Spring 2012: Cures

GLOBALIST The Yale

Spring 2012 / Vol. 12, Issue 3

CURING

THE GLOBAL HEALTH IMBALANCE

Conservation and oil in the Amazon 6 * Monitoring the Egyptian election 8 * South Tyrol, a town of two nations 10

LETTER FROM THE EDITOR 3

GLOBALIST The Yale

An Undergraduate Magazine of International Affairs Spring 2012 / Vol. 12, Issue III www.tyglobalist.org

This magazine is published by students of Yale College.

Yale University is not responsible for its contents.

Send comments, questions, and letters to the editor to sanjena.sathian@yale.edu.

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Log on to tyglobalist.org and click the Subscribe link in the upper right corner.

Journalism Advisory Board Steven Brill, Yale Dept. of English Nayan Chanda, Director of Publications, MacMillan Center Daniel Kurtz-Phelan, Foreign Affairs Jef McAllister, Time Magazine Nathaniel Rich, The Paris Review Fred Strebeigh, Yale Dept. of English

Academic Advisory Board Harvey Goldblatt, Professor of Medieval Slavic Literature, Master of Pierson College Donald Green, Director, Institution for Social and Policy Studies Charles Hill, Yale Diplomat-in-Residence Ian Shapiro, Director, MacMillan Center Ernesto Zedillo, Director, Yale Center for the Study of Globalization

DEAR

www.tyglobalist.org

GLOBALIST

READERS,

O

ur world is unwell. Global health is increasingly a vital topic to understand in approaching major problems around the world. American foreign policy now cannot operate without an understanding of the health of populations around the world. We have learned to fear the outbreak of deadly pandemics, from H1N1 to anthrax. Some have seen the tragedies of healthcare worldwide as an opportunity for charity, and private companies have stepped in to offer aid where government programs have neglected to. The complex web of global health policy is one that pulls in many actors—from American senators to student volunteers to the pharmaceutical industry to researchers in university labs.

The Globalist’s third issue of the 2011-2012 school year is taking on these complexities. Sophie Broach’s article investigates the back-and-forth in a debate between high and low-tech solutions to sleeping sickness and the shocking research community behind it all. David Carel’s piece is a firsthand account of the world of Washington’s global health policymaking and the health lobbyist community’s attempt to create change. Seth Kolker tells a fascinating tale of sexual education in Nicaragua, and Angelica Calabrese’s article transports the reader to Haiti, where cell phone technology is revolutionzing modern healthcare. The writers for this issue have pushed far beyond the modern media’s representations of illness and wellness. Their investigative and in-depth reporting provides a crucial voice in the increasingly important healthcare discussion—one which sees the march towards global health equity in terms of the stories and lives of individuals.

As always, this issue of the Globalist also features a variety of topics unrelated to the theme.

Amelia Earnest’s portrait of an Ecuadorian community’s confrontation with the oil industry is a fresh look into an underreported issue, while Erin Biel’s perspective on monitoring elections in Egypt takes a hot topic from the news and offers a reminder of the urgency behind it for the citizens of Cairo.

Our website has content updated daily, and young writers now have the opportunity to develop a “beat” by writing regularly online. The Globalist has also been able to enjoy the company of several guests so far this semester, including Sarah Stillman ’06, who shared insights about her work for the New Yorker, and Fred Strebeigh, professor of non-fiction writing at Yale, who led an inspiring workshop for Globalistas in January. As with all magazines, we could not exist without support from donors. Please consider making a contribution or purchasing a subscription by emailing Executive Director Jessica Shor (jessica.shor@yale.edu). With our online presence and increasingly large footprint on campus, I hope you will continue your faithful readership of the Globalist.

I am incrediby excited to present the third issue of the year: CURES. Yours,

Sanjena Sathian Editor-in-Chief, The Yale Globalist Production & Design Editors Jay Pabarue, Anisha Suterwala Managing Editor for Online Raisa Bruner

ON THE COVER:

Global health under the microscope.

(Ilustrations by Kate Liebman)

Pictures from CreativeCommons used under Attribution Noncommercial license. http://creativecommons.org/licenses/by-nc/3.0/

Director of Online Development Lauren Hoffman

Editor-in-Chief Sanjena Sathian

Executive Director Jessica Shor

Managing Editors Jeffrey Dastin, Nikita Lalwani, Charlotte Parker, Adele Rossouw

Publisher Jason Toups

Associate Editors Marissa Dearing, Cathy Huang, Diana Saverin, Emily Ullmann, Maggie Yellen Copy Editor TaoTao Holmes

Editors Emeriti Raphaella Friedman, Uzra Khan, Sibjeet Mahapatra, Angela Ramirez, Eli Markham, Alexander Krey, Sophie Broach

Directors of Development Conrad Lee, Margaret Zhang Events Coordinator Julie Kim

Editors-at-Large Rae Ellen Bichell, Jeffrey Kaiser, Catherine Osborn, Diego Salvatierra

www.tyglobalist.org

CONTENTS

TABLE OF CONTENTS 5

Spring 2 01 2 / Vo l. 1 2, Issue 3

8

6

19 24

FOCUS: Cures 16 | An Education

28 | Mining for Tuberculosis

A slow march towards sex ed curricula.

By Seth Kolker

Trying to shake a nasty cough.

By Ashley Wu

19 | Calling for Health

30 | The Next Generation

Cell phones are a game changer for health workers in Haiti.

By Angelica Calabrese

21 | A Village Scarred

AIDS lobbyists demand more.

By David Carel

33 | Letter from Brazil

China’s forgotten lepers.

By Jessica Shor

Healing mind, body, and spirit.

By Alexis Cruzzavala

23 | Letter from Orissa

34 | A Woman’s Right to Birth

What is the impact of voluntourism?

By Anisha Suterwala

The dangers of childbirth in Guatemala.

By Cathy Huang

24 | Milking the Tsetse for All its Worth

37 | A Conversation with Nathan Wolfe

A swarm of research surrounds Tsetse flies.

By Sophie Broach

FEATURES 6 | Treasures in the Forest A community fights big oil.

By Amelia Earnest

The life of a professional disease hunter.

By Rachel Brown

8 | Observing the Revolution How far has Egypt come?

By Erin Biel

10 | From Südtirol to Alto Adige

12 | The Commission and the King Bahrain under international law.

By Diana Reisman

An Italian town’s German heritage.

By Sophia Clementi

The Yale Globalist is a member of Global21, a network of student-run international affairs magazines at premier universities around the world.

6 FEATURE

the yale globalist: spring 2012

Pipes running along the Cananaco River transport oil through Ecuador’s Yasuní territory. (Earnest/TYG)

Treasures in the Forest An Ecuadorian indigenous group fights the oil industry as a battle is waged over the Yasuní territory.

I

n 1940, the shaman of the Huaorani tribe had a strange vision.

It told him of a foreign people that would soon come to his village. A few months later, the oil workers arrived.

The oil workers came to the tribe’s isolated home in eastern Ecuador with intentions of exploiting the land.

They had no way of knowing that the forest would fight back. The Huaorani speared the foreigners to death as a sign to the outside world: stay away. The call of oil, however, drowned out the message.

The oil workers returned shortly after— but this time, they brought guns. And so began the 70-year battle for the territory known as Yasuní.

At the convergence of the Amazon basin, the equator, and the Andes Mountains rests one of the most biodiverse—and contested—places on Earth: Yasuní National Park. The 2.5 million protected acres of wetlands and rainforests are home to one-third of all types of Amazonian birds, hundreds of rare species of mammals, reptiles, and fish, and more tree species in 2.5 acres than exist in Canada and the United

By Amelia Earnest States combined.

Yet some argue that the real treasure of Yasuní lies beneath its fecund soil.

Almost 900 million barrels of crude oil lurk below the forest floor, threatening the future of the flora and fauna of Yasuní. A tug of war between conservationists, colonists, oil companies, and illegal loggers is raging in this ecological hotspot, an interplay whose collateral damage may just be the indigenous peoples who call Yasuní their home.

Three tribes live in the Yasuní. The Huaorani, a hunter-gatherer tribe that has lived in the region for thousands of years, is the only one of the three to have made contact with the outside world. The other two tribes, the Taromenane and Tagaeri, remain in complete isolation deep within the heart of the forest. Surviving off of what they catch with blow darts, scavenge from trees, or have flown in by the government sporadically for them, the Huaorani are torn between embracing and rejecting the outside world that they are only now coming to understand.

After the Huaorani tribe’s initial and violent rejection of the oil industry’s pres-

ence, petroleum companies began to employ a more suble tactic: religion. After being permitted by the Huaorani warriors to live alongside the tribe, the Christian missionaries, sent by companies like Texaco, used the naïveté and newfound trust of the Huaorani to convince the part of the tribe living in Bameno, a small Huaorani settlement in block 16 of Yasuní, to relocate.

“Many died in this time,” said Penti as he flicked a bead of sweat from his brow with his three-fingered hand, a product of a hunting accident. As the present-day chief of the Huaorani in Bameno, Penti is collecting the history of the Huaroni and writing a book about their struggle to exist in a changing world.

According to Penti, there were only two types of health problems before the outsiders came—wounds and pain. Along with their drills and Bibles, the outsiders brought pox, diarrhea, fevers, and diseases that caused blood to fill the lungs. The Huaorani died not only from these diseases, but also as a product of their new land limitations. The oil company’s use of the Huaorani’s territory had caused relative

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www.tyglobalist.org “crowding” with the other two tribes, increasing the number of inter-tribe skirmishes. Meanwhile, additional tribesmen were lost to Christianity. Those who the missionaries converted moved away from the forest and into civilization.

Eventually, some of the Huaorani moved back to Bameno and restarted a traditional settlement that today consists of 92 people. On paper, Bameno is protected from illegal logging, encroaching oil exploitation, and other infringements by the 1979 establishment of Yasuní National Park, and by the government’s declaration of the park as a Biosphere Reserve and an “Intangible Zone.” The actual pragmatism of these bureaucratic measures, however, is dubious.

“They made this line to separate the Intangible Zone, but in reality, to us, this does not exist,” said Penti. Penti is attempting to encourage self-representation of the tribe by teaching the younger Huaorani Spanish (no documents are translated by the government into native Huaorani language) and purchasing a laptop computer, which he uses to advocate for his tribe.

With the present economic climate and a national economy that is 60 percent dependent on oil exports, Ecuador faces considerable pressure to develop untapped fossil fuel resources beneath Yasuní. Alexandra Almeida, director of the Ecuadorian environmental NGO Acción Ecológica, spoke of many instances in which the oil companies have taken advantage of Ecuador’s economic weaknesses: Shell’s purchase and refusal to release a patent for a hydrogen car, the disappearance of the short-lived governmental ministry, the Institute for Alternative Energy Sources, and the subsidization of oil within Ecuador. Measures like these keep oil as a crutch for a flailing economy. Although Yasuní National Park now enters its gauntlet, the fight to preserve the dignity of the territory is only a small part of a larger trend, as Ecuadorians attempt to break free from the deep and slimy hold of oil that has permeated every facet of Ecuadorian economics and politics.

In 2007, Rafael Correa, Ecuador’s current president, created “Project Yasuní, an Initiative to Change History” in order to prevent the exploitation of Yasuní’s oil.

This will preserve the forest and avoid the 407 million metric tons worth of carbon dioxide (CO2) emissions that would re-

sult from the consumption of the oil. The project is meant to provide an incentive to keep the oil underground by compensating Ecuador for its loss of profit with a sum of around $3.6 billion—roughly half the value of untapped crude oil—over a period of ten years.

This fund will come from a coalition of nations concerned with preserving Yasuní’s unique natural habitat. The money would be delivered either as a direct donation to the fund, or through the purchase of Yasuní Guarantee Certificates, papers that can be used in the European Union for carbon credits as a part of the cap-and-trade system. These certificates would ensure that a given amount of CO2 would remain trapped underground forever. The capital would then be placed into a trust fund to gain interest.

Despite the plan’s thoroughness and its initial warm reception in the international community, differing visions about the use of the fund debilitated initial fundraising efforts. Most foreign nations wanted assurance that the fund would be used only for environmental protection, while Correa wanted to use it as a piggy bank for domestic projects, the same way that the oil profits would have been utilized.

In an effort to expedite donations, President Correa declared that if the fund did not reach $100 million by December 2011, prospection of Yasuní oil fields would begin. Cornered by his own dramatic ultimatum, Correa conceded, guaranteeing that funds would only be used to develop green technologies. As a result, the $100 million goal was reached by the deadline, though the future of the project, dependent on the remaining $3.5 billion, is still hazy.

The Ecuadorian government’s instability adds to the complexity of the initiative’s fundraising. Although Correa has been in power since 2007, there were 10 presidents in the 10 years before him, two of whom served for only three days. This constant shifting of power has made foreign entities hesitant to invest in Ecuador, as they are unsure whether the next leader will uphold Correa’s promises.

And if the initiative fails? If the developed world does not bring enough money to the table, the fate of Yasuní will fall to a

referendum of the people of Ecuador. According to Paula Carreras, the head of the Programa de Reparación Ambiental y Social, a governmental ministry, if the referendum does not support the project, “Plan B” will go into effect. “Plan B” involves exploiting oil in two currently protected rainforest areas. “It’s no big deal really,” Carreras said.

“There are 160 [oil waste] pits inside Yasuní and around it.

‘Plan B’ involves two additional pits.”

Since the beginning of the oil industry’s presence in Yasuní, there has been a divide within the Huaorani. Some despise the pollution and foreign influences that oil companies have had on their territory; they desire only to live life as their ancestors did. But a surprisingly large faction sees the oil presence as an opportunity to earn wages and find outside food and medical support for the tribes. “They [the oil companies and the Huaorani] have grown and developed together, hand in hand,” said Carreras. The construction of two roads in the ’80s and ’90s near Huaorani territory has exacerbated this divide in the tribe and increased their dependence on oil company handouts.

But the key to preserving Huaorani culture, according to José Valdivieso, the director of the NGO Conservación y Desarollo, lies in avoiding that oil dependency by fostering sustainable income from farming and tourism, and choosing strong, skeptical Huaorani leaders who refuse to be used as pawns by oil corporations.

The shaman of Bameno sat with three other elders of the Huaorani tribe, the last relics of an undocumented way of life. His cheeks were streaked with the vivid orange powder of the spiny achiote fruit, his papery skin crinkled into a thousand valleys as he smiled serenely. “We are very old and will not be here if you ever return,” he said. “But we want to tell you that the Huaorani will always be here.”

The 2.5 million protected acres of wetlands and rainforests are home to one-third of all types of Amazonian birds.

AMELIA EARNEST ’14 is a Global Affairs major in Pierson College. Contact her at amelia.earnest@yale.edu.

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the yale globalist: spring 2012

Observing the Revolution

Thousands of women lined up along El Said El Bakry Street in Zamalek, Cairo, on Nov. 28, 2011, the first day of the Egyptian parliamentary elections. Many spent all day waiting in line to cast their vote. (Biel/TYG)

B

By Erin Biel

y the time I arrived at the women’s polling station, at around 9:30 a.m., the line was already winding down El Sa’id El Bakry Street in both directions and continuing along 26th of July Street.

Women had been waiting for three hours along these main thoroughfares of the Zamalek neighborhood in Cairo. Making my way around the crowd toward the front of the line, I found the source of the problem: No one was being permitted into the polling station. A few minutes later, I observed some minor movement. One of the Egyptian women in line told me dubiously that the guards at the polls wanted to let the elderly in first. It made no sense, then, that the group entering was composed solely of men, all clearly under the age of 55.

Four American classmates and I had been encouraged by our American University in Cairo professor, Dr. Saad Eddin Ibrahim, a prominent democracy activist, to perform “unofficial” election monitoring in Cairo on the first day of the Egyptian parliamentary elections. It was diffi-

cult as a foreigner to be granted an official election-monitoring badge. Egypt’s ruling military council, the Supreme Council of the Armed Forces (SCAF), had originally refused to let foreign organizations observe the elections, claiming that it would be an infringement upon national sovereignty. Ultimately they conceded, permitting the Carter Center, the National Democratic Institute (NDI), the International Republic Institute (IRI)—three American NGOs—and a spattering of other organizations to monitor the polls.

Unofficial observers, like me, were to tweet our observations via the “#egyelections” hashtag that bloggers and political activists used throughout the three month-long People’s Assembly, or Lower House, parliamentary elections. This hashtag, though important in notifying ordinary citizens about election wrongdoings, had no legal recourse to back it up. It was the judges stationed at each polling location who were responsible for identifying and addressing election violations.

As word of the illegal delay in open-

Men could wait in line for 15 minutes and be at the front of the line, ready to vote; women expected to wait all day.

ing the poll spread, I caught a glimpse of one of my female Egyptian friends further down the line. I approached her and told her about the men entering the polling station. She responded, “We blocked off our entire day to wait in line, so we kind of expected this.”

More disconcerting than the voting inefficiencies was the stark contrast between the women’s and men’s polling stations. There were about four men’s polling stations in Zamalek, compared to only one for women. Men could wait in line for fifteen minutes and be at the front of the line, ready to vote; women, like my Egyptian friend, could expect to wait all day.

I wandered over to one of the men’s polling stations along Mohamed Thakeb Street, just minutes away. Unlike the women’s polling station where I saw very few, if any, of the Muslim Brotherhood’s Freedom and Justice Party (FJP) members handing out flyers, the FJP had set up shop about 30 yards from the men’s polling station entrance. With three laptops perched on a standard card table, the men offered to help voters find their correct neighborhood polling stations. They wore blue lanyards around their necks with FJP badges that were uncannily (perhaps purposely) similar to those that the election monitors and press were wearing. Their party had

FEATURE 9

www.tyglobalist.org the strongest presence at the men’s polling station. At one point, a man jolted out of the queue to shoo away a twenty-something year-old FJP member who was holding up a campaign sign immediately next to the polling entrance, a violation of ethical campaigning rules.

A few minutes later, a man who spoke perfect English approached our group of five Americans and asked us amiably if we had any questions for him. He told us that, contrary to rumors I had been reading on Twitter, the ballots in Zamalek did contain official stamps. He claimed that the whole process was running like clockwork.

He went on to express his disdain for the FJP and all other Islamist parties, and also admitted that this was his first time voting, as he had never had the desire to vote in previous, less than legitimate elections. He told us of the widely held opinion that the elections, while important in their own right, did not mean a great deal to him in the greater scheme of Egypt’s transition. The more important task, he said, would be Parliament’s selection of a constitutional committee and the actual document that it produces. Many fear that the constitution’s drafting committee will have little, if any, power as a result of the “supra-constitutional principles” that SCAF has proposed. According to these proposals, the military would have veto power over the constitutional process and exclusive oversight of its own budget.

Concerns about SCAF’s power are real and well warranted. Since SCAF took over the government in February, there have been repeated reports of media censorship, sexual abuse of female protesters, and trials of civilians in military courts. It is imperative that SCAF grant Parliament the independence it needs in order to formulate a new constitution in which human rights are formidably enshrined. It is time for SCAF to go “back to their barracks”—a phrase commonly invoked in Egyptian society—and promptly.

There is a widespread belief that SCAF will attempt to retain some level of power even after there is an ostensible transition from military to civilian rule. After all, the military has served as the foundation of Egyptian politics since the fall of the Egyptian monarchy in 1952, and every president since has emerged from the top ranks of the armed forces.

Heba Morayef, a researcher for Human

A young boy looks on at the voters entering a men’s polling station in Zamalek, Cairo. (Biel/TYG) Rights Watch’s Middle East and North Africa program, emphasized SCAF’s wide involvement in decision-making: “They want to protect their immunities, protect their veto on defense-related issues, protect their control of the economy, and protect themselves against any investigations. What I think they want is to formally hand over power to a civilian president that they know they can work with.”

Many would claim that SCAF has already found politicians it can work with, even though the presidential race is not slated to begin until March. Perhaps unsurprisingly, given FJP’s presence at polling stations like Zamalek, “Islamists” won over 70 percent of the vote for the Lower House of Parliament. The Muslim Brotherhood’s FJP secured 47 percent, (235 of the 498 seats) of the Lower House, while the more hard-lined Al-Nour Party came in second with 25 percent (125) of the seats.

The “liberal” and secular parties, particularly the ones launched after the Revolution by the very youth activists who had been active in Tahrir Square, were relegated to single digit percentages.

These youth activists and other liberal Egyptians are concerned that the Muslim Brotherhood is too conciliatory toward SCAF. On January 27th, the oneyear anniversary of the Friday “Day of Anger,” these civilians clashed with FJP supporters. A crowd primarily composed of youth gathered in front of the Muslim Brotherhood’s stage in Tahrir, yelling antiSCAF chants. They were drowned out by

Quranic verses reverberating from the Brotherhood’s sound system.

While the Muslim Brotherhood has made public gestures in favor of women’s rights, a preservation of the Camp David Accords between Egypt and Israel, and freedom of religion, individual Brotherhood members have contradicted one another, and the Brotherhood’s true “platform” is nebulous. Nevertheless, high-level officials from the U.S. State Department have already engaged in regular dialogue with Brotherhood leaders, a clear acknowledgement that the United States accepts the results of the Egyptian elections thus far and is intent upon working constructively with the new parliament in the future.

Maintaining this ongoing dialogue with the Brotherhood is of particular importance as tension mounts between SCAF and the United States, attenuating the 30 year-old alliance between the two countries. Many of the same organizations that SCAF formally invited to perform election monitoring, such as NDI and IRI, now face criminal charges for operating without proper registration and receiving foreign funding. 43 pro-democracy workers, 16 of whom are American, are to be put on trial and none are permitted to leave the country. I shudder to think that perhaps one of the individuals I saw donning the NDI election monitor uniform of brown vest and blue lanyard in Zamalek could now be subject to these accusations.

The Egyptian Revolution is far from over. The Egyptian people have repeatedly demonstrated their dedication to having their voices heard, whether through month-long sit-ins or day-long lines at election polls. Now it is the point of seeing those demands through, and that will have to come via new political channels: the democratically elected Egyptian Parliament and, ultimately, the president. As these political figures take their seats in the parliament building, located just meters from Tahrir, it will be imperative that these representatives do not shut their ears to the calls for change that continue to emanate from the Square.

ERIN BIEL ’13 is a Global Affairs and Ethnicity, Race & Migration double major in Ezra Stiles College. Contact her at erin.biel@yale.edu.

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the yale globalist: spring 2012

From Südtirol to Alto Adige A region of Italy is caught between two languages, cultures, and allegiances.

By Sophia Clementi

E

veryone born within the borders of the boot extending into the Mediterranean Sea has the right to the same maroon-colored passport. The bold print reading “REPUBBLICA ITALIANA” above the golden laurel leaves surrounding the European star leaves no doubt as to the nationality that the document bestows upon its owner.

Everyone born in the northern Italian region of South Tyrol also possesses these passports. But in their case, the Italian print on the pages, the iconic Italian imagery, and the signature of the Italian government official do not tell all. Unmarked on their passports is the story of a historically Germanic region caught in the middle of two cultures, two languages, and two histories.

A walk through the heart of Bolzano, the South Tyrolian capital, reveals a Germanic city dating back to the Middle Ages.

Narrow pathways covered by stone arches lead to cobblestone squares buzzing with

Bolzano is surrounded by the Italian Alps. (Courtesy Creative Commons) the activity of lively outdoor markets.

The Waltherplatz - Piazza Walther - Walther Square surrounds a raised statue of Walther von der Vogelweide, a celebrated Middle High German lyric poet. Leaving the city center by crossing the Talferbrülcke - Ponte Talvera - Talferbridge, visitors immediately see the white fascist victory arch towering over the Siegesplatz - Piazza della Vittoria - Victory Square. This younger Italian part of town is home to huge buildings recalling classic Roman architecture. Stylized columns line covered sidewalks along the wide road connecting the old and the new Bolzano.

South Tyrol became part of Italy in 1919 after the Allied Nations promised Italy the right to annex the region, if the nation switched allegiances during the First World War. In the blink of an eye, a region which had belonged to Austria and the German tradition for over a thousand years became “Italian.”

Italy wasted no time Italianizing its newly gained Germanic territory. The government encouraged Italians to settle

The statue of Walther von der Vogelweide adorns the town square. (Courtesy Creative Commons)

in the region. It forbade the use of the German language, prohibited Germans schools, and altered German names, even if new Italian substitutes had to be invented. A common language serves as a bearer of tradition and a means to selfunderstanding. By taking away German, Italy sought to alter identity and assert authority over the Germanic population.

The South Tyrolians did not accept their fate easily. After years of protests, bombings, political struggle, and even a hearing before the United Nations General Assembly, they saw South Tyrol declared an autonomous bilingual province of the Italian state in 1972. Today, the region is held up as a successful example of peaceful coexistence in ethnic border regions.

Nonetheless, the cultural and linguistic differences that caused those protests have not disappeared. Both Italian and German are accepted as official languages in the region today. Of the 500,000 inhabitants of South Tyrol, 26.5 percent are native Italian speakers, 69.1 percent are native German speakers, and 4.4 percent speak Ladin, another local language. The larger cities are home to most of the Italian speakers, whereas more Germans live in the rural areas.

Zeitungen - giornali - newspapers in two languages are sold side by side at every newsstand; kanale - canali - television channels from Italy, Austria, and Germany can be viewed by pressing one button on a remote; Italian and German lieder - canzoni - songs are sprinkled between the typical American top 40 on the local radio station.

Everything illustrates the everyday ethnic multiplicities. But the German-speaking population still needs to master the Italian language to live their daily lives in South Tyrol. The Italian-speaking majority, on the

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www.tyglobalist.org other hand, does not necessarily require German fluency to operate in the region.

After 90 years in which four generations of German-speaking South Tyrolians have walked the fine line between assimilation and cultural resilience, the question arises: Will subsequent generations become more and more Italian?

T

he school system is one of the strongest indicators of the ethnic and cultural issues at constant play in the region. From kindergarten through the lyceum, the equivalent of high school, children must enroll in either German or Italian schools. Two separate ministries of education, one Italian and one German, oversee the parallel activities of two distinct academic systems.

Starting in first grade, instruction of the “other” language is mandatory in both Italian and German schools. The approach to this teaching varies by region and teacher. “At first, I attended German school in a town where about 75 percent of the population are native Italian speakers,” said Greta Unterlechner, a current high school senior. “Italian was taught like a second mother tongue.” But when she switched to her current German-speaking lyceum in Bolzano, she noticed that Italian became the foreign language. “I think the teaching methods strongly depend on the percentage of Italian-speaking families present,” she observed.

A South Korean-born student who attends a German lyceum also noticed a difference in the instruction of Italian during the progressing stages of her education.

“In elementary and middle school, Italian was taught like a foreign language in the sense that we would study vocabulary, grammar, and syntax,” she said. “In the lyceum on the other hand, it was completely different.

Our Italian classes basically mirrored Italian instruction at the Italian high schools.”

By the time students attend high school in South Tyrol, their schedules include the same number of German and Italian classes a week.

While native German speakers often learn to speak Italian fluently, not many native Italian speakers can claim fluency in the second language by the time they

(Courtesy Creative Commons) graduate, as the German language is often not highly valued in the Italian education system.

Many teachers are aware of the inadequacy of language instruction. Professor Bruno Klammer, who co-founded the Association of Private Schools in South Tyrol to obtain government funding for both German and Italian private schools in the region, recognizes the good intention behind extensive foreign language instruction. “There is, however, a surprising downward movement in the level of language competence in both ethnic groups,” he noted. He added that many students do not even acquire the bilingualism necessary to study at the Free University of Bolzano, a university that prides itself on trilingual usage of English, German, and Italian in all of its departments.

Most students choose to attend schools with members of the same linguistic group. In order to break down that language barrier, some families purposefully enroll their children in the other school system to guarantee dual fluency. Increasingly, Italian families are choosing to send their children to German schools because the rigorous German schooling system tends to enjoy a better academic reputation. Having taught at German lyceums for many years, Klammer explained, “Many forward-thinking Italian families enrolled their children in the German education system to ensure their German skills and provide them with greater chances abroad.”

The linguistic divide remains obvious, but national alliance has not remained equally unchanged.

History shapes national belonging, and in schools, it is a subject where differences between German and Italian instruction exist. While both schools include a special history of South Tyrol in their coursework, each also places greater focus on its own history.

After the Italian annexation of South Tyrol, strong support for rejoining Austria and the German nation dominated the part of the population lacking Italian patriotism. As time progressed, the German-speaking minority realized the hopelessness of a reunion with the Germanic nation. A minority began to strive towards self-determination. Even today, a small minority group wishes for an independent nation.

The simple truth is that most have long accepted the unchangeable identity of the region as part of Italy. The unique political situation continues to shape the self-understanding of German speakers. “We are German-speaking Italians,” one student whose family owns a popular hotel in the mountains above Bolzano declared. “Too much has changed in the past century for me to feel a strong bond to the Austrian or German culture,” echoed another student.

“Personally, I feel Italian.”

Today’s youth certainly did not grow up amidst the same rough reality of Italian oppression that shaped their grandparents’ youth. Still, some students feel no tie to Italian nationality. Alexa Ladinser, a 20-year-old pharmaceutics student who grew up in a rural area, shares this view because “[her] language and culture are not Italian.”

The concept of nationality is being blurred everywhere by increased human mobility and greater cross-cultural exchange. Unterlechner said, “I see myself as a part of the new, bilingual, and bicultural generation.” This duality may only grow stronger as today’s youth come of age in a globalizing world. South Tyrol will continue to shape its place within the Italian nation while retaining its Germanic history. Subsequent generations will become more “Italian” as time progresses.

But they will also retain their South Tyrolian identity, setting them apart from the rest of the boot.

SOPHIA CLEMENTI ’14 is an Ethics, Politics and Economics major in Saybrook College. Contact her at sophia.clementi@yale.edu.

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the yale globalist: spring 2012

The Commission and the King Bahrain lets international law decide its Arab Spring.

By Diana Reisman

T

he cavernous reception hall of Bahrain’s royal palace overflowed with qaffiyas, jalabiyas, and some Western attire. The press and political elite gathered to witness the Bahrain Independent Commission of Inquiry (BICI) present a 500-page, velvet-bound report to the King summarizing their findings and recommendations before the royal court.

The buzz of voices stopped and all stood as the King, Crown Prince, and Prime Minister took their places on the dais, across from the five members of the Commission. Chairman of the Commission Chérif Bassiouni addressed the King in Arabic.

“The Commission’s investigations revealed that many detainees were subjected to torture and other forms of physical and psychological abuse while in custody,” Bassiouni said solemnly. As Bassiouni reviewed the violations of international law committed by the state to suppress Arab Spring protestors, King Hamad listened quietly.

Most left the ceremony speechless, but some others could not stop talking. In this region of the world, the king serves as the mediator—and ultimate judge—of internal conflict. But for the first time in Bahrain’s history, a king yielded this authority and opened his government’s actions to international appraisal without the prompting of the international community. Bahrain blazed a new, and hopefully successful, trail of conflict resolution.

The island state of Bahrain, a former protectorate of the United Kingdom and current home to the U.S. Fifth Naval Fleet, sits between Saudi Arabia and Iran—and between modernization and tradition. The kingdom reflects the uncertain future facing much of the Middle East as it grapples with changing political tides and citizen demands. The ruling Al-Khalifas are Sun-

ni Muslims, yet some 65 percent of their subjects are Shiites. This has not made governing easy.

Despite becoming a constitutional monarchy in 2001, Bahrain has not reformed quickly enough to satisfy many of its citizens. The Arab Spring reached Bahrain in February of 2011. Only a few thousand Bahrainis gathered in the main roundabout initially, but the government responded quickly and with excessive force.

A young protester died. The next day, thousands more turned out for the victim’s funeral procession and clashed with security forces. Several deaths later, the protesters set up a permanent camp and some attacked Sunni communities and Sunni expatriate workers.

The Crown Prince tried to negotiate to no avail. The King then issued a National Safety Decree establishing martial law.

Some two thousand protesters, opposition leaders, and religious leaders were arrested. While police released many without charge, others were tortured, forced to sign confessions, and tried in special courts. Over the course of two months, 30 civilians and five security officers were killed.

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n the 21st century, no state is an island, as every revolt in the Arab Spring has demonstrated. Was the situation any different from the Arab Spring in other countries? Radically so: While Bahrain’s crackdown provoked the traditional outrage of human rights groups and engaged the attention of the United Nations, the King’s response was unique. Under mounting pressure, it was the King himself who created BICI. He ordered the Commission to recommend measures to prevent further rights abuses by the government.

“I think the role of the King was very important,” said Philippe Kirsch, a Canadian diplomat, BICI Commissioner, and

former president of the International Criminal Court. “It is no secret that there were different trends both in the government and in the opposition, some more open to reform and a dialogue than others.

It was a courageous act on the part of the King to put in the hands of an independent inquiry, in effect, a judgment of the way Bahrain authorities conducted themselves, thereby risking, and indeed receiving, serious criticism by the commission of some of that conduct.”

The BICI, assisted by a team of some fifty investigators, technical assistants, and consultants, spent nearly five months gathering information on the crackdown.

In the twenty-first century, no state is an island, as every revolt in the Arab Spring has demonstrated.

They interviewed victims, witnesses, and the accused and then analyzed the evidence in terms of international human rights law. The final report harshly criticized the government’s reaction to the initial peaceful protest. It admonished the security forces for excessive use of lethal force against civilians, for torture, and for securing forced confessions. It also criticized the government for violating its obligation to respect its citizens’ freedoms of expression, association, and assembly.

However, the report expressed the view that if the opposition had agreed to negotiate with the Crown Prince, it would have paved the way for significant political and socio-economic reforms and would have averted the violence that ensued.

Following the ceremony, the King and Crown Prince spoke to me, expressing their support of the recommendations.

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King Hamad (center) Crown Prince Salman (right) Prime Minister Khalifa (left). (Reisman/TYG) Some members of the opposition were guardedly optimistic as well. But a close advisor to the Court, who declined to speak under his own name, was more cautious.

While he described the BICI as “unprecedented” and a positive example to which future international commissions might look, he explained that if the Commission’s effort were to fail, this innovative form of conflict resolution would be dismissed as nothing more than an interesting but unworkable political experiment.

“There had been two main kinds of commissions of inquiry before: purely national commissions, which have existed for a long time with variable results, and a growing number of international commissions set up by international organizations, for example, in the UN system, by the Security Council and the Human Rights Council,” Kirsch remarked. “To my knowledge, BICI was the only one of its kind.”

Last year, the Human Rights Council proposed the UN Independent International Commission in Libya to investigate the violations committed by the Gaddafi regime and other forces involved in the Libyan Civil War. Coincidentally, two ex-

perts serving in that commission were members of the BICI. The Moroccan Equity and Reconciliation Commission was established in 2004 and conducted internally; it investigated the crimes committed during “the lead years” following Moroccan independence and compensated the victims. But the Moroccan experiment was composed of Moroccans only.

“BICI was unique in that it was a commission set up nationally but was exclusively composed of foreign, truly independent experts who were not susceptible to be influenced by any groups engaged in domestic politics,” said Kirsch.

And BICI was unique in other ways as well: It had neither the well-trained investigators of the Human Rights Council nor the power to recruit Bahrainis. The BICI had to hire its own external investigators—lawyers, judges, and former police officers—fluent in Arabic from elsewhere in the Middle East, but with little experience in the country and little in this field of work.

Often, the Commission had to respond to violations that were ongoing. A prisoner whom they interviewed in jail was allegedly being tortured. Midnight raids were still

being conducted. A trial was in progress with a defendant who had no lawyer. Accurate information became itself a critical factor. In the midst of violent conflicts, the truth is the first casualty. Competing halftruths further inflame the problem.

The Middle East is afire with demand for change. It is also a laboratory for ways to achieve it. The heady victory in Tunisia may be contrasted with the more uncertain futures of Egypt and Libya. The elephant in the room is Iran, whose violent revolution some 30 years ago has not brought democracy, human rights, or economic security to its people. In Bahrain, thanks to the King’s initiative, international law has been invited to produce an accurate record of the latest conflict and to outline a guide for the way forward. If government and opposition take advantage of this opportunity, Bahrain’s experience may prove to be a prime lesson in how to resolve internal conflict peacefully.

DIANA REISMAN ’14 is a History major in Berkeley College. Contact her at diana.reisman@yale.edu.

In America: The leading cause of death is heart disease, followed by cancer.

Illustrations by Kate Liebman

In the lowestincome countries in the world:

The #1 killer is lower respiratory illness, followed by HIV/AIDS. 34 million people were living with HIV/ AIDS in 2010, and 7 million were waiting for treatment. Of all maternal childbirth deaths globally, 99% are in the developing world. There are 3-5 million cases of cholera each year and several thousand people die from the disease even though 80% of cholera cases can be treated with oral rehydration salts.

Many diseases that devastate low-income countries have simple treatments. Is global heatlth equity the

CURE?

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the yale globalist: spring 2012

An Education The grassroots struggle for sex ed in Nicaragua.

By Seth Kolker

(Courtesy Alfred Ocampos)

Activist Alfredo Ocampos

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T

he glistening latex of the condom stretched thinner and thinner up Alfredo Ocampos’ arm until it turned white around his thick knuckles.

The condom reached from his fingertips to his elbow, covering his entire arm.

A dozen Nicaraguan teenagers standing in a half circle around Ocampos exchanged glances. The boys’ crossed arms and uneasy chuckles betrayed nervousness . The girls’ eyes wandered away from the scene and upward to the foliage of the matapalo tree. They seemed to understand the point that Ocampos was making, though: Any young man who refuses to use a condom because he is “too big to fit” is just plain wrong.

In Nicaragua, people have a lot of babies, and they have them young. Teenage girls in Nicaragua have the highest fertility rate of any country in Central America: According to a 2008 report by the Guttmacher Institute, half of Nicaraguan women had their first child before turning 20. More than half of those births were unplanned. And although data from the United Nations (UN) show that Nicaragua’s adolescent fertility rate has fallen over the past decade, more than one in 10 teenage girls still give birth every single year.

For the past two decades, Nicaraguans could not learn about sex in school legally.

In response to this policy, social activists like Ocampos have formed an extensive network of advocacy organizations. These private groups have sought to provide what they see as an essential education for Nicaragua’s youth, despite political and religious barriers.

The state did not always ban sexual education. In 1980, a socialist government came to power with Daniel Ortega as its president. Ortega lambasted the recently ousted Somoza dictatorship for keeping the country uneducated as a means to preserve power. In a highly publicized reversal of this policy, the new administration

put in place successful literacy campaigns across the country. Sexual education became part of the public school curriculum as well.

Dr. Auxiliadora Marenco designed the first of Ortega’s reform programs. “I started to teach [sexual education] in the psychology department of the University of Central America, and that was the first time it had ever been taught in Nicaragua,” she said. Soon after, the Ortega administration introduced more basic sexual education programs to the country’s primary and secondary schools as well.

But the new developments were shortlived. By 1990, discontent with the Sandinista government prompted a woman named Violeta Chamorro to run against Ortega.

Chamorro beat Ortega and instated a new conservative government that appealed directly to the Catholic Church.

At the time, Marenco helped run the government’s program for youth. Doing so required a special grant. “When the government of Violeta Chamorro won, the Ministry of Health took [our funds] and put them who knows where. What matters is that the program disappeared. Everything that had to do with sexual education, they ordered burned,” Marenco said.

No other sources could confirm Marenco’s allegation that the new administration took to extremes such as burning books and pamphlets on sexual topics.

Regardless, all sexual education in public primary and secondary schools stopped when Chamorro came to power.

Soon after, family planning in Nicaragua disintegrated even further. The Guttmacher Institute reported that the rate of unplanned adolescent births jumped from 34 to 54 percent between 1998 and 2001 alone, and condom use remained excep-

Teenage girls in Nicaragua have the highest fertility rate of any country in America: according to the Guttmacher Institute, half of Nicaragua’s women had their first child before turning 20.

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tionally low. Even leading figures struggled to get their voices heard: Marenco retreated back from the front lines to a post at her old university, which she still holds today.

Yet Nicaraguans did not sit idly by during the 1990s. Even as government officials buckled under pressure from religious leaders to keep sexual education out of schools, independent programs began to take root.

Most of these groups fought for women’s rights, gay rights, or an end to domestic violence. But in order to achieve these goals, the activists focused their efforts on teaching young people all about sex. It was in this newly privatized movement that advocates like Ocampos found their calling.

Ocampos is unconventional and bold.

Disgusted by how hierarchies “tear apart” social relationships, he refuses to be called the formal “usted” and asks that everyone refer to him as “tú” or “vos” instead. He can rattle off acronyms of dozens of local and national sexual rights organizations, but he especially loves talking about a group called Young Agents of Change (YAC).

Ten years ago, Ocampos co-founded YAC in the province of Matagalpa. His organization focuses on preventing violence against women and promoting civil rights for Nicaraguans who are gay, lesbian, bisexual, or transgender. Like the women’s groups of the 1990s, YAC tries to make comprehensive sexual education programs a reality for the country’s youth as a way to improve Nicaragua’s sexual climate from the ground up.

Ocampos pulls condoms over his arm in rural villages, distributes literature on pregnancy prevention methods, and answers questions about physical abuse in relationships. His efforts do not stand alone: Some organizations promote safe sex by having men face off in condom inflation competitions. Others pass out condoms from ubiquitous “Eskimo” ice cream carts. And educational pamphlets are becoming more available every day Few scientists have taken up Ocampos’ fight. Still, some researchers hope to learn whether the

“Everything that had to do with sexual education, they ordered burned.”

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the yale globalist: spring 2012

A pro-condom public service announcement taped to a toilet in León, Nicaragua reads, “Because I love me and I love you, we always use a condom!” (Kolker/TYG) efforts of decentralized organizations such as Ocampos’ are really working. In 2000, a group of European and Latin American researchers reported in The Lancet that leaving condoms in motel rooms in Managua increased the frequency of condom use during sexual encounters. But leaving pamphlets promoting sexual health actually lowered that frequency.

Dr. Danilo Medrano was the Nicaraguan sexual health expert that the research team brought on board to provide local know-how. “Maybe they don’t show up to read, but only to have sexual relations,” said Medrano of the motels’ clients. He admits that changing sexual behavior through education is a challenge: It goes against a long history of cultural machismo that discourages safe sex and fails to condemn sexual violence.

And he claims that Nicaragua’s single biggest morally influential institution, the Catholic Church, has never addressed these topics.

Yet Medrano remains optimistic that real change is still possible. He turned his

pamphlets into posters and hung them on motel walls, and that innovative presentation successfully increased condom use.

“We’ve been able to achieve some changes in the law. For example, domestic violence is now actually a crime in the penal code. Even the conservative culture of the Church has been affected,” he said. Some sermons now tackle controversial issues such as machismo and violence against women.

In 2008, the UN partnered with Nicaragua’s Ministry of Education to develop a comprehensive pamphlet on sexual health for distribution to schoolteachers nationwide and use in the classroom.

But within days, the Catholic Church was in an uproar over the documents. “[The government] withdrew the materials even before they could reach teachers’ hands,” said Marenco. A new pamphlet took its place, one that Marenco called “more moderate” and that the Church was willing to accept. It explained the biological basics of sex but was silent on all major hot-button topics—homosexuality, virginity, and abortion.

Changing sexual behavior through education is a challenge: It goes against a long history of cultural machismo that discourages safe sex and fails to condemn sexual violence.

Still, misunderstandings about these controversial topics are what lie at the very root of Nicaragua’s sexual health crisis, according to activists like Ocampos.

He teaches comprehensive sexual education as a means to ending sexual violence and intolerance; Marenco does it to help couples see sex as healthy and pleasurable. Even if students learn about the biological mechanics of sex, their conceptions of these deeper social issues might remain unchanged.

“Now, the old government and all that was done in the ’80s has been left in history,” said Marenco. Since Ortega rose again to the presidency in 2007, this time as a more moderate candidate, he has not heralded any major developments. The current administration still maintains close ties to the Catholic Church and provides public sexual education only grudgingly.

In 2008—the same year as the scandal over the education pamphlets—a total ban on abortions took effect in Nicaragua.

School instructors now teach the biological basics of sex to Nicaragua’s youth, and adolescent fertility rates are trending downwards. But the tough questions about sex are still being addressed only through spectacle.

Back in that little community, under the matapalo tree, the half circle of young Nicaraguans huddled close around Ocampos as he delivered his concluding speech.

The students were interested to learn. But after years and years of setbacks in their education, learning through this kind of hit-and-run performance is simply not enough.

The group broke and a dozen teenagers turned to go home, back to lives of schoolwork and fieldwork. Some of them seemed quiet and reflective. But already, a few of them were cracking jokes about the presentation, laughing off its lessons.

Ocampos hopes to return to this community next year. When he does, chances are that at least one of these kids will have a new baby of his or her own. Maybe Ocampos will have better luck with that one.

SETH KOLKER ’14 is a Global Affairs major in Jonathan Edwards college. Contact him at seth. kolker@yale.edu.

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Calling for Health Cell phones in Haiti are pushing progress in public health.

By Angelica Calabrese

Doctor and nurse testing an infant for HIV with the Caris Foundation’s dried blood spot test. (Calabrese/TYG)

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n a bright, whitewashed nurse’s office overlooking Port-au-Prince, a cell phone trills loudly, and a nurse promptly answers.

Marie-Claire*, a young HIV-positive mother with an HIV-positive child, is calling with a question about her child’s medication.

Her voice crackles over the phone. The nurse responds to her questions. As the conversation ends, a sob interrupts MarieClaire’s Creole and she begins to cry––not out of despair or hopelessness, but rather out of gratitude for something small, basic, and increasingly ordinary: a cell phone.

Just a few months before, such an in-

teraction––let alone such a prompt reply to a medical question––would never have been possible. But the growing use of cell phones across Haiti has made communication between health workers and patients much faster and easier. Now, instead of losing hours navigating Haiti’s under-developed transportation systems and scaling its mountainous landscape, patients, community health workers, nurses, and doctors can access one another promptly via cell phone.

Mobile phone usage has grown rapidly in Haiti in recent years. Pay-as-yougo credit plans, increasingly widespread coverage, and handsets equipped with SIM cards for as low as five dollars have

allowed mobile phone usage to increase exponentially over the past six years.

This phenomenon has been seen in lowincome countries around the world, and governments and health organizations have seized the opportunity presented by this expanding mobile infrastructure to move healthcare out of hospitals and city centers and into villages and the hands of local people. Although most agree that there has not been enough proper scientific evaluation quite yet, pilot programs have shown promise in countries like South Africa, Ghana, Uganda, and Malawi.

Organizations such as the International Federation of Red Cross and Red Crescent Societies (IFRC), the Caris Foundation,

20 FOCUS: CURES 20 Partners in Health (PIH), and Health eVillages have followed in the footsteps of those across the Atlantic and are now beginning to execute such programs in Haiti.

PIH and Health eVillages have implemented what are known as patient-facing programs, which focus on the mobile technology used by community health workers (CHWs). Among CHWs, cell phones are used as guides for delivery of care, reporting devices, and means of communication with supervisors.

Organizations like IFRC and the Caris Foundation have chosen patient-based programs, which instead provide the patient with the technology. IFRC has focused on providing information to community members through their mobile phones. They partnered with telecommunications company Voilà to develop the Trilogy Emergency Relief Application (TERA), which allows IFRC to send early warnings about hurricanes and educational messages about domestic violence, sanitation, and cholera prevention via SMS to at-risk peoples.

The Caris Foundation has integrated a patient-based program into everyday treatment. Instead of working only with the patients who already own cell phones, and in the hopes of more patient contact and greater adherence to medication, Caris has begun to provide cell phones to individual mothers, like Marie-Claire. In Haiti, Caris nurses support testing and treatment of pediatric HIV. The organization works with HIV-positive mothers who have undergone Mother to Child Transmission Prevention (MTCTP) and tests their infants shortly after birth. If the infant tests positive despite MTCTP, treatment must begin as soon as possible.

Treatment requires a constant supply of antiretroviral medication, and frequent appointments are necessary to keep the medications up to date. If children do not take the drug regularly, they can develop resistance, making the disease much more difficult to control. Moreover, nonadherent patients who miss appointments or don’t pick up their ARV medication can be challenging to track down, especially if they lack a cell phone or a fixed address.

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n mid-2010, Caris began to give cell phones to such unreachable and often non-adherent mothers. Since then,

the yale globalist: spring 2012

contacting and treating patients has become much simpler. Each phone is programmed with the numbers of the local Caris Foundation office and the patient’s health provider, so when mothers have questions, they call the Caris nurses with their cell phone, and Caris nurses can call the mothers regularly with appointment reminders. Nathaniel Segaren, M.D., director of Caris’s pediatric HIV program in Haiti, envisions the new initiative as “a holistic method of integrating the HIV care system with the individual, so that the actual patient has access to health providers directly and health providers have direct access to the patients.”

But patient-based programs such as those implemented by Caris and the IFRC face two main challenges: illiteracy and lack of electricity access. Many of the most successful patient-based mobile health innovations, such as the SMS-based patient check-up program Project Masiluleke in South Africa, rely on patient literacy. However, in South Africa, the literacy rate is 89 percent, while in Haiti, the literacy rate hovers around 50 percent, meaning that many of the people receiving the IFRC/ TERA text messages may not even be able to read them.

Access to electricity poses another obstacle to patient-based programs. According to the 2007 Haiti Energy Sector Development Plan released by the Haitian Ministry for Public Works, Transportation and Communications, only 12.5 percent of the Haitian population has access to electricity, and the 2010 earthquake likely decreased this figure—which means that keeping cell phones charged and in working condition can be especially difficult.

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ue to these concerns as well issues with confidentiality and reliability, organizations like PIH and Health eVillages find it more appealing to focus on patient-facing programs via community health workers. With such employees, organizations can even provide solar powered sources of portable electricity.

But working with CHWs is not perfect. Jonathan Payne of PIH pointed out that adding cell phones to the communication interactions between CHWs and their supervisors illuminated some of the problems with the supervision and management of the CHWs. Since most inter-

national aid organizations are funded for direct patient care, it is not uncommon to find too few supervisors and managers to oversee the CHWs, what Payne refers to as “thin middle management.” Patricia Mechael, Ph.D., Executive Director of the mHealth Alliance, made a similar observation, affirming that “technology is only as good as the systems it’s supporting.” If there are inefficiencies in those systems, there will be inefficiencies in the use of the technology.

As Josh Nesbit, CEO of Medic Mobile, cautioned, whether patient-facing or patient-based, mobile technology “isn’t a solution. It’s a tool that becomes a solution when people use it effectively and it changes outcomes.” Payne added that although mHealth innovations have great potential to improve remote diagnostics, clinical decision support, and surveillance activities, accomplishing any of these goals effectively requires a large investment into electronic medical records, pharmacies, and lab systems. The current infrastructure in Haiti may not have developed enough yet to support effective implementation of such programs.

The responsibility thus falls on the government. “Governments need to invest their own resources in mobile health as a public health program,” Mechael suggested, citing Rwanda as an example. But between the recent cholera epidemic, reconstruction efforts after the earthquake, and President Martelly’s focus on education, government-sponsored mobile health does not appear to be coming anytime soon.

Women like Marie-Claire find cell phones a blessing. Marie-Claire is young and has not yet disclosed her or her child’s status to her family. When she finds herself with no one to turn to, she often calls the office for the nurses’ help and advice.

Her cell phone allows her to care for her child more effectively, even letting her set an alarm to remind her of her child’s regular medication times. She feels supported and, “encouragé,” encouraged.

ANGELICA CALABRESE ’14 is a Global Affairs major in Morse College. Contact her at angelica.calabrese@yale.edu. *Name has been changed upon request.

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A Village Scarred Twenty-five years after leprosy was officially eliminated in China, there have been few attempts to address poverty in former leprosy colonies.

By Jessica Shor

W

ang Zhidi sat on the dirt terrace outside his mountaintop home in Ta’erdi, gazing over the river that cuts through the verdant valley below. The sun shone on his two chickens, picking through the chili peppers he had set out to dry on the ground. The only sound was the whisper of the summer breeze that cools this pocket of rural Sichuan. Throughout southwestern China, there are hundreds of bucolic villages like this one, nestled amongst hills dotted with mud huts and farmers tending their crops.

But Wang did not move to Ta’erdi for the clean air and pristine landscape. He does not live, as so many people in China do, on revered ancestral lands, passed down through his family for generations.

Instead, government health authorities sent the 63-year-old to Ta’erdi to be quarantined from the healthy population when he contracted leprosy more than 30 years ago. Although he was cured of leprosy in the 1980s, Wang claimed he has left the village fewer than a dozen times since he arrived, and he ekes out a living farming corn, cabbage, and sweet potatoes to eat, and tobacco to sell. Earning 3,000 Yuan each year—about $500—Wang supports himself and two orphans whose parents died of leprosy several years ago.

“Life here is very difficult. It is often bitter,” Wang said. But he doesn’t need to say it. Ta’erdi’s steep paths and eroding soil, Wang’s gnarled hands, the limping gaits of other villagers: They tell the story of China’s 605 leprosy villages for him.

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eprosy first appeared in China more than 2,500 years ago, and it has been feared and stigmatized for just as long. This stigma stems more from the

Wang Zhidi (right) has had leprosy for over 30 years. (Shor/TYG) physical disfigurement leprosy causes, most notably skin lesions and deformed extremities, than from high levels of contagion. Roughly 95 percent of humans have a natural immunity to the disease, and if it is caught early enough it is curable for the five percent who are susceptible.

Prior to 1949, foreign missionaries administered leprosy hospitals in China.

When Mao Zedong came to power, however, government health authorities took over efforts to record and treat cases of leprosy. They took a characteristically harsh, systematic approach that established leprosy villages like Ta’erdi and exiled infected individuals from cities to the countryside.

Though exact numbers of village residents are unavailable, 475,000 cases of leprosy were reported in China between

1950 and 2000. Southwestern provinces like Yunnan, Guizhou, Guangxi, and Sichuan––impoverished, sparsely populated, and inhabited largely by ethnic minorities––became prime locations to quarantine an estimated 200,000 leprosy patients.

For decades, the government forbade the patients from leaving these villages.

Wang, the Ta’erdi resident, claimed that this is how he arrived at his scenic yet isolated home. Before he contracted leprosy, he was married, had two children, and worked in a small coal plant. “I was just your regular, common person,” he said.

“I worked, raised a family, participated in political exercises, and had a normal life.”

But in 1977, Wang got sick. Patches of his skin became rough and discolored, and he felt weak. He attributes his leprosy to something he ate, but leprosy cannot be

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transmitted through food. More likely, he contracted leprosy from somebody close to him. When health officials conducted an annual survey of his work unit and discovered his leprosy, they did not explain to him the nature of his disease, but ordered him to Ta’erdi nonetheless.

“When I arrived, there was nothing here,” Wang explained, sweeping his gnarled hand across the valley before him.

He estimated there were fewer than 50 people living in the hills around Ta’erdi, mostly members of the Yi ethnic group.

“They didn’t help us much, and the government didn’t give us anything. No wood to build houses, no farm tools, no seeds.”

Wang was relatively lucky: Five years after his diagnosis, health authorities cured Wang through multi-drug therapy. Yet for residents, life in the village was—and still is—a daily struggle to produce enough food to sustain themselves, an undertaking complicated by their physical disabilities from the disease.

Min Zhou, a researcher at the Chinese Academy of Medical Sciences’ Department of Leprosy Control, explained that the initial push to cure leprosy largely succeeded. “Health workers in all of the counties with leprosy used the drugs.

Rural or near urban areas, rich or poor, either way. Basically all the leprosy patients were cured,” he said. Both Min’s research and World Health Organization surveys conclude that at the national level, leprosy now occurs at a rate of less than one infection per 100,000 people; China has reached the official level of elimination. Today, treatment efforts have ended and residents of leprosy villages have the right to come and go as they please.

the yale globalist: spring 2012

in villages like Ta’erdi, where the steep hillsides and narrow paths render even walking an arduous task.

For assistance, Ta’erdi’s disabled residents rely on younger relatives, but those individuals face their own unique set of problems.

Wang’s young neighbor, for example, has an infant son who suffers from a cleft lip.

“I tried to get treatment,” the neighbor, Su Kaiwen, said. She recalled the two-hour hike, half-hour boat ride, and six-hour drive on unpaved roads required to reach the closest hospital.

“But once I got to the doctor, he said the surgery would cost 3,000 Yuan. That’s how much income I earn in a year, so I couldn’t afford it.” Among other Ta’erdi residents, stories abound of births on mud floors, untreated broken bones, and new outbreaks of leprosy in the village.

It is not only the difficulty of travel that keeps Ta’erdi residents in the village and away from medical care, but also the massive social stigma that leprosy carries in China. The visible scars of the disease make blending in difficult.

“People stare at you,” Wang said, describing his trips out of Ta’erdi. “Shop owners won’t hand goods directly to you, and little kids point.” This shame has prevented Wang from seeing his wife and children in the 30 years since he arrived at Ta’erdi.

“They got rid of our leprosy, but then they abandoned us,” says Wang. “We’re still sick.

All of us are still sick. But there’s no help here.”

“People stare at you. Shop owners won’t hand goods directly to you, and little kids point.”

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ut official elimination has not cured Ta’erdi of its ills, and official permission to reenter cities has not made it easier to leave.

In her research, Min found that roughly 71 percent of residents in China’s leprosy village—more than 13,000 people—suffer from physical disabilities. Half of those disabilities are so severe that the individuals cannot care for themselves, especially

Ta’erdi are served primarily by NGOs, which provide medical supplies, preventive care, and treatment from volunteer doctors. They implement basic development projects as well. “We see the same thing over and over,” explained Yuek Ming Poon, the China Country Director for Leprosy Mission I n t e r n at i o n a l , the world’s largest NGO focusing on leprosy treatment.

“Better transportation has improved quality of life somewhat, but otherwise we’re the only support many of these villages receive.”

Residents of China’s leprosy villages are well aware of the opportunities in cities that elude them as social and economic barriers keep them in the hills. While a liberalizing economic climate has raised hundreds of millions of Chinese out of poverty, gaps in income and services between urban and rural areas have increased sharply in recent years. Those disparities spark an estimated 500 protests each day across China.

Wang does not envision Ta’erdi becoming a site of protest, since residents face daily struggles just to survive. That lack of political incentive may be why the government has ignored these villages after the initial leprosy elimination effort. Whatever the reason, Wang sees the current state of places like Ta’erdi as indicative of broader government failures.

“I had a normal life, but the government put me here because of my disease, and now I’m stuck. Now the kids also grow up stuck here.” He pointed to his chickens, which have abandoned the drying chili peppers in favor of grubs in Wang’s sweet potato field. “I have two chickens, some potatoes, and three mouths to feed. Now we need the government again, but where is it? It’s not here.”

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ike most Ta’erdi residents, Su and Wang receive government welfare stipends, but they total less than five dollars per month. And whereas health officials visited the village twice a month during the 1980s and 1990s, Ta’erdi has not received a visit from government healthcare providers in more than two years.

“They got rid of our leprosy, but then they abandoned us,” said Wang. “We’re still sick. All of us are still sick. But there’s no help here.”

Ignored by the government and cut off from population centers, villages like

JESSICA SHOR ’13 is an Anthropology major in Ezra Stiles college. Contact her at jessica.shor@yale.edu.

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www.tyglobalist.org

Letter from... Orissa What is the worth of international volunteers?

By Anisha Suterwala

U

ma, one of the nurses, hip checked me as she left the operating theater. Housed on the second floor of Kalinga Eye Hospital and Research Center, the theater was cool and bare, with a faint scent of rubbing alcohol in the air. Twin beds sat next to each other, the gap in between filled by an operating microscope. A surgeon sat at the head of the beds, as nurses like Uma brought in a train of elderly patients for cataract surgeries. Each surgery went quickly—in

Unnervingly, the overwhelming attitude toward volunteers among the nurses was one of shy deference, as though we had some sort of miracle cure. under eight minutes. Uma’s eyes twinkled.

“You are standing for too long,” she said.

“There are too many mausas and mausis today. You will not be too tired to do English in evening?” I laughed. It was true that the day’s outreach trip to the villages had brought back far more mausas, elderly patients, than usual, but I would never be too tired to teach Uma English.

I spent two weeks at the hospital as a volunteer for Unite for Sight (UFS). UFS, an NGO, funds the cataract surgeries that the hospital performs. This partnership fits into a new model of development, one created in response to criticisms that NGOs provide temporary, unsustainable fixes. A four-story hospital, KEHRC provides ophthalmological care, free and for small fees, to people in Dhenkanal, Orissa, India, and surrounding rural areas. Every

few days, the hospital sends an outreach bus with nurses and an optometrist to the villages surrounding Dhenkanal. The hospital holds eye care camps, in which it screens the elderly in villages for cataracts. Those identified with cataracts are taken back to the hospital, where they undergo surgery in one eye, spend the night recovering, and are driven back to their respective villages the next morning.

My role at the hospital was an undeserved one, that of a supervisor. For purposes of accountability, one or two UFS volunteers must stand in on the operations, signing off as each occurs. I, the untrained, undergraduate volunteer, felt presumptuous acting as an overseer to a well-qualified surgeon. Unnervingly, the overwhelming attitude toward volunteers among the nurses was one of shy deference, as though we had some sort of miracle cure. I was also––to the delight of many of the nurses––the only Indian volunteer in my group, and although because of this they accepted me much more quickly than they did my conspicuously white counterparts, I also felt hyperaware of my own Americanisms. Often I would find myself looking blankly at them when they made religious or cultural references. I ate my rice with a fork.

W

hat I did at Kalinga was not medical voluntourism; volunteers were strictly (and sensibly) not allowed to engage in any kind of medical practice. It was in a sense, however, development voluntourism. Most volunteers spent only a short amount of time at the hospital, working on largely self-designed administrative projects that rarely transferred effectively to incoming volunteers, like editing hospital literature and consolidating medical reports. I could say that because the hospital needed us only for such minor tasks, the sustainable development partnership between Unite

The operating theater at Kalinga. (Suterwala/TYG) for Sight and Kalinga has accomplished its goal of empowering the community, but I cannot help but feel that we would have been more useful if we had medical training. The lack of training meant that we made little impact on the actual patients of the hospital. They flew under our radars, coming in for surgeries, and perhaps murmuring a word or two in Oriya to us, before returning to their home villages.

Who we might have touched, I think, are the nurses. When I think of the hospital and my time there, I think mostly of Uma. I spent my evenings struggling through “learn English from Hindi” books with her, trying to improve her English.

She wants to master English, which she already speaks reasonably well, so that she can become a teacher in the nearby town of Calcutta and establish a career before she marries. The caveat: Other than the volunteers who come through, she can find no one in her small town to teach her. I could help her because I speak passable Hindi. Most of the other volunteers did not. But my two weeks there were not nearly enough. KEHRC makes a lasting impact on the community in providing eye care. UFS makes a lasting impact in supporting KEHRC. But we volunteers—are we ever around long enough to make any impact at all?

ANISHA SUTERWALA ’14 is an English major in Timothy Dwight College. Contact her at anisha. suterwala@yale.edu.

Milking t h e Tsetse A strange parasite and its insect host have drawn research attention to a neglected disease, but some say victims might never benefit.

Courtesy Goeffrey Atardo

for

All its Worth

by Sophie Broach

A

soft buzzing filled the air in Yale’s tsetse fly insectary, as Brian Weiss heated a pool of cow blood on a metal tray. The warm, humid room mimicked the climate of the tsetse flies’ native African range, where they feast on the blood of live cattle and humans. Weiss, an associate research scientist, carefully fed the flies through a whitish synthetic membrane, and within seconds, their bellies swelled into round scarlet beads.

Weiss hopes that the lab-bred flies in this small, white room will one day yield high-tech ways to fight sleeping sickness in the jungles and savannas of Africa, where the deadly disease ravages communities. But others argue work like his siphons funding and attention away from old-fashioned eradication techniques, such as fly trapping, that could be saving lives today.

From a research standpoint, though, the tsetse fly is one of the most fascinating insects around. Only three in 10,000,000 known insects reproduce the way they do: with live births. “The mother tsetse fly ovulates into a uterus where she supplies [the larva] with milk––like a mammal,” Weiss said, grinning. Tsetse fly milk contains many of the same proteins as human milk and transmits tsetse flies’ unique symbiotic bacteria directly to the young.

Tsetse flies often harbor parasites known as trypanosomes, which rival their hosts in sheer bizarreness. As one of the most ancient eukaryotes, trypanosomes exhibit fascinating variations in their metabolism and genetics.

Trypanosomes also cause sleeping sickness.

“It’s a terrible disease. If it’s not treated, it’s 100 percent lethal,” said Weiss, breaking out of his usual cheerfulness for a moment. Clad in a t-shirt that spelled out “Hawaiian Style” in loopy, colorful font, Weiss seemed an incongruous figure to describe the gruesome effects of the disease.

Once the parasites cross into the central nervous system,

patients experience insomnia, overwhelming daytime drowsiness, and neurological deterioration. Some become violent or suicidal, and finally, all slip into a coma from which they never wake. The World Health Organization (WHO) estimates some 30,000 people suffer from the disease today, and 60 million more may be at risk.

Sleeping sickness affects people exclusively in rural Sub-Saharan Africa. For this reason, it falls into the category of neglected diseases: those tropical diseases First World companies cannot turn a profit from treating. If sleeping sickness affected people in the developed world, Weiss thinks we would already have a cure. “Pharmaceutical companies couldn’t care less about producing drugs or vaccines for [sleeping sickness] because there’s no money in it,” he said.

David Molyneux, a professor of tropical health sciences at the Liverpool School of Medicine, however, doesn’t think we need a new drug or vaccine to eliminate sleeping sickness from Africa. Over the last 50 years, Molyneux has studied trypanosomes and advised health organizations on control programs both from his home in Britain and from West Africa.

“I apologize for being sort of a Luddite,” Molyneux told me at the beginning of our conversation. “It’s just staggering that people don’t apply what we know already. It’s amazing that people have a very narrow view that only high-tech can work,” he said. He advocates simply screening at-risk populations and limiting tsetse fly populations with insecticides and traps.

Molyneux estimates that researchers now know more about the molecular biology and biochemistry of trypanosomes than about any other non-mammal cells, but this deep knowledge has rarely translated into new ways to fight the disease. If all the money spent on high-tech research in labs like the one at Yale had been used for simple, short-term ways to limit sleeping sickness on the

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ground in Africa, Molyneux said, the disease would no longer exist. He and a small but vocal group of other scientists find the funds spent on research shockingly disproportionate to the funds spent on easy, proven control strategies.

Molyneux points out that French, British, and Belgian colonizers nearly managed to eliminate sleeping sickness from vast swathes of Africa by screening vulnerable populations and trapping tsetse flies. In the early 1900s, the Portuguese completely eradicated sleeping sickness from the island of Principe by enlisting agricultural workers to wear backpacks covered in sticky flypapers. When the colonial powers fell in the 1960s, so did the health programs they had established, and sleeping sickness resurged.

Joseph Ndung’u has replicated earlier colonial successes in modern day Kenya.

He served as director of the Kenya Trypanosomiasis Research Institute from 1995 to 2004, and when he first began, Kenya was reporting over 100 new cases of sleeping sickness per year. “By 2004 we were hardly reporting any cases of the disease,” he said. Ndung’u largely credits bands of motorcycle-riding mobile screening teams for the decline.

Concern for fighting sleeping sickness rarely foregrounds research on trypanosomes and tsetse flies. Rather, the fascinating biological characteristics of the parasite and fly draw scientists. But simply studying the organisms that cause the disease does not mean the research will ever affect sleeping sickness control strategies. “There’s no relationship between a trypanosome in a mouse at Yale… and the realities of stopping sleeping sickness in Africa,” insisted Molyneux. “And the people who are doing this research have probably not set foot in Africa anyway,” he said sneeringly.

Weiss has visited Africa, but only on a family vacation. He candidly described the path that led him to study tsetse flies, which had nothing to do with suffering Africans. “Since as long as I can remember, I’ve been interested in insects. Since I was a kid I was playing with bugs and ants,” he said. Weiss eventually decided to pursue a career in entomology. “And I was advised early on that if you ever want to prosper… you should consider working with some sort of insect that spreads disease. Granting agencies are more interested in curing

the yale globalist: spring 2012 malaria or sleeping sickness than studying the flight patterns of a butterfly,” he said.

One scientist, who edits medical journals on tropical diseases and wished to remain anonymous, has found researchers often overstate the practical implications of their studies on trypanosomes and tsetse flies in grant proposals.

Meanwhile, he, like Molyneux, does not see research into new treatment development as “a major priority.” “Some of the figures we see quoted in proposals are outrageous.

It’s a bit worrying,” he said. Some exaggerate the number of new cases reported each year or overemphasize the toxicity of available drugs to make their cases for funding seem more urgent,” he said.

“Most of the drugs needed to treat [sleeping sickness] are extremely toxic, and I think five percent of people who are treated die from toxicity of the drugs before the parasites can get them,” said Weiss. The medicine Melarsoprol, to which he was referring, contains both arsenic and antifreeze, and the death rate does indeed fall somewhere between 5 and 10 percent.

Some sleeping sickness patients still receive Melarsoprol today, but now less toxic drugs exist and have largely replaced it. The WHO has used the relatively nontoxic and more effective drug Eflornithine since 2001. Nicknamed the “resurrection drug,” Eflornithine miraculously jolts sleeping sickness patients out of comas, but researchers at Aventis originally developed the ingredient in hopes of creating a lucrative cancer treatment. Another less toxic drug, Nifurtimox, has also appeared recently, but it initially aimed to cure Chagas disease in South America. Neither of these emerged from the sleeping sickness research community.

Some controversial, high-tech ways to combat sleeping sickness, such as Sterile Insect Technique (SIT), have emerged from labs studying tsetse flies and trypanosomes. While Ndung’u’s conventional strategies were reducing disease in Kenya,

the International Atomic Energy Agency (IAEA) and the government of Tanzania were using this expensive method to wipe out sleeping sickness on the island of Zanzibar. First, they used low-tech strategies to reduce the number of tsetses, but these efforts stopped just short of completely eradicating them, to Molyneux’s bewilderment. “Why wouldn’t you just use insecticides a little longer and get the numbers down completely?” he asked. Then the IAEA used radiation to sterilize millions of tsetse fly males and released them into the wild. Hapless tsetse females unwittingly mated with sterile males, and the population eventually died out. These sterile males could of course have become infected with trypanosomes themselves, and in the short-term, they might have actually spread the disease the IAEA wanted to eradicate.

Despite the success of SIT on Zanzibar in achieving its end goal, neither Molyneux nor Ndung’u advocated the strategy.

Applying the technique on a large scale on mainland Africa would prove absurdly time-consuming and costly, they said.

Molyneux called it “completely mad.”

When asked about this subject, Ndung’u laughed, explaining that planning for any SIT technology has to begin 10 to 15 years in advance. By Molyneux’s estimates, using SIT to eradicate tsetse flies across all of Africa, after raising and sterilizing male flies from all 23 existing subspecies, would require roughly $19 quadrillion—around 17,000 times the Sub-Saharan Africa’s 2010 GDP. Molyneaux, Ndung’u, and others worry that the quest for expensive new solutions will lead to more inefficient campaigns like Zanzibar’s and draw money away from simpler methods like those used in colonial Principe and modern Kenya. The research community and groups working on sleeping sickness control in the field sometimes draw funding from the same sources. Ndung’u ticked off a few examples, his voice growing faster and more agitated: “The Wellcome Trust, the E.U.,

In the United States, yearly spending on health care exceeds $7,000 per person, according to the WHO. But in the Central African Republic, that number is $32. In the Congo, $23.

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www.tyglobalist.org the Gates Foundation.” Such groups have poured money into a search for new drugs that will probably take 10 years to develop, but in Kenya, Ndung’u saw sleeping sickness fall from epidemic proportions to near elimination in less than that amount of time.

Even if a new solution emerged in less than 10 years, it might make little difference. Sleeping sickness continues to plague Africa not so much because health workers lack tools to fight it, but because they lack the opportunities to use existing tools. “Too often, scientists, whoever they are wherever they are, fail to take into account the realities of health in Africa, and how you deliver health in Africa,” Molyneux said.

Few in the developed world can imagine these realities. In the United States, yearly spending on health care exceeds $7,000 per person, according to the WHO. But in the Central African Republic (CAR), that number is $32, and in the Congo, $23. “It doesn’t matter if you have the new magic bullet solution or an old technology, you’re still going to have [the same] problems. This is not a scientific problem. This is a health systems problem,” said Molyneux.

Conflict exacerbates the problems posed by poor health systems, limiting aid workers’ access to vulnerable populations. Last year, only the war-torn CAR and the Democratic Republic of the Congo reported over 1,000 new cases of sleeping sickness, according to Ndung’u. “You can map sleeping sickness by the number of Kalashnikovs out there,” said Molyneux. The lack of established infrastructure also hinders control efforts.

The DRC, a country nearly the size of Western Europe, has only around 300 miles of passable roads.

Weiss’s research at Yale, though, could provide a solution to these previously insurmountable obstacles. He has been working to create tsetse flies that resist trypanosome infection, in other words, tsetse flies that won’t carry sleeping sickness. Trypanosomes live in tsetse

flies’ guts along with a kind of symbiotic bacterium called Sodalis. Weiss plans to genetically modify Sodalis to produce a compound that kills trypanosomes. Ideally, millions of these designer flies would be released in Africa, not unlike what occurs during SIT. However, these flies could never spread infection. This plan also takes advantage of tsetse flies’ unique reproductive biology: Tsetse fly mothers would transmit these special genetically modified bacteria to their children when nursing them. Eventually, this kind of trypanosome-killing bacteria would exist in all tsetse flies’ guts in an area, and sleeping sickness could become a thing of the past.

Unlike screening people or administering treatments, no aid workers would need to penetrate dangerous or extremely remote areas to implement Weiss’s technique successfully. “That’s the beauty of it. You could just drop ‘em from an airplane,” he said.

When asked how long before anyone might benefit from this research, Weiss groaned and after a pause, said, “Oh god. Well maybe in an ideal world, if everything worked perfectly… I don’t know, 10 to 15 years.” He has successfully managed to remove Sodalis from the tsetse fly gut, genetically modify it, and reinsert it, but the quest to find a way to make Sodalis produce something

“It still doesn’t matter if you have the new magic bullet solution or an old technology, you’re still going to have [the same] problems.

This is not a scientific problem— this is a health systems problem.”

that kills trypanosomes without harming the fly continues.

Serap Aksoy, the principal investigator at Yale’s lab, also thinks Weiss’s work will have many applications for the field— eventually. But in the meantime, she hopes studying these organisms could produce unforeseen medical discoveries affecting diseases beyond sleeping sickness. A softspoken woman who smiles often, Aksoy explained how research on trypanosomes has already produced important medical discoveries. Scientists studying trypanosomes were the first to learn how infectious organisms can change their surface molecules to repel a host’s immune system, and this knowledge has influenced understanding of diseases ranging from HIV to malaria. “Maybe this didn’t generate immediate solutions for the sleeping sickness community, but people forget about the wide-ranging impact of this kind of research on trypanosomes,” Aksoy said.

“I think this foundation that we’re building will probably open up huge avenues for future generations [to control sleeping sickness],” Aksoy said of her lab’s research in general. She rejected the notion that control efforts in Africa should take precedence over lab research. “I think it’s like comparing apples and oranges.

We need both,” she said. So, for now, the dream of a new, better way to fight sleeping sickness thrives in the warm air of the Yale lab, right alongside its humming, well-fed tsetse flies.

SOPHIE BROACH ’13 is a History major in Pierson College. Contact her at sophie.broach@yale.edu.

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the yale globalist: spring 2012

Mining for Tuberculosis Silica dust and AIDS plague South African miners.

By Ashley Wu

A

chest X-ray hangs in Mr. Mkoko’s door. The cavity in the upper left corner confirms what his constant coughing already indicated: He has contracted tuberculosis.

Mineworkers in South Africa, used to frequent terminations due to occupational lung disease, colloquially say that their coworkers have been “sent home to die.”

Though Mkoko was personally unsuccessful in fighting through the tangled web of legal statutes to obtain care or compensation, those who succeed him may have more luck.

South African miners are in a particularly fatal position because they are exposed to both some of the highest concentrations of silica dust and highest rates of HIV in the world. “Gold mining in other parts of the world does not have this problem,” said Jonathan Smith, a professor at the Yale School of Public Health. “It’s not like it is in Peru, where mining is something more akin to industrialized panning for gold. Ore in South Africa is surrounded by silica dust.”

Immune cells in the lungs are predisposed to attack silica dust particles in the same way that they would react to true viral vectors. So the immune system becomes paralyzed in the battle to engulf a ceaseless supply of new silica particles.

Continued exposure to silica dust eventually scars the lung tissue and results in silicosis, a permanent condition that cannot be treated. Given the rates of HIV in South Africa, particularly among miners, the combination of these two immunodeficiency disorders increases the risk of contracting tuberculosis by about 15 times.

It is no surprise, then, that tuberculosis prevalence among South African gold miners is the highest among any demographic population in the world––and 28 times the level of declared emergency by the World Health Organization.

But these facts and figures have been known for years. Not only do effective

methods of controlling silica dust exist, but the world has also had an affordable cure for tuberculosis for half a century now. Ultimately, complexities of South African law, coupled with the legal power of mining conglomerates, have been the biggest obstacles to resolving this epidemic.

“B

e prepared for a mess,” Smith warned as he began a discussion of why mining companies are able to flaunt existing compensation laws. The mining companies’ legal power has stymied governmental attempts to improve safety conditions. A 2008 government audit of the mining industry stated that the list of safety violations committed by mines “goes on and on.”

The first major legal obstacle is that the mining industry operates under a complex third party labor contract system. Thirdparty agencies, not the mining conglomerates themselves, go into remote villages and recruit men to work. “As such, the miners can’t sue the contracting companies because they are simply an interme-

diary,” said Smith. “The contracting company didn’t expose them to high levels of dust or disease, the mining company did.

There is no legal claim there.”

This loophole aside, South African law also contains two conflicting compensatory schemes for occupational lung diseases. The first, the Occupational Diseases in Mines and Works Act (ODIMWA), was enacted in 1973 and provides disabled miners with a small lump sum. “But the bottom line is that the compensation payable under ODIMWA is particularly low, around R16,000 [or $2,062]” said mining law expert Warren Beech of the South African firm Webber Wentzel. The second scheme, enacted in 1993, is the Compensation for Occupational Injuries and Diseases Act (COIDA). Under COIDA, employees receive monthly compensation in exchange for signing away their right to sue employers. Payments are determined on a sliding scale based on disability level, similar to American Social Security Disability payments.

“Keep in mind, though, no one gets this compensation anyway,” said Smith.

An X-ray of a lung infected with tuberculosis. (Courtesy Jonathan Smith)

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In their termination notices, miners are told that they are unfit to work due to occupational lung disease.

(Courtesy Jonathan Smith) A Deloitte audit of the mining industry found that only 400 out of 28,000 miners who filed ODIMWA claims in an 18-month period were granted awards. When they sign their contracts with the mining company, miners essentially give up their right to sue, Smith explained. Thus, former miners like Thembekile Mankayi are considered lucky if they can even get an ODIMWA award.

In March 2011, Mankayi’s groundbreaking case against AngloGold Ashanti was brought to the South African Constitutional Court, after the High Court rejected his right to appeal. “For the first time, a miner was asserting that he was entitled to damages outside of the four corners of the ODIMWA act, [that] he was not precluded from a common law claim because of COIDA,” said Bonita Meyersfeld, associate professor of law at the University of Witwatersrand, Johannesburg.

Mankayi’s case, which held that his occupational lung disease was a result of his exposure to harmful dusts and gases, was effectively a test of COIDA’s section 35(1).

Though he died two days before he could see the Constitutional Court rule in favor of his case, the judgment “opened the door for claims against employers on a civil basis even in the case of coverage by ODIMWA,” according to Beech. Given the 300 to 500,000 former mineworkers who suffer from occupational lung diseases, mining companies would stand to lose a substantial sum if more cases are successfully brought to court. Collectively, these settlements would be worth up to R700 million (about $85 million), according to Beech.

Though the Mankayi case cements the legal right for miners to bring civil claims against mining corporations, it may yet be unrealistic to expect a tide of change.

“Again, you have the implementation problem. It is great in terms of an abstract right, but in terms of bringing actual justice, it’s going to be easier said than done,” said Gregg Gonsalves, former program coordinator for the Aids and Rights Alliance for South Africa’s tuberculosis campaign.

Civil cases in the High Court typically last

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Even considering all the recent legal progress, it is possible that the exasperating impunity under which mining companies operate may continue. Nindi points out a central difficulty of her own litigation: “On paper, everything seems fine.

AngloAmerican reports that the silica dust levels in their mines adhere to the legally required maximum. But if that were true, every year we wouldn’t have thousands of miners being diagnosed with silicosis and dying.”

Indeed, big mining companies like AngloAmerican are also quick to call attention to the fact that they have programs to give workers access to medical treatment and drugs. But Gonsalves makes it clear that these programs make little practical difference. “First off, no one notices that many of the smaller mines don’t have these programs. And miners only get six months of treatment. They also have to

“On paper, everything seems fine. AngloAmerican reports that the silica dust levels in their mines adhere to the legally required maximum. But if that were true, every year we wouldn’t have thousands of miners being diagnosed with silicosis and dying.” four to five years, involving litigation costs far out of reach of individual miners’ ability to pay. Since most of South Africa’s constitutional litigation is done through NGOs, progress in litigation really depends on whether NGOs are willing to recognize the potential in these mining cases.

Early indications of interest are encouraging. Sayi Nindi, a lawyer working with the nonprofit Legal Resources Center, currently has funding from Legal Aid South Africa to proceed with litigation in the Blom et al v. Anglo American group claim. The scope of the Blom case is even more ambitious than Mankayi’s, aiming to hold mining conglomerates like Anglo American responsible for the dangerous safety conditions and silica levels in their mines. If successful––the decision will hopefully arrive by the end of this year–– Nindi believes that mining companies will be forced to form a compensation scheme that can be applied to the all the affected ex-miners.

get sick while they’re on the job in order to get the treatment—an issue if the disease contracted is silicosis, which is permanently incurable and only later leads to life-threatening tuberculosis.”

The Mankayi and Blum cases undoubtedly comprise an important first step towards forcing mining companies to be accountable for their role in the silicosistuberculosis epidemic. Laws in South Africa that mandate mines to provide basic safety equipment and limit the level of silica dust already exist. Perhaps, faced with evidence that occupational lung diseases are developed as a direct result of work-related conditions, the closing of the COIDAODIMWA loophole, and the possibility of paying group claims worth millions of dollars, mining companies may finally have the incentive to comply with these laws.

ASHLEY WU ’15 is in Morse College. Contact her at ashley.wu@yale.edu.

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the yale globalist: spring 2012

The Next Generation New generations of AIDS activists are taking the fight for global health equity to new heights.

By David Carel

I

t was barely 8:00 in the morning on Saturday, Oct. 30, 2010. I stood in line with a group of other Yale and Harvard students for President Obama’s afternoon speech in Bridgeport, Connecticut. Before proceeding through the wall of metal detectors and into the stadium, we stuffed banners into our pants and jammed signs and chant lyrics into our jackets, wallets, shoes, and anywhere else we could hide them.

Following several speeches by Representative Himes, Senator Blumenthal, and a host of other politicians, Obama took the stage, galvanizing an energy and applause which thundered throughout the arena. In two separate groups on either side of the stage, we slowly unfurled the banners beneath our feet, stood up, and began shouting, “Broken promises kill, fund global AIDS. Broken promises kill, fund global AIDS.” “Excuse me! Excuse me, young people!” the president responded. “…We’re funding global AIDS, and the other side is not.

So I don’t know why you think this is a useful strategy to take.”

“You promised more! Fifty billion.” We shot back in perfect unison, anticipating his evasion, drawing attention back to the promises he had made in 2008.

After several more minutes of back and forth with the president, we were spat on, kicked, and shoved. The signs were ripped from our hands as we were escorted out by security.

The decision to protest the president was not an easy one. Most of us were and continue to be staunch Obama supporters and cringed at the thought of harming his public image. But after fierce debates and careful calculation, we found ourselves protesting the administration’s waning

commitment to the fight against global HIV/AIDS. In a twist of fate, merely two weeks later, the architect of Obama’s global health policy, Dr. Ezekiel Emanuel, paid a visit to Yale for a guest lecture on global health ethics. At the heart of Emanuel’s plan for Obama’s global health policy lay the belief that AIDS occupies too much of our national attention and budget. He emphasized that there are a host of other ailments and concerns, such as childhood respiratory and diarrheal diseases, which

“It’s always AIDS, AIDS, AIDS. Why do you guys all waste your time yelling at me about my AIDS funding? Why aren’t you out there fighting for maternal and child health and neglected diseases?” affect more lives in the developing world and can be treated more cheaply than fighting HIV/AIDS. Over the course of the day, I met face to face with Emanuel, along with Jared Augenstein and Nick DeVito, two students at the Yale School of Public Health and co-founders of the Student Global Health and AIDS Coalition on campus.

Over breakfast, Emanuel shared a few nasty words about AIDS activists, including many whom I had worked with or befriended over the preceding months.

He chastised me for joining an outdated movement that had selfishly hijacked U.S. global health policy.

“It’s always AIDS, AIDS, AIDS. Why do

you guys all waste your time yelling at me about my AIDS funding? Why aren’t you out there fighting for maternal and child health and neglected diseases?”

His brow furrowed in contempt, as he embarked on a verbal tirade mocking my criticisms of his policy agenda. He scoffed at my accusations in a self-confident and smug tone well-known throughout Washington.

The truth was, I was immensely uncomfortable with Emanuel’s accusations.

I still fundamentally disagreed with his claims that AIDS treatment was too expensive and cost-ineffective, but I, too, began to wonder why AIDS activists weren’t doing more for other diseases. The AIDS movement had become so prominent in the United States largely because the disease affected Americans on a scale that malaria, tuberculosis, and other infectious diseases simply do not. As part of the new generation of AIDS activists divorced from any personal history of HIV, why wasn’t I doing more for global health equity broadly?

Even within the AIDS activism movement, there was considerable divergence.

In conference calls with AIDS activists around the country, meetings in D.C., and mass list-serve emails, we, the new, younger generation, often struggle with the title “AIDS activists.” We come from a different world than the older generation of activists, who fought for their own lives and the lives of their loved ones as HIV/AIDS tore through the nation in the ’80s and ’90s. The vast majority of us have never truly known HIV. We were barely infants at a time when the epidemic was sweeping violently through this country, a dismal era when HIV was a death sentence and entire communities––homosexuals, African Americans, drug users, and others––were being decimated. Our genera-

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tion, having learned about global health largely through travelling and working in the developing world, is less HIV focused and more interested in the broad issue of global health.

T

his past summer I found myself replaying my debate with Emanuel in my head. I was in the U.S. embassy in Maseru, Lesotho, on a short vacation after two and half months working on a Zulu youth empowerment project in South Africa. During the trip, I had the opportunity to meet with the President’s Emergency Plan for AIDS Relief (PEPFAR) and Center for Disease Control (CDC) teams in Lesotho that coordinate the United States’ AIDS treatment and prevention programming in the country. As we sat down in the board room, the first thing they began telling me about was a new “mother-baby pack,” a kit of maternal and child services for pregnant women in remote Lesotho who have no access to any obstetric or

post-natal care. The pack, they explained, allowed community health workers to provide comprehensive pre- and post-natal care in the women’s homes, offering a wide range of both diagnostics and treatments for these women.

“And who pays for these?” I asked, confused as to why a PEPFAR official, rather than a maternal and child health expert, was proudly showing this kit to me.

“PEPFAR does!” she shot back, equally confused about why I was asking such an obvious question.

As it turns out, among the cohort of tests and diagnostic tools included in the mother and child kit is a rapid HIV test.

This HIV test was enough, the PEPFAR official explained, for PEPFAR to cover the entire cost of the kit and visit to the woman. An AIDS relief program was shouldering the entire cost of what was at most 10 percent HIV/AIDS and 90 percent maternal and child health.

The real question, however, was: Why

was PEPFAR, an AIDS program, funding the mother-baby pack in the first place?

Why is there no President’s Emergency Plan for Maternal Health Relief?

F

or years, ever since President Bush announced PEPFAR in his 2003 State of the Union Address, the U.S. government has been captivated by the narrative that AIDS funding is a vital part of American foreign policy, a crucial program not only for humanitarian reasons but also for national security. As the narrative went, AIDS was decimating a generation of young adults in Africa, many of them in the prime of their lives, and it was leaving a vacuum of social unrest in its wake which terrorism was primed to fill. If nothing was done to stop AIDS, millions of children would be left without parents or stable economies; governments would deteriorate, and organizations like al-Qaeda would capitalize on the social unrest to recruit from the dregs of a desperate African

Commitments and Disbursements, 2002 - 2010

Commitments Disbursements

32 32 FOCUS: CURES population.

This argument still reigns today. Last December I found myself face to face with Senator Pat Toomey’s (R-PA) national security advisor, a man of military background. I entered the meeting with apprehension, convinced that my calls for global health funding, 40 cents for a day of antiretrovirals and pennies for neglected tropical disease treatment, would be trounced by $150 million fighter jets and over $3 billion in monthly spending in Afghanistan. I sat down and began my well-rehearsed AIDS lobbyist script, calling on Senator Toomey

the yale globalist: spring 2012

AIDS activism and demand that our politicians support neglected global health priorities, or ride the wave of AIDS sympathy to expand the funding and opportunities for global health more broadly. If PEPFAR can mobilize bipartisan support for a program which supports global health efforts everywhere from antiretroviral treatment for AIDS patients to mother and child kits, the global health activist movement would be foolish not to capitalize and latch onto it.

Tragically, there may never be U.S. funding for neglected tropical diseases,

“People just don’t realize that fighting AIDS is important for our national security,” Gingrich lectured. “I actually have a call tomorrow morning with Bono to discuss just this point.” to promote the extremely bipartisan cause of PEPFAR for its public health, humanitarian, and national security benefits.

Before I could continue, his national security advisor interrupted, “You know, people just don’t realize that this PEPFAR is so important for our national security.

Without it, AIDS is gonna leave a vacuum which the terrorists are gonna fill.”

Just months prior at the Wild Irish Breakfast in New Hampshire, I had a remarkably similar conversation with Newt Gingrich while calling on him to include strong AIDS policy in his presidential campaign platform.

“People just don’t realize that fighting AIDS is important for our national security,” Gingrich lectured me. “I actually have a call tomorrow morning with Bono to discuss just this point.” Friends, others from the Yale Global Health and AIDS Coalition, and fellow global health political activists at colleges across the country have reported similar comments from senior Republican Congressmen, Mitt Romney, Rick Santorum, and others.

Over the last decade, AIDS has captured the imagination of Washington, particularly Republican political leadership, in a way that childhood diarrheal diseases and women’s health have not. Emanuel was right––AIDS has received a disproportionate amount of funding and attention from the United States. Advocates and activists have two broad-stroke options to rectify this imbalance: withdraw from our

maternal and child health, or basic primary health at a level anywhere near that of AIDS. Obama’s and Emanuel’s efforts to increase funding across the board for global health, though noble, have fallen tragically short in the face of our current political reality. Until we learn to embrace this reality, one where AIDS funding not only garners immense political support but also funds mother-baby packs and other areas of global health, global health funding may continue to suffer. *

A

*

*

re you HIV positive?” someone asked from across the circle.

“No…actually…I’m not,” I was barely able to reply before the young African-American man sitting to my right politely chastised my interrogator for his intrusive comment.

“We don’t put people in that kind of position, O.K.?”

I was sitting in the basement of St. Luke’s Church in downtown Philadelphia at the weekly meeting of ACT UP Philly, an organization that advocates for people living with AIDS through direct political action. I sat among young, openly lesbian white women covered in piercings, tattooed African Americans, ex-cons, and homeless men. As the meeting progressed and some openly discussed their perilous histories of drug abuse and the circumstances under which they had contracted

HIV, the group advanced their plans to sway Philadelphia’s Mayor Nutter on the city’s HIV/AIDS policies and efforts to start a low income AIDS housing project.

As a 20-year-old male from the suburbs, white, Jewish, heterosexual, and HIV negative, I was the demographic elephant in the room. It was these individuals sitting around St. Luke’s church and all those around the nation that they represent who put HIV/AIDS on our nation’s radar. Though it began as a fight literally between life and death to secure access to AIDS treatment in the U.S., an unparalleled international solidarity began to form with individuals in the developing world who faced the very same battle.

This movement grew into the AIDS activists that we see today.

It is far from coincidental that it is AIDS that has dominated our nation’s global health funding. Modern America has been spared the massive burdens of malaria, tuberculosis, hookworm, and the challenges to maternal care faced by the poor in the developing world. AIDS is unique in this regard, spanning oceans and national borders in both the developed and developing world. As much as Emanuel and I may wish otherwise, the United States likely will never produce a childhood diarrhea or maternal health activist movement with the same force and urgency as the AIDS movement.

Whether because of the national security-oriented political landscape or the story of the HIV epidemic in the U.S., our foreign policy is inextricably bound by its history. The AIDS activists of a generation ago, like the group in that church basement, with whom Emanuel disapprovingly lumped me during our debate, laid the foundation for a much broader global health equity movement than Emanuel gives them credit, and perhaps than they ever imagined. It is on their shoulders that I and the rest of our generation of AIDS global health activists proudly stand. It is time not to halt that momentum of AIDS activism but to nurture it, inching the world closer and closer to global health equity.

DAVID CAREL ’13 is an Economics major in Pierson College. Contact him at david.carel@yale.edu.

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www.tyglobalist.org

Letter from... Brazil One community preserves traditional holistic healing.

By Alexis Cruzzavala

T

he pungent scent of cinnamon lingered on my clothing for days after I left the dense forest of northeastern Brazil’s National Park, Chapada Diamantina. I can remember waking up as the sun began to rise and falling asleep to the nightly rain.

The air in the chapada was purer than it was in Bahia’s capital, Salvador, and the people spoke more softly and with less urgency than big city folk. Everything in the chapada hummed with life, but a quieter, more peaceful life than the hustle and bustle of Brazil’s biggest cities.

People from all over South America flock to the Chapada Diamantina to experience the mystical powers the jungle has over its visitors and residents. Many come for the hikes or the chance to escape into the wild, but all are struck by the sense of rejuvenation that comes from living in a sustainable community with roots in holistic healing. The communities of the chapada pride themselves in supporting a philosophy and way of life that attends to the health of not only the body, but also of the mind and spirit.

When I arrived, I was surprised by the unwavering faith these people placed in holistic medicine—so different from my modern lifestyle. Herbal tea and salves were valued above fast-acting pills, and a combination of yoga and meditation was believed to fight off future diseases like cancer. It sounded absurd. I wanted to understand, but I also wanted to make them understand how unlikely it was that a meager cup of nine-herb tea was going to cure the hideous cough that was plaguing me. As a foreigner unversed in the subtleties of local language and culture, though, it seemed safest to be still and listen.

For just over a week, I spent my days working in Horto Vale Flora, the community garden. There, nestled in the park alongside other students, biologists, no-

Seu Santinho conducts an earwax removal used to prevent infection and to improve hearing. (Cruzzavala/TYG) mads, and the local medicine man, I met some of the people responsible for the preservation of the community’s holistic healing practices.

E

miliano Evangelista Neto, or Seu Santinho as he is fondly called, is a stocky man with leathery hands, slurred speech, and the ability to identify nearly every plant in the national park.

Born in Conceição dos Gatos in 1955, Seu Santinho inherited the duty of medicine man from his father, and for over 30 years has worked with medicinal plants native to Chapada Diamantina. With his volunteers, Seu Santinho maintains an expansive medicinal garden teeming with plants that do everything from soothing a sore throat to exhibiting antiviral properties. When he is not assisting local midwives with births

and postnatal care, Seu Santinho collects plants to make his famous nine-herb tea, which he freely distributes to anyone experiencing flu-like symptoms. It was this very tea that became the topic of many of our conversations over dinner: He was eager to have me try his method before turning towards the nearest box of antibiotics.

I was hesitant, but there was no harm in trying, and his esteem in the community certainly didn’t hurt.

Along with this attention to physical health, Seu Santinho and the other residents of the Chapada Diamantina dedicate just as much time to the betterment of the mind and spirit. To complement the tea that was supposedly healing me, I was encouraged to meditate once a day and to devote my mornings to the community garden. As Reuben, a Bolivian nomad who works alongside Seu Santinho, told me, “You must be willing to walk into nature knowing that every living creature or plant can teach you something new about the world. When you listen and learn, your mind is healing… and your spirit thanks you when you find connection with nature.

These are the things that will cure the world.”

Perhaps the philosophies behind holistic medicine are outdated or lack sufficient scientific support to hold true in today’s culture of fast-acting pills and treatments.

But in a society discredited by modern medical standards, it is a discovery to find a group of people who are healthy, strong, focused, and connected to the natural world around them. I found myself feeling calmer, more energized, and even happier after only a few days in the chapada. And by the time I left, my month-long cough had miraculously subsided.

ALEXIS CRUZZAVALA ’13 is an Anthropology major in Davenport College. Contact her at alexis.cruzzavala@yale.edu.

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the yale globalist: spring 2012

A Woman’s Right to Birth

By Cathy Huang

Two Guatemalan rural midwives take a break from their assessment. NGOs test the women on their delivery procedures to determine which technologies and methods to implement. (Courtesy Marcin Szczepansk)

S

alud Alarcon, 15 years old with brunette ringlets framing her grinning face, has written her favorite saying onto the first page of every fresh notebook she purchased for school: “No hay mal que dure cien años.” There is no evil that lasts 100 years. There is nothing one can’t endure.

For Salud, whose mundane high school routine in Antigua, Guatemala presents her few real stressors, this saying reminds her that she is lucky. She entered the world on a humid evening in February, barely surviving a fight against her mother’s umbilical cord, which had wrapped

around her, trapping her inside her mother’s uterus.

A woman’s first labor lasts, on average, eight hours. Salud’s mother was in labor for over twenty painful hours before hemorrhaging to death after Salud was finally extracted. The birth attendant left the house with few things to say. Salud’s father prepared a low-key funeral. Two years later, he remarried.

Of the 500,000 women’s deaths each year from complications that arise during childbirth, 99 percent occur in developing countries, where a woman’s lifetime risk of dying from pregnancy and related complications is almost 40 times greater than that of her counterparts in devel-

oped countries. A woman’s risk of dying in childbirth in the United States is one in 3,700 whereas in Latin America the risk is one in 130. In Guatemala, with its 13 million residents, a population that doubles about every 22 years, promising natural resources and mounting tourism, the maternal mortality statistics are more than sobering—they are unacceptable.

With the second most skewed income distribution in the Western hemisphere, Guatemala is split, geographically and culturally, between the rural indigenous people of Mayan descent who carve their villages in the highlands, and the urbanized Ladino population. As estimated by Hurtado and Saenz de Tejada, the Ministry

FOCUS: CURES 35

www.tyglobalist.org of Public Health and Social Assistance in Guatemala, there are 248 deaths out of every 100,000 live births. Maternal mortality among indigenous Mayan women in certain rural areas, however, may be as high as 446 in 100,000. These statistics make pregnancy in Guatemala more dangerous than pregnancy in any other Latin American country.

The causes of maternal mortality in Guatemala, the most common of which are postpartum hemorrhage, puerperal sepsis (a bacterial infection of the blood), or eclampsia (unmitigated seizures) are all attributable to abnormally prolonged labor that is quickly detected by trained obstetricians. But the majority of rural Guatemalans who speak indigenous languages and practice centuries-old home remedies will never set foot in a hospital.

Not surprisingly, the health of indigenous Guatemalan mothers and children is dramatically poorer than that of the Ladino population. Rural women will only trust their local midwives at their bedsides.

T

raditional midwives attend 80 percent of home and in-clinic births in Guatemala and virtually 100 percent of births in rural areas, where drug-less, tool-less home birthing is the only option. Unfortunately, there are only 20 trained midwives for every 10,000 Guatemalans. But Western medical training might not yield lower mortality rates: Several field studies suggest that many obstetrical routines have cultural rather than medical determinants. In the mid1990s, an independent researcher hired by the World Health Organization to survey routine obstetrical practice around the world concluded that only 10 percent of all routine obstetrical procedures were scientifically based. The evidence points to childbirth as a largely cultural or spiritual event in a woman’s life. “[Some] rural midwives bring relics to the bedside,” said Dr. Jean Albright, the director of a global health project at the University of Michigan designed to expose medical students to the ethnic, religious, and linguistic barriers to equalizing rural health care access in the Guatemalan highlands. “Some of the traditional communities in the highlands don’t have what we refer to as ‘biomedical beliefs.’ They simply don’t get the point of hospitals or physicians.”

Albright had to send her first batch of student health workers back to Ann Arbor so she could spend a year calibrating the program to better suit these ethnic divides. Understanding midwifery, traditional or otherwise, precedes any attempts to build hospitals or wrestle with a corrupt and Ladino-dominated national health care bureaucracy.

A targeted global health intervention will wisely select the most instrumental player in the rural childbirth gamble, the comadrona, the traditional midwife, as the locus of progress. But do researchers and global health workers force midwives to speak their jargon of elapsed seconds, bacterial this or that, pre- or ante-natal precautions, or do they try to make room in their proposed professional and resultsbased interventions for the fact that childbirth is spiritual before it is medical?

Jennifer Houston, a practicing midwife in both Antigua, Guatemala and Catskill, New York, believes in the latter.

“Traditional midwives have knowledge and skills that are unique and different from the biomedical or ‘technocratic’ model,” she argues. “The unique gifts that traditional midwifery has to offer, unexposed to biomedicine, is a profound trust and belief in the sacredness of birth and women’s power.”

Nearly 15 years ago, Houston founded Ixmucane, a birthing center disguised

nominal fees to a local comadrona for several months worth of home cooking and for cot space. Upon arrival, the foreign nurses would shadow their midwife hosts for several weeks under a program called Midwives for Midwives. Houston, whose birthing center was forced to close after the national government dropped its promised funding, emphasizes the need to respect the sanctity of childbirth.

Midwives for Midwives still facilitates home stays, and while visiting nurses must submit reports about tools and educational methods they believe would best work in fighting prolonged labor in rural contexts, there is little mention of offering professional instruction—no “graduation” or approval system for a midwife’s skills— only culturally adapted suggestions for preventing life or death situations.

“We’re working to reverse the global trend of devaluing traditional systems, and to prevent the natural process of birth from becoming a total medical and technological procedure done to women,” said Houston resolutely. Her tone, authoritative and fearless, suits a woman who delivered all of her own children at home with only herbal medications.

Pregnant women in developed countries often enter labor under the much-appreciated spell of an epidural. Whether at the preventative stage, through the use of contraceptives, family planning, shopping

But in countries like Guatemala, where the perspective insisting that women exist to deliver is still prevalent, birth, as Houston argues, is done to women. as a quaint colonial house in the narrow streets of Antigua. The center hosted several foreign nurses each year who paid

for an ob-gyn, or during delivery itself, being able to choose drugs or agree to Caesarean sections, women have choices. But

2005 WORLDWIDE MATERNAL MORTALITY (deaths per 100,000 live births)

Developed regions Africa . . .

Asia . . . .

Latin America .

. . . .

Data source: WHO Maternal Mortality Report, 2005

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. 9 . 820 . 330 . 130

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the yale globalist: spring 2012

troduction of professional midwives could be empowering in new ways, too. “[Women] choose the traditional birth attendant because that is all they know.

That’s the tradition. But if you have trained professionals, women can ask for what they really want and what they really need … not just feel like they have to say ‘yes’ to anybody.”

Childbirth is spiritual and empowering. But it sometimes involves no choice for the women involved. Childbirth is, for many women, a celebration, a milestone.

But childbirth can be deadly.

A rural woman in labor is examined by an American doctor. If she needs a C-section, she will need to be transported two hours to the nearest hospital. Rural midwives don’t have the equipment or training to perform safe C-Sections. (Courtesy Marcin Szczepansk) in countries like Guatemala, where the perspective insisting that women exist to deliver is still prevalent, birth, as Houston argues, is done to women.

By allowing rural midwives to host educated, foreign nurses, and by making room for their ritualistic or “unscientific” birthing methods, exchange programs like Midwives for Midwives aim to empower midwives by letting them know that their jobs are valued. Even if biomedical childbirth with its blood pressure cuffs and cervix dilation readings remains a foreign concept in the Guatemalan highlands, midwives learn that their art demands skills—skills to be shared and developed—and that they possess a gift rare among women in their rural communities: an education.

B

ut according to Daniela Adabi, exchange and cultural accommodation is not enough. Abadi’s missions as a midwife with Doctors Without Borders have taken her to Cambodia, Thailand, Nicaragua, and, most recently, back to her home in the lush valleys surrounding Lake Atitlan in southwest Guatemala.

It’s there that she plans to launch a professional midwife training center. Abadi, a French-educated Argentinian, speaks slowly about her experiences with maternal mortality, enunciating her syllables above the rapid metronome of raindrops on her corrugated metal roof.

“The responses from the local women have been good. Most of them accept the idea that things need to be improved,” explains Abadi, whose proposed project

will recruit graduating high school senior girls and offer them professional obstetric training, the kind dispensed to home birth attendants in the United States. Abadi’s model replaces home stays with on-site instruction, and will collaborate with local universities to provide some sort of initial certifications for its first graduates.

“This will be a model where you don’t just impose on the women where to give birth, how to give birth but also [provide] workshops, classes around nutrition, around child care.” Abadi, unlike Albright or Houston, is a local. Health workers dream of places like Lake Atitlan, with its lush climate punctuated by the occasional intense rains and its hushed Mayan tradition tucked into all hours of the day, but Abadi knows the local school systems, some of the local midwives, and has faith that her proposed model has calibrated itself to fit the culture.

For the few women who complete their high school education in the Atitlan highlands, there are few skills-based jobs.

The only other alternative in the health professions is assistant nursing, which tends to be less appealing than marrying young and rearing children. And while Abadi concedes that “there [will be] a lot of challenges” to her model, the biggest challenge will be to have trained midwives recognized by the community they serve and by the national health system. But by reinforcing technical education and offering a program that a midwife can say she graduated from, women can find confidence in their skills and status. And the in-

I

n Xelaju, Salud Alarcon is studying to become a doctor. She regularly complains about her homework and often procrastinates by playing soccer at the gimnasio downtown. Her urban upbringing affords her the opportunity to study in school and pursue higher education. It even has her considering an unlikely path to medicine.

“Maths is so hard,” she mumbled. “But it will be worth it. I want to make people feel good.”

Over the years, Salud’s voice has developed an undeniably warm, maternal timbre. Despite harboring the usual teenage anxieties about boys and fashion, she speaks to her younger step-siblings and shares her career dreams with a mature inflection. One day, she will live up to her name and might even, as a physician, help propagate what it represents. “Salud” in Spanish, after all, translates to “health.”

For women in the rural highlands, the legitimization of existing female roles, as midwives and valued homemakers, is the closest thing to female professional development. Whether the process will involve ritual exchange or diploma exchange is unclear. But a woman’s agency rests at the center of every movement to fight maternal mortality. These movements offer the promise of education, of cultural understanding, and of advanced medical methodologies. Above all else, they offer women the ability to choose health in the face of tradition.

CATHY HUANG ’14 is in Morse College.

Contact her at cathy.huang@yale.edu.

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www.tyglobalist.org

A Conversation with Nathan Wolfe

Q & A

Nathan Wolfe’s research takes him far outside the confines of a lab. As director and founder of the Global Viral Forecasting Initiative (GVFI), an organization Time Magazine dubbed the “CIA of infectious disease,” Dr. Wolfe travels the globe tracking emerging viruses in hopes of preventing the next pandemic. RACHEL BROWN reports.

Q:

Would you mind briefly describing the work you do as a “virus hunter?”

A:

My job and the mission of my organization is to decrease the global risks associated with threats from microbes of any sort. A lot of the story of these microbial threats has to do with our relationship and contact with animals, so we’re very interested in the contact between human and animal species and understanding how microbes flow into the human population.

Q:

Do you think that viruses that originated in animals are becoming more significant to human diseases, like Avian Flu and Swine Flu, for example?

A:

If you think about “new viruses” in humans, there are only really two ways that you can get something because [viruses] are changing all the time, but they’re not continuing to come into existence. The only two ways you can get it are (1) that it’s been in your ancestors for some time or (2) that it comes from another species. Things that are in little pockets of humans can then emerge more broadly, but basically the entire story has to do with animals.

But it has always been the case that it’s been about animal viruses. What’s really changed is the global interconnectivity of human populations. A virus that crosses into humans, that fifty or a hundred years ago would have had a really good chance of either dying out or just staying put locally, now has a global stage on which to

(Courtesy Bart Nagel)

do its thing.

HIV is a great example. HIV is a virus that’s been in chimpanzee populations for at least some hundreds of thousands of years. And humans have been hunting chimpanzees for the entire duration of that period. So you have to imagine that the particular chimpanzee virus that jumped from a chimp to a human in the early 20th century, and then in the last part of the 20th century spread around the world to be the HIV/AIDS pandemic, was not the first one of these chimpanzee viruses to jump into humans. But one of the major factors in the late 20th century was that instead of the virus just basically burning itself out in a little village in rural Central Africa, we had a situation where the world was completely interconnected.

Q:

How do you explain your research to local hunters and other community members who might not have the same level of science background?

A:

Even in places where there’s a large percentage of individuals who have no more than a primary level of education, these folks understand much more about the forest that they work in and the animals that they work with than we ever will as visitors. When we say things like, “some of these animals are going to be ill and there’s the potential that humans can contract the illnesses from the animals, and sometimes those illnesses can spread,” it’s a very intuitive thing for a lot

of people that we work with. For us it’s very much a collaborative exercise. Many of the people in these communities [even] assist us in collecting specimens.

Q:

How do you see the link between opportunities for disease control and economic and human development in these regions?

A:

One of the things you find when you go to these villages is that most people want to be on the grid. Their first desires are for better roads so they have easier contact with economic opportunities and infrastructure. And so there’s a tremendous, and you have to assume very rational, desire to be a part of the interconnected planet.

From my perspective, one of the challenges is that these roads provide avenues for transmission and movement of diseases both from these rural biodiverse areas to the rest of the world, but also from the rest of the world to these rural communities. But the connectivity also provides us with the opportunity to understand what’s going on in these communities and to improve health infrastructure and early detection. It’s also very important that we get together and really take seriously the problems of poverty in rural regions because in some ways there’s a very clear poverty link.

RACHEL BROWN ’15 is in Saybrook College.

Contact her at rachel.brown@yale.edu.

Winter Break: Globalista Style

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