Fall 2010 Issue 3.2
Transcending Borders Innovative approaches to health care delivery
Realizing Global Mental Health Genomics and Global Health Power of Integrated Health Care www.juxtapose.ca | ISSN 1918-7653
The Global Health Specialist and Major Programs provide interdisciplinary undergraduate programs of study that include courses from the various medical departments, life sciences, social sciences, and humanities leading to an honours B.Sc. degree. The emphasis of these programs is to integrate the study of health sciences with select courses in the social sciences and humanities. Students will receive a solid foundation in life science courses together with insights from the humanities and social sciences and, at the same time, fulfill their distribution requirements. The Global Health programs are intended for a specific cohort of students who are interested in applying their experiences in the health sciences and related disciplines to assist with health issues, particularly in developing countries. For example, knowledge of several science-related disciplines, including ecology, environmental issues, and resource management will assist with the logistics of foreign aid to developing countries to help deal with natural disasters. The Global Health programs allow students to integrate courses in sciences, political science, resource management, ecology, and the environment, in addition to courses from the humanities and social sciences. The goal of the programs is to provide a multi-disciplinary education focused on global health issues relevant to humans while maintaining flexibility within course selection. For more information visit http://www.hmb.utoronto.ca
Juxtaposition would like to thank the following sponsors:
Photograph by: Nadine Balmores
Juxtaposition Global Health Magazine 4 5 9 13 16 20 26 28
Fall 2010 Volume 3 Issue 2
Letter from the Editors Realizing Global Mental Health: Roadblocks and Solutions for Developing Countries Shane Wong and Yukwal Wong Photo Essay: ยกPURA VIDA! Volunteer Reflections on Summer in Costa Rica/Panama Maggie Siu, Jonathan Liu and Nadine Balmores
Editors in Chief Editorial Division Managing Editors Editors
Genomics and Global Health: Initiatives in the Developing World Jennifer Kwan Health Systems Improvement and the Power of Integrated Health Care Jacqueline Wong The Past, Present and Future of Haiti Luchen Wang, Jennifer Kwan and Lucy Duan Haiti Timeline Luchen Wang Report on the 2010 Health and Human Rights Conference Lucy Duan and Jennifer Siu
Executive Division Administrative Director Productions Editor Productions Associates Sponsorship Director Sponsorship Associate Publicity Director Webmaster Strategic Advisors
Jennifer Kwan Jacqueline Wong Lucy Duan Jill Murray Sarah Dawsom William Fung Athena Hau Charlotte Hunter Michelle (Yunjeong) Lee Kathleen Nelligan Jennifer Siu William To Bing Wang Jacky Chan Maggie Siu Michelle Lee Bing Wang Corina Wong Gretta Moy Raissa Chua Anna Nguyen Andrey Mikhaylov Kadia Petricca Brian Park
Website: http://www.juxtapose.ca Email: firstname.lastname@example.org Address: 529-21 Sussex Ave, Toronto, Canada M5S 1J6
Fall2010 | Juxtaposition 3
Photograph by: Nadine Balmores
4 Juxtaposition | Fall2010
Health care across the world today is changing. Developing and developed nations alike are engaging in conversations of evolving health care as developing nations kick start their burgeoning health systems and developed nations realize that theirs need critical revitalization. We welcome you back to the sixth issue of Juxtaposition Global Health Magazine by taking a discerning look at how developing nations are managing their health care systems and the difficulties that they are facing in doing so. This issue, entitled Transcending Borders: Innovative Approaches to Health care Delivery, marks the start of our sixth year in publication. We are lucky this year to welcome back many members of our executive team as well as some of our long-term sponsors. We are perpetually grateful to the McLaughlin-Rotman Centre for Global Health and the Human Biology Department at the University of Toronto for their contributions to our publication and for their support of this issue in particular. We begin this issue with a look at mental health and its neglect in the developing world in an article by Shane Wong and Yukal Wong. They discuss Ethiopia’s alienation of mental health matters from primary health care, the “psychiatric brain drain” that is creating a shortage of qualified health professionals in developing countries, and the changes that must be made to create an effective method of dealing with mental health problems. Our featured photo essay, Pura Vida, offers a glimpse of the current state of health care for local families in Costa Rica and Panama. This is captured through the eyes of nineteen university students, who are part of the humanitarian organization called Volunteers for Intercultural and Definitive Adventures (VIDA). A fellow VIDA student, Maggie Siu, expands upon this cultural snapshot in her essay on the effects of student volunteerism abroad. She offers a critical analysis of the benefits and problems that can arise in a local community as a result of studentbased volunteering missions. We switch perspectives and leave the grassroots nature of VIDA’s medical program with Jennifer Kwan’s look into the numerous ongoing
government-driven initiatives in genomics research that have recently emerged in India, Thailand, and Mexico. Jennifer interviews Dr. Abdullah Daar, Co-Director of the McLaughlinRotman Centre for Global Health, for his perspective on genomic developments. One such interesting initiative involves genome-wide association studies in Thailand that have been used to design anti-retroviral drugs that provide beneficial treatment while limiting adverse reactions in patients. Always important to a consideration of a nation’s health is an understanding of the forces at play behind the provision of health care itself. Jacqueline Wong delves into an analysis of different methods of health care delivery and their relative efficacies. She sheds light on many of the limitations in health care systems and concludes by proposing improvements on these limitations. Next, we have included our editorial team’s interview with Drs. Melanie Newton and Alissa Trotz of the Caribbean Studies Department at the University of Toronto. They offer an illuminating view of the aftermath of the earthquake in Haiti, the role of the Canadian government in the disaster relief, and the reconstruction of Haiti, including its health care system. Further on the topic of foreign developments, Lucy Duan and Jennifer Siu report on the 2010 Health and Human Rights Conference presented by the University of Toronto International Health Program (UTIHP). They discuss recently proposed international projects, such as the Health Impact Fund, which is aimed to improve accessibility to medicines globally. An important part of the process of international health evolution is to keep an open-minded view of the plethora of health issues prominent across the world. Change requires an awareness of the current state; we hope that as you read through this issue our articles challenge you to think about the status of international health and how you can make an impact. We hope you enjoy our issue and look forward to hearing from you. Sincerely,
Jennifer Kwan & Jacqueline Wong
Editors in Chief 10/11, Editorial and Executive Divisions
Realizing Global Mental Health: Roadblocks and Solutions for Developing Countries Shane S. Wong1 and Yukwal Wong2 1 2
Stanford University School of Medicine Department of Psychology, University of Toronto
Mental illnesses represent five of the ten global leading causes of disability, but the poorest countries continue to spend the lowest percentages of their health budgets on mental health. Reasons include a lack of legal rights and national mental health policies, codified discrimination against the mentally ill, a perception that mental disorders are a distinct health domain, and â€˜brain drainâ€™- the migration of mental health professionals to higher-income countries. Despite an effective cost-benefit ratio, mental health services remain neglected in developing countries. Political, administrative and financial commitments are needed from the many stakeholders to employ evidence-based interventions at different levels of the health system, such as integration of mental health services with primary health care and innovative training projects like the Toronto Addis Ababa Psychiatry Project. With renewed attention to politics, leadership, planning, advocacy, education and participation, mental health care reform in developing countries can lead to basic care that is effective, affordable, and above all, morally justified.
he World Health Organization estimates that 450 million people around the globe suffer from mental disorders everyday, and one in every four people will develop one or more mental disorders at some stage in life.1 Together, mental health problems represent five of the ten leading causes of disability, amounting to 14% of the global burden of disease and nearly one-third of the disabilities in the world.2 DALY (disability-adjusted life year) projections by WHO predict that by the year 2030,
depression alone will become the third leading cause of illness.3 Yet mental health care remains overlooked on the global health agenda. Currently, one of the biggest barriers to progress in global mental health is the lack of mental health policies in most developing countries. What is the current situation of mental
health policy in developing countries today? And what can we do to improve it towards providing better mental health care in developing countries? Mental health remains a low priority for developing countries.4 Developing countries tend to prioritize the control of infectious diseases, and the promotion of
Left in the wayside is a long list of mental disordersâ€” all of which make up only 2% of the global health budget. Fall2010 | Juxtaposition 5
reproductive, maternal, and child health over investments in mental health.5 Left in the wayside is a long list of mental disorders that include affective disorders, schizophrenia, and substance abuse—all of which make up only 2% of the global health budget.6 A recent analysis of the World Health Organization’s Atlas Project, a comprehensive set of health statistics at country, regional, and global levels, showed widespread, systematic, and long-term neglect in the provision of adequate mental health resources for developing countries.7 The trend indicates that the poorest countries are spending the lowest percentages of their health budgets on mental health.8 This leaves populations having the highest need for mental health care with the lowest capacity for access. The most obvious cause of this neglect is the lack of national mental health policies for many developing countries. Globally, one third of all countries have no mental health policies or plans for their implementation, and in Africa, this proportion increases to nearly half.9 Moreover, of the countries that do have policies, nearly 40% have not revised them since 1990.10 This means that substantial recent developments in mental health care, such as the introduction of less harmful secondgeneration atypical antipsychotic medication for schizophrenia, have not been incorporated into many national policies since the 1994 revision to the Diagnostic and Statistical Manual of Mental Disorders.11,12 A mental health policy is often derived from legislation that protects the basic human and civil rights of people with mental disorders. However, nearly a quarter of countries, comprising 31% of the world’s population, do not have specific legal protection for people with mental illness.13 Furthermore, discrimination against the mentally ill is widespread, often formalized, and 6 Juxtaposition | Fall2010
sometimes even codified in law. For example, although most countries have some provision for disability benefits, 45% of developing countries specifically exclude mentally ill people from such entitlements.14 Without updated mental health policies and legislation to protect the basic rights of the mentally ill, little can be done to coordinate mental health services and activities to reduce the burden of mental illness on a national scale.
In most countries, mental disorders are regarded as a distinct health domain from physical disorders, with separate services and budgets. Even in governments that do have mental health policies, attaining mental well-being can still be a challenge. In most countries, mental disorders are regarded as a distinct health domain from physical disorders, with separate services and budgets.15 In Ethiopia, for example, psychiatric service remains separate from primary health care, both in terms of legislation and government funding.16 By stressing the separate contributions of mental and physical disorders to disability and mortality, public health may have unwittingly alienated mental health from mainstream efforts to improve health and reduce poverty. This separation can lead policy makers to perceive that investments into mental health have an unaffordable opportunity cost. According to Dr. Clare Pain, Director of the Toronto Addis Ababa Psychiatry Project, the lack of investments is demonstrated in Ethiopia by the extra work psychiatrists had to engage in, such as proposing policies that would allow vans to transport much-
needed psychiatric nurses to the rural hospitals.17 In addition to a lack of integration and health resources, mental health policy in developing countries often fails to prevent “psychiatry brain drain,” or the problematic migration of mental health professionals to countries with higher incomes.18 Like many other developing countries, Ethiopia lacks local psychiatry training programs.19 For local physicians interested in psychiatry, training often has to occur out of the country. Once these physicians leave there are few incentives to return. In 2006, only 12 psychiatrists remained in Ethiopia—an average of one psychiatrist per 5.83 million Ethiopians.20 The numbers are similar elsewhere: Chad, Liberia and Sierra Leone have only one psychiatrist in each country, while Rwanda and Afghanistan have only two psychiatrists each.21 Unfortunately, most developing countries continue to give low priority to mental health policies, despite evidence that mental illnesses contribute to an unrealized disability burden, have longterm effects on the quality of life, and ironically, have treatments that are relatively cost effective compared to those for other conditions.22 An analysis by the Disease Control Priorities in Developing Countries reported that a basic mental health package, including antipsychotic medications and psychosocial treatments, can be implemented for US$3 to US$4 per capita. This can help reduce 2000 to 3000 DALYs per 1 million population in developing countries in Africa and South Asia.23 This cost-benefit ratio is comparably as effective in investment of intervention methods as that for the treatment of other chronic disorders, such as drug treatments in AIDS and diabetes.24 To progress from awareness to real changes, political, administrative and financial commitments are needed from the many stakeholders. Governments,
mental health professionals, human rights advocates, community leaders, and other stakeholders in mental health care need to work cohesively to propagate mental health reform in their countries. Governments must update mental health policies, implement national mental health legislation, allocate a greater share of financial resources to mental health service, and promote public education. Community leaders and family members must facilitate the provision of social support for the mentally ill by building on
local resources and facilitate livelihoods and interventions for inclusion within the community. Human right groups must advocate for and protect the rights of the mentally ill. Governments of developed countries must increase funding for mental health in internationaldevelopment, especially in capacity building and professional training. Innovative approaches are also needed to promote the awareness of mental disorders and efficiently use available resources to ensure that basic mental
Woman in Accra, Ghana. Photo credit: 7 Nation Army Wikimedia Photo source: http://mediaglobal.org/article/2010-08-14/mental-illness-as-a-silent-predator-inthe-developing-world
health care reaches all individuals. The successes of certain countries that have developed their mental health system despite low-income levels offer useful lessons. In India, judicial intervention from the Supreme Court of Canada has pressured the Indian government to increase resources towards mental health care after repeated failures to implement the new mental health legislation.25 By focusing on government efforts to increase priority and funding for mental health, India has revitalized their national programme; rejuvenated district mental health programmes; increased accessibility to essential psychotropic medication; and increased public education and relevant research.26 This example demonstrates the potential effectiveness of using moral and ethical arguments based on human rights and social responsibility, in accordance with the UN Charter and existing international laws, to help extend mental health care services.27
Integrating mental health services with primary health care is another important approachâ€Ś Integrating mental health services with primary health care is another important approach, which has seen recent success in developing countries. Under this framework, the interconnection between mental health and physical diseases and injuries are emphasized.28 As mental health care services and budgets no longer form a distinct health domain, they will no longer be perceived to have an unaffordable opportunity cost. Furthermore, a transition to primary health care will promote the transition of health care delivery to a communitybased model, making access much easier for rural populations.28 According to Dr. Fall2010 | Juxtaposition 7
Suzan Song, a child psychiatry fellow at Stanford University, this grassroots approach to service delivery mobilizes existing community resources such as HIV counselors who deal with frequent depression among the chronically ill, and educates priests and traditional healers on common mental health issues.29 A case study is the government of Brazil, which adopted in 1990 the Pan American Health Organization’s Caracas Declaration that promoted psychiatric reform and incorporation of mental health programmes in primary care.30 The two main features of the reform programme were the Community Mental Health Services, which were established to care for people with severe psychiatric disorders, and the Return Home Programme, which provided financial support for families that welcomed relatives who had spent a long time in mental institutions back to their communities.31 These reforms have paved way for universal coverage and muchimproved access to mental health care services in Brazil.32 Indeed, a systematic review of community-based models of care by the School of Public Health at the University of North Carolina has shown that such models improve clinical outcomes, with some cost savings.33 Perhaps, according to one anonymous mental health practitioner, this is because “it is at the local level, at the level of villages, chiefs, and church healers, where you can find people who genuinely care.” To expand the mental health workforce and prevent ‘psychiatry brain drain,’ local psychiatry residency programs have been shown to be an effective approach. One success story has been the Toronto Addis Ababa Psychiatry Project (TAAPP) initiative. Since 2003, TAAP has, under the leadership of Dr. Clare Pain, organized three trips a year to provide mental health education in Ethiopia, sending two staff psychiatrists and one resident from the University of Toronto to Addis Ababa 8 Juxtaposition | Fall2010
University for a month at a time on a volunteer basis.34 Canadian psychiatrists bring with them a curriculum of relevant seminars and clinical teaching, including didactic lectures, journal clubs, clinical supervision of cases, and clinical skills training through simulated patient encounters. In just five years, the number of psychiatrists in Addis Ababa University has increased from 14 to 34, the Addis Ababa University’s Psychiatry Department has doubled their faculty number, and psychiatry residents are providing clinical care in regional hospitals outside of Addis Ababa for the first time.
…a concerted and sustained effort can indeed improve mental health care in developing nations. Despite the major barriers in mental health policy, including its separation from primary health care and the lack of local training programs, a concerted and sustained effort can indeed improve mental health care in developing nations. The most obvious need is for governments to allocate much higher priority and larger proportions of public resources to mental health. While difficult tradeoffs between public policy investments will need to be made, mental health policy in developing countries has been unfairly disadvantaged by the widespread neglect and the endemic stigma attached to mental illness. Other stakeholders, including mental health professionals in developed countries, community leaders, human rights advocates, legislators, and policy makers, must also scale up evidence-based interventions at different levels of the health system. Together with renewed attention to politics, leadership, planning, advocacy, education and participation, mental health care reform
in developing countries will lead to basic care that is effective, affordable, and above all, morally justified.
References 1. WHO (2002). Mental Health Global Action Programme. Geneva, Switzerland: World Health Organization. 2. WHO (2002). Mental Health Global Action Programme. Geneva, Switzerland: World Health Organization. 3. Mathers, C. D.& Loncar, D. (2006). Projections of Global Mortality and Burden of Disease 2002 to 2030, PLoS Medicine 3: 442. 4. Mathers CD, Loncar D (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 3: 442. 5. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M., & Rahman, A. (2007). No health without mental health. Lancet 370: 859–877. 6. WHO (2002). Mental Health Global Action Programme. Geneva, Switzerland: World Health Organization. 7. Saxena S, Sharan, P Garrido M, Saraceno, B. (2006). World Health Organization’s Mental Health Atlas 2005: Implications For Policy Development. World Psychiatry 5: 179-84. 8. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370: 877-889. 9. WHO (2005). Mental Health Atlas. Geneva, Switzerland: World Health Organization. 10. WHO (2005). Mental Health Atlas. Geneva, Switzerland: World Health Organization. 11. Barnes T.R., Davies L., et al (2006). “Randomized controlled trial of the effect on Quality of Life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1)”. Arch. Gen. Psychiatry 63 (10): 1079-87. 12. Krueger, R.F., Watson, D., Barlow, DH. et al. (2005). Toward a Dimensionally Based Taxonomy of Psychopathology Journal of Abnormal Psychology 114: 4. 13. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370: 877-889. 14. Thornicroft G. (2006). Shunned: discrimination against people with mental illness. Oxford, UK: Oxford University Press. 15. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M., & Rahman, A. (2007). No health without mental health. Lancet 370: 859–877. 16. Pain, Clare. (2008). Personal Interview at Mount Sinai Hospital. 23 January 2008. 17. Pain, Clare. (2008). Personal Interview at Mount Sinai Hospital. 23 January 2008. 18. Ndetei D, Karim S, Mubbashar M. (2004). Recruitment of consultant psychiatrists from low- and middle-income countries. Int Psychiatry 6: 15–18. 19. Pain, Clare. (2008). Personal Interview at Mount Sinai Hospital. 23 January 2008. 20. Pain, Clare. (2008). Personal Interview at Mount Sinai Hospital. 23 January 2008. 21. WHO (2005). Mental health atlas. Geneva, Switzerland: World Health Organization. 22. Patel V, Araya R, Chatterjee S, et al. (2007). Treatment and prevention of mental disorders in low and middle income countries. Lancet: 612-619. 23. Hyman S, Chisholm D, Kessler R, et al. (2006). Mental disorders. Disease Control Priorities in Developing Countries (2nd ed); 605-625. 24. Patel V, Araya R, Chatterjee S, et al. (2007). Treatment and prevention of mental disorders in low and middle income countries. Lancet: 612-619. 25. Dhanda A. (2006). Laws relating to the custody, care and treatment of persons with mental disorder. In: Dhanda A, ed. 26. Planning Commission, Government of India. (2006). Towards faster and more inclusive growth: an approach to the 11th five year plan. New Delhi: Planning Commission, Government of India. 27. Jones, M. (2005). Can international law improve mental health? Some thoughts on the proposed convention on the rights of people with disabilities. Int J Law Psychiatry 28: 183–205. 28. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 370: 877-889. 29. Song, Suzan (2009). Personal Interview at Stanford University. 1 April 2009. 30. Levav I, Restrepo H, Guerra de Macedo C. (1994).The restructuring of psychiatric care in Latin America: a new policy for mental health services. J Public Health Policy 15: 71–85. 31. Levav I, Restrepo H, Guerra de Macedo C (1994). The restructuring of psychiatric care in Latin America: a new policy for mental health services. J Public Health Policy 15: 71–85. 32. WHO-AIMS report on mental health system in Brazil. Geneva: WHO, 2007. 33. Wiley-Exley, E. (2007).Evaluations of community mental health care in low and middle-income countries: A 10-year review of the literature. Soc Sci Med 46: 1231–41. 34. Pain, Clare. (2008). Interview at Mount Sinai Hospital. 23 January 2008.
By the roadside| A Panamanian scene.
Maggie Siu1 and Jonathan Liu2 Photographs by: Nadine Balmores 1 2
Department of Human Biology: Global Health, University of Toronto, ON, Canada University of Western Ontario, ON, Canada
August 2009: A photo essay by the University of Toronto chapter of Volunteers for Intercultural and Definitive Adventures (VIDA) The University of Toronto organized its first medical and dental service teams for VIDA in the summer of 2009. From August 15th to 27th, nineteen undergraduate students joined four translators, an administrative assistant, two local dentists and three local doctors, one of whom acted as a guide, and embarked on a humbling and eye-opening journey around Costa Rica and Panama.
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A typical clinic | Local doctors work with university studnet volunteers to provide much needed health care to underserved communities.
Black teeth | A young girl receives much needed dental care.
Non-medicinal therapy | Postclinic festivities bring life and smiles back to a Panimanian hospice.
10 Juxtaposition | Fall2010
olunteers for Intercultural and Definitive Adventures (VIDA) is a non-profit, humanitarian organization created in 2007 that aims to provide free medical, dental and veterinary services to underprivileged communities in Central America, while offering students worldwide a unique, hands-on volunteer experience. Volunteer groups travel the region for two weeks, setting up field clinics and working along-side local health care professionals to treat basic illnesses and to provide basic dental and veterinary care. At the same time, students are also given a chance to explore Central America and its various cultures, and to learn about tropical medicine and preventative health care measures. Since VIDA is supported financially by the volunteers participating on the trip, the organization appropriately focuses not only on improving health care in Central America, but also equally on providing a rich learning experience for volunteers. They ensure safety and fun through experienced, bilingual staff and a well-organized schedule of events. It thus provided the perfect opportunity for those with very little experience abroad and was appealing to parents and students alike. The trip started in San JosĂŠ, Costa Rica, where VIDA is based, by orienting volunteers to duties of the medical and dental clinics through one day of training by local health care professionals. Volunteers learned about the health care systems in Central America, and the importance of community education and public health. The medical team was also given an introduction to preventative medicine and the treatment of tropical and common diseases, and was taught to do basic physical exams, take vitals and record clinical histories. The dental team, on the other hand, was given a brief overview of common oral diseases and the anatomy of the mouth, and was taught to do field extractions, cavity filling and manual cleanings. Even though translators were present, a quick Spanish lesson was also taught during
Top: One-by-one | Volunteers enter a secluded community to set up a clinic. Left: A long wait | Pre-clinic opening in the early morning is met with a crowd of anxious patients and family members.
the orientation day, with the aim of giving the volunteers more independence. Also through inevitable repetition in the clinics, volunteers learned basic phrases needed to communicate with locals. However, at times, language barriers became obstacles even to those fluent in Spanish, since many of the communities visited speak specific indigenous languages. The team traveled on a tourist bus to set up clinics in different schools and community centers in Turrialba (Costa Rica), the Changuinola area, and the village of Cañazas (Panama). Volunteers in the medical team were responsible for their own stethoscopes and blood pressure cuffs. Other supplies, including medicines, tests, dental equipment and dental chairs were collected through donations and brought along in large bins strapped to the top of the bus. VIDA attempts to reach out to communities that do not have regular access to health care. As a result, volunteer teams travel to secluded regions of the country. An example of this was the journey to an indigenous community
near Changuinola. Its isolation was reflected in the fact that the village could only be accessed through a single, narrow bridge. Upon entering this community, volunteers experienced an odd exchange with the local people, where both groups seemingly took a minute just to stare at each other. On the one hand, volunteers, most with their cameras out by this point, were literally entering a new world. On the other hand, from the locals’ perspective, a very large, new group of strangers had just waltzed into their community. Even though VIDA staff made arrangements with community leaders beforehand, there was no formal introduction, and as a volunteer, it was thus easy to feel like an intruder. Volunteers were told to dress in scrub suits for the clinic days, certainly not for sterilization as used in hospitals, but more so for professionalism. They acted as identifiers in the clinics and reassured patients of the quality of care they were receiving. It is unsettling, however, to think about how by doing so, the srub suits also masked the students’ inexperience,
and may have made them appear to be more skilled than was merited. This hands-on aspect of VIDA trips, however, was one of the main reasons students were drawn into participating. Under staff supervision, students had the opportunity to surpass formal training to perform such procedures as dental extractions and abdominal examinations. On some other trips, students could even do injections and PAP tests. In Canada, most patients would not allow anyone to perform a PAP test unless they were fully certified to do so, while most of VIDA’s volunteers are undergraduate students with no medical training at all. However, in a handbook that the medical volunteers received in 2009, it was recorded that in the two years since VIDA’s creation, four cases of cancer had been detected through PAP smears in the clinics. Where should one draw the line between ethical considerations, and this surge of human, monetary and material resources? Volunteers worked closely with local staff during the trips. However, with a large medical service group, much time was spent waiting with the patients for Fall2010 | Juxtaposition 11
A curious stare | Two young patients at the clinic wait for their turn to receive the care and support they deserve.
a doctor to become available in order to confirm a diagnosis and to prescribe medication. This allowed volunteers to give patients the time and attention that they probably otherwise would not be able to receive from their overworked health care system. Volunteers also helped promote preventative medicine, for example by using the time to explain how to use condoms properly. Many tropical diseases are also dependent on the environment and hygiene. For example, countless cases of parasites can be found where there is unsafe drinking water. During the clinics, patients were reminded to filter their water, because otherwise, the parasites would simply return even after treatment. Language barriers certainly made health promotion difficult for volunteers though. Thus, with an effort, there were many ways for volunteers to help and to engage in the local population during clinics. Students simply had to understand and accept their limitations, know what jobs 12 Juxtaposition | Fall2010
should be left for those who are qualified, and always respect the local population. VIDA brings volunteers to underprivileged communities in countries that depend mostly on the government to address their health care issues, but where generally government efforts are not enough to cover every person in the country. More problems arise when specialists refuse to work in rural areas, preventing many of the communities located far away from any hospital, or primary health center for that matter, from receiving much needed care. Arguably, these communities can be found all over the world, even in Canada, but the problem is certainly worse when there are greater distances between urban and rural areas, and where a greater percentage of the population is living in poverty. Organizations like VIDA provide this much needed care, but in the long run, will the organization’s efforts isolate the communities even more, as they become dependent on health care that
comes to them? VIDA’s efforts are also highly dependent on volunteer interest. Is this actually the most sustainable way of providing health care to these communities? These are long-term problems common to many organizations that send volunteers abroad. Nevertheless, VIDA continues to spark many students’ interest in health and culture, and continues to attract and send more teams to more places each year. As Dr. Sanchez, the 2009 University of Toronto group’s guide, put it during her thank you speech at the end of the trip, “what’s most important is that big or small, I hope we were able to make a difference in somebody’s life”. Students have since organized a University of Toronto club dedicated to promoting VIDA’s efforts, and in raising funds to allow more students the opportunity to join a team. For more information on VIDA, visit http://www. vidavolunteertravel.org/, or contact the Uof T team at email@example.com.
Genomics and Global Health: Initiatives in the Developing World Jennifer Y. Y. Kwan Department of Laboratory Medicine and Pathobiology, University of Toronto, ON, Canada
Dr. Abdallah Daar, professor of Public Health Sciences and of Surgery at the University of Toronto and director of Ethics and Commercialization, McLaughlin-Rotman Centre for Global Health, University Health Network and University of Toronto, was interviewed last year for his view on the state of genomics across the globe. His research has focused on genomic initiatives developed in countries such as Mexico, India, and Thailand. Genomics research was once viewed as a tool that was beneficial mostly to the technologically advanced and wealthy countries and was predicted to create an inequality in the delivery of medicine between first and third world countries. However, from the views of both Dr. Daar and other recent reports, it seems that many developing countries have come to understand the benefits to medical care that genomic research can provide and have taken steps to invest in this technology.
enomics is reshaping the way people view health care delivery. Studying the human genome has promised to reveal crucial information that will help medical scientists develop more effective vaccines, drugs, and personalized treatments. Improved molecular diagnostic tools also have the potential to advance predictive and preventive health care measures. There are many ongoing research projects that are currently harvesting genomic information to understand the relationship between genetics and disease. Recently, in April 2010, the International
Cancer Genome Consortium identified genetic abnormalities in fifty of the most prevalent cancers. 1 It is now certain that different cancers result in significantly different genetic profiles. 1 As a result, the consortium has set up online databanks to make their findings accessible to others in the medical field and help advance medicine towards treatments tailored to genetic information.1 Genomic research is paving the way for more effective therapies to treat many conditions in addition to cancer. However, in order to implement the use of genomics globally, scientists must learn more about the
genetic similarities and variations among different human populations across the globe.
Genomics in countries
From the discovery of the DNA double-helix by Watson and Crick in 19532, interest in genetics and genomics has steadily been on the rise. It is likely that genomics will play a significant role in the delivery of medicine to the public in the future for developed countries. Whether it can be extended to the developing world and whether or Fall2010 | Juxtaposition 13
Global collaboration is the key to solving both the problem of genomic sovereignty and resource shortages. not the disparity in the pace of research and innovation between first and third world countries will create inequality in the delivery of medicine and health care around the world has been unclear. The â€œgenomic divideâ€? was a term coined by Drs. Abdallah Daar and Peter Singer of the University of Toronto to epitomize this potential outcome.3 Between 1975 and 1996, only 1% of the new drugs developed were designed with the goal of managing and treating diseases that predominantly occurred in tropical regions. 4 This reality is representative of the attention placed on some developing countries in terms of health. To understand how genomics is beginning to be incorporated into less developed countries, the state of health care in Mexico, India, and Thailand will be examined. These countries have developed a strong national interest in investing in genomics as a means to improve health care and have recently developed new initiatives with this in mind. By revealing more about the genomic variation within their own populations, they have the potential to target specialized conditions that are of a more regional concern and improve their local health care.
Mexico In 2004, the National Institute of Genomic Medicine (INMEGEN) was founded in Mexico.5 This relatively new organization is a government-funded program, which aims to investigate genetic diseases, to complete genomic studies on the Mexican population, and to invest in genomics through services and commercial products.5 Through the Mexican HapMap Project, INMEGEN has been able to collect DNA samples from the Mexican population to 14 Juxtaposition | Fall2010
study genomic information of its local populations and allow the country to invest in medical care that targets diseases that are prevalent in Mexicans, such as asthma, diabetes, and hypertension.5 Recently, in 2009, one of the first genomewide genotyping efforts on the Mexican
Dr. Abdallah Daar
Mestizo people was used by researchers to ameliorate methods of identifying genes associated with diseases commonly faced by this sub-population.6 Results from this and other studies will increase understanding regarding the association of genetic profiles and various complex diseases and may contribute to medical advances. In addition to the genotyping project, INMEGEN is embarking on a nutrigenomics project by studying molecular nutrition and its relationship to health and disease.5
India India is home to the second largest
population in the world.7 A country with a large population like this one requires an equally substantial medical system to meet its needs. However, the countryâ€™s medical system has faced many obstacles, including its inability to afford importing cutting-edge technologies of developed countries to deal with modern medical dilemmas. With the high prevalence of chronic and infectious diseases plaguing the population, India is investing in its own genomic research as an alternative solution to utilizing the expensive medical technology from overseas. In 2003, the Indian Genome Variation (IGV) Initiative was established; it is a government funded program that supports research of six laboratories of the Council of Scientific and Industrial Research (CSIR).7 The IGV database includes the genetic information of 15,000 unrelated individuals and has been made publicly available to the academic community through an online internet portal.7 Progress in genomic research is hoped to increase cost-effectiveness of health care in India by improving diagnostic methods, focusing on early detection, and advancing treatment options.7 The IGV is an important project for India as it will provide crucial insights into the extent of genomic variation among its sub-populations and the project will also help gear the country towards a knowledge-based society on par with developed countries.7 In addition, interest in genomic diversity stimulated research on the Indian Parsi population.7 There are approximately 69,000 Parsis living in India.7 The small size of their population combined with their unique cultural practices have made them susceptible to extinction.7 By studying the genetic profiles of these people through the genotyping project, Avesthagenome, it is hoped that the knowledge uncovered will improve medical care for the Parsis and help them maintain a viable population size and
reduce their likelihood of extinction.7
Thailand In 2004, the Thailand Centre of Excellence for Life Sciences (TCELS) was established.8 By 2008, TCELS had already shown remarkable advances in areas such as pharmacogenomics, genetic services, posttraumatic stress disorder studies, and clinical and research infrastructure.8 The TCELS pharmacogenomics project was a genome-wide association study involving patients with adverse drug reactions. In studies of reactions to antiretroviral drugs, it was found that different reactions manifested depending on the genetic profile of the person; this information has proved invaluable to developing safe treatments, such as those for HIV patients.8 TCELS has also been committed to providing quality genetic services including genetic testing (e.g. DNA analysis) to all users and patient care for people with genetic disorders.8 As a response to Thailand’s major spending on treatments for patients with mental health conditions, TCELS launched a study on 3,000 tsunami survivors and their relatives to learn more about posttraumatic stress disorders and develop more cost-effective treatments.8 Lastly, as TCELS’ board advisor, Prof. Pornchai Matangkasombut has noted, “TCELS’ role is to position Thailand in the global life sciences industry and services.” The organization has certainly done so by establishing notable infrastructure such as the Clinical Research Collaboration Network, Tsunami PTSD Genomics Center, and Mental Health Genetic Development Foundation.8
New ideas lead to new problems Exciting genomic initiatives are underway across the globe, but as with all novelties, there comes new problems as well. The United States and Canada are dealing with issues such as patient
privacy, while less developed countries are tackling problems that focus more on genomic sovereignty and resource shortages. Dr. Daar defines genomic sovereignty as the desire of nations to protect and benefit from the totality of their genomic resources, whether human, animal or plant. For example, Mexico has passed a genomic sovereignty law that restricts the export of biological samples, among other similar measures. Dr. Daar noted that while genomic sovereignty is certainly a valid response to this phenomenon, it may complicate the very goals upon which this phenomenon is based since the protection of genomic resources will ultimately restrict the amount of collaboration that can occur between countries.
…the protection of genomic resources will ultimately restrict the amount of collaboration that can occur between countries. Resource shortages in developing countries are also inhibiting the progress of their genomic research. Availability of funding for research and accessibility to the latest technology is causing countries to have varying levels of opportunity to benefit from genomic information. Genomic research has advanced rapidly in the past two decades and will only continue to do so with the free flow of information among scientists and research institutes around the world and continual investment in genomic research. Vast amounts of genetic information can be compiled and analyzed in comparative studies and ultimately lead to better health care solutions for different ethnic populations globally. However, Dr. Daar pointed out that
studying genomic variation across subpopulations is only a half-way effort since pharmacogenomics and other benefits of personalized medicine will ultimately be based on mutations that differ among individuals. Sequencing genomes of individuals and incorporating personalized medicine in the clinic are possibilities for the future.
Global development As can be seen, countries around the world are learning more about the genomes of their local populations each and every day. Genomics research was once viewed as being beneficial only to the technologically advanced and wealthy countries, but many developing countries have come to understand the benefits to medical care that genomic research can provide in the future and have taken steps to invest in this technology. However, global collaboration is the key to solving both the problem of genomic sovereignty and resource shortage that are faced by countries such as India, Mexico, Thailand and other developing countries. Now, the next step is for all countries to continue to approach genomics as a global effort. The free flow of information, knowledge, and skills will rapidly advance genomics research and its applications will ultimately benefit both the developed and developing countries.
References 1. The International Cancer Genome Consortium. International network of cancer genome projects. 2010. Nature 464: 993-998. 2. Watson J.D., and Crick F.H.C. A structure for deoxyribose nucleic acid. 1953. Nature 171: 737-738. 3. Dowdeswell, E., Daar, A., and Singer, P. Bridging the genomics divide. 2003. Global Governance 9. 4. Trouiller, P. and Olliaro, P. Drug development output from 1975 to 1996: What proportion for tropical diseases? 1999. International Journal of Infectious Diseases 3(2): 61-63. 5. Herrera, S. Mexico launches bold genome project. 2005. Nature Biotechnology 23: 1030. 6. Silva-Zolezzi, I. et al. Analysis of genomic diversity in Mexican Mestizo populations to develop genomic medicine in Mexico. 2009. PNAS 106(21): 8611-8616. 7. Hardy, B. et al. From diversity to delivery: the case of the Indian Genome Variation initiative. 2008. Nature Review Genetics 9: S9-14. 8. Thailand Center of Excellence for Life Sciences. 2008. The Scientist 24(11): 88.
Fall2010 | Juxtaposition 15
Health Systems Improvement and the Power of Integrated Health Care Jacqueline M.K. Wong Department of Human Biology: Health and Disease, University of Toronto, ON, Canada
Primary health care has been globally regarded as the ideal model of health care. It promises health care for all individuals within a community according to that community’s specific needs and at an affordable cost. This goal has been hard to achieve, however, because comprehensive, or horizontal, methods of health care provision have been impeded by an influx of short and specific, or vertical, health care initiatives. Lack of integration between these health care delivery methods retards the delivery of effective health care to communities, and so proper integrative strategies are important for the maximization of health care finances and resources. This article highlights the advantages of integrated horizontal and vertical strategies of health care delivery. Limitations in practical implementation still remain, and greater financial inputs, recognition of the values behind health care integration, planned partnerships, and a commitment to research are necessary to achieve the full goals of primary health care.
he current era of health care policy began at the WHO/ UNICEF Conference at Alma Ata in 1978, where the revolutionary idea of primary health care (PHC) was formally institutionalized at the international level.1 PHC is essential health care provided for a community through their full participation and at an accessible cost, contributing to the community’s selfdetermination. It is integral to the health system of the community and contributes to its social and economic development.2 PHC was intended to facilitate the goal of “Health for All by the Year
16 Juxtaposition | Fall2010
2000”3 through horizontal health care, i.e. health programs implemented through a community’s existing health system.4 Horizontal health programs do not target a specific disease, but rather involve local stakeholders, train existing health workers, educate the community, and provide ongoing solidarity and technical support to strengthen the community’s overall health system. The Millennium Villages Project, for instance, used a horizontal health care approach: it sought to improve the health of poor communities worldwide through community-led health care
and infrastructure advancements.5 This new strategy was seen as an alternative to vertical health care, which until that time had addressed specific diseases or health priorities outside of a community’s health system4, but was unable to sustain its benefits over a long period of time.6 An example of a vertical program would be the World Health Assembly’s Direct Observed Treatment Strategy (DOTS), which implemented tuberculosis-specific treatment measures.7 Unfortunately, early attempts at the new horizontal approach, which occurred in Swaziland, Bolivia, and Cameroon,
demonstrated that serious practical limitations restrained the theoretical efficacy of PHC.8 These limitations included inadequate education of health workers, insufficient human resources, and absent financial support from domestic and international governments.8 This perceived impracticality quickly gave rise to the alternate concept of Selective Primary Health Care (SPHC), presented by Walsh and Warren in 19799 in response to the lofty and supposedly unachievable goals proposed for PHC. SPHC presented a cost-effective interim strategy to tackle the highest burden diseases10, while preserving PHC’s goal of strengthening health systems.8 Opponents rejected this cost-effective strategy as the myopic response of rich countries to a view of global health care, since care is often most expensive to provide in poor regions.10 In addition, SPHC was often less costly than PHC only because of short-sighted restrictions in the training of health care personnel, which over the long term lead to a reduced quality of health care.12 SPHC represented a vertical approach to PHC that was ineffective for the same reasons inherent in other vertical strategies: shortsighted and narrow care. As a result, SPHC was largely disregarded by the health systems community, which reverted to the original Alma Ata Conference concept of primary health care, renamed as Comprehensive Primary Health Care (CPHC).6 This concept, in one form or another, has dominated health systems discourse for the past thirty years and continues to be one of the most powerful policy guidelines today. The reaffirmation of PHC has led to the integration of past vertical theory with present horizontal policy13; this is a new concept which is accepted by the health care community as the model of bestpractice for health care implementation. Vertical and horizontal integration,
in theory, is most effective because it utilizes the strengths of both systems of health care while compensating for the weaknesses of each.
A horizontal program fills this void by providing disease prevention and long term care for a community. Advantages of Horizontal Health Care Vertical programs, such as the DOTS, are short term and specific by nature. These programs are heavily criticized for a lack of sustainable treatment once a program has ended. The focus on the elimination of a disease in infected patients misses the larger picture of the socioeconomic determinants that also impact the health of a community. A horizontal program fills this void by providing disease prevention and long term care for a community.14 Horizontal programs achieve both these goals by educating communities about the nature of diseases, instructing individuals already infected about ways to prevent disease transmission, and informing community members of lifestyle choices that will impact their chance of being infected.14 All these areas of health systems inputs can significantly decrease the burden of disease in a community. Horizontal programs are also more cost-effective than vertical programs in the long run; when countries at a comparable economic level are weighed against each other, those that implement health systems based on a PHC model show better overall results in health care.15 Finally, horizontal programs are best able to meet the specific demands of a
community. Community members’ full participation in their health system leads to localized care and self-determination4, which furthers the socioeconomic needs of the specific community. This is in stark contrast to vertical programs such as “mass campaigns,” which provide massproduced medications to all communities regardless of socioeconomic condition or the status of the community’s health system.16 Such mass campaigns, for instance malaria eradication programs, sacrifice effectiveness for efficiency: the goal is, for example, to immunize as many individuals as possible even while immunization may not be the ideal method of disease eradication within a specific community.
…tangible results give investors incentives to continue to provide funds for more vertical programs. Advantages Health Care
Vertical programs have historically been the program of choice for investors because of the clear results that these short-term initiatives produce.17 Campaigns focused on specific diseases can easily present positive results to investors, and these tangible results give investors incentives to continue to provide funds for more vertical programs. This financial support is enhanced by the media: undeniably, the relative media attention given to disease-specific programs, such as those against HIV/ AIDS, greatly outweighs that given to health systems development.13 Vertical programs, therefore, have a tremendous advantage over solely horizontal programs, which lose financial support because of unfocused results. Resulting in part from greater financial Fall2010 | Juxtaposition 17
inputs, vertical programs also boast more specialized technology and better trained health care workers.6 These benefits, when integrated into the health care system, can educate public health workers on how to provide more advanced care for their communities and can increase the amount of resources available to depleted health systems. If properly integrated, vertical programs can significantly increase the quality of health care that a community receives.
Concerns of Integration Concerns, however, still exist as to whether vertical and horizontal integration will successfully improve the health care of nations overall. A mounting concern is that a lack of coordination during integration may limit effectiveness and may give rise to parallel structures within a given health system. This is compounded by the possibility that vertical programs will preferentially attract health care workers away from the public health care system through benefits such as wage incentives.18 Even if integration is successful, focus on one specific group of the population may implicitly denote other groups as less important.10 This can create a shortage of resources and patient care for individuals afflicted with diseases outside of â€œhighest burdenâ€? consideration.14 Overall, while properly integrated programs can greatly benefit health, careful consideration of the nature of this integration is mandatory. This is especially true since evidence demonstrating the actual effects of implementation is lagging behind.19 This leads to speculation within the health care community about the ultimate benefits, if any, that health systems integration today is producing.
Practical Implications of Primary Health Care According to the WHO, PHC offers a way of tackling the three greatest emerging 18 Juxtaposition | Fall2010
problems of the 21st century: 1) the globalization of an unhealthy Western lifestyle; 2) unregulated urbanization, and 3) a rapidly aging population.15 PHC is therefore crucial for an increased quality of life as the 21st century progresses. Integration of disease-specific programs offers a tremendous possibility in furthering the fight to give adequate health care to all, although this approach still has a long way to go. Four factors continue to be serious barriers to successful integration of disease-specific programs and the greater health care system: 1. Greater Financial Inputs Health system efficacy in most cases is directly correlated to the amount of per capita spending on health care.20 Thus, for greater health system efficacy, greater financial inputs must be put into the system. Even as global funding
continues to rise, serious gaps in funding and tenable future investors continue to present serious barriers to the solvency of health care programs. As integrated programs scale up their efforts to provide long term care, they create an even greater need for financial resources. From 20042005, for example, funding for the Global Plan to Stop TB fell short by 20%, even with a concurrent rise in overall global funding for tuberculosis (TB) treatment. 2. Recognition of Values The values behind health care integration drastically impact the effectiveness of PHC initiatives.3 Greater inequalities are created when community participation is implemented solely for program access to community resources, rather than for the goal of community selfdetermination of health care. Community health care workers are often not trained
Bringing health care to peopleâ€™s homes, Afghanistan. Photo credit: WHO/Chistopher Black. Photo source: http://www.who.int/whr/2008/media_centre/photos/en/index.html
for independent functioning, are not given independence over their tasks, and lack resources needed for their roles.3 Loss of control over community resources and inadequate inclusion of local health care workers creates future community dependency. Project initiatives must recognize the values behind their goals in order to work towards PHC goals while avoiding regressive outcomes. 3. Planned Partnerships According to an article in Globalization and Health, a majority of integrations thus far have resulted from only accidental overlaps between horizontal and vertical programs, instead of from planned partnerships maximizing the benefits of each program.21 At the most superficial level, efforts to incorporate diseasespecific programs at least cast attention back onto the subject of PHC and its merits as a health care model. A much more effective situation would result, however, if disease programs predicted their own effects and worked towards purposeful integration into the broader health system. Research today still shows misalignment between vertical program policy claims and the actual effects of program policies.22 For example, researchers have shown that while nearly all proponents of disease-specific programs claim to be strengthening health systems, most actually work to further their own exclusive goals.22 Thus, disease programs should pay more explicit attention towards the overarching needs and wants of the health system, and not just their own specific goals.23 4. Commitment to Research Health systems inputs are long-term, and this has correspondingly led to a delay between resource inputs into and concrete outputs from the health system.24 Subsequent analysis is therefore long overdue on whether or not program
policy is in line with health systems strengthening. There is still limited conclusive information pertaining to the benefits of integrated approaches, even though theory suggests that integration is the most effective approach.6 Even since 1994, when the WHO declared that more research pertaining to health systems inputs was in dire need, the amount of research surrounding this important topic has remained almost negligible.23 A commitment to research should be adopted by all integrated programs to alleviate the gaps in knowledge that currently exist. Research is a powerful tool in shaping health care policy and influencing the quality of life of countless communities. This commitment to research is necessary for progress to be made in the health care world. Without further improvements in financial inputs, value recognition, planned partnerships, and research commitments, we cannot hope to achieve the goals of primary health care and health for all.
Concluding Remarks Integration of vertical and horizontal programs has the potential to achieve significant positive results for the health care system. Among these potential benefits are strengthened infrastructures, reduced disease stigmatization, better health research and care facilities, community empowerment, heightened education and health worker training, enhanced capacity, and more advanced technologies and medicines.21 Certain negative consequences of integration still loom on the sidelines, especially in terms of human resource misallocation and inefficiency through parallel structures, and must be carefully avoided in implementation. Integration can have a powerful impact if disease-specific programs commit to policies of horizontal care. The four areas of focus present obvious targets
for further program improvements in the upcoming years. Only by addressing these crucial issues can we further the discussion and debate over diseasespecific program integration into the holistic health system. Without further improvements in financial inputs, value recognition, planned partnerships, and research commitments, we cannot hope to achieve the goals of primary health care and health for all.
References 1. Smith, Duane L., and John H. Bryant. “Building the infrastructure for primary health care: an overview of vertical and integrated approaches.” Social Science and Medicine, 1988: 909-917. 2. World Health Organization/UNICEF. Primary health care, declaration VI. Geneva and New York: World Health Organization, 1978. 3. Zakus, J. David L. “Resource dependency and community participation in primary health care.” Social Science and Medicine 46, no. 4-5 (1998): 475-494. 4. Oliveira-Cruz, Valeria, Christoph Kurowski, and Anne Mills. “Delivery of priority health services: searching for synergies within the vertical versus horizontal debate.” Journal of International Development 15 (2003): 67-86. 5. The Millenium Project. (2006). Millenium villages: a new approach to fighting poverty. Retrieved June 9, 2009, from UN Millenium Project: www.unmilleniumproject.org/mv/index.htm 6. Mills, Anne. “Vertical vs horizontal health programmes in Africa: idealism, pragmatism, resources, and efficiency.” Social Science and Medicine, 1983: 1971-1981. 7. Msuya, J. (2003). Horizontal and vertical delivery of health services: what are the trade offs? Washington DC: The World Bank. 8. Zakus, David, and Andrea A. Cortinois. “Primary health care and community participation: origins, implementation, and future.” Chap. 3 in World health systems: challenges and perspectives, edited by Bruce Fried and Laura Gaydos, 270-295. Chicago: Health Administration Press, 2002. 9. Walsh, JA, and KS Warren. “Selective primary health care: an interim strategy for disease control in developing countries.” The New England Journal of Medicine 301, no. 18 (1979): 967-974. 10. Cueto, Marcos. “The origins of primary health care and selective primary health care.” American Journal of Public Health, 2004: 18641874. 11. Rifkin, Susan B., and Gill Walt. “Why health improves: defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’.” Social Science and Medicine, 1986: 559-566. 12. Unger, Jean-Pierre, and James R. Killingsworth. “Selective primary health care: a critical review of methods and results.” Social Science and Medicine, 1986: 1001-1013. 13. Cassels, Andrew. “Aid instruments and health systems development: an analysis of current practice.” Health Policy and Planning, 1996: 354-368. 14. Buve, Anne, Sam Kalibala, and James McIntyre. “Stronger health systems for more effective HIV/AIDS prevention and care.” International Journal of Health Planning and Management, 2003: S41-S51. 15. World Health Organization. “WHO urges change for ailing health systems.” 2008. 16. Mills, Anne. “Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches?” Bulletin of the World Health Organization, 2005: 315-316. 17. Canadian Public Health Association Position Paper. “Sustainability and equity: primary health care in developing countries.” 1990. 18. Pfeiffer, J. “International NGOs and primary health care in Mozambique; the need for a new model of collaboration.” Social Science and Medicine 56 (2003): 725-738. 19. Capdegelle, P. Integration in health services. Concepts, evidence, and perspectives. Effective health care in developing countries project. Unpublished mimeo, Liverpool School of Tropical Medicine, 1999. 20. Bermejo, Alvaro. “Towards a global fund for the health MDGs?” The Lancet, 2009: 2110. 21. Yu, Dongbao, Yves Souteyrand, Mazuwa A. Banda, Joan Kaufman, and Joseph H Perriens. “Investment in HIV/AIDS programs: does it help strengthen health systems in developing countries.” Globalization and Health 4, no. 8 (2008). 22. Campbell, Carol. “Strengthening health systems ‘rhetoric, not reality’.” Science and Developmental Network, June 3, 2009: 1-2. 23. Travis, Phyllida, et al. “Overcoming health-systems constraints to achieve the Millennium Development Goals.” The Lancet 364 (2004): 900-906. 24. The Systemwide Effects of the Fund Research Network. “Measuring the effects of the Global Fund on broader health systems.” 2005.
Fall2010 | Juxtaposition 19
Interview with Dr. Melanie Newton & Dr. Alissa Trotz:
The Past, Present and Future of Haiti Luchen Wang1, Jennifer Kwan2, and Lucy Duan2 1 2
Department of Human Biology, University of Toronto, Toronto, ON, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
Months after the January 12 earthquake, many are looking to Haiti’s past for solutions to the health, social, and economic problems now entwined with the country’s future. In a two-hour interview conducted by the Juxtaposition team spring of 2010, Dr. Melanie Newton and Dr. Alissa Trotz, professors at the University of Toronto whose research has focused extensively on the Caribbean, discuss the international community’s initial response to the earthquake. In order to gain a better understanding of Haiti as the country works towards reconstruction, we bring the subject of Haiti’s past, present, and future back to the spotlight with the hope of rediscovering the vibrant country buried beneath the devastation.
uxtaposition( JP): What do you believe, 2 months after the earthquake, are the most important considerations governments and institutions must make in engaging Haiti with regards to the recovery process? Dr. Newton: One of the problems right now is that the Haitian government is being treated as an observer as conversations about rebuilding Haiti are taking place. In the past, this has been the attitude that has sidelined the Haitian government—this constant dismissal of the Haitian government as too corrupt to be trusted. That’s not going to lead to any positive solutions and is one of the first things that need to change. Dr. Trotz: I believe a way has to
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be found to genuinely involve Haitians at a popular level so that they have a real say in reconstruction and rebuilding efforts. It seems clear to me that if popular representatives had been meaningfully engaged, if they were at the table when social and economic policies were being designed, then Haiti’s policies would have been very different. We would not have witnessed the huge social disparities that pre-dated and disastrously amplified the effects of the earthquake. I think the important thing is to recognize that it is not as if Haitian people are not organizing at the popular level. Caribbean philosophers and historians like CLR James and Walter Rodney
advise us to look for the social motion on the ground, and both believed firmly in the project of self-emancipation of the working people of the region. It’s a question of perspective. The answers to these huge challenges faced by the Haitian people cannot come from outside; they must be generated from within. The capacity for change exists; the question is how to build upon that. The second consideration relates to how to enable the Haitian government to play a meaningful role in the life of its own country as well as in relation to the region and the international community. There are currently more NGOs operating per capita in Haiti than there are
in any other country, yet Haiti is a country in which an earthquake could produce such devastating results. That’s pretty shocking. And it’s shocking because it says something about the ways in which NGOs have been used particularly since the 1990s to undermine the Haitian state, and the ways in which the NGOs have borne the burden of providing services which really should have been provided by the Haitian state. They have been seen in some quarters as a replacement for the state, and the problem with that is that the NGOs become more accountable to funders, to actors outside of Haiti, and ultimately less answerable to the local population they are supposed to serve.
…a way has to be found to genuinely involve Haitians at a popular level so that they have a real say in reconstruction and rebuilding efforts. If there were a stronger Haitian state—and we might compare this with Chile, where the earthquake of February 2010 was of greater magnitude, but the destruction far less severe —I do not believe that we would have ended up with a situation in which the Haitian government had to even turn over the airport to the United States military because it could not manage the relief process. JP: What about the Canadian government? Are we a major player in Haiti? Dr. Newton: Canada is a major player in Haiti on multiple levels. Canada has one of the largest Haitian Diasporas, which has historically been very influential in Haitian politics. For several decades, Canadian aid organizations have played an important role in Haiti.
Since around 2000, the Canadian government has taken on an increasingly high-profile role as an arbiter of international discussions about Haiti. In 2001 and 2003, there were conferences in Montreal at which a concept called the ‘responsibility to protect’—the idea that the ‘international community’ should intervene if the state was failing—was elaborated. This might make sense on the surface, but it is a resurgence of the concept of imperial trusteeship, a veiled excuse for intervening in the politics of less powerful countries if we don’t like the direction in which things are going. In that regard, Canada was one of the leading forces that went into Haiti in February 2004 and removed President Jean-Bertrand Aristide from office. Since then, the Canadian RCMP has been leading the retraining of the Haitian national police. So Canada has taken a leading role in both the articulation of international policy regarding intervention in Haiti and the UN mission that has been in Haiti since 2004. JP: Why is our government so interested in Haiti; what are we doing there? Dr. Newton: I think it’s very important for people to understand this. Haiti has a long history of incredibly vibrant and, to many western countries, extremely threatening popular democratic condition. Even before the earthquake, most of the effective community support is being provided by Haitians for other Haitians. It’s a highly organized place. At every level and every community and every workplace, people are organized; they are incredibly engaged in politics. It’s not an accident that you get such a popular upsurge like the Lavalas movement, which brought Aristide to power. And this kind of popular organization terrifies western governments because they are not so easily controllable from outside; they are accountable to no one except their own people. The U.S. sees this as a threat
to their regional and hemispheric interests. So Canada is now taking on a leading role, with U.S. consent, in implementing certain policies in Haiti with the interest of the United States in mind. JP: What are your thoughts about health or programs aimed at improving health in Haiti? Dr. Newton: In Haiti, there are a range of studies that show a direct connection between the degree of democracy and the impact on the health of women, children, and the susceptibility of people to violence. Health is also one area where we can see how aid programs for Haitians could be improved. For example, programs that engaged grassroots organizations to reduce the spread of AIDS were major success stories. And that was because they worked so closely with women, the poor, and organizations that genuinely represented community interests. It was also because they established a good relationship with the Haitian government, one that wasn’t mediated by foreign aid organizations. The same is true for reforestation projects that engage with local knowledge about what kinds of projects would best meet the economic and social needs of particular communities. Those are examples of things that did work, and they worked because they were based on the assumption that Haitians have solutions for Haitian problems—and what they need is support—not paternalistic dictation of what they need to do. Dr. Trotz: Growing up in Guyana, I became very aware of how Cuban medical diplomacy has supported health infrastructure across the Caribbean. Two years ago, for example, and with students from our Caribbean Studies Programme at New College, I visited a rural cottage hospital in Guyana that was staffed entirely by Cuban doctors, Cuban nurses, and Guyanese doctors trained in Cuba. I mention this here because Cuba has Fall2010 | Juxtaposition 21
Haitians have solutions for Haitian problems — and what they need is support — not paternalistic dictation of what they need to do. been also very supportive of Haiti when it comes to health care. One of the things that we saw very little coverage of in the aftermath of the earthquake was the fact that among the first medical personnel on the ground were Cuban doctors, who had been there before the earthquake and had established long-term relationships with Haitian communities.
think a reconstruction of Haiti’s economy has to also ensure that women have access to and clear legal control of the land that they farm.
JP: Women have been shown to play important roles in improving the health status of populations as well as the health systems under which these populations operate. What are your thoughts on engaging Haitian women in the recovery process?
JP: Dr. Trotz, in your publication, Rethinking Caribbean transnational connections: Conceptual itineraries, you discuss Caribbean cross-border networks developed by migrants and how such networks extend to transnational connections between Caribbean communities that are outside the Caribbean, such as cross-border connections between communities in the US and Canada. What role do you think such networks will play in the recovery process?
Dr. Trotz: It is essential to engage Haitian women centrally in any reconstruction conversation, as they are often the ones who have kept people alive and communities together in the absence of adequate state functioning and provision. This caring work tends to fall disproportionately on women. Women have also been central in the efforts of Haitians to come together in the aftermath of the earthquake to provide safe communities for displaced peoples, and will be key players in relation to addressing the psycho-social traumas at the level of the family and community in ways that pay attention and respect to culture. Dr. Newton: The majority of Haiti’s women, who farmed the land and have historically been the main producers of food in Haiti, have been excluded from being able to own land outright in the past. In the 20th century, foreign interests in reorienting the Haitian economy towards industrial production have only further served to alienate particularly women and the poor from land. So I
Dr. Trotz: I think the Haitian Diaspora is absolutely important. It is important on two levels. One is the historical role of remittances in the context of the Haitian economy. Remittances are sent back by ordinary working people and I often characterize them as grassroots responses on a transnational scale to structural inequalities in the world that we live in. Paradoxically, so many migrants have had to largely separate from their families—and find work elsewhere—in order to keep their families together in other kinds of material ways. The Diaspora has extensive economic and social ties and therefore that will become very important in terms of reinvesting in communities at home. The second issue we need to consider is the extent to which the Haitian Diaspora has actively taken part in discussions about what needs to be done after the earthquake. In the reports I saw from the Montreal Relief conference organized approximately two weeks after the earthquake, I could be wrong, but it
22 Juxtaposition | Fall2010
was not at all clear to me that the Haitian Diaspora was actively engaged as an equal partner, or even as a partner at all, in the discussions. This raises huge questions about the extent to which the Diaspora is being consulted in the reconstruction process. It also draws attention to the need for the Diaspora to organize and insist that they be involved in those discussions. The Diaspora can also play a central role in shifting public and media perceptions about Haiti’s history and about Haiti after the earthquake. We are constantly reminded of the powerful role the media plays in directing public attention to and away from Haiti. What are your thoughts on this dynamic? Dr. Newton: I would say that most foreign media about Haiti generally regurgitates a lot of the stereotypes about Haiti—that Haiti is so poor, that Haiti is a failed state, and that the Haitian government is corrupt. The effects have largely been negative. This is especially true about the emphasis on the images, very invasive images, of Haitian dead bodies. It is almost as if the conventions that govern western media about not showing dead and dismembered bodies do not apply to Haitians, that Haitian bodies can be displayed in almost pornographic kinds of ways for others to see. However, some media organizations were clearly questioning that narrative to some degree and attempting to understand Haitian ideas for solutions to the country’s difficulties. Whether that will be maintained is another question. Dr. Trotz: A couple of things in the mainstream media have really disturbed me. I do not believe that one needed to be constantly bombarded with images of dead bodies in order to evoke sympathy from the Canadian public. I believe that we are far more aware and intelligent than that. I think one needs to really think about the disturbing politics of representation in which some bodies seem to matter more
than others. It was almost as if Haitian pain was a spectacle that was put there for us to consume, and I found this shocking and quite frankly racist. The second thing in the mainstream media that has concerned me was the message that Haitians need charity and that all the western agencies and the U.S. military was “doing” on behalf of Haitians because they could not help themselves. Many alternative reports— including some coming out of the Caribbean—were talking about how Haitians were organizing their own relief efforts immediately after the earthquake struck and helping themselves. My worry is about the effect of those images of Haitians, both in terms of denying the Haitian people any agency, and in terms of the kinds of responses such images evoke. It’s as if we are being engaged to respond to disaster, suffering, through acts of consumption. There’s something about that that I find really worrying. I’m interested in thinking about how we can build a more robust practice of citizenship and see these questions as not just about people out there, but also very much about how we see and understand ourselves and the wider structural forces that underpin these tragedies. JP: What do you believe we can do to help other than donate money?
Dr. Newton: One official in the government of Aristide, Patrick Elie, had this quote when asked this question: “Become citizens of your own country.” There is this notion that our governments are not as responsible for what they do elsewhere as they are for domestic policies. And this is a problem, because at the very basic level we should be concerned about what an organization of the sheer size and impact of CIDA is doing with our taxpayer money—about the potential political ramifications of aid projects that are designed to implement objectives which are questionable. We should be concerned, for example, about the role of the Canadian police force in training the Haitian national police, which is one of the most dangerous armed forces in Haiti. We should be concerned about how this language of corruption in the Haitian government can actually be the vehicle for the export of some of the most corrupt aspects of our political system. I think the other thing we should do is to rethink this concept of development. How do we really even talk about a world in which we think about “developing” other people? It’s a very problematic way of imagining the world. And maybe we should be rethinking this along the lines of more solidarity and human exchange. But what people ought to be thinking about if they are really serious and interested
in Haiti is to find an organization, learn something about it, and establish a relationship with them. Think about the kind of relationship the organization has with the country and communities they work with, about the actual impact the money it uses has in the community, about whether their work involves, in a genuine way, the local people in the decisionmaking process. That is where you can donate your money to—in the context of actually building a human connection, and not “save someone,” especially when you’ve never really seen and don’t know anything about that person. The act of giving to someone else ought to be also about transforming yourself and about developing a relationship with them. And that should be the basic, beginning principle of any kind of economic exchange. JP: Is there anything else about our engagement with Haiti in the immediate aftermath of the earthquake that you found particularly concerning? Dr. Newton: The response was a panicked and quite negative reaction to the catastrophe. There was an immediate assumption that Haitians were somehow a dangerous population to be contained and that we have to bring in foreign troops. Some degree of security might be necessary, but not ten thousand U.S.
From left to right: Dr. Alissa Trotz, Jennifer Kwan, Lucy Duan, Luchen Wang, and Dr. Melanie Newton.
Fall2010 | Juxtaposition 23
troops who were unqualified to determine which aid organizations can come in and which cannot. Dr. Trotz: In both the Haitian and Chilean earthquake, the language of the media quickly turned to security and looting when in fact people were desperately hungry. Somehow, the interests of private property became more important than the question of human life and dignity. It’s a sad commentary on the kinds of values that we seem to be moving to embrace, and it’s important for us to critique and really challenge those inhuman priorities. JP: From the interview that previous international activities in Haiti seem to have done more harm than good. Do you think our efforts may someday help lead to sustainable solutions to Haiti’s problems? Dr. Trotz: In recent years in one of my large undergraduate classes, I have been showing a PowerPoint slide of the 2004 Indian Ocean tsunami. You would be surprised, shocked in fact at how few students recalled what the picture referred to. The tsunami was such a global event at the time, and yet it has slipped from our consciousness. To me, that’s one of the dangers of engaging disasters through acts of charity or practices of consumption. We often don’t think about these critical events in a more robust or connected way that can exceed the immediate aftermath of the disaster. And so my worry is that, like the tsunami, in two years time we might be in the same position with regard to the 2010 earthquake in Haiti. On the other hand, I think the Canadian public has certainly been more aware of Haiti than at any point in the past. And it seems to me that the opportunity is there now for us to seize the moment and to build upon the efforts of many people who are seeking out meaningful ways of engaging the Canadian government, avenues of information beyond the mainstream media, and other ways of 24 Juxtaposition | Fall2010
offering solidarity to the Haitian people. Dr. Newton: I think ultimately the solution to Haiti’s issues lies in Haiti. On our part, it depends on how well we understand the reason Haiti is so important particularly to Canada, France, and the United States. I think that unfortunately, the collusion of local elites in Haiti coupled by a very corrupt aid policy has had tremendous effects in Haiti. The end result of which, in part, is the devastation that resulted from the earthquake. Those kinds of policies, in the absence of an active citizenry informed about what their governments are doing in their name, will continue to be perpetuated in Haiti. I think it’s important for democratic governments here that we challenge that. JP: What about the efforts of the international community? Dr. Newton: As I’ve mentioned, Haiti has an incredibly vibrant and active popular democracy. In terms of my sense of the whole, I think just as the international community was unable to stop the Haitian revolution, they’re not going to be able to hold back forever this popular voice. So yes, I do have hope that things will change in Haiti. JP: The earthquake has altered Haiti’s infrastructure. Can you tell us something about this infrastructure? Do you believe its destruction has allowed Haiti to start anew in some respects? Dr. Newton: Just to give you some background here. Literally, the infrastructure, the roads, the telecommunications networks, was built in Haiti during the U.S. occupation from 1915 to 1934. And it was designed entirely for the purpose of establishing large, foreign-owned agricultural estates in the countryside, bringing their produce to urban centres, and giving the marines situated in Port-au-Prince effective control over the entire country. That
same infrastructure is part of the reason why it has been so hard to get aid to people who need it because it was never designed to actually further effective communication between the government and the people—because it was never actually designed to provide services. It was entirely about imperial rule and economic exploitation. Neither foreign agencies, nor foreign governments, nor the Haitian government has ever been interested in redesigning the system because it facilitated a strong central government that allowed for effective economic exploitation of people.
[The Haitian] infrastructure is part of the reason why it has been so hard to get aid to people…because it was never actually designed to provide services. So because that infrastructure has been so heavily damaged, this is now an opportunity to redistribute economic and political power in the country as well as to provide people with the effective means to settle down across the country and develop vibrant economies away from Port-au-Prince. It is now possible to reestablish what used to be provincial centres that shared its political power and represented local interests. Dr. Trotz: I read a piece online by a Chilean doctor José Antonio Gutiérrez, who was on the ground at the time of the earthquake in Chile in February. One of the things he mentioned was the destruction of many of the roads that had been built by private contractors, and he linked this to the fact that the contractors had cut down on materials to save money; profits had trumped over
basic concerns of safety and the collective security of the population living near or using those roads. So this idea of “Who is going to profit out of this latest disaster in Haiti” is something that we need to keep in mind as we think about reconstruction in Haiti. JP: We had discussed the importance of re-establishing a rural agricultural economy in Haiti. It is often believed that economies gradually move from agricultural economies to industrial economies. Why is it so important for Haiti to focus more on agriculture? Dr. Newton: Historically, populations across the Caribbean have been self-sufficient in producing certain basic staples. There was an assumption after decolonization that agriculture was outdated, and so policies were implemented to industrialize. What has now happened across much of the Caribbean is that countries like Haiti have the physical resources to produce their own food, but can no longer compete with cheaply imported food from abroad. People in these countries have lost complete control over their ability to feed themselves, over their ability to have economic impendence, and over their ability to act as political agents so that their governments couldn’t simply use food as a bargaining chip.
…Haiti [has] the physical resources to produce their own food, but can no longer compete with cheaply imported food from abroad. One consequence of this situation was the massive riots in Haiti that occurred during the 2005 crisis, when people could suddenly no longer afford basic items like rice—because they were all imported
from abroad. The situation also has environmental consequences. Because the Haitian government has never genuinely invested in the rural economy, people have been forced to try to grow food on plots of land that they know are environmentally unsustainable in the long term. So Haiti, a country that used to be a jungle, is now one of the most deforested landscapes in the entire world. So it’s critical that you have strong, democratic, government support that is based on autonomous food production in some kind of rurallybased agricultural system. The centralized, corporatized, system of food production on which we are all dependent is not a sustainable model. Dr. Trotz: In fact, according to some reports, the Caribbean is now, including Haiti, one of the highest net food importers in the world. Local markets are being displaced by agro-exporting centers North America, Europe, and South America. So Haitian small farmers are being pushed off the land, and this is one of the things that have led to the migration to, and pressure upon, Port au Prince. So agriculture really needs to be one of the immediate priorities in post-earthquake Haiti. We should be critical of the kinds of things we see emerging from some of the big donor conferences, including and especially the emphasis on industries like export-assembly, which have been shown to be deeply exploitative, particularly of women, and which also encourage outmigration from rural areas because of their location. JP: Is there anything else you like leave us with? Dr. Trotz: The earthquake offers an opportunity to really rethink how we want to engage Haiti. We have to start becoming an active public—not only on Haiti, because there will be other disasters that come after Haiti. It’s about opening our eyes to all of these kinds of ways in which we are connected, and thinking
about the kinds of priorities that shape these connections. That to me is the lesson that we can draw. As Canadians, we should also begin looking at the fact that just a fraction of the monies actually committed to Haiti has translated into actual contributions. This is nothing new; it happened after the 2008 hurricane season and it has happened elsewhere in relation to other disasters. Something is absolutely wrong with this picture, and as we enter into a hurricane season, which some are predicting looks as if it will be a repeat of 2008, which was really disastrous for the Caribbean, we need to be thinking about this failure to translate commitments into actual resources, when so many Haitians remain displaced, under tents. What sort of promises were those and how do we challenge that? Dr. Newton: I hope that people would take the earthquake as an opportunity to learn about Haiti. It is an incredible place—the only place to have a revolution lead by slaves, who not only overturned slavery, but also kicked out the imperial power. You can’t get a more thrilling human story than that. The Haiti story of survival is a really empowering story. There is a quote from a Canadian man who led an organization called Third World Awareness that takes young people to the Caribbean to work in community projects. He said before he went to Haiti that he felt sorry for the people, thinking how sad it was that we here in Canada have everything and Haitians have nothing. Going to Haiti changed his view, after his trip there he realized: “They have nothing, but they also have everything.” And that’s the kind of place that Haiti is. It is very poor, but it’s also rich in things, very human and fundamental things, that we have forgotten, and that we can learn from.
Fall2010 | Juxtaposition 25
Haiti Timeline A brief look at the history of Haiti: 1492 - present Luchen Wang Department of Biochemistry and Cell and Molecular Biology, University of Toronto, ON, Canada
26 Juxtaposition | Fall2010
1492: From Columbus Christopher Columbus arrives on the island that now encompasses Haiti and the Dominican Republic on December 5, 1492, and claims it for Spain. European diseases wipe out a significant portion of the indigenous population.
1697: Pearl of the Antilles Spain surrenders the western portion of the island to France in 1697. Slaves from Africa are brought in to work on plantations. The place grows to become one of France’s richest colonies, gaining the name “Pearl of the Antilles.”
1791: The Haitian Revolution In 1791, the slaves of the French colony rise in rebellion, marking the start of the Haitian revolution. The revolution is a success. In 1804, the former colony becomes the first independent black nation in the world, and the only nation in history to gain independence through an armed rebellion of slaves. The place is declared Ayiti, the indigenous Taíno word for land of high mountains.
1915—34: American Occupation The United States occupies Haiti from 1915-1934. The U.S. exercises immense authority over the country. The constitution of Haiti is revised to align with U.S. interests. The country’s biracial minority is privileged over blacks.
1957—86: Oppression From 1957-1986, François Duvalier and later his son rules the country under an oppressive military regime. Many Haitians leave for other countries.
1990: Lavalas The country’s first democratic election takes place in 1990. A mass movement called lavalas or “the flood” sweeps the country, bringing a priest called JeanBertrand Aristide to power.
1994—2006: Exile Aristide’s reforms become unpopular with the ruling Haitian élite, and a coup ousts him from power eight months into his presidency. He returns to power from
1994 -1996 and is elected again in 2004. In 2006, opposing groups stage a coup that forces him into exile.
2004—08: Storms Hurricanes hit Haiti in 2004 and 2008. Deteriorating infrastructure and a long history of poverty, disease, and corruption continue to affect the country.
2010: Earthquake On January 12, 2010 at 4:53 PM, an earthquake of magnitude 7.0, with the epicenter 25 kilometers southwest of Port-Au-Prince, hits the country.
Photo Sources 1. http://www.sonofthesouth.net/revolutionary-war/lithographs/ columbus-landing-new-world.htm 2. http://www.ablogabouthistory.com/wp-content/ uploads/2009/08/slavery.jpg 3. http://gallery.nen.gov.uk/imagelarge73273-e2bn.html 4. http://www.associatedcontent.com/image/324609/index. html?cat=4 5. http://www.ibobbycreek.com/tag/dictator/ 6. http://sfbayview.com/2008/the-rebirth-of-konbit-in-haiti/ , http:// www.haitiaction.net/News/FL/8_13_4.html 7. http://www.wehaitians.com/drug%20probe%20targets%20aristide. html 8. http://www.thedailygreen.com/cm/thedailygreen/images/hu/ hurricane-hanna-haiti-www-lg.jpg 9. http://www.mirror.co.uk/news/top-stories/2010/01/16/ armed-survivors-of-haiti-earthquake-in-desperate-hunt-forfood-115875-21971160/
Fall2010 | Juxtaposition 27
The 2010 Health and Human Rights Conference International Development March 5th-6th, 2010 Hosted by the University of Toronto International Health Program Lucy Duan1 and Jennifer Siu2 1 2
Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada Department of Human Biology: Health and Disease, University of Toronto, Toronto, ON, Canada
28 Juxtaposition | Fall2010
The University of Toronto’s International Health Program’s (UTIHP) 2010 Health and Human Rights Conference, held from March 5-6th, focused on international development. The Health Impact Fund (HIF) was one innovative idea discussed at the event. It was proposed by a team of researchers lead by philosopher Thomas Pogge and economist Aidan Hollis in 2008. The HIF aims to make new medicines accessible to all individuals, regardless of cost and requires governmental aid and commitment. In this article we discuss the issues with current pharmaceutical companies and why there is a need for the HIF. Is the HIF feasible for countries to invest their money into? What additional factors need to be addressed before the HIF can be implemented in society and what are the reasons why individuals may be against this idea? Furthermore, the University of Toronto chapter of Allied for Essential Medications (UAEM) was present as an NGO at the conference. Its goals are to advocate changes to the Canadian regulations on accessibility to medicine. This article also examines how students at the University of Toronto are getting involved in the crisis surrounding accessibility to medicine.
he University of Toronto’s International Health Program’s (UTIHP) 2010 Health and Human Rights Conference took place on March 5-6th, focusing on international development. This year’s student-run conference succeeded in attracting the attendance and enthusiasm of over 150 students, friends, family, and faculty. Over the course of a short two-day period, inspiring student musical talent was showcased and stimulating speeches were given from experts passionate about the sustainability of international development.
[The HIF] aims to make new medications accessible for all individuals. The Health Impact Fund During one particularly interesting heated discussion between the speakers and audience during the interactive panel sessions, the benefits and limitations of a relatively new idea, The Health Impact Fund (HIF), were introduced. The HIF was proposed by a team of researchers lead by Yale philosopher Thomas Pogge and Calgary economist Aidan Hollis in 2008.1 It is a proposed mechanism that aims to make new medications accessible to all individuals, unencumbered by the problem of cost. The HIF movement is a response to the ineffectiveness of
the global pharmaceutical industry in reaching those individuals who most need their help. Currently, the pharmaceutical industry must serve two primary needs: to create new medications relevant to the most pressing global health concerns, and to enable universal access to these medications. Up to very recently, however, it seems that only the first mandate is being met since new medications are unaffordable by the majority. The proposed HIF would resolve this conflict by rewarding pharmaceutical companies on the basis of health impact and guaranteeing low prices on innovative products. This would help eliminate the central obstacle that pharmaceutical research faces: difficulty in profiting from products aimed for those who cannot afford it. Though in writing the HIF seems appealing, many questions were raised during discussions following the presentation Nathaniel Lipkus, a lawyer and consultant to the HIF. He notes that that funding for the HIF will not be easy since it requires not only government incentive, but also longterm commitment. With the recent years’ global decline in economic stability, governments will not invest in the HIF without rigorous research into its sustainability. In addition, it will be difficult to define measures that will appropriately assess and quantify the effectiveness of the health impact. Additional research and a pilot of the HIF
are in progress, working to find a solution to these concerns.
…funding for the HIF will not be easy since it requires not only government incentive, but also long-term commitment. Furthermore, there are additional social factors to consider. Those against the HIF argue that drug manufactures need no incentive to develop drugs for those individuals living in third world countries – they would do this regardless of any reward. If this is true, the HIF would make little, if any, progress in its efforts to increase accessible innovative medicine to those who need it most. Such a case is exemplified by Merck and Co. Inc., a large pharmaceutical company which donated a drug, Ivermectin, used to treat millions of individuals suffering from a devastating parasitic disease, Onchocerciasis, or River Blindness.2 Prior to the late 1980s, this parasite affected millions of people in Africa, causing a severe and painful inflammation of the eye and eventual blindness.2 At that time, there was no 100% effective Onchocerciasis treatment and those afflicted could not afford other drugs which served to alleviate pain. Upon the discovery of Ivermectin, Merck and Co. Inc. pledged to provide the drug Fall2010 | Juxtaposition 29
free of charge to anyone who needed it, in perpetuity. Is the situation with Merck and Co. Inc. a case of social philanthropy by one individual, or is it an overarching attitude possessed by large pharmaceutical companies alike? It seems that the latter seems to be more realistic when considering that the drug companies are responsible to their shareholders. Because of this, social welfare will not likely create the motivation necessary for major changes in the distribution of medicine.
Campus Support This global debate of access to essential medications has been a growing presence at the University of Toronto (U of T). The U of T chapter of Universities Allied for Essential Medications (UAEM) was present at the conference to represent the student voice in the struggle for accessible medicine to all. UAEM is a non-profit organization with over 80 chapters at universities around the world with a strong mandate: to ensure that publicly funded research institutions, including universities, will be part of the solution to the access to medications by promoting medical innovation in the interest of the public and ensuring that all people, regardless of income, have access to essential medications and technologies. A consensus statement drafted by UAEM has been signed by ten Nobel laureates and hundreds of luminaries across all fields of science, law, public policy, as well as civil society and organizations.3 UAEM at U of T is most active in advocacy and engagement of faculty and university administrators. In April of last year, UAEM co-hosted
a workshop entitled “Universities, Innovation and Global Medicine Access” in collaboration with the Initiative for Drug Equity and Access (IDEA) of the Faculty of Pharmacy, at the Munk Centre for International Studies. Dr. James Orbinski keynoted a stimulating interdisciplinary forum attended by over 90 academic researchers, innovation experts, university administrators and civil society representatives (as well as UAEM student members) from around the world. The objective of the forum was to examine the role of university research and innovation policies in ensuring access to life-saving university drugs by low- and middle-income countries. A Statement of Principles and Commitment was drafted and signed by many of the delegates in attendance, serving as UAEM’s international Academics for Access campaign.4 Furthermore, last fall, member Aria Ilyad Ahmad, represented UAEM before the Canadian Senate Committee on Banking, Trade and Commerce. She urged its members to pass Bill S-232, which proposed an amendment to make Canada’s Access to Medications Regime more accessible.5 While Parliamentary prorogue this year expired the Senate bill, UAEM is collaborating with the Canadian Legal AIDS Network this fall in vocally demanding the passage of a similar bill in the House of Commons (Bill C-393).6 UAEM is continuing its dialogue with faculty and administrators this year with the goal of establishing an advisory committee that can serve to better understand the research, innovation and commercialization landscape of Canada’s most research-intensive university. The ultimate aim will be to adapt UAEM’s
…social welfare will not likely create the motivation necessary for major changes in the distribution of medicine. Global Access Licensing Framework, with the purpose of creating a strategy that university transfer offices can adopt to promote global access to their technologies.7 Clearly the topic of access to essential medications has garnered attention and support from world leaders, scientific experts, and humanitarians worldwide. The goals of the HIF and UAEM are crucial to the advancement of global health. Their subsequent strategies targeted to achieving those goals are growing in strength. Careful and meticulous planning, expansion of global awareness, and continuing support from students and world leaders alike, will push the movement toward universally accessible medicines to reality.
References 1. Aidan Hollis and Thomas Pogge. The Health Impact Fund: Making New Medicines Accessible for All. Incentives for Global Health, 2008. 2. Rosemary Drisdelle. Eliminating River Blindness. Merck and Co. Inc. and Ivermectin, 2007. 3. “Notable signatories | Universities Allied for Essential Medicines.” Universities Allied for Essential Medicines, Sept. 20, 2010. http:// essentialmedicine.org/cs/notable-signatories 4. “Academics for Access.” Universities Allied for Essential Medicines, Sept. 20, 2010. http://www.academicsforaccess.org/ 5. Richard Elliot. Making CAMR Work: Streamlining Canada’s Access to Medicines Regime. Canadian HIV/AIDS Legal Network, 2009. 6. “Fixing Canada’s Access to Medicines Regime (CAMR): 20 Questions % Answers.” Canadian HIV/AIDS Legal Network, Sept 20, 2010. http:// www.aidslaw.ca/publications/publicationsdocEN.php?ref=965. 7. “Global Access Licensing Framework” Universities Allied for Essential Medicines, Sept. 20, 2010. http://essentialmedicine.org/sites/default/ files/archive/galf-1-1.pdf.
…publicly funded research institutions, including universities, will be part of the solution to the crisis surrounding the access to medications… 30 Juxtaposition | Fall2010
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At the heart of the availability of innovative health technologies is the problem of the uncertain path and unacceptable time lag from discovery and development to commercialization and delivery of appropriate and affordable products to people in the developing world.
The MRC is an academic centre at the University Health Network and University of Toronto. We work at the nexus of translational research, the developing world and entrepreneurship. We use At the heart of the availability of innovative health technologies is the problem of the uncertain path scholarly research to help move technologies from the lab to the village. and unacceptable time lag from discovery and development to commercialization and delivery of appropriate and affordable products to people in the developing world. Our Mission is to conduct translational research in global health and help researchers and companies get their life sciences technologies to those who need them in the developing world. At the heart of the availability of innovative health technologies is the problem of the uncertain path The MRC is an academic centre at the University Health Network and University of Toronto. We and unacceptable time lag from discovery and development to commercialization and delivery of work at the nexus of translational research, the developing world and entrepreneurship. We use Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics, appropriate and affordable products to people in the developing world. scholarly research to help move technologies from the lab to the village. vaccines, drugs and other life science solutions. Our Mission is to conduct translational research in global health and help researchers and companies The MRC is an academic centre at the University Health Network and University of Toronto. We at the get their life sciences technologies to those who need them in the developing world. work nexus of translational research, the developing world and entrepreneurship. We use Visit us at: scholarly research to help move technologies from the lab to the village. Website: www.mrcglobal.org Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics, Facebook: www.facebook.com/globalhealthengage vaccines, drugs and other life science solutions. Our Mission is to conduct translational research in global health and help researchers and companies Twitter: http://twitter.com/mrcglobal get their life sciences technologies to those who need them in the developing world. Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics, Visit us at: vaccines, drugs and other life science solutions. Website: www.mrcglobal.org Facebook: www.facebook.com/globalhealthengage Twitter: http://twitter.com/mrcglobal Visit us at: Website: www.mrcglobal.org Facebook: www.facebook.com/globalhealthengage Twitter: http://twitter.com/mrcglobal
Transcending Borders - Innovative Approaches to Healthcare Delivery, Juxtaposition Issue 3.2, Fall 2010