Family Planning

In seminar #5, Yury took us through a few case studies on Reproductive Health and Family Planning. We also went through different scenarios concerning issues of family planning in the developing world, and discussed how we would approach these issues, keeping in mind context and cultural sensitivity. The most interesting message I took away from this seminar is how far-reaching and pervasive the effects of good family planning can reach. Proper contraceptive use, for example, will not only positively affect the health of the mother, but also ensures significant resources available for every family member to thrive. Essentially, proper family planning procedures ensures the health and livelihood of every single family member.

Moreover, proper family planning initiatives enter the realm of tackling social stigmas and cultural perceptions. If contraceptive use is generally frowned upon in a society, couples will be far less likely to use it or seek out alternative options. In addition, if getting an abortion carries a stigma in a society, it is far more likely for women to attempt unsafe self-abortions. These issues are among the multitude that can be addressed in a particular society to try to normalize family planning procedures and educate couples on all of their options.

Finally, another important point addressed by the seminar was the importance of including men in the conversations on family planning. This is an aspect of family planning often overlooked, but it actually quite important. If men are educated on the benefits of proper family planning—especially the impact on the health of their wife—they would be far more likely to agree with complying. Men’s compliance is vital for proper family planning to work successfully, and it is important to address them specifically in family planning initiatives.

For more videos about the impact of family planning please visit: http://www.pathfind.org/site/PageServer?pagename=WalkWithUs_video

World Bank and IMF

Angel's Seminar was helpful at introducing the goals of the World Bank and IMF and the various economic theories used to try to attain them. I am looking forward to learning more from the seminars series. I found a brief 7 minute BBC video on examples in recent history of how The World Banks strategy has backfired and actually created more Poverty in many countries across the globe.

http://www.youtube.com/watch?v=DrynBzUpyag

9 AM

Women & Global Health

When we discuss aspects of global health and define the problems that exist, we must always remember that each and every barrier to health that exist is that much higher for women. HIV, malnutrition, endemic tropical diseases. Women not only suffer from these diseases right alongside the men, but they also face the complications of repeated pregnancies which further increase their mortality rate. Not only are they facing the health risks associated with reproduction, but they also often lose the chance to receive an education and establish any independence.

Hundreds of thousands of women die each year in developing countries as a result of pregnancy-related complications. Millions of women want to delay or completely avoid pregnancy but are unable to due to lack of access to effective contraceptives or the inability to make the decision for herself to use contraceptives. Adolescent girls face repeated pregnancies beginning at an early age and often miss their opportunity to, at best, finish an education, or to even survive childbirth or worsening malnutrition and make a health transition into adulthood.

While working in Ghana several years ago, I participated in a community outreach program that involved traveling by foot through villages and administering Depo Provera shots to women while their husbands were working in the fields during the day. These women would be waiting at the road on the first Monday of every 3 months, desperate to receive their shot and have the comfort of knowing that they had prevented a pregnancy for another 3 months without their husbands' knowledge. They were able to sleep peacefully at night without worrying that their husband will refuse to wear a condom, will feel the bumps of Norplant in their arm or the string of an IUD in their uterus, or find a packet of pills.

It seems that the international community has recognized that in order to meet goals such as improving worldwide rates of malnutrition or decreasing poverty, women's reproductive rights must be protected and access to reproductive health care needs to be readily available. Once this crucial goal can be met, women will be able to contribute to their societies and, most importantly, will suffer just a little less.

Patents

Courtesy Yousuf Ahmed:

So in the beginning of our last GHLP session (sad day), we saw a video on a alternative system to the current patent system. Right now, if a pharmaceutical company develops a drug, it patents said drug for a specific amount of time, usually between 6-20 years, which means that no other pharmaceutical company may manufacture said drug or research on said drug without a license to do so. It’s a way to reward inventors for their hard work, yet this practice has come under fire for stifling innovation, creating unreasonable barriers to drug availability through high prices, and the overall lack of new medications.

What this patent pool tries to do is fix these disparities, specifically with respect to HIV medications in Africa. A patent pool is a sort of sharing agreement between companies, meaning that the companies can cooperate and use otherwise unavailable drugs and research in order to develop new treatments. For HIV specifically, this can mean that new combination medications can be developed so rather than taking 3 pills at a time, one can be sufficient, or that new children centric medications can be researched. And for the inventors, they are paid a fair royalty for using their work in new applications, new drugs. Sound perfect right? What reasonable individual could say no to this?

Pharmaceutical companies for one find it easy at times to say no. Why? I can’t really say for certain, because I’m not on the board of a major pharma house, but in my experience working at a small pharma company the reason that drives most of these companies away from such a power sharing agreement is just that basic idea, they have to share power. Corporations exist to serve their investors, and they do that through the accumulation of power and wealth. In their eyes, the patent pool is a move away from that basic idea, for the patent pool would cut into their profits and increase their competition. There is no perceived benefit in the eyes of the company.

So how could a patent pool be attractive to the companies involved? One benefit is by decreasing the cost of research through increasing cross talk between different companies, previously underserved markets can open for better business exposure. Innovation increases as patents become open, look at the patents on the steam engine where once the patent was lost and the field opened, innovation dramatically grew. And with all this cooperation comes the fair royalty payments, meaning while the companies wouldn’t be getting as much as they could with a normal licensing deals, they would still be compensated at some level for their product. And finally, while I made a effort to explain that corporations have no real need to act morally, at the end of the day a corporation is made up of individuals, and it is through these individuals that we can change our view on global corporations to one that is more ethical and moral.

http://www.youtube.com/watch?v=Vj0dbFgjoh4

A few sessions ago, we discussed primary health care and what exactly that term means to us. What services fall under the umbrella of providing primary health care? Most people would argue that primary health care includes the basics, providing immunizations, preventative care, and emergency care. But where does the category of mental health belong? I think the majority of the time, mental health tends to fall into the background amidst larger international efforts of trying to combat the global killers including HIV/AIDS, malaria, TB, etc. Unfortunately mental health is not only underrepresented in terms of allocated resources, but also in terms of recognition as a significant health issue.

Last summer, I spent some time traveling throughout Rwanda, and I was reminded of those memories as we discussed mental health in post-genocide Rwanda in the seminar. Walking through the streets of Kigali, it was difficult to imagine the destruction and horror that gripped the country in 1994. From an outsider's perspective, it appeared that everyone now identified as a Rwandan. Not once did we hear the words Tutsi or Hutu come up in casual conversations. It appeared the country had successfully moved on; the infrastructure was impressive in Kigali and a quiet peace seemed to resonate through the small city. But upon closer inspection and some deeper conversations with some Rwandans, it became apparent that many people had not forgotten--the hotel owner in Kigali who lost both his mother and father and most of his siblings--the young woman working at the Gikongoro genocide memorial where over 50,000 people, mostly women and children, were slaughtered and buried in mass graves. Now walking through the streets, I would look at each person and wonder the impact the genocide had on them. Were they old enough to remember seeing their parents killed? How many family members did they lose? Or how many people did they kill? As these thoughts and questions ran through my head, I began to wonder how oftenRwandans asked these same questions in their own heads, adn what effect these thoughts would have on their overall wellbeing and health. Many of the survivors stories have been shared at the Kigali Memorial Centre, and here are the words of 11-year-old survivor Chantal, "The killers should be put away where I'll never have to see them again. Life imprisonment would do. Just as long as I never have to come across them somewhere, looking after their children, after they took away our parents who brought us up so lovingly."

While post-genocide Rwanda provides a somewhat radical situation to consider the mental health needs of individuals, it is a good place to start. Making mental health a priority post-genocide in Rwanda was recognized as an important strategy for regrowth and rebuilding; however, how often is mental health regarded as a priority or key component in health initiatives in other countries with less drastic circumstances? The challenge remains that health is complex, and it becomes increasingly complex as we consider the impact that stress from poverty, violence, war, etc. can have on an individual's mental health and overall wellbeing.

News from the Front: Success and Failure of Malaria Fighters on Zanzibar

In 2005, 20% of children who presented at health clinics on Zanzibar, an island province of Tanzania off the coast of East Africa, tested positive for malaria. By 2008 less than one percent did. In 2004, 416,911 malaria cases were counted among a population of just over 1 million. By 2007, the number of cases dropped to 14,547.

Wiped from the United States by 1951, malaria remains an obstinate problem in Africa. It causes approximately 1 million deaths each year and drains an estimated $12 billion in annual medical costs and lost productivity in Africa. Since African countries began focused, systematic efforts to reduce prevalence and morbidity of malaria in the 1950s, there have been few bright spots. Zanzibar stands as one of the few places in the world where government efforts along with support from international organizations have brought the disease to its knees.

Zanzibar’s efforts to combat malaria represent a case study in the power and pitfalls of international efforts at disease eradication. The island’s first full-scale malaria control program began in 1958 as a collaboration between the national government, the WHO and UNICEF. By 1968 prevalence fell to 7.8 percent and malaria was no longer considered a health problem and the program was abandoned. Soon thereafter the dangers of this decision became apparent when prevalence rates were measured at 54% in 1973.

The next major attempt to combat malaria began in 1981. The joint initiative between USAID and the Zanzibar Malaria Control Program (ZMCP) lasted six years and was mired in problems from the start. Poor communication between USAID, ZMCP and island health ministries hampered efforts. Among other failings, the ZMCP procured agricultural insecticides unsuitable for use in homes and baseline surveys of disease prevalence were never made and it became difficult to monitor progress and make evidence-based decisions. Eventually the program was terminated without measurable, and certainly not lasting, benefits.

In 2005 the most recent, and so far most successful, effort to eradicate malaria began. Supported by resources and expertise from the African Development Bank, ZMCP, the WHO, Medecins Sans Frontiers and other international organizations, the program was centered around a combination of insecticide-treated bed nets, widespread home spraying, rapid diagnostic kits, lifesaving drugs and public education. Since the program started disease prevalence has been reduced to 1%.

The success of malaria reduction and elimination efforts on Zanzibar is heartening but should be taken with a grain of salt. Epidemiologists who debate the effectiveness of strategies to curb malaria in developing countries agree that islands like Zanzibar, which have a relatively low possibility for reintroduction of the disease, represent the “lowest of the low-hanging fruit”. Additionally, lower exposure to Plasmodium falciparum, the disease-causing parasite, in early childhood will reduce natural immunity, making future generations more susceptible to malaria epidemics. Finally, and vexingly, Zanzibar remains heavily reliant upon external funding for its efforts to control malaria.

Zanzibar has become a poster child for malaria eradication efforts. The most recent efforts showcase the finest that public health proponents and international organizations can hope to achieve in their efforts to eliminate the disease. The island is used on countless websites as an example of the good that international development organization can affect. Moving forward, it will become increasingly important that Zanzibaris and international organizations refuse to become complacent and allow the events of 1968 to repeat themselves. As one of the most famous and often-cited examples of the effectiveness of good global health policy, international organization won’t let that happen any time soon.

Leadership Brain Drain

“Who should be the ideal steward for health to best serve the public's interest?” – In my opinion, this question, raised during our policy seminar, focuses the problems of global health policy and foreign aid onto one salient topic: infrastructure. Infrastructure is a critical backbone to the delivery of any global health policy, and it relies on leadership. A significant amount of leadership behind global health policy and especially foreign aid is concentrated outside of the countries targeted with aid. It makes sense to me that this is unsustainable. We need homegrown leaders managing policy at the ground level. Physicians are probably the most important piece of infrastructure in the global health blueprint, and often enough the nations requiring their leadership to sustain global health advances find it absent.

Physicians are the highest trained leaders within medical society and can best direct the execution of global health policy. Too often, we find that these physicians are lost to developed nations. In Zambia, roughly 600 medical students have been trained at university, yet only 50 have remained to work within the Zambian public health sector. These forces are not unique to Zambia.

“Many Ugandan doctors are poorly paid and have left to

practise in the health systems of more affluent countries,

including South Africa where one of the medical schools

has several senior faculty members from Uganda. The

South African Medical Journal describes a “medical

carousel”, in which doctors seem to be continually moving

to countries with a perceived higher standard of living.4

Pakistani doctors move to the UK, UK doctors move to

Canada, and Canadians move to the USA.”

-quote from “Medical Migration…”

Obviously, the reasons for moving are incentive-based and not malicious in intent. Physicians leave for honorable reasons including economic opportunity, intellectual stimulation, family concerns, and even safety. What’s even more striking to me is the degree to which developed nations like Canada and the United states actively seek out foreign-trained doctors to fulfill their health system’s demand. This perpetuates the brain drain, with foreign doctors comprising the vast majority of the doctors practicing in inner-city hospitals. I think the bottom line is simple: without properly trained doctors, how can developing nations ever hope to properly execute global health policy and sustain health growth?

So how can we fix this? Perhaps soft power (name drop, woot!!!) could help. Developed nations behind the “drain” of “brain drain” must seek to train physicians at a number sufficient to satisfy the demand of their populations. The US could use policy to increase medical school seats and residency slots to satisfy demand and rely less on filling spots with foreign doctors. Developing countries could complement these moves by creating both incentives and policies to encourage physicians to remain in their home countries. At the very least, developed nations could compensate developing nations for the money lost in training a doctor that immigrates. These manners are only a few methods to encourage reduction in medical brain drain, but I like them because they require international collaboration between developed and developing nations to work. If we can begin to slow brain drain, maybe we can then build the infrastructure necessary for developing nations to wean themselves off foreign aid and become the stewards and champions of their own health reform.

Quick refs:

1. Bundred, P., and C. Levitt. "Medical Migration: Who Are the Real Losers?" The Lancet 356.9225 (2000): 245-46.

2. Pang, Tikki, Mary A. Lansang, and Andy Haines. "Brain Drain and Health Professionals A Global Problem Needs Global Solutions." BMJ 324 (2002).