at the World Health Organization (WHO) headquarters, surrounded by some of the most influential figures in healthcare, all brought together by a collective commitment to a burgeoning global health movement.

W

alking into the building on the first day of WHA66 was surreal.

The fact of the matter was that

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education and development

WHA66 continued

I 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 polio was reaffirmed.

T

he extraordinary appeared to become the mundane in the high-powered world of the WHA. On an average day, I would sit and talk to the Minister of Health from Sweden, stand in line for coffee next to CEO Seth Berkley of the GAVI Alliance, 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 near Hollywood, I’ve never been more “star-struck” in my life.

N

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 active. Although all the “official” business 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 one another and their strategies for ad-

education and development

Inside the Serpentine Lounge (the local coffee shop) vocating health needs of their country.

Moreover, I was also able to interview representatives from different countries and different sectors – asking the agent from Johnson&Johnson about the reasons for-profit companies get involved in public health promotion efforts in the first place. If that wasn’t enough scholastic enrichment for one day, there was an endless agenda of meetings, lectures, and side events to

attend. It felt like a global health playground! I spent 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 post2015 development agenda, and spent my evenings rubbing elbows with delegates from around the world at cocktail hours discussing the use mHealth in developing nations.

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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: l 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) l 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/) l 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 l Contact your local Ministry of Health for potential opportunities through their offices.

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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.

I

n 2013, the World Health organization published the following staggering statistics relating to road traffic accidents. In 2012 alone, 1.27 million reported deaths occurred worldwide on highways, motorways, major roads, and minor roads. Cyclists and pedestrians accounted for 50% of these victims.

Presented with the challenge to create a program to better understand and mitigate this growing problem, we focused our efforts on a single region of continental Africa. With growing populations and urbanization, the rate at which road traffic accidents occur is steadily rising. In what ways are we able to mitigate both the occurrence and effect of road traffic accidents in Ghana?

The Mu Yensa Project

T

he Mu Yensa Project (Akan: “In Our Hands”) is a proposed plan to tackle the MVA issue beginning in Ghana.

The project is fashioned on three pillars of operation: Community Involvement, 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

M

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 Program. It is ideal given its proximity to our stakeholders, 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

M

u Yensa will follow a 4-phase cyclical approach – Red, yellow, green and black. These colours carry great significance as Red represents the blood of those who die annually due

education and development to preventable MVAs; Yellow represents the hope of the country; Green symbolizes the capacity for growth and the black star of their flag signifies the empowerment of the Ghanaian people.

RED PHASE: Stakeholder engagement. In the first 4 months we will focus primarily on networking with stakeholders and collecting and processing data.

YELLOW PHASE: Introductory 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 have been constructed using working parts of old and damages vehicles. Additionally, refurbished cars are assembled by untrained mechanics, which exacerbates the vehicles precarious safety standing.

In collaboration with the department of Mechanical Engineering at the University of Ghana, we will implement a program through which local mechanics will be taught highly specialized skills that will be required to obtain certification. Engineering students running the course will ideally receive academic credit for their efforts, mechanics will attend free of charge and

motorists who have their vehicle serviced regularly by certified mechanics will be rewarded with points through their existing driver’s licensing system.

RECYCLED REFUSE ROAD DIVIDERS: Head on collisions are of critical concern. These kinds of accidents are most common on roads with little division of traffic and are often caused by unlawful overtaking. We have designed this operation to not only tackle road traffic accidents, but the growing amounts of unfiltered refuse on land and in Ghanaian landfills.

Located in Accra, the Oblogo landfill is the largest open dumping site in Ghana. Adjacent to the Densu River, which supplies 50% of Accra’s drinking water, it collects 1200 tonnes of waste from the city daily. No buffer zone exists 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 streamline traffic. These barriers will divide pedestrians, 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 importantly, reflective.

Minor Strategies: The Mu Yensa project also involves several secondary strategies to build awareness and unity within the community.

Mu Yensa Project Memorial Statue made entirely of scrap metal.

Firstly, a memorial statue will be constructed using the metal of vehicles destroyed in road accidents. This memorial will serve as a constant reminder

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of the Mu Yensa initiative, as well as a site for those affected to honour their deceased loved ones.

Secondly, a reallocation of resources within law enforcement will allow trained officers into high occupancy areas to direct traffic where there are streets devoid of effective signage.

Finally, modeled from successful efforts in Rwanda, soap operas, specifically radio soap operas will be used to create a discussion of the issues surrounding road traffic accidents.

Urunana – a Rwandan Radio Soapreached an estimated 10 million people each week, spreading awareness of Health Poverty.

In order to create a presence for the project in the city, educational workshops will be held in the popular marketplaces and schools, along with the distribution of branded reflective accessories, which also function to increase pedestrian visibility.

Reducing the number of deaths by road traffic accidents will require the combined efforts of authority figures and general citizens alike. Though our proposed efforts in Madina are only the 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 Backache, 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.

N O R O T

TO

S K N I TH GLOBAL HEALTH INNOVATIONS SOLUTIONS

PRESENTS

AND

www.TorontoThinks.wordpress.com

TORONTO THINKS F I R S T G LO B A L H E A LT H C A S E C O M P E T I T I O N I N C A N A D A