Yghr 1.1 (Fall 2013) by Yale Global Health Review

From the Editors December 2013 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. YGHR is a hub for discussion and engagement on all issues relevant to global health â&#x20AC;&#x201C; in print and online, at Yale and beyond. We invite you to explore this inaugural issue, which explores issues from health reforms in Cuba to public-private partnerships in Japan and healthcare discrimination in Israel to new methods for improving quality of care in Uganda. Looking ahead to our quarterly publications, we welcome your submissions for future issues.

Sarah Eckinger

Austin Jaspers

Theresa Oei

Founders and Editors-In-Chief The Yale Global Health Review

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. Submit pitches and manuscripts to yaleglobalhealthreview@gmail.com

www.yaleglobalhealthreview.com 3

YGHR Founders, Editors-in-Chief SARAH ECKINGER AUSTIN JASPERS THERESA OEI Editors MICHAELLA BAKER, CONNOR BUECHLER, AMY CHANG, ELIJAH GOLDBERG, MOKTAR JAMA, DEBORAH LEFFELL, ALISON MOSIER-MILLS, CAROLINA TROMBETTA Production and Design AMY CHANG, MARIA DE LAS MERCEDES MARTINEZ, LAKSHMI VARANASI Online Editor CONNOR BUECHLER Director of Finance MOKTAR JAMA

Webmaster SAKSHI KUMAR

Assistant Webmaster ELIJAH GOLDBERG Events Coordinator ANEESA NOORANI

Writers SHIRIN AHMED, MILLIE CHAPMAN, ELISABETH GEORGE, JULIET GLAZER, ELIJAH GOLDBERG, CODY KAHOE, JESSICA LOPEZ, ALY MOORE, THERESA OEI, HILARY ROGERS, ALEXANDER WARD, DAMIEN WEIKUM, LAUREN WESTON, SAWSAN ZAHER

PUBLISHED BY JOSEPH MERRITT & COMPANY

For more information about the Yale Global Health Review, please visit us on the web at www.yaleglobalhealthreview.com Cover by Sarah Eckinger

INSIDE Research and Field Work 14 Global Health Spectrums: Nutrition, Disease and Students Intern Impact by Hilary Rogers 22 Rethinking Priorities in Global Health: Focusing on Quality of Care at Walimu by Elijah Glodberg

25 Ghana: The Evolving Problem of Mental Health by Aly Moore 53 Spina Bifida in Kenya: Beyond the Case Studies by Millie Chapman

Global Health Today 9 Educating Leaders Around the World by Elisabeth George and Shirin Ahmed 12 The Interdiciplinary Investments: Collaboration in Global Health by Theresa Oei

42 Honduras: Impacting Public Health Through Development by Lauren Weston

46 The BRICS Wall of Protection: How Patent Standards Will Determine the Future State of Health in South Africa by Alexander Ward

Opinion 6 Turkey: The Path to Healthy Governance

by Cody Kahoe

28 Beyond ARVs: Prescribing Housing to end AIDS in New York City by Juliet Glazer

34 Life Off the Map by Sawsan Zaher 38 Cuba: Agricultural Reform in the Special Period by Jessica L贸pez

Q&A 20 Meredith Mira: UCS Global health Advisor by Aneesa Noorani 31 Elizabeth Bradley and Lauren Taylor: Authors of The American Healthcare Paradox by Austin Jaspers

55 Citations

22 6

Turkey:

The Path to Healthy Governance Writing & Photography by Cody Kahoe

n times of crisis and catastrophe, civilians are accustomed to heeding the advice of the medical community, often on matters beyond health. An aura of intellectual honesty and altruism seems to divorce the medical community from political bias and self-interest. However, the conduct of the Turkish medical community during last summer’s Gezi Park protests demonstrates that we must scrutinize the statements of even our most trusted professional order. On Monday, May 27, 2013, a small group of environmentalists began a sitin at Gezi Park, a patch of green adjacent to one of Istanbul’s main tourist attractions and monuments, Taksim Square.1 After a few days of demonstrations, Turkish police, acting on orders from the top levels of government, donned gas masks and riot shields and evicted the protestors with tear gas and water hoses. However, this small environmental demonstration quickly escalated, growing into the largest protest movement

Turkey has seen in 30 years, focused against the ruling Justice and Development Party (AKP). Over the next several weeks, Turkish riot police fired over 130,000 gas canisters at the protestors, the country’s entire yearly supply.2 The young, poorly trained police force consistently used the gas incorrectly, firing canisters directly at protestors, into closed spaces, and at close range.3 According to the Turkish Medical Association (TMA), eight thousand had been injured and five killed in thirteen cities by mid-July. The Turkish medical community, led by the TMA, strongly condemned the crackdown.4 TMA called for an end to the violence, criticized the Ministry of Health’s legal attempts to keep doctors from caring for injured protestors, and called the use of gas “savage.”5 Such criticisms are routine in any incident of government suppression, but the statement hinted at a broader political conflict between Turkish doctors and the government: “[The]

Turkish Medical Association calls [on] the government to act responsibly and stop the barbaric violence immediately. [. . .] We urgently call the international community to act against brutal suppression of democratic demands.”6 The TMA did not stop at criticizing the government’s overreaction to the protests, but rather went so far as to imply that the AKP acted undemocratically and should yield to the protestors’ demands. The Turkish medical community’s reaction to the protests was not just about safeguarding civilians. Rather, Turkish doctors took advantage of the protests to inflict political damage on the AKP, with whom they were engaged in a preexisting partisan feud. Not only are Turkish doctors part of the young, liberal, professional class that opposes the center-right, subtly Islamist politics of the AKP, they also share in a long tradition of zealous secularism present in Turkey since the 1920s. While most histories

Protesters in front of the Republic Monument, which depicts Atatürk’s founding of the Turkish Republic, in Istanbul’s Taksim Square, adjacent to Gezi Park.

focus on the military’s role in Turkey’s founding, many of the Young Turks who promoted hardcore secularism during that period were originally members of the medical community. This “militant secularism” persists today. Shuaib Raza, Yale College ’14, spent the summer conducting cancer research in hospitals around Istanbul and saw the consequences firsthand.

Raza explains: “People of faith are still restricted in whom they could shadow as medical residents, and it is still really difficult to find a place to pray at or around medical campuses.” It remains taboo if not explicitly prohibited to wear a veil in hospitals, medical schools, and other health areas. Other statements by the TMA demonstrate how deep this anti-AKP bias

runs. In a June 29th press release, the TMA denounced Prime Minister Erdoğan’s “projects to create ‘religiously devout generations’ fit to his thinking, his ‘ideas’ that intervene in women’s private life from abortion to fertility, his authoritarian style of governing and plans for dictatorship.”7 Far from an objective discussion of legitimate health violations, the document is a polemic

against the AKP’s political and social ideology. And their claims are sometimes less than strictly factual. In a video featured prominently on the home page of the TMA’s web site, Caghan Kizil, Ph.D., at the “Science for Gezi Conference” in New York, argued that “one can see that the lives of the people in Turkey are being treated with a mystic, agnostic, and fatalistic future. One can see that the science academies in Turkey are in crisis due to [the AKP’s] partisan approaches.”8 Another panelist in the video presented as undisputed fact what was an unsubstantiated, perhaps totally unfounded, rumor, that Turkish police had spiked water canons with chemical agents to inflict further injury on protestors.9 With these statements, medical advocates played into the uncertainty and hysteria surrounding the protests to take political shots at the AKP rather than sifting through fact and fiction on the ground. Turkish doctors oppose healthcare reform undertaken by AKP. Since 2003, the AKP has revamped the Turkish healthcare system, “increasing the ratio of private to state health provision and making health care available to a larger share of the population.”10 In just 7 years, over-

all satisfaction with health care services around Turkey among the public jumped from 39.5% to 73.04%.11 The reforms improved insurance coverage, promoted competition between private and public hospitals, reduced the burden of disease, improved service, reduced private and public healthcare costs, and provided patients with new rights.12 However beneficial these actions were to Turkish citizens, the medical community strongly opposed them. Etem Erol, Turkish Professor at Yale, explains that the reforms stopped abusive double-billing policies, by which state doctors also sent patients to their own private practices and made sure that state doctors on the public payroll actually came to their public hospitals. Raza, along with international experts, concludes that the reforms “were both necessary and good for the consumer.”13 Yet, as both Erol and Raza describe, doctors have taken a firm stand against the reforms and against the AKP partially because they curbed abuses and reduced the medical community’s autonomy, placing healthcare professionals under the guidance of the Ministry of Health.14 This historically strong bias against the AKP places the TMA’s criticisms of the government crack-

down in a self-interested light. The irony is that, due to the AKP healthcare reforms, the medical establishment was actually prepared to react better to injuries sustained during the antiAKP protests than it would have been ten years ago. Of course, this does not excuse the government’s excessive and poorly executed crackdown. Nonetheless, the response of the Turkish medical community demonstrates that observers, not only in Turkey but worldwide, must consider the political motivations behind the statements and advocacy of professional groups. Even medical organizations are not outside politics, and even their actions can serve their own financial and social interests. In many ways, the TMA’s reaction during the demonstrations was as much for political purpose as for public health. This episode demonstrates that people must remember to take the word of even trusted, purportedly unbiased medical groups with a grain of salt. Politics touches everything. www

Cody is a junior in Calhoun College. He is interested in Middle Eastern and Turkish political history. You can reach him at f.kahoe@yale.edu.

Educating Leaders Around the World Writing by Elisabeth George & Shirin Ahmed & Photography by GHLI

lthough often overlooked, effective leadership and management are critical to strengthening health systems and achieving large-scale goals. The Yale Global Health Leadership Institute (GHLI), led by Elizabeth H. Bradley, PhD and Michael Skonieczny, MPA, develops leadership through education and research programs that strengthen health systems and promote health equity and quality of care. In collaboration

with international partners, GHLI’s leadership development programs center on evidence-based solutions that can be scaled up, data-based decision-making, leadership that enhances individual and group capacity, and an applied learning experience. To develop and support sustained quality collaborations designed to promote effective leadership capacity and efficient health management systems, GHLI partners with universities, foundations, and

other non-profit agencies. One example of such collaboration is the Human Resource for Health Program in Rwanda whereby GHLI joins universities across the U.S to support the Rwandan Ministry of Health in their efforts to develop skilled workers to meet the country’s health care delivery needs. This program brings together experts from various specialties in an interdisciplinary effort to strengthen the pipeline of health care professionals –

with a focus on developing more effective residency programs at the National University of Rwanda and associated teaching hospitals. The health management program trains health care workers from across the country to take on leadership roles in hospital administration. Another example is our work with USAIDâ&#x20AC;&#x2122;s Leadership, Management, and Governance Project, with which GHLI delivers a Senior Leadership Program. The program focuses on strengthening skills in performance monitoring, evidence-based decision making and key practices in leadership, management, and governance. GHLI has also de-

veloped a framework for scale up and replication which defines the criteria needed to sustain successful health interventions. The AIDED approach proposes five components essential to the process of scale up: assessing the landscape, refining the innovation, developing support and engaging the community, and spreading the innovation. Breakthroughs in medicine and public health often require decades and significant resources to successfully spread in other settings GHLI also conducts research on health care quality inside the U.S., including research to improve health outcomes for patients with heart attacks and to identify organizational fac-

tors associated with high quality hospital and hospice care. GHLIâ&#x20AC;&#x2122;s research approach has revealed hospital practices associated with faster treatment for heart attack patients, better rates of survival and reduced hospital readmissions. - GHLI On Campus Within the Yale University campus, GHLI coordinates the Strategic Thinking in Global Health Course and the Leadership Speaker Series. The course identifies core principles for the development and implementation of grand strategy in addressing common global health problems. Students apply these principles of strategic problem solving

at both conceptual and practical levels. Topics include political and policy analysis, organizational theory, and leadership skills central to addressing global health issues in low- and middleincome countries. The Speaker Series provides exposure to leaders in the field who engage with students in active debate and deliberation on pressing issues related to global health with - Convening Colleagues from Around the World Soon after its establishment, GHLI recognized the need for a forum where policymakers, practitioners and researchers from different countries could gather to collaboratively problem solve, exchange ideas and share successful approaches to address critical issues in global health. To answer this need, GHLI hosts an annual multi-country, teambased leadership conference at Yale that aims to strengthen country delegations’ leadership capacity while supporting the development of actionable work plans to address targeted health issues. Delegations are supported by Yale faculty, facilitators and student fellows before, during, and after the weeklong conference. To date, the GHLI conference has convened delegations from

Brazil, Ghana, Liberia, Rwanda, Ethiopia, Mexico, South Africa and Trinidad and Tobago that have focused on early childhood development, non-communicable diseases, mental health, maternal and child health, human resource development and building management capacity.

across Africa, why can’t we find medicines and supplies in the same places?” Additionally, the Senior Leadership Program is expanding to other countries, including Tanzania, in collaboration with the International Committee of the Red Cross. GHLI hopes to continue providing innovative Senior Leadership Programs to - The Future of Global help health workers around Health at Yale the globe find solutions to complex challenges. GHLI Under the leadership of is committed to finding new, Yale President Peter Sa- efficient ways to provide lovey, a commitment to quality health care for all. global health continues www to expand in strength and depth across the University. GHLI will be a large part of these efforts, supporting new programs with new partners in more countries around the world. In a more recent collaboration, GHLI joined Project Last Mile in Tanzania where our team examined how private and public sectors can work together for the benefit of the local population. GHLI teamed with supply chain experts in the Coca-Cola system and the country’s Medical Stores Department to improve access to critical medicines in more than 5000 locations. It looks into Elisabeth George is the comfactors that help or hinder munications assistant at GHLI. effective partnerships -- foShirin Ahmed is a Program cused on the question: “If a Manager at GHLI. bottle of Coca-Cola can be You can reach her at shirin.ahmed@yale.edu found in rural communities

The Interdisciplinary Investments: Collaboration in Global Health

Writing by Theresa Oei

Photography by Janice Car for the CDC and the NIAID.

he global health field is, by nature, interdisciplinary. It encompasses technological innovation, scientific research, medical care, policymaking, and economic development. Non-Governmental Organizations (NGOs) and Non-Profit Organizations (NPOs), however, typically address only one or two of these issues in an attempt to impact the overall improvement of health. We have become increasingly aware that this strategy is minimally effective; the root causes of global health issues are not singular in nature. Multidisciplinary problems require multidisciplinary solutions, yet these connections and collaborations are often difficult to achieve. According to the

World Health Organization, developing-world diseases like HIV/AIDS, malaria, tuberculosis, and NTDs affect over 1 billion people, yet there is a striking lack of attention devoted to such maladies. This is, in large part, due to the lack of financial incentives for pharmaceutical companies to research and create effective drugs. Even developed drugs are often shelved while companies shift their focus to high-demand products that garner greater fiduciary rewards. The biggest obstacle to progress in combatting infectious disease isn’t a lack of technology or knowledge; rather, it is a misdirected focus. In May 2013, the Japanese government created a public private partner-

ship in global health with its pharmaceutical companies. The objective of this Global Health Innovative Technology Fund, financed by the Bill and Melinda Gates Foundation, is to treat infectious diseases in developing countries using Japanese technologies. This non-profit organization will facilitate collaboration by funding organizations and proposals with a focus on malaria, tuberculosis and neglected tropical diseases. This new venture is unique in its approach to improving health in impoverished countries in that it addresses the multidisciplinary concern. “[Our goal is] to catalyze new innovations from Japan, reaping the benefits of Japan’s drug and vaccine development capacities

and expertise. We will do this for the world’s poorest of the poor and for the future growth of developing nations,” says Dr. Kiyoshi Kurokawa, who leads the GHIT Fund, highlighting the redirection of Japan’s resources to focus on eradicating infectious disease. Japan has long ben at the forefront of technological development, making important contributions in the fight against smallpox and polio, but only 2.1% of Japanese funds allotted for Official Developmental Assistance go to health. With a thriving healthcare system and one of the highest life expectancies in the world, Japan has the capability to make significant contributions globally. Through the GHIT Fund, Japan hopes to increase their leadership in global health to benefit developing nations. The GHIT began by funding and facilitating the TB Alliance, MMV (Medicines for Malaria Venture), and DNDi (Drugs for Neglected Diseases Initiative). Through GHIT support, these product development partnerships have access to Japanese pharmaceutical compound libraries and the financial resources to develop potentially effectual drugs. At the 5th Tokyo International Conference on

African Development, the GHIT Fund announced thirteen groundbreaking agreements: the Alliance will develop compounds against drug resistant TB strains, the MMV will seek new treatments that bypass similar obstacles, and the DNDi will find treatments for leishmaniasis, Chagas disease, and sleeping sickness. The Global Health Investment Fund, an organization headed by Bill and Melinda Gates in partnership with Grand Challenges Canada, is primarily financial in nature and aims to increase collaboration between investors. They will finance late-stage clinical trials of high impact drugs, vaccines, and diagnostic tools specifically targeting child mortality. Both of these projects are novel public private partnerships that fund collaborations between the private sector, NGOs, NPOs,

research scientists, and government agencies. This innovative step forward in developing medicines and technologies will redirect resources and inspire creativity to help eradicate disease in the developing world. www

Theresa Oei is a Junior in Pierson College majoring in Molecular Biophysics and Biochemistry. You can reach her at theresa.oei@yale.edu

Global Health Spectrums: Nutrition, Disease, and Student Intern Impact

Writing & Photography by Hilary Rogers

his year’s Global Health Leadership Institute’s annual conference was held during the first week of June 2013. GHLI invited four teams from Brazil, Ghana, Trinidad & Tobago, and Uganda, each team made up of health and government professionals. The teams came to Yale with a particular health issue that they wanted to work on in their country. The week was packed with lectures by Yale faculty on strategic thinking and team building, and breakout sessions within the country teams to develop strategies to bring back to their countries. My tasks as the “student fellow” during the

week of the conference were to conduct background research, help with presentations, take notes, and aid in moderating discussion. My most important task, however, was getting to know the Ugandans, as they would be the only people I would know a week later when I arrived in Uganda. I think this is one of the more subtle qualities of a Yale partnership that does not get discussed as often as others. My feeling of “fitting in” early on was due to the established relationships between Yale School of Medicine faculty and some of the Ugandans, which allowed me to be a respected and valued team member from the

start. I had to be proactive to maintain this perception, but the inclusiveness at the beginning allowed me to feel comfortable and therefore demonstrate my abilities. The Ugandans – Professor Harriet Mayanja-Kizza, Dr. Doreen Birabwa-Male, Professor Moses Kamya, Dr. Charles Mondo, and Dr. Gerald Mutungi – were doctors, public health and medicine professors, and government officials. They work in Kampala, the capital city, in the Makerere University College of Health Sciences, Mulago National Referral Hospital, and the Ministry of Health. Most of them had worked together in some as-

pect in the past, and a few of them were even “OGs” or “OBs” (Old Girls/Boys: friends from university). The Ugandans brought to the conference the issue of rising noncommunicable diseases in Uganda. The World Health Organization (WHO) classifies non-communicable diseases (NCDs) as chronic non-infectious diseases, such as the most common worldwide problems of cardiovascular disease, cancer, respiratory disease, and diabetes. Low and middleincome countries account for 80% of non-communicable disease-related deaths worldwide. The WHO has predicted that Africa will have the greatest regional increase in NCD-related

death over the next decade. Rates of noncommunicable disease in Uganda are low compared to those of high-income countries like the United States, but they are rising at a rapid rate, and the economic and healthcare infrastructures of the country are not prepared. Ridden by internal conflict and infectious disease, Uganda does not yet have the policies, resources, or specialists to effectively prevent and manage these diseases. Furthermore, NCDs lead to huge economic burdens on individuals, families, and the healthcare system. The World Economic Forum considers NCDs to be one of the top threats to global economic development.

Currently, NCDs account for 25% of deaths in Uganda. Two of the most common NCDs are diabetes and hypertension. The overall prevalence of diabetes is relatively low, estimated at 2.9%, but there are regions with considerably high proportions. For example, the prevalence of Type 2 diabetes in the districts of Kampala and Mukono is 8.1%. Of this population, nearly 80% of women are overweight and an association among overweight, hypertension, and diabetes in women is observed. The prevalence of hypertension in the southwest regions of the country ranges from 2030%. The Uganda NCD Alliance, an organization that promotes advocacy and out-

reach to advance action on NCDs, recently conducted a WHO STEPS survey on NCD risk factors in Kasese, a rural district in western Uganda. The results show the prevalence of hypertension to be 22%, diabetes 9%, and high levels of risk factors, such as physical inactivity, overweight, and heavy tobacco smoking (51%, 15.6%, and 9.6%, respectively). In one of my informal discussions with Pro-

“SILENT KILLERS” across the top. She began to describe the intricacies of the biological, social, and economic factors that lead to diabetes and hypertension’s being “silent.” In the two months I was in Uganda, I came across this phenomenon twice. The story, both times, went something like this: “I saw my uncle over the weekend at a family gathering. He seemed to be in good condition. I got a

fessor Harriet Mayanja, a conference delegate and the Dean of Makerere University College of Health Sciences in Kampala, she took out a notepad and wrote

call this morning – he passed away in the night...” There is a lack of knowledge of these diseases and their risk factors, both in the public and healthcare personnel. There

are now 560,000 registered patients in Uganda with diabetes, but it is predicted that an additional 560,000 people are unaware they have the chronic disease. One major reason for this is the lack of screening and early detection of NCDs. In order to tackle this issue, the Ugandan team proposed a strategy of improving awareness and risk factor screening. With the objective “to build capacity in prevention, clinical care, health worker training, and research to enable the provision of effective and integrated management of NCDs,” the overall strategy became known as the Uganda Initiative for the Integrated Management of NCDs – UINCD, for short. UINCD’s first year goals include the implementation of two pilot programs: 1) improvement of screening and 2) integration of NCD care in one clinic, both taking place in the Mulago hospital. In a pre-project audit, we found that an adequate number of blood pressure and blood sugar screenings were happening only in the wards you would expect – cardiology, diabetes, and hypertension. Meanwhile, little to no screening was going on in more general wards, like the Assessment Center, similar to a walkin clinic, and the Casualty

Ward, which we would consider an emergency room. High blood pressure and blood sugar are modifiable risk factors for NCDs. Early detection of these vital signs can prevent the progression of diseases such as hypertension and diabetes mellitus. Although the hospitals and clinics are overburdened with the number of patients each day, even more people do not use the established healthcare system due to lack of money or transportation to the hospital, use of alternative methods, or other reasons. It is important to catch people with risk factors when they eventually do make their first contact with the hospital. They may have come in with a broken ankle or the flu, but screening is a cost-effective method that has the potential to reduce mortality from NCDs and increase awareness of NCDs and their prevention. Once patients do come into the Mulago National Referral Hospital to receive care, they find a fragmented system. As a health system built to care for infectious disease, it is not prepared to effectively manage the complexity of patients with chronic disease. The medical units are organized by subspecialty in Mulago. For instance, the Heart Institute is on the ground floor, while the

Diabetes Clinic is on the fourth. The wards are independent of each other and each has its own staff. Due to the overlap of some diseases, a patient with NCDs may end up receiving care in three of these clinics. This fragmented system leads to low quality care, repetitive tests, poor follow-up and compliance, and more issues as well. Per the suggestion of the Yale School of Medicine Dr. Asghar Rastegar, Dr. Jeremy Schwartz and Dr. Tracy Rabin, the Ugandan team decided to use this concept for their second goal this year, the piloting of an integrated clinic for NCDs. The plan is to turn an empty space in the hospital into this pilot clinic and hire one physician and a few nurses to go through training and run it. They will conduct assessments on the quality and improvement of their work to see if it is successful. If both of these pilot projects are successful, they will look to officially establish them as permanent programs and expand them to smaller hospitals and clinics across the country. Without a degree in clinical medicine or hospital administration, there were a few aspects of these two projects to which I could not adequately contribute. This is often an issue we come across with summer

internships in college – with limited practical skills, how can we make an impact? My summer in Uganda taught me that I have skills that I took for granted, like paper writing and people skills, which turned out to be the skills I relied on the most. I used these as I wrote the Ugandan team’s proposal for the Innovation Award, a chance to receive $25,000 from GHLI in cash and inkind contributions to help their strategy. Half of my summer was dedicated to developing the proposal. I like to think of this intern work, not as “busy work,” but rather “behind the scenes work.” Much more than just writing, I conducted background research, reached out to similar organizations, and, most importantly, managed the team. The founders of UINCD, the delegates of the GHLI conference, are exceptionally successful professionals, which means they are exceptionally busy. They are invested in many projects along with their full-time jobs, so finding a time all six of us could meet was difficult. As the summer went on, I realized that the most efficient way of gathering the team’s ideas and opinions on proposal drafts was to meet one-on-one with each member. This was a benefit not only to the progression of the project, but

I like to think of this intern work, not as “busy work,” but rather “behind the scenes work.” also my own growth, as I had the opportunity to directly learn from such knowledgeable health professionals. While NCDs have not been prioritized in the past, there has been recent development to change this. In 2006, the Ministry of Health (MoH) established a NCDs program. Dr. Gerald Mutungi, one of the conference delegates and a MD/MPH by training, is the Program Manager. I had the opportunity of joining the program for the second half of my summer and conducting a project that I will use for my Masters of Public Health thesis. The NCDs program has recently partnered with the World Diabetes Foundation and will receive funding for the improvement

of NCDs programs and policies in the near future. To see what areas of the NCDs care spectrum were lacking the most resources, the MoH needed to conduct a needs assessment. This is where I came in – with the supervision of the assistant program manager, I had the responsibility of writing a 14 page needs assessment that tried to comprehend the situation of personnel, medicines, equipment, guidelines, standard operating procedures, referral system, and more within the regional referral hospitals, district hospitals, and health clinics around the country. The second to last week of my time in Uganda was spent on a road trip throughout the eastern and northern parts of the country to do a trial run of the needs assessment. As fulfilling as it was to see my hard work implemented by the

MoH, the situations we saw were disheartening. Hundreds of patients and family members waited on the hospital grounds to receive care. Images from this trip, of bulging bellies on malnourished children and disabilities that are easily prevented in Western countries, will remain with me forever. In a hospital that sees 300 diabetes patients in one day alone, there was one functional blood pressure machine for the entire facility. Some of the hospitals experienced stock outs of critical medicines, like insulin, at least once in a financial year. At the same time, however, we met inspirational people along the way. There was Nurse Evelyn*, a hospital nurse who specialized in diabetes in Arua, a district part of the region that was devastated by Kony and the Lord’s Resistance Army. With one or two assistants,

depending on the day, she was the only nurse to staff the diabetes ward of the hospital. She managed hundreds of patients each day by herself, working long hours and maintaining the most organized patient registers we had seen during our trip and in Kampala. People like Nurse Evelyn and the members of UINCD prove to me that there are determined NCDs leaders and advocates to champion the movement to prioritize NCDs and improve their prevention and management. Global health internships offer the opportunity to become an integral part of groundbreaking movements that will hopefully progress to countrywide changes. My inclusion into

the Uganda team gave me real responsibility and tasks that strengthened my program management, proposal writing, and needs assessment skills, and gave me a firsthand view of Ugandaâ&#x20AC;&#x2122;s complex health issues. I observed the spectrum of malnutrition in Uganda, from undernutrition, subsequent infectious disease, and disability, to obesity and dietrelated diseases. The double burden of undernutrition and chronic disease offers a new area of global health to explore, one that is just starting to gain interest. Just this October, The New York Times published two feature articles examining breast cancer in Uganda, issues of delay in diagnosis and treatment and also ef-

forts for improvement. , We must use this momentum to generate more partnerships and innovation, and thus raise NCDs as a global priority, strengthen research and health system capacity, and develop comprehensive strategies to prevent disease *Name has been changed.

www

Hilary Rogers is in her second year of the BA/MPH program at the Yale School of Public Health. She now studies Chronic Disease Epidemiology and Global Health. You can reach her at hilary.rogers@yale.edu.

Q&A

Meredith Mira

By Aneesa Noorani Photography by UCS Meredith Mira is a new career advisor at the Yale Center for International and Professional Experience and the Undergraduate Career Services, focusing on Global and Public Health, as well as Non-Allopathic/ NonOsteopathic Health Professions.

YGHR: What are the benefits of doing global health fieldwork? What types of experiences should students be seeking for exposure to the field? My answer to this question stems from my doctoral degree in the sociology of education, where I studied how students from various racial and socioeconomic backgrounds become motivated to engage in social change efforts in their communities. Global health is one type of social change effort; although the majority of global health fieldwork will happen outside of a student’s home community, I expect that they will develop some similar ways of thinking about power, inequality, politics, and culture. Students can learn many useful things in the classroom, but by working in the field, students learn how to engage with people across difference and gain a sense

of how challenging it can be to translate classroom theory into on-the-ground practice. Understanding health through the lens of other people’s cultures and being able to communicate across cultures are fundamental parts of global health; fieldwork is an important way to learn how to do both. However, in order for students to understand health on an international scale, I think it’s important for them to also gain an understanding of the health challenges in their own backyard, including New Haven, their home community, and the US more broadly.

at the undergraduate level is something many universities are in the midst of developing; we’re at a unique turning point and there are exciting avenues that are opening up. In the past, it seemed that an advanced degree, such as a PhD or MD, was required for many global health positions; however, now that the number of undergraduate global health programs is increasing, we’re starting to see more opportunities for internships and entrylevel positions in global health organizations. In addition, there are an increasing number of opportunities for undergraduate YGHR: Global health is students, along with other an extremely interdisciplin- health profession graduate ary field of study, ranging students (e.g. nurses, physifrom medicine to economics cian assistants, doctors), to to international relations. observe and ethically assist How do you advise students in clinical settings around on the different paths one the world. Ultimately, the can take in global health? path that students take into The study of global health global health grows out of

their own personal background; I see it as part of my job to elicit the story of what is motivating them to work in this arena. By starting our conversation at the ground level, I am more poised to help students put their passions into the right context. YGHR: What are some useful skills for someone working in the global health field, and how would a student go about learning those skills? To begin, it’s essential for a student to understand themselves and where they come from. If students are not grounded in who they are when they walk into a room, they cannot even begin to engage meaningfully with others or be sensitive to the social context of each situation. But just as fish don’t know they are swimming in water, we sometimes can’t see our own cultural environment; indeed, everything around us simply seems “normal.” As such, we often need others to help us understand the water we’re swimming in. There are many courses in the humanities – anthropology, sociology, history, etc. – that can be a great starting point not only to help students understand other people’s cultures, but also to help them start the process of making their own familiar surroundings seem “strange.”

Students must also learn to listen. When students come to college, they are often encouraged to take leadership roles. My definition of leadership comes out of a community organizing paradigm, where leadership is defined as enabling others to achieve shared purpose in the face of uncertainty. In this way, leadership isn’t about taking the lead and having everyone else follow you. Instead, it’s about building relationships with the people around you, listening to their interests, needs, and resources, and then collaborating as a structured team in order to pool your resources towards the achievement of a strategic goal. YGHR: Occasionally students do global health fieldwork and have a negative take-away. What do you think students can do to avoid this and get the most out of their experiences? In the field of global health, change is incremental, and students might get to the end of a summer experience and feel as though they have accomplished very little. But often it is this kind of “negative experience” that students learn from the most because it helps them put things in perspective. Students learn that change doesn’t happen quickly, that applying theory to practice

is often harder than it seems, or that they were trying to apply their own paradigm of thinking and behaving to a new community with different norms and ways of approaching health. That said, significant preparation should be done in advance to make these summer experiences the best they can be. Students should start by learning as much as possible about the community in which they are going to work, including its healthcare history along with its cultural, political, and religious norms. One useful way to begin this process is by connecting with Yalies who have traveled to these communities in the past. In addition, students should take steps to clarify their own cultural norms and biases and to prepare themselves to understand that their host communities have their own norms and ways of being. Finally, it is essential to have a supervisor or mentor on site and to set realistic expectations with them – including goals, limitations, norms for communication, and expected final deliverables – prior to embarking on the experience. www

Aneesa is a sophomore in Pierson College. You can reach her at aneesa.noorani@yale.edu

Rethinking Priorities in Global Health: Focusing on Quality of Care at Walimu

By Elijah Goldberg & Photography by Walimu

couple of years ago I was fortunate enough to meet a talented group of doctors from Uganda and the United States who have dedicated their lives to the study of severe illness. Together, these doctors and I formed Walimu, a non-profit organization that works to improve the quality of medical care for severely ill hospitalized patients in resource-limited settings. Walimu aims to address a major gap in global health. As the global health community developed over the past half century, efforts

centered on massive disease prevention or broader health system reform. Large-scale initiatives sought to increase funding for health-systems, prevent the spread of specific, high-burden diseases, or spur development of new cures. Smaller initiatives provided an alternative to the government-run health system, setting up missionstyle centers of excellence for the poor, though never enough of them. There were few systematic efforts to improve the actual quality of health care delivered. Why? The reasoning

was that in settings with severely limited resources, and a severely sick population, access and prevention, not the standard of care, should be the priorities. Broader quality of care would come after there were enough doctors, drugs, resources, and money. This is an understandable mindset, particularly given the impression that good care requires a lot of money. Hospitals like Memorial Sloan-Kettering or the Cleveland Clinic conjure up images of quality, but certainly not affordability. For societies where

access to any healthcare at all is a struggle for many, quality is a second priority, and a distant one at that. The access and prevention first mindset has been changing. This change is due in part to a growing body of evidence on what constitutes appropriate assessment and management in resource-limited settings. The global health community has developed guidelines and algorithms, based on decades of randomized controlled trials and other studies, for health workers with access to few resources. But perhaps more importantly, the evidence shows that not only can good care be delivered with few resources, better care can also end up costing a lot less. One particularly successful approach to high quality care with few resources is referred to as â&#x20AC;&#x153;syndromic management.â&#x20AC;? In the typical developing setting, patients are routinely assessed and treated improperly for a variety of reasons. Diagnostic support is minimal, drugs are scarce, and clinical knowledge is often limited. Many patients come in with syndromes of multiple, overlapping conditions challenging even by devel-

oped standards. Syndromic management provides clinicians with guidance on how to act decisively, particularly in life-threatening situations, even without a full picture of the disease state of the patient. Clinicians treat based on the signs, symptoms, patient history and local epidemiology and follow broadly standardized, evidence based algorithms that are often adapted to the setting.

a standard of care achievable in almost any setting. IMCI is important because it works. Implemented in 75 countries, IMCI has decreased mortality for children under five, improved health worker performance and increased quality of care. IMCI is also typically cheaper, sometimes costing up to six times less.1 In just one example, a randomized study of IMCI implementation in Tanzania found a 13% drop in mortality over two years compared to standard care, and costs were similar or lower.2 IMCI demonstrates that there are more ways to improve health outcomes than simply boosting resources. Following the development of the IMCI, several of our doctors participated in the development of the Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual, which provides guidance in a similar format as the IMCI to health providers at district hospitals. The unfortunate truth is that despite the potential to improve care cheaply, the IMAI and IMCI standards are not met everywhere. The doctors I work with know this all too well. They work on the

For societies where access to any healthcare at all is a struggle for many, quality is a second priority, and a distant one at that. Perhaps the most well known set of syndromic management guidelines is the Integrated Management of Childhood Illness (IMCI). Developed by the World Health Organization in the 1990s, IMCI has gathered all of the relevant data on how to best care for children in resource-limited settings and compiled it in one simple, accessible set of standards. IMCI assumes a minimum amount of diagnostic support and drug availability, providing

wards of Uganda, enrolling patients into their studies and adding to the evidence base for appropriate care. But what they see all too frequently is care that is not tied to strong medical evidence. Patients go undiag-

dedicated to disseminating the guidelines. We are an in-country partner for the Alliance and support their efforts to scale training. In addition, we developed the Severe Illness Management Support (SIMS) program,

A doctor at Mulago Hospital assessing a patient with a Walimu diagnostic kit.

nosed, or improperly managed. And while the lack of resources plays a role, it is only part of the explanation. Walimu was founded to bridge the gap between what we know works and what actually happens everyday on the wards. We work primarily as a strategic and implementation partner for the IMAI-IMCI Alliance, an organization

which supports the training through a series of behavioral change interventions that enable uptake and reinforce adoption of the IMAI guidelines. The program includes essential diagnostic equipment to enable health worker uptake of recommended practices, point-ofcare access to the guidelines via mobile phones or tablet computers, and regular per-

formance feedback to reinforce adherence to IMAI management guidelines. Even as we support the training efforts of the Alliance, we are exploring new ways to change health provider behavior. At Mulago National Referral Hospital, we have begun a continuous quality improvement program. The program collects data on essential tasks for severe illness management, feeds that data back to ward staff, and then works with ward staff to design quality improvement projects. We hope to gradually transform management on the ward to adhere to international standards of excellence. A focus on quality of care can yield great improvements in health, even while decreasing the cost of care. As the evidence base for resource-limited settings grows, the global health community should add quality alongside access and prevention as a central goal of international efforts. www

Elijah is a Junior in Pierson College. He is interested in leveraging technology and data to improve global health. You can reach him at elijah.goldberg@yale.edu.

Ghana

The Evolving Problem of Mental Health Writing & Photography by Aly Moore

2005, only 32,875 people were hospitalized or given outpatient consultations in Ghana, representing a 98% treatment gap. Although mental, neurological, and substance use disorders combine for up to 13% of the global burden of disease, only an estimated 3.6% of Ghana’s current health budget is allocated for mental health. John Mahama, the current president of Ghana, has spoken at length about raising awareness to change the current attitude of “mental health [as] an afterthought.” Mahama started by making the Ministry of Health and the Ghana Health Service launch a national campaign to raise awareness about mental health and reduce stigma associated with mental health patients. In August 2011, President Mahama assured citizens that mental health would be adequately ad-

dressed in the government’s plans to upgrade all national, regional and district health facilities. Mahama met with a group of Ghanaians who had attended the Yale Global Health Leadership Institute (GHLI) conference, where they focused on ways to address the rising mental health problems in their country. The journey through the Ghanaian mental health system started for me when I met Patrick Geoghegan OBE, then-CEO of the South Essex Partnership and Trust (SEPT). His passion for global health inspired my journey to England the following summer to work for SEPT. In England, I worked on Patrick’s ongoing project with the SEPT Global Health Charity in Ghana, conducting intensive research on the status of the Mental Health Bill in Ghana. I was given the opportunity to interview the

key players in development and improvement of psychiatric hospitals in Ghana and charged with producing a report with the potential to truly impact policy. The report is structured in two sections: The first describes SEPT’s achievements in Ghana while the second critically analyzes unfinished policy work. SEPT Global Health Charity was founded in October 2010 to raise funds to send a container of medical supplies and equipment to the Pantang Hospital in Accra, Ghana. It has since sent eight 20-foot containers and raised a staggering £25,000 to support the improvement of the mental health facilities at Pantang Hospital. The funds raised were largely used to cover the cost of shipping the containers to the Ghanaian facilities, while the contents of the

containers were donated by SEPT, including necessary living-space improvements such as furniture and medical supplies such as syringes, drug trolleys, and cannulas. While these items are often taken for granted in the UK, in the Pantang Hospital, they were treasures. According to one of the Pantang physicians, Dr.

Anna Puklo-Dzadey, ,“The contents of the containers will help provide some of the most basic things that those in the developed world would take for granted and will go a long way to improving patient care and comfort. I’m extremely grateful to Patrick for arranging the shipment to us and thank the staff of SEPT for doing

their bit to help.” Beyond physical supplies, the containers brought hope, motivation and joy to the staff and patients at the Pantang Hospital. SEPT also raised enough funds to purchase 20 beds, at a cost of £200.00 for each bed complete with bedding, to furnish a new assessment ward, which Patrick proudly opened in December of 2010. ** As relationships with the various members of Pantang Hospital, Accra, Ghana and Yale grew, Patrick became involved in the collaborative effort to help pass and implement new mental health policy in Ghana. In 2004, the WHO began working with Ghana’s Ministry of Health to craft legislative reform for the country’s mental health system, based on WHO guidelines. Together they drafted a bill that, while providing few specifics about patient care and facility staffing, presented a new vision for the mental health system. The bill

emphasized best practices for treatment, respect for human rights, accountability, and a shift from institutional care toward communitybased treatment and integration of mental health into general medical practice. While completed in 2006, the bill tragically stalled before Parliament. However, with the added weight of international interest in recent years, the Ghana Mental Health Bill was passed on March 3, 2012. If the bill is properly implemented, the legislation has the potential to serve as a model for other countries in West Africa, or, more broadly, other lowincome countries working to strengthen mental health services. Although passage of the 2012 Ghana Mental Health Bill was a major milestone, it did not expand and enhance the workforce enough to implement the provisions set forth within and improve upon current mental health services. The bill also relies on a substantial amount of additional funding and administrative action, which has not been forthcoming. An ongoing Supreme Court case examining the legitimacy of President John Mahama’s administration continues to monopolize national attention. The trials are broadcast live on

television, and the population of Ghana watches eagerly, since the country’s future hinges in no small part on the ruling. Perri Kasen, 2013 GHLI Fellow, comments, “Though entirely fascinating… the Supreme Court case has created huge roadblocks in implementing the Mental Health Bill, as many action items require Presidential approval.” The current holdups with the bill concern more than just the president. Ghana is faced with a significant capacity issue as well as a training issue – do the people that are required to implement the new provisions have the requisite political expertise to complement their clinical training? Ghana will need a knowledgeable individual to single-mindedly pursue the next steps for mental health, pushing the bill forward and providing a tangible plan for the future. As of yet, no one has stepped forward. While the majority of the bill has yet to be enacted, the successes of smaller scale projects give reason to celebrate. Collaboration with Yale and SEPT has encouraged the exchange of models and ideas and Patrick is currently working to continue this interplay through an academic exchange between the physicians within the different

countries. Hopefully, the doctors of Ghana will take back models of care, such as the structure of Assessment Wards, which will improve patient conditions and lead to lessened stigma. Reciprocally, doctors from the U.S. and England could learn much on the ground in Ghana. Ghanaian physicians are very proud of their ability to work within the suboptimal conditions they are given; they have avoided any major Cholera outbreaks, for example, in a facility without running water. My experience with SEPT shows the need to focus on implementation as the necessary follow up for policy change. Passing the bill was the easy part; we must recommit to improving mental health in Ghana as we move from policy to reality. www

Aly Moore is a Senior in Branford College. She is interested in public health and entrepreneurship. You can reach her at aly.moore@yale.edu

Beyond ARVs: Prescribing Housing to End AIDS in NYC

Writing by Juliet Glazer

he relationship between homelessness and health has been widely documented. One aspect of this relationship came to light in the late 1980s as the fight against the AIDS virus began. According to the Centers for Disease Control, people who are homeless are far more likely to be HIV positive. Housing status predicts HIV risk and outcomes independently of a range of individual characteristics and service use variables, including race/ethnicity, history of substance use, mental illness, and primary care and case management.1 Moreover, the National Alliance to End Homelessness reports that up to 50% of people living with HIV/ AIDS (PLWHA) are at risk of becoming homeless due to prolonged absences from work due to sickness, and also due to the high cost of the anti-retroviral medicines used to treat the disease.2 An end to HIV may be in sight, through increasing the use of antiretroviral drugs. These drugs are ex-

tremely effective if taken as prescribed. Anti-retrovirals works to suppress the HIV virus to undetectable levels, such that transmission becomes impossible. However, living on the streets or in emergency shelters is a significant barrier to starting and following up on antiretroviral treatment plans, and to maintaining good overall health. Insufficient food, untreated mental illness, intravenous drug use and living in close quarters in shelters and single room occupancy (SRO) hotels with people who have TB are some of the major factors that worsen health outcomes by decreasing treatment uptake and follow-through for homeless and unstably housed PLWHA. Ending the AIDS epidemic will require ending transmission by increasing the use of antiretroviral drugs, and this will necessitate a special focus on homelessness. In 1990, there were an estimated 35,000 homeless people living with HIV/ AIDS (PLWHA) in New

York City but, there were fewer than 350 supportive housing units.3 Virginia Shubert, Charles King, and Keith Cylar founded an organization called Housing Works in 1992 to combat this problem. Housing Works’ mission is to show that HIV-positive homeless persons can be successfully housed, thus improving their health, through providing a harm-reduction approach to fighting HIV. The harm-reduction approach holds clients responsible for their behavior rather than for their status as intravenous drug users or returning prisoners, for example. In a 1995 article on Housing Works, Shubert and Mary Ellen Hombs wrote that “viewing homelessness as the ‘result’ of individual pathology that must be corrected will lead inevitably to the questionable denial of essential housing and services.”4 Rather than requiring abstinence from drugs or alcohol, which may be very difficult for clients to maintain, Housing

A Housing Works demonstration outside City Hall in Manhattan, on November 9th 2010. Photograph by Ginny Schubert.

Works focuses on providing needle exchange services and mental health counseling, among other supports. Housing Works also brings a unique approach to AIDS activism through public health research. I spoke with Shubert, who heads the research department at Housing Works, about the integral role of research in policy advocacy and activism.5 Though Shubert trained and worked as a lawyer and originally pursued advocacy for the homeless through the courts, she has since turned to research. She worked on two legal cases that made the importance of public health research in activism clear for

her. The first case, Mixon v. Grinker, involved a homeless, HIV positive man who had contracted tuberculosis in the city’s shelter system but was denied support for individual housing. Shubert won the case after a doctor at Harlem Hospital published a study that used DNA testing to prove the man’s particular strain of tuberculosis had been rampant in the shelter where he had stayed. In the second case, Shubert worked for plaintiffs who sued the city because rental assistance applications were not processed in the 45-day time period mandated by law. Shubert was able to win the case after conducting a study with outside research-

ers that tracked the rental assistance application process for clients in a new Housing Works residence, proving that it took the city an average of 191 days to process applications. Shubert says that the two cases “showed the power of having an academic researcher demonstrate something that you know is true but you can’t prove.” Shubert has since shifted her focus to research. Since 2005, she has convened the Housing and HIV/AIDS Research Summit along with the National Coalition for Housing and the Ontario HIV Treatment Network, to promote research on the interrelations between HIV and

housing in North America. With Housing Works, she has developed a method for “action-oriented participatory research, to involve the community under study in the design and implementation of research. For a study at Housing Works’ Women’s Transitional Housing Program for women returning from prison and jail in Bedford-Stuyvesant, Brooklyn, Shubert and her colleagues developed a set of research questions in conjunction with the case managers and residents at the housing facility. While the case managers were concerned that researchers not ask women about intimate partner violence, residents were happy to discuss the topic, leading the researchers to revise their question set to reflect a compromise. Shubert expresses sadness that the most effective kind of research in the advocacy world focuses on the cost-effectiveness of intervention programs. At Housing Works, “the whole point is to create an evidence base to support increased funding for similar kinds of housing programs, and to prove that [they are] cost effective,” she says. At worst, politicians view housing programs as a competing need, rather than an essential right and central support. However, she says that

“if you can prove that savings in Medicaid or savings from reduced jail time will offset all or part of the cost of housing, you’re much more likely to get the housing funded or to hold onto the funding for housing.” Other offsets from supportive housing include fewer emergency room visits and ambulance rides. Shubert and the research teams she works with have been successful in demonstrating cost-offsets from supportive housing intervention programs. Current research gaps are both national and global. Shubert says that the global issues of poverty and HIV are often perceived as “so intractable that there aren’t many interventions being tried to address the problems;” consequently, cost-effective, interventionbased research projects are difficult to design. Nationally, Shubert points to a gap in research on the unique risks and circumstances that HIV positive transgender women face. Shubert also identifies a lack of research on intermediate level housing supports that could bridge the gap between involved and costly housing programs that are heavily supportive, and nonintrusive rental assistance programs. “How little can you interfere in someone’s life and still provide effective interventions?” she wonders.

Housing Works has recently succeeded in involving New York State with a project to strategize an end to AIDS. The strategy will focus on ending new transmissions by accomplishing the goal of moving 90% of HIV positive people to having undetectable viral loads on antiretroviral drug treatment programs. Housing Works has taken on the challenge with its own clients, and is developing studies in conjunction with researchers at the University of Pennsylvania on the use of cash incentives for case managers and clients to maintain undetectable viral loads. Looking forward, Shubert says, “It would be wonderful to be able to say they’ve ended AIDS at least in terms of new transmissions at Housing Works.” New paradigms for intervention-based and costeffectiveness global health research will help to achieve the goal of ending AIDS in New York, across the nation, and across the globe. www

Juliet is a sophomore Silliman College. She is studying anthropology and is interested in international policy on HIV and housing issues. You can reach her at juliet.glazer@yale.edu.

Q&A

ELIZABETH BRADLEY + LAUREN TAYLOR

Authors of the new book, The American Health Care Paradox By Austin Jaspers Photography from The American Healthcare Paradox Elizabeth Bradley is a professor of public health at Yale University, Faculty Director of the Yale Global Health Leadership Institute, and the Master of Branford College. Lauren Taylor is a graduate of Yale College (BA) and Yale School of Public Health (MPH) and now studies global health and medical ethics at Harvard Divinity School, where she is a Presidential Scholar. Their book, The American Health Care Paradox, was released on November 5, 2013.

YGHR: How did your collaboration on The American Health Care Paradox begin? Lauren Taylor: The book really started with a peer review article back in 2010 that examined health and social service expenditures in 34 OECD countries. It reframed the conversation around health care investment in the United States. It found that social service investments were critical and showed that the ratio of health to social service spending was very predictive of some key health outcomes like life expectancy, infant mortality, and maternal mortality. Following the publication of that paper, Betsy and I wrote a New York Times op-ed that was very well received. We were deluged with emails and among them was an offer to do this book â&#x20AC;&#x201C; an opportunity to expand upon a central thesis and dive deeper

into circumstances surrounding the U.S.’s allocation of resources in the health and social service sector. YGHR: What is the “paradox?” Elizabeth Bradley: The paradox is that U.S. spends double what the average OECD country spends per capita on health care, but our health outcomes are among the very worst in the OECD. Most people would think that if you are spending more on medical care, you would get more for it.

the rest of the globe, it was not England or Canada, but some of the Scandinavian countries. These were countries that were getting attention for well-planned and coordinated health and social service systems. The way that we have written about them, they are not to be taken as models for what the U.S. should do. Rather, they are appropriate comparisons because they are very different from the U.S. model. The hope is that we can learn from them, but take lessons and adapt them in a uniquely American way.

YGHR: What changes are feasible in America’s YGHR: Your research and existing economic and writing takes a global per- political structure? What spective to understand the is the first step and who paradox of American health should drive these changes? care. What countries or settings offered useful par- EB: The book is not about allels? What were the lim- making policy recommendaits of those comparisons? tions, instead it illuminates this paradox. We look at evLT: When we were looking idence to try to understand to make international com- it better. Hopefully, it will parisons, we made some provoke a new discourse careful decisions: We had about health in the U.S. It experience working with would be premature to make the National Health Service policy from this, though we in the U.K. and we thought have thought about practiabout going to Canada. But cal implications. What do we decided not to go that di- you do first? Start to talk rection because we felt that about health differently. those comparisons were There is a lot more that desomewhat tired. When we termines the health of our looked at the statistics to population than our medical see who was outperforming care system. Getting that

message across is important to all sectors. The book gives the implication that incentives must be aligned: our health care system must address the social determinants of health and our social services coordinate with health services. Over the long term, we would hope to see infrastructures emerge with new models for caring for people that consider the whole person and the myriad of tools you can use to bring about health – not just medical care YGHR: How do social services impact population health? LT: There’s a strong literature suggesting both the impact of social determinants of health. Sixty percent of premature deaths can be attributed to social, behavioral and environmental factors. We drill down into the literature about specific social determinants of health – like education or employment – and their power to confer important benefits to health over the long term, and reduce health care spending. EB: In the book, we highlight several cases of individuals that bring to life how a lapse in a social service creates health problems. You take Barry, for example, who is a well-educated,

ing health care organizations integrate social care with health care?

business executive. He falls on bad luck, gets laid off in 2008, and then tries to start other businesses that go bad. Over time, he becomes tremendously depressed over this and picks up poor eating habits. He was always heavy, but becomes substantially obese. He loses his house and doesn’t have insurance. This person is looking at a lifetime of tremendous chronic illness, which began from problems with employment. In another example, Martha is a person who called an ambulance every other week because she was lonely. She got transported to the hospital along with a full medical work-up – every other week. If she had had someone she could have talked with or an adult day care center, such services might have reduced her reliance on medical services and reduce the expenses substantially. YGHR: How can exist-

with the social service sector or in our understanding of the social determinants of health. I’m optimistic that we’re focused on this, but I hope we can broaden our EB: Physicians horizons about what the know that this root of the problem really is. is a huge problem. They wish EB: I would add another they could work note of optimism. The ACA with a social achieves the goal of insuring worker, to pre- everyone and this forces the scribe housing American public to think or employment about how they’re using beyond medical care. The these dollars. By virtue of question is: how do we cre- the fact that we will be sharate communication between ing one big pool of spending, physicians and people work- it will be in all of our best ining in social services? We terests to ask if we are doing highlighted several orga- this as efficiently as we can. nizations that went out to integrate physicians with LT: The research on this community centers. It can book left us optimistic. be done; now we need to There are grassroots inknow how it can be scaled. novators here in the U.S. who are working to address YGHR: What about US health and social services in health care discourse makes a coordinated, holistic way. you optimistic? Though sometimes I am discouraged by the narrow LT: I’m optimistic that ev- reform conversations, the eryone is focused on health past two years of interviewright now – we really have ing and interacting with the attention of the nation. these frontline entrepreThe President has placed a neurs has left me optimistic. spotlight on health in the nawww tional agenda. The conversation as it currently stands could be broadened. One of the key messages of the Austin Jaspers in a junior in book is that the problem Trumbull College. He is interwith health care in the U.S. ested in health care policy both is not with the health care in- in the US and abroad. You can reach him at dustry itself, but lies instead austin.jaspers@yale.edu.

Life Off the Map

Writing by Sawsan Zaher Photography by Adalah

June 2013, the Israeli Supreme court ruled to dismiss a petition submitted by several organizations—including Adalah, the Legal Center for Arab Minority Rights—to cancel a health access-limiting provision of the National Insurance Law. Previously, the National Insurance Law, which governs the operations of the National Institute of Israel (NII), granted payment of a monthly child allowance to any family in Israel with children under the age of 18. In 2009, however, the law was amended to condition eligibility for allowances granted to children under the age of five on receipt of a vaccination issued by the Ministry of Health. Though these changes and similar welfare policies are seemingly innocuous, they align, in reality, with other policies intended to expel the Palestinian-Bedouins from Israeli land. According to the Ministry, the new provision was implemented to illustrate the importance of vaccinations to both the health of the children and the public; the requisite vaccination, they claimed, was meant to prompt reluctant parents to see their children vaccinated at an early age. While similar welfare payment and school enrollment restrictions—

labeled by some as “sanctions”—in other countries like the United States have indeed been legitimate and strengthened the quality of public and child health, a closer look at the situation in Israel lends an entirely different perspective on these instated provisions and their underlying motivations. For the Palestinian-Bedouin citizens of Israel living in the Naqab—the southern area of Israel, also known as “Negev”—the provision has had punitive effects. In Israel today, more than 70,000 Bedouins live in what are called “unrecognized villages.” These 35 villages, not recognized by Israel, do not exist on official maps and are consequently not entitled to water, electricity, or other essential services like health and education. Vaccinations can be obtained in some of these regions at mother and child centers, but these centers—established only after persistent demands from villagers and human rights organizations—are limited in capacity and can provide only partial services. The Health Insurance Law of 1995 stipulates that health centers are to be provided by the Ministry of Health in an equal and accessible manner to all residents. Yet, existing in only 8 of the 36 villages, mother

and child centers are operated only once a week, by one doctor and one accompanying nurse. In addition to this, their operations have historically been shortlived—in 2009 alone, the Minister of Health ordered the closure of three Mother and Child clinics in three different unrecognized villages, under the allegation that nurses and doctors were unwilling to serve unrecognized villages. These clinics had served 18,000 altogether and were only re-opened after Adalah’s petitioning of the Israeli Supreme Court. Due to the lack of health services in the Naqab, the health status of Bedouin children is a plight. For example, according to Physicians for Human Rights—Israel, 80% of the children in the Ber Sheva hospital are Bedouin children. Infant mortality rates as reported by the Ministry of Health have reached 14.7/1000 among the Bedouin children while a significantly smaller rate of 3.9/1000 is seen among the Jewish children. Bedouin children comprise the highest percentage of children not receiving vaccinations, reaching about 20%, and the malnutrition rate of Bedouin children in unrecognized villages reaches 10%, surpassing the national rate of 8%.

As the State clinics in the unrecognized Bedouin villages continue to fail, the refusal of essential services in these regions has served to pressure villagers to leave. Such deprivation of essential services and rights has reached an extreme extent—despite petitions, common cases include that of an 8 year-old Bedouin girl who, suffering from cancer, has been deprived of the electricity necessary to refrigerate her medicine. In a similar vein, six unrecognized villages have been refused connectivity to water. In each case, the Supreme Court has accepted the State’s arguments that refusal to provide these rights and services is legitimate and appropriate as a tool for pressuring the villagers to evacuate the land they live on. The court has consequently dismissed each petition. In the water case for example, the court upheld the State’s argument that connecting the villages to water would “encourage the continuing phenomenon of the unrecognized villages.” The Court agreed the State could legally deny permanent water sources, which would create an “incentive for the Bedouins to move to villages established by the state itself.” The State’s legal obligation to provide equal

and accessible health, education, and welfare services has thus been suspended, creating an environment where rule of law is only applied selectively, bypassing altogether the rights of the Palestinian-Bedouins in the unrecognized villages. The State’s policy of evacuating the villagers comes with long-standing efforts to force evictions and home demolitions, for the establishment of new Jewish settlements on the vacated land. The unrecognized village of A-Arakib in particular stands as particular testimony to the State’s policy. Carried out this past October under the claim that a forest will be planted on the land, this demolition of A-Arakib will be its 55th time in history. Since the establishment of the State of Israel, Bedouins have struggled to keep their land and continue living with dignity, though they are neither trespassers nor foreigners to the land in the Naqab—they have lived and known it for centuries, even prior to Israel’s establishment. In the present-day, the Prawer Bill—a plan of best practices for evacuating Bedouins from unrecognized villages, named after the official assigned by the prime minister to the task— is at the foreground of politi-

cal discussion in the Israeli Parliament. Approved in a first reading by the Parliament and scheduled for second and third readings next month, the bill, if enforced, would leave more than 70,000 Bedouins roofless. In light of a situation in which health care services are not being provided— due to political motivations foreign and irrelevant to the State’s obligation to fulfill the citizens rights based on the law—it can only be concluded that establishing the conditional eligibility for child allowance was yet another punitive step set by the State to intensify its pressure in evacuating the Bedouins. www

Sawsan Zaher is a 2013 Yale World Fellow and Director of the Economic, Social, and Cultural Rights Unit of Adalah: The Legal Center for Arab Minority Rights in Israel. Contact her at sawsan.zaher@yale.edu.

CUBA

Writing by Jessica Lopez

Agricultural Reforms in the Special Period

Photograph by Kara Sheppard-Jones.

Cuba’s economic crisis in the 1990’s, known as the Special Period, saw the enactment of the most concentrated health reforms in a single decade. These reforms were prompted by the 1989 collapse of the Soviet block; Cuba’s most important trading partner at the time. Imports decreased by 75 percent overall and oil imports by 53 percent.1 The Cuban government, facing a U.S. embargo, had to quickly enact reforms that would save the country from economic and political chaos. Efforts to gain international influence and domestic legitimization via

health did not start only after the fall of the Soviet bloc. There are various speeches of Castro declaring Cuba would become a “world medical power” well before the fall.2 His words more readily imply the goal of political power and influence for the government than health and wellbeing for the domestic population; his phrasing evokes goals of “socioeconomic development, scientific achievement, a model health system, and international influence.”3 By focusing national efforts on health reform, Castro could simultaneously demonstrate Cuban power and

legitimize the government. The U.S. Embargo, imposed in the 1960s, made it difficult to obtain essential items. Its reinforcement during the Special Period proved critical in creating an enemy Castro could utilize in promoting his health reforms. He could easily and correctly accuse the United States for the lack of medical materials and food shortages. Thus, health reforms became a metaphor for the Cuban struggle against imperialism. They became tainted with political goals hidden behind a “moral architecture” that divided the world “into us and

them, good and evil, healthy and diseased.”4 After the collapse of the Soviet bloc in 1989, Cuban dependency on Soviet foodstuffs meant the country had to quickly devise a plan to provide its citizens with basic agricultural products. From 1990 to 1994, food production decreased by about 40 percent.5 A tightening of the US trade embargo in 1992, through the Cuban Democracy Act6 as well as hurricanes in 1993, 1996, and 2001, further devastated the vulnerable Cuban economy. Starvation and malnutrition became a common experience for many Cubans, who were forced to cut calorie-intake.7 In addition to a changed diet, the 1990’s subjected Cubans to a change in lifestyle as the majority of citizens were forced to walk or bike to their destination due to the unavailability of fuel.8 Because of the presence of organic food and increased bicycle use, there was a decrease in deaths linked to obesity. Between 1997 and 2002 deaths caused by diabetes declined by 51%, coronary heart disease mortality dropped 35%, and stroke mortality by 20%. Obesity in the southern coastal city of Cienfuegos tumbled from 14.3% in 1991 to 7.2% in 1995. There were also major public health problems

caused by insufficient nutrition. The most notable of these problems was the optic neuropathy of the 1990s. Food was strictly rationed, and the state was supposed to provide six pounds of rice, six pounds of sugar, twenty ounces of beans, fourteen eggs, and twelve ounces of meat substitute called picadillo texturizado. Picadillo consists of small amounts of meat mixed with large amounts of soy and animal blood for weight and protein. The government was also supposed to provide “Cerelac,” a soy-based milk-substitute. Maria, a Cuban woman who lived in Havana in 1996 told a World Affairs reporter that she believed eating so much soy caused her friend’s optic neuropathy problems.9

the Pan American Health Organization (PAHO) determined that 50,000 of 11 million inhabitants were suffering from optic neuropathy, deafness, sensory neuropathy, and a spinal cord disorder that impaired walking and bladder control. They determined the cause was a spare diet caused by food shortages combined with physical exertion cased by an inefficient transportation system. This caused a severe thiamine deficiency and the outbreak of blindness.11 Although lack of meat was an evident health problem, if someone was discovered with beef or pork in the refrigerator, the individual could be sentenced to jail for up to four years.12 Because the agricultural revolution affected the cuisine and the health The of Cuba, it also affected the Special Period is social fabric of the Special Period. The increased use sometimes of human resources and increased privatization in referred to in agriculture caused a shift Cuba as la tempo- in social practices. The rada de vaca flaca, population was collectively subjected to these changes “the skinny cow while undergoing an economic crisis, thus increasing period.” the importance of human in Maria’s friend’s optic teractions and relationships. neuropathy problems were The Special Period is somenot an isolated case. Re- times referred to in Cuba as ports of a mysterious disease La temporada de vaca flaca, that blinded people began “the skinny cow period,” in in 1993.10 Physicians from reference to the shortage

A farm in Cuba during the Special Period. Photograph by Adam Jones.

of food during this period. The shortage of food led to moral dilemmas for people who were torn between sharing with their neighbors and providing only for their immediate family. The importance of honorable behavior and hospitality in Cuban culture caused further dilemmas regarding food’s power to incite feelings of shame in Cubans.13 The collective experience of a hungry society defined the creation of a national

identity rooted in struggle – physical, mental, and moral. Cuba’s achievement in the health level of its population through agricultural reform is undeniable, yet inapplicable to most nations. The government’s central control over the economy and its attempt to allocate resources equitably is unique to Cuba’s socialist regime. In addition to agricultural reform, Cuba’s physician-based high-technology system also contrib-

uted to the improvement of Cuban health statistics. Other developing nations often do not focus their resources on the heath sector in the way Cuba has. For them, a paramedic-based, low-technology system is a cheaper and more realistic alternative.14 While it can be argued that the goals of the government are irrelevant to the success in improvements in population health, it is imperative to notice it

Period are admirable because they demonstrate that a Third World country can achieve First-World health statistics even during a crisis; however, Cuba’s approach cannot be fully endorsed because health success extends beyond statistics. The success of Cuba in health statistics does not make up for its failures in housing or medical provisions. Admirable health statistics do little to mask the poverty of the nation. Paul Farmer, a prominent health care activist, during a discussion with fellow Harvard professors, complemented Cuba’s public health. While other professors argued that Scandinavian countries were the best example of how to provide great public health and political freedom, Farmer said they “were talking about managing wealth” and in Cuba’s has a direct effect on the vestments that were instead case, he “was talking about 17 quality of life of every Cuban directed to the health sec- managing poverty.” Cuba’s individual. Castro’s focus on tor.15 Country health indica- successes then stem from efhealth statistics as keys to in- tors trivialized the health of fectively treating one very ternational recognition and an individual to a generaliza- superficial determinant of influence caused the Cuban tion that became a metaphor health (statistics) in a coungovernment to neglect sec- for the health of the “body try perpetually in la lucha. www tors that equally affected politic.” Because of this view Cubans. If the government of health indicators, Cuban had been concerned with officials regard countries the overall wellbeing of its with poor health indicators people or with socioeco- as “diseased” countries with Jessica Lopez is a junior in Jonanomic development, sectors less interest in improving than Edwards College, studying such as housing and trans- their population’s health.16 the History of Science, Medicine, portation would have re- Cuba’s achieve- and Public Health. You can reach ceived the supplemental in- ments during the Special her at jessica.a.lopez@yale.edu.

Honduras:

Impacting Public Health Through Development Writing & Photography by Lauren Weston

did not know what public health development work meant when I left for Honduras in March; and I am not sure most of the people on my trip knew either. We were Global Public Health

el, and some cement. We lacked the context to understand our projects in the greater scheme of improving the health of poor people in low-middle income countries. We did not see that

about three hours from Tegucigalpa—the capital of the country. Many of the people from El Juté have never even been to the city. 90% don’t own cars and most public buses do not make it as far

this Brigade was just the beginning and not the end. There are about 360 people and 70 homes in the village of El Juté, Honduras. A typical home has one bedroom, a room with a stove, cemented walls, dirt floors, and a pour-flush latrine in the back. There is no electricity, nor are there doors to separate the inside from the outside. El Juté is tucked away in the mountains

as El Juté; they cannot negotiate the 45-minute drive along winding dirt paths made for traveling by horse. It is no wonder the people do not leave often. Children attend one school building until 6th grade but are forced to make the difficult decision about whether to leave all they’ve ever known for high school in the city. This profound level of exclusion from the rest of Honduras has shaped

The beginnings of a stove.

Brigade volunteers that would spend a week in the rural village of El Juté empowering communities to prevent common illnesses through in-home infrastructure development. Our understanding of this work was limited to our assigned projects: building latrines, ventilated stoves, and concrete floors. We did not understand that public health work was more than the result of a hammer, shov-

Global Bridges focused on three tasks: laying concrete floors, constructing indoor stoves, and building latrines. Here, workers stack concrete blocks for the latrine structure (above) and finish by fitting tin doors to the front (below).

daily habits in El Juté. People live according to the sun—men wake up when it rises at 4 am and go to bed when it sets. They are agricultural subsistence farmers who work the land, look after cattle, chickens, and horses and grow their own crops for their families to eat each day. Women spend their time cooking in front of the stove and taking care of the children. I noticed that many of the adult men were missing teeth. A Brigade staff member suspected that this was because they didn’t brush their teeth enough or didn’t have the resources to do so. Doctor visits are infrequent as the closest health center is two hours away by foot. If there is a surplus of crops, the men can sell the extra in a nearby town to make a profit. Each project is associated with improved health status: building and lining properly functioning latrines enhances sanitation and the disposal of waste. Improved latrines feature a clean water basin for dish washing and hand washing with soap after defecation. Pouring concrete floors in the bedrooms and kitchen area contributes to infant health status and hygiene. The dirt floor is their playground. Before they can even walk, these children

crawl, play with their toys on the ground, and immerse themselves in a sea of bacteria that finds its way into their mouths and bodies. The construction of the concrete floors provides a clean foundation for the home and reduces indoor pollution from the outside dirt. The improved stove has a chimney that funnels fumes from burning biomass fuels outside of the home and prevents women and children from inhaling indoor air pollution. Ventilation directly increases longevity because indoor pollution is linked to conjunctivitis, respiratory infections, cardiovascular disease and chronic obstructive pulmonary disease. At the end of the day, the projects themselves are not the champions of health improvement. I have learned that it is more important to focus on maintaining health status with these developments—the role of proper hygiene. Without proper hygiene, the concrete floor, and latrine are rendered useless. The reason is this simple: If people don’t wash their hands after using the latrine, bacteria will spread as they touch food and interact with other people. Or, if people don’t clean the concrete floors, indoor pollution will eventually accumulate and lead to diseases that shorten life expectancy.

It’s hard to imagine that seemingly small habits and changes in our households can impact our health. In fact, environmental health accounts for roughly 1/3 of the total burden of disease on a household, community wide and global scale. Now we know that hygiene is at the heart of development work and health status. We also know that the maintenance of hygiene is out of Brigaders’ control, as it depends on the health habits of the community. But what happens if the families cannot afford soap? What happens when crops fail and there is no surplus to generate income? We are left with a central question of what comes next after Global Brigades has left. In other words, who is responsible for the maintenance of public health and hygiene in El Juté? Is it the community members themselves, the local, and national government? Or is it a combination of them all? As volunteers, our work is done at the end of the week when we have finished installation. The sustainable developments simply prevent the further spread of infectious diseases and bacteria but do not ensure permanent and adequate hygiene. This is dependent on economic opportunity and whether

families can continuously afford amenities like soap. Therefore, health status cannot be understood in isolation. It is inherently tied to the economic opportunities of the families. If women can spend less time cooking on more efficient stoves, perhaps they can spend more time helping to produce surplus crops or pursuing

hours away by foot from the nearest health center, they will continue to have a lower health than people in the city. Although the health centers are free, indirect costs, including a dayâ&#x20AC;&#x2122;s worth of work and pay, are an incredible burden. The role of the local and national governments is critical at this point. They

the government. But with 58% of the national rural population living in extreme poverty , the government needs to act. It is responsible for stocking medicines at local health centers and making sure that even the poor have a chance at receiving equitable treatment. This is why it is difficult to measure the success of pub-

Volunteers flatten a new concrete floor.

educational opportunities. If men are healthier, they are less likely to suffer from disease and can spend more time working and providing for the family. The same goes for children who can then attend more school, perform higher, and either work for their families or go to high school and seek broader opportunities. Increased profit and economic opportunity are steps in the right direction. But as long as community members are two

are responsible for ensuring access to basic health services and initiating community health education programs, even in the poorest and most rural communities. But the governmentsâ&#x20AC;&#x2122; commitment to rural people is shameful. Politicians visit the communities, promising aid and infrastructure during campaigns, and then default on their promises once theyâ&#x20AC;&#x2122;ve been elected to office. The community people have grown tired of this political cycle, and have lost trust in

lic health work because the job is never really done. Our Brigade work was just the starting platform for an upward trajectory that is dependent on government commitment, loyalty, and belief in health as a fundamental human right for all people. www

Lauren Weston is a Sophomore in Pierson College. She is interested in global health, public policy and speaking Spanish. You can reach her at lauren.weston@

The BRICS Wall of Protection: What South Africaâ&#x20AC;&#x2122;s patent policy means for the future of national health

Writing by Alexander Ward 46

2001, the Doha Declaration guaranteed flexibility of public health initiatives within the WTO’s Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). Included in the new legislation is the right for countries to issue compulsory licenses (CLs) for life-saving drugs, outline country-specific terms for the acquisition of these licenses, and adopt stricter patentability standards. Although these new regulations have the ability to lower healthcare costs and increase government revenues if implemented in concert, South Africa’s intellectual property (IP) policy has failed to adjust accordingly. - IP Policy in South Africa Lenient patent standards, bureaucratic roadblocks to compulsory licenses, and the lack of a patent examination and opposition system characterize South African IP policy. Currently, patent applications need only meet the soft requirements of a regulatory bureau. South Africa does not provide channels for third party opposition or oversight, allowing applications to escape public scrutiny during the filing process. As a result, patents are granted on the assumption

of validity, not subject to public discourse until after approval—at which point revocation of the patent is more difficult. Additionally, patents are often granted for the “ever-greening” of drugs, a pharmaceutical company’s attempt to extend the life of a patent through small adjustments to the drug, namely new forms, uses, or formulations that have only a marginal impact on efficacy and delay the entrance of generic alternatives. Because South Africa does not explicitly prohibit these strategies, patents extend long past their initial 20year lifespan. Consequently, Drugs are delayed from entering the generic market, where competition can drive prices down. While patents undergo little inspection upon submission, CLs are difficult to obtain. CL applications face opposition by large pharmaceutical companies and fierce litigation battles, costing generic drug companies time and money that deter the production of generics. South Africa has yet to grant a CL for any type of drug and relies instead on generics for which the patent has expired. While these drugs have undoubtedly improved the public health landscape in South Africa, new diseases and mutations, especially HIV,

necessitate the procurement of generics for drugs currently under patent. IP policy in South Africa discourages South African innovation and facilitates patent acquisition by foreign companies. In 2008, 1,988 of the 2,442 patents granted in South Africa came from American or European countries, while just 16 were identifiable from South African companies.1 Public health concerns aside, it is clear that current IP policy largely serves the interests of multinational companies (MNCs) seeking to capitalize on lenient patentability standards. While it is likely that South Africa hopes to procure foreign direct investment (FDI) by extending patents to MNCs, the tradeoff has been the stifling of domestic innovation. South Africa has resultantly been unable to contain the lifespan of foreign pharmaceutical patents, failing to cultivate a generic drug industry that would enhance access to affordable drugs. Furthermore, the Companies and Intellectual Properties Commission (CIPC) derives little benefit from the current system, generating much lower revenues than those seen in the IP offices of comparable nations, who charge higher patent filing and retention fees. In other BRICS coun-

A map of the BRICS Countries. Image by João Felipe.

tries, proactive adjustments to IP policy have facilitated generic drug manufacturing, lowering the cost of life-saving medicines, generating remarkable government revenues, and spurring economic growth. - IP Policy in the BRICS There exist marked differences between IP policy in South Africa and the other BRICS countries. Brazil, Russia, India, and China employ both an examination system to evaluate the validity of a patent and pre- and post-grant opposition measures allowing for third party intervention. Electronic patent databases allow for quick searches and access to patents filed in other countries, creating a more comprehensive portrait of the patent landscape. As a result, it is easier for these

countries to reject patents on evidence of ever-greening, including lack of an inventive step and minimal contribution to the public good. To put the effects of these policy differences into perspective, Brazil granted 273 pharmaceutical patents between 2003 and 2008 while South Africa granted 2,442 in 2008 alone. Each country features different policy nuances that allow them to derive benefit from IP policy. The first case study is India, who—through its development of a patent application process, increase of patent filing fees, and commitment to fostering a robust domestic drug industry—has used TRIPS flexibilities to further healthcare and development goals. Patents filed in India undergo a rigorous examination process, including publication

in a patent journal that examiners then inspect for true innovation. Third party preand post-grant opposition opportunities also allow the public to analyze both the patent filing and the examiners’ work, effectively creating a system of checks and balances that ensures patents granted are legitimate. Economically, the new policies have led India’s IP department to increase its contribution to government revenue. The patent office generated R 417,339,975 in revenue in 2010-2011, nearly double the amount accrued in 200910, when profits totaled R 195,000,000.2 Revenue growth has been disproportionately positive in comparison to growth in the number of patent filings. Over the 20-year lifespan of a patent, patent retention costs

an average of R 1,786 per year, with initial filing and examination fees amounting to R 887.3 The sum of South Africa’s average annual retention fee (R 143) and its initial filing fee (R 730) amounts to less than 10% of India’s equivalent figure.4 Furthermore, since 2005, when CLs were first required to override patents in the country, India has become a standard bearer for affordable healthcare through generic drug manufacturing and compulsory licensing. Granting a CL to Natco Pharma for Bayer’s kidney and liver cancer drug Nexavar, the Indian government in 2012 successfully brought down drug price from Bayer’s $5,600 per month to $175 per month, less than 4% of the original price.5 Through capitalization on TRIPS flexibilities, India has constructed an IP policy that rewards genuine innovation, drives government revenue, and benefits a robust generic drug industry. In Brazil, too, IP policy changes have been used to bring its citizens access to more affordable healthcare, through the facilitated development of an enormous domestic pharmaceutical industry. Policy initiatives, such as the 1996 amendment providing for CLs, have allowed the generics industry to expand,

with sales multiplying by eight times between 2002 and 2009 and over 2,700 new products being registered.6 Article 68 of Brazil’s IP Law even requires patent owners to manufacture their products in Brazil or accept compulsory licensing of those products. Just one month after defending its position in a meeting with the WTO, Brazil gained access to two HIV drugs from Merck, at discounts of 59% and 65%.7

Generic drugs now produce sales of $5.5 billion per year, comprising 20% of the pharmaceutical industry. Brazil has issued CLs on drugs currently under patent and has leveraged their IP policy against the interests of the international pharmaceutical industry to procure significant price reductions for life-saving drugs. In 2005, Brazil announced that it would issue CLs for anti-

Sister Kasiyamuhuru displays anti-retrovial pills which are given to patients testing HIV positive. Photograph by the Elizabeth Glaser Pediatric AIDS Foudation.

retroviral drugs, which had assumed 85% of their total AIDS program budget. After a series of unsuccessful meetings with Merck Sharp and Dohme, Brazil then acted in 2007 on their previous assertion by issuing a CL for Efavirenz, a drug used to treat HIV, dramatically decreasing prices. But beyond just demonstrating the importance of CL issuances, Brazil is a testimony to how the threat itself of CL issuance has also been critical in lowering healthcare costs. In 2001, Roche agreed to sell Viracept in Brazil at a 40% discount to avoid a compulsory license. Later in 2005, the same fear of CLs allowed Brazil to obtain Kaletra, another HIV drug, at a 46% discount, as well as a technology transfer upon patent expiration.8 By using their IP policy as a counterbalance to the interests of pharmaceutical companies, the Brazilian government facilitates access to more affordable healthcare for its citizens. Like Brazil and India, China has established a rigorous patent examination system that relies on criteria such as novelty, inventiveness, and utility.9 In evaluating this last parameter, China assesses empirical evidence of drug efficacy, based on results from clinical trials. While providing for pre-

and post-grant opposition, China also allows for the reexamination of a rejected patent, should the patent filer believe their application to be misevaluated. In this way, the patent office displays a commitment to both public and private interests. In 2008, China explicitly allowed for more developed countries to export generic drugs to countries without their own manufacturing capabilities, with the approval of the â&#x20AC;&#x153;August 30 decision,â&#x20AC;? a piece of WTO legislation designed to promote CLs. Also known as the early working exception, the Bolar exception was also established to enable generics companies to prepare for the manufacture of a drug still under patent. Third parties can thus be ready to distribute the generic version of a drug immediately upon patent expiry, ensuring continued and increased drug access.10 The development of an IP policy implementing TRIPS flexibilities would move South Africa closer to controlling its AIDS epidemic. Adjustments to the current policy would encourage genuine innovation and ensure that public health issues take precedent over the interests of private companies. In doing so, South Africa could improve public health while also

driving economic growth and government revenue. - Learning from the BRICS The IP policies of the other BRICS countries provide valuable references for developing South Africaâ&#x20AC;&#x2122;s own IP policy. Features like patent examination systems, pre- and post grant opposition, and increased filing fees would both legitimize South African IP policy and bolster the strength of the patent office. It would first ensure that patents granted in South Africa represent genuine innovation and are neither ever-greening technologies nor useless inventions. In a related vein, the number of patents filed would be reduced, allowing the patent office to concentrate on conducting more comprehensive examinations of the higher-quality pool of filings. Through pre- and postgrant opposition rights, the public would also gain the chance to serve as patent regulatory authorities and have greater voice in IP developments in South Africa. As it is, drug companies and their lobbyists enjoy a disproportionate influence in IP policy. Bringing South African patent filing and retention fees in line with those of the countries previously examined

Leaders of the BRICS Nations in 2012. From left to right, Dilma Rousseff, president of Brazil, Vladimir Putin, president of Russia, Manmohan Singh, prime minster of India, Li Keqiang, premier of the People’s Republic of China, and Jacob Zuma, president of South Africa. Photograph by Panalto.

would grant patents greater legitimacy and offer patent holders increased incentive to market their products. Adjusting patent fees, incorporating an examination system, and facilitating pre- and post-grant opposition should be the foundation of a revamped South African IP policy. In the implementation of a new IP policy for South Africa, a cost-effective strategy can be developed from the successes of other BRICS patent offices. To accommodate the expenses of building a vertically structured patent examination system and database—which would ensure confidentiality of patent fil-

ings and give the South African government complete control over domestic IP— patent-filing fees should be raised. An alternative would be to use aspects of other BRICS patent offices’ examination systems and patent databases. India and Brazil, for example, have shown competency and rigor in patent procedures and could absorb at least a portion of South African patent filings. Access to an established examination system would both serve to legitimize South African patents and ensure that South African patents could be marketed across the world, a factor essential to establishing South Af-

rica in the global economy. The only disadvantage to using foreign patent offices would be the increased risk of IP theft and greater difficulty in process regulation. In this author’s opinion, it would be best to create a combination of these two approaches. South Africa should establish a viable examination system within the context of a reworked patent filing protocol while also utilizing foreign patent databases to perform the search process. In this way, South Africa could retain control over its patent filings while drawing on the valuable resources of other countries.

- Economic Effects of IP Policy and Compulsory Licensing Opponents of stringent IP policies and CLs often form arguments based on the measures’ perceived effects on economic growth, specifically FDI. Critics assert that MNCs are less likely to invest in countries where patents are more difficult to obtain and where there is potential for a patent’s override by a CL. China is often cited as an example of this principle—FDI has increased rapidly, in face of a government reluctant to issue CLs for the production of pharmaceuticals. However, no empirical evidence exists to support the link between increased FDI and lenient patentability standards, or a lack of CLs. In fact, South Africa’s own FDI has decreased nearly 50% from 2008-2012, falling from $9 billion to $4.6 billion, which represents a decline in percentage of GDP from 3.3% to 1.2%. South Africa has also fallen behind its peers in high-technology exports over the past two decades. The country’s share of global high-technology exports stagnated at 0.07% from 1992-2005, while Brazil—a country featuring strict patentability standards—saw a share that grew from 0.29%

to 0.49% during the same period, as its generic drug industry gained momentum.11 FDI and IP policy do not have a strong direct correlation, and FDI in South Africa has suffered under the current legislation. Lack of robust economic growth and FDI under South Africa’s current IP policy supports the need for a change in patent laws and for the issuance of CLs, which would allow South Africa to take advantage of escalating drug demand on the continent. With African pharmaceutical spending expected to reach $30 billion by 2016, facilitating generic drug production through the issuance of CLs would give South Africa an opportunity to compete in a growing market.12 South African generics companies would enjoy competitive advantages in transport costs and local political relationships, making them attractive for contracts with sub-Saharan countries. Though generic producers are currently constrained by high prices for Active Pharmaceutical Ingredients (API), which are currently monopolized by China, it is likely that generics companies in Africa could negotiate better rates and thus become more attractive to the market. This option should be

explored and would allow South African companies to enjoy a more developed infrastructure, to make the continent more pharmaceutically self-sufficient. South Africa cannot hope to enjoy the benefits of new IP policy or CLs without the political will of government. To give TRIPS flexibilities, the Doha Declaration, and WTO legislation meaning, the South African government must take initiative to use this legislation for the good of the people. In Brazil, the government’s use of legislation to counter the interests of Big Pharma allowed the country to bring down drug prices and, in some cases, issue CLs. Through the strength of their political will, Brazil was able to stand up to the interests of the pharmaceutical researchers and manufacturers of America (PhARMA) and have since garnered more affordable healthcare and massive economic benefits. South Africa can mirror Brazil’s success in resisting the efforts of pharmaceutical lobbyists. - Conclusion IP policy will play an increasingly important role in shaping South Africa’s response to the HIV/AIDS epidemic. In a country struggling to meet its public health goals on account of

artificially high drug prices influenced by foreign pharmaceutical companies, the acquisition of cheaper drugs through CLs and the institution of a patent examination system to ensure high standards for innovation would allow the country to treat more people suffering from HIV/AIDS. The

resulting support of bona fide inventions with cutting edge technology would also drive South Africa forward. South Africa can learn from the IP policies of the BRICS and should collaborate with these countries for the exchange of resources and ideas. With a combination of political will

and thoughtful policymaking, South Africa can better combat HIV incidence. www

Alex Ward is a Junior in Saybrook College. He is interested in Global Health and Development policy. You can reach him at alexander.ward@yale.edu.

Spina Bifida in Kenya

Beyond the Case Studies Writing by Millie Chapman

pina bifida is a neurological disorder caused by the incomplete closing of the neural tube during embryonic development. It can lead to paralysis, abnormalities of the cerebellum, and orthopedic problems, among others. There is a high rate of Spina bifida in Kenya, where I spent this past summer geolocating, and creating a database for, spina bifida cases. These cases were recorded by the pediatric neurosurgery team at Kijabe AIC Hospital, a referral hospital for all of East Africa. An increased

understanding of spina bifida is important due to the permanence of neural tube defects and the extreme shortage of pediatric neurosurgeons in Kenya. The goal for the project was to construct a data set to approximate relative incidence of spina bifida in the areas of Kenya served by Kijabe Hospital in order to explain the high rate of spina bifida in Kenya and potentially establish a link between this disease and malaria. Luke Myhre (DC â&#x20AC;&#x2DC;14) and I formulated a study to search for a geographical

correlation between the two diseases. The link between spina bifida and Malaria is a logical hypothesis since both Plasmodium falciparum, the parasite responsible for malaria, and neural tube development depend on prenatal folate levels. The proven efficacy of folic acid supplements in reducing the incidence of spina bifida may contribute to the reduction of malaria if a clear link between these diseases can be established. Upon arrival at Kijabe Hospital, we had the opportunity to meet with

Neurosurgeon Leland Albright. Having practiced in Africa for 8 years as one of two neurosurgeons in East Africa, Dr. Albright had a significant number of cases from all over Kenya. He was able to introduce us to Billy Nganga, the database administrator for Bethany Kids (a funding program to pay for all pediatric neurosurgery cases at Kijabe). Billy, a previous spina bifida patient treated by Bethany Kids in 2004, helped us with the acquisition of the case data. We were eventually able to find over 1800 cases with listed hometowns to use in the incidence maps and seasonality graphs we created. However, while on early morning rounds in Kijabe with the neurosurgery team, I realized that clinical data could not possibly tell the whole story. Even the best neurosurgical treatments cannot always cure spina bifida patients. Dr. Albright is incredibly skilled. He is the first author on a popular textbook used in medical education today and practiced for over thirty years in the U.S. before relocating to Kenya. Even so, his patients would return to the hospital with multi-drug resistant UTIâ&#x20AC;&#x2122;s, infected shunts, and severe malnutrition. They received the requisite treatment, but surgery was not always sufficient to

give these children a chance at a healthy life. And these were the lucky children. These were the children who made it to the hospital. My summer in Kenya showed me that there is more to medicine than clinical practice, more to health than high life expectancy, more to spina bifida cases than surgery. There is a social component to health, which includes inequity, stigmatization, and medical access. There is a human component to medicine; a component of understanding health and illness that hard science, medical procedures and statistics do not address. I hope that the research we did this summer becomes a paper of incidence maps and seasonality graphs and translates into meaningful impact. It addresses the larger social issue through policy changes that focus on the needs of individual patients from inadequate access to medical resources to decreased stigma of neurological disorders. I hope an analysis of the diseaseâ&#x20AC;&#x2122;s spread will help propose preventative measures for expectant mothers and reduce spina bifida and malaria incidence, because palliative care simply will not address every facet of this problem. www

Millie Chapman is a Senior in Timothy Dwight College. She studies African cultures. You can reach her at melissa.chapman@ yale.edu

Citations From “Turkey: The Path to Healthy Governance” by Cody Kahoe 1. For a short look at the protests’ origins, see http://www.aljazeera.com/news/europe/2013/06/2013624472314251.html 2. Arsu, Sebnem. “Turkish Protesters Are Still Said to Be Ailing From Tear Gas.” The New York Times. September 25, 2013. http://www.nytimes.com/2013/09/26/world/europe/turkish-protesters-are-still-said-tobe-ailing-from-tear-gas.html?_r=0 3. “Turkey: End Incorrect, Unlawful Use of Teargas.” Human Rights Watch. July 17, 2013. http://www.hrw. org/news/2013/07/16/turkey-end-incorrect-unlawful-use-teargas 4. “Press Release and Open Letter: Nobel Laureates Condemn Turkish Government’s Treatment of Protesters and Doctors.” Jadaliyya. July 22, 2013. http://www.jadaliyya.com/pages/index/13104/press-releaseand-open-letter_nobel-laureates-cond 5. http://www.ttb.org.tr/en/index.php/tuem-haberler-blog/179-ttb/1216-is-volunteer-health-services-and-humanitarian-intervention-to-gezi-park-protestors-legal-or-not6. “Urgent Call from Turkish Medical Association.” Turkish Medical Association. June 16, 2013. http://www. ttb.org.tr/index.php/Haberler/cagri-3870.html 7. “We Have Been Practicing Medicine Here on This Land for Thousands of Years and Keep Doing That!” Turkish Medical Association. June 29, 2013. 8. “Home Page.” Turkish Medical Association. Accessed October 18, 2013. http://www.ttb.org.tr/en/ 9. It turned out that the water canons had been spiked but only with a dye to identify protestors and rioters after the fact. 10. “Country Profile: Turkey.” Library of Congress—Federal Research Division. August 2008. http://lcweb2. loc.gov/frd/cs/profiles/Turkey.pdf 11. Tatar, Mehtap, Salih Mollahaliloğlu, Bayram Şahin, Sabahattin Aydın, Anna Maresso, and Cristina Hernández-Quevedo. “Turkey: Health System Review.” Health Systems in Transition. Vol. 13, No. 6. (2011). 12. Ibid. 13. Ibid.: Akinci, F., S. Mollahaliloglu, H. Gürsöz, and F. Ogücü. “Assessment of the Turkish health care system reforms: a stakeholder analysis.” Health Policy. September 2012. http://www.ncbi.nlm.nih.gov/ pubmed/22652336; Dombey, Daniel. “Reforms prove bitter pill for Turkey’s doctors.” Financial Times. 30 April 2012. http:// www.ft.com/intl/cms/s/0/81faf2f2-92be-11e1-b6e2-00144feab49a.html#axzz2jPLlrV1o. 14. Turkish Government urged to Restore Powers to Medical Association.” World Medical Association. April 28, 2012. http://www.wma.net/en/40news/20archives/2012/2012_08/

From “Rethinking Priorities in Global Health: Focusing on Quality of Care at Walimu” by Elija Glodberg 1. “Integrated Management of Childhood Illness (IMCI),” WHO. last modified 2013, http://www.who.int/ maternal_child_adolescent/topics/child/imci/en/. 2. Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Dr Joanna RM Armstrong Schellenberg PhD, et. al. The Lancet - 30 October 2004 ( Vol. 364, Issue 9445, Pages 1583-1594 ) DOI: 10.1016/S0140-6736(04)17311-X

From “Beyond ARVs: Prescribing Housing to end AIDS in New York City” by Juliet Glazer 1. Shubert, Virginia and Bernstein, Nancy. Moving from Fact to Policy: Housing is HIV Prevention and Health Care. AIDS Behav (2007). 2. National Alliance to End Homelessness. “Homelessness and HIV/AIDS.” Aug. 2006. Available from http://www.endhomelessness.org. Quoted in National Coalition for housing. “HIV/AIDS and Homelessness.” July 2009. http://www.nationalhomeless.org/factsheets/hiv.html 3. Shubert, Virginia and Hombs, Mary Ellen. “Housing Works: Housing Opportunities for Homeless Persons.” Clearinghouse Review (1995). 4. Ibid. 5. Phone interview with Ginny Shubert, conducted by Juliet Glazer. October 14th 2013.

From “The Cuban Special Period” by Jessica López 1. Hugh Warwick, “Cuba’s Organic Revolution,” Forum for Applied Research and Public Policy, 16 (2001): 54. 2. Julie M. Feinsilver, Healing The Masses: Cuban Health Politics at Home and Abroad, (Los Angeles: Berkeley: University of California Press, 1993), 5. 3. Ibid. 4. Julie M. Feinsilver, Healing The Masses: Cuban Health Politics at Home and Abroad, 22. 5. Ibid. 6. Hugh Warwick, “Cuba’s Organic Revolution,” 54. 7. Rory, Caroll. “ Economic crisis boost to health of Cubans.”The Guardian, September 26, 2007. http:// www.guardian.co.uk/world/2007/sep/27/cuba.international (accessed March 10, 2013). 8. Ibid., 72. 9. John Sweeney, “Seven Days in Havana: How Castro’s Market Socialism Works,” World Affairs, 159, no. 1 (1996): 16. 10. Sergio Diaz-Briquets, and Jorge F. Perez-Lopez, “The Special Period and The Environment,” 289. 11. Ibid.

12. Ibid., 17. 13. Christiane Paponnet-Cantat, “The Joy of Eating: Food and Identity in Contemporary Cuba,” 26. 14. Julie M. Feinsilver, Healing The Masses: Cuban Health Politics at Home and Abroad, 198. 15. Julie M. Feinsilver, Healing The Masses: Cuban Health Politics at Home and Abroad, 199. 16. Ibid., 23. 17. Tracy Kidder, Mountains Beyond Mountains, (New York: Random House, 2003), 194.

From “The BRICS Wall of Protetion: How patnet standards will determine the furture state of health in South Africa” by Alexander Ward 1. “TAC and MSF welcome government’s announcement that the draft IP policy will be presented to Cabinet on 5 December 2012,” last modified October 29, 2012, http://www.fixthepatentlaws.org/?p=459. 2. “Patent Office’s revenue up at Rs 250 crores; to hire 257 examiners,” last modified Apr. 3, 2012, http:// www.deccanherald.com/content/151032/patent-offices-revenue-up-rs.html. 3.”Patent Cost per Country,” last modified 2013, http://www.patentvista.nl/kosten_taksen_overzicht_ en.php. 4. Ibid. 5. “India Rejects Bayer Plea Against Cheap Cancer Drug,” last modified March 5, 2013, http://bigstory. ap.org/article/india-rejects-bayer-plea-against-cheap-cancer-drug. 6. “Portal Brasil,” last modified 2013, http://www.brasil.gov.br/sobre/science-and-technology/health-technology/the-pharmaceutical-industry/. 7.“Timeline for US-Thailand Compulsory License Dispute,” last madified April 2009, http://infojustice.org/ wp-content/uploads/2012/11/pijip-thailand-timeline.pdf. 8. “Timeline for US-Thailand Compulsory License Dispute.” 9.” Intellectual Property Rights and Access to Affordable ARVs in China,” last modified April 12, 2013, http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/intellectua l-property-rights-andaccess-to-affordable-arvs-in-ch/.” 10. Ibid. 11. “The Economics of Intellectual Property in South Africa,” last modified June 2009, http://www.wipo.int/ export/sites/www/freepublications/en/economics/1013/wipo_pub_1013.pdf. 12. “Africa: A ripe opportunity,” http://www.imshealth.com/ims/Global/Content/Insights/Featured%20 Topics/Emerging%20Markets/IMS_Africa_Opportunity_Whitepaper.pdf.