YGHR 1.2 (Spring 2014)

CONTENTS

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GLOBAL HEALTH TODAY Arab World: Changing Public Health

6

Chayma Boussayoud

Cuba: Medicine and Medical Internationalism

9

Adam Willems

Haiti: Improving the Maternal Health Situation through Increased Contraceptive Usage

12

Rachel Arnesen

The Secret Theft of Human Rights

15

Lindsey Hiebert

Ecuador: Listening to a Community and Building Partnerships

17

Adam Beckman and Nora Moraga-Lewy

Nigeria: Female Genital Cutting: The 20th Century’s Attempt to Ban a Harmful Traditional Practice

20

Sarah Eckinger

China: Atrocities Overlooked as Individuals Prioritize Their Best Interests in Drug Addiction “Rehabilitation”

23

Sophia Kecskes

Syria: At the Brink of a War Zone

26

Sarah Yazji

New Orleans: “Laissez le bons temps rouler!”

30

Juan Diaz

Ghana: Redefining Ability: Lessons Learned from Survivors of Disabilities

32

Ellie Dupler

Senegal: Key Insights Coming from the Smallest of Places

34

Talia Katz

36

Lorraine James

How Global Health Helps

39

Alicia Ding

Your Future in Global Health: Some of What You Need to Know and What You Don’t Need to Know

40

Richard Skolnik

Yemen: Health Inequity between the Genders

42

Teresa Logue, 1st place

Health as a Human Right

45

Anna Blazejowskyj, 2nd place

Hong Kong: The Effects of Science, Politics, and Race on the Public Health Responses to the 1894 Bubonic Plague

49

Candice Hwang, 3rd place

HEALTH AND HUMAN RIGHTS

FIELD WORK

QUESTION AND ANSWER Alice Miller

OPINION

CLASS CONTEST WINNERS

LETTER FROM THE EDITORS

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April 2014 Dear Readers, The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors.

With the success of our inaugural issue last Fall, we are continuing to engage the Yale community through thought-provoking scholarship and writing on all issues relevant to global health. Our second issue explores topics focused on the theme of “Health and Human Rights� from HIV care initiatives in Ecuador to refugee clinics in Syria and drug rehabilitation in China to recognizing premature births as a global health concern. All of the articles from this issue and our first issue are available on our website for your perusal. Looking ahead to our future publications, we welcome your submissions.

Sarah Eckinger

Austin Jaspers

Theresa Oei

Founders and Editors-in-Chief, The Yale Global Health Review

ABOUT

The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus.

SUBMIT

Submit pitches and manuscripts to yaleglobalhealthreview@gmail.com.

All articles published represent the opinions of the authors and do not reflect the official policy of YGHR or the institution(s) with which the author is affiliated, unless this is otherwise indicated. yaleglobalhealthreview.com or twitter.com/YaleGHR Sponsored by the Yale Undergraduate Organizations Committee and the MacMillan Center Published by Joseph Merrit & Company

TEAM

5 LEADERSHIP FOUNDERS, EDITORS-IN-CHIEF EDITORS

DIRECTOR OF FINANCE EVENTS COORDINATOR

Sarah Eckinger Austin Jaspers Theresa Oei Michaella Baker Alicia Ding Katherine Fang Moktar Jama Deborah Leffell Alison Mosier-Mills Aneesa Noorani Carolina Trombetta Moktar Jama Aneesa Noorani

PRODUCTION PRODUCTION AND DESIGN

ASSISTANT PRODUCTION AND DESIGN ONLINE EDITOR WEBMASTER

Katherine Fang Mercedes Martinez Lakshmi Varanasi Elijah Goldberg Connor Buechler Sarah Eckinger

WRITERS Rachel Arnesen, Adam Beckman, Anna Blazejowskyi, Chayma Bousayoud, Juan Diaz, Alicia Ding, Ellie Dupler, Sarah Eckinger, Lea Hammer, Lindsey Hiebert, Candice Hwang, Lorraine James, Talia Katz, Sophia Kecskes, Teresa Logue, Richard Skolnik (Lecturer in Health Policy and Management, Yale ‘72), Adam Willems, Sarah Yazji

cover design by Sarah Eckinger

layout design by Katherine Fang

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GLOBAL HEALTH TODAY

Changing Public Health

By Chayma Boussayoud

From Morocco to Syria, the Arab World has made significant progress in the health of its population in the last 20 years, most notably in reducing the prevalence of infectious disease and prenatal and maternal mortality. As seen in the Global Burden of Disease Study of 2010, the prevalence of chronic diseases has increased and has generally become the main contributor to the burden of disease. However, the significant economic and political variance in the region contributes to vastly different changes in the burdens of diseases in its constituent countries over the past two decades.

Diseases related to over-nutrition and sedentary lifestyles are most prevalent in the higher-income countries, while under-nutrition, infectious diseases, and poor environmental and sanitary conditions continue to plague the lowerincome countries. Going forward, Arab countries must address their public health challenges by strengthening their health systems and improving health education.

The Global Burden of Disease (GBD) Study of 2010 sheds light on the changes in the health of the Arab World from 1990 to 2010. The study uses DALYs, which are disability-adjusted life years, measuring the number of health years lost to disabilities and deaths, throughout the last two decades.

This term is critical in understanding the burden of disease, or the impact of health problems, on a population. Also important is the distinction between communicable and non-communicable diseases: the former are infectious diseases, like malaria, while the latter are chronic diseases that aren’t transmissible, like heart disease. It is useful to group the data into the three World Bank income groupings of the 22 countries in the Arab League in order to consider how health changes and challenges have varied in the different groupings.

From 1990 to 2010, in high-income Arab countries including Bahrain, Kuwait, Qatar, Saudi Arabia, and the United Arab Emirates, the burden of disease has remained non-communicable and the prevalence of infectious diseases has decreased. Firstly, noncommunicable diseases and accidents contributed to a greater percentage of DALYs lost in 2010 than in 1990.

For instance, road related injuries increased more than 60%, while major depressive disorders increased 113%, especially affecting women. Together with ischemic heart disease, they make up the top three contributors to DALYs lost. Additionally, the causes of deaths became more non-communicable as well, with deaths due to ischemic heart disease increasing nearly 60% and those attributed to diabetes increasing almost 200%. Simultaneously, DALYs lost to and deaths caused by infectious and neonatal diseases decreased. For

courtesy of Wikimedia Foundation

ARAB WORLD

instance, pre-term birth complications, the top contributor to DALYs lost in 1990, decreased 43% in prevalence in 2010. Lower respiratory infections and congenital anomalies were also less prevalent. In sum, high-income countries have undergone the epidemiological transition, meaning that their burden of disease is increasingly non-communicable rather than communicable.

Risk factors for death and disability in high-income Arab countries have shifted to become more centered on over-nutrition and sedentary lifestyles.

High blood pressure and body mass index (BMI) were among the biggest risk factors for DALYs in both 1990 and 2010. Both factors increased in prevalence in the 20-year period.

Other dietary-related risks such as high blood plasma glucose have increased.

Additionally, smoking has also increased in prevalence. However, improvements have been made in poor environmental conditions, like household air pollution.

Overall, risk factors for disease in high-income Arab countries have become overwhelmingly related to overnutrition, smoking, and lack of exercise, which contribute to the shift of disease burden to primarily non-communicable diseases.

In the past 30 years, the burden of disease shifted to become more noncommunicable and less communicable in middle-income Arab countries as well.

This group of countries includes all of

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GLOBAL HEALTH TODAY North Africa, Iraq, Jordan, Lebanon, and Yemen. Contrary to the highincome countries, these countries suffered in 1990 from a burden of disease that was almost equally infectious and non-communicable. Over twenty years, lost DALYs continued to be a mixture of both types of diseases, with non-communicable diseases increasing in prevalence and dominating the burden of disease. For instance, the prevalence of heart disease and stroke both increased more than 40%. The prevalence of major depressive disorder also increased significantly, especially among women. Infectious diseases saw a decrease in prevalence, even though they still figured heavily into the burden of disease. Lower respiratory infections, diarrheal diseases, and preterm birth complications decreased 50%, 67%, and 21% respectively in 2010. Similarly, the causes of death also reflected the double burden of disease, although infectious and birth-related diseases decreased. Overall, middle-income Arab countries are currently undergoing the epidemiological transition, showing significant improvements in DALYs lost to and deaths caused by communicable disease while simultaneously exhibiting a burden of disease that is more noncommunicable.

The risk factors of disease and

deaths in middle-income Arab countries have also shifted to over-nutrition and other characteristics of sedentary lifestyles. In 1990, the top risk factors of deaths included diet and lifestyle habits such as smoking and high BMI, but also included environmental factors like ambient particulate matter (PM) pollution. Contrary to the high-income countries, the top risks of DALYs lost were childhood underweight and suboptimal breastfeeding, with each risk factor affecting more than 5 million individuals. Twenty years later, the risk factors for deaths and DALYs lost were no longer communicable or birth-related but rather included dietary risks, high blood pressure and BMI, and smoking as the top contributors. Overall, middleincome Arab countries are increasingly manifesting risk factors that lead to non-communicable diseases, displaying improvements with regards to prenatal health, sanitation, and access to safe water.

The burden of disease and death in the low-income Arab World, including Somalia, Djibouti, Comoros, and Mauritania, saw increased prevalence of non-communicable disease, although infectious disease is still dominant. In 1990, the top causes of DALYs lost were all communicable, related to birth or under-nutrition. The top causes of death

also generally reflected this trend and included respiratory infections, diarrhea, malaria, malnutrition and stroke. Fastforward twenty years, and the top causes of DALYs are still infectious or birth-related, although significant headway has been made in reducing their prevalence. For instance, protein-energy malnutrition decreased 26%, while diarrheal diseases decreased 34%. Noncommunicable diseases are increasingly present in statistics of disease burden, as evidenced by the increase in prevalence of both stroke and ischemic heart disease by more than 25%. Additionally, certain infectious and birth-related diseases have actually begun affecting more of the population, illustrating the battle low-income Arab countries wage against preventable communicable diseases.

For instance, the prevalence of malaria and pre-term birth complications both increased about 37% from 1990 to 2010, posing a serious challenge to the health, economy, and development of low-income countries.

From 1990 to 2010, the risk factors for disease and disability in low-income Arab countries continued to reflect the predominantly communicable and prenatal nature of disease, with improvements made in under-nutritionand sanitation-related factors. The risk factors for DALYs lost have largely

courtesy of Jill Gramdnerg

The LWF community urgent care center in Turmus’ayya, a village north of Ramallah, Palestine.

8 remained tied to the environment and under-nutrition, but notably, factors related to over-nutrition, which include dietary risks and high blood pressure, have been introduced into the population. Firstly, the prevalence of childhood underweight and suboptimal breastfeeding was each reduced by 35% in 2010. Other shifts were seen in sanitation-related risk factors that indicate improvements. For instance, poor sanitation as a risk factor for DALYs decreased over the twentyyear period. Low water quality and poor access, a common risk factor for diseases like malaria and diarrhea, also saw a significant reduction These shifts in risk factors are important because they indicate that low-income Arab countries face a double burden of disease: while risk factors associated with communicable disease remain prevalent, non-communicable risk factors are also increasingly significant.

It is apparent from the GBD data that the prevalence of non-communicable diseases has increased throughout the Arab World. The greatest contributors to DALYs lost and deaths now include heart disease, stroke, major depressive disorder, and diabetes. However, these observations greatly depend on the income of the country. Risk factors that are related to over-nutrition and a sedentary life-style are also increasingly being seen across the region in general, while poor environmental and sanitary conditions overwhelmingly plague lowincome countries. Overall, the average life expectancies of both sexes across the Arab World increased from 65 in 1990 to 70.3 in 2010. These changes indicate that in the Arab World, there is an aging population increasingly suffering from chronic diseases.

Improvements are attributed to the increased investment in health and education that these countries have carried out. For instance, in Tunisia, the National Institute of Public Health conducted a series of health reforms beginning in the 1990s that have increased the number of public health centers and physicians and expanded coverage under insurance schemes.

As a result, vast improvements in malnutrition and diarrheal disease

GLOBAL HEALTH TODAY rates have been observed in the last two decades. Increased investments in education, especially for women, have contributed to the decrease in maternal and infant mortality in the Arab World.

In Egypt, the average number of years of education for women increased from 2.7 years in 1990 to 5.3 years in 2009.

In correlation, diarrheal diseases in Egypt decreased by 84% and preterm birth complications decreased by 39%.

In addition, the GBD has noted the cultural importance of child-birth and the strong familial networks of support have contributed to a reduction in maternal and child mortality.

With these improvements come challenges. First, the aging population presents an enormous financial strain to the rest of the population, exacerbated by the fact that Arab countries generally spend little of their GDP on healthcare.

For instance, 4.5% of Yemen’s GDP in 2006 was spent on health, while governmental share of total health expenditures were 46%, indicating that the financial burden of paying to ensure good health rested largely on individual and private expenditures. The high rates of infectious disease in low-income Arab countries pose a significant financial strain and a huge threat to economic and social development. Additionally, the high rates of road-related injuries have come with increasing vehicular use without corresponding improvements in infrastructure. The high prevalence of depressive disorders among women is also a challenge that must be addressed.

Considering the challenges facing the Arab World, there are several priority steps that should be taken.

First, governments need to establish or expand health insurance schemes to finance the rising costs of healthcare and increase coverage in order to ultimately improve health outcomes. To that end, there needs to be continued reform of health systems in the region, specifically to train health professionals and improve the content of health services. Facing these challenges will require using more financial resources. In addition, priority should also be given to health education and preventive care. For instance, nutritional education and anti-smoking campaigns could have far-reaching

impacts considering the high rates of smoking in the region –as high as 50% among men in some countries – and the high rates of obesity among women, of whom more than 50% are overweight.

Fortunately, there has been much more attention paid to health in the Arab World in the last two decades. NGOs have partnered with governments and ministries of public health to evaluate opportunities for and challenges to progress. The first Arab public health conference was held in Dubai in 2013 and brought health experts from across the globe to discuss opportunities and challenges that must be addressed.

The second conference of the series will be held in 2015, and is devoted to “benchmarking public health interventions.”

The lessons presented by the GBD study should be therefore used as a roadmap for health progress in the Arab World, to address the challenges of the future. Professor Ali Mokad, Director of Middle Eastern Initiatives at the Institute for Health Metrics and Evaluation, which published the GBD study, said: “We have a long way to go…

I want countries to take the data and use it for planning policies and data. We should all share lessons – both success and failures.” Indeed, as the Arab World faces an era of turmoil and change, there is vast opportunity to continue improving the health of its citizens.

History has proved as much.

www

Chayma Boussayoud is a sophomore in Ezra Stiles College majoring in Mollecular, Cellular and Developmental Biology.

You can contact her at chayma.boussayoud@yale. edu.

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GLOBAL HEALTH TODAY

CUBA

Medicine and Medical Internationalism

By Adam Willems

major trading partner until the USSR’s collapse. The fall of the Soviet bloc marked the beginning of the Special Period, in which Cuba saw its imports and exports decrease by 75 and 79 percent respectively. Facing a serious fuel shortage, “transportation systems buckled… twenty-four-hour power

courtesy of Franklin Reyes

outages became [regular, Havana’s] water delivery system worsened, and sanitation systems became intermittent Cuban medicine is unique in its and unreliable… [making] for international focus. Even while its people a desperate health scenario”. The faced a severe shortage of physicians, government had to privatize areas of the the revolutionary government sent economy in order to reduce the number its first medical team abroad in 1960 of employees on the government to respond to an earthquake payroll, which marked a blow in Chile. With a significantly to the ideological goals of the larger medical workforce today revolutionary government. compared to immediately after the Luckily, Cuba found a new Revolution, the scope of Cuban ideological partner and Petro Papi medical internationalism has in 1998 in the form of Venezuelan increased dramatically- more than president Hugo Chávez, who 30,000 Cuban health professionals had control over the world’s sixth currently work in 70 countries, largest confirmed oil reserves. On a joining the ranks of approximately superficial level, Chávez and Castro 135,000 Cuban health workers in were natural trading partners total that have served in over 100 because they were both socialists. countries. These individuals have More importantly, the constitution helped millions of lives, having that the Hugo Chávez’s government administered over 5 million vaccine redrafted after his election in 1998 doses between 1998 and 2004. reflects and supports many aspects The nature of Cuban medical of Fidelismo. Article 83 declares intervention abroad varies from health a “fundamental social c o u n t r y t o c o u n t r y. W h i l e right,” while Article 84 resolves to Venezuela receives physicians in create a national system of public exchange for subsidized oil, the health managed by the state. Such Cuban government elsewhere has similar views on medicine were a seen millions of dollars in medical natural source of healthy bilateral diplomacy generate relatively little relations. Especially since the political and economic returns. signing of the Cuba-Venezuela The worst periods of social and Dr. Jóse Castañeda, dentist, is Agreement in 2004, these two economic turmoil in the history of nations have enjoyed a level of deep responsible for ensuring the health revolutionary Cuba, the months collaboration. of children in this school.

Children do immediately after the Revolution Given the sparse provision of as well as the “Special Period,” took not lose the opportunity to see what public health care in Venezuela place when the government did the doctor is doing. Location: Bolivar four years after having declared it not have a primary benefactor. The Children Center. St. Catherine parish a human right in its constitution, USSR had supported Cuba since Jacinto Plaza, Merida State, Venezuela. a pro-Chávez mayor established the early 1960s, and was Cuba’s Date: May 6, 2004.

10 Plan Barrio Adentro (Inside the Neighborhood), which created health clinics within poor urban areas lacking healthcare alternatives. Since only two of the fifty initial Venezuelan applicants agreed to work in these centers, Barrio Adentro opted to import Cuban doctors who were more than willing to work in these disenfranchised neighborhoods.

Even with only 100 physicians, the first year saw over 9 million health consultations.

Given the incredible results achieved within the first few months of operation, Chávez decided to transform Barrio Adentro into a national program, rechristening it Missión Barrio Adentro (MBA). Instead of paying for these medical services directly, Article IV of the Cuba-Venezuela Agreement of 2004 called “for preferential pricing for Cuba’s expropriation of professional services vis-à-vis a steady supply of Venezuelan oil, joint investments in strategically important sectors for both countries, and the provision of credit”. Through this method, 31,000 Cuban doctors and dentists took and continue to take part in the program at any given moment in hundreds of clinics across Venezuela, carrying out approximately 150 million consultations and saving about 20,000 lives each year.

The program nevertheless has drawn criticism. First, many of Venezuela’s doctors claim MBA is a threat to their livelihoods. However, Cuban medical workers tend to operate in areas where no other doctors are found. These areas, which tend to be violent and poor, are unappealing to most Venezuelan doctors, who may stand to enjoy more secure employment opportunities (both literally and economically) in wealthier areas. In fact, a number of Cuban personnel have been random victims of violence in the barrios.

Meanwhile, Rachel Jones, in The Lancet, deems MBA a half-success, given that the Venezuelan government did not meet its goals on paper. For example, physicians occupied only 30 percent of clinics built, partly because four thousand Cuban health workers had been sent to work in Bolivia and in other countries. However, Feinsilver notes the improvement in health indicators due

GLOBAL HEALTH TODAY to MBA, and asserts: “anyone who has worked on the ground in the social and economic development and has tried to implement large-scale social programs… knows the difficulty in accurately determining targets to be achieved and more importantly, achieving them and on time.”

Lastly, and most importantly, opposition figures accuse MBA of being “a politically motivated waste of billions”, largely ineffective at treating diseases once individuals actually contract them. The government funds preventative Cuban health care through $3 billion in oil savings annually, utilizes unnecessarily expensive drugs purchased through the Cuban government, and spends four times more on international politics than social programs. Venezuelans still endure medicine and medical machine shortages. There is a persistent lack of doctors, as native physicians often find work abroad because of unrealistic price caps placed on medical procedures. For instance, dialysis treatment has been capped at 200 bolivars ($30), despite costing 5,000 bolivars. Even though the Venezuelan government does spend more than Cuba in their arrangement, and though these doctors focusing on preventative care are unable to treat serious diseases, their presence is better than the pre-Chávez alternative for many in the barrios ridden with easilypreventable diseases.

A less controversial product of Cu b a n - Ve n e z u e l a n re l a t i o n s i s Op e r a c i ó n Mi l a g ro ( Op e r a t i o n Miracle). Since 2005, Cuban medical workers in 37 clinics located in eight countries have provided eye surgery to over 1.6 million individuals from around the world, many of whom are residents of Bolivarian Alliance for the Americas (ALBA) member states, which is a trading bloc designed as an alternative to the American-supported North American Free Trade Association (NAFTA). Interestingly enough, even Mario Terán, who assassinated Che Guevara in 1967, received eye treatment from a team of Cuban doctors working in the El Chapare region of Bolivia. As in the case of MBA, Venezuela funds the Cuban doctors, who then provide optical surgeries free of charge.

Finally, Article IV of the CubaVenezuela Agreement states: “the Republic of Cuba… will offer free training of Venezuelan personnel”. The Latin American School of Medicine (ELAM) is an internationally oriented institution based in Cuba. Founded in 1999, the primary goal of ELAM is to create an “army of doctors” dedicated to promoting Cuban medical internationalism. From approximately thirty countries worldwide, ELAM graduates are expected to return to their home countries to work in underprivileged areas, employing the education they acquired in Cuba concentrating on preventative medicine.

At ELAM’s first graduation in 2005, Castro pledged to provide 100,000 scholarships to prospective medical professionals from primarily the Global South over the next decade, 60,000 of

“

Many countries lack an existing support network as exists in Venezuela for physicians who wish to work in underprivileged areas.

”

which would be set aside for Venezuelan medical students.

At the same ceremony, the Chávez government vowed to establish a second ELAM campus in Venezuela. Eight years later, ELAM Dr. Salvador Allende on the outskirts of Caracas boasts 476 medical students from 23 countries, and 1,000 students are enrolled for 2014. Given that Cuban doctors cannot stay in these countries forever, these medical schools create thousands of physicians that make long-term medical interventions possible, which “are necessary in order to address the most pressing, albeit basic, conditions of suffering”.

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GLOBAL HEALTH TODAY

Wikimedia Foundation

Graduation of doctors at the Karl Marx theater in Havana, July 2007.

In reality, ELAM graduates often face obstacles when returning to their home communities. Many countries lack an existing support network as exists in Venezuela for physicians who wish to work in underprivileged areas. Instead, doctors with little financial savings have to work out of their own pocket to serve their communities, covering the cost of establishing clinics and day-to-day expenses. Consequently, as Ecuadorian ELAM graduate Gonzalo lamented: “[ELAM graduates] will take their degrees and work in the private sector.

There is money for them there. That is where all doctors are going to go; none of them are working in the communities.

There is no other place for them to go.”

Clearly, Cuba benefits greatly from an economic standpoint in this oil-for-doctors trading scheme. Saving billions of dollars through subsidized oil on top of $1.2 billion in joint venture projects has made Venezuela

an invaluable trading partner for Cuba.

Apart from Cuban doctors and their families, average Cubans have benefitted as well, since they now have a greater selection of consumer goods originating from Venezuela.

Cuban medical diplomacy in Venezuela has developed a deep political connection as well. After the CubaVenezuela Agreement of 2004, these two nations have drastically altered the regional political arena by challenging American dominance on the continent, particularly through ALBA. Since belonging to this organization provides development opportunities such as Operación Milagro and subsidized goods, a growing number of leftist governments have opted to become ALBA member nations.

Cuba does sacrifice some benefits by sending a quarter of its medical professionals abroad. This includes a decreased doctor-to-patient ratio of

approximately 1:170 and a medical system less personalized than it used to be. Nevertheless, given the overwhelmingly positive political and economic consequences of Cuba’s relationship with Venezuela, “oil-fordoctors” has no doubt been one of the most significant medical missions in Cuba’s history.

www

Adam Willems is a freshman in Pierson College.

You can contact him at adam.willems@yale.edu.

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GLOBAL HEALTH TODAY

HAITI

Improving the Maternal Health Situation through Increased Contraceptive Usage

By Rachel Arnesen Each day, about 800 women die from complications related to pregnancy or childbirth. While 800 deaths per day is an alarming statistic, what is even more shocking is that almost all of these deaths—over 99% of which occur in developing countries—are preventable.

In the past 20 years, organizations such as the World Health Organization (WHO) have implemented various programs and initiatives in efforts to lower maternal mortality rates worldwide, under the platform of “providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States.”

Substantial progress has been made, with the global maternal mortality rate decreasing 47% over the past 20 years.

However, in addition to these somewhat successful efforts, another important strategy for lowering the global maternal mortality rate worth investigation is how contraceptive devices can be used to limit the number of unwanted or dangerous pregnancies worldwide to thus help lower the global maternal mortality rate.

Haiti, a nation whose maternal mortality rates are not only almost twice as high as the worldwide rates, but whose lifetime risk for dying because of childbirth is the highest in the Western Hemisphere at 1 out of 47, is an example of a country that could benefit greatly from increased contraceptive usage. However, in order to make feasible the strategy of using contraceptives to lower maternal mortality rates, the rampant gender inequality present in Haiti first needs to be reduced, and women and girls need to be empowered to take control of their

own reproductive health.

One method of investigating the need for contraception in a given region is to look at the difference between a country’s desired fertility rate and the actual fertility rate, or the difference between the number of children a woman wishes have and the number of children she actually has. Haiti’s difference of approximately 1.5 between the actual and wanted fertility rates suggests a fundamental underlying problem in Haiti’s family planning infrastructure.

This fundamental problem is further illustrated through the nation’s high percentage of women with an unmet need for family planning, defined as women who are “fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child.” Haiti’s courtesy of K. Musser/Wikimedia Foundation

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GLOBAL HEALTH TODAY

courtesy of Jean François Leblanc courtesy of Jose Jose

unmet need for family planning for married women is 40%, the highest of the 53 nations for which data is available.

Unmet need is an important indicator of a nation’s state of contraceptive usage and maternal health, as women who do not wish to become pregnant but are not using an effective method of birth control account for approximately 82% of unplanned pregnancies globally.

Addressing the issue of unmet need would “contribute substantially to reducing levels of unplanned births, induced abortions, maternal deaths and DALYs [disability adjusted life years].”

Studies estimate that providing universal access to modern family planning and thus averting unintended pregnancies could help prevent 2035% of maternal deaths worldwide, equivalent to approximately 100,000 yearly maternal deaths. The Safe Motherhood Initiative, a global campaign aimed at decreasing maternal mortality, identifies family planning as one of four primary strategies to reduce maternal mortality in developing countries, along with antenatal care, safe delivery, and postnatal care. Despite the apparent numerous benefits of modern contraceptives in developing countries, over 25% of women of childbearing age do not have access to modern contraceptives. However, merely providing access to areas with high-unwanted pregnancy rates is ineffective unless there is a strong underlying infrastructure in these areas to ensure sustained contraception availability for all demographics of the target population. The target population must also be receptive to increasing contraceptive usage; otherwise no amount of education and increased supply of contraceptives will have a substantial impact. The obstacles encountered in trying to increase contraceptive use in Haiti can be divided into three categories: logistical issues, educational issues, and—the most important in terms of long term sustainability—cultural issues.

If contraceptive usage increases, gender inequality in Haiti is the primary cultural barrier that must be overcome.

Haiti’s constitution technically provides for “equal protection before the law” for both men and women; however,

top: A new health care center in Trouin, Haiti, equipped with a delivery room. bottom: An advertisement for “Panther” condoms. there is no national legislation that bans and punishes discrimination against women. On July 6, 2005, the Haitian government passed a decree that modified the categorization of rape as “a crime against morals to a crime against the person.” While this was a very important step towards positive change for women, the decree still does not specify what constitutes rape nor does it recognize sexual harassment or spousal rape as crimes.

Traditional gender norms tend to discourage women from talking about sex or family planning and perpetuate the supposed ideal of a virginal and pure bride. In general, traditional gender roles “establish and reinforce women’s subordination to men and drive poor sexual and reproductive health outcomes for both men and women.” There is great variability amongst the Haitian population depending on age, education level, and region of the country when

it comes to subscription to traditional beliefs and ideals. However, traditional Haitian beliefs, which are still held by substantial subsets of the general population, espouse traditional gender norms that insist that girls not engage in premarital sex but should instead merely prepare themselves for marriage. Teenage boys, on the other hand, are allowed to have sex before marriage as part of their “training,” as male sexuality is “closely associated with prestige and affirming manhood.” Equating manliness with having multiple sexual partners and sexual risks while maintaining the female norm of being “passive and under-educated about their sexual and reproductive health” engenders massive, negative implications for female reproductive health and maternal mortality rates.

Traditional gender roles also impede mass societal acceptance and usage of condoms, one of the simplest methods

14 to help limit unwanted pregnancies and potentially lower maternal mortality rates. In December 2010, the UN found that only 5.3% of Haitian women aged 15-49 who were married or in a union reported their partner wearing a male condom for contraceptive purposes.

When doctors told women that they should use condoms to protect against sexually transmitted diseases, many responded: “most men here don’t like to use condoms.” The refusal of men to wear condoms because they believe that they will experience a decrease in sexual pleasure is a direct result of the dominant masculine society that is still largely prevalent in Haiti today.

Because of the same social values that promote male virility as a sign of manliness, many Haitian women have their reproductive health choices made for them by their male partners. In a survey of pregnant women in rural Haiti, 94% of women reported that their husband or male partner made their health decisions for them, 4% reported that their mother was the primary decision maker for health concerns, and only 2% of the women surveyed reported that they made their own decisions in matters of their own health.

The availability of contraceptives, including condoms, will only be effective in increasing contraceptive usage. This is especially true as there already exists a “functioning health care services and an adequate program infrastructure throughout the country,” which includes having a society in which a majority of the population holds views about gender that allow women to make their own decisions about their personal reproductive health.

In recent years, however, there have been some positive signs that traditional gender roles might be shifting. There has been an increase in the number of organizations aimed at empowering Haitian women and ameliorating the overall destitution of much of the Haitian population and lack of women’s rights prevalent in much of Haitian society. In the aftermath of the 2010 earthquake, the Haiti Adolescent Girls Network created a series of “protective girl-only spaces” called “Espas Pa Mwen” or “My Space,” to help empower

GLOBAL HEALTH TODAY adolescent girls to “build much-needed social capital and economic assets,” by providing a place where girls can feel “unconditionally safe” and interact with trained mentors that help them “focus on their interests, skill building, and each other.” As of 2012, over 550 teenage girls regularly use the spaces, which are located at seventeen different sites thanks to the sponsorship of over forty different organizations. The organization also provides training to women on pertinent issues such as child safety, public health, and different methods to generate income.

One of the most prominent women’s organizations in Haiti is “Solidarite Fanm Ayisyen” (SOFA), translated to the title “Haitian Women’s Solidarity,” a nationally run group focused on “women’s right to health, the promotion of the par ticipation of women in decision-making, and stopping feminization of poverty.” SOFA has over 5,000 active members from all different backgrounds, and it has introduced new programs promoting female rights and education about violence against women in partnership with local schools. These organizations and others with similar objectives, while relatively new, are starting to make significant, positive impact on the social status of women in Haiti. Once women bring in their own income and no longer completely depend on their husbands for financial resources, they will no longer be seen as liabilities. Instead, they hopefully will be able to have more of a say in their own reproductive health and family planning.

Once the primary gender inequality obstacles to women’s access to contraceptives have been addressed, the focus should shift to the secondary issue of family planning education. A system needs to be put in place that provides information about reproductive health issues as well as information about different contraceptive options.

In order to increase contraceptive usage rates in the long term, Haitians need to be educated about the different forms of contraception and their respective positives and negatives. Ideally, a system will also be put in place in which Haitian health workers are trained to educate youth about safe sex and contraceptive

usage, as well as how to administer different forms of birth control. This model is sustainable, as eventually foreign workers can be phased out so that the reproductive health care and family planning services in Haiti can be run entirely by Haitians.

In this day and age, Haiti’s high maternal mortality rate and high unmet need for contraception is utterly unacceptable. As Hernando Clavijo, a United Nations Population Fund Haiti Representative stated, “‘[Haiti’s] population is growing very fast [but] the environmental and economic situations are terrible. Every sector must realize contraception is a key factor for longterm development of the country…

It’s also a human rights issue, a woman should have the right to decide how many children she’ll have.” The underlying social beliefs and traditions of Haiti must be altered in order to enact long-term, sustainable change that will eventually lead to lower maternal mortality rates.

The changes that must be made to empower women to allow them to make their own reproductive choices will have a ripple effect well beyond the realm of maternal health. The empowerment of women could not only lead to a decrease in the unmet contraceptive need, reduce the number of unplanned and unwanted pregnancies and lower the maternal mortality rate, but also help lessen the widespread extreme poverty found throughout much of Haiti. Increased contraceptive usage is by no means the only method of lowering maternal mortality rates. However, contraception is certainly an important factor that once implemented, will hopefully effect positive change in multiple realms of Haitian society, improving not only Haiti’s maternal health situation but also the situation for women throughout the country.

www Rachel Arnesen is a freshman in Branford College.

You can contact her at rachel.arnesen@yale.edu.

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GLOBAL HEALTH TODAY

THE SECRET THEFT OF HUMAN RIGHTS

Birth and human rights are closely related; rights are principles and standards that protect individuals, and they are earned at birth, when individuals can begin to fruitfully take advantage of them. Many obstacles prevent human rights from being fulfilled, including oppressive regimes and discrimination. Birth, the same event that invites the realization of human rights, can also present an obstacle. Birth and the immediate days following it offer the highest concentrated risk of death in a person’s lifespan.

Approximately 15 million babies are born too soon each year, and each one has an unfair disadvantage.

Up to 25% of preterm babies will experience blindness and 40% of extremely preterm births will suffer from chronic lung diseases, among other chronic inflictions. These infants come into a world that is often not ready for their entrance or prepared to support them.

Furthermore, prematurity has been historically left off the global agenda.

The issue of prematurity is not deliberately neglected. Parents and professionals have advocated for the issue; people who have personally

Lindsey Hiebert

By Lindsey Hiebert

witnessed the suffering of a one-pound baby struggling to breathe. The struggles of preterm birth are predominantly experienced in isolated hospital rooms in developed countries, while in developing countries many preterm babies are never given the chance to survive at all due to the lack of intensive care. The victims have no voice and rely on others to speak for their pain and needs. One challenge in gaining support and global attention has been the lack of reliable

16 data. Although preterm birth is an ancient health issue, the first data on its global and regional rates was not published until 2009 by the World Health Organization and the March of Dimes Foundation.

Born Too Soon, the Global Action Report on Preterm Birth, is a joint effort of almost 50 international, regional and national organizations, and is led by the March of Dimes, The Partnership for Maternal, Newborn & Child Health, Save the Children, and the World Health Organization. The report is in support of the Every Woman Every Child effort, which was initiated by UN SecretaryGeneral Ban Ki-moon at the United Nations Millennium Development Goals Summit in September 2010. Every Woman Every Child aims to save the lives of 16 million women and children by 2015. The first report was released in 2012 and showed that of 65 countries with reliable trend data, all but 3 showed an increase in preterm birth rates over the past 20 years. Preterm birth is a global problem, but “global” does not mean it is not plaguing our domestic communities as well. The United States’ rate of preterm birth ranks 131st out of 184 countries’, a ranking that is similar in magnitude to those of many developing countries. Nonetheless, a survival gap exists between wealthy and poor countries wherein 90% of extremely preterm babies, with less than 28 weeks gestation age, die within the first few days of life in low-income countries, and only 10% or less of the same gestational age die in high-income countries. The two biggest priorities from the Born Too Soon report are first to close the survival gap for babies in low-income countries with improved obstetric and newborn care, and second to develop innovative solutions to prevent preterm birth worldwide.

For a complicated issue such as preterm birth, both effective prevention and care are critical to reducing the global burden. The 2012 report identified that a knowledge gap limits progress in prevention measures, while an action gap limits progress in improving care.

Contrary to popular belief, 75% of premature births can be prevented without intensive care. Extremely

GLOBAL HEALTH TODAY low-cost, highly effective measures such as skin-to-skin contact, known as Kangaroo Mother Care, and additional support for breastfeeding could lead to 450,000 fewer deaths due to preterm birth each year. Moreover, the provision of antenatal corticosteroids could save around 375,000 lives each year and basic neonatal resuscitation training with programs such as Helping Babies Breathe from the American Academy of Pediatrics and other partners has the potential to reduce preterm mortality by 10%.

Despite the gloomy reality of preterm birth, hope does exist. In the United States, the national preterm birth rate which reached a peak in 2006 at 12.8%, is finally beginning to decline.

Much of this success is due to support and leadership of organizations such as the March of Dimes. For example, the “Healthy Babies are Worth the Wait” campaign urges health care providers and patients not to schedule a delivery until at least 39 completed weeks of pregnancy, unless there is a medical reason to do so. A Leapfrog Group survey of 757 hospitals found that the average rate of early elective deliveries was 17% in 2010. In addition, babies delivered at 36 to 38 weeks had two and a half times the number of complications compared with those delivered at 39 to 40 weeks . The March of Dimes reports that a baby’s brain at 35 weeks gestation weighs only two-thirds of what it will weigh at 39 to 40 weeks. This 39 Weeks initiative gained momentum after Intermountain Healthcare system instituted a strict monitoring routine in 2001, and the rate of Caesarean sections dropped from 28% to less than 3% after six years .

Interdisciplinary approaches to addressing root causes of preterm births are being further explored in the context of transdisciplinary research centers. Two centers currently exist. The first and the original center is the Prematurity Research Center at Stanford University School of Medicine. The second is an Ohio Collaborative of the University of Cincinnati College Of Medicine, Cincinnati Children’s Hospital Medical Center, the Ohio State University Wexner Medical Center, Nationwide

Children’s Hospital, and the Case Western Reserve University MacDonald Women’s Hospital, Rainbow Babies & Children’s Hospital, and MetroHealth System. These centers bring together basic sciences such as genetics, genomics, molecular biology and developmental biology, clinical sciences, epidemiology, and social sciences such as sociology and anthropology, in addition to engineering, computer science and bioinformatics.

These centers have a commitment to craft investigational collaborations, integrated datasets, and innovative analytic tools that will generate new insights into the complex causes of preterm birth. Current projects include the Sociobiology of Racial Disparities in Preterm Birth, Evolutionary Synthesis of Human Pregnancy, and Pattern Recognition Discovery, which uses new computer-based pattern recognition techniques found in other industries such as credit card fraud detection and social media advertisement targeting.

For some issues, politics and legal terms cannot capture the entirety of what is at stake. The birth of a child is an experience that transcends the limitations of political parties, governmental differences, and even arguments about the inefficiencies of one health care system compared to another. Children are the most vulnerable members of our society, and those born prematurely are especially vulnerable. As human rights begin at birth, every baby has the right to a healthy birth.

www

Lindsey Hiebert is a junior in Pierson College majoring in American Studies.

You can contact her at lindsey.hiebert@yale.edu.

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GLOBAL HEALTH TODAY

ECUADOR Listening to a Community and Building Partnerships

By Adam Beckman and Nora Moraga-Lewy “Why are you working on HIV in Ecuador?”

This question has challenged Yale undergraduates, MPH candidates, and Global Health Fellows who comprise the former Yale-Ecuador HIV Clinic

Initiative. Each of us has lived for up to twelve weeks in a small Ecuadorian town, dedicated full-time to research projects, an education initiative, and a testing clinic – all focused on HIV. Given that less than 0.4% of Ecuadorians are HIV-positive, “Why HIV?” is an excellent question. For the past fifteen months, our organization – now Student Partnerships for Global Health – has

tried to respond. We have reevaluated the work our group does and why we do it, and have devoted ourselves to new community-based projects.

In 2010, Yale junior, Sam Vesuna (YC ’12), interned in Guayaquil, Ecuador. In the middle of the summer, he met a doctor who invited him to visit a government hospital three hours away. The two arrived in Manglaralto, a

Adam Beckman

Left to right: Tam Nguyen (YC ’14), Rachel Wilkinson (YC ’16), and Nora Moraga-Lewy (YC ’16) present a charla about HIV.

18 coastal village of 6,000 with dirt roads, a quiet beach, and small concrete houses.

Towns like Valdivia, San Pedro, Olon, and a dozen others – most described by the World Health Organization as severely impoverished – surround Manglaralto. Every year, more than 20,000 townspeople flock to the modestly sized Manglaralto Hospital for care including immunizations, prenatal check ups, simple lab tests, and C-sections. The six doctors there see as many as ten patients an hour. Inspired by conversations with the hospital leadership about the need for an HIV testing and education program, Sam and the Hospital Director created a plan for Yale students to return the following summer to assist the laboratory with an HIV testing campaign. Six months later, Sam had connected with Fundación VIHDA, an NGO working to prevent vertical transmission in a region of Ecuador with disproportionately high rates of HIV, and recruited a small group of passionate students to found the Yale-Ecuador HIV Clinic Initiative.

For three summers, Yale students returned to this site and built on the initiative that Sam had launched.

With Yale School of Public Health faculty advisors, each cohort of students collected data as part of collaborative research projects. For instance, Stewart Dandorf (YSPH ’12), Hilary Rogers (YC ’13, YSPH ’14), and Farrah Khan (YC ’13) published an evaluation of barrier to HIV testing at Manglaralto Hospital. Fabi Fernandez (YC ’15, YSPH ’16) and Hannah Mogul-Adlin (YC ‘14) conducted an ethnographic study of sex-work in Ecuador, looking at the effects of legalization on power dynamics and condom usage. Katherine McDaniel (YC ’14), Erinma Kalu (YC ’14, YSPH ’15), Adam Ford (YC ’13) and Lauren Mellor-Crummey (YC ’14) investigated the effects of machismo on perceptions of HIV. In addition to surveys and qualitative interviews, over spring break and summer trips, YEHCI members collaborated with Fundación VIHDA to assist Manglaralto Hospital in conducting over 2,300 HIV tests.

Starting in 2011, YEHCI teams also formed relationships with three local schools and delivered short presentations

GLOBAL HEALTH TODAY about HIV and sexually transmitted diseases to over 6,000 people. Each year, the new student group had the advantage of being able to build on the work of past teams.

Our partners in Ecuador as well as students and faculty at Yale have, over the years, emphasized the many benefits that YEHCI offered to those involved. Manglaralto Hospital, Fundación VIHDA, Colegio Fiscal Técnico de Manglaralto, and other local partners have told us how they value growing multi-year partnerships with a group of students, rather than receiving volunteers one summer for a few weeks with little to no followup. While college students returning from global health field experiences often report, in hindsight, feeling underprepared, YEHCI participants benefited from many weeks of meeting with Yale students from previous trips to prepare research projects, discuss aspects of the local culture, and learn from the challenges that past students faced at the site. Faculty members at Yale, and other global health experts who advised us, valued the fact that each summer team was interdisciplinary, composed of a combination of freshman, sophomore, juniors, medical students, MPH candidates, and nursing students.

For these reasons, YEHCI grew every year, and each fall more Yale students apply for the available spots.

Even with this positive feedback, the organization kept returning to a fundamental question: What is the purpose of our work? Some would argue that any global health field experience that does no harm and exposes students to new or surprising perspectives is worthwhile, especially if their time in low- or middle-income countries leads them to devote parts of their adult lives to underserved populations. Yet in meetings with Professors Richard Skolnik and Kaveh Khoshnood, two of our primary faculty advisors, we pushed ourselves to consider whether we were adding the most possible value in our work, including whether HIV was a top concern to the people in the community where we worked. We centered these conversations around data from our past projects, and carefully considered what

it would mean for the “Yale-Ecuador HIV Clinic Initiative” to stop its work on HIV. While Professors Skolnik and Khoshnood encouraged us to continue the research projects we had already spent four months preparing, everyone in the room ultimately agreed we would also use our time in Manglaralto in the summer of 2013 to re-evaluate our projects with an eye to the future.

In the midst of conducting research, education, and testing projects this past summer, the eight summer team members devoted many hours to discussing with members of the community what our role should be going forward. In these conversations, we forced ourselves to keep the possibility on the table that we had no business returning to Manglaralto again; our primary concern was to understand the needs of this region and to determine, with our partners, whether we truly could add any value. When we conducted an informal needs assessment with a sample of sixty community members, the results showed that adolescent pregnancy, diabetes, and hypertension were the leading issues.

Conversations with local government officials, doctors at the hospital, members of El Juvenil de Desarrollo (a group of local young adults), and widely respected community elders highlighted these same health concerns.

Although our time was limited, we tried to respond right away to what we were hearing. Led by Ariel Kirshenbaum (YC ’14) and Sophie Shimer (YC ’14), we worked with Colegio Fiscal Técnico de Manglaralto to facilitate classroom conversations about sexual relationships using a curriculum reviewed by the school’s administrators.

This job required our extreme sensitivity to cultural differences, and a specialist at the World Bank advised us via Skype that we were approaching the issue in the right way. In addition, Isabel Beshar’s (YC ’14) research on risk perceptions of diabetes enabled us to learn more about NCDs in this area of Ecuador. Towards the end of the summer, we met a nurse at a non-profit clinic, Futuro Valdivia, who began discussing with us future projects about NCDs and malnutrition that would greatly benefit the people that her clinic serves.

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GLOBAL HEALTH TODAY

Nora Moraga Lewy

Left to right: Nicola Soekoe (YC ’16), Ariel Kirshenbaum (YC ’14), and Julia Randall (University of Massachusetts Medical School ’16) speak with the epidemiologist at Manglaralto Hospital.

When we returned to Yale, we built on this groundwork to found Student Partnerships for Global Health (SPGH).

SPGH begins with an understanding that there are vast disparities in access to health care and health education throughout the world. While we as students are not trained physicians or public health experts, we are passionate about doing anything we can to reduce inequality and the burden of disease.

Our aim is to learn about a community and ask: How can we use our skills and resources to address a public health problem in partnership with existing in-country organizations?

With collaborative, interdisciplinary student teams, we use any skills we can offer (survey collection, data analysis, education) to assist in addressing a specific public health problem in each community with which we are working.

The projects abroad are done with longterm commitments to our partners and future members of the Yale organization itself.

This mission will guide two teams this summer, one in Manglaralto, and the other in León, Nicaragua.

The team returning to Manglaralto

will carry out projects that have been designed directly with the staff at Futuro Valdivia and other partners. For example, José Gutierrez (YSN ‘16) will lead a project evaluating a program for two hundred malnourished children at Futuro Valdivia, supported by the Downs Fellowship. The León team will work in collaboration with Universidad Nacional Autónoma de Nicaragua-León and the New Haven-León Sister City Project. Kimberly Vasquez (YSPH ’15) will lead the qualitative portion of an investigation about ARV adherence at a clinic of HIV-positive patients, also supported by the Downs Fellowship.

Since October, members of SPGH have met several times per week and – in addition to arranging the details of the summer projects – have prepared by speaking with experts from AYUDA (a diabetes organization in Ecuador), the Ecuadorian Ministry of Health, the Pan American Health Organization, the Inter-American Development Bank, and more. Additionally, led by Rachel Wilkinson (YC ’16), members of the SPGH Campus Team this semester organized a weekly speaker series to hear from Yale faculty experts before the

summer teams go into the field.

Global health work confronts complex issues with limited resources and it involves collaboration with partners who are often thousands of miles away; requires cross-cultural sensitivity; and demands adaptability and resourcefulness for surprises in the field. This work is even harder for students, who are often further constrained by lack of experience, resources, on-site knowledge, and preparation time.

These were the challenges we grappled with as we asked ourselves the question, “Why HIV in Ecuador?”

And over the last year and a half, we have strengthened and evolved our partnerships to develop the most rigorous, relevant projects we can.

We believe that these interdisciplinary teams, working closely with in-country partners, Yale faculty mentors, and student support, are best equipped to make meaningful contributions to host communities.

www

Adam Beckman is a sophomore in Timothy Dwight College majoring in Molecular, Cellular and Developmental Biology.

You can reach him at adam.beckman@yale.edu.

--Nora Moraga-Lewy is a sophomore in Branford College majoring in Environmental Studies.

You can reach her at nora.moraga-lewy@yale.edu.

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HEALTH AND HUMAN RIGHTS

NIGERIA courtesy of Amnon Shavit

Female Genital Cutting: The 20th Century’s Attempt to Ban a Harmful Traditional Practice

By Sarah Eckinger

When examining the history of health in Nigeria, many of the diseases and illnesses that have plagued the country are of natural origin, sprouting from bacteria or parasites that thrive in warm countries, or growing from viruses that jumped from animals to humans. Others are chronic and affect people as they live and age. But in certain

situations, people have been subjected to “man-made illnesses,” as in the case of Female Genital Cutting, or FGC. Every year, more than 3 million girls undergo FGC in Africa alone, many of whom have had negative health repercussions. Nigeria is one of fourteen countries in Africa where the majority of families practice FGC. Doctors, health professionals, and activists view FGC as a disease, and a commonly practiced tradition that needs to be changed.

Beginning in the 1960s, international, federal and local organizations focused on ending FGC practices in Nigeria. By examining the attempted eradication of FGC in the 20th century, future activists may be able to learn from the successes and failures of the past.

It is difficult to determine the exact number of Nigerian women and girls who have received FGC. According to the World Health Organization, approximately 40% of Nigerian females

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HEALTH AND HUMAN RIGHTS have undergone FGC, while another study reported even higher percentages of 60-90%. The discrepancy can be attributed to several problems in FGC data collection. In Nigeria, FGC varies drastically from town to town and family to family. Three major ethnic groups: the Hausa, Ibo, and Yoruba, practice FGC at much higher rates than any other groups in the country. Researchers have a difficult time conducting studies because of unreliable case reporting, and disagreement over what “constitutes” FGC. The latter issue is a problem because there are several different types of FGC. WHO defines four different types of FGC, which range from the removal of the clitoral hood and/or part of the clitoris, to removal of some or all of the labia, to the sewing together of the labia to narrow the vaginal opening.

Immediately after the cutting takes place, hemorrhage, shock and severe pain are the three most commonly reported problems, all of which can lead to death. In the long term, FGC can cause pelvic inflammatory disease, which leads to about 25% of infertility in Nigeria. The retention of menstrual blood and urine caused by the decreased size of the vaginal opening can cause abdominal swelling and infection. Studies have also linked FGC and obstetric morbidity. Many women report extreme pain during menstruation and with the ripping of stitches that occurs when they first have sex. Additionally, FGC is known to cause psychological problems in women, including depression and neuroses.

Though FGC is dangerous, its practice has continued into the 21st century because of its traditional role as a rite of passage. In Nigeria, many young girls see it as a rite of passage that every one of their friends, around the age of twelve, goes through to become a woman. Societal implications of “beauty” and “cleanliness” are also tied into FGC. Gerry Mackie, in his ethnographic study of Nigerian women, found that “many believe that the only people who do not do FGC are unfaithful women or indecent people.”

Some of this stems from these historical

womanhood ceremonies, but much of it comes from the importance of remaining a virgin until marriage. Women often undergo FGC when they are children so that their husbands can determine whether or not they have been sexually active. Because certain types of FGC decrease the size of the vaginal opening, women on their wedding nights are expected to “rip open,” and if there is evidence that this has already been done then a husband is often suspicious.

Though female genital cutting is ingrained in some Nigerian cultures, different groups throughout history have opposed it. Activism dates back to the early 1900s, when colonial doctors and missionaries, shocked by the practices they witnessed, appealed to

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such traditions, and planned research studies throughout Africa, including in Nigeria. The results were published in 1998 in Female Genital Mutilation: An Overview, which continues to serve as an important text for FGC eradication activism. Other organizations, such as the United Nations, issued more general statements that grouped FGC in a “catch-all net” of dangerous practices.

In 1993, the UN stated that, “No one shall be subjected to torture or cruel, inhuman, or degrading treatment.” The Action of the Fourth World Conference on Women in Beijing 1995 declared that, “Violence against women both violates, impairs, and nullifies the enjoyment of their human rights.”

International statements indicated that the world wanted to show support and an earnest concern for the welfare of girls and women affected by FGC. And although Nigeria, was bound as a member state of the UN and WHO to adhere to their declarations, these generalized statements were often hard to realize, or more simply not enforced. A more practical route for implementing these practices would be to create a national legislature in Nigeria, s u p p o r t e d b y Ni g e r i a n s themselves instead of as pressure from the West. A few attempts were made in the 1990s to create such laws.

In 1996, legislation known as “The Children’s Decree,” which would put the declaration of the Fourth World Conference on Women into Nigerian law, was proposed. That same year, the Federal Ministry of Health wrote a national policy for the eradication of FGC, vowing to increase the number of doctors who were trained to prevent and treat FGC, raise public awareness of dangers, and increase education. But by 1999, the same year that Mrs. Stella Obasanjo, Nigeria’s first lady, made her declaration for zero tolerance for FGC, only one of Nigeria’s 36 states had adopted the policy into law.

Why, by the end of the 20th century, had Africa’s most populous country, with such high rates of FGC, passed no federal laws banning the practice?

Why, by the end of the 20th century, had Africa’s most populous country, with such high rates of FGC, passed no federal laws banning the practice?

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their governments to outlaw the practice.

Any attempts to destroy the tradition were fought off by Nigerians (since most colonial attempts to “improve” the health of the Nigerian population had ulterior motives), and colonizers generally retreated. In the 1960s, Western doctors practicing in Nigeria renewed the conversation when several published articles in medical journals depicting the horrible health problems that FGC was causing. This began the modern fight to end FGC by the western world.

In the 20th century, much of the effort to end FGC in Nigeria began with broad statements from international organizations. In the 1970s, the World Health Organization responded to these articles by promising to “promote an end to harmful traditional practices,” such as FGC. In the 1980s, they pledged to create international legislature banning

22 The answer lies in one of global health’s biggest problems: advocating the end of a cultural tradition for the sake of improved health. Many of Nigeria’s tribes practiced FGC as a cultural or religious ceremony. Ending the practice equaled conceding to Western doctors and legislatures who believed they knew best for the Nigerian people, even though the former had little understanding of their culture. Emmanuel Baba, in his discussion of women’s rights, stated, “This Western concern over genital mutilation offers a case study in how the well-intentioned efforts of Americans to improve the lot of oppressed people… can have precisely the opposite effect.”

Indeed, the Nigerian government may not have passed anti-FGC laws because of the lack of ethnocultural empathy from Western-run international organizations. The best efforts to eliminate the practice instead came from within Nigerian communities.

Community leaders were best equipped to handle this job, as they had both the understanding of the traditions and the desire to keep their neighbors healthy.

Schoolteachers and local public health officials headed the education efforts in

HEALTH AND HUMAN RIGHTS their towns. The health dangers of FGC were taught as part of middle school curricula, and communities provided practitioners with alternative jobs.

Adult men and women who had grown up with these traditional practices were the most difficult group to convince of the harms of FGC. Local nongovernmental organizations, or NGOs, played a large role in teaching Nigerian communities about the positive attributes of eliminating a harmful traditional practice. One of these, the National Association of Nigerian Nurses and Midwives’s Campaign for Eradication of FGM was active in Nigeria in the late 1980s. It focused on empowering individuals to teach their friends and family about the health implications of FGC. It also incorporated FGC education into family planning and family health contexts. Women’s Issues Communication Services Agency is another NGO that created a travelling museum group active in Nigeria in the 1990s. It displayed paintings and sculptures inspired by FGC, promoting eradication dialogue in the communities it visited.

L o c a l c a m p a i g n s we re m o re

successful than their federal or international counterparts because they dealt with the issues of cultural traditions. Communities used a horizontal approach by working directly with people to integrate new, healthier practices in a traditional society, while broader efforts utilized vertical methods by focusing just on fixing the issue at hand and not on understanding what caused it. Though the fight against Female Genital Cutting is far from over, 20th century efforts have pointed modern activists in a positive direction: support community activism and the desire to end FGC.

www

Sarah Eckinger is a junior in Trumbull College majoring in History of Science, History of Medicine.

You can reach her at sarah.eckinger@yale.edu.

courtesy of Anthony MacMillan/Telegraph & Argus

Nigerian-born Yemi Fagborun says FGM should be taken more seriously.

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HEALTH AND HUMAN RIGHTS

CHINA

Atrocities Overlooked as Individuals Prioritize Their Best Interests in Drug Addiction “Rehabilitation”

By Sophia Kecskes

prosperity of those in upper classes while systematically disenfranchising all others. International leaders ignore underlying realities to promote their own economic and political partnerships with

courtesy of Stringer Shanghai/Reuters

In the past few decades, China has developed significantly; this is most notably demonstrated in its strengthening middle class and the associated improvements in their quality of life, such as the electrification of rural areas and a vastly improved education s y s t e m . Ye t , when one more deeply investigates aspects of Chinese society not typically highlighted, one discovers a very different national reality. Inmates take an oath to resist drugs at a mandatory Children line Wuhan, China. the streets begging for food China, so change is unlikely. This article scraps, millions of individuals immigrate addresses one specific systemic injustice illegally to urban areas in a desperate that is typically overlooked: China’s drug search for employment, and a deeply addiction rehabilitation program. corrupt legal system perpetuates the

The 2008 Anti-Drug Law of the People’s Republic of China altered Chinese policy regarding drug abuse, calling for the treatment and rehabilitation of illicit drug users. The official Chinese position, as published by the Chinese Embassy to the United States is, “…that drugs are a worldwide public hazard confronting the whole of mankind, and drug control is an imminent and common responsibility incumbent to international society.”

While the Anti-Drug Law seems to have good intentions, in reality it rehab center in permits the detention and torture of drug users, ultimately perpetuating their addictions and fostering a multitude of human rights abuses. The 2010 Human Rights Watch report “Where Darkness

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HEALTH AND HUMAN RIGHTS

Knows No Limits” explained that this law “expands police power and removes legal protections from people suspected of drug use,” legalizing random drug tests and violating the rights guaranteed to them under Chinese and international law. Forced labor as a mechanism to “re-educate” citizens is engrained as a Chinese political tactic and has been legal since 1957. Re-education centers

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While the United Nations has called on international states and organizations to cease funding rehabilitation centers, international groups have largely ignored these requests.

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from the time of Chairman Mao’s rule are now re-purposed to house drug abusers, using similar labor camp tactics as before to combat drug use.

“In China, to be a drug addict is to be an enemy of the government,” explains Zhang Wenjun, head of Guiding Star, an organization that provides assistance to recovering addicts. More than a half million individuals are held in these centers at a given time, serving a minimum of two-year sentences, most without ever receiving a fair trial. In camps, individuals are denied rehabilitation counseling and treatment, and those with medical conditions such as tuberculosis and HIV are usually denied medical attention. Concealed drug use is rampant and vocational training to prepare addicts for their release is non-existent. Individuals are forced to contribute unpaid labor for long hours to employers who have contracts with the local police. Vicedirector of Daytop, an Americanaffiliated drug-treatment residence in China, Wang Xiaoguang, describes the centers as little more than “business ventures run by the police.”

Further, these camps are ineffective in achieving their stated goal of reducing drug use in China. Zhang Wenjun explained that within two-years of their release, 98% of individuals relapse and many are forced to return to the camps.

Wenjun attributes this failure in part to the stigma of addiction; those arrested for drug abuses are identified as addicts on their national identification cards, meaning they’re never able to escape their past actions and usually are not hired for stable jobs, perpetuating their cycles of addiction.

In March of 2012, twelve United Nations agencies, including the UN Office on Drugs and Crime, the World Health Organization, the UN Children’s Fund, and UNAIDS issued a joint statement calling on member states to “close compulsory drug detention and rehabilitation centers and implement voluntary, evidence-informed and rights-based health and social services in the community.” The statement explains, “There is no evidence that these centers represent a favorable or effective environment for the treatment of drug dependence.” Further, while the United Nations has called on international states and organizations to cease funding rehabilitation centers, international groups have largely ignored these requests. For example, a 2012 Harm Reduction International report highlighted more than a million dollars that Australia, Luxemburg, and Sweden provided for capacity building in drug detention centers in Vietnam that are known to subject drug users to forced labor and torture.

Also, in June 2012 the United States announced $400,000 of support for the Lao National Commission for Drug Control and Supervision in Laos. As long as drug centers are supported by international funding and continue to be profitable for Asian nations, there is no incentive for these centers to change their tactics or switch to more just, comprehensive strategies that promote actual rehabilitation.

The aforementioned 2010 Human

courtesy of Jacksoncam

Female opium addict hides her face at Mazar-i-Sharif detox centre.

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HEALTH AND HUMAN RIGHTS

courtesy of Reuters courtesy of Kaushik Narasimhan

Top: Inmates listen to a speech, Shanxi province, September 1, 2010. Bottom: Pills.

Rights Watch report, “Where Darkness Knows No Limits,” calls for swift and strong reform of the Chinese drug rehabilitation system, with action requested from both Chinese officials and police as well as their international partners and the center’s funding sources. It asks Chinese policymakers to clarify the goals of the Anti-Drug Law and establish guidelines for its implementation that are widely enforced throughout the nation. The Human Rights Watch report explains that these guidelines should entail fair trials for accused drug users, a restriction on drug tests barring cases of reasonable suspicion of drug use, and abolition of forced labor and a shift to medicallybased rehabilitation strategies. This

would mean removing accused drug user identification from individuals’ national identification cards, ensuring that injection drug users can seek testing and treatment for HIV/AIDS without being detained, and expanding access to voluntary, affordable, communitybased outpatient drug dependency treatment. Furthermore, the report asks the international community to stop funding and demand the closure of compulsory drug detention centers and to enforce international law to protect the rights of accused drug users.

If the international community unifies its efforts to lobby China to alter the way in which it addresses drug abuse within its borders, the rights of thousands of individuals can be

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If the international community unifies its efforts to lobby China to alter the way in which it addresses drug abuse within its borders, the rights of thousands of individuals can be protected.

”

protected, gains can be made in lowering rates of drug abuse in China through medically sound rehabilitation strategies, and the practice of punishing individuals stuck in the vicious cycle of poverty and addiction can be abolished.

Impetus for action, however, is not strong. International leaders are likely to ignore abuses in favor of self-interested economic and political partnerships with China. While politicians recognize that atrocities occur, they are likely to respond by ignoring these underlying realities, avoiding the confrontation of China’s harsh and seemingly insurmountable challenges. However, one must remember there is still hope that this tendency will change and global leaders and Chinese policy makers will alter their actions.

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Sophia Kecskes is a freshman in Pierson College.

You can reach her at sophia.kecskes@yale.edu.

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HEALTH AND HUMAN RIGHTS

SYRIA

At the Brink of a War Zone

By Sarah Yazji

It was July 2012 and the second time I visited the Turkish-Syrian border to volunteer at the refugee rehabilitation clinic. A young Syrian boy lay nearly unconscious and whimpering on the operating table. His light hair, torn clothes, and small body were blackened by dust.

His severely mutilated arm and leg were carefully propped up. I heard the few doctors around me state, “third degree burns,” in horror. The child was a victim of a rocket that blasted his home to pieces. The room was tense.

Every time a child came into the procedure room, this tenseness grew heavier.

The children served as a reminder of the reality of the bloodshed in Syria.

The following day I visited Zakaria in his small room on the second floor of the center. Using his good hand, Zakaria was punching buttons on his grandfather’s old Nokia cell phone as he played Tetris and scrolled through the phone’s settings to pass time. His tired eyes looked up at me when I walked in, and he asked me to sit beside him as he went to the pictures on the phone.

He showed me pictures of his mother, two sisters and little brother, and he shared with me stories of their childhood adventures. His eyes grew wide and excited as he recounted these stories, and I sat with him for hours thinking about how he did not know that he was now an orphan.

---Over this past spring break, four Yalies, Mansur Ghani ‘14, Zunaira Arshad ‘17, Moustafa Moustafa MS ’14, and I, joined a group of seven other students on a trip to southern Turkey for two weeks. Our group’s aim was to gain first-hand experiences of the situation and relief work on the ground and develop ways in which students can contribute to the cause.

For the majority of the members before this trip, the extent of their familiarity with the situation of Syria came from the infamous statistics that are stamped and regularly updated on the fact sheets of UNHCR and UNICEF or that make their way to the lower banners of broadcasting networks: over 130,000 reported dead, over 2 million refugees, over 5.5 million children

A family at Atmah camp.

27 HEALTH AND HUMAN RIGHTS

courtesy of S端leyman Tapsiz

28 the few functioning makeshift hospitals in Aleppo was struck and demolished.

Each hour the available medical facilities and resources shift or fail as shelling or airstrikes continue in Syria.

This phenomenon extends beyond the hospitals and clinics and ultimately comes down to the systematic targeting of doctors and medical personnel.

For physicians, remaining inside Syria means conceding personal security and the safety of family and friends. Every physician we met recounted colleagues, doctors, nurses and medical students who were captured, brutally tortured, and killed by the government regime.

Over 400 doctors alone have been killed since the start of the war.

It is no wonder that out of the 6,000 physicians that practiced in and around the largest city in Syria, Aleppo, only 6

remain. One of these physicians, one of the hidden heroes from Aleppo, told us how densely populated areas in the city are struck several times in the same spot.

He then explained how the regime uses a tactic of murdering the medical response team by having snipers set up around the site to take down any person who attempts to pull out the bodies. When we asked him what drives him to stay in Aleppo despite the enormous danger he faces, he shrugged and said this isn’t a question he can answer. He then asked, “What if that child who needs help was my ten year old son?”

Just five days ago in Aleppo over 40 barrel bombs were dropped in two neighborhoods. In this city of over 2 million, only one licensed anesthesiologist remains. We were given the honor to have met this man

Sarah Yazji

directly harmed by the conflict and the numbers grow by the thousands each day.

These statistics depersonalize the situation. The lives ruined, lost, and forever changed do not emanate from these digits, nor do these numbers tell you about the child who watched his family murdered in front of his eyes or the 19-year-old with paralyzed legs who was carried half-conscious to the nearest makeshift hospital or the pregnant mother who, along with her fetus, was instantly killed by the sniper bullet that pierced her belly. These stories, unique yet replayed each day with new victims, have characterized the lives of Syrians for over three years.

On our trip this spring break, we were given the opportunity to meet the advocates and the victims. We met the hidden heroes who enter Syria to help with the knowledge that their lives will be placed severely at risk. We met refugees who just crossed out of Syria; their children shake and cry at the sound of Turkish motorcars and planes.

We provided a hand to hold, an ear to listen, and, ultimately, a voice to share their stories.

From our trip, we learned that the humanitarian and medical situation of Syria is constantly changing and consistently insufficient to the needs to say the least. It is ideal to imagine that when a city in Syria is under shelling, there is a nearby hospital taking in the influx of the traumatically injured, but the absolute truth is that there is no such thing as a “safe zone” in these cities. It is precisely the hospitals and medical system that are targets of the Syrian government forces as part of their sick game to destroy rescue efforts. The UN Commission of Inquiry has even reported that, “the denial of medical care as a weapon of war is a distinct and chilling reality of the war in Syria.”

As a result of this targeting, makeshift hospitals are hugely kept hidden, moving from homes to schools to offices in an effort to relocate after the previous hospital site is destroyed or infiltrated.

During our visit to southern Turkey, reports came in to the main NGO coordinating internal medical relief efforts, Union of Syrian Medical Relief Organizations (UOSSM), that one of

HEALTH AND HUMAN RIGHTS

A woman carrying her child as she crosses the border from Syria as a refugee.

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HEALTH AND HUMAN RIGHTS

all photos by Sarah Yazji

Top left: Zakaria. Bottom left: Refugee children in the Kilis Refugee Camp. Right: A group of Syrian refugee children. during his short trip to the border. He told us how in response to the utter lack of nurses and physicians to care for the civilians of Aleppo, he trained a carpenter to perform invasive procedures such as intubation and IV catheter insertions into the jugular and femoral veins. These are the realities of medical care in Syria.

With these unimaginable stories and with what we have witnessed, we have learned to reevaluate our understanding of what constitutes standard medical care. We have learned about the frustrating reality of the health situation inside this once-thriving country. We have learned about how deeply politics within governments and even within NGOs ultimately decide the extent of external aid to the victims of this war.

But even more so, we have learned that the real work and differences are made by those who are on the ground. These incredible individuals who uphold

what remains of the healthcare system in this war zone, distributing resources, providing treatment, and reporting the stories, are rarely spoken of in the media, but they are the most essential components to saving lives in Syria.

The Syrian health system lacks many things, most notably stability and resources. We have been exposed to this depressing truth, but that is only a part of it. During our time spent there we learned that innovative ideas, lasting friendships and hard work have been put to the test and succeeded amidst the war.

Despite the fact that this conflict enters its fourth year, the Syrian people remain steadfast in battling and eventually overcoming the injustices and crimes they have dealt with ceaselessly.

We as students have chosen to travel to the brink of this war zone to listen to the witnesses and connect to the relief efforts, but it is even more important that we share the unbelievable tragedies

and resilience of these people. For three years, from the eyes of the Syrians, the world has silently watched the tragedy, but it only takes your voice, your advocacy, and your effort to provide relief, in your own capacity, that can truly change their lives.

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Sarah Yazji is a sophomore in Branford College.

You can reach her at sarah.yazji@yale.edu.

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FIELD WORK

NEW ORLEANS courtesy of Marcello Casal/Angica Brazil

OraQuick HIV test.

“Laissez le bons temps rouler!” *

By Juan Diaz

Commonly associated with the debauchery and decadence of Mardi Gras, New Orleans is a city occupying a unique place in American history.

Its racial and cultural makeup speaks to African, French, and Spanish influences during its colonization, and its socioeconomic disparities reflect a

legacy of slavery and racism. Recovering from Hurricane Katrina has not been easy for this city, and its difficult path to reconstruction has been hampered by the city’s long-standing social and economic inequities. Of note is the city’s fight against HIV/AIDS: New Orleans is the metropolitan area with the 3rd largest HIV/AIDS case rate in the US. At the forefront are community organizations like NO/AIDS Task Force, which

emerged in the early 1980s to tackle the rapidly advancing AIDS epidemic in the region. During the summer of 2013, I interned at NO/AIDS Task Force, in the organization’s Community Awareness Network Office. As an intern, I partook in its efforts against an epidemic that continues to silently ravage our nation’s most marginalized communities.

My internship began with rapidHIV-testing training, a month-long

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FIELD WORK process that prepared me for Louisiana’s HIV tester certification. One of my formative experiences during that first month was sitting in training seminars with a diverse group of people– from health care providers to graduate students to social workers–all were taking part in their state’s battle against the HIV epidemic.

Meanwhile, I continued working at the organization’s satellite office on Frenchman Street, where I performed tasks like creating promotional materials for the organization’s youth services, calling our clients about additional sexual health resources, and managing the front desk during our syringe access hours. I was exposed not only to the wide-ranging work that goes on in the public health and nonprofit sectors, but also to the diverse communities that made up our clientele.

When I finally obtained my certification, my internship shifted toward HIV testing. Because it was critical that the organization reach out to at-risk communities, I was sent to places like gay clubs and bathhouses.

There, I would work with a partner to test any and all interested parties. It was intimidating at first: there I was, speaking about “risk factors” and offering to demonstrate proper condom use to the people who were living in one of the epicenters of our nation’s HIV epidemic. Most people were polite and kind, declining to confront my naiveté or test my knowledge as only a patient and friendly Southerner could.

Sometimes, I would meet with a patient who knew very little about the testing process or about safer sex methods. It was here where I realized how health inequities take on multiple forms, besides inaccessibility to medicine, or lack of health insurance.

On more than one occasion I met with a young queer person, unclear about the urban myths about HIV. Whereas I received a comprehensive (and often graphic) sexual health education in high school, I realized that there were many Louisianans that did not.

On one occasion, I was asked to volunteer my testing skills at an outreach event geared toward New Orleans’ growing Latino population. I met people from immigrant backgrounds not

unlike mine. I realized how much public health efforts still have to go in accessing marginalized communities. Many had never had an HIV test, or perhaps had only heard of safer sex in passing.

Speaking as best as I could in a Spanish not practiced in months, I relayed as much information as I could, provided all the condoms that were allowed, and had conversations with a familiar community. It was through HIV testing that I realized the work that remains to be done in communities of color, and in impoverished communities. New Orleans confirmed to me how much more expansive the scope of inequality is in our country. It is most often the communities that are already facing discrimination and impoverishment that are disproportionately pushed into the crosshairs of the HIV epidemic.

Fast forward to December 2013: an article popped up on my Facebook feed, alarmingly alerting me to “Human Rights violations in New Orleans.” I clicked and found a Human Rights Report confirming what my coworkers at NO/AIDS relayed to me months earlier.

The very act of possessing a condom can be seen as a transgression. The Human Rights Report claims that sex workers are being searched and if found with a condom, can be found guilty of solicitation, among other crimes. Trans individuals are especially harassed by a police force that calls them “things,” and presumes their guilt. I almost couldn’t believe it when coworkers initially informed me that merely giving a condom to a person in a car during one of New Orleans’ many festivals could be construed as solicitation by the local police force. In addition to racial and economic disparities, New Orleans is dealing with a judicial and legal system that implicitly posits safe sex as an illegal act. To understand the city’s HIV/AIDS crisis is to understand a linked network of injustices that have contributed to this city’s suffering.

While one may be inclined to blame the people of New Orleans for the fractured and corrupt state of their local governmental institutions, I choose to believe instead in the power of systemic violence. Centuries of inequality and discrimination in the state of Louisiana have aggravated its HIV crisis. There

is only so much that organizations like NO/AIDS can do in the face of retrograde policies on the part of elected officials. This fact was reinforced during my internship: the 2013 federal sequester forced our organization to put off on hiring an additional staff person.

In the meantime, community organizations like NO/AIDS continue to race against time, and with limited funding, to ensure that they reach as much of the people as they can. The battle against AIDS will involve far more than the time and energy of our community organizations and public health workers, however. Tackling HIV will require the committed work of legislators and policy makers in fixing other aspects of deeply unjust institutions. We must come together to pressure our governments – at all levels – to recognize people’s access to health care and medicine as a human right. The failure of governments to provide for this right is intimately tied to other forms of injustice. The HIV/AIDS epidemic and the blow it has dealt marginalized communities are consequences of government neglect, racial inequity, and economic marginalization.

While we must recognize the committed work of private and nongovernmental actors, we must also be willing to recognize the role that the state can play in defeating epidemics. As advocates for the health of all humans, our struggle to end global health inequities will require us to demand and craft policy that confronts destructive economic systems, entrenched racism, and regressive ideas about sexuality. The story of New Orleanians, continually surviving and reconstructing in the face of devastation, provides us with a powerful example of resilience.

www *Cajun French for “Let the good times roll!”

Juan Diaz is a junior in Morse College majoring in History of Science, History of Medicine.

You can reach him at juan.diaz@yale.edu.

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FIELD WORK

GHANA

Redefining Ability: Lessons Learned from Survivors of Disabilities The rolling hills of Ghana.

By Ellie Dupler

Ellie Dupler

Yefreme Ellie. Mefiri America.

My introduction in broken Twi echoed over the buzz of mosquitos and the cries of babies suffering from conjunctivitis worse than most western health workers could ever imagine. Despite the pain and blindness the 450 people sitting before me in the sweltering church were enduring, they smiled in appreciation at my attempt to speak their language. More grateful than I could express with my limited knowledge of Twi, I grinned at the welcome.

Last summer, I spent nine weeks interning with Unite for Sight, aiding eye clinics with sight restoration in over 40 rural villages throughout Ghana. We set off each day by dawn, driving up to four hours along bumpy gravel roads to reach the most underserved villages in the country. Our goal? To screen visual acuity, prescribe and distribute antibiotics and glasses, and refer the unhealthiest and poorest patients for fully-funded surgeries in Accra to restore their vision. While I am now able to distinguish between various eye drops and lens prescriptions with ease, the two months that I spent travelling around Ghana taught me

much more than how to care for eyes.

Through this experience, I was exposed to the full depth of misconceptions about health conditions and the effects of gaps in healthcare that ravish the developing world. I gained insight not only into pressing global health issues, but also saw for the first time what it means for health to be a fundamental human right.

The fourth day of outreach, the term

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FIELD WORK

for over a month at this point, these were not the first polio victims I had seen left crippled by a disease that is today nearly unheard of in the developed world. However, seeing such a multitude of polio survivors in one place was overwhelming and left me burning with questions. How could such a preventable disease be claiming so many lives each year? What would be the future for these men? No employer would hire them.

Many would never marry.

It is absurd that in a world where modern medical technology has made it possible to prevent illnesses such as polio, more time, effort, and money are not being invested to make treatments and preventative measures such as the polio vaccine accessible to all. It is not only the privileged who deserve protection from these diseases. It is essential to remember that all individuals have equal rights to protect themselves, their loved ones, and their futures, and that no life is more valuable than any other.

My experiences with Margaret and the polio victims serve as vivid reminders of the real world effects of health policy and social injustice, and have caused me to grow immensely in my understanding of health and human rights. In these cases and more, despite adverse circumstances that often show little signs of improving in the near future, I witnessed determination and perseverance that left an indelible mark on my heart. Eight months after leaving Ghana, these people and others like them who are still waiting and hoping for medical miracles and rights to treatment and education to arrive in the developing world are the driving force behind nearly everything I do.

Ellie Dupler

attributed to the days we spent traveling a job she accepted with great pride and to various villages, is one that left a vivid at which she excelled. The experience was mark on my heart and one that I refer a testament to the detrimental effect that to often in drawing connections between medical misunderstanding can have on a health and human rights. To be honest, person’s life. Margaret had just as much there are many days from which I can right as her peers to pursue education no longer remember specific happenings, and be treated as a capable individual, days that are blurs of eye exams and long but the lack of health knowledge and drives through winding dusty roads. But misconceptions of disabilities in her on the fourth day, I met Margaret. rural village blinded her family and We p u l l e d u p t o a c e m e n t teachers and deprived her of these schoolhouse which had been partially rights. It was an eye-opening example converted into an outreach center. As I would later come to expect as the daily norm, twenty or thirty schoolchildren rushed to the van to greet the “obrunis”, the Ghanaian word for “white person”. They clambered over one another, yelling and cheering, but one girl, perhaps five or six years of age, held back and watched the welcome from afar. Over the course of an hour-long pre-exam health presentation that the eye doctors gave to our patients, I saw the other children repeatedly push around and laugh at the little girl; I later learned her name was Margaret.

Naturally, I was intrigued by her behavior and sought to befriend her. Margaret appeared to be a normal girl with a bright smile and beautiful eyes. She was in every way inviting and playful A Unite For Sight optometrist examining and cheerful, but not once did preschoolers eyes at a school in Accra.

I hear her talk throughout all of our interactions. I later learned that of the need for health education, better Margaret was mute; she had not, and resources and open communication would never speak, and was thus the about pressing health issues in the target of much ridicule from her peers, developing world. teachers, and people in the village.

In Ghana, I understood for the first I only had one day to spend in that time what it was for healthcare to not particular village and I spent as much of be just a privilege, but a fundamental it as I could trying to discern what life human right. One day, I got lost in a could possibly be like for a young girl maze of stalls while browsing at a street growing up without the ability to talk market and wandered in one direction in a place where most of the population, until I finally made my way out. When who possessed little medical knowledge, I reached the edge of the vendors’ heavily misunderstood conditions such territories, I came upon a dusty open as Margaret’s. I learned that Margaret was field where about 15 one-legged men kept out of school, bullied, and thought ran around on crutches after an allto be dumb and incapable of learning. but-flattened soccer ball, governed by Knowing that her lack of speech was a one-armed referee. Witnessing the no indicator of intelligence, I taught bond between the men was inspiring, Margaret to be my assistant for the day, but saddening. Having been in Ghana

www Ellie Dupler is a sophomore in Berkeley College majoring in Global Affairs.

You can reach her at ellie.dupler@yale.edu.

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FIELD WORK

SENEGAL courtesy of The African Meningococcal Carriage Consortium

The sub-Saharan African meningitis belt stretches from Ethiopia to Gambia and Senegal.

Key Insights Coming from the Smallest of Places

By Talia Katz

“i te foosi long.” You don’t know anything.

Did I correctly understand my host mother’s succinct Malinke phrase?

Did I really know nothing? Her remark, though valid, struck me hard.

Intelligence had always been the one character trait I clung too. And as if to crystallize the meaning of her sentence, Sunkara Camara, the woman whom I would call mother for the next seven months, proceeded to specify the extent of my incompetency. You don’t know how to chop an onion. You don’t know how to cook rice. You don’t know how to do laundry in the river. You don’t know how to dust. You don’t know even know how to speak Malinke. And then again, “i te foosi long.” You don’t know anything.

In October 2012, I arrived in Tomboronkoto, a rural village of around 800 people located in the southeastern corner of Senegal in West Africa. A few months prior, I had

graduated high school; however, instead of immediately accepting my place at Yale College, I became a Global Citizen Year fellow, deferring my freshman year in order to immerse myself in a new community. According to the sparse, one page “fact sheet” I guarded in my backpack- I was to assist a midwife at the local health clinic and teach English and math courses at the middle school. Unlike many other gap year programs, Global Citizen Year models their experience after the first phase of the Peace Corps training. During that time, the volunteer concentrates on observation and integration. While Global Citizen Year fellows hold community “apprenticeship” positions, their primary objective is to watch, see, and learn. Only through becoming a part of the community, can one understand community needs and the appropriate ways for filling them, if they should be fulfilled at all.

Of course, I could complete all of the aforementioned tasks- though my laundry techniques left much to be

desired and my onion slices never fell as symmetrically as those of the other women. Sure, I could boil water and add rice to a pot, but I lacked many of the requisite language skills necessary to purchase rice from the grocer. Moreover, I had a poor understanding of the intricate analog rituals surrounding the serving of the rice dish.

As the months went by, my new proficiency in the Malinke language informed a certain degree of cultural fluency, strengthening my relationships with both Sunkara and the members of the community at large. Understanding who did laundry for whom disclosed information on social relationships within the village. Watching women plan menus and distribute meal portions to groups in the family elucidated the socio-economic factors contributing to nutrition and health. Mastering quotidian chores, in the style of the Malinke women, proved imperative to understanding the cultural aspects of international development work.

As international NGOs and other

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FIELD WORK multilateral agencies ephemerally breezed through the village, starting initiatives and seldomly seeing them through, I began to understand why Sunkara had so adamantly insisted that I learn to cook rice. During the month of November, in conjunction with other Senegalese volunteers, I worked to carry out a mass Meningitis A vaccination campaign. Given the diversity of ethnic groups in Senegal, not even all of the Senegalese volunteers could speak Malinke and Pulaar. My ability to explain basic health terms, and even just count, allowed us to safely target the highest risk populations and to do so in the most dignified and efficient manner. Throughout the month of December, I traveled with a midwife throughout the region of Kedougou.

Through serving Kane (a rice dish with peanut sauce) at the family planning workshops and prenatal consultations, we were able to reach and provide service to a higher number of women. During the month of January, a group of Italian businessmen visited Tomboronkoto, wishing to combat malnutrition through donating fruit juicing machines.

Through translating during a meeting between the Italians, the village chief, and the local health workers, I helped facilitate a dialogue wherein the Italians developed a new strategy, this time in conjunction with the community.

Cross-culturally, there exists a tendency to devalue the domestic labor of women.

Yet, it was only through immersing myself in this incredibly powerful and important set of obligations that I began to understand the fundamental operations of Tomboronkoto- the health challenges and opportunities. On the eve of my departure from the village, Sunkara proudly proclaimed in front of the entire village “sani sani, ite mussoo malinke laa.” Now, you are a Malinke woman.

The ability to spend eight months living with the Camara family in Tomboronkoto was a privilege, a commitment of time that I understand not all can afford to make. Yet as I close this article, I want to insist on the importance of direct people to people contact informing public health agendas. In falsely equating “large scale projects” with “large scale success” we

reduce the efficacy of the solution, and more importantly, reduce the humanity of those groups for whom we are supposedly working. Grassroots development work performed by locally led organizations, such as Tostan (in the West African context), prove that small models provide big results. As we seek to solve our generation’s largest challengesbe it infectious disease, malnutrition, or infant mortality we must not forget that key insights may come from the “smallest” of places. Without a careful eye, “i te foosi long.” You don’t know anything.

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Talia Katz is a freshman in Ezra Stiles college majoring in Anthropology.

You can reach her at talia.katz@yale.edu.

Talia Katz

A hangout spot near Tomboronkoto on the Gambia river.

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QUESTION AND ANSWER

Q&A

Professor Alice Miller

By Lorraine James YGHR: How do you straddle the line between academia and advocacy? Being taken seriously but also making sure that your work has meaningful impact for populations in the near future?

Alice Miller: You need mutual respect between advocates and scholars; they have a lot to teach each other.

The academic should understand that the ideal is not what’s possible in the real world. Their ideas are to help do a better job and not a blueprint for how activists should act… It’s more important to be relevant in the midst of things than to be understood as perfect.

There’s a tendency in human rights work in general – particularly concerning sexuality and human health – to make people innocents: “an innocent person was raped or got HIV. If an innocent person getting raped is a terrible thing, does that mean that it’s okay to rape guilty people?” It’s a great tactic…

A great poster. Many advocates tend toward highlighting innocents as a way of making their claim stronger.

My work as a scholar is to point out the ways in which claims about innocents are often quite dangerous to long-term change because guilty people, in the general sense and not just the political sense, need rights too. People who don’t live blameless lives still have

the right not to be tortured, not to be raped, the right to live in a house.

If you’re a scholar, your allegiance is to your idea or institution. As your question implies, sometimes scholarship is understood as being above the fray.

And that’s how it gets respect. I’ve been lucky enough to work with a kind of coterie of scholar activists – people who are committed to long-term social change and also committed to rigorous thinking and are willing to be in the fray.

It’s an interesting challenge.

YGHR: Would the new law passed in Uganda be something that falls within your scope?

AM: Which one? The one on women and pornography or the one on anti-gay?

YHGR: The one on anti-gay.

AM: Part of what I’m doing by asking the other question is that one of the interesting things about doing health and sexuality is that right now, stuff on gay rights is on everyone’s radar, but stuff on women’s rights not on everyone’s radar! Uganda also passed a law about women and pornography that, among other things, makes women wearing short skirts forbidden and that women shouldn’t read certain things or be in certain areas to protect their virtue.

Nobody knows about that because the kinds of women’s rights conversations are not on the agenda but the gay rights one

courtesy of Alice MIller

Professor Alice Miller is an Associate Professor (Adjunct) of Law at Yale Law School and co-director of the new Global Health Justice Partnership. As an expert in health, human rights, and gender, Professor Miller also holds positions at the Yale School of Public Health and the Jackson Institute for Global Affairs. Her research has focused on gendering humanitarian law, abolition of the death penalty, sexual and reproductive health, and LGBT rights.

is. I work on both, so I want attention to both.

YGHR: Do you ever get frustrated when people only get concerned about human rights when it’s in the news?

AM: Yes. Both when it’s in the news and the way that it’s in the news which goes back to my discussion of innocents being the kind of headline grabbing version.

For example, Nicholas Kristof, as a New York Times editorialist, has incredible space to talk about and tries to bring attention to all kinds of things from obstetric fistula in SubSaharan Africa to sexual violence in the Sudan. But it turns out that his kind of attention-grabbing writing is actually counterproductive to sustainable longterm change.

Obstetric fistula is a condition for women that generally happens if you’ve had prolonged labor in childbirth or sometimes particularly vicious sexual violence. Basically, the wall between your vaginal wall and intestinal wall is broken down, so that you leak feces and urine.

You don’t die of it, you are often sick, but you’re definitely outcast.

Kristof has been doing a series of columns about the horrors of this, which is great; people should know about the horrors of this terrible condition – the women don’t die but they nonetheless suffer. On the other hand, he focuses on treatment because he doesn’t want

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QUESTION AND ANSWER to do the politics of contraception or birth control.

Unfortunately, because of the way that a couple of Op-Eds have run, people think that what we need are what they call vagina doctors, doctors to treat people. Which is great work because obviously it’s helping any woman who suffers. But you can’t treat your way out of this problem. A functioning health system alongside with good clean water, good air, good food, and the ability to move about and make decisions to control your life are the most fundamental things that can give you good health. But those are not the stuff of headlines.

For those of us who do health and human rights, we spend a lot of time trying to think about how is it we can really get long term system change while dealing with the headlines we face every day. Can we use these headlines strategically and still accomplish the longterm systems change even though the headlines are all about individual heroes and individual victims. That’s a big part of health and human rights work.

YGHR: What is one accomplishment you are proud of? What is something you are not very proud of?

AM: I think the proudest is having been part of a group of people who help to open up the conversation about sexuality as a human right. The “not proud” is that it instantly turned into a much too rigid conversation about gay identity in one corner and sexuality and women’s rights in the other. We fell into our own rut of belief that “what matters to women about sexuality is rape and what matters to other people about sexual difference is gayness, and that’s mostly men”. That‘s a real problem. I was part of the good part of the conversation and part of the bad part of the conversation.

YGHR: This kind of sounds like the Uganda law debate we talked about earlier.

AM: Exactly! At root they represent the same impulse to control anything that is gender nonconforming, anything that threatens a certain image of masculinity and femininity–against which nobody lives perfectly. It’s a thing used to govern and repress people; whether it’s

heterosexual women, heterosexual men, or people who prefer to live a different gender life, or women who would like to live without husbands. All of those people are equally repressed under these systems, but we only get headlines on a few. It’s an odd moment; twenty years ago you couldn’t get newspapers to talk about the harm against people with same-sex behavior. Now you can’t get them to stop. Twenty years ago, we couldn’t get them to think of rape as a problem for women’s human rights, now I can’t get them to think of anything else.

We were onto something, but we didn’t budge all the background conservative ideas around it.

YGHR: Consider the following WHO statement: “Indeed, inadvertent discrimination is so prevalent that all public health policies and programs should be considered discriminatory until proven otherwise, placing the burden on public health to affirm and ensure its respect for human rights.” Can you give an example of a nuanced public health program that seemed valid but has underlying it very discriminatory elements?

AM: Let’s say you run a health service, a clinic, and your hours are 9-5 because those are work hours. Who aren’t you going to see at your clinic?

YGHR: People who have to work from 9-5.

AM: Exactly, people who are the poorest are often the ones with the least ability to manipulate their work hours to get health services for themselves or their children. If you’re going to have a clinic, how do you have hours to accommodate the people who are the most marginalized? If you are punching a time clock, if you have to lose pay to go see a doctor or take your kid to a doctor, that’s not a choice you can make.

You can locate a community clinic in a poor part of town, but if your hours don’t meet what people can do, you will only get a certain number of people and won’t get others.

You need to say now I need to have different hours or now I need to have a mobile van if I want to work with street folks. No matter how good your services are, you haven’t thought through barriers

that people face.

Similarly, maybe not in the U.S. anymore, but it used to be that women couldn’t get health services without their husbands’ permission. So if you’re set up planning, but you haven’t understood how it is that a woman can walk through the door and actually get information about family planning. If you haven’t thought about the ways in which she’s required to produce a male heir, no matter what you’re telling her, she may or may not be able to act on it. In that sense, you aren’t helping her enjoy her health and human rights, and you may be actively contributing to further barriers.

A human rights analysis around health services would require you to think about material barriers that people face above the contents of your services.

YGHR: How do you react when people criticize international health efforts as hypocritical or a misuse of resources when the United States itself has big health/human rights-related issues?

AM: The US is always the site of its own problems, and, because we hold one quarter of the world’s wealth, we are always part of other people’s problems.

I don’t see how you cannot do both. In our Global Health Justice Partnership we try to do projects both inside and outside the US to remind people that both are happening.

If you do a project that says I’m going to fix other people, but I’m not going to acknowledge what’s wrong with the U.S., then you’re wrong. If you do a project that says the U.S. is a part of the problem, especially if you’re talking about anything related to the world bank, (IMF), our policies are part of the problem– they are PART, not the only part, of the solution.

You can’t be high-handed.

I think it’s a combination of always having both eyes wide open, one looking internally and one looking externally.

And making clear that when you think you’re doing international work, you’re not just re-imposing US values. Not just saying the U.S. screwed up by imposing one kind of value, but now I’m going to fix it by imposing another kind of value.

What’s you’re actual accountability to people who are most affected in another country – can they yell at you? Do you

38 know what they’re doing? Do you know what they need? Do you know how diverse they are? Do you know how many “they”s there are? How many different kinds of groups can do what kind of work?

What’s the best relationship to be in?

Maybe you need to be visible, maybe you need to be invisible. Maybe they need a U.S. partner for validity, maybe they don’t need a U.S. partner because it will invalidate them?

At any given moment, it will be complicated.

YGHR: What is the most common or most problematic misconception you hear from students or the public about health and human rights?

AM: One of the biggest misconceptions, particularly in the United States, is that health is produced by more healthcare. That is a really, really, really big problem. If you know Betsy Bradley’s work, the percentage of good health outcomes that are affected by health care by itself is somewhere between 20 and 30% But health is affected by a whole range of other factors – social determinants. They’re things that matter – everything from where you live to what food you get to what kind of play space your kids have. Those things are the building blocks of health – adding

QUESTION AND ANSWER healthcare is an important component but not the majority of what makes good health.

In my specific work around sexual health, the misconceptions include things like “rape happens in all wars at the same rate against all women.”

It turns out, in some wars, it doesn’t happen at all. In some wars, one side rapes and the other side doesn’t. For me, it’s about finding variation. People who work on the ground, who go into refugee camps, know this; you need to deal with men who were raped too; that women are having many different kinds of sex, some chosen, some forced, not all of which is rape from the enemy. When you’re designing programs that do health interventions in conflicts, you need to design services where people are at and that meet people’s needs that are much more varied. Varied stories are really hard to make headlines on.

YGHR: What do you think is ONE BIG concern in human rights and sexual health today?

AM: The fact that we still see the problems as separate – that we’ve divided off gay rights from women’s rights.

That we think sexual health isn’t about housing rights.

I think the biggest problem is we have to prioritize, but we have to not

separate. The biggest problem is working on things in silos as if you could pull one thread and fix it. I think you have to identity your threads and be clear, but you can never just pull one thread.

Therefore, silver bullet solutions are a big problem – short-term technological solutions to health problems, basically solutions that the Gates Foundation likes to fund.

YGHR: Rather than institutional and structural change?

AM: Right. And of we want technology on our side: of course we want new vaccines, of course we want mosquito nets, of course we want new immunizations. But by themselves, they don’t work; unfortunately right now, the biggest money is flowing towards those issues. That kind of single thread driven answer is a problem.

www Lorraine James is a junior in Trumbull College majoring in Molecular, Cellular, and Developmental Biology and American Studies.

You can reach her at lorraine.james@yale.edu

courtesy of the AFP

Women protest against the new anti-pornography and dress code legislation on Feb. 26, 2014, in Kampala, Uganda.

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OPINION

HOW GLOBAL HEALTH HELPS

By Alicia Ding

In “Towards a common definition of global health,” written in a 2009 edition of the Lancet, members of the Consortium of Universities for Global Health (CUGH) Executive Board defined it as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.”

Perhaps it is appropriately vague to accommodate all of the various ways in which people “do” global health, which includes working with Nongovernmental Organizations (NGOs), increasing awareness of a cause, figuring out more effective ways to distribute and equitize health resources, and forming partnerships between high income countries and low-and-middle income countries. However, global health, at its broadest definition, is essentially nations helping each other solve issues relating to health.

As a result, partnerships have grown in popularity, but they often emphasize the shortcomings and at times elitism of global health. It is often industrialized nations that determine the terms of a partnership and then base definitions of global health off of these working relationships. In addition, most of the panels that have gathered to discuss the goals and objectives of global health partnerships consist mainly of members from high income countries and not their low income counterparts. This was seen most notably in the CUGH conference that took place in 2008, on which the 2009 Lancet article based its definition of global health. Only four out of the 50 conference attendees represented “partner” institutions,

while the others were all from the United States or Canada. One of the “partner” institution representatives pointedly asked if the only way for them to implement partnerships was to “look for an even poorer country to work in.” Although the report of the meeting acknowledged that there were still conflicting attitudes towards partnerships (with the “partner” institutions feeling less approval than the US and Canadian ones), the 2009 Lancet article did not mention this.

Thus, the inequality in partnerships does not necessarily stem from the direct benefits that both nations receive, but from the positions in which the partnership places the member countries. However, this inequality may be unfortunately inherent in any global health practice because of the connotations of helping another nation.

Receiving help means acknowledging that a problem exists and often implies that the nation does not have sufficient resources or means to solve the problem on its own, and providing help comes with connotations of having both the knowledge and abundance of resources to aid another nation. Because global health also developed from imperialistic roots, it is still challenging for “helping” nations (often western ones) to avoid having these connotations.

How, then, can one nation aid another without seeming paternalistic when paternalism always seems to be implied in helping? Consulting the nation being helped is clearly an obligation. The increase in popularity of partnerships shows that nations involved in global health genuinely have good intentions and want to move towards equitable relations through these partnerships.

But forming them is not enough; higher income countries should constantly consult with and learn about the practices of the countries with which they work in order to make these relationships productive for both members. As soon as one considers global interactions, culture becomes a tremendous factor. Learning about the culture of other nations and working with it instead of viewing it as a barrier obviously requires more effort and time, but will help nations decide if the expertise and tools they have are the ones they should be using. We must not impose the practices of one nation upon another just because those practices happen to work in the cultural context of the former. By admitting that we do not necessarily have the best, or the only solutions, and by framing solutions in the context and culture of the nation we are trying to help, we allow for more ideas and, thus, potential solutions to a problem. Pursued in that way, global health can become a much more effective and equitable field for all nations involved.

www

Alicia Ding is a sophomore in Pierson College majoring in Molecular, Cellular, and Devolpmental Biology.

You can reach her at alicia.ding@yale.edu.

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OPINION

YOUR FUTURE IN GLOBAL HEALTH Some of What You Need to Know and What You Don’t Need to Know

Richard Skolnik, BA Yale College 1972, is a Lecturer at the Yale School of Public Health who has been deeply involved in health and development work for almost 40 years. From 1976-2001, he worked at the World Bank where his focus was on health systems development, family planning and reproductive health, child health, the control of communicable diseases, and nutrition in low-income countries. He has served on advisory groups for organizations such as the WHO, the Harvard Humanitarian Initiative, the Global Health Leadership Institute at Yale University, and the Global Fund.

Skolnik has peer reviewed numerous books, reports, and articles on global health issues and is the author of the undergraduate textbook on Global Health, Global Health 101.

By Richard Skolnik Students regularly come to me asking what they need to know to work in Global Health. They also frequently ask what I wish I had known when I was their age (which was almost too long ago to remember, of course)! At the invitation of the editors, let me offer some comments below on “what I would want to know (and not know) if I were you.” Hopefully, this will help answer at least some of the questions that are on students’ minds, as they think about pursuing Global Health.

Let me start by saying that most

of you should stop trying to plan every minute of your life and stop believing that you lack worth if you are not sure exactly what you want to do professionally. As my friend Robert Hecht, of the Results for Development Institute, says so well, most of what we worked on professionally in our long careers in Global Health did not exist when we were at Yale. There was no AIDS. There was no cry for Universal Health Coverage. There was no GAVI Alliance, Global Fund, or Global Program for the Eradication of Polio. Thus, it is important to have a strong understanding of Global Health issues, the kinds of problems that might

arise in the future, and the questions one needs to raise to help understand them.

However, it is not possible to “know all the answers now.”

A similar point holds true in terms of your knowledge of both health and development. Some of you may wish to specialize in particular topics and on particular regions of the world. However, your career will be best served if you get a broad understanding now of critical issues in health and development, as they play out across a range of countries, and couple that with the beginning of technical specialization. First, this will allow you to put your specialized interests in context. Second, it will help

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OPINION

courtesy of Richard Skolnik

ensure you are learning the lessons of experience from different places and are able to apply them in a range of settings.

Third, it will prepare you to work on different parts of the world as needs change. I “lived and died” for Southeast Asia when I was at Yale and the needs there were vast at the time. Yet, I worked largely on Africa and South Asia at the World Bank, at a time when much of Southeast Asia saw very rapid economic growth and a widespread reduction of poverty.

I cannot stress enough how important it is for you to find “role models” as you develop a better sense of what you might wish to do professionally. When I came to Yale, I wanted to be a physician. Then, after spending a year in the Philippines on the Experimental Five-Year BA, I decided I should work in the new field of “development” instead, with a focus on health and education. Yet, I had no idea what people did in this field, who the key players were, or how they got where they were professionally. I might have heard of the US Centers for Disease Control and Prevention (CDC) and smallpox, but I certainly knew nothing of the great and more silent heroes of Global Health and development. You can learn an enormous amount from looking for such people, learning about their lives, and seeing if you can attach yourselves to them or their work.

In fact, I cannot stress enough the importance of mentors. I realized a little too late in my career how exceptionally important it is to have people from whom one can learn. A huge share of my personal and professional growth is the result of having had a number of exceptional mentors. Those who know me will be amused (but not surprised!) that I was told not to speak while on field visits in my first year at the World Bank. So, I listened carefully that year both to the masterful diplomatic French of my mentors and the well thought out content in their words. From other mentors I learned to speak slowly and take breaths between my words; ensure that ethical issues were paramount in all of our work, even in environments where they were not so explicitly mentionedto think and act more strategically; and, to understand the emergence of HIV, just as it began. Among many other things, I also learned the centrality of nutrition to all matters health and development.

I also learned much about how to manage and motivate people and work diplomatically but rigorously with a wide array of country partners. In the courses you take, the internships you undertake, the summer employment you get, and in your long-run career, you want to identify people from whom you can learn and then learn all you can from them.

You should also understand that if you want to work in Global Health, with a focus on the poor in poor countries, then you must spend time living and working in low-and middle countries. Unfortunately, this is an area to which Yale students need to pay much more attention. A summer is NOT the same as living in a country for a year or two. Nor are two summers.

The best understanding of health and development issues comes from extended periods of time in countries, living as close to local families, as possible. I was fortunate that Yale had both a five-year program in my day and that I could also participate in the Yale-China program when I graduated. I would encourage many more Yale students to take a semester or longer abroad and to do so in places where one can get first-hand experience with health and development problems among the poor. Perhaps Yale can refine its fellowship programs a bit to facilitate and encourage more students to do this. Many students also fail to realize that spending a semester studying in Senegal, or doing a project there on community-based insurance for the poor can actually enhance medical school applications, rather than doom them.

As always, there is much more I can say. However, these are the few points with which I would begin to offer some thoughts on what I wished I had known when I was in college and what I would want YOU to know, and not know, as you consider a career in Global Health.

www

Richard Skolnik, BA Yale College 1972, is a Lecturer at the Yale School of Public Health.

You can reach him at richard.skolnik@yale.edu.

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CLASS CONTEST WINNER: 1ST PLACE

YEMEN

Health Inequity between the Genders

By Teresa Logue

Key Health Inequities Yemen has major inequities in health status, the most obvious of which occur across income (poor-rich) and geographic (rural-urban) lines. In terms of health outcomes, children in

courtesy of Dana Smillie/Woeld Bank

Introduction Though it is the second largest country in the Arabian peninsula, Yemen has the second lowest Human Development Index (HDI) in the entire Asia region. The population of Yemen experiences crushing poverty nationwide, and a low life expectancy at birth, (63 for males and 66 for females. Accordingly, Yemen’s total health expenditure of $40 per capita annually is among the lowest in the world. Spending just 1.8% of its GDP on health, Yemen’s health system remains grossly underfunded and underdeveloped. As part of the 2011 Arab Spring, Yemeni citizens rose up in protest against their unresponsive government, calling for social sector reform. The new coalition government has grappled with, among other things, improving the delivery of health care services across the country, but reform has been progressing slowly. However, it is urgently needed, especially to correct for major inequities. Yemen’s overall loss in potential human development due to inequality was 32.3% in 2013.

Gender-based disparities represent Yemen’s biggest health justice issue, and should be immediately addressed.

Women receive awareness sessions and health education in rural areas of Hodaidah, Yemen. the poorest quintile are twice as likely to suffer life-threatening diarrhea and acute respiratory infections (ARIs) as those in the richest quintile.

In terms of health care utilization, children in the richest quintile are 6 times as likely to receive full immunization and 1.5 times as likely to receive medical treatment for ARIs as those in the poorest quintile. About 74% of women in the highest income quintile give birth with a professional delivery attendant, compared to only 17% of women in the lowest quintile. Where available, health services are underutilized by the poor due to inability to pay user fees. Out-of-pocket (OOP) spending is rampant, and accounts for 75% of total health care expenditure. As a share of total consumption expenditure, households in the poorest quintile spend half of what those in the richest spend on health, suggesting that health expenses

discourage the poor from seeking care.

While cash-transfer programs like the Social Welfare Fund exist to offset some of this burden, about half the transfers from public programs leak to the nonpoor. Furthermore, the rich often subvert Yemen’s health system and seek medical care elsewhere, such that 30% of total health expenditure in Yemen is spent abroad.

A second major inequity occurs between urban and rural populations.

The majority (75%) of Yemenis live in rural areas. In rural Yemen, direct state control is weak, which results in low coverage of health services, no emergency medicine, and childhood deaths from preventable diseases. Only 25% of rural areas are covered under public sector services, compared to an 80% coverage rate in urban areas.

Just 26% of deliveries in rural areas are attended by skilled health personnel, as

CLASS CONTEST WINNER: 1ST PLACE opposed to 62% of births in urban areas.

Food insecurity is a “long-term chronic emergency” in Yemen, with malnutrition notably worse in the rural governorates.

The prevalence of severe stunting in children between 2 and 5 years old is also higher in rural areas (33.2%) than urban ones (23.5%). There is a 12-percentage point difference in measles immunization coverage between children in urban and rural areas.

While income-based and geographicbased disparities are most apparent from indicators of child and maternal health in Yemen, gender-based inequities overlay both, representing Yemen’s biggest health justice problem. Yemen has a Gender Inequality Index (GII) value of 0.747, ranking last out of all 148 countries in UNDP’s 2012 index.

Yemen’s high maternal mortality ratio of 200 betrays the low health status of women in Yemen. Because 42% of female deaths in the reproductive age range are linked to childbirth, maternal mortality is the most pressing women’s health issue. A woman in Yemen has a 1 in 39 chance of dying in pregnancy or childbirth over her lifetime, and about 7 Yemeni women die each day from childbirth. Only 36% of births are attended by skilled health personnel, due to lack of access to formal care. In all but one governorate in Yemen, half or more of all women report not having access to a formal health care provider. Yemen holds one of the shortest median birth intervals in the world at 25.3 months, and just 54% of demand for family planning services is met. Significant barriers impede female access to health care: twice as many men as women can afford medical care, preventative care, regular visits, and medications. The majority (71%) of women must be accompanied by a male relative on visits to health care providers. This constraint often applies in times of emergency and can further prevent a pregnant woman from receiving proper obstetric care.

Rationale for Addressing GenderBased Inequities Gender-based inequities should be addressed immediately; and improvements in women’s health have trickle-down benefits for children and for society at large. Lack of access to

maternal health care retards not only the health status of the mother, but that of the child too: and just 14% of women in Yemen have at least 4 antenatal care visits and only 12% of infants are exclusively breastfed for the first six months as per WHO recommendations, which implies childhood underweight. Beyond access to maternal care, women’s status in society is associated with health outcomes in children: empowering women to make decisions at home and in their communities enables them to provide better care and nutrition for their children. It was estimated that if women had equal status relative to men in nearby South Asia, the under-three child underweight rate in the region would decrease by 13%.

Improving the social status of women will improve both mother and child health. Finally, the elimination of gender inequities and the reduction of maternal mortality are linked to increases in GDP per capita and economic growth.

Addressing Gender-Based Inequities Yemen should look to the Sri Lankan example of addressing maternal mortality by coupling interventions to extend health care to women with policy efforts to improve their autonomy and social standing. Sri Lanka has seen exceptional progress in achieving high women’s health outcomes, especially in the context of its low GDP per capita average annual growth rate (3.0%), which is comparable to Yemen’s (1.1%). Over the past 50 years, Sri Lanka’s maternal mortality rate declined from 340 to 13, and its percentage of female deaths in the reproductive age range due to maternal causes dropped from 19% to 1.2%.

Interestingly, low female mortality in Sri Lanka today has been linked to transferring agency for health-related decision-making to women. To achieve this, Sri Lanka aggressively invested in mass education of girls, which was “the single most important reason why infant and child health has improved.”

Ed u c a t i o n h a s b rough t women autonomy, made them knowledgeable about health, increased demand for skilled attendance at birth and family

43 planning services, and encouraged them to take a more active role in child care.

Yemen has low rates of female literacy (30%) and secondary education amongst women (7.6%). Accordingly, men tend to be the decision-makers for the family, and community health workers target their health message guidelines to them.

Yemen should prioritize the education of girls to empower women to take on this role instead. Further, education is directly linked to access to health services in Yemen, with 71% of Yemeni women with secondary education reporting access to a health care provider.

Encouraging women’s political participation, as well as outlawing child marriage and female genital mutilation, are additional cost-effective policy avenues to improve the status of women in Yemen. Holding just 0.7% of seats in parliament, women have a paucity of political power. Child marriage is currently unregulated, and over half of girls are married before 18, with some married as young as 8. Many become pregnant soon after, and Yemen’s adolescent fertility rate is very high, at 66.1. Most child brides have insufficient information on family planning, and so little to no control over how far apart their pregnancies are spaced.

Along with young age, this makes them more vulnerable to complications from pregnancy. At a prevalence of 38.2%, female genital mutilation is a pervasive problem, especially because FGM exposes both women and their babies to significant risk during childbirth.

I n a d d i t i o n t o w o m e n’s empowerment, Sri Lanka’s program to reduce maternal mortality rested on extensive investment in health infrastructure; and Yemen should look to the Sri Lankan model for service provision. In the 1930s, Sri Lanka began building an extensive health service network to offer basic preventative and curative services for free to the entire population, including those in rural areas, which is still in place today. At its lowest level, the architecture is comprised of small health units staffed by a medical officer, who has access to a strong referral system and reliable emergency transport. In 1950, the government began developing and integrating a program of public health

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CLASS CONTEST WINNER: 1ST PLACE

courtesy of Martin Chico/International Committee for the Red Cross

A woman gets a check up at the ICRC sponsored Majaz health center near Sa’ada, Yemen. midwifery into the system. Sri Lanka’s public health midwives undergo 18 months of clinical training before being assigned to serve a community of 3,000 to 5,000 people in which they live. As frontline workers, they provide family planning services, visit pregnant women, register them for care, provide advice, and report to a network of supervisors with the area medical officer at the top. When necessary, they conduct home deliveries and, if complications arise, arrange for immediate transfer to hospitals; however, due to the typical long distances for such transport, 98% of deliveries in Sri Lanka today occur in institutions.

Yemen should replicate the Sri Lankan health infrastructure model by strengthening its existing primary health services and then supplementing that structure with strategic investments in midwifery and maternal health. As it stands, just 25% of rural areas in Yemen are covered by health services.

There exists no referral network or emergency transport system, and rugged roads compound this problem. Human resources for health are inefficiently used: most health centers “only hire one general practice doctor who assumes the role of doctor, midwife and pharmacist.”

In larger institutions, because doctors do not rotate shifts, only a limited time frame is dedicated to emergency care.

Yemen should expand its health infrastructure, particularly in rural areas, by building up additional basic health facilities staffed by nurses and medical officers, who are supported by a strong referral network of doctors to provide higher-level care. Next, Yemen should invest in public health midwives, aiming to train an additional 5,000 midwives to reach a ratio of 1 midwife per 5,000 women. (Though to do so, the Yemeni government must first incorporate midwives into the formal health care sector, and regulate midwifery practice.) The government has taken steps towards increasing its midwifery workforce, but only in areas without a health center. This is the wrong approach: instead, the two should go hand-in-hand as in Sri Lanka. Ideally, the role of the midwife should be to provide antepartum and postpartum care at the patient’s home and to assist with delivery at a clinic or hospital.

Institutional deliveries ensure access to higher-level care if birth complications arise, which is not available in most rural areas due to Yemen’s lack of a functioning emergency transport system.

Today, 80% of deliveries in Yemen take place at home.

Yemen can expect that making the same strategic investments as Sri Lanka in basic health infrastructure and a public health midwifery program while instituting policy reform to empower women to make health-related decisions will generate a comparable outcome. The amazing scale of Sri Lankan progress in improving women’s health status, where maternal deaths have halved every 12 years from 1935 to today, is achievable and affordable for Yemen too. For, Sri Lanka’s great improvements in women’s health occurred at a relatively low cost: the nation spends just 3.5% of its GDP on health! Yemen should look to the Sri Lankan experience to address its genderbased disparities, and, in doing so, will see significant benefits to the health of women, children and its society at large.

www Teresa Logue is a sophomore in Saybrook College majoring in American Studies.

You can reach her at teresa.logue@yale.edu.

CLASS CONTEST WINNER: 2ND PLACE

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HEALTH AS A HUMAN RIGHT

By Anna Blazejowskyj

The idea of health as a human right presents a very complex, multidimensional dilemma. One of the greatest problems that arises in the health debate is that there is not a single, universal definition of health, nor a definite means by which to attain it. The World Health Organization

defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” but does little to explain what complete well-being entails. Taking this definition set forth by the leading international health authority, it becomes obvious that the right to health is about more than biomedical treatments of ailments; to fully examine health one

must incorporate an understanding of the social determinants that impact one’s ability to attain the best possible care. In comparing the United States and South Africa in their approaches toward healthcare, the historical contrast in which these approaches are based, and the steps taken in response to the debate of health as a human right, it becomes apparent that although the

courtesy of David Sachs

Hundreds of activists gathered in front of the Supreme Court building to rally and show their support for the Affordable Care Act during the second day of hearings regarding the law.

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CLASS CONTEST WINNER: 2ND PLACE

all photos by Anna Blazejowskyi

CLASS CONTEST WINNER: 2ND PLACE United States is often considered to have a more advanced understanding of health than South Africa, South Africa is on the forefront of the movement toward the realization of healthcare as a human right.

When looking at a nation’s response to the debate of health as a human right, it is necessary to examine the history and culture in which present day perceptions and policies are based.

In particular, it is important to focus on a nation’s practices towards marginalized populations. As Paul Farmer posits, “suffering is rarely separate from the actions of the politically powerful,” and thus it is necessary to frame the political context that contributes to the suffering that would naturally be associated with a violation of the right to health. In the case of South Africa, an analysis of the current political climate in regards to health is not complete without examining the practices of the Apartheid regime. To begin, the Apartheid system was not merely for the segregation of the races. During Apartheid, whites were considered legally superior to Blacks, Coloreds, and Indians, and the government made sure that services that non-whites received, including medical care, were also inferior. For example, hospitals were assigned to particular racial groups and most were concentrated in white areas. With 14 different health departments, the system was characterized by fragmentation and duplication. But more than the lack of access to care, the Apartheid system created many structural barriers that limited access to both “named” resources such as education as well as “unnamed” resources such as acceptance and power; these structural barriers ultimately constrained the agency of the non-white population, leading to ingrained feelings of inferiority.

However, on a more positive note, the inspiring, thoughtful leadership of Nelson Mandela and his counterparts also had a profound impact on the South African population. As William Gumede writes in his introduction to Mandela’s No Easy Walk to Freedom, the African National Congress’s success “turned the struggle against apartheid into a moral struggle”. The fight for liberation

brought to the forefront the ideals of equality and democracy, setting the stage for more recent battles for health rights and equalities.

To compare, the United States was founded as a democratic nation, where equality and a democratic voice were intended to be inherent for every individual. However, history did not play out in such a manner, and within the context of the capitalist system, the economically powerful are often the driving forces of legislation. The neoliberal model of governance and the mantra of success of the individual have created a system of gaping inequalities, where profits take precedent over the rights of the greater population.

C o r p o r a t i o n s a re a n e x t re m e l y powerful force, and one place where their influence can be clearly seen is in the implementation of healthcare, specifically in terms of the provision of pharmaceuticals. As a legacy of the American dream, individuals demand access to the best care that money can buy. However, concurrently, those without money are left with little to no adequate care. Healthcare became viewed as a commodity, and the procurement of health required a necessary level of wealth. A minimal government system was designed to help the poorest of the poor, but healthcare for everyone was not considered in the context of a right until recent times.

As a result of the historical and governmental context of these two nations, several challenges and inequities arise in both the United States and South Africa in the process of attaining health as a human right. To begin, the greatest challenge in the United States lies in the economic aspects of healthcare implementation. As a wealthy, developed nation, the United States has one of the least efficient healthcare systems; in 2010, the Commonwealth Fund ranked seven developed countries on their health care performance and the US came in last place. Moreover, in rankings released by the WHO’s World Health Report that compared nations based on an index of five factors – health, health equality, responsiveness, responsiveness equality, and fair financial contribution – the United States was ranked 37th in

47 the world. Although it came in 15th place in terms of performance, the US came in first place in terms of greatest overall expenditure per capita. To understand the vast amount of money spent on the health in the United States, it is necessary to note that in 2009, 17.6% of the GDP was spent on healthcare in the United States – approximately $8,086 per capita or a total health expenditure of $2.5 trillion.

Even with such expenditure, 22,000 people in the United States die every year because they lack health insurance and have dangerously limited access to care. Insurance premiums reaching levels of about $13,375 per family per year demonstrate the extensive – bare minimum – costs for attaining care. A focus on high-level tertiary care over primary prevention results in extremely high costs and unfavorable health outcomes, with a large portion of the population with little or no access to the most fundamental care. In terms of direct ideals about health as a human right, the National Economic and Social Rights Initiative summarizes the US approach quite clearly: “The United States does not recognize the right to health in its public policy, has no national health care plans, and falls short of taking a comprehensive approach to health protection.” Quite similarly, a key issue within the South African system healthcare implementation is efficient appropriation of funds. Within the context of the current system, inequities between the public and private sector result in poor outcomes in comparison to similar middle-income countries.

According to the National Treasury’s Fiscal Review for 2011, 48.5% of governmental health expenditure was spent on the private system and 49.2% was spent in the public sector. Although these numbers do not seem worrisome at first glance, it is important to note that the private system covers only 16% of the population, a majority of whom have additional private insurance coverage.

Thus, the 84% of the population that relies on public system must seek care in a system that lacks appropriate infrastructure and adequate personnel.

Not only is a large portion of funds set aside for private system, but doctors are

48 also concentrated there: 73% of general practitioners practice within the private sector. Another fundamental challenge in South Africa is the AIDS epidemic.

According to Brand South Africa, in 2011, the overall HIV prevalence rate in South Africa was 10.6%, and 16.6% of the adult population (aged 15–49) was HIV positive. Moreover, there are 5.38 million people living with HIV, up from 4.21 million only ten years earlier.

What compounds the problems of HIV care is the incredibly high rates of TB co-morbidity. As stated in a national health profile, problems with TB are becoming more prevalent – “because of late detection and poor treatment management, drug-resistant forms of TB have increased significantly, with about 5,500 cases diagnosed during 2009”. Overall, the high prevalence of these extremely transmissible infectious diseases among the poorest population leads to an incredibly high pressure on the public medical system, testing the boundaries of the nation’s limited resources and thereby increasing the burden to providing health for all.

However, these difficulties should not overshadow the successes made in recent years to implement policies supporting the idea of health as a human right, particularly in South Africa.

While the high prevalence of AIDS may be one of the most tragic problems for the South African population, it is also one of the leading motives for the promotion of health rights for all. One of South Africa’s greatest successes in the healthcare realm was the Treatment Action Campaign’s (TAC) successful legal challenge of excessive pricing of AIDS-related pharmaceuticals.

In particular, the TAC argued that “profiteering by GlaxoSmithKline (GSK), the patent holder of AZT, from an essential medicine was a violation of the right to life – and demanded a price reduction.” This became a legal battle – challenging the necessary action related to the constitutional promise of a “right to life” – as well as a moral dilemma. Attention to the issue of inadequate care and health as a human right was brought to the forefront; at its 2009 National Congress, the TAC made its vision clear: “In the context

CLASS CONTEST WINNER: 2ND PLACE of the HIV/AIDS epidemic, the TAC aims to achieve universal access to prevention, treatment and care for all people living with HIV/AIDS and other illnesses.” In its efforts, the TAC not only secured more affordable AIDS medications but also made a push for the introduction of additional resources into the heath system, particularly for the poor. Moreover, in addition to the access to affordable treatment enabled by the TAC campaign, the South African government has taken several steps to increasing the access to healthcare for all South Africans. National immunization programs have increased the rates of children receiving primary vaccines, and the national prevention of mother-tochild program (PMTCT) assures that all pregnant women are offered HIV testing and counseling. Also, the National Strategic Plan for HIV/AIDS and TB aims to address the socio-structural drivers of HIV/AIDS, maintain health and wellness, and protect human rights of sufferers. But most importantly, South Africa is in the process of implementing a National Health Insurance Scheme (NHI). Due to be phased in over the course of fourteen years starting in 2012, the aim of the NHI is to “promote equity and efficiency to ensure that all South Africans have access to affordable, quality health care services regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.”

In comparison, the United States has made few moves to try to implement n a t i o n a l st r a t e gi es for medi cal intervention. Although HIV rates in the nation are high – with 1,148,200 persons aged 13 years and older living with HIV infection in the United States according to the Centers for Disease Control and Prevention – the illness does not have a profound effect on as large a portion of the American population as in South Africa. If following the South African model of an overwhelming health burden being the key catalyst for a movement towards health as a human right, it may be some time until one particular disease spurs the American people to action. First, although the burden of non-communicable diseases in the United States is high, there is

not a single ailment that is profound enough to lead the American people to unite in protest. Moreover, a different political and economic legacy has left a nation apathetic towards the political scene – even when grand political action is mobilized, change is caught up in a long time struggle against profits and bureaucracy. However, successes too have been accomplished in the United States in regards to the promise of healthcare for all, especially in recent years. In particular, the Patient Protection and the Affordable Care Act signed into effect under President Obama has made an unprecedented step to increase efforts at universal healthcare provision.

Among a few of its many changes, the act, known as Obama Care, prevents insurance companies from not providing coverage due to pre-existing conditions, increases the medical benefits of seniors – including lowering the cost of medicines and providing free preventative care, and expands Medicaid to an estimated 15 million of the US’s poorest citizens.

Although the legislation has been approved, it will be interesting to see how US ventures into the idea of health as a right for all people will play out over the next few years.

Health as a human right has not been at the top of the healthcare agenda.

However, as vast changes are made to healthcare in the upcoming years, it is vital that the importance of health as a human right is stressed in the process of policy implementation. To begin, healthcare should no longer be considered a commodity, its delivery swayed by profits, but rather a necessity that must be guaranteed to all. Change does not come easily, but as progress in South Africa has shown, it is at the hands of the people to fight with strength and determination for the right to health, and thereby the right to life.

www Anna Blazejowskyj is a junior in Calhoun College majoring in Psychology.

You can reach her at anna.blazejowskyj@yale.edu.

49

CLASS CONTEST WINNER: 3RD PLACE

HONG courtesy of Harvard University Library

KONG

The Effects of Science, Politics, and Race on the Public Health Responses to the 1894 Bubonic Plague

By Candice Hwang In the 18th and 19th century, there was an influx of Westerners in China, bringing with them their concepts of how state medicine and public health should be run. In Hong Kong, which became a British colony in 1842, the imported British ideas clashed with local traditions and caused conflict over the public health response to the 1894 bubonic plague epidemic (Chan 12). The conflict manifested in placard campaigns mounted by the Chinese against the intrusive measures imposed by the colonialist government of Hong Kong (Benedict 145). On June 11, 1894, this conflict escalated

into a Chinese-led mob attack on two American missionary women who were treating plague victims (Benedict 146).

The causes underlying this conflict stem from disease framing, power politics, and colonial exceptionalism.

In the late 1800s, two primary forces managed public health in Hong Kong: the first was the British colonial government and the second was the native Chinese “extra-bureaucratic activist elite” (Benedict 131). Starting in the late Ming and early Qing Dynasties, Chinese elites had promoted the shantang, or “benevolent societies”, movement that formed charities and non-governmental organizations all over the country (Smith 309). In Hong Kong, the preeminent shantang responding to

the plague was the Donghua Hospital Directorate. The Donghua Hospital dealt with the epidemic by setting up a hospital branch dedicated to treating plague victims with classical Chinese therapies. They also sought to return the sick and dying to their families in Mainland China (Benedict 137).

These practices were opposed by the British government, which advocated quarantine and prevented anyone from emigrating. Furthermore, in an attempt to clean up the unsanitary conditions to which the plague was attributed, the British destroyed the entire Taipingshan district of Hong Kong, tearing down three hundred fifty houses and displacing seven thousand Chinese (Benedict 146). As one could

50 imagine, these policies did not foster a peaceable relationship between the locals and the government.

Underlying this conflict between the Donghua Directorate and the British government was the fundamental difference between traditional Chinese medicine and Western biomedicine.

The bubonic plague as a disease did not exist in the Chinese medical lexicon.

Rather, symptoms of the plague, such as fevers, were seen to be a set of exogenous heat illnesses. In fact, the idea of “disease” is not useful in explaining traditional Chinese medicine, since “unlike biomedicine, which rests on the assumption that motion and change are abnormal and need to be explained, Chinese medicine begins with the proposition that transformation is intrinsic to existence” (Benedict 101).

In other words, for the Chinese, a fixed cause-and-effect relationship did not exist for illnesses, and illnesses were not contagious. This way of thinking made it difficult for the Chinese to understand British justifications for quarantine.

The fact that Western biomedicine had not yet found the true physiological cause for the bubonic plague did not help the government’s case. Not until 1898, when Paul Simond published a paper showing how the plague traveled by rat flea, was the microbial cause of the bubonic plague determined. At the time, European sanitarians in Hong Kong still believed miasmas or “bad air” caused the plague (Benedict 141). Westerners regarded their miasma theory as superior because it supposedly relied on empirical proof, unlike Chinese traditional medicine (Macpherson 56). However, it is important to note that this “empirical proof ” was based on correlation rather than causation. Indeed, statistics showed how over 2,500 people died of the plague in the unsanitary Chinese neighborhoods, while the total number of cases among non-Chinese was below ten (Benedict 142). But unsanitary environments are not the direct cause of the bubonic plague. At heart, both the Chinese tradition theory of medicine and the Western theory of miasma are human interpretations of worldly phenomena. In fact, the metaphorical similarities are astounding. Europeans conducted massive climatology studies

CLASS CONTEST WINNER: 3RD PLACE throughout the 1800s to determine the effect of temperature and moisture on various medical conditions (Macpherson 27).

In the same vein, traditional Chinese medicine examined the balance of “warm” and “cool” elements of the body.

Western biomedicine studied the climate of the land, while traditional Chinese medicine studied the climate of the body.

The fact is that the 1894 plague in Hong Kong brought into conflict two systems of disease framing, both of which were ironically unscientific and ineffective against the bubonic plague (Benedict 147). Instead, the weaknesses in each theory left room for each to undermine the other.

Yet the British government insisted on carrying out their policies as a way of asserting political power. The shantang were successful in setting up medical facilities and providing proper methods for removing the dead. However the foreigners living in Hong Kong saw the response as inadequate because it was directed by Chinese civic leaders rather than by British government officials (Benedict 135). Beginning in the 1870s, European sanitarians living in Hong Kong consistently lobbied for the British colonial administration to overhaul the public health system.

In response, a permanent Sanitary Board was created in 1883. The power of the Sanitary Board, however, was continuously curbed by local landlords who did not want to expend money to clean up their properties (Benedict 139).

The government saw the 1894 epidemic as an opportunity to consolidate power for the Sanitary Board and justify large-scale public health interventions.

These included authorized houseto-house searches to remove plague victims or corpses, forced quarantine of suspected plague victims to a factoryturned-hospital, and the aforementioned destruction of Taipingshan district (Benedict 144). All of these actions caused the Chinese to view British authorities as inhumane and hostile to Chinese values.

The colonialist authorities saw no issues with carrying out these changes because they perceived the Chinese as unsanitary and backwards. They perceived themselves to be responsible

and knowledgeable as they carried out the “white man’s burden” (Kipling). On a visit to Shanghai, French doctor PaulEdouard Galle recorded that Chinese housing was extremely overcrowded, with “low, narrow structures packed with numerous families, each occupying just a few square meters” (Macpherson 38). Ventilation was poor, and a foul smell permeated the whole city. Galle also remarked on the filthy living habits of Chinese who “went unwashed from cradle to grave” (Macpherson 38). In line with colonial exceptionalism, the mindset of incoming Europeans was to identify all the deficiencies in foreign cities and mold them to become more like the great cities of Europe.

The British public health interventions in Hong Kong were heavy-handed, insensitive, and informed by faulty science. In the end, however, the public health overhaul did confer benefits to the Chinese in Hong Kong and in other cities around China. By the late 1890s, public health legislation was firmly in place in Shanghai and Hong Kong. Streets were cleaned up and waterworks were installed (Macpherson 267). Even the local Chinese marveled at the changes that Westerners had brought to their cities. As Cheng Kuan-ying and other reformist writers described, “When strangers first come to Shanghai…and see how clean and broad the streets are…they cannot help asking in delight: ‘Who has had the power to do this?’ The answer was the Westerners.” (Macpherson 261) When the next bubonic plague epidemic hit in Manchuria in 1910, the Chinese government put into place Western-style public health institutions to quarantine the disease (Benedict 163). The conflict of 1894 – and its underlying scientific, political, and racial causes ¬– was put aside in face of a new century.

www

Candice Hwang is a sophomore in Ezra Stiles College.

You can reach her at xueying. hwang@yale.edu.

CITATIONS

51

Arab World: Changing Public Health 1.

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Institute for Health Metrics and Evaluation. “Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2010)”, March 2013, http://www.healthmetricsandevaluation.org/gbd/research/project/global-burden-diseases-injuries-and-risk-factors-study-2010 3.

“Arab World”, The World Bank, http://data.worldbank.org/region/ARB 4.

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Cuba: Medicine and Medical Internationalism 1.

2.

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30.

Huish, Cuba in Global Health, 2 Kirk and Erisman, Cuban Medical Internationalism, 117 “Cuba’s Economy.”

Huish, Cuba in Global Health, 41 Brotherton, Revolutionary Medicine, 174 Marroquí, Cuba, Isla de Milagros, 68 Ibid, 89 Marroquí, Cuba, Isla de Milagros, 120 PAHO, Missión Barrio Adentro, 26 Feinsilver, Window into Cuba, 67 PAHO, Missión Barrio Adentro, 82 “Venezuela–Cuban Doctors Helping” Jones, “Chávez Misses Goals” Feinsilver, Oil for Doctors, 6 “Venezuela Health Care Collapse” Garrett, “Castrocare in Crisis” Feinsilver, Oil for Doctors, 5 Ibid.

Huish and Kirk, Development of ELAM, 80 Huish, Cuba in Global Health, 58-9 “Bolivia Proscribes Solidarity” Marroquí, Cuba, Isla de Milagros, 165 “Latin American Medical School” “Venezuela’s ELAM (excerpts)” “Mil jóvenes cursarán estudios” Huish, Cuba in Global Health, 12 Interestingly enough, Huish also asserts that Cuba is only able to engage in such long-term missions because of its one-party system, which is more likely to stick to long-term goals than a multi-party state whose practices change on a regular basis.

Huish, Cuba in Global Health, 125 Ibid, 34 Brotherton, Revolutionary Medicine, 180

Haiti: Improving the Maternal Health Situation through Increased Contraceptive Usage 1.

Islam, Monir. “The Safe Motherhood Initiative and Beyond.” Bulletin of the World Health Organization 85.10 (2007): 735. Oct. 2007. Web. 5 Nov. 2013.

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“By Choice, Not by Chance: Family Planning, Human Rights and Development.”. UNFPA, 2012. Web. 08 Nov. 2013. ii.

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“A Profile of Police and Judicial Response to Rape in Port-au-Prince.” Mission des Nations Unies pour la Stabilisation en Haïti.

June 2012. Web. 8 Nov. 2013.

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“A Profile of Police and Judicial Response to Rape in Port-au-Prince.” Mission des Nations Unies pour la Stabilisation en Haïti.

June 2012. Web. 8 Nov. 2013.

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“2010 Human Rights Report: Haiti.” Bureau of Democracy, Human Rights, and Labor. U.S. Department of State, 2011. Web. 8 Nov. 2013.

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WHO, UNICEF, UNFPA, and The World Bank. Trends in Maternal Mortality: 1990 to 2010 : WHO, UNICEF, UNFPA, and The World Bank Estimates. Geneva: World Health Organization, 2012. Print. 40.

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Colin, Jessie M. “Cultural and Clinical Care for Haitians.” Haiti. LCDR US Public Health Service, Indian Health Services, 2004. Web. 8 Nov. 2013.

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Colin, Jessie M. “Cultural and Clinical Care for Haitians.” Haiti. LCDR US Public Health Service, Indian Health Services, 2004. Web. 8 Nov. 2013.

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“By Choice, Not by Chance: Family Planning, Human Rights and Development.” State of World Population 2012. UNFPA, 2012. Web. 08 Nov. 2013. 40.

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“World Contraceptive Use 2011.” UN Population Division. United Nations Department of Economic and Social Affairs, Population Division, 2011. Web. 3 Nov. 2013.

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Leys, Tony. “Family Planning Is a Delicate Subject in Haiti.” Haiti: Family Planning and Women’s Health. Pulitzer Center on Crisis Reporting, 29 Apr. 2013. Web. 08 Nov. 2013.

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White, Kari, Maria Small, Rikerdy Frederic, Gabriel Joseph, Reginald Bateau, and Trace Kershaw. “Health Seeking Behavior Among Pregnant Women in Rural Haiti.” Health Care for Women International 27.9 (2006): 822-38. Taylor & Francis Online. Web. 19 Oct. 2013. 830.

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Simelela, N. “Women’s Access to Modern Methods of Fertility Regulation.” International Journal of Gynecology and Obstetrics 94.3 (2006): 292-300. ScienceDirect. Web. 4 Nov. 2013. 296.

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“Haiti Adolescent Girls Network.” Abundance Foundation. Tomorrow Partners, 2013. Web. 14 Nov. 2013.

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Siddiqi, Anooradha. “Missing the Emergency: Shifting the Paradigm for Relief to Adolescent Girls.” The Coalition for Adolescent Girls. The Coalition for Adolescent Girls, 2012. Web. 14 Nov. 2013. 6.

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Siddiqi, Anooradha. “Missing the Emergency: Shifting the Paradigm for Relief to Adolescent Girls.” The Coalition for Adolescent Girls. The Coalition for Adolescent Girls, 2012. Web. 14 Nov. 2013. 6.

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Coriolan, Anne-Marie. “Solidarite Fanm Ayisyen (SOFA).” Haitian Women Network. Haitian Women Network, 2010. Web. 14 Nov. 2013.

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Golla, Anne Marie. “Measuring Women’s Economic Empowerment.” International Center for Research on Women. ICRW, 2012. Web. 29 Nov. 2013.

21.

Bracken, Amy. “Haiti’s Children Pay the Price of Poverty.” NACLA Report on the Americas 39.5 (2006): 22-25. PRISMA. Web. 3 Nov. 2013. 22.

The Secret Theft of Human Rights 1.

March of Dimes, PMNCH, Save the Children, World Health Organization. Born Too Soon: The global action report on preterm birth. 2012 2.

March of Dimes, California Maternal Care Collaborative, and Maternal, Child and Adolescent Health Division; Center for Family Health California Department of Public Health. A California Toolkit to Transform Maternity Care: Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. 2011 3.

Bates, E., et al. (2010). “Neonatal outcomes after demonstrated fetal lung maturity before 39 weeks of gestation.” Obstet Gynecol 116(6): 1288-1295.

4.

March of Dimes, California Maternal Care Collaborative, and Maternal, Child and Adolescent Health Division; Center for Family Health California Department of Public Health.

5.

March of Dimes Foundation. Prematurity Research Center. Accessed 5 March 2014. Prematurityresearch.org.

Ecuador: Listening to a Community and Building Partnerships 1.

(UNAIDS) UJPoHA. Global Report: UNAIDS Report on the Global AIDS Epidemic: 2010. 2010.

2.

The NGO emphasized that three out of four people with HIV do not know their status, and the literature described Ecuador as a country at risk for a growing epidemic.

3.

Hetherington, Erin, and Hatfield, Jennifer (2012) ““I really wanted to be able to contribute something”: understanding student motivations to create meaningful global health experiences.” Canadian Medical Education Journal 3:2, e107-e117.

4.

The rest of the Summer 2013 team included: Maggie Wilson (YSPH ’14), Nicola Soekoe (YC ’16), Vishaal Prabhu (YC ’14), Adam Beckman (YC ’16), Julia Randall (University of Mass. Medical School ’16), and Rahela Aziz-Boze (University of Mass. Medical School ’16) 5.

José’s fellow team members include: Sarah Merchant (YC ’17), Lily Vanderbloemen (YC ’16), Stephanie Granada (YC ’15), and Suhana Sarkar (YSPH ’15).

6.

Kimberly’s fellow team members include: Dan Michelson (YC ’17), Sarah McAlister (YC ’16), and Natalia Forbath (YC ’15).

7.

Hetherington, Erin, and Hatfield, Jennifer (2012) ““I really wanted to be able to contribute something”: understanding student motivations to create meaningful global health experiences.” Canadian Medical Education Journal 3:2, e107-e117.

8.

Hunt, Matthew, and Godard, Beatrice (2013) “Beyond procedural ethics: Foregrounding questions of justice in global health research ethics trainings for students.” Global Public Health: An International Journal for Research, Policy and Practice, 8:6, 713-724.

Nigeria: Female Genital Cutting: The 20th Century’s Attempt to Ban a Harmful Traditional Practice 1.

The term FGC will be used in this essay instead of Female Genital Mutilation or Female Castration because of its less “charged”

CITATIONS

53

connotation.

2.

Charlotte Feldman-Jacobs. “Commemorating International Day of Zero Tolerance to Female Genital Mutilation.”

3.

Elizabeth Heger Boyle. Female Genital Cutting: Cultural Conflict in the Global Community. (Baltimore: Johns Hopkins University Press, 2002), 83.

4.

World Health Organization. Female Genital Mutilation: An Overview. (Geneva: WHO, 1998), 11.

5.

Oka Obono, ed. A Tapestry of Human Sexuality in Africa. (Auckland: Action Health Incorporated, 2010), 141.

6.

WHO, Female Genital Mutilation, 17.

7.

Family Health Department, Federal Ministry of Health. “Elimination of Female Genital Circumcision in Nigeria.” (Abuja: World Health Organization, 2007), 1.

8.

WHO, Female Genital Mutilation, 26.

9.

Bernard E. Owumi, ed. Primary Health Care in Nigera: Female Circumcision. (Ibadan: University of Ibadan, 1997), 11.

10.

Tracy Slanger. “Female Genital Cutting in Edo State, Southwest Nigera: Its Prevalence, Social Correlates, and Association with Obstetric Morbidity.” AFRASLib African & Asian Health Series, vol 3 (2004).

11.

Family Health Department.“Elimination of Female Genital Circumcision in Nigeria,” 5.

12.

Owumi, Primary Health Care in Nigera: Female Circumcision,12.

13.

Frances A. Althaus. “Female Circumcision: Rite of Passage or Violation of Rights?” International Family Planning Perspectives, vol 23, no 3 (1997).

14.

Charles L Geshekter. “The Recurring Debate Over Female Circumcision.” (Chico: California State University, 1985), 4.

15.

Bettina Shell-Duncan. Female “Circumcision” in Africa. (Boulder: Lynne Rienner Publishers Inc., 2000), 254.

16.

Ibid, 2.

17.

Anika Rahman. Female Genital Mutilation: A Practical Guide to Worldwide Laws & Policies. (London: Center for Reproductive Law, 2000), 10.

18.

Ibid, 12.

19.

Sami A. Aldeeb Abu-Sahlieh. Male and Female Circumcision Among Jews Christians and Muslims. (Warren Center: Shangri-La Publications, 2001), 59.

20.

Ibid, 60.

21.

Kingsley Ufuoma Omoyibo. Adolescent Females’ Reproductive Health in Nigera. (Berlin: Peter Lang, 2002), 38.

22.

Ibid, 40.

23.

Anika Rahman. Female Genital Mutilation: A Practical Guide to Worldwide Laws & Policies, 201.

24.

Charlotte Feldman-Jacobs. “Commemorating International Day of Zero Tolerance to Female Genital Mutilation.”

25.

Babatunde, Emmanuel. Women’s Rights versus Women’s Rites: A Study of Circumcision Among the Ketu Yoruba of South Western Nigeria. (Trenton: Africa World Press Inc., 1998), 179.

26.

Ibid, 45.

27.

Obioma Nnaemeka, ed. Female Circumcision and the Politics of Knowledge: African Women in Imperialist Discourses.

(London: Praeger, 2005), 41.

28.

Ibid, 42.

China: Atrocities Overlooked as Individuals Prioritize Their Best Interests in Drug Addiction “Rehabilitation” 1.

“Narcotics Control in China,” last modified June 2000, http://www.china-embassy.org/eng/zt/mzpkz/t36387.htm 2.

John Ruwitch. “A jail by another name: China labor camps now drug detox centers.” Reuters, December 2, 2013, http://www. reuters.com/article/2013/12/02/us-china-camps.

3.

Ruwitch. “A jail by another name.”

4.

Andrew Jacobs, “China Turns Drug Rehab into a Punishing Ordeal.” The New York Times, January 7, 2010, http://www. nytimes.com/2010/01/08/world/asia/08china.html.

5.

Jacobs, “China Turns Drug Rehab into a Punishing Ordeal.”

6.

“Where Darkness Knows No Limits,” published January 7, 2010, http://www.hrw.org/node/87466.

7.

Jacobs, “China Turns Drug Rehab into a Punishing Ordeal.”

8.

Jacobs, “China Turns Drug Rehab into a Punishing Ordeal.”

9.

“Joint statement: Compulsory drug detention and rehabilitation centers,” published March 6, 2012, http://www.unodc.org/ documents/southeastasiaandpacific//2012/03/drug-detention-centre/JC2310_Joint_Statement6March12FINAL_En.pdf.

10.

“Joint statement: Compulsory drug detention and rehabilitation centers.”

11.

“Partners in Crime: International Funding for Drug Control and Gross Violations of Human Rights.” Published June 2012. http://www.ihra.net/files/2012/06/20/Partners_in_Crime_web1.pdf.

12.

“U.S. Announces New Support for Lao Law Enforcement.” Published June 8, 2012. http://laos.usembassy.gov/ pres_06072012new.html.

13.

“Where Darkness Knows No Limits.”

New Orleans: “Laissez le bons temps rouler!”

1.

Cajun French for “Let the good times roll!”

2.

“Louisiana HIV/AIDS Facts,” published December 31, 2010, http://www.lphi.org/home2/section/generic-160. “The Baton Rouge metropolitan area ranked 2nd for AIDS case rates among the largest metropolitan areas in the U.S. in 2008; New Orleans metropolitan area ranked 3rd.”

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CITATIONS

3.

One must be certified to provide a free rapid HIV test, as they are paid for by Louisiana and federal funds.

4.

Julia Lurie, “When Having Condoms Gets You Arrested,” Mother Jones, December 21, 2013, http://www.motherjones.com/ mojo/2013/12/condom-possession-sex-workers-evidence-prostitution.

5.

Lurie, “When Having Condoms Gets You Arrested.”

6.

A theory espoused by Partners in Health founder, Paul Farmer, which posits that systems of oppression interface with and amplify illness and death in impoverished communities. Thus, neglect on the part of the state and of non-governmental actors is a form of violence inflicted upon the poor.

How Global Health Helps 1.

Koplan et al. “Towards a common definition of global health.”

2.

Dyar, Oliver-James. “What is Global Health?”

3.

Crane, Joanna. “Unequal ‘Partners,’” pp. 87 4.

Crane, Joanna. “Unequal ‘Partners,’” pp. 87 5. Ibid.

Yemen: Health Inequity between the Genders 1.

Wikipedia. List of countries by Human Development Index. Available at: http://en.wikipedia.org/wiki/List_of_countries_by_ Human_Development_Index. Accessed on 5 December 2013.

2.

The United Nations Population Fund (UNFPA). Yemen Factsheet. Available at: http://www.unfpa.org/sowmy/resources/docs/ country_info/profile/en_Yemen_SoWMy_Profile.pdf. Accessed on 5 December 2013.

3.

The World Health Organization (WHO). Yemen. Available at: http://www.who.int/countries/yem/en/. Accessed on 5 December 2013.

4.

J Holst, CA Gericke. Healthcare financing in Yemen. The International Journal of Health Planning and Management; 27(3).

Available at: http://www.ncbi.nlm.nih.gov/pubmed/22532485. Accessed on 5 December 2013.

5.

The United Nations Development Programme (UNDP). Human Development Report 2013: Yemen HDR 2013 Statistical Explanation. Available at: www.undp.org/content/dam/rbas/img/docs/Yemen.docx. Accessed on 5 December 2013.

6.

The U.S. Agency for International Development (USAID). Yemen. Available at: http://www.usaid.gov/yemen. Accessed on 5 December 2013.

7.

Ibid.

8.

UNDP. Human Development Report 2013: Yemen HDR 2013 Statistical Explanation.

9.

The United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Reliefweb: Yemen Health Equity and Financial Protection Datasheet. Available at: http://reliefweb.int/sites/reliefweb.int/files/resources/PDF1_192.pdf. Accessed on 5 December 2013.

10. http://reliefweb.int/sites/reliefweb.int/files/resources/PDF1_192.pdf 11.

The United Nations (UNICEF). At a glance: Yemen. Available at: http://www.unicef.org/infobycountry/yemen_statistics.html.

Accessed on 5 December 2013.

12.

Public Health Mapping & GIS at WHO. Health System Observatory: Yemen. Available at: http://gis.emro.who.int/ HealthSystemObservatory/PDF/Yemen/Exec%20summary.pdf. Accessed on 5 December 2013.

13.

UNDP. Republic of Yemen: Poverty Assessment. Available at: http://www.undp.org.ye/reports/Volume_I_Main_Report.pdf.

Accessed on 5 December 2013.

14.

Ibid.

15.

J Holst, CA Gericke. Healthcare financing in Yemen.

16.

UNFPA. Yemen Factsheet.

17.

Public Health Mapping & GIS at WHO. Health System Observatory: Yemen.

18.

Wikipedia. Health in Yemen. Available at: http://en.wikipedia.org/wiki/Health_in_Yemen. Accessed on 6 December 2013.

19.

UNICEF. At a glance: Yemen.

20.

Jihan Anwar. The Current Reality of Malnutrition in Yemen. NationalYemen: The Facts As They Are. Available at: http:// nationalyemen.com/2012/10/22/the-current-reality-of-malnutrition-in-yemen/. Accessed on 5 December 2013.

21.

UNDP. Republic of Yemen: Poverty Assessment.

22. Ibid.

23.

UNDP. Human Development Report 2013: Yemen HDR 2013 Statistical Explanation.

24. Ibid.

25.

IRINNews. Yemen: Five thousand more midwives needed – UNFPA. Available at: http://www.irinnews.org/report/78291/ yemen-five-thousand-more-midwives-needed-unfpa. Accessed on 6 December 2013.

26.

Jamela Saleh Al-Raiby. Partnerships to Save Yemeni Women’s Lives. Huffington Post: Global Motherhood Blog. Available at: http://www.huffingtonpost.com/jamela-saleh-alraiby/yemen-women_b_1311149.html. Accessed on 5 December 2013.

27.

Rachel Cooke. Is this the worst place on earth to be a woman? The Guardian: The Observer. Available at: http://www. theguardian.com/lifeandstyle/2008/may/11/women.humanrights. Accessed on 5 December 2013.

28.

Quandl. Yemen – All Health Indicators. Available at: http://www.quandl.com/health/yemen-all-health-indicators. Accessed on 5 December 2013.

29.

International Foundation for Electoral Systems (IFES). Focus on Yemen: Health Care Access Topic Brief. Available at: http:// www.ifes.org/Content/Publications/Papers/2010/Focus-on-Yemen-Health-Care-Access-Topic-Brief.aspx. Accessed on 5 December 2013.

30.

Countdown to 2015: Maternal, Newborn & Child Survival. Yemen Factsheet. Available at: http://www.countdown2015mnch.

CITATIONS

55

org/documents/2013Report/Yemen_Accountability_profile_2013.pdf. Accessed on 5 December 2013.

31.

USAID. DHS Comparative Reports 28: Trends in Birth Spacing. Available at: http://www.measuredhs.com/pubs/pdf/CR28/ CR28.pdf. Accessed on 5 December 2013.

32.

IFES. Focus on Yemen: Health Care Access Topic Brief.

33.

Ibid.

34.

International Foundation for Electoral Systems (IFES) with The Institute for Women’s Policy and the Canadian International Development Agency (CIDA). The Status of Women in the Middle East and North Africa (SWMENA) Project: Morocco Healthcare.

Available at: http://www.ifes.org/Content/Publications/Papers/2010/~/media/Files/Publications/Papers/2010/swmena/2010_Morocco_ Healthcare_English.pdf. Accessed on 5 December 2013.

35.

Quandl. Yemen – All Health Indicators.

36.

Lisa Smith, Usha Ramakrishnan, Aida Ndiaye, Lawrence Haddad, Reynaldo Martorell for the International Food Policy Research Institute (IFPRI). The Importance of Women’s Status for Child Nutrition in Developing Countries. Available at: http://www.ifpri. org/sites/default/files/pubs/pubs/abstract/131/rr131toc.pdf. Accessed on 5 December 2013.

37.

Ibid.

38.

Ce Shen, John Williamson. Maternal mortality, women’s status, and economic dependency in less developed countries: a cross-national analysis. Social Science & Medicine: 49 (1999), 197-214. Available at: https://www2.bc.edu/~jbw/documents/ WilliamsonShen1999.pdf. Accessed on 5 December 2013.

39.

Jayati Ghosh. Women’s health is more than an economic issue. The Guardian: Poverty Matters Blog. Available at: http://www. theguardian.com/global-development/poverty-matters/2011/nov/23/womens-health-more-than-economics. Accessed on 5 December 2013.

40.

UN Data. GDP per capita average annual growth rate. Available at: http://data.un.org/Data.aspx?d=SOWC&f=inID%3A93.

Accessed on 5 December 2013.

41.

Liya Kebede. Redefining “Impossible” When It Comes To Maternal Mortality. Huffington Post: Impact Blog. Available at: http://www.huffingtonpost.com/liya-kebede/redefining-impossible-whe_b_428996.html. Accessed on 5 December 2013.

42.

CGDEV. Case 6. Note that this data implicates changes to the health system, not general improvements in living conditions, in bettered maternal health status.

43.

Indrani Pieris, Bruce Caldwell. Health Transition Review 7, 1997, 171-185. Available at: http://htc.anu.edu.au/pdfs/Pieris1.pdf.

Accessed on 5 December 2013.

44.

Thankam Sunil. Reproductive Health in Yemen. Available at: http://www.wilsoncenter.org/sites/default/files/Sunil%20 Presentation.pdf. Accessed on 5 December 2013.

45.

UNDP. Human Development Report 2013: Yemen HDR 2013 Statistical Explanation.

46.

Jamela Saleh Al-Raiby. Partnerships to Save Yemeni Women’s Lives.

47.

IFES, CIDA. SWMENA Project: Focus on Yemen: Health Care Access Topic Brief. Available at: http://www.ifes.org/Content/ Publications/Papers/2010/~/media/Files/Publications/Papers/2010/swmena/Yemen_Health_Care_Topic_Brief.pdf. Accessed on 5 December 2013.

48.

UNDP. Human Development Report 2013: Yemen HDR 2013 Statistical Explanation.

49.

Human Rights Watch (HRW). “How Come You Allow Little Girls to Get Married?”: Child Marriage in Yemen. Available at: http://www.hrw.org/sites/default/files/reports/yemen1211ForUpload_0.pdf. Accessed on 5 December 2013.

50.

UNDP. Human Development Report 2013: Yemen HDR 2013 Statistical Explanation.

51.

HRW. “How Come You Allow Little Girls to Get Married?”

52.

WHO. Female genital mutilation and other harmful practices. Available at: http://www.who.int/reproductivehealth/topics/fgm/ prevalence/en/. Accessed on 6 December 2013.

53.

Center for Global Development (CGDEV). Case 6: Saving Mothers’ Lives in Sri Lanka. Available at: http://www.cgdev.org/doc/ millions/MS_case_6.pdf. Accessed on 5 December 2013.

54.

Ibid.

55.

Ibid.

56.

UNFPA. The State of the World’s Midwifery: Organization of midwifery services in Sri Lanka. Available at: http://www.unfpa. org/sowmy/resources/docs/background_papers/01_ArulkumaranS_SriLankaServices.PDF. Accessed on 6 December 2013.

57.

Amira Nasser. Yemen’s Ailing Healthcare Affects Mothers, Children. Yemen Times. Available at: http://www.yementimes.com/ en/1588/health/1117/Yemen%E2%80%99s-ailing-healthcare-affects-mothers-children.htm. Accessed on 6 December 2013.

58.

Ibid.

59.

Ibid.

60.

Ibid.

61.

IRINNews. Yemen: Five thousand more midwives needed – UNFPA. 62.

Amira Nasser. Yemen’s Ailing Healthcare Affects Mothers, Children. Yemen Times. Available at: http://www.yementimes.com/ en/1588/health/1117/Yemen%E2%80%99s-ailing-healthcare-affects-mothers-children.htm. Accessed on 6 December 2013.

63.

Ibid.

64.

CGDEV. Case 6: Saving Mothers’ Lives in Sri Lanka.

65.

The World Bank. Health expenditure, total (% of GDP). Available at: http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. Accessed on 6 December 2013.

Health as a Human Right 1.

World Health Organization. Preamble to the Constitution of the World Health Organization. New York: Office Records of the World Health Organization, 1946.

2.

Paul Farmer, “On Suffering and Structural Violence: Social and Economic Rights in the Global Era” in Partner to the Poor: A

56

CITATIONS

Paul Farmer Reader, ed., Haun Saussy. (Los Angeles: University of California Press, 2010), 337.

3.

“Health care in South Africa,” last reviewed July 2, 2012, http://www.southafrica.info/about/health/health.htm.

4.

Pamela Braboy Jackson et al., “Race and Psychological Distress: The South African Stress and Health Study.” Journal of Health and Social Behavior 51 (2010): 471, doi: 10.1177/0022146510386795 5.

Nelson Mandela. No Easy Walk to Freedom, ed. William Gumede. (Cape Town: Kwela, 2013), Introduction.

6.

PLoS Medicine Editors, “Drug Companies Should be Held More Accountable for Their Human Rights Responsibilities,” PLoS Medicine 9 (2010): 1-2. doi: 10.1371/journal.pmed.1000344 7.

Adam Taylor and Samuel Blackstone, “These Are The 36 Countries That Have Better Healthcare Systems Than The US,” Business Insider, June 29 2012, http://www.businessinsider.com/best-healthcare-systems-in-the-world-2012-6.

8.

“Health Expenditures,” last updated February 13, 2014, http://www.cdc.gov/nchs/fastats/hexpense.htm 9.

“Human Right to Health,” last updated January 2008, http://www.nesri.org/sites/default/files/Right_to_Health.pdf 10.

“Employer Health Benefit Survey,” released August 20, 2013, http://kaiserfamilyfoundation.files.wordpress. com/2013/08/8465-employer-health-benefits-2013-chartpack.pdf 11.

“Human Right to Health.”

12.

“Health care in South Africa.”

13.

“Health care in South Africa.”

14.

Mark Heywood, “South Africa’s Treatment Action Campaign: Combining Law and Social Mobilization to Realize the Right to Health.” Journal of Human Rights Practice 4 (2009): 20, doi: 10.1093/jhuman/hun006 15.

Heywood, “South Africa’s Treatment Action Campaign,” 23.

16.

“Health care in South Africa.”

17.

“HIV in the United States: At a Glance,” last updated December 2, 2013, http://www.cdc.gov/hiv/statistics/basics/ataglance. html.

18.

“Obama Care Facts: Facts on the Affordable Care Act,” last updated December 20, 2013, http://obamacarefacts.com/ obamacare-facts.php.

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