Issue 9, July 2006 P ERSPECTIVE Stay Informed. Get Involved. S Best Buys for Global Health © Crack Palinggi/Reuters/Corbis; permissions through “Rx for Survival” While it may be assumed that the major burdens of disease fall on developing countries, the truth is that microorganisms travel—and adapt. A growing movement of people and goods in an increasingly globalized world means that viruses have more modes of transport, making communicable diseases a concern for all. But it’s non-communicable diseases—like heart disease for example—that remain the world’s #1 killers and affect individuals in developed and developing countries alike. A child receives the polio vaccine in May 2005 in Jakarta, Indonesia. Children under ﬁve years old are brought to polio vaccination posts across the region as part of a national immunization day. Although diseases tend not to discriminate, it is those in poor countries who have little means to ﬁght back and poverty remains a common root cause of ill health. With goverments often committing few resources to healthcare and pharmaceutical companies concerned primarily about their bottom lines, international agencies struggle to ﬁll the voids. There are interventions though where a little bit of money can go a long way. And innovative solutions to health crises—often with the active involvement of local communities—have occured in countries all over the globe. http://us.oneworld.net www.oneworld.net Table of Contents Editor’s Letter In-Depth Taking the Global Pulse - Threats and Solutions Making Money Count - Best Buys to Save Lives Lessons Learned - Getting Healthcare to All From the Frontlines © Bill and Melinda Gates Foundation My Experience - Community Approaches Interview - Featuring Maurice Middleberg Viewpoints - Insights from NGOs Get Involved! Community Space - What do you think? Take Action! (Web Only) Thanks to the following OneWorld partners for their participation! 2 In Kenya, a young girl receives a check-up from her doctor. Editor’s Letter Dear reader, I must confess that I wasn’t initially all that excited about working on an e-zine on the topic of global health. All of us have our strengths, and weaknesses. For my part, I cringe at the sight of blood and have never been drawn to the medical profession overall—although I remain grateful to the many people who devote themselves to serving others in this way! Having said this, I became increasingly interested in global health as I learned more about it. What surprised me was what the mainstream media does—and doesn’t—pay attention to on this topic. Of course, the “topic de jour” in the media world today is potential outbreaks of communicable diseases like bird ﬂu. Don’t get me wrong. If we have a mass pandemic, that’s extremely serious and the way the world community is working together on these threats is an inspiring story in itself. But, the #1 killer in the world today are cardiovascular diseases (CVDs), causing around 17.5 million deaths a year. As one of the stories in this issue points out, CVDs actually account for three times as many deaths in developing countries as AIDS, tuberculosis, and malaria combined. Our diet and lifestyle choices—in the developed world included—have a lot to do with these phenomenal death tolls. And, coming in at a close second are the nearly 11 million children that die annually from largely preventable diseases—diseases that could be cured with fairly low-cost and simple solutions. Alas, these statistics rarely seem reported in the mainstream press because—as one reporter told me—it is old news. Old or not, are resources really going to where they would do the most good? That’s the primary question that this e-zine examines. Billionaire Warren Buffett’s surprising donation to the Gates Foundation in late June to help fund global healthcare is a very welcome development, but makes the allocation of resources more relevant than ever. And, it’s still true that international private and public institutions have had to ﬁll in the gaps because pharmaceutical companies are looking to make proﬁts, many governments don’t make healthcare a priority, and those in poorer countries can rarely afford expensive treatment options. Under this reality, what interventions can save the most lives? We’ve tried to offer examples in this issue of health solutions—largely preventive in nature—that have made a difference when ﬁnancial resources are limited. And, some of the most inspiring examples come from communities that mobilize themselves to get the services they need. But, regardless of the success stories that we share in this issue, the links between poverty and health cannot be overlooked. Poverty is a root cause of many of the diseases prevalent in low-income countries. The environment ﬁts in that equation too because a healthy environment leads to healthier people. Maybe innovations that take a more holistic approach to all three will be the “best buys for global health” in the future. Zarrín T. Caldwell Editor, OneWorld Perspectives OneWorld United States http://us.oneworld.net 3 In-Depth Taking the Global Pulse Threats and Solutions “I am optimistic that in the next decade, people’s thinking will evolve on the question of health inequity. People will ﬁnally accept that the death of a child in the developing world is just as tragic as the death of a child in the developed world. And the expanding capacities of science will give us the power to act on that conviction.” Bill Gates, Jr. Speaking at the 2005 World Health Assembly With the growing movement of people and goods across the globe, communicable diseases have become a mounting concern for all—witness current media attention to the avian ﬂu or the 2003 SARS scare. What may be an isolated incident in a village in Southeast Asia today can become a global pandemic tomorrow. The globalization of disease is one reason why the international community— through organizations like the World Health Organization (WHO)—has tried proactively to stop potential outbreaks at their source. © Wang Haiyan/China Features /Corbis; from “Rx for Survival” Despite overwhelming media attention paid to emerging infectious diseases like avian ﬂu, the number of people currently affected by these diseases is actually very low compared to many other less publicized dangers. When such global health threats do emerge, however, collaboration between research institutions, national governments, international organizations, the private sector, and citizens is vital and can make an important difference, especially where strong health systems are not in place. Consider the campaign against smallpox. A highly infectious disease that dated back to ancient Egypt, smallpox was one of the world’s deadliest killers, taking hundreds of millions of lives in the 20th Century. Thanks to worldwide collaboration on containing the disease, it has now been completely eradicated. The international community’s efforts to combat river blindness in subSaharan Africa and eliminate polio in Latin America are among other notable achievements. (See “Lessons Learned” for more success stories.) Globally, life expectancy has increased more over the past 50 years than at any other time in history. But one’s chances of living a long and healthy life often depend on one’s access to health care, and many lives—particularly in developing countries—continue to be cut short by infectious diseases. Nearly three million people died as a result of HIV/AIDS in 2005, and some 40 million continue to live with the virus—most in Africa. Over 1.6 million succumbed to tuberculosis last year, and nearly 1 million died from malaria. Masks protect students in China from the highly contagious SARS outbreak in 2003. Hitting 27 countries in four months, it demonstrated the speed at which a virus can spread in a globalized world. 4 Many international and civil society groups have focused their attention on combating these three diseases. Yet there are other signiﬁcant health threats that—in combination with the effects of poverty— are taking even heavier tolls. In many cases though, millions could still be saved with simple interventions. A Worldwide Survey Nearly 11 million children under the age of ﬁve still die every year from diarrhea, acute respiratory infections, and other childhood diseases. That’s as many children as all those under ﬁve currently living in the largest 10 U.S. states: from California to New Jersey. The good news is that, only decades ago, this ﬁgure was far higher and many more lives are now being saved due to dramatic increases in global immunization programs. From 1977 to 1990, for example, the number of children under 12-months immunized worldwide increased from ﬁve percent to 75 percent. “The global community has [also] learned how to effectively and efﬁciently deliver affordable vaccination programs at scale,” explains Robert Steinglass, an international advisor who has consulted on immunization programs with Ministries of Health and other organizations in over 50 countries. “We already know how to vaccinate children even in the most crowded urban slums, most impenetrable jungles, and most inaccessible mountain villages.” But despite coordinated efforts to equip the world’s children with basic vaccines to prevent common causes of death like measles and tetanus, funding for child survival has remained stagnant in recent years. With a global focus on AIDS and other high-proﬁle killers, short shrift is being given to longer-term, lower-proﬁle campaigns to vaccinate children. More than two million children a year are still dying from vaccine-preventable diseases, notes UNICEF. Although costs for administering oral rehydration liquids can vary widely, this is another simple solution that can cure the diarrhea that killed almost 1.7 million children in 2005. Better pre-natal, delivery, and post-natal care for mothers and infants could also signiﬁcantly reduce the approximately four million deaths that occur annually during the In-Depth Taking the Global Pulse Worldwide Deaths, 2005 Source: World Health Organization (All ﬁgures in millions & rounded) 0.5 2.4 1.6 0.9 2.8 0.5 2 3.4 7.6 4 2.3 1.7 3.8 0.9 1 17.5 Tuberculosis HIV/AIDS Diarrheal Diseases Childhood Diseases Malaria Respiratory Infections Cancers Cardiovascular Diseases Nutritional Deficiencies Respiratory Diseases Digestive Diseases Genital Diseases Other Perinatal Conditions Maternal Conditions Other Communicable Diseases ﬁrst month of life. The international community recognized these problems when, at a global conference in September 2000, heads of state committed themselves to eight Millennium Development Goals. Two of the eight goals focus on achieving major reductions in childhood and maternal mortality by 2015. A 2005 report on these goals notes good progress in some countries, but cites ongoing high death tolls among women and children in subSaharan Africa and South Asia. Top Killers Reconsidered Statistically, poor people in poor countries are the least able to defend themselves against communicable diseases—due to lack of access to prevention, treatment, and healthcare generally. But that is not the case with non-communicable diseases, which target individuals in rich and poor countries alike. According to the WHO, over 35 million deaths were caused in 2005 by non-communicable diseases, (those that cannot be passed from human to human). These diseases may develop over a long period of time and, among others, include stroke, diabetes, and cancer. 5 Cardiovascular diseases (CVDs)— primarily including heart disease—took about 17.5 million lives in 2005 and are now the leading cause of death globally. Once considered “lifestyle diseases” among those in wealthy countries, they are now the ﬁrst or second leading cause of death in some developing countries. While rarely reported, CVDs actually account for three times as many deaths in developing countries as AIDS, tuberculosis, and malaria combined. In fact, 65 percent of global deaths from CVDs now occur in developing countries. It has become clear that the death toll from CVDs is becoming a crisis in many countries and particularly impacts the poor. Lack of exercise and diets with increasing amounts of saturated fats, sugar, and salt have contributed to the incidence of cardiovascular diseases. Approximately ﬁve million deaths a year can also be attributed to tobacco use, with about one-half to two-thirds of long term smokers (most of them in developing countries) expected to die from diseases caused by their addiction. Increases in tobacco taxes and restricting Non-Communicable Diseases smoking in public places are among proposed solutions. Follow the Money? Global health activists have long claimed that many diseases in low-income countries are being neglected by those with the power to fund their eradication. (These would include dengue and trachoma, for example, which mostly affect vulnerable populations in tropical climates.) In the 1990s, civil society groups like the Global Forum for Health Research and Medecins sans Frontieres pointed out that less than 10 percent of global health research resources were being applied to the health problems of developing countries, which accounted for over 90 percent of the world’s health problems. This imbalance became known as the “10/90 gap.” While investment in health research has risen in the past few years, these organizations claim that there is still a massive under-investment in health research relevant to the needs of lowand middle-income countries. With an eye toward their bottom lines, big pharmaceutical companies typically invest in research and development for new drugs and vaccines that promise a Taking the Global Pulse proﬁt. In other words, the money lies in ﬁnding cures for killers like heart disease, which are also prevalent in the developed world. As a 2005 story from the Science and Development network points out, “During the past 30 years, just one percent of new compounds marketed have been for developing world diseases. And even within these, research priorities (and funding) are skewed towards HIV/AIDS, malaria, and tuberculosis. One reason for this is that such diseases have a crossover with the developed world.” The Drugs for Neglected Diseases Initiative and the Institute for OneWorld Health are among groups working to get more funding directed to neglected disease research. For their part, multinational drug companies generally assert that they have played an important role in developing and producing essential medicines. Neglected diseases account for a very small percentage of deaths in low income countries, they note—compared to major killers like respiratory and diarrheal infections. A December 2003 paper prepared by the International Federation of Pharmaceutical Manufacturers Associations called for public debate to focus on the “most crucial health problems of developing countries.” Tropical diseases, adds Philip Stevens, director of health projects at the International Policy Network, account for only 0.5 percent of all deaths. He goes on to say that developing country governments—not pharmaceutical companies—should be blamed for neglecting the health care of their citizens, due to the high taxes and tariffs they often put on essential medicines and their failure to invest in sanitation, health care, and education. A February 2006 story from Inter Press Service reviews government expenditures on health across countries in the Asia-Paciﬁc region, showing that a country like India, for example, spent only 1.3 percent of its gross domestic product on health in 2002. 6 Critics fault pharmaceutical companies, however, for investing in “lifestyle” drugs aimed at correcting problems like erectile dysfunction (because rich people can afford them) instead of treatments needed by the poor. Perhaps it is some of this bad press that has led some companies—like GlaxoSmithKline, Astra-Zeneca, and Novartis—to develop centers dedicated to global disease research. For them though, this work is done on a “no-proﬁt, no-loss” model. As such, and to better share the costs and risks associated with the development of new drugs, public and private sector organizations have begun to collaborate more extensively. Largely funded by the Bill & Melinda Gates Foundation, these public private partnerships are growing. They include the Medicines for Malaria Venture, which brings together government agencies, research institutions, and private companies to explore ways to develop and deliver new antimalarial drugs. Lab technicians at work in the Rawalpindi Leprosy Hospital, Pakistan. To facilitate research into diseases primarily impacting those in the developing world, advocates have also called for an overhaul of the patent system. While patent laws give pharmaceutical companies ﬁnancial incentives to develop new drugs, they often prevent developing countries from getting access to cheap, generic medicines that they need to save lives. As a broader attempt to reconcile the needs of both companies and patients, the Center for Global Development— through an initiative called Making Markets for Vaccines—has proposed market-based solutions to encourage pharmaceutical companies to invest in researching new vaccines for developing countries. “We all know that good medical care is vital,” says Dr. Paulo Ivo Garrido, minister of health for the Republic of Mozambique, “but unless the root social causes that undermine people’s health are addressed, the opportunity for well being will not be achieved.” Examining Root Causes While developing new drugs is certainly one approach to treating those afﬂicted with life-threatening diseases, many would argue that poverty is the main cause of the diseases prevalent in lowincome countries. In fact, the WHO estimates that diseases associated with poverty account for about half of years of life lost to ill health in the poorest countries. © IRIN News In-Depth A number of civil society organizations working in the health sector argued before the UN last October that, although global health partnerships were critical to addressing the problems in developing countries, they would not have much impact if “neither poverty-related root causes of ill health nor strengthening of health systems [was] addressed.” Those living in slum communities, for example, often have little access to basic amenities like water and sanitation. Indoor air pollution from cooking fuels, food contamination, and crowded, ramshackle dwellings open to the elements all promote illness. In-Depth Taking the Global Pulse Additional Article Sources © John Haskew/International Federation of Red Cross and Red Crescent Societies Various international organizations are also involved in supplying potable water to poor communities—UNICEF is a major funder and there are initiatives like the CARE campaign that helped three million people in 34 countries gain access to clean water and sanitation, reducing the illness caused by poor hygiene. Perhaps the most innovative work comes from using energy efﬁcient sources to improve public health in remote areas, such as a UNDP project that has installed solar-powered water pumps in Guatemala, the use of camels in Ethiopia to transport vital medicines in solarpowered refrigerators, or using wastes to power community-controlled biogas plants in India that, among others, can provide cheap electricity, smoke-free kitchens, better sanitation, and topquality fertilizer. Environment Links Former Norwegian Prime Minister Thorbjørn Jagland adds that “poverty and ill health are among the main driving forces behind environmental degradation and a healthy environment is essential for good health and effective poverty alleviation.” In contrast, deforestation can exacerbate diseases like malaria, unclean water can carry cholera, and air pollution can cause respiratory infections. While the connections between health, poverty, and the environment are increasingly discussed in international fora, programs that link them still seem rare. But, there are exceptions. The Partnership for Clean Indoor Air is one. Claiming that nearly 2 million people die yearly because of indoor air pollution from traditional open-ﬁre cook stoves, one of the nonproﬁts involved in this coalition, Trees, Water & People, has worked with local partners in Central America to install safer and more fuelefﬁcient stoves in homes. 7 Source: Nova Independent Resources A Red Cross volunteer weighs a young girl to check for malnutrition. Many families are suffering hunger and hardship as a result of drought and locust plagues that have destroyed their crops. With all the family’s money being spent on food, there is nothing left for disease prevention or healthcare. Camels carry medecins—and the solar panels to keep them cool—in northern Africa. Several reports from the Disease Control Priorities Project were referenced in this research. See current and prior issues of the World Health Organization’s World Health Report; the 2003 report is particularly relevant to the topic of this e-zine and was referenced for this issue. For more information on smallpox, see the Wikipedia entry. A booklet called “Global Health Opportunities” from the Global Health Council highlights priorities for improving health in the world’s poorest communities. A site called Immunization Basics was referenced in research for this article. Check out a fact sheet on neglected diseases from the World Health Organization. An article from the Financial Times titled “An antidote to neglected diseases” was referenced for this story. The comments by Thorbjørn Jagland noted above can be found within some good papers on the links between poverty, health, and the environment. Note a paper called “Diseases of Poverty and the 10/90 Gap.” A 2003 article from The Boston Globe reviews the number of lives that could be saved with basic care. In-Depth Making Money Count Best Buys to Save Lives Keeping people healthy is a complicated task, involving good nutrition, distribution of medicine, the availability of health facilities and qualiﬁed practitioners, scientiﬁc research, education, vigilance, and much, much more. It’s no surprise that in poorer communities and less developed countries—where resources for healthcare may be lacking—death and disease rates are usually higher and quality of life signiﬁcantly lower. But as healthcare interventions have become more effective and technological innovations have brought the world closer together, many have argued that the poor should no longer have to suffer the burdens of disease and other health conditions to the extent that they still do. This is particularly true when a variety of preventive measures exist that are relatively low-cost and which, if implemented, could help ensure that people do not get sick in the ﬁrst place— and need more expensive treatments as a result. As most working in the ﬁeld will attest, a penny of prevention is still worth a pound of cure. Cost-Effective Proposals Widely considered to be one of the most cost-effective measures in public health, childhood immunizations can offer a lifetime of immunity from certain diseases. According to the World Bank, it costs $17, on average, for a child to be fully immunized against six common diseases, including tetanus, polio, and measles. While considered a “best buy” in most cases, these costs may still be prohibitive for countries like Ethiopia, whose health budget is only $3 per capita 8 per year. In these situations, international ﬁnancial assistance may be necessary to ensure expanded vaccination programs— one reason that the Global Alliance for Vaccines and Immunizations (GAVI) was launched in 2000. This alliance of public and private partners has raised over $6 billion—including a new international ﬁnancing facility—to develop and deliver immunization programs in developing countries. GAVI claims that its programs have led to the vaccination of some 100 million children. A more grassroots approach to child survival was seen in Nepal, where nutritional deﬁciencies remained a major public health problem in the 1980s. Community leaders moved into action and mobilized an army of volunteers to get needed Vitamin A capsules to some three million children in 93 districts. Launched in 1993, the effort included training women volunteers and organizing rallies and was later praised by the World Bank as one of the most cost-effective health interventions ever. While initiatives like these are heartening, the fact remains that needs outstrip health resources almost everywhere—and particularly so in developing countries. So how is a policy maker to decide where to put limited funds? Some 500 scientists, economists, and health practitioners tried to answer this question by launching three new reports in April 2006 that looked at a range of options for poor nations. With over 40 consultations involving developing-country participants, the Disease Control Priorities Project (DCPP) provides a comprehensive survey of global health and recommends a number of cost-effective interventions for low-and middle-income countries. Among preventive steps recommended are: the use of insecticide-treated bed nets in malaria-endemic zones; vaccinating children against major childhood diseases; teaching family members to promote basic hygiene to reduce diarrhea in children and treat it with oral rehydration therapy; promoting 100-percent condom use and education to populations most at risk of contracting HIV/AIDS; increasing taxes on tobacco products to reduce the prevalence of cancer, cardiovascular, and respiratory diseases; and regulating salt and saturated fat in manufactured foods. © A. Waak/Pan American Health Organization “Assuring that cost-effective interventions to address the major burdens of disease are delivered and available to everyone is the only way to close the health gap between the haves and the have nots.” Disease Control Priorities Project “For an immunization program to be effective, there needs to be a functioning health system with trained and motivated workers. If the systems aren’t working, large parts of the population won’t receive vaccines or other critical health interventions,” says World Bank Senior Health Specialist Amie Batson. Making Money Count The UN’s Millennium Project has also recommended a range of “Quick Wins” to achieve the Millennium Development Goals—a set of targets identiﬁed by the international community to substantially reduce poverty and improve public health by 2015. Health-related recommendations include providing regular de-worming treatments to all schoolchildren in affected areas, providing micronutrient supplements (especially Vitamin A and Zinc) to pregnant and lactating women and children under ﬁve, expanding access to sexual and reproductive health information, and eliminating user fees for basic health services in all developing countries. The list of simple interventions goes on and on. A PBS series that aired in late 2005 titled “Rx for Survival” implicated unclean water and malnutrition as important risk factors for 80 percent of childhood deaths. The International Food Policy Research Institute (IFPRI) adds that more than one-third of the population in sub-Saharan Africa has diets deﬁcient in essential vitamins and minerals, which can be the cause of illness or premature death. IFPRI is thus working with African health and agricultural leaders to harness technology to breed staple crops that include more essential nutrients. Case Study on Newborns According to Save the Children, which has a special program on Saving Newborn Lives, about four million babies die each year in the ﬁrst month of life, most in Africa and South Asia. A series on neonatal survival by the British medical journal The Lancet claims that at least three million of these lives could be saved by low-cost, low-technology interventions that are not currently reaching those in need. For example, at least a quarter of a million babies could be saved annually, says The Lancet, if pregnant women were given two 20-cent injections to prevent neonatal tetanus. 9 “Most newborn deaths could be prevented,” adds Save the Children “if women had access to basic health care such as immunizations to protect expectant mothers and newborns against tetanus, skilled midwifery care during childbirth, timely and appropriate treatment of newborn infections, and proper attention to hygiene, warmth, and breastfeeding for new babies.” While these seem like simple solutions, one of the main problems is reaching new mothers in impoverished or remote parts of the world. Many lives can be saved when care is provided within the ﬁrst week of life and especially when caregivers can detect infections early. The International Confederation of Midwives is working closely with the UN Population Fund to try and address the global shortage of midwives, particularly in underserved areas. © George S. Blonksy/Global Health Council In-Depth And as with other examples cited above, government support is crucial. Sri Lanka, Indonesia, Honduras, and Botswana all reduced neonatal mortality by about half in the 1990s due, in part, to political commitment at the highest levels to improving newborn care services. Easy access to family planning services is also high on the agenda of many groups working in public health. With between 20 and 40 percent of infant deaths directly linked to high-risk pregnancy, groups like the Center for Health and Gender Equity and the International Women’s Health Coalition advocate making information available to women so that they can make informed choices about their sexual and reproductive health before such crises occur. Equal Opportunity Diseases Cardiovascular diseases—like heart disease and stroke—are now the world’s #1 killers and take a heavy toll in both rich and poor countries alike (see “Taking the Global Pulse: Threats and Solutions”). Not surprisingly, cardiovascular diseases have increased in developing countries as traditional meals have increasingly been replaced with the largely unhealthy fast-food diets prevalent in the West. Costs for treating these diseases can also be prohibitive. Access to low-cost drugs (like aspirin) can help those at risk, says the DCPP, but reducing smoking and changes in diet and lifestyle can also go a long way to curbing the prevalence of these diseases. Increasing one’s physical activity and the consumption of fruits and vegetables, while decreasing the intake of sodium and sugar-based beverages, are among simple solutions for warding off these killers. Promoting lifestyle changes can be difﬁcult anywhere, but the DCPP cites the case of Finland, where a comprehensive program focused on diet and lifestyle modiﬁcation managed to reduce the mortality rate by approximately 75 percent between 1972 and 1992. As the above example demonstrates, when governments—in conjunction with an active civil society—implement national public education programs to prevent disease, it can make a big difference. Determined action by the Ugandan government to address the HIV/AIDS epidemic, for example, was said to be a big factor in reducing its prevalence in that country. Many working on curbing AIDS—a disease which also has a big impact in the developed world—are Making Money Count © IRIN News of actors working in global health without the guidance of an overall strategic framework. One of the main problems lies in the limited ﬁnancial resources that are committed to health. With many developing country governments devoting a very small percentage of their national budgets to health, substantial The military escorts a World Health Organization needs are only partially convoy on the road between Bossangoa and Bangui in the met by external Central African Republic. assistance agencies, international foundations, and coalitions optimistic about the development of (see “Taking the Global Pulse: Threats microbicides. Although testing is still and Solutions”). Plus, the World Health underway, this cream or gel that women Organization says there is shortage of can use before sexual intercourse may almost 4.3 million doctors, midwives, help prevent the spread of the disease— nurses, and support workers worldwide, especially in societies where women with the shortage most severe in poor have little or no power to say no to sex. countries. Delivering the Goods While the international community has the technology and the experience to ensure that many lives could be saved with fairly low-cost means, getting the solutions to those suffering from preventable diseases is not as simple as it might seem. According to a January 2006 article called “The New World of Global Health” published in Science magazine, “Many countries...face cumbersome procurement policies that make it difﬁcult to translate dollars into drugs. Shortages of trained health-care workers mean that those drugs that are available may not be used properly. Corruption has bedeviled a few large grants, whereas many other aid recipients have found themselves drowning in the required paperwork.” The article also points to the problems created by a proliferation 10 Where human resources are concerned, some communities have drawn on local village health workers and volunteers. The story of Nepal’s mobilization to distribute Vitamin A capsules is one such example raised by the “Rx for Survival” series. Or, take the Bangladesh Rural Advancement Committee—an NGO that has trained thousands of women in basic health science and family planning. With nearly 40,000 community health volunteers to monitor patients, they have reached millions and have helped to cut child mortality rates in half in Bangladesh. Neighborhood health promoters in El Alto, Bolivia (known as manzaneras) visit residents door-to-door. Although volunteers, some of the manzaneras are elected by neighborhood councils and bring needed care to those who were not taking advantage of standard healthcare facilities. Ashoka’s Changemakers program has also identiﬁed social entrepreneurs globally who are bringing healthcare to low-income communities in creative ways, including offering free health services to rural populations in India and using microenterprise to improve access to safe drinking water in Kenya, among others. These are just a few of the efforts that have proven that innovative solutions can be found for the world’s seemingly insurmountable public health problems. © Partners for Health Reformplus In-Depth In November 2004, nearly 124,000 residents of a rural area in Peru cast ballots to pinpoint the health problems they wanted targeted in the region’s ﬁve-year strategic plan. Be the Change! Unsure what you can do to ensure health for all? Take a look at OneWorld’s action page to learn about key initiatives that need support or volunteers. You can also help to raise awareness about the importance of healthcare globally. In-Depth Lessons Learned Getting Healthcare to All There have been spectacular improvements in public health over the past half-century. In fact, more progress has been made in this time than in many millennia of earlier human history— especially in developing countries. In 1950, average life expectancy in developing countries was approximately 40 years. Today, it is about 65 years. The death rate for children under ﬁve has also been halved during this period. Despite these successes, large gaps in mortality and life expectancy between industrialized and developing countries remain. Ninety-nine percent of total childhood deaths in the world occur in poor countries, for example. Many of the health risks faced by those in developing countries are linked to poverty—poor nutrition, limited access to quality healthcare, and environmental threats. The global community has increasingly recognized that it cannot rely exclusively on economic and social development alone, however, as the source of health improvements. With the recognition of the toll that diseases like HIV/AIDS takes in many of the poorest countries, and an understanding that infectious diseases that emerge in developing countries have potential worldwide consequences, global commitments to improving health in poor countries have risen to an unprecedented level. But history shows that it is possible to improve the health of the poor—even in the face of grinding poverty and weak health systems. In Millions Saved, the Center for Global Development (CGD) documented 17 health interventions in poor countries that have succeeded in saving millions of lives. These programs—implemented at national, regional, or global levels—had to meet 11 a set of rigorous selection criteria to be included in the book. The programs, therefore, represented a special fraction of health efforts: they had to be large scale; cost-effective; last at least ﬁve years; result in major improvements in human health; and be well evaluated. Elements of Success Above all, we learned that poverty does not condemn a health program to failure. Some of the world’s poorest countries have seen major public health successes. Throughout sub-Saharan Africa, for example, a campaign to combat guinea worm reached thousands of poor, remote villages and reduced the prevalence of the disease by 99 percent. In Sri Lanka, despite relatively low national income and health spending, commitment by the government to providing a range of “safe motherhood” services led to a decline in maternal mortality—from 486 to 24 deaths per 100,000 live births over four decades. A program in Bangladesh used house-to-house visits to promote the use of oral rehydration therapy to treat dehydration in children and was able to teach 13 million mothers how to make and use a simple salt-and-sugar solution to save the lives of their children. The Bangladesh Rural Advancement Committee (BRAC) trains thousands of women from rural areas in basic health science, which has vastly improved child mortality rates in Bangladesh. © WGBH Educational Foundation and Vulcan Productions, Inc./“Rx for Survival” This special in-depth feature was authored by Dr. Ruth Levine, director of programs and senior fellow at the Center for Global Development. These achievements did not come without challenges. In almost all of the cases featured in Millions Saved, there were moments when the disease seemed insurmountable, the technology was still on the drawing board (or too expensive, or unusable in developing country conditions), the funding was nowhere in sight, international agencies were squabbling, and no one appeared ready to take up the challenge. In these instances, a combination of science, luck, money, vision, and management talent came together to overcome daunting obstacles and transform the lives of millions of individuals and countless communities. The successes also shared common elements, which were put together in unique ways in each case. While no single recipe emerges, there was a remarkably consistent list of ingredients: political leadership and champions, technological innovation, expert consensus, management that effectively used information, and sufﬁcient ﬁnancial resources. In some of the cases, the participation of the affected community and the involvement of nongovernmental organizations (NGOs) were also central features. Mobilizing political leadership Virtually all of the successful cases show the importance of visible, high-level commitment to a health initiative. In Thailand, for instance, the government showed strong leadership and vision in its early efforts to curb a growing HIV epidemic, making a bold commitment that led to one of the very few successes in HIV prevention on a national scale. Individual champions are also key to rallying resources and international resolve. The near-eradication of guinea worm from Africa and Asia is due in large measure to the personal involvement and advocacy of U.S. President Jimmy Carter and former African heads of state General Toumani Toure and General Yakubu Gowon. These leaders visited endemic countries, mobilized the commitment of political and public health communities, and raised both awareness and ﬁnancial resources. The guinea worm campaign also beneﬁted from the participation of a wide range of partners, including UN agencies like UNICEF and the World Health Organization (WHO), private companies and foundations, NGOs, more than 14 donor countries, and the governments of 20 countries in Asia and Africa. Making Technological Innovation Work Lessons Learned evidence. For example, the World Bank and the WHO helped China revamp its ﬁght against tuberculosis, the leading cause of death of Chinese adults. They recommended the introduction of DOTS (directly observed treatment, short-course) strategy, which is a way to package a variety of elements of successful TB control. At the heart of the approach is a system in which patients are watched by health workers as they take their medicine—a requirement to ensure that the full course of treatment is taken, and the risk of drug-resistance is minimized. Many health improvements turn on the development of a new technology—a drug, vaccine, or pesticide—that is appropriate to the conditions of the developing world. New technology often permits an existing program to work more effectively, or achieve rapid health gains. The Latin American initiative to eliminate Chagas disease—a parasitic ailment that produces severe and sometimes fatal heart problems—gained great momentum in the 1980s, for example, with the development of a synthetic pesticide that was both more effective and more acceptable to the population than the earlier one. Subsequently, in 1991, China launched the world’s largest DOTS program, which resulted in a 37 percent decline in the disease’s prevalence. In Morocco, the government joined forces with the WHO and an international group of partners to launch a comprehensive strategy to both prevent and treat the blinding parasitic disease of trachoma in that country. The program included providing low-cost surgery, antibiotics, and a better water supply. Both the campaigns in China and Morocco proved the importance of having agreement among health experts. For the technology to take hold, however, there must also be a concerted and large-scale effort to make it available at an affordable cost. Often this happens through a “public-private partnership” in which the private sector either donates the product or provides it at concessionary prices and the public sector (both national governments and donor agencies) take responsibility for distribution. These deals may be brokered or facilitated by international NGOs, such as The Carter Center. Most of the cases highlighted in Millions Saved represent achievements of the public sector, but some show the special role that NGOs can play, especially if they have a large reach and strong management. In Bangladesh, the huge NGO BRAC carried out the world’s largest oral rehydration program, reaching more than 13 million mothers and preventing vast numbers of childhood deaths. NGOs such as Sight Savers International have also played a key role in distributing ivermectin—the antibiotic that treats river blindness— throughout sub-Saharan Africa. NGOs are often able to get to places where governments can’t—or won’t—go and they can be more ﬂexible than the public sector in working with communities. Beyond service delivery, NGOs have Getting Expert Consensus New strategies to ﬁght disease are often based on expert agreement about what will work best, supported by solid 12 Including NGOs a valuable role to play as watchdogs and advocates. For example, healthpromoting NGO coalitions in Poland and South Africa formed the backbone of advocacy efforts that led to sweeping tobacco control legislation in both countries. © Marko Kokic/International Federation of Red Cross and Red Crescent Societies In-Depth Water is the most abundant resource in the world, yet in many countries a liter bottle of pure safe drinking water is more costly than its equivalent in gasoline. Most of child-related deaths throughout the world are related to drinking unsafe water. Managing Well Good health service delivery requires that trained and motivated workers are in place and that they have the supplies, equipment, transportation, and the supervision to do their job well. This requires good management. Polio has been largely eradicated in Latin America due, in large part, to the establishment of national inter-agency coordinating committees in each country. These committees worked with ministries of health to develop national plans of action, set immunization strategies, and optimize the use of resources. They were composed primarily of technical experts, but also included donor agency representatives from many countries. In-Depth Lessons Learned The plans of action they developed now serve as an important management tool for planning other health interventions. Conveying Information In each and every case, information was used to raise awareness, to shape design, and/or to motivate. In China, for example, research showed that iodine deﬁciency posed a threat to children’s mental capacity. Raising awareness about the health problem focused political and technical attention on it and prompted government action. © A. Waak/Pan American Health Organization In Egypt, information from community trials and market research revealed consumer preferences that were essential for the design of a national oral rehydration program. Because the program depended in large measure on effective communication with mothers, it was important to gather information in the early stages to shape its design. Finally, in the guinea worm eradication campaign, information was disseminated in monthly publications that highlighted progress in different countries. Sharing this information motivated the countries involved in the campaign and kept pressure on those lagging behind. Babies’ diets are often deﬁcient in iron, zinc, calcium, vitamin B-6 and other micronutrients. The Global Health Council notes that anemia affects more than 70 percent of six-to12-month-olds in countries as diverse as Bolivia, Kazakhstan, and Cambodia. 13 Involving Communities In some of the cases proﬁled, the communities whose health was affected by a disease played a strong and active role in its eradication. Tens of thousands of communities across Central and East Asia, for example, organized and managed the local distribution of ivermectin—the antibiotic that treats river blindness. Because the affected communities assumed full responsibility for distribution of the drug, it increased the long-term sustainability of the program. “Village volunteers”—who were selected by the community and trained by NGOs—also served on the front line in the guinea worm campaign by distributing ﬂiers, raising public awareness, and identifying and containing cases. Predicting funding It doesn’t necessarily take vast sums of money to make public health work because cost-effective interventions can be employed. What is needed, however, is steady funding to ensure that the programs can be sustained for a long enough period of time to have a major impact. In many of the cases we researched, a large share of the funding came from external donors. Some $560 million was invested over 30 years by many donors to virtually halt the transmission of river blindness in 20 West African countries; a $26 million grant from USAID to Egypt helped the country prevent 300,000 child deaths from diarrheal disease; and, $88 million came from an extensive list of donors and NGOs to cut the number of people affected by debilitating ailments caused by guinea worm from 3.5 million to just 35,000. The payoffs are huge. Eradicating smallpox from the globe cost the donor community less than $100 million. The U.S., the campaign’s largest donor, saves its total contribution every 26 days because vaccination is no longer required. The economic beneﬁts of controlling river blindness were seen in improved agricultural productivity and other poverty-reducing outcomes. One analysis estimated that each dollar spent on the program generated $1.17 in economic beneﬁts. The Human Payoff Beyond the economic reasons for caring about health are the human ones. In light of the cases we studied, it is impossible to argue that little can be done to close the health gap between rich and poor. It will certainly not be easy, or fast, or without signiﬁcant technical, operational, and political challenges. But, as these experiences demonstrate, the potential exists to change the course of human history for the better through effective public health programs in developing countries. Click here to see references for this story. Click here to subsribe to OneWorld Perspectives; it’s free! From the Frontlines My Experience Community Approaches of clothes and a copy of Where There Is No Doctor. Shortly after I arrived, I was awakened in the middle of the night by a girl who said I had to come help deliver a baby. Although I knew nothing about delivering babies, I stumbled across camp where I was relieved to ﬁnd the mother-to-be well attended by an experienced community midwife. As she let me stay and watch, and as I followed along in the book, I recognized that “untrained” people have a lot of skills and knowledge and that “trained” health workers—like me—have a lot to learn. Having worked in community health for 24 years, I have come to the conclusion that there really are no “magic bullets” or “quick wins” in public health. While teaching a mother how to rehydrate a sick child will certainly save lives, it won’t change the conditions that condemn children to suffer dehydration and chronic diarrhea. These problems are caused by a lack of access to safe drinking water, which, in turn, is caused by the violence of poverty. Ultimately, scenarios like this can change when people are allowed to plan their own strategies for development and have the resources to implement them. That’s what the book Where There Is No Doctor does for health. It’s a village healthcare handbook written to be accessible to people with limited access to formal education. It helps people solve their immediate problems and then puts forward a vision of community control of healthcare—of community solutions to the root causes of ill health. My experience with this resource began when I was only 22 and had arrived to volunteer in refugee camps in rural Honduras. Salvadoran refugees were streaming over the border, running for their lives from the Salvadoran military (funded by the U.S. government) in the midst of a civil war. They were malnourished, terriﬁed, wounded, and carried nothing but the clothes on their backs. For my part, I had a suitcase full 14 In the weeks and months that followed, I found that Where There Is No Doctor was very useful in helping me—and a crew of refugees—set up nutrition programs, and water and sanitation systems, and provide extra training to people who had always taken care of their own health. Despite the alien environment of the refugee camps, everyone was learning the basic skills and knowledge to become effective health workers. The accessible presentation of information and selfreliant focus made the book an incredibly useful tool for all of us. Another thing I learned from Where There Is No Doctor is that compassion can be a powerful medicine. Although surrounded by the Honduran military for a week, I was asked to help Ricardo, only 18 months old, who was extremely dehydrated and malnourished. He was the kind of kid you look at and are sure he isn’t going to make it. His mother Marcela was barely able to walk. Her husband, a school teacher, had been murdered. Her daughter had died as they were trying to get to the border. We desperately wanted to help save Ricardo, but there didn’t seem much we could do for him. Marcela was told to feed him every hour, but she was disheartened that he couldn’t keep anything down. She was convinced he was going to die. What this exhausted, traumatized woman really needed from me was food, rest, help washing diapers and caring for her son, and emotional support. When we ﬁnally escaped from the army’s clutches, Marcela had access to more organized support in the camp and Ricardo survived. In the long run, efforts to redress the inequality and poverty that keep people sick are what will really bring about lasting health in their communities. Months later, Marcela approached me and asked if she could become a health promoter in the camps. She eventually became one of the best health workers I ever trained. Marcela would sit and talk for hours about her plans to return to her village and start a health promotion program there. She planned to set up a communal garden so there would be vegetables for the children; she would stock basic medicines and she would engage people to build latrines and teach them about safe drinking water and sanitation. Marcela joined the ﬁrst group of refugees to return to El Salvador in 1986 while the war was still raging. Despite the risk of being singled out as a community organizer—a sure death sentence if she was captured by the military or death squads—Marcela did exactly what she planned. When I ﬁnally left Central America many years later, I went to work for the Hesperian Foundation, the nonproﬁt that developed this book. My ﬁrst task was to help women and women’s organizations in more than 40 countries address their special health concerns for a new book, Where Women Have No Doctor. This large international network participated in every aspect of the book’s development—from determining the content, critiquing drafts, contributing stories of successes and challenges, and even providing some of the illustrations. The voices and collective wisdom of these women helped craft a book that has been widely used in different cultures and translated into 34 languages. I was thrilled to work with a group of Chinese colleagues in 2001 to produce a major Chinese edition of the manual, of which more than 100,000 copies were distributed to rural communities. community health. A family in Mexico, for example, just sent us plans of how they improved our latrine designed to be accessible to those in wheelchairs. In short, groups from all over the world are sharing experiences with us about how they are challenging the forces that keep them sick. Information provided by Hesperian’s books and by health development programs is critical to helping people treat and solve their own health problems. But, in the long run, efforts to redress the inequality and poverty that keep people sick are what will really bring about lasting health in their communities. Resources like ours are designed to accompany people beyond that ﬁrst curative step towards a healthier future. The Uhuru, a motorcycle with a special sidecar, performs a vital function as an emergency ambulance. In Africa, millions of people live in remote villages, miles from clinics and hospitals. In a medical emergency, people have few options for reaching a hospital quickly. Riders for Health runs transportation systems for health programs in Africa and provides motorcycles to deliver medicines and health education to hard-to-reach areas of Africa. 15 Yaqui Indians in Mexico used Hesperian’s environmental health materials at a recent workshop on pesticide poisoning. Sarah Shannon Executive Director Hesperian Foundation © Riders for Health; from “Rx for Survival” All of this work has conﬁrmed that people suffering from inequality know what the problems are that keep them sick. And, the most forward-looking of them have come up with their own solutions. We are currently working with sweatshop workers as well as organizations ﬁghting environmental devastation to develop books on workers’ health and environmental health. Disability is also a central concern for My Experience © Hesperian Foundation From the Frontlines Be the Change! Unsure what you can do to ensure health for all? Take a look at OneWorld’s action page to learn about key initiatives that need support, or volunteers. You can also help to raise awareness about the importance of healthcare globally. From the Frontlines Interview Featuring Maurice Middleberg of the Global Health Council Maurice Middleberg is vice president for public policy at the Global Health Council. What would you identify as the top “best buys” in global health today? There are a handful of interventions that together could save millions of lives and enormously reduce suffering. There are the interventions that save children— immunization, preventing or treating diarrhea, pneumonia, and malaria and keeping newborns warm and clean. Family planning and having skilled birth attendants are the keys to protecting the health of women. The methods for preventing and treating HIV are known and more affordable. Detecting and treating tuberculosis through shortcourse therapy is highly cost-effective. In the area of non-communicable diseases, the most important steps are taxing tobacco, promoting use of aspirin and inexpensive drugs for cardiovascular disease, and installing speed bumps to reduce the toll of trafﬁc accidents. Add to that list better nutrition for young children and pregnant women and you have an incredibly powerful set of affordable, effective interventions. Two good resources for best buys in global health include the Disease Control Priorities Project and the Global Health Council’s Global Health Opportunities Report. 16 Is too much attention being paid to emerging infectious diseases at the expense of other serious health threats? Only if we spend the money foolishly and create false trade-offs. The threat of pandemics, such as avian inﬂuenza, is very important and highlights the interconnectedness of health around the globe. Although many are concerned about domestic preparedness, the reality is that a dangerous mutation of the disease would probably originate in a developing country that lacks surveillance to detect the disease early, or the health and communication systems to contain it. It would be wiser to invest in health systems in developing countries so that we can both protect ourselves from a potential pandemic and help address current diseases, but without diverting money from the “best buys” noted above. New medicines for treatment of many diseases (like HIV/AIDS) are priced out of reach for many, how do you see this changing? The amount available for healthcare in poor countries is very low, or about $30 per person per year (compared to almost $6,000 per person in the U.S.) This small amount must cover drugs and all other healthcare costs. To change this reality, developing countries themselves must devote a greater percentage of their national income to health—it is now about ﬁve percent on average—and they must use effective approaches to health insurance and other ways of paying for healthcare. The poorest countries, however, simply don’t have the money to provide essential healthcare. Countries such as Niger or Afghanistan, which have very low per capita incomes, only spend about $10 per person on healthcare. Hence, wealthy countries must make a long term commitment to helping with such care in these nations, including private philanthropy and a continuing commitment by pharmaceutical companies to make essential medicines available. And, resources must be used as efﬁciently as possible, which means focusing on making the best buys available to those most in need. Are funding priorities in global health misplaced? If so, how? We have seen very important increases in funding in the past years for speciﬁc diseases, including HIV/AIDS and malaria. However, U.S. investments in child health and family planning—two of the very “best buys” in global health— have remained stagnant and funding is at risk of being reduced. Child health and family planning are two of the most successful programs in the history of public health, having triggered huge declines in infant mortality and birth rates. We need to look at past successes and invest in getting the programs that work to the people who need them the most. These investments should also build long term capacity. Almost one million additional health workers are needed in Africa to provide essential care, for example. What is your perspective on the links between health and poverty? Poverty means vulnerability. Illness can tip a poor family into disaster as the household loses income, depletes its meager savings, and borrows money to pay for care. Families end up making excruciatingly difﬁcult choices about whether to eat, or to pay for drugs—unless there are effective health programs in place to buffer them from such ﬁnancial crises. From the Frontlines Interview © Abigail Mithoefer/Global Health Council Stay Informed. Ill health means children do less well in school and adults are less productive. Besides poor health being a drag on economic growth, there’s also tremendous inequity in who gets health care. The poor simply don’t get their fair share. Poverty is often compounded by other forms of discrimination based on gender, ethnicity, or caste. So, it’s a challenge to make sure that health reaches those already most marginalized or deprived. Fortunately, there are lots of good examples of programs that reach the poor. Such programs are either speciﬁcally targeted at the disadvantaged, or seek universal coverage of very basic services that will most beneﬁt the poor. Mexico, for example, subsidizes basic care for the poor. What are some of the best local initiatives that you have seen and what innovations are you most excited about in 2006? The most exciting work that I have seen is when communities—rural villages and poor urban neighborhoods—take responsibility for their own health and mobilize to secure the services they need. Good health isn’t given; it’s demanded and secured. 17 I have seen communities in places as diverse as India, Nepal, Uganda, and Guatemala organize to build on the resources they already have and negotiate with others to obtain what they lack. I have seen individuals and groups work incredibly hard to educate themselves and each other about how to protect their health. That’s real development work—not transferring a drug or a procedure. What has inspired your own personal commitment to this work? My parents are Holocaust survivors. They taught me at an early age that there is no “over there”; there’s only “over here.” They understood that the world is a small place, although they never used the term “global village.” I always wanted to be part of that bigger world. Once I became involved in global health I saw the astonishing resilience, creativity, and strength of communities and health workers coping with very scant resources. That has always been a humbling and inspiring experience and I feel privileged to be part of the process of making heath services available to all. WHAT’S UNIQUE ABOUT ONEWORLD.NET? • News and Perspectives you haven’t heard, from trusted nonproﬁts helping people on the ground and across the globe. • In-depth information and analysis on 80 topics and 60 countries. • A global community of people who care about development and social justice—all voices heard and represented. STAY INFORMED Sign Up for Free! www.oneworld.net • Receive the OneWorld Daily Headlines, or visit us on Yahoo! News. • Select our RSS feeds on topics and countries you care about. • Get context and NGO viewpoints from Perspectives Magazine. • Get the latest online videos on OneWorld TV, or global audio feeds on OneWorld Radio! Get Involved. From the Frontlines Viewpoints CORE Group The good news is that one simple, lowtech approach can cut these deaths by at least 20 percent: use of insecticidetreated mosquito nets. These nets protect sleeping children during the night hours when malaria-carrying mosquitoes are active and biting. Nets treated with insecticide can kill or repel mosquitoes before they ﬁnd a way under a net or through a hole in a torn net. The nets are also important for shielding pregnant women who are vulnerable to infection and, if not protected, may give birth to underweight infants or lose their babies altogether. “Each year, malaria infection causes more than one million deaths in Africa, with threequarters of these occurring in children under age ﬁve .... The good news is that one simple, low-tech approach can cut these deaths by at least 20 percent: use of insecticide-treated mosquito nets” Insecticide-treated nets can cost anywhere from 60 cents to $4.00 each. Government and non-governmental organization (NGO) subsidies and voucher schemes have enabled many Africans—who might not have been able to afford them otherwise—to own treated nets. Even at the higher end of the price 18 range though, insecticide-treated nets are considered one of public health’s most cost-effective “best buys.” Of course, ensuring that nets are used is a separate, and equally daunting, challenge. Mistrust, cultural beliefs, and perceived inconvenience each contribute to low or intermittent use. In Tanzania, for example, a recent health survey found that only 16 percent of pregnant women and children under age ﬁve had slept under an insecticide-treated net the night before the survey. Further research conducted by members of the Tanzania NGO Alliance Against Malaria found that villagers in the country’s rural Tanga region equated mosquito nets with burial shrouds. “Who wants to sleep in a cofﬁn?” one resident asked. Villagers who saw posters of babies sleeping contentedly on a bed protected by a mosquito net also wondered if nets were meant for wealthy people with beds, instead of “people like us who sleep on mats.” The most common complaint was that nets were “too stiﬂing” to use in the hot, dry season. As front-line development workers, NGOs are working hard to promote use of insecticide-treated nets through activities such as supporting village health workers to visit local households, training traditional birth attendants to counsel pregnant women to use nets, promoting village drama and musical performances, and broadcasting educational radio spots. In Tanzania, for example, the CocaCola Africa Foundation and Population Services International recently teamed up to introduce a storybook in public schools that talks about the beneﬁts of using insecticide-treated nets. Similar NGO-private sector initiatives have taken place in Ghana, like NetMark’s work with commercial partners to distribute nets. © John Haskew/IFRC Malaria infection shouldn’t be a rite of childhood, but for many of Africa’s children it’s an all too common occurrence. Each year, malaria infection causes more than one million deaths in Africa, with three-quarters of these occurring in children under age ﬁve. That’s an unnecessarily high toll for a disease that is both preventable and treatable. The International Federation of Red Cross and Red Crescent Societies (IFRC) began distributing over two million long-lasting insecticide-treated mosquito nets in Niger in December 2005 in an effort to protect 3.5 million children from malaria. NGOs must continue to partner with governments, donors, the private sector, and multilateral organizations like the World Health Organization’s Roll Back Malaria campaign to ensure that insecticide-treated nets are made available to pregnant women and young children at an affordable cost, and are being used consistently. Taking a comprehensive approach will allow this public health “best buy” to realize its full potential. Julia Ross Communications Manager CORE Group From the Frontlines Viewpoints Pan American Health Organization To improve the chances for childhood survival, the World Health Organization (WHO) and UNICEF a decade ago launched a strategy known as Integrated Management of Childhood Illness (IMCI). It takes a “holistic” approach to child health and considers the child as a whole rather than focusing on individual diseases or symptoms. IMCI initially focused on teaching healthcare providers to detect, and more effectively treat, the most common illnesses of children under ﬁve. More recently, it has turned its attention to family and community behaviors and how these affect children’s health. The result is Community IMCI, a collection of “family practices” that families and communities can use to help stimulate physical and mental development, prevent illness, and ensure that children get the healthcare they need both in and outside the home. Four of IMCI’s key practices have been singled out by the Pan American Health Organization (PAHO) as especially critical to child health in Latin America 19 and the Caribbean. They are: exclusive breastfeeding of babies for their ﬁrst six months; ensuring that children get a full course of immunizations before their ﬁrst birthday; learning to recognize when sick children need treatment outside the home; and ensuring good prenatal care for pregnant women. PAHO’s experience in the town of Chao, Peru, shows that Community IMCI can have a real effect on parents’ knowledge about child health. A recent survey showed that 95 percent of mothers now know that babies should be breastfed exclusively for the ﬁrst six months, compared with only 34 percent ﬁve years ago. Three-quarters know how to treat a child’s infection versus just over half before Community IMCI was introduced. And 90 percent of mothers have kept their children up-to-date on their vaccines, compared with 58 percent in the past. In an unexpected development, cases of malaria dropped almost 99 percent between 2000 and 2004. Public health workers credit the decline to IMCI’s success in getting Chao’s citizens active on issues of public health. Achieving results such as these requires the involvement of a wide range of actors to help raise awareness and encourage behavior change. In Chao, as elsewhere, this has meant involving everyone from the mayor and the police, to the Red Cross, labor unions, “mothers’ clubs,” and schools. Training teachers to include maternal and child health themes in their classrooms has proved a particularly effective way of reaching parents through their kids. Today, IMCI and its key practices are being implemented in more than 100 countries around the world. The © Yadira Pacheco/World Vision—Peru Photo from CORE Group Web site. Every year nearly 11 million children in the developing world die before reaching their ﬁfth birthday. Most of these deaths result from diarrhea, pneumonia, measles, malaria, and problems surrounding childbirth (such as asphyxia, birth trauma, and low birth weight). Underlying factors include malnutrition, poor access to healthcare, and a lack of healthcare knowledge at home. Because nutrition plays such a critical role in maternal and child survival and health, dissemination of state-of-the-art information and the establishment of quality nutrition programs are vital. challenge now is to scale these efforts up, from small-scale projects to universal implementation. This can only be achieved with increased backing from governments, international agencies, non-governmental organizations, and individual donors. With increased support, IMCI can continue to be a global health “best buy” and help more families, communities, and health care providers do their part to ensure that every child has the chance to survive and thrive. Christopher J. Drasbek Regional IMCI Advisor Pan American Health Organization For more information, see IMCI sites at PAHO and WHO. From the Frontlines Viewpoints Sound Partners for Community Health In a country where a few national media outlets control much of the news that Americans get, Sound Partners for Community Health has spent the last eight years helping local media collaborate with communities to tell their own stories. Radio, television, and print journalists have worked with local partners, like health agencies, to improve the health of their communities. Although the Sound Partners projects are local, they focus on health concerns that are common across the United States, including children’s health, the special needs of vulnerable populations, chronic illness, addictions, and end-of-life issues. We have found that by linking local media with ordinary people, partnerships form that invigorate and change communities. Six ideals are at the heart and soul of every project: partnerships, local voices, local media, empowerment, vulnerable populations, and social marketing. What this means in practice is that Sound Partners believes that each project should have a local focus and solution. WBHM-FM, Birmingham, Alabama, the Oasis Women’s Counseling Center, and the University of Alabama at Birmingham School of Public Health worked to decrease the stigma surrounding mental illness, especially as it affects African-Americans. Using a creative approach, the project broadcast a radio soap opera called “Body Love.” The storyline drew listeners into an ongoing saga starring African-American women dealing with mental health topics in everyday life. In Eureka, California, public television station KEET collaborated with commercial radio station KHUM to reduce the high rate of methamphetamine use in their county. They worked with local schools, drug counseling professionals, and community leaders to raise awareness and educate the public about the terrible consequences of meth use. © Dr. Georgia Hall; Sound Partners Locally produced broadcasts that feature ﬁrst-person stories about everyday problems in American communities can both generate awareness and lead to solutions. There are hundreds of success stories. KUSP Radio in Santa Cruz, California partnered with Planned Parenthood and KION-TV, for example, to engage youth and their parents in a dialogue about reproductive health, drug use, violence, and healthcare access. The youth were empowered by learning how to produce radio documentaries. And, by bringing their concerns to the airwaves, community awareness improved. In conjunction with KCUW radio in Oregon, stories about diabetes recovery are told by individuals from Paciﬁc Northwest Indian reservations. Here, elders work in a Hopi community’s senior center. 20 Hawaii Public Radio focused their Sound Partners project on the unique healthcare and cultural concerns of Native Hawaiians, particularly chronic diseases such as diabetes. Joining with a commercial station and a Native Hawaiian non-proﬁt health organization, the project hosted “ﬁsh and poi gatherings” to promote dialogue around nutrition and health concerns. In the United States, corporations and commercial media can spend millions of dollars nationally on slogans and slick advertisements that sound good, but have little impact on improving the heath of the average American. What makes Sound Partners a “best buy” is its demonstration that a small grant of money, shared between local media and community organizations, can be leveraged to make a big difference in changing health behaviors at the local level. Sallie Bodie & Alison Highberger Freelance Consultants Sound Partners for Community Health Additional Note: Since its beginning in 1997, Sound Partners has funded 148 programs with $5.4 million in grants, ranging from $15,000 to $35,000. The projects have won 109 awards. Sound Partners for Community Health is a joint program of the Benton Foundation and the Robert Wood Johnson Foundation. Get Involved! Community Space What Do You Think? By contemporary standards, there is an incredible economic imbalance in the affordability of quality health between the high-income countries and the lowincome ones. Access to medical care by people—especially in developing countries—has been further compounded by the process of globalization, economic and development programs that make social spending a luxury for poor nations, rampant political strife, the emergence of drug resistance microbes, the rapid spread of disease around the world, ever increasing cross-border travel and trade, as well as the HIV/ AIDS pandemic. As it is now, staying alive in the developing countries is a monumental risk that has no alternative. Charles Ebere Department of Social Sciences University of The Gambia, West Africa At 2.6 billion, half the developing world lacks a toilet and there are nearly as many without it today as there were in 1990. The result is massive and daily pollution of the environment with human faeces. Faeces—and drinking water and food contaminated by faeces—carry pathogens implicated in some 1.8 million deaths per year from diarrhoea, and 2 billion cases of parasitic worm infections. Before the vaccine was discovered in 1937, sanitation was the main measure to combat yellow fever, and today it is the only method of controlling dengue. The economic beneﬁts from investing in toilets are difﬁcult to calculate, but returns are 21 thought to range from $3 per dollar investment to $34, which is large enough to rival other healthcare interventions. A sanitary toilet can be as basic as a pit in the ground, covered by a slab with a hole, and surrounded by a fence for privacy. In Bangladesh, some families are constructing their own toilets from scrap for under $5. Shahin Yaqub New York Until recently, all expert diagnosis of x-rays in Mali had to take place in the capital, Bamako, or sometimes up to 1,000 kilometres from the regional hospital where the ﬁrst analysis was made. A new tele-radiology project provides a solution for this problem by offering the possibility to send or receive x-ray scans and diagnoses over the Internet. This enables regional and local doctors to send patients’ x-rays to Bamako where trained radiologists and specialized doctors can make a quick diagnosis and suggest the best course of treatment. Instead of their knowledge and expertise remaining in the city, it is now being applied in remote places. See this link for more information. Anna Gerrard International Institute for Communication and Development The Netherlands An accident victim, a young man, had to die because he could not make a deposit as demanded by the hospital authorities. A Good Samaritan volunteered to pay the initial deposit, but much blood was lost and the man died. In a government hospital in one of the states in the north, the medical director had to pay the bill of a dying patient for a blood transfusion before he was admitted. Thanks doctor! Rawlings Okorie Lagos, Nigeria I believe the greatest health challenge the world is facing today are the pharmaceutical companies’ monopoly on medicine, especially HIV/AIDS treatments. I think health is a human right and, like water, governments and companies simply cannot deny, privatize, or charge people. The world should mobilize and purchase large quantities of generic medicine and distribute them to the people that need them. We have an obligation to uphold human rights, regardless of corporate control and the risk associated with going against it. To quote those who protested water privatization, and activists around our world: The People United, We’ll Never Be Defeated. Thank you. Andrew deSouza Burlington, Ontario, Canada Student © Rotary International Welcome to Perspectives’ Community Space. Below are some of the comments we received as we were putting together July’s edition on “Best Buys in Global Health.” While some have been edited down for space reasons, we have taken pains not to alter the “voice” of the contributors. Add your thoughts to the interactive Community Space page on the OneWorld Web site!” An infant is examined in a rural area of Kenya. Get Involved! Community Space There is a huge unmet need for contraception in many parts of the world. Most women don’t know that they are “not fertile” for about 2/3 of their cycles. With this knowledge (Fertility Awareness) many women with no access to medical care or contraceptive technology could have much more control over when they become pregnant. Simpliﬁed versions of fertility awareness are available for women who are illiterate. (Note: FA is not the inaccurate Rhythm Method, but rather is a system of body observation.) Ilee Richaman Fertility Awareness Center New York While heart disease, cancer, obesity, and smoking dominate health concerns in industrial countries, infectious diseases are the overriding health concern in developing countries. Many countries lacking the funds to invest in vaccines for childhood diseases today will pay a far higher price tomorrow. Ensuring access to a safe and reliable water supply for the estimated 1 billion people who lack it also is essential. For treating the symptoms of diarrheal disease (often caused by contaminated water), a UNICEF oral rehydration therapy campaign has made impressive gains, reducing deaths from diarrhea among children from 4.6 million in 1980 to 1.5 million in 1999. Few investments have saved so many lives at such a low cost. For more information on achieving better health for all, see this link. Lester R. Brown President, Earth Policy Institute Washington, DC The best way to stay healthy diet-wise is to eliminate a completely ﬂesheating diet, and replace it with the food originally designed for man—cereals, 22 grains, nuts, vegetables and fruits— nature’s own storehouse of immunity against most of the world’s causes of ill health. One would expect that with numerous medical opinions on how increasingly dangerous it is for people to rely as much as they do on eating the ﬂesh of animals, governments would massively support research on plant and vegetable substitutes. But instead, we are faced with contrasting opinion in support of disease-infested ﬂesh-foods as diverse and contradictory as the selﬁsh interests of the food companies and lobbyists they represent. Many more people die annually from diet-related heart and coronary diseases than any other. The secret to good health is therefore diet discipline. Dziedzorm Kwaku Segbeﬁa Ghana Institute of Journalism Accra-Ghana, West Africa. To provide effective healthcare in developing nations, an organization must create programs that take into account the needs, cultures, and resources of the recipients. For example, to improve infant nutrition, programs must utilize local foods and not introduce those that won’t be available once the organization leaves. By learning what beneﬁciaries need, want, and can provide for themselves, we can ensure that programs will be fully utilized and achieve the greatest good. Cathy Skoula Action Against Hunger New York We need vitamins and minerals (micronutrients) in minute quantities for growth, brain development, and immunity against diseases. Deﬁciencies in vitamin A, iron, zinc and iodine have major negative effects on the health, development, and survival of children. Preventing micronutrient malnutrition saves lives and breaks cycles of poverty in developing countries, costing pennies per person, per year. Nobel laureate economists in the Copenhagen Consensus ranked investments in micronutrient programs second only to ﬁghting HIV/AIDS. Zahra Popatia and Karen Luttrell Micronutrient Initiative Ottawa, Canada Many businesses are involved in programs to improve global health. For example, the poorer sections of rural Indian households spend 12 percent of their income on healthcare, making its availability, affordability and quality a major national issue. In India, Royal Philips Electronics is using a custombuilt tele-clinical van, complete with diagnostic equipment and dedicated doctors, to provide quality healthcare at an affordable price. Read more at this link. Danielle Carpenter World Business Council for Sustainable Development Geneva, Switzerland Click here to subsribe to OneWorld Perspectives; it’s free!