Harvard College Global Health Review- Spring 2011 by Rajarshi Banerjee

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From the Editors

What Is Global Health? 4

Medicine, Industry, and Empire: Tracing the Evolution of Global Health Alyssa Botelho

Organization Spotlight: UNICEF Combating the Notion of Children as Commodities Neda Shahriari

Eesha Dave

Global Health and U.S. Policy: Implementation Controversy and the Example of PEPFAR

Leeann Saw

Beyond Medicine: Career Opportunities in Global Health Hannah Semigran

Global Health at Harvard: Ideals to Implementation Exposing Students to the Field via the Classroom Shalini Pammal

Interviews

The Global Health Web: An Integrated Approach Toward Solving Global Problems

content

An Interview with Dr. Anthony Fauci Farhan Murshed

Rural Health in the United States: A Domestic Look at Global Health Ryan Lee

No Vaccine This Time: Battling a Parasite with a Weapon of Health Education Charlotte Lee

The Health Disparity of Indigenous Australians: A Comparitive Perspective Mark Ragheb

The Expert Perspective 34

Viewing Global Health Through a Different Lens: The Eyes of the Patient

Dr. Priya Agrawal & Susan E. Sheridan

Interviews 38

An Interview with Dr Priya Agrawal, BMBCh, MA, MPH

An Interview with Susan E. Sheridan, MIM, MBA

41 44

Pratyusha Yalamanchi

A Diagnosis Transformed into a Mission: An Interview with Cancer Survivor, Advocate, and Reseacher Dr. Felicia Knaul Pratyusha Yalamanchi

Panorama

Student Submissions

Medicine and Maturity: Cultural Integration of Male Circumcision for HIV Prevention Sarah McCuskee

Global Obesity

Homan Mohammadi

ShelterBox: Innovations for Long-term Recovery or Shortlived Relief?

Sheba Mathew

48 50

A Semester in Kenya: The Intersection of Health Access and Poverty Ariella Dagi

Making Clean Water Accessible: Project ACWA Alex Almore

January in Bahia Trevor Thompson

The Harvard College Global Health Review, Spring 2011 Editors-in-Chief Managing Editors Alison Kraemer ‘12 Justin Banerdt ‘13 Lavinia Mitroi ‘12 Annemarie Ryu ‘13

Section Editors Staff Interviewers Judy Park ‘13 (Features) Angela Primbas ‘12 (Student Spotlight) Daniel Wilson ‘14 (Panorama) Pratyusha Yalamanchi ‘13 (Experts and Interviews)

Ava Carter ‘13 Farhan Murshed ‘11

Staff Writers Design Board Alyssa Botelho ‘13 Eesha Dave ‘13 Charlotte Lee ‘14 Ryan Lee ‘13 Sheba Mathew ‘13 Sarah McCuskee ‘13

Homan Mohammadi ‘14 Shalini Pammal ‘13 Mark Ragheb ‘12 Leeann Saw ‘13 Hannah Semigran ‘14 Neda Shahriari ‘12

Samuel Mendez ‘14 (Chair) Herbert Castillo ‘14 Ketsia Saint-Armand ‘14 Melissa Sanchez ‘14

Board of Expert and Faculty Advisers David Bloom, PhD

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

Allan Brandt, PhD

Dean of the Graduate School of Arts and Sciences; Professor of the History of Science

Arachu Castro, PhD, MPH

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

Cecil Haverkamp

Coordinator of Strategic Partnerships and Global Health Practice, Harvard School of Public Health

Graduate Student Board of Advisers Eitan Bernstein Yvette Efevbera Michael Frick Subhada Hooli Laura Khan

Sophia Qiu Sophie Miller Danae Roumis Andrew Thorne-Lyman

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

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global health review Dear Reader,

From the Editors

Given the recent explosion in enthusiasm and funding for global health pursuits since the turn of the century, global health is a term that has undoubtedly become familiar to you (evidenced by the fact that you have picked up our journal). However, you must be asking: why is it that we, as a publication with a mission to report on persons, organizations, concepts, and issues pertaining to global health, are asking what constitutes global health, as though we do not know? To be honest, we believe that global health is imperfectly defined and inadequately understood both by students like us and experienced individuals in the discipline. In fact, “global health” is a two-sided term that refers both to the state of health in populations at an international level and to the research- and practice-based field that aims to overcome health disparities globally. Despite this outwardly bipolar identity, global health today is actually less of a field and more of a challenge or contemporary paradigm. The field of global health, or global health as an academic endeavor and career choice, is still a very young newcomer to the collection of imaginable professions. In this issue, our fifth since the founding of the HCGHR in the Fall of 2008, we seek to accomplish the daunting feat of defining global health as a field, in a context that promises to be unmatched by any other source reporting on global health to date. HCGHR staff writers have set out in our Features section to answer “What is Global Health?” by exploring its complex history, its controversial place in U.S. policy, its associated diverse career paths, and its implementation in scholarly pursuits at Harvard. Our writers have also underscored UNICEF as a model organization for global health fieldwork and outlined the ways that global health draws attention to issues outside of the clinical realm, including poverty, gender equality, and education. Our Panorama section appropriately complements this exploration, covering salient topics that are of significant interest to many members of the global health community. These include HIV prevention strategies, the growing obesity epidemic, disaster relief, healthcare for underserved rural populations, disease eradication, and health challenges for indigenous populations. Our student submissions and expert contributions

Volume II, Number 2, Spring 2011

further expand our global health definition by giving firsthand accounts that will familiarize you with the concerns and activities of workers in the field. This past January, the HCGHR acquired status as an official, independent student organization on campus, autonomous from our original parent organization, the Harvard College Global Health and AIDS Coalition (HCGHAC). Our organization, to the best of our knowledge, is the only undergraduate-run global health publication in the U.S. The novelty of the HCGHR as an organization is not without coincidence - it is indicative of the novelty of global health as a burgeoning field. Thus, in working to elucidate a definition that describes the field, we help to define and improve ourselves in the process. For cultivating our continued growth and expansion, we are extremely grateful to our Advisory Boards, comprised of brilliant Harvard faculty members, experts, and graduate students, and for the financial support from the Harvard Global Health Institute. Finally, we hope you will view us on our newly revamped website to be launched soon through our current link: http://hcghreview.org/hcghr/. We desire that this online forum will allow our publication to offer a more interactive experience outside of our printed edition and give you the opportunity to join in the dialogue that this and future issues seek to cultivate. In addition to educating you about global health, our greater wish is that we can inspire a generation of young people to be engaged global citizens dedicated to combating global disease, poverty, and inequality. We thank you for reading and hope that you enjoy what we have prepared. Sincerely, Alison Kraemer and Lavinia Mitroi Editors-In-Chief “Where once it was the physician who waged bellum contra morbum, the war against disease, now it’s the whole society.” -Susan Sontag

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Medicine, Industry, and Empire: Tracing the Evolution of Global Health

t is difficult to imagine a line of work less contentious than that of global health. Undeniably benevolent and unabashedly idealistic, it is a field that draws admiration across lands near and far. Yet while global health enamors, the field also escapes definition. It is at once an effort dictated by the formal declarations of signatory nations, the missions of forprofit and non-profit organizations to cultivate health as a “global public good,” the struggles against epidemic disease, natural disasters, bioterrorist threats, and the preservation of market capitalism in today’s world economic order. As these myriad efforts are difficult to synthesize, their origins are also difficult to trace: global health refuses to present an obvious development from the medicine of varied locales. Though global health’s history remains elusive, one aspect of its evolution is clear. As Dr. Jeremy Alan Greene, a History of Science professor at Harvard University and Associate Physician at Brigham & Women’s Hospital describes, “Global health was not buffered from the economic and political context of its time, but happened in concert with it.” In this vein, Birn, Pillay, and Holtz explore the development of global health in their Textbook of International Health through “a political economy approach” that views health “in the context of the political, economic, and social structures of societies.” They argue that health is but one facet of “who owns what, who controls

By Alyssa Botelho

whom, and how these factors are shaped by and reflect the social and institutional [demographics].” In doing so, it becomes important to draw distinctions between the terms public health, international health, and finally, today’s global health. These are terms that can ultimately be explained from their historical origins by tracing health regulation from the 1300s to today’s most innovative health efforts. Health’s Expansionist Eye: Colonial and Tropical Medicine In order to understand the concerted evolution of global medicine, it becomes essential to ask why citizens— and their governments—became concerned with the spread of disease across borders in the first place. Of course, public sanitation efforts and theories of disease causation can be traced to the world’s earliest civilizations—from Rome to Mesoamerica to the Middle East. However, health regulation on a trans-continental scale first appeared during the Middle Ages with the Black Death. To this day, the bubonic plague remains the most destructive epidemic that man has faced—taking over 25 million lives throughout Europe and Asia. Indeed, it was the plague that prompted Venetians to enforce the first quarantine (a 40-day detention for ships entering their harbor) and religious orders throughout Europe to establish the first hospitals. However, global health as it is known today is rooted in the health

Photo Courtesy of the History of Medicine

challenges that arose with the global expansion of European imperialism: colonial medicine. Nearly three hundred years before Western nations turned inward to scrutinize health reform during the Industrial Revolution, health regulation was firmly on the agendas of European conquerors. Medical practitioners often traveled as members of colonial conquests, many of whom attempted to control epidemics for Spanish conquistadors. Most often, their care entailed the protection of invading settlers and colonial profit at the expense of their indigenous

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neighbors, and later, of their slaves. By the 1800s, health threats to colonizers increased as conquest deepened in “the tropics,” a term that did not simply describe middle-latitude territories, but an invented domain of the imperial powers. For white conquerors, “the tropics” was an alien world where “the familiar forms of temperate life were threatened, overturned, and inverted.”1 The health development that arose out of these Asian, African, and Caribbean territories is labeled today as tropical medicine. A classic case study in tropical medicine is the battle against malaria, a menace against European colonizers that halted the productivity of their plantation slaves and fueled the rise of bacteriological research. One pioneer in this effort was the British physician and parasitologist Patrick Manson, who not only researched the link between the malaria parasite and its mosquito vector, but also helped establish schools of tropical medicine in Britain to bolster the development of international cash crops (and recruit the laborers to harvest them). With the case of malaria being just one example, global health’s earliest efforts hark to a dark imperialistic history that tackled health concerns not out of benevolence or even of mutual benefit, but purely out of exploitation. Looking Inward: The Rise of Public Health As colonial ventures escalated in the mid-1700s, Europe was undergoing both an imperial and an internal transformation. The Industrial Revolution brought about a massive shift from feudalism to capitalism that prompted the English government to scrutinize the health of its own people. As the factory system and power-driven machinery made industry king, the standard of living in England’s urban centers plunged. Sanitation and city planning were virtually nonexistent, and cholera,

Photo Courtesy of the History of Medicine.

tuberculosis, and diphtheria were rampant. Suddenly, health reform emerged at the forefront of the domestic agenda in the establishment of modern public health, “a concept coined in the early 1800s to distinguish government efforts for the preservation and protection of health from private actions.” Edwin Chadwick and Friedrich Engels were at the forefront of these public health agendas, though the two men supported divergent solutions. Chadwick, a British lawyer and civil servant, demanded improvement in public sanitation but did not work for labor reform, denying that “poverty itself was the cause of illness.”1 Engels took an opposing position, attributing the “cause of ill health to the exploitation of the industrial working class under the capitalist economic system.” These efforts would later shape his work with Karl Marx in the 1848 Communist Manifesto. The birth of public health was not isolated to Britain alone. Similar social and labor movements appeared throughout Europe in the mid-1800s, including health reforms sparked by the founding of France’s Second Republic and the work of Rudolf Virchow in Prussia. International Health By the mid-1900s, the independent

domains of colonial medicine and public health were drawn together in Europe’s fight against cholera, a disease that “would bridge the distance between colonial and metropolitan health.” It was an illness that raged both in the urban squalor of industrial Europe and the “tropical” colonies along the equator. Suddenly, the health concerns of imperialists and industrial capitalists merged in the development of international health. Though decades removed from the height of imperialism, the term reflected an interest “to protect international commerce and fend off epidemics of diseases, such as cholera and plague, that might cause social unrest or reduce worker productivity.” Determined to halt further cholera pandemics, national public health strategies were channeled into international efforts; one of the first was the 1851 International Sanitary Conference (coincidentally, the year of the first World’s Fair in London) that brought together 12 European states to combat cholera. Others quickly followed suit: among them was Jean Henri Dunant, who inspired the founding of the Red Cross in 1864, the founders of L’Office Internationale d’Hygiène Publique (OIHP), or the “Paris Office” in 1909, and the League of Nations Health Organization (LNHO) in 1920. Instead of a colonial medicine that

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promoted blatant imperial repression, international health offered aid with an air of benevolence and an implicit interest in the expansion of global capitalism. The leader of this new effort was the Rockefeller Foundation, which likely coined the term “international health” itself. Established in 1913 by John D. Rockefeller, this philanthropic foundation carried out disease campaigns in countless countries and colonies and founded several American schools of public health. The foundation’s unique philanthropic independence allowed it to strategically fight diseases that were least costly, complex, and time-consuming: a model still used by global health organizations today. The Rockefeller Foundation was just one member of a powerful team of public and private multilateral organizations, with the OIHP, the LNHO, and the Red Cross being just a few. Their work, a marriage of colonial medicine and public health, cannot be considered without acknowledging the simultaneous rise of imperialism and industrialization. Indeed, health is not a neutral domain; it is ingrained in a struggle for power and influence of one nation over the other, or of a state over its people. Today, we must wonder how global health diverges from this aim, if at all. As Greene explains, “It becomes important to understand the colonial basis that prefigured global health in order to engage with the consequence of current strategies and negotiate resistance.” Contemporary Global Health In their 2006 article, Brown et al. address the ambiguous shift from international health to what they term global “public” health, which was a synthesis of colonial medicine and public health sparked by the first multilateral organizations of the 1900s. They explain that the term global health supersedes the political and ideological charge of its predecessor to convey shared

susceptibility in promoting health in a globalized era. This globalization, of course, cannot be limited to the transfer of money or manufactured goods, but must include migrating peoples and the diseases they carry with them. Birn et al. contend that this new term transcends the precedent of international health to “refer to the health needs of people across the world, irrespective of borders, thus depoliticizing the field.” In the wake of the physical and economic destruction of Europe and Asia in World War II, a restructuring of enormous colonial blocs of power placed a great emphasis on international cooperation. In this new political landscape, an unprecedented network of international organizations appeared, with the most notable being the World Health Organization (WHO), the World Bank, and bilateral aid agencies in formal colonial powers. The ratification of the WHO in 1948 consolidated the strategies and personnel of the Rockefeller Foundation and its contemporaries on an unprecedented level. Though the divided alliances of the Cold War were a hindrance, the decades following WWII were formative ones. In these years, the WHO initiated a worldwide immunization program, ensured the affordability of baseline medications, and directed groundbreaking vertical disease campaigns—the most notable being the eradication of smallpox from 1967 to 1980. In conjunction with the WHO, the World Bank directed the allocation of financial resources to allow countries to develop public health programs within their national borders. Though the WHO and the World Bank are the giants of global health today, smaller bilateral organizations may be most reminiscent of global health’s imperialistic roots. Today’s developed nations provide targeted healthcare assistance to weaker allies to advance the home nation’s security and economic interests. The United States,

with the United States Agency for International Development (USAID) as its flagship agency, remains the largest bilateral donor in the world today. Alongside these forces, one cannot exclude the newest facets of global health network: the rise of for-profit pharmaceutical and insurance companies, public-private partnerships (PPPs), and innovative non-governmental organizations (NGOs). The influence of “big pharma” such as the Merck Company or the “corporate philanthropy” of Shell, Exxon, or even Nestlé, though concerning, is undeniable. The work of PPPs like the Global Fund to Fight AIDS or the Stop TB Partnership has bolstered the work (though not the autonomy) of the WHO. Finally, one must not forget the efforts of revolutionary NGOs like Oxfam, Doctors Without Borders, and Partners in Health, all of which bring explicit missions of social justice to their work abroad. Only by tracing back to the quarantines of the bubonic plague can today’s incredibly varied arena of global health players be illuminated. However, unlike conquistadors or labor reformers, today’s health leaders must tackle the fragmentation and accountability of PPPs and NGOs, scrutinize the conflicting agendas of the public and private sectors, and maintain the bureaucratic efficiency of multilateral organizations. Nonetheless, their visions are fundamentally built upon those of their predecessors. Today’s efforts may not be so far removed from those of American colonizers, tropical bacteriologists, British social reformers, or of philanthropist-oil-tycoons after all. As Greene stresses, “Only with history can we begin to render the present unfamiliar, and approach global health with a keener sensitivity and patience.” Indeed, only with this purview can one truly realize that “the development of biomedicine, public health, and empire are far more interrelated than it first seems.”•

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Organization Spotlight: UNICEF Combating the Notion of Children as Commodities By Neda Shahriari

s global recession permeated the atmosphere in the 1980s, developing countries became particularly vulnerable to the impoverished economic conditions of the time. Not surprisingly, children in these countries were more vulnerable, in terms of unmet needs. James P. Grant, the third Executive Director of UNICEF starting in 1980, began the “child survival and development revolution” in order to combat the death of millions of children due to preventable illnesses. Central to the success of this effort was the expansion of immunization, to protect against “childhood killers” such as tuberculosis, Photo Courtesy of John T Imm (c) 2010

diphtheria, whooping cough, tetanus, polio and measles. Under James Grant’s leadership, UNICEF was able to greatly reduce the child mortality rate in developing countries. Originally, UNICEF was created in 1946 in order to assist the children of war-torn countries in Europe, China, and the Middle East following World War II. In 1953, however, UNICEF’s outreach towards children became more generalized in addressing the needs of children in the developing world. As mentioned, UNICEF has been involved in many global health efforts. In an interview with HCGHR,

Patrick McCormick, Emergencies Communication Officer at UNICEF New York, commented on a particularly notable triumph: “Polio is one of the most successful global health issues that UNICEF has been involved in. Since it was formed in 1988, the polio partnership has been instrumental in reducing polio cases by 99 percent. And, despite setbacks, we are very close to eradication.” According to an annual report published, UNICEF has attenuated child mortality from 34,000 deaths per day in 1990 to 22,000 in 2010. Evidently, its success is rooted in implementing preventative measures; that is, UNICEF has provided “immunizations, health care, improved nutrition, clean water, protection, and education for millions of vulnerable children and their families.”5 More recently, in the aftermath of the destructive earthquake that occurred in Haiti on January 12, 2010, UNICEF, with the assistance of generous donors, has helped prevent the “second wave of death” that could have occurred due to disease and malnutrition. Haiti’s need for a relief organization that focuses specifically on paramount issues affecting children has become increasingly salient as children have increasingly been exploited for monetary gain. By taking advantage of Haitians’ present vulnerabilities, traffickers have been buying children for as little as 76 pence each.

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Frequently, they deceive parents into believing that their children will be placed with families of higher financial status who can provide them with improved standards of living. In an interview with HCGHR, Kristen Mangelinkx, director of the New England Region of the U.S. Fund for UNICEF, noted, “With Haiti, specifically, families from rural areas think

“If you are trafficked, it means you are like a commodity or thing. You’re not a person, you’re not respected by others, and you don’t respect yourself either.” that they are giving their children a better life by sending them into the city to live with middle class families, but Photo Courtesy of John T Imm (c) 2010

they sign them up for a life of being restaveks, which are essentially child household laborers.” The rise in the prevalence of child trafficking following the Haitian disaster was not only initially identified by UNICEF, but has remained a critical concern for the organization. Children are often exploited for use in prostitution, forced labor, and illegal adoptions. “If you are trafficked, it means you are like a commodity or thing. You’re not a person, you’re not respected by others, and you don’t respect yourself either. You are not treated well in terms of food and clothing and are often sexually abused,” commented Anne Kelley, director of the Southern California Region of the U.S. fund for UNICEF, in an interview with HCGHR. UNICEF’s recent efforts in combating child trafficking has, similar to its past, helped improve the health outcomes of children in an indirect way. Although child trafficking is usually deemed a human rights issue, it should also be viewed as a global health issue. Impoverished living conditions, in conjunction with poor nutrition, can cause increased prevalence of scabies, tuberculosis, and other communicable

diseases. Furthermore, trafficking can cause psychological trauma, including anxiety, depression, phobias and panic attacks. It must also be noted that child trafficking is not limited to the developing world, but occurs in industrialized countries as well. Concerning the link between child trafficking and health, Mangelinkx noted, “It’s all interconnected. The child protection piece of what we do is typically not funded at the same level as some of the other health initiatives, like the water initiative, but it’s the basis for all the other issues down the road for children who are vulnerable to abuse, exploitation and trafficking.” Although successful restorative efforts in Haiti have been documented and lauded, only the issues of nutrition and housing have been prominently targeted by other aid organizations while other issues have gone to the backwater. UNICEF, on the other hand, has vigorously sought to combat the issue

“Birth registration in developing countries is a chief concern, because if children are deemed to be non-existent, they become more vulnerable to child trafficking.” of child trafficking. According to an article in the Telegraph, “the charity is funding the Brigade de Protection des Mineurs (BPM)—working in conjunction with the police—which monitors the camps and Haitian borders to

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pinpoint vulnerable children.” Birth registration in developing countries is a chief concern, because if children are deemed to be non-existent, they become more vulnerable to child trafficking. “Many children are born in remote areas, where there are no doctors or even midwives. The birth of a baby is never officially recorded. Thus, it’s hard for the child to get into school, to get health services, to inherit anything, or even to immigrate to another country. Not having a birth certificate is a huge problem. This is another thing that UNICEF works on: to have the government create systems, policies, and procedures so that every child’s birth is recorded,” Kelley explained. UNICEF has assisted in the expansion of the BPM in order to increase the government’s capacity to serve as a social protection network for children. Their success is reflected in the fourfold increase in the number of officers

serving on the brigade. Included in the BPM monitoring role is the deterrence of child trafficking through the inspection of the travel documents of minors crossing the border. Between May and December 2010, the BPM was able to stop approximately 1,437 children from crossing the border between Haiti and the Dominican Republic. In addressing the issue, UNICEF has employed preventative measures like education. As delineated by Ms. Kelley, “One of the things that UNICEF really focuses a lot of its attention on is teaching children that they have rights: they have a right to an education, they have a right not to be sold, they have a right not to be used as a soldier, they have a right to protect themselves and have control over their bodies, and they have a right to good food. UNICEF teaches this to children— educating kids is a huge way of stopping

trafficking because if we can educate kids about what trafficking means, then children are better able to understand that they are not ‘things’. Rather, they have a right to be respected.”9 Undoubtedly, the impact of these kinds of interventions on child health outcomes is significant. Beyond the issue of child trafficking, UNICEF has made progress in other health-related efforts. Recently, the Haitian Ministry of Health, in collaboration with UNICEF, initiated the “Strategic Nutrition Framework for Cholera Response in Haiti” in order to prevent the proliferation of cholera and reduce associated mortality amongst children. UNICEF, which has field offices in over 150 countries, continues to facilitate the healthy development of children around the world by advocating for better health, sanitation, education, and protection. •

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The Global Health Web: An Integrated Approach Toward Solving Global Problems By Eesha Dave

espite having a straightforward name, “global health” is not simple. In fact, according to Jeffrey Koplan, M.D., M.P.H., and colleagues from the Consortium of Universities for Global Health, “The global in global health refers to the scope of problems, not their location.” The field extends beyond just treating health and illnesses in a given area. They say that “global health has to embrace the full breadth of important health threats.” It is intertwined with many other fields and issues such as economics, technology and human rights, and often brings attention to them. Global health recognizes that improving health and providing effective interventions is not just accomplished through clinical means, but that social and economic factors also play a role in the delivery and success of global health projects. Because of this integrated approach, global health organizations have been able to increase awareness of other prevalent issues. Since global health encompasses such a spectrum of problems and regions around the world, it is truly interdisciplinary in nature. Donald Thea, M.D. from the Boston University Center for Global Health and Development, says that global health is really “part of the larger development dynamic and in order for you to achieve success in health and the international setting, you need to have an interdisciplinary

approach.” Even the problems that are not the commonly heard buzzwords of global health, such as AIDS and malaria, impact the lives of all individuals and thus global health tries to improve them through a multidimensional approach, which leads us to focus on not just purely health. There has been a greater focus on the role economics plays in people’s lives due to the growth of global health. Researchers have realized that economic ability and income significantly impact health, access to healthcare, and one’s lifespan. In one study, the National

Bureau of Economic Research investigated populations aged 50 and older across different incomes and noted differences in their lifespan. Families with daily per capita expenditures (DPCE) of $4 or less had similar chances of survival, and these chances of survival increased with income thereafter. A mother in a family that has a DPCE between $6 and $10 has a 36 percent higher chance of survival than a family with a DPCE of only $1 or $23. Given these statistics, many global health entities have turned their attention to poverty and sought to increase

Photo courtesy of the Bill and Melinda Gates Foundation

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treatment access for those with financial barriers. Matthew Fox, M.D., also at the Boston University Center for Global Health and Development, is involved with a project titled the Economics and Epidemiology of HIV/AIDS Care and Treatment. This program studies the costs and benefits of HIV/AIDS treatment and searches for cost-effective ways to provide treatment to patients. The program also tries to find ways to improve the HIV and TB treatment programs in nations’ health systems. Fox and his group look for ways to intervene and keep patients in treatment programs. In an interview with the HCGHR, he said that “one of the biggest things we look at is the things that make these patients drop out of programs” and then “given a set of interventions of what we could do, what are the most cost-effective.” Prevention and affordable treatment are essential to health. In addition, according to Thea, the Boston University Center for Global Health and Development has an “approach to health [that] is really quite difficult to separate from the development perspective.” Thus the many projects of the center are intertwined with building on both a physical and personal level. One project titled “Addressing the Needs of Women Living with HIV in Vietnam” works on providing HIV affected women with more than just medical knowledge. While the project provides them with information about HIV, antiretroviral therapy, and mother-to-child disease transmission, it also recognizes the importance of educating and empowering women. Thus, it also teaches them how to manage and generate income, educating them about micro-credit services. The program places a strong emphasis on gender-based violence and trains GBV service providers so that

they may educate and provide counseling to suffering women. Accordingly, the issue of gender equality has received significantly more attention in global health agendas due to its links to health-related problems. A publication summarizing a roundtable discussion entitled “Women, Girls, and Gender Equality Principle” of the U.S. Global Health Initiative (GHI) published by the Kaiser Family Foundation highlights the role of gender inequality that has emerged through the study of global health. The publication states that “there are many factors directly and indirectly related to improving health outcomes for women and girls.” It also “empha-

“...the issue of gender equality has received significantly more attention in global health agendas due to its links to health-related problems.” sized the importance of ‘linkages’ and integration among U.S. global health programs as well as between health and other U.S. development efforts (e.g., education, governance, etc.).” Educating women and girls, providing them with guidance, and empowering them are essential to developing strong citizens, consumers, and workers. These women are ultimately a key component of families and societies, so it is essential to provide them with a strong foundation so that they are able support themselves and maintain their health.

The Global Health Council also recognized this need to educate women, and provide them with income and decision-making power. This is especially critical in societies where men have more sexual partners than women do (making women more susceptible to diseases) and in societies where violence towards women is permitted. Partners in Health (PIH) is an NGO that aims to provide healthcare to some of the most struggling regions of the world. Its oldest and largest project, Zanmi Lasante, is based in Haiti and now serves over 1.2 million people. This project has expanded over the past 25 years and now includes hospitals, pediatric wards, operating rooms, specialized medical clinics and pharmacies. However, beyond these medical resources, PIH recognizes the importance of education and its connection to health. Thus, it has also worked to set up a dozen schools as part of this program. Since the earthquake that struck Haiti in 2010 left about 30,000 children in need of aid, PIH in collaboration with the Progress and Development Foundation, created Kay Timoun, an education program implemented in settlements in the Port-Au-Prince area. These programs are designed to help earthquake affected children aged 6 to 14. The school focuses 60 percent of its curriculum on math, science, and humanities subjects and 40 percent on non-academic activities such as extracurricular activities, sports, and psychosocial support. Evidently, global health draws attention to other fields due to its interrelated nature. A health problem is often caused by other problems—economic, social or physical—and studying global health helps bring them to light and helps us realize that often improving one problem is a means toward solving another.•

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Global Health and U.S. Policy: Implementation Controversy and the Example of PEPFAR

n January 28, 2003, in his State of the Union address, former United States President George W. Bush made a bold request. He asked Congress to authorize an emergency plan for AIDS relief and to commit $15 billion over the following five years to the project. Bush suggested that such a commitment would be “a work of mercy beyond all current international efforts to help the people of Africa,” and he hoped that it might “turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.” In response to the President’s entreaties, Congress approved the “United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003,” and in May of that year,

By Leeann Saw President Bush signed the act into law. The establishment of the President’s Emergency Plan for AIDS Relief, or PEPFAR, brought the United States to the forefront of government-run global health initiatives. According to PEPFAR’s official website, the initiative is “the largest by any nation to combat a single disease internationally.” During George W. Bush’s presidency, PEPFAR saw significant success in its projects. A study published in 2009 by Eran Bendavid, M.D., of Stanford Medical School, showed that PEPFAR reduced the death toll from HIV/AIDS by more than 10 percent in the program’s twelve African “focus” countries in the period from 2003 to 2007. Though the researchers “could not see a change in prevalence rates that

Ministry of Health poster for a village level public health center in Cambodia; courtesy of Cecil Haverkamp.

[were] associated with PEPFAR,” they estimated that the program had saved about a million lives through treatment during the four-year period.4 As a result, response to the program has been largely positive, but one of the most controversial aspects of the initiative, the Bush administration’s implementation of the “Abstinence, Be Faithful, Use Condoms (ABC)” prevention strategy, raises important questions about the efficacy of United States’ global health policy. Under Bush, PEPFAR funded abstinence programs over condom distribution programs, with 40 million of the 61 million people reached by PEPFAR-supported outreach projects participating in programs only promoting abstinence (A) and being faithful (B). Domestic critics suggested that this system placed the interests of American Christian groups over the needs of African patients, with some even claiming that the policy “reconfirmed global views of the United States as a unilateral power imposing its view on others.” The Bush administration countered these claims by contending that “abstinence is the only guaranteed way to prevent sexual infection,” pointing to evidence from various African countries in which A and B programs were shown to be effective. However, the major objection of the African recipient countries themselves and of workers on the ground was that the policy restricted aid groups from responding to the direct needs of African communities. Indeed, in a 2006 U.S. Government Accountability

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Office (GAO) study, 17 of the 20 country teams required to meet the A and B spending requirements reported that meeting the requirement “[challenged] their ability to develop interventions that [were] responsive to local epidemiology and social norms.” For example, in order to meet PEPFAR’s requirements, several country teams had to limit condom distribution to specific high-risk populations such as commercial sex workers and substance abusers. This led to stigmatization of condom use in some countries, potentially leading to unsafe sexual practices and more infections. This type of objection from countries on the receiving end of American global health aid is a common one. The national health ministries and local authorities of receiving countries are often sidestepped and their nominal stewardship and responsibility ignored when foreign aid programs are implemented, leading to initiatives that address the specific needs of their populations inefficiently or not at all.

“Doing things through local systems might take longer, but it means that when you leave the country, there is capacity that will still continue.” -Haverkamp Cecil Haverkamp, who coordinates global health practice and partnerships at the Harvard School of Public Health, observed this problem while working for the World Health Organization in Cambodia, a nation where over a

Donor and UN vehicles outside a meeting of health partners in Cambodia; courtesy of Cecil Haverkamp.

hundred NGOs operate in the health sector alone (many of them Americanfunded), but where a weak ministry of health has no idea “who is doing what where.” The result, according to Haverkamp, is that aid is doing little to build a health system and is often not channeled to the areas where it would be most beneficial. For example, in an interview with the HCGHR, he notes, “Cambodia now has a prevalence of HIV of one percent, but a majority of the NGOs are working on HIV. At the same time many kids are dying of diarrhea and other conditions, but they can’t access help because they don’t have HIV.” Much of the work under PEPFAR is important and genuinely generous, he says, but as the critics on the ground in Africa and Asia identified, fundamental aspects of its approach and policy undermine local ownership and needs. The examples of Cambodia and PEPFAR suggest broader issues in U.S. global health policy. “With donor agendas dominating, local priorities are ignored and systems get distorted,” Haverkamp states, “not because local government

and communities don’t know what the real problems are, but because the thing that dominates is the agenda that people bring from outside of the country.” Furthermore, program sustainability can be achieved only if receiving countries can be given more influence over aid priorities. As Haverkamp puts it, “Doing things through local systems might take longer, but it means that when you leave the country, there is capacity that will still continue.” From the perspective of U.S. global health policy, PEPFAR has been overall a great success. The initiative has saved more than a million lives, and with President Barack Obama’s 2009 pledge to increase its budget to $48 billion for the 20092013 fiscal years, its human impact will continue to grow. Yet one of the major controversies that emerged from its implementation raises very important questions about the future of the Obama administration’s new Global Health Initiative. How can the United States better align its aid with the priorities of local governments and communities, and how can its delivery systems be modified to both save lives and build local capacity?•

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Beyond Medicine: Career Opportunities in Global Health

ow more than ever, both educational and professional interest in global health is exploding. From as early as their undergraduate years, students are increasingly expressing interest in applying their skills to this all-encompassing and rapidly growing field. Today, there are over 20 accredited schools of public health that specifically offer a concentration in international and global health, a statistic that may have been unthinkable just 20 years ago. Back then, only 22 percent of United States medical schools offered even a single course on the subject of international health, whereas now almost all medical schools have created some avenue for students to pursue their interest in global health. Paralleling these developments in education, global health has recently been attracting professionals outside of the medical domain, with specialists from academia, management, law, communications, business, and other fields increasingly finding valuable roles within the field. As a result, the bounds of global health work have expanded to include the health consequences that arise from trauma, violence, war, displacement, and general upheaval in low to middle income countries. Ted Schrecker, Associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, stated in an interview with HCGHR, “Global health is a very big and diverse field, and there is no one career path; instead,

By Hannah Semigran

it very much depends on [the student’s] own particular interests and background.” Indeed, Schrecker, who currently advises masters and Ph.D. students in population health, carries a diverse background in environmental policy consulting and studies “the interface of science, ethics, and law.” A self-described political scientist in training, Schrecker’s first endeavor in global health occurred nine years ago when he participated in a research project funded by the Canadian government to enumerate commitments made to health care in preparation for the 2002 Alberta G8 Summit. Of the report, Schrecker said in an interview with the HCGHR, “I’m sure [the government] thought that they would get a pat-on-the-back and a 25-page report, but instead they received a 300-page book called ‘Fatal Indifference: The G8, Africa, and Global Health.’” Since then, Schrecker believes that his greatest professional achievement to date is his research for the Globalization Knowledge Network, one of the nine transnational commissions of the World Health Organization (WHO). Much of his research has consequently found its way into the WHO’s final report on the Social Determinants of Health. Echoing Schrecker, Director of Programs at Partners In Health (PIH) Jenna LeMieux highlighted the wide range of careers in global health. “Within global health, there are many avenues for engagement—not dissimilar from the multifaceted health

care systems in the developed world. Individuals from a broad range of medical specialties, management, policy and other backgrounds all play important roles,” she told HCGHR. LeMieux obtained an M.B.A. at Harvard Business School, and worked for several years in Boston in the nonprofit sector. She began her career with PIH as a Project Manager at PIH’s site in Malawi, where she provided general management support in a start-up environment. In her current role in Boston, she provides “cross-site accompaniment and support to staff in the field.” She also serves as a link between PIH’s global sites and domestically based functions.

“Global health has recently been attracting professionals outside of the medical field...” The field of communications increasingly makes important contributions to global health work, as it allows for the easy dissemination of information on health issues around the world. Sarah Arnquist, freelance journalist and case writer for the Global Health Delivery (GHD) Project, noted an emerging demand in the field for mediabased skills: “In global health, because so many organizations are self-publishing so much, they are hiring content

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developers and multimedia producers for their websites and print materials. There is a lot of potential in media, not just for traditional advocacy.” Arnquist majored in journalism as an undergraduate and said she gravitated toward this field for “social justice reasons.” She received an M.P.H. in 2009 and currently works for GHD, which connects “a platform of online professional virtual communities [to link] isolated practitioners and [foster] knowledge and exchange among people working in global health.” Her job is to prepare educational case studies for use in academic settings. For those interested in the journalistic aspect of health, Arnquist advised, “Get experience writing. It doesn’t have to be about global health—write for anything you can write for, get edited, learn online tools, learn how to use web content management systems, and multimedia tools”. Professionals with legal background can also find a niche within global health, as Brook Baker, a law professor at Northeastern University and AIDS activist, demonstrates through his 30-year teaching career. After going on a six-month sabbatical in 1997 in Durban, South Africa and attending an International AIDS conference there

in 2000, he started to become involved in HIV/AIDS advocacy efforts: “What began [for me] as a curricular focus on increasing HIV-related content in South Africa’s law curriculum quickly metamorphosed to AIDS treatment activism.” Working with Health GAP (Global Access Project), Baker advocated for a decrease in price of AIDS medicines and the acquisition of resources towards comprehensive AIDS prevention and treatment. Health GAP was instrumental in advocating for the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the U.S. President’s Emergency Plan For AIDS Relief (PEPFAR) program. Baker studied economics as an undergraduate. Of his career, he said, “My entire identity as a law professor is now organized around the response to HIV/AIDS. For me, AIDS is a lens to the world—from our most intimate acts to the structures of the global economy and almost everything in between.” As an academic, Baker teaches a Global AIDS Policy seminar at Northeastern and writes extensively on HIV/AIDS advocacy debates. He is currently on a four-month sabbatical at the University of KwaZulu-Natal in Durban. “The global health movement needs

Photo courtesy of Judy Park

people with real, practical expertise in a broad number of areas. In particular, it needs people who can adapt technologies and programs to the realities of resource-poor settings at the same time that these practical experts fight the political structures that impede their work,” he asserted. Nava Ashraf, an Associate Professor of Business Administration at Harvard Business School (HBS), views development and health with a similar perspective. After studying economics as an undergraduate, Ashraf anticipated a career in development but was initially unsure of whether or not she wanted to enter the medical field. “I thought that as a doctor, I would most directly help [communities], but the entire system might not be correct. Economics, however, is an integral part to improving people’s lives,” she commented. Today, Ashraf teaches a course on field experiments at HBS, and her research continues to generate insight into what influences human behavior in order to better design systems. Ashraf added, “If you want a seat at the table where [organizations] are making big decisions on policy, you need a Ph.D. in economics, which is what gave me a language and a strong theoretical discipline.” As advice to newcomers to the field, Ashraf recommended “learning statistics and economics well to tackle assumptions that arise in the field with a language people understand” and “cultivating an enormous amount of discipline and humility.” As evident by the wide variety of professionals within global health, there is not just one correct career path to take in the field, but rather, each path can be tailored to an individual’s particular interests and strengths. “There are many viable, worthwhile, and necessary paths to take, but one thing that is most important is to reflect on what interests you as an individual,” Schrecker stressed. •

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Global Health at Harvard: Ideals to Implementation Exposing students to the field via the classroom

n recent years, some of the most captivating international issues permeating social consciousness relate to the global health field. From shocking natural disasters in Haiti and Pakistan to infectious disease control in developing countries, these and other global health issues have resonated with professionals, students, and donors alike. Most recently, the tragic earthquake in Japan instantly garnered attention and support from around the world. In striving to foster a collaborative system of individuals dedicated to this line of work, Harvard has been at the forefront of the academic push for enhanced global health education and exposure. President Drew Faust pronounced global health as a top priority in a May 2010 press release announcement to the Harvard community, celebrating the efforts of the newly established Harvard Global Health Institute (formerly the “Harvard Initiative for Global Health” or HIGH). Sue J. Goldie, Roger Irving Lee Professor of Public Health, was appointed as the director of the Institute. Faust also appointed two faculty leaders to direct the “critically important educational and training efforts.” Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine at Harvard Medical School (HMS), oversees global health medical education and physician training, and David Cutler, the Otto Eckstein Professor of Applied

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Economics in Harvard’s Department of Economics and a member of the faculty of the Harvard Kennedy School, directs undergraduate and graduate programs in global health. Faust cited a need to “engage and equip” students to work in the global health movement: “We need to support the very best researchers and the work of our outstanding faculty, in fields stretching across the spectrum of inquiry from immunology to epidemiology, health policy, history, molecular biology, and philosophy.” In the 86th Harvard School of Public Health (HSPH) Commencement Ceremony, Dean Julio Frenk emphasized the cross-disciplinary nature and breadth of professional diversity applicable to global health problems, stating that it is not only an “integration across disciplines, but also, integration across levels of analysis, with a capacity to examine problems from the gene to the globe.” Drawing from these ideas, a new field of global health could encompass widespread capabilities from globalization and health linkages to conflict management among overall expertise, by shaping global professionals to have the skills and networks to manage an effort on the ground. Echoing this sentiment, HSPH student Danae Roumis says that the graduate school “brings people that do bench science together with people that do global health delivery.” Roumis says that an effective global health department consists of the best aspects of other departments across

varied fields that are all united in this specific global health application. “The passion demonstrated by undergraduates around issues of social justice, human rights and world health inequities has created an unprecedented demand for global health courses, field experiences, and a Secondary Field in Global Health and Health Policy,” said Goldie. “While we hope that some of the best and brightest students will graduate from Harvard inspired to choose career paths of leadership in global health, we are committed to providing every student with the opportunity to acquire a global health outlook.” She points out that the foundational courses in global health supported by the Institute are now offered in the General Education Program, and that high student enrollment is indicative of the interest in global health from students with a broad range of interests and areas of study. Goldie described close to 500 students entering the lottery or requesting admission to her course “Societies of the World 24: Global Health Challenges,” which was capped just below 200. Rebekah Getman, Education Program Manager, states “this year we had over 800 undergraduates take one of the secondary field’s four foundational courses: Societies of the World 24; Societies of the World 25: Health Culture and Community, taught by Paul Farmer and Arthur Kleinman; Science of Living Systems 19: Nutrition and

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global health review Global Health, taught by Christopher Duggan, Wafaie Fawzi, and Clifford Lo; and Empirical and Mathematical Reasoning 20: The Business and Politics of Health, taught by David Cutler.” The Secondary Field curriculum offered by the College espouses an interdisciplinary tenet of evolving global health conceptions. Professor Duggan endeavors to portray this field as “the ultimate disciplinary science” in Science of the Living Systems 19, which has attracted substantial undergraduate enrollment since its introduction to the general education curriculum. Duggan says that a strong academic focus is crucial to an appreciation of field work and aspects of global health concerns can be blended into academia across departments given the diverse skill sets needed to tackle these problems. “Harvard can continue to rely on teaching and research while reaching out to the undergraduate campus… collaborative research continues to be a good way for Harvard to perform global health,” says Duggan to the HCGHR. Likewise, he states that Harvard has an important role in global health in its responsibility to “train tomorrow’s leaders.” Considering the future of global health curricula, Cecil Haverkamp, Coordinator of Strategic Partnerships and Global Health Practice in the Department of Global Health and Population at HSPH, believes in a combined theoretical and experimental approach for a thorough student experience. Global health curricula would thus encompass education about the substance of a problem in the classroom and then subsequently expose students to the orchestration of a global health initiative through placement in various regions around the world. Cutler, who led the effort to create the Secondary Field in Global Health and Health policy, points out that responsibility for global health education does not just involve classroom education [press release, May 18, 2010], “it also means providing students with the ability to

interact with the world and practice what they learn.” Similarly, Farmer, has emphasized the “need to draw on the strengths of the HMS, HSPH and the teaching hospitals—and especially on the work of our partner sites—to help tackle the biggest challenge of our time: understanding and improving delivery of services in this country and in others.” [press release, May 18, 2010] Through summer internships offered by the Institute, students are able to experience this two-pronged approach to global health. For example, the Nutrition and Global Health Program introduces students to global health through Science of the Living Systems 19 and subsequently allows students to apply their classroom instruction via research, clinical and field placements in India, Tanzania and Brazil. Similarly, the Institute offers graduate students fellowships for global health research. “This year, we received over 270 applications for undergraduate summer internships. We’ll be supporting up to 80 student interns working on global health projects with Harvard faculty on campus and in over 15 countries,” said Jonathan Colburn, Internships Program Manager. In addition, the Institute is working in partnership with the Medical School’s Department of Global Health and Social Medicine and Partners In Health to propose a new study abroad program that would, as Getman states,

“integrate scholarship and experience in the field to give undergraduates unparalleled exposure to global health practice and research.” Dr. Goldie notes, “Many of our global health internships and curriculum development efforts are made possible through the generosity of donors like Mark and Lisa Schwartz and Katherine States Burke and T.R. Burke. The Vice Provost for International Affairs, Jorge Dominguez, is also a key partner assisting the global health community as we seek to strengthen international opportunities.” The combination of academic classes, internships and other extracurricular offerings offers wide-ranging access to opportunities in global health to foster a strong community of scholars dedicated to addressing the growing challenges and complexities which arise in global health. “The most critical global health challenges of the 21st century demand interdisciplinary solutions and we need to equip students with the knowledge, skills and values to be able to address them,” Goldie says. She emphasizes that the Harvard Global Health Institute is committed to strengthening an emerging field of global health and to preparing a future generation of scholars and leaders. She adds, “The investment of faculty across the university to engage in undergraduate education in global health has never been greater.” •

Courtesy of the Harvard Global Health Institute

INTERVIEWS

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An Interview with Dr. Anthony Fauci Farhan Murshed, Staff Interviewer

Photo Courtesy of Dr. Fauci

HCGHR: Have there been any promising updates to federal HIV vaccine research or the anti-AIDS pill? Fauci: Over the last year and a half, it has been really quite a big year for the issue of various prevention modalities. Let me give you some specifics. About a year and a half ago, we had first indication after literally two decades or more of unsuccessful attempts to get the faintest positive signal that a vaccine can block acquisition of HIV. There was a trial that was sponsored in collaboration with the United States Army, the Ministry of Health of Thailand, and my institute, the National Institute of

Dr. Fauci was appointed Director of NIAID in 1984. He oversees extensive basic and applied research intended to prevent, diagnose, and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism. Dr. Fauci serves as a key advisors to the White House and Department of Health and Human Services on global AIDS issues, and on initiatives to improve medical and public health preparedness against emerging infectious disease threats. Dr. Fauci has made many contributions to basic and clinical research on the pathogenesis and treatment of immune-mediated and infectious diseases. He has pioneered the field of human immunoregulation, delivered many major lectureships all over the world, and is the recipient of numerous prestigious awards for his scientific accomplishments, including the Presidential Medal of Freedom, the National Medal of Science, the George M. Kober Medal of the Association of American Physicians, the Mary Woodard Lasker Award for Public Service, the Albany Medical Center Prize in Medicine and Biomedical Research, and 35 honorary doctoral degrees from universities in the United States and abroad.

Allergy and Infectious diseases. Here at NIH, the trial was a trial of a certain product of candidate vaccine that was tried in Thailand in 16,000 volunteers to determine – and these were relatively lower-risk individuals, mostly heterosexual individuals – it showed that in fact there was a modest, at best, but nonetheless a clear signal of efficacy which really is the starting point of trying to now improve greatly on that and determine the cause of immunity. Point number one, there’s been this modest success, but nonetheless an important proof-of-concept in the arena of vaccines. More dramatically, over the last 12 months, has been the Caprisa study,

which was a study of a 1% tenofovir gel compared to placebo in Africa, in women, as a topical microbicide. And again we have discouraging failures in prior trials with microbicides which did not incorporate into the gel or the cream a specific anti-retroviral drug. This one was different because it was the first time that a well-established anti-retroviral drug, in this case tenofovir, in the formulation of a 1% gel was incorporated and the results again were actually, not overwhelming, but clear and highly significant. It was about 39% efficacy. Of note, it was strongly related behavior because many of the women skipped sexual encounters without

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doing the gel. So, if there was a better adherence, the results would’ve very likely been better. Probably the most dramatic recent advance in the arena of prevention has been the iPrEx study or PrEP in which men who have sex with men were given either a placebo or a daily pill of Truvada, which as you know is combination of two drugs – emtricitabine and tenofovir And the results were really striking from two standpoints. It was highly significant with the study as a whole about 43.8% efficacy. Importantly, in individuals who said, who verbally declared, that they used the drug the vast majority of times, the efficacy went up from 44% to over 70-72%. But even more importantly, for those drug levels indicated that they actually did take the drug and drug was absorbed properly, the efficacy of prevention was about 90%. So those three issues are now building up the concept that we been aiming for for some time now of prevention as a combination approach incorporating treatment modalities as part of prevention modalities. So its been actually – the short answer to your question is that this has been a very interesting and gratifying year to year and a half particularly in the arena of prevention modalities. HCGHR: Considering both cost and prevention, what is the long-term outlook, expectations, and hopes for the future of HIV and AIDS treatment? Fauci: That’s an excellent question, but I’d like to divide it into two elements. One is fundamental to prove the concept of biological interventions, to prove that they actually work. And then how do you actually implement them and what are the cost-benefit/riskbenefit ratio then. And let me explain what I mean. Certainly if you have treatment

of larger numbers of individuals in programs that were starting here in the States, in certain pilot cities such as Washington and South Bronx and in other cities around the country. Of seeking out testing – linking to care and treatment - is that the more people you put on treatment, the less likely that those people will infect others. That costs money. But in the long run, the combination of treating people who are infected, implementing pre-exposure prophylaxis in relevant, appropriate high-risk groups in which you have shown scientifically that it works. Together with interventions, such as circumcision, topical microbicides, and the vaccine in the long-range – which doesn’t necessarily have to be as effective as say the small-pox or polio vaccine, but gives a rather good but not superb decrease in acquisition. Like 31% is clearly not good enough for primetime. But if you can get it up to 60-65% in combination with condom use, PrEP [Pre-Exposure Prophylaxis], circumcision, topical microbicides, behavioral modifications, and you can actually in the long run turn around the dynamics of the epidemic. Because once you get fewer and fewer people getting infected, when you mathematically model that, then fewer and fewer people will infect other people. And it comes off as a self-propagating phenomenon. But we’re not there yet. We haven’t reached that critical point where the actual dynamics of the epidemic can get turned around, but my long-term outlook is that despite cost of doing this, in the long-run, it will ultimately save a lot of money. HCGHR: How does NIAID support innovation in vaccine research? Fauci: Innovation in science almost always comes from the creative individual ideas of investigators. So the support

that we - at my institute that I direct – give directly or indirectly, really always incorporates creative ideas that come from individuals. So you have to be able to support fundamental, basic undifferentiated research that would lead to new discoveries. On the other hand, you take a more proactive role and you set up situations where there are reagents available, there are clinical trials (networks) that can be used to test the vaccine, there are individuals that do molecular epidemiology to be able to determine what the particular dynamics of an epidemic is and what is the predominant strains in a particular area. So let me give you one example of what we mean by a combination of individual investigator ideas and programmatic assistance to steer in the direction of where you want to go. Right now, structure-based vaccine design is hot. We know with HIV that if you depend upon the natural traditional, time-honored paradigms of how you develop a vaccine against a particular virus for example – you generally look at how you can induce an immune response by the vaccine that is similar to the immune response that’s generated by natural infection. Because even with diseases that cause considerable degrees of morbidity and/or mortality like smallpox which kills 15-20% of people but 80-85% survive and their immune system subsequently gives them lifelong protection. The same thing with measles – many children get very sick, some die; but at the end of the die, the overwhelming majority of them mount an immune response that turns out to be protective. You can say the same for polio. You can say the same for a variety of infections. So we, as vaccinologists, determine how we’re going to plan a vaccine tend to like to as the old-time infectious diseases people used to say, and that we even say to this day, is the best vaccine

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INTERVIEWS

HCGHR: You are one of the world’s most respected and highly cited immunologists as well as the director of a national institute - how do you manage your commitments as a scientist and an administrator? What compels you to do both?

Photo Courtesy of Dr. Fauci Dr. Fauci is a member of the National Academy of Sciences, the American Academy of Arts and Sciences, the Institute of Medicine (Council Member), the American Philosophical Society, and the Royal Danish Academy of Science and Letters, as well as other professional societies including the American College of Physicians, the American Society for Clinical Investigation, the Association of American Physicians, the Infectious Diseases Society of America, the American Association of Immunologists, and the American Academy of Allergy Asthma and Immunology. In addition to being an editor of Harrison’s Principles of Internal Medicine, he has served as author, coauthor, or editor of more than 1,100 scientific publications.

is one that mimics natural infection. That’s absolutely not the case with HIV because we know as challenging as this is, the immune system does not naturally handle HIV very well at all. In fact, in an almost astounding way there is not well-documented cases of individuals with truly established HIV infection who have naturally cleared the virus from their body. We have a small, small percentage of longterm, elite nonprogessors, but that is a very small fraction. Most of the people can’t handle the virus well with their immune system. When we develop a vaccine, we’ve got to show the immune system components of the virus that when you make an immune response against it, it can actually protect you from the

acquisition of infection. That is a very difficult, challenging thing, but by using what we call structure-based vaccine design, we can pinpoint that part of the virus, which when you make a response against it, you can broadly neutralize the virus. That work is in progress and that is what we support directly and indirectly. In answer to your question, what are we doing to directly or indirectly support innovation – that’s what we’re doing: we’re funding everything from fundamental basic science like the structure-based design of a particular epitope that will be used as an immunogen – to supporting large-scale clinical trials to test these types of vaccines in populations throughout the world.

Fauci: It really comes down to making choices in life, but this to me is the engine that drives me. I make a major investment of time traditionally – I would say traditionally – but historically over the last 26 years that I’ve been director in order to maintain my scientific activity as well as my administrative activity, you have to invest what some people might call an inordinate amount of time. I do that because I believe that as a scientist I can contribute, but also being an active practicing scientist really does help my judgement as an administrator about the directions that research should be going. Not that they all come from me, but it allows me to better understand and facilitate how the creative ideas of others can be best implemented. What compels me to do both is that we’re dealing with a historic, devastating pandemic. Not very many people in their lifetime can have the opportunity to work in an area in which if you are successful in pushing the field forward, the impact on the lives of so many people can be profound. So it’s that: keeping you’re eye on what the goal is allows you to work 17 hours a day plus and weekends; and I’m not saying that as – oh poor old me I’m working so hard – it’s like I wouldn’t do anything else other than that. HCGHR: What are the main challenges of serving dual roles, both as a public health advocate and a public servant? Fauci: The tension really is my very being, my career, the thing that makes

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me tick is a burning desire for being an advocate of – both not only in my scientific endeavors but my bully pulpit capabilities as the director of a large institute, my access to bodies like the Congress and various administrations – the balance and the challenges are that you have to articulate in a convincing manner the important thing you are doing and the support for the field balanced against the fact that the people you need to rely on – like the United States taxpayers, Congress, various Presidents that I’ve had to deal with – they have a lot of other priorities other than yours, so you’ve got to be able to work within the system to put for the best arguments forward for the kinds of things you think are important. Which was really the thing I spent a lot of time on years ago in 2002-2003 when I worked very, very closely with the Bush administration to convince them to put together – and I mathematically did it and scoped it out which is now called the PEPFAR program. I mean that was the result of months and months and months of pushing and giving models and arguing for the importance of that was luckily for us to an administration that was actually very amenable to doing such a broad, highly-expensive game-changing public health initiative.

that - when he was Secretary of HHS under George W. Bush – is that we unquestionably live in a global society. This is not the way it was decades and decades ago. So, when you live in a global society and we’re all interconnected economically, politically, and from a security standpoint, a healthy world is economically beneficial and secure when you have people who are not suffering needlessly from diseases, from hunger, from health issues well beyond HIV – it maybe goes to nutrition and things like that. So the arguments that I make about why we need to consider global health as a primary important goal for us is that it really encompasses everything we do because we no longer live in a provincial society, we’re no longer isolationistic, we are a country that is part of a global community. So the healthier that community is, the better we function economically, politically, and from a security standpoint.

HCGHR: In negotiations on the global stage – how do you weigh the interests of the United States with other global health actors? For example, are there any effective foreign policy arguments that relate infectious disease to national security?

Fauci: First of all, the passion and desire to good, to serve mankind on a global level is considered by some to be overly idealistic. It isn’t. It’s a very noble goal and you should not lose that passion and you should not lose that idealism. Number one. Number two: in order to be a player that can implement or exercise your idealism in a meaningful way, you need to have training. You need to have some type of credential to put you in an arena, in which you go beyond just being idealistic and altruistic, and you can actually move and implement your idealism and your altruism.

Fauci: Well, it goes even beyond national security. First of all, I made that argument years and years ago. And I’ve had extensive discussions with administration officials including people Colin Powell - when he was Secretary of State - and Tommy Thompson who was a big advocate of

HCGHR: Our final question is, what advice do you have for aspiring scientists, researchers, and global health workers – both useful principles and any possibly pragmatic steps?

So for people at your stage of school, I’d say continue with the training – and the different types of approaches are different for different people. I happen to take the medical school approach, the scientific approach, and I eased into administration only because I saw that I could have greater impact being a scientist in an administrative position who understands the science and the public health needs that for me was my pathway to being able to implement my idealism, my penchant for public service, and my altruism. A different pathway may be good for other people so you don’t really don’t want to get into the situation that there are only very well-defined pathways that you must follow. You just need the degree of training that will position you into how you can best utilize your talents to implement and exercise the honorable and admirable idealism that so many people have at your stage in life. I might also add that please be heads up that things will impact your career direction, your career trajectory, and where you ultimately are that are beyond your control. There are things you have no control over that might put you in a position to be able to have a major impact, so you’ve got to keep your antennas up, you’ve got to keep your mind open, to be able to take advantage of opportunities that will allow you to implement the goals and idealism that you have. I can tell you many times over the last few decades in my own career, things popped up, opportunities that I was ready seize, that if I had not been ready to do that, I wouldn’t have had the opportunity to have the impact I have now. So hang on to your idealism. Hang onto your commitment to public service. Get as good training as you can in the arena that you are comfortable with, that you like and enjoy, and keep a major open mind about opportunities that will come your way.•

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Medicine and Maturity:

Cultural Integration of Male Circumcision for HIV Prevention

By Sarah McCuskee

alled the “most compelling evidence-based [HIV] prevention strategy to emerge since the results from mother-to-child transmission clinical trials,” voluntary medical male circumcision (VMMC) is being scaled up in Kenya’s Nyanza province because it provides protection from HIV to men engaging in heterosexual intercourse. In Botswana, a similar intervention is simply termed “male circumcision” (MC). Both are voluntary and medical—so why the difference in terminology? The word “medical” in the Kenyan terminology seems straightforward; it is meant to denote that VMMC is performed for medical reasons. These reasons are compelling. MC has been shown, in three randomized controlled trials in Kisumu, Kenya, Rakai District, Uganda, and Orange Farm, South Africa, to “reduce…the risk of heterosexually acquired HIV infection in men by approximately 60%.” Further research has shown reductions in human papillomavirus (HPV) acquisition and infection in both men and

Photo Courtesy of Harvard-Botswana AIDS

their female sexual partners, as well as reduced bacterial vaginosis in women and inflammatory anaerobes on circumcised men’s penises. Mathematical modeling predicts that large-scale implementation of MC in “African countries with high HIV prevalence and where male circumcision is not now routinely practiced, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.” MC could be an effective medical intervention. However, it is often not strictly medical, but is influenced by culture and politics. Dr. Rebeca Plank, of the Harvard-Botswana AIDS Institute Partnership, told the HCGHR that “in many parts of southern Africa circumcision is a rite of passage to adulthood.” Similarly, Dr. Naomi Bock, Medical Officer in the Center for Disease Control (CDC) Global HIV/AIDS Department, explained to the HCGHR that “historically there has been a lot of identity connected to whether the men in a particular tribe or community are circumcised.” Integration of the

medical and cultural aspects of MC is imperative for traditionally circumcising tribes, while non-traditionally-circumcising tribes like the Luo in Kenya’s Nyanza province emphasize the medical nature of male circumcision. To address these cultural issues, Kenya’s Ministry of Health met with Luo representatives, tribal elders, and donors. Bock told the HCGHR that the community “recognized the public health benefit [of VMMC] but it needed to be very clear that it was a voluntary procedure,” so “voluntary medical” was included in the Kenyan terminology. The term “voluntary” has varying meanings. Where MC is a rite of passage, “the very notion of obtaining assent for circumcision may be culturally alien” because assent is assumed. In Botswana, mothers tend to decide independently to circumcise their babies, even while claiming that others’ approval is required. Plank explained to the HCGHR that this may be due to familiarity with MC: “the town where they’re still traditionally circumcising

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and doing initiation is the town where we’ve had the highest success rates.” In Kenya’s rapid scale-up of VMMC for adult men, each man decides for himself. Decision-making capacity thus often depends upon two factors: whether the community traditionally circumcises, and whether MC is neonatal or adult. As Dr. Ronald Gray, Professor in Population and Family Planning at the Johns Hopkins Bloomberg School of Public Health, told the HCGHR, “it would be ideal to do neonatal circumcision.” It is a tenth the cost of and safer than adult MC, which has a higher risk of complications. It also reduces behavioral disinhibition, the possibility that newly circumcised men engage in riskier behaviors due to perceived invulnerability to HIV. Detractors of neonatal MC argue that it is unethical because it is an elective surgery; however, its protective effects make it comparable to a “childhood vaccine” in areas of high HIV prevalence, and parents routinely make decisions in their child’s interest about vaccines. Gray advocates a “dual track” which includes both “catch-up” MC

for sexually active adults and neonatal MC for long-term HIV prevention. But for some communities, neonatal MC might be culturally impossible. Bock emphasizes that “it has to be up to the community. It’s quite possible that communities which are traditionally circumcising [adolescents] would not want to give that up.” While medical benefits make it ethical to provide MC services, the procedure must always be voluntary, so cultural factors may necessarily overshadow cost or even medical ease or safety in its implementation. Voluntariness for men is not the only ethical issue involved, however. “The other thing that’s interesting,” Plank told the HCGHR, “is thinking about how it’s going to impact women.” MC could undermine women’s ability to insist on condom use because it helps protect men against HIV. This is problematic because MC does not protect women from HIV, many other sexually transmitted infections, or unwanted pregnancy. It is thus advisable to integrate MC with education and counseling for men and their female partners, and to stress women’s roles as decision makers.

Swaziland shirt produced by Population Services International (PSI) promoting male circumcision with condom use; courtesy of the Harvard-Botswana AIDS Coalition.

Photo Courtesy of Harvard-Botswana AIDS Institute Partnership

Education is also important to mitigate behavioral disinhibition, which could decrease MC’s population-level benefits. Gray’s studies in Uganda, which included counseling as part of the MC package, did not show evidence of behavioral disinhibition, but studies over longer time scales are necessary. Similarly, population-level benefits, which translate to decreased HIV infection in men and women, have been shown in modeling studies, but longer trials are needed to show this epidemiologically. Widespread, population-level decrease in HIV prevalence with implementation of MC is probable. Models suggest that “male circumcision in subSaharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years.” Plank told the HCGHR that “if you use clean needle exchange, treatment for pregnant women during gestation and delivery and breastfeeding so they don’t transmit it to the babies, male circumcision, and vaginal microbicide, with oral preexposure prophylaxis, then you basically protect everyone who’s at risk for HIV right now.” This combination of interventions, if implemented widely, “raises the possibility of reducing the prevalence of HIV to such low levels that it is no longer a major public health problem.” In light of this evidence, an extensive MC-based intervention makes sense. However, it would be more appropriately implemented as a series of small, local interventions. The difference between VMMC, in Nyanza province, and MC, in Botswana, is important because culture will continue to determine interventions’ successes. Furthermore, a multi-disciplinary approach to HIV prevention and sexual health is necessary. Though limited resources are a major challenge, Plank believes “this can make an impact now.” With cultural integration, it likely will. •

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Global Obesity

By Homan Mohammadi

lobal obesity and malnutrition have been major public health problems for centuries. In the past two decades, however, obesity has emerged as a prominent problem not only in developed nations but also in the developing world. In 1995, there were 15 million overweight children under the age offive worldwide, and according to data collected in 2000, there are over 300 million obese adults. Obesity leads to epidemics of chronic diseases such as diabetes, hypertension, cardiovascular complications. These chronic diseases have never before been encountered at such high rates in developing countries and lead to substantial public health consequences. To prevent growth of global obesity, governments must pass legislation that provides social, cultural, and public health solutions to this growing problem. Such policies should target children and young adults, whose health is an indicator of future obesity problems.

Dr. Frank Hu, Professor of Nutrition and Epidemiology at the Harvard School of Public Health and author of Obesity Epidemiology, stated in an interview with the HCGHR that “Policies should place focus on preventional obesity, which is a major public health priority. Obese children are more likely to become obese adults, and much more likely to develop early onset of chronic diseases that have substantial ramifications in terms of productivity, health care costs, and longevity. For these reasons, I think preventional childhood obesity is the most important global health priority for many developed and developing countries.” Obesity is a complex problem caused by an array of different factors – genetic, behavioral, social, economic, and political. As such, epidemiologists believe that obesity must be tackled from multiple layers, and not solely from the viewpoint of drugs and medications. Organizations such as the

International Obesity Taskforce promote healthy diet and lifestyle at an individual level; at social and population levels, governmental organizations aim to develop better policies that promote the consumption of healthy foods and create an environment that is inducible to physical activity. Scientists point towards common cultural and social habits as the primary causes of obesity – consuming fast-food and soft drinks, and living sedentary lifestyles. These factors contribute to obesity in all regions of the world. The solution to these universal problems, however, is not standard across the globe. Different countries are at different stages of economic development and at varying points of nutritional transition. Policy makers aim to create policies that are not only tailored to specific cultures and societies, but also sensitive to the economic and political stage a nation may be in. Though specific policies need to be made for specific regions

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of the globe, Dr. Hu stated, “there should be some coordination – overarching policies – that apply to global food policies and create a healthy environment that benefits physical activity and reduces pollution.” Historically, obesity epidemics parallel economic development and urbanization. A direct consequence of economic growth is the proliferation of fast-food restaurants (serving unhealthy fatty foods and sugar-loaded soft drinks) and sedentary lifestyles. Is economic development a hindrance to solving global obesity? Is obesity an inevitable byproduct of economic growth? The correlation between economic development and obesity is particularly concerning because the current speed of urbanization is unprecedented in Asian nations such as China and India and is continuously increasing in other developing regions of the world such as SubSaharan Africa. Government officials and policy makers of these nations face a challenging task: to align nutrition- and obesity-related policies with economic development. In most developing nations, economic growth is the highest of priorities, which has led many governments to overlook the long-term consequences of the rapid rate of urbanization. To the question of how obesity policies and economic growth may be aligned, Dr. Hu responds: “Policy makers need to reconsider their strategies for development, because chronic diseases have the potential to negatively impact economic gains. We can use financial incentives to promote healthy food and discourage unhealthy eating.” Epidemiologists believe that policy makers can help create healthy, friendly environments that promote physical activities such as walking and bicycling. Such policies have ramifications not only for problems of obesity, but can help decrease pollution, protect

the environment, and prevent chronic diseases – factors that can cut national spending over time. Dr. Hu commented that “Healthy diet and lifestyle can and should be complimentary to economic development. Nations can save large sums of money in the long run by preventing long term chronic diseases.” Though obesity epidemics started in the US, they have since spread to almost every nation of the world. As Dr. Hu likes to put it: “Obesity has no boundaries”. It is important to understand that American policies have important implications for global policies. Though the US obesity epidemic began to escalate in the 70s and 80s, the issue has not been considered a top national priority by the American government until recently. The Obama

“Though obesity epidemics started in the US, they have since spread to almost every nation of the world.” administration has begun to address this issue seriously, as Michelle Obama has launched a campaign to increase awareness of childhood obesity and to develop very comprehensive strategies combating this problem. The newly passed house reform bill included specific policies for promoting nutritious diets and active lifestyles, creating a healthy social environment for children. There are encouraging signs that obesity prevalence in the United States has leveled off over the past few years – a trend that may be related to the increase of obesity awareness, promotion of

healthy lunches in schools, and increase of physical activity in children and adults alike. Though obesity levels have remained constant, the figures remain extremely high. Policy makers thus face a huge challenge to reverse the obesity trend, promoting healthy lifestyles across the United States. More importantly, the actions of the US administration and policy makers set precedence for the rest of the world to follow. If the United States actively promotes healthy eating and physical exercise, then other countries will follow in our footsteps and implement policies to battle global obesity. The healthcare systems of many nations take unilateral approaches to tackling malnutrition and obesity. In most developing nations, however, obesity and malnutrition are present in the same regions of the population. As a result, the healthcare system and policies of many nations have to be adapted to deal with the double burden of these diseases. Dr. Hu commented that “To deal with under-nutrition, most healthcare systems focus on supplementation of calories, which, in many cases, can cause obesity in the long run. When tackling poverty and underweight populations, officials often do not consider the obesity consequences. When overfed, starving children become overweight. Traditional solutions to undernourishment focus solely on calorie and protein intake, and not the quality of diet (vitamins, etc.). If starving child receive too many calories and proteins, they will develop subsequent obesity problems.” For such reasons, Dr. Hu mentioned, there needs to be an adjustment of the way in which nations address starvation and weight control problems. It is only with the development of new policies and the alignment of economic interests that all nations – developed and developing – can adequately address the problem of global obesity. •

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ShelterBox:

Innovations for Long-term Recovery or Short-lived Relief? By Sheba Mathew

n March 11th, an 8.9 magnitude earthquake struck the coast of northern Japan, triggering a tsunami and a nuclear emergency in what the Japanese Prime Minister Naoto Kan called the “worst crisis” the country has faced since World War II. As people in Sendai climbed to higher levels to escape flooding, international humanitarian organizations scrambled to mobilize supplies and resources for victims of the disaster. Among the organizations preparing to respond was ShelterBox, a British charity that has worked in disaster areas on every continent, including the Haiti earthquake, delivering tents and other relief supplies in a single box to disaster areas. In response to the earthquake, ShelterBox mobilized a team of experienced volunteers who are part of a ShelterBox Response Team (SRT) that also served during the Indian Tsunami in 2004 and other disasters. In less than 24 hours, they were on the ground in Tokyo. Yet even within 48 hours of the first earthquake strike, rescue and relief

Photo Courtesy of Shelter Box

operations were hindered by fires, aftershocks, and flooding. The situation in Japan remained unclear, and working with local authorities to assess needs was the best that ShelterBox and many other relief organizations could do. In disaster situations, the loss of life generally reaches its peak within the first two to three days after a disaster. The need for coordination, familiarization, and assessment among international relief organizations such as ShelterBox during this crucial period raises the question of their role and effectiveness in the immediate and long-term aftermath of a disaster. Relief experts argue that while international assistance is important, the more a local population can contribute immediately, the more sustainable are the long-term reconstruction solutions. Hilarie Cranmer M.D., M.P.H., an assistant professor at Harvard Medical School who ran a field hospital in Haiti immediately after the earthquake, stated that the local population has “the most knowledge of what will work and be most effective, but often they are ignored after the initial surge”. Paving a sustainable road to recovery

and reconstruction after a widespread crisis has become particularly salient in the shadow of the Haitian reconstruction, which, a year out, has left donors, volunteers, and Haitians frustrated and fatigued. Stephanie Rosborough, M.D., M.P.H., who also ran the field hospital in Haiti, attributes the slow progress and “chaos” of the response to the large number of professionals who were untrained in humanitarian and disaster response but who wanted to help. “We were very well reminded of the need for training to do humanitarian response,” Rosborough said, adding, “This is not charity work. The people that we are doing this for have actual legal rights. And so the work we are doing is rights-fulfillment.” In an effort to combat the wellintentioned but often burdensome work of an untrained volunteer, ShelterBox recruits its SRTs through it rigorous International Disaster Relief Academy. SRT training consists of a three-day introductory course and a nine-day residential training course. Upon passing the Academy, volunteers are welcomed into a four-member SRT as trainees. Cranmer cited ShelterBox in Haiti

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as “one of the most efficient and useful NGOs” that she met for its ability to “adapt to needs, and to roll out supplies as promised”. ShelterBox’s “supplies” are packaged inside its boxes, which are valued at roughly $1000 each and contain essential survival items that vary based on locale but generally include a tent said to house up to 10 people, a basic toolkit, a portable stove, and bowls and mugs. While Rosborough puzzled over the failure to include difficult-to-find hygiene items such as soap and feminine products, she did cite the greater number of mugs and utensils to accommodate larger family sizes as a sign of the organization’s adaptability. Yet both Cranmer and Rosborough find fault with what is perhaps most emblematic to ShelterBox: the tent. Founder of ShelterBox Tom Henderson began working on this project in an Photo Courtesy of Shelter Box

attempt to innovatively fill the void in disaster-relief shelter. Rosborough says that, “Most of the time when you’re talking about disaster shelter, you’re not talking about months or weeks, you’re talking about years”. Especially when internally displaced people ultimately want to go home and want something they can easily take home with them, “there’s nothing about a tent that makes it sustainable shelter,” Rosborough noted. “The tent certainly provides recipients with physiological and psychological empowerment,” said David Ager, lecturer on Social Entrepreneurship at Harvard College. However, the distribution of the tents fails to engage the local population in participating in their own rebuilding. “The question is,” said Ager, “what is the innovation here?” “This is not charity work…the

work we are doing is rights-fulfillment.” Despite the fact that the humanitarian community hasn’t found the perfect shelter, Rosborough claims that, “what’s been most successful is giving people basic building supplies and tools and letting them create from local resources most of their houses.” This strategy meets expert opinions that user-participation in making design decisions results in a more positive longterm product. One thing is certain in the uncertain field of humanitarian work: innovation is necessary. ShelterBox may be credited for its innovative and portable solution to short-term disaster relief. Yet, from the very beginning, the innovation must proceed even further to recruit the local population to contribute to rebuilding their homes and their livelihoods. •

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Rural Health in the United States: A Domestic Look at Global Health By Ryan Lee

ighteen percent of Americans live in rural areas of the United States. At 56 million, this rural population is comparable to the entire populations of Burma or Italy. Rural health in the United States is often considered a domestic public health concern, but using the broader lens of global health to examine the characteristics and challenges of American rural health can yield valuable insights. In global health, it is essential to have a clear, comprehensive picture of the population and the environment to design and implement effective interventions and healthcare. Rural communities often suffer from economic disadvantages. Americans living in rural areas are more likely to work for the small, locally-owned businesses that have been hit hardest by the recent rises in Photo Courtesy of Wikimedia Commons

health insurance premiums. Smaller businesses have almost no bargaining power, lack resources to keep up with ever-evolving coverage options, and pay higher overhead costs per employee. As a result, insured employees in small businesses pay on average 17 percent more for health benefits than their peers at large companies. The higher costs of health insurance compounded with the higher rates of poverty in rural areas lead to drastically reduced health insurance coverage. In a March 2010 population survey, Paul Fronstin of the Employee Benefit Research Institute reports that the uninsured are found disproportionately among blue-collar workers, the self-employed, and those working in small businesses. The uninsured population in rural America represents a large financial burden on rural hospitals and

emergency departments (EDs). Under the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals are required to evaluate and stabilize all patients seeking medical care regardless of their ability to pay. Most medical costs for self-pay or uninsured patients are ultimately written off as financial losses. Rural hospitals, which are primarily public (45.7%), nonprofit (38.6%), or church-run (6.6%), frequently provide significant amounts of such uncompensated care; one recent study estimates that over one quarter of all uncompensated ED charges fall on rural hospitals. The costs of uncompensated care at rural hospitals have been mitigated in part through the establishment of federally qualified community health centers (CHCs), which aim to provide healthcare access to the poor and uninsured. Data from the Health Resources and Services Administration (HRSA) indicate that CHCs provided care for more than 15 million individuals in 2006, of whom 71% were at or below poverty level, 40% were uninsured, and nearly two thirds were of minority race/ethnicity. The presence of CHCs has been shown to be associated with a significant reduction in uninsured ED visit rates in rural counties. This is one example of the tiered care that Janice Probst, Associate Professor in the Department of Health Services Policy and Management and Director of the South Carolina Rural Health Research Center at the

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University of South Carolina, says is vital in rural health both in the U.S. and abroad. “Think creatively about who your providers are and what they can do,” she suggests. To have someone working “at the height of their skill with appropriate tie-ins at the next highest skill level is something that is applied pretty much universally in rural health. We do it with practitioner skills, we do it with critical access hospitals…[which] take care of the short term conditions and relay out the more complicated ones – that notion of making do as creatively as you can with the resources and the personnel you can keep in place is key globally and in the U.S.” Increased usage of physician assistants, dental hygienists, nurses, and other mid-level practitioners is one way of addressing another main concern in rural health: recruiting and retaining physicians. Too few medical students consider practices or careers in rural health. On top of the common conception that rural practice is not lucrative, there has been almost no focus on rural healthcare in standard medical education and training. Research shows that physicians are more likely to work in rural health if they are exposed to rural medicine during their schooling and residency training, if their specialties are in more ruralfriendly fields (e.g. family medicine), or if they themselves are from rural backgrounds. Specialized programs tailored to produce rural health professionals by focusing on these factors are springing up at medical schools throughout the country. However, the challenges faced by incoming rural physicians may not be what they might have expected. As Ann Cook, Research Professor and Director of the National Rural Bioethics Project at the University of Montana, says, “In any given community, healthcare providers are going to have to figure out ‘what it takes’ to live and work there. And they have to decide if they are

willing to practice given the constraints they may face.” Some of these constraints are the direct result of providing care in a small community where everyone knows everyone. Rural culture, which often emphasizes trust, mutuality, and caring for one another as family, can influence the physician’s every decision. How will the physician’s advice or decisions affect relationships and life outside the workplace? How does the physician make the decision between sacrificing relationships and social standing or pursuing the safer, more effective, or cheaper option for care? In a 2008 paper, Cook and fellow bioethicist Helena Hoas, Research Director of the National Rural Bioethics Project, wrote that practicing rural healthcare sometimes “requires a deeper examination of who gets healthcare, and how much, and what kind, and from whom, and under what conditions… It brings to the fore emotional issues such as fear, anger, and guilt as well as perceptions of relationships that can be honored or sacrificed.” These considerations can affect a health professional’s ability to discern and carry out the course of action leading to the best Photo Courtesy of Wikimedia Commons

possible care. In a survey, one healthcare provider explained the situation: “the burden…falls on the professional on being able to blend these problems of knowledge, emotion, and finances.” Without adequate training to deal with these issues, it is little wonder that rural healthcare providers often experience burnout. Faced with economic hardships and physician shortages, rural health in the United States has much in common with global health in rural and remote areas. Cook notes that at the National Rural Bioethics Project, “We regularly receive queries from throughout the world because rural communities and marginalized communities, wherever they may be located, certainly share some common features.” Rural populations in the United States could surely benefit in turn from a broader, global view of rural health. Careful considerations of the specific needs and constraints of rural communities are necessary to implement effective, efficient healthcare. In studying and understanding global health, it is important to remember that not all of the constituent populations of global health live abroad.•

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No Vaccine This Time: Battling a Parasite with a Weapon of Health Education

Photo Courtesy of the Carter Center

n 1977, the last case of small pox was reported in Somalia. Three years later, the WHO announced the success of the global eradication of smallpox, a miraculous feat in the history of medicine. In a mere span of thirty years, history is about to repeat itself again, in the form of a tropical parasitic disease—Guinea Worm disease—caused by Dracunculus medinensis. Unlike the eradication of smallpox, the overwhelmingly successful eradication of guinea worm disease cannot be attributed to a simple medical tool, such as a vaccine, but was due to a strenuous effort of implementing health education to change people’s behavior and perception towards a historically debilitating worm parasite. The Carter Center, an organization centered on health and human rights that was created by President Jimmy Carter in 1982, has been at the forefront of combating this disease since the 1980s; with an estimated 3.5 million people afflicted in 1986, the Carter Center’s efforts have been critical in decreasing the incidence by more than

99%. The WHO proclaimed eradication as a goal in 1986, and as of October 2009, 187 countries and territories are WHO-certified as free from dracunculiasis. Most recently, Nigeria and Niger are two countries that have achieved success in halting transmission. In Nigeria, the last case was reported in 2008. The overall success in eradication is apparent through a steep decline in the number of reported cases, such as when comparing the number of cases in 2010 to 10,674 cases merely five years ago, in 2005. However, progress has not always been rapid. In an interview with HCGHR, Dr. Donald R. Hopkins, MD, MPH, the renowned leader of The Carter Center’s Guinea Worm Eradication Campaign and river blindness eradication efforts, who is currently the Vice President of The Carter Center’s Health Programs, provided much insight into the challenges behind the campaign. As Dr. Hopkins told HCGHR, “A main thing that has been different

By Charlotte Lee [between the start of the campaign and now] is realizing that achieving that goal is much slower than expected.” Nevertheless, today, only a few cases remain endemic in areas of Southern Sudan, Mali, Ghana and Ethiopia—so few that the media has proposed Guinea Worm Disease to be close to extinction. Such a public health success story requires the tireless work and collaboration between countries, health agencies and afflicted people. In particular, a key theme throughout the campaign to eradicate Guinea Worm Disease has been empowerment. As Dr. Hopkins describes, a big challenge in health education was to persuade people in afflicted communities that it is possible to protect themselves against this disease; initially, “we had advocated for clean drinking water, but there is an increased focus now, compared to the beginning, on health education and using cloth filters.” Furthermore, communities living in extreme poverty must not only tackle living below subsistence level, but must live with a much higher risk of contracting this parasitic disease. Not only is the

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individual affected, but the entire community carries the burden of a disease that has no known cure, nor gives the individual immunity after contraction. Without proper guidance and attention, the parasite’s life cycle perpetuates within, and severely cripples the community. The most evident symptom—a worm emerging from a painful blister somewhere on your body, usually through the skin of the foot or lower leg—appears only a year after contraction. Children and adults alike are thoroughly debilitated by this parasite, unable to work or attend school, and to treat it, there is no alternative but to painfully tie the worm around a rod and slowly pull it out a few centimeters every day. The root of the problem is contaminated water from stagnant sources, infested with Guinea Worm larvae, which is consumed and used by almost everyone in the local communities. Yet, convincing local communities of the cause was a challenge, as Dr. Hopkins relates: although “many people realized

how horrible the disease was…it was necessary to convince them…that we can prevent it”. He further emphasizes that the most important technique used to persuade people was to “filter some of the drinking water through a cloth and backwash that into some glass or jar, and then, hold that glass up to the light”. This visual demonstration proved effective: “people could see that the water had stuff floating around in it”. Furthermore, changing much of the local communities’ mentality required getting past long-standing cultural barriers. Two key barriers explained by Dr. Hopkins were traditional beliefs, and condescension. First, “because people had lived with this parasite for so long, they had all kinds of explanations for why they were getting the disease”. Secondly, “most populations affected… were marginalized within their own societies [and] people with political power didn’t pay attention to them”. To tackle the latter issue of neglect and condescension for afflicted individuals, Dr. Hopkins and his teams

Using cloth filters to obtain clean drinking water; photo courtesy of the Carter Center.

motivated the politically powerful through both a humanitarian, and a very effective economic angle. Since afflicted individuals were suffering through planting and harvesting seasons, which was “compromising their ability to grow food for themselves, for the country, and for export”, the economic argument proved very persuasive, and also underscores the politics involved in treatment of global health issues. Dr. Hopkins also conversed with HCGHR regarding how the public’s perception of such disease control and prevention programs differs from the reality of the situation. He stresses how in general, people from the US and more affluent countries find it hard to relate to the difficult lives that diseasestricken communities have, and the paucity of resources actually available. Furthermore, many believe that “the US is technically more advanced…[so there is an] under appreciation for other cultures, and for the intelligence of these people” who are very talented even though they are physically poor. Thus, teams going into these communities must approach the people with understanding and respect; as Dr. Hopkins highlights, people from other countries must work very hard to not be perceived as simply going into a country, thinking that “we have all the answers and we are here to save poor people”. Such a mindset reflects ignorance and disrespect of cultural values. Ultimately, the campaign for guinea worm disease eradication was a relatively inexpensive 300 million dollar endeavor that has become a driving force for other public health initiatives. Although numerous diseases remain unresolved—river blindness, schistosomiasis, malaria among others—The Carter Center’s GWD campaign has left an important imprint on the history of mankind. For those who may have doubted the power of health education in saving lives, think again. •

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The Health Disparity of Indigenous Australians: A Comparative Perspective By Mark Ragheb

ith significant attention and resources in global health targeting populations in developing countries, the issue of indigenous health in affluent nations has been widely overlooked. In the case of Australian Aborigines, the evidence shows a present health crisis in the population. Life expectancy for Indigenous Australians is markedly lower that the general Australian population, with a 60 year life expectancy for males and 67 for females, respectively. Both the male and female life expectancy for Indigenous Australians is roughly 15-20 years younger than the general Australian population. The Indigenous Australian life expectancy is comparable to developing nations such as Pakistan, Guatemala, and Iran. Moreover, Indigenous Australians has fared significantly worse than the Maori of New Zealand, Native Americans and Canadians, and other indigenous populations. For example, the approximate 15-20 year gap in life expectancy between Indigenous Australians and the rest of the Australian population is reduced to 3, 8, and 7 percent in Canadian, American, and New Zealander native populations respectively. The pressing health challenges facing the native Australian population are wide-ranging. Disparities in chronic diseases, communicable diseases, and mental health all contribute

to the relative inequality which is faced by the indigenous population. Chronic disease is the biggest single killer within the indigenous community. The standardized mortality rate (SMR), a measure of mortality rate used to measure differential health outcomes between non-indigenous and indigenous populations show 15-fold increase in mortality from diabetes, 10-fold increase in mortality from nutritional and metabolic disorders, 3-fold increase in morality from circulatory disorders in female indigenous populations. For communicable diseases, rates of Hepatitis A are 12-fold and rates of Chlamydia infection present themselves at an 8-fold higher rate, relative to the

non-indigenous population. Substance abuse and linked mental health issues also put significant burden on the indigenous population. For example, excessive alcohol consumption accounted for 7% of all deaths in the indigenous population in 2003, and accounts for the greatest disease burden for young indigenous males (aged 15-34 years). With such significant and broad health disparities facing the Indigenous Australian population, pinpointing the best strategy in terms of alleviating such issues poses a significant problem. Dr. Gregory Keane, a psychiatrist who has worked with indigenous communities in remote areas, points to alleviating the

Young indigenous girl- Northern Territory, AU; photo courtesy of cybil_unrest (Flickr).

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social determinants of health as the critical policy goal needed for health gains in the population. According to Dr. Keane, “The delivery of primary health care didn’t seem to be the problem. What really concerned me were the poor living conditions – the geographical isolation, poor attainment of education, evidence of domestic violence and neglect. So the problems really were the social determinants of health that seemed to be missing.” To put into perspective the relative lack of resources facing Indigenous Australians, their unemployment rates are more than double (20% versus 9%) than that of the native New Zealand and Hawaiian populations with a relative income more than 10 times less the other respective populations. Multiple theories have emerged as to why Australia has been relatively

Both the male and female life expectancy for Indigenous Australians is roughly 15-20 years younger than the general Australian population. unsuccessful at providing the necessary health and social services required to improve the situation of their native population. Due to the historical similarities between the experiences of indigenous groups, some have focused on certain post-colonial, contemporary policies espoused by the Australian government which may have led to stagnation in health gains which were seen in

Indigenous man, Ayers rock in the background; photo courtesy of Emanuel Masselli (Flickr).

other indigenous populations. Arguments have been made that the official policy of assimilation, which was supported by the government, discouraged the establishment of indigenous-specific health programs, and lack of such targeted programs and interventions may have participated in the relative disadvantage of Indigenous Australians. Others have focused on establishments of treaties between the Maori population in New Zealand and Native Americans in the U.S. which, even with treaty abuses, may have had a useful role in the development of necessary social and economic services, and that the absence of a formal treaty in Australia impeded such gains. While the reasons behind historical health inequality are not completely evident, the recognition that such inequality has contributed to the current disparities faced by Indigenous Australians is critical to promoting policy change. As described by Dr. Keane, “you can’t genuinely understand someone’s social situation and what’s led to their poor health until you know what’s happened to their community”. The poor health conditions faced by indigenous Australians catalyzed

policy changes beginning in the 1970’s with the establishment of health services targeted towards the indigenous population. However, the chronic lack of investment by the federal government for indigenous health services has resulted in little improvement in the overall health of the Indigenous population of Australia over the last few decades. While funding increases were seen in the mid to late 1990’s, the federal government still spends per capita 75 cents for Indigenous Australians for every dollar spent on the general population, yet the needs index call for 200% spending on health for Indigenous Australians. Ultimately, recognition of historical inequality and catalysis of innovate and sustainable policy changes are what will drive change. It is unquestionable with commitment this is an attainable goal for the government of Australia. As explained by Dr. Keane, “true reconciliation is only going to come when we have demonstrated a long-term concerted effort at improving health, education, employment, housing and one that recognizes that solutions are not going to be seen in one or two election cycles.”•

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Viewing Global Health Through a Different Lens: The Eyes of the Patient

Photo Courtesy of Susan Sheridan

Introduction ssues of global health are typically tackled from a physician or health professional standpoint. Health care is intended for patients, yet patients are often not consulted during care and are rarely considered advocates for themselves. One doctor and patient form a unique patient-physician bond as they

come together to empower patients, particularly mothers, to advocate for themselves and their loved ones. Through their role as leaders in the World Health Organization Patient Safety, experts Dr. Priya Agrawal and Susan E. Sheridan discuss the importance of patient advocacy and the development of The Mother/Baby 7-day mCheck, a checklist used by mothers in the seven days after birth to understand their own health as well as that of their newborns and detect danger signs in time to receive the necessary treatment. I had the pleasure of interviewing both of them to provide insight as to how their differing personal and professional backgrounds led to the development of a tool that may drastically improve maternal and newborn health globally as well as their views on the role of patient advocacy in the field of global health today. â&#x20AC;&#x201C; Pratyusha Yalamanchi

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Harnessing the power of patients towards a healthier future for all. An active project: the Mother/Baby 7-day mCheck By Dr. Priya Agrawal BMBCh, MA, MPH & Susan E. Sheridan, MIM, MBA The importance of patient safety is formally recognized

n October 2004, The World Health Organization (WHO) launched a patient safety program in response to a World Health Assembly Resolution (2002) urging WHO and Member States to pay the closest possible attention to the problem of patient safety. Its establishment underlined the importance of patient safety as a global health-care issue.

A new kind of PPP: patient-provider partnership Patients for Patient Safety (PFPS), was established as one of the main action areas of WHO Patient Safety, underlining the commitment to a patient-centered approach. It is designed to ensure that the perspective of patients and families, consumers and citizens in both developed and developing countries, is a central reference point in shaping the important work of WHO Patient Safety. (See statement of case at http://www.who. int/patientsafety/patients_for_patient/ statement/en/index.html.) PFPS emphasizes the importance and power of partnerships between patients/consumers and healthcare

providers and systems as evidenced in the London Declaration (http://www.who. int/patientsafety/patients_for_patient/ London_Declaration_EN.pdf ). PFPS highlights the central role patients and consumers can play in efforts to improve the quality and safety of health care around the world. PFPS works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programs, both within countries and in the global programs of WHO Patient Safety. The ultimate purpose of PFPS is to improve health-care safety in all healthcare settings throughout the world by involving consumers and patients as partners. Patients for Patient Safety has had the unique opportunity to work with patients from all of the six WHO regions, offering workshops, hosting focus groups, creating patient videos, conducting surveys, and partnering with providers and policy makers. Over the years, several patient safety themes have emerged as a call to action from the patient population. One important theme that has surfaced is the need to engage mothers and the patient population in the prevention of harm to mothers and their newborns globally.

The Mother/Baby 7-day mCheck The birth of a newborn - a time to rejoice or a time to mourn? Bringing new life into this world should be celebrated and a time of joy and happiness for the mother and family. However, for too many mothers in low and middle income countries, their happiness is overshadowed by the knowledge and real fear that their baby might not survive the first hours or days of life. Over 3 million babies die in the first week of life every year. That is 450 newborn children dying every hour. Millions more suffer severe illness each year, and an unknown number are affected with lifelong disabilities. Moreover, the risk of maternal illness or death remains high both at birth and in the week after delivery. Each hour, 40 women die during childbirth or in the week after delivery. The real tragedy is that many of these deaths are preventable. Evidence shows that delayed recognition of early warning signs and delayed access to healthcare are the most common reasons for the majority of these deaths.

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The mother – a passive or active participant? In 2010, WHO Patients for Patient Safety, a global network of patients for patient safety champions, many of whom have suffered the consequences of poor care themselves, decided that they could not ignore this neglected tragedy any more. The potential of patient empowerment for these women is clear, and yet until now, it has been overlooked. W i t h information and increased awareness, mothers could reliably identify potential complications—in themselves and in their newborns—and access care in a timely fashion before the health situation deteriorates and leads to death. There is no reason why mothers and their families should not be engaged as an active participant in the provision of healthcare for themselves and their newborn.

ensure safe discharge from skilled care, to facilitate a mother’s decision to access skilled care in a timely manner, and to empower mothers with knowledge. It is aimed specifically at use by patients and is being developed using an innovative patient-centered approach combining expert consensus with global patient perspectives from a comprehensive and diverse group of patients from

mHealth component will use text or pre-recorded audio messages and interactive voice response (IVR) technology. The IVR system will help mothers further explore the nature and severity of any particular danger sign, as well as provide options for what to do next. It will link the mother to a healthcare provider or transport/emergency services. The opportunity cost of traveling to a health facility for many of these women is very high and using mobile technology will help the mothers to avoid unnecessary use of precious resources. SMS alerts will be possible so that a mother and her baby have the best possible chance to receive timely and appropriate care. The use of mobile phonesand communication devices for health – “mHealth” – has emerged as an important innovation with huge potential to empower patients and strengthen health systems globally. Mobile phone use is proliferating at an extraordinary rate, even in the most remote and marginalized populations of the world.

“SAFER MOTHERS...SAFER BABIES Empowering mothers of the world with precious knowledge to help prevent harm.”

By mothers, for mothers WHO Patient Safety and others have demonstrated improved outcomes through the use of clinical checklists to improve the safety of patients. All the checklists to date have been aimed at use by healthcare professionals. In keeping with the belief that safer care starts with the patient, the Patients for Patient Safety Program of WHO Patient Safety has chosen to target the first patient-held checklist style tool at mothers and their babies to increase safety during the high-risk postnatal period. The tool will provide a series of safety checks for common danger signs for a mother and her baby in the first seven days after birth. The aim of the tool is threefold: to

Mexico, Costa Rica, Kenya, Uganda, Pakistan, Poland, Egypt, United Kingdom, Argentina, Indonesia, China, Australia and the refugee population from Boise, Idaho.

The Mother/Baby 7-day mCheck The tool uses well recognized, evidence-based danger signs for a mother and her baby in the first seven days after birth to trigger questions that a mother can ask herself during this period. Upon identifying any of these danger signs in either herself or her baby, the tool can help a mother make an informed decision about the severity and urgency of the problem and when to access skilled care.

mHealth – using phones to increase access to quality care mHealth (mobile phone) technology will be used to enhance the paper-based checklist tool, delivering the checklist in a format appropriate for illiterate populations, and ensuring timely communication linkages between clients and health services. The

A new way for health? The developing world is struggling to achieve the Millennium Development Goals and the developed world is struggling with healthcare reform. The use of ‘new ways’ should not be underestimated. This is just one innovation that leverages the checklist approach and mobile technology while engaging and empowering one of the richest untapped global resources…the passion, the wisdom and the determination of the patient population…..….. so that all in healthcare are as safe as possible as soon as possible” (London Declaration 2005). •

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Photo Courtesy of Susan Sheridan

“...engaging and empowering one of the richest untapped global resources…the passion, the wisdom and the determination of the patient population…..…..so that all in healthcare are as safe as possible as soon as possible.” (London Declaration 2005)

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An Interview with Dr. Priya Agrawal, BMBCh, MA, MPH Pratyusha Yalamanchi, Experts and Interviews Section Editor

Dr. Priya Agrawal, BMBCh, MA, MPH is a practicing Obstetrician & Gynecologist and Global Womenâ&#x20AC;&#x2122;s Health Research Fellow from the United Kingdom. She is a graduate of Cambridge University (2000), University of Oxford (2003) and Harvard School of Public Health (2006). She has been working as the Obstetric Lead on the WHO Safe Childbirth Checklist Program with Dr. Atul Gawande at the Harvard School of Public Health and is now working on the Deanâ&#x20AC;&#x2122;s Special Initiative on Women and Health at the School of Public Health. She is also Senior Advisor for WHO Patient Safety.

Photo courtesy of Dr. Agrawal

HCGHR: How has your own background as a physician influenced your involvement with Patients for Patient Safety(PFPS)? Agrawal: I have experienced both sides of the doctor-patient relationship. Professionally I am a practicing ob gyn. Most medical schools teach the importance of good communication (albeit

with variable quality). Some take this into their practice and some ignore it. For me, the benefits of patient information and patient involvement became obvious very early on. As I hit the wards, I was surprised with how easy and how often medical errors were made. Seemingly simple omissions could cause patient anxiety, increased time in hospital, and even sometimes

poor clinical outcomes. Involving the patients every step of the way and keeping them in the driving seat became not only good practice, but critical if I wanted to ensure best patient care. I realized that the best advocate for the patient was not me but the patient themselves. I tell them to chase appointments, demand explanations when uncertain,

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[and] check that they are receiving the care they expected. I have seen that they are more likely to adhere to their drug regime and the doctorâ&#x20AC;&#x2122;s management plan and attend appointments. From the other side of the fence, a relative of patients and as a patient myself, I have experienced the devastating effect of entering the hospital: the loss of control and the fear that comes with uncertainty. Giving patients responsibility for their own care is not an unnecessary burden. It is a way of empowering them to take control both in and out of the hospital. Patients need to be at the center of their care. They need to be empowered to be the final safety check in a system where errors are made and accepted far too often. HCGHR: What do you consider to be the major obstacles to patient advocacy in the field of global health? Agrawal: One of the major obstacles to patient centered care is the medical profession. Unfortunately, giving patients more control is often felt as a loss of control for clinicians rather than as a healthy partnership. Negative perceptions and cultural stigmas are present across the globe. There is an unhealthy and unfounded fear that it will lead to chaos, increased litigation, wasted time in unnecessary explanations to people unable to understand, increased demand for unnecessary care. Especially in the developing world, the old western and very patriarchic ways of teaching and practicing medicine have continued and have led to a belief that the doctor should not be questioned and the patient is just a passive recipient. HGCHR: What is the story behind the Mother/Baby 7-day mCheck? What kinds of questions are included on the checklist?

Agrawal: The story behind the Mother/Baby 7-day mCheck is an excellent example of why patients and their representatives should be invited to participate in healthcare meetings. Sue Sheridan was at the first international consultation meeting that we held for the WHO Safe Childbirth Checklist Program which is a checklist aimed at healthcare providers to improve the quality of care delivered during labor and delivery. We had decided that this clinical checklist would address care up to and including discharge. Sue suggested that their could be a counterpart patientheld checklist that then worked to address the continuum of care from clinical discharge into the community. When the patients for patient safety community asked for a concrete project to work on, focus group discussions were carried out with mothers, grandmothers and their families across the world to gather their opinion if this was indeed an area of need. The answer was a resounding yes. It seemed that there was an overall dissatisfaction with the information women received to look after themselves and their newborns in the hours and days after delivery. Many of these women had suffered the consequences and were desperate to be involved in providing a solution for the mothers of the future. The questions, which are actually presented as culturally appropriate images so that literacy is not a barrier, are targeted to address the major causes of mortality and morbidity for mothers and newborns. Each picture addresses a critical danger sign that if present should push the mother to seek care whether by calling the number given on the checklist or attending the nearest healthfacility. The tool starts at the point of discharge so the healthcare provider can use it as a reminder also for ensuring all appropriate checks are done and in this way confirm that the mother knows

how to check for the danger signs. HCGHR: What are the benefits of the checklist? How can it be implemented? Agrawal: The benefits of checklists have been proven in many industries like aviation and in different areas of healthcare like ICU and safe surgery. All programs have shown that good implementation is critical to the success of any intervention. In these settings, the implementation process needs to be simple, scalable and sustainable. We are using the patient network to ensure implementation is acceptable and feasible in a variety of different settings. Ideally, the tool would be distributed and the patients engaged during the antenatal visits. However, as in many of these settings, attendance for antenatal care is at best intermittent, initially we have decided to introduce it at the point of discharge. Initial usability cycles will be crucial for ensuring that the mhealth component works in all settings with a variety of country infrastructures and cultural practices. HCGHR: How can mHealth connect mothers to quality care. Are there alternatives for mothers without access to mobile technology? Agrawal: It is important to remember that mHealth technology is not the solution for all healthcare. A functioning health system cannot be replaced. However, mHealth is a way initially to overcome suboptimal health systems and in the long term to help strengthen them. For any tool that is hoping to be widely applicable equity in access and coverage is critical and very important to all WHO intervention programs. Therefore the paper version of this tool is a standalone tool, i.e. if you have this

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danger sign please seek healthcare. The mHealth component is not necessary to the success and effectiveness of the tool, it is there to further enhance the benefits of the tool. HCGHR: Based on your work with maternal and newborn health, what do you see as the greatest gender disparities in health care today? Agrawal: Gender equality is at the heart of development. If we don’t eradicate gender disparity, we cannot end world poverty. The argument for gender equality is no longer just a moral one, it is a pragmatic one. When women gain equal rights, they deliver social and economic benefits for their families, communities and nations. The role of gender disparity and its contribution to the tragedy of maternal and newborn mortality is well recognized. It starts early, baby girls are breastfed for less time in the hurry to become pregnant again to deliver a boy, due to a lack of access to toilet facilities in schools and household chores, girls will not be sent to school, women find

it difficult to negotiate contraceptive use knowing that each pregnancy could potentially kill them, lack of health literacy and financial dependence stops them accessing healthcare and on and on. Proximate factors include lower levels of education, literacy and socioeconomic status but ultimately the root cause is the low social status of women in the developing world. The root causes need to be addressed but disruptive methods can be used as well. Microfinance focused on giving women financial independence have been shown to work. Schemes to incentivize women attending healthcare at critical points like antenatal care and skilled care for labor and delivery can ensure better access to care. Our tool works to empower women with information as to when to seek care and the tool hopes to give them negotiation power to attend for care. The return on investment in women is high. This message needs to reach the policymakers, often men. HCGHR: What are the benefits of looking at global health from a

patient advocacy standpoint? Agrawal: Slowly the developed world is seeing the benefits of a patient centered approach to healthcare improved clinical outcomes, increased efficiency, better quality of care. This is one area where the benefits to be reaped are potentially even greater in developing countries where using the untapped resources of patients and their families can help to overcome shortages of healthworkers, poor linkages between different parts of the health system and limited resources. The alternative to our tool would be community visits by healthworkers which would be more expensive and would require increased supply of healthcare workers. This tool helps to save costs whilst ensuring that those in need are managed appropriately. Patients and their families should be considered a disruptive innovation a resource that will lead to reduced cost and higher quality. A resource that can lead to better outcomes for patients and staff. A resource that can lead to better health of nations. •

“When women gain equal rights, they deliver social and economic benefits for their families, communities and nations. The role of gender disparity and its contribution to the tragedy of maternal and newborn mortality is well recognized... Microfinance focused on giving women financial independence have been shown to work. Schemes to incentivize women attending healthcare at critical points like antenatal care and skilled care for labor and delivery can ensure better access to care. ”

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An Interview with Susan E. Sheridan, MIM, MBA Pratyusha Yalamanchi, Experts and Interviews Section Editor

Photo courtesy of Susan Sheridan

HCGHR: How has your own personal background influenced your involvement with Patients for Patient Safety(PFPS)? Sheridan: Personally, in patient safety in general, I had two family members suffer from two egregious events in health care. My son suffered brain damage when he was five days old from

newborn jaundice. There were visible signs that I was unaware of and because I didnâ&#x20AC;&#x2122;t know the dangers of jaundice, I, unfortunately, learned the hard way with my son. Four years later, my husband had a malignant pathology that was never communicated to my doctor or my husband. He died when he was fortyfive of a cancer in his spine that went

Susan E. Sheridan, MIM, MBA is Expert Lead for Patients for Patient Safety, WHO Patient Safety and is Co-Founder and Past President of PICK - Parents of Infants and Children with Kernicterus - (www.pickonline.org) and Co-Founder and Past President of Consumers Advancing Patient Safety (www. patientsafety.org).

untreated when the appropriate tests and pathologies that indicated he had cancer [were done.] So obviously, I became very passionate about patient safety. I got involved in some projects here in the United States where patients, especially mothers, partnered with the healthcare system, the joint commission, NIH, and other governmental health care

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Photo Courtesy of Susan Sheridan

agencies and professional groups and together, changed the face of care. I got to see how the mothers and other consumers were an important part of transforming healthcare. It exposed me to a new world: testifying in Washingtion, getting more involved in policy making, etc. I was able to see that positive change could take place and once I was invited by the World Health Organization to lead Patients for Patient Safety (PFPS), it was something that I had lived, I believed in, and had the great honor of witnessing throughout the world. Patients [can] unite with the health care system, health care providers, and policy makers to make a difference. The global patient population is an

enormous untapped resource to help transform health care on a global scale. HCGHR: Based on your background in the field, what do you see as the major obstacles to patient advocacy in the field of global health? Have you witnessed any negative perceptions and cultural stigmas? Sheridan: Patients and consumers have really not been a part of designing health care. We are newcomers. I think there is a perception that health care is too complicated for us to understand. I think there is a perception that advocacy can be misinterpreted as being adversarial. However, having said that, I do see

the doors opening globally as the appreciation for patients who will look at the broad picture of health care and safety and appreciate partnership to advocate for change. I think there have been advocates in the past that chose a different approach that had been adversarial. While I believe that they may have been a minority, this has created a negative perception and change is hard â&#x20AC;&#x201C; especially in health care. Another obstacle is that there really arenâ&#x20AC;&#x2122;t pathways for patients to have a voice. Through Partners for Patient Safety, I see pathways developing. HCGHR: What was the inspiration behind the Mother/Baby 7 day mCheck?

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Sheridan: First of all, I am a mother of a child who suffers unnecessarily from what is a very common newborn disorder globally. Jaundice is the number one newborn disorder. So I live as a mother who wishes everyday that I had asked the questions. I wish everyday I had known the danger signs to look for. Thus, I was personally motivated to get involved. Second, PFPS went around the world doing workshops and found many other mothers with newborns who had died or suffered unnecessarily. Thus, maternal and newborn safety was always a topic of discussion and a priority. Because of the high maternal and newborn death globally and due to the Millennium Development Goals, the World Health Organization decided to do a safe childbirth clinical checklist for doctors and nurses and improve care throughout the world. They realized that one of the big steps to improving newborn care is to educate the mom and I agreed wholeheartedly. After all, there is nothing more powerful than a mother on a mission. The questions [on the checklist] are intended for mothers to recognize signs in themselves and their babies that are danger signs that could lead to harm or death. We want a mother to recognize

in herself if she has an infection, if she is hemorrhaging, if she sees jaundice in her baby, if the baby is dehydrated, if the baby is having seizures, etc. We are providing both written and pictorial descriptions of these danger signs as well as a cell phone application where if a mother sees one of these danger signs, she is provided with a decision process that can lead to necessary treatment. HCGHR: Has PFPS faced any resistance towards its advocacy efforts? Sheridan: Yes, initially, it is not uncommon [to face resistance] when we introduce the concept of patients partnering in advocacy of a better health care system. While it is not unusual to see resistance at first, honestly, once we have had the opportunity to spend time in countries and lead PFPS workshops, the resistance decreases and there is a greater willingness to understand and collaborate. In health care, it is important to provide evidence-based medicine and evidence that patients as advocates can improve health care. We have overcome many of these hurdles in various countries. Additionally, in many countries, there are cultural barriers when

it comes speaking up to a health care professional, challenging a physician, or advocating for something novel. While these are natural barriers, we have worked to raise awareness in a positive manner to demonstrate that partnerships with patients can improve outcomes. After all, the secret to advocacy is persistence. Persistence and a forward, positive spirit of partnership and [a willingness to] reach out towards like-minded patients and physicians opens many doors. HCGHR: You have both been involved in the fight for patient advocacy for some time now. How have efforts improve over the last few decades? Sheridan: Growth in numbers. Because of technology and social networking tools, we have been connected globally such that the positive effects of patient advocacy can be felt exponentially. Patients are now publishing in health care journals, on survey teams for health governing agencies, and are involved in research. We still have a ways to go but seeing all of the recently generated involvement and momentum behind the patient-physician partnership is a promising sign.â&#x20AC;˘

â&#x20AC;&#x153;Persistence and a forward, positive spirit of partnership and [a willingness to] reach out towards like-minded patients and physicians opens many doors.â&#x20AC;?

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A Diagnosis Transformed into a Mission:

An Interview with Cancer Survivor, Advocate, and Reseacher Dr. Felicia Knaul

Photo courtesy of Dr. Knaul

Pratyusha Yalamanchi, Experts and Interviews Section Editor HCGHR: Non-communicable diseases make the largest contribution to mortality both globally and in the majority of low- and middleincome countries. Based on your background in the field, what do you see as the major obstacles to progress in the fight against NCD, specifically cancer? Knaul: The obstacles should be considered both on the demand and supply side. On the demand side, obstacles explore what the patient, family, and local community can do. Some of the greatest obstacles we face are associated with stigma, discrimination, and machismo when discussing womenâ&#x20AC;&#x2122;s cancers. There is a lack of knowledge not only about anything related to treatment and protection, but because community members have never seen anyone survive the disease, they donâ&#x20AC;&#x2122;t have the hope or belief that recovery is

possible and are thus less willing to put themselves through treatment. These are the major demand side variables. I call it machismo in Latin America but it can be called discrimination or gender discrimination around the world. On the supply side, we must think globally as well as on a national and local [level]. Globally, although I think things are improving tremendously, particularly with the work around the NCD conference, the truth is that there has been little stewardship and high fragmentation. To date, groups of individuals have tended to work on their own disease and been less willing to work on other diseases or consider the community and overall health system. There is a general lack of stewardship at the highest levels in global health when we think about these various diseases. Individuals and institutions that work on these diseases must work more closely with those

that work with health systems. Then, at the country level, we also have major barriers to early detection of certain cancers and diseases [in areas] where primary health care systems are generally designed to deal with so-called communicable and acute disease rather than early detection and healthy lifestyles associated with noncommunicable or chronic diseases. Furthermore, in terms of the infrastructure needed for early detection, it is severely lacking when we think about mammography and cervical cancer detection. On the treatment side, we tend to [think that we] have a few oases that [in reality,] are more like just small loci where people can be treated at later stages of the disease. One last category to highlight is that there is very little available in survivorship care because a) there are few survivors and b) this is a novel and new

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FELICIA MARIE KNAUL OCTOBER 2010 Biosketch

Felicia Knaul, MA, PhD (Economics, Harvard University), is director of the Harvard Global Equity Initiative and Associate Professor at Harvard Medical School. As director of the Harvard Global Equity Initiative, she serves as the Secretariat for the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. After being diagnosed with breast cancer in 2007, Dr. Knaul founded Cáncer de Mama: Tómatelo a Pecho - recently registered as a Mexican non-governmental association - a program that promotes research, advocacy, awareness, and early detection initiatives for breast cancer in Latin America. Her book, Tómatelo a Pecho, released in October of 2009, recounts her personal experience with breast cancer and as founder of the program. Dr. Knaul has more than 120 academic and policy publications and holds visiting academic appointments at the National Institute of Public Health of Mexico, and the Mexican Health Foundation where she has led a research group focused on health and the economy since 2000. Dr. Knaul is a board member of numerous organizations including: the Union for International Cancer Control; the International Advisory Board on Cancer for the Beth Israel Deaconess Medical Center; the Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research at Princess Margaret Hospital; the Harvard-Mexico Foundation; as well as, the Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer in Saudi Arabia. She has held senior government posts at the Ministries of Education and Social Development in Mexico and at the Department of Planning in Colombia. Additionally, she has also worked for several bilateral and multilateral agencies including WHO, the World Bank, the Inter-American Development Bank, and UNICEF. Dr. Knaul is Canadian, and resides in Boston and Mexico City. She and her husband, Dr. Julio Frenk, have two children, Hannah and Mariana Havivah.

area where we are considering the long term nature of some of these diseases and once you get past the acute situation of treatment, there is much left to do in both developing as well as developed countries. HCGHR: From your dissertation at Harvard, commitment to breast cancer research and advocacy work, and work with HGEI, you are a true advocate for gender equality. What do you see as the major gender disparities in

breast cancer today? Knaul: First, there is a discrimination faced by people who are poor. Then, there is discrimination [against] those who are ill, particularly those who are visibly ill. Then, you are a women. You can call it “discrimination cubed.” Furthermore, there may also be an ethnicity issue or cultural segregation. This means that you need get past all of these [barriers] both in terms of community and family reactions such as possible

rejection due to stigma, costs associated with the disease, or a lack of productivity that accompanies symptoms. Then, you have to overcome barriers associated with accessing treatment, which is more severe in some nations than others. Ageism is another issue and [provides an] additional layer of discrimination; older women often face higher obstacles to treatment, perhaps because of a lack of productivity. [For instance,] when I’ve gone to

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the field to train for early detection of breast cancer and have finished the discussion, I ask “So are each of you going to have a breast clinical exam and mammogram in the clinic?” and the universal response is “Absolutely not.” [I reply,] “I just told you it can save your life. Early detection is very important.” But they still say no. They don’t [want to get tested] because they just don’t want to know. A woman would explain, “If I am diagnosed with breast cancer, my partner will leave. The issue is not being alone but not being able to support my children.” Let me provide another anecdote. Once a woman stood up in the middle of a hospital auditorium filled with over 200 people and said to me, “Una mujer sin pechos es fea.” She truly believes that a woman without breasts is ugly. If you have all of those layers coming at you before you ever get near health care system, it is difficult to seek treatment and prevention strategies. HCGHR: How has your own battle with breast cancer shaped your work as director of HGEI? Knaul: In many ways. I had always worked on health financing and health systems in particular populations with difficult circumstances, particularly children, but I had never worked on a specific disease. Having breast cancer and being diagnosed and treated in a middle income, developing country, has changed my voice and ability to project the results and evidence-based information found as a researcher into constructive evidence-based advocacy. The other thing that it has done is to bring a very different understanding for me of health and health systems. First because I am a patient now, but [also] speaking as a researcher of health systems, it is completely different to be able to trace through the deficiencies of

a health system structure in respect to a particular disease because you have gone through every step of it. You [can] think of where the holes are in the delivery of care and quality of regulation of financing in ways that if you don’t take a tracer disease approach, you can’t address. It has provided me with a whole new window to understand the deficiencies and strengths of health systems. HCGHR: As the recent founder of Cáncer de Mama: Tómatelo a Pecho (Breast Cancer: Take it to Heart), what do you think are the key factors that will influence breast cancer detection and awareness initiatives in Latin America over the next 20 years? Knaul: The first is coming out as women who live with the disease and are post-chemotherapy and showing other women that it is possible - that the disease is not a death sentence. Second is the kind of financial protection provided by popular health insurance in Mexico. We can now say that for a number of cancers, any person diagnosed, regardless of socio-economic status, has full health insurance for treatment. I also think we will see some innovations, hopefully, on the delivery side where some of what we now know about delivering care and recent advances in the medical technology and technology of communication will make it easier to bring cancer care closer to the patient. This way the patient isn’t always asked to travel constantly for treatment like chemotherapy. Innovations as a result of technology will change how care is delivered so that we no longer will have to always bring the patient close to specialist, except for very specific encounters. This, I hope, can bring down costs and expand access to care, particularly to women and children who are ill and lack the ability to travel.

HCGHR: What is the mechanism by which this can be achieved? Knaul: Some of the projects we have, like Partners in Health (PIH) and Dana-Farber are working in Malawi, Rwanda, and Haiti to link primary care physicians via skype, e-mail, and phone calls to well-intentioned individuals like oncologists in places like Dana-Farber. We’ve seen a similar model of twinning launched in 1991 by St. Jude for pediatric care that has been successful in 20 countries. In Mexico, the pilots that are going on are basically to equip primary clinics, secondary level hospitals, and in some cases, even home-based care with a telephone or skype link to a state or national cancer institute, to define the treatment and guarantee the safety [of a patient] and be able to support a physician or nurse if there are any side effects or reactions to the treatment observed. Those are pilot projects but I think that they can really be expanded. In fact, even if you look at how modern cancer care is provided in New England, more and more satellites have been able to provide the same quality of care to institutions two hours away as you would get in downtown Boston. The difference is that in developing countries, you don’t have a means of access to institutions two hours away and even if you do, there is no Dana-Farber out there. HCGHR: How can negative perceptions and cultural stigmas associated with diseases such as breast cancer be altered in the developing world? Knaul: I think it is going to be a battle that may be longer than a few years. The more women diagnosed that can lead normal lives, participate in the labor market and community, and have a voice in politics, the further we are [in the fight]. In terms of breast cancer, [as patients,]we must demonstrate that we

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are still contributing members of communities and have the ability to undertake normal daily lives whether or not we have breasts, whether or not we have hair, whether or not we have ovaries, or whether or not we have lost our uterus. Likewise, if another kind of cancer is generating a loss of a limb, it should be treated in a similar manner. The message I believe that we must push forward goes beyond breast cancer. It is the idea that beauty goes beyond having breasts or having hair – it is the beauty of the person that matters. I feel like the most powerful image is conveyed not when I share my story, but when my husband, Dean Frenk, stands up in front of a group of women in a community and says, “Believe me. A woman is more than her breasts. I know what I’m talking about.” HCGHR: Will you describe your efforts leading the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) and what you see as the future of this initiative? Knaul: There are several pieces to the work that we do. One is to facilitate and manage what I think is a very unusual, diagonal conversation between global health and public health specialists like Dean Frenk and disease-specific, cancer-specific individuals and oncologists. Facilitating this throughout the task force is leading to a series of important ideas and conclusion strategies not only for cancer, but actually for other noncommunicable and chronic disease strategies as well. The second piece that I do is to help run and push forward the innovation initiative work in Mexico through working with the Mexican government and the state level governments in five states on innovations in training and capacity building for promoters, nurses,

and physicians at the primary level, for innovative delivery of technology and care information. Luckily, because of GTF.CCC, we can also learn from ties to other pilot programs and reach out to many others occurring in different parts of the world.

“If I walk into a hospital, I wouldn’t just pull out the women suffering from breast cancer and help only those women, but rather I would combine my resources to strengthen the hospital as a whole to provide better care to all of its patients.” The third is that we are preparing a Lancet commission report, the fourth of its type, which will hopefully be published in September to coincide with UN Summit, that is a roadmap for identifying and realizing cancer in developing countries as a priority. [It will] also develop strategies for improving access to prevention-only detection treatment and survivorship. HCGHR: With over 100 publications and experience working with countless organizations like WHO, World Bank, and UNICEF, you are a true global health leader. What advice do you have for aspiring undergrads interested in the field of global health? Knaul: First, I think that experience

working in the field in a lower, middle-income country is quite crucial. Whatever one can do to maintain those ties and that research work is extremely important to making us good global health professions and leaders. One should fight very hard not to lose that as you navigate a system that may make you more of a bureaucrat than a field researcher. Second, we must strive for evidence-based advocacy. I think that we should and have the duty to translate work that we do into results and into the health of people and in my case, specifically those who live in resourcelimited settings. I think that in public health, it is not enough to simply share results but you have to ask how you can apply results and there are many ways we can do that. Sometimes it is simply sharing the results to advocates and at other times, it is doing the advocacy [work] yourself. Third is that we must not try not to work in silos on our own specific topic or disease. We must adopt a diagonal approach, where we ask what we can learn and contribute to others. We have been recently struggling with this question of how one prioritizes and chooses between diseases and individuals. If I walk into a hospital, I wouldn’t just pull out the women suffering from breast cancer and help only those women, but rather I would combine my resources to strengthen the hospital as a whole to provide better care to all of its patients. I believe that that is our duty and objective as those working in global health. HCGHR: Any last words to our readers? Knaul: I am extremely enthused and thrilled by the interest in students across the university in issues in global health and look forward to collaborating in the future. •

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A Semester in Kenya: The Intersection of Health Access and Poverty Ariella Dagi, Contributing Writer

n the spring of my junior year, I took a leave of absence to work in a hospital in rural Kenya. Having completed courses in pre-med and global health, I wanted to test my interests with my hands. My focus was clinical, but I also wanted to contribute with my given skill set. I soon discovered that drugs were called by multiple names, both scientific and local, confusing doctors on short-term rotations as much as it had me. I created an index of medications available and local toxins unfamiliar to Western-trained physicians. My time in Kenya was spent with compassionate individuals who had devoted their lives to addressing pressing medical needs of the deeply impoverished. Nevertheless, they were ill-equipped to address the underpinnings of poverty and illness. The hospital lacked a plan for creating sustainability or responding to systematic problems. On one occasion, logistical problems led to a hospital shortage of anesthesia making surgery impossible for two weeks. On another, syringes were unavailable throughout Kenya for a week due to mismanaged ordering and accounting. This lack of focus on the long term was also a matter of internal culture. Just as important as analyzing the structures and cultures of foreign societies was a look inward to evaluate those of the provider. To deliver and optimize healthcare in the developing world requires effectively operating within existing systems while simultaneously working towards improving structural and cultural barriers to health, and I

Photo courtesy of Ariella Dagi

sought exposure to alternate models for this. Last summer, in search of additional experience and another viewpoint, I returned to East Africa to conduct research on a treatment of hydrocephalus. My task was to manage a retrospective study requiring home

visits to collect data from patients. The resulting set of trips led me to begin to understand the effect of infrastructural problems and marked my first exposure to the way in which a single sick individual can affect an entire village. *** At the end of a long day in â&#x20AC;&#x153;the

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bush,” as the hospital staff called it, I was caked in dirt. The short strips of paved road on the main highway had been more pothole than blacktop. The smaller inroads to the villages were all dirt, some bumpy, sandy, or steep enough that a traveler could only pass on foot. Leaving each morning always took longer than anticipated, even as my expectations of time were lengthened by knowledge bred by experience. My Ugandan colleague Moses was particularly frustrated by the multi-person taxi operators, whose conniving tactics often prompted his launch into a criticism of Uganda’s disjointed infrastructure and lack of regulation. Travel was part of our job, though, and although the delay was exasperating and inefficient, we could afford the expense. For the hospital’s patients, however, travel could be prohibitively expensive, let alone the lost income from time away from work and the difficulty of finding a caretaker for children left at home. After a long bumpy ride, a stop at a small center to find a someone familiar with the local unmarked passageways, many stops to ask directions, and a climb on foot up a slippery hill, we finally came to the home of a patient on our list: Shadrak, a boy of about eight years. The presence of outsiders was immediately visible, and as we entered the family compound many neighboring children and adults dropped their work and followed. Moses and I inquired about the patient from the sisters, prompting them to call the mother and get the small-stapled document that serves as a patient identification card and miniature medical record. They also hurried to bring Shadrak. The child was in horrible condition and was stuck in a cramped position such that when he was picked up his whole body remained stiff and

immobile. Shadrak was passed like an object, and indeed, he did not move much or make a decipherable sound. After speaking with the mother it became clear that she had lost all hope for him and had decided, in a moment of family triage jarringly common to the extreme poor, that her healthier children were more likely to survive and thus deserved as much of her attention and resources as she could muster. After more consultation, we began to understand why she had given up hope: following effective treatment for hydrocephalus at the hospital where Moses and I worked, Shadrak was referred to one local hospital for orthopedic treatment and another for nutritive care. The mother brought him to each but they said they could not treat Shadrak – for monetary reasons, lack of vacancy, or the necessity of unobtainable bureaucratic documentation – and turned her away. Unfortunately, in her mind, so had our hospital; when she left she was told that her son was, from the hospital’s neurological perspective, cured. To return for a scheduled follow-up without any urgent need was out of the question for this family with no expendable income. The mother could not obtain comprehensive care for her child, and what had been a real but improvable need for physical therapy turned into a life sentence for disability and correspondingly neglect. Moses and I demonstrated some simple techniques for muscle stretching and strengthening that could help Shadrak, but his muscles had severely atrophied over the elapsed five years. Though his position was dire, human contact could benefit him, hopefully for his long-term health but at the very least palliatively. Beyond that, after stressing to the mother that her son’s condition was not her own fault as common stigma contended, the opportunity remained to

Ariella Dagi Harvard College Class of 2011

Ariella Dagi is a senior in Cabot House. She has concentrated in Visual and Environmental Studies at Harvard and is interested in multi-disciplinary approaches to global health. Prior to writing this article she spent her junior spring working at a hospital in Kapsowar, Kenya and the following summer doing research about, in, and around Mbale, Uganda. explain the possibilities her son once had so that if her fellow villagers had a similar problem she might still encourage them to seek help. A single suffering individual with a curable condition that goes untreated kills more than just one. There is an old rabbinic saying that to save one life is like saving a world. Conversely, one death affects all those who knew the person. However, in settings of extreme poverty like those I saw in East Africa, the effect of one death is more literal. When a person dies of a treatable cause, the expectations of a community morph to exclude living individuals with that condition from their society, pushing them to the outskirts so as to conserve what little they have for those who have a better chance at survival and some measure of prosperity. In essence, one person’s death determines many’s exclusion from life. Expectations of health outcomes become self-fulfilling prophecies, both by determining the reactions from within a community and the sense of responsibility to help from without. •

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Making Clean Water Accessible: Project ACWA Alex Almore, Contributing Writer

Photo courtesy of Alex Almore

ccess to clean water is critical to health and a basic human right. In Agyementi, Ghana, toxic water coupled with poor sanitation has caused community members to be plagued by preventable diseases such as trachoma, guinea worm, and diarrhea—all acquired through exposure to toxic water and lack of adequate hygienic disposal. When I traveled to Agyementi, Ghana this winter to conduct evaluations for the African Development Initiative (ADI), I could not anticipate the instructiveness and personal significance of the experience. The African Development Initiative (ADI) is a non-profit organization founded by two Harvard graduates, Darryl W. Finkton, Jr. ‘10, and Sangu J. Delle ’10 that uses sustainable development to empower communities in

rural Ghana. Project Access to Clean Water for Agyementi (Project ACWA) is one of ADI’s primary initiatives; ACWA has successfully worked with Agyementi in building a borehole and iron treatment plant for an improved water supply as well as installing 27 household Ventilated-Improved Pit (VIP) Latrines (with 20 more in the planning stages). Prior to Project ACWA, a polluted water stream capable of serving a population of less than 300 people (based on the World Health Organization standard of 15 liters per day) was actually serving about 2,000 people. In addition, there were no safe excreta disposal systems in the community, resulting in open defecation. The health impact after implementation of ACWA was quickly indicated by the reduction in cases

of stomach pain and diarrhea. One woman reported that the water presence near our homes has “improved our menstrual hygiene and made us feel secure even in front of others.” Besides these vital health advancements, Project ACWA has decreased the necessary time spent collecting water which has in turn increased pupil attendance and punctuality, given more time for agricultural and business activities, and has provided numerous social and psychological benefits. It’s an honor to be part of a team with such noteworthy success, like ADI. As a member of the undergraduate leadership team, I was requested to assist the organization by spearheading the assessment of the 27 VIP Latrines in preparation for the next round of building. Ventilated-Improved Pit (VIP)

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latrines obtain their name by using a pipe/chimney technology to circulate air and eliminate odor, flies, and the diseases that they bring. To examine the facilities and ensure our VIP latrines are working and being maintained correctly, I looked at a range of characteristics, some including: net quality, pipe access to the sun, odor, presence of flies, the presence of hand washing materials and hygienic paper. All of these characteristics contributed to the overall quality of the latrine. While the assessment was overwhelmingly satisfactory, it also shed light on some issues that reflected the need for some reinforcement of our work in the community. ADI achieved early success in changing a miniscule hand-washing rate in Agyementi to 25% compliance, yet my observations of hand-washing facilities in or near the latrines suggested little improvement since this initial success. In order for the VIP technology to work appropriately, the pipes must have unblocked access to the sun, there cannot be any lid/coverage of the pit, and net quality must be maintained; however, assessments suggested that each of these requirements had varied salience and too must be reiterated. After this, we were able to proceed to take the necessary steps for the next round of latrines. After remapping the community and receiving a generous donation from the Rhodes Scholarsâ&#x20AC;&#x2122; South African Forum, community members began the construction of the new latrines. We are approaching universal latrine coverage of Agyementi, which is a great accomplishment. This project sheds light on the intricacies of health issues in the developing world and the magnitude of the level of change that needs to occur to improve health, especially through sanitation. Innovative and thoughtful approaches are necessary to conquer multifaceted problems like the ones facing Agyementi.â&#x20AC;˘

Alex Almore Harvard College Class of 2012

Hailing from Midlothian, Virginia, Alexandra Almore is a junior in Winthrop House concentrating in Neurobiology and African American Studies. Alex is Co-President of Students Taking on Poverty (STOP), Director of the College Bound Mentoring Program, and the newly elected President for the multinational NGO, the African Development Initiative. For fun, she writes for the Crimson Arts and last year was a member of the Harvard Cheerleading Team. This past summer, Alex conducted malaria research in Sierra Leone with the NGO Global Minimum as well as development work in the Dominican Republic and Haiti with the NGO Children of the Border. In the winter of 2010, she traveled to Ghana to assess existing programming and conduct preliminary research for a microfinance program in Agyementi, Ghana with the African Development Initiative.

Photo courtesy of Alex Almore

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January in Bahia Trevor Thompson, Contributing Writer

his January, I spent three weeks in Bahia, Brazil as a participant of the Collaborative Public Health Field Course, co-sponsored by the David Rockefeller Center for Latin American Studies (DRCLAS) and the Harvard School of Public Health (HSPH). This marked the first year in which undergraduate seniors were allowed to apply. Three seniors were selected, along with a student from the Kennedy School of Government, and several students from HSPH, to spend three weeks in Bahia, Brazil (during the summer). Upon arriving in an area with weather, geography, food, and residents that put Massachusetts to dire shame, we spent our first week in Salvador listening to lectures about the endemic diseases, the Brazilian health care system, statistics, and human rights. After each lecture, participants went on site visits that included trips to an emergency room, a hospital, a favela (a slum), rural visits, and a zoonotic control center. My disease group worked on tegumentary leishmaniasis, a vector-borne disease spread by the sand fly that is often misdiagnosed with leprosy and several other diseases that result in lesions on the skin. My group, composed of three Brazilian participants, two students from HSPH, and myself, had moved with another group into a rural area, Jiquirica Valley. We found that only one doctor was responsible for leishmaniasis diagnosis and treatment for Jiquirica and eight neighboring municipalities. A full time researcher, this doctor was only able to perform treatment and diagnosis one week every month. After familiarizing ourselves with

the health policies, personnel, and facilities in Jiquirica, analyzed data collected from leishmaniasis patients from Jiquirica from 2002 to 2010. We were able to contribute information regarding the detection coefficients of tegumentary leishmaniasis in the municipality of Jiquirica and other municipalities of Jiquirica Valley, locations with the highest number of cases, gender and age distributions of cases, occupational characteristics of infected persons, and proportions of infected persons that owned different animals in the municipality. Combining this data with information we had gathered on the healthcare infrastructure of the area, we proposed an integration of leishmaniasis control into the primary care system. This included trainings and education protocol for health professionals, and a new system of task delegation

Photo courtesy of Trevor Thompson

Trevor Thompson Harvard College Class of 2011

Trevor, a senior in Leverett House, grew up in Marietta, GA. Last summer he was a participant in the IOP/HIGH Internship with the Stop TB Department of the WHO in Geneva, Switzerland. He is interested in issues of environmental health and justice, particularly in light of climate change and as applied to marginalized groups in the U.S. and around the world. Trevor will graduate in May with a degree in Environmental Science and Public Policy, a secondary in African-American Studies, and a language citation in Spanish. for health workers in the community. The response from the community was overwhelmingly positive and we hope to continue to hear encouraging news. This trip was extremely productive for me both professionally and personally. The previous summer I had interned at the World Health Organization, but had never experienced public health fieldwork. It is important for students to travel and gain new types of experiences when able. I made great friends and learned so much within a short time period. Whether or not I choose to look into further work on neglected tropical diseases (or, as a professor put it, “diseases of the neglected population”), this experience has made a lasting impact on my life. I hope that other students interested in global health, Latin America, or neglected diseases will take a serious look into this program. •

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